Proximal Femoral Nail Antirotation II versus Dynamic Hip Screw for Intertrochanteric Fractures: A Systematic Review of Stable and Unstable Patterns

Abstract Background: Background: Intertrochanteric femoral fractures represent a substantial burden in geriatric trauma, contributing to considerable morbidity and mortality worldwide. The selection of optimal fixation strategy continues to generate debate within the orthopedic community, with both the Dynamic Hip Screw (DHS) and Proximal Femoral Nail Antirotation II (PFNA-II) serving as primary treatment modalities. This systematic review synthesizes current evidence comparing the clinical efficacy and safety profiles of PFNA-II and DHS across different fracture stability patterns. Methods: We performed a comprehensive literature search encompassing PubMed, PubMed Central, Cochrane Library, and Google Scholar databases through October 2025. Our inclusion criteria targeted randomized controlled trials, meta-analyses, systematic reviews, and comparative cohort investigations. Primary endpoints included functional recovery metrics (Harris Hip Score), perioperative parameters (surgical duration, hemorrhage volume), and postoperative adverse events (implant migration, fixation failure, infectious complications, revision surgery rates). Results: This review incorporated 54 studies representing diverse patient populations. Evidence demonstrates that PFNA-II confers superior outcomes in unstable fracture configurations, manifesting as reduced surgical time, diminished perioperative blood loss, accelerated weight-bearing mobilization, and decreased rates of mechanical complications including cut-out and fixation failure. In stable fracture patterns, both devices yield comparable clinical results, with DHS potentially offering economic advantages. The biomechanical characteristics of PFNA-II, particularly its helical blade architecture, appear advantageous in osteopenic bone and complex fracture geometries including reverse obliquity patterns and lateral wall deficiency. Conversely, certain studies indicate elevated reoperation risk associated with intramedullary fixation systems. Conclusion: Contemporary evidence supports PFNA-II as the preferred fixation method for unstable intertrochanteric fractures, demonstrating measurable benefits in perioperative metrics and complication profiles. For stable fracture patterns, both PFNA-II and DHS represent valid treatment options, with selection potentially influenced by surgeon expertise and healthcare economics. Additional high-quality prospective investigations are warranted to establish long-term functional outcomes and comprehensive cost-effectiveness analyses.