traditionally , intertrochanteric fractures were operated with a sliding hip screw with a side plate . in the early 1990s , a new method of an intramedullary nail in the proximal femur with an interlocking screw in the femoral head was introduced29 ) . in cases of unstable intertrochanteric fracture in the elderly , osteoporosis and comminution often result in delayed full weight - bearing and a high rate of complications that are treated with internal flxation including compression hip screw ( chs ) and proximal femur nail antirotation ( pfna)210 ) . recently , many reports in the literature consider that prosthetic replacement is the preferred treatment for selected unstable comminuted intertrochanteric fractures in the elderly1112 ) . however , unlike a femoral neck fracture , an intertrochanteric fracture has a good blood supply , ensuring bone healing in the case of proper flxation . also , arthroplasty has a number of disadvantages , including greater blood loss , increased operation time and greater soft tissue injury , which are especially important issues in elderly patients8 ) . the purpose of this study was to determine whether there were differences in clinical and radiologic outcomes among bipolar hemiarthroplasty ( bh ) , chs and pfna in treating comminuted intertrochanteric fractures ( ao / ota classification , a2 [ 22 , 23 ] ) at postoperative 1 year . the institutional review board of soonchunhyang university cheonan hospital approved the design and protocol of this study . from march 2010 to december 2012 , total of 150 restrospective consecutive patients were enrolled to perform this study in three groups - bh , 50 cases ; chs , 50 cases ; pfna , 50 cases . the inclusion criteria were : unstable intertrochanteric fractures ( ao / ota classification , a2 [ 22 , 23 ] ) , no contraindication to anesthesia , and pre - injury independent walking with or without aids . the exclusion criteria were : reoperation , expire and follow up loss within postoperative 1 year , suspected pathological fracture , significant senile dementia , and osteoarthritis or rheumatoid arthritis in the fractured hip . the bh group included 20 males and 30 females with a mean age of 81.8 years old ( standard deviation [ sd ] , 6.9 ; range , 71 - 101 years old ) , the chs group included 21 males and 29 females with a mean age of 77.3 years ( sd , 8.8 ; range , 65 - 93 years old ) , and the pfna group included 21 males and 29 females with a mean age of 73.8 years ( sd , 9.5 ; range , 65 - 94 years old ) . there was significant differences in the mean age among these three groups , but there were no significances in the body mass index and dual energy absorptiometry ( table 1 ) . bh and chs were performed by yss and pfna were performed by jsp , because of surgeon 's preference for unstable intertrochanteric fractures in same center . the prosthesis for bh was the bencox stem and the corenbipolar cup ( corentec , seoul , korea ) . osteosynthesis was performed using chs ( dynamic hip screw system ; tradimedics , seongnam , korea ) and pfna ( synthes , solothurn , switzerland ) . at postoperative 1 year , the functional outcome was evaluated using harris hip score ( hhs)13 ) and the degree of pain was measured by visual analogue scale ( vas)13 ) . pain while walking was assessed on a vas ( 0 to 100 ) and scores exceeding thirty were regarded as substantial pain . mobility were evaluated by use of the koval classiflcation1415 ) , which grades ambulatory ability as independent community ambulatory ( grade 1 ) , community ambulatory with cane ( grade 2 ) , community ambulatory with walker or crutches ( grade 3 ) , independent household ambulatory ( grade 4 ) , household ambulatory with cane ( grade 5 ) , household ambulatory with walker or crutches ( grade 6 ) , and nonfunctional ambulatory ( grade 7 ) . anteroposterior radiographs of the hip were taken at each follow - up for the evidence of union , subsidence of the stem , migration of internal fixation , and heterotopic ossification , ipsilateral limb length discrepancy ( lld ) for radiologic shortening was checked at each group . anteroposterior radiographs of the hip were obtained in the supine position at a source - to - film distance of 110 cm with the x - ray beam centered on the superior aspect of the pubic symphysis and perpendicular to the patient16 ) . radiologic outcome was evaluated by ipsilateral lld between immediate postoperative length and length of postoperative 1 year after adjusting difference of magnification . each lld was checked from hip center to wiring area of lesser trochanter ( or distal tip of lesser trochanter , if there was no wiring ) in bh ( fig . 2 ) , and from hip center to distal locking screw in pfna ( a , postoperative length ; a ' , length of postoperative 1 year ) ( fig . magnification adjustment were performed using the ratio of stem length between postoperative length and length of postoperative 1 year ( b , postoperative stem length ; b ' , the length of stem at postoperative 1 year ) in bh . in chs , the length of plate was used to adjust difference of magnification ( b , postoperative plate length ; b ' , the length of plate at postoperative 1 year ) . in pfna , the length of nail was used to adjust difference of magnification ( b , postoperative nail length ; b ' , the length of nail at postoperative 1 year ) . radiologic lld ( shortening)= [ a(b'/b)]-a ' baseline patient characteristics and perioperative clinical data were analyzed for all patients , and by gender and operation type with descriptive statistics . bi - variable tests of association were based on either pearson 's chi - square or fisher 's exact tests for categorical variables . a robust analysis of variance ( anova ) was used for continuous variables and the kruskal - wallis test was used for for ordinal variables . all tests were two - sided , and statistical significance was accepted for a p - value of < 0.05 , and statistical analysis was performed using spss statistical software ( version 16 ; spss inc . , in clinical outcomes , the mean hhs of bh was 7317 , the mean hhs of chs was 7119 , and the mean hhs of pfna 7415 . the mean koval score of bh was 2.81.7 , the mean koval score of chs was 3.02.3 , and the the mean koval score of pfna was 2.52.2 . the mean vas score was 2.83.8 in bh group , 2.83.6 in chs group , and 3.04.1 in pfna group . there were no significances in clinical outcome including hhs , the koval score , and the vas score among these three groups ( table 2 ) . in radiologic outcomes , there was significant differences in radiologic limb discrepancy in plain radiographs at 12 months postoperatively ( radiologic shortening : bh group , 2.33.7 mm ; chs group , 5.16.3 mm ; pfna group , 3.0 4.1 mm ; p=0.000 ) ( table 2 ) . all of the 150 patients achieved fracture union without fixation loss or stem loosening , and there were no cases of infection , heterotrophic ossification . intertrochanteric hip fractures account for approximately half of all hip fractures in the elderly population17 ) . among these fractures , however , the choice of surgical options for intertrochanteric fractures is controversial6 ) . in this study there are various reports comparing clinical outcome , but few reports published for radiological outcome after 1 year postoperatively24891022 ) . the bh with full coated stem , initial stability and long - term biologic fixation can be obtained even in osteoporotic proximal femur with large bone defect1123 ) . however , bh was associated with significantly longer operation time , intraoperative blood loss , intraoperative blood salvage , and total volume of blood transfused than internal fixation23 ) . chs can provide satisfactory flxation , but failure rates of 4 - 20% have been reported in the treatment of intertrochanteric fractures112224 ) . intramedullary flxation using pfna has the theoretical advantages of closed insertion through a small incision and a shorter lever arm , which reduces the risk of fatigue failure of the implant25 ) . however , its main drawback is the possibility of femoral shaft fracture , especially at the site of the distal locking screw hole826 ) . because internal fixation of unstable intertrochanteric fractures in osteoporotic patients necessitates a prolonged period of protected weight bearing and is frequently associated with problems such as loss of fixation , nonunion , and cut - out of the lag screw in chs and pfna . varus collapse and shortening are mechanical complications of unstable or severely osteoporotic intertrochanteric fractures19 ) . however , in spite of these problems , it is very important advantage to preserve normal joint and bone viability in chs and pfna . first , other important factors for clinical and radiological outcomes were not evaluated , such as demographic characteristics about preinjury ambulatory state and instability risk and , radiographic findings about the defect of posteromedial cortex , extension to subtrochanteric area , presence of osteoporosis . second , preoperative true limb length could not investigated , and radiologic landmarks to adjust magnification could be checked ambiguously by the patient position . thrid , we could not evaluate the clinical and radiological outcomes such as complications after operation . although there was no significant differences in clinical outcomes among three groups at postoperative 1 year , notable differences were observed in lld according to selection of operative methods ( bh < pfna < chs ) . meaningful shortening could be originated during fracture healing in osteosynthesis , compared to arthroplasty , and that could induce limping . this study supports all of three methods ( bh , chs , pfna ) could improve clinical outcomes in comminuted intertrochanteric fractures . however , different limb length shortening ( bh < pfna < chs ) could be arisen by selection of operation methods , surgeons could consider these outcomes .
purposein comminuted intertrochanteric fractures , various operative options have been introduced . 
 the purpose of this study was to determine whether there were differences in clinical and radiologic outcomes among bipolar hemiarthroplasty ( bh ) , compression hip screw ( chs ) and proximal femur nail antirotation ( pfna ) in treating comminuted intertrochanteric fractures ( ao / ota classification , a2 [ 22 , 23])materials and methodswe retrospectively evaluated total 150 patients ( bh , 50 ; chs , 50 ; pfna , 50 ) who were operated due to intertrochanteric fractures from march 2010 to december 2012 and were older than 65 years at the time of surgery . 
 we compared these three groups for radiologic and clinical outcomes at 12 months postoperatively , including harris hip score , mobility ( koval stage ) , visual analogue scale and radiologic limb length discrepancy ( shortening).resultsthere was no statistical significance among three groups in clinical outcomes including harris hip score , mobility ( koval stage ) , visual analogue scale . 
 however , there was significant differences in radiologic limb discrepancy in plain radiographs at 12 months postoperatively ( radiologic shortening : bh , 2.3 mm ; chs , 5.1 mm ; pfna , 3.0 mm ; p=0.000).conclusionthere were no clinical differences among bh , pfna , and chs in this study . 
 however , notable limb length shortening could be originated during fracture healing in osteosynthesis , compared to arthroplasty ( bh < pfna < chs ) .