Introduction 1 7 7 7 16 4 10 28 7 26 32 35 Patients and methods A total of 308 patients who were treated for trochanteric femoral fractures between 1992 and 2005 with a minimum age of 60 years were enrolled in this study. Seventeen patients with pathologic fractures due to metastases were excluded. Information about survival after 1 year could be achieved from 283 of the 291 patients. P 24 19 1 Fig. 1 X P  ® 1 ® 1 P Table 1 Description of the baseline variables within the treatment groups  Arthroplasty DHS PFN Age (years) 83 ± 7 79 ± 9 75 ± 12 Number of patients 132 109 42 Gender  Female  115 (87%) 80 (73%) 26 (62%)  Male 17 (13%) 29 (27%) 16 (38%) ≥4 comorbidities 63 (48%) 56 (51%) 17 (41%) Fracture type  A1 37 (28%) 57 (52%) 7 (17%)  A2 82 (63%) 48 (44%) 29 (69%)  A3 12 (9%) 5 (4%) 6 (14%) Year of injury  1992–1999 111 (84%) 72 (66%) 0 (0%)  2000–2005 21 (16%) 37 (34%) 42 (100%) Outcome variables 2 10 Table 2 The distribution of fracture type and treatment and its specific mortality  1992–1999 2000–2005 1992–2005 n Death Mortality (%) n Death Mortality (%) n Death Mortality (%) A1 71 19 26.8 29 4 13.8 100 23 23.0  THR 34 9 26.5 0 0  34 9 26.5  HA 0 0  3 1 33.3 3 1 33.3  DHS 37 10 27.0 19 3 15.8 56 13 23.2  PFN 0 0 0.0 7 0 0.0 7 0 0.0 A2 95 28 29.5 66 13 19.7 161 41 25.5  THR 65 24 36.9 6 2 33.3 71 26 36.6  HA 0 0  12 1 8.3 12 1 8.3  DHS 30 4 13.3 18 2 11.1 48 6 12.5  PFN 0 0  30 8 26.7 30 8 26.7 A3 17 6 35.3 5 1 20.0 22 7 31.8  THR 12 5 41.6 0 0  12 5 41.6  HA 0 0  0 0  0 0   DHS 5 1 20.0 0 0  5 1 20.0  PFN 0 0  5 1 20.0 5 1 20.0 All fractures 183 53 29.0 100 18 18.0 283 71 25.1  THR 111 38 34.2 6 2 33.3 117 40 34.2  HA 0 0  15 2 13.3 15 2 13.3  DHS 72 15 20.8 37 5 13.5 109 20 18.4  PFN 0 0  42 9 21.4 42 9 21.4 THR HA PFN DHS Surgical technique ® ® 2 ® 3 Statistics P The influence of treatment on mortality was checked by a multiple logistic regression model adjusted for the presence of preoperative comorbidities (four or more vs. up to three), fracture classification, age, gender, complications requiring revision surgery and year of surgery. 34 34 P 0 P 0 P 0 All analyses were conducted with the SPSS statistic software for Windows 12.0 (SPSS, Chicago, IL, USA). Results Surgery P P P P P Mortality 2 Influence of gender and age 2 P 4 P Fig. 2 P P P P  Influence of comorbidities 3 P P 4 P 2 Table 3 The prevalence and relative risks of the most common comorbidities Comorbidity n P P RR OR CI 95% P Heart attack 124 0.340 0.43 1.12 1.19 0.56–2.14 0.69 Cardiac arrhythmia 47 0.354 0.01** 1.10 1.16 1.02–2.43 0.04* Cardiac insufficiency 111 0.304 0.82 1.44 1.79 0.67–3.18 0.55 Hypertonus 154 0.268 1.00 0.98 0.97 0.55–1.73 0.92 Pulmonary diseases 66 0.288 0.73 1.07 1.1 0.57–2.16 0.77 Anemia 47 0.319 0.35 1.26 1.43 0.69–2.96 0.33 Renal insufficiency 47 0.261 1.00 0.85 0.81 0.38–1.75 0.60 Cerebral diseases 127 0.336 0.30 1.42 1.81 1.02–3.22 0.04* Diabetes mellitus 92 0.326 0.28 1.24 1.41 0.79–2.52 0.25 Metabolic diseases 30 0.233 0.82 0.75 0.7 0.27–1.80 0.46 Alcohol/nicotine/other drugs 29 0.321 0.35 1.51 1.98 0.79–4.99 0.14 Gastrointestinal disease 42 0.244 0.31 0.76 0.71 0.32–1.64 0.43 Others 57 0.304 0.85 1.01 1.01 0.51–2.03 0.96 P 0 P 0 P 0 P P Table 4 Multiple logistic regressions analysis of a 1-year mortality after proximal femoral fractures of elderly patients Description of the analysis Influence of interaction of kind of treatment and fracture classification after adjusting age, gender, comorbidities, revision surgery and date of surgery  Odds ratio 95% CI P Relative risk e  A1*PFN 0.000 0.000 0.999 0.00  A1*DHS 0.638 0.228–1.787 0.392 0.71  A2*TEP 1.391 0.566–3.420 0.472 1.25  A2*PFN 1.124 0.272–4.647 0.872 1.08  A2*DHS 0.372 0.112–1.237 0.107 0.46  A3*TEP 2.120 0.502–8.954 0.307 1.59  A3*PFN 1.017 0.087–11.833 0.989 1.01  A3*DHS 1.093 0.096–12.387 0.943 1.06 c  70–79 years 1.231 0.334–4.532 0.755 1.19  80–89 years 2.798 0.785–9.970 0.112 2.23  >90 years 6.381 1.603–25.403 0.009 3.61 d  Female gender 0.338 0.161–0.708 0.004 0.44 Influence: comorbidities complications and year of surgery   ≥4 comorbidities 2.238 1.219–4.109 0.009 1.78  Revision surgery 1.195 0.448–3.184 0.722 1.13  Surgery after 2000 0.775 0.343–1.752 0.541 0.83 Relative risks (RR) are computed from OR (odds ratio) by the following formula: P 0 P 0 P 0 RR < 1.0 represents a minor risk of mortality; RR > 1.0 represents a major risk of mortality compared with patients without this criteria Number of cases in all models: 282 a b c d e Influence of fracture-classification and treatment 1 2 P P 4 4 2 P P 4 Influence of complications P P The DHS had a revision rate of 8.1%, while the PFN needed reoperations in nine cases (22.5%). The main reason was cutting out of the screw in the osteoporotic bone and postoperative hematoma. Due to cutting out and fixation failure secondary hip arthroplasty was performed after failed internal fixation ten times. It happened six times (5.4%) after a DHS and four times (9.8%) after a PFN. P Rehabilitation P P P Discussion 4 5 9 28 12 15 21 23 31 3 8 13 28 26 16 25 29 30 4 6 22 33 11 28 4 10 14 7 7 17 20 26 3 4 4 27 3 13 4 10 18 3 Fig. 3 Examples of treatment of A2-type fractures with a hemiendoprosthesis and tension band wires. Depending on the fracture type different ways of fixating the trochanteric region with wires were used. In the case of a calcar fragment reaching distal to the lesser trochanter a temporary reduction with a cerclage wire or reduction bone clamp was used before reaming. Final fixation of the greater trochanter was performed after reduction of the hip with cerclages or a tension band  19 30 16 29