While intramedullary fixation may have less operative morbidity than sliding plate systems, there also may be a loss of stability and strength of the fixation. In a biomechanical study with simulated unstable intertrochanteric fractures in cadaver femurs, multiple Ender's pins were 18% stronger than the single Harris nail. Compression hip screws were three times stronger than the Harris nail and two and one-half times stronger than Ender's pins. The compression hip screw was five times more rigid than either condylocephalic system.
Sliding compression screw systems have been successful for internal fixation of unstable intertrochanteric fractures. This approach does, however, require exposure of the fracture site and insertion of several screws with associated increased operative time and blood loss compared to intramedullary methods. Although sliding screw and nail systems allow collapse into a stable condition, the result usually still loads the internal fixation device in bending. Conversely, intramedullary devices are more in line with load as indicated by the trabecula of the proximal femur.