Fracture stability modifies the risk profile and outcomes of proximal femoral nailing versus hemiarthroplasty for elderly intertrochanteric fractures.

BACKGROUND

With population aging, intertrochanteric fractures (ITFs) in elderly individuals are increasingly common, and the choice between proximal femoral nail antirotation (PFNA) and hemiarthroplasty (HA) remains under debate, particularly regarding the optimal balance between early mobilization and the risk of long-term implant failure or revision. This study aimed to investigate this trade-off through a retrospective cohort comparison of PFNA and HA in elderly ITF patients stratified by fracture stability.

METHODS

This retrospective cohort study reviewed 372 elderly patients with ITF treated from 2016 to 2022. Patients were grouped by surgery (PFNA or HA) and stratified by fracture stability (AO/OTA classification). The primary outcome was the Harris hip score (HHS) at 12 months post-operatively; secondary outcomes included perioperative metrics and complications.

RESULTS

Overall, PFNA group demonstrated higher 12-month HHS (87.9 ± 5.8 vs. 84.6 ± 6.3, p < 0.001) despite longer operative duration, hospital stays, and delayed weight-bearing (p < 0.05) than HA. Subgroup analysis revealed no difference in HHS at 12 months for stable ITF patients. In the unstable subgroup, HA enabled earlier weight-bearing (4.5 ± 3.3 vs. 8.5 ± 3.7 days, p < 0.001), but PFNA demonstrated significantly better 12-month HHS (88.3 ± 6.3 vs. 82.5 ± 6.3, p < 0.001), with less blood loss and lower costs.

CONCLUSIONS

For stable ITFs in elderly patients, the PFNA and HA yield comparable outcomes. For unstable ITFs, a clinical trade-off exists: HA provides faster early mobilization, whereas PFNA offers superior long-term hip function. Implant choice should be tailored to patient life expectancy and functional goals.