Controversies and Evidence in Surgical Decision-Making for Unstable Intertrochanteric Fractures in Older Adults: Total Hip Arthroplasty Versus Cephalomedullary Nailing and a Four-Domain Stratified Algorithm

Abstract

Background: Unstable intertrochanteric fracture (ITF) in older adults is associated with substantial disability and mortality. Cephalomedullary nailing (CMN) is widely regarded as first-line treatment for unstable ITF [1]. However, severe comminution and osteoporosis may increase fixation-failure risk, whereas primary arthroplasty—particularly total hip arthroplasty (THA)—has been proposed for selected patients to enable immediate stability and early full weight bearing, leading to ongoing controversy. Objective: To synthesize guideline recommendations and comparative evidence for THA versus CMN in older adults with unstable ITF, and to propose a pragmatic four-domain stratified decision algorithm (Figure 1). Methods: A narrative evidence synthesis focused on high-yield sources, including international guidelines and pivotal clinical evidence: randomized-trial–based systematic reviews/meta-analyses and representative observational/database studies [2–5,12]. Outcomes included perioperative metrics, early mobilization and rehabilitation, functional scores, complication profiles, reoperation, and mortality, as well as the burden of conversion THA after failed fixation [9,10].
Results: Available evidence suggests arthroplasty may facilitate earlier mobilization and better short-term function [3–5], while longer-term functional superiority is inconsistent and overall complication, reoperation, and mortality differences are often not significant [3–5,12]. Fixation failure after CMN is influenced by modifiable technical factors (e.g., implant position, reduction quality, lateral wall/medial support) [6–8]. THA introduces procedure-specific risks (dislocation, periprosthetic fracture); stability strategies such as dual-mobility constructs may reduce dislocation in high-risk populations [11]. Conclusion: CMN remains the default strategy for most older adults with unstable ITF [1]. Primary THA should be reserved for carefully selected patients at very high fixation-failure risk and high failure cost, considering pre-fracture function, concomitant symptomatic hip disease, and system readiness within an experienced arthroplasty pathway (Figure 1).