Intramedullary nailing compared with primary total hip arthroplasty for pertrochanteric fractures in autonomous elderly patients

Aims: The optimal surgical strategy for pertrochanteric fractures in elderly patients remains debated. While intramedullary nailing is the standard of care, primary total hip arthroplasty (THA) has been proposed to enhance early recovery. This study compared functional outcomes, complications, and survival between both techniques in autonomous elderly patients. Methods: This monocentric randomized controlled trial was conducted between January 2015 and October 2017. Patients aged ≥ 70 years with pertrochanteric fractures and a pre-fracture Parker score ≥ 5 (indicating outdoor walking ability) were randomized to intramedullary nailing (n = 35) or cementless dual-mobility THA with trochanteric fixation (n = 34). Immediate full weightbearing was allowed in both groups. Functional outcomes were assessed at six weeks, six months, and 12 months using the Harris Hip Score (HHS), Postel-Merle d'Aubigné score, Parker mobility score, and visual analogue scale for pain. The primary endpoint was HHS at six months. Mortality, complications, and long-term survival were recorded. Results: A total of 69 patients were analyzed. At six months, the mean HHS was 85.7 (SD 11.2) in the osteosynthesis group and 82.5 (SD 10.7) in the THA group (p = 0.291). Functional recovery, autonomy, and pain were comparable up to 12 months. Operating time was longer in the THA group (p < 0.001), while complication rates were similar. One-year mortality was 21.7% with no between-group difference. At a median follow-up of 4.1 years, 80% of patients had died. Kaplan-Meier analysis showed no difference in overall survival (p = 0.953). No secondary conversion to arthroplasty occurred. Conclusion: No clinically meaningful difference in functional outcomes or overall survival was detected. The observed HHS difference (3.2 points) fell below our a priori threshold and well below the closest available minimal clinically important difference estimate. In the absence of a detectable functional or survival benefit, routine primary THA does not appear justified in this population.