Pertrochanteric Fracture — Intramedullary Nail or Primary Total Hip Arthroplasty?

Polish version · Research Updates, Literature and Evidence-Based Medicine

In older adults who had been mobile before injury, primary total hip arthroplasty did not accelerate functional recovery after a pertrochanteric fracture compared with a modern intramedullary nail. This was the finding of a small randomised trial published on 9 September 2026. Importantly, immediate full weight bearing was allowed in both groups.

Why is this study interesting?

Intramedullary nailing remains the standard treatment for pertrochanteric fractures. Advocates of primary arthroplasty have argued that, in an older patient, it may avoid the risk of fixation failure and facilitate early mobilisation. The trade-off is a more extensive operation, the need to reconstruct the trochanteric region and the risks inherent to joint replacement.

French investigators compared these strategies in a group in whom the argument for arthroplasty might appear particularly persuasive: patients older than 70 years who had been able to walk outside the home before the fracture.

Question and methods

This was a prospective, single-centre, open-label randomised trial conducted from 2015 to 2017. Of 460 patients screened, 70 were randomly assigned to treatment and 69 were included in the analysis: 35 underwent intramedullary nailing and 34 underwent uncemented total hip arthroplasty with a dual-mobility cup and trochanteric stabilisation.

The mean age was 84.7 years and 82.6% of participants were women. Eligibility required a pre-injury Parker Mobility Score of at least 5, indicating the ability to walk outside the home with or without assistance. Patients with dementia, severe cognitive impairment and pathological fractures were among those excluded. Immediate full weight bearing was permitted in both groups, and both groups followed the same rehabilitation programme.

The primary endpoint was the Harris Hip Score at six months. The investigators also assessed function at six weeks and one year, pain, mobility, complications, operating time, mortality and subsequent reoperations. The analysis followed the original treatment allocation.

Results

• At six months, the mean Harris Hip Score was 85.7 after intramedullary nailing and 82.5 after arthroplasty; the difference was not statistically significant (p=0.291).
• At six weeks, the scores were 70.4 and 69.7, respectively, and at 12 months 88.7 and 88.1, with no advantage for either strategy.
• Pain, autonomy and the other functional measures were similar through one year. Function improved over time in both groups, but average mobility at one year had not fully returned to the pre-fracture level.
• The median operating time was 30 minutes for nailing and 94 minutes for arthroplasty (p<0.001).
• There was one early mechanical failure in the fixation group. In the arthroplasty group, one patient sustained both a dislocation and a deep infection requiring reoperation.
• One-year mortality was 21.7% and did not differ between groups.
• At a median follow-up of 4.1 years, 80% of the original cohort had died; there was no difference in survival. No patient underwent secondary conversion from fixation to arthroplasty.

Clinical interpretation for an orthopaedic surgeon

The study does not support the proposition that the additional burden of primary THA provides a functional advantage in an older person who had been mobile before injury. Particularly relevant is the fact that full weight bearing was also permitted after intramedullary nailing. In this protocol, the argument that arthroplasty is necessary mainly to allow immediate weight bearing was therefore not supported.

The 3.2-point difference in Harris Hip Score at six months was not statistically significant and was also clearly below the closest available estimates of a minimal clinically important difference. Arthroplasty, meanwhile, required more than three times as long in the operating room.

Limitations

• The sample was small, and complete six-month functional data were available for 56 of 69 patients; missing results were mainly due to deaths.
• The trial was not designed as a formal equivalence study. It shows no large clinical superiority of arthroplasty, but it does not prove that the two strategies are identical.
• The population was highly selected: patients with dementia were excluded and pre-injury mobility had to be preserved. The result cannot be extrapolated to every patient with a hip fracture.
• The fractures were AO/OTA A1–A2 patterns; the study does not settle management for every extremely unstable or unreconstructable fracture.
• Uncemented femoral stems were used, reflecting the centre’s practice in 2015–2017. No cost analysis was performed.
• Assessments were performed by treating clinicians, and surgeon experience differed between groups: arthroplasties were more often performed by more senior surgeons.
• The long-term follow-up covered survival and major hip-related events, but not repeated functional measurements.

What might this change in practice — and what does the study not show?

The findings support retaining intramedullary nailing as a proportionate treatment for most pertrochanteric fractures in previously mobile older adults when stable fixation can be achieved and early weight bearing is possible. They do not provide a basis for routinely replacing nailing with primary THA solely because of age.

The study does not show that arthroplasty has no role. A different strategy may be justified in unreconstructable destruction of the proximal femur, advanced pre-existing joint disease, a pathological fracture or as salvage after failed fixation — situations that this trial did not assess.

Source

Piercecchi A, Bordet A, Labattut L, Maczynski A, Baulot E, Martz P. Intramedullary nailing compared with primary total hip arthroplasty for pertrochanteric fractures in autonomous elderly patients: a prospective randomized study. Bone & Joint Open. 2026;7(9):1178–1186. Published 9 September 2026. DOI: 10.1302/2633-1462.79.BJO-2026-0142.R1. PubMed | open full text.

Content prepared by: Tomasz Poboży - orthopaedic surgeon.