Comparative efficacy of cementless bipolar hemiarthroplasty and proximal femoral nail anti-rotation in unstable intertrochanteric fractures: A meta-analysis

Abstract

BACKGROUND

Unstable intertrochanteric fractures in elderly patients require effective surgical management, with both cementless bipolar hemiarthroplasty (CBHA) and proximal femoral nail anti-rotation (PFNA) being valid treatment options to reduce morbidity and mortality.

AIM

To evaluate and compare the outcomes of CBHA and PFNA in treatment of unstable intertrochanteric fractures.

METHODS

A comprehensive search was conducted to identify relevant studies discussing the outcomes of using both CBH and PFNA in treatment of unstable intertrochanteric fractures. Studies published up to January 1, 2025 were searched across multiple databases, including PubMed, EMBASE, Scopus, Web of Science, Cochrane Library, and Google Scholar. Full texts of the selected articles were retrieved, reviewed, and independently assessed by the investigators. Discrepancies were resolved by consensus, with any remaining disagreements being arbitrated by a third author.

RESULTS

This meta-analysis included three studies, all of which were retrospective, involving a total of 240 patients. The follow-up period for participants was at least 12 months. CBHA was associated with significantly higher blood loss compared to PFNA [mean differences (MD): 129.14, 95%CI (52.51, 205.77), P = 0.001], though heterogeneity was high (I² = 97%). Operative time showed no significant difference initially [MD: 6.10, 95%CI (-13.34, 25.54), P = 0.54], but after excluding one study, BHA had longer operative times [MD: 21.51, 95%CI (18.60, 24.41), P < 0.00001]. Hospital stay and Harris scores showed no significant differences between groups. CBHA facilitated faster progression to weight-bearing [MD: -11.92, 95%CI (-22.46, -1.39), P = 0.03] and a lower incidence of prosthetic loosening [risk ratio: 0.21, 95%CI (0.05, 0.92), P = 0.04]. Refracture and thrombus formation rates were comparable between the two groups.

CONCLUSION

CBHA offers shorter weight-bearing duration and reduced prosthetic loosening but incurs greater blood loss and longer operative times compared to PFNA. Both techniques show comparable functional recovery, hospital stay, refracture, and thrombus risks. Clinical choice should prioritize early mobilization or surgical minimalism, guided by patient needs. Further prospective studies are warranted.

Key Words: Cementless bipolar hemiarthroplasty; Proximal femoral nail anti-rotation; Unstable intertrochanteric fractures; Meta-analysis; Unstable, Functional outcomes; FFNA

Core Tip: This meta-analysis compares cementless bipolar hemiarthroplasty (CBHA) and proximal femoral nail anti-rotation (PFNA) for unstable intertrochanteric fractures. CBHA enables earlier weight-bearing and reduces prosthetic loosening but results in greater blood loss and longer operative times than PFNA. Both approaches show similar functional recovery, hospital stays, and complication rates (refracture/thrombosis). The choice between CBHA (optimal for early mobilization) and PFNA (preferred for minimal invasiveness) should be individualized based on patient factors. Prospective studies are needed to refine selection criteria.

INTRODUCTION

Intertrochanteric femur fractures constitute nearly fifty percent of all hip fractures caused by low-energy mechanisms, including falls from a standing position[1]. Unstable intertrochanteric hip fractures account for approximately 25% of all hip fractures in the elderly population and are increasing in prevalence[2]. Fragility hip fractures manifest in a specific demographic characterized by risk factors such as advanced age, female sex, osteoporosis, a history of falls, and gait abnormalities[3]. The underlying poor bone quality and unstable nature of these fractures make them difficult to manage[4]. Surgical intervention must enhance the patient's probability of a positive outcome by accurately realigning the fracture with minimal surgical trauma, selecting the appropriate implant, and ensuring its proper placement.

The optimal treatment modality for unstable trochanteric fractures remains contentious. Three common surgical interventions for unstable intertrochanteric fractures (ITF) are dynamic hip screw (DHS), proximal femoral nail (PFN), and bipolar hemiarthroplasty (BHA)[5]. The DHS is a standard extramedullary fixation utilizing a locking compression mechanism. The DHS remains the gold standard for intertrochanteric fracture fixation, demonstrating reliable clinical outcomes with low rates of nonunion and mechanical failure[6]. However, this method shows significant limitations in unstable fracture patterns, with studies reporting complications including screw cutout, femoral head collapse, and medial shaft displacement[7,8] particularly secondary to excessive lag screw sliding. These biomechanical drawbacks, render the technique less suitable for complex or unstable fractures.

The modern generation intramedullary device, the proximal femoral nail antirotation (PFNA), was developed by the AO/ASIF group in 1997 as an evolution of the PFN. It is specifically designed for unstable intertrochanteric fractures[9]. Unlike its predecessor's screw system, the PFNA features a unique helical blade that compacts rather than removes bone, achieving superior fixation through enhanced cancellous bone compression. This design ensures greatest stability in osteoporotic bone while biomechanically preventing rotation and varus collapse[10,11]. In contrast to conventional screw fixation, the blade's enhanced bone-implant interface provides superior stabilization of the femoral head and neck.

Hemiarthroplasty implants for femoral neck fractures are classified according to articulation type (unipolar/bipolar)[12,13] and fixation method (cemented/uncemented)[14-17]. Cemented fixation, although contentious in elderly patients with femoral neck fractures, is typically favoured for individuals with poor bone quality, as indicated by the 2016 DOV (Dutch Orthopaedic Association) guidelines. Cemented prostheses exhibit enhanced fixation stability, reduced implant-related complications, and improved functional outcomes[18,19], yet they pose risks of cement-related toxicity and embolism that could trigger cardiovascular events[20-22]. Conversely, uncemented implants avoid bone cement implantation syndrome and its related perioperative mortality risks[23], although they may jeopardize initial stability in osteoporotic bone.

The choice between CBHA and PFNA, as well as the optimal treatment method for treating unstable femoral intertrochanteric fractures, remains a topic of controversy due to the advantages and disadvantages of each method. This study aims to address the lack of a meta-analysis comparing these two techniques by analysing their clinical and functional outcomes.

MATERIALS AND METHODS

The meta-analysis was conducted and documented in accordance with the guidelines established in the Cochrane Collaboration Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)[24]. On January 18, 2025, the meta-analysis was officially registered on PROSPERO under the identifier #CRD42025635409.

Search strategy

A comprehensive systematic search was conducted across multiple databases, including PubMed, Scopus, EMBASE, the Cochrane Library, Web of Science, and Google Scholar, to ensure a thorough exploration of the available literature. This search covered the entire duration of each database, from their establishment up to January 1, 2025, using predefined keywords and search strategies tailored to capture all relevant studies. The following Medical Subject Heading (MeSH) keywords and their combinations were used in the search: (hemiarthroplasty OR "femoral head replacement" OR "cementless bipolar" OR bipolar OR "hemi-arthroplasty" OR "cementless bipolar hemiarthroplasty" OR "bipolar hemiarthroplasty") AND ("proximal femoral nail" OR PFNA OR "PFN-A") AND ("Femoral Fractures"[MeSH] OR "Hip Fractures"[MeSH] OR "intertrochanteric fractures" OR "intertrochanteric fracture" OR "trochanteric fractures" OR "trochanteric fracture" OR "pertrochanteric fractures" OR "pertrochanteric fracture" OR "femoral intertrochanteric fracture" OR "intertrochanteric femoral fractures" OR "IFFs" OR "IFF").

Eligibility criteria

The PICOT algorithm was used in the following manner: Patients diagnosed with unstable intertrochanteric fractures comprised the population (P). The intervention (I) involved fixation using cementless bipolar hemiarthroplasty. The comparison (C) was with patients treated using the PFNA. The outcomes (O) evaluated several critical factors to compare the efficacy of the two interventions, including operation time, intraoperative blood loss, and hospital stay duration. Functional recovery was assessed using Harris Hip Scores, while postoperative complications, such as refracture, thrombus formation, and prosthetic loosening, were monitored. The ability to bear weight early after surgery was also considered a key functional outcome. The timing (T) for follow-up was a minimum of 12 months.

The study inclusion criteria were: (1) Both prospective and retrospective studies that directly compared CBHA with PFNA; (2) Patients with unstable intertrochanteric fractures classified using recognized systems, such as the AO/OTA or Evans–Jensen classifications; (3) A minimum follow-up period of 12 months; and (4) Articles published in English. Excluded were: (1) Studies involving other fixation methods or patients with pathological fractures, polytrauma, or other concurrent injuries affecting outcomes; (2) Studies lacking quantitative data; and (3) Technical notes, abstracts, editorials, comments, letters, case reports, case series, and cadaveric studies.

Study selection

Four authors reviewed the titles and abstracts of articles, selecting those pertinent to the research topic for further evaluation. The full text of the article was then obtained if the title or abstract corresponded with the study objectives. The first and second authors were consulted to address any disagreements. Articles without complete text access were omitted from the analysis. All articles derived from these procedures were evaluated, and their eligibility for inclusion was deliberated among the researchers. A manual review of the references from the included studies was performed to identify further pertinent research beyond the search strategy. All disputes and discrepancies were resolved through careful deliberation and agreement among the reviewers. Since the data for this meta-analysis was sourced from published articles, ethical approval was not required for this study.

Data extraction

Four authors meticulously extracted data from all eligible studies and systematically organized it into a structured Excel spreadsheet and a formatted table in a Word document. Arranged it into a systematic Excel spreadsheet and a formatted table in a Word document. Subsequent cross-checking was conducted, and discrepancies were resolved through consensus among the reviewers. Information retrieved included the author, year of publication, number of patients, mean age, duration of follow-up, type of fracture, conclusion, and patient demographics (age and sex). Clinical outcomes, encompassing operative duration, intraoperative haemorrhage, length of hospitalization, weight-bearing period, Harris Hip Scores, and postoperative complications such as refracture, thrombus formation, and prosthetic loosening, were also collected.

Quality assessment

The assessment of bias risk was conducted independently by two authors (MS, SA). The author utilized the Newcastle–Ottawa Scale[25] to evaluate the quality of observational studies. Discrepancies were resolved through discussions with the first author. A summary of the quality assessment by Newcastle-Ottawa Scale is shown in Table 1[26-28].

Table 1 Quality assessment of the included cohort studies using the Newcastle-Ottawa Scale tool.

Ref.	Selection				Comparability	Outcome			Overall quality	Quality
	Representativeness of the exposed cohort	Selection of the non-exposed cohort	Ascertainment of exposure	Outcome was not present at start of study	Control of 2 important factors	Assessment of outcome	Follow-up long enough	Adequacy of follow-up of cohort	Assessment
Cai et al[26], 2022		*	*	*	**	*	*		7	Very good
Song et al[27], 2022		*	*	*	**	*	*		7	Very good
Zhou et al[28], 2019		*	*	*	**	*	*	*	8	Very good

Statistical analysis

Continuous outcomes were assessed using mean differences (MD), while binary endpoints were analyzed with risk ratios (RR), both accompanied by their corresponding 95% confidence intervals (CI). Statistical analyses were conducted utilizing CMA (Version 5.4). Heterogeneity was evaluated utilizing the P value statistic. A P value less than 0.10 was deemed indicative of significant heterogeneity, whereas a P value greater than 0.10 suggested homogeneity. The interpretation of heterogeneity followed the protocols established in the Cochrane Handbook for Systematic Reviews of Interventions[29]. A fixed-effects model was employed to assess outcomes in the absence of significant heterogeneity. When heterogeneity was substantial (P value below 0.10), a random-effects model was utilized to evaluate the outcomes.

RESULTS

Study selection

A thorough computerized search was performed across various databases, yielding a total of 374 records. After eliminating duplicates, 158 records were retained for a further review. The review of titles and abstracts led to the exclusion of 148 articles. The complete texts of the remaining 10 articles were rigorously evaluated according to established inclusion and exclusion criteria, resulting in the exclusion of 7 articles. In conclusion, three studies[26-28] fulfilled the eligibility criteria and were incorporated into the meta-analysis. Figure 1 illustrates a summary of the selection process.

Figure 1 Flowchart of study search and inclusion criteria.

Study characteristics

This review included three retrospective studies[26-28], all conducted in China and published in BMC Musculoskeletal Disorders. The studies spanned different periods: Cai et al[26] (2014–2019), Song et al[27] (2012–2016), and Zhou et al[28] (2008–2012). Together, these studies assessed 240 elderly patients with unstable intertrochanteric fractures, comparing CBHA and PFNA. The classification systems varied slightly, with Cai et al[26] using the AO classification and the other two studies[27,28] employing the Evan-Jensen classification. While the proportion of patients treated with CBHA and PFNA was roughly similar in each study, Zhou et al[28] had the largest group for both interventions. The mean ages of patients were consistently high across all studies, reflecting the elderly demographic, with CBHA patients being slightly older than their PFNA counterparts in each study. The follow-up durations also varied, with Cai et al[26] reporting the longest at 24 months, in contrast, the other two studies[27,28] had a minimum follow-up duration of 12 months. Table 2 presents the characteristics of the selected studies.

Table 2 Characteristics of included studies.

Ref.	Country	Journal	Study design	Study period	Fractures classification		Number of patients		Sex as male/female		Average age in year		Follow-up in months	Conclusion
							CBHA	PFNA	CBHA	PFNA	CBHA	PFNA
(1) Cai et al[26], 2022	China	BMC Musculoskeletal Disorders	Retrospective	June 2014 to June 2019	AO classification		36	34	16/20	16/18	82.19	80.88	24 months	Cementless bipolar hemiarthroplasty showed no obvious advantage over PFNA in the perioperative period in elderly patients with osteoporotic unstable intertrochanteric fractures. However, the joint replacement allowed for earlier ambulation after the operation and rapid recovery of the hip joint function
					Class	CBH/PFNA
					A2.2	17/22
					A2.3	19/12
(2) Song et al[27], 2022	China	BMC Musculoskeletal Disorders	Retrospective	January 2012 to December 2016	Evan-Jensen classification		30	32	9/21	5/27	81.0	79.9	12 months	The bipolar hemiarthroplasty allows an earlier return to weight-bearing activity, but ultimately has the same effective treatments as the PFNA for the elderly with unstable comminuted ITFs
					Class	CBH/PFNA
					3	5/5
					4	8/7
					5	17/20
(3) Zhou et al[28], 2019	China	BMC Musculoskeletal Disorders	Retrospective	March 2008 to December 2012	Evan-Jensen classification		47	61	27/20	36/25	83.8	83.5	Minimum 12 months	Both PFNA and Cementless bipolar hemiarthroplasty are safe and effective treatments for femoral intertrochanteric fracture in elderly patients. Nonetheless, cementless bipolar hemiarthroplasty allows faster mobilization and recovery
					Class	CBH/PFNA
					III	22/27
					IV	17/22
					V	11/12

Clinical outcomes

Blood loss: Blood loss was reported by the three studies[26-28]. The total number of patients was 113 in the BHA group and 127 in the PFNA group. CBHA was associated with a statistically significant increase in the amount of blood loss in ml compared to PFNA under the random effect model [MD: 129.14 with 95%CI (52.51, 205.77), P = 0.0010] (Figure 2A). The pooled studies were heterogeneous (P < 0.00001, I² = 97%). However, after leaving Cai et al[26] 2022, the pooled studies were homogeneous (P = 0.18, I² = 44%), and BHA was associated with a statistically significant increase in the amount of blood loss in ml compared to PFNA [MD: 162.05 with 95%CI (136.91, 187.20), P < 0.00001] (Figure 2B).

Figure 2 Meta-analysis comparing bipolar hemiarthroplasty and proximal femoral nail anti-rotation outcomes. A: Blood loss between groups; B: Blood loss analysis excluding Cai et al[26], 2022; C: Operative time comparison; D: Operative time analysis excluding Song et al[27], 2022.

Operative time

Operative time was reported by the three studies[26-28]. The total number of patients was 113 in the BHA group and 127 in the PFNA group. There was no statistically significant difference between the two groups under the random effect model [MD: 6.10 with 95%CI (-13.34, 25.54), P = 0.54] (Figure 2C). The pooled studies were heterogeneous (P < 0.00001, I² = 96%). However, after leaving Song et al[27] 2022, the pooled studies were homogeneous (P = 0.40, I² = 0%), and BHA was associated with a statistically significant increase in the operative time in minutes compared to PFNA [MD: 21.51 with 95%CI (18.60, 24.41), P < 0.00001] (Figure 2D).

Hospital stay

Hospital stay duration was reported by the three studies[26-28]. The total number of patients was 113 in the BHA group and 127 in the PFNA group. There was no statistically significant difference between the two groups under the fixed effect model [MD: -0.47 with 95%CI (-1.15, 0.21), P = 0.17] (Figure 3A). The pooled studies were homogeneous (P = 0.11, I² = 55%).

Figure 3 Meta-analysis comparing bipolar hemiarthroplasty and proximal femoral nail anti-rotation outcomes. A: Hospital stay duration (days); B: Weight-bearing duration (days); C: Harris score comparison.

Weight bearing

Weight-bearing duration was reported by the three studies[26-28]. The total number of patients was 113 in the BHA group and 127 in the PFNA group. Bipolar hemiarthroplasty was associated with a statistically significant reduction in the weight-bearing duration compared to PFNA under the random effect model [MD: -11.92 with 95%CI (-22.46, -1.39), P = 0.03] (Figure 3B). The pooled studies were heterogeneous (P < 0.00001, I² = 100%), and the heterogeneity couldn't be solved by the leave-one-out sensitivity analysis.

Harris score

Harris score was reported by the three studies[26-28]. The total number of patients was 113 in the BHA group and 127 in the PFNA group. There was no statistically significant difference between the two groups under the fixed effect model [MD: 2.01 with 95%CI (-0.24, 4.26), P = 0.08] (Figure 3C). The pooled studies were homogeneous (P = 0.19, I² = 39%).

Refracture

Refracture was reported by two studies[26-27]. The total number of patients was 66 in the BHA group and 66 in the PFNA group. There was no statistically significant difference between the two groups under the fixed effect model [RR: 0.68 with 95%CI (0.20, 2.27), P = 0.53] (Figure 4A). The pooled studies were homogeneous (P = 0.37, I² = 0%).

Figure 4 Meta-analysis of complications between bipolar hemiarthroplasty and proximal femoral nail anti-rotation. A: Refracture incidence; B: Thrombus formation; C: Thrombus formation after excluding Cai et al[26], 2022; D: Prosthetic loosening incidence.

Thrombus formation

Thrombus formation was reported by the three studies[27-28]. The total number of patients was 113 in the BHA group and 127 in the PFNA group. There was no statistically significant difference between the two groups under the random effect model [RR: 1.33 with 95%CI (0.34, 5.12), P = 0.68] (Figure 4B). The pooled studies were heterogeneous (P = 0.09, I² = 59%). However, after leaving Cai et al[26] 2022, the pooled studies were homogeneous (P = 0.38, I² = 0%), and there was no significant difference between the two groups [RR: 2.49 with 95%CI (0.76, 8.20), P = 0.13] (Figure 4C).

Prosthetic loosening

Prosthetic loosening was reported by the three studies[26-28]. The total number of patients was 113 in the BHA group and 127 in the PFNA group. Bipolar hemiarthroplasty was associated with a statistically significant reduction in the incidence of prosthetic loosening compared to PFNA under the fixed effect model [RR: 0.21 with 95%CI (0.05, 0.92), P = 0.04] (Figure 4D). The pooled studies were homogeneous (P = 0.88, I² = 0%).

DISCUSSION

Orthopedic surgery continues to be a topic of debate and complexity regarding the management of unstable intertrochanteric fractures in elderly patients, particularly those with osteoporosis. Comparing the results of CBHA and PFNA in the treatment of these fractures was the objective of this systematic meta-analysis.

Recently, Ramadanov et al[30] conducted a retrospective study of 552 patients examining the influence of operative time on complication rates and mortality following hip hemiarthroplasty. Their findings indicated that patients with operational durations over the 86-minute cut-off faced a 111.8% elevated mortality risk relative to those below this limit, and the likelihood of complications increased by 2.2% for each additional minute of operation time. In this meta-analysis, no significant difference in operative time was initially observed between the two groups. However, after excluding one outlier study due to heterogeneity, PFNA demonstrated a shorter mean surgical duration (53.8 minutes). Abulsoud et al[31] recently conducted a case-control study comparing positioning approaches in 96 unstable trochanteric fractures, where supine positioning resulted in significantly longer operative times (67.27 ± 6.28 minutes) vs lateral decubitus (53.96 ± 4.19 minutes).

The continued preference for supine positioning in clinical practice stems from several evidence-based advantages. From an anesthesiology standpoint, the supine position provides superior position offers greater physiological comfort for patient management. A study by Ding et al[32], who successfully treated 45 patients with femoral ITFs using supine positioning. Their study demonstrated that closed reduction and anti-rotational intramedullary nailing in the supine position provides a safe and feasible treatment approach, offering the combined benefits of minimal surgical trauma, reduced complication rates, and favorable clinical outcomes for femoral ITF management. Conversely, Kakumanu et al[33] indicated that performing proximal femoral nailing in the lateral decubitus position enhances the identification of entry points and diminishes operational duration. This entry points provides intraoperative flexibility, enabling the transition to alternate surgical approaches when required[34]. The lateral decubitus posture poses technical difficulties, notably restricted fluoroscopic vision of the femoral head during lateral imaging, especially when inserting proximal locking devices. Due to these competing considerations, no consensus exists regarding the optimal patient positioning for proximal femoral nailing in hip fracture management, particularly for geriatric patients[31].

Our analysis revealed significantly greater intraoperative blood loss in CBHA compared to PFNA primarily due to CBHA's more extensive soft tissue dissection and femoral canal preparation. Notably, the CBHA studies in our meta-analysis employed different surgical approaches (two lateral, one posterior), findings from Micicoi et al[35] and Charles et al[36] found no significant variations in blood loss between the two hemiarthroplasty techniques. While tranexamic acid (TXA) administration is known to reduce postoperative haemoglobin drop and transfusion requirements[37], its use was undocumented in these studies. Only one study[26] compared transfusion requirements between CBHA and PFNA, reporting that CBHA patients required approximately four times more blood units on average than PFNA patients. The blood loss pattern was studied by Park et al[38], who analysed 356 bipolar hemiarthroplasty cases and found total calculated blood loss substantially exceeded visible blood loss - a finding later confirmed by Guo et al’s who conducted cross-sectional study of 212 patients[39]. Importantly, PFNA’s blood-sparing advantages extend beyond CBHA comparisons, with meta-analyses[40,41] confirm its superiority over Gamma nails and dynamic hip screws (DHS) in reducing blood loss.

Our analysis demonstrated significantly earlier achievement of full weight-bearing in patients treated with CBHA compared to PFNA. This is especially relevant for elderly patients, as delayed mobilization is often associated with increased morbidity and mortality. To facilitate early weight bearing in PFNA cases, cement augmentation may be employed to enhance implant stability, thereby potentially allowing earlier mobilization, as demonstrated by Keppler et al[42].

Additionally, the study showed significantly lower rates of prosthetic loosening in the CBHA cohort compared to PFNA patients, suggesting CBHA may offer superior long-term implant stability. This advantage is particularly relevant for elderly osteoporotic patients, where compromised bone quality often reduces the reliability of intramedullary fixation. However, no significant differences were observed in outcomes including Hip Harris Score, hospital stays, thrombus formation or refracture rates.

Numerous studies have reported favorable outcomes with cementless bipolar hemiarthroplasty for patients with unstable intertrochanteric fractures[43-45]. These studies highlight benefits such as early mobilization, reduced pain, and improved functional recovery in elderly patients. Despite these findings, the American Academy of Orthopaedic Surgeons recommends the use of cephalomedullary devices as the preferred treatment option for unstable intertrochanteric fractures[46].

Several important limitations must be acknowledged. First, the meta-analysis incorporated only a limited number of comparable studies meeting our inclusion criteria, which may have influenced the observed heterogeneity in results. While sensitivity analysis resolved some heterogeneity for certain outcomes, significant variability persisted across studies. Second, all included studies were conducted exclusively in China, potentially may limit generalizability to other populations. Third, despite our comprehensive literature search, the possibility of publication bias remains as unpublished studies could have altered our conclusions.

These limitations underscore the need for focused future research, particularly (1) Multi- center prospective studies with diverse populations to enhance generalizability; (2) Randomized controlled trials comparing patient-reported outcomes, long-term implant survival (≥ 5 years), and cost-effectiveness, and (3) Extended follow-up studies specifically targeting elderly osteoporotic patients - all of which would provide stronger evidence to guide clinical decision-making for unstable intertrochanteric fractures.

CONCLUSION

CBHA and PFNA offer different advantages and disadvantages in the treatment of unstable intertrochanteric fractures. CBHA enables earlier postoperative weight-bearing and exhibits enhanced implant stability, thereby diminishing the risks of prosthetic loosening and mechanical failure. Nonetheless, these benefits are offset by increased intraoperative blood loss, extended surgical duration. Conversely, PFNA provides a minimally invasive technique characterized by reduced operative durations and diminished acute physiological strain, though it entails postponed full weight-bearing and a higher incidence of prosthetic loosening.

The functional recovery, length of hospital stays, and incidence of major adverse events (refracture and thrombosis) appeared to be similar between the two methods. The decision between CBHA and PFNA should be personalized, emphasizing early mobilization for higher-functioning patients or minimally invasive stabilization for those with diminished physiological reserve.

Future prospective studies utilizing standardized outcome measures are essential to refine patient selection criteria and elucidate long-term comparative outcomes.