Background: Elderly individuals often have unstable intertrochanteric femoral fractures (IFF), which are difficult to treat due to their complexity and poor health. Restoring mobility and reducing problems requires effective care. Modern surgical alternatives include PFNA and primary hemiarthroplasty, both having pros and cons. This study compared the clinical and functional outcomes of PFNA versus primary hemiarthroplasty in treating unstable intertrochanteric femoral fractures in aged patients. Methods: The study included 60 elderly people with unstable IFF (AO type 31 A2 and A3) treated. Individuals were allocated into 2 groups: PFNA (n=30) and hemiarthroplasty (n=30). Data on demographic characteristics, perioperative details, post-operative complications, and functional outcomes (Harris Hip Score) were collected and analyzed using SPSS software. Results: The PFNA group had significantly shorter operating times (78.4 ± 10.5 minutes) and less intra-operative blood loss (150.2 ± 30.4 mL) compared to the hemiarthroplasty group (112.6 ± 15.8 minutes, 280.7 ± 50.6 mL; p<0.001). The PFNA group also required fewer perioperative blood transfusions and had a shorter hospital stay (8.4 ± 2.3 days vs. 10.5 ± 2.8 days; p=0.002). Functional outcomes, assessed by the Harris Hip Score, were significantly better in the PFNA group at 3, 6, and 12 months postoperatively. The incidence of post-operative complications was slightly higher in the hemiarthroplasty group, though not statistically significant. Conclusion: PFNA delivers improved functional results, shorter operating times, less intra-operative blood loss, fewer blood transfusions, and shorter hospital stays for elderly unstable intertrochanteric femoral fractures. Both treatment methods have benefits and should be chosen depending on patient conditions and surgeon ability. Recommendations: It is advisable to conduct additional research in the future with a greater number of participants in order to validate these findings and improve treatment guidelines. Additionally, individualized patient assessment should guide the choice of surgical intervention to optimize outcomes.