Background and Aim <p>Bipolar hemiarthroplasty (BHA) and proximal femoral nail (PFN) represent the two predominant interventions in contemporary clinical practice. This review was conducted to address the lack of consensus regarding the superiority of these two interventions. This study aims to perform a systematic review and meta-analysis to assess the superiority of PFN compared to BHA by evaluating postoperative outcomes, including mortality rates and Harris Hip Scores (HHS). Furthermore, secondary outcomes such as injury to surgery time, revision surgery rates, intra-operative blood loss, duration of immobilization, and length of hospitalization were evaluated.</p> Methodology <p>Four electronic databases (PubMed, Scopus, Web of Science, and the Cochrane Library) were searched for relevant articles published. Inclusion criteria included human studies with randomized controlled trial (RCT) or observational cohort designs (prospective or retrospective) that directly compared bipolar hemiarthroplasty (BHA) with proximal femoral nail (PFN) for unstable intertrochanteric femoral fractures in elderly patients (aged ≥ 60&#xa0;years). Exclusion criteria included animal studies, articles not available in English, and studies comparing non-relevant outcomes. Two independent reviewers performed data extraction using standardized forms. Review Manager 5.4 (RevMan) software was employed for meta-analysis using random-effects models with assessment of heterogeneity using <i>I</i>² statistics and subgroup analyses by study design and surgical approach. This study is registered with PROSPERO (ID: CRD42022322759).</p> Results <p>We analysed a total of 13 studies published between 2012 and 2025. There were 11 retrospective cohort and two randomized controlled studies. The number of patients in these studies ranged from 44 to 308. There was a significant difference in HHS between the two groups with a standard mean difference (MD) of  − 7.60 (range − 10.83 to − 4.36), favouring the PFN group. The BHA group had a greater mortality rate with odds ratio (OR) of 1.47 (range 1.14 to 1.90). Moreover, intraoperative blood loss (MD: 206.86) and period of immobilization (MD: 0.35) were lower in the PFN group. There were no difference in the rate of revision surgery (OR- 0.76), period of hospitalisation and injury to surgery time (MD:  − 1.35).</p> Conclusion <p>Proximal femoral nailing demonstrates advantages in intraoperative blood loss, transfusion requirements, and long-term Harris Hip Score compared with bipolar hemiarthroplasty for unstable intertrochanteric femoral fractures in the elderly. However, bipolar hemiarthroplasty offers important advantages in early mobilization, immediate weight-bearing, and simplified rehabilitation protocols. Patient-specific factors, including age, estimated life expectancy, cognitive status, comorbidity burden, and functional reserve, should guide the choice between these interventions. This recommendation is based on moderate-to-low certainty evidence (predominantly observational data with 2 RCTs). Further high-quality randomized controlled trials are needed.</p>