With the accelerating global aging population, the incidence of hip fractures in the elderly continues to rise, posing a significant public health challenge. Among these, trochanteric fractures, as one of the most common types, are of particular concern due to their high mortality and disability rates (1). Currently, surgical intervention is the primary treatment for patients deemed medically fit, aiming to achieve early mobilization and functional recovery (2). However, a considerable number of patients in clinical practice are of advanced age, frail, and have multiple comorbidities, for whom the risks of surgery are significantly elevated, thus often leading to a shift toward conservative management (3). For this specific population, evidence regarding the most appropriate treatment strategy remains insufficient (4). Due to significant selection bias, traditional retrospective comparative studies struggle to accurately evaluate the true effects of different treatment modalities. Therefore, this study aims, through a descriptive design, to systematically present the clinical course and outcome profiles of elderly intertrochanteric fracture patients with different baseline characteristics who selected different treatment pathways (home-based recuperation, inpatient conservative treatment, inpatient surgical treatment). This aims to provide a reference for clinical decision-making, particularly for the individualized treatment of frail elderly patients.

This study aimed to systematically describe treatment pathways and outcomes in elderly intertrochanteric fracture patients, based on clinical decisions. Unlike analytical studies designed to test hypotheses, this study focused on comprehensive observation and documentation of current clinical practice, rather than comparing the superiority of different treatments or making causal inferences. As treatment group allocation was not randomized but resulted from non-random, real-world decisions based on patients’ baseline health status, personal preferences, and clinical assessment, there were systematic and clinically meaningful differences in key baseline indicators such as age, comorbidities, and functional status among the groups (Table 1). This inherent selection bias means that any differences in outcomes cannot be simply attributed to the treatment modality itself. Therefore, this study deliberately avoided formal statistical comparisons of outcome measures (Table 2). All presented results should be regarded as descriptive reports of typical prognostic features under different clinical pathways. Its scientific value lies in providing a real-world spectrum of outcomes for the clinical management of this special population and establishing a baseline for subsequent targeted research.

The methodological design of this study was systematically optimized for the particularities of elderly hip fracture patients, primarily reflected in three key aspects: first, in the selection of assessment indicators, we moved away from the Harris Hip Score, which requires professional medical personnel, and instead adopted BADL and IADL as primary functional evaluation tools (14). This innovation allowed patients’ daily caregivers to participate in the assessment process, significantly enhancing the feasibility of long-term follow-up in community and home settings. Second, in terms of data collection methods, we fully considered the mobility challenges of elderly hip fracture patients and employed telephone follow-up as the primary method. This strategy effectively reduced the loss to follow-up rate due to geographical barriers and physical limitations, ensuring data completeness (15). The reliability of telephone follow-up is further supported by its cost-effectiveness and ability to identify psychosocial needs in elderly populations, as evidenced in previous studies (16). Finally, regarding indicator attributes, we strictly selected objective clinical indicators (e.g., radiological evidence of union, survival rate, readmission rate), minimizing measurement errors associated with cognitive impairment in elderly patients (17). These targeted methodological improvements collectively form a research framework suitable for the frail elderly population, providing methodological support for obtaining high-quality clinical research evidence.

The study results showed a high degree of concordance between the chosen treatment pathway and the patients’ baseline health status. Specifically, patients with the best baseline status (Group C, mean age 77.4 years, CCI 1.2, preoperative BADL 82.6) predominantly received surgical treatment (18, 19); whereas patients with the poorest baseline status (Group A, mean age 85.8 years, CCI 3.2, preoperative BADL 55.9) more often opted for home-based recuperation or conservative treatment. This finding is consistent with a Norwegian study on hip fracture pathways, which reported that younger and healthier patients were more likely to be assigned to home-based or specialized rehabilitation pathways, while older and frailer patients tended to receive conventional rehabilitation or nursing home care, highlighting the universal practice of risk-stratified decision-making (20). This “tailor-made” clinical decision-making pattern fully embodies the core principle of individualized treatment for elderly hip fractures—namely, comprehensive assessment based on the patient’s physiological reserve, functional status, and surgical risk, rather than deciding solely based on fracture type (no significant difference in AO/OTA classification distribution among the three groups). This risk-stratified decision logic, on one hand, reflects respect for the heterogeneity of elderly patients in clinical practice, and on the other hand, explains that the observed outcome differences among the treatment groups (e.g., lowest complication rate and best functional recovery in Group C) are largely attributable to patient selection bias rather than the absolute superiority of the treatment modality itself.

The pattern of outcome differences revealed in this study provides important implications for clinical decision-making. Although causal inference is limited by the descriptive design, the regular outcome differences observed across the three groups clearly delineate three distinct clinical pathways and their general outcomes: for patients whose physical condition permits (Group C), surgical treatment is an active and effective pathway (21). Patients in this group, who were selected for surgery based on their better baseline status, were observed to have? the shortest fracture healing time (12.3 weeks), a 1-year survival rate of 95.42%, and the highest functional recovery scores (BADL: 78.9). These outcomes are consistent with the expected prognosis for a healthier patient population. For high-risk patients unable to undergo surgery but receiving medical supervision (Group B), inpatient conservative treatment provided vital life support (22). Although functional recovery in this group was intermediate, their 1-year survival rate (91.75%) was notably higher than the rate observed in Group A (83.95%). This difference underscores the potential impact of inpatient medical supervision even when surgery is not feasible, within the context of differential baseline risks. This indicates that even when surgery is not feasible, active inpatient medical intervention (e.g., managing complications, professional nursing care) is crucial for stabilizing the condition and prolonging survival. This finding is supported by a multicenter cohort study which demonstrated that non-operative management for frail elderly patients with limited life expectancy yielded non-inferior quality-of-life outcomes (EQ-5D utility scores) compared to surgical management, with lower rates of adverse events, highlighting its viability as an alternative to surgery in this population (3). The outcomes observed in Group A, which comprised the frailest patients who forewent inpatient treatment, were the least favorable. This highlights that disengagement from systematic medical supervision may carry significantly higher risks for this particularly vulnerable population (23). The trend of all outcome indicators in this group was the least favorable, particularly the 1-year survival rate (83.95%) and functional recovery levels were considerably lower than the other two groups. This highlights that for these patients, even without surgery, disengagement from systematic medical supervision may carry significantly higher risks (24). These findings provide valuable prognostic references for treatment pathway selection in elderly patients with different health statuses.

The differences in complication profiles observed in this study clearly outline the distinct risk contours specific to each treatment pathway. Complications in Group C were primarily concentrated in surgery-related areas, such as local issues like implant loosening, failure, and surgical site infection, reflecting the unavoidable technical risks of invasive procedures (25); however, due to early mobilization post-surgery, the incidence of systemic medical complications (e.g., hypostatic pneumonia, deep vein thrombosis) was relatively low (26). Group B presented a dual-high-risk situation: on one hand, the lack of stable fracture fixation led to a significant increase in orthopedic complications like malunion and non-union; on the other hand, prolonged immobilization induced a series of medical complications such as pulmonary infection, urinary tract infection, and pressure sores (27). Group A, having received no definitive treatment, was most prominently characterized by fracture healing impairment, with rates of delayed union, non-union, and malunion significantly higher than the other groups. Concurrently, the timely detection and management of various complications faced challenges due to the lack of professional medical monitoring (28). This differentiated pattern of complication distribution indicates that clinical decision-making essentially involves weighing different risk spectra: surgery primarily bears technique-related risks, conservative treatment faces the dual pressure of orthopedic and medical complications, while home-based recuperation bears the compound risk of poor fracture healing and insufficient complication management. Identifying and understanding these risk spectra are of great importance for guiding individualized treatment decisions.

While the absolute outcome rates (e.g., specific survival percentages or complication frequencies) may vary across institutions due to differences in patient demographics and healthcare resources, the fundamental pattern of risk-stratified decision-making observed in our study is likely to have broad external validity. The consistent alignment between treatment selection and baseline frailty status reflects a universal clinical approach to managing heterogeneous elderly populations. This suggests that the key finding—that treatment pathways are tailored to individual patient characteristics rather than being applied uniformly—may be generalizable across diverse settings, even if the specific outcomes differ.

This descriptive study systematically presents new treatment pathways and associated outcome spectra of elderly patients with trochanteric fractures of varying health statuses in clinical practice. The study found that treatment selection was highly matched with patients’ baseline health status: patients with better functional status and fewer comorbidities mostly underwent surgery and had the best prognosis; older, frailer patients with more comorbidities tended toward conservative treatment or home-based recuperation, with correspondingly higher prognostic risks. The three treatment pathways exhibited characteristic complication profiles: the surgery group was dominated by internal fixation-related issues, the conservative treatment group combined fracture healing problems with risks of immobilization-related complications, and the home-based recuperation group was most notable for fracture healing impairment. The outcome spectrum provided by this study offers an important reference for clinical expectation management, emphasizing the importance of tailoring treatment decisions based on individual patient circumstances.