OBJECTIVE: To investigate the surgical treatment options for elderly patients with intertrochanteric fractures. Hip fractures account for the first place in elderly patients, and for elderly patients over 80 years old, their surgical treatment options are one of the current debates among orthopedic surgeons due to poor general condition and more comorbidities, especially osteoporosis, with methods including external fixation, internal fixation, and custom-made artificial femoral head replacement. Unreasonable surgical choices may lead to serious complications or even patient death. METHODS: A retrospective analysis of 126 patients over 80 years of age admitted in the last 3 years with artificial femoral head replacement with femoral spur and internal fixation with PFNA or DHS was performed to analyze: intraoperative bleeding, perioperative blood consumption, operative time, postoperative complications (joint dislocation, internal fixation failure), perioperative mortality, mean postoperative survival time, internal fixation failure and joint dislocation during follow-up time The mean survival time after surgery, internal fixation failure and joint dislocation at follow-up time. Results: The average operation time of artificial femoral head replacement was about 70 minutes, and the average time of internal fixation by PFNA or DHS was 60 min, the intraoperative bleeding was about 400 ml for joint replacement and 200 ml for internal fixation, and the perioperative blood consumption was about 1000 ml for joint replacement and 800 ml for internal fixation. 1 case of postoperative cerebral infarction, 1 case of central infarction in the joint replacement group, 1 case of pulmonary infarction, 1 case of stress ulcer, and 2 cases of infection. There was 1 perioperative death (stress ulcer), no difference in survival rate at 2 years after surgery, 2 cases of internal fixation displacement and cut out and 1 case of joint dislocation at the follow-up time. Opinions: 1. Perioperative management is the most important factor for patients with high-grade intertrochanteric fractures; 2. Artificial femoral head replacement is still greater than internal fixation in terms of bleeding, trauma, and surgical risk, and the indications should be strictly controlled: advanced age, severe osteoporosis, unstable fracture, and good muscle strength of the lower limbs, and no mental illnesses such as Alzheimer’s disease; 3. Selection is based on the technical level of the surgeon. Joint replacement requires a high level of technical operation and should be completed in the shortest possible time, otherwise there is more intraoperative bleeding and great risk. 4. The preoperative pulmonary condition is crucial to the choice of anesthesia and the choice of surgical treatment; 5. The cooperation with the anesthesiologist during the joint replacement is crucial.