Implant design for the correction of osteoporotic unstable intertrochanteric fractures in elderly patients is a controversial issue. Our study aims to compare the efficacy of PFNA and cementless bipolar hemiarthroplasty (CBH) in treating osteoporotic unstable intertrochanteric fractures in the elderly. We retrospectively assessed 70 elderly patients, aged > 70 years old, with intertrochanteric fractures (AO/OTA 31-A2 fractures) from 2014 to 2019. Among them, 34 patients received PFNA and 36 patients received CBH, accompanied with 2-year follow-ups. Additionally, the efficacy difference between the two implants was compared. Both groups had similar general variables like age, gender, fracture site, degree of osteoporosis, fracture classification, ASA score, basic diseases, preoperative preparation time, anesthesia mode, amount of postoperative blood loss, hospital length of stay, along with postoperative blood transfusions and postoperative complications (P > 0.05). Conversely, significant differences were observed among intraoperative variables (amount of blood loss, amount of blood transfusions, operative time, number of intraoperative fluoroscopy), postoperative variables (weight-bearing time out of bed), and Harris hip function score within 12 months of operation (P < 0.05). CBH 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.