Objective To investigate the therapeutic effect of artificial femoral head replacement and proximal square rotation intramedullary nail (PFNA) fixation in elderly patients with intertrochanteric fracture (IFF). Methods 70 elderly patients with IFF who visited our hospital from August 2021 to September 2023 were selected as the study objects. The patients were divided into control group and study group by random number table, with 35 cases in each group. The control group received PFNA fixation. The study group was treated with artificial femoral head replacement. Perioperative indexes, hip function (Harris hip function score), pain degree [visual analogue scale (VAS)] and complications were analyzed and compared between the two groups. Results The operation time, intraoperative blood loss and incision length of the study group were significantly increased than those of the control group. The time of getting out of bed and staying in hospital were significantly shorter than those in control group (P < 0.05). At 3 months and 6 months after surgery, the Harris hip function score in both groups was significantly higher than that before surgery, and at 6 months after surgery, the Harris hip function score in both groups was significantly higher than that at 3 months after surgery. The Harris hip function scores of the study group at 3 months and 6 months after surgery were significantly higher than those of the control group (P < 0.05). Pain scores in both groups were significantly lower than those before surgery at 3 and 2 weeks after surgery, and pain scores in both groups at 2 weeks after surgery were significantly lower than those in 3 days after surgery, and pain scores in the study group at 3 days after surgery were significantly lower than those in the control group (P < 0.05). Two weeks after surgery, the pain scores of the two groups were not significantly different (P > 0.05). The complication rate of the study group was significantly lower than that of the control group (P < 0.05). Conclusion Both PFNA internal fixation and artificial femoral head replacement can effectively treat IFF in the elderly, but artificial femoral head replacement is safe and reliable, which can help shorten the time of getting out of bed and staying in hospital after surgery, accelerate the recovery of hip function, relieve pain and reduce complications.