Objective To evaluate the role of distal stabilization in the treatment of elderly osteoporotic unstable femoral intertrochanteric fractures with the Asian-type proximal femoral nail antirotation-Ⅱ (PFNA-Ⅱ). Methods A retrospective analysis was performed on the clinical data of 110 elderly patients with osteoporotic unstable femoral intertrochanteric fractures admitted to Tangshan Second Hospital and Tangshan Workers Hospital from May 2018 to May 2020. According to the length of implanted PFNA-Ⅱ main nail, the patients were divided into short intramedullary nail group (n=54, a nail of 240 mm in length to ensure 3-point fixation) and long intramedullary nail group (n=56, a nail of 325 mm to ensure 4-point fixation). The surgical indicators, incidence of complications and follow-up data were compared between the two groups. SPSS statistics 25.0 was used for data analysis, and the intergroup diffe-rences were compared with student′s t test or Chi-square test for different data types. Results There were no statistical differences in operation time, intraoperative bleeding loss and length of hospital stay between the two groups (P>0.05). Long intramedullary nail group showed better results in intraoperative fluoroscopy time, complication incidence, partial weight-bearing time, full weight-bearing time, fracture healing time, proportion of recovery to preoperative walking ability, refracture rate of femoral shaft when compared with the short intramedullary nail group (P<0.05). At six months after operation and at the last follow-up, the neck-shaft angle [(103.53°±6.29°) vs (90.37°±5.88°), (139.47°±6.5°) vs (116.01°±6.52)°] and Harris score [(71.40±4.15) vs (62.33±4.01), (85.79±4.81) vs (74.98±4.58)] were better in the long than the short intramedullary nail group (P<0.05). Conclusion The fourth point distal fixation factor can ensure the 4-point fixation of intramedullary nail fixation in the treatment of elderly osteoporotic unstable intertrochanteric fractures, and achieve the overall distal stability of the intramedullary nail. For these patients, the treatment effect of long intramedullary nails is better than that of short nails, which can reduce the refracture rate of the femoral shaft.