This prospective randomized clinical trial enrolled 24 patients aged over 65 years with acetabular fractures between 2018 and 2022. Patients were randomized in a 1:1 ratio to undergo open reduction and internal fixation (ORIF) or a combined hip procedure (CHP) consisting of ORIF with concomitant total hip arthroplasty (THA). The outcomes of interest were functional scores, including the Western Ontario and McMaster Universities Arthritis (WOMAC) Index hip score, Oxford Hip Score (OHS), Harris Hip Score (HHS), Parker Mobility Test, and SF-12 physical and mental component scores. Other important outcomes included radiographic findings, operative duration, postoperative complications, revision surgery, and development of posttraumatic osteoarthritis (OA). Outcomes were assessed at serial follow-up intervals up to approximately four years. Overall, the results of the study revealed no statistically significant differences between ORIF and CHP in functional outcome scores or overall complication rates. CHP was associated with a significantly longer operative time but demonstrated a lower rate of posttraumatic osteoarthritis and fewer revisions, while also permitting earlier postoperative weight-bearing in a greater proportion of patients.