Extracapsular hip fractures occur frequently in the elderly as a result of low-energy trauma. Achieving stable fixation in osteoporotic bone to allow early weight bearing is a key objective in the treatment of these injuries. Many of the intraoperative decisions facing surgeons are directed by first determining fracture stability. Unstable fracture patterns should be fixated with intramedullary nails, aiming to control motion around the implant and at the fracture site. Torsion control devices provide additional stability and control, although their exact indications are not precisely defined. Complications that arise as a result of the early loading can be avoided with a good surgical reduction, meticulous technique, and proper implant selection. Mechanical complications include cutout, inordinate proximal femoral shortening, delayed union, early implant fracture, nail toggle, and cut through/medial migration.

Extracapsular hip fractures in the pertrochanteric and subtrochanteric region occur frequently in the elderly as a result of low-energy trauma sustained in osteoporotic bone. In such fractures, the blood supply to the femoral head and neck remains intact postinjury. The ensuing high rate of union makes open reduction and internal fixation a viable treatment option. Therefore, failures tend to be mechanical in origin. Achieving stable fixation in osteoporotic bone to allow early weight bearing, while avoiding failure, is a key objective in the treatment of these injuries with intramedullary (IM) nails. Mechanical failure, by definition, occurs when the implant breaks in response to loading or, as more commonly seen in osteoporotic fractures, when the implant loses fixation in bone.1 Although complications may not prevent fracture union per se, they still adversely affect the outcome potentially resulting in a need for additional procedures.

As there are few prospective studies on extracapsular hip fractures, information guiding physicians in clinical practice is limited. This issue is compounded by the fact that mechanical failures occur infrequently, and the low number of failures investigated in the literature affects the research power and validity, as demonstrated by the wide confidence intervals that often accompany the related statistical findings. This article reviews the current practices for preventing complications after IM fixation of osteoporotic extracapsular hip fractures. The importance of good surgical technique and proper implant selection will be highlighted while discussing recent developments in the literature.