While the rate of failure following hip fracture surgery for extracapsular hip fractures in the elderly is low, an incidence of implant cutout from the femoral head remains regardless of whether fixation is by sliding hip screw or intramedullary nail. In general, a well-executed osteosynthesis is the best assurance of a good outcome with few complications, and typically a less than ideal placement of the implant in the femoral head is the reason for cut-out and failure of the operation. It is clear that there is no difference in the incidence of complications or functional outcome between a sliding hip screw and an intramedullary nail for pertrochanteric fractures (AO/OTA 31-A1 and A2), while the implant of choice in the elderly for the true intertrochanteric fracture (AO/OTA 31-A3; reverse intertrochanteric) is a nail. However, what is less clear is whether there are newer ideas and/or implant designs that represent true advances in the treatment of extracapsular fractures in the elderly. The following review focuses on just this issue.