Approximately 150,000 intertrochanteric fractures occur each year in the United States, accounting for approximately 7% of all osteoporotic fractures and placing a tremendous burden on the health care system, with approximately $6 billion spent annually on intertrochanteric fractures. According to the AO fracture typology (see Figure 1), A1 fractures are generally considered stable fractures, A3 fractures are unstable fractures, and A2-1 fractures are stable fractures, while A2-2 and A2-3 fractures are considered unstable fractures because of the morphology of the fracture line and medial comminution of the fracture. Figure 1 Schematic diagram of the AO intertrochanteric fracture (31-A). type A A1 fracture is a simple and mildly comminuted fracture. type B A2: more comminuted fracture, medial femoral spur or lateral femoral wall comminution and/or fracture line extending below the femoral rotor. type C A3: unstable fracture, anteversion fracture or transverse fracture. Depending on the type of fixation, the treatment of intertrochanteric fractures is divided into two types of internal fixation: extramedullary fixation with a plate system and intramedullary fixation with an intramedullary nail system. Stable intertrochanteric fractures can be treated well with extramedullary plate fixation (powered hip screw system). Intramedullary fixation is more expensive and although it does not show significant clinical advantages over extramedullary plate fixation, it has theoretical biomechanical advantages and has recently become a routine treatment option for unstable fractures. Eric Swart, MD, of California, USA, found that the use of powered hip screws in stable intertrochanteric fractures was more cost-effective, while intramedullary nail fixation in anterior intertrochanteric fractures had the best medical costs and benefits, taking into account, among other things, the failure rate of internal fixation therapy. Their findings were published in the October 2014 issue of JBJS Surgery. The authors developed a cost and medical value assessment model (see Table 1) based on data from the last 8 years of literature on the failure rate of internal fixation and the cost of powered hip screws and intramedullary nailing, patient survival, and revision surgery to provide a sensitivity analysis of the costs and benefits when using powered hip screws and intramedullary nailing for fixation of different types of intertrochanteric femoral fractures, respectively. Table 1 Input values for each condition when assessing the cost-effectiveness of intertrochanteric fractures The final finding was that the failure rate of internal fixation and the price of internal fixation were important factors in the choice of internal fixation method. When the failure rate of powered hip screws was 5% higher than that of intramedullary nailing, intramedullary nailing provided a significant advantage, not only in terms of reduced medical costs but also in terms of improved quality of life. When the difference between the failure rate of powered hip screws and intramedullary nailing is less than 5%, the medical costs of intramedullary nailing increase, but the quality of life of the patient is still improved. When the failure rate of powered hip screws is 1.9% higher than that of intramedullary screws, the cost-effectiveness of the increased cost of intramedullary fixation is less than $50,000/QALY, even though intramedullary screws cost $1,200 more than powered hip screws. ($50,000 / QALY is approximately $50,000 per QALY purchased by the patient). When the failure rate of powered hip screws is 5% higher than intramedullary nailing, intramedullary nailing demonstrates a lower cost and better health value for the patient. For A1 stable fractures, sliding hip screws have the best cost-effectiveness ratio and are the most valuable. In contrast, intramedullary nailing is more appropriate for unstable A3 fractures. For type A2 fractures, although the cost-effectiveness ratio is strongly influenced by the rate of internal fixation failure, 70% of patients benefit from powered hip screws with a cost-effectiveness ratio of $100,000/QALY. Therefore, the authors conclude that powered hip screws are cost-effective for stable intertrochanteric fractures (A1 and non-retrograde A2 fractures). For unstable fractures of the anteversion type A3, the use of intramedullary fixation may make more sense. The authors also acknowledge that these conclusions are strongly influenced by the failure rate of internal fixation, and that changes in the failure rate of internal fixation can significantly affect the results of the cost-effectiveness analysis.