Approximately 50% of all hip fractures are extracapsular and typically treated with extramedullary or intramedullary fixation. Modern intramedullary nails used for internal fixation of extracapsular fractures are generally cephalomedullary nails secured by at least one cephalic screw. Different designs have been developed, varying in length, diameter, neck shaft angle, number of cephalic screws or blades, ability to slide and/or compress, ability to control rotation, construction materials and insertion-point. Articles published in all languages up to January 2019, are listed in PubMed and Scopus electronic databases about the association between the number of cephalic screws and the rate of complications and functional outcome. Twenty articles were included following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Sliding hip screws (SHS) were the standard of care for hip fractures from the 1950s to the 1990s, but presently intramedullary nails are more commonly used. There has been a more than 20-fold relative increase in the utilization of intramedullary nails since 1999. With the emergence of value-based healthcare, there is a growing interest of how best to provide high-quality care in a clinical and cost-effective manner, acknowledging limited healthcare budgets. The present systematic review assessed the long-term outcomes of the most commonly used nails using double cephalic screws compared with single screw devices in patients with unstable intertrochanteric fractures. The development of new technologies may allow a lower incidence of complications, a reduction in operative time and a lower intraoperative blood loss.