This study examined the incidence and risk factors associated with lateral helical blade migration and trochanteric pain with the trochanteric fixation nail. A retrospective review was performed of 141 cases of pertrochanteric femur fracture treated with a trochanteric fixation nail at a level I trauma center over a period of 42 months. Exclusion criteria included follow-up of less than 60 days, preexisting osteonecrosis of the femoral head, and prophylactic trochanteric fixation nail treatment. Patient demographics, operative findings, and radiographic findings were recorded. Medical records were reviewed to identify symptomatic hardware. Overall, 27 patients (19.1%) were symptomatic, and 3 (2.1%) required revision surgery for blade prominence. Of the patients, 42 (30%) had lateralization of greater than 1 cm, and 16 of these (38.1%) were symptomatic (P<.02). A risk factor for lateralization was AO classification, with 46.1% of type A2 fractures showing lateralization of greater than 1 cm. The quality of calcar reduction nearly reached statistical significance, and 44.8% of patients who had inadequate reduction had lateralization of greater than 1 cm compared with 26.4% of patients who had adequate reduction (P=.054). Lateralization of greater than 1 cm was directly associated with the presence of symptoms (P<.001) and removal of hardware because of trochanteric pain (P=.007). Multivariate analysis showed that increasing tip-apex distance, inadequate calcar reduction, and greater fracture severity were predictive of excessive lateralization of greater than 1 cm. Nearly 20% of patients had lateral hip pain associated with cephalomedullary fixation. Final lateralization of the helical blade of greater than 1 cm was a very strong predictor of symptoms. During preoperative counseling, surgeons should caution patients about this relatively frequent and likely underreported complication. [Orthopedics. 2017; 40(5):e886-e891.].