Introduction: Cut-out is the most frequently reported mechanical failure of internal fixation of pertrochanteric fractures. The purpose of this study was to examine if hydroxyapatite-coated screw thread on a sliding hip screw (SHS) could reduce screw migration within the femoral head in patients with stable pertrochanteric fractures. Materials and methods: In a double-blinded randomized controlled study, 37 patients at mean age 78 (range 56–96), with pertrochanteric fracture (Evans I, II, IV) received surgery with a SHS with a hydroxyapatite-coated or a non-coated lag screw thread. Radiostereometry and standard radiographs were obtained 1 day, 6 weeks, 3- and 6 months post-operatively to evaluate screw and fracture migration and fracture reposition. The two groups were combined to describe fracture migration. Results: There was similar and small screw migration in the femoral head between the two groups at 6 weeks, 3- and 6 months (p > 0.12). Fracture migration occurred predominantly in the first 6 weeks, where fracture impaction was 5.95 mm (CI 95% 2.87 to 9.04) and anterior rotation of the femoral head was -2.94° (CI 95% − 5.22 to − 0.66). Migration of the fracture (total translation) correlated to the post-operative fracture reposition (p = 0.002), but not significantly to screw migration (p = 0.09). Neither screw total translation (rho 0.06, p = 0.79) nor fracture total translation (rho 0.04, p = 0.77) correlated with bone mineral density. Conclusion: There was no clinical benefit of hydroxyapatite coating on lag screw migration in this patient cohort. Migration of the pertrochanteric fractures was higher with poor fracture reposition but fractures generally stabilized after 6 weeks follow-up. The study was registered at ClinicalTrials.gov (NCT05677061). Level of evidence II: Patient-blinded prospective randomized study. Trial registration number The study was registered at ClinicalTrials.gov (NCT05677061).