UNLABELLED: Stopping denosumab causes a temporary rebound in bone resorption, even when zoledronate is administered afterwards. We analyzed 65 women with postmenopausal osteoporosis or cancer treatment-induced bone loss...UNLABELLED: Stopping denosumab causes a temporary rebound in bone resorption, even when zoledronate is administered afterwards. We analyzed 65 women with postmenopausal osteoporosis or cancer treatment-induced bone loss who received a single zoledronate infusion 6 months after their last denosumab dose. Blood levels of the bone turnover marker CTX were modeled over time, showing a nonlinear increase peaking between 6 and 9 months and partially declining by 12 months. The rebound pattern was comparable in both groups, and only one vertebral fracture occurred. These findings show that the rebound is only partially mitigated by zoledronate. BACKGROUND: Denosumab (Dmab) discontinuation triggers a rebound in bone resorption that may be only partially mitigated by zoledronate (ZOL). However, the temporal pattern of this rebound under real-world conditions remains poorly defined. We aimed to model continuous serum C-terminal telopeptide of type I collagen (s-CTX-I) trajectories after Dmab withdrawal and ZOL rescue and to compare rebound profiles between postmenopausal osteoporosis (PMO) and cancer treatment-induced bone loss (CTIBL). METHODS: Sixty-five women who received a single 5-mg ZOL infusion 6 months after Dmab discontinuation were retrospectively analyzed (30 PMO, 35 CTIBL). s-CTX-I measurements obtained from -30 to +360 days relative to ZOL were modeled with linear mixed-effects regression using natural cubic splines (knots 0, 180 days), adjusting for age and Dmab duration. RESULTS: s-CTX-I increased nonlinearly, peaking at 6-9 months post-ZOL and reaching a partial plateau by 12 months. The spline model fits the data substantially better than a linear specification (ΔAIC > 20). No interaction was found between time and indication (PMO vs CTIBL; p > 0.3), indicating comparable rebound trajectories across groups. Peak s-CTX-I values remained below the upper reference limit for premenopausal women. Rebound intensity (Δs-CTX-I) was not associated with percentage bone mineral density (BMD) gain at the lumbar spine, femoral neck, or total hip during Dmab therapy. Only one vertebral fracture occurred during follow-up. CONCLUSIONS: In real-world practice, bone resorption rebounds after Dmab discontinuation in a reproducible, nonlinear pattern despite ZOL rescue, peaking around 6-9 months. Although peak s-CTX-I values remained within the premenopausal reference range, rebound magnitude was unrelated to prior densitometric response, supporting a biologically driven reactivation of remodeling. The similarity between PMO and CTIBL suggests a shared biological mechanism and supports individualized, turnover-guided monitoring rather than fixed-timing strategies.
Schini M, Johansson H, Harvey NC
… +85 more, Lorentzon M, Liu E, Vandenput L, Leslie WD, Åkesson KE, Anderson FA, Azagra-Ledesma R, Bager CL, Beaudart C, Bischoff-Ferrari HA, Biver E, Bruyère O, Cauley JA, Center JR, Chapurlat R, Christiansen C, Cooper C, Crandall CJ, Cummings SR, da Silva JAP, Dawson-Hughes B, Diez-Perez A, Dufour AB, Eisman JA, Elders PJM, Ferrari S, Fujita Y, Fujiwara S, Glüer CC, Goldshtein I, Goltzman D, Gudnason V, Hall J, Hans D, Hoff M, Hollick RJ, Huisman M, Iki M, Ish-Shalom S, Jones G, Karlsson MK, Khosla S, Kiel DP, Koh WP, Koromani F, Kotowicz MA, Kröger H, Kwok T, Lamy O, Langhammer A, Larijani B, Lippuner K, McGuigan FEA, Mellström D, Merlijn T, Nguyen TV, Nordström A, Nordström P, Obermayer-Pietsch B, Ohlsson C, O'Neill TW, Orwoll ES, Pasco JA, Rivadeneira F, Schei B, Schott AM, Shiroma EJ, Siggeirsdottir K, Simonsick EM, Sornay-Rendu E, Sund R, Swart KM, Szulc P, Tamaki J, Torgerson DJ, van Schoor NM, van Staa TP, Vila J, Wareham NJ, Wright NC, Yoshimura N, Zillikens M, Zwart M, Kanis JA, McCloskey EV
UNLABELLED: In this meta-analysis of international cohorts, current smoking is confirmed as a significant BMD-independent predictor of future fracture with a stronger relationship in men than in women. A causative and re...UNLABELLED: In this meta-analysis of international cohorts, current smoking is confirmed as a significant BMD-independent predictor of future fracture with a stronger relationship in men than in women. A causative and reversible effect of smoking on fracture risk is suggested by past smoking having a significantly lower risk than current smoking. PURPOSE: In this meta-analysis of international cohorts, the aim was to examine the relationship of current and past smoking with fracture risk to provide an update for future iterations of the FRAX tool. METHODS: The risk of fracture associated with current and past smoking was estimated using an extended Poisson model applied separately to each of 58 prospective international cohort studies. Covariates included current time since start of follow up, current age, and in an additional model, BMD at the femoral neck. The results of the different studies were merged by using inverse-variance weighted β-coefficients. RESULTS: This analysis included a total of 1,691,024 participants (61.2% women, overall mean age 58.8 years). Current smoking, documented in 12.1% of all participants (15.2% and 10.1% respectively in men and women), was associated with a significantly increased risk of any clinical fracture, osteoporotic fracture, major osteoporotic fracture, and particularly hip fracture in both sexes. The hazard ratio (HR) for fracture was greater in men than in women for all fracture categories [e.g. hip fracture HR (95% confidence interval): 1.78 (1.58-2.00) vs. 1.64 (1.50-1.78)]. Low BMD explained about 19-54% of the increase in risk. When compared with never smoking, past smoking was associated with a significantly lower risk than current smoking [e.g. hip fractures for men, HR in past smokers: 1.08 (1.05-1.12) vs. 1.73, 95%CI (1.46-2.05) in current smokers]. CONCLUSIONS: Our results confirm the association between current smoking and increased fracture risk that is partly independent of BMD; these data will be used to inform future iterations of FRAX.
Osteoporos Int
· 2026 Feb · PMID 41733627
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BACKGROUND: Osteoporosis and osteopenia are common skeletal diseases in middle-aged and elderly individuals, characterized by reduced bone mineral density (BMD), microstructural deterioration, and increased fragility, si...BACKGROUND: Osteoporosis and osteopenia are common skeletal diseases in middle-aged and elderly individuals, characterized by reduced bone mineral density (BMD), microstructural deterioration, and increased fragility, significantly raising the risk of pathological fractures and mortality. Tai Chi, a traditional Chinese exercise, has gained increasing attention for its potential benefits in managing osteoporosis and osteopenia due to its gentle movements, moderate intensity, and adaptability to various populations. Studies have demonstrated that Tai Chi may significantly improve BMD in critical areas such as the lumbar spine and hip. However, existing research on the effects of Tai Chi on osteoporosis and osteopenia in middle-aged and elderly people remains inconclusive. OBJECTIVE: We aim to evaluate the effects of Tai Chi exercise on BMD in middle-aged and elderly individuals with osteoporosis or osteopenia through a systematic review and meta-analysis. METHODS: A comprehensive literature search was conducted across 7 databases (PubMed, Web of Science, EMBASE, Cochrane, Wanfang Database, VIP Database, and CNKI) up to February 16, 2025. RESULTS: A total of 19 randomized controlled trials (RCTs) met the inclusion criteria. Overall, Tai Chi significantly improved BMD in key skeletal regions, including: lumbar spine (L-L) (WMD = 0.05 g/cm, 95% CI 0.02 to 0.08, p = 0.0003), femoral neck (WMD = 0.05 g/cm, 95% CI 0.02 to 0.08, p = 0.001), greater trochanter (WMD = 0.05 g/cm, 95% CI 0.02 to 0.08, p = 0.002), and Ward's triangle (WMD = 0.04, 95% CI 0.02 to 0.06, p < 0.0001). Subgroup analysis indicated that Tai Chi practice for more than 24 weeks significantly improved BMD in the lumbar spine (L-L) (WMD = 0.05, 95% CI 0.02 to 0.07, p < 0.0001), femoral neck (WMD = 0.03, 95% CI 0.02 to 0.04, p < 0.0001), greater trochanter (WMD = 0.04, 95% CI 0.02 to 0.06, p = 0.0003), and Ward's triangle (WMD = 0.04, 95% CI 0.02 to 0.07, p < 0.0001). Furthermore, less than 200 min per week of Tai Chi had a positive effect on BMD in these key areas: lumbar spine(L-L) (WMD = 0.04, 95% CI 0.01 to 0.07, p = 0.006), femoral neck (WMD = 0.03, 95% CI 0.01 to 0.05, p = 0.007), greater trochanter (WMD = 0.06, 95% CI 0.03 to 0.09, p < 0.0001), and Ward's triangle (WMD = 0.05, 95% CI 0.02 to 0.07, p < 0.0001). CONCLUSION: Long-term Tai Chi exercise significantly improves BMD in individuals with osteoporosis and osteopenia. A regimen of more than 24 weeks with a total weekly exercise time of 120-200 min is recommended for optimal effect.
UNLABELLED: In older adults, incorporating one-third-radius BMD increased osteoporosis diagnoses and improved fracture risk prediction. Radius osteoporosis independently predicted fractures, outperforming spine BMD. Tota...UNLABELLED: In older adults, incorporating one-third-radius BMD increased osteoporosis diagnoses and improved fracture risk prediction. Radius osteoporosis independently predicted fractures, outperforming spine BMD. Total hip BMD remained the strongest predictor. Adding radius measurements enhances detection of skeletal fragility, especially when hip data are unavailable or uncertain. PURPOSE: In older adults, one-third radius BMD may add value to fracture risk assessment because it is unaffected by degenerative changes that can inflate spine and hip BMD, although its prognostic utility remains uncertain. We aimed to determine whether one-third radius BMD predicts incident fractures independently or alongside spine and hip BMD, and to evaluate its contribution to osteoporosis classification relative to standard sites. METHODS: This cohort included 707 adults aged ≥65 years (63.5% women) from the São Paulo Ageing & Health (SPAH) study with baseline DXA scans at the spine, hip, and one-third radius. Fragility fractures were recorded over 4.3±0.8 years. Multivariate logistic regression models assessed associations between site-specific osteoporosis (T-score≤-2.5) or BMD (per SD decrease) and fracture risk. RESULTS: Including one-third radius BMD increased osteoporosis diagnoses by up to 8.6% in women and 8.2% in men, and by 11.1% and 15.7% among individuals who fractured. In women, osteoporosis at the one-third radius independently predicted fracture risk (RR=1.61; 95% CI: 1.04-2.48), whereas spine or hip osteoporosis alone did not. In continuous models, lower hip and radius BMD-but not spine BMD-were associated with higher risk; total hip BMD showed the strongest association and remained significant in multisite models (RR=1.72; 95%CI: 1.06-2.78; p=0.028), while radius BMD lost significance. In men, few fracture events precluded multivariable analysis. CONCLUSIONS: Including one-third radius BMD improves fracture risk prediction in older adults, particularly when hip measurements are unavailable or inconclusive. It captures skeletal fragility that spine BMD may miss, enhancing identification of high-risk individuals for treatment.
Osteoporos Int
· 2026 Feb · PMID 41724830
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UNLABELLED: Sociodemographic risk factors and injury circumstances of proximal humerus fractures are insufficiently investigated. In this study, having Norwegian background and being unmarried carried the highest fractur...UNLABELLED: Sociodemographic risk factors and injury circumstances of proximal humerus fractures are insufficiently investigated. In this study, having Norwegian background and being unmarried carried the highest fracture risk. More fractures were sustained outdoors in winter versus summer. Knowledge of the injury circumstances and identifying vulnerable high-risk groups may inform preventive measures. PURPOSE: The incidence, sociodemographic risk factors, and injury circumstances of proximal humerus fractures (hereafter called humerus fractures) remain insufficiently investigated. We aimed to examine variation in humerus fracture risk by age, sex, marital status, education, and country background, and to describe injury location and seasonal distribution of humerus fractures. METHODS: In this register-based cohort study, humerus fractures sustained 2012-2022 in individuals born < 1952 living in Oslo were identified from the Norwegian Patient Registry. Information on country background, marital status, and education was obtained from Statistics Norway. Incidence rate ratios (IRRs) were estimated by Poisson regression and age-standardized incidence rates (in individuals ≥ 70 years) were calculated. RESULTS: Based on 3,520 humerus fractures (79% women) among 100,982 individuals, incidence rates were 62 (95% CI 59, 64) and 22 (95% CI 20, 24) per 10,000 person years in women and men, respectively, and increased substantially with age. Humerus fracture risk was lower in all country background categories compared to Norway (reference), with the lowest risk observed for the category mainly including individuals from Asia/Africa: IRR 0.49 (95% CI 0.38, 0.65) in women and IRR 0.37 (95% CI 0.24, 0.57) in men. An IRR of 1.17 (95% CI 1.03, 1.33) was found in unmarried compared to married women, with a corresponding IRR of 1.70 (95% CI 1.37, 2.11) in unmarried versus married men. Humerus fracture numbers peaked during winter. CONCLUSIONS: Having Norwegian background and being unmarried carried the highest humerus fracture risk. Identifying vulnerable high-risk groups is important when planning future healthcare services.
PURPOSE: Patients with Parkinson's disease, often accompanied by osteoporosis, have a higher risk of osteoporotic fractures. However, a large cohort study assessing the preventive effect of bisphosphonates for osteoporot...PURPOSE: Patients with Parkinson's disease, often accompanied by osteoporosis, have a higher risk of osteoporotic fractures. However, a large cohort study assessing the preventive effect of bisphosphonates for osteoporotic fracture on patients with Parkinson's disease is scarce. METHODS: This retrospective cohort study included nearly whole population of South Korea during 2002 to 2018 from the national patient database of Korea National Health Insurance Service. Of 608,202 patients with Parkinson's disease, a total of 7335 patients were selected for index regression model and 5806 patients were further selected for landmark model of 1 year after diagnosis of osteoporosis. Occurrence of osteoporotic fracture was set defined as outcome variable for both regression models. RESULTS: Regression analysis with a landmark model one year after the index diagnosis of osteoporosis showed that the use of bisphosphonates had a significant preventive effect on osteoporotic fractures (hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.73-0.96, p = 0.012). In index regression model, higher age, larger waist circumference, smoking, and history of lymphoma were significant risk factors of osteoporotic fractures. Higher weight and higher physical activity score were significant preventative factors. CONCLUSION: In the regression analysis with landmark model with 5806 patients, higher age, heavy alcohol consumption, smoking, and history of solid tumor were significant risk factors of osteoporotic fractures. Higher weight was a significant preventative factor.
Fitzgerald C, Burley C, Wright K
… +3 more, McLeod K, Asadi S, Parmenter B
Osteoporos Int
· 2026 Feb · PMID 41718839
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People living with osteoporosis can experience worse mental health and quality of life (QoL), including pain and psychological distress than those without. Psychological stress and poor mental health are associated with...People living with osteoporosis can experience worse mental health and quality of life (QoL), including pain and psychological distress than those without. Psychological stress and poor mental health are associated with an increased risk of osteoporosis (OP). We conducted a systematic review and meta-analysis of randomised controlled trials investigating the effect of exercise on mental health, QoL and pain in people living with OP. A systematic review and meta-analysis was conducted following PRISMA guidelines (PROSPERO: CRD42023440020). Inclusion criteria were randomised controlled trials investigating exercise in people diagnosed with OP, including QoL, mental health, and/or pain outcomes. Exclusion criteria were non-human studies or studies not translatable into English. An electronic search of the literature was performed from inception to December 2025 in PubMed, EMBASE, PsycINFO, CINAHL, Scopus, and Web of Science. Bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. The Consensus on Exercise Reporting Template was used to assess reporting quality. Three authors independently extracted data into Microsoft Excel. Data were analysed using Cochrane Review Manager Web (version 9.4.1), including mean differences (MD) and standardised mean differences (SMD) using a random-effects inverse variance model. Moderator analyses assessed modality, intensity, duration, frequency, setting, participant age, the presence of fracture (%), the nature of fracture and the osteoporosis diagnosis (postmenopausal or other). Certainty and quality of evidence were assessed using the GRADE approach. Twenty-three trials (n = 2120, mean age 67.1 ± 5.98yrs, 95.1% female) were included: five resistance training, six balance training, six combined resistance and balance training, three multi-modality, two Clinical Pilates, one aquatic, one combined aerobic, strength and Yi Jin Jing. A total of 1135 participants underwent exercise (low-high intensity, 2-7 times weekly) for 19 ± 12 weeks targeting upper, lower and full body, with seventeen studies reporting progression. Exercise improved mental health (SMD 0.53 [0.25, 0.81], p = 0.0002, moderate certainty evidence), QoL (SMD 0.62 [0.29, 0.95], p = 0.0003, moderate certainty evidence) pain (SMD 0.36 [0.17, 0.55], p = 0.0002, low certainty evidence), and pain at rest MD - 1.69 [- 2.38, - 0.99], p < 0.00001, moderate certainty evidence). Clinical Pilates was most effective for mental health (p = 0.006), QoL (p < 0.00001) and pain (p = 0.01). For mental health, the largest effect was seen with interventions performed three times per week for 4-11 weeks. Reporting quality varied (CERT, mean 11.1 ± 3.4, range 5-18), as did bias, with concerns regarding evidence certainty, internal validity and statistical conclusion validity bias. Exercise improves mental health, QoL, and pain. Pilates appeared most effective for all outcomes; however, resistance training was also effective for both QoL and pain. Further high-quality research following standardised reporting guidelines is needed for people living with osteoporosis. KEY POINTS: • Exercise improves mental health, quality of life and pain for people living with osteoporosis. Pilates was most effective, while resistance training also showed an effect for quality of life and pain outcomes. Further high-quality research is needed for people living with osteoporosis and poor mental health.
Mizuno T, Tsukamoto M, Teramoto H
… +8 more, Hamasaki T, Shirakawa T, Nakagawa T, Yamasaki T, Tsukisaka J, Adachi N, Fujiwara S, Okimoto N
Osteoporos Int
· 2026 Feb · PMID 41711824
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UNLABELLED: Community-wide Fracture Liaison Services and educational outreach to local physicians on osteoporosis can effectively reduce the fragility fracture burden at the population level in a super-aged society. PURP...UNLABELLED: Community-wide Fracture Liaison Services and educational outreach to local physicians on osteoporosis can effectively reduce the fragility fracture burden at the population level in a super-aged society. PURPOSE: Effective prevention of osteoporosis and fractures requires not only implementing a Fracture Liaison Service (FLS) but also enhancing osteoporosis awareness among local physicians, residents, and the municipality. We examined the impact of multidisciplinary, municipality-supported FLS and osteoporosis awareness activities on the incidence of clinical vertebral and hip fractures in a rapidly ageing urban Japanese population. METHODS: We conducted a population-based pre-post observational study of residents aged ≥ 65 years in Kure, Japan, following the introduction of community-wide FLS and osteoporosis awareness activities. Residents were enrolled in the National Health Insurance or Senior Elderly Care System between 2015 and 2021. Fracture events were identified using insurance claims data and ICD/treatment codes. RESULTS: Overall, the incidence of clinical vertebral fractures tended to increase until 2017 and then tended to decrease thereafter; the incidence of hip fractures tended to decrease after 2017 in females but not in males. Compared with the incidence in 2017, the age-sex-adjusted incidence ratio was 0.76 (95% CI 0.70-0.83) for clinical vertebral fractures and 0.87 (95% CI 0.78-0.96) for hip fractures in 2015. In 2021, the incidence ratio was 0.89 (95% CI 0.82-0.96) for clinical vertebral fractures and 0.85 (95% CI 0.76-0.94) for hip fractures. During this period, an increase in the number of prescriptions and changes in the prescribing patterns were observed. CONCLUSIONS: Significant reductions in the incidence of both clinical vertebral and hip fractures among women were demonstrated after the launch of a comprehensive fracture prevention project supported by the local government.
CLINICAL RELEVANCE: Although patients with remote or brief prior exposure to osteoporosis treatments are strictly not "treatment naive," osteoporosis treatment effects on bone mineral density and bone turnover resolve ov...CLINICAL RELEVANCE: Although patients with remote or brief prior exposure to osteoporosis treatments are strictly not "treatment naive," osteoporosis treatment effects on bone mineral density and bone turnover resolve over time. It would therefore be useful to categorize patients with remote or brief prior exposure to osteoporosis treatment as "clinically treatment naive." This lack of clarity of who can be categorized as clinically treatment naive may disadvantage patients at very high fracture risk with brief or remote prior exposure who may face barriers to bone-building therapies. Access may be restricted to those who have never received treatment, based on the mistaken assumption that brief or remote prior exposure significantly impairs treatment response. Here, we summarize how clinically treatment-naive has been defined in protocols for pivotal trials of approved osteoporosis therapies and recent practice guidelines in North America. Consistent definitions are proposed for initial therapies for patients at high-to-very-high fracture risk. Bisphosphonates are discussed in greater detail owing to their unique bone-binding properties, leading to more persistent, albeit finite, antiresorptive activity after discontinuation. A discussion of possible lingering effects of long-term bisphosphonates on bone strength and predisposition to atypical femoral fractures was beyond the scope of this report. In contrast, non-bisphosphonate therapies resolve relatively rapidly after discontinuation, necessitating timely transition to another agent to prevent reversal of anti-fracture efficacy. OBSERVATIONS: Proposed definitions of treatment-naive for the therapies discussed here are treated with oral bisphosphonate for ≥ 1 year or received ≥ 1 annual IV bisphosphonate dose and discontinued ≥ 2 years ago; treated with oral bisphosphonate for > 3 months and < 1 year and discontinued 1-2 years ago; discontinued oral bisphosphonate after ≤ 3 months; received last denosumab injection ≥ 12 months ago; and discontinued abaloparatide, romosozumab, or teriparatide ≥ 12 months ago. CONCLUSIONS: In conclusion, a unified definition could aid multidisciplinary care teams and healthcare decision-makers in making treatment sequencing decisions.
Wändell P, Li X, Ranch Lundin H
… +3 more, Carlsson AC, Sundquist J, Sundquist K
Osteoporos Int
· 2026 Apr · PMID 41701230
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UNLABELLED: This nationwide cohort study compared recurrent osteoporotic fracture risk in first- and second-generation immigrants to native Swedes. First- and second-generation immigrant men had lower risks; first- and s...UNLABELLED: This nationwide cohort study compared recurrent osteoporotic fracture risk in first- and second-generation immigrants to native Swedes. First- and second-generation immigrant men had lower risks; first- and second-generation immigrant women had similar risks to native Swedes. Variations were observed by region of origin, suggesting differences in fracture susceptibility among immigrant groups. PURPOSE: To analyse the risk of a recurrent osteoporotic fracture in immigrants using Swedish-born individuals with Swedish-born parents as referents. METHODS: A nationwide open cohort study including individuals ≥ 50 years of age at baseline (N = 296,118) with a previous fracture. Immigrants were classified as first- or second-generation immigrants, i.e. foreign-born or Swedish-born individuals with at least one foreign-born parent. Osteoporotic fractures were defined as at least one registered diagnosis of fractures in the hip, humerus, forearm, vertebrae, or pelvis in the National Patient Register between January 1, 2010, and December 31, 2018. Logistic regression analysis estimated odds ratios (ORs) with 95% confidence intervals (95% CI) for a second osteoporotic fracture in individuals with a first osteoporotic fracture. Logistic regression models were stratified by sex and adjusted for age, comorbidities, and sociodemographic status. RESULTS: A total of 33,172 fractures (men n = 7,428, and women n = 25,744) were registered in the first-generation study, and 12,979 (men n = 3,607 and women n = 9,372) in the second-generation study. Fully adjusted ORs (95% CI) were for all foreign-born men 0.90 (0.82-0.98) and women 0.95 (0.91-1.00), and for men with foreign-born parents 0.85 (0.73-0.99), and women 1.00 (0.91-1.09). Groups with statistically significant lower odds included men from Asia, women from Eastern Europe, Baltic countries, Asia and Latin America, and men with parents from the Nordic countries. CONCLUSIONS: Among first- and second-generation men, the risk of a second fracture was slightly lower than that of native Swedes, while among first- and second-generation women, the risk was similar to the reference group.
Balziano S, Margalit I, Kollender R
… +4 more, Yahav D, Freidlander A, Prat D, Yelin D
Osteoporos Int
· 2026 Feb · PMID 41699106
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UNLABELLED: Fever often delays urgent hip fracture surgery due to infection concerns. This study found that operating early, despite fever, did not increase complications or death compared to waiting. Thus, early surgery...UNLABELLED: Fever often delays urgent hip fracture surgery due to infection concerns. This study found that operating early, despite fever, did not increase complications or death compared to waiting. Thus, early surgery appears to be a feasible option for selected patients, avoiding the risks associated with surgical delay. PURPOSE: The optimal timing of hip fracture surgery in patients with preoperative fever remains uncertain. Although early surgery generally improves outcomes, fever often prompts delays because of concerns about underlying infection. METHODS: We retrospectively reviewed 208 patients (median age 83 years, 58% women) with low-energy hip fractures and documented preoperative fever (T > 38 °C) treated at a tertiary trauma center from 2012 to 2023. Patients were categorized by surgical timing: early (≤48 h, n = 108) or delayed (>48 h, n = 100). The primary outcome was one-year all-cause mortality, obtained from the national registry. Secondary outcomes were postoperative length of hospital stay and deep surgical site infection requiring surgical intervention. RESULTS: One-year mortality was 20.4% (22/108) in the early group and 31.0% (31/100) in the delayed group (p = 0.079). Median postoperative length of stay was shorter after early surgery (6 days, IQR 4-11) than after delayed surgery (9 days, IQR 5-14; p = 0.031). Deep surgical site infection occurred in 1/108 (0.9%) early patients and 4/100 (4.0%) delayed patients (p = 0.148). Patients selected for early surgery had fewer systemic signs of illness, including lower CRP levels, less desaturation, and less frequent bacterial infections-suggesting that clinical judgment influenced surgical timing. Among patients with confirmed bacterial etiology, early surgery did not increase deep surgical site infection rates or one-year mortality compared to delayed surgery. CONCLUSION: Early surgery in febrile hip fracture patients may be safe when guided by individualized assessment. Our findings support developing structured clinical criteria to aid surgical timing decisions, warranting further validation through larger prospective studies.