Abstract
<title>Abstract</title> <p>Background Osteoporotic hip fractures cause significant morbidity, mortality, and healthcare burden. Substantial gaps persist in osteoporosis diagnosis and secondary fracture prevention, particularly in Saudi Arabia. Aims To evaluate the osteoporosis care gap, mortality outcomes, and predictors of mortality among patients with fragility hip fractures at a tertiary care center in Riyadh, Saudi Arabia. Methods This retrospective cohort study included 273 patients aged ≥ 50 years admitted with fragility hip fractures between 2016 and 2024. Kaplan–Meier analysis estimated survival; Cox proportional hazards regression identified predictors of mortality. Results Mean age was 76.2 ± 9.4 years. Only 12.5% underwent DXA before fracture and 21.6% received post-fracture osteoporosis treatment, leaving 78.4% untreated. Kaplan–Meier-estimated mortality was 2.2% at 30 days, 16.3% at 1 year, and 42.0% at 5 years; median survival was 6.1 years (95% CI 5.3–8.7). Increasing age independently predicted higher mortality (HR 1.05/year; 95% CI 1.02–1.08; p < 0.001), and surgical management was associated with lower mortality hazard (HR 0.32; 95% CI 0.13–0.84; p = 0.02), though this should be interpreted cautiously given the small non-operative group. Refracture was documented in 32 patients (11.7%); among the 14 patients with recorded refracture dates, the median time to refracture was 1.38 years. Discussion These findings highlight persistent missed opportunities for secondary fracture prevention and the need for coordinated post-fracture osteoporosis care. Conclusion Fragility hip fractures in Saudi Arabia are associated with substantial mortality and a major osteoporosis care gap. Structured post-fracture pathways, particularly fracture liaison services, are needed to strengthen secondary fracture prevention.</p>