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Objectives and questions: This study retrospectively analyzes the impact of complex geriatric rehabilitation therapy (CGRT) on patients with intramedullary nailing for proximal femur fractures by evaluating preoperative patient characteristics, intraoperative factors, and postoperative outcomes. The findings may help to further optimize patient care and improve functional and clinical outcomes.

Material and methods: In this single-center retrospective cohort study, data from 346 patients aged ≥70 years who underwent cephalomedullary nailing for low-energy per-, inter-, or subtrochanteric femoral fractures between 2019 and 2024 were analyzed. Patients were stratified according to whether CGRT was implemented. Clinical, laboratory, radiological, and functional outcomes were assessed. Statistical analyses were conducted using SAS, SPSS, and GraphPad Prism. Group comparisons were performed using univariate methods, and multivariable logistic regression was applied to identify factors associated with in-hospital mortality.

Results: A total of 346 patients (64.7% female) were included, of whom 148 (42.8%) received CGRT. Patients in the treatment group were older (median 86 vs. 84 years; p = 0.019) and had a higher comorbidity burden, reflected by a greater number of comorbidities (median 7 vs. 5; p = 0.005) and a higher age-adjusted Charlson Comorbidity Index (median 6 vs. 5; p = 0.036). Cement augmentation was performed more frequently in patients receiving CGRT (16.2% vs. 6.6%; p = 0.005). Barthel Index (POD 3-7) was lower (median 35 vs. 45; p < 0.001), and length of hospital stay was longer (median 19 vs. 10 days; p < 0.001) in the treatment group. However, initiation of baseline osteoporosis therapy at discharge was more frequent (52.7% vs. 21.2%; p < 0.001), post-fracture mobility was better, and in-hospital mortality was significantly lower among patients receiving CGRT (2.7% vs. 13.8%; p < 0.001). Multivariable logistic regression identified CGRT as an independent factor associated with reduced in-hospital mortality.

Discussion and conclusions: A considerable proportion of deaths were caused by severe acute complications, including septic and cardiac events, suggesting clinical instability. Initiation of CGRT may have been limited and may have introduced selection bias.Complex geriatric rehabilitation therapy was associated with lower in-hospital mortality, better post-fracture mobility and improved initiation of osteoporosis baseline therapy, despite advanced age, higher comorbidity burden and reduced early functional outcomes.