Association of surgical timing and early verticalization with 12-month mortality after proximal femur fracture: a prospective cohort study of 641 patients

Purpose Proximal femur fractures (PFFs) are associated with high mortality. Both early surgical treatment and early mobilization strategies, including verticalization, are considered key components of patient management. However, the combined association of surgical timing and early verticalization with mortality has not been fully explored.Objective To evaluate the association between the timing of surgery and early verticalization, considered in combination, and 12-month mortality in patients undergoing surgery for proximal femur fracture.Methods In this prospective cohort study, 641 patients aged ≥ 65 years underwent surgery for PFF at a Level I Trauma Center between July 2021 and December 2022. Patients were assessed for nutritional status, cognitive status, and comorbidities and categorized by surgical and verticalization timing. Early verticalization was defined as assisted upright positioning within 72 h after surgery. The primary outcome was 12-month mortality. Associations were analyzed using univariate and multivariable logistic regression.Results Surgery within 48 h and verticalization within 72 h were associated with lower 12-month mortality (p = 0.007 and p = 0.048). Patients undergoing both early surgery and early verticalization had a lower mortality rate (11.1%), compared to those with delayed surgery and rehabilitation, who had the highest (21.5%). Early verticalization was associated with lower mortality in univariate analysis, but this association was not confirmed after adjustment for confounders. Patients undergoing early verticalization generally had more favorable baseline characteristics.Conclusions The combination of early surgical treatment and early verticalization is associated with mortality outcomes in patients with proximal femur fractures. These findings highlight the importance of considering both surgical and rehabilitation timing as part of an integrated care pathway, while acknowledging that causality cannot be established in this observational study.Clinical trial number not applicable.