The Effect of Preoperative Intravenous Iron Supplementation on Mortality and Blood Transfusion Requirements in Elderly Patients Undergoing Hip Fracture Surgery: A Prospective Randomized Controlled Trial

Background/Objectives: Hip fractures in elderly patients are associated with high morbidity and mortality, often worsened by perioperative anemia. Although restric-tive transfusion strategies are recommended, the role of preoperative intravenous iron, particularly ferric carboxymaltose (FCM) remains unclear. This study aimed to investigate whether preoperative IV FCM reduces mortality and transfusion requirements in geriatric hip fracture patients managed under a restrictive transfusion strategy. Methods: In this prospective, randomized controlled trial, 220 patients aged ≥65 years undergoing surgery for hip fractures were allocated to receive either a single 1000 mg dose of intravenous FCM approximately 12 hours before surgery or no iron supplementation. All patients were managed with a standardized restrictive transfusion strategy. Primary outcome was all-cause mortality at 6 and 12 months. Secondary outcomes included perioperative transfusion requirement, hemoglobin trends, and length of hospital stay. Results: The FCM group demonstrated significantly lower mortality at both 6 months (22.9% vs. 39.0%, p = 0.011) and 12 months (28.4% vs. 42.9%, p = 0.028) compared to the control group. Multivariate logistic regression identified preoperative FCM administration as an independent protective factor for mortality. Transfusion rates (30.9% vs. 45.5%, p = 0.02) and transfusion index were significantly lower in the FCM group. Discharge hemoglobin levels were higher in the FCM group, although no significant difference was observed at 6-week follow-up. The difference in hospital stay duration did not reach statistical significance. Conclusions: Preoperative intravenous FCM administration could reduce both short- and long-term mortality and transfusion needs in geriatric hip fracture patients managed under a restrictive transfusion protocol. These findings support further investigation of FCM as a component of perioperative blood management in this high-risk population.