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To determine whether hip fracture surgery (HFS) without transfusion affects postoperative mortality and complications in elderly patients.Retrospective comparative study.Three hundred fourteen patients ≥65 years of age who underwent HFS between May 2003 and December 2014. Patients were divided into 2 groups: those who consented to blood transfusion if needed and those who did not. One-to-one propensity score matching generated 50 matched pairs of patients.Patients underwent HFS with or without blood transfusion. In the no transfusion group, simultaneous administration of erythropoietin and iron was used as an alternative.The primary outcome was postoperative mortality (90-day, 1-year, overall). The secondary outcomes were hemoglobin change and the incidence of postoperative complications.HFS using a no transfusion protocol was not associated with increased mortality at any time point. Mean hemoglobin levels were significantly different between the 2 groups on postoperative day 1 (11.0 ± 1.3 vs. 10.5 ± 1.6, P = 0.002) but levels completely recovered within 2 weeks in both groups. There was also no difference in postoperative complication rates between the 2 groups, and overall hospital stays and charges were similar.An HFS protocol without blood transfusion was not associated with increased mortality or complications in elderly patients.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.