Osteoporosis is a systemic skeletal disease characterized by a decreased bone density and a deterioration in bone quality (microarchitectural changes), leading to compromised bone strength and an enhanced risk of fractures [
1]. The prevalence of osteoporosis increases with age and is more common among women than men [
2]. The most recent data estimate that one in three women over the age of 50 and one in five men over the age of 65 will suffer a bone fragility fracture, confirming it as one of the major problems facing health systems worldwide [
3]. Osteoporotic fractures occur when a mechanical stress applied to the bone exceeds its strength. The most frequent fracture sites are the proximal femur, the vertebrae, the proximal humerus, and the distal radius [
4]. According to the World Health Organization (WHO), fragility fractures result from low-energy trauma due to mechanical forces equivalent to a fall from a standing height or less, which would not ordinarily cause a fracture. It is now believed that skeletal fragility requires both decreased bone density and poor bone quality, defined as alterations in bone architecture, bone geometry, and the material properties of the microstructural constituents as well as the presence of microdamage [
5‐
7].
According to numerous evidences, the pathogenesis of osteoporosis is complex and probably affects bone strength depending on multiple interactions between local and systemic regulators of bone cell function, such as osteoblasts, osteoclasts and osteocytes [
8,
9] and on the reduction in cross-linking between collagen fibers, the decrease in structural horizontal trabeculae and the thinning of vertical trabeculae [
10‐
12]. In this complex fragility framework, it is well known that fragility fractures after a surgical treatment could lead to a terrible complication such as implant failure: for proximal femoral fracture the implant failure rate is estimated up to 6% [
13,
14]. For this reason, elderly osteoporotic patients who generally present with poor bone quality, comminuted and unstable fracture patterns are at increased risk of early mechanical failure and therefore show an indication for augmentation [
15]. Fixation augmentation techniques are defined as any surgical procedure that increases implant stability. They include a variety of biological and orthobiological materials, such as polymethylmethacrylate (PMMA), bone grafts, calcium phosphate ceramics including blocks, cements and coatings, and modified implants [
16]. Thermal damage and cement leakage are the two most common complications [
17,
18]. According to various studies, augmentation techniques are safe; however, possible outcomes include stroke, heart attack, embolism or infection are all possible outcomes [
19,
20]. When using cement, fragility fractures have a lower complication rate than total joint replacement, as the cement is injected at a lower pressure [
20]. Furthermore, among the potential benefits of augmentation, lower re-intervention rates and a reduction in total hospital stay have been observed [
21].
To date, there is no global consensus on the possible indications for using augmentation techniques in fractured patients. Therefore, in this systematic review we would like to investigate whether there is unambiguous evidence about the use of augmentation techniques in different sites of fragility fractures occurring in the elderly population affected by osteoporosis.