ObjectiveThe aim of this study was to assess the clinical outcomes of C arm fluoroscopy-guided percutaneous kyphoplasty (PKP) in elderly patients with osteoporotic vertebral compression fractures (OVCF) and to explore how age, body mass index (BMI), and osteoporosis severity influence these outcomes.MethodsWe retrospectively reviewed 167 OVCF patients treated with PKP between January 2022 and December 2023. Pain intensity (VAS), functional disability (ODI), Cobb angle, anterior vertebral body height, overall response rate, patient satisfaction (5 point Likert scale), and health related quality of life (SF 36) were assessed before and after surgery. Logistic regression identified independent predictors of suboptimal clinical and satisfaction outcomes.ResultsCompared with baseline, postoperative VAS decreased from 7.83±1.27 to 1.31±1.53, ODI from 45.39±7.12 to 3.31±1.39, Cobb angle from 22.31°±3.87° to 17.91°±1.83°, and vertebral height from 22.39±9.12 mm to 30.31±3.79 mm (all P<0.001). The overall success rate was 100% (marked improvement in 60.5%, moderate in 39.5%). Multivariate analysis demonstrated that age≥76 years, BMI≥23.4 kg/m², and severe osteoporosis significantly increased the risk of less favorable outcomes (P<0.05). The mean satisfaction score was 4.52±0.63, with 85% of patients reporting satisfaction. The SF 36 total score improved from 52.3±8.7 to 78.6±9.2 (P<0.001), most notably in the bodily pain domain (82.5 vs. 30.1).ConclusionC arm–guided PKP provides excellent pain relief, restores vertebral height and alignment, and enhances function and quality of life in elderly OVCF patients. Advanced age, higher BMI, and greater osteoporosis severity are key risk factors for suboptimal clinical and satisfaction outcomes, underscoring the importance of personalized preoperative evaluation and management.