Purpose <p>Compare 1-year clinical and functional outcomes of combined hip procedures (CHP) involving open reduction and internal fixation and acute total hip arthroplasty (THA) for elderly acetabular fractures with those of THA for femoral neck fractures (FN) and hip osteoarthritis (OA).</p> Methods <p>IRB-approved registry used to compare three cohorts with minimum 1-year follow up at an academic center. Fifteen patients &gt; 55 years old with acetabular fractures who underwent combined hip procedure were identified. CHP cohort was propensity-matched at a minimum 3:1 ratio to FN and OA cohorts who underwent THA. All patients underwent posterior approach for THA. The Functional Ambulation Classification score was used to evaluate independent ambulatory ability. Comparative analyses performed using ANOVA and Chi-Squared tests.</p> Results <p>118 patients with mean age 70.76 ± 9.37 years were identified. OA cohort had the highest BMI (<i>p</i> = 0.040), lowest rate of diabetes (<i>p</i> = 0.027), and highest pre-operative assistive device use (<i>p</i> &lt; 0.001). CHP cohort had the longest operative time (<i>p</i> &lt; 0.001), largest intraoperative blood loss (<i>p</i> &lt; 0.001), and greatest need for transfusion (<i>p</i> &lt; 0.001). CHP cohort had the longest hospital stay (<i>p</i> &lt; 0.001) and experienced the highest rates of medical complications (<i>p</i> &lt; 0.05) compared to the other groups. CHP cohort had the lowest Functional Ambulation Classification score at all post-operative time points up to 1 year. No differences observed in readmission or mortality rates among cohorts.</p> Conclusion <p>CHP involving open reduction and internal fixation and acute THA for elderly acetabular fractures had worse one-year functional outcomes and higher postoperative complication rates compared to THA for less severe indications, such as FN fractures and OA.</p> <p><i>Level of evidence</i> III.</p>