Purpose <p>Glucagon-like peptide-1 receptor agonists (GLP-1RA) improve glycemic control and support weight management in type 2 diabetics, but their safety during the perioperative period in fracture surgery remains unclear. We hypothesized that preoperative use of GLP-1RA would not increase postoperative complications after surgical fixation of femoral neck fractures.</p> Methods <p>We conducted a retrospective propensity score–matched cohort study within an integrated United States health system. Adults with type 2 diabetes undergoing open reduction and internal fixation or closed reduction and percutaneous pinning for AO OTA 31B femoral neck fractures from 2016 to 2023 were included. Exposure was active GLP-1RA use at admission. Matching was 1:2 on age, sex, body mass index, smoking status, and Elixhauser Comorbidity Index. Primary outcomes were aspiration pneumonitis and composite medical complications at 30, 90, and 365 days. Secondary outcomes were implant failure, nonunion, malunion, revision surgery, and mortality.</p> Results <p>We matched 112 GLP-1RA users to 224 patients not using a GLP-1RA. Aspiration pneumonitis was not significantly different (1.8% vs. 2.2%, <i>P</i> = .790). There were no significant differences in length of stay (<i>P</i> = .256), time to surgery (<i>P</i> = .965), ACE (30/90/365-day <i>P</i> &gt; .80), composite medical complications at 30, 90, or 365 days (all <i>P</i> ≥ .363), or mortality/discharge to hospice through 365 days (<i>P</i> = .120). Revision surgery within 365 days occurred in 0% of GLP-1RA users vs. 4.5% in nonusers (<i>P</i> = .063).</p> Discussion <p>Preoperative GLP-1RA use was not associated with higher perioperative morbidity or mortality after femoral neck fracture fixation and may be linked to fewer reoperations. Larger multicenter studies are warranted.</p> Level of evidence <p>III, retrospective cohort.</p>