Purpose <p>To investigate the correlation between postoperative serum bone metabolism levels and fracture healing in elderly patients with osteoporotic vertebral compression fractures (OVCFs).</p> Methods <p>110 OVCF patients treated in the hospital from February 2023 to January 2024 were enrolled in this study. The patients were divided into the Normal healing and Delayed healing groups based on postoperative fracture healing. The general information of the two groups was first compared, and then serum levels of procollagen type I N-terminal propeptide (P1NP), osteoprotegerin (OPG), osteocalcin (BGP), and alkaline phosphatase (ALP) were measured in the patients. The correlation between postoperative bone metabolism levels and bone mineral density (BMD) and postoperative Oswestry disability index (ODI) were analyzed using Spearman’s correlation test. Independent risk factors affecting postoperative fracture healing time were analyzed using multifactorial logistic regression. The value of serum bone metabolism indexes in assessing delayed postoperative fracture healing was analyzed using the receiver operating characteristic (ROC) curves.</p> Results <p>In the Delayed healing group, the age, proportion of comorbid diabetes mellitus, postoperative ODI, and fracture healing time were significantly higher than those in the Normal healing group. Conversely, the postoperative calcium-phosphorus product, 25-hydroxyvitamin D [25(OH)D₃] level, and postoperative BMD T-value were lower than those in the Normal healing group (<i>P</i> &lt; 0.05). Serum P1NP, OPG, BGP, and ALP levels were higher in the Normal healing group than in the Delayed healing group (<i>P</i> &lt; 0.05). Spearman’s correlation test demonstrated that serum P1NP, OPG, BGP, and ALP levels were all positively correlated with BMD T-value and negatively correlated with ODI in elderly OVCF patients (all <i>P</i> &lt; 0.05). Low serum P1NP level, low serum OPG level, low serum BGP level, and low serum ALP level were independent risk factors affecting fracture healing in elderly OVCF patients (<i>P</i> &lt; 0.05). The results of ROC analysis showed that the area under the curves (AUCs) of serum P1NP, OPG, BGP, and ALP in assessing delayed postoperative fracture healing in elderly OVCF patients were 0.888, 0.890, 0.894, and 0.856, respectively.</p> Conclusions <p>Delayed postoperative fracture healing in elderly OVCF patients might be affected by serum P1NP, OPG, BGP, and ALP levels, and serum bone metabolism levels can be an auxiliary judgment indicator of delayed postoperative fracture healing.</p>