Background <p>This retrospective case series evaluated mortality outcomes in patients with Vancouver B1 periprosthetic fractures (PPFs) managed non-operatively using a matched cohort approach. We hypothesize that mortality rates will not significantly differ between operative and non-operative management of Vancouver B1 PPFs, as treatment decisions are likely driven by fracture complexity and patient comorbidities rather than a direct survival benefit of surgical intervention.</p> Methods <p>Thirty patients with Vancouver B1 PPFs managed non-operatively between 2011 and 2017 across five major Australian trauma centers were identified. Patients were propensity-matched to 60 operatively managed patients, matched by age, ASA score, length of stay, follow-up duration, and fracture sub-type (B1). Mortality rates at 30 days, 1 and 5 years were compared between the non-operative and operatively managed groups. For the non-operative group alone, the impact of weight-bearing status on mortality was assessed.</p> Results <p>There was no significant difference in mortality rates between the non-operative and operative cohorts at 30-day (3.3%; 1.7%; <i>P =</i> 1.00), 1 year (20.0%; 3.3%; <i>P =</i> 0.09) and 5 years (33.3%; 30.0%; <i>P =</i> 0.78). For the non-operative group alone, there was no significant difference in mortality rates between WBAT and non-WBAT groups at 30 days (7.7%; 0.0%; <i>P</i> = 0.400), 1 year (15.4%; 17.6%; <i>P</i> = 0.839) and 5 years (30.8%; 35.3%; <i>P</i> = 0.781),</p> Conclusion <p>Comparable 5-year mortality rates were identified between non-operatively and operatively managed Vancouver Type B1 periprosthetic femoral fractures. Despite differences in age and comorbidities, non-operative management may be a viable option for selected patients, underscoring the need for further research to refine treatment guidelines.</p> Clinical trial number <p>Not applicable.</p>