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Background Hip fracture is a condition with high mortality and morbidity in elderly frail patients. Intraoperative fluid optimization may be associated with benefit in this population. We investigated whether intraoperative fluid management using pulse-contour analysis cardiac monitoring, compared with standard care in patients undergoing spinal anaesthesia, would provide benefits in terms of reduced time until medically fit for discharge and postoperative complications. Methods Patients undergoing surgical repair of fractured neck of femur, aged >60 yr, receiving spinal anaesthesia were enrolled in this single-centre, blinded, randomized, parallel group trial. Patients were allocated to either anaesthetist-directed fluid therapy or a pulse-contour-guided fluid optimization strategy using colloid (Gelofusine) boluses to optimize stroke volume. The primary outcome was time until medically fit for discharge. Secondary outcomes included postoperative complications, mobility, and mortality. We updated a systematic review to include relevant trials to 2014. Results We recruited 130 patients. Time until medically fit for discharge was similar in both groups, mean [95% confidence interval (CI)] 12.2 (11.1–13.5) vs 13.1 (11.9–14.5) days (P=0.31), as was total length of stay 14.2 (12.9–15.8) vs 15.3 (13.8–17.2) days (P=0.32). There were no significant differences in complications, function, or mortality. An updated meta-analysis (four studies, 355 patients) found non-significant reduction in early mortality [relative risk 0.66 (0.24–1.79)] and in-hospital complications [relative risk 0.80 (0.61–1.05)]. Conclusions Goal-directed fluid therapy during hip fracture repair under spinal anaesthesia does not result in a significant reduction in length of stay or postoperative complications. There is insufficient evidence to either support or discount its routine use. Clinical trial registration ISRCTN88284896.