Objective To evaluate the clinical effect of Taohong Siwu Decoction combined with unilateral percutaneous vertebroplasty (PVP) in the treatment of osteoporotic vertebral compression fractures (OVCF) in the elderly.Methods A total of 142 elderly patients with OVCF who were admitted to Wuhan First Hospital from June 2019 to June 2021 were selected and grouped randomly into study group and control group. Both groups received unilateral PVP surgery, and the study group also received Taohong Siwu Decoction treatment on the same day as the operation. The comprehensive efficacy, level of injured vertebrae, Cobb angle, bone mineral density, bone metabolism indexes, bone regeneration indexes, and degree of pain and dysfunction were compared between the two groups.Results The total excellent and good rate of the study group was higher than that of the control group (P <0.05). The differences of the level of injured vertebrae before and after the treatment were greater in the study group relative to the control group (P < 0.05). The bone mineral density of L₁-L₄ and proximal femur in the study group was higher than that in the control group (P < 0.05). The change of in the study group was greater than that in the control group (P < 0.05). The differences of serum levels of BALP, OC, tP Ⅰ NP and β-CTX before and after the treatment were higher compared with the control group (P < 0.05). Besides, the differences of bone regeneration indexes, VAS score, and ODI before and after the treatment in the study group were significantly higher than those in the control group (P < 0.05).Conclusions Taohong Siwu Decoction can promote fracture healing, alleviate pain and dysfunction, improve bone mineral density, and regulate the activity of osteoblasts and osteoclasts in elderly patients undergoing unilateral PVP.