Objective To investigate the associations of hip muscle area and visceral fat area (VFA) with bone strength parameters measured by dual-energy X-ray absorptiometry (DXA) and their predictive values for hip fracture in elderly patients with osteoporosis.Methods We retrospectively analyzed clinical data from 87 elderly osteoporosis (OP) patients (observation group) and 41 elderly patients with low bone mass (control group) treated at Sichuan Orthopedic Hospital from January 2021 to June 2022. The bone strength parameters measured by DXA, the hip muscle area and VFA were compared between the observation group and the control group. The patients were followed up for 2 years, and the elderly individuals with OP were divided into the occurrence group and the non-occurrence group based on whether they experienced hip fractures. The clinical data of the occurrence group and the non-occurrence group were compared, and the influencing factors of hip fractures in elderly OP patients were analyzed. The predictive values of the cross-sectional area (CSA) of gluteus medius and gluteus minimus, CSA of gluteus maximus, VFA and their combination for hip fractures in elderly OP patients were determined.Results The cortical thickness ratios of the femoral shaft, talus, and the femoral neck, section modulus and total hip bone mineral density (BMD) in observation group were all lower than those in the control group (P < 0.05). The CSA of gluteus medius and gluteus minimus and that of gluteus maximus in the observation group were lower than those in the control group (P < 0.05), and the VFA in the observation group was higher than that in the control group (P < 0.05). The CSA of gluteus medius and gluteus minimus was positively correlated with the cortical thickness ratios of femoral shaft, talus, and the femoral neck, section modulus and total hip BMD (r = 0.567, 0.575, 0.671, 0.634 and 0.465, all P < 0.05). The CSA of gluteus maximus was positively correlated with the cortical thickness ratios of femoral shaft, talus, and the femoral neck, section modulus and total hip BMD (r = 0.589, 0.667, 0.532, 0.479 and 0.586, all P < 0.05). The VFA was negatively correlated with the cortical thickness ratios of femoral shaft, talus, and the femoral neck, section modulus and total hip BMD (r = -0.614, -0.652, -0.437, -0.483 and -0.564, all P < 0.05). The age, prevalence of rheumatoid arthritis, proportion of individuals lacking sunlight exposure and VFA in the occurrence group were higher than those in the non-occurrence group (P < 0.05), and the total hip BMD, the CSA of gluteus medius and gluteus minimus and the CSA of gluteus maximus in the occurrence group were lower than those in the non-occurrence group (P < 0.05). High total hip BMD [O^R = 0.385 (95% CI: 0.125, 0.648) ], CSA of gluteus medius and gluteus minimus [O^R = 0.252 (95% CI: 0.111, 0.573) ], and CSA of gluteus maximus [O^R = 0.232 (95% CI: 0.101, 0.527) ] were protective factors for hip fractures in elderly OP patients (P < 0.05), while high VFA [O^R = 3.732 (95% CI: 1.641, 8.490) ] was a risk factor for hip fractures in elderly OP patients (P < 0.05). The sensitivities of the CSA of gluteus medius and gluteus minimus, CSA of gluteus maximus, VFA and their combination for predicting hip fractures in elderly OP patients were 77.78% (95% CI: 0.519, 0.926), 83.33% (95% CI: 0.577, 0.956), 88.89% (95% CI: 0.639, 0.981), and 88.89% (95% CI: 0.639, 0.981), with the respective specificities being 85.51% (95% CI: 0.745, 0.925), 82.61% (95% CI: 0.712, 0.903), 73.91% (95% CI: 0.617, 0.834), and 92.75% (95% CI: 0.832, 0.973).Conclusions The CSA of gluteus medius and gluteus minimus and that of gluteus maximus are positively but the VFA is negatively correlated with bone strength parameters measured by DXA in elderly OP patients. The combination of the three indicators yields a higher predictive value for hip fractures in elderly OP patients.