What is the clinical evidence from this study?

Study design: Systematic Review. Population: Distal femur fractures (n=31213). Intervention: Early surgery (within 2 days of admission or injury) vs. Delayed surgery (3 or more days after admission). Primary outcome: 30-day mortality (OR 0.77, 95% CI 0.56-1.05).

June 19, 2026Archives of Orthopaedic and Trauma Surgery0 citationsOpen Access

Association between timing of surgery and postoperative outcomes in older adults with distal femur fractures: a systematic review and meta-analysis

SHShota HoshikaCreighton University NYNorio YamamotoHiroshima Kyoritsu Hospital NSNatsumi SakaScientific Research WorkS Peer Support Group

Key Result

Early surgery within 2 days was not associated with a significant reduction in 30-day mortality compared to delayed surgery in older adults with distal femur fractures (adjusted OR 0.77).

Key Points

Evaluate the relationship between surgical timing and clinical outcomes in older adults with distal femur fractures.
Conducted a systematic review and meta-analysis
Included 16 retrospective cohort studies with 31,213 patients
Primary outcome was 30-day mortality and secondary outcomes included longer-term mortality and complications.
Early surgery showed no significant reduction in 30-day mortality (OR: 0.77, 95% CI: 0.56–1.05)
No significant differences observed in longer-term mortality at 90 days (OR: 0.91, 95% CI: 0.51–1.60), 180 days (OR: 0.46, 95% CI: 0.12–1.77), or 1 year (OR: 0.61, 95% CI: 0.34–1.09)
Postoperative complications did not differ significantly for cardiac (OR: 0.71, 95% CI: 0.48–1.07) or pulmonary events (OR: 1.07, 95% CI: 0.77–1.47).

Study Design

Type

Systematic Review (n=31,213)

Multicenter

Yes

Structured PICO

Does early surgery reduce 30-day mortality in older adults with distal femur fractures?

Population

31,213 older adults (aged 60 years or older, median 80.7% female) with distal femur fractures from 16 retrospective cohort studies, followed for a median of 2.2 years.

Exposure

Early surgery

Comparator

Later/delayed surgery

Outcome

30-day mortalityhard clinical

Early surgery for distal femur fractures in older adults was not associated with a clinically meaningful reduction in short-term mortality or complications compared to later surgery.

Main Result

Odds Ratio: 0.77 (95% CI 0.56–1.05)

Absolute Event Rate: 1.4% vs 1.8%

Limitations

Small number of patients included, resulting in wide confidence intervals and reduced statistical precision
All included studies were retrospective cohort studies, making them prone to selection bias and information bias
Many studies relied on crude odds ratios and did not adequately control for key confounders
Inclusion of different surgical procedures may have contributed to clinical heterogeneity
Definitions of early surgery varied across studies (time from admission vs. time from injury)
Heterogeneous outcome definitions and incomplete reporting of complications limited cross-study comparability

Abstract

The association between surgical timing and clinical outcomes in older adults with distal femur fractures remains unclear. We conducted a systematic review and meta-analysis to evaluate whether earlier surgery is associated with improved outcomes in this population. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two independent reviewers searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform from inception to October 8, 2024. The primary outcome was 30-day mortality, and secondary outcomes included longer-term mortality and postoperative complications. Risk of bias was assessed using the Quality in Prognosis Studies tool, and the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach. Of 6,101 records screened, 16 retrospective cohort studies comprising 31,213 patients met the inclusion criteria. Early surgery was not associated with reduced 30-day mortality (adjusted odds ratio OR: 0.77, 95% confidence interval CI: 0.56–1.05; low-certainty evidence) or with longer-term mortality at 90 days (crude OR: 0.91, 95% CI: 0.51–1.60), 180 days (crude OR: 0.46, 95% CI: 0.12–1.77), or 1 year (crude OR: 0.61, 95% CI: 0.34–1.09). Similar findings were observed for postoperative complications: cardiac complications (OR: 0.71, 95% CI: 0.48–1.07), pulmonary complications (OR: 1.07, 95% CI: 0.77–1.47), and pulmonary embolism (OR: 1.14, 95% CI: 0.62–2.16). Heterogeneity across outcomes was low to moderate, and definitions of early surgery varied among studies. Overall, this meta-analysis did not demonstrate a clinically meaningful association between surgical timing and short-term clinical outcomes in older adults with distal femur fractures. Sensitivity analyses consistently suggested lower mortality with earlier surgery, likely reflecting stricter definitions of early surgery and improved control of time-related bias. This meta-analysis did not demonstrate a clinically meaningful association between surgical timing and short-term clinical outcomes in older adults with distal femur fractures. Given the heterogeneity in definitions and study designs, high-quality prospective studies with standardized timing are warranted.

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