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

Clinical Snapshot

Key Findings

• P Value: Not explicitly reported in abstract; all CIs cross 1.0, indicating non-significance for all primary and secondary outcomes

• Effect Size: Adjusted OR 0.77 for 30-day mortality; crude ORs for longer-term mortality ranged from 0.46 (180-day) to 0.91 (90-day), none reaching statistical significance

• Primary Outcome: 30-day mortality: early surgery was not associated with a statistically significant reduction (adjusted OR 0.77, 95% CI: 0.56–1.05; low-certainty evidence by GRADE)

• Nnt Or Sensitivity: NNT not calculable from available data given non-significant results; sensitivity analyses using stricter early surgery definitions consistently suggested lower mortality with earlier surgery, indicating potential benefit when timing thresholds are more precisely defined

• Confidence Interval: 30-day mortality: 95% CI 0.56–1.05; 90-day: 0.51–1.60; 180-day: 0.12–1.77; 1-year: 0.34–1.09; cardiac complications: 0.48–1.07; pulmonary complications: 0.77–1.47; pulmonary embolism: 0.62–2.16

Clinical Application

The findings do not provide sufficient evidence to mandate a specific surgical timing threshold for distal femur fractures in older adults. Current practice variation in timing is reflected in the included literature. Multidisciplinary perioperative optimisation (anaesthesia, geriatric medicine, orthopaedics) remains the standard approach regardless of timing decisions. In Australian practice, distal femur fractures in older adults are managed within orthopaedic and orthogeriatric frameworks. The Australian Commission on Safety and Quality in Health Care (ACSQHC) and RACGP guidelines emphasise early surgical intervention for hip fractures (within 48 hours), but no equivalent national standard exists specifically for distal femur fractures. This meta-analysis suggests the evidence base is insufficient to extend hip fracture timing benchmarks directly to distal femur fractures. Implants used for fixation (retrograde intramedullary nails, locking plates) are TGA-approved and widely available on the Australian Register of Therapeutic Goods. PBS-listed perioperative medications (anticoagulants, analgesics) are relevant to postoperative complication management. Orthogeriatric co-management models, increasingly adopted across Australian tertiary centres, may independently influence outcomes beyond surgical timing alone. Adults aged ≥60 years presenting with distal femur fractures requiring surgical fixation, particularly those with comorbidities where surgical timing decisions are clinically complex

Abstract

INTRODUCTION: 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. MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

References

1. 1.Hoshika, S., Yamamoto, N., Saka, N., Tsuge, T., Sato, T., Isaji, Y., & Nakao, S. (2026). Association between timing of surgery and postoperative outcomes in older adults with distal femur fractures: a systematic review and meta-analysis. Archives of Orthopaedic and Trauma Surgery. https://doi.org/10.5312/wjo.v5.i4.402