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

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.