Timing of surgery in patients with hip fracture: a systematic review with meta-analysis and trial sequential analysis (2017–2024)

Abstract

Purpose To evaluate how the timing of surgery impacts mortality and postoperative complications in hip fracture patients. Methods We searched PubMed, EMBASE, and Web of Science databases from May 2017 to April 12, 2024, to identify relevant clinical trials. Data extraction was performed independently by two authors. Summary effect size measures were calculated using a random-effects model with robust variance estimation. Results Our analysis included 14 clinical studies involving 3,395,673 patients. For cohort studies, patients who underwent surgery after 12 h demonstrated similar risks of 1-year and 30-day mortality and postoperative complications, such as pneumonia and atrial fibrillation/flutter, compared with those operated on within 12 h. Conversely, surgery performed after 24 h was linked to significantly higher risks of in-hospital mortality, 3-month mortality, cardiovascular complications, delirium, stroke, infections, and atrial fibrillation/flutter compared with surgeries within 24 h. Patients who had surgery after 48 h experienced significantly higher 30-day and in-hospital mortality rates, pulmonary embolism, pneumonia, cardiovascular complications, deep venous thrombosis, delirium, and stroke compared with those operated on within 48 h. For RCTs, surgical delay beyond 24 h significantly increased the risks of delirium and stroke. Conclusion This meta-analysis suggested that hip surgery within 48 h is generally associated with lower risks of mortality and major postoperative complications. This time window should be interpreted as a pragmatic clinical benchmark rather than a strict biological threshold.