Natsumi Saka

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.

Background Primary external fixation (EF) is a crucial method in orthopedic trauma, particularly for complex fractures with soft tissue damage. Despite its importance in damage control surgery, the patterns of EF use in Japan remain underexplored. This study aimed to elucidate the trends and regional differences in EF usage for fracture treatment in Japan and identify factors associated with its variation across regions. Methods We analyzed data from the National Database of Health Insurance Claims (NDB) covering inpatient surgeries from 2018 to 2022. The primary outcome was the EF usage ratio, calculated as the number of primary EFs procedures divided by the total number of internal fixations. The trend of the EF usage ratio over five-year period was assessed by Cochrane-Armitage trend test for temporal trends. We also evaluated the associations between EF usage and factors such as population, region, and emergency care availability. Results A total of 610,326 internal fixations and 29,546 EF procedures were identified, with the EF usage ratio increasing from 4,532 out of 119,223 cases (3.8%) in 2018 to 6,861 out of 126,000 cases (5.4%) in 2022 (p < 0.01). Regional EF usage in total of five-year period ranged from 228 out of 8,103 cases (2.8%) in Oita to 814 out of 9,075 cases (9.0%) in Nagasaki, representing a threefold difference. While 12 prefectures showed statistically significant increases in EF usage, no specific factors were found to explain the regional variations in EF utilization. Conclusion EF usage in Japan has risen over the past five years, with notable regional differences. Further research is needed to identify the causes of these variations and promote consistent trauma care across the country.

Objective: To compare clinical outcomes of patients treated by female surgeons versus those treated by male surgeons. Background: It remains unclear as to whether surgical performance and outcomes differ between female and male surgeons. Methods: We conducted a meta-analysis to compare patients’ clinical outcomes—including patients’ postoperative mortality, readmission, and complication rates—between female versus male surgeons. MEDLINE, Embase, CENTRAL, ICTRP, and ClinicalTrials.gov were searched from inception to September 8, 2022. The update search was conducted on July 19, 2023. We used random-effects models to synthesize data and GRADE to evaluate the certainty. Results: A total of 15 retrospective cohort studies provided data on 5,448,121 participants. We found that patients treated by female surgeons experienced a lower postoperative mortality compared with patients treated by male surgeons [8 studies; adjusted odds ratio (aOR), 0.93; 95% CI, 0.88–0.97; I ²=27%; moderate certainty of the evidence]. We found a similar pattern for both elective and nonelective (emergent or urgent) surgeries, although the difference was larger for elective surgeries (test for subgroup difference P=0.003). We found no evidence that female and male surgeons differed for patient readmission (3 studies; aOR, 1.20; 95% CI, 0.83–1.74; I ²=92%; very low certainty of the evidence) or complication rates (8 studies; aOR, 0.94; 95% CI, 0.88–1.01; I ²=38%; very low certainty of the evidence). Conclusion: This systematic review and meta-analysis suggests that patients treated by female surgeons have a lower mortality compared with those treated by male surgeons.

Our meta-epidemiological study aimed to describe the prevalence of reporting effect modification only on relative scale outcomes and inappropriate interpretations of the coefficient of interaction terms in nonlinear models on categorical outcomes. Our study targeted articles published in the top 10 high-impact-factor journals between 1 January and 31 December 2021. We included two-arm, parallel-group, interventional superiority randomized controlled trials to evaluate the effects of modifications on categorical outcomes. The primary outcomes were the prevalence of reporting effect modifications only on relative scale outcomes and that of inappropriately interpreting the coefficient of interaction terms in nonlinear models on categorical outcomes. We included 52 articles, of which 41 (79%) used nonlinear regression to evaluate effect modifications. At least 45/52 articles (87%) reported effect modifications based only on relative scale outcomes, and at least 39/41 (95%) articles inappropriately interpreted the coefficient of interaction terms merely as indices of effect modifications. The quality of the evaluations of effect modifications in nonlinear models on categorical outcomes was relatively low, even in randomized controlled trials published in medical journals with high impact factors. Researchers should report effect modifications of both absolute and relative scale outcomes and avoid interpreting the coefficient of interaction terms in nonlinear regression analyses.