Nighttime intramedullary nailing of femoral fractures is not associated with worse outcomes: a 13-year Level I trauma center cohort.

backgroundWhether nighttime orthopedic trauma surgery adversely affects outcomes remains controversial. Evidence specifically addressing intramedullary fixation across femoral fracture locations remains limited. This study evaluated whether nighttime surgery was associated with a higher rate of recorded postoperative complications than daytime surgery.

methodsThis retrospective observational cohort included adult patients with nonperiprosthetic femoral fractures treated with intramedullary fixation between January 2010 and January 2023 at a single Level I trauma center. Of 311 screened records, 23 were excluded because the patient was younger than 18 years (n = 17) or the fracture was periprosthetic (n = 6), leaving 288 procedures (242 daytime and 46 nighttime). The primary outcome was any recorded postoperative complication during available follow-up. Secondary outcomes included radiographic abnormality, delayed union (> 24 weeks), nonunion, revision surgery, and mortality. Surgeon experience was categorized as senior surgeon or resident. Exploratory fracture-location subgroup analyses and multivariable logistic regression were performed.

resultsNighttime patients were younger (35.1 ± 19.1 vs. 46.6 ± 24.6 years, p < 0.001), more frequently male (82.6% vs. 64.0%, p = 0.014), more often injured by a high-energy mechanism (80.4% vs. 56.6%, p = 0.002), and underwent surgery sooner after trauma (4.0 [2.0-10.0] vs. 18.0 [7.0-48.0] hours, p < 0.001). Residents were the recorded primary surgeon in 54.3% of nighttime and 39.3% of daytime procedures (p = 0.057). After adjustment for demographic, injury, fracture-location, time-to-surgery, and surgeon-experience variables, nighttime surgery was not associated with the primary outcome (adjusted odds ratio 0.45, 95% confidence interval 0.15-1.38; p = 0.163). Delayed union (28.3% vs. 19.4%, p = 0.233) and revision surgery (4.3% vs. 12.4%, p = 0.130) did not differ significantly.

conclusionsIn this single-center cohort, nighttime intramedullary fixation of femoral fractures was not associated with higher observed rates of postoperative complications, impaired fracture healing, or revision surgery compared with daytime fixation. These findings suggest that operative timing alone may not be a major determinant of outcome within an organized Level I trauma system. Nevertheless, the small nighttime cohort, unequal group sizes, fracture heterogeneity, and limited statistical precision require cautious interpretation and preclude definitive conclusions regarding equivalence or subgroup-specific safety. Larger multicenter studies with standardized assessment of surgeon experience, staffing, fatigue, and fracture-specific outcomes are warranted.