Concomitant Malnutrition and Frailty Are Uncommon, but Significant Risk Factors for Mortality and Complication Following Primary Total Knee Arthroplasty

Medium to long term of self-report outcomes of high tibial osteotomy in advanced age patients

PURPOSE

This study aimed to investigate the mid- to long-term benefits of high tibial osteotomy in advanced age patients.

METHODS

This retrospective study was conducted in our hospital from January 2017 to January 2021 with data prospectively collected, 47 patients with knee osteoarthritis who over 65 years old were included, and a 1:1 propensity score (PS) of patients < 65 years were matched according to gender, body mass index, and side. Patient demographics, intraooperative and postoperative variables, and patient self-reported outcomes were compared. A generalized linear model was used to screen possible risk factors.

RESULTS

A total of 94 consecutive patients were included; the average age of advanced age group was 69.47 + 4.26 years and 57.87 + 5.51 years in the younger group. There were no statistically difference in K-L grade, smoke, drink, comorbidity, ASA, blood loss, operative duration, length of stay, surgical site infection, hinge fracture, DVT, and preooperative and postoperative aFTA; significantly statistical difference of the eFI was found between two groups (P < 0.05). Two groups had comparable VAS and MOMAC scores at one year postoperatively (P > 0.05), while the younger group had lower VAS and WOMAC scores than the advanced age group at the end of follow-up (P < 0.05). Generalized linear model showed both age and eFI were associated with WOMAC scores; there was a statistically significant difference in the effect of eFI on WOMAC scores at different ages (P > 0.05).

CONCLUSIONS

Compared with younger patients, advanced age patients have similar short-term benefits, but less long-term benefits. We recommend that patients proposed for HTO be discriminated by eFI, and patients with higher scores should be cautiously selected.

Age-adjusted 5-factor modified frailty index as a valuable tool for patient selection in bilateral simultaneous total knee arthroplasty

Although bilateral simultaneous total knee arthroplasty (BSTKA) is an effective treatment for bilateral knee osteoarthritis, safety concerns and lack of precise patient selection criteria persist. The purpose of this retrospective study was to determine the complication rate and the role of frailty in patient selection for BSTKA. We analyzed data from 434 patients who underwent BSTKA between February 2012 and January 2021, examining demographic factors and preoperative blood test results. Complications occurred in 77 patients (18%), with anemia requiring transfusion being the most common (26 patients, 5.9%). In the univariate analysis, age ≥ 75 years, age-adjusted Charlson Comorbidity Index ≥ 5, age-adjusted 5-factor modified Frailty Index (aamFI-5) ≥ 3, hemoglobin ≤ 11.0 g/dL, albumin ≤ 3.5 g/dL, estimated glomerular filtration rate < 45 ml/dl/1.73 m2, and D-dimer ≥ 2.0 μg/mL contributed to postoperative complications (p < 0.05). Multivariate analysis identified aamFI-5 ≥ 3 as an independent risk factor (p = 0.002). Our findings underscore the practical utility of aamFI-5 in predicting complications after BSTKA, providing valuable guidance to surgeons in the selection of BSTKA candidates and ultimately improving clinical outcomes.

Shoulder arthroscopy in elderly patients: malnutrition and early postoperative outcomes

Background

This study investigates the association between the Geriatric Nutritional Risk Index (GNRI), a simple, readily available malnutrition risk index, and 30-day postoperative complications following shoulder arthroscopy.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify all patients aged ≥65 years who underwent shoulder arthroscopy between 2015 and 2021. The study population was indexed into 3 cohorts of preoperative GNRI: normal/reference (GNRI >98), moderate malnutrition (92≤ GNRI ≤98), and severe malnutrition (GNRI <92). Multivariate logistic regression analysis was conducted to investigate the connection between preoperative GNRI and postoperative complications.

Results

Severe malnutrition was independently significantly associated with a greater likelihood of any complication (odds ratio [OR]: 11.70, 95% confidence interval [CI]: 8.58-15.94; P < .001), sepsis (OR: 26.61, 95% CI: 10.86-65.21; P < .001), septic shock (OR: 7.53, 95% CI: 1.56-36.32; P = .012), blood transfusions (OR: 25.38, 95% CI: 6.40-100.59; P < .001), pulmonary embolism (OR: 7.25, 95% CI: 1.27-41.40; P = .026), surgical site infection (OR: 22.08, 95% CI: 7.51-64.97; P < .001), nonhome discharge (OR: 15.75, 95% CI: 9.83-25.23; P < .001), readmission (OR: 2.69, 95% CI: 1.52-4.74; P < .001), unplanned reoperation (OR: 6.32, 95% CI: 2.23-17.92; P < .001), length of stay >2 days (OR: 23.66, 95% CI: 16.25-34.45; P < .001), and mortality (OR: 14.25, 95% CI: 2.89-70.40; P = .001).

Conclusion

GNRI-based malnutrition is strongly predictive of perioperative complications following shoulder arthroscopy in geriatric patients and has utility as an adjunctive risk stratification tool.

The geriatric nutritional risk index as a strong predictor of adverse outcomes following total shoulder arthroplasty

Background

This study investigates the association between the Geriatric Nutritional Risk Index (GNRI), a simple readily available measure of malnutrition risk, and 30-day postoperative complications following total shoulder arthroplasty (TSA).

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent TSA between 2015 and 2021. The study population was divided into 3 groups based on preoperative GNRI: normal/reference (GNRI > 98), moderate malnutrition (92 ≤ GNRI ≤ 98), and severe malnutrition (GNRI < 92). Logistic regression analysis was conducted to investigate the connection between preoperative GNRI and postoperative complications.

Results

Compared to normal nutrition, moderate malnutrition was independently significantly associated with a greater likelihood of any complications (odds ratio [OR]: 1.74, 95% confidence interval [CI]: 1.54-1.96; P < .001), blood transfusions (OR: 1.52, 95% CI: 1.09-2.11; P = .013), failure to wean off a ventilator within 48 hours (OR: 3.84, 95% CI: 1.26-11.72; P = .018), wound dehiscence (OR: 15.80, 95% CI: 1.61-155.28; P = .018), nonhome discharge (OR: 1.90, 95% CI: 1.63-2.22; P < .001), readmission (OR: 1.54, 95% CI: 1.19-1.99; P = .001), unplanned reoperation (OR: 1.87, 95% CI: 1.27-2.74; P = .001), length of stay > 2 days (OR: 1.85, 95% CI: 1.63-2.12; P < .001), and mortality (OR: 3.38, 95% CI: 1.32-8.71; P = .011). Severe malnutrition was independently significantly associated with a greater likelihood of any complication (OR: 3.33, 95% CI: 2.80-3.97; P < .001), sepsis (OR: 9.83, 95% CI: 2.94-32.85; P < .001), pneumonia (OR: 3.30, 95% CI: 1.71-6.38; P < .001), unplanned reintubation (OR: 5.77, 95% CI: 2.47-13.51; P < .001), urinary tract infection (OR: 2.15, 95% CI: 1.19-3.87; P = .011), stroke (OR: 3.57, 95% CI: 1.18-10.84; P = .024), blood transfusions (OR: 5.27, 95% CI: 3.86-7.20; P < .001), failure to wean off a ventilator within 48 hours (OR: 7.64, 95% CI: 2.29-25.55; P < .001), Clostridioides difficile infection (OR: 4.17, 95% CI: 1.21-14.32; P = .023), nonhome discharge (OR: 3.56, 95% CI: 2.92-4.34; P < .001), readmission (OR: 2.05, 95% CI: 1.46-2.89; P < .001), length of stay > 2 days (OR: 3.27, 95% CI: 2.73-3.92; P < .001), and mortality (OR: 4.61, 95% CI: 1.51-14.04; P = .007).

Conclusion

Malnutrition based on GNRI is a strong predictor of complications following TSA, with increasing severity related to an increased rate of complications.

Age-Adjusted Modified Frailty Index Predicts 30-Day Complications and Mortality in Aseptic Revision Total Hip and Knee Arthroplasty

BACKGROUND

The age-adjusted modified frailty index (aamFI) has been demonstrated to effectively predict postoperative complications and healthcare resource utilization in patients undergoing primary total joint arthroplasty. The purpose of this study was to evaluate the applicability of aamFI in patients undergoing aseptic revision total hip (rTHA) and knee arthroplasty (rTKA).

METHODS

A national database was queried for patients undergoing aseptic rTHA and rTKA from 2015 to 2020. A total of 13,307 rTHA and 18,762 rTKA cases were identified. The aamFI was calculated by adding 1 additional point for age ≥73 years to the previously described 5-item modified frailty index (mFI-5). The area under the curve was calculated and compared to compare predictive accuracy between mFI-5 and aamFI. Logistic regression was used to investigate the relationship between aamFI and 30-day complications.

RESULTS

The incidence of incurring any (≥1) complication increased from 15% for aamFI 0 to 45% for aamFI ≥5 after rTHA and from 5 to 55% after rTKA. Patients who had an aamFI ≥3 (reference aamFI = 0) had increased odds (rTHA: odds ratio (OR) 3.5, 95% confidence interval (CI) 2.9 to 4.1, P < .001; rTKA: OR 4.2, 95% CI 4.4 to 5.1, P < .001) of incurring at least 1 complication. The aamFI, compared to mFI-5, was a more accurate predictor of any complication (rTHA P < .001; rTKA P < .001) and 30-day mortality (rTHA P < .001; rTKA P < .003).

CONCLUSION

The aamFI is an excellent predictor of complications in patients undergoing rTHA and rTKA. The addition of chronological age to the previously described mFI-5 improves the predictive value of this simple metric.

Nutritional Laboratory Studies Prior to Total Knee Arthroplasty: Practice Versus Publication

BACKGROUND

Recent emphasis has been placed on nutritional status assessment prior to total knee arthroplasty (TKA), including multiple American Academy of Orthopaedic Surgeons publications recommending specific laboratory studies; however, the frequency with which surgeons obtain these laboratory studies remains unclear. We sought to assess the incidence of ordering nutritional laboratory studies in the 90 days prior to TKA, utilizing data from a large administrative claims database.

METHODS

With use of the PearlDiver database, we identified 557,670 patients undergoing primary TKA from 2011 to 2020 with a metabolic panel or blood cell count claim within 90 days prior to TKA. We then determined the incidence of prealbumin, transferrin, vitamin D, and zinc laboratory tests claimed 90 days prior to TKA. Associations between claims and the year of surgery, patient demographics, and clinical characteristics were assessed by comparing proportions and chi-square testing.

RESULTS

Nutritional laboratory studies were infrequently claimed within 90 days prior to TKA, with studies for prealbumin being performed in 2.2% of patients; transferrin, 1.9%; vitamin D, 10.2%; and zinc, 0.2%. From 2011 to 2020, there was a moderate but steady increase in the proportion of patients with claims for prealbumin (change from 0.8% in 2011 to 3.4% in 2020; p < 0.001), transferrin (0.8% to 2.7%; p < 0.001), and vitamin D (7.6% to 9.4%; p < 0.001) laboratory tests but there was less of a change for zinc (0.1% to 0.2%; p < 0.001). There were weak-to-absent associations of age, gender, obesity, diabetes, and anemia with laboratory claims.

CONCLUSIONS

Despite multiple publications and recommendations, nutritional laboratory studies are infrequently ordered prior to TKA. Although there has been a slight increase in the use of nutritional laboratory studies over the past decade, patient factors such as gender and obesity were not associated with this increase. Understanding current practice patterns may help target future areas for improvement.

LEVEL OF EVIDENCE

Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Concomitant malnutrition and frailty are significant risk factors for poor outcome following two-stage revision for chronic periprosthetic joint infection

BACKGROUND

Two-stage revision remains the gold standard for periprosthetic joint infection (PJI) treatment. Although previous studies have examined malnutrition and frailty independently, their cumulative effects are not clear. Therefore, this study aimed to assess the individual and combined influence of malnutrition and frailty on the two-stage revision surgery.

METHODS

Patients with chronic PJI undergoing two-stage revision were retrospectively included. The definition of PJI is completely consistent with the evidence-based definition of PJI recorded by the MSIS in 2018. Preoperative serum albumin levels and 11-item modified frailty index scores were collected. Four cohorts were created: (1) Normal (N), (2) Frail (F), (3) Malnourished (M), and (4) Malnourished and frail (MF). Demographic data, comorbidities, and postoperative complications were collected and compared between the four cohorts.

RESULTS

A total of 117 consecutive patients were enrolled, 48% of patients were healthy (27.4% F, 16.2% M, and 9.4% MF). MF group showed lower scores on the physical composite scale of the 12-item short-form health survey (SF12-PCS), mental composite summary (SF12-MCS), Harris hip score (HHS), and knee society score (KSS) (P < 0.05). The incidence of reinfection in the MF group was higher than that in all other groups (MF vs. N; odds ratio [OR] 3.7, 95% confidence interval [CI] 1.37 - 8.82, P = 0.032). The incidence of complications in the MF group was higher than that in all other groups (MF vs. N; OR 4.81, 95% CI 1.58-9.26, P = 0.018). Postoperative transfusion events (OR 2.92, 95% CI 1.27-3.09, P = 0.021), readmission at 60 days after the operation (OR 4.91, 95% CI 1.82-13.80, P = 0.012) was higher in the MF patients. In addition, the extended length of stay after the operation was highest in the MF patients, with an OR of 5.78 (95% CI 2.16-12.04, P = 0.003).

CONCLUSION

The concurrent presence of concomitant malnutrition and frailty in patients with PJI is related to poor prognosis and may be a predictor of the efficacy of two-stage revision. Future research will be needed to describe the benefits of improving these risk factors for patients with PJI.

Frailty combined with nutritional risk score in predicting postoperative complications of elderly patients with gastrointestinal malignancies

OBJECTIVE

Exploring the predictive power of frailty combined with nutritional risk on postoperative complications in elderly gastrointestinal malignancies patients.

METHODS

Elderly patients who underwent gastrointestinal cancer surgery at Gastrointestinal Surgery Department of the Affiliated Hospital of Binzhou Medical University from August 2021 to June 2022 were selected as the research subjects. The patients' frailty and nutritional status were assessed using the Fried Frailty Scale and the NRS2002 Nutritional Risk Scale within 24 h of admission. Observing and recording the diagnosis and treatment of postoperative complications during the hospitalization.

RESULTS

202 patients were enrolled, including 119 patients (58.91%) with nutritional risk and 89 patients (44.06%) with frailty. Frailty was an independent risk factor for postoperative complications [OR = 5.904, 95%CI (3.103, 11.233)]. The AUC value of frailty assessment was 0.780, which was greater than the AUC value of NRS2002 score of 0.705 (P < 0.01). The AUC value of frailty assessment combined with NRS-2002 score was 0.844, which was significantly higher than that alone (P < 0.01).

CONCLUSIONS

The ability of frailty to predict postoperative complications is better than the NRS-2002 score. Frailty combined with nutritional risk assessment can increase the predictive power of postoperative complications in elderly gastrointestinal malignancies patients.

The Impact of Frailty on Outcomes Following Primary Total Hip Arthroplasty in Patients of Different Sex and Race: Is Frailty Equitably Detrimental?

BACKGROUND

Whether frailty impacts total hip arthroplasty (THA) patients of different races or sex equally is unknown. This study aimed to assess the influence of frailty on outcomes following primary THA in patients of differing race and sex.

METHODS

This is a retrospective cohort study utilizing a national database (2015-2019) to identify frail (≥2 points on the modified frailty index-5) patients undergoing primary THA. One-to-one matching for each frail cohort of interest (race: Black, Hispanic, Asian, versus White (non-Hispanic), respectively; and sex: men versus women) was performed to diminish confounding. The 30-day complications and resource utilizations were then compared between cohorts.

RESULTS

There was no difference in the occurrence of at least 1 complication (P > .05) among frail patients of differing race. However, frail Black patients had increased odds of postoperative transfusion (odds ratio [OR]: 1.34, 95% confidence interval [CI]: 1.02-1.77), deep vein thrombosis (OR: 2.61, 95% CI: 1.08-6.27), as well as >2-day hospitalization and nonhome discharge (P < .001). Frail women had higher odds of having at least 1 complication (OR: 1.67, 95% CI: 1.47-1.89), nonhome discharge, readmission, and reoperation (P < .05). Contrarily, frail men had higher 30-day cardiac arrest (0.2% versus 0.0%, P = .020) and mortality (0.3 versus 0.1%, P = .002).

CONCLUSION

Frailty appears to have an overall equitable influence on the occurrence of at least 1 complication in THA patients of different races, although different rates of some individual, specific complications were identified. For instance, frail Black patients experienced increased deep vein thrombosis and transfusion rates relative to their non-Hispanic White counterparts. Contrarily, frail women, relative to frail men, have lower 30-day mortality despite increased complication rates.

The Impact of Frailty Is Age Dependent in Patients Undergoing Primary Total Knee Arthroplasty: The Age-Adjusted Modified Frailty Index

BACKGROUND

Frailty is a well-established risk factor in patients undergoing total knee arthroplasty (TKA). How age modifies the impact of frailty on outcomes in these patients, however, remains unknown. In this study, we aimed to describe and evaluate the applicability of a novel risk stratification tool-the age-adjusted modified Frailty Index (aamFI)-in patients undergoing TKA.

METHODS

A national database was queried for all patients undergoing primary TKA from 2015 to 2019. There were 271,271 patients who met inclusion criteria for this study. First, outcomes were compared between chronologically young and old frail patients. In accordance with previous studies, the 75th percentile of age of all included patients (73 years) was used as a binary cutoff. Then, frailty was classified using the novel aamFI, which constitutes the 5-item mFI with the addition of 1 point for patients ≥73 years. Multivariable logistic regressions were then used to investigate the relationship between aamFI and postoperative outcomes.

RESULTS

Frail patients ≥73 years had a higher incidence of complications compared to frail patients <73 years. There was a strong association between aamFI and complications. An aamFI of ≥3 (reference aamFI of 0) was associated with an increased odds of 30-day mortality (odds ratio [OR] 8.6, 95% CI 5.0-14.8), any complication (OR 3.1, 95% CI 2.9-3.3), deep vein thrombosis (OR 1.5, 95% CI 1.2-1.8), and nonhome discharge (OR 6.1, 95% CI 5.8-6.4; all P < .001).

CONCLUSION

Although frailty negatively influences outcomes following TKA in patients of all ages, chronologically old, frail patients are particularly vulnerable. The aamFI accounts for this and represents a simple, but powerful tool for stratifying risk in patients undergoing primary TKA.

The association between frailty and mortality among lower limb arthroplasty patients: a systematic review and meta-analysis

Background

Some studies associate frailty and postoperative mortality in hip or knee replacement patients, and others have explored the relationship between the frailty index and changes in postoperative mortality in hip or knee replacement patients, but their findings are not consistent. This meta-analysis and systematic review aimed to pool the results of existing studies to explore whether frailty is an independent risk factor for postoperative mortality in patients with lower limb arthroplasty (including hip or knee arthroplasty).

Methods

On December 15, 2021, we searched the relevant articles from the PubMed, Embase, Medline (via Ovid), China National Knowledge Infrastructure (CNKI) and Wan Fang Med Online databases. We used the Newcastle–Ottawa Scale (NOS) to assess the quality of the articles that met the exclusion and inclusion criteria. R Studio was used to analyze the effect sizes (based on the random model integration) on the extracted data. Meanwhile, potential publication bias and sensibility analysis were performed.

Results

We included seven studies, which included a total of 460,594 patients, for quantitative analysis. Overall, frailty increased the risk of mortality in lower limb arthroplasty patients compared to those without frailty, as measured by a pooled risk ratio (RR) of 2.46 (95% confidence interval [CI]: 1.81–3.33). Additionally, subgroup analysis based on population revealed that the pooled RRs for total knee arthroplasty (TKA) patients in three studies and total hip arthroplasty (THA) patients in four studies were 2.61 (95% CI: 2.26–3.02) and 3.18 (95% CI: 1.92–5.28), respectively, for TKA patients in three studies and THA patients in four studies. Additionally, these statistically significant positive associations persisted in subgroup analyses by study design, geographic region, and follow-up period.

Conclusion

Frailty is an independent risk factor for postoperative mortality in patients undergoing lower limb arthroplasty, according to our findings. This suggests that frailty may be a predictor of preoperative risk stratification for patients with such elective surgery and could alert doctors and nurses of early screening and medical care interventions in patients with such a need for surgery to reduce postoperative mortality in lower limb arthroplasty patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03369-w.

Modified Frailty Index Combined with a Prognostic Nutritional Index for Predicting Postoperative Complications of Hip Fracture Surgery in Elderly

Aim: There is currently no consensus on the best risk assessment technique for predicting complications after hip surgery in the elderly, which is hindering the accuracy of surgical risk assessment. The goal of this study was to build a risk assessment model and evaluate its predictive value using the modified frailty index (5-mFI) and the prognostic nutritional index (PNI).Methods: A retrospective investigation was undertaken on 150 patients (aged ≥60 years) who had hip fracture surgery. Using univariate and multivariate logistic regression models, the relationship between combined 5-mFI and PNI and the evaluation of postoperative unfavorable outcomes such as infection and unscheduled intensive care unit (ICU) admission was investigated. Finally, utilizing receiver operating characteristic (ROC) curve analysis, the model's predictive value for adverse outcomes following hip fracture surgery in elderly patients was assessed.Results: Univariate and multivariate logistic analyses revealed that preoperative PNI, 5-mFI, ASA, and gender acted as independent predictors of adverse outcomes after hip fracture surgery in the elderly. According to the ROC curve analysis, the predictive model demonstrated a high predictive value for total postoperative complications (AUC: 0.788; 95%CI: 0.715-0.860; p<0.01), infectious complications (AUC: 0.798; 95% CI: 0.727-0.868; P<0.001), and unplanned ICU admission (AUC: 0.783; 95% CI: 0.705-0.861; P<0.001).Conclusions: The multivariable evaluation model, which included 5-mFI and PNI, showed a high predictive value and can hence be applied to predict the adverse outcomes in elderly patients undergoing hip fracture surgery.

The impact of frailty on short-term mortality following primary total hip and knee arthroplasty due to osteoarthritis

BACKGROUND

We determined the association between frailty and short-term mortality following total hip and knee arthroplasty (THA/TKA) for osteoarthritis and also the impact of THA/TKA on short-term mortality compared with a control population.

METHODS

Frailty was assessed using a frailty index (categorised: fit, mild, moderate, severe frailty). The association between frailty and short-term mortality following THA/TKA was assessed using Cox regression. Mortality following THA/TKA was also compared with a control population with osteoarthritis but no previous THA/TKA, matched on year of birth, sex and quintile of index of multiple deprivation.

RESULTS

A total of 103,563 cases who had a THA, 125,367 who had a TKA and matched controls contributed. Among those who had surgery, mortality increased with increasing frailty; adjusted hazard ratio (HR) (95% CI) at 30 days in severely frail versus fit: following THA, 2.85 (1.84, 4.39) and following TKA, 2.14 (1.29, 3.53). The predicted probability of 30-day mortality following THA/TKA varied by age, sex and frailty: following THA, from 0.05% among fit women aged 60-64 years to 6.55% among men with severe frailty aged ≥90 years. All-cause 30-day mortality was increased in fit cases following THA and TKA, respectively, versus fit controls (adjusted HR (95% CI), 1.60 (1.15, 2.21) and 2.98 (1.81, 4.89)), though not among cases with mild, moderate or severe frailty versus controls in the same frailty category.

CONCLUSION

Short-term mortality increased with increasing frailty following THA/TKA. Comparison of mortality among cases and controls may be affected by a 'healthy surgery' selection effect.

The Age-Adjusted Modified Frailty Index: An Improved Risk Stratification Tool for Patients Undergoing Primary Total Hip Arthroplasty

BACKGROUND

Frailty and increasing age are well-established risk factors in patients undergoing total hip arthroplasty (THA). However, these variables have only been considered independently. This study assesses the interplay between age and frailty and introduces a novel age-adjusted modified frailty index (aamFI) for more refined risk stratification of THA patients.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2015 to 2019 for patients undergoing primary THA. First, outcomes were compared between chronologically younger and older frail patients. Then, to establish the aamFI, one additional point was added to the previously described mFI-5 for patients aged ≥73 years (the 75th percentile for age in our study population). The association of aamFI with postoperative complications and resource utilization was then analyzed categorically.

RESULTS

A total of 165,957 THA patients were evaluated. Older frail patients had a higher incidence of complications than younger frail patients. Regression analysis demonstrated a strong association between aamFI and complications. For instance, an aamFI of ≥3 (compared to aamFI of 0) was associated with an increased odds of mortality (OR: 22.01, 95% confidence interval [CI] 11.62-41.68), any complication (OR: 3.50, 95% CI 3.23-3.80), deep vein thrombosis (OR: 2.85, 95% CI 2.03-4.01), and nonhome discharge (OR 9.61, 95% CI 9.04-10.21; all P < .001).

CONCLUSION

Chronologically, older patients are impacted more by frailty than younger patients. The aamFI accounts for this and outperforms the mFI-5 in prediction of postoperative complications and resource utilization in patients undergoing primary THA.

Nutritional Assessment and Interventions in Elective Hip and Knee Arthroplasty: a Detailed Review and Guide to Management

PURPOSE OF REVIEW

8.5 to 50% of total joint arthroplasty (TJA) patients are reported to have preoperative malnutrition. The narrative review identifies the relationship between preoperative malnutrition for TJA patients and postoperative outcomes as well as the use of perioperative nutritional intervention to improve postoperative complications.

RECENT FINDINGS

Biochemical/laboratory, anthropometric, and clinical measures have been widely used to identify preoperative nutritional deficiency. Specifically, serum albumin is the most prevalent used marker in TJA because it has been proven to be correlated with protein-energy malnutrition due to the surgical stress response. However, there remains a sustained incidence of preoperative malnutrition in total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients due to a lack of agreement among the available nutritional screening tools and utilization of isolated laboratory, anthropometric, and clinical variables. Previous investigations have also suggested preoperative malnutrition to be a prognostic indicator of complications in general, cardiac, vascular, and orthopaedic surgery specialties. Serum albumin, prealbumin, transferrin, and total lymphocyte count (TLC) can be used to identify at-risk patients. It is important to employ these markers in the preoperative setting because malnourished TKA and THA patients have shown to have worse postoperative outcomes including prolonged length, increased reoperation rates, increased infection rates, and increased mortality rates. Although benefits from high-protein and high-anti-inflammatory diets have been exhibited, additional research is needed to confirm the use of perioperative nutritional intervention as an appropriate treatment for preoperative TJA patients.

Is Frailty Associated with Adverse Outcomes After Orthopaedic Surgery?: A Systematic Review and Assessment of Definitions

BACKGROUND

There is increasing evidence supporting the association between frailty and adverse outcomes after surgery. There is, however, no consensus on how frailty should be assessed and used to inform treatment. In this review, we aimed to synthesize the current literature on the use of frailty as a predictor of adverse outcomes following orthopaedic surgery by (1) identifying the frailty instruments used and (2) evaluating the strength of the association between frailty and adverse outcomes after orthopaedic surgery.

METHODS

A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched to identify articles that reported on outcomes after orthopaedic surgery within frail populations. Only studies that defined frail patients using a frailty instrument were included. The methodological quality of studies was assessed using the Newcastle-Ottawa Scale (NOS). Study demographic information, frailty instrument information (e.g., number of items, domains included), and clinical outcome measures (including mortality, readmissions, and length of stay) were collected and reported.

RESULTS

The initial search yielded 630 articles. Of these, 177 articles underwent full-text review; 82 articles were ultimately included and analyzed. The modified frailty index (mFI) was the most commonly used frailty instrument (38% of the studies used the mFI-11 [11-item mFI], and 24% of the studies used the mFI-5 [5-item mFI]), although a large variety of instruments were used (24 different instruments identified). Total joint arthroplasty (22%), hip fracture management (17%), and adult spinal deformity management (15%) were the most frequently studied procedures. Complications (71%) and mortality (51%) were the most frequently reported outcomes; 17% of studies reported on a functional outcome.

CONCLUSIONS

There is no consensus on the best approach to defining frailty among orthopaedic surgery patients, although instruments based on the accumulation-of-deficits model (such as the mFI) were the most common. Frailty was highly associated with adverse outcomes, but the majority of the studies were retrospective and did not identify frailty prospectively in a prediction model. Although many outcomes were described (complications and mortality being the most common), there was a considerable amount of heterogeneity in measurement strategy and subsequent strength of association. Future investigations evaluating the association between frailty and orthopaedic surgical outcomes should focus on prospective study designs, long-term outcomes, and assessments of patient-reported outcomes and/or functional recovery scores.

CLINICAL RELEVANCE

Preoperatively identifying high-risk orthopaedic surgery patients through frailty instruments has the potential to improve patient outcomes. Frailty screenings can create opportunities for targeted intervention efforts and guide patient-provider decision-making.

Factors Affecting 30-Day Mortality following Primary Elective Total Knee Arthroplasty: A Database Study of 326,157 Patients

Despite its rarity, the risk of mortality following primary elective total knee arthroplasty (TKA) is a critical component of surgical decision-making and patient counseling. The purpose of our study was to (1) determine the overall 30-day mortality rate for unilateral primary elective TKA patients, (2) determine the 30-day mortality rates when stratified by age, comorbidities, and preoperative diagnosis, and (3) identify the distribution of (i) patient demographics, (ii) baseline comorbidities, and (iii) preoperative diagnoses between mortality and mortality-free cohorts. A total of 326,157 patients underwent primary elective TKA (2011-2018) were identified through retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were divided into 30-day mortality (n = 320) and mortality-free (n = 325,837) cohorts. Patient demographics, preoperative comorbidities, and preoperative diagnoses were compared. Age group, American Society of Anesthesiology (ASA) score, and modified Charlson Comorbidity Index (CCI) scores were normalized per 1000 and stratified by preoperative diagnosis. The overall mortality rate was 0.098%. Older age (p < 0.001) and male gender (p < 0.001) were associated with increased mortality. There was no association between mortality and race (p = 0.346) or body mass index (BMI) class (p = 0.722). All reported comorbidities except smoking status were significantly greater in the mortality cohort (p < 0.05). For ASA scores of I, II, III, and IV, the number of deaths per 1,000 were 0.16, 0.47, 1.4, and 4.4, respectively. For CCI scores of 0, 1, 2, 3, 4, and 6, mortality rates per 1,000 were 0.76, 2.1, 7.0, 11, 29, and 7.6, respectively. Mortality rates for a preoperative diagnosis of osteoarthritis (OA) versus non-OA were, respectively, 0.096% and 0.19% (p < 0.001). Increased age, male gender, increased comorbidity burden, and non-OA preoperative diagnoses are associated with higher rates of 30-day postoperative mortality. There were no significant associations between BMI or race and 30-day mortality. These findings aid in identifying of higher-risk patients, who can then receive appropriate counseling or preoperative interventions to reduce the risk of perioperative mortality.

New-Onset Depression After Total Knee Arthroplasty: Consideration of the At-Risk Patient

BACKGROUND

Postoperative new-onset depression (NOD) has gained recent attention as a previously unrecognized complication which may put patients at risk for poor outcomes after elective total hip arthroplasty. We aimed to investigate risk factors for the development of NOD after total knee arthroplasty (TKA) and assess its association with postoperative complications.

METHODS

This is a retrospective, population-level investigation of elective TKA patients. Patients with a preoperative diagnosis of depression were excluded from this study. Two groups were compared: patients who were diagnosed with depression within one year after TKA (NOD) and those who did not (control). The association of both preoperative patient factors and postoperative surgical and medical complications with NOD was then determined using multivariate and univariate analyses.

RESULTS

Of 196,728 unique TKA patients in our cohort, 5351 (2.72%) were diagnosed with NOD within one year of TKA. Age <54 year old, female gender, preoperative anxiety disorder, drug, alcohol, and/or tobacco use, multiple comorbidities, and opioid use before TKA were all associated with a diagnosis of NOD postoperatively (all P < .001). Postoperative NOD was associated with periprosthetic fracture (OR 2.11; 95% CI 1.29-3.52; P = .033), aseptic failure (OR 1.61; 95% CI 1.24-2.07; P = .020), prosthetic joint infection (OR 1.55, 95% CI 1.30-1.85; P < .001), stroke (OR 1.24; 95% CI 1.09-1.42; P = .006), and venous thromboembolism (OR 1.24; 95% CI 1.12-1.37; P < .001).

CONCLUSION

Post-TKA NOD is common and is associated with poor outcomes. This may aid surgeons in developing both anticipatory measures and institute preventative measures for patients at risk for developing NOD.

Preoperative Patient Factors and Postoperative Complications as Risk Factors for New-Onset Depression Following Total Hip Arthroplasty

BACKGROUND

Depression is known to be a risk factor for complication following primary total hip arthroplasty (THA), but little is known about new-onset depression (NOD) following THA. The purpose of this study is to determine the incidence of NOD and identify risk factors for its occurrence after THA.

METHODS

This is a retrospective cohort study of the Truven MarketScan database. Patients undergoing primary THA were identified and separated into cohorts based on the presence or not of NOD. Patients with preoperative depression or a diagnosis of fracture were excluded. Patient demographic and comorbid data were queried, and postoperative complications were collected. Univariate and multivariate regression analysis was then performed to assess the association of NOD with patient-specific factors and postoperative complications.

RESULTS

In total, 111,838 patients undergoing THA were identified and 2517 (2.25%) patients had NOD in the first postoperative year. Multivariate analysis demonstrated that preoperative opioid use, female gender, higher Elixhauser comorbidity index, preoperative anxiety disorder, drug or alcohol use disorder, and preoperative smoking were associated with the occurrence of NOD (P ≤ .001). The following postoperative complications were associated with increased odds of NOD: prosthetic joint infection (odds ratio [OR] 1.82, 95% confidence interval [CI] 1.42-2.34, P < .001), aseptic revision surgery (OR 1.47, 95% CI 1.06-2.04, P = .019), periprosthetic fracture (OR 1.72, 95% CI 1.13-2.61, P = .01), and non-home discharge (OR 1.59, 95% CI 1.42-1.77, P < .001).

CONCLUSIONS

NOD is common following THA and there are multiple patient-specific factors and postoperative complications which increase the odds of its occurrence. Providers should use this information to identify at-risk patients so that pre-emptive prevention strategies may be employed.