Patient frailty as a risk assessment tool in surgical management of long bone fractures

Modified frailty index can help predict complications following tibial plateau fracture fixation: a NSQIP study involving 2213 patients

PURPOSE

The 5-item modified frailty index (mFI-5) has been established as a reliable indicator of poor postoperative outcomes following a variety of orthopaedic procedures. This study aims to determine whether the mFI-5 can be used by surgeons to predict the likelihood of postoperative complications in patients undergoing open reduction internal fixation (ORIF) for tibial plateau fractures.

METHODS

From 2006 to 2019, patients aged 50 years or older undergoing ORIF for tibial plateau fracture were identified in the National Surgical Quality Improvement Program database. The mFI-5 was calculated based on the sum of the presence of 5 conditions: diabetes, congestive heart failure, hypertension, chronic obstructive pulmonary disease, and dependent functional status. Chi-squared tests and multivariable regression analysis were used to evaluate the association of different mFI-5 scores with postoperative complications.

RESULTS

The study analyzed 2213 patients with an average age of 63 years. Multivariable regression analysis demonstrated that in comparison to patients with a mFI-5 score of 0, those with a score of 1 had an increased risk of prolonged hospital stay (OR 1.31) and discharge to a non-home location (OR 1.50) while those with a score of 2 or greater were at an increased risk of readmission (OR 2.30), wound complication (OR 5.37), pulmonary complication (OR 4.56), urinary tract infection (OR 4.79), prolonged hospital stay (OR 1.89), and discharge to a non-home location (OR 3.01).

CONCLUSION

The mFI-5 is a reliable instrument for determining the likelihood of postoperative complications following ORIF for tibial plateau fracture repair.

LEVEL OF EVIDENCE

III.

The Relationship Between Frailty and Functional Outcomes, Range of Motion, and Reoperation After Reverse Total Shoulder Arthroplasty for Proximal Humerus Fracture

The objective of this study was to investigate whether frailty is associated with functional outcomes, motion, and reoperation at a minimum of 2 years after reverse total shoulder arthroplasty (rTSA) for proximal humerus fracture. We performed a retrospective study of 153 patients who underwent rTSA for proximal humerus fracture at two level 1 trauma centers from 2003 to 2018 with minimum 2-year follow-up. Frailty was assessed using the modified 5-item frailty index (mFI). The primary outcome variable was the American Shoulder and Elbow Surgeons (ASES) shoulder score at minimum 2-year follow-up. The secondary outcome variables were the Shoulder Pain and Disability Index (SPADI), the Shoulder Subjective Value (SSV), the 0 to 10 numeric rating scale (NRS) pain score, surgical complication, and reoperation. Bivariate comparisons were made between mFI and outcome variables. The mean age of the 153 patients was 70 years, and 76% were women. Forty patients (26%) had a mFI score of 0, 65 patients (42%) had a mFI score of 1, 40 patients (26%) had a mFI score of 2, and 8 patients (5%) had a mFI score of 3. Twenty-seven patients (18%) had complications, and 21 patients (14%) underwent reoperation. At minimum 2-year follow-up, mFI was not associated with ASES shoulder score, SPADI, SPADI pain or disability subscales, SSV, NRS pain score, active and passive shoulder forward flexion, abduction, and external rotation, complication, or reoperation. Provided they survive the initial physiologic insults of trauma and surgery, patients with higher mFI scores treated with rTSA for proximal humerus fracture can expect similar medium-term restoration of shoulder function. [Orthopedics. 2023;46(5):274-279.].

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.

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.

Visualizing Frailty: Exploring Radiographical Measures of Frailty in Trauma Patients

Purpose: This study assessed the relationship of core muscle sarcopenia, myosteatosis, and L1 attenuation to the 5-factor modified frailty index (mFI-5), discharge disposition, and post-admission complications in orthopedic and general trauma patients. It was hypothesized that reduced sarcopenia, L1 attenuation, and increased myosteatosis is associated with higher mFI-5 scores (≥ 0.3), discharge into care, and increased post-admission complications.Methods: This prospective cohort study was performed at a Level 1 trauma center. Patients were surveyed and metrics of the mFI-5 were used. Frail was categorized as a mFI-5 score ≥ 0.3. Recent abdominal computed tomography (CT) scans were used to extract radiographical information of total psoas cross-sectional area, psoas myosteatosis, and L1 vertebrae attenuation.Results: There were 140 patients who consented to the study, of which 83 had available abdomen and pelvis CT scans. The mean age was 43.19 (± 17.36), and 65% were male (<i>n</i> = 52). When comparing the frail (16%, <i>n</i> = 13) and not frail (84%, <i>n</i> = 70) patients, there was a significant difference in mean psoas myosteatosis (<i>p</i> < 0.0001) and the attenuation of the L1 vertebrae (<i>p</i> < 0.001). On multivariate analysis when accounting for age, myosteatosis of the psoas muscles was predictive of an mFI-5 score ≥ 0.3.Conclusion: The findings suggest that myosteatosis and L1 attenuation are associated with frailty indices (mFI-5) after traumatic injury. Future studies are needed to prospectively assess the validity of both radiographical and index-based markers of frailty in predicting post-traumatic complications, mortality, and hospital utilization.