Peri-operative management of frailty in the orthopedic patient

Adverse outcomes following pelvic fracture: the critical role of frailty

PURPOSE

Pelvic fractures among older adults are associated with an increased risk of adverse outcomes, with frailty likely being a contributing factor. The current study endeavors to describe the association between frailty, measured using the Orthopedic Frailty Score (OFS), and adverse outcomes in geriatric pelvic fracture patients.

METHODS

All geriatric (65 years or older) patients registered in the 2013-2019 Trauma Quality Improvement Program database with an isolated pelvic fracture following blunt trauma were considered for inclusion. An isolated pelvic fracture was defined as any fracture in the pelvis with a lower extremity AIS ≥ 2, any abdomen AIS, and an AIS ≤ 1 in all other regions. Poisson regression models were employed to determine the association between the OFS and adverse outcomes.

RESULTS

A total of 66,404 patients were included for further analysis. 52% (N = 34,292) were classified as non-frail (OFS 0), 32% (N = 21,467) were pre-frail (OFS 1), and 16% (N = 10,645) were classified as frail (OFS ≥ 2). Compared to non-frail patients, frail patients exhibited a 88% increased risk of in-hospital mortality [adjusted IRR (95% CI): 1.88 (1.54-2.30), p < 0.001], a 25% increased risk of complications [adjusted IRR (95% CI): 1.25 (1.10-1.42), p < 0.001], a 56% increased risk of failure-to-rescue [adjusted IRR (95% CI): 1.56 (1.14-2.14), p = 0.006], and a 10% increased risk of ICU admission [adjusted IRR (95% CI): 1.10 (1.02-1.18), p = 0.014].

CONCLUSION

Frail pelvic fracture patients suffer from a disproportionately increased risk of mortality, complications, failure-to-rescue, and ICU admission. Additional measures are required to mitigate adverse events in this vulnerable patient population.

Assessing frailty in elderly patients with hip fractures: A retrospective review comparing geriatrician and orthopedic trainee assessments

To assess the correlation of orthopedic surgery residents compared with expert geriatricians in the assessment of frailty stage using the Clinical Frailty Scale (CFS) in patients with hip fractures. A retrospective chart review was performed from January 1, 2015 to December 31, 2019. Patients admitted with a diagnosis of hip fracture were identified. Those patients with a CFS score completed by orthopedic residents with subsequent CFS score completed by a geriatrician during their admission were extracted. Six hundred and forty-eight patients over age 60 (mean 80.5 years, 73.5% female) were admitted during the study period. Orthopaedic residents completed 286 assessments in 44% of admissions. Geriatric medicine consultation was available for 215 patients such that 93 patients were assessed by both teams. Paired CFS data were extracted from the charts and tested for agreement between the 2 groups of raters. CFS assessments by orthopedic residents and geriatrician experts were significantly different at P < .05; orthopedic residents typically assessed patients to be one CFS grade less frail than geriatricians. Despite this, the CFS assessments showed good agreement between residents and geriatricians. Orthopaedic surgery residents are reliable assessors of frailty but tend to underestimate frailty level compared with specialist geriatricians. Given the evidence to support models such as orthogeriatrics to improve outcomes for frail patients, our findings suggest that orthopedic residents may be well positioned to identify patients who could benefit from such early interventions. Our findings also support recent evidence that frailty assessments by orthopedic surgeons may have predictive validity. Low rates of initial frailty assessment by orthopedic residents suggests that further work is required to integrate more global comprehensive care.

The impact of frailty evaluation on the risk of venous thromboembolism in patients with hip fracture following surgery: a meta-analysis

BACKGROUND

Frailty has been associated with a higher incidence of overall postoperative complications and mortality. However, the influence of frailty on the risk of venous thromboembolism (VTE) in patients with hip fracture following surgery remains unclear. We performed a meta-analysis to systematically evaluate the above association.

METHODS

PubMed, Embase, Cochrane Library, Wanfang and CNKI were searched for relevant observational studies comparing the incidence of postoperative VTE in patients of hip fracture with and without frailty. Data collection, literature searching, and statistical analysis were conducted independently by two authors. Using a heterogeneity-incorporating random-effects model, the results were pooled.

RESULTS

In this meta-analysis, 9509 patients from nine cohort studies were included. Pooled results showed that compared to those without frailty, patients with frailty at admission had a higher incidence of postoperative VTE (odds ratio [OR]: 2.59, 95% confidence interval [CI]: 1.25-5.39, p = 0.01; I2 = 66%). Subgroup analysis suggested the association between frailty and postoperative VTE was more remarkable in studies of patients with frailty prevalence < 50% (OR 6.28, 95% CI 3.31-11.90, p < 0.001; I2 = 8%) as compared to those ≥ 50% (OR 1.30, 95% CI 0.80-2.11, p = 0.28; I2 = 0%; p for subgroup difference < 0.001). Further meta-analyses showed that frailty at baseline was associated with a higher incidence of deep venous thrombosis (OR 3.15, 95% CI 1.33-7.47, p = 0.009; I2 = 59%), but not pulmonary embolism (OR 1.13, 95% CI 0.59-2.16, p = 0.72; I2 = 0%).

CONCLUSION

Frailty is associated with a higher incidence of postoperative VTE in patients with hip fracture.

Frailty and prognosis of patients with kidney transplantation: a meta-analysis

BACKGROUND

The prevalence of frailty among candidates and recipients of kidney transplantation (KT) is well-established, yet the impact of frailty on clinical outcomes following KT remains uncertain. To address this knowledge gap, we conducted a systematic meta-analysis to comprehensively assess the aforementioned relationship.

METHODS

The present study conducted a comprehensive search of PubMed, Embase, and Cochrane Library databases to identify relevant observational studies that compared mortality risk and other clinical outcomes of KT recipients with and without frailty. Two authors independently conducted data collection, literature searching, and statistical analysis. The results were synthesized using a heterogeneity-incorporating random-effects model.

RESULTS

In this meta-analysis, 6279 patients from 13 cohort studies were included, and 1435 patients (22.9%) were with frailty before KT. There were higher mortality rates among frail patients at admission, compared to those without frailty (risk ratio [RR]: 1.97, 95% confidence interval [CI]: 1.57 to 2.47, p < 0.001; I2 = 19%). Subgroup analysis suggested the association between frailty and high mortality risk after KT was consistent in studies of frailty assessed via Physical Frailty Phenotype or other methods, and in studies of follow-up duration < or ≥ 5 years. In addition, frailty was associated with higher incidence of delayed graft function (RR: 1.78, 95% CI: 1.21 to 2.61, p = 0.003; I2 = 0%), postoperative complications (RR: 1.88, 95% CI: 1.15 to 3.08, p = 0.01; I2 = 0%), and longer hospitalization (RR: 1.55, 95% CI: 1.22 to 1.97, p < 0.001; I2 = 0%).

CONCLUSION

Following KT, frail patients are at higher risks for all-cause mortality, delayed graft function, postoperative complications, and longer hospital stays.

The association of frailty with clinical and economic outcomes among hospitalized older adults with hip fracture surgery

Frailty is a common condition among older adults with hip fracture. In our study analyzing National Inpatient Sample data, frailty was found to be associated with up to six times increase in in-patient mortality, 55% increased length of hospital stay, and 29% increase in hospital cost.

INTRODUCTION

Hip fracture is a significant public health issue posing adverse health outcomes and substantial economic burden to patients and society. Frailty is a prevalent geriatric condition associated with poor clinical outcome among older adults. The association between hip fracture and frailty on both clinical and economic outcomes at the national level has not been estimated. We aimed to determine the association between frailty and in-hospital mortality, length of hospital stay (LOS), and total hospital cost among older patients aged ≥ 65 years who underwent surgery for hip fracture.

METHODS

We did an analysis of administrative data using the National Inpatient Sample (NIS) data from 2016 and 2017. Our analysis included data on 29,735 hospitalizations. We first conducted a descriptive analysis of the patient characteristics (demographics and clinical) and hospital-related factors. Three multivariable regression analysis models were then used to determine independent associations between frailty and in-hospital mortality, LOS, and total hospital cost. All three models were adjusted for patients' demographic and clinical characteristics and hospital-related factors.

RESULTS

Moderate and high frailty risk were associated with higher odds of death (OR = 2.94 and 95% CI 1.91-4.51 and OR = 5.99 and 95% CI 3.79-9.47), increased LOS (17% and 55%, p < 0.0001), and higher total hospital cost (7% and 29%, p < 0.0001) respectively compared to low frailty risk.

CONCLUSION

Frailty was associated with mortality, LOS, and hospital cost after adjusting for patient demographic, clinical, and hospital-related factors. Further research is needed to explore what pre-surgical measures can be assessed to mitigate in-hospital mortality and hospital cost in frail older patients hospitalized for hip fracture surgery.