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

Association of frailty with adverse outcomes in surgically treated geriatric patients with hip fracture: A meta-analysis and trial sequential analysis

OBJECTIVE

Some studies have associated frailty and prognostic outcomes in geriatric hip fracture patients, but whether frailty can predict postoperative outcomes remains controversial. This review aims to assess the relationship between frailty and adverse postoperative outcomes in geriatric patients with hip fracture.

METHODS

Based on electronic databases, including PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, Chinese National Knowledge Infrastructure, and WanFang Data, we systematically searched for studies that investigated the association between frailty and adverse outcomes among patients aged 60 or over after hip fracture surgery. Stata 17.0 and Trial Sequential Analysis viewer software were used to obtain pooled estimates and verify whether the sample size was sufficient and the evidence robust.

RESULTS

Twenty-one studies involving 49,196 patients were included for quantitative analysis. Compared with nonfrail patients, frail patients had a higher risk of inpatient mortality (risk ratio [RR] = 1.93, 95% confidence interval [CI]: 1.66-2.23), 30-day mortality (RR = 2.13, 95% CI: 1.23-3.70), and 1-year mortality (RR = 2.44, 95% CI: 1.47-4.04). Frailty can significantly predict postoperative complications (RR = 1.76, 95% CI: 1.38-2.23), including delirium, pneumonia, cardiac complications, urinary tract infection, and surgical site infection; the association between frailty and deep venous thrombosis/pulmonary embolism and acute kidney injury needs further analysis. Trial sequential analysis showed that the findings regarding mortality were reliable and robust.

CONCLUSION

This meta-analysis provides detailed information indicating that frailty is a substantial predictor of mortality and selected postoperative complications.

Retrospective Analysis of Risk Factors in Geriatric Hip Fracture Patients Predictive of Surgical Intensive Care Unit Admission

INTRODUCTION

Although numerous risk factors and prediction models affecting morbidity and mortality in geriatric hip fracture patients have been previously identified, there are scant published data on predictors for perioperative Surgical Intensive Care Unit (SICU) admission in this patient population. Determining if a patient will need an SICU admission would not only allow for the appropriate allocation of resources and personnel but also permit targeted clinical management of these patients with the goal of improving morbidity and mortality outcomes. The purpose of this study was to identify specific risk factors predictive of SICU admission in a population of geriatric hip fracture patients. Unlike previous studies which have investigated predominantly demographic, comorbidity, and laboratory data, the present study also considered a frailty index and length of time from injury to presentation in the Emergency Department (ED).

METHODS

A total of 501 geriatric hip fracture patients admitted to a Level 1 trauma center were included in this retrospective, single-center, quantitative study from January 1, 2019, to December 31, 2022. Using a logistical regression analysis, more than 25 different variables were included in the regression model to identify values predictive of SICU admission. Predictive models of planned versus unplanned SICU admissions were also estimated. The discriminative ability of variables in the final models to predict SICU admission was assessed with receiver operating characteristic curves' area under the curve estimates.

RESULTS

 Frailty, serum lactate > 2, and presentation to the ED > 12 hours after injury were significant predictors of SICU admission overall (P = 0.03, 0.038, and 0.05 respectively). Additionally, the predictive model for planned SICU admission had no common significant predictors with unplanned SICU admission. Planned SICU admission significant predictors included an Injury Severity Score (ISS) of 15 and greater, a higher total serum protein, serum sodium <135, systolic blood pressure (BP) under 100, increased heart rate on admission to ED, thrombocytopenia (<120), and higher Anesthesia Society Association physical status classification (ASA) score (P = 0.007, 0.04, 0.05, 0.002, 0.041, 0.05, and 0.005 respectively). Each SICU prediction model (overall, planned, and unplanned) demonstrated sufficient discriminative ability with the area under the curve (AUC) values of 0.869, 0.601, and 0.866 respectively. Finally, mean hospital Length of Stay (LOS) and mortality were increased in SICU admissions when compared to non-SICU admissions.

CONCLUSION

Of the three risk factors predictive of SICU admission identified in this study, two have not been extensively studied previously in this patient population. Frailty has been associated with increased mortality and postoperative complications in hip fracture patients, but this is the first study to date to use a novel frailty index specifically designed and validated for use in hip fracture patients. The other risk factor, time from injury to presentation to the ED serves as an indicator for time a hip fracture patient spent without receiving medical attention. This risk factor has not been investigated heavily in the past as a predictor of SICU admissions in this patient population.

Comparison of three frailty scales for prediction of prolonged postoperative ileus following major abdominal surgery in elderly patients: a prospective cohort study

BACKGROUND

To determine whether frailty can predict prolonged postoperative ileus (PPOI) in older abdominal surgical patients; and to compare predictive ability of the FRAIL scale, the five-point modified frailty index (mFI-5) and Groningen Frailty Indicator (GFI) for PPOI.

METHODS

Patients (aged ≥ 65 years) undergoing major abdominal surgery at our institution between April 2022 to January 2023 were prospectively enrolled. Frailty was evaluated with FRAIL, mFI-5 and GFI before operation. Data on demographics, comorbidities, perioperative management, postoperative recovery of bowel function and PPOI occurrence were collected.

RESULTS

The incidence of frailty assessed with FRAIL, mFI-5 and GFI was 18.2%, 38.4% and 32.5% in a total of 203 patients, respectively. Ninety-five (46.8%) patients experienced PPOI. Time to first soft diet intake was longer in patients with frailty assessed by the three scales than that in patients without frailty. Frailty diagnosed by mFI-5 [Odds ratio (OR) 3.230, 95% confidence interval (CI) 1.572-6.638, P = 0.001] or GFI (OR 2.627, 95% CI 1.307-5.281, P = 0.007) was related to a higher risk of PPOI. Both mFI-5 [Area under curve (AUC) 0.653, 95% CI 0.577-0.730] and GFI (OR 2.627, 95% CI 1.307-5.281, P = 0.007) had insufficient accuracy for the prediction of PPOI in patients undergoing major abdominal surgery.

CONCLUSIONS

Elderly patients diagnosed as frail on the mFI-5 or GFI are at an increased risk of PPOI after major abdominal surgery. However, neither mFI-5 nor GFI can accurately identify individuals who will develop PPOI.

TRIAL REGISTRATION

This study was registered in Chinese Clinical Trial Registry (No. ChiCTR2200058178). The date of first registration, 31/03/2022, https://www.chictr.org.cn/ .

Malnutrition-Related Health Outcomes in Older Adults with Hip Fractures: A Systematic Review and Meta-Analysis

Hip fracture is a common condition in older adults, leading to disability and mortality. Several studies have demonstrated the association between nutritional status and the risk of a negative health outcome after fractures. In this systematic review, we evaluated the association between malnutrition and mortality, changes in mobility/living arrangements, and postoperative complications, such as delirium, in older patients with hip fractures. A literature search on the PubMed, Web of Science, and Scopus databases, up to September 2023, was conducted to identify all studies involving older subjects that reported an association between MNA/GNRI/PNI/CONUT and health outcome after hip fracture. Meta-analysis was performed by a random-effects model using risk values (RR, OR, and HR) extracted from the 14 eligible selected studies. Malnutrition significantly increased the risk of any analyzed adverse outcome by 70% at 1 month, and up to 250% at 1 year. Malnutrition significantly increased delirium risk by 275% (OR = 2.75; 95% CI 1.80-4.18; p ≤ 0.05), mortality risk by 342% (OR = 3.42; 95% CI 2.14-5.48; p ≤ 0.05), mortality hazard risk by 351% (HR = 3.51; 95% CI 1.63-7.55; p ≤ 0.05) at 1 month, and transfer-to-more-supported-living-arrangements risk by 218% (OR = 2.18; 95% CI 1.58-3.01; p ≤ 0.05), and declined mobility risk by 41% (OR = 1.41; 95% CI 1.14-1.75; p ≤ 0.05), mortality risk by 368% (OR = 3.68; 95% CI 3.00-4.52; p ≤ 0.05), and mortality hazard risk by 234% (HR = 2.34; 95% CI 1.91-2.87; p ≤ 0.05) at 1 year. Malnutrition of older patients increases the risk of death and worsens mobility and independence after hip fractures. The results of the present study highlight the importance of nutritional status evaluation of older subjects with hip fractures in order to prevent potential adverse outcomes (Registration No: CRD42023468751).

Prognostic nutritional index (PNI) is an independent risk factor for the postoperative mortality in geriatric patients undergoing hip arthroplasty for femoral neck fracture? A prospective controlled study

INTRODUCTION

Hip fracture is very common in advanced ages, and it is very likely that this condition is accompanied by nutritional deficiencies. The aim of this study was to investigate the effect of prognostic nutritional index (PNI) on postoperative mortality in geriatric patients who underwent hip arthroplasty for femoral neck fracture.

MATERIALS AND METHODS

Geriatric patients (aged ≥ 70 years) who underwent hip arthroplasty for femoral neck fracture were prospectively recruited. The patients' demographic data, time until surgery, total hospital stay, perioperative blood transfusion, duration of surgery and anesthesia, serum albumin level, total lymphocyte count, PNI value, and first-year mortality were examined. They were divided into two groups as patients who died and those who did not die within the 1st year, and between-group comparisons for continuous and categorical variables were made using independent t test and Chi-square test, respectively. Receiver operating characteristic (ROC) curve was constructed, and a cutoff value for PNI was determined based on sensitivity and specificity values.

RESULTS

The total number of participants was 124. The mean age was 80.40 ± 7.19 years: 77 (62.1%) were female and 47 (37.9%) were male. PNI was statistically significant for 1-year mortality in multivariate Cox regression analysis (p < 0.05). According to ROC curve analysis, the area under the curve for PNI level was found to be 0.764 (95% CI 0.670-0.857), and this value was statistically significant (p < 0.001). The sensitivity and specificity for the 38.4 cutoff value were 83.9% and 39.8%, respectively. The mean age, time after surgery, total hospital stay, and preoperative blood transfusion need were found to be statistically higher in the patients with low PNI levels (≤ 38.4) than those in the other patients (> 38.4) (p < 0.05 for all).

CONCLUSION

PNI seems to be an independent risk factor on mortality after hip fracture surgery in geriatric patients. PNI is a preventable and correctable risk factor that affects patient survival.

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.

The Addition of the Geriatric Nutritional Risk Index to the Prognostic Scoring Systems Did Not Improve Mortality Prediction in Trauma Patients in the Intensive Care Unit

Background

Malnutrition is prevalent among critically ill patients and has been associated with a poor prognosis. This study sought to determine whether the addition of a nutritional indicator to the various variables of prognostic scoring models can improve the prediction of mortality among trauma patients in the intensive care unit (ICU).

Methods

This study's cohort included 1,126 trauma patients hospitalized in the ICU between January 1, 2018, and December 31, 2021. Two nutritional indicators, the prognostic nutrition index (PNI), a calculation based on the serum albumin concentration and peripheral blood lymphocyte count, and the geriatric nutritional risk index (GNRI), a calculation based on the serum albumin concentration and the ratio of current body weight to ideal body weight, were examined for their association with the mortality outcome. The significant nutritional indicator was served as an additional variable in prognostic scoring models of the Trauma and Injury Severity Score (TRISS), the Acute Physiology and Chronic Health Evaluation (APACHE II), and the mortality prediction models (MPM II) at admission, 24, 48, and 72 h in the mortality outcome prediction. The predictive performance was determined by the area under the receiver operating characteristic curve.

Results

Multivariate logistic regression revealed that GNRI (OR, 0.97; 95% CI, 0.96-0.99; p=0.007), but not PNI (OR, 0.99; 95% CI, 0.97-1.02; p=0.518), was independent risk factor for mortality. However, none of these predictive scoring models showed a significant improvement in prediction when the GNRI variable is incorporated.

Conclusions

The addition of GNRI as a variable to the prognostic scoring models did not significantly enhance the performance of the predictors.

Predictive Value of Prognostic Nutritional Index for Early Postoperative Mobility in Elderly Patients with Pertrochanteric Fracture Treated with Intramedullary Nail Osteosynthesis

BACKGROUND

Early postoperative mobilization is essential for orthogeriatric patients. The prognostic nutritional index (PNI) is widely used to evaluate nutritional status. This study sought to investigate the predictive value of PNI for early postoperative mobility in patients with pertrochanteric femur fractures.

MATERIALS AND METHODS

This study included 156 geriatric patients with pertrochanteric femur fractures treated with TFN-Advance™ (DePuy Synthes, Raynham, MA, USA). Mobility was evaluated on the third postoperative day and by discharge. Stepwise logistic regression analyses were performed to evaluate the association significance of PNI with postoperative mobility together with comorbidities. The optimal PNI cut-off value for mobility was analyzed using the receiver operating characteristic (ROC) curve.

RESULTS

Three days postoperatively, PNI was an independent predictor of mobility (OR: 1.14, 95% CI: 1.07-1.23, p < 0.01). By discharge, it was found that PNI (OR: 1.18, 95% CI: 1.08-1.30, p < 0.01) and dementia (OR: 0.17, 95% CI: 0.07-0.40, p < 0.001) were significant predictors. PNI correlated weakly with age (r = -0.27, p < 0.001). The PNI cut-off value for mobility on the third postoperative day was 38.1 (specificity = 78.5%, sensitivity = 63.6%).

CONCLUSIONS

Our findings indicate that PNI is an independent predictor of early postoperative mobility in geriatric patients with pertrochanteric femur fractures treated with TFNA™.

Mapping knowledge structure and global status of sarcopenia in geriatric hip fractures: A bibliometric and visualized study

Background

Sarcopenia in geriatric hip fractures is attracting increased attention in recent years. This study aimed to explore the bibliometric characteristics and current status of sarcopenia research in hip fractures of older patients.

Methods

Publications related to sarcopenia in geriatric hip fracture published between January 2000 and July 2022 were extracted from the Science Citation Index Expanded, and bibliometric and visualized studies were performed by VOSviewer, Citespace, and R.

Results

The 1,223 articles used in our study were written by 6,326 authors from 1,879 organizations in 60 countries, published in 388 journals, and cited 37,198 references from 5,422 journals. The United States contributed the most publications (288 publications). The journal with the largest number of papers was Osteoporosis International (62 publications), and the Journals of Gerontology Series A - Biological Sciences and Medical Sciences had been more cited than any other journals in this field (3,302 citations). The University of Melbourne published the biggest number of papers (72 publications) focusing on sarcopenia in geriatric hip fractures while the California Pacific Medical Center Research Institute had the largest citations (4,239 citations). Cawthon PM was the most productive and influential author in the field. keywords were classified into 6 clusters: Cluster 1 (sarcopenia in aging), Cluster 2 (osteoporosis), Cluster 3 (bone density), Cluster 4 (body composition), Cluster 5 (physical performance), and Cluster 6 (risk factor).

Conclusion

Geriatric hip fracture is one of the most significant health issues in the aging society. In the past 20 years, an increasing number of studies were performed to explore the relationship between sarcopenia and hip fracture in older adults. The United States showed the strongest influence in this field, including publication numbers, citations, institutions, funding agencies, and authorship. Sarcopenia in aging, osteoporosis, bone density, body composition, physical performance, and risk factors may become the future hotspots in this field.