Effects of Frailty on Outcomes Following Surgery Among Patients With Hip Fractures: A Systematic Review and Meta-Analysis

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.

Preoperative inflammatory biomarkers reveal renal involvement in postsurgical mortality in hip fracture patients: an exploratory study

Background

Hip fractures in frail patients result in excess mortality not accounted for by age or comorbidities. The mechanisms behind the high risk of mortality remain undetermined but are hypothesized to be related to the inflammatory status of frail patients.

Methods

In a prospective observational exploratory cohort study of hospitalized frail hip fracture patients, 92 inflammatory markers were tested in pre-operative serum samples and markers were tested against 6-month survival post-hip fracture surgery and incidence of acute kidney injury (AKI). After correcting for multiple testing, adjustments for comorbidities and demographics were performed on the statistically significant markers.

Results

Of the 92 markers tested, circulating levels of fibroblast growth factor 23 (FGF-23) and interleukin-15 receptor alpha (IL15RA), both involved in renal disease, were significantly correlated with 6-month mortality (27.5% overall) after correcting for multiple testing. The incidence of postoperative AKI (25.4%) was strongly associated with 6-month mortality, odds ratio = 10.57; 95% CI [2.76-40.51], and with both markers plus estimated glomerular filtration rate (eGFR)- cystatin C (CYSC) but not eGFR-CRE. The effect of these markers on mortality was significantly mediated by their effect on postoperative AKI.

Conclusion

High postoperative mortality in frail hip fracture patients is highly correlated with preoperative biomarkers of renal function in this pilot study. The effect of preoperative circulating levels of FGF-23, IL15RA, and eGFR-CYSC on 6-month mortality is in part mediated by their effect on postoperative AKI. Creatinine-derived preoperative renal function measures were very poorly correlated with postoperative outcomes in this group.

Correlation Between Anesthesia Methods and Adverse Short-Term Postoperative Outcomes Depending on Frailty: A Prospective Cohort Study

Purpose

This study aims to investigate how the type of anesthesia used during major orthopedic surgery may impact adverse short-term postoperative outcomes depending on frailty.

Methods

To conduct this investigation, we recruited individuals aged 65 years and older who underwent major orthopedic surgery between March 2022 and April 2023 at a single institution. We utilized the FRAIL scale to evaluate frailty. The primary focus was on occurrences of death or the inability to walk 60 days after the surgery. Secondary measures included death within 60 days; inability to walk without human assistance at 60 days; death or the inability to walk without human assistance at 30 days after surgery, the first time out of bed after surgery, postoperative blood transfusion, length of hospital stay, hospital costs, and the occurrence of surgical complications such as dislocation, periprosthetic fracture, infection, reoperation, wound complications/hematoma.

Results

In a study of 387 old adult patients who had undergone major orthopedic surgery, 41.3% were found to be in a frail state. Among these patients, 262 had general anesthesia and 125 had neuraxial anesthesia. Multifactorial logistic regression analyses showed that anesthesia type was not linked to complications. Instead, frailty (OR 4.04, 95% CI 1.04 to 8.57, P< 0.001), age (OR 1.05, 95% CI 1.00-1.10, P= 0.017), and aCCI scores, age-adjusted Charlson Comorbidity Index, (OR 1.36, 95% CI 1.12 to 1.66, P= 0.002) were identified as independent risk factors for death or new walking disorders in these patients 60 days after surgery. After adjusting for frailty, anesthesia methods was not associated with the development of death or new walking disorders in these patients (P > 0.05).

Conclusion

In different frail populations, neuraxial anesthesia is likely to be comparable to general anesthesia in terms of the incidence of short-term postoperative adverse outcomes.

Orthogeriatric Care Following Hip Fracture: Improving Post-Operative Outcomes in an Aged Population

INTRODUCTION

Hip fractures globally are associated with high levels of morbidity, mortality, and significant financial burden. This audit aimed to assess the impact of orthogeriatric liaison care on post-operative outcomes following surgical management of neck or femur fractures.

METHODS

Here, 258 patients who underwent hip fracture surgery over 1-year were included. Data were collected as an audit following the transition to an orthogeriatric liaison care model, involving regular orthogeriatric review (thrice weekly ward rounds, daily board rounds), superseding orthogeriatric review as requested. The audit is meant to assess the development of post-operative non-surgical site infection (NSSI) and mortality and duration of inpatient stay. Outcomes were compared to previous data from our hospital site in 2015/2016.

RESULTS

Patients with severe cognitive impairment and systemic disease (Abbreviated Mental Test Score (AMTS) < 7 and American Society of Anesthesiologists (ASA) grade ≥ 3) showed significantly elevated NSSI risk, consistent across the study periods. Both periods demonstrated an increased risk of NSSI associated with admission from nursing homes. Despite the 2021/2022 cohort being notably older, NSSI risk decreased from 40.6% to 37.2% after implementing the orthogeriatric care model. NSSI risk was notably reduced for severe cognitive impairment (51.6% vs. 71%), and the p-value was 0.025. Average hospital stay decreased post-intervention (2.4 days shorter), with a notable reduction for NSSI patients (3.4 days shorter). Overall mortality rates were similar, although mortality due to infection was significantly reduced in 2021/2022 (44.4% vs. 93.3%), and the p-value was 0.003.

CONCLUSION

The orthogeriatric liaison care model significantly decreased NSSI only in individuals with severe cognitive impairment and infection-associated mortality. This highlights the integral role of orthogeriatricians in the care of elderly hip fracture patients.

Longitudinal characteristics of physical frailty and its components in men and women post hip fracture

BACKGROUND

Frailty is an important geriatric syndrome predicting adverse health outcomes in older adults. However, the longitudinal characteristics of frailty components in post-hip fracture patients are less understood. Adopting the Fried frailty definition, we examined the longitudinal trends and sex trajectory differences in frailty and its components over 1 year post-fracture.

METHODS

Three hundred and twenty-seven hip fracture patients (162 men and 165 women with mean age 80.1 and 81.5) from Baltimore Hip Studies 7th cohort with measurements at 22 days after admission, and months 2, 6, and 12 post-fracture were analyzed. Frailty components included: grip strength, gait speed, weight, total energy expenditure, and exhaustion. Longitudinal analysis used mixed effect models.

RESULTS

At baseline, men were sicker with worse cognitive status, and had higher weight and grip strength, but lower total energy expenditure than women (p < 0.001). The prevalence of frailty was 31.5%, 30.2%, and 28.2% at months 2, 6, and 12 respectively, showing no longitudinal trends or sex differences. However, its components showed substantial recovery trends over the post-fracture year after confounding adjustments, including increasing gait speed, reducing risk of exhaustion, and stabilized weight loss and energy expenditure over time. Particularly, while men's grip strength tended to remain stable over first year post surgery within patients, women's grip strength reduced significantly over time within patients. On average over time within patients, women were more active with higher energy expenditures but lower grip strength and weight than men.

CONCLUSION

Significant recovery trends and sex differences were observed in frailty components during first year post-fracture. Overall frailty status did not show those trends over months 2-12 since a summary measure might obscure changes in components. Therefore, frailty components provided important multi-dimensional information on the complex recovery process of patients, indicating targets for intervention beyond the global binary measure of frailty.

Concurrent Negative Impact of Undernutrition and Heart Failure on Functional and Cognitive Recovery in Hip Fracture Patients

Evidence on the effects of frailty, undernutrition, and heart failure (HF) on patients with hip fractures is scarce. This retrospective cohort study aimed to examine the effects of undernutrition and HF on outcomes in patients who underwent convalescent rehabilitation after hip fracture. Undernutrition was defined as body mass index (BMI) < 20.0 (Low BMI). Heart failure (HF) was defined as a B-type natriuretic peptide (BNP) > 100 (High BNP). The study outcomes included the Functional Independence Measure motor domain (FIM-motor) and cognitive domain (FIM-cognition) at discharge. To consider the effects of low BMI, high BNP, and the simultaneous presence of both ("low BMI and high BNP"), we used multivariate linear regression analyses to examine whether these were associated with the outcomes. A total of 110 (mean age 87.4 years, 24.8% male) were analyzed. As a result, low BMI (β = -0.088, p = 0.027) and high BNP (β = -0.053, p = 0.015), each alone, were significantly associated with the FIM motor at discharge, whereas the simultaneous presence of "low BMI and high BNP" was significantly associated with the FIM motor at discharge, while the strength of the association was greater than each association alone (β = -0.152, p = 0.010). Further, the simultaneous presence of "low BMI and high BNP" was significantly associated with FIM cognition at discharge (β = -0.109, p = 0.014). Comprehensive multidisciplinary management is needed, including preoperative or early postoperative nutritional support and rehabilitation, followed by rehabilitation nutrition care management, in patients with hip fracture.

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.

Validation of the orthopedic frailty score for measuring frailty in hip fracture patients: a cohort study based on the United States National inpatient sample

BACKGROUND

The Orthopedic Frailty Score (OFS) has been proposed as a tool for measuring frailty in order to predict short-term postoperative mortality in hip fracture patients. This study aims to validate the OFS using a large national patient register to determine its relationship with adverse outcomes as well as length of stay and cost of hospital stay.

METHODS

All adult patients (18 years or older) registered in the 2019 National Inpatient Sample Database who underwent emergency hip fracture surgery following a traumatic fall were eligible for inclusion. The association between the OFS and mortality, complications, and failure-to-rescue (FTR) was determined using Poisson regression models adjusted for potential confounders. The relationship between the OFS and length of stay and cost of hospital stay was instead determined using a quantile regression model.

RESULTS

An estimated 227,850 cases met the study inclusion criteria. There was a stepwise increase in the rate of complications, mortality, and FTR for each additional point on the OFS. After adjusting for potential confounding, OFS 4 was associated with an almost ten-fold increase in the risk of in-hospital mortality [adjusted IRR (95% CI): 10.6 (4.02-27.7), p < 0.001], a 38% increased risk of complications [adjusted IRR (95% CI): 1.38 (1.03-1.85), p = 0.032], and an almost 11-fold increase in the risk of FTR [adjusted IRR (95% CI): 11.6 (4.36-30.9), p < 0.001], compared to OFS 0. Patients with OFS 4 also required a day and a half additional care [change in median length of stay (95% CI): 1.52 (0.97-2.08), p < 0.001] as well as cost approximately $5,200 more to manage [change in median cost of stay (95% CI): 5166 (1921-8411), p = 0.002], compared to those with OFS 0.

CONCLUSION

Patients with an elevated OFS display a substantially increased risk of mortality, complications, and failure-to-rescue as well as a prolonged and more costly hospital stay.

Development of a Frailty Index in the Irish Hip Fracture Database

INTRODUCTION

In older people, hip fracture can lead to adverse outcomes. Frailty, capturing biological age and vulnerability to stressors, can indicate those at higher risk. We derived a frailty index (FI) in the Irish Hip Fracture Database (IHFD) and explored associations with prolonged length of hospital stay (LOS ≥ 30 days), delirium, inpatient mortality and new nursing home admission. We assessed whether the FI predicted those outcomes independently of age, sex and pre-operative American Society of Anaesthesiology (ASA) score.

MATERIALS AND METHODS

A 21-item FI was constructed with 17 dichotomous co-morbidities, three 4-level ordinal pre-morbid functional variables (difficulty with indoor mobility, outdoor mobility, and shopping) and nursing home provenance (yes/no). The FI was computed as the proportion of items present and divided into tertiles (low, medium, high risk). Independent associations between FI and outcomes were explored with logistic regression, from which we extracted adjusted Odds Ratios (aOR) and Areas Under the Curve (AUC).

RESULTS

From 2017 to 2020, the IHFD included 14,615 hip fracture admissions, mean (SD) age 80.4 (8.8), 68.9% women. Complete FI data were available for 12,502 (85.5%). By FI tertile (low to high risk), prolonged LOS proportions were 5.9%, 16.1% and 23.1%; delirium 5.5%, 13.5% and 17.6%; inpatient mortality 0.6%, 3.3% and 10.1%; and new nursing home admission 2.2%, 5.9% and 11.3%. All associations were statistically significant (p < 0.001) independently of age and sex. AUC analyses showed that the FI score, added to age, sex, and ASA score, significantly improved the prediction of delirium and new nursing home admission (p < 0.05), and especially prolonged LOS and inpatient mortality (p < 0.001).

CONCLUSIONS

A 21-item FI in the IHFD was a significant predictor of outcomes and added value to traditional risk markers. The utility of a routinely derived FI to more effectively direct limited orthogeriatric resources requires prospective investigation.

Hip fracture incidence and post-fracture mortality in Victoria, Australia: a state-wide cohort study

Hip fractures are a major public health concern. Number of hip fractures cases increased by 20% from 2012 to 2018. Factors associated with post-fracture mortality included men, those who are frail, living in a non-metropolitan region, or residing in a residential aged care facility. Our results are useful for planning healthcare interventions.

PURPOSE

Hip fractures are a major public health concern in Australia. Data on hip fracture incidence and mortality are needed to plan and evaluate healthcare interventions. The aims of the study were to investigate (1) the time-trend in absolute number and incidence of first hip fractures, and (2) factors associated with mortality following first hip fractures in Victoria, Australia.

METHODS

A state-wide cohort study of all patients aged [Formula: see text] 50 years admitted to a Victorian hospital for first hip fracture between July 2012 and June 2018. Annual age-standardized incidence rates were calculated using population data from Australian Bureau of Statistics. Multivariate negative binomial regression was used to investigate factors associated with post-fracture mortality.

RESULTS

Overall, 31,578 patients had a first hip fracture, of whom two-thirds were women and 47% were [Formula: see text] 85 years old. Absolute annual numbers of first hip fractures increased by 20%. There was no significant change in age- and sex-adjusted incidence. In total, 8% died within 30 days and 25% within 1 year. Factors associated with 30-day mortality included age (≥ 85 years old versus 50-64 years old, mortality rate ratio [MRR] 8.05, 95% confidence interval [CI] 5.86-11.33), men (MRR 2.11, 95% CI 1.88-2.37), higher Hospital Frailty Risk Scores (high frailty versus no frailty, MRR 3.46, 95% CI 2.66-4.50), admission from a residential aged care facility (RACF) (MRR 2.28, 95% CI 1.85-2.82), and residing in a non-metropolitan region (MRR 1.22, 95% CI 1.09-1.38). The same factors were associated with 1-year mortality.

CONCLUSION

The absolute increase in hip fractures highlights the need for interventions to reduce fracture risk, especially for those at higher risk of post-fracture mortality, including men and those who are frail, living in a non-metropolitan region, or residing in a RACF.

The mortality burden of frailty in hip fracture patients: a nationwide retrospective study of cause-specific mortality

PURPOSE

Frailty is a condition characterized by a reduced ability to adapt to external stressors because of a reduced physiologic reserve, which contributes to the high risk of postoperative mortality in hip fracture patients. This study aims to investigate how frailty is associated with the specific causes of mortality in hip fracture patients.

METHODS

All adult patients in Sweden who suffered a traumatic hip fracture and underwent surgery between 2008 and 2017 were eligible for inclusion. The Orthopedic Hip Frailty Score (OFS) was used to classify patients as non-frail (OFS 0), pre-frail (OFS 1), and frail (OFS ≥ 2). The association between the degree of frailty and both all-cause and cause-specific mortality was determined using Poisson regression models with robust standard errors and presented using incidence rate ratios (IRRs) with corresponding 95% confidence intervals (CIs), adjusted for potential sources of confounding.

RESULTS

After applying the inclusion and exclusion criteria, 127,305 patients remained for further analysis. 23.9% of patients were non-frail, 27.7% were pre-frail, and 48.3% were frail. Frail patients exhibited a 4 times as high risk of all-cause mortality 30 days [adj. IRR (95% CI): 3.80 (3.36-4.30), p < 0.001] and 90 days postoperatively [adj. IRR (95% CI): 3.88 (3.56-4.23), p < 0.001] as non-frail patients. Of the primary causes of 30-day mortality, frailty was associated with a tripling in the risk of cardiovascular [adj. IRR (95% CI): 3.24 (2.64-3.99), p < 0.001] and respiratory mortality [adj. IRR (95% CI): 2.60 (1.96-3.45), p < 0.001] as well as a five-fold increase in the risk of multiorgan failure [adj. IRR (95% CI): 4.99 (3.95-6.32), p < 0.001].

CONCLUSION

Frailty is associated with a significantly increased risk of all-cause and cause-specific mortality at 30 and 90 days postoperatively. Across both timepoints, cardiovascular and respiratory events along with multiorgan failure were the most prevalent causes of mortality.