Is Frailty Associated with Adverse Outcomes After Orthopaedic Surgery?

Abstract

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.

Influence of frailty and its interaction with comorbidity on outcomes among total joint replacement

“…However, the extent to which frailty impacts perioperative surgical and acute medical complications in TJA has been explored in relatively few large-scale studies [ 18 – 20 ]. In the review of Lemos et al, it was pointed out that some studies have shown that preoperatively frail patients were closely related to perioperative complications and mortality after joint replacement [ 21 ]. However, the sample size in the existing studies is far smaler than the sample size of this experiment [ 22 – 24 ].…”

Significant deterioration in quality of life and increased frailty in patients waiting more than six months for total hip or knee arthroplasty

“…14 Therefore, our findings suggestthatpatientswaitingmorethansixmonthsforsurgery willbemorefrailandbeatanincreasedriskofperioperative complicationsandmortality. 14 Thiswillalsohavecostimplications for healthcare systems managing the complications andlongerlengthofstayinhospital. 14,44 The independent factors associated with deterioration in HRQoLandincreasingfrailtycouldbeusedtoidentifypatients whoareatrisk,andinterventionscouldbeofferedwhilethey await surgery.…”

“…Deterioration in HRQoL leads to an increased morbidity and progressive frailty, and increasing frailty is associated with increased mortality,lengthofstayinhospital,andtherateofreadmission. [13][14][15] Thus, patients awaiting THA and KA may have a greatly increased risk of perioperative complications and longerlengthsofstay. 16 PatientsatriskofworseningHRQoL or increasing frailty while waiting for surgery may benefit fromfocusedpreoperativemanagementtooptimizethemfor surgery and prevent their deterioration.…”

Dementia is a surrogate for frailty in hip fracture mortality prediction

“…In regard to hip fractures, frail patients with dementia have been found to be less likely to receive in-hospital rehabilitation, while frail patients that do receive rehabilitation often experience poorer outcomes [ 51 , 52 ]. Frailty has also been observed to be associated with increased mortality, morbidity, as well as a reduced quality of life after hip fracture surgery [ 53 – 55 ]. Moreover, frail patients are at an increased risk of developing dementia, which may partially explain the high prevalence of dementia among hip fracture patients [ 9 , 29 , 56 ].…”