How Much Does ‘Frailty’ Contribute to Adverse Surgical Outcomes?

A new systematic review from Stanford University has found that despite substantial variability in frailty measurements, frailty is indeed “highly associated” with postoperative outcomes in orthopedic surgery. The study, “Is Frailty Associated with Adverse Outcomes After Orthopaedic Surgery?” appears in the December 2021 edition of JBJS Reviews.

“With the aging population,” said co-author Robin N. Kamal, M.D., M.B.A., medical director of Value Based Care and Orthopaedics in the Department of Orthopaedic Surgery at Stanford University, “an increasing number of orthopaedic procedures are being done on older adults and frailty is a known risk factor for adverse outcomes after surgery. Some studies suggest the prevalence of frailty is as high as 40% in some populations, suggesting it is becoming a global epidemic. Care delivery will therefore increasingly require diagnosing and treating frailty, including orthopaedic surgery clinics, to optimize patient outcomes.”

The researchers used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching PubMed, Scopus, and the Cochrane Central Register of Controlled Trials to identify articles reporting on outcomes after orthopaedic surgery within frail populations; 82 articles were ultimately included.

The modified frailty index was the most frequently used frailty instrument (38% of the studies used the modified frailty index with 11 items, and 24% of the studies used the modified frailty index with 5 items); a total of 24 different instruments were identified. Total joint arthroplasty (22%), hip fracture management (17%), and adult spinal deformity management (15%) were the most studied procedures; complications (71%) and mortality (51%) were the most often reported outcomes; 17% of studies reported on a functional outcome.

“The most common method of diagnosing frailty in orthopaedic surgery was using the modified frailty index, which is a comorbidity-based measure, but there was considerable heterogeneity in frailty instruments used,” Dr. Kamal told OTW. “Frailty was highly associated with adverse post-operative outcomes after orthopaedic surgery. Future research in this field should focus on the influence of frailty in orthopaedic surgery using prospective study designs, long-term outcomes, and patient-reported outcomes.”

When OTW asked how this work might alter practice, Dr. Kamal stated, “Preoperatively identifying high-risk orthopaedic surgery patients through frailty instruments has the potential to improve patient outcomes and direct appropriate site of service of patients. Frailty screenings can also create opportunities for targeted intervention efforts and guide shared decision-making to align treatments with patient-specific risks of surgery.”