Till Örebro universitet

PURPOSE: Frailty has gained recognition as a crucial determinant of patient outcomes following traumatic spinal injury (TSI), particularly due to its increasing incidence in elderly populations. The aim of the current investigation was therefore to compare the ability of several frailty scores to predict adverse outcomes in surgically managed isolated TSI patients without spinal cord injury.

METHODS: All adult patients (18 years or older) who suffered an isolated TSI due to blunt trauma, and required surgical management, were extracted from the 2013-2021 Trauma Quality Improvement Program database. The ability of the Orthopedic Frailty Score (OFS), the Hospital Frailty Risk Score (HFRS), the 11-factor (11-mFI) and 5-factor (5-mFI) modified frailty index, as well as the Johns Hopkins Frailty Indicator to predict adverse outcomes was compared based on the area under the receiver-operating characteristic curve (AUC). Subgroup analyses were also performed on patients who were ≥ 65 years old and those who were injured due to a ground-level fall (GLF).

RESULTS: A total of 39,449 patients were selected from the TQIP database. The 5-mFI and 11-mFI outperformed all other frailty scores when predicting in-hospital mortality (5-mFI AUC: 0.73) (11-mFI AUC: 0.73), any complication (5-mFI AUC: 0.65) (11-mFI AUC: 0.65), and FTR (5-mFI AUC: 0.75) (11-mFI AUC: 0.75). Among the 14,257 geriatric patients, however, the OFS demonstrated the highest predictive ability for in-hospital mortality (AUC: 0.65). The OFS (AUC: 0.64) also performed on the same level as both the 5-mFI (AUC: 0.63) and the 11-mFI (AUC: 0.63) when predicting FTR in this population. Among the 9616 patients who were injured due to a GLF, the OFS performed on par with the 5-mFI and 11-mFI when predicting in-hospital mortality and FTR.

CONCLUSION: Simpler scores like the 5-factor modified Frailty Index and Orthopedic Frailty Score outperform or perform on par with more complicated frailty scores when predicting mortality, complications, and failure-to-rescue in surgically managed isolated traumatic spinal injury patients without spinal cord injury, particularly among geriatric patients and those injured in a GLF.

INTRODUCTION: As the incidence of traumatic spine injuries has been steadily increasing, especially in the elderly, the ability to categorize patients based on their underlying risk for the adverse outcomes could be of great value in clinical decision making. This study aimed to investigate the association between the Revised Cardiac Risk Index (RCRI) and adverse outcomes in patients who have undergone surgery for traumatic spine injuries.

METHODS: All adult patients (18 years or older) in the 2013-2019 TQIP database with isolated spine injuries resulting from blunt force trauma, who underwent spinal surgery, were eligible for inclusion in the study. The association between the RCRI and in-hospital mortality, cardiopulmonary complications, and failure-to-rescue (FTR) was determined using Poisson regression models with robust standard errors to adjust for potential confounding.

RESULTS: A total of 39,391 patients were included for further analysis. In the regression model, an RCRI ≥ 3 was associated with a threefold risk of in-hospital mortality [adjusted IRR (95% CI): 3.19 (2.30-4.43), p < 0.001] and cardiopulmonary complications [adjusted IRR (95% CI): 3.27 (2.46-4.34), p < 0.001], as well as a fourfold risk of FTR [adjusted IRR (95% CI): 4.27 (2.59-7.02), p < 0.001], compared to RCRI 0. The risk of all adverse outcomes increased stepwise along with each RCRI score.

CONCLUSION: The RCRI may be a useful tool for identifying patients with traumatic spine injuries who are at an increased risk of in-hospital mortality, cardiopulmonary complications, and failure-to-rescue after surgery.

BACKGROUND: Traumatic spinal injuries are associated with a high risk of morbidity and mortality. The aim of this study is to investigate which variables best predict adverse outcomes in patients who had surgery for isolated traumatic spinal injury without spinal cord injury.

METHODS: The American College of Surgeons Trauma Quality Improvement Program database was used to identify adult (18 years or older) surgically managed patients with an isolated traumatic spinal injury, without spinal cord injury admitted between 2013 and 2021. An isolated injury was defined as a spine Abbreviated Injury Scale score ≥2 and an Abbreviated Injury Scale score ≤1 in the remaining body regions, as well as corresponding International Classification of Diseases, Ninth and Tenth Revision, codes. The predictive value of demographic, clinical, and comorbidity data was evaluated using logistic regression models and ranked using the permutation importance method.

RESULTS: A total of 39,457 patients were included in the study, of whom 554 died during hospitalization. The most important variables for predicting in-hospital mortality were age, sex, Glasgow Coma Scale on admission, Orthopedic Frailty Score, and cervical spine injury. The most important variables for predicting complications were age, cervical spine injury, the need for cervical spine surgery, Revised Cardiac Risk Index, and alcohol use disorder. Finally, age, cervical spine injury, sex, Glasgow Coma Scale on admission, and Orthopedic Frailty Score had the highest relative importance when predicting failure to rescue. Models based on the five most important variables for each outcome demonstrated an excellent predictive ability for in-hospital mortality (area under the receiver operating characteristic curve [AUROC], 0.84; 95% confidence interval [CI], 0.82–0.86) and failure to rescue (AUROC [95% CI], 0.86 [0.84–0.87]) as well as an acceptable predictive ability for complications (AUROC [95% CI], 0.72 [0.71–0.73]).

CONCLUSION: The most important factors identified to predict mortality, complications, and failure to rescue in traumatic spinal injury patients without spinal cord injury who undergo surgery were patients' age, sex, frailty, cervical spine injury that necessitated surgical intervention, and cardiovascular risk.

INTRODUCTION: The number of patients with hip fractures continues to rise as the average age of the population increases. Optimizing outcomes in this cohort is predicated on timely operative repair. The aim of this study was to determine if patients with hip fractures who are frail or have a higher cardiac risk suffer from an increased risk of in-hospital mortality when surgery is postponed >24 h.

METHODS: All patients registered in the 2013-2021 TQIP dataset who were ≥65 years old and underwent surgical fixation of an isolated hip fracture caused by a ground-level fall were included. Adjustment for confounding was performed using inverse probability weighting (IPW) while stratifying for frailty with the Orthopedic Frailty Score (OFS) and cardiac risk using the Revised Cardiac Risk Index (RCRI). The outcome was presented as the absolute risk difference in in-hospital mortality.

RESULTS: A total of 254,400 patients were included. After IPW, all confounders were balanced. A delay in surgery was associated with an increased risk of in-hospital mortality across all strata, and, as the degree of frailty and cardiac risk increased, so too did the risk of mortality. In patients with OFS ≥4, delaying surgery >24 h was associated with a 2.33 percentage point increase in the absolute mortality rate (95% CI: 0.57-4.09, p = 0.010), resulting in a number needed to harm (NNH) of 43. Furthermore, the absolute risk of mortality increased by 4.65 percentage points in patients with RCRI ≥4 who had their surgery delayed >24 h (95% CI: 0.90-8.40, p = 0.015), resulting in a NNH of 22. For patients with OFS 0 and RCRI 0, the corresponding NNHs when delaying surgery >24 h were 345 and 333, respectively.

CONCLUSION: Delaying surgery beyond 24 h from admission increases the risk of mortality for all geriatric hip fracture patients. The magnitude of the negative impact increases with the patient's level of cardiac risk and frailty. Operative intervention should not be delayed based on frailty or cardiac risk.

BACKGROUND: Both dementia and frailty have been associated with worse outcomes in patients with hip fractures. However, the interrelation and predictive value of these two entities has yet to be clarified. The current study aimed to investigate the predictive relationship between dementia, frailty, and in-hospital mortality after hip fracture surgery.

METHODS: All patients registered in the 2019 National Inpatient Sample Database who were 50 years or older and underwent emergency hip fracture surgery following a traumatic fall were eligible for inclusion. Logistic regression (LR) models were constructed with in-hospital mortality as the response variables. One model was constructed including markers of frailty and one model was constructed excluding markers of frailty [Orthopedic Frailty Score (OFS) and weight loss]. The feature importance of all variables was determined using the permutation importance method. New LR models were then fitted using the top ten most important variables. The area under the receiver-operating characteristic curve (AUC) was used to compare the predictive ability of these models.

RESULTS: An estimated total of 216,395 patients were included. Dementia was the 7th most important variable for predicting in-hospital mortality. When the OFS and weight loss were included, they replaced dementia in importance. There was no significant difference in the predictive ability of the models when comparing the model that included markers of frailty [AUC for in-hospital mortality (95% CI) 0.79 (0.77-0.81)] with the model that excluded markers of frailty [AUC for in-hospital mortality (95% CI) 0.79 (0.77-0.80)].

CONCLUSION: Dementia functions as a surrogate for frailty when predicting in-hospital mortality in hip fracture patients. This finding highlights the importance of early frailty screening for improvement of care pathways and discussions with patients and their families in regard to expected outcomes.

INTRODUCTION: Hip fracture patients, who are often frail, continue to be a challenge for healthcare systems with a high postoperative mortality rate. While beta-blocker therapy (BBt) has shown a strong association with reduced postoperative mortality, its effect in frail patients has yet to be determined. This study's aim is to investigate how frailty, measured using the Orthopedic Hip Frailty Score (OFS), modifies the effect of preadmission beta-blocker therapy on mortality in hip fracture patients.

METHODS: This retrospective register-based study included all adult patients in Sweden who suffered a traumatic hip fracture and subsequently underwent surgery between 2008 and 2017. Treatment effect was evaluated using the absolute risk reduction (ARR) in 30-day postoperative mortality when comparing patients with (BBt+) and without (BBt-) ongoing BBt. Inverse probability of treatment weighting (IPTW) was used to reduce potential confounding when examining the treatment effect. Patients were stratified based on their OFS (0, 1, 2, 3, 4 and 5) and the treatment effect was also assessed within each stratum.

RESULTS: A total of 127,305 patients were included, of whom 39% had BBt. When IPTW was performed, there were no residual differences in observed baseline characteristics between the BBt+ and BBt- groups, across all strata. This analysis found that there was a stepwise increase in the ARRs for each additional point on the OFS. Non-frail BBt+ patients (OFS 0) exhibited an ARR of 2.2% [95% confidence interval (CI) 2.0-2.4%, p < 0.001], while the most frail BBt+ patients (OFS 5) had an ARR of 24% [95% CI 18-30%, p < 0.001], compared to BBt- patients within the same stratum.

CONCLUSION: Beta-blocker therapy is associated with a reduced risk of 30-day postoperative mortality in frail hip fracture patients, with a greater effect being observed with higher Orthopedic Hip Frailty Scores.

Introduction: Pelvic fractures among the elderly are associated with an increased risk of adverse outcomes. Frailty, a condition of depleted physical reserves which increases with age, is likely a contributing factor for such unfavorable events. We endeavored to describe the association between frailty, measured using the Ortho-pedic Frailty Score (OFS), and adverse outcomes in geriatric pelvic fracture patients.

Methods: All geriatric (≥65yrs) patients registered in the 2013 to 2019 TQIP database with an isolated pelvic fracture following blunt trauma were considered for inclusion. An isolated pelvic fracture was defined as any fracture in the ilium, ischium, pubis, sacrum, coccyx, or acetabulum with an AIS ≤1 in all other regions except for abdominal and lower extremity. Patients were categorized as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). Poisson regression models were employed to determine the association between the OFS and adverse outcomes adjusting for confounders including angiographical and surgical interventions.

Results: A total of 66,404 patients met inclusion criteria, of whom 52% were classified as non-frail, 32% as pre-frail, and 16% as frail. Compared to non-frail patients, frail patients exhibited 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 composite 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].

Conclusion: Frail geriatric patients suffering a pelvic fracture have disproportionately increased risk for complications, mortality, and failure-to-rescue. Additional measures are required to mitigate adverse events in this vulnerable population.

Introduction: Pelvic fractures among the elderly are associated with an increased risk of adverse outcomes. Frailty, a condition of depleted physical reserves which increases with age, is likely a contributing factor for such unfavorable events. We endeavored to describe the association between frailty, measured using the Ortho-pedic Frailty Score (OFS), and adverse outcomes in geriatric pelvic fracture patients.

Methods: All geriatric (≥65yrs) patients registered in the 2013 to 2019 TQIP database with an isolated pelvic fracture following blunt trauma were considered for inclusion. An isolated pelvic fracture was defined as any fracture in the ilium, ischium, pubis, sacrum, coccyx, or acetabulum with an AIS ≤1 in all other regions except for abdominal and lower extremity. Patients were categorized as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). Poisson regression models were employed to determine the association between the OFS and adverse outcomes adjusting for confounders including angiographical and surgical interventions.

Results: A total of 66,404 patients met inclusion criteria, of whom 52% were classified as non-frail, 32% as pre-frail, and 16% as frail. Compared to non-frail patients, frail patients exhibited 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 composite 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].

Conclusion: Frail geriatric patients suffering a pelvic fracture have disproportionately increased risk for complications, mortality, and failure-to-rescue. Additional measures are required to mitigate adverse events in this vulnerable population.

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 & GE; 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.

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.