Frailty Index Is Associated With Periprosthetic Fracture and Mortality After Total Knee Arthroplasty

Preoperative Anemia Is Associated With Worse Joint-Specific Postoperative Outcomes, but Is Not Associated With Health-Related Quality of Life or Patient Satisfaction After Total Knee Arthroplasty

BACKGROUND

The primary aim assessed whether preoperative anemia was associated with a worse knee-specific functional outcome after total knee arthroplasty (TKA). The secondary aims assessed the association of preoperative anemia with generic health and patient satisfaction.

METHODS

A retrospective cohort study was undertaken to compare patients who did and did not have anemia (Hb <13.0 g/dL for men and Hb <11.5 g/dL for women). During a 1-year period, 497 patients underwent a total knee arthroplasty with complete preoperative and postoperative data, including 215 (43.3%) men and 282 (56.7%) women, who had a mean age of 70 years (range 45-93). Patient demographics, comorbidities, preoperative and postoperative (1 year) Oxford Knee Score (OKS), EuroQol 5 dimension (EQ-5D), postoperative Forgotten Joint Score (FJS), and patient satisfaction were collected. Regression analyses were used to adjust for confounding factors between the groups.

RESULTS

The 56 (11.3%) patients who had anemia were older (4.6 years, P < .001) and more likely to have chronic obstructive pulmonary disease (P = .004), connective tissue (P = .047), or kidney disease (P = .011) compared to those who did not have anemia. There were no differences in the preoperative OKS (P = .752) or EQ-5D (P = .762) scores between the groups. When adjusting for confounding differences, there was a significantly lower postoperative OKS (-3.0 points, P = .035) and FJS (-11.6 points, P = .011) associated with the anemia group. There were no significant differences in the EQ-5D (P = .118) or patient satisfaction between groups (odds ratio 0.84, P = .976).

CONCLUSION

Preoperative anemia is associated with a lower postoperative joint-specific functional outcome. It is not clear if these differences are clinically meaningful. No difference in patient satisfaction was observed.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Derivation and validation of an epigenetic frailty risk score in population-based cohorts of older adults

DNA methylation (DNAm) patterns in peripheral blood have been shown to be associated with aging related health outcomes. We perform an epigenome-wide screening to identify CpGs related to frailty, defined by a frailty index (FI), in a large population-based cohort of older adults from Germany, the ESTHER study. Sixty-five CpGs are identified as frailty related methylation loci. Using LASSO regression, 20 CpGs are selected to derive a DNAm based algorithm for predicting frailty, the epigenetic frailty risk score (eFRS). The eFRS exhibits strong associations with frailty at baseline and after up to five-years of follow-up independently of established frailty risk factors. These associations are confirmed in another independent population-based cohort study, the KORA-Age study, conducted in older adults. In conclusion, we identify 65 CpGs as frailty-related loci, of which 20 CpGs are used to calculate the eFRS with predictive performance for frailty over long-term follow-up.

Successful Plate Fixation with Long Intramedullary Fibula Bone Graft for Periprosthetic Femur Fracture: A Case Report

Background and objectives: Treatment of a displaced or comminuted periprosthetic distal femur fracture is challenging, especially in patients with osteoporosis. In this case report, we shared our successful surgical experience of using a long intramedullary fibula bone graft in a plate fixation surgery for a periprosthetic distal femur fracture in an extremely elderly patient with osteoporosis. Case report: A 95-year-old woman with severe osteoporosis (bone mineral density level: −3.0) presented with right knee pain and deformity after a fall, and a right periprosthetic distal femur fracture was identified. The patient underwent an open reduction and an internal plate fixation surgery with the application of a long intramedullary fibular bone graft. Due to a solid fixation, immediate weight-bearing was allowed after the surgery. She could walk independently without any valgus or varus malalignment or shortening 3 months after the surgery. A solid union was achieved 4 months postoperatively. Conclusions: We present a case wherein a long intramedullary allogenous fibula strut bone graft was used successfully to treat a right periprosthetic femur fracture in an extremely elderly patient. A long allogenous fibula bone graft can act not only as a firm structure for bridging the bone defect but also as a guide for precise component alignment. We believe this treatment option for periprosthetic fractures is beneficial for achieving biological and mechanical stability and facilitates early mobilization and weight-bearing for the patient.

Distal femoral replacement or internal fixation for management of periprosthetic distal femur fractures: A systematic review

BACKGROUND

The number of periprosthetic fractures above a total knee arthroplasty continues to increase. These fractures are associated with a high risk of morbidity and mortality. Techniques for addressing these fractures include open reduction internal fixation (ORIF) and revision arthroplasty, including distal femoral replacement (DFR). The primary aim of this review is to compare mortality and reoperation rates between ORIF and DFR when used to treat periprosthetic distal femur fractures.

METHODS

A systematic review including MEDLINE, Embase and Cochrane Library databases was completed from inception to April 10, 2021. Studies including a comparator cohort were meta-analyzed.

RESULTS

Fourteen studies were identified for inclusion, of which, five had sufficient homogeneity for inclusion in a meta-analysis. 30-day and 2-year mortality was 4.1% and 14.6% in the DFR group. There was no statistically significant difference between ORIF and DFR (log Odds-Ratio (OR) = -0.14, 95 %CI: -0.77 to 0.50). The reoperation rate in the DFR group was 9.3% versus 14.8% for ORIF, with no difference between groups (log OR = 0.10, 95 %CI: -0.59 to 0.79). There was no difference in rates of deep infection (log OR = 0.22, 95 %CI: -0.83 to 1.28). Direct comparison of functional outcomes was not possible, though did not appear significant.

CONCLUSION

DFR in the setting of periprosthetic distal femur fractures is equivalent to ORIF with respect to mortality and reoperation rate and thus a safe and reliable treatment strategy. DFR may be more reliable in complex fracture patterns where the ability to obtain adequate fixation is difficult.

Frailty Transitions One Year After Total Joint Arthroplasty: A Cohort Study

BACKGROUND

Total joint arthroplasty (TJA) is prevalent and offered to patients regardless of frailty status experiencing pain, disability, and functional decline. This study aims to describe changes in levels of frailty 1 year after TJA.

METHODS

We identified a retrospective cohort of adult patients undergoing primary TJA between 2005 and 2016 using an institutional total joint registry. Associations between categorized frailty deficit index (FI) and change in FI were analyzed using linear regression models. Mortality, deep periprosthetic joint infection, and reoperation were analyzed using time to event methods.

RESULTS

In total, 5341 patients (37.6% non-frail, 39.4% vulnerable, and 23.0% frail) with items necessary to determine FI at 1 year after TJA were included. Preoperatively, 29% of vulnerable patients improved to non-frail 1 year later, compared to only 11% regressing to frail. Four in 10 frail patients improved to vulnerable/non-frail. Improvements in activities of daily living (ADL) were more evident in frail and vulnerable patients, with >30% reduction in the percentage of patients expressing difficulties with walking, climbing stairs, and requiring ADL assistance 1 year after TJA. Increases in frailty 1 year after TJA were associated with significantly increased rates of mortality (hazard ratio [HR] 1.50, 95% confidence interval [CI] 1.24-1.82, P < .001), deep periprosthetic joint infection (HR 3.98, 95% CI 1.85-8.58, P < .001), and reoperation (HR 1.80, 95% CI 1.19-2.72, P = .005).

CONCLUSION

Frailty states are dynamic with patient frailty shown to be modifiable 1 year after TJA. Preoperative frailty measurement is an important step toward identifying those that may benefit most from TJA and for postoperative frailty surveillance.

Is Frailty Associated with Adverse Outcomes After Orthopaedic Surgery?: A Systematic Review and Assessment of Definitions

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.

Frailty measurements in hospitalised orthopaedic populations age 65 and older: A scoping review

Aims and Objectives

To identify and compare frailty instruments used with hospitalised orthopaedic patients aged over 65.

Background

Frailty predicts clinical events in orthopaedic patients aged over 65. However, the strengths and limitations of different approaches to measuring frailty in this population are rarely discussed. As such, a comprehensive review to address the gap is needed.

Design

Scoping review using Arksey and O’Malley framework.

Methods

PubMed, CINAHL, PsycINFO, Scopus and EMBASE databases were searched to identify studies published from 2006 to 2020 regarding frailty instruments in older orthopaedic patients. The Preferred Reporting Items for Systematic Reviews and Meta‐analyses were followed.

Results

The initial search resulted in 1,471 articles. After review against inclusion and exclusion criteria, a final set of 31 articles containing 15 unique frailty instruments were evaluated. Most of the articles were from Western countries. Fried's phenotype and Frailty Index were commonly used. The frailty index was mostly modified to measure frailty. In hip fracture, physical function items were frequently modified in the measurement of frailty. Trained physicians and nurses administered most frailty instruments. Frailty screening was commonly conducted at hospital admission and used to prognosticate both postoperative complications and hospital outcomes. Most instruments could be completed within 10 min. Reported psychometrics had acceptable reliability and validity.

Conclusion

Many reliable frailty measures have been used in the inpatient orthopaedic settings; however, evidence is still lacking for a gold standard frailty instrument. More research is needed to identify the best‐performing measure. Frailty evaluation in patients with physical limitations is challenging with existing instruments. Clinical context, resources required and instrument quality are essential factors in selecting a frailty instrument.

Relevance to clinical practice

Musculoskeletal symptoms in older patients may bias frailty assessment. Proactive frailty screening with valid and practical instruments is vital to strengthen preoperative risk stratification and improve post‐surgical outcomes.

Effects of preoperative frailty on outcomes following surgery among patients with digestive system tumors: A systematic review and meta-analysis

BACKGROUND

Frailty is common in patients who undergo digestive system tumor surgery. This review aimed to explore the effects of preoperative frailty on multiple outcomes following surgery among patients with digestive system tumors.

METHODS

PubMed (Medline), Embase, Web of Science, and other databases were searched from the inception of each database to April 2021. Meta-analysis or qualitative synthesis was performed to examine the relationship between preoperative frailty and adverse postoperative outcomes.

RESULTS

A total of 29 studies encompassing 122,548 patients were included. Through meta-analysis, frailty was associated with an increased risk of total complications (risk ratio [RR] 1.44; 95 % confidence interval [CI] 1.39 to 1.50), major complications (RR 1.72; 95 % CI 1.51 to 1.95), 30-d mortality (RR 2.40; 95 % CI 2.14 to 2.70), and 5-year mortality (RR 1.74; 95 % CI 1.35 to 2.24). Through qualitative synthesis, compared with non-frail patients, two studies found that frail patients had a worse quality of life, and three studies reported that frail patients experienced greater rates of non-home discharge. However, two studies demonstrated inconsistent conclusions regarding the relationship between frailty and functional status.

CONCLUSIONS

Preoperative frailty was an important risk factor for multiple adverse postoperative outcomes of patients with digestive system tumors, including objective clinical outcomes and patient-centered outcomes. Future studies focusing on the effects of frailty on patient-centered outcomes such as quality of life and functional status are needed.

Accuracy of Predictive Algorithms in Total Hip and Knee Arthroplasty Acute Periprosthetic Joint Infections Treated With Debridement, Antibiotics, and Implant Retention (DAIR)

BACKGROUND

Debridement, antibiotics, and implant retention (DAIR) failure remains high for total hip and knee arthroplasty periprosthetic joint infection (PJI). We sought to determine the predictive value of the CRIME80 and KLIC for failure of DAIR in acute hematogenous (AH) and acute postoperative (AP) PJIs, respectively.

METHODS

We identified 134 patients who underwent DAIR for AH PJI with <4 weeks of symptoms after index arthroplasty and 122 patients who underwent DAIR for AP PJI <90 days from index. In the AH group, 15 patients (11%) failed at 90 days and overall, 33 (25%) had failed by 2 years. In the AP group, 39 (32%) failed at 90 days and overall, 52 (43%) failed by 2 years. Logistic regression models were used to determine the area under the curve (AUC) to establish thresholds using the Youden index.

RESULTS

For the AP cohort, AUCs were below 0.66 for KLIC, Charlson comorbidity index, Elixhauser comorbidity index, and McPherson host grade. For the AH cohort, 90-day AUCs were 0.70 for CRIME80 and below 0.66 for Charlson comorbidity index, Elixhauser comorbidity index, and McPherson host grade. In multivariate analysis controlling for age, sex, and body mass index, the CRIME80 AUC improved to 0.77 at 90 days.

CONCLUSION

To the authors' knowledge, this study represents the first external validation of the KLIC and CRIME80 for predicting DAIR failure in a North American population. The results indicate that alternative methods for predicting DAIR failure at 90 days and 2 years for acute PJI are needed.

LEVEL OF EVIDENCE

Prognostic III.

A Systematic Review and Meta-Analysis of Preoperative Frailty Instruments Derived From Electronic Health Data

BACKGROUND

Frailty is a strong predictor of adverse outcomes in the perioperative period. Given the increasing availability of electronic medical data, we performed a systematic review and meta-analysis with primary objectives of describing available frailty instruments applied to electronic data and synthesizing their prognostic value. Our secondary objectives were to assess the construct validity of frailty instruments that have been applied to perioperative electronic data and the feasibility of electronic frailty assessment.

METHODS

Following protocol registration, a peer-reviewed search strategy was applied to Medline, Excerpta Medica dataBASE (EMBASE), Cochrane databases, and the Comprehensive Index to Nursing and Allied Health literature from inception to December 31, 2019. All stages of the review were completed in duplicate. The primary outcome was mortality; secondary outcomes included nonhome discharge, health care costs, and length of stay. Effect estimates adjusted for baseline illness, sex, age, procedure, and urgency were of primary interest; unadjusted and adjusted estimates were pooled using random-effects models where appropriate or narratively synthesized. Risk of bias was assessed.

RESULTS

Ninety studies were included; 83 contributed to the meta-analysis. Frailty was defined using 22 different instruments. In adjusted data, frailty identified from electronic data using any instrument was associated with a 3.57-fold increase in the odds of mortality (95% confidence interval [CI], 2.68-4.75), increased odds of institutional discharge (odds ratio [OR], 2.40; 95% CI, 1.99-2.89), and increased costs (ratio of means, 1.54; 95% CI, 1.46-1.63). Most instruments were not multidimensional, head-to-head comparisons were lacking, and no feasibility data were reported.

CONCLUSIONS

Frailty status derived from electronic data provides prognostic value as it is associated with adverse outcomes, even after adjustment for typical risk factors. However, future research is required to evaluate multidimensional instruments and their head-to-head performance and to assess their feasibility and clinical impact.

Variation and trends in reasons for knee replacement revision: a multi-registry study of revision burden

Background and purpose - Studies describing time-related change in reasons for knee replacement revision have been limited to single regions or institutions, commonly analyze only 1st revisions, and may not reflect true caseloads or findings from other areas. We used revision procedure data from 3 arthroplasty registries to determine trends and differences in knee replacement revision diagnoses.Patients and methods - We obtained aggregated data for 78,151 revision knee replacement procedures recorded by the Swedish Knee Arthroplasty Register (SKAR), the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), and the Kaiser Permanente Joint Replacement Registry (KPJRR) for the period 2003-2017. Equivalent diagnosis groups were created. We calculated the annual proportions of the most common reasons for revision.Results - Infection, loosening, and instability were among the 5 most common reasons for revision but magnitude and ranking varied between registries. Over time there were increases in proportions of revisions for infection and decreases in revisions for wear. There were inconsistent proportions and trends for the other reasons for revision. The incidence of revision for infection showed a uniform increase.Interpretation - Despite some differences in terminology, comparison of registry-recorded revision diagnoses is possible, but defining a single reason for revision is not always clear-cut. There were common increases in revision for infection and decreases in revision for wear, but variable changes in other categories. This may reflect regional practice differences and therefore generalizability of studies regarding reasons for revision is unwise.

How Is Surgical Risk Best Assessed? A Cohort Comparison of Measures in Total Joint Arthroplasty

BACKGROUND

We designed this study to determine whether a Frailty Deficit Index (FI) confers added risk stratification beyond more traditional methods. The associations of preoperative scores on FI, American Society of Anesthesiologists (ASA) physical status, and Charlson Comorbidity Index (CCI) with complications after total joint arthroplasty (TJA) were compared.

METHODS

Using a single institution cohort of adult patients ≥50 years undergoing primary or revision TJA from 2005 to 2016, we assessed how well the FI, CCI, and ASA scores predicted risk of mortality, infection, and reoperation. We performed 7 models for each outcome: FI, ASA, and CCI alone, FI + ASA, FI + CCI, ASA + CCI, and FI + ASA + CCI. Cox proportional hazards regression methods were used to calculate the concordance (C-) statistic, a measure of discrimination.

RESULTS

Of 18,397 TJAs included, 98.9% were alive 1 year postoperatively. For mortality, all models had concordance between 0.76 and 0.79, with the FI + ASA + CCI model performing highest (C-statistic 0.79; 95% confidence interval [CI] 0.76-0.82). Unadjusted, FI had the strongest concordance (C-statistic 0.77). In FI + ASA + CCI, each increase in 1 comorbidity (of 32 total comorbidities) in the FI was significantly associated with a 12% increase in the rate of mortality (hazard ratio [HR] 1.12, 95% CI 1.07-1.17, P < .001), 10% increase in infection (HR 1.10, 95% CI 1.06-1.14; P < .001), and 6% increase in reoperation (HR 1.06, 95% CI 1.05-1.08, P < .001).

CONCLUSION

Identifying at-risk patients preoperatively is crucial and may result in adjustment of postoperative care. FI was independently associated with risk of adverse outcomes following TJA even after taking into account other predictive measures.

Three Risk Stratification Tools and Postoperative Pneumonia After Noncardiothoracic Surgery

BACKGROUND

Postoperative in-hospital pneumonia is a serious complication. This study aims to investigate the association between 3 preoperative stratification tools (American Society of Anesthesiologists Physical Status [ASA-PS] score, Charlson Comorbidity Index [CCI], and Rockwood Frailty Deficit Index [FI]) and risk for postoperative pneumonia.

METHODS

We identified adult patients who developed postoperative pneumonia following noncardiothoracic surgery under general anesthesia, between January 1, 2016 and December 31, 2017. Patients with postoperative pneumonia were 1:1 matched to control subjects based on age, sex, and the exact type of operations. Medical records were reviewed to identify variables that may be associated with risk for developing postoperative pneumonia. Analyses adjusted for clinical characteristics were performed using the conditional logistic regression, taking into account 1:1 matched set case-control study design.

RESULTS

We identified 211 cases of postoperative pneumonia, and all 3 tested stratification tools were associated with increased risk: ASA-PS (after all adjustments of American Society of Anesthesiologists (ASA) III, odds ratio 4.17 [95% confidence interval 1.74-10.01]; ASA > III 24.03 [6.54-88.32]), CCI (CCI values > 3, 1.29 [1.02-1.63] per unit CCI score), and frail FI score 3.25 (1.45-7.27). Because of incomplete intake documentation, the FI could not be calculated in 57 (13.5%) patients, but these "unknown frailty" patients were also at increased risk for postoperative pneumonia, 3.15 (1.29-7.72).

DISCUSSION

Three commonly used stratification indices (ASA-PS score, CCI, and FI) were associated with increased risk for postoperative pneumonia. Patients unable to complete intake form to calculate the FI were also at increased risk.

Concomitant Malnutrition and Frailty Are Uncommon, but Significant Risk Factors for Mortality and Complication Following Primary Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) demand continues to rise, but we are also gaining greater insight into patient risk factors for postoperative complications and excess resource utilization. There has been growing interest in frailty and malnutrition as risk factors, although they are often mistakenly used interchangeably. We aimed at identifying the incidence of their coexistence, and the magnitude of risk they confer to TKA patients.

METHODS

We queried the American College of Surgeons-National Surgery Quality Improvement Program database to identify 4 patient cohorts: healthy/normal serum albumin, healthy/hypoalbuminemic patients, normoalbuminemic/medically frail patients (defined by modified frailty index), and hypoalbuminemic/frail patients. We performed both univariate and multivariate analyses to quantify the risk conferred by each condition in isolation, and in coexistence.

RESULTS

Of 179,702 elective TKA cases from 2006 to 2018, 18.6% of patients were frail only, 3.0% were hypoalbuminemic -only, and just 1.2% were both frail and hypoalbuminemic. The raw rate of any complication was highest in frail/hypoalbuminemic patients (8.7%), 5.2% in hypoalbuminemic patients, 4.8% in frail patients, and just 3.4% in healthy patients (P < .001); the multivariate model revealed odds ratio of a complication in frail/hypoalbuminemic group of 2.40 (95% confidence interval = 1.27-1.63; P < .001). Mortality within 30 days was highest in the frail/hypoalbuminemic cohort (1.0%), and just 0.1% in healthy patients, and the multivariate model noted an odds ratio of 9.43 for these patients (95% confidence interval = 5.92-14.93; P < .001). The odds of all studied complications were highest in the frail/hypoalbuminemic group.

CONCLUSION

Frailty and hypoalbuminemia represent distinct conditions and are independent risk factors for a complication after TKA. Their coexistence imparts a synergistic association with the risk of post-TKA complications.

What Factors Are Associated With Implant Failure?

PURPOSE

Recognition of patient-specific risk factors should reduce implant failure. The purpose of this study was to identify risk factors associated with implant failure and to determine if these factors differ over time after implant placement.

METHODS

The investigators implemented a retrospective case-controlled study and enrolled a sample composed of patients who had 1 or more implants removed from December 1, 2007 to February 29, 2020. Risk factors were grouped into demographic, medical history, and treatment-related variables. The primary outcome variable was whether the patient's implant failed, with control patients including those without implant failure. The duration was recorded for follow-up from the time of implant placement to the last visit or implant removal. Backward variable selection was used to predict whether an implant failed within 1 year, 1 to 4 years, or after 4 years in 3 multivariable logistic regressions.

RESULTS

Of 224 patients in this cohort, 82 experienced an implant failure. The mean age was 58.6 ± 15.3 years, and 53.1% were females. Patients with osteoporosis had an increased risk of failure in each period. Alcohol use, smoking, depression, and penicillin allergy were all associated with an increased probability of failure within 1 or more of the periods considered.

CONCLUSIONS

This study has identified multiple discrete risk factors for implant failure and has demonstrated that these factors are associated with implant failure at different periods after placement.

Neuraxial anesthesia is associated with improved survival after total joint arthroplasty depending on frailty: a cohort study

Background

Frailty increases risk for complications after total joint arthroplasty (TJA). Whether this association is influenced by anesthetic administered is unknown. We hypothesized that use of neuraxial (spinal or epidural) anesthesia is associated with better outcomes compared with general anesthesia, and that the effect of anesthesia type on outcomes differs by frailty status.

Methods

This single-institution cohort study included all patients (≥50 years) from January 2005 through December 2016 undergoing unilateral, primary and revision TJA. Using multivariable Cox regression, we assessed relationships between anesthesia type, a preoperative frailty deficit index (FI) categorized as non-frail (FI <0.11), vulnerable (FI 0.11 to 0.20), and frail (FI >0.20), and complications (mortality, infection, wound complications/hematoma, reoperation, dislocation, and periprosthetic fracture) within 1 year after surgery. Interactions between anesthesia type and frailty were tested, and stratified models were presented when an interaction (p<0.1) was observed.

Results

Among 18 458 patients undergoing TJA, more patients were classified as frail (21.5%) and vulnerable (36.2%) than non-frail (42.3%). Anesthesia type was not associated with complications after adjusting for age, joint, and revision type. However, in analyzes stratified by frailty, vulnerable patients under neuraxial block had less mortality (HR=0.49; 95% CI 0.27 to 0.89) and wound complications/hematoma (HR=0.71; 95% CI 0.55 to 0.90), whereas no difference in risk by anesthesia type was observed among patients found non-frail or frail.

Conclusions

Neuraxial anesthesia use among vulnerable patients was associated with improved survival and less wound complications. Calculating preoperative frailty prior to TJA informs perioperative risk and enhances shared-decision making for selection of anesthesia type.