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Background With a growing number of elderly patients requiring elective and non-elective procedures, frailty-based preoperative risk stratification is an emerging tool in orthopedic surgery to minimize adverse postoperative outcomes. This paper sought to understand the current literature regarding preoperative Orthopedic Frailty Risk Stratification (OFRS) and describe the disparate frailty indices and their capabilities for discrimination in predicting adverse postoperative outcomes. Methods A literature search was conducted in Pubmed, Cochrane, and Scopus for articles published during or prior to February 2024 assessing frailty following surgery for orthopedic pathologies. Qualitative variables including study characteristics and application of frailty were collected and synthesized. Quantitative meta-analysis was performed for pooled odds ratio (OR) and area under the curve (AUC) of frailty for mortality and complications. All methods were performed in accordance with PRISMA guidelines. Results Of the 81 included articles, over half (52%) addressed traumatic orthopedic pathologies with traumatic hip fractures being the most studied in the OFRS (25 studies). Less common categories included oncology, sports, and foot/ankle. Functional status and independence were the most common frailty domain (25, 96.2%) and component across scales (20, 76.9%), respectively. The 5-Item Modified Frailty Index (mFI-5) was the most common frailty index (28 publications). Meta-analysis demonstrated increasing frailty was an independent predictor of mortality (30-day OR: 2.89, 95% CI: 2.00–4.18; 1 year OR: 1.81, 95% CI: 1.48–2.22, p  < 0.001), major complications (OR: 1.63, 95% CI: 1.10–2.41, p  = 0.02), and Clavien-Dindo IV complications (OR: 3.26, 95% CI: 2.18–4.87, p  < 0.001). Frailty had good discriminatory accuracy for predicting mortality at 30-days (AUC: 0.71, 95% CI: 0.68–0.74, p  < 0.001), 3-months (OR: 0.75, 95% CI: 0.65–0.83, p  < 0.001), and 1-year (OR:0.74, 95% CI: 0.73–0.75, p  < 0.001). Conclusions The orthopedic surgery frailty literature is extremely heterogeneous, with disparate frailty scales implemented to measure varying outcomes across many orthopedic pathologies. Despite no consensus on exact scales or definitions, various frailty indices have predicted adverse outcomes.

Introduction Revision arthroplasty is an invasive procedure with increased morbidity relative to primary joint arthroplasty. Therefore, patients with metastatic cancer (Met) undergoing revision total joint arthroplasty (rTJA) may be at greater risk. This study assesses early postoperative outcomes among Met patients undergoing rTJA. Materials and Methods We reviewed the National Surgical Quality Improvement Program (NSQIP) database from 2015 to 2020 to evaluate rTHA/rTKA with Met and Non-Met. Univariate analysis and multivariate logistic regression were used to evaluate associations of Met patients compared with outcomes using odds ratio (OR) and 95% confidence interval (CI). Discriminatory accuracy was assessed using Receiver operating characteristic (ROC) curve and quantified using C-statistic. Results Adjusted analysis revealed Met patients undergoing rTKA were more likely to experience any complication (OR: 2.56, CI: [1.48–4.43]), major complication (OR: 2.17, CI: [1.24–3.82]), and mortality (OR: 7.99, CI: [2.70–23.65]). Met patients undergoing rTHA had higher associations with any complication (OR: 2.40, CI: [1.65–3.49]), major complication (OR: 2.19, CI: [1.47–3.25]), DVT (OR: 4.82, CI: [1.92–12.10]), and mortality (OR: 3.67, CI: [1.43–9.41]). Frailty had superior predictability of extended length of stay (C: 0.625 [0.619–0.630]) and mortality (C: 0.851 [0.824–0.880]). Conclusions Patients with metastatic cancer have elevated risk of complications after revision arthroplasty but may have moderate predictability by frailty assessment. Surgeons can utilize this information to emphasize protective strategies to mitigate risk during and following total joint arthroplasty. Level of Evidence III.

Introduction: The use of frailty indices in orthopedics has grown in popularity to predict surgical outcomes in at-risk populations. While multiple instruments have been used to assess frailty in revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA), there are no comprehensive analyses of the variable indices in this context. The purpose of this study is to thoroughly examine the current landscape of frailty scales used to predict outcomes for rTHA and rTKA. Methods: A comprehensive database search was conducted in accordance with PRISMA guidelines, using the terms: (frailty) AND (\"revision\" AND (\"arthroplasty\" OR \"knee\" OR \"hip\" OR \"joint\")). Two blinded reviewers assessed eligibility of studies, conducted a critical appraisal using the Cochrane Risk of Bias, and performed data extraction utilizing a predefined form. Results: There were seven studies which met final inclusion criteria, consisting of 159,594 patients. Included articles utilized national databases (5) and retrospective chart reviews (2). The frailty indices utilized to analyze rTHA and rTKA consisted of the Hospital Frailty Risk Score (3), CARDE-B index (1), mFI-5 (2), aamFI (1), and a modified MFI (1). Common outcomes reported were mortality within thirty days of the operation (4), readmission within thirty days (3), greater length of stay (2), and any complication within thirty days (2). HFRS was found to be associated with thirty-day readmission and complications. Frailty assessment via the CARDE-B index demonstrated superior capability to predict thirty-day mortality. When compared to the mFI-5, the aamFI showed statistical superiority in its ability to predict thirty-day mortality and complications for both rTHA and rTKA. Conclusion: Frailty assessment as a means of predicting certain outcomes has proven efficacy when applied to the revision arthroplasty. However, due to the lack of comparative analysis in current literature, each has a unique, proven clinical utility without a definitive gold standard for universal assessment. This heterogeneity among frailty scales used for revision total joint arthroplasty has led to inconsistent results and a lack of solidarity, reducing surgeons’ capacity for preoperative optimization and risk stratification. Introduction: The use of frailty indices in orthopedics has grown in popularity to predict surgical outcomes in at-risk populations. While multiple instruments have been used to assess frailty in revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA), there are no comprehensive analyses of the variable indices in this context. The purpose of this study is to thoroughly examine the current landscape of frailty scales used to predict outcomes for rTHA and rTKA. Methods: A comprehensive database search was conducted in accordance with PRISMA guidelines, using the terms: (frailty) AND (\"revision\" AND (\"arthroplasty\" OR \"knee\" OR \"hip\" OR \"joint\")). Two blinded reviewers assessed eligibility of studies, conducted a critical appraisal using the Cochrane Risk of Bias, and performed data extraction utilizing a predefined form. Results: There were seven studies which met final inclusion criteria, consisting of 159,594 patients. Included articles utilized national databases (5) and retrospective chart reviews (2). The frailty indices utilized to analyze rTHA and rTKA consisted of the Hospital Frailty Risk Score (3), CARDE-B index (1), mFI-5 (2), aamFI (1), and a modified MFI (1). Common outcomes reported were mortality within thirty days of the operation (4), readmission within thirty days (3), greater length of stay (2), and any complication within thirty days (2). HFRS was found to be associated with thirty-day readmission and complications. Frailty assessment via the CARDE-B index demonstrated superior capability to predict thirty-day mortality. When compared to the mFI-5, the aamFI showed statistical superiority in its ability to predict thirty-day mortality and complications for both rTHA and rTKA. Conclusion: Frailty assessment as a means of predicting certain outcomes has proven efficacy when applied to the revision arthroplasty. However, due to the lack of comparative analysis in current literature, each has a unique, proven clinical utility without a definitive gold standard for universal assessment. This heterogeneity among frailty scales used for revision total joint arthroplasty has led to inconsistent results and a lack of solidarity, reducing surgeons’ capacity for preoperative optimization and risk stratification. KCI Citation Count: 0

Background Frailty is an established risk factor for adverse outcomes following total joint arthroplasty, including higher rates of prosthetic joint infection (PJI), reoperation rates, and readmission, which may be greater in the setting of revision. The purpose of this study is to compare the association of frailty indices with mortality and complications following septic revision arthroplasty. Methods A query from The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was performed for adult patients undergoing revision total knee or hip arthroplasty between 2015 and 2020, which records perioperative data (30 days postoperatively) for over 700 centers nationwide. PJI cases without revision arthroplasty were excluded. The RAI-rev and mFI-5 frailty scores were calculated for each patient. Outcomes included major complications, mortality, non-home discharge (NHD), DVT, readmission within 30 days, wound complications, pulmonary complications, cardiac complications, and postoperative infection. T-test and binary logistic regression assessed associations with frailty scores and outcomes. Predictability was evaluated through multivariate regression analysis, and its discriminative accuracy was measured using receiver operating curve (ROC) analysis and C-statistics. Results A total of 4395 patients were included (median age: 66 [IQR 59-73]). Within the cohort, 46.44% were female and 38.02% exhibited NHD. RAI-rev demonstrated increased association compared to mFI-5 with mortality (OR: 1.20 vs 1.10, CI: 95%) and NHD (OR: 1.15 vs 1.05, CI: 95%). RAI-Rev demonstrated significantly superior discriminatory accuracy when compared to mFI-5 for NHD (Cs: 0.670 vs 0.602, P < 0.001) and mortality (Cs: 0.795 vs 0.574, P < 0.001). Conclusions Frailty may have a distinct association with mortality and NHD following septic rTJA, especially when assessed by the revised Risk Analysis Index. This understanding is important to educate the patient and their family and provide insight into the necessary resources and surveillance needed to manage frail patients undergoing septic revision total joint arthroplasty.

ABSTRACT Background: With the increasing amount of elective spine fusion patients presenting with cardiac disease and congestive heart failure, it is becoming difficult to assess when it is safe to proceed with surgery. Assessing the severity of heart failure (HF) through ejection fraction may provide insight into patients' short- and long-term risks. Purpose: The purpose of this study was to assess the severity of HF on perioperative outcomes of spine fusion surgery patients. Study Design/Setting: This was a retrospective cohort study of the PearlDiver database. Patient Sample: We enrolled 670,526 patients undergoing spine fusion surgery. Outcome Measures: Thirty-day and 90-day complication rates, discharge destination, length of stay (LOS), physician reimbursement, and hospital costs. Methods: Patients undergoing elective spine fusion surgery were isolated and stratified by preoperative HF with preserved ejection fraction (P-EF) or reduced ejection fraction (R-EF) (International Classification of Diseases-9: 428.32 [chronic diastolic HF] and 428.22 [chronic systolic HF]). Means comparison tests (Chi-squared and independent samples t-tests, as appropriate) compared differences in demographics, diagnoses, comorbidities, procedural characteristics, LOS, 30-day and 90-day complication outcomes, and total hospital charges between those diagnosed with P-EF and those not R-EF. Binary logistic regression assessed the odds of complication associated with HF, controlling for levels fused (odds ratio [OR] [95% confidence interval]). Statistical significance was set at P < 0.05. Results: Totally 670,526 elective spine fusion patients were included. Four thousand and seventy-seven were diagnosed with P-EF and 2758 R-EF. Overall, P-EF patients presented with higher rates of morbid obesity, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, and hypertension (all P < 0.001). In relation to No-HF, P-EF patients had higher rates of 30-day major complications including pulmonary embolism, pneumonia, cerebrovascular accident (CVA), myocardial infarctions (MI), sepsis, and death (all P < 0.001). Furthermore, P-EF was associated significantly with increased odds of pneumonia (OR: 2.07 [1.64-2.56], P < 0.001) and sepsis (OR: 2.09 [1.62-2.66], P < 0.001). Relative to No-HF, R-EF was associated with significantly higher odds of MI (OR: 3.66 [2.34-5.47]), CVA (OR: 2.70 [1.67-4.15]), and pneumonia (OR: 1.85 [1.40-2.40]) (all P < 0.001) postoperative within 30 days. Adjusting for prior history of MI, CAD, and the presence of a pacemaker R-EF was a significant predictor of an MI 30 days postoperatively (OR: 2.2 [1.14-4.32], P = 0.021). Further adjusting for history of CABG or stent placement, R-EF was associated with higher odds of CVA (OR: 2.11 [1.09-4.19], P = 0.028) and MI (OR: 2.27 [1.20-4.43], P = 0.013). Conclusions: When evaluating the severity of HF before spine surgery, R-EF was associated with a higher risk of major complications, especially the occurrence of a myocardial infarction 30 days postoperatively. During preoperative risk assessment, congestive HF should be considered thoroughly when thinking of postoperative outcomes with emphasis on R-EF.

Background: Chiari malformation (CM) is a cluster of related developmental anomalies of the posterior fossa ranging from asymptomatic to fatal. Cranial and spinal decompression can help alleviate symptoms of increased cerebrospinal fluid pressure and correct spinal deformity. As surgical intervention for CM increases in frequency, understanding predictors of reoperation may help optimize neurosurgical planning. Materials and Methods: This was a retrospective analysis of the prospectively collected Healthcare Cost and Utilization Project's California State Inpatient Database years 2004-2011. Chiari malformation Types 1-4 (queried with ICD-9 CM codes) with associated spinal pathologies undergoing stand-alone spinal decompression (queried with ICD-9 CM procedure codes) were included. Cranial decompressions were excluded. Results: One thousand four hundred and forty-six patients (29.28 years, 55.6% of females) were included. Fifty-eight patients (4.01%) required reoperation (67 reoperations). Patients aged 40-50 years had the most reoperations (11); however, patients aged 15-20 years had a significantly higher reoperation rate than all other groups (15.5% vs. 8.2%, P = 0.048). Female gender was significantly associated with reoperation (67.2% vs. 55.6%, P = 0.006). Medical comorbidities associated with reoperation included chronic lung disease (19% vs. 6.9%, P < 0.001), iron deficiency anemia (10.3% vs. 4.1%, P = 0.024), and renal failure (3.4% vs. 0.9%, P = 0.05). Associated significant cluster anomalies included spina bifida (48.3% vs. 34.8%, P = 0.035), tethered cord syndrome (6.9% vs. 2.1%, P = 0.015), syringomyelia (12.1% vs. 5.9%, P = 0.054), hydrocephalus (37.9% vs. 17.7%, P < 0.001), scoliosis (13.8% vs. 6.4%, P = 0.028), and ventricular septal defect (6.9% vs. 2.3%, P = 0.026). Conclusions: Multiple medical and CM-specific comorbidities were associated with reoperation. Addressing them, where possible, may aid in improving CM surgery outcomes.

Background/Objectives: Comparative studies often use the p value to convey statistical significance, but fragility indices (FI) and fragility quotients (FQ) may better signify statistical strength. The use of aspirin as venous thromboembolism (VTE) chemoprophylaxis following elective arthroplasty has been debated between the orthopedic and cardiac fields. The purpose of this study was to apply both the FI and FQ to evaluate the degree of statistical fragility in the total joint arthroplasty (TJA) literature regarding aspirin (ASA) use for VTE prevention. Methods: We performed a systematic search for TJA clinical trials from 2004 to 2023 reporting comparisons between ASA and other chemoprophylaxis methods for VTE. The FI of each outcome was calculated through reversal of a single outcome event until significance was reversed. The FQ was calculated by dividing each fragility index by study sample size and interquartile range (IQR) was calculated. SPSS Meta-analysis function was used to calculate the Mean Effect Size Estimate and 95% Confidence Intervals for each outcome. Results: Of 245 articles screened, 39 met search criteria, with 10 RCTs included for analysis (n = 11,481 patients). There were 38 outcome events reported, with three significant (p < 0.05) outcomes and 35 non-significant (p > 0.05) outcomes identified. The overall FI and FQ for all 38 outcomes were 6 (IQR: 5–7) and 0.059 (IQR: 0.044–0.064), respectively. Seven studies (70%) reported a loss-to-follow-up (LTF) greater than the overall FI. There was no increased risk of DVT, PE, or mortality with use of ASA (all p > 0.2). Conclusions: Despite showing non-inferiority in preventing venous thromboembolic events in TJA overall, the highest-level peer-reviewed literature concerning aspirin use following total joint arthroplasty is considered statistically fragile due to high loss-to-follow-up. In addition to the reporting of the p value, the fragility index and quotient can further provide insight into the strength and trustworthiness of outcome measures.

Previously promising short-term H-Wave® device stimulation (HWDS) outcomes prompted this retrospective cohort study of the longer-term effects on legacy workers’ compensation chronic pain claimants. A detailed chart-review of 157 consecutive claimants undergoing a 30-day HWDS trial (single pain management practice) from February 2018 to November 2019 compiled data on pain, restoration of function, quality of life (QoL), and polypharmacy reduction into a summary spreadsheet for an independent statistical analysis. Non-beneficial trials in 64 (40.8%) ended HWDS use, while 19 (12.1%) trial success charts lacked adequate data for assessing critical outcomes. Of the 74 final treatment study group charts, missing data points were removed for a statistical analysis. Pain chronicity was 7.8 years with 21.6 ± 12.2 months mean follow-up. Mean pain reduction was 35%, with 89% reporting functional improvement. Opioid consumption decreased in 48.8% of users and 41.5% completely stopped; polypharmacy decreased in 36.8% and 24.4% stopped. Zero adverse events were reported and those who still worked usually continued working. An overall positive experience occurred in 66.2% (p < 0.0001), while longer chronicity portended the risk of trial or treatment failure. Positive outcomes in reducing pain, opioid/polypharmacy, and anxiety/depression, while improving function/QoL, occurred in these challenging chronic pain injury claimants. Level of evidence: III

Adult cervical deformity is a structural malalignment of the cervical spine that may present with variety of significant symptomatology for patients. There are clear and substantial negative impacts of cervical spine deformity, including the increased burden of pain, limited mobility and functionality, and interference with patients’ ability to work and perform everyday tasks. Primary cervical deformities develop as the result of a multitude of different etiologies, changing the normal mechanics and structure of the cervical region. In particular, degeneration of the cervical spine, inflammatory arthritides and neuromuscular changes are significant players in the development of disease. Additionally, cervical deformities, sometimes iatrogenically, may present secondary to malalignment or correction of the thoracic, lumbar or sacropelvic spine. Previously, classification systems were developed to help quantify disease burden and influence management of thoracic and lumbar spine deformities. Following up on these works and based on the relationship between the cervical and distal spine, Ames-ISSG developed a framework for a standardized tool for characterizing and quantifying cervical spine deformities. When surgical intervention is required to correct a cervical deformity, there are advantages and disadvantages to both anterior and posterior approaches. A stepwise approach may minimize the drawbacks of either an anterior or posterior approach alone, and patients should have a surgical plan tailored specifically to their cervical deformity based upon symptomatic and radiographic indications. This state-of-the-art review is based upon a comprehensive overview of literature seeking to highlight the normal cervical spine, etiologies of cervical deformity, current classification systems, and key surgical techniques.

Current chronic pain treatments primarily target symptoms and are often associated with harmful side-effects and complications, while safer non-invasive electrotherapies like H-Wave® device stimulation (HWDS) have been less explored. The goal of this study is to evaluate first responder-reported effects of HWDS on job-related and quality-of-life measures. This is a retrospective cohort study where first responders were surveyed following voluntary use of HWDS regarding participant experience, frequency of use, job-related performance, and quality-of-life. Responses were analyzed using means comparison tests, while bivariate analysis assessed responses associated with HWDS usage. Overall, 92.9% of first responder HWDS users (26/28) reported a positive experience (p < 0.0001), with 82.1% citing pain reduction (p = 0.0013), while 78.6% indicated it would be beneficial to have future device access (p = 0.0046). Participants using H-Wave® were at least six times more likely to report higher rates of benefit (100% vs. 0%, p = 0.022), including pain reduction (91.3% vs. 8.7%, p = 0.021) and improved range-of-motion (93.3% vs. 69.2%, p = 0.044). Spending more time with family was associated with better job performance following frequent HWDS use (50% vs. 8.3%, p = 0.032). Repetitive first responder H-Wave® use, with minimal side effects and easy utilization, resulted in significant pain reduction, improvements in job performance and range-of-motion, and increased time spent with family, resulting in overall positive experiences and health benefits. Level of Evidence: III.