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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.

Study Design Retrospective Cohort Study. Objectives To determine the predictive capability between the 5-factor modified frailty index (mFI-5) scores and adverse clinical and radiographic outcomes following single-level transforaminal lumbar interbody fusion (TLIF). Methods All patients over the age of 50 undergoing single-level open or minimally invasive TLIF from 2012 to 2021 with a minimum follow-up of 1 year were identified. Deformity, trauma, emergency, and tumor cases were excluded as were patients undergoing revision surgeries. An mFI-5 score was computed for each patient using a set of five factors which included hypertension requiring medication, chronic obstructive pulmonary disease, diabetes mellitus, congestive heart failure, and partially or fully dependent functional status. Univariate and multivariate logistic regression analysis were performed to evaluate the impact of mFI-5 scores on readmissions, reoperations, and postoperative complications. Results 156 patients were included and grouped according to their level of frailty: no-frailty (mFI = 0, n = 67), mild frailty (mFI = 1, n = 59), and severe frailty (mFI = 2+, n = 30). Multivariate analysis found high levels of frailty (mFI = 2+) to be independent predictors of reoperation (OR: 16.9, CI: 2.7 - 106.9, P = .003) and related readmissions (OR = 16.5, CI: 2.6 - 102.7, P = .003) as compared to the no-frailty group. An mFI-5 score of 2+ was also predictive of any complication (OR = 4.5, CI: 1.4 - 14.3, P = .01) and adjacent segment disease (ASD) (OR = 12.5, CI: 1.2 - 134.0, P = .037). Conclusion High levels of frailty were predictive of related readmissions, reoperations, any complications, and ASD in older adult patients undergoing single-level TLIF.

Background There are various frailty assessment tools in the world, and the application choice of frailty assessment tools for the elderly perioperative population varies. It remains unclear which frailty assessment tool is more suitable for the perioperative population in China. To validate the Perioperative Frailty Index (FI-32) derived from the Chinese Hospital Information System by investigating the impact of preoperative frailty on postoperative outcomes, and ascertain the diagnostic value of FI-32 for predicting postoperative complications through comparing with the FRAIL scale and the modified Frailty Index (mFI-11). Methods A prospective cohort study was conducted in a tertiary hospital. Elderly patients who were 60 years or older and underwent selective operation were included. The FI-32, FRAIL scale, and mFI-11 were assessed. Demographic, surgical variables and outcome variables were extracted from medical records. The data of readmission and mortality within 30 days and 90 days of surgery were ascertained by Telephone follow-up by professionally trained researchers. Multiple logistic regression was used to examine the association between frailty and complications. Receiver operating characteristic curves(ROC) were used to compare FI-32 with mFI-11 and FRAIL, to explore the predictive ability of frailty. Results 335 patients qualified for the inclusion criteria and were enrolled in the study, and among them, 201 (60.0%) were females, and the Median( P 25 , P 75 )age at surgery was 69 (65,74) years. The prevalence of frailty in the study population was 16.4% (assessed by FI-32). After adjusting for concomitant variables including demographic characteristics (such as gender, BMI, smoking, drinking, average monthly income and educational level) and surgical factors (such as surgical approach, surgical site, anesthesia method, operation time, intraoperative bleeding, and intraoperative fluid intake), there was a statistically significant association between frailty and the development of postoperative complication after surgery ( OR  = 3.051, 95% CI :1.460–6.378, P  = 0.003). There were also significant differences in mortality within 30 days of surgery, the length of hospital stay (LOS) and the hospitalization costs. FI-32, FRAIL and mFI-11 showed a moderate predictive ability for postoperative complications, the Area Under Curves (AUCs) were 0.582, 0.566 and 0.531, respectively. With adjusting concomitant variables associated with postoperative complications, the AUCs of FI-32, FRAIL and mFI-11 in the adjusted prediction models were 0.824, 0.827 and 0.820 respectively. Conclusions The FI-32 has a predictive effect on postoperative adverse outcomes in elderly Chinese patients. Compared to FRAIL and mFI-11, the FI-32 had the same ability to predict postoperative complications, and FI-32 can be extracted directly from HIS, which greatly saves the time for clinical medical staff to evaluate perioperative frailty.

Introduction: Gulf War Illness (GWI) is a chronic, multisymptom (e.g., fatigue, muscle/joint pain, memory and concentration difficulties) condition estimated to affect 25% to 32% of Gulf War (GW) veterans. Longitudinal studies suggest that few veterans with GWI have recovered over time and that deployed GW veterans may be at increased risks for age-related conditions.We performed a retrospective cohort study to examine the current health status of 703 GW veterans who participated in research studies at the San Francisco VA Health Care System (SFVAHCS) between 2002-2018. We used the Veterans Affairs Frailty Index (VA-FI) as a proxy measure of current health and compared the VA-FIs of GW veterans to a group of randomly selected age-and sex-matched, non-GW veterans. We also examined GW veterans' VA-FIs as a function of different GWI case definitions and in relationship to deployment-related experiences and exposures.Results: Compared to matched, non-GW veterans, GW veterans had lower VA-FIs (0.10 + 0.10 vs. 0.12 + 0.11, p<0.01). However, the subset of GW veterans who met criteria for severe Chronic Multisymptom Illness (CMI) at the time of the SFVAHCS studies had the highest VA-FI (0.13 + 0.10, p<0.001). GW veterans who had Kansas GWI exclusionary conditions had higher VA-FI (0.12 + 0.12, p<0.05) than veterans who were Kansas GWI cases (0.08 + 0.08) and controls (i.e., veterans with little or no symptoms, 0.04 + 0.06) at the time of the SFVAHCS research studies. The VA-FI was positively correlated with several GW deployment-related exposures, including the frequency of wearing flea collars.Discussion: Although GW veterans, as a group, were less frail than non-GW veterans, the subset of GW veterans who met criteria for severe CDC CMI and/or who had Kansas GWI exclusionary conditions at the time of the SFVAHCS research studies were frailest at index date. This suggests that many ongoing studies of GWI that use the Kansas GWI criteria may not be capturing the group of GW veterans who are most at risk for adverse chronic health outcomes.

Background The prevalence and significance of frailty are seldom studied in hospitalized patients. Aim of this study is to evaluate the prevalence of frailty and to determine the extent that frailty predicts delirium, falls and mortality in hospitalized older patients. Methods In a prospective study of 220 older patients, frailty was determined using the Cardiovascular Health Study (CHS) and the Study of Osteoporotic Fracture (SOF) frailty index. Patients were classified as nonfrail, prefrail, and frail, according to the specific criteria. Covariates included clinical and laboratory parameters. Outcome variables included in hospital delirium and falls, and 6-month mortality. Results The CHS frailty index was available in all 220 patients, of which 1.5% were classified as being nonfrail, 58.5% as prefrail, and 40% as frail. The SOF frailty index was available in 204 patients, of which 16% were classified as being nonfrail, 51.5% as prefrail, and 32.5% as frail. Frailty, as identified by the CHS and SOF indexes, was a significant risk factor for 6-month mortality. However, after adjustment for multiple risk factors, frailty remained a strong independent risk factor only for the model with the CHS index (OR 4.7, 95% CI 1.7-12.8). Frailty (identified by CHS and SOF indexes) was not found to be a risk factor for delirium or falls. Conclusions Frailty, as measured by the CHS index, is an independent risk factor for 6-month mortality. The CHS and the SOF indexes have limited value as risk assessment tools for specific geriatric syndromes (e.g., falls and delirium) in hospitalized older patients.

Background and Objectives: This retrospective cohort study aimed to evaluate the predictive validity of four frailty indices—Modified Frailty Index-5 (mFI-5), Edmonton Frail Scale (EFS), Clinical Frailty Scale (CFS), and Trauma-Specific Frailty Index (TSFI)—in forecasting postoperative complications and functional outcomes in elderly patients with proximal humerus fractures (PHFs) treated either surgically or conservatively. Materials and Methods: A total of 244 patients aged ≥60 years with PHFs treated at Erzurum Hospital between January 2018 and January 2023 were included. Patients were categorized into surgical (n = 110) and conservative (n = 134) groups. Surgical procedures included open reduction and internal fixation (n = 88), hemiarthroplasty (n = 10), and reverse shoulder arthroplasty (n = 12). Frailty was retrospectively assessed using mFI-5, EFS, CFS, and TSFI based on 24-month follow-up data. Outcomes included complications, reoperations, rehospitalizations, and functional results measured by the American Shoulder and Elbow Surgeons (ASES) score. Results: The overall complication rate was 13.1%, with nonunion being the most common. Reoperation and rehospitalization rates were 10.6% and 20%, respectively. The mean ASES score was 71.3 ± 15.2, with 60% of patients achieving good or excellent outcomes. Frailty scores, particularly mFI-5 and EFS, were significantly higher in the conservatively treated group compared to the surgical group (p < 0.01). Across both treatment modalities, patients with higher frailty scores had significantly increased complication rates; however, this effect was more pronounced in the surgical group. Multivariate logistic regression revealed that mFI-5 significantly predicted complications, reoperations, and rehospitalizations (p < 0.001). EFS was associated with reoperation risk (p = 0.018), while CFS and TSFI were not significantly correlated with any of the outcomes. Conclusions: Among the evaluated indices, mFI-5 showed the strongest predictive accuracy for adverse outcomes in elderly PHF patients. Notably, the negative impact of frailty was more evident among surgically treated patients. Routine frailty assessment may facilitate better risk stratification and individualized treatment planning in this population.

Background: The incidence of rotator cuff tears increases with age, and operative management is usually required in patients with persistent symptoms. Although several studies have analyzed the effect of age and comorbidities on outcomes after rotator cuff repair, no study has specifically examined the consequence of frailty. Purpose: To determine the best frailty/comorbidity index for predicting functional outcomes after arthroscopic rotator cuff repair. Study Design: Cohort study; Level of evidence, 3. Methods: The authors conducted a retrospective cohort study of 340 consecutive patients who underwent unilateral arthroscopic rotator cuff repair at a tertiary hospital between April 2016 and April 2018. All patients had undergone arthroscopic double-row rotator cuff repair with subacromial decompression by a single fellowship-trained shoulder surgeon. Patient frailty was measured using the Modified Frailty Index (MFI), Clinical Frailty Scale (CFS), and Charlson Comorbidity Index (CCI), calculated through retrospective chart review based on case notes made just before surgery; patient age and sex were also noted preoperatively. Functional outcomes using the Oxford Shoulder Score (OSS), Constant Shoulder Score (CSS), University of California Los Angeles (UCLA) Shoulder Score, and visual analog scale for pain were measured preoperatively and at 3, 6, 12, and 24 months postoperatively. Results: The MFI was a consistent significant predictor in all functional outcome scores up to 24 months postoperatively (P < .05), unlike the CFS and CCI. Sex was also a significant predictor of postoperative OSS, CSS, and UCLA Shoulder Score, with male sex being associated with better functional outcomes. Patients with higher MFI scores had slower functional improvement postoperatively, but they eventually attained functional outcome scores comparable with those of their counterparts with lower MFI scores at 24 months postoperatively. Conclusion: The MFI was found to be a better tool for predicting postoperative function than was the CFS or CCI in patients undergoing arthroscopic rotator cuff repair. The study findings suggest that a multidimensional assessment of frailty (including both functional status and comorbidities) is important in determining functional outcomes after arthroscopic rotator cuff repair.

Although the association between a single assessment of frailty index (FI) and clinical outcomes has been revealed in prior studies, there is a lack of knowledge about the prognostic value of FI at different time points and the changes in repeated measurements of FI. Hence, we sought to determine the clinically meaningful changes in FI and reveal the association with the changes and a composite outcome of mortality and institutionalization. This study was based on a longitudinal study of the Pyeongchang Rural Area cohort that included people aged 65 years or older, ambulatory and living at home. Individuals were divided into the worsened group (changes in FI ≥ 0.03 during 2 years) and the stable group (changes in FI < 0.03 during 2 years). The incidence of a composite outcome was compared between the two groups and the relationship was adjusted for age, sex, baseline FI, and follow-up FI. Of the 953 participants, 403 (42.3%) and 550 (57.7%) were included in the worsened group and the stable group, respectively. The worsened group had a significantly higher risk of the composite outcome than the stable group (HR, 2.37 [95% CI, 1.54-3.67]; p < 0.001). Although the higher risk remained significant after adjusting for age, sex, and baseline FI, the statistical significance disappeared after adjusting for follow-up FI (p = 0.614). The aggravation of FI in the worsened group was predominantly due to aggravation of FI domains, such as activities in daily living, cognitive function and mood, and mobility rather than comorbidity burden. Aggravation of FI was associated with a composite outcome regardless of baseline FI, and the association was significantly reflected in the follow-up measurement of FI. The worsening FI was mainly attributable to functional geriatric domains.

Total en bloc spondylectomy (TES) is an effective treatment for spinal tumors. However, its complication rate is high, and the corresponding risk factors remain unclear. This study aimed to clarify the risk factors for postoperative complications after TES, including the patient’s general condition, such as frailty and their levels of inflammatory biomarkers. We included 169 patients who underwent TES at our hospital from January 2011–December 2021. The complication group comprised patients who experienced postoperative complications that required additional intensive treatments. We analyzed the relationship between early complications and the following factors: age, sex, body mass index, type of tumor, location of tumor, American Society of Anesthesiologists score, physical status, frailty (categorized by the 5-factor Modified Frailty Index [mFI-5]), neutrophil-to-lymphocyte ratio, C-reactive protein/albumin ratio, preoperative chemotherapy, preoperative radiotherapy, surgical approach, and the number of resected vertebrae. Of the 169 patients, 86 (50.1%) were included in the complication group. Multivariate analysis showed that high mFI-5 scores (odds ratio [OR] = 2.99, p < 0.001) and an increased number of resected vertebrae (OR = 1.87, p = 0.018) were risk factors for postoperative complications. Frailty and the number of resected vertebrae were independent risk factors for postoperative complications after TES for spinal tumors.

Purpose Functional status and chronic health status are important baseline characteristics of critically ill patients. The assessment of frailty on admission to the intensive care unit (ICU) may provide objective, prognostic information on baseline health. To determine the impact of frailty on the outcome of critically ill patients, we performed a systematic review and meta-analysis comparing clinical outcomes in frail and non-frail patients admitted to ICU. Methods We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PubMed, CINAHL, and Clinicaltrials.gov. All study designs with the exception of narrative reviews, case reports, and editorials were included. Included studies assessed frailty in patients greater than 18 years of age admitted to an ICU and compared outcomes between fit and frail patients. Two reviewers independently applied eligibility criteria, assessed quality, and extracted data. The primary outcomes were hospital and long-term mortality. We also determined the prevalence of frailty, the impact on other patient-centered outcomes such as discharge disposition, and health service utilization such as length of stay. Results Ten observational studies enrolling a total of 3030 patients (927 frail and 2103 fit patients) were included. The overall quality of studies was moderate. Frailty was associated with higher hospital mortality [relative risk (RR) 1.71; 95% CI 1.43, 2.05; p  < 0.00001; I 2  = 32%] and long-term mortality (RR 1.53; 95% CI 1.40, 1.68; p  < 0.00001; I 2  = 0%). The pooled prevalence of frailty was 30% (95% CI 29–32%). Frail patients were less likely to be discharged home than fit patients (RR 0.59; 95% CI 0.49, 0.71; p  < 0.00001; I 2  = 12%). Conclusions Frailty is common in patients admitted to ICU and is associated with worsened outcomes. Identification of this previously unrecognized and vulnerable ICU population should act as the impetus for investigating and implementing appropriate care plans for critically ill frail patients. Registration: PROSPERO (ID: CRD42016053910).