The Archives of Bone and Joint Surgery

The Archives of Bone and Joint Surgery

Higher Modified Frailty Index Score is Associated with Increased 30-Day Postoperative Complications Following Surgical Treatment of Tibial Shaft Fractures

Document Type : RESEARCH PAPER

Authors
Mitchell S. Mologne 1
Theodore Quan 2
Jacob D. Mikula 3
Alexander R. Garcia 4
Matthew J. Best 3
Savyasachi C. Thakkar 4
1 Washington University School of Medicine, St. Louis, MO, USA
2 George Washington School of Medicine and Health Sciences, Washington, DC, USA
3 Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
4 Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, BA, USA
10.22038/abjs.2024.75059.3470
Abstract
Objectives: This study was conducted to determine if factors comprising the mFI were correlated with 
adverse outcomes following surgical intervention of tibial shaft fractures.
Methods: We identified patients 50 years or older with tibial shaft fractures that were managed surgically from a 
national database from 2007-2019. The 5-item mFI score, which comprised of diabetes, hypertension, congestive 
heart failure, dependent functional status, and chronic obstructive pulmonary disease, was calculated for each 
patient. Regression analysis was used to evaluate the association of different mFI scores with thirty-day 
postoperative outcomes.
Results: 1,159 total patients (mean age of 65 years) were included in this study. After controlling for confounding 
variables on multivariate analysis, compared to patients with a mFI of 0, those with a score of 1 had an increased 
risk of major complications (OR 5.11; p=0.038), minor complications (OR 3.11; p=0.004), readmission (OR 2.75; 
p=0.020), postoperative transfusion (OR 2.22; p=0.037), prolonged hospital stay (OR 1.88; p<0.001), and non-home 
discharge (OR 1.52; p=0.014). Similar increased risk of complications was seen for patients with a mFI of 2 
compared to those with a score of 0: major complications (OR 9.49; p=0.004), readmission (OR 3.73; p=0.003), 
postoperative transfusion (OR 4.07; p<0.001), prolonged hospital stay (OR 2.50; p<0.001), and non-home discharge 
(OR 2.32; p<0.001).
Conclusion: Higher scores on the mFI were associated with higher complication rates in patients following surgical 
treatment of tibial shaft fractures. The modified frailty index is a useful tool for surgeons to assess risk before 
operation.
 Level of evidence: III
Keywords
Complications
Frailty
Internal fixation
mFI
NSQIP
Tibia
Subjects
  1. Connelly CL, Bucknall V, Jenkins PJ, Court-Brown CM, McQueen MM, Biant LC. Outcome at 12 to 22 years of 1502 tibial shaft fractures. Bone Joint J. 2014; 96-B (10):1370-1377. doi:10.1302/0301-620X.96B10.32914.
  2. Larsen P, Elsoe R, Graven-Nielsen T, Laessoe U, Rasmussen S. Decreased muscle strength is associated with impaired long-term functional outcome after intramedullary nailing of femoral shaft fracture. Eur J Trauma Emerg Surg. 2015; 41(6):673-681. doi:10.1007/s00068-014-0488-2.
  3. Laurila J, Huttunen TT, Kannus P, Kääriäinen M, Mattila VM. Tibial shaft fractures in Finland between 1997 and 2014. Injury. 2019; 50(4):973-977. doi:10.1016/j.injury.2019.03.034.
  4. Patel KH, Logan K, Krkovic M. Strategies and outcomes in severe open tibial shaft fractures at a major trauma center: A large retrospective case-series. World J Orthop. 2021; 12(7):495-504. 2021; 12(7):495-504. doi:10.5312/wjo.v12.i7.495.
  5. Lin CA, Swiontkowski M, Bhandari M, et al. Reaming Does Not Affect Functional Outcomes after Open and Closed Tibial Shaft Fractures: The Results of a Randomized Controlled Trial. J Orthop Trauma.2016; 30(3):142-8. doi: 10.1097/BOT.0000000000000497.
  6. Smith C, Ades R, Lo Y, Stallone S, Khokhar S, Gruson K. Predictors of Return to Emergency Department and Readmission Following Primary Elective Total Shoulder Arthroplasty. Arch Bone Jt Surg. 2024; 12(7).
  7. Aderinto J, Keating JF. Intramedullary nailing of fractures of the tibia in diabetics. J Bone Joint Surg Br. 2008; 90(5):638-642. doi:10.1302/0301-620X.90B5.19854.
  8. Wahl TS, Graham LA, Hawn MT, et al. Association of the Modified Frailty Index with 30-Day Surgical Readmission. JAMA Surg. 2017; 152(8):749-757. doi:10.1001/jamasurg.2017.1025.
  9. Phen HM, Jones C, Kravets VG, et al. Impact of Frailty and Malnutrition on Outcomes after Surgical Fixation of Lower Extremity Fractures in Young Patients. J Orthop Trauma. 2021; 35(4):e126-e133. doi:10.1097/BOT.0000000000001952.
  10. Mahajan A, Kumar N, Gupta B. Delayed Tibial Shaft Fracture Healing Associated with Smoking: A Systematic Review and Meta-Analysis of Observational Studies Conducted Worldwide. Int J Environ Res Public Health. 2021; 18(19):10228. doi:10.3390/ijerph181910228.
  11. Malik AT, Kim J, Yu E, Khan SN. Discharge to Inpatient Care Facility After Anterior Lumbar Interbody Fusion: Incidence, Predictors, and Postdischarge Outcomes. World Neurosurg. 2019; 122:e584-e590. doi:10.1016/j.wneu.2018.10.108.
  12. Otero J, Arnold MR, Kao AM, et al. Short-term Outcomes of Esophagectomies in Octogenarians-An Analysis of ACS-NSQIP. J Surg Res. 2019; 235:432-439. doi:10.1016/j.jss.2018.07.044.
  13. Holzgrefe RE, Wilson JM, Staley CA, Anderson TL, Wagner ER, Gottschalk MB. Modified frailty index is an effective risk-stratification tool for patients undergoing total shoulder arthroplasty. J Shoulder Elbow Surg. 2019; 28(7):1232-1240. doi:10.1016/j.jse.2018.12.004.
  14. Velanovich V, Antoine H, Swartz A, Peters D, Rubinfeld I. Accumulating deficits model of frailty and postoperative mortality and morbidity: its application to a national

 

database. J Surg Res. 2013; 183(1):104-110. doi:10.1016/j.jss.2013.01.021.

  1. Amer KM, Congiusta DV, Suri P, Merchant AM, Vosbikian MM, Ahmed IH. Patient frailty as a risk assessment tool in surgical management of long bone fractures. J Clin Orthop Trauma. 2020; 11(Suppl 4):S591-S595. doi:10.1016/j.jcot.2020.01.007.
  2. Liodakis E, Bergeron SG, Zukor DJ, Huk OL, Epure LM, Antoniou J. Perioperative Complications and Length of Stay After Revision Total Hip and Knee Arthroplasties: An Analysis of the NSQIP Database. J Arthroplasty. 2015; 30(11):1868-1871. doi:10.1016/j.arth.2015.05.029.
  3. Smith EJ, Kuang X, Pandarinath R. Comparing hospital outcomes between open and closed tibia fractures treated with intramedullary fixation. Injury. 2017; 48(7):1609-1612. doi:10.1016/j.injury.2017.03.038.
  4. Chimukangara M, Helm MC, Frelich MJ, et al. A 5-item frailty index based on NSQIP data correlates with outcomes following paraesophageal hernia repair. Surg Endosc. 2017; 31(6):2509-2519. doi:10.1007/s00464-016-5253-7.
  5. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987; 40(5):373-383. doi:10.1016/0021-9681(87)90171-8.
  6. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998; 36(1):8-27. doi:10.1097/00005650-199801000-00004.
  7. Lakomkin N, Kothari P, Dodd AC, et al. Higher Charlson Comorbidity Index Scores Are Associated With Increased Hospital Length of Stay After Lower Extremity Orthopaedic Trauma. J Orthop Trauma. 2017; 31(1):21-26. doi:10.1097/BOT.0000000000000701.
  8. Menendez ME, Neuhaus V, van Dijk CN, Ring D. The Elixhauser comorbidity method outperforms the Charlson index in predicting inpatient death after orthopaedic surgery. Clin Orthop Relat Res. 2014; 472(9):2878-2886. doi:10.1007/s11999-014-3686-7.
  9. Sinclair ST, Emara AK, Orr MN, McConaghy KM, Klika AK, Piuzzi NS. Comorbidity indices in orthopaedic surgery: a narrative review focused on hip and knee arthroplasty. EFORT Open Rev. 2021; 6(8):629-640. doi:10.1302/2058-5241.6.200124.
  10. Ondeck NT, Bohl DD, Bovonratwet P, et al. Discriminative ability of commonly used indices to predict adverse outcomes after poster lumbar fusion: a comparison of demographics, ASA, the modified Charlson Comorbidity Index, and the modified Frailty Index. Spine J. 2018; 18(1):44-52. doi:10.1016/j.spinee.2017.05.028.
  11. Subramaniam S, Aalberg JJ, Soriano RP, Divino CM. New 5-Factor Modified Frailty Index Using American College of Surgeons NSQIP Data. J Am Coll Surg. 2018; 226(2):173-181.e8. doi:10.1016/j.jamcollsurg.2017.11.005.
  12. Lee J, Alfonso AR, Kantar RS, et al. Modified Frailty Index Predicts Postoperative Complications following Panniculectomy in the Elderly. Plast Reconstr Surg Glob Open. 2020; 8(7):e2987. doi:10.1097/GOX.0000000000002987.
  13. Patel NP, Elali F, Coban D, et al. The 5-factor modified Frailty Index (mFI-5) predicts adverse outcomes after elective Anterior Lumbar Interbody Fusion (ALIF). N Am Spine Soc J. 2022; 13:100189. doi:10.1016/j.xnsj.2022.100189.
  14. Pean CA, Thomas HM, Singh UM, DeBaun MR, Weaver MJ, von Keudell AG. Use of a Six-Item Modified Frailty Index to Predict 30-day Adverse Events, Readmission, and Mortality in Older Patients Undergoing Surgical Fixation of Lower Extremity, Pelvic, and Acetabular Fractures. J Am Acad Orthop Surg Glob Res Rev. 2023; 7(1):e22.00286. doi:10.5435/JAAOSGlobal-D-22-00286.
  15. Traven SA, Reeves RA, Althoff AD, Slone HS, Walton ZJ. New Five-Factor Modified Frailty Index Predicts Morbidity and Mortality in Geriatric Hip Fractures. J Orthop Trauma. 2019; 33(7):319-323. doi:10.1097/BOT.0000000000001455.
  16. Abboud A, Masrouha K, Hanna T, Saghieh S. Union Following Biological and Rigid Fixations of Distal Tibia Extra-articular Fractures. Arch Bone Jt Surg. 2020; 8(2):162-167. doi:10.22038/abjs.2019.36760.1972.
  17. Tracy BM, Wilson JM, Smith RN, Schenker ML, Gelbard RB. The 5-Item Modified Frailty Index Predicts Adverse Outcomes in Trauma. J Surg Res. 2020; 253:167-172. doi:10.1016/j.jss.2020.03.052.
  18. Yong PH, Weinberg L, Torkamani N, et al. The Presence of Diabetes and Higher HbA1c Are Independently Associated With Adverse Outcomes After Surgery. Diabetes Care. 2018; 41(6):1172-1179. doi:10.2337/dc17-2304.
  19. Saiz AM Jr, Stwalley D, Wolinsky P, Miller AN. Patient Comorbidities Associated With Acute Infection after Open Tibial Fractures. J Am Acad Orthop Surg Glob Res Rev. 2022; 6(9):e22.00196. doi:10.5435/JAAOSGlobal-D-22-00196.
  20. Upfill-Brown A, Hwang R, Clarkson S, et al. Rates and timing of short-term complications following operative treatment of tibial shaft fractures. OTA Int. 2021; 4(4):e158. doi:10.1097/OI9.0000000000000158.

 

 

 

 

The Archives of Bone and Joint Surgery
Volume 12, Issue 9
September 2024
Pages 637-644

  • Receive Date 06 October 2023
  • Revise Date 10 July 2024
  • Accept Date 15 June 2024