Association of a Modified Frailty Index with Postoperative Outcomes after Ankle Fractures in Patients Aged 55 and Older

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1 Association of a Modified Frailty Index with Postoperative Outcomes after Ankle Fractures in Patients Aged 55 and Older Rishin J. Kadakia MD; Cathy Vu MD; Andrew Pao MD; Shay Tenenbaum MD, Jason T. Bariteau MD AOFAS Annual Meeting 2017 July Seattle, Washington

2 Disclosure NO CONFLICT TO DISCLOSE Association of a Modified Frailty Index with Postoperative Outcomes after Ankle Fractures in Patients Aged 50 and Older Rishin J. Kadakia MD Cathy Vu MD Andrew Pao MD Shay Tenenbaum MD Jason T. Bariteau MD Our disclosures in the Final AOFAS Mobile App. We have no potential conflicts with this presentation.

3 The Aging Population The elderly population is rapidly growing Age Groups as a Percentage of Total Population in the USA Sporer SM, Weinstein JN, Koval KJ. The geographic incidence and treatment variation of common fractures of elderly patients. J. Am. Acad. Orthop. Surg. 2006;14(4): Hobbs F, Stoops N. Demographic Trends in the 20 th Century, U.S. Census Bureau, Census 2000 Special Reports, CENSR-4 Table5, November 2002, Ankle fractures are the third most common fracture in the elderly

4 Physiologic Age Healthier lifestyles and medical advancements has a created a generation of healthier and more active elderly individuals The elderly population is a spectrum of patients ranging from those with several comorbidities to those physiologically very healthy Is a patient s age still a reliable tool for risk stratification alone in today s world?

5 Frailty Defined: Decrease in physiologic reserve as well as multisystem impairments which is separate from the normal process of aging There are several validated frailty scoring systems used in clinical research The Modified Frailty Index (MFI) is an example that is frequently used Increased scores on the MFI have been shown to predictive of poor postoperative outcomes in several surgical subspecialties

6 Purpose Determine if there is a relationship between frailty and postoperative outcomes in elderly patients with ankle fractures

7 Methods Design & Population: Retrospective ( ) National Surgical Quality Improvement (NSQIP) database Collects demographic, preoperative factors, and postoperative outcomes within 30 days Patients identified by CPT codes Patients > 55 years of age included in the study Postoperative complications: infections, wound complications, medical complications MFI score and ASA class calculated using collected variables Statistics: Bivariate and Multivariate logistic analysis was used to determine relationship between postoperative outcomes and the MFI score Collected Variables: Wound class, age, demographics, comorbidities 30 day-reoperation rates, postoperative complications, hospital/icu length of stay, readmissions Study Population N (%) Total 6749 Age, years ( SD) 64.4 (10.3) Male 2194 (32.5)

8 MFI and postoperative outcomes Increasing MFI associated with increased incidence of postoperative complications Mean length of stay (days) Hospital stay ICU stay Complications (%) Infection Wound Cardiac Pulmonary Heme Renal Reoperation Readmission MFI score Increasing MFI associated with increased hospital and ICU length of stay MFI score

9 MFI and postoperative outcomes Odds Ratio 95% CI p value Secondary Outcomes Infection <0.001 Wound Medical Complication Cardiac <0.001 Pulmonary <0.001 Renal Hematologic Reoperation <0.001 Readmission <0.001 Bivariate Analysis: Each unit increase in MFI score was associated with significantly increased odds ratio of all outcomes of interest

10 Multivariable analysis: 30 day reoperation Variable Odds Ratio 95% CI p value Modified frailty index Age ASA Class 1 Reference Wound Class I Reference II III <0.001 IV <0.001 Gender (Reference=male) Higher MFI scores associated with increased 30 day reoperation rates

11 Conclusions Elderly patient population consists of a spectrum of patients and age alone may not enough for risk stratification Frailty accounts for age, comorbidities, and the patient s overall well-being concept of physiologic age Modified Frailty Index can be used to predict postoperative outcomes following surgical fixation of ankle fractures in older patients Useful adjuvant when considering surgical morbidity and when discussing outcomes with patients and families

12 References 1. U.S. Department of Health and Human Services: Administration for Community Living [Internet]. Washington DC; Administration for Community Living; c2014. Administration of Aging (AoA): Projected Future Growth of the older population [cited 2016 Nov 9]. Available from: 2. Centers for Disease and Control Prevention: Home and Recreational Safety [Internet] Atlanta: Centers for Disease and Control Prevention, c Older Adult Falls:Get the facts [cited 2016 Nov 9]. Available from: 3. Sporer SM, Weinstein JN, Koval KJ. The geographic incidence and treatment variation of common fractures of elderly patients. J. Am. Acad. Orthop. Surg. 2006;14(4): Christensen K, Doblhammer G, Rau R, Vaupel JW. Ageing populations: the challenges ahead. Lancet 2009;374: Federal Interagency Forum on Aging-Related Statistics. Older Americans 2012: key indicators of well-being [cited 2016 Nov 9] Available from 6. Freedman VA, Martin LG, Schoeni RF. Recent trends in disability and functioning among older adults in the United States: a systematic review. JAMA. 2002;288: Hsu RY, Lee Y, Hayda R, DiGiovanni CW, Mor V, Bariteau JT. Morbidity and mortality associated with geriatric ankle fractures: A Medicare Part A Claims Database Analysis. J Bone Joint Surg Am Nov 4;97(21): Kulminski AM, et al. Cumulative deficits better characterize susceptibility to death in elderly people than phenotypic frailty: lessons from the cardiovascular health study. J Am Geriatr Soc. 2008; 56: Farhat JS, Velanovich V, Falvo AJ, Horst HM, Swartz A, Patton JH Jr, Rubinfeld IS. Are the frail destined to fail? Frailty index as predictor of surgical morbidity and mortality in the elderly. J Trauma Acute Care Surg Jun;72(6): Rockwood K, Song X, MacKnight C et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005; 173: Velanovich V, Antoine H, Swartz A, Peters D, Rubenfeld I. Accumulating deficits model of frailty and postoperative mortality and morbidity: its application to a national database, J. Surg Res. 183 (2013) Patel KV, Brennan KL, Jupiter DC, Shar A, Davis ML. Association of a modified frailty index with mortality after femoral neck fracture in patients aged 60 year and older. Clin Orthop Relat Res, 2014 Mar; 472(3): American College of Surgeons National Surgical Quality Improvement Program. User Guide for the 2014 Participant Use Data File. American College of Surgeons National Surgical Quality Improvement Program website. January [Cited 2016 Nov 9] Available from: Adams P et al. Frailty as a predictor of morbidity and mortality in inpatient head and neck surgery. JAMA Otolaryngol Head Neck Surg 2013 Aug 1;139(8): Hopkins TJ et al. Associations between ASA Physical Status and postoperative mortality at 48 h: a contemporary dataset analysis compared to a historical cohort. Perioper Med (Lond) oct 20;5:29