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Use of a 5-Item Modified Frailty Index for Risk Stratification in Patients Undergoing Surgical Management of Distal Radius Fractures

      Purpose

      Compared with cast treatment, surgery may expose patients with distal radius fractures to undue risk. Surgical intervention in this cohort may offer less benefit than previously thought and appropriate patient selection is imperative. The modified Frailty Index (mFI) predicts complications after other orthopedic surgeries. We hypothesized that this index would predict, and might ultimately prevent, complications in patients older than 50 years with distal radius fractures.

      Methods

      We retrospectively reviewed the American College of Surgeons—National Surgery Quality Improvement Program (ACS-NSQIP) database, including patients older than 50 years who underwent open reduction and internal fixation of a distal radius fracture. A 5-item mFI score was then calculated for each patient. Postoperative complications, readmission and reoperation rates, as well as length of stay (LOS) were recorded. Bivariate and multivariable statistical analysis was then performed.

      Results

      We identified 6,494 patients (mean age, 65 years). Compared with patients with mFI of 0, patients with mFI of 2 or greater were nearly 2.5 times as likely to incur a postoperative complication (1.7% vs 7.4%). Specifically, the rates of Clavien-Dindo IV, wound, cardiac, and renal complications were increased significantly in patients with mFI of 2 or greater. In addition, as mFI increased from 0 to 2 or greater, 30-day reoperation rate increased from 0.8% to 2.4%, 30-day readmission from 0.8% to 4.6%, and LOS from 0.5 days to 1.44 days. Frailty was associated with increased complications as well as rates of readmission and reoperation even when controlling for demographic data, LOS, and operative time. Age alone was not significantly associated with postoperative complications, readmission, reoperation, or LOS.

      Conclusions

      A state of frailty is highly predictive of postoperative complications, readmission, reoperation, and increased LOS following open reduction and internal fixation of distal radius fractures. Our data suggest that a simple frailty evaluation can help inform surgical decision making in patients older than 50 years with distal radius fractures.

      Type of study/level of evidence

      Prognostic II.

      Key words

      Fractures of the distal radius constitute one of the most common fractures encountered and treated by upper extremity surgeons, representing an estimated 17.5% to 22.2% of all fractures.
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      Outcome following nonoperative treatment of displaced distal radius fractures in low-demand patients older than 60 years.
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      Functional outcomes after open reduction and internal fixation for treatment of displaced distal radius fractures in patients over 60 years of age.
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      • Deml C.
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      Distal radial fractures in the elderly: operative compared with nonoperative treatment.
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      Unstable distal radius fractures in the elderly patient—volar fixed-angle plate osteosynthesis prevents secondary loss of reduction.
      • Arora R.
      • Lutz M.
      • Deml C.
      • Krappinger D.
      • Haug L.
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      A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older.
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      A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly.
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      An economic analysis of outcomes and complications of treating distal radius fractures in the elderly.
      • Lutz K.
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      • Symonette C.
      • Grewal R.
      Complications associated with operative versus nonsurgical treatment of distal radius fractures in patients aged 65 years and older.
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      Comparison of treatment outcomes between nonsurgical and surgical treatment of distal radius fracture in elderly: a systematic review and meta-analysis.
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      • Ezzat A.
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      • Duarte M.P.
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      Volar plate fixation in patients older than 70 years with AO type C distal radial fractures: clinical and radiologic outcomes.
      Therefore, at present, it remains unclear which elderly patients are likely to benefit from surgical fixation of unstable distal radius fractures.
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      We hypothesized that the 5-item mFI could predict several complications after surgical fixation of distal radius fractures.

      Methods

      Data collection

      Data for this study were collected from the American College of Surgeons—National Surgery Quality Improvement Program (ACS-NSQIP) database. The NSQIP database is an international, prospective database that collects preoperative and 30-day outcome data for patients undergoing surgical operations across multiple subspecialties. The number of cases contributed to the database per year has increased from 152,490 in 2006 to over 885,000 in 2015 across all specialties. The database captures 95% of 30-day outcomes by observing in hospital morbidity and mortality and then confirming 30-day outcomes by contacting patients via writing and phone call at the end of the period. In addition, surgical clinical reviewers and random audits ensure the accurate collection of data.
      In the present study, the NSQIP database was queried for patients based on Current Procedural Terminology codes. The following codes were used: 25607 (open treatment of extra-articular distal radius fracture with internal or external fixation), 25608 (open treatment of intra-articular distal radius fracture with internal fixation of 2 fragments), and 25609 (open treatment of intra-articular distal radius fracture with internal fixation of 3 or more fragments). All patients from 2007 to 2015 were initially included in this study. Patients younger than 50 years and those with open injuries were excluded. In addition, in an attempt to capture only patients with an isolated injury, those who had another surgery unrelated to their distal radius were excluded. Lastly, patients meeting sepsis or presepsis criteria prior to surgery were excluded, and patients with incomplete data were also excluded from analysis.

      Patient demographics

      Patient demographic data were collected and included the following information: sex, age, race, American Society of Anesthesiology (ASA) classification, body mass index (BMI), and wound classification.

      Modified frailty index

      The 5-item mFI used in this study included the following 5 patient history items: history of diabetes mellitus, congestive heart failure (new diagnosis or exacerbation of chronic congestive heart failure within 30 days of surgery), hypertension requiring medication, history of chronic obstructive pulmonary disease or pneumonia, and nonindependent functional status (partially or completely dependent in activities of daily living within the last 30 days prior to surgery). These variables and how they relate to the Canadian Study on Health and Aging Frailty index can be seen in Table 1. The 5-item mFI has been used previously to successfully predict complications in other surgical subspecialties and was recently validated against the 11-item mFI score.
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      • et al.
      A 5-item frailty index based on NSQIP data correlates with outcomes following paraesophageal hernia repair.
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      • et al.
      The effect of Frailty Index on early outcomes after combined colorectal and liver resections.
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      New 5-Factor Modified Frailty Index using American College of Surgeons NSQIP Data.
      The 5-item and 11-item mFI have a Spearman rho correlation of 0.95 and both have C statistics greater than 0.9 and 0.7 for mortality and postoperative complication, respectively, indicating strong predictive ability.
      • Subramaniam S.
      • Aalberg J.J.
      • Soriano R.P.
      • Divino C.M.
      New 5-Factor Modified Frailty Index using American College of Surgeons NSQIP Data.
      The 5-item-mFI score was calculated for every patient. In order to compare the 5-item mFI to the originally described 11-item mFI, the 11-item mFI was calculated for a subset of patients for whom these data were available. In addition to the 5-item mFI variables, the 11-item mFI includes the following variables: history of transient ischemic attack or cerebrovascular accident, prior cerebrovascular accident with residual neurological deficit, history of myocardial infarction (MI), history of peripheral vascular disease or rest pain, history of prior percutaneous coronary intervention or angina, and history of impaired sensorium. The 5-item mFI score was calculated by simply adding the number of variables present in patients (possible scores, 0–5). The 11-item mFI score was calculated by adding the number of variables present and dividing that number by 11.
      Table 1Translation of Variables from Canadian Study on Health and Aging to NSQIP and 5-Item mFI
      CSHA-FINSQIP 5-Item mFImFI Variable
      History of diabetes mellitusDiabetes mellitus—noninsulin1
      Diabetes mellitus—insulin
      Diabetes mellitus—oral
      Congestive heart failureCongestive heart failure within 30 d before surgery2
      Hypertension requiring medicationHypertension requiring medication3
      Lung problemsHistory of COPD4
      Pneumonia
      Changes in everyday activityFunctional health status before surgery—partially dependent5
      Problems with getting dressedFunctional health status before surgery—totally dependent
      Problems with bathing
      Problems with carrying out personal grooming
      Problems with cooking
      Problems with going out alone
      COPD, chronic obstructive pulmonary disease; CSHA-FI, Canadian Study of Health and Aging Frailty Index; mFI, Modified Frailty Index.

      Outcome and Complication Data

      The 30-day outcome data was collected for each patient. Complications were classified into the following broad categories: wound (wound dehiscence or other complication, not including surgical site infection), cardiac (cardiac arrest or MI), pulmonary (pneumonia, pulmonary embolism, unplanned reintubation), hematology (deep vein thromboembolism, need for transfusion), renal (progressive renal insufficiency, acute kidney failure), and adverse hospital discharge (discharge to other than home). In addition, data for all complications (the primary outcome of this study) were analyzed as well as Clavien-Dindo IV complications. Clavien-Dindo IV complications are those that are life threatening and cause end-organ dysfunction. For this study, Clavien-Dindo IV complications included cardiac arrest, MI, septic shock, pulmonary embolism, and renal failure. Both 30-day readmission and reoperation data were also collected and analyzed (Fig. 1) .

      Statistical analysis

      For each complication, bivariate analysis was performed using Pearson chi-square analysis to compare the incidence of the complication among patients with varying mFI scores. A P value of less than .05 was considered statistically significant. To further examine the differing complication rates between patients with different mFI scores, multivariable logistical regression was performed to control for possible confounding variables. This was performed using a model controlling for age, race, BMI, total hospital length of stay (LOS), and total operative time. Patients with mFI score of 0 were used as a reference group. Hospital LOS and operative time were included because these are factors potentially associated with complication rates.

      Results

      Patient demographics

      From 2007 to 2015, 6,494 patients who were 50 years old or older and underwent operative fixation of a distal radius fracture, were identified from the NSQIP database. Of these, 6,423 patients had complete data for further analysis. The majority of the identified patients were women (82.8%) and the mean patient age was 65 years (± 9.6 years). Included patients were predominantly Caucasian (77.8%) with the next most common race being identified as “other/unknown.” Most patients had either a normal BMI (18.5–24.9; 33.6%) or were overweight by BMI (25–29.9; 32.2%). In addition, nearly all identified patients had an ASA class of 3 or less (98.3%), with the majority (56.4%) being ASA class 2 (Table 2). The majority (5,355; 82.5%) of patients were treated on an outpatient basis, and 1,139 were inpatients (17.5%).
      Table 2Patient Demographics
      Variable%, unless otherwise noted
      Total number of patients (n)6,494
      Gender
       Male17.2
       Female82.8
      Age (mean, SD), y65.07 (9.60)
      BMI (mean, SD), kg/m
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      The epidemiology of distal radius fractures.
      28.24 (6.90)
       Underweight (< 18.5)1.9
       Normal weight (18.5–24.9)33.6
       Overweight (25.0–29.9)32.2
       Obese (30.0–34.9)18.3
       Severely obese (35.0–39.9)8.0
       Morbidly obese (≥ 40.0)6.1
      ASA class
       1—Normal healthy11.6
       2—Mild systemic disease56.4
       3—Severe systemic disease30.2
       4—Severe systemic disease with threat to life1.7
       5—Critically ill0.0
      Race
       White77.8
       African American2.7
       Asian3.0
       Other/unknown16.4
      Wound classification
       I—Clean98.0
       II—Clean, contaminated1.2
       III—Contaminated0.6
       IV—Dirty0.2

      5-Item mFI scores versus 11-item traditional mFI

      To ensure that the 5-item index was appropriately sensitive, we analyzed a subset of patients in which all 11 items of the mFI were available (n = 1,312 patients). The results of this subgroup analysis closely mirrored the results of the 5-item index.

      5-Item mFI scores

      The calculated Frailty Index for all patients in the study sample ranged from 0 to 5; however, for statistical and practical considerations, these are reported in the following groups: 0, 1, and 2 or greater. The number of patients with each mFI level were as follows: mFI = 0 in 3,421 patients (53.3%); mFI = 1 in 2,241 (34.9%); mFI = 2 in 676 patients (10.5%); mFI = 3 in 79 patients (1.2%); mFI = 4 in 5 patients (0.1%); and mFI = 5 in 1 patient. When grouped, the number of patients with mFI score of 2 or greater was 761 (12%) (Table 3). While statistically different, patients who were treated on an outpatient and inpatient basis had clinically similar 5-item mFI scores (0.58 and 0.71, respectively; P < .05).
      Table 3Adverse Outcome Versus mFI Score
      OutcomeOverallmFI ScoreP Value
      0 (N, %)1 (N, %)≥ 2 (N, %)
      n = 3,421n = 2,241n = 761
      Readmission
      mFI 0 versus ≥ 2 statistically significant.
      102, 1.629, 0.838, 1.735, 4.6< .05
      Reoperation
      mFI 0 versus ≥ 2 statistically significant.
      73, 1.126, 0.829, 1.318, 2.4< .05
      Any complication
      mFI 0 versus ≥ 2 statistically significant.
      198, 3.158, 1.784, 3.756, 7.4< .05
      Clavien-Dindo IV
      mFI 0 versus ≥ 2 statistically significant.
      17, 0.32, 0.18, 0.47, 0.9< .05
      Infection15, 0.210, 0.33, 0.12, 0.3.48
      Wound
      mFI 0 versus ≥ 2 statistically significant.
      1, 0.00, 0.00, 0.01, 0.1.02
      Cardiac
      mFI 0 versus ≥ 2 statistically significant.
      3, 0.00, 0.01, 0.02, 0.3.01
      Pulmonary12, 0.24, 0.16, 0.32, 0.3.38
      Hematology3, 0.00, 0.02, 0.11, 0.1.16
      Renal
      mFI 0 versus ≥ 2 statistically significant.
      2, 0.00, 0.00, 0.02, 0.3< .05
      Adverse hospital D/C
      mFI 0 versus ≥ 2 statistically significant.
      884, 13.8359, 10.5358, 16.0167, 21.9< .05
      D/C, discharge.
      mFI 0 versus ≥ 2 statistically significant.

      mFI and 30-day postoperative complications

      Clavien-Dindo class IV complications (Fig. 2) increased from 0.1% to 0.9% (odds ratio [OR], 10.53; 95% confidence interval [95% CI], 1.13–98.51; P < .05) (Table 4) the rate of any complication increased from 1.7% to 7.4% at mFI of 0 and 2 or greater (P < .05), respectively. In addition, by systems, whereas overall incidence was low, there were statistically higher rates of cardiac, renal, and wound complications associated with increasing mFI (P < .05). Frailty was also associated with adverse hospital discharge, as patients with mFI of 2 or greater were over 1.5 times as likely to be discharged to a location other than home than were patients with mFI of 0 (OR, 1.68; 95% CI, 1.32–2.14; P < .05, Table 3). When comparing complication incidence among inpatients with outpatients, inpatients had significantly higher rates of complications (7.1% vs 2.2%, respectively; OR, 2.74; 95% CI, 2.01–3.74; P < .05).
      Figure thumbnail gr2
      Figure 2The effect of mFI score on A readmission, reoperation, and any complication and B length of hospitalization is shown. Error bars represent SD. All 4 parameters were statistically significant with mFI 0 compared with mFI ≥ 2 (P ≤ .01).
      Table 4Multivariable Logistic Regression For All Complications, 30-Day Readmission, 30-Day Reoperation, Clavien-Dindo IV Complications, And Adverse Hospital Discharge
      A multivariate model controlling for age, sex, bmi, total hospital length of stay, and total operative time is shown.
      mFIAll Complications30-D Readmission30-D ReoperationClavien-Dindo IV ComplicationsAdverse Discharge
      OR95% CIOR95% CIOR95% CIOR95% CIOR95% CI
      0RefRefRefRefRef
      11.571.072.301.340.792.281.281.071.536.070.7251.571.281.071.53
      ≥22.461.573.872.671.474.861.681.322.1410.531.1398.511.681.322.14
      AGE1.010.991.021.010.991.041.010.991.041.010.991.021.010.991.04
      REF, reference value.
      A multivariate model controlling for age, sex, bmi, total hospital length of stay, and total operative time is shown.
      Frailty was also associated with longer total hospitalization stays. Hospital LOS increased from 0.5 days (± 3.4 days) in patients who had an mFI of 0 to 1.44 days (± 12.9 days) in patients who had an mFI of 2 or greater (P < .05; Fig. 3).
      Figure thumbnail gr3
      Figure 3An easy mnemonic for clinical integration is shown. There is higher risk associated with surgical intervention with addition of each of the following historical factors. COPD, chronic obstructive pulmonary disease.
      Multivariable analysis demonstrated that mFI remained an important predictor of developing any type of complication even after adjusting for patient demographic variables, LOS, and total operative time (Table 4). Both ASA class (OR, 2.2; 95% CI, 1.7–2.9; P < .05) and mFI of 2 or greater (OR, 2.5; 95% CI, 1.6–3.9; P < .05) were significantly associated with complications. There was no significant association of age with postoperative complications (OR, 1.01; 95% CI, 0.99–1.02; P < .05).

      mFI and 30-day reoperation and readmission

      As mFI increased from 0 to 2 or greater, 30-day reoperation rate increased from 0.8% to 2.4%, respectively (P < .05). Similarly, readmission increased in a linear fashion from 0.8% to 4.6% (P < .05; Tables 3, 4 and Fig. 2). When controlling for discharge disposition, mFI was found to be a stronger predictor of 30-day readmission than age, as patients with an mFI of 2 or greater had a 2.7 times higher chance of readmission than those with mFI of 0 (OR, 2.7; 95% CI, 1.5–4.9; P < .05), whereas age had an OR of 1.0 (95% CI, 1.0–1.0; P < .05).
      The mFI was the only variable found to be significantly associated with reoperation as mFI of 2 or greater had an OR of 2.7 (95% CI, 1.3–5.7; P < .05) whereas ASA and age were not found to have a significant association with reoperation (OR, 1.4; 95% CI, 0.9–2.2; P =.12; and OR, 1.0; 95% CI, 1.0–1.0; P < .05, respectively) (Table 4).

      Discussion

      As the elderly population continues to grow and remain active, the incidence of distal radius fractures in this population is likely to increase.
      • Christensen K.
      • Doblhammer G.
      • Rau R.
      • Vaupel J.W.
      Ageing populations: the challenges ahead.
      The management of distal radius fractures in this population remains controversial. The 2010 American Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary was “unable to recommend for or against surgical treatment of patients aged >55 years with distal radius fractures… [as] the available evidence does not demonstrate any difference between casting and surgical fixation in patients aged 55 years.”
      • Lichtman D.M.
      • Bindra R.R.
      • Boyer M.I.
      • et al.
      Treatment of distal radius fractures.
      Subsequent studies have continued to demonstrate generally similar functional outcomes when comparing nonsurgical management with surgical fixation.
      • Arora R.
      • Lutz M.
      • Deml C.
      • Krappinger D.
      • Haug L.
      • Gabl M.
      A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older.
      • Diaz-Garcia R.J.
      • Oda T.
      • Shauver M.J.
      • Chung K.C.
      A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly.
      • Ju J.H.
      • Jin G.Z.
      • Li G.X.
      • Hu H.Y.
      • Hou R.X.
      Comparison of treatment outcomes between nonsurgical and surgical treatment of distal radius fracture in elderly: a systematic review and meta-analysis.
      • Chen Y.
      • Chen X.
      • Li Z.
      • Yan H.
      • Zhou F.
      • Gao W.
      Safety and efficacy of operative versus nonsurgical management of distal radius fractures in elderly patients: a systematic review and meta-analysis.
      Despite these controversies, Medicare data suggests a trend toward continued growth in the rate of surgical fixation for the treatment of distal radius fractures in this population.
      • Chung K.C.
      • Shauver M.J.
      • Birkmeyer J.D.
      Trends in the United States in the treatment of distal radial fractures in the elderly.
      In elderly patients, whereas fracture characteristics are important, other factors such as the patient’s functional demands and preexisting comorbidities should play a role in decision-making to mitigate risk.
      • Kodama N.
      • Imai S.
      • Matsusue Y.
      A simple method for choosing treatment of distal radius fractures.
      In this population, multiple studies suggest that fracture reduction and malunion may not correlate with functional outcomes and satisfaction as well as it does in younger patients.
      • Jaremko J.L.
      • Lambert R.G.
      • Rowe B.H.
      • Johnson J.A.
      • Majumdar S.R.
      Do radiographic indices of distal radius fracture reduction predict outcomes in older adults receiving conservative treatment?.
      • Anzarut A.
      • Johnson J.A.
      • Rowe B.H.
      • Lambert R.G.
      • Blitz S.
      • Majumdar S.R.
      Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively treated distal radius fractures.
      • Synn A.J.
      • Makhni E.C.
      • Makhni M.C.
      • Rozental T.D.
      • Day C.S.
      Distal radius fractures in older patients: is anatomic reduction necessary?.
      • Gruber G.
      • Zacherl M.
      • Giessauf C.
      • et al.
      Quality of life after volar plate fixation of articular fractures of the distal part of the radius.
      • Trumble T.E.
      • Schmitt S.R.
      • Vedder N.B.
      Factors affecting functional outcome of displaced intra-articular distal radius fractures.
      With little definitive evidence supporting one treatment strategy over the other, appropriate care should be selected in a shared manner and the patients should be provided current, evidence-based counseling with regards to their individualized risk.
      • Huetteman H.E.
      • Shauver M.J.
      • Nasser J.S.
      • Chung K.C.
      The desired role of health care providers in guiding older patients with distal radius fractures: a qualitative analysis.
      In this, 2 types of risk should be considered. The first is the risk of general adverse medical events (eg, kidney failure, longer total hospitalization) and the second is risk specifically incurred by the surgery (eg, wound complications, reoperation). Although the second type of risk most informs the decision to operate or not, both types are valuable for prognosis and both risks are increased in frail patients.
      This investigation confirmed our hypothesis that the 5-item mFI predicts complications after distal radius fracture and can be used to stratify risk before surgery. We caution readers in their interpretation of the statistical significance of wound, cardiac, and renal complications because the overall incidence of these complications was very low. For this reason, logistic regression could not be performed given a small sample bias. Similarly, although Clavien-Dindo IV complications were significantly higher in frail patients, the 95% CI for this parameter is very wide and it is possible the OR overestimates the actual relative risk. Similarly, the current study reports an increase in hospital LOS with increasing mFI (Fig. 3); however, the large SDs indicate that this difference may be driven by a few large outliers.
      Another important consideration is that the NSQIP database includes only operative patients, and therefore, our study could not directly compare complications in patients treated surgically and nonsurgically. However, and interestingly, in our cohort only 12% of included patients had an mFI score of 2 or greater. Although the proportion of the total population presenting with distal radius fractures and an mFI score of 2 or greater is unknown, this finding may suggest that surgeons are already incorporating a concept of frailty into surgical decision making and are choosing to treat frail patients nonsurgically when possible. Whereas our study also found that patients who were treated on an inpatient basis had higher rates of complications, this was not surprising because these patients also had significantly higher mFI scores. Importantly, our study found no association strictly between age and readmission, reoperation, or postoperative complications.
      We elected to primarily utilize the condensed 5-item mFI for 2 reasons. First, as a matter of practicality, complete data for the 11-item mFI were only available for 1,312 patients compared with the 5-item mFI, which had complete data for 6,423 patients. This required only 71 patients to be excluded for missing data. Second, our goal was to identify a simple, clinically applicable tool that could be reasonably integrated into clinical practice.
      • Chimukangara M.
      • Helm M.C.
      • Frelich M.J.
      • et al.
      A 5-item frailty index based on NSQIP data correlates with outcomes following paraesophageal hernia repair.
      A simple tally of 5 memorable items (Fig. 3) can be used immediately at the patient’s bedside to discuss the appropriate level of risk with each patient. This 5-item index has been used previously and has recently been validated against the 11-item mFI.
      • Subramaniam S.
      • Aalberg J.J.
      • Soriano R.P.
      • Divino C.M.
      New 5-Factor Modified Frailty Index using American College of Surgeons NSQIP Data.
      There are several limitations to this study, many of which are inherent to large database studies and specifically to the NSQIP database.
      • Hentz V.R.
      Commentary regarding "Risk factors for complications following open reduction internal fixation of distal radius fractures" and "Rsk factors for 30-day postoperative complications and mortality following open reduction internal fixation of distal radius fractures.".
      First, the NSQIP database is limited in that it includes outcomes only up to 30 days after surgery, perhaps artificially decreasing the observed complication rate. In addition, many orthopedic outcomes that may be of interest—postoperative range of motion, pain, radiographic alignment, tendon rupture, malunion and nonunion, symptomatic hardware, and others—are not included in the NSQIP database, and therefore, these complications are not captured by our study. In addition, the NSQIP database captures only data for patients treated in a hospital setting (both inpatient and outpatient) and excludes patients who were treated at an ambulatory surgery center. Surgery for distal radius fractures is commonly performed at ambulatory surgery centers, and these patients generally have less major medical comorbidities than those treated in a hospital setting.
      • Crawford D.C.
      • Li C.S.
      • Sprague S.
      • Bhandari M.
      Clinical and cost implications of inpatient versus outpatient orthopedic surgeries: a systematic review of the published literature.
      This represents a potential source of selection bias. Lastly, we chose to analyze our results using mFI cutoffs of 0, 1, and 2 or greater. This was based on precedence in the literature but may limit conclusions that can be made about each individual frailty score.
      • Chimukangara M.
      • Helm M.C.
      • Frelich M.J.
      • et al.
      A 5-item frailty index based on NSQIP data correlates with outcomes following paraesophageal hernia repair.
      In conclusion, although operative fixation of distal radius fractures has a generally low complication rate, frail patients with distal radius fractures are at significantly higher risk for complication. The 5-item mFI is an effective risk assessment tool to guide preoperative counseling and surgical decision making in patients older than 50 years. Additional studies are required to prospectively validate the 5-item mFI and to analyze complications not included in the present study as well as to quantify complication rates past 30 days.

      Acknowledgments

      M.L.S. is a consultant for Miami Device Solutions, Miami, FL.

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