Is Frailty Associated with Adverse Events after Total Joint Arthroplasty?

Lisa A. Mandl^1,2, Abigail M. Schmucker³, Nathaniel Hupert⁴, Mayu Sasaki³, Charles N. Cornell^5,6, Michael B. Cross^5,6, Alejandro Gonzalez Della Valle^5,6, Mark P. Figgie^6,7, Seth A. Jerabek^5,6, Jackie Szymonifka¹ and Steven K. Magid^8,9, ¹Rheumatology, Hospital for Special Surgery, New York, NY, ²Medicine - Rheumatology, Weill Cornell Medicine, New York, NY, ³Quality Research Center, Hospital for Special Surgery, New York, NY, ⁴Medicine, Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, ⁵Surgery, Hospital for Special Surgery, New York, NY, ⁶Surgery, Weill Cornell Medicine, New York, NY, ⁷Orthopaedics, Hospital for Special Surgery, New York, NY, ⁸Medicine - Rhuematology, Hospital for Special Surgery, New York, NY, ⁹Medicine, Weill Cornell Medicine, New York, NY

Meeting: 2017 ACR/ARHP Annual Meeting

Date of first publication: September 18, 2017

Keywords: activities of daily living (ADL), complications, outcomes and total joint replacement, PROMIS

Session Information

Date: Tuesday, November 7, 2017

Title: Orthopedics, Low Back Pain and Rehabilitation

Session Type: ACR Concurrent Abstract Session

Session Time: 4:30PM-6:00PM

Background/Purpose: The increased volume of TJA due to the aging population requires a better understanding of the effect of physiological frailty, in addition to chronological age, on TJA-associated complications. If frailty is associated with poor outcomes, it is potentially modifiable.

Methods: Community-dwelling patients ≥65yo scheduled for elective total knee (TKA) or hip (THA) arthroplasty were recruited from a musculoskeletal specialty hospital. All patients were medically approved for surgery. Pre-operative frailty was defined as at least 3/7 frailty characteristics based on the Fried frailty phenotype and a composite frailty score previously validated in surgical populations (Table 1). Pre-operatively subjects completed the PROMIS-29, SF-12, Depression Screening (CES-D 10), Lubben Social Network Scale (LSNS-18), Katz Index of Independence in Activities of Daily Living (ADL), and Hip/Knee Injury and Osteoarthritis Outcome Score (HOOS/KOOS). Grip strength was measured and normalized by age and gender. Adverse events were obtained from medical records and by phone 30 days post-discharge. Stepwise multivariable logistic regressions were performed to ascertain if frailty, or any of its components, were independent risk factors for short-term adverse events (AEs).

Results: 464 subjects enrolled (mean age 73 (range 65-94), 95% white, 61% female, 60% TKA, 40% THA). 8% were frail (9% THA, 8% TKA). 17% had difficulty with at least 1 Katz ADL (14% THA, 19%TKA).

Among patients who reached 30-day follow-up, 180/373 (48%) had 263 AEs and 35/373 (9%) had 51 severe AEs. There were no significant differences in AEs or severe AEs between frail and non-frail patients. Controlling for gender, age, and which joint was replaced, independent predictors of having ≥1 AEs included pre-operative anemia (OR=3.14; 95% CI 1.08-9.15) and PROMIS-29 Anxiety (OR=1.05; 95% CI 1.02-1.08). Having a hip rather than knee replaced decreased the risk of severe AEs (OR=0.39; 95% CI 0.17-0.88).

For THA patients, older age was associated with increased risk of AEs (OR=1.07; 95% CI 1.01-1.13), while better SF-12 PCS was protective (OR=0.94; 95% CI 0.90-0.98).

For TKA patients, a higher PROMIS Anxiety score was associated with an increased risk of AEs (OR=1.04; 95% CI 1.003-1.08). Having ≥1 Katz ADL dependency was associated with an increased risk of severe AEs (OR=2.51; 95% CI 1.03-6.11).

Our composite measure of frailty did not predict AEs in any model.

Conclusion: A substantial proportion of medically-cleared TJA patients at this high-volume center were frail. Having ADL dependency was associated with a 2.5x increased risk of severe AEs among TKA. Whether frailty is associated with long-term AEs, pain, or function needs to be established in longitudinal trials.

Table 1: Frailty Characteristics
	Total Hip Replacement (N=277)	Total Knee Replacement (N=187)	All (N=464)
Individual Frailty Characteristics, %	2.7	2.6	2.6
Unintentional weight loss of ≥ 10lbs in last year	2.7	2.6	2.6
≥1 Dependency on the Katz ADL	13.5	18.5	16.5
Weakness (grip strength >1 SD below mean for age/gender norm)	33.2	39.4	36.9
Anemia (pre-operative hematocrit <35%)	6.1	5.8	6.0
Poor nutrition (pre-operative albumin <3.4 g/dL)*	0	0	0
≥1 falls in past 6 months	16.6	14.2	15.2
Exhaustion (answered “moderate” or “most” for CES-D 10 questions about effort and getting going)	29.5	20.4	24.0
Frailty: >3 characteristics, %	8.6	8.1	8.3

* 277/464 (115 THA, 162 TKA) patients had albumin levels recorded.

Disclosure: L. A. Mandl, None; A. M. Schmucker, None; N. Hupert, None; M. Sasaki, None; C. N. Cornell, Exactech, 5,HSS Journal, 6; M. B. Cross, Acelity, 5,Acelity Surgical Advisory Board, 5,Bone and Joint Journal 360, 6,Exactech, Inc, 5,Intellijiont, 5,Intellijoint, 1,Journal of Orthopaedics and Traumatology, 6,Link Orthopaedics, 5,Smith & Nephew, 5,Techniques in Orthopaedics, 6,Theravance Biopharma, 5,Zimmer, 5; A. Gonzalez Della Valle, None; M. P. Figgie, Lima, 7,Mekanika, 1; S. A. Jerabek, Stryker, 5; J. Szymonifka, None; S. K. Magid, None.

To cite this abstract in AMA style:

Mandl LA, Schmucker AM, Hupert N, Sasaki M, Cornell CN, Cross MB, Gonzalez Della Valle A, Figgie MP, Jerabek SA, Szymonifka J, Magid SK. Is Frailty Associated with Adverse Events after Total Joint Arthroplasty? [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). https://acrabstracts.org/abstract/is-frailty-associated-with-adverse-events-after-total-joint-arthroplasty/. Accessed .

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