JAAOS - 2026-06-23 - Journal Article
Frailty is a Vital Tool for Predicting Outcomes Following Prophylactic Femur Fixation.
Sbaih O, Koltenyuk V, Gupta N, Dixon L, Gill V, Ogburn M, Williamson TK, Alderete J
Topics
Key Takeaway
Each 1-point increase in RAI-rev independently raised 30-day mortality odds by 5% (OR 1.05), and RAI-rev outperformed mFI-5 for mortality discrimination (C-statistic 0.73 vs. 0.57) in patients undergoing prophylactic femoral fixation for metastatic disease.
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Summary
This study used ACS-NSQIP (2015–2020) to evaluate whether preoperative frailty—measured by RAI-rev and mFI-5—predicts 30-day adverse outcomes in patients undergoing prophylactic vs. pathologic femoral fixation for metastatic disease. After propensity score matching on age, BMI, sex, functional status, and ASA class, pathologic fracture fixation carried 2.79× higher 30-day mortality odds vs. prophylactic fixation (OR 2.79, 95% CI 1.61–4.82). RAI-rev demonstrated superior mortality discrimination (C-statistic 0.73) compared to mFI-5 (C-statistic 0.57, P<0.001), and each 1-point RAI-rev increase corresponded to a 5% incremental mortality risk increase.
Key Limitation
NSQIP does not capture tumor type, Mirels score, implant construct, adjuvant radiation, or systemic oncologic therapy, making it impossible to control for disease-specific variables that independently drive outcomes in this population.
Original Abstract
BACKGROUND
Frailty measures have become increasingly common in the literature as proposed mechanisms for identifying patients at risk of adverse postoperative outcomes. Prophylactic femur fixation in patients with metastatic disease can prevent future fracture and improve quality of life; however, these patients are inherently high-risk surgical candidates. The role of this study is to characterize the relationship between frailty and postoperative outcomes in patients undergoing prophylactic femoral fixation (ProphFF) and compare the predictive ability of different frailty measures for adverse outcomes in this population.
METHODS
Data from the 2015 to 2020 American College of Surgeons National Surgical Quality Improvement Program database was used. The study focused on patients aged ≥18 years undergoing ProphFF and those undergoing PathFF. Frailty was measured using both the revised Risk Analysis Index (RAI-rev) and the five-factor modified Frailty Index (mFI-5). Primary outcomes included 30-day mortality, major complications, unplanned readmission, and unplanned revision surgery, nonhome discharge, and extended length of stay. Propensity score matching was employed to adjust for baseline differences of age, body mass index, sex, functional status, and ASA between ProphFF and PathFF groups. Statistical methods included multivariable logistic regression and receiver operating characteristic curve analysis to evaluate the relationships between frailty measures and postoperative outcomes.
RESULTS
A total of 921 patients (57.7% female, median age 65 years [IQR, 56 to 72 years]) undergoing ProphFF or PathFF were included. Multivariable analysis demonstrated that increasing frailty increased odds of 30-day mortality, with each 1-point increase in RAI-rev and mFI-5 associated with a 5% (OR: 1.05, 95% CI, 1.01 to 1.08; P < 0.01) and 31% (OR: 1.31, 95% CI, 1.01 to 1.71; P < 0.05) higher mortality risk, respectively. Propensity score matching resulted in 842 patients (421 prophylactic and 421 pathologic). Patients undergoing PathFF had higher likelihood of mortality compared with patients undergoing ProphFF (OR: 2.79, 95% CI, 1.61 to 4.82; P < 0.01). RAI-rev (C-statistic 0.73 [95% CI, 0.71 to 0.75]) had superior discrimination for mortality compared with mFI-5 (C-statistic 0.57 [95% CI, 0.54 to 0.59], P < 0.001).
DISCUSSION
Increasing preoperative frailty scores, particularly as measured by the revised Risk Analysis Index, were independent predictors of mortality and morbidity in patients undergoing prophylactic femur fixation. Pathologic fracture fixation demonstrated higher risk of revision surgery and mortality compared with prophylactic fixation. These findings suggest that the RAI-rev may be a valuable tool for identifying high-risk patients and optimizing surgical candidate selection before prophylactic femur fixation, potentially improving outcomes in this complex patient population.