Travis Bailey

Association of a frailty screening initiative with postoperative survival at 30, 180, and 365 days

Importance As the US population ages, the number of operations performed on elderly patients will likely increase. Frailty predicts postoperative mortality and morbidity more than age alone, thus presenting opportunities to identify the highest-risk surgical patients and improve their outcomes. Objective To examine the effect of the Frailty Screening Initiative (FSI) on mortality and complications by comparing the surgical outcomes of a cohort of surgical patients treated before and after implementation of the FSI. Design, Setting, and Participants This single-site, facility-wide, prospective cohort quality improvement project studied all 9153 patients from a level 1b Veterans Affairs medical center who presented for major, elective, noncardiac surgery from October 1, 2007, to July 1, 2014. Interventions Assessment of preoperative frailty in all patients scheduled for elective surgery began in July 2011. Frailty was assessed with the Risk Analysis Index (RAI), and the records of all frail patients (RAI score, ≥21) were flagged for administrative review by the chief of surgery (or designee) before the scheduled operation. On the basis of this review, clinicians from surgery, anesthesia, critical care, and palliative care were notified of the patient’s frailty and associated surgical risks; if indicated, perioperative plans were modified based on team input. Main Outcomes and Measures Postoperative mortality at 30, 180, and 365 days. Results From October 1, 2007, to July 1, 2014, a total of 9153 patients underwent surgery (mean [SD] age, 60.3 [13.5] years; female, 653 [7.1%]; and white, 7096 [79.8%]). Overall 30-day mortality decreased from 1.6% (84 of 5275 patients) to 0.7% (26 of 3878 patients, P < .001) after FSI implementation. Improvement was greatest among frail patients (12.2% [24 of 197 patients] to 3.8% [16 of 424 patients], P < .001), although mortality rates also decreased among the robust patients (1.2% [60 of 5078 patients] to 0.3% [10 of 3454 patients], P < .001). The magnitude of improvement among frail patients increased at 180 (23.9% [47 of 197 patients] to 7.7% [30 of 389 patients], P < .001) and 365 days (34.5% [68 of 197 patients] to 11.7% [36 of 309 patients], P < .001). Multivariable models revealed improved survival after FSI implementation, controlling for age, frailty, and predicted mortality (adjusted odds ratio for 180-day survival, 2.87; 95% CI, 1.98-4.16). Conclusions and Relevance Implementation of the FSI was associated with reduced mortality, suggesting the feasibility of widespread screening of patients preoperatively to identify frailty and the efficacy of system-level initiatives aimed at improving their surgical outcomes. Additional investigation is required to establish a causal connection.

Development and Initial Validation of the Risk Analysis Index for Measuring Frailty in Surgical Populations

Importance Growing consensus suggests that frailty-associated risks should inform shared surgical decision making. However, it is not clear how best to screen for frailty in preoperative surgical populations. Objective To develop and validate the Risk Analysis Index (RAI), a 14-item instrument used to measure surgical frailty. It can be calculated prospectively (RAI-C), using a clinical questionnaire, or retrospectively (RAI-A), using variables from the surgical quality improvement databases (Veterans Affairs or American College of Surgeons National Surgical Quality Improvement Projects). Design, Setting, and Participants Single-site, prospective cohort from July 2011 to September 2015 at the Veterans Affairs Nebraska–Western Iowa Heath Care System, a Level 1b Veterans Affairs Medical Center. The study included all patients presenting to the medical center for elective surgery. Exposures We assessed the RAI-C for all patients scheduled for surgery, linking these scores to administrative and quality improvement data to calculate the RAI-A and the modified Frailty Index. Main Outcomes and Measures Receiver operator characteristics and C statistics for each measure predicting postoperative mortality and morbidity. Results Of the participants, the mean (SD) age was 60.7 (13.9) years and 249 participants (3.6%) were women. We assessed the RAI-C 10 698 times, from which we linked 6856 unique patients to mortality data. The C statistic predicting 180-day mortality for the RAI-C was 0.772. Of these 6856 unique patients, we linked 2785 to local Veterans Affairs Surgeons National Surgical Quality Improvement Projects data and calculated the C statistic for both the RAI-A (0.823) and RAI-C (0.824), along with the correlation between the 2 scores (r = 0.478; P < .001). Of these 2785 patients, there were sufficient data to calculate the modified Frailty Index for 1021, in which the C statistics were 0.865 (RAI-A), 0.797 (RAI-C), and 0.811 (modified Frailty Index). The correlation between the RAI-A and RAI-C was 0.547, and the correlations of the modified Frailty Index to the RAI-A and RAI-C were 0.301 and 0.269, respectively (all P < .001). A cutoff of RAI-C of at least 21 classified 18.3% patients as “frail” with a sensitivity of 0.50 and specificity of 0.82, whereas the RAI-A was less sensitive (0.25) and more specific (0.97), classifying only 3.7% as “frail.” Conclusions and Relevance The RAI-C and RAI-A represent effective tools for measuring frailty in surgical populations with predictive ability on par with other frailty tools. Moderate correlation between the measures suggests convergent validity. The RAI-C offers the advantage of prospective, preoperative assessment that is proved feasible for large-scale screening in clinical practice. However, further efforts should be directed at determining the optimal components of preoperative frailty assessment.

Weightbearing computed tomography of the foot and ankle : emerging technology topical review

In the last decade, cone-beam computed tomography technology with improved designs allowing flexible gantry movements has allowed both supine and standing weight-bearing imaging of the lower extremity. There is an increasing amount of literature describing the use of weightbearing computed tomography in patients with foot and ankle disorders. To date, there is no review article summarizing this imaging modality in the foot and ankle. Therefore, we performed a systematic literature review of relevant clinical studies targeting the use of weightbearing computed tomography in diagnosis of patients with foot and ankle disorders. Furthermore, this review aims to offer insight to those with interest in considering possible future research opportunities with use of this technology. Level of Evidence: Level V, expert opinion.

Total ankle replacement in patients with haemophilic arthropathy: primary arthroplasty and conversion of painful ankle arthrodesis to arthroplasty

There are two general surgical approaches for operative treatment of end‐stage haemophilic ankle arthropathy: ankle arthrodesis and total ankle replacement (TAR).

Conversion of painful tibiotalocalcaneal arthrodesis to total ankle replacement using a 3-component mobile bearing prosthesis

BACKGROUND The aim of this study was to assess the short-term clinical and radiographic outcomes in patients who underwent conversion of a painful tibiotalocalcaneal arthrodesis to a total ankle replacement. METHODS Six patients with painful ankle arthrodesis after tibiotalocalcaneal arthrodesis were included in this study. In all patients, conversion to total ankle replacement was performed using a 3rd-generation, non-constrained, cementless three-component prosthesis. The outcomes were analyzed at a mean follow-up of 3.4±1.9years (range 1.0-6.5). RESULTS One patient with painful arthrofibrosis underwent two open arthrolysis procedures at 1.2 and 5.6 years post index surgery, respectively. No revision of tibial or talar prosthesis components was necessary in this study. All patients reported significant pain relief and significant improvement in functional status. CONCLUSION In the present study, the conversion of a painful ankle arthrodesis following tibiotalocalcaneal arthrodesis to a total ankle replacement was a reliable surgical treatment.

Using a Modified Frailty Index to Predict Mortality Risk after Tracheostomy

Objectives: Evaluate the utility of a modified frailty index to predict post-operative mortality in patients undergoing tracheostomy. Methods: A retrospective chart review was conducted including all patients who underwent tracheostomy between 2007 and 2012. A modified frailty index consisting of 11 items based on the Revised Minimum Data Set Mortality Rating Index was retrospectively applied using the patients’ status immediately prior to tracheostomy. The resultant 6-month predicted mortality was compared to the Veterans Health Administration Surgical Quality Improvement Program’s (VASQIP) 30-day predicted mortality as well as actual mortality. Results: A total of 100 patients underwent tracheostomy during the study period. No patients were excluded. Sixty-nine patients died within the study period. The 1, 6, and 12-month mortality rates after tracheostomy were 25%, 43%, and 59% respectively. The predicted 30-day mortality risk was 9.1% for non-survivors compared to 5.2% for survivors (p = 0.05). The predicted 6-month mortality risk was 40.5% for non-survivors compared to 25.4% for survivors (p = 0.0003). The VASQIP calculator and modified frailty index both differentiated mortality risks between patients who survived less than 6 months versus greater than 6 months (p = 0.004 and 0.001, respectively). However, neither the VASQIP or modified frailty index differentiated mortality risks for head and neck cancer patients who survived less than 6 months versus greater than 6 months (p = 0.46 and 0.13, respectively). Conclusions: The modified frailty index identifies non-cancer patients at high risk of post-operative mortality after tracheostomy but does not identify high-risk patients with head and neck cancer.