Frailty Indices Versus Historic Risk Proxies To Predict 30-day Postsurgical Complications After Upper Extremity Tendon Reconstruction: A 4,250-patient Database Study
Arya A. Akhavan, MD1, Helen Liu, BS2, Eric Alerte, BS2, Taylor Ibelli, BS, MSc2, Suhas K. Etigunta, BS2, Abigail Katz, BS2, Annet S. Kuruvilla, BS3, Peter J. Taub, MD, FACS, FAAP2.
1Johns Hopkins Hopsital, Baltimore, MD, USA, 2Icahn School of Medicine at Mount Sinai, New York, NY, USA, 3Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA.
Upper extremity trauma may occur in patients with a wide range of demographics and comorbidities. Traumatic tendon injury in the hand, while potentially soft tissue-sparing, is nonetheless associated with significant postoperative recovery and functional deficit. Complications during the recovery period, such as infection, may place repairs at risk of rupture or adhesion. As such, predicting 30-day postoperative complications in upper extremity tendon repair is valuable. Historical risk proxies include smoking status, extreme age, and male gender, but recent orthopedic surgery literature suggests frailty measures such as the modified Charlson Comorbidity Index (mCCI) may be stronger predictors. The modified 5-item frailty index (mFI-5), another frailty measure, has been shown to be a strong predictor of 30-day postsurgical complications after open distal radius fracture treatment, using the American College of Surgeonsí National Surgical Quality Improvement Program (NSQIP) database. The authors hypothesized that the mFI-5 and mCCI are more predictive of 30-day postoperative complications in upper extremity tendon reconstruction, as compared to historic risk proxies.
A retrospective review was performed of all patients from the NSQIP database who underwent upper extremity tendon reconstruction between January 1st, 2013 and December 31st, 2019. Patients with hand/wrist flexor tendon, extensor tendon, and pulley repairs were included. Patients were excluded if a concurrent procedure other than upper extremity tendon repair was performed. The mFI-5 and mCCI scores were calculated for each patient, and complications data were recorded. Age, BMI, number of major comorbidities, ASA class, mFI-5 score, and mCCI score were compared as predictors of all-cause 30-day complications, 30-day surgical site complications of any kind, length of stay, and aggregate Clavien-Dindo complication severity score, using univariate and multivariate logistic regression (p<0.05).
A total of 4,250 patients were analyzed. The strongest predictor for all-cause complications was an ASA class of 4, followed by ≥3 major comorbidities, an ASA class of 3, and an mFI-5 score of ≥2. The strongest predictors of surgical site complications were an ASA class of 3, 2 major comorbidities, and smoking status. The strongest predictors of complication severity were ASA class ≥4, ≥3 major comorbidities, and an mFI-5 score of ≥2. Association with overnight stay or admission was strongest with ASA class ≥4 and an mCCI score of ≥4. Age was not a significant predictor of any outcome measure studied.
Frailty measures, such as the mFI-5 and mCCI, are stronger predictors than age, with respect to postsurgical complications after upper extremity tendon reconstruction. Further work is necessary to appropriately characterize the value of ASA classification as a risk assessment measure, as many patients with a high class may have concurrent traumatic injuries. The impact of specific components of the mFI-5 score and mCCI score on postoperative complication risk remains unclear.
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