Preoperative frailty assessment with ultrasound in elderly patients scheduled for total knee arthroplasty.

BACKGROUND: Frailty, a decline in physical and cognitive reserve capacity, renders patients susceptible to various stressors and has been linked to adverse outcomes and increased healthcare utilization. This study aimed to determine whether ultrasound measurements of the rectus abdominis (RA) and biceps brachii (BB) could predict frailty in patients scheduled for total knee arthroplasty. METHODS: Frailty was assessed using the Clinical Frailty Scale in adults aged ≥60 years. Ultrasound measurements of the rectus abdominis, BB, and quadriceps femoris muscles, along with thigh circumference measurements, were obtained before surgery. The predictive ability of the unadjusted and BMI- and body surface area (BSA)-adjusted measurements were evaluated using receiver operating characteristic curve analysis and area under the curve (AUC) values. Postoperative outcomes, such as admission to the intensive care unit or skilled nursing facility, delirium, falls, re-hospitalization, and 30-day mortality were recorded. RESULTS: We analyzed data from 148 patients. BB thickness provided a fair prediction of frailty. Average measurements of both BB adjusted for BMI (0.708, 95% CI 0.602-0.814; P<0.001), and BSA (0.708, 95% CI 0.598-0.817; P<0.001) had the highest AUC values. RA muscle measurements could not discriminate frailty. The BMI-adjusted measurements for: right quadriceps femoris thickness (AUC 0.614, 95% CI 0.503-0.725; P=0.044), left thigh circumference (AUC 0.648, 95% CI 0.528-0.769; P=0.016), and average thigh circumference (AUC 0.630, 95% CI 0.511-0.750; P=0.033) had statistically significant but poor AUC values. CONCLUSIONS: Preoperative ultrasound measurements of the bilateral BB can fairly predict frailty in patients scheduled for total knee arthroplasty.

The relationship between urinary incontinence and abdominal muscle thickness in community-dwelling older women undergoing comprehensive geriatric assessment.

PURPOSE: Urinary incontinence (UI) is one of the most common geriatric syndromes in older adults, especially in women. The aim of this study is to show the relationship between urinary incontinence and abdominal muscle thickness measured by muscle ultrasonography (US) in community-dwelling older women adults. METHODS: Eighty-seven community-dwelling older women participated in our study. The presence and the type of UI were recorded. Clinical and demographic characteristics were collected, and a comprehensive geriatric assessment was performed on all participants. Abdominal muscle layer thicknesses were evaluated with muscle US. RESULTS: The prevalence of UI was 55.2% (n = 48) of the study population. The median [IQR] age of the patients in the UI group was 73.0 [69.0-77.5] years and it was 69.0 [67.0-73.0] years in patients without UI (p = 0.007). Abdominal muscle thicknesses were measured smaller in patients with UI than those without UI except for internal oblique muscle thickness. The median [IQR] rectus abdominis muscle thickness was lower in patients with UI than in patients without UI, and the difference was statistically significant (p < 0.003). RA muscle was associated with UI regardless of age, polypharmacy, malnutrition, and frailty (OR: 0.58; 95% CI 0.38-0.89; p = 0.01). CONCLUSIONS: We have shown that UI was independently related to the rectus abdominis muscle thickness, which may reflect the function and mass of the pelvic floor muscles.

Computed tomography-based body composition profile as a screening tool for geriatric frailty detection.

OBJECTIVE: To assess prevalence of CT imaging-derived sarcopenia, osteoporosis, and visceral obesity in clinically frail and prefrail patients and determine their association with the diagnosis of frailty. MATERIALS AND METHODS: This cross-sectional study was constructed using our institution's pelvic trauma registry and ambulatory database registry. The study included all elderly pelvic trauma patients and ambulatory outpatients between May 2016 and March 2020 who had a comprehensive geriatric assessment and CT abdomen/pelvis within 1 year from the date of the assessment. Patients were dichotomized in prefrail or frail groups. The study excluded patients with history of metastatic disease or malignancy requiring chemotherapy. RESULTS: The study cohort consisted of 151 elderly female and 65 male patients. Each gender population was subdivided into frail (114 female [75%], 51 male [78%]) and prefrail (37 female [25%], 14 male [22%]) patients. CT-imaging-derived diagnosis of osteoporosis (odds ratio, 2.5; 95% CI: 1.2-5.5) and sarcopenia (odds ratio, 2.6; 95% CI: 1.2-5.6) were associated with frailty in females, but did not reach statistical significance in males. BMI and subcutaneous adipose tissue at L3 level were statistically lower in the frail male group compared to the prefrail group. BMI showed strong correlation with the subcutaneous area at the L3 level in both genders (Spearman's coefficient of 0.8, p < 0.001). Hypoalbuminemia and visceral obesity were not associated with frailty in either gender. CONCLUSION: This proof-of-concept study demonstrates the feasibility of using CT-derived body-composition parameters as a screening tool for frailty, which can offer an opportunity for early medical intervention.

Preoperative Point-of-Care Ultrasound to Identify Frailty and Predict Postoperative Outcomes: A Diagnostic Accuracy Study.

BACKGROUND: Frailty is increasingly being recognized as a public health issue, straining healthcare resources and increasing costs to care for these patients. Frailty is the decline in physical and cognitive reserves leading to increased vulnerability to stressors such as surgery or disease states. The goal of this pilot diagnostic accuracy study was to identify whether point-of-care ultrasound measurements of the quadriceps and rectus femoris muscles can be used to discriminate between frail and not-frail patients and predict postoperative outcomes. This study hypothesized that ultrasound could discriminate between frail and not-frail patients before surgery. METHODS: Preoperative ultrasound measurements of the quadriceps and rectus femoris were obtained in patients with previous computed tomography scans. Using the computed tomography scans, psoas muscle area was measured in all patients for comparative purposes. Frailty was identified using the Fried phenotype assessment. Postoperative outcomes included unplanned intensive care unit admission, delirium, intensive care unit length of stay, hospital length of stay, unplanned skilled nursing facility admission, rehospitalization, falls within 30 days, and all-cause 30-day and 1-yr mortality. RESULTS: A total of 32 patients and 20 healthy volunteers were included. Frailty was identified in 18 of the 32 patients. Receiver operating characteristic curve analysis showed that quadriceps depth and psoas muscle area are able to identify frailty (area under the curve-receiver operating characteristic, 0.80 [95% CI, 0.64 to 0.97] and 0.88 [95% CI, 0.76 to 1.00], respectively), whereas the cross-sectional area of the rectus femoris is less promising (area under the curve-receiver operating characteristic, 0.70 [95% CI, 0.49 to 0.91]). Quadriceps depth was also associated with unplanned postoperative skilled nursing facility discharge disposition (area under the curve 0.81 [95% CI, 0.61 to 1.00]) and delirium (area under the curve 0.89 [95% CI, 0.77 to 1.00]). CONCLUSIONS: Similar to computed tomography measurements of psoas muscle area, preoperative ultrasound measurements of quadriceps depth shows promise in discriminating between frail and not-frail patients before surgery. It was also associated with skilled nursing facility admission and postoperative delirium.

Impact of Total Psoas Area and Lean Muscular Area on Mortality after Endovascular Aortic Aneurysm Repair.

BACKGROUND: Sarcopenia has assumed growing relevance as a morbimortality predictor after major abdominal surgery. The aim of this study is to access total psoas muscle area (TPA) and lean muscle area (LMA) impact in morbimortality after elective endovascular abdominal aortic aneurysm repair (EVAR). METHODS: Asymptomatic patients submitted to aortic endoprosthesis implantation between January 1, 2014 and December 31, 2018 at our vascular surgery department were retrospectively evaluated. After exclusion criteria were applied, 105 patients were included in the study; preoperative computed tomography scans were evaluated using OSIRIX software (Bernex, Switzerland). Two observers independently calculated TPA at the most caudal level of the L3 vertebra and respective density, therefore calculating LMA. Patients were separated by tertiles with the lowest being considered sarcopenic and with higher muscle steatosis and compared with the higher tertiles. Patient demographics and intraoperative and postoperative period variables were collected. Charlson comorbidity index was calculated and surgical complications classified according to Clavien-Dindo. The intraclass correlation coefficient and Bland-Altman plot were made to characterize interobserver variability. Survival analysis was performed with the Kaplan-Meier method, and differences between survival curves were tested with the log-rank test. The effect of sarcopenia on patient survival was assessed using Cox proportional hazard models. RESULTS: Considering TPA, univariate analyses revealed that patients in the lower tertile had inferior survival (P = 0.03), whereas multivariate analyses showed increased likelihood of mortality (P = 0.039, hazard ratio (HR) 3.829). For LMA, univariate analyses revealed that patients in the lower tertile had inferior survival (P = 0.013), whereas multivariate analyses showed increased likelihood of mortality (P = 0.026, HR 4.153). When analyzing patients in the lowest tertile of both TPA and LMA, both univariate (P = 0.002) and multivariate (P = 0.018, HR 4.166) analyses reveled inferior survival. CONCLUSIONS: Our study reveals reduced survival in patients with low TPA and low LMA submitted to elective EVAR; these factors should probably be taken into consideration in the future for preoperative risk evaluation and surgical planning.

Role of Frailty and Comorbidity Status in Predicting Morbidity and Mortality in Patients with Acute Mesenteric Ischemia.

BACKGROUND: This study was performed to determine the association of frailty and comorbidity status with postoperative morbidity and mortality in patients with acute mesenteric ischemia (AMI). METHODS: Patients diagnosed with AMI between April 2006 and September 2019 were enrolled in this study. Frailty was evaluated by sarcopenia which was diagnosed by third lumbar vertebra psoas muscle area (PMA). Comorbidity status was evaluated by the Charlson Comorbidity Index (CCI) score. Univariate and multivariate analyses evaluating the risk factors for postoperative morbidity and mortality were performed. RESULTS: Of the 174 patients, 86 were managed conservatively and 88 underwent surgery. In surgically managed patients, 39.8% developed complications within 30 days of surgery. Ten patients died within 30 days of the operation. In the univariate analyses, white blood cell >10 g/L, low PMA, CCI score ≥2, and bowel resection were associated with postoperative complications. Multivariate analysis revealed that low PMA, CCI score ≥2, and bowel resection were independent predictors of postoperative complications. CONCLUSIONS: This study demonstrated that low PMA, CCI score ≥2, and bowel resection were independent risk factors for postoperative complications in patients with AMI. Preoperative assessment of frailty using PMA and the evaluation of comorbidity status using CCI may serve as helpful tools in preoperative risk assessment and should be integrated into scoring systems for surgically treated AMI.

FGF23-related hypophosphatemia in patients with low bone mineral density and fragility fractures: challenges in diagnosis and management.

PURPOSE: Hypophosphatemia (HP) can be observed in patients evaluated for skeletal fragility. We investigated prevalence of HP among outpatients referred for low bone density or fragility fractures, HP-associated clinical and biochemical features and outcomes of recommended diagnostic algorithm in our cohort. METHODS: Chronic HP (phosphate ≤ 2.7 mg/dL over 6 months or longer) was retrospectively investigated among 2319 patients. In renal wasting-related HP, intact FGF23 was assessed; non-suppressed FGF23 prompted the performance of 68Ga-DOTATOC PET/CT in the suspicion of tumor-induced steomalacia (TIO). RESULTS: Renal wasting-related HP (median 2.2, range 1.6-2.6 mg/dL) was observed in 19 patients (0.82%). FGF23 levels were suppressed in two patients diagnosed with renal tubular disease, increased in one and within normal range in most patients. X-linked hypophosphatemic rickets was diagnosed in one woman. In the remaining 16 patients, highly prevalent fragility fractures (50%) and severely reduced bone mineral density were detected, though diagnostic criteria for osteomalacia were not fulfilled. 68Ga-PET was performed in nine patients and was positive in four. While intact FGF23 levels alone failed to differentiate PET's outcomes (positive: FGF23 median 70.5 pg/mL; negative: 52 pg/mL, P = 0.462), the coexistence of multiple biochemical and radiologic alterations performed better in prediction of PET's positivity. CONCLUSION: Mild, apparently unexplained HP is observed in 0.82% of patients with low bone density or fragility fractures. In asymptomatic patients with isolated mild hypophosphatemia, the probability of finding an underlying tumor disease is very low, and utility of extensive and expensive diagnostic workup should be carefully considered in this setting.

Effect of Low Skeletal Muscle Mass on Post-operative Survival of Patients With Abdominal Aortic Aneurysm: A Prognostic Factor Review and Meta-Analysis of Time-to-Event Data.

OBJECTIVE/BACKGROUND: Low psoas muscle mass is associated with increased mortality and morbidity after surgery. Recent evidence has linked low psoas muscle mass with survival after abdominal aortic aneurysm (AAA) repair. The aim of this study was to investigate the prognostic role of low skeletal muscle mass in survival of patients with AAA undergoing open or endovascular aneurysm repair (EVAR). METHODS: A review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO registration number: CRD42018107793). The prognostic factor of interest was degenerative loss of skeletal muscle. A time-to-event data meta-analysis was performed for all cause mortality using the inverse variance method and the results were reported as summary hazard ratio (HR) and 95% confidence interval (CI). Pooled estimates of peri-operative outcome data were calculated using the odds ratio (OR) or risk difference (RD) and 95% CI. Random-effects models of meta-analysis were applied. RESULTS: Seven observational cohort studies reporting a total of 1,440 patients were eligible for quantitative synthesis. Patients with low skeletal muscle mass had a significantly higher hazard of mortality than those without low skeletal muscle mass (HR 1.66, 95% CI 1.15-2.40; p = .007). Subgroup analysis including only patients who underwent EVAR showed a marginal survival benefit for patients without low skeletal muscle mass (HR 1.86, 95% CI 1.00-3.43; p = .05). Meta-analysis of two studies found no significant difference in peri-operative mortality (RD 0.04, 95% CI -0.13 to 0.21) and morbidity (OR 1.58, 95% CI 0.90-2.76; p = .11) between patients with and without low skeletal muscle mass. CONCLUSION: There is a significant link between low skeletal muscle mass and mortality in patients undergoing AAA repair. Prospective studies validating the use of body composition for risk prediction after aortic surgery are required before this tool can be used to support decision making and patient selection.

Derivation and validation of thoracic sarcopenia assessment in patients undergoing thoracic endovascular aortic repair.

OBJECTIVE: Sarcopenia, as assessed by computed tomography (CT)-based measurements of muscle mass, is an objective and patient-specific indicator of frailty, which is an important predictor of operative morbidity and mortality. Studies to date have primarily focused on psoas-defined sarcopenia, which may not be valid among patients with thoracic aortic disease. Using psoas sarcopenia as the reference for sarcopenia, the purpose of this study was to create and to validate a new thoracic-level method of measuring sarcopenia as a novel method to assess frailty among patients undergoing thoracic endovascular aortic repair. METHODS: Prospectively collected data of patients undergoing thoracic endovascular aortic repair for thoracic aortic dissection, aneurysm, or injury using a conformable thoracic graft were reviewed. Patients with preoperative abdominal and thoracic CT imaging were included. Thoracic muscle mass was measured on axial images at the T12 level using our newly established standardized computer-assisted protocol. Psoas sarcopenia was measured at the L3 level using standard methods. Optimal sex-specific diagnostic T12 measurements were determined by receiver operating characteristic (ROC) curve analysis. A subset of scans were reviewed in duplicate by two trained observers and intraobserver and interobserver reliability tested by intraclass correlation coefficient. Agreement between T12 and L3 sarcopenia was tested by Cohen κ (scale, 0-1). RESULTS: There were 147 patients included for analysis, including 34 dissection, 80 trauma, and 33 aneurysm patients. ROC curve analysis yielded sarcopenic cutoff values of 106.00 cm2/m2 for women and 110.00 cm2/m2 for men at the T12 level. Based on ROC curve analysis, overall accuracy of T12 measurements was high (area under ROC curve, 0.91 for men and 0.90 for women). Quantitative interobserver and intraobserver reliability yielded excellent intraclass correlation coefficient values (>0.95). Qualitative interobserver reliability yielded nearly perfect Cohen κ values (>0.85). Qualitative intraobserver reliability of calculating sarcopenia at both the T12 and L3 levels was fair for both readers (0.361 and 0.288). There was additionally a general correlation between changes in muscle area at L3 with changes at T12 during 48 months. CONCLUSIONS: Thoracic sarcopenia can be readily and reliably reproduced from CT-derived measurement of T12-level muscle area. This approach may be used as an alternative method to objectively define sarcopenia in patients without abdominal CT imaging. Future studies to assess the predictability of thoracic vs abdominal sarcopenia on postoperative outcomes will enhance the utility of these tools.

Association between frailty and bone loss in patients undergoing maintenance hemodialysis.

Frailty is significantly associated with bone loss in the general population. However, it is unclear whether this association also exists in patients undergoing hemodialysis who have chronic kidney disease-mineral and bone disorder (CKD-MBD). This study aimed to assess the association between frailty and bone loss in patients undergoing hemodialysis. This cross-sectional study included 214 (90 women, 124 men) Japanese outpatients undergoing maintenance hemodialysis three times per week, with a mean age of 67.1 years (women) and 66.8 years (men). Frailty was defined based on criteria set forth by the Cardiovascular Health Study (CHS)-19 (21.1%) women and 47 (37.9%) men were robust, 41 (45.6%) women and 43 (34.7%) men were pre-frail, and 30 (33.3%) women and 34 (27.4%) men were frail. For bone mass, quantitative ultrasound (QUS) parameters (speed of sound, broadband ultrasound attenuation, stiffness index) of the calcaneus were measured. The association between frailty and QUS parameters was determined separately for women and men using multivariate analysis of covariance (ANCOVA), with adjustments for clinical characteristics including age, body mass index, hemodialysis vintage, diabetes, current smoking, serum albumin, phosphate, corrected calcium, intact parathyroid hormone, and medication for CKD-MBD (vitamin D receptor activator, calcimimetics). ANCOVA revealed that all QUS parameters declined significantly with increasing levels of frailty in both sexes (P < 0.05). In conclusion, frailty (as defined by CHS criteria) should be considered a risk factor for bone loss in patients undergoing hemodialysis.

The association between brain volume, cortical brain infarcts, and physical frailty.

Physical frailty is an age-associated syndrome of decreased reserve leading to vulnerability to physiological stressors and associated with negative outcomes. The underlying structural brain abnormalities of physical frailty are unclear. We investigated the association between brain volume, cortical brain infarcts, and physical frailty. In this multicenter study, 214 nondemented participants were classified as frail (n = 32), prefrail (n = 107), or nonfrail (n = 75) based on the Fried frailty phenotype. The associations between frailty and brain volumes and cortical brain infarcts were investigated by linear or logistic regression analyses. Participants in the frail group showed a lower total brain volume (-19.67 mL [95% confidence interval -37.84 to -1.50]) and lower gray matter volume (-12.19 mL [95% confidence interval -23.84 to -0.54]) compared to nonfrail participants. Frailty was associated with cortical brain infarcts [frail 16% [n = 5], prefrail 11% [n = 12], and nonfrail 3% [n = 2]). Reduced total brain volume and gray matter volume and increased cortical brain infarcts seem therefore to be part of the structural substrate of the physical frailty phenotype.

Impact of frailty on complications in patients with thoracic and thoracolumbar spinal fracture.

OBJECTIVES: It is well-documented that geriatric patients are at risk for serious injuries after fracture due to pre-existing medical conditions, physical changes of aging, and medication effects. Frailty has been demonstrated to be a predictor of morbidity and mortality in inpatient head and neck surgery, and for surgical intervention for adult spinal deformity and degenerative spine disease. However, the impact of frailty on complications following thoracolumbar/thoracic fractures are unknown and has not been previously assessed in the literature, particularly in a nationwide setting. PATIENTS AND METHODS: This was a retrospective study of the prospectively-collected American College of Surgeons National Surgical Quality Improvement database for the years 2007 through 2012. Patients who underwent spinal decompression (+/- fusion) or an alternative intervention, defined as vertebroplasty or kyphoplasty (VP/KP) for thoracic or thoracolumbar fracture were identified. Frailty status was determined using a modified frailty index from the Canadian Study of Health and Aging Frailty Index, with frailty defined as a score = 0.27. 30-day morbidity and mortality were compared between frail and non-frail patients in each treatment group. RESULTS: A total of 303 patients were included in this study. Of these, 38% of patients had VP/KP and 62% underwent surgery. Within the VP/KP cohort, 26% were frail. The proportion of these patients who developed at least one complication was 3.3% versus 3.6% for non-frail patients (p = 1.0). The 30-day mortality for frail versus not frail patients in this cohort was 0% versus 2.4% (p = 1.0). Among the surgical group, 13% were frail. In contrast, the likelihood of complications was 33.3% among frail patients and 4.2% for non-frail patients (p < 0.001). Frail patients also had a 16.7% 30-day mortality rate as compared to 0.6% in the non-frail group (p = 0.001). When comparing the frail versus non-frail patients overall, frail patients had a complication rate of 16.7%, as opposed to 4.0% in non-frail patients. CONCLUSION: Frailty and surgical intervention are correlated with a higher 30-day complication rate in patients with thoracic and thoracolumbar fracture. This finding is an important consideration for surgical decision-making and patient counseling on treatment options.

Is sarcopenia a useful predictor of outcome in patients after emergency laparotomy? A study using the NELA database.

Introduction Studies have reported on the use of frailty as a prognostic indicator in patients undergoing elective surgery. Similar data do not exist for patients undergoing emergency surgery. The aim of this study was to evaluate the effect of preoperative sarcopenia measured by computed tomography (CT) on outcome following emergency laparotomy. Materials and methods Data from the National Emergency Laparotomy Audit database were retrieved for patients who had undergone an emergency laparotomy over 12 months at York NHS Foundation Trust. Sarcopenia was assessed by psoas density and area on preoperative CT. Mortality rates at 30 days and 1 year were recorded. Secondary outcomes included discharge rates to non-independent living. Results A total of 259 patients were included. Overall cohort 30-day and 1-year mortality was 13.9% (36/259) and 28.2% (73/259), respectively. Sarcopenia measured by psoas density was associated with increased mortality compared with patients who did not develop sarcopenia at 30 days (29.7%, 19/64, vs. 8.7%, 17/195; P < 0.001; odds ratio, OR, 4.42; 95% confidence interval, CI 2.13-9.26) and at 1 year (57.8%, 37/64, vs. 18.5%, (36/195; P < 0.001; OR 6.05; 95%CI 3.28-11.18). An increase in mortality was seen in patients with sarcopenia measured by psoas area at 30 days (21.3%, 13/61, vs. 9.1%, 17/187; OR 2.71; 95%CI 1.23-5.96, P = 0.013) and at 1 year (42.6%, 26/61, vs. 20.9%, 39/187; OR 2.82; 95% CI 1.52-5.23, P < 0.001). Conclusions Sarcopenia assessed by measurement of psoas density and area on CT is associated with increased mortality following emergency laparotomy. The use of sarcopenia as a predictive tool merits further attention and may be useful in patients undergoing emergency surgery.

Low skeletal muscle mass outperforms the Charlson Comorbidity Index in risk prediction in patients undergoing pancreatic resections.

INTRODUCTION: Low skeletal muscle mass is a known predictor of morbidity and mortality in patients undergoing major pancreatic surgeries. We sought to combine low skeletal muscle mass with established risk predictors to improve their prognostic capacity for postoperative outcome and morbidity. METHODS: As established parameters to predict preoperative mortality risk for patients, the ASA classification and the Charlson Comorbidity Index (CCI) were used. The Hounsfield Units Average Calculation (HUAC) was measured to define low skeletal muscle mass in 424 patients undergoing pancreatic resections for malignancies. Patients in the lowest sex-adjusted quartile for HUAC were defined as having low skeletal muscle mass (muscle wasting). Multivariable Cox regression analysis was utilized to identify preoperative risk factors associated with postoperative morbidity. RESULTS: Median patient age was 63 years (19-87), 47.9% patients were male, and half the cohort had multiple comorbidities (Charlson Comorbidity Index [CCI]>6, 63.2%), 30-day mortality was 5.8% (n = 25). Median HUAC was 19.78 HU (IQR: 15.94-23.54) with 145 patients (34.2%) having low skeletal muscle mass. Preoperative frailty defined by low skeletal muscle mass was associated with an increased risk for postoperative complications (OR 1.55, CI 95% 0.98-2.45, p = 0.014), and a higher 30-day mortality (HR 5.17, CI 95% 1.57-16.69, p = 0.004). With an AUC of 0.85 HUAC showed the highest predictability for 30-day mortality (CI 95% 0.78-0.91, p = 0.0001). Patients with CCI ≥6 and low skeletal muscle mass defined by the HUAC had a 9.78 higher risk of dying in the immediate postoperative phase (HR 9.78, CI 95% 2.98-12.2, p = 0.0001). CONCLUSION: Low skeletal muscle mass predicts postoperative mortality and complications best and it should be incorporated to conventional risk scores to identify high risk patients.

Impact of Frailty and Comorbidities on Surgical Outcomes and Complications in Adult Spinal Disorders.

STUDY DESIGN: Retrospective review of surgically treated 481 adult patients with spinal disorders. OBJECTIVE: The aim of this study was to elucidate the effect of frailty and comorbidities on postoperative health-related quality of life (HRQoL) and complication rates. SUMMARY OF BACKGROUND DATA: Elective surgeries for spinal disorders not only improve clinical outcomes but also have high complication rates. METHODS: We retrospectively reviewed the results of consecutive elective spine surgeries for 156 adult spinal deformities (ASDs: 65 ±â€Š9 years), 152 degenerative spondylolisthesis (DS: 64 ±â€Š10 years), or 173 lumbar spinal canal stenosis (LSCS: 71 ±â€Š9 years) with follow-up of at least 2 years. Modified Frailty Index (mFI) and Charlson Comorbidity Index (CCI) were determined from baseline demographics. We compared the prevalence and the influence of mFI and CCI on postoperative outcomes and complication rates. RESULTS: The mFI and CCI were significantly worse in ASD than in others (mFI: ASD 0.09 ±â€Š0.12, DS 0.06 ±â€Š0.06, LSCS 0.04 ±â€Š0.05, P < 0.01. CCI: ASD 2.1 ±â€Š1.6, DS 1.4 ±â€Š0.7, LSCS 1.6 ±â€Š0.9, P < 0.01). Postoperative HRQoL deteriorated as mFI worsened in ASD (nofrail: Oswestry Disability Index [ODI] 26 ±â€Š11, Scoliosis Research Society Questionnaire [SRS] 3.7 ±â€Š0.7; prefrail: ODI 32 ±â€Š12, SRS 3.6 ±â€Š0.6; frail: ODI 42 ±â€Š15, SRS 3.2 ±â€Š0.7). In DS and LSCS, however, SF-36 physical component score and mental component score improved regardless of mFI and CCI. The 2-year major complications rate increased with frailty (36%, 58%, and 81%) in ASD, but not in others. CONCLUSION: ASDs were more frail and had more comorbidities than the other populations. In ASD, postsurgical outcomes and complication rates deteriorated as frailty and CCI increased, whereas surgery produced favorable outcomes and acceptable complication rates in DS and LSCS regardless of frailty and CCI. Careful patient selection and treatment of comorbidities before surgery may decrease complications and improve outcomes for the surgical treatment of ASD. LEVEL OF EVIDENCE: 4.

Sarcopenia predicts poor long-term survival in patients undergoing endovascular aortic aneurysm repair.

OBJECTIVE: Sarcopenia measured by decreased psoas muscle size has been used as a surrogate for frailty and correlates with adverse outcomes in both the short and long term after many major operations. Our aim was to evaluate this measure as a predictor of outcomes in patients undergoing endovascular aortic aneurysm repair (EVAR). METHODS: Once Institutional Review Board approval was obtained, all patients who underwent EVAR from December 2010 to March 2016 at a Veterans Affairs hospital were assessed for sarcopenia by total psoas muscle area (TPA) measured on axial computed tomography scan immediately inferior to the fourth lumbar (L4) superior end plate. Outcomes including length of stay and mortality were collected from the medical record. RESULTS: There were 135 patients who underwent EVAR at a median age of 70 years. Median aneurysm size was 5.5 cm. Length of stay was >2 days in 25% of patients (n = 33), with the most common reasons for delayed discharge including respiratory complications (8.9% [n = 12]) and urinary retention (4.0% [n = 9]). Low TPA was not associated with extended length of stay (P = .40). Patients with lowest tertile TPA had 42% 5-year survival compared with 93% survival observed for the remaining two-thirds of patients (P = .01). Multivariate analysis revealed increased likelihood of mortality at 5 years for patients in the lowest tertile for TPA (odds ratio, 3.9; 95% confidence interval, 1.2-12.9) as well as for patients with chronic kidney disease (odds ratio, 5.2; 95% confidence interval, 1.5-18.0). CONCLUSIONS: Preoperative sarcopenia does not appear to affect length of stay but does portend worse long-term survival. This simple preoperative measurement may help vascular surgeons tailor repair thresholds and avoid nonbeneficial procedures.

Low total psoas area as scored in the clinic setting independently predicts midterm mortality after endovascular aneurysm repair in male patients.

OBJECTIVE: Preoperative sarcopenia is an established risk factor for poor outcomes after surgery. Methods for assessing sarcopenia are either complex, time consuming, or poorly validated. We aimed to assess the interobserver reliability of scoring psoas area at the level of the L3 vertebra and to evaluate whether sarcopenia scored by this simple and rapid method correlated with other fitness scoring methods or impacted on mortality and duration of stay for patients undergoing endovascular aneurysm repair (EVAR). METHODS: We had access to 191 preoperative computed tomography scans of patients who underwent EVAR. For each scan the axial slice at the most caudal level of the L3 vertebra was extracted. Three observers independently calculated the combined cross-sectional area of the left and right psoas muscle at this level. Interobserver variability was calculated as per Band and Altman. Psoas area was normalized for patient height with sarcopenia defined as total psoas area of <500 mm2/m2. The effect of sarcopenia on patient survival was assessed using Cox proportional hazards models. Kaplan-Meier curves are also presented. RESULTS: Interobserver reliability of scoring psoas area was acceptable (reproducibility coefficient as percent of mean for each observer pair: 7.92%, 7.95%, and 14.33%). Sarcopenic patients had poorer survival (hazard ratio, 2.37; P = .011) and an increased hospital duration of stay (4.0 days vs 3.0 days; P = .008) when compared with nonsarcopenic patients. Sarcopenic patients were more likely to self-report as unfit (12.4% vs 33.3%; P = .004). Sarcopenia did not correlate with an increased rate of postprocedure complications. CONCLUSIONS: Psoas area scoring has good interobserver reliability. Preoperative sarcopenia as defined by psoas area was associated with poorer survival and of longer length of stay. As all patients being worked up for an endovascular aortic aneurysm repair will undergo a computed tomography scan, this method is a rapid and effective way to highlight patients in the clinic setting who have an increased risk of morbidity and mortality after EVAR.

Psoas Muscle Area Predicts All-Cause Mortality After Endovascular and Open Aortic Aneurysm Repair.

OBJECTIVE: Psoas muscle area (PMA) is a validated surrogate for muscle mass that can be easily measured from a clinical CT scan. This study sought to determine whether PMA was associated with post-operative mortality after endovascular or open aortic aneurysm repair. METHODS: A retrospective review was undertaken of patients who underwent elective endovascular or open aortic aneurysm repair between 2010 and 2015 at a tertiary vascular center in Montreal, Quebec, Canada. Pre-operative CT scan images were analyzed with the CoreSlicer.com software tool to measure PMA at the axial level of the L4 vertebrae. Measurements were made by two independent observers blinded to clinical data. The primary endpoint was all-cause mortality. RESULTS: The cohort consisted of 149 patients with a mean age of 75.6 ± 8.8 years. The mean PMA was 24.0 ± 5.8 cm2 in males, and 14.3 ± 3.1 cm2 in females. There were 31 deaths over a mean follow-up of 22.4 months. After adjusting for age, sex, revised cardiac risk index, and surgical approach, Cox regression revealed a graded association between PMA and all-cause mortality with a hazard ratio of 0.86 per cm2 (95% CI 0.79-0.93). Addition of PMA to the model with the clinical covariates resulted in an improvement in C-statistic from 0.57 to 0.67, and BIC from 307 to 301 (with lower BIC values preferred). CONCLUSIONS: PMA is independently associated with all-cause mortality after elective endovascular and open aortic aneurysm repair, and may be integrated into the pre-operative risk assessment to optimize care in high-risk frail patients.