Comparison of frailty and other risk indices in prediction of perioperative complications following surgical intervention for proximal humerus fractures

Aims Proximal humerus fractures (PHFs) often occur in a population at risk for complications following surgery. The purpose of this study is to assess the associations of frailty with complications of surgical intervention for PHFs. Methods The American College of Surgeons National Surgical Quality Improvement Program database was queried from January 2015 to December 2020 for patients aged ≥ 60 years who were undergoing surgery for PHFs. Tiered frailty scores were calculated by the revised risk analysis index (RAI-Rev) and the modified five-term frailty index (mFI-5) factor. Outcomes included 30-day mortality, readmission, length of stay, and complications. Analysis of variance and binary logistic regression were used to assess associations with odds ratio (OR) and 95% CI. Discriminatory accuracy was quantified by receiver operating characteristic curve analysis and C-statistics. Results A total of 6,020 patients with PHFs underwent surgical intervention (51% frail or severely frail). The use of reverse total shoulder arthroplasty (rTSA) for PHFs increased over time (OR 1.14 (95% CI 1.11 to 1.18)), whereas all other procedures decreased. Frail patients were more likely to experience a complication after surgery (OR 2.92 (95% CI 2.48 to 3.43)). Overall, rTSA had higher rates of complications (17% (OR 0.93 (95% CI 0.86 to 0.99)) and non-home discharge (32% (OR 0.84 (95% CI 0.79 to 0.90)). However, these decreased from 2015 to 2020. The RAI-Rev had superior predictability to mFI-5 for any complication (area under the curve (AUC) 0.674 vs 0.601), postoperative blood transfusion (AUC 0.704 vs 0.618), and non-home discharge (AUC 0.778 vs 0.637). Conclusion Frail patients have a three-times higher 30-day complication risk following proximal humerus surgery. rTSA is associated with higher rates of complications compared with internal fixation, but has steadily narrowed the gap over time. While the long-term outcomes and functional benefit should be considered, preoperative frailty assessment can be predictive of perioperative complications and disposition in this population. Cite this article: Bone Joint J 2026;108-B(1):103–108.