The Trauma-specific Frailty Index Identifies Orthopaedic Trauma Patients at Risk for Stepdown Admission, Skilled Nursing Facility Discharge, and Prolonged Hospitalization

Objectives To compare the Trauma-Specific Frailty Index (TSFI) with an institutional Perioperative Geriatric Score (PGS) for predicting postoperative level of care, discharge disposition, and length of stay in older adults undergoing operative fixation of lower-extremity fractures. Methods Design: Retrospective cohort study. Setting: Two hospitals within a single academic health system: an urban level I and a suburban level III trauma center. Patient Selection Criteria: Patients aged ≥65 years who underwent operative fixation of lower-extremity fractures between January 1 and June 30, 2025; nonoperative fractures and encounters lacking primary outcome data were excluded. Frailty was measured with the TSFI (0–1 deficit-accumulation index). Perioperative risk was measured with an institutional PGS combining vasopressor use, blood loss, cardiac comorbidity, case duration, and delay to surgery. Outcome Measures and Comparisons: Primary outcomes were postoperative level of care, discharge disposition, and hospital length of stay; 90-day readmission and mortality were secondary. Multivariable regression adjusted for age, sex, body mass index, and fracture type. Results Among 248 patients (median age, 78 years; 64.1% female), higher TSFI values were associated with stepdown admission (odds ratio [OR] 2.43; 95% confidence interval [CI], 1.13–5.21), intensive care unit admission (OR 2.79; 95% CI, 1.16–6.70), discharge to a skilled nursing facility (OR 1.96; 95% CI, 1.11–3.47), and longer length of stay (OR 1.61; 95% CI, 1.19–2.17). The PGS showed weaker associations, reaching significance only for intensive care unit admission (OR 1.16; 95% CI, 1.07–1.26). Ninety-day readmission and mortality were too infrequent for reliable estimates. Conclusions The TSFI outperformed an institutional perioperative geriatric triage score in predicting postoperative care escalation and discharge disposition in lower-extremity fracture patients. Incorporation of frailty assessment into orthopaedic trauma workflows may improve risk stratification, counseling, and resource planning.