In older adults undergoing surgical fixation or arthroplasty following upper limb fractures, does frailty predict post-operative complications and mortality? A systematic review and meta-analysis

Background There is growing recognition of the role of clinical frailty and its impact on health outcomes in aging cohorts. Frailty may be associated with mortality and complications following fracture; however, its impact on upper limb outcomes has yet to be quantified. This systematic review aims to evaluate the association between pre-operative frailty and post-operative mortality and complications in adults undergoing surgical treatment for upper limb fractures. Secondary outcomes included reoperation, adverse discharge destination and length of stay. Methods MEDLINE, EMBASE, and Cochrane CENTRAL databases were searched on January 31, 2025, to identify studies that assessed pre-operative patient frailty and post-operative outcomes in adults following traumatic upper limb fractures. Data on 30-day mortality, post-operative complications, reoperation, hospital readmission, adverse discharge, Clavien-Dindo IV complications, and length of stay were extracted. Data were pooled using random-effects and fixed effects models for meta-analyses. Grading of Recommendations Assessment, Development and Evaluation assessment was used to assess the quality of available evidence. Results Of the 4,013 records identified, 9 retrospective cohort studies were eligible for inclusion. Frailty was significantly associated with increased risk of 30-day mortality (odds ratio [OR] = 3.40, 95% confidence interval [CI] = 2.90-3.99, P < .001), post-operative complications (OR = 2.78, 95% CI=1.99-3.88, P < .001), adverse discharge (OR = 2.96, 95% CI=1.75-5.02, P < .001), and hospital readmission (OR = 3.73, 95% CI=1.86-7.46, P < .001). No statistically significant association between frailty and reoperation was found (OR = 1.61, 95% CI=1.36-1.91, P < .001). Grading of Recommendations Assessment, Development and Evaluation assessment found moderate certainty for post-operative complications and reoperation, and low to very low certainty for 30-day mortality, readmission, adverse discharge, Clavien-Dindo IV complications, and length of stay. Conclusion Pre-operative frailty is associated with increased early mortality, post-operative complications, adverse discharge, and hospital readmission following surgical treatment for upper limb fractures in adults. Future prospective investigations are needed to standardize frailty screening and inform surgical decision-making in upper limb fractures.