Letter to the Editor: Frailty Is Associated With Increased 30-day Readmissions and Costs After Total Shoulder Arthroplasty

To the Editor,

The recent article, “Frailty Is Associated With Increased 30-Day Readmission and Cost After Total Shoulder Arthroplasty” [6], contributes substantially to the growing knowledge base about frailty in orthopaedic surgery. The authors used the Hospital Frailty Risk Score (HFRS) to demonstrate that frailty is associated with increased odds of 30-day readmission, reoperation, and major surgical and medical complications as well as longer length of stay and higher hospitalization costs. These findings highlight the importance of identifying patients who have signs of frailty early in the perioperative period to improve surgical outcomes and resource allocation.

The HFRS is calculated based on the presence and weighted severity of 109 diagnostic codes from the ICD-10. This list of 109 codes includes but is not limited to falls and fractures, delirium or dementia, and pressure ulcers [4]. It has been validated in large cohorts as a tool to identify patients at risk of adverse outcomes because of frailty, particularly in hospital-based settings. Although the HFRS offers a comprehensive approach, its complexity and reliance on accurate data collection may limit its utility in real-time preoperative decision-making.

Instead of using such a cumbersome and complex tool, I suggest that clinicians who wish to gauge their patients’ levels of frailty without looking up 109 parameters (which may or may not be available in patients’ medical records) might instead measure grip strength using a Jamar dynamometer [1]. Grip strength is an inexpensive, quick, and objective measure of frailty that correlates strongly with postoperative outcomes, including morbidity, disability, and mortality [8]. One study has demonstrated “a predictive link” between grip strength and all-cause and disease-specific mortality [2].

Frailty is associated with an increased risk of surgical complications after hip and knee arthroplasty [9, 10] and spine surgery [3]. In total shoulder arthroplasty (TSA) specifically, Lee et al. [7] found that grip strength positively correlated with postoperative abduction strength and Constant-Murley scores. These findings provide procedure-specific validation that grip strength not only reflects overall health but also is associated with functional outcomes in shoulder surgery.

Nearly a quarter of adults who live in the community (as opposed to those who live in skilled nursing facilities) are categorized as having frailty [5]. Therefore, it is important to have a robust, simple, and cost-effective way to measure frailty in clinical practice. Taken together, all of these findings suggest that frailty, and specifically grip strength, should be integral to preoperative evaluation. Grip strength testing could be used as a bedside screening tool to identify high-risk TSA candidates and inform clinical decision-making.

I commend the authors for their important contribution [6] and hope this letter adds to the conversation on integrating practical frailty assessment into orthopaedic care.