Too frail is to fail: Frailty portends poor outcomes in the elderly with type II odontoid fractures independent of management strategy

Abstract Type-II odontoid fractures are common and highly morbid injuries, particularly among elderly patients. However, few risk stratification resources exist to predict outcomes and guide management decision making. Frailty indices have been increasingly utilized for these purposes in elective surgery, but have not been assessed for trauma. A single-center prospective trauma registry identified patients aged ≥ 80 years with type-II odontoid fractures. Frailty was the independent variable, using three independent indices: modified-5-item frailty (mFI-5), modified Charlson comorbidity (mCCI), and Davies. 97 patients had complete frailty data and sufficient follow up information, with median mIF-5 of 2 (range 0–4; 34 frail, mFI-5 > 2), median mCCI score of 6 (range 4–14), and median Davies score of 2 (range 0–7). For all indices, increasing score was associated with mortality, mIF-5 (HR = 1.76, 95%CI = 1.06–2.88), mCCI (HR = 1.10, 95%CI = 1.01–1.20), and Davies scores (HR = 1.21, 95%CI = 1.08–1.37). Median post-injury survival among patients with mIF-5 of ≤ 2 was 10-fold longer than patients with mIF-5 of > 2 (70 vs. 710 days, p = 0.0026). After adjusting for initial treatment strategy, frailty status remained an independent predictor of patient mortality; mIF-5 (HR = 1.72, 95%CI = 1.02–2.80), mCCI (HR = 1.10, 95%CI = 1.01–1.20), and Davies scores (HR = 1.21, 95%CI = 1.08–1.37). Among octogenarian patients with type-II odontoid fractures, frailty was associated with increased mortality, independent of treatment strategy.