The Surgeon · Mar 2, 2026

Predicting postoperative risk in adult men undergoing ankle fracture surgery: Development of a novel composite frailty score

By Sabet CJ, Jain B, Hammadeh BM et al.

BACKGROUND: Ankle fractures represent one of the most common orthopedic injuries, with over five million cases annually in the United States. As surgical populations age, comprehensive preoperative risk stratification becomes increasingly critical for optimizing patient outcomes and resource allocation. While individual frailty indices such as the Risk Analysis Index (RAI), Geriatric Nutritional Risk Index (GNRI), and American Society of Anesthesiologists (ASA) classification have demonstrated predictive value for postoperative complications, no composite scoring system has been validated for ankle fracture surgery. METHODS: This retrospective cohort study analyzed 10,626 adult male patients who underwent surgical treatment for isolated ankle injuries between 2015 and 2021 using the ACS NSQIP database. Patients were stratified using RAI (robust ≤20, normal 21-30, frail 31-40, very frail ≥41), GNRI nutritional risk categories, ASA classification, and a novel Combined ASA-RAI-Preoperative Acute Severe Condition (CARP) score. Primary outcomes included 30-day mortality, major complications, extended length of stay, non-home discharge, unplanned readmission, and reoperation. Model discrimination was assessed using receiver operating characteristic curve analysis with internal validation via bootstrap resampling. RESULTS: The cohort demonstrated low overall mortality (0.16%) but significant morbidity across frailty tiers. CARP demonstrated superior discriminative performance compared to individual indices for major complications (AUC 0.757 vs RAI 0.701, p = 0.025), minor complications (AUC 0.879 vs ASA 0.793, p = 0.002), and extended length of stay (AUC 0.735 vs mFI-5 0.669, p < 0.001). Bootstrap validation confirmed model stability with bias-corrected AUCs maintaining statistical significance. CONCLUSIONS: The novel CARP score provides enhanced risk stratification for ankle fracture surgery compared to traditional individual indices, enabling more precise preoperative counseling and perioperative optimization in this high-volume surgical population.

doi.org/10.1016/j.surge.2026.02.009PubMed 41775619Biomarkers