Citations

Objectives: Femoroacetabular impingement (FAI) is classically described as restricted internal rotation in flexion resulting in labral and cartilage pathology. Despite 20 years of FAI research, there is still limited understanding of the drivers of symptomatology in the subset of patients with underlying FAI morphology. While the prevalence of FAI morphologies is substantially higher in men, numerous studies have shown more women being treated for FAI compared to men. Soft-tissue laxity and hip instability are increasingly recognized as a potential contributor to symptoms in addition to FAI. The Beighton score is a well-accepted means to quantify soft-tissue laxity and has been validated for self-scoring. The purpose of the current study was to (1) investigate the prevalence of soft-tissue laxity in male and female patients presenting with symptomatic FAI in a multicenter prospective cohort study, and (2) correlate soft-tissue laxity with patient primary complaints of either mobility, stability, or pain. Methods: A prospective multicenter cohort study of 696 FAI patients undergoing primary hip arthroscopy surgery was performed and utilized for the current study. Inclusion criteria are patients aged 14 to 45 years old with idiopathic FAI not caused by childhood disease. Exclusion criteria are previous ipsilateral hip procedures or disease processes such as neuromuscular disease or Tonnis 2 or greater osteoarthritis. The Beighton score was assessed by electronic patient self-scoring. Beighton scores >4 were considered a marker of soft-tissue laxity. The MSP index was utilized to have patients rank from most to least the biggest problems with their hip: Mobility (M), Stability (S), or Pain (P). The chi-square or Fisher exact test were utilized to compare groups. Results: The prevalence of Beighton scores >4 was 57.2% in female patients, compared to 29.3% in male patients (p < 0.001). In female patients, 44.4%, 22.6%, and 7.7% had Beighton scores of 5+, 7+, and 9 respectively, compared to 16.7%, 5.8%, and 1.8% in male patients (all p < 0.005). In the overall FAI cohort, pain was the primary complaint in 72.1% of patients, compared to 24.2% complaining primarily of mobility and 3.7% complaining primarily of stability. Among female patients, the presence of soft-tissue laxity (relative to thresholds of Beighton 4, 5, 7, and 9) did not significantly influence the patient primary complaints (with pain being the predominant complaint). Overall, 85 female patients had a Beighton score of 7 or greater and only 2.4% reported stability of the hip as a primary complaint, compared to 2.4% of female patients with a Beighton <7. Stability was more commonly indicated as a second most important factor in the setting of soft-tissue laxity, compared to mobility. Among female patients with a Beighton >7, 29.5% reported stability as a primary or secondary complaint, compared to 15.2% of female patients with a Beighton score <7. Conclusions: Over half of female patients undergoing FAI surgery have underlying soft-tissue laxity as measured by the Beighton score. In the setting of soft-tissue laxity, patient primary symptomatic complaint remains pain, but a secondary complaint is significant more likely to be stability rather than mobility (compared to FAI patients without soft tissue laxity complain of mobility secondarily over stability). Further research is needed to better understand the role of soft-tissue laxity in the pathophysiology of FAI and the outcomes of surgical treatment.

Objectives: Nonoperative management vs. early reconstruction for partial tears of the medial ulnar collateral ligament (MUCL) remains controversial, with the most common treatment options for partial tears consisting of rest, rehab, platelet rich plasma (PRP), and/or surgical intervention. However, whether the improved outcomes reported for treatments such as MUCL reconstruction (UCLR) or nonoperative management with a series of PRP injections justifies their increased upfront costs remains unknown. Thus, the purpose of this study was to compare the cost-effectiveness of an initial trial of physical therapy alone, an initial trial of physical therapy plus a series of PRP injections, and early UCLR to determine the preferred cost-effective treatment strategy for baseball pitchers with partial tears of the MUCL. Methods: A Markov Chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1,000 simulated pitchers undergoing nonoperative management with and without PRP vs. early UCLR for partial MUCL tears. Utility values, RTP rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing each treatment strategy at our institution. Outcome measures included costs, acquired playing-years (PYs), and the incremental cost-effectiveness ratio (ICER). Results: Mean total costs resulting from nonoperative management without PRP, nonoperative management with PRP, and early UCLR were $22,520, $24,800, and $43,992, respectively. On average, early UCLR produced an additional 4.0 PYs over the 10-year time horizon relative to nonoperative management, resulting in an ICER of $5,395/PY, which falls well below the $50,000 willingness-to-pay threshold (WTP). Overall, early UCLR was determined the preferred cost-effective strategy in 77.5% of pitchers included in the microsimulation model, with nonoperative management with PRP determined the preferred strategy in 15% of pitchers and nonoperative management alone in 7.5% of pitchers. Conclusions: Based on Monte Carlo microsimulation and probabilistic sensitivity analysis, early UCLR was demonstrated to be more cost-effective than an initial trial of nonoperative management for partial tears of the MUCL for the majority of high-level baseball pitchers. It is important to note that this model does not consider the unique experiences, goals, situations, career trajectory, and pitching horizons of individual patients, and thus a shared decision-making discussion should be conducted regarding optimal initial treatment for partial MUCL tears. This is particularly true as many athletes can successfully be treated non-operatively, which generally results in a quicker return to play when successful compared to surgery.

Objectives: Wrestling is a physically demanding sport with young athletes prone to traumatic shoulder instability (SI). However, there is a paucity of data evaluating the results of shoulder instability surgery (SIS) in this cohort of athletes. The purpose of this study is to assess reoperation rates, patient-reported outcomes (PRO), and return to wrestling (RTW) following SIS in a cohort of competitive wrestlers. Methods: All competitive wrestlers with a history of SI and subsequent surgery at a single institution between 1996 and 2020 were identified. All directions of SI (anterior SI [ASI], posterior SI [PSI], and traumatic multidirectional SI [TMDI]) were analyzed. Exclusion criteria included revision SIS and less than 2 years of clinical follow-up. Patients were contacted for determination of reinjury rates, return to wrestling (RTW), and Western Ontario Shoulder Instability index (WOSI) scores. Results: Ultimately, 104 wrestlers were included at a mean follow-up of 5.2 years (range, 2.0 – 22.0). Fifty-eight (55.8%) wrestlers presented for evaluation after a single SI event while 46 (44.2%) sustained multiple events prior to presentation. ASI was the most common direction (n = 79; 76.0%) followed by PSI (n = 14; 13.4%), and TMDI (n = 11; 10.6%). Surgical treatment was most commonly an arthroscopic soft tissue stabilization (n = 88; 84.6%), followed by an open soft tissue repair (n = 13; 12.5%) and open bony augmentation (n = 3; 2.9%) (Table 1). RTW occurred in 57.3% of wrestlers at a mean of 9.8 ± 9.6 months. Recurrent instability was the most common complication in 18 (17.3%) wrestlers. Revision SIS was performed in 15 (14.6%) wrestlers (Table 2). Across the entire cohort, Kaplan-Meier survivorship free from recurrent instability (Figure 1) and revision surgery (Figure 2) was 91.4% and 98.1% at 1 year, 90.4% and 92.5% at 2 years, 71.9% and 70.7% at 5 years, and 71.9% and 66.5% at 10 years, respectively. Pre-operative recurrent instability was an independent risk factor for post-operative recurrent instability (Hazard ratio [HR], 3.8; 95% confidence interval [CI], 1.33 – 11.03; P = .012). Conclusions: Anterior shoulder instability was the most common direction among competitive wrestlers presenting for SIS. Wrestlers with multiple dislocations prior to initial clinical presentation were 3.8 times more likely to experience post-operative recurrent instability.

Objectives: The purpose of this study was to radiographically assess changes in 1) patellar height, 2) anterior tibial translation (ATT), and 3) posterior tibial slope following supratubercle ACW-PTO and to compare changes in patellar height to a cohort of medial opening proximal tibial osteotomies (MOW-PTO). Methods: Patients who underwent supratubercle ACW-PTO by a single surgeon from July 2019-February 2023 were included. Institutional Review Board approval was obtained for this study. Radiographic assessment at four time points (preoperative, postoperative day 1, 3 months and 6 months) of patellar height (via the Caton Dechamps and Insall Salvati ratios), posterior tibial slope, and anterior tibial translation of the lateral tibial plateau relative to the lateral femoral condyle was completed. A comparison cohort of patients undergoing MOW-PTO was included for comparison of patellar height. Results: Patellar height averages ( n=16) after ACW-PTO using the Caton-Deschamps ratio (Figure 1) demonstrated a significant increase in patellar height on postoperative day 1 ( p=0.004), but were not significantly different at 3 and 6 months postoperatively (Table 2). Conversely, averages of patellar height after MOW-PTO ( n=28) demonstrated no difference on postoperative day 1, but then was significantly decreased by 6 months postoperatively ( p=0.005) (Table 1). There was a significant difference between the closing and opening-wedge cohorts when comparing the difference in patellar height using the CD ratio between preoperative and 6 months ( p=0.011). Anterior tibial translation in the ACW-PTO cohort was significantly decreased by an average of 9.0 mm from preoperative to postoperative values ( p<<0.001) (Figure 2). Posterior tibial slope in the ACW-PTO cohort was significantly decreased by an average of 11.8° from preoperative to postoperative values ( p<<0.001). Conclusions: Supratubercle ACW-PTO performed for ACL failure in the setting of increased tibial slope did not induce significant changes in patellar height postoperatively. Furthermore, following ACW-PTO there was a significant decrease in anterior tibial translation and posterior tibial slope.

Objectives: A DFO can be performed via two techniques: a lateral opening wedge (LOW) osteotomy and a medial closing wedge (MCW) osteotomy. Small case series have looked at how leg length is affected by a lateral opening wedge DFO, however, there is a lack of research comparing these leg length changes to medial closing DFO. Additionally, no studies have presented a model for predicting the leg length changes that will occur following DFO of either technique. Given that limb length differences can lead to accelerated osteoarthritis, back pain, hip pain, and other issues, being able to predict which technique can help prevent this pathology without a secondary procedure would be an important finding. Finally, the medial closing wedge osteotomy can allow for immediate weight-bearing while the lateral opening wedge does not and typically has associated cost with bone grafting. Therefore, we designed this study to validate a tool designed to predict leg length changes after distal femoral osteotomy (DFO) and compare changes following medial closing wedge (MCW) and lateral opening wedge (LOW) techniques. Methods: A collaborative retrospective review was performed of patients from Rush and Mayo Clinic databases who received a DFO and had full-length standing radiographs both pre-and postoperatively. For each preoperative radiograph, the region on the medial (for LOW) or lateral (for MCW) distal femur cortex that would be the “hinge point” during DFO was identified. The distances from the center of the femoral head to the hinge point (“A”), from the hinge point to the center of the tibial plafond (“B”), and the resultant angle at the hinge point (“α”) were measured (Figure 1). Figure 2 demonstrates the equation used to plot a graph of the predicted leg length changes corresponding to the change in α angle produced by DFO. Final leg length was calculated on postoperative radiographs, and the difference between predicted and true leg length changes was compared using paired Wilcoxon signed rank exact tests. Results: 10 MCW and 10 LOW patients were included. For both LOW (n=10) and MCW (n=10) osteotomies, the predicted leg length change was equivalent to the true change measured on postoperative radiographs (LOW P=0.16; MCW P=0.85). LOW DFO’s had 5.10 ± 2.77 mm (range: 1.45-10.87 mm) of leg lengthening, compared to 2.61 ± 1.25 mm (range: 0.50-4.56 mm) of leg shortening (p<0.001) for MCW (Figure 3). On average, there was 0.85 mm of lengthening (range 0.5-1.3 mm) for every 1° of mechanical axis correction with LOW DFO, compared to 0.45 mm of shortening (range: 0.1-1.4 mm) per 1° of MCW correction. Conclusions: This study presents a tool to accurately and reliably predict the leg length changes seen after both medial closing and lateral opening wedge DFO’s. Knowing what leg length changes to expect with each DFO technique is a useful tool that surgeons can utilize during surgical planning. Preoperative radiographic imaging can be used to predict leg length change following DFO with high reliability and accuracy. Surgeons can expect approximately 0.85mm of lengthening per 1° of DFO correction when performing LOW, compared to 0.45mm of shortening per 1° correction for MCW osteotomies.

Objectives: Hip arthroscopy is rapidly advancing, with literature increasingly reporting positive outcomes at short- and mid-term follow-up; however, available long-term data remains limited. The purpose of this study is to evaluate long-term outcomes of primary hip arthroscopy at minimum 10-year follow-up at two academic centers by describing patient-reported outcomes (PROs) and determining reoperation, revision, and total hip arthroplasty (THA) rates. Methods: Primary hip arthroscopies performed between January 1988 and April 2013 at 2 academic centers were evaluated for postoperative PROs including Visual Analogue Scale (VAS), Tegner Activity Scale score, Hip Outcome Score Activities of Daily Living and Sport Scale (HOS-ADL/HOS-SS), modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), 12-item International Hip Outcome Tool (iHOT-12), surgery satisfaction, function, and reoperations. Results: Two-hundred ninety-four primary hip arthroscopies with a mean age of 40±14 years; 66% female; and a mean body mass index (BMI) of 27±6 kg/m 2 were followed for mean 12±3 years (range: 10-24). Labral debridement and repair were performed in 41% and 59% of patients, respectively. All patients underwent interportal capsulotomy and 2% underwent T-capsulotomy. Eleven percent of patients underwent capsular repair. At final follow-up, patients reported mean VAS at rest of 2±2, with use of 3±3, iHOT-12 of 68±27, NAHS of 81±18, mHHS of 79±17, HOS-ADL of 82±19, and HOS-SS of 74±25. Mean surgical satisfaction was 8.4±2.4 (Table 1). Sixty-five hips (23%) underwent THA and 33 (11%) underwent revision arthroscopy (Table 2). Risk factors for THA included older age (p<0.001), higher BMI (p<0.001), lower lateral center-edge angle (p=0.039), larger alpha angle (p=0.001), higher Tönnis grade (p=0.011), labral debridement (p=0.004), and capsular nonrepair (p=0.030). Patients undergoing combined labral and capsular repair demonstrated a THA conversion rate of 3% compared to 31% for patients undergoing combined labral debridement and capsular nonrepair (p=0.006) (Table 3). Labral repair trended towards increased 10-year THA-free survival (84% vs. 77%, p=0.085) while capsular repair demonstrated significantly increased 10-year THA-free survival (97% vs 79%, p=0.032) (Figure 1). Conclusions: At minimum 10-year follow-up, patients undergoing primary hip arthroscopy demonstrated high rates of satisfaction and acceptable outcome scores. In total, 11% of patients underwent revision hip arthroscopic surgery with a THA conversion rate of 23%. Conversion to THA was associated with patient factors including older age and higher Tönnis grade as well as potentially modifiable surgical factors including labral debridement and capsular nonrepair.

Objectives: Meniscal allograft transplantation (MAT) is an accepted and effective treatment option in the context of unsalvageable menisci, particularly in young and active patients. It has been shown to reduce pain and improve knee function in previously symptomatic patients. However, there is still limited knowledge about the long-term survival rates of allografts, the durability of clinical results, and the influence of patient-specific parameters, such as leg alignment, tibial slope, and preoperative International Cartilage Regeneration & Joint Preservation Society (ICRS) grade. The purpose of this study was to determine (1) the long-term clinical success rate after MAT with bony fixation in a large, single-center cohort of consecutive patients, and (2) if patient-specific and procedural variables influence the clinical, anatomic, and subjective outcomes and risk of failure. Methods: Data on 185 consecutive knees undergoing MAT in a single institution were prospectively collected and screened for inclusion in this study. The minimum follow-up time was 2 years. Radiographic variables (International Cartilage Regeneration & Joint Preservation Society [ICRS] grade and Kellgren and Lawrence grade) were assessed preoperatively and at follow-up. Subjective patient-reported outcome measures (PROMs), Lysholm score, Knee Disability and Osteoarthritis Outcome Score (KOOS) including subscores, International Knee Documentation Committee (IKDC) score, and visual analog score (VAS) were collected preoperatively and at follow-up. Clinical failure was defined as revision surgery due to graft failure or conversion to total knee arthroplasty (TKA). Anatomic failure was considered a tear covering >20% of the allograft, any peripheral tear, and unstable peripheral fixation leading to dislocation of the graft. Subjective failure was defined as Lysholm score ≤65. Preoperative tibial slope and leg alignment were assessed. Survival analyses were performed utilizing the Kaplan-Meier estimate. Univariate and multivariate analyses were performed to determine risk factors for clinical and anatomic failure. Results: A total of 157 knees met inclusion criteria (Table 1). After a mean follow-up time of 7 ± 3.5 years, 127 (80.9%) knees were free of clinical, anatomic, and subjective failure. Fourteen (8.9%) knees experienced clinical failure, 26 (16.6%) knees were identified as anatomic failure, and 13 patients (8.3%) suffered from subjective failure with a reported Lysholm score of ≤65 at a mean follow-up of 7 years. Concurrent osteochondral allograft transplantation was identified as a predictor of both clinical (HR 4.55; 95% CI 1.46-14.17; p=0.009) and anatomic failure (HR 3.05; 95% CI 1.34-6.92; p=0.008). Cartilage damage of ICRS grade 3 or 4 of the index compartment conveyed an increased risk for clinical (HR 3.41; 95% CI 1.05-11.01; p=0.04) and anatomic failure (HR 3.04; 95% CI 1.31-7.11; p=0.01) (Table 2). There were no differences in outcomes between medial and lateral MAT. High-grade cartilage damage (defined as ICRS grades 3 and 4) preoperatively (HR 10.67; 95% CI 1.037-109.768; p=0.046), patients age over 25 (HR 5.44; 95% CI 0.120-246.070; p=0.384), and a body mass index >30 (HR 2.24; 95% CI 0.748-6.705; p=0.149) were associated with subjective failure. Considering the entire study population, PROMs including KOOS and IKDC were significantly improved at final follow-up compared to preoperative scores across all measurements (p<0.005). Conclusions: MAT showed good-to-excellent clinical results at a mean follow-up of 7 years. Low ICRS lesion grade was associated with a higher clinical and anatomic survival rate. Patients with concurrent osteochondral allograft transplantation are at higher risk of clinical and anatomic failure, but still report significantly improved PROMs. These results suggest MAT has a lasting beneficial effect both as in isolation and in complex cases with one or more concurrent procedures.

Objectives: Anterior cruciate ligament (ACL) reconstruction remains one of the most common procedures performed on the knee with over 250,000 being performed each year in the United States. Although common, results of ACL reconstructions remain less impressive than would be expected. Getgood et al showed a 40% failure of ACL reconstructions including recurrent ACL tears and continued rotational instability. 1 The group found that by adding a lateral extra-articular tenodesis (LET) decreased the failure rate to 25%. Sommerfeldt et al identified recurrent ACL instability as a risk factor for meniscal tears after ACL reconstruction. 2 In patients with a medial meniscal tear after ACL reconstruction, the decision to proceed with revision ACL reconstruction is straightforward when the graft is completely torn. However, the best approach for a medial meniscal tear after ACL reconstruction with recurrent rotational instability when the ACL graft is intact or partially torn has not been determined. The purpose of this study was to evaluate clinical outcomes of patients with intact or partially torn ACL grafts with continued rotational instability and a medial meniscal tears treated with revision ACL reconstruction, ACL reconstruction with lateral extra-articular tenodesis (LET) and isolated LET. We hypothesized that an isolated LET would have similar clinical outcomes compared to the ACL and ACL+LET groups at 2 years. Methods: A retrospective review was performed of all patients with medial meniscal tears after ACL reconstruction. Patients were included in the study if the ACL graft was intact or partially torn with an exam consistent with residual or recurrent rotational instability. Residual ACL instability was determined by a pivot shift of 2 or more on examination. Patients with a grade 3 Lachman’s and partial ACL tear were treated with ACL reconstruction and not included in the study. Over time, the senior author evolved in the treatment of these patients from ACL reconstruction to ACL reconstruction with LET to isolated LET. Patients were placed into different groups based on which treatment they underwent. Clinical outcomes included recurrent meniscal tears, residual rotational instability and recurrent ACL graft tears. Patient reported outcomes (PROs) included IKDC and Lysholm scores at 6, 12, and 24 months. In athletes, we also calculated the percentage of return to play. Results: A total of 47 patients were included in the study including 19 patients in LET group, 12 patients in the ACL+LET group, and 16 patients in the ACL group. The patient demographics between the 3 groups were similar. Ligamentous laxity was identified in 42% of the LET group, 50% of the ACL+LET group and 44% of the ACL group. Partial ACL tears were identified in 63% of the LET group, 75% in the ACL+LET group and 62% of the isolated ACL group. The 6-month International Knee Documentation Committee (IKDC) and Lysholm scores were significantly higher for the isolated ACL group compared to the ACL+LET group and isolated LET groups. However, at the 12 and 24-month follow-up the LET and ACL+LET groups had significantly higher IKDC and Lysholm scores compared to the isolated ACL group (Figures 1 and 2). There was no difference between the LET group and ACL+LET group’s IKDC or Lysholm scores at time point. The ACL group showed a significantly higher percentage of patients with a post operative positive pivot shift (44%) compared to the ACL+LET group (8.3%) and isolated LET group (10.5%) at the 2-year postoperative visit (p=0.02). No difference was seen between the LET and ACL+LET groups with regards to residual pivot shift (p=0.88). Recurrent meniscal tears were significantly higher in the ACL group (31.3%) compared to the LET (5.3%) and ACL+LET (8.3%) groups (p=.04). There was no difference with regards to postoperative graft tearing with 5.3% of LET group, 0% of ACL+LET and 12.5% of the ACL group having a postoperative graft tear. There was a significantly higher rate of return to play in the LET group (90%) compared to the ACL+LET group (71.4%) and ACL group (75%). Return to play at the same or higher level was also significantly higher in the LET group (80%) compared to the ACL+LET (57.1%) and ACL group (50%). Conclusions: In patients with partially torn or intact ACL grafts with residual rotational instability and medial meniscal tears, the addition of a LET with or without revision ACL reconstruction leads to improved patient outcomes, a lower rate of residual rotational instability and recurrent meniscal tearing compared to an isolated revision ACL reconstruction. The addition of an ACL reconstruction to LET in patients with intact or partially torn ACL grafts and meniscal tearing did not decrease the rate of residual pivot shift or recurrent meniscal tears compared to an isolated LET. Isolated LET in this patient population leads to a higher return to play and play at same or higher level compared to an isolated ACL revision or ACL revision with LET. Isolated LET in this patient population is an acceptable option. [Figure: see text][Figure: see text]

BACKGROUND: Apelin is an endogenous prepropeptide that regulates cardiac homeostasis and various physiological processes. Intravenous injection has been shown to improve cardiac contractility in patients with heart failure. However, its short half-life prevents studying its impact on left ventricular remodeling in the long term. Here, we aim to study whether microparticle-mediated slow release of apelin improves heart function and left ventricular remodeling in mice with myocardial infarction (MI). METHODS: A cardiac patch was fabricated by embedding apelin-containing microparticles in a fibrin gel scaffold. MI was induced via permanent ligation of the left anterior descending coronary artery in adult C57BL/6J mice followed by epicardial patch placement immediately after (acute MI) or 28 days (chronic MI) post-MI. Four groups were included in this study, namely sham, MI, MI plus empty microparticle-embedded patch treatment, and MI plus apelin-containing microparticle-embedded patch treatment. Cardiac function was assessed by transthoracic echocardiography. Cardiomyocyte morphology, apoptosis, and cardiac fibrosis were evaluated by histology. Cardioprotective pathways were determined by RNA sequencing, quantitative polymerase chain reaction, and Western blot. RESULTS: The level of endogenous apelin was largely reduced in the first 7 days after MI induction and it was normalized by day 28. Apelin-13 encapsulated in poly(lactic-co-glycolic acid) microparticles displayed a sustained release pattern for up to 28 days. Treatment with apelin-containing microparticle-embedded patch inhibited cardiac hypertrophy and reduced scar size in both acute and chronic MI models, which is associated with improved cardiac function. Data from cellular and molecular analyses showed that apelin inhibits the activation and proliferation of cardiac fibroblasts by preventing transforming growth factor-β–mediated activation of Smad2/3 (supporessor of mothers against decapentaplegic 2/3) and downstream profibrotic gene expression. CONCLUSIONS: Poly(lactic-co-glycolic acid) microparticles prolonged the apelin release time in the mouse hearts. Epicardial delivery of the apelin-containing microparticle-embedded patch protects mice from both acute and chronic MI-induced cardiac dysfunction, inhibits cardiac fibrosis, and improves left ventricular remodeling.

Aim This study aims to evaluate the impact of frailty on the outcomes of older patients with pulmonary embolism (PE). Methods Using the National Inpatient Sample database, we identified 288 070 patients aged 65 or older who were admitted with a primary diagnosis of PE from 2017 to 2019. Frailty was assessed using the Hospital Frailty Risk Score (HFRS), and patients were categorized into low‐, intermediate‐, and high‐frailty‐risk groups. Multivariate logistic regression was used to calculate adjusted odds ratios for all outcomes. Results These patients were categorized into low‐risk (57.6%, 161 420), medium‐risk (39.9%, 111 805), and high‐risk (2.5%, 7075) groups. High‐risk patients, predominantly females with multiple comorbidities, exhibited significantly higher mortality rates and adverse outcomes. The HFRS showed a good discriminating ability in predicting mortality (area under the receiver operating characteristic curve = 0.7796). Frailty was associated with increased use of advanced therapeutic interventions and critical care resources such as thrombolysis, catheter‐directed therapies, inferior vena cava filter placement, mechanical ventilation, vasopressor use, and intensive care unit admission. Conclusion Frailty markedly affects outcomes in older PE patients. The HFRS offers a valuable prognostic tool in this population, suggesting that integrating frailty assessments into clinical practice could enhance care strategies and improve patient outcomes. Our findings underscore the need for further research to refine frailty‐based care paradigms. Geriatr Gerontol Int 2024; 24: 924–929 .