Hypoalbuminemia Is an Independent Risk Factor for 30-Day Mortality, Postoperative Complications, Readmission, and Reoperation in the Operative Lower Extremity Orthopaedic Trauma Patient

Abstract

Introduction: Malnutrition, as indicated by hypoalbuminemia, is known to have detrimental effects on outcomes after arthroplasty, geriatric hip fractures, and multiple general surgeries. Hypoalbuminemia has been examined in the critically ill but has largely been ignored in the orthopaedic trauma literature. We hypothesized that admission albumin levels would correlate with postoperative course in the nongeriatric lower extremity trauma patient. Methods: Patients with lower extremity (including pelvis and acetabulum) fracture who underwent operative intervention were collected from the ACS-NSQIP database. Patients younger than 65 years were included. Patient demographic data, complications, length of stay, reoperation rate, and readmission rate were collected, and patient modified frailty index scores were calculated. Poisson regression with robust error variance was then conducted, controlling for potential confounders. Results: Five thousand six hundred seventy-three patients with albumin available were identified, and 29.6% had hypoalbuminemia. Hypoalbuminemic patients had higher rates of postoperative complications [9.3% vs. 2.6%; relative risk (RR) 1.63] including increased rates of: mortality (3.2% vs. 0.4%; RR 4.86, 95% confidence interval 2.66–8.87), sepsis (1.5% vs. 0.5%, RR 2.35), and reintubation (2.3% vs. 0.4%; RR 3.84). Reoperation (5.5% vs. 2.6%, RR 1.74) and readmission (11.4% vs. 4.1%; RR 2.53) rates were also higher in patients with low albumin. Conclusion: Hypoalbuminemia is a powerful predictor of acute postoperative course and mortality after surgical fixation in nongeriatric, lower extremity orthopaedic trauma patients. Admission albumin should be a routine part of the orthopaedic trauma workup. Further study into the utility of supplementation is warranted, as this may represent a modifiable risk factor. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Malnutrition and its effects in severely injured trauma patients

“…Thirteen cohort studies reported on the prevalence of malnutrition in severely injured trauma patients (Table 1 ). The prevalence of malnutrition ranged from 7 to 76% in trauma patients in general [ 10 , 25 – 32 , 34 – 36 ].…”

“…Thirteen cohort studies about the prevalence of malnutrition in severely injured trauma patients were found, published between 1987 and 2019 (Table 1) [10,[25][26][27][28][29][30][31][32][33]. Outcomes were reported in ten articles, of which six described the general trauma population with severe injuries [10,25,31,[33][34][35], four described the geriatric trauma population [26,27,30,34]. The risk of bias in the included cohort studies was generally low ( Table 2).…”

“…Thirteen cohort studies reported on the prevalence of malnutrition in severely injured trauma patients ( Table 1). The prevalence of malnutrition ranged from 7 to 76% in trauma patients in general [10,[25][26][27][28][29][30][31][32][34][35][36]. Six studies specifically reported the prevalence of malnutrition on geriatric patients admitted with traumatic injuries.…”

“…Ten studies reported on clinical outcomes, such as mortality, hospital length of stay, quality of life, and complications associated with malnutrition, six in the general trauma population [10,25,31,[33][34][35] and four in the geriatric trauma population specifically [26,27,30,36] (Table 1). Malnutrition was associated with higher morbidity, delayed mobilization both after conservative and operative treatment, higher in-hospital mortality, prolonged hospital length of stay, reoperation and readmissions [10,31,[33][34][35]. In malnourished patients with traumatic brain injuries, neurological outcome after 6 months was less favorable, classified as death, persistent vegetative state or severe disability according to the Glasgow Outcome Scale (adjusted odds ratio 12.5; 95% confidence interval 2.6-61.0) compared to well-nourished patients [25].…”

Medical Comanagement of Hip Fracture Patients Is Not Associated with Superior Perioperative Outcomes: A Propensity Score-Matched Retrospective Cohort Analysis of the National Surgical Quality mprovement Project

“…Hypoalbuminemia, as a marker of malnutrition and frailty, was defined as a preoperative serum albumin level <3.5 g/dL, which has demonstrated independent predictive value for adverse outcomes in hip fracture patients in the NSQIP. 15,16 Predicted morbidity and mortality rates are calculated as probabilities available for each patient in the PUF based on a NSQIP hierarchical regression analysis of patient-level factors to predict outcomes (eg, not including hospital or provider factors). We also examined the relationship in regard to participation in a standardized hip fracture program (SHFP), which is a multidisciplinary protocolized pathway for hip fracture patients that may include order sets, structured care coordination, involvement of multidisciplinary therapy personnel, and daily milestones and discharge criteria.…”