Role of Hypoalbuminemia as an Independent Predictor of 30-Day Postoperative Complications Following Surgical Fixation of Ankle Fractures

Abstract

Background:

Malnutrition is known to be negatively associated with outcomes after multiple orthopedic procedures. We hypothesized that admission albumin levels, as a marker for malnutrition, would correlate with postoperative outcomes. The purpose of this study was to investigate this relationship following surgery for ankle fracture.

Methods:

This is a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients undergoing operative fixation of an ankle fracture were identified. A total of 6138 patients with albumin available for analysis were identified. Baseline patient information, preoperative serum albumin levels, 30-day postoperative complications, readmission, reoperation, and length of stay data were then collected. Poisson regression with robust error variance was performed to assess the effect of preoperative serum albumin level on postoperative outcomes.

Results:

The mean albumin level was 3.86 g/dL and 20.3% (1246/6138) of patients with available albumin levels were hypoalbuminemic. Multivariate analysis revealed that an albumin level <3.5 g/dL was an independent risk factor for complications (relative risk [RR], 1.42; 95% confidence interval [CI], 1.13-1.78; P = .002) and readmission (RR, 1.54; 95% CI, 1.13-2.08; P = .006). Additionally, when analyzed as a continuous variable, albumin level was negatively correlated with risk of mortality (RR, 0.37; 95% CI, 0.19-0.72; P = .003). Patients with hypoalbuminemia also had significantly longer lengths of stay (4.5 vs 2.1 days; P < .001).

Conclusion:

While complication rates after fixation of ankle fractures remain low, hypoalbuminemia was a predictor of postoperative course. Malnutrition, therefore, may help inform the decision between surgical and conservative management of patients with ankle fractures potentially amenable to nonoperative management. Additionally, hypoalbuminemia should trigger heightened awareness and prophylactic therapy where appropriate.

Level of Evidence:

Level III, comparative study.

Keywords

albumin malnutrition outcomes complications ankle fracture hypoalbuminemia

Get full access to this article

View all access options for this article.

References

Adogwa

Elsamadicy

Mehta

Cheng

Bagley

Karikari

. Preoperative nutritional status is an independent predictor of 30-day hospital readmission after elective spine surgery. Spine. 2016;41(17):1400-1404.

Adogwa

Martin

Huang

, et al. Preoperative serum albumin level as a predictor of postoperative complication after spine fusion. Spine. 2014;39(18):1513-1519.

Aldebeyan

Nooh

Aoude

Weber

Harvey

. Hypoalbuminaemia—a marker of malnutrition and predictor of postoperative complications and mortality after hip fractures. Injury. 2017;48(2):436-440.

American College of Surgeons A. User guide for the 2015 ACS NSQIP participant use file (PUF). https://www.facs.org/~/media/files/quality%20programs/nsqip%20peds/pt_peds_acs_nsqip_puf_userguide_2015.ashx. Published October 2016. Accessed December 4, 2019.

Anbar

Beloosesky

Cohen

, et al. Tight calorie control in geriatric patients following hip fracture decreases complications: a randomized, controlled study. Clin Nutr. 2014;33(1):23-28.

Bell

Bauer

Capra

Pulle

. Multidisciplinary, multi-modal nutritional care in acute hip fracture inpatients—results of a pragmatic intervention. Clin Nutr. 2014;33(6):1101-1107.

Belmont

Jr Davey

Rensing

Bader

Waterman

Orr

. Patient-based and surgical risk factors for 30-day postoperative complications and mortality after ankle fracture fixation. J Orthop Trauma. 2015;29(12):e476-e482.

Blotter

Connolly

Wasan

Chapman

. Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus. Foot Ankle Int. 1999;20(11):687-694.

Bohl

Shen

Hannon

Fillingham

Darrith

Della Valle

. Serum albumin predicts survival and postoperative course following surgery for geriatric hip fracture. J Bone Joint Surg Am. 2017;99(24):2110-2118.

10.

Bohl

Shen

Kayupov

Cvetanovich

Della Valle

. Is hypoalbuminemia associated with septic failure and acute infection after revision total joint arthroplasty? A study of 4517 patients from the National Surgical Quality Improvement Program. J Arthroplasty. 2016;31(5):963-967.

11.

Bohl

Shen

Kayupov

Della Valle

. Hypoalbuminemia independently predicts surgical site infection, pneumonia, length of stay, and readmission after total joint arthroplasty. J Arthroplasty. 2016;31(1):15-21.

12.

Chermesh

Hajos

Mashiach

, et al. Malnutrition in cardiac surgery: food for thought. Eur J Prev Cardiol. 2014;21(4):475-483.

13.

Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37(8):691-697.

14.

Cross

Thomas

Garcia

Della Valle

. Evaluation of malnutrition in orthopaedic surgery. J Am Acad Orthop Surg. 2014;22(3):193-199.

15.

Day

DeHeer

. Reversal of the detrimental effects of chronic protein malnutrition on long bone fracture healing. J Orthop Trauma. 2001;15(1):47-53.

16.

Dindo

Demartines

Clavien

. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205-213.

17.

Eneroth

Olsson

Thorngren

. Nutritional supplementation decreases hip fracture-related complications. Clin Orthop Relat Res. 2006;451:212-217.

18.

Ernst

Wilson

Ahn

Shapiro

Schenker

. Malnutrition and the orthopaedic trauma patient: a systematic review of the literature. J Orthop Trauma. 2018;32(10):491-499.

19.

Evans

Martindale

Kiraly

Jones

. Nutrition optimization prior to surgery. Nutr Clin Pract. 2014;29(1):10-21.

20.

Buerba

Grauer

. Preoperative nutritional status as an adjunct predictor of major postoperative complications following anterior cervical discectomy and fusion. Clin Spine Surg. 2016;29(4):167-172.

21.

Ganesh

Pietrobon

Cecílio

WAC

Pan

Lightdale

Nunley

. The impact of diabetes on patient outcomes after ankle fracture. JBJS 2005;87(8):1712-1718.

22.

Garcia

Dines

Craig

Gulotta

. Malnutrition: a marker for increased complications, mortality, and length of stay after total shoulder arthroplasty. J Shoulder Elbow Surg. 2016;25(2):193-200.

23.

Greene

Wilde

Stulberg

. Preoperative nutritional status of total joint patients. Relationship to postoperative wound complications. J Arthroplasty. 1991;6(4):321-325.

24.

Hommel

Bjorkelund

Thorngren

Ulander

. Nutritional status among patients with hip fracture in relation to pressure ulcers. Clin Nutr. 2007;26(5):589-596.

25.

Huang

Greenky

Kerr

Austin

Parvizi

. The effect of malnutrition on patients undergoing elective joint arthroplasty. J Arthroplasty. 2013;28(8 Suppl):21-24.

26.

Jones

. Biological basis of fracture healing. J Orthop Trauma. 2005;19(10 Suppl):S1-S3.

27.

Kadakia

Bariteau

Pao

Tenenbaum

. Association of a modified frailty index with postoperative outcomes after ankle fractures in patients aged 50 years and older. Foot Ankle Orthop. 2017;2(3).

28.

Koval

Maurer

Aharonoff

Zuckerman

. The effects of nutritional status on outcome after hip fracture. J Orthop Trauma. 1999;13(3):164-169.

29.

Lavernia

Sierra

Baerga

. Nutritional parameters and short term outcome in arthroplasty. J Am Coll Nutr. 1999;18(3):274-278.

30.

Lawson

Doshi

Barton

Cobden

. The effect of unselected post-operative nutritional supplementation on nutritional status and clinical outcome of orthopaedic patients. Clin Nutr. 2003;22(1):39-46.

31.

Liu

Ahn

Raspovic

, et al. Increased rates of readmission, reoperation, and mortality following open reduction and internal fixation of ankle fractures are associated with diabetes mellitus. J Foot Ankle Surg. 2019;58(3):470-474.

32.

Moghadamyeghaneh

Hwang

Hanna

, et al. Even modest hypoalbuminemia affects outcomes of colorectal surgery patients. Am J Surg. 2015;210(2):276-284.

33.

Nasell

Ottosson

Tornqvist

Linde

Ponzer

. The impact of smoking on complications after operatively treated ankle fractures—a follow-up study of 906 patients. J Orthop Trauma. 2011;25(12):748-755.

34.

Olofsson

Stenvall

Lundstrom

Svensson

Gustafson

. Malnutrition in hip fracture patients: an intervention study. J Clin Nurs. 2007;16(11):2027-2038.

35.

Pincus

Ravi

Wasserstein

, et al. Association between wait time and 30-day mortality in adults undergoing hip fracture surgery. JAMA. 2017;318(20):1994-2003.

36.

Segal

Wilson

Staley

Michael

. The 5-item modified frailty index is predictive of 30-day postoperative complications in patients undergoing kyphoplasty vertebral augmentation. World Neurosurg. 2018;116:e225-e231.

37.

Tantigate

Kirschenbaum

, et al. Timing of open reduction and internal fixation of ankle fractures. Foot Ankle Spec. 2018;12(5):401-408.

38.

Tobert

Hamilton-Reeves

Norian

, et al. Emerging impact of malnutrition on surgical patients: literature review and potential implications for cystectomy in bladder cancer. J Urol. 2017;198(3):511-519.

39.

Wilson

Boissonneault

Schwartz

Staley

Schenker

. Frailty and malnutrition are associated with inpatient postoperative complications and mortality in hip fracture patients. J Orthop Trauma. 2019;33(3):143-148.

40.

Wilson

Farley

Erens

Guild

III . General vs spinal anesthesia for revision total knee arthroplasty: do complication rates differ? J Arthroplasty. 2019;34(7):1417-1422.

41.

Wilson

Holzgrefe

Staley

Schenker

Meals

. The effect of malnutrition on postoperative complications following surgery for distal radius fractures. J Hand Surg. 2019;44(9):742-750.

42.

Wilson

Holzgrefe

Staley

Schenker

Meals

. Use of a 5-item modified frailty index for risk stratification in patients undergoing surgical management of distal radius fractures. J Hand Surg Am. 2018;43(8):701-709.

43.

Wilson

Lunati

Grabel

Staley

Schwartz

Schenker

. Hypoalbuminemia is an independent risk factor for 30-day mortality, postoperative complications, readmission, and reoperation in the operative lower extremity orthopaedic trauma patient. J Orthop Trauma. 2019;33(6):284-291.

44.

Frank

Vann

Sonn

Moric

Della Valle

. Is potential malnutrition associated with septic failure and acute infection after revision total joint arthroplasty? Clin Orthop Relat Res. 2015;473(1):175-182.

45.

Zou

. A modified Poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159(7):702-706.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.17 MB