Shoulder
Malnutrition: a marker for increased complications, mortality, and length of stay after total shoulder arthroplasty

https://doi.org/10.1016/j.jse.2015.07.034Get rights and content

Background

Malnutrition is an established risk factor for postoperative complications. The purpose of this investigation was to determine the overall prevalence of malnutrition in total shoulder arthroplasty (TSA) patients, the differences in prevalence across obesity subgroups, and the overall complication risk of malnourished patients compared with normal patients.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for TSA cases from 2005 to 2013 for this retrospective cohort study. Malnutrition was defined as preoperative albumin concentration of <3.5 g/dL. Rates of postoperative complications were compared between normal and malnourished patients.

Results

We identified 4,655 TSA cases, with preoperative albumin measurements available for 1681 patients (36.1%). Propensity score adjustment successfully reduced selection bias, with adjusted P values of >.05 for demographics, body mass index, and modified Charlson Comorbidity Index. Of the cohort with albumin measurements, 7.6% of patients were malnourished according to our criteria. Bivariate analysis showed malnourished patients had higher rates of pulmonary complications, anemia requiring transfusion, extended length of stay (LOS), and death (all P < .05). Propensity-adjusted multivariable logistic regression demonstrated that malnutrition was significantly associated (all P < .05) with postoperative transfusion (odds ratio, 2.49), extended LOS (odds ratio, 1.69), and death (odds ratio, 18.09).

Conclusion

The overall prevalence of malnutrition was 7.6%. Malnourished patients were at a significantly increased risk for blood transfusion, longer hospital LOS, and death within 30 days of surgery. Multivariable analysis showed TSA patients with preoperative albumin levels of <3.5 g/dL are at much higher risk for morbidity and death after surgery than patients with albumin levels within normal reference ranges.

Section snippets

Materials and methods

This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. TSA cases were identified from the database using Current Procedural Terminology (CPT; American Medical Association, Chicago, IL, USA) code 23472, from 2005 to 2013. This CPT code covers anatomic and reverse TSA. The study excluded patients who underwent emergency surgery, had preoperative contaminated wound classifications, and missing data including

Results

We identified 4,655 TSA patients, of whom 1681 (36.1%) had preoperative albumin measurements. Compared with those without preoperative albumin measurements, patients with albumin data were more likely to be female, older in age, and have a higher obesity classification and higher modified CCI (Table I). The unadjusted P values trended toward statistical significance, particularly for the differences in sex (P = .095) and obesity classification (P = .071). To adjust for selection bias between

Discussion

The clinical implications of malnutrition are significant in orthopedic surgery patients. Numerous spine and arthroplasty studies have reported increased complications and LOS in these patients,14, 17, 25, 29, 31, 41 but there is a paucity of research on malnutrition in shoulder arthroplasty. Our study found hypoalbuminemia, as a marker of malnutrition, was present in 7.6% of all shoulder arthroplasty patients. These malnourished patients had a propensity-adjusted increased risk of anemia

Conclusion

Malnutrition is an important preoperative comorbidity to consider before shoulder arthroplasty, with an overall incidence of 7.6% in this shoulder arthroplasty cohort. Malnourished patients were at a significantly increased risk of anemia requiring transfusion (2.49), extended LOS (1.69), and death (OR, 1.88-173.98) within 30 days of surgery. In addition the prevalence of morbid obesity was greater in malnourished patients than in controls. Overall, shoulder arthroplasty patients with

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

References (49)

  • M. Kuzuya et al.

    Lack of correlation between total lymphocyte count and nutritional status in the elderly

    Clin Nutr

    (2005)
  • R. Lawson et al.

    The effect of unselected post-operative nutritional supplementation on nutritional status and clinical outcome of orthopaedic patients

    Clin Nutr

    (2003)
  • H. Lee et al.

    Importance of serum albumin level in the preoperative tests conducted in elderly patients with hip fracture

    Injury

    (2009)
  • D. Lieberman et al.

    Inpatient rehabilitation outcome after hip fracture surgery in elderly patients: a prospective cohort study of 946 patients

    Arch Phys Med Rehabil

    (2006)
  • C.J. Linberg et al.

    Shoulder arthroplasty in morbidly obese patients

    J Shoulder Elbow Surg

    (2009)
  • M.Z. Molnar et al.

    Associations of pretransplant serum albumin with post-transplant outcomes in kidney transplant recipients

    Am J Transplant

    (2011)
  • J.S. Pruzansky et al.

    Prevalence of modifiable surgical site infection risk factors in hip and knee joint arthroplasty patients at an urban academic hospital

    J Arthroplasty

    (2014)
  • T.K. Smith

    Nutrition: Its relationship to orthopedic infections

    Orthop Clin North Am

    (1991)
  • P.R. Aldinger et al.

    Complications in shoulder arthroplasty: an analysis of 485 cases

    Int Orthop

    (2010)

  • User guide for the 2013 participant use data file

    (2014)
  • B.A. Basques et al.

    General compared with spinal anesthesia for total hip arthroplasty

    J Bone Joint Surg Am

    (2015)
  • J.M. Beiner et al.

    Postoperative wound infections of the spine

    Neurosurg Focus

    (2003)
  • D.D. Bohl et al.

    Extramedullary compared with intramedullary implants for intertrochanteric hip fractures: thirty-day outcomes of 4432 procedures from the ACS NSQIP database

    J Bone Joint Surg Am

    (2014)
  • D.D. Bohl et al.

    Variations in data collection methods between national databases affect study results: a comparison of the Nationwide Inpatient Sample and National Surgical Quality Improvement Program databases for lumbar spine fusion procedures

    J Bone Joint Surg Am

    (2014)

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    This study used data from the National Surgical Quality Improvement Program, with no human identifying information, and was thus exempt from Investigational Review Board approval.

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