Is There Synergistic Effect Between Obesity and Hypoalbuminemia on Postoperative Outcomes Among Primary Total Shoulder Arthroplasty Recipients?

The Role of Perioperative Nutritional Status and Supplementation in Orthopaedic Surgery: A Review of Postoperative Outcomes

» Identification of malnourished and at-risk patients should be a standardized part of the preoperative evaluation process for every patient.» Malnourishment is defined as a disorder of energy, protein, and nutrients based on the presence of insufficient energy intake, weight loss, muscle atrophy, loss of subcutaneous fat, localized or generalized fluid accumulation, or diminished functional status.» Malnutrition has been associated with worse outcomes postoperatively across a variety of orthopaedic procedures because malnourished patients do not have a robust metabolic reserve available for recovery after surgery.» Screening assessment and basic laboratory studies may indicate patients' nutritional risk; however, laboratory values are often not specific for malnutrition, necessitating the use of prognostic screening tools.» Nutrition consultation and perioperative supplementation with amino acids and micronutrients are 2 readily available interventions that orthopaedic surgeons can select for malnourished patients.

The geriatric nutritional risk index as a strong predictor of adverse outcomes following total shoulder arthroplasty

Background

This study investigates the association between the Geriatric Nutritional Risk Index (GNRI), a simple readily available measure of malnutrition risk, and 30-day postoperative complications following total shoulder arthroplasty (TSA).

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent TSA between 2015 and 2021. The study population was divided into 3 groups based on preoperative GNRI: normal/reference (GNRI > 98), moderate malnutrition (92 ≤ GNRI ≤ 98), and severe malnutrition (GNRI < 92). Logistic regression analysis was conducted to investigate the connection between preoperative GNRI and postoperative complications.

Results

Compared to normal nutrition, moderate malnutrition was independently significantly associated with a greater likelihood of any complications (odds ratio [OR]: 1.74, 95% confidence interval [CI]: 1.54-1.96; P < .001), blood transfusions (OR: 1.52, 95% CI: 1.09-2.11; P = .013), failure to wean off a ventilator within 48 hours (OR: 3.84, 95% CI: 1.26-11.72; P = .018), wound dehiscence (OR: 15.80, 95% CI: 1.61-155.28; P = .018), nonhome discharge (OR: 1.90, 95% CI: 1.63-2.22; P < .001), readmission (OR: 1.54, 95% CI: 1.19-1.99; P = .001), unplanned reoperation (OR: 1.87, 95% CI: 1.27-2.74; P = .001), length of stay > 2 days (OR: 1.85, 95% CI: 1.63-2.12; P < .001), and mortality (OR: 3.38, 95% CI: 1.32-8.71; P = .011). Severe malnutrition was independently significantly associated with a greater likelihood of any complication (OR: 3.33, 95% CI: 2.80-3.97; P < .001), sepsis (OR: 9.83, 95% CI: 2.94-32.85; P < .001), pneumonia (OR: 3.30, 95% CI: 1.71-6.38; P < .001), unplanned reintubation (OR: 5.77, 95% CI: 2.47-13.51; P < .001), urinary tract infection (OR: 2.15, 95% CI: 1.19-3.87; P = .011), stroke (OR: 3.57, 95% CI: 1.18-10.84; P = .024), blood transfusions (OR: 5.27, 95% CI: 3.86-7.20; P < .001), failure to wean off a ventilator within 48 hours (OR: 7.64, 95% CI: 2.29-25.55; P < .001), Clostridioides difficile infection (OR: 4.17, 95% CI: 1.21-14.32; P = .023), nonhome discharge (OR: 3.56, 95% CI: 2.92-4.34; P < .001), readmission (OR: 2.05, 95% CI: 1.46-2.89; P < .001), length of stay > 2 days (OR: 3.27, 95% CI: 2.73-3.92; P < .001), and mortality (OR: 4.61, 95% CI: 1.51-14.04; P = .007).

Conclusion

Malnutrition based on GNRI is a strong predictor of complications following TSA, with increasing severity related to an increased rate of complications.

The Impact of Hypoalbuminemia on Postoperative Complications in Patients Undergoing Shoulder Arthroplasty: A Meta-Analysis

OBJECTIVES

The objective of this meta-analysis was to investigate the association between hypoalbuminemia and postoperative complications in patients undergoing shoulder arthroplasty.

METHODS

This meta-analysis study was registered in PROSPERO (CRD42023442466) and adhered to the PRISMA guidelines. Studies focused on shoulder arthroplasty that compared hypoalbuminemia and normal albumin levels were included. A systematic literature search was conducted in PubMed, EMBASE, Scopus, and the Cochrane Collaboration database. Seven comparative studies were included, and odds ratios with a 95% confidence interval were calculated for the dichotomous variables. A fixed-effect model was used when there was no statistical evidence of heterogeneity, and a random-effect model was used when significant heterogeneity was observed. Review Manager 5.4 software was used for data analysis.

RESULTS

The meta-analysis included a total of 20,290 patients from seven studies. Hypoalbuminemia was significantly associated with a higher risk of readmissions (OR 2.92, 95%CI 1.74 to 4.91), reoperations (OR 3.23, 95%CI 1.98 to 5.27), an increase in hospital stay duration (MD 1.59, 95%CI 0.86 to 2.32), and complications such as death (OR 5.75, 95% CI 2.98 to 11.08; studies = 4), thromboembolic events (OR 2.43, 95% CI 1.46 to 4.06; studies = 4), cardiac events (OR 2.78, 95% CI 1.07 to 7.24; studies = 3), pulmonary infections (OR 3.09, 95% CI 1.54 to 6.20; studies = 3), systemic infections (OR 2.19, 95% CI 1.51 to 3.16; studies = 3), and transfusions (OR 3.16, 95% CI 2.23 to 4.48; studies = 2). However, there was no significant association between hypoalbuminemia and renal complications, surgical site infections, urinary tract infections, wound problems, or cardiovascular events.

CONCLUSION

This meta-analysis provides strong evidence that hypoalbuminemia is associated with a higher risk of postoperative complications in patients undergoing shoulder arthroplasty.