The Geriatric Nutritional Risk Index Is an Independent Predictor of Adverse Outcomes for Total Joint Arthroplasty Patients

Increasingly severe malnutrition according to the geriatric nutritional risk index is associated with a greater risk of postoperative adverse events

BACKGROUND

This study investigates the association between the geriatric nutritional risk index (GNRI), a readily available index measuring the risk of malnutrition, and 30-day postoperative complications following revision total knee arthroplasty (rTKA).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients ≥ 65 who underwent rTKA between 2015 and 2021. The study population was divided into three groups based on preoperative GNRI: normal/reference (GNRI > 98), moderate malnutrition (92 ≤ GNRI ≤ 98), and severe malnutrition (GNRI < 92). Multivariate logistic regression analysis was conducted to investigate the association between preoperative GNRI and postoperative complications.

RESULTS

Compared to normal nutrition, moderate malnutrition was independently significantly associated with a greater likelihood of experiencing any complication, blood transfusions, surgical site infection (SSI), non-home discharge, readmission, length of stay (LOS) > 2 days, and mortality. Severe malnutrition was independently significantly associated with a greater likelihood of experiencing any complication, septic shock, pneumonia, unplanned reintubation, cardiac arrest or myocardial infarction, stroke, blood transfusions, still on ventilator > 48 h, SSI, wound dehiscence, acute renal failure, non-home discharge, readmission, unplanned reoperation, LOS > 2 days, and mortality. Severe malnutrition was independently significantly associated with a greater number of complications and had a stronger association with complications compared to moderate malnutrition.

CONCLUSION

Malnutrition identified by GNRI has strong predictive value for short-term postoperative complications following rTKA in geriatric patients and may have utility as an adjunctive risk stratification tool for geriatric patients undergoing rTKA.

Geriatric Nutritional Risk Index and Postoperative Outcomes Following Head and Neck Cancer Surgery

BACKGROUND

The geriatric nutritional risk index (GNRI) is a tool to assess preoperative nutritional status that can be calculated simply based on height, weight, and serum albumin. This study assesses the utility of GNRI in predicting postoperative complications in patients undergoing major head and neck cancer (HNC) surgery.

METHODS

Retrospective review of the 2016-2020 National Surgical Quality Improvement Program database. Patients were categorized into GNRI > 98 (normal nutritional status), GNRI 92-98 (moderate malnutrition status), and GNRI < 92 (severe malnutrition status). Univariable and multivariable binary logistic regression analyses were performed.

RESULTS

Sixteen thousand seven hundred eight-nine patients undergoing HNC resection were included. On multivariable analysis, moderate and severe malnourishment based on GNRI remained significantly associated with any surgical complication, any medical complication, any complication, Clavien-Dindo grade IV complications, and 30-day mortality.

CONCLUSIONS

GNRI may have utility as a potentially modifiable preoperative prognostic factor that can be optimized to improve complications and mortality following HNC resection.

LEVEL OF EVIDENCE

Level 4.

Impact of low body mass index on reoperation risk and complications after joint arthroplasty: a cohort study

PURPOSE

The risks associated with low body mass index (BMI) in arthroplasty patients are underexplored. While outcomes of patients with elevated BMI are well-documented, low BMI patients may also face unique challenges, including malnutrition, osteopenia, and increased surgical risks and postoperative complications. To evaluate the impact of low BMI on reoperation risk and other complications compared with normal BMI among patients undergoing total hip or knee arthroplasty.

METHODS

This retrospective cohort study analyzed electronic health records of patients with BMI < 25 kg/m² who underwent hip or knee arthroplasty at Sunnybrook Holland Orthopaedic & Arthritic centre, Toronto, Canada between April 2, 2012, and April 6, 2023. Patients were stratified into low BMI (< 20 kg/m²) and normal BMI (20-24.9 kg/m²) groups, with their outcomes followed until November 2024. The main exposure was BMI categorized as low or normal. Other covariates controlled for were relevant demographics and comorbidities. The primary outcome was the risk of reoperation. The secondary outcome was composite complications (persistent pain, wound issues, and radiographic abnormalities). Survival analysis was performed with probabilities visualized with Kaplan-Meier curves. Multivariate Cox proportional hazards models were employed adjusting for potential confounders.

RESULTS

Among 1,162 included patients (mean [standard deviation] age, 68.8 [11.1] years; 70.1% women), 182 (15.7%) had low BMI and 980 (84.3%) had normal BMI. Kaplan-Meier curves demonstrated significantly higher risks of reoperation and composite complications in patients with low BMI compared to those with normal BMI (both p < 0.001). After adjusting for other covariates, low BMI was independently associated with increased risks of reoperation (adjusted Hazard Ratio (aHR), 5.8; 95% confidence interval (CI), 2.8-12.1; p < 0.001) and composite complications (aHR, 7.5; 95% CI, 3.9-14.5; p < 0.001).

CONCLUSIONS

In this large cohort of arthroplasty patients, BMI < 20 kg/m² was associated with elevated risks of reoperation and composite complications. These findings emphasize the importance of tailored preoperative optimization and vigilant postoperative care for this high-risk population.

LEVEL OF EVIDENCE

Level III.

Malnutrition and perioperative nutritional rehabilitation in major operations

Background

Malnutrition is a potentially preventable risk factor for surgery. This systematic review examines nutritional management strategies aiming to enhance surgical outcomes.

Methods

A systematic search was conducted in PubMed for English-language studies published between July 1, 2004, and July 1, 2024, involving adult surgical patients. Study selection focused on four key themes: (1) nutritional screening and assessment, (2) preoperative nutritional therapy, (3) nutritional support in critically ill surgical patients, and (4) postoperative nutritional rehabilitation. Studies in non-surgical cohorts, letters, and case reports were excluded. Reference lists of relevant studies were manually screened for additional sources.

Results

Of 2763 studies identified, 251 met the inclusion criteria and 85 were added after manual screening, contributing to a total of 341 papers for the review. The prevalence of malnutrition varied widely by procedure, with the highest rates observed in pancreatic and esophagogastric operations. Preoperative malnutrition was strongly associated with increased postoperative complications, infections, prolonged hospital stay, and higher mortality. The Malnutrition Universal Screening Tool (MUST) was effective in identifying at-risk patients. Preoperative nutritional interventions, including dietitian-led counseling, oral supplementation, and enteral or parenteral nutrition, may reduce complications and improve outcomes. Critically ill patients benefited from structured enteral and parenteral strategies. Early postoperative nutrition within enhanced recovery after surgery (ERAS) protocols are linked to less complications and shorter hospital stay.

Conclusion

Malnutrition significantly impacts surgical outcomes, necessitating early identification and intervention. Standardized management is key to improving recovery and reducing complications. Future research should focus on refining diagnostic tools, assessing nutritional requirements, optimizing perioperative nutritional strategies, and establishing long-term nutritional follow-up guidelines for surgical patients.

Perioperative Geriatrician Assessment Is Associated with a Lower Risk of Emergency Department Visits After Total Joint Arthroplasty

BACKGROUND

Previous research has underscored the benefits of geriatrician consultation in improving outcomes for older patients undergoing hip fracture repair, highlighting enhanced functional outcomes and reduced morbidity. However, the impact of geriatrician care in outcomes for patients undergoing elective total joint arthroplasty (TJA) has yet to be described. We aimed to determine whether preoperative or postoperative geriatrician involvement was associated with differences in the length of hospital stay and emergency department (ED) visits after TJA.

METHODS

This retrospective cohort study screened the medical records of patients ≥65 years of age undergoing primary elective TJA in a network of tertiary hospitals. Geriatrician consultations occurring within a period spanning 90 days before to 90 days after TJA were recorded. Bivariate analysis and multivariable regression models were used to assess the relationship between receiving these consultations and changes in the length of stay and ED visits.

RESULTS

A total of 16,076 patients undergoing primary TJA were included. Of these surgical procedures, 9,677 (60.2%) were total knee arthroplasties and 6,087 (37.9%) were total hip arthroplasties; 1,416 (8.8%) of cases had geriatrician visits. Patients had lower odds of requiring postoperative ED visits when they had at least 1 geriatrician appointment within the week preceding an arthroplasty (odds ratio [OR], 0.97 [95% confidence interval (CI), 0.68 to 0.99]; p = 0.005). This effect was most notable for 65-year-old patients (OR, 0.66 [95% CI, 0.45 to 0.98]).

CONCLUSION

This study reports promising evidence supporting the benefits of perioperative geriatrician visits on TJA outcomes. Preoperative visits were shown to be associated with decreased odds of ED visits after TJA in patients for up to 90 days postoperatively. Thus, geriatrician involvement in elective TJAs has the potential to improve outcomes and reduce morbidity and costs for patients and reduce costs for surgeons and institutions.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Preoperative geriatric nutritional risk index predicts prognosis and postoperative complications in elderly patients undergoing non-cardiac surgery: a retrospective cohort study

BACKGROUND

Little evidence on the association between geriatric nutritional risk index (GNRI) with prognosis and postoperative complications was observed. This study examined the potential prognostic value of GNRI in elderly patients undergoing non-cardiac surgery.

METHODS

This retrospective analysis was data retried from the Chinese elderly patients' perioperative database (CEPPD), a multicenter registry, from June 1st, 2012 to August 15th, 2019. Patients were categorized into at-risk group (GNRI ≤ 98) and no-risk group (GNRI > 98). Kaplan-Meier analysis and multivariate Cox proportional hazard regression were used to explore the association between GNRI and overall survival (OS). Multivariate logistic regression and linear regression were used to explore the association of the GNRI with postoperative complications. A propensity score matching (PSM) analysis was also conducted at a 1:1 ratio using the greedy nearest-neighbor method.

RESULTS

The final analysis included 28,762 elderly patients undergoing non-cardiac surgery. The PSM cohort included 7,063 patients in each group. The 1-year OS rate was 90.2% in the at-risk group vs. 96.3% in the no-risk group (P < 0.001). In Kaplan-Meier analysis, OS was significantly shorter in the at-risk group (P < 0.001 for both before matching and PSM). In multivariable Cox regression, at-risk GNRI was independently associated with OS in both the overall analysis (HR: 1.682; 95% CI: 1.502-1.882; P < 0.001) and the PSM cohort (HR: 1.501; 95% CI: 1.316-1.711; P < 0.001). At-risk GNRI was also independently associated with postoperative heart injury, acute renal injury, pulmonary infection, surgical site infection, intensive care unit (ICU) admission, longer ICU length of stay (LOS), and longer postoperative LOS.

CONCLUSIONS

Preoperative at-risk GNRI was associated with poor survival outcome and higher risk of postoperative complications in elderly patients undergoing non-cardiac surgery.

Hypoalbuminemia and Postoperative Outcomes Following Major Salivary Gland Resection

Objective

Hypoalbuminemia (HA) is a proxy for malnutrition that has been associated with postoperative complications in several surgical subspecialties. This study investigates the association between pre-operative HA and complications following major salivary gland (MSG) resection.

Methods

Patients undergoing outpatient, elective MSG resection were extracted from the 2005 to 2020 National Surgical Quality Improvement Program database. Demographics and comorbidities were compared between HA (preoperative serum albumin < 3.5 g/dL) and non-HA cohorts. To determine associations between albumin status and postoperative complications, univariate and multivariable binary logistic regression analyses were performed.

Results

A total of 5774 patients undergoing MSG resection were included, of which 321 (5.6%) had preoperative HA. HA was associated with older age on univariate analysis (65.2 vs. 60.2 years, p < 0.001). Multivariable analysis found HA to be independently associated with any surgical complication (OR 2.03, 95% CI 1.09-3.56, p = 0.019) and length of stay (LOS) ≥ 90th percentile (OR 1.58, 95% CI 1.04-2.38, p = 0.032).

Conclusion

Preoperative HA may be a poor prognostic factor associated with an increased risk of surgical complications and prolonged LOS among patients undergoing MSG resection.

Level of Evidence

4.

Preoperative Hypoalbuminemia Predicts 30-day Complications in Head and Neck Microvascular Surgery

INTRODUCTION

Hypoalbuminemia, a marker for poor nutritional status, has been associated with postoperative complications, including head and neck cancer surgery. This study investigates the impact of hypoalbuminemia on head and neck microvascular free tissue transfer reconstruction.

METHODS

This retrospective cohort study queried the 2005-2021 American College of Surgeons National Surgical Quality Improvement Program databases. Reconstructive cases performed by otolaryngologists (CPT: 15756, 15757, 15758, 15842, 20955, 20956, 20957, 20962, 20969, 20970, 20972, 20973, 43116, 43496, 49006, and 49906) with available preoperative albumin, BMI, and age were included. Hypoalbuminemia was defined as a preoperative albumin <3.5 g/dL. Univariate and multivariable logistic regression were performed.

RESULTS

A total of 3,886 cases met the inclusion criteria, of which 835 (21.5%) had hypoalbuminemia. The hypoalbuminemia cohort was older, had lower BMI, had higher ASA classification, and had worse functional health status. Adjusted multivariable logistic regression showed that hypoalbuminemia was associated with unplanned return to the operating room within 30 days (OR: 1.36, p < 0.01), unplanned reoperation (OR: 1.36, p < 0.01), any complication (OR: 1.77, p < 0.01), surgical complications (OR: 1.94, p < 0.01), and medical complications (OR: 1.34, p = 0.01). Hypoalbuminemia was correlated with a longer hospital stay, superficial surgical site infection, wound dehiscence, transfusion, deep vein thrombosis, and acute renal failure.

CONCLUSION

Hypoalbuminemia is a risk factor for postoperative complications after microvascular free tissue transfer for head and neck reconstruction. This study suggests that preoperative optimization of hypoalbuminemia may be beneficial for these patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 135:648-656, 2025.

Modifications to the Geriatric Nutritional Risk Index Predicts Complications After Total Joint Arthroplasty

BACKGROUND

Preoperative malnutrition is a known risk factor for postoperative complications following total joint arthroplasty (TJA); however, there is scant literature comparing which nutritional index is best at predicting these outcomes. The purpose of this study was to investigate the utility of the Maastricht index, Onodera's Prognostic Nutritional Index, the Geriatric Nutritional Risk index, and a novel, modified Geriatric Nutritional Risk Index (mGNRI) in predicting periprosthetic joint infection (PJI), wound complications (WCs), readmission, and reoperation rates after TJA.

METHODS

A single-center, retrospective cohort study was performed of patients who underwent primary TJA from January 2016 to December 2021. The 90-day preoperative albumin, prealbumin, and total lymphocyte count were collected. Outcome measures were PJI, WC, readmission, and return to the operating room. Youden's index (YI) and Receiver operator characteristic curves were used to determine optimal cutoff points. Multivariable logistic regression was used to adjust for potential confounders, including body mass index, age, and the Charlson comorbidity index.

RESULTS

There were 1,575 patients included in the study. The mGNRI had the greatest accuracy (area under the curve = 0.633; optimal cutoff point = 92.8) in predicting postoperative adverse outcomes. Complication rates were significantly higher in the low mGNRI group (≤ 92.8). When controlled for body mass index, Charlson comorbidity index, and age, the odds of PJI, WC, readmission, and reoperation in patients who had low mGNRI were 6.61 (P = 0.005), 3.04 (P = 0.021), 2.25 (P = 0.020), and 2.75 (P = 0.024), respectively.

CONCLUSIONS

The mGNRI is an easy-to-calculate nutritional index and an excellent predictor of postoperative complications following TJA. The mGNRI outperformed Geriatric Nutritional Risk index, Maastricht index, and Onodera's Prognostic Nutritional Index in predicting postoperative complications. Our results suggest that patients who fall below the mGNRI threshold of 92.8 should be carefully considered for nutritional optimization prior to TJA.

Geriatric Nutritional Risk Index is a risk factor for long-term decreases in patient-reported outcome measures following total knee arthroplasty

Purpose

Total knee arthroplasty (TKA) is an effective treatment for alleviating pain and improving function in patients with end-stage knee osteoarthritis. However, factors influencing long-term patient-reported outcome measures (PROMs) remain underexplored. This study aimed to evaluate the relationship between preoperative nutritional status, specifically the Geriatric Nutritional Risk Index (GNRI), and the long-term decline in PROMs following TKA.

Methods

We conducted a retrospective cohort study including patients who underwent TKA between 2000 and 2009. PROMs were assessed using the Knee Society Score (KSS) at two time points: an initial evaluation in 2012 (median postoperative 4 years) and a follow-up in 2023 (median 13 years). Preoperative GNRI, body mass index (BMI), and other demographic and clinical data were collected from medical records. Statistical analysis included paired t-tests and multivariate logistic regression to identify independent risk factors for long-term decline in KSS scores.

Results

A total of 75 patients completed follow-up assessments. Over the 11-year follow-up period, there was a significant decrease in the KSS functional activity scores (p < 0.001), with 47 patients experiencing a decline exceeding the minimal clinically important difference. A multivariate analysis revealed low preoperative GNRI (p = 0.0043) as a significant risk factor for long-term decline in PROMs.

Conclusion

Preoperative malnutrition, as indicated by a low GNRI, is a significant risk factor for long-term decline in functional outcomes following TKA. These findings highlight the importance of preoperative nutritional interventions and rehabilitation for improving the long-term outcomes of patients undergoing TKA.

Level of Evidence

Level III, retrospective cohort study.

Severe malnutrition predicts early postoperative complications in aseptic revision 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 revision 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 2022. The study population was divided into three 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 not independently associated with postoperative complications. Compared to normal nutrition, severe malnutrition was independently associated with a greater likelihood of experiencing any complication (odds ratio (OR) 3.08, 95% confidence interval (CI) 1.80-5.27; P < 0.001), blood transfusions (OR 3.68, 95% CI 1.40-9.66; P = 0.008), non-home discharge (OR 2.99, 95% CI 1.50-5.98; P = 0.002), and length of stay >2 days (OR 3.10, 95% CI 1.77-5.42; P < 0.001).

Discussion

Severe malnutrition based on GNRI is a predictor of early complications following revision TSA, however moderate malnutrition is not.

Effects of acute-phase COVID-19-related indicators on pulmonary fibrosis and follow-up evaluation

BACKGROUND

Post-COVID-19 pulmonary fibrosis is a significant long-term respiratory morbidity affecting patients' respiratory health. This exploratory study aims to investigate the incidence, clinical characteristics, and acute-phase risk factors for pulmonary fibrosis in COVID-19 patients. Additionally, it evaluates pulmonary function and chest CT outcomes to provide clinical evidence for the early identification of high-risk patients and the prevention of post-COVID-19 pulmonary fibrosis.

METHODS

We retrospectively analyzed 595 patients hospitalized for COVID-19 from January 2022 to July 2023. Patients were divided into fibrosis and nonfibrosis groups on the basis of imaging changes. Baseline data, including demographics, disease severity, laboratory indicators, and chest imaging characteristics, were collected. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for pulmonary fibrosis. Pulmonary function and chest CT follow-ups were conducted for the fibrosis group. The data were processed via SPSS 26.0, with P < 0.05 considered statistically significant.

RESULTS

The incidence of pulmonary fibrosis was 4.37%, with 2.08% in moderate cases and 8.22% in severe cases. Significant differences were found between the fibrosis and nonfibrosis groups in sex; disease severity; NLR; ALB and LDH levels; and percentages of lung reticular lesions, consolidations, and GGOs (P < 0.05). Multivariate analysis revealed LDH (OR = 1.004, 95% CI 1.000-1.007, P = 0.035), ALB (OR = 0.871, 95% CI 0.778-0.974, P = 0.015), lung reticular lesion volume (OR = 1.116, 95% CI 1.040-1.199, P = 0.002), and lung consolidation volume (OR = 1.131, 95% CI 1.012-1.264, P = 0.030) as independent risk factors. The follow-up results revealed significant improvements in pulmonary function, specifically in the FVC%, FEV1%, and DLCO%, but not in the FEV1/FVC. Quantitative chest CT analysis revealed significant differences in lung reticular lesions, consolidation, and GGO volumes but no significant difference in honeycomb volume.

CONCLUSIONS

The incidence of pulmonary fibrosis post-COVID-19 increases with disease severity. LDH, ALB, lung reticular lesions, and consolidation volume are independent risk factors for patients with fibrosis.

Preoperative Nutrition Impacts Retear Rate After Arthroscopic Rotator Cuff Repair

BACKGROUND

A rotator cuff retear following arthroscopic rotator cuff repair (ARCR) is a concern in older patients. However, only a few of its risk factors are amenable to preoperative intervention. We aimed to elucidate the relationship between preoperative nutritional status and rotator cuff retears after ARCR.

METHODS

This single-center retrospective study included patients aged ≥65 years with rotator cuff tears who underwent ARCR. The Geriatric Nutritional Risk Index (GNRI) was used to assess preoperative nutritional status. Data collection encompassed patient demographics, clinical assessments, and surgical specifics. Patients were divided into healed and retear groups based on 2-year post-ARCR magnetic resonance imaging results. Logistic regression analysis was conducted to adjust for confounding factors and detect independent risk factors for retears. The GNRI cutoff value for retear prediction was determined by a stratum-specific likelihood ratio; clinical outcomes were compared based on the cutoff values obtained.

RESULTS

Overall, 143 patients were included. The retear rate was 20.3%. The albumin level, GNRI, postoperative shoulder strength of abduction and external rotation, and postoperative Japanese Orthopaedic Association and Constant scores in the retear group were significantly lower than those in the healed group. The logistic regression analysis showed that low risk of morbidity and mortality (compared with no risk) based on the GNRI (odds ratio [OR], 3.39) and medial-lateral tear size per mm (OR = 1.10) were independent risk factors for a retear 2 years after ARCR. Stratum-specific likelihood ratio analysis identified data-driven strata as GNRI < 103, 103 ≤ GNRI < 109, and GNRI ≥ 109. Univariate analysis showed that patients with GNRI < 103 had a significantly higher retear risk than those with 103 ≤ GNRI < 109 and those with GNRI ≥ 109. Logistic regression analysis showed that GNRI < 103 compared with 103 ≤ GNRI < 109 (OR = 3.88) and GNRI < 103 compared with GNRI ≥ 109 (OR = 5.62), along with the medial-lateral tear size per mm (OR = 1.10), were independent risk factors for a retear at 2 years after ARCR.

CONCLUSIONS

When assessing the risk of a retear after ARCR, GNRI ≥ 103 may indicate good preoperative nutritional status. However, more data are essential to ascertain the importance of this finding.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

The Interrelation of Blood Urea Nitrogen-to-Albumin Ratio with Three-Month Clinical Outcomes in Acute Ischemic Stroke Cases: A Secondary Analytical Exploration Derived from a Prospective Cohort Study

Objective

This study targeted elucidating the intricate correlation of the blood urea nitrogen (BUN)-to-albumin (BUN/Alb) ratio with adverse outcomes (AOs) at 3-month in acute ischemic stroke (AIS) cases within a Korean cohort.

Methods

The cohort involved a comprehensive dataset of 1850 AIS cases from a South Korean hospital, spanning from January 2010 to December 2016. To discern the linear relationship of the BUN/Alb ratio with AOs in AIS cases, utilization of a binary logistic regression model (BLRM) was implemented. Additionally, it was attempted to utilize sophisticated statistical techniques, such as generalized additive models (GAMs) and smooth curve fitting methods, to unravel the nonlinear association of the BUN/Alb ratio with AOs in such patients.

Results

The incidence of AOs was determined to be 28.49%, with the median BUN/Alb ratio being 3.85. After adjusting for a number of covariates, the BLRM disclosed that the linear association of BUN/Alb ratio with the risk of AOs particularly in AIS cases did not achieve statistical significance. However, a noticeable nonlinear relationship emerged, with an inflection point identified at 2.86. To the left of this inflection point, the relationship is not statistically significant. On the right side of the inflection point, there was a remarkable 9.47% rise in the risk of AOs (odds ratio (OR) = 1.09, 95% confidence interval (CI): 1.00, 1.19, P = 0.04).

Conclusion

The outcomes illuminate the complex and nonlinear relationship of the BUN/Alb ratio with 3-month AOs in AIS cases. This study established a robust groundwork for the future research, underscoring the potential clinical utility of monitoring the BUN/Alb ratio to enhance the prognostic assessment and management of AIS cases.

Geriatric nutritional risk index as a predictor for surgical site infection in malignant musculoskeletal tumours of the trunk

BACKGROUND AND OBJECTIVE

Surgical site infection (SSI) is common in surgery for malignant musculoskeletal tumours, specifically those arising from the trunk. In this study, we investigated the risk factors for SSI after resection of musculoskeletal tumours of the trunk.

METHODS

This retrospective observational study included 125 patients (72 males, 53 females) with musculoskeletal tumours of the trunk in our hospital from 1 April 2008 to 31 August 2023. The incidence of SSI and its risk factors were investigated.

RESULTS

SSI was observed in 26% (32/125), and the median time to SSI was 22 days. On multivariate analysis, the following were identified as risk factors for SSI: tumours arising caudal to Jacoby's line (hazard ratio [HR] 4.04; P = .0107), soft tissue reconstruction (HR 3.43; P = .0131), and low Geriatric Nutritional Risk Index (GNRI) (HR 0.96; P = .0304). Patients were classified into two risk categories based on GNRI scores: the risk group (GNRI ≤98) and no risk group (>98). The risk group showed a significantly lower overall noninfection survival rate (P = .023).

CONCLUSION

Tumours arising caudal to Jacoby line, soft tissue reconstruction, and lower GNRI were risk factors for SSI. Preoperative and postoperative nutritional interventions should be considered to improve GNRI.

Geriatric Nutritional Risk Index and 30-Day Postoperative Mortality in Geriatric Burn Patients

INTRODUCTION

The geriatric nutritional risk index (GNRI) can easily identify malnutrition-associated morbidity and mortality. We investigated the association between preoperative GNRI and 30-d mortality in geriatric burn patients who underwent surgery.

METHODS

The study involved geriatric burn patients (aged ≥ 65 y) who underwent burn surgery between 2012 and 2022. The GNRI was computed using the following formula: 1.489 × serum albumin concentration (mg/L) + 41.7 × patient body weight/ideal body weight. Patients were dichotomized into the high GNRI (≥ 82) and low GNRI (< 82) groups. GNRI was evaluated as an independent predictor of 30-d postoperative mortality. The study also evaluated the association between GNRI and sepsis, the need for continuous renal replacement therapy (CRRT), major adverse cardiac events (MACE), and pneumonia.

RESULTS

Out of 270 patients, 128 (47.4%) had low GNRI (< 82). Multivariate Cox regression analysis revealed that low GNRI was significantly associated with 30-d postoperative mortality (hazard ratio: 1.874, 95% confidence interval [CI]: 1.146-3.066, P = 0.001). Kaplan-Meier analysis revealed that the 30-day mortality rate differed significantly between the low and high GNRI groups (log-rank test, P < 0.001). The 30-d postoperative mortality (hazard ratio: 2.677, 95% CI: 1.536-4.667, P < 0.001) and the incidence of sepsis (odds ratio [OR]: 2.137, 95% CI: 1.307-3.494, P = 0.004), need for CRRT (OR: 1.919, 95% CI: 1.101-3.344, P = 0.025), MACE (OR: 1.680, 95% CI: 1.018-2.773, P = 0.043), and pneumonia (OR: 1.678, 95% CI: 1.019-2.764, P = 0.044), were significantly higher in the low GNRI group than in the high GNRI group.

CONCLUSIONS

Preoperative low GNRI was associated with increased 30-d postoperative mortality, sepsis, need for CRRT, MACE, and pneumonia in geriatric burn patients.

The Geriatric Nutritional Risk Index Is an Independent Predictor for Adverse Outcomes After Anterior Cervical Discectomy and Fusion

BACKGROUND

Malnutrition frequently is associated with increased complications and worse outcomes after surgery. The purpose of this study was to determine whether malnutrition status determined using the Geriatric Nutritional Risk Index (GNRI) can serve as an independent risk factor for complications in patients undergoing anterior cervical discectomy and fusion (ACDF).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2011 to 2016 for patients age ≥65 years who underwent ACDF. Patients were categorized into 3 groups based on the GNRI: >98, normal nutritional status; 92-98, moderately malnourished; and <92, severely malnourished. Multivariate logistic regression models adjusted for covariates of demographics, comorbidities, and operative metrics were used to evaluate GNRI as an independent risk factor for postoperative outcomes.

RESULTS

A total of 3148 patients who underwent ACDF were analyzed, of whom 78.9% had normal nutrition, 16.1% were moderately malnourished, and 5.0% patients were severely malnourished. On multivariate analysis, moderate and severe malnutrition were found to be independent risk factors for any complication, pulmonary complications, pneumonia, unplanned intubation, and hospital length of stay >6 days (P < 0.05 for all). In addition, moderate malnutrition was a risk factor for failure to wean from ventilation for >48 hours and 30-day readmission. Severe malnutrition was an independent risk factor for septic shock and nonhome discharge.

CONCLUSIONS

In elderly patients after ACDF, malnutrition determined using GNRI is an independent risk factor for 30-day complications, readmissions, prolonged hospital length of stay, and nonhome discharge.

Revision Total Hip Arthroplasty: Evaluating the Utility of the Geriatric Nutritional Risk Index as a Risk Stratification Tool

Background

This study investigates the association between the Geriatric Nutritional Risk Index (GNRI), a measure of malnutrition risk, and 30-day postoperative complications following revision total hip arthroplasty (rTHA).

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients ≥65 who underwent aseptic rTHA between 2015 and 2021. The final study population (n = 7119) was divided into 3 groups based on preoperative GNRI: normal/reference (GNRI >98) (n = 4342), moderate malnutrition (92 ≤ GNRI ≤98) (n = 1367), and severe malnutrition (GNRI <92) (n = 1410). Multivariate logistic regression analysis was conducted to investigate the association between preoperative GNRI and 30-day postoperative complications.

Results

After controlling for significant covariates, the risk of experiencing any postoperative complications was significantly higher with both moderate (odds ratio [OR] 2.08, P < .001) and severe malnutrition (OR 8.79, P < .001). Specifically, moderate malnutrition was independently and significantly associated with deep vein thrombosis (OR 1.01, P = .044), blood transfusions (OR 1.78, P < .001), nonhome discharge (OR 1.83, P < .001), readmission (OR 1.27, P = .035), length of stay >2 days (OR 1.98, P < .001), and periprosthetic fracture (OR 1.54, P = .020). Severe malnutrition was independently and significantly associated with sepsis (OR 3.67, P < .001), septic shock (OR 3.75, P = .002), pneumonia (OR 2.73, P < .001), urinary tract infection (OR 2.04, P = .002), deep vein thrombosis (OR 1.01, P = .001), pulmonary embolism (OR 2.47, P = .019), acute renal failure (OR 8.44, P = .011), blood transfusions (OR 2.78, P < .001), surgical site infection (OR 2.59, P < .001), nonhome discharge (OR 3.36, P < .001), readmission (OR 1.69, P < .001), unplanned reoperation (OR 1.97, P < .001), length of stay >2 days (OR 5.41, P < .001), periprosthetic fractures (OR 1.61, P = .015), and mortality (OR 2.63, P < .001).

Conclusions

Malnutrition has strong predictive value for short-term postoperative complications and has potential as an adjunctive risk stratification tool for geriatric patients undergoing rTHA.

Rethinking risk prediction: The role of albumin and other parameters in implant-associated complications after hip or knee arthroplasty

BACKGROUND

Total hip (THA) or knee (TKA) arthroplasty is still a traumatic and challenging operation that induces inflammation, with a particularly high risk of acute-phase reaction. The aim of this study was to predict the likelihood of implant-associated complications during the preoperative and postoperative course.

METHODS

The prospective observational, non-interventional study of patients diagnosed with primary knee or hip osteoarthrosis undergoing THA or TKA during the study period was conducted. The inflammatory and malnutrition parameters were collected for each patient one day before surgery, two days after surgery, and in outpatient follow-up.

RESULTS

Of 159 patients analysed, 12 developed implant-associated complications. The albumin, prealbumin, Intensive Care Infection Score (ICIS), Nutritional Risk Index, and white blood cell counts were found to be potential predictors. Notably, preoperative albumin levels significantly differed between groups with and without complications (P-value = 0.042).

CONCLUSION

Our study definitively shows that WBC, prealbumin, Nutritional Risk Index, ICIS as a novel marker, and significantly albumin, outperform C-reactive protein in predicting implant-associated complications in hip and knee arthroplasty.

Preoperative nutritional status and postoperative health outcomes in older adults undergoing spine surgery: Electronic health records analysis

AIM

To examine whether a high nutritional risk status, assessed via the Geriatric Nutritional Risk Index (GNRI), is independently associated with postoperative health outcomes, including unplanned intensive care unit (ICU) admissions, infectious complications, and prolonged length of stay in older patients undergoing spine surgery.

METHODS

We conducted a retrospective descriptive study analyzing electronic health records from a tertiary hospital, including data from 1,014 patients aged ≥70 undergoing elective spine surgery between February 2013 and March 2023.

RESULTS

High nutritional risk patients had significantly higher odds of unplanned ICU admission, infectious complications, and prolonged length of stay compared to low-risk patients. For each one-point increase in GNRI, there was a significant 0.91- and 0.95-fold decrease in the odds of unplanned ICU admission and infectious complications, respectively.

CONCLUSION

GNRI screening in older patients before spine surgery may have potential to identify those at elevated risk for postoperative adverse outcomes.

Association Between Hemoglobin-Albumin-Lymphocyte-Platelet Index and Mortality in Hospitalized COVID-19 Omicron BA.2 Infected Patients

Background

The hemoglobin-albumin-lymphocyte-platelet (HALP) index is a novel biomarker reflecting systemic inflammation and nutritional status which are important for coronavirus disease 2019 (COVID-19) mortality. However, the association between HALP and mortality in patients with COVID-19 has yet to be investigated.

Methods

A cohort of COVID-19 Omicron BA.2 infected patients admitted to the Shanghai Fourth People's Hospital, School of Medicine, Tongji University from April 12, 2022 to June 17, 2022 was retrospectively analyzed. Laboratory examinations on hospital admission, including hemoglobin, albumin, and lymphocyte and platelet, were collected. The association between baseline HALP and in-hospital poor overall survival (OS) was assessed using Kaplan-Meier curves, Cox regression models, interaction, and stratified analyses.

Results

A total of 2147 patients with COVID-19 Omicron BA.2 infection were included in the final analyses, and mortality in the hospital was 2.65%. Multivariate analysis indicated that low HALP index was independently associated with in-hospital mortality of COVID-19 patients [hazard ratio (HR) = 2.08; 95% confidence interval (CI) = 1.17-3.73]. Subgroup analysis demonstrated that low HALP index was an independent risk factor for in-hospital mortality in COVID-19 patients with age ≥70 (HR = 2.22, CI = 1.18-4.15) and severe cases (HR = 2.09, CI = 1.13-3.86).

Conclusion

HALP index is independently related to in-hospital poor OS for COVID-19 Omicron BA.2 infected patients, especially for age ≥70 and severe cases. HALP index on hospital admission is a useful candidate biomarker for identifying high risk of mortality in COVID-19 Omicron BA.2 infected patients.

Associations of postoperative outcomes with geriatric nutritional risk index after conventional and robotic-assisted total knee arthroplasty: a randomized controlled trial

BACKGROUND

The association between postoperative outcomes of robotic-assisted total knee arthroplasty (RA-TKA) and nutrition status among elderly adults remained unclear. The authors aimed to evaluate these associations and provide a nutrition status reference for the surgical technique selection of TKA.

METHODS

In the present study, the authors used data from a multicenter, prospective, randomized controlled project, which recruited patients underwent TKA therapy. A total of 88 elderly adults (age ≥65 years old) were included in this study. Their preoperative and postoperative demographic data and radiographic parameters were collected. Clinical outcomes, including postoperative hip-knee-ankle (HKA) angle deviation, knee society score (KSS), 10 cm visual analog scale, and so on, were observed and compared between the RA-TKA group and the conventional TKA group. Logistic regression was performed to adjust several covariates. In addition, according to the results of restricted cubic splines analyses, all participants were categorized into two groups with GNRI≤100 and GNRI >100 for further subgroup analyses.

RESULTS

Our results showed despite having a lower postoperative HKA angle deviation, the RA-TKA group had a similar postoperative KSS score compared with the conventional TKA group in elderly adults. Among elderly patients with GNRI>100, RA-TKA group achieved significantly more accurate alignment (HKA deviation, P =0.039), but did not obtain more advanced postoperative KSS scores because of the compensatory effect of good nutrition status. However, among elderly patients with GNRI≤100, RA-TKA group had significantly higher postoperative KSS scores compared to the conventional TKA group ( P =0.025) and this association were not altered after adjustment for other covariates.

CONCLUSION

Considering the clinical outcomes of conventional TKA may be more susceptible to the impact of nutrition status, elderly patients with GNRI≤100 seem to be an applicable population for RA-TKA, which is more stable and would gain significantly more clinical benefits compared with conventional TKA.

Geriatric nutritional risk index and adverse medical outcomes among Egyptian patients admitted to a geriatric hospital: a prospective cohort study

BACKGROUND

Elderly are one of the most heterogeneous and vulnerable groups who have a higher risk of nutritional problems. Malnutrition is prevalent among hospitalized elderly but underdiagnosed and almost undistinguishable from the changes in the aging process. The Geriatric Nutritional Risk Index (GNRI) is a tool created to predict nutrition-related complications in hospitalized patients. This study aims to measure the prevalence of nutritional risk using the GNRI among hospitalized elderly Egyptian inpatients and to determine the association between the GNRI and selected adverse clinical outcomes.

METHODS

A hospital-based prospective cohort study was conducted among 334 elderly patients admitted to a tertiary specialized geriatric university hospital in Cairo, Egypt from August 2021 to June 2022. Within 48 hours after hospital admission, socio-demographic characteristics, blood biomarkers, anthropometric measurements, and nutritional risk assessment by the GNRI score were obtained. Patients were divided into three groups based on their GNRI: high, low, and no nutritional risk (GNRI<92, 92-98, and >98) respectively. Patients were followed up for the occurrence of adverse outcomes during hospital stay (bed sores, Healthcare-Associated Infections (HAIs), hospital Length of Stay (LOS), and hospital mortality) and three months after discharge (non-improvement medical status, appearance of new medical conditions, hospital readmission and 90-day mortality). Multivariable regression and survival analysis were conducted.

RESULTS

The prevalence of high-nutritional risk was 45.5% (95% CI, 40%-51%). Patients with high risk had significantly longer LOS than those with no risk. The high-nutritional risk was significantly associated with the development of bed sores (Adjusted Odds Ratio (AOR) 4.89; 95% CI, 1.37-17.45), HAIs (AOR: 3.18; 95% CI, 1.48-6.83), and hospital mortality (AOR: 4.41; 95% CI, 1.04-18.59). The overall survival rate was significantly lower among patients with high-nutritional risk compared to those with no risk.

CONCLUSION

GNRI is a simple and easily applicable objective nutritional screening tool with high prognostic value in this Egyptian sample of patients. The findings of this study signal the initiation of the application of this tool to all geriatric hospitals in Egypt.

Shoulder arthroscopy in elderly patients: malnutrition and early postoperative outcomes

Background

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

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify all patients aged ≥65 years who underwent shoulder arthroscopy between 2015 and 2021. The study population was indexed into 3 cohorts of preoperative GNRI: normal/reference (GNRI >98), moderate malnutrition (92≤ GNRI ≤98), and severe malnutrition (GNRI <92). Multivariate logistic regression analysis was conducted to investigate the connection between preoperative GNRI and postoperative complications.

Results

Severe malnutrition was independently significantly associated with a greater likelihood of any complication (odds ratio [OR]: 11.70, 95% confidence interval [CI]: 8.58-15.94; P < .001), sepsis (OR: 26.61, 95% CI: 10.86-65.21; P < .001), septic shock (OR: 7.53, 95% CI: 1.56-36.32; P = .012), blood transfusions (OR: 25.38, 95% CI: 6.40-100.59; P < .001), pulmonary embolism (OR: 7.25, 95% CI: 1.27-41.40; P = .026), surgical site infection (OR: 22.08, 95% CI: 7.51-64.97; P < .001), nonhome discharge (OR: 15.75, 95% CI: 9.83-25.23; P < .001), readmission (OR: 2.69, 95% CI: 1.52-4.74; P < .001), unplanned reoperation (OR: 6.32, 95% CI: 2.23-17.92; P < .001), length of stay >2 days (OR: 23.66, 95% CI: 16.25-34.45; P < .001), and mortality (OR: 14.25, 95% CI: 2.89-70.40; P = .001).

Conclusion

GNRI-based malnutrition is strongly predictive of perioperative complications following shoulder arthroscopy in geriatric patients and has utility as an adjunctive risk stratification tool.

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.

Does the geriatric nutritional risk index predict complication rates and implant survivorship in revision total joint arthroplasty?

INTRODUCTION

Malnutrition is associated with poorer outcomes after revision total joint arthroplasty (rTJA), though no universal metric for assessing malnutrition in rTJA patients has been reported. This study sought to determine if malnutrition as defined by the Geriatric Nutritional Risk Index (GNRI) can independently predict short-term complication rates and re-revision risk in patients undergoing rTJA.

METHODS

All patients ≥ 65 years old undergoing rTJA from 2011 to 2021 at a single orthopaedic specialty hospital were identified. Preoperative albumin, height, and weight were used to calculate GNRI. Based on the calculated GNRI value, patients were stratified into three groups: normal nutrition (GNRI > 98), moderate malnutrition (GNRI 92-98), and severe malnutrition (GNRI < 92). Chi-squared and independent samples t-tests were used to compare groups.

RESULTS

A total of 531 rTJA patients were included. Patients with normal nutrition were younger (p < 0.001), had higher BMI (p < 0.001). After adjusting for baseline characteristics, patients with severe and moderate malnutrition had longer length of stay (p < 0.001), were less likely to be discharged home (p = 0.049), and had higher 90-day major complication (p = 0.02) and readmission (p = 0.005) rates than those with normal nutrition. 90-day revision rates were similar. In Kaplan-Meier analyses, patients with severe and moderate malnutrition had worse survivorship free of all-cause re-revision at 1-year (p = 0.001) and 2-year (p = 0.002) follow-up compared to those with normal nutrition.

CONCLUSION

Moderate and severe malnutrition, as defined by GNRI, independently predicted higher complication and revision rates in rTJA patients. This suggests that the GNRI may serve as an effective screening tool for nutritional status in patients undergoing rTJA.

Limiting Factors for Indication of Hip and Knee Arthroplasty in Chile: The International Perception of Risk Initiative

BACKGROUND

An aging population with a resultant higher incidence of osteoarthritis have increased the need for total hip (THA) and knee arthroplasty (TKA) worldwide. The purpose of this study was to explore what medical and social risk factors are considered relevant by Chilean orthopaedic surgeons in decisions regarding indications for THA or TKA.

METHODS

An anonymous survey was sent to 165 hip and knee arthroplasty surgeons who were members of the Chilean Orthopedics and Traumatology Society. From a total of 165 surgeons, 128 (78%) completed the survey. The questionnaire included demographic data, place of work, and inquired about medical and socioeconomic factors that could affect surgical indications.

RESULTS

Factors that limited indications for elective THA/TKA included body mass index (81%), elevated hemoglobin A1c (92%), lack of social support network (58%), and low socioeconomic status (40%). Most respondents made decisions based on personal experience or literature review rather than hospital or departmental pressures. Of the respondents, 64% believe that some patient populations would benefit from better care if payment systems adjusted for their socioeconomic risk factors.

CONCLUSION

In Chile, limitations regarding the indication for THA/TKA are most influenced by the presence of modifiable medical risk factors such as obesity, uncompensated diabetes, or malnutrition. We believe that the reason surgeons limit surgeries for such individuals is to promote better clinical outcomes, and not in response to pressure from paying entities. However, low socioeconomic status was perceived to impair the ability to achieve good clinical outcomes by 40% of the surgeons.

Correlation between admission hypoalbuminemia and postoperative urinary tract infections in elderly hip fracture patients

PURPOSE

This study aimed to evaluate the correlation between hypoalbuminemia upon admission and the incidence of postoperative urinary tract infections (UTIs) in elderly patients with hip fractures.

METHODS

A retrospective analysis was performed on the medical records of elderly patients who underwent surgical treatment for hip fractures at a level I trauma center from 2013 to 2023. Serum albumin levels were measured upon admission, and hypoalbuminemia was defined as a total albumin level < 35 g/L. Multivariable logistic regression and propensity score matching analysis were utilized to control and reduce potential confounding factors, aiming to obtain adjusted odds ratios (ORs) and 95% confidence intervals (CI) for UTIs to determine the strength of the association.

RESULTS

This observational cohort study included 1279 patients, among whom 298 (23.3%) developed UTIs. Patients with albumin levels < 35 g/L had significantly greater odds of developing UTIs compared to those with albumin levels ≥ 35 g/L (OR 1.86, 95% CI 1.28-2.70). Further analysis, dividing albumin levels into quartiles, demonstrated that patients in the Q2 group (38.0-40.9 g/L; OR 1.38, 95% CI 0.88-2.17), Q3 group (35.0-37.9 g/L; OR 1.69, 95% CI 1.06-2.71), and Q4 group (15.3-34.9 g/L; OR 2.67, 95% CI 1.61-4.43) had notably higher odds of developing UTIs compared to those in the Q1 group (41.0-52.0 g/L).

CONCLUSIONS

The presence of hypoalbuminemia upon admission in elderly patients undergoing hip fracture surgery is strongly correlated with the occurrence of postoperative UTIs. Furthermore, this association exhibits a clear dose-response relationship.

Preoperative incidence and risk factors of deep vein thrombosis in Japanese patients undergoing total hip arthroplasty

PURPOSE

Preoperative deep vein thrombosis (DVT) is a risk factor for postoperative venous thromboembolism (VTE), causing severe mortality. Early detection of preoperative DVT is essential to prevent postoperative VTE. However, little is known regarding preoperative DVT in patients undergoing major surgery. The present study aimed to determine the incidence and risk factors of preoperative DVT in patients admitted for total hip arthroplasty (THA).

METHODS

From August 2017 to September 2022, 243 patients admitted for THA at our institution were enrolled in this study. Patients medical records and preoperative laboratory data were retrospectively collected. According to the results of lower-limb ultrasonography, patients were divided into either the non-DVT (n = 136) or DVT (n = 43) group. The incidence of DVT and independent risk factors for preoperative DVT were investigated using univariate and multivariate logistic regression analyses.

RESULTS

The mean age was 74.0 ± 8.4 years. Preoperative DVT was diagnosed in 43 of the 243 (17.7%) patients. The risk of DVT was significantly high (p < 0.05) in patients with advanced age, increased D-dimer levels, and malnutrition status, as assessed by the Geriatric Nutritional Risk Index (GNRI). Multivariate analysis showed that advanced age, increased D-dimer level, and malnutrition status assessed by the GNRI were independent risk factors for preoperative DVT.

CONCLUSION

A high incidence of preoperative DVT was observed in patients undergoing THA. Advanced age, increased D-dimer levels, and malnutrition assessed by the GNRI increased the risk of preoperative DVT. Screening high-risk subgroups for preoperative DVT is necessary to prevent postoperative VTE.

Defining Clinically Meaningful Subgroups for Risk Stratification in Patients Undergoing Revision Total Hip Arthroplasty: A Combined Unsupervised and Supervised Machine Learning Approach

BACKGROUND

Studies developing predictive models from large datasets to risk-stratify patients under going revision total hip arthroplasties (rTHAs) are limited. We used machine learning (ML) to stratify patients undergoing rTHA into risk-based subgroups.

METHODS

We retrospectively identified 7,425 patients who underwent rTHA from a national database. An unsupervised random forest algorithm was used to partition patients into high-risk and low-risk strata based on similarities in rates of mortality, reoperation, and 25 other postoperative complications. A risk calculator was produced using a supervised ML algorithm to identify high-risk patients based on preoperative parameters.

RESULTS

There were 3,135 and 4,290 patients identified in the high-risk and low-risk subgroups, respectively. Each group significantly differed by rate of 30-day mortalities, unplanned reoperations/readmissions, routine discharges, and hospital lengths of stay (P < .05). An Extreme Gradient Boosting algorithm identified preoperative platelets < 200, hematocrit > 35 or < 20, increasing age, albumin < 3, international normalized ratio > 2, body mass index > 35, American Society of Anesthesia class ≥ 3, blood urea nitrogen > 50 or < 30, creatinine > 1.5, diagnosis of hypertension or coagulopathy, and revision for periprosthetic fracture and infection as predictors of high risk.

CONCLUSION

Clinically meaningful risk strata in patients undergoing rTHA were identified using an ML clustering approach. Preoperative labs, demographics, and surgical indications have the greatest impact on differentiating high versus low risk.

LEVEL OF EVIDENCE

III.

Machine Learning on Medicare Claims Poorly Predicts the Individual Risk of 30-Day Unplanned Readmission After Total Joint Arthroplasty, Yet Uncovers Interesting Population-level Associations With Annual Procedure Volumes

BACKGROUND

Unplanned hospital readmissions after total joint arthroplasty (TJA) represent potentially serious adverse events and remain a critical measure of hospital quality. Predicting the risk of readmission after TJA may provide patients and clinicians with valuable information for preoperative decision-making.

QUESTIONS/PURPOSES

(1) Can nonlinear machine-learning models integrating preoperatively available patient, surgeon, hospital, and county-level information predict 30-day unplanned hospital readmissions in a large cohort of nationwide Medicare beneficiaries undergoing TJA? (2) Which predictors are the most important in predicting 30-day unplanned hospital readmissions? (3) What specific information regarding population-level associations can we obtain from interpreting partial dependency plots (plots describing, given our modeling choice, the potentially nonlinear shape of associations between predictors and readmissions) of the most important predictors of 30-day readmission?

METHODS

National Medicare claims data (chosen because this database represents a large proportion of patients undergoing TJA annually) were analyzed for patients undergoing inpatient TJA between October 2016 and September 2018. A total of 679,041 TJAs (239,391 THAs [61.3% women, 91.9% White, 52.6% between 70 and 79 years old] and 439,650 TKAs [63.3% women, 90% White, 55.2% between 70 and 79 years old]) were included. Model features included demographics, county-level social determinants of health, prior-year (365-day) hospital and surgeon TJA procedure volumes, and clinical classification software-refined diagnosis and procedure categories summarizing each patient's Medicare claims 365 days before TJA. Machine-learning models, namely generalized additive models with pairwise interactions (prediction models consisting of both univariate predictions and pairwise interaction terms that allow for nonlinear effects), were trained and evaluated for predictive performance using area under the receiver operating characteristic (AUROC; 1.0 = perfect discrimination, 0.5 = no better than random chance) and precision-recall curves (AUPRC; equivalent to the average positive predictive value, which does not give credit for guessing "no readmission" when this is true most of the time, interpretable relative to the base rate of readmissions) on two holdout samples. All admissions (except the last 2 months' worth) were collected and split randomly 80%/20%. The training cohort was formed with the random 80% sample, which was downsampled (so it included all readmissions and a random, equal number of nonreadmissions). The random 20% sample served as the first test cohort ("random holdout"). The last 2 months of admissions (originally held aside) served as the second test cohort ("2-month holdout"). Finally, feature importances (the degree to which each variable contributed to the predictions) and partial dependency plots were investigated to answer the second and third research questions.

RESULTS

For the random holdout sample, model performance values in terms of AUROC and AUPRC were 0.65 and 0.087, respectively, for THA and 0.66 and 0.077, respectively, for TKA. For the 2-month holdout sample, these numbers were 0.66 and 0.087 and 0.65 and 0.075. Thus, our nonlinear models incorporating a wide variety of preoperative features from Medicare claims data could not well-predict the individual likelihood of readmissions (that is, the models performed poorly and are not appropriate for clinical use). The most predictive features (in terms of mean absolute scores) and their partial dependency graphs still confer information about population-level associations with increased risk of readmission, namely with older patient age, low prior 365-day surgeon and hospital TJA procedure volumes, being a man, patient history of cardiac diagnoses and lack of oncologic diagnoses, and higher county-level rates of hospitalizations for ambulatory-care sensitive conditions. Further inspection of partial dependency plots revealed nonlinear population-level associations specifically for surgeon and hospital procedure volumes. The readmission risk for THA and TKA decreased as surgeons performed more procedures in the prior 365 days, up to approximately 75 TJAs (odds ratio [OR] = 1.2 for TKA and 1.3 for THA), but no further risk reduction was observed for higher annual surgeon procedure volumes. For THA, the readmission risk decreased as hospitals performed more procedures, up to approximately 600 TJAs (OR = 1.2), but no further risk reduction was observed for higher annual hospital procedure volumes.

CONCLUSION

A large dataset of Medicare claims and machine learning were inadequate to provide a clinically useful individual prediction model for 30-day unplanned readmissions after TKA or THA, suggesting that other factors that are not routinely collected in claims databases are needed for predicting readmissions. Nonlinear population-level associations between low surgeon and hospital procedure volumes and increased readmission risk were identified, including specific volume thresholds above which the readmission risk no longer decreases, which may still be indirectly clinically useful in guiding policy as well as patient decision-making when selecting a hospital or surgeon for treatment.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Screening and Management of Malnutrition in Total Joint Arthroplasty

Malnutrition is an increasingly prevalent problem in patients undergoing total joint arthroplasty (TJA). Increased risks associated with TJA in the setting of malnourishment have been well documented. Standardized scoring systems in addition to laboratory parameters such as albumin, prealbumin, transferrin, and total lymphocyte count have been developed to identify and evaluate malnourished patients. Despite an abundance of recent literature, there is no consensus on the best approach for screening TJA patients from a nutritional standpoint. Although there are a variety of treatment options, including nutritional supplements, nonsurgical weight loss therapies, bariatric surgery, and the involvement of dieticians and nutritionists, the effect of these interventions on TJA outcomes has not been well characterized. This overview of the most current literature aims to provide a clinical framework for approaching nutrition status in arthroplasty patients. A comprehensive understanding of the tools available for managing malnourishment will facilitate improved arthroplasty care.

Association between blood urea nitrogen to serum albumin ratio and in-hospital mortality of patients with sepsis in intensive care: A retrospective analysis of the fourth-generation Medical Information Mart for Intensive Care database

BACKGROUND

This study aimed to investigate the relationship between the blood urea nitrogen to serum albumin ratio (BAR) and in-hospital mortality in patients with sepsis.

MATERIALS AND METHODS

This is a retrospective cohort study. All septic patient data for the study were obtained from the intensive care unit of Beth Israel Deaconess Medical Center. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using multivariable Cox regression analyses. Survival curves were plotted and subgroup analyses were stratified by relevant covariates.

RESULTS

Among 23,901 patients, 13,464 with sepsis were included. The overall in-hospital mortality rate was 18.9% (2550/13464). After adjustment for confounding factors, patients in the highest BAR quartile had an increased risk of sepsis death than those in the lowest BAR quartile (HR: 1.42, 95% CI: 1.3-1.55), using BAR as a categorical variable. When BAR was presented as a continuous variable, the prevalence of in-hospital sepsis-related death increased by 8% (adjusted HR: 1.08, 95% CI: 1.07-1.1, P < 0.001) for each 5-unit increase in BAR, irrespective of confounders. Stratified analyses indicated age interactions (P < 0.001), and the correlation between BAR and the probability of dying due to sepsis was stable.

CONCLUSION

BAR was significantly associated with in-hospital mortality in intensive care patients with sepsis. A higher BAR in patients with sepsis is associated with a worse prognosis in the ICU in the USA. However, further research is required to confirm this finding.

Moderate-to-Severe Malnutrition Identified by the Controlling Nutritional Status (CONUT) Score Is Significantly Associated with Treatment Failure of Periprosthetic Joint Infection

The prevalence and role of malnutrition in periprosthetic joint infection (PJI) remain unclear. This study aimed to use measurable nutritional screening tools to assess the prevalence of malnutrition in PJI patients during two-stage exchange arthroplasty and to explore the association between malnutrition and treatment failure. Our study retrospectively included 183 PJI cases who underwent 1st stage exchange arthroplasty and had available nutritional parameters, of which 167 proceeded with 2nd stage reimplantation. The recently proposed Musculoskeletal Infection Society (MSIS) Outcome Reporting Tool was used to determine clinical outcomes. The Controlling Nutritional Status (CONUT), Nutritional Risk Index (NRI), and Naples Prognostic Score (NPS) were used to identify malnutrition at 1st and 2nd stage exchange, respectively. Multivariate logistic regression analyses were performed to determine the association between malnutrition and treatment failure. Restricted cubic spline models were further used to explore the dose−response association. Additionally, risk factors for moderate-to-severe malnutrition were evaluated. Malnourished patients identified by CONUT, NPS, and NRI accounted for 48.1% (88/183), 98.9% (181/183), and 55.7% (102/183) of patients at 1st stage, and 9.0% (15/167), 41.9% (70/167), and 43.1% (72/167) at 2nd stage, indicating a significant improvement in nutritional status. We found that poorer nutritional status was a predictor of treatment failure, with CONUT performing best as a predictive tool. Moderate-to-severe malnutrition at 1st stage identified by CONUT was significantly related to treatment failure directly caused by PJI (odds ratio [OR] = 5.86), while the OR was raised to 12.15 at 2nd stage (OR = 12.15). The linear dose−response associations between them were also confirmed (P for nonlinearity at both 1st and 2nd stage > 0.05). As for total treatment failure, moderate-to-severe malnutrition as determined by CONUT was associated with a 1.96-fold and 8.99-fold elevated risk at the 1st and 2nd stages, respectively. Age ≥ 68 years (OR = 5.35) and an increased number of previous surgeries (OR = 2.04) may be risk factors for moderate-to-severe malnutrition. Overall, the prevalence of malnutrition in PJI patients is very high. Given the strong association between moderate-to-severe malnutrition identified by CONUT and PJI treatment failure, COUNT could be a promising tool to evaluate the nutritional status of PJI patients to optimize treatment outcomes.

Malnutrition and Postoperative Outcomes Following Transcervical Zenker Diverticulectomy

OBJECTIVES

Hypoalbuminemia has been used as a proxy for poor nutrition, and has been associated with poor postoperative outcomes in varying surgical procedures. This study investigates the association between albumin status and complications following transcervical Zenker diverticulectomy.

STUDY DESIGN

Retrospective database review.

METHODS

The National Surgical Quality Improvement Program database was queried for patients who underwent transcervical Zenker diverticulectomy between 2005 and 2018. Univariate and multivariable analyses were conducted to determine associations between albumin status and postoperative complications.

RESULTS

318 patients undergoing transcervical Zenker diverticulectomy with available albumin values were queried. The mean serum albumin was 3.90 g/dL (SD = 0.56). Univariate analysis showed that hypoalbuminemia was associated with increased age (77.68 vs. 70.03 years) and female gender (54.4% vs. 45.6%), as well as sepsis (p = 0.045), reintubation (p = 0.040), urinary tract infection (p = 0.017), any medical complication (p < 0.001), any life-threatening complication (p = 0.017), and mortality (p = 0.012). Multivariable analyses found no associations between hypoalbuminemia and mortality (OR 33.136, 95% CI N/A, p = 1.000), any medical complication (OR 1.154, 95% CI 0.326-4.079, p = 0.824), any life-threatening complication (OR 0.604, 95% CI 0.079-4.586, p = 0.604), and length of stay (p = 0.249).

CONCLUSIONS

This study suggests no association between hypoalbuminemia and postoperative complications in transcervical Zenker diverticulectomy. Hypoalbuminemia and malnutrition may not be a contraindication for surgery correcting Zenker diverticulectomy.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:1402-1408, 2023.