The Archives of Bone and Joint Surgery

The Archives of Bone and Joint Surgery

Prospective Study Investigating the Prevalence and Evolution of Malnourishment in the Acute Orthopaedic Trauma Patient

Document Type : RESEARCH PAPER

Authors
Reza Firoozabadi 1
Benjamin Hamilton 1
Courtney O’Donnell 2
Julie Agel 1
Stephen Benirschke 1
Patricia Kramer 1
Michael B. Henley B. Henley 1
1 University of Washington, Seattle WA, USA
2 University of Colorado School of Medicine, Aurora CO, USA
10.22038/abjs.2021.47718.2341
Abstract
Background:Orthopaedic trauma surgeons believe that nutritional status is important. The primary aim of this study
was to prospectively investigate the prevalence and progression of malnourishment in orthopaedic trauma patients and
determine when and what labs should be ordered. The secondary aim was to determine if malnourished patients had
increased complications.
Methods: Prospective cohort study of orthopaedic trauma patients at a Level I trauma center. Assessment of nutritional
status over the hospital course was performed using the Rainey MacDonald nutritional index (RMNI) and nutritional
laboratory markers on admission, day 3, day 7, and 6 weeks post-op.
Results: 98 patients were enrolled and included. On admission, 60%, 41%, and 38% of patients were malnourished
based on albumin, prealbumin, and RMNI values, respectively, with 31% in severe acute-phase response (APR)
as determined by CRP. By day 3, a significant increase in the percent of malnourished patients was noted based
on the laboratory markers, 85%, 90%, and 80%, respectively, with 70% in severe APR. On day 7, values stabilized
at 74%, 89%, 69%, with 56% in severe APR. At six weeks, malnourishment persisted in 13%, 19%, and 12%
of patients, with 4% in severe APR. Older patients demonstrated a greater depression of nutritional markers
throughout the hospital stay.
Conclusion: The prevalence of malnourishment, based on serum nutritional markers, in the presence of acute
orthopaedic injury is substantial, and it continues to rise during the acute hospital stay. Recommend obtaining prealbumin
or albumin levels on hospital day 3 to assess nutritional status.
Level of evidence: II
Keywords
Complications
Nutrition
Malnourishment
Orthopaedic trauma
Nutritional status
  1. Ezzati M, Lopez AD, Rodgers AA, Murray CJ. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. World Health Organization; 2004.
  2. Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact of disease-related malnutrition. Clinical nutrition. 2008;27(1):5-15.
  3. Barker LA, Gout BS, Crowe TC. Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. International journal of environmental research and public health. 2011;8(2):514-27.
  4. Middleton MH, Nazarenko G, Nivison-Smith I, Smerdely P. Prevalence of malnutrition and 12-month incidence of mortality in two Sydney teaching hospitals. Internal Medicine Journal. 2001;31(8):455-61.
  5. Neumayer LA, Smout RJ, Horn HG, Horn SD. Early and sufficient feeding reduces length of stay and charges in surgical patients. Journal of Surgical Research. 2001;95(1):73-7.
  6. Kinosian B, Jeejeebhoy KN. What is malnutrition? Does it matter?. Nutrition (Burbank, Los Angeles County, Calif.). 1995;11(2 Suppl):196-7.
  7. Mahan LK, Arlin MT. Nutritional care in anaemia. Krause’s Food, Nutrition & Diet Therapy, 8th ed. Philadelphia, PA: WB Saunders. 1992:557-68.
  8. Jensen GL, Bistrian B, Roubenoff R, Heimburger DC. Malnutrition syndromes: a conundrum vs continuum. Journal of Parenteral and Enteral Nutrition. 2009;33(6):710-6.
  9. Jensen GL, Mirtallo J, Compher C, Dhaliwal R, Forbes A, Grijalba RF, et al. Adult starvation and disease-related malnutrition: a proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committee. Journal of Parenteral and Enteral Nutrition. 2010;34(2):156-9.
  10. Hartl WH, Jauch KW. Metabolic self-destruction in critically ill patients: origins, mechanisms and therapeutic principles. Nutrition. 2014;30(3):261-7.
  11. National Alliance for Infusion Therapy the American Society for Parenteral Enteral Nutrition Public Policy Committee Board of Directors. Disease-related malnutrition and enteral nutrition therapy: a significant problem with a cost-effective solution. Nutr Clin Pract. 2010;25(5):548-54.
  12. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010;39(4):412-23.
  13. Benton MJ, Whyte MD, Dyal BW. Sarcopenic obesity: strategies for management. AJN The American Journal of Nursing. 2011;111(12):38-44.
  14. Han TS, Tajar A, Lean ME. Obesity and weight management in the elderly. British medical bulletin. 2011;97(1):169-96.
  15. Milte R, Miller M. Dietetic care of hip fracture patients across Australia: are we doing enough?. Nutrition & Dietetics. 2011;68(3):214-20.
  16. Nikkel LE, Fox EJ, Black KP, Davis C, Andersen L, Hollenbeak CS. Impact of comorbidities on hospitalization costs following hip fracture. J Bone Joint Surg Am. 2012;94(1):9-17.
  17. Wyers CE, Reijven PL, Evers SM, Willems PC, Heyligers IC, Verburg AD, et al. Cost-effectiveness of nutritional intervention in elderly subjects after hip fracture. A randomized controlled trial. Osteoporosis International. 2013;24(1):151-62.
  18. Guo JJ, Yang H, Qian H, Huang L, Guo Z, Tang T. The effects of different nutritional measurements on delayed wound healing after hip fracture in the elderly. Journal of Surgical Research. 2010;159(1):503-8.
  19. Symeonidis PD, Clark D. Assessment of malnutrition in hip fracture patients: effects on surgical delay, hospital stay and mortality. Acta orthopaedica belgica. 2006;72(4):420.
  20. Nicholson JA, Dowrick AS, Liew SM. Nutritional status and short-term outcome of hip arthroplasty. Journal of Orthopaedic Surgery. 2012;20(3):331-5.
  21. O’Daly BJ, Walsh JC, Quinlan JF, Falk GA, Stapleton R, Quinlan WR, et al. Serum albumin and total lymphocyte count as predictors of outcome in hip fractures. Clinical nutrition. 2010;29(1):89-93.
  22. Puskarich CL, Nelson CL, Nusbickel FR, Stroope HF. The use of two nutritional indicators in identifying long bone fracture patients who do and do not develop infections. Journal of orthopaedic research. 1990;8(6):799-803.
  23. Devoto G, Gallo F, Marchello C, Racchi O, Garbarini R, Bonassi S, et al. Prealbumin serum concentrations as a useful tool in the assessment of malnutrition in hospitalized patients. Clinical chemistry. 2006;52(12):2281-5.
  24. White JV, Guenter P, Jensen G, Malone A, Schofield M, Group AM, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). Journal of the Academy of Nutrition and Dietetics. 2012;112(5):730-8.
  25. Bell JJ, Bauer JD, Capra S, Pulle RC. Concurrent and predictive evaluation of malnutrition diagnostic measures in hip fracture inpatients: a diagnostic accuracy study. European journal of clinical nutrition. 2014;68(3):358-62.
  26. Bell JJ, Bauer JD, Capra S, Pulle RC. Quick and easy is not without cost: implications of poorly performing nutrition screening tools in hip fracture. Journal of the American Geriatrics Society. 2014;62(2):237-43.
  27. Bae HJ, Lee HJ, Han DS, Suh YS, Lee YH, Lee HS, et al. Prealbumin levels as a useful marker for predicting infectious complications after gastric surgery. Journal of Gastrointestinal Surgery. 2011;15(12):2136-44.
  28. Shum J, Markiewicz MR, Park E, Bui T, Lubek J, Bell RB, et al. Low prealbumin level is a risk factor for microvascular free flap failure. Journal of Oral and Maxillofacial Surgery. 2014;72(1):169-77.
  29. Gariballa S, Forster S. Effects of acute-phase response on nutritional status and clinical outcome of hospitalized patients. Nutrition. 2006;22(7-8):750-7.
  30. Shenkin A. Serum prealbumin: is it a marker of nutritional status or of risk of malnutrition?. Clinical chemistry. 2006;52(12):2177-9.
The Archives of Bone and Joint Surgery
Volume 10, Issue 7
July 2022
Pages 592-600

  • Receive Date 17 May 2020
  • Revise Date 25 June 2020
  • Accept Date 13 December 2021