Perspective

Malnourished patients had increased risk for short-term complications after TSA

The prevalence of preoperative malnutrition was 7.6% with a significant proportion of normal weight and obese patients found to be malnourished.

Patients who were malnourished prior to total shoulder arthroplasty experienced a significantly increased risk for blood transfusion, longer hospital length of stay and death within 30 days of surgery, according to results.

“Surgeons should think about ordering preoperative albumin levels in patients who are high-risk, as this may improve risk stratification before surgery,” Grant H. Garcia, MD, of Hospital for Special Surgery, told Orthopedics Today.

Malnutrition in TSA patients

Grant H. Garcia, MD
Grant H. Garcia

Using the American College of Surgeons National Surgical Quality Improvement Program database, Garcia and his colleagues identified 4,655 patients who underwent total shoulder arthroplasty (TSA) from 2005 to 2013. Researchers collected preoperative albumin measurements from 36.1% of patients and patients with a concentration of less than 3.5 g/dL were considered malnourished. Rates of postoperative complications were compared between normal and malnourished patients.

In addition to an observed prevalence of preoperative malnutrition (7.6% of patients), malnourished patients tended to be older, female, have a modified Charlson Comorbidity Index of 5 or greater, have an American Society of Anesthesiologists Physical Status Classification of 3 or greater, have pulmonary comorbidities, diabetes, a history of transient ischemic attack or cerebrovascular accident and a history of chronic steroid use.

Compared with controls, researchers found a significantly increased proportion of normal weight and obese class 3 patients were malnourished. Such patients experienced a higher risk of requiring a blood transfusion, developing postoperative pulmonary complications or death and having an extended length of stay vs. controls, a multivariable logistic regression analysis found.

“We were surprised at the increased risk of mortality in this patient population,” Garcia said. “Overall, we found malnutrition increased the risk of mortality by as much as 18 times.”

Although results showed a trend toward an increased risk of any major complication among malnourished patients after TSA, it did not reach significance.

Obesity and malnourishment

According to Garcia, orthopedists should be aware that using a patient’s weight is a poor screening tool for detecting malnutrition, as many of the malnourished patients were obese or morbidly obese.

“Malnourishment is a modifiable risk factor and in many cases, [TSA] is an elective procedure,” Garcia said. “Understanding patients with low preoperative albumin are at a higher risk of complications may warrant preoperative evaluation in the select populations. Finally, understanding some of these malnourished patients were also obese is important information for screening purposes.”

He added, “The next step for this area of research would be a randomized controlled trial comparing preoperative supplementation for these malnourished patients and investigating if complications are reduced.” – by Casey Tingle

Disclosure: Garcia reports no relevant financial disclosures.

Patients who were malnourished prior to total shoulder arthroplasty experienced a significantly increased risk for blood transfusion, longer hospital length of stay and death within 30 days of surgery, according to results.

“Surgeons should think about ordering preoperative albumin levels in patients who are high-risk, as this may improve risk stratification before surgery,” Grant H. Garcia, MD, of Hospital for Special Surgery, told Orthopedics Today.

Malnutrition in TSA patients

Grant H. Garcia, MD
Grant H. Garcia

Using the American College of Surgeons National Surgical Quality Improvement Program database, Garcia and his colleagues identified 4,655 patients who underwent total shoulder arthroplasty (TSA) from 2005 to 2013. Researchers collected preoperative albumin measurements from 36.1% of patients and patients with a concentration of less than 3.5 g/dL were considered malnourished. Rates of postoperative complications were compared between normal and malnourished patients.

In addition to an observed prevalence of preoperative malnutrition (7.6% of patients), malnourished patients tended to be older, female, have a modified Charlson Comorbidity Index of 5 or greater, have an American Society of Anesthesiologists Physical Status Classification of 3 or greater, have pulmonary comorbidities, diabetes, a history of transient ischemic attack or cerebrovascular accident and a history of chronic steroid use.

Compared with controls, researchers found a significantly increased proportion of normal weight and obese class 3 patients were malnourished. Such patients experienced a higher risk of requiring a blood transfusion, developing postoperative pulmonary complications or death and having an extended length of stay vs. controls, a multivariable logistic regression analysis found.

“We were surprised at the increased risk of mortality in this patient population,” Garcia said. “Overall, we found malnutrition increased the risk of mortality by as much as 18 times.”

Although results showed a trend toward an increased risk of any major complication among malnourished patients after TSA, it did not reach significance.

Obesity and malnourishment

According to Garcia, orthopedists should be aware that using a patient’s weight is a poor screening tool for detecting malnutrition, as many of the malnourished patients were obese or morbidly obese.

“Malnourishment is a modifiable risk factor and in many cases, [TSA] is an elective procedure,” Garcia said. “Understanding patients with low preoperative albumin are at a higher risk of complications may warrant preoperative evaluation in the select populations. Finally, understanding some of these malnourished patients were also obese is important information for screening purposes.”

He added, “The next step for this area of research would be a randomized controlled trial comparing preoperative supplementation for these malnourished patients and investigating if complications are reduced.” – by Casey Tingle

Disclosure: Garcia reports no relevant financial disclosures.

    Perspective
    Michael L. Pearl

    Michael L. Pearl

    As surgeons, we know too well how obesity challenges our ability to get the best result for our patients. Surgical exposure is more difficult, wound healing may suffer and mobility is problematic even for upper extremity procedures because patients need their arms to get around. We learn from these authors several things while not obvious are important. Malnutrition (albumin less than 3.5 g/dL) is more common in patients who are overweight and obese, in older patients, in women and those with comorbidities. Moreover, it may be present in 7.6% (one in 13) of patients undergoing shoulder arthroplasty. Surgical complications, even death, are expectedly more common and probably underestimated by this study, as the authors acknowledge their database does not look beyond 30 days after surgery.

    • Michael L. Pearl, MD
    • Orthopedics Today Editorial Board member Kaiser Permanente Los Angeles

    Disclosures: Pearl reports no relevant financial disclosures.