Preoperative malnutrition is associated with increased early complications and higher two-year nonunion risk after Tibial shaft fracture fixation.

Abstract

BACKGROUND: Malnutrition is a potentially modifiable risk factor that may influence perioperative complications and fracture healing. This study evaluated the association between preoperative laboratory-defined malnutrition and short-term complications and 2-year outcomes following operative fixation of tibial shaft fractures. METHODS: Using the TriNetX Research Network (112 healthcare organizations), adults (≥18 years) undergoing operative management for tibial shaft fracture were identified. Preoperative malnutrition was defined as albumin ≤3.5 g/dL and/or leukocytes ≤1.5 × 10³/µL within 1 year prior to the index event. Cohorts were propensity score matched 1:1 on demographics and comorbidities. Outcomes were assessed from day 1 post-index through 90 days (medical/surgical complications) and 730 days (healing-related and limb outcomes). Risk ratios (RR) and hazard ratios (HR) with 95% confidence intervals (CI) were reported. RESULTS: After matching, 44,780 patients were included in each cohort (89,560 total), with good balance across covariates (all SMDs <0.10). At 90 days, malnutrition was associated with higher risk of acute respiratory failure/mechanical ventilation (13.9% vs 3.4%; RR 4.10 [95% CI 3.88-4.33].; HR 4.32 [4.09-4.57].), sepsis (5.2% vs 1.2%; RR 4.35 [3.97-4.77].; HR 4.47 [4.07-4.91].), postoperative infection (5.7% vs 1.8%; RR 3.14 [2.90-3.39].; HR 3.23 [2.99-3.50].), acute kidney injury (8.6% vs 3.0%; RR 2.90 [2.73-3.08].; HR 2.99 [2.81-3.18].), and DVT/PE (6.5% vs 2.7%; RR 2.36 [2.21-2.52].; HR 2.42 [2.26-2.59].) (all p < 0.001). At 2 years, malnutrition was associated with increased nonunion (4.4% vs 1.6%; RR 2.69 [2.47-2.92].; HR 2.85 [2.62-3.10].), chronic osteomyelitis (12.5% vs 3.9%; RR 3.19 [3.02-3.36].; HR 3.50 [3.32-3.69].), hardware removal (10.1% vs 6.0%; RR 1.68 [1.61-1.76].; HR 1.83 [1.74-1.92].), and amputation (1.4% vs 0.4%; RR 3.47 [2.95-4.08].; HR 3.59 [3.05-4.23].) (all p < 0.001). Revision fixation did not differ (8.4% vs 8.1%; p = 0.096). CONCLUSIONS: Preoperative laboratory-defined malnutrition was independently associated with substantially higher 90-day morbidity and increased 2-year nonunion and limb-complication risk following operative tibial shaft fracture management. These findings support preoperative nutritional risk stratification and targeted optimization efforts in this population.

AI evidence extraction

Main findings

In propensity score–matched cohorts (44,780 per group), preoperative laboratory-defined malnutrition was associated with higher 90-day risks of acute respiratory failure/mechanical ventilation, sepsis, postoperative infection, acute kidney injury, and DVT/PE (all p<0.001). At 2 years, malnutrition was associated with increased nonunion, chronic osteomyelitis, hardware removal, and amputation (all p<0.001), while revision fixation did not differ (p=0.096).

Outcomes measured

• 90-day medical/surgical complications (acute respiratory failure/mechanical ventilation, sepsis, postoperative infection, acute kidney injury, DVT/PE)
• 2-year outcomes (nonunion, chronic osteomyelitis, hardware removal, amputation, revision fixation)

Limitations

• Observational retrospective database study (TriNetX); residual confounding possible despite propensity score matching
• Malnutrition definition based on available labs (albumin and/or leukocytes) within 1 year prior; may misclassify nutritional status
• Outcomes based on database records/coding; potential measurement/coding errors

{
    "study_type": "cohort",
    "exposure": {
        "band": null,
        "source": null,
        "frequency_mhz": null,
        "sar_wkg": null,
        "duration": "Preoperative (within 1 year prior to index event) laboratory-defined malnutrition (albumin ≤3.5 g/dL and/or leukocytes ≤1.5 × 10^3/µL)"
    },
    "population": "Adults (≥18 years) undergoing operative fixation for tibial shaft fracture identified in the TriNetX Research Network (112 healthcare organizations)",
    "sample_size": 89560,
    "outcomes": [
        "90-day medical/surgical complications (acute respiratory failure/mechanical ventilation, sepsis, postoperative infection, acute kidney injury, DVT/PE)",
        "2-year outcomes (nonunion, chronic osteomyelitis, hardware removal, amputation, revision fixation)"
    ],
    "main_findings": "In propensity score–matched cohorts (44,780 per group), preoperative laboratory-defined malnutrition was associated with higher 90-day risks of acute respiratory failure/mechanical ventilation, sepsis, postoperative infection, acute kidney injury, and DVT/PE (all p<0.001). At 2 years, malnutrition was associated with increased nonunion, chronic osteomyelitis, hardware removal, and amputation (all p<0.001), while revision fixation did not differ (p=0.096).",
    "effect_direction": "harm",
    "limitations": [
        "Observational retrospective database study (TriNetX); residual confounding possible despite propensity score matching",
        "Malnutrition definition based on available labs (albumin and/or leukocytes) within 1 year prior; may misclassify nutritional status",
        "Outcomes based on database records/coding; potential measurement/coding errors"
    ],
    "evidence_strength": "low",
    "confidence": 0.7800000000000000266453525910037569701671600341796875,
    "peer_reviewed_likely": "yes",
    "keywords": [
        "malnutrition",
        "albumin",
        "leukocytes",
        "tibial shaft fracture",
        "operative fixation",
        "propensity score matching",
        "TriNetX",
        "complications",
        "nonunion",
        "osteomyelitis",
        "amputation"
    ],
    "suggested_hubs": []
}

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