JOT - 2026-07-02 - Journal Article
Uncorrected Preoperative Malnutrition Is Associated with Worse Outcomes After Operative Fixation of Diaphyseal Tibial Fractures.
Pereira DE, McCoy L, Harrison NJ, Bushe K, Kotzur T, McAndrew C, Berkes M, Obey M, Wilson JL
Topics
Key Takeaway
Preoperative malnutrition in tibial shaft fracture patients doubles the risk of infection, thromboembolic events, and sepsis (RR>2.0), and postoperative nutritional correction reduces but does not eliminate this risk—residual elevated risk for revision and infection persists (RR>1.4) even after normalization.
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Summary
This multicenter retrospective cohort study across 50 North American centers examined whether serum malnutrition markers predicted postoperative complications after OTA/AO 42 tibial shaft fracture fixation and whether postoperative nutritional correction mitigated risk. Malnourished patients had significantly higher rates of nonunion (RR=1.4), revision (RR>1.4), infection (RR>2.0), fixation failure (RR=1.3), thromboembolic events (RR>2.0), and sepsis (RR>2.0) versus matched controls. Postoperative correction reduced risk for nonunion and fixation failure to levels comparable to well-nourished controls, but revision and infection risk remained elevated (RR>1.4, p=0.002).
Key Limitation
The specific serum markers and threshold values defining malnutrition and its 'correction' are not disclosed, making it impossible to directly implement a screening or intervention protocol based on this study alone.
Original Abstract
OBJECTIVES
To evaluate whether serum markers of malnutrition were associated with postoperative complications after tibial shaft fracture fixation, and whether postoperative correction mitigates this risk.
METHODS
Design: Retrospective cohort study.
SETTING
Multicenter (50 healthcare centers; North American national database).
PATIENT SELECTION CRITERIA
Adult patients ≥18 years of age undergoing fixation of tibial shaft fractures (OTA/AO 42) between January 1, 2013, and December 31, 2022, with a minimum of one year of follow-up were included. Patients with a history of malignancy or Gustilo-Anderson type III open fractures were excluded from the study.
OUTCOMES MEASURES AND COMPARISONS
The primary outcome was the occurrence of postoperative complications. Patients with serum markers for malnutrition were compared to matched controls. Malnourished patients with subsequently normalized serum markers were compared to previously matched healthy cohorts and cohorts with persistent malnutrition.
RESULTS
Following matching, a total of 10,722 patients were included for primary analysis: 5,361 malnourished patients with mean age 52 (range 18-90), 53.6% male and 5,361 control with mean age 53.2 (range 18-90) with 52.9% male. Preoperative malnutrition was associated with significantly higher rates of postoperative complications, including nonunion (RR=1.4), revision surgery (RR>1.4), infection (RR>2.0), failure of fixation (RR=1.3), thromboembolic events (RR>2.0), and sepsis (RR>2.0) (all p < 0.001). Among patients with preoperative malnutrition, those with uncorrected postoperative serum markers demonstrated higher risks of nonunion, revision, infection, and implant failure compared to those with serum markers that were corrected postoperatively (RR>2.0, all p<0.001). However, when compared to patients with normal preoperative nutrition values, individuals with postoperatively corrected malnutrition remained at increased risk for revision and infection (RR>1.4, all p=0.002) but not nonunion (6.5% vs. 5.6%, p>0.05) or failure of fixation (4.6% vs. 4.1%, p>0.05).
CONCLUSIONS
Malnutrition was associated with adverse surgical outcomes following tibial shaft fracture fixation, with significantly higher rates of nonunion, revision procedures, infection, wound complications, thromboembolic events, and medical morbidity compared with patients with normal preoperative nutrition. Postoperative correction of nutritional deficiencies reduced complication risk; however, residual risk remained elevated relative to patients with normal preoperative nutritional markers. These findings highlight malnutrition as a partially modifiable risk factor in tibial shaft fracture repair and support nutritional optimization as a part of postoperative management to improve patient outcomes.
LEVEL OF EVIDENCE
Level III.