Injury - 2026-04-01 - Journal Article
Nutritional vulnerability predicts complications in patients with femoral shaft fractures.
Boutany M, Saad J, Abdelnour D, Elmenini H, Hilo AK, Francis L, Suhrawardy A, Mehaidli A, Vaidya R
Topics
Key Takeaway
Laboratory-defined malnutrition (albumin ≤3.5 g/dL and/or leukocytes ≤1.5×10³/µL) was associated with a 2.29-fold increased risk of acute respiratory failure and 2.43-fold increased risk of osteomyelitis after femoral shaft fracture fixation in a propensity-matched cohort of 21,886 patients.
Summary Depth
Choose how much analysis to show on this article page.
Summary
This study used the TriNetX Research Network (112 healthcare organizations) to determine whether laboratory-defined malnutrition independently predicts complications after operative femoral shaft fracture fixation, comparing propensity score-matched malnourished and non-malnourished adults. Malnutrition was associated with significantly elevated 90-day risks across all nine acute complication categories, with the largest effect sizes for respiratory failure (RR 2.29), sepsis (RR 2.09), and DVT/PE (RR 1.68). At 2 years, osteomyelitis (RR 2.43) and revision fixation (RR 1.47) were significantly higher in the malnourished cohort, while nonunion/malunion rates did not differ (RR 1.06, p=0.472).
Key Limitation
The retrospective database design cannot confirm that malnutrition preceded the fracture event rather than reflecting acute-phase hypoalbuminemia from the injury, limiting causal inference about nutritional status as a modifiable risk factor.
Original Abstract
BACKGROUND
Malnutrition is common in orthopaedic trauma and may increase postoperative morbidity. This study evaluated the association between laboratory-defined malnutrition and 90-day medical complications and 2-year fracture-related complications after femoral shaft fracture fixation.
METHODS
Using the TriNetX Research Network (112 healthcare organizations), adults (≥18 years) undergoing operative fixation of femoral shaft fractures were identified. Malnutrition was defined as albumin ≤ 3.5 g/dL and/or leukocytes ≤ 1.5× 10³ /µL measured within 1 year before the index procedure; patients without documented laboratory-defined malnutrition served as controls. Cohorts were propensity score-matched 1:1 on demographics, comorbidities, and selected laboratory measures. Complications were assessed from postoperative day 1 through 90 days (acute respiratory failure/mechanical ventilation, DVT/PE, transfusion, postoperative infection, wound disruption, myocardial infarction, sepsis, acute kidney injury, and emergency department visit) and through 730 days (nonunion/malunion, osteomyelitis, revision fixation, and hardware removal). Risk ratios (RR) with 95 % confidence intervals (CI) were reported.
RESULTS
After matching, 10,943 patients remained in each cohort with good covariate balance (all standardized mean differences <0.10). Within 90 days, malnutrition was associated with higher risk of acute respiratory failure/mechanical ventilation (21.7 % vs 9.5 %; RR 2.29 [95 % CI 2.14-2.45]), sepsis (6.1 % vs 2.9 %; RR 2.09 [1.84-2.39]), DVT/PE (9.7 % vs 5.8 %; RR 1.68 [1.53-1.85]), acute kidney injury (12.8 % vs 8.3 %; RR 1.55 [1.44-1.68]), postoperative infection (4.4 % vs 2.6 %; RR 1.68 [1.46-1.94]), wound disruption (3.1 % vs 1.9 %; RR 1.68 [1.42-2.00]), transfusion (10.9 % vs 8.5 %; RR 1.29 [1.19-1.40]), myocardial infarction (2.4 % vs 1.8 %; RR 1.30 [1.08-1.56]), and emergency department visit (16.4 % vs 14.3 %; RR 1.15 [1.08-1.23]) (all p ≤ 0.005). At 2 years, malnutrition was associated with higher risk of osteomyelitis (1.1 % vs 0.4 %; RR 2.43 [1.74-3.38]), revision fixation (5.9 % vs 4.0 %; RR 1.47 [1.31-1.66]), and hardware removal (9.3 % vs 8.1 %; RR 1.15 [1.06-1.26]) (all p ≤ 0.001), while nonunion/malunion did not differ (3.0 % vs 2.9 %; RR 1.06 [0.91-1.23]; p = 0.472).
CONCLUSIONS
Laboratory-defined malnutrition was independently associated with substantially increased 90-day morbidity and higher 2-year infectious and reoperative complications after femoral shaft fracture fixation. These findings support nutritional risk stratification and motivate prospective studies evaluating targeted perioperative optimization.