Elsevier

Bone

Volume 143, February 2021, 115567
Bone

Full Length Article
Preoperative hypoalbuminemia: Poor functional outcomes and quality of life after hip fracture surgery

https://doi.org/10.1016/j.bone.2020.115567Get rights and content

Highlights

  • Low albumin levels prevalent in hip fracture patients

  • Low albumin independently associated with poorer recovery after hip fracture surgery

  • No association between BMI and recovery after hip fracture surgery

Abstract

Aims

Hip fracture patients have severe deterioration of their quality of life and function after their injury. Markers of malnutrition such as low albumin and low body mass index (BMI) have been shown to increase mortality and complication rates but their effect on recovery of quality of life and function after hip fracture surgery is unclear. The main aim of this paper is to further investigate if low albumin affects recovery after hip fracture surgery, while additionally studying low BMI as a possible risk factor for poor recovery.

Patients and methods

Retrospective analysis of 971 patients who underwent surgery for fragility hip fractures between January 2012 and December 2016 was performed. Demographic data, preoperative serum albumin and haemoglobin levels, BMI, Charlson Comorbidity Index (CCI), type of surgery (fixation vs replacement) and site of surgery were obtained. Patients were assessed using the Parker Mobility Scale (PMS), Harris Hip Score(HHS), Medical Outcomes Study 36-item Short-Form Health Survey (SF36) at pre-fracture, 6 weeks and 6 months after surgery. HHS was not available pre-operatively. Patients were grouped according to their albumin levels (low ≤35 g/L or normal) and BMI (underweight <18.5 or normal). Univariate and multivariate analyses were performed to examine the association between albumin and BMI and 6-month scores.

Results

On univariate analysis, patients with low albumin ≤35 g/L had lower baseline PMS and SF36 Physical Functioning (PF) score. On multivariate analysis, preoperative hypoalbuminemia was associated with lower 6-month HHS, PMS and SF36 PF scores even after accounting for baseline scores and other confounders.

BMI had no effect on 6-month scores.

Conclusion

Low albumin (≤35 g/L) is prevalent in elderly hip fracture patients and is associated with slower recovery of function and quality of life after surgery. Low albumin can be a useful prognostic tool to identify patients with poor recovery for further intervention or rehabilitation after hip fracture surgery.

Introduction

Patients' health status, quality of life and physical function are severely affected after sustaining a hip fracture. Majority of recovery takes place within the first six months after surgery and many patients do not return to their pre-fall quality of life and function [[1], [2], [3]]. Earlier return to function may reduce demand of hip fracture patients on healthcare resources and socioeconomic burden [4]. There are increasing number of studies which examine the modifiable risk factors which affect recovery after hip fracture including improved rehabilitation, implant modification and minimizing surgical delay [4].

Malnutrition is prevalent in older people with hip fracture and reduces the ability for these patients to recover from their injury. Patients with hip fractures and malnutrition have increased complications including sepsis, delirium and pressure ulcers, longer length of stay and higher mortality [5].

Markers of malnutrition include low serum albumin and low body mass index (BMI) levels and both markers have been separately found to affect hip fracture outcomes.

Miyanishi et al. found that BMI <18.9 was an independent significant risk factor for mortality in hip fracture patients [6] while Schaller found that hip fracture patients with BMI <22 also had increased mortality [7]. Higher risk of developing an adverse cardiac event of any type in underweight patients with hip fractures was demonstrated by Batsis et al. [8] while Akinleye et al. demonstrated that patients at either extreme of the BMI spectrum are at greatest risk of major adverse events following hip fracture surgery [9].

Uriz-Otano et al. found that hypoalbuminemia was one of the strongest predictive factors for long-term mortality [10] after hip fracture surgery while Miyanishi et al. found that survival rates were significantly worse in patients below a cutoff point of 36 g/L [6]. Bohl et al. found that patients with hypoalbuminemia had higher rates of death, sepsis and longer length of hospital stay [11]. Similarly, Aldebeyan et al. found that hypoalbuminemia alone was a predictor of postoperative complications including unplanned intubation, prolonged ventilation, sepsis, require blood transfusion, mortality and increased length of stay [12].

However, few studies have examined the effect of low serum albumin or low BMI levels on function and quality of life after hip fracture surgery. The primary aim of this study is to investigate if low albumin affects recovery after hip fracture surgery, while additionally studying low BMI as a possible risk factor for poor recovery. Our hypothesis is that low albumin is independently associated with poorer recovery of function and quality of life after hip fracture surgery.

Section snippets

Study population/selection criteria

Retrospective analysis of 971 patients who underwent surgery for fragility hip fractures between January 2012 and December 2016 were performed. Surgeries performed included hip replacement (e.g., hemiarthroplasty, total hip replacement) and fixation procedures (e.g., intramedullary nail insertion, dynamic hip screw insertion). We excluded individuals whose fractures were due to pathological causes such as malignancy, avascular necrosis, and previous hip surgery and high energy trauma.

Results

Our cohort of 971 individuals had a mean age of 77 years. 29% were male and 71% female. 54% underwent replacement and 46% underwent fixation. 6% of patients were moderate-severely underweight (BMI <17), 7% mildly underweight (BMI 17–18.49), 54% normal range (BMI 18.5–24.9), 33% overweight (BMI ≥25). 41% of patients had hypoalbuminemia (preoperative serum albumin ≤35 g/L). 39% had moderate to severe anaemia and 27% had CCI >2. The demographic characteristics of our cohort can be seen in Table 1.

Discussion

Hip fracture leads to worsening function and quality of life, and majority of patients in this study do not return to their pre-fall quality of life and function even after surgery (Fig. 1), which is a result consistent with the findings of previous studies [[1], [2], [3]].

About two-fifths of patients in our study had low albumin using a cut-off preoperative serum albumin of ≤35 g/L. Similar large proportions of hip fracture patients with low albumin are found in the literature. Both Koval et

Conclusion

Malnutrition as indicated by hypoalbuminemia is prevalent in this cohort of elderly patients studied with fragility hip fractures. Preoperative hypoalbuminemiahas been shown in this study to be associated with slower recovery and is a significant risk factor for lower 6-month function and quality of life after surgery for hip fracture. Preoperative albumin may be used as a prognostic tool for post-surgical recovery in patients with fragility hip fractures. Further studies will be required to

CRediT authorship contribution statement

SHAOEN DAVID SIM: Methodology, Formal analysis, Investigation, Writing - original draft, Visualization. YILIN EILEEN SIM: Formal analysis, Writing - review & editing. KENNY TAY: Writing - review & editing.TET SEN HOWE: Conceptualization, Writing - review & editing, Supervision, Project administration. MENG AI PNG:Writing - review & editing.CHEE CHENG PAUL CHANG: Writing - review & editing. HAIRIL RIZAL ABDULLAH: Writing - review & editing. JOYCE SUANG BEE KOH: Conceptualization, Writing -

Acknowledgements

We would also like to thank staff from the Orthopaedic Diagnostic Centre, Singapore General Hospital, for their help in extracting data and assessment of outcome scores.

Formatting of funding sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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