Is it time to Reassess The Role of Preoperative HypoalbuminemiaAmong Geriatric Distal Femur Fracture Patients?

Abstract

Background: Hypoalbuminemia, blanketly defined as Albumin < 3.5 g/dL, is often utilized as a threshold associated with postoperative complications and mortality among orthopedic and non-orthopedic surgical procedures. Albumin level is influenced by a myriad of factors including liver function, malnutrition, and inflammation. This study evaluates the role preoperative albumin as an independent risk factor for mortality and increased length of stay (LOS) among distal femur fracture (DFF) patients.

Methods: Between 2010 and 2019, the National Surgical Quality Improvement Program (NSQIP) identified isolated closed distal femur fractures preoperative albumin levels using International Classification of Diseases 9th and 10th revisions (ICD9/ICD10) codes [S72.4*; 821.2*]. Albumin was categorized as both continuous and categorical variables: marked hypoalbuminemia (< 2.5 g/dL), mild hypoalbuminemia (2.5-3.5 g/dL), normal albuminemia (3.5-4.5 g/dL) or hyperalbuminemia (> 4.5 g/dL). Primary outcomes included in-hospital mortality and LOS.

Results: The incidence rate of hypoalbuminemia was 54.6% (419/767). Multivariable logistic regression analysis demonstrated that when compared to patients with baseline marked hypoalbuminemia, patients with mild hypoalbuminemia and normal serum albumin reported a respective 82% (OR 0.18, 95% CI [0.04, 0.71], p = 0.014) and 80% (OR: 0.20, 95% CI [0.05, 0.89], p = 0.034) decreased odds of in-hospital mortality. Similarly, a 53.7% (OR 0.46, 95% CI [0.23, 0.94], p = 0.033), 71.1% (OR 0.29, 95% CI [0.14, 0.60], p = 0.001), and 82.8% (OR 0.17, 95% [0.04, 0.75], p = 0.020) decreased odds of exceeding mean LOS was observed among mild hypoalbuminemic, normal, and hyperalbuminemic patients compared to patients with baseline marked hypoalbuminemia.

Conclusion: Preoperative hypoalbuminemia is an independent risk factor for increased LOS and mortality among DFFs, controlling for confounding factors. Prospective investigation of albumin risk stratification is warranted to differentiate contributable effects of chronic malnutrition and traumatic inflammatory albumin downregulation among geriatric trauma patients.

Level of evidence: Prognostic Level III.

Keywords: Albumin; Distal femur fracture; Fragility Fracture; Geriatric; Hypoalbuminemia; Length of Stay; Malnutrition; Orthopedic trauma.