Skip to main content
Orthopedics, 2018;41(6):354–362
Published Online:https://doi.org/10.3928/01477447-20181010-05Cited by:21

Abstract

Malnutrition is not uncommon in arthroplasty patients, and hypoalbuminemia has been shown to be predictive of postoperative complications. The authors sought to compare albumin concentration with a global assessment of physical health, the American Society of Anesthesiologists (ASA) score, to further discriminate the importance of albumin in predicting postoperative complications. A cohort of 128,412 patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) were identified from 2005 to 2015 through use of the American College of Surgeons National Surgical Quality Improvement Program database. Patients were divided based on surgery performed, albumin concentration (with <3.5 g/dL defining hypoalbuminemia), and ASA score (≤2 vs >2). Postoperative complications were evaluated through multivariable regression analyses adjusted for age, sex, body mass index, and current smoking status. The study population included 48,751 THA and 79,661 TKA patients. On multivariable analyses, both hypoalbuminemia and ASA score were significant (P<.05) predictors of complications such as death, superficial infection, pneumonia, renal insufficiency, reintubation, transfusion, readmission, and reoperation. Furthermore, hypoalbuminemia more robustly predicted deep infection for THA patients, as well as superficial infection for TKA patients. American Society of Anesthesiologists score was otherwise predictive of more postoperative complications than hypoalbuminemia within the TKA group and provided similar predictability within the THA group. Albumin is associated with complications following THA and TKA, and if used in conjunction with ASA score, albumin contributes to enhanced risk stratification. The authors recommend that a preoperative albumin concentration be obtained and efforts made to modify this risk factor prior to elective arthroplasty. [Orthopedics. 2018; 41(6):354–362.]

  • 1.Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007; 89(4):780–785.

    > Crossref MedlineGoogle Scholar
  • 2.Plate JF, Brown ML, Wohler AD, Seyler TM, Lang JE. Patient factors and cost associated with 90-day readmission following total hip arthroplasty. J Arthroplasty. 2016; 31(1):49–52.10.1016/j.arth.2015.07.030

    > Crossref MedlineGoogle Scholar
  • 3.Hooper GJ, Rothwell AG, Hooper NM, Frampton C. The relationship between the American Society of Anesthesiologists physical rating and outcome following total hip and knee arthroplasty: an analysis of the New Zealand Joint Registry. J Bone Joint Surg Am. 2012; 94(12):1065–1070.10.2106/JBJS.J.01681

    > Crossref MedlineGoogle Scholar
  • 4.Johnson CC, Sodha S, Garzon-Muvdi J, Petersen SA, McFarland EG. Does preoperative American Society of Anesthesiologists score relate to complications after total shoulder arthroplasty?Clin Orthop Relat Res.2014; 472(5):1589–1596.10.1007/s11999-013-3400-1

    > Crossref MedlineGoogle Scholar
  • 5.Lai K, Bohm ER, Burnell C, Hedden DR. Presence of medical comorbidities in patients with infected primary hip or knee arthroplasties. J Arthroplasty. 2007; 22(5):651–656.10.1016/j.arth.2006.09.002

    > Crossref MedlineGoogle Scholar
  • 6.Baker PN, van der Meulen JH, Lewsey J, Gregg PJNational Joint Registry for England and Wales. The role of pain and function in determining patient satisfaction after total knee replacement: data from the National Joint Registry for England and Wales. J Bone Joint Surg Br. 2007; 89(7):893–900.10.1302/0301-620X.89B7.19091

    > Crossref MedlineGoogle Scholar
  • 7.Cullen DJ, Apolone G, Greenfield S, Guadagnoli E, Cleary P. ASA Physical Status and age predict morbidity after three surgical procedures. Ann Surg. 1994; 220(1):3–9.10.1097/00000658-199407000-00002

    > Crossref MedlineGoogle Scholar
  • 8.Greenfield S, Apolone G, McNeil BJ, Cleary PD. The importance of co-existent disease in the occurrence of postoperative complications and one-year recovery in patients undergoing total hip replacement: comorbidity and outcomes after hip replacement. Med Care. 1993; 31(2):141–154.10.1097/00005650-199302000-00005

    > Crossref MedlineGoogle Scholar
  • 9.Jolles BM, Zangger P, Leyvraz PF. Factors predisposing to dislocation after primary total hip arthroplasty: a multivariate analysis. J Arthroplasty. 2002; 17(3):282–288.10.1054/arth.2002.30286

    > Crossref MedlineGoogle Scholar
  • 10.Khan M, Rooh-ul-Muqim , Zarin M, Khalil J, Salman M. Influence of ASA score and Charlson Comorbidity Index on the surgical site infection rates. J Coll Physicians Surg Pak. 2010; 20(8):506–509.

    > MedlineGoogle Scholar
  • 11.Peersman G, Laskin R, Davis J, Peterson MG, Richart T. ASA physical status classification is not a good predictor of infection for total knee replacement and is influenced by the presence of comorbidities. Acta Orthop Belg. 2008; 74(3):360–364.

    > MedlineGoogle Scholar
  • 12.Courtney PM, Rozell JC, Melnic CM, Sheth NP, Nelson CL. Effect of malnutrition and morbid obesity on complication rates following primary total joint arthroplasty. J Surg Orthop Adv. 2016; 25(2):99–104.

    > MedlineGoogle Scholar
  • 13.Cross MB, Yi PH, Thomas CF, Garcia J, Della Valle CJ. Evaluation of malnutrition in orthopaedic surgery. J Am Acad Orthop Surg. 2014; 22(3):193–199.10.5435/JAAOS-22-03-193

    > Crossref MedlineGoogle Scholar
  • 14.Slattery E, Patchett S. Albumin as a marker of nutrition: a common pitfall. Ann Surg. 2011; 254(4):667–668.10.1097/SLA.0b013e318230646a

    > Crossref MedlineGoogle Scholar
  • 15.Jain S, Gautam V, Naseem S. Acute-phase proteins: as diagnostic tool. J Pharm Bioallied Sci. 2011; 3(1):118–127.10.4103/0975-7406.76489

    > Crossref MedlineGoogle Scholar
  • 16.Bohl DD, Shen MR, Kayupov E, Della Valle CJ. Hypoalbuminemia independently predicts surgical site infection, pneumonia, length of stay, and readmission after total joint arthroplasty. J Arthroplasty. 2016; 31(1):15–21.10.1016/j.arth.2015.08.028

    > Crossref MedlineGoogle Scholar
  • 17.Kamath AF, Nelson CL, Elkassabany N, Guo Z, Liu J. Low albumin is a risk factor for complications after revision total knee arthroplasty. J Knee Surg. 2017; 30(3):269–275.

    > MedlineGoogle Scholar
  • 18.Kim HJ, Koh WU, Kim SG, et al.Early postoperative albumin level following total knee arthroplasty is associated with acute kidney injury: a retrospective analysis of 1309 consecutive patients based on kidney disease improving global outcomes criteria. Medicine (Baltimore). 2016; 95(31):e4489.10.1097/MD.0000000000004489

    > Crossref MedlineGoogle Scholar
  • 19.Oztürk A, Ozkan Y, Akgöz S, Yalçin N, Aykut S, Ozdemir MR. The effect of blood albumin and total lymphocyte count on short-term results in elderly patients with hip fractures. Ulus Travma Acil Cerrahi Derg. 2009; 15(6):546–552.

    > MedlineGoogle Scholar
  • 20.Fu MC, McLawhorn AS, Padgett DE, Cross MB. Hypoalbuminemia is a better predictor than obesity of complications after total knee arthroplasty: a propensity score-adjusted observational analysis. HSS J. 2017; 13(1):66–74.10.1007/s11420-016-9518-4

    > Crossref MedlineGoogle Scholar
  • 21.Lavernia CJ, Sierra RJ, Baerga L. Nutritional parameters and short term outcome in arthroplasty. J Am Coll Nutr. 1999; 18(3):274–278.10.1080/07315724.1999.10718863

    > Crossref MedlineGoogle Scholar
  • 22.Nelson CL, Elkassabany NM, Kamath AF, Liu J. Low albumin levels, more than morbid obesity, are associated with complications after TKA. Clin Orthop Relat Res. 2015; 473(10):3163–3172.10.1007/s11999-015-4333-7

    > Crossref MedlineGoogle Scholar
  • 23.Walls JD, Abraham D, Nelson CL, Kamath AF, Elkassabany NM, Liu J. Hypoalbuminemia more than morbid obesity is an independent predictor of complications after total hip arthroplasty. J Arthroplasty. 2015; 30(12):2290–2295.10.1016/j.arth.2015.06.003

    > Crossref MedlineGoogle Scholar
  • 24.Helkin A, Jain SV, Gruessner A, et al.Impact of ASA score misclassification on NSQIP predicted mortality: a retrospective analysis. Perioper Med (Lond). 2017; 6:23.10.1186/s13741-017-0076-1

    > Crossref MedlineGoogle Scholar
  • 25.Yuwen P, Chen W, Lv H, et al.Albumin and surgical site infection risk in orthopaedics: a meta-analysis. BMC Surg. 2017; 17(1):7.10.1186/s12893-016-0186-6

    > Crossref MedlineGoogle Scholar
  • 26.Wolters U, Wolf T, Stützer H, Schröder T. ASA classification and perioperative variables as predictors of postoperative outcome. Br J Anaesth. 1996; 77(2):217–222.10.1093/bja/77.2.217

    > Crossref MedlineGoogle Scholar
  • 27.Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008; 466(7):1710–1715.10.1007/s11999-008-0209-4

    > Crossref MedlineGoogle Scholar
  • 28.Namba RS, Inacio MC, Paxton EW. Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees. J Bone Joint Surg Am. 2013; 95(9):775–782.10.2106/JBJS.L.00211

    > Crossref MedlineGoogle Scholar
  • 29.Koh IJ, Kim GH, Kong CG, Park SW, Park TY, In Y. The patient's age and American Society of Anesthesiologists status are reasonable criteria for deciding whether to perform same-day bilateral TKA. J Arthroplasty. 2015; 30(5):770–775.10.1016/j.arth.2014.12.004

    > Crossref MedlineGoogle Scholar
  • 30.Kudsk KA, Tolley EA, DeWitt RC, et al.Preoperative albumin and surgical site identify surgical risk for major postoperative complications. JPEN J Parenter Enteral Nutr. 2003; 27(1):1–9.10.1177/014860710302700101

    > Crossref MedlineGoogle Scholar
  • 31.Inagaki E, Farber A, Eslami MH, et al.Preoperative hypoalbuminemia is associated with poor clinical outcomes after open and endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2017; 66(1):53–63.10.1016/j.jvs.2016.10.110

    > Crossref MedlineGoogle Scholar
  • 32.Gonçalves LB, de Jesus NMT, Gonçalves MB, Dias LC, Deiró TC. Preoperative nutritional status and clinical complications in the postoperative period of cardiac surgeries. Braz J Cardiovasc Surg. 2016; 31(5):371–380.

    > MedlineGoogle Scholar
  • 33.Garcia GH, Fu MC, Dines DM, Craig EV, Gulotta LV. Malnutrition: a marker for increased complications, mortality, and length of stay after total shoulder arthroplasty. J Shoulder Elbow Surg. 2016; 25(2):193–200.10.1016/j.jse.2015.07.034

    > Crossref MedlineGoogle Scholar
  • 34.Aldebeyan S, Nooh A, Aoude A, Weber MH, Harvey EJ. Hypoalbuminaemia: a marker of malnutrition and predictor of postoperative complications and mortality after hip fractures. Injury. 2017; 48(2):436–440.10.1016/j.injury.2016.12.016

    > Crossref MedlineGoogle Scholar
  • 35.Adogwa O, Martin JR, Huang K, et al.Preoperative serum albumin level as a predictor of postoperative complication after spine fusion. Spine (Phila Pa 1976).2014; 39(18):1513–1519.10.1097/BRS.0000000000000450

    > Crossref MedlineGoogle Scholar
  • 36.Mak PH, Campbell RC, Irwin MGAmerican Society of Anesthesiologists. The ASA physical status classification: inter-observer consistency. Anaesth Intensive Care. 2002; 30(5):633–640.

    > Crossref MedlineGoogle Scholar
  • 37.Haynes SR, Lawler PG. An assessment of the consistency of ASA physical status classification allocation. Anaesthesia. 1995; 50(3):195–199.10.1111/j.1365-2044.1995.tb04554.x

    > Crossref MedlineGoogle Scholar
  • 38.Djaladat H, Bruins HM, Miranda G, Cai J, Skinner EC, Daneshmand S. The association of preoperative serum albumin level and American Society of Anesthesiologists (ASA) score on early complications and survival of patients undergoing radical cystectomy for urothelial bladder cancer. BJU Int. 2014; 113(6):887–893.10.1111/bju.12240

    > Crossref MedlineGoogle Scholar

We use cookies on this site to enhance your user experience. For a complete overview of all the cookies used, please see our privacy policy.

×