Clinical Scorecard: Nutritional markers differ in arthroplasty risk

At a Glance

Key Highlights

• The systematic review included 58 studies and 2,076,289 patients; heterogeneity prevented meta-analysis.
• Frailty was associated with poorer clinical outcomes, including increased mortality, complications, infections, and longer hospital stays.
• Malnutrition identified using ESPEN-recommended criteria was associated with increased mortality, postoperative pain, and longer hospital stays.
• Sarcopenia was associated with adverse postoperative outcomes, including prosthetic joint infection and poorer functional outcomes.
• Associations varied by nutritional measure: BMI below 18.5 alone was generally not associated with adverse outcomes, while hypoalbuminemia was associated with adverse outcomes despite not being an ESPEN-recommended standalone diagnostic marker.

Guideline-Based Recommendations

Diagnosis

• The review evaluated nutritional disorders using ESPEN-recommended criteria and other definitions used in the included studies.
• Serum albumin is no longer recommended by ESPEN as a standalone diagnostic marker of malnutrition.

Management

• The authors called for prospective studies to determine whether treating nutritional disorders improves postoperative outcomes or reduces costs.

Monitoring & Follow-up

• The review assessed mortality, postoperative complications, reoperation and revision, prosthetic joint and surgical site infections, patient-reported outcomes, hospital length of stay, and health care costs.

Risks

• Frailty was associated with increased mortality, postoperative complications, infections, and longer hospital stays across included arthroplasty populations.
• Malnutrition identified using ESPEN-recommended criteria was associated with increased mortality, postoperative pain, and longer hospital stays.
• Sarcopenia was associated with adverse postoperative outcomes, including prosthetic joint infection and poorer functional outcomes.
• Study heterogeneity and moderate or serious risk of bias limit the ability to quantify associations.

Patient & Prescribing Data

The review covered 2,076,289 patients undergoing primary or revision hip or knee arthroplasty or surgery for hip fracture.

The review did not establish whether treating nutritional disorders improves outcomes. In one primary total knee arthroplasty study, 30-day mortality was 0.2% among patients with frailty versus 0.1% among those without frailty; the reported odds of death were 2.35 times higher.

Clinical Best Practices

• Interpret nutritional risk in light of the measure used; associations differed across frailty, malnutrition, and sarcopenia definitions.
• Do not treat serum albumin as a standalone ESPEN-recommended diagnostic marker of malnutrition.
• Consider the review's limitations when applying its findings: 34 studies had moderate risk of bias, 24 had serious risk, and heterogeneity prevented pooled analysis.

Related Resources & Content

• Journal of Experimental Orthopaedics