Poor Nutritional Status Increases Risk of Postoperative Adverse Events after Surgical Management of Traumatic Ankle Fracture

Category: Trauma; Ankle Introduction/Purpose: Worldwide, 663 million individuals suffer from undernourishment. Malnutrition is unequivocally characterized as a risk factor for impaired recovery and increased infection after elective surgery. Despite this, there is little data on the role of malnourishment in the acute trauma setting, where preoperative optimization poses difficulty. We investigate infectious outcomes in patients with poor nutritional status undergoing surgical management of ankle trauma. Methods: We performed a retrospective study of adult patients from the National Trauma Data Bank 2011-2016. Patients missing baseline or comorbidity information, dead on arrival, or with a pilon fracture or stress fracture were excluded. Enhanced ICD-9 algorithms were used to identify patients with severe protein-calorie malnutrition and chronic deficiency. Baseline characteristics were compared using bivariate analysis. Multivariate logistic analysis was employed to investigate the association of poor nutritional status with adverse events, adjusting for age, sex, race, insurance, injury severity score, presence of shock, injury mechanism, significantly different comorbidities, open fracture, and admission year. Outcomes included death, severe adverse events (death, deep surgical site infection (SSI), myocardial infarction (MI), cardiac arrest, deep vein thrombosis (DVT), pulmonary embolism (PE), sepsis, stroke, compartment syndrome), minor adverse events (acute kidney injury (AKI), pneumonia, superficial SSI, urinary tract infection (UTI)), infectious events (deep SSI, organ/space SSI, superficial SSI), and any adverse event. Results: Overall, 109,850 patients were included, and 267 patients (0.2%) were diagnosed with poor nutritional status. Patients with poor nutritional status were older (56 vs. 51 years), more likely to present in shock (7.5% vs. 2.3%) and due to motor vehicle collision mechanism (all P< 0.001). Poor nutritional status patients had increased rates of alcoholism, bleeding disorder, congestive heart failure, diabetes, hypertension, COPD, dementia as well as history of MI, peripheral vascular disease, and cirrhosis (all P< 0.001). In-hospital mortality was greater in malnourished patients (2.6% vs. 0.9%, P=0.01). Multivariate analyses demonstrated an association of poor nutritional status with increased likelihood of in-hospital mortality (OR=3.00, P< 0.001), major complication (OR=1.71, P=0.005), minor complication (OR=3.50, P< 0.001), and infectious adverse event (OR=3.03, P< 0.001). Conclusion: Poor nutritional status is independently associated with postoperative complications and infectious adverse events in a subset of foot and ankle trauma patients undergoing surgical management. Further investigation is necessary to understand the role of preoperative and postoperative nutritional supplementation in malnourished trauma patients to improve outcomes. These findings suggest that increased nutritional screening may assist in the identification and management of patients at risk of death and postoperative complications, respectively, and thereby help optimize risk stratification, inform patient expectations, and guide outcomes-based reimbursements in the management of traumatic ankle fracture.