This study found that PNI, age, time to admission, hypertension, combined injuries, and operation types were independent factors for perioperative adverse outcomes in patients with femoral fractures, and PNI was a better independent predictor than age and time to admission. Our findings suggest that preoperative nutritional status cannot be underestimated and that interventions should be considered for patients with femoral fractures, where necessary.
The PNI uses the combined effects of hypoalbuminemia and lymphocytopenia to assess the immunologic and nutritional aspects of surgical patients (13, 17), and it is a pre-treatment nutritional risk stratification tool (18). Accumulating evidence indicates that approximately 20–40% of the patients show an acute, prolonged, and profound decrease in serum albumin levels after surgery (17), and this is even more serious in patients with femoral fractures; lower serum albumin levels and total lymphocyte counts are important risk factors for predicting the 1-year mortality of elderly patients with intertrochanteric fractures (19). Consistently, in this study, multivariate regression analysis showed that the nutritional status at admission was negatively correlated with perioperative adverse outcomes in patients with femoral fractures. Although age (P < 0.001), time to admission (P = 0.004), hypertension (P = 0.034), combined injures (P = 0.006), and operative types (P < 0.001) were also independent predictors, they are factors that are not necessarily controllable. Notably, the ROC curve analysis showed that PNI could provide more accurate prediction than other independent predictors in this study, including age and time to admission. Because the ALB level is one main measure included in the PNI (in addition to lymphocyte concentration), the ALB level might also be associated with adverse outcomes. Nevertheless, the PNI was superior to ALB in predicting perioperative adverse outcomes in patients with femoral fractures (P = 0.038). Collectively, PNI was a better and regulatable predictor of perioperative adverse outcomes. Therefore, nutritional assessment at admission and appropriate intervention strategies are necessary for patients with femoral fractures.
The conservative therapy of traditional Chinese orthopaedics is easily accepted by patients (particularly the elderly population) in China, especially in minority nationality regions (Guizhou is a multi-ethnic province of China). Some patients might choose conservative treatment using Chinese medicine in Chinese medical clinics or at home before a surgical operation. Therefore, it is reasonable that some patients were admitted to the hospital after sustaining the fracture for > 22 days in this study. Although traditional Chinese medicine has a long history and has curative effects on fracture rehabilitation, our findings suggest that early admission after trauma (within 2 days) for surgical treatment is beneficial to patients with femoral fractures, especially elderly patients.
Hypertension is closely related to vascular endothelial cell injury and is often accompanied by dyslipidaemia, and both vascular endothelial cell injury and dyslipidaemia are associated with the formation of venous thrombus. In this study, we observed that thrombus accounted for 77.4% (123/159) of perioperative adverse outcomes. This finding suggests that hypertension is an independent risk factor for perioperative adverse outcomes.
Operation types were classified into only two primary categories in this study: hemi/total hip replacement and internal fixation (mainly consisting of intramedullary nailing, cannulated-screw, and plate-screw internal fixation). The former is primarily performed in elderly patients with proximal femoral fractures, and the latter is performed commonly in younger or non-hip fracture patients. There are differences in incision, operating time, degree of ache, blood loss, and hospital stay among patients treated by different surgical methods. This present study comprehensively evaluated the above-mentioned surgery-related factors using univariate and multivariate analyses. The results indicated that the number of patients with femoral fractures who underwent internal fixation was 3.7 times as many as that of patients with femoral fractures who underwent hemi/total-hip replacement. The possible reasons were more severe pain, bleeding, inflammation, activity limitation, and a longer bedridden period in internal fixation-treated patients than in hemi/total-hip replacement patients.
There are several limitations of this study. First, the body mass index (BMI) was not evaluated in this study. The BMI is an indicator for the assessment of nutritional status and a good predictor of morbidity and mortality (20); however, the height values were not documented in this study, mainly because patients with femoral fractures were unable to stand up to provide an accurate height measurement. Second, the lipid profile was not measured in most enrolled patients. Further studies are needed to evaluate the lipid profile (total cholesterol, triglycerides, and lipoprotein levels) because the lipid profile is associated with the risk of venous thrombus (21–23). Third, the duration that a patient is bedridden is closely associated with lower limb vein thrombus, hypostatic pneumonia, and bedsores, and it was not assessed in this retrospective study. Fourth, we did not observe the long-term complications and mortality. Further studies are needed to evaluate the aforementioned issues and explore the effects of preoperative nutritional treatment on perioperative adverse outcomes in patients with femoral fractures.