Health Policy and Economics| Volume 31, ISSUE 11, P2415-2421, November 2016

Malnutrition Increases With Obesity and Is a Stronger Independent Risk Factor for Postoperative Complications: A Propensity-Adjusted Analysis of Total Hip Arthroplasty Patients



      Obesity is frequently associated with complications after total hip arthroplasty (THA) and is often concomitant with malnutrition. The purpose of this study was to investigate the independent morbidity risk of malnutrition relative to obesity.


      The National Surgical Quality Improvement Program from 2005 to 2013 was queried for elective primary THA cases. Malnutrition was defined as albumin <3.5 g/dL. Propensity scores for having preoperative albumin data were determined from demographics, body mass index, and overall comorbidity burden. Patients were classified as nonobese (body mass index 18.5-29.9), obese I (30-34.9), obese II (35-39.9), or obese III (≥40). Complications were compared across nutritional and obesity classes. Multivariable propensity-adjusted logistic regressions were used to examine associations between obesity and malnutrition with 30-day outcomes.


      A total of 40,653 THA cases were identified, of which 20,210 (49.7%) had preoperative albumin measurements. Propensity score adjustment successfully reduced potential selection bias, with P > .05 for differences between those with and without albumin data. Malnutrition incidence increased from 2.8% in obese I to 5.7% in obese III patients. With multivariable propensity-adjusted logistic regression, malnutrition was a more robust predictor than any obesity class for any postoperative complication(s) (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.25-2.08), major complications (OR 1.63, 95% CI 1.21-2.19), respiratory complications (OR 2.35, 95% CI 1.27-4.37), blood transfusions (OR 1.71, 95% CI 1.44-2.03), and extended length of stay (OR 1.35, 95% CI 1.14-1.59).


      Malnutrition incidence increased significantly from obese I to obese III patients and was a stronger and more consistent predictor than obesity of complications after THA.


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      1. Obesity and overweight (fact sheet). World Health Organization, Geneva, Switzerland2015 ([accessed 20.02.16])
        • Ogden C.L.
        • Carroll M.D.
        • Kit B.K.
        • et al.
        Prevalence of childhood and adult obesity in the United States, 2011-2012.
        JAMA. 2014; 311: 806
        • Sahyoun N.R.
        • Hochberg M.C.
        • Helmick C.G.
        • et al.
        Body mass index, weight change, and incidence of self-reported physician-diagnosed arthritis among women.
        Am J Public Health. 1999; 89: 391
        • Losina E.
        • Thornhill T.S.
        • Rome B.N.
        • et al.
        The dramatic increase in total knee replacement utilization rates in the United States cannot be fully explained by growth in population size and the obesity epidemic.
        J bone Jt Surg Am. 2012; 94: 201
        • Workgroup of the American Association of Hip and Knee Surgeons Evidence Based Committee
        Obesity and total joint arthroplasty: a literature based review.
        J Arthroplasty. 2013; 28: 714
        • Mihalko W.M.
        • Bergin P.F.
        • Kelly F.B.
        • et al.
        Obesity, orthopaedics, and outcomes.
        J Am Acad Orthop Surg. 2014; 22: 683
        • Buerba R.A.
        • Fu M.C.
        • Gruskay J.A.
        • et al.
        Obese Class III patients at significantly greater risk of multiple complications after lumbar surgery: an analysis of 10,387 patients in the ACS NSQIP database.
        Spine J. 2014; 14: 2008
        • Bradley B.M.
        • Griffiths S.N.
        • Stewart K.J.
        • et al.
        The effect of obesity and increasing age on operative time and length of stay in primary hip and knee arthroplasty.
        J Arthroplasty. 2014; 29: 1906
        • Ward D.T.
        • Metz L.N.
        • Horst P.K.
        • et al.
        Complications of morbid obesity in total joint arthroplasty: risk stratification based on BMI.
        J Arthroplasty. 2015; 30: 42
        • Garcia G.H.
        • Fu M.C.
        • Dines D.M.
        • et al.
        Malnutrition: a marker for increased complications, mortality, and length of stay after total shoulder arthroplasty.
        J Shoulder Elbow Surg. 2016; 25: 193
        • Nelson C.L.
        • Elkassabany N.M.
        • Kamath A.F.
        • et al.
        Low albumin levels, more than morbid obesity, are associated with complications after TKA.
        Clin Orthop Relat Res. 2015; 473: 3163
        • Cross M.B.
        • Yi P.H.
        • Thomas C.F.
        • et al.
        Evaluation of malnutrition in orthopaedic surgery.
        J Am Acad Orthop Surg. 2014; 22: 193
        • Via M.
        The malnutrition of obesity: micronutrient deficiencies that promote diabetes.
        ISRN Endocrinol. 2012; 2012: 103472
        • Bohl D.D.
        • Shen M.R.
        • Kayupov E.
        • et al.
        Hypoalbuminemia independently predicts surgical site infection, pneumonia, length of stay, and readmission after total joint arthroplasty.
        J Arthroplasty. 2016; 31: 15
        • Fu M.C.
        • Buerba R.A.
        • Grauer J.N.
        Preoperative nutritional status as an adjunct predictor of major postoperative complications following anterior cervical discectomy and fusion.
        Clin Spine Surg. 2016; 29: 167
        • American College of Surgeons
        User guide for the 2013 ACS NSQIP participant use data file.
        2014 ([accessed 20.02.16])
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • et al.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373
        • Basques B.A.
        • Toy J.O.
        • Bohl D.D.
        • et al.
        General compared with spinal anesthesia for total hip arthroplasty.
        J Bone Jt Surg Am. 2015; 97: 455
        • Bohl D.D.
        • Fu M.C.
        • Gruskay J.A.
        • et al.
        “July effect” in elective spine surgery: analysis of the American College of Surgeons National Surgical Quality Improvement Program database.
        Spine. 2014; 39: 603
        • Sundararajan V.
        • Henderson T.
        • Perry C.
        • et al.
        New ICD-10 version of the Charlson comorbidity index predicted in-hospital mortality.
        J Clin Epidemiol. 2004; 57: 1288
        • D'Agostino Jr., R.B.
        Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group.
        Stat Med. 1998; 17: 2265
        • Dowsey M.M.
        • Choong P.F.
        Obesity is a major risk factor for prosthetic infection after primary hip arthroplasty.
        Clin Orthop Relat Res. 2008; 466: 153
        • Friedman R.J.
        • Hess S.
        • Berkowitz S.D.
        • et al.
        Complication rates after hip or knee arthroplasty in morbidly obese patients.
        Clin Orthop Relat Res. 2013; 471: 3358
        • Watts C.D.
        • Houdek M.T.
        • Wagner E.R.
        • et al.
        High risk of wound complications following direct anterior total hip arthroplasty in obese patients.
        J Arthroplasty. 2015; 30: 2296
        • Nicholson J.A.
        • Dowrick A.S.
        • Liew S.M.
        Nutritional status and short-term outcome of hip arthroplasty.
        J Orthop Surg (Hong Kong). 2012; 20: 331
        • Lavernia C.J.
        • Sierra R.J.
        • Baerga L.
        Nutritional parameters and short term outcome in arthroplasty.
        J Am Coll Nutr. 1999; 18: 274
        • Greene K.A.
        • Wilde A.H.
        • Stulberg B.N.
        Preoperative nutritional status of total joint patients. Relationship to postoperative wound complications.
        J Arthroplasty. 1991; 6: 321
        • Pruzansky J.S.
        • Bronson M.J.
        • Grelsamer R.P.
        • et al.
        Prevalence of modifiable surgical site infection risk factors in hip and knee joint arthroplasty patients at an urban academic hospital.
        J Arthroplasty. 2014; 29: 272
        • Bavaresco M.
        • Paganini S.
        • Lima T.P.
        • et al.
        Nutritional course of patients submitted to bariatric surgery.
        Obes Surg. 2010; 20: 716
        • Walls J.D.
        • Abraham D.
        • Nelson C.L.
        • et al.
        Hypoalbuminemia more than morbid obesity is an independent predictor of complications after total hip arthroplasty.
        J Arthroplasty. 2015; 30: 2290