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Tischler EH, McDermott JR, Vummidi S, Mahmoud SA, Gross JM, Malik AN, Suneja N. Is it time to Reassess The Role of Preoperative HypoalbuminemiaAmong Geriatric Distal Femur Fracture Patients? Arch Orthop Trauma Surg 2024; 145:66. [PMID: 39694920 DOI: 10.1007/s00402-024-05725-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2024] [Accepted: 12/09/2024] [Indexed: 12/20/2024]
Abstract
BACKGROUND Hypoalbuminemia, blanketly defined as Albumin < 3.5 g/dL, is often utilized as a threshold associated with postoperative complications and mortality among orthopedic and non-orthopedic surgical procedures. Albumin level is influenced by a myriad of factors including liver function, malnutrition, and inflammation. This study evaluates the role preoperative albumin as an independent risk factor for mortality and increased length of stay (LOS) among distal femur fracture (DFF) patients. METHODS Between 2010 and 2019, the National Surgical Quality Improvement Program (NSQIP) identified isolated closed distal femur fractures preoperative albumin levels using International Classification of Diseases 9th and 10th revisions (ICD9/ICD10) codes [S72.4*; 821.2*]. Albumin was categorized as both continuous and categorical variables: marked hypoalbuminemia (< 2.5 g/dL), mild hypoalbuminemia (2.5-3.5 g/dL), normal albuminemia (3.5-4.5 g/dL) or hyperalbuminemia (> 4.5 g/dL). Primary outcomes included in-hospital mortality and LOS. RESULTS The incidence rate of hypoalbuminemia was 54.6% (419/767). Multivariable logistic regression analysis demonstrated that when compared to patients with baseline marked hypoalbuminemia, patients with mild hypoalbuminemia and normal serum albumin reported a respective 82% (OR 0.18, 95% CI [0.04, 0.71], p = 0.014) and 80% (OR: 0.20, 95% CI [0.05, 0.89], p = 0.034) decreased odds of in-hospital mortality. Similarly, a 53.7% (OR 0.46, 95% CI [0.23, 0.94], p = 0.033), 71.1% (OR 0.29, 95% CI [0.14, 0.60], p = 0.001), and 82.8% (OR 0.17, 95% [0.04, 0.75], p = 0.020) decreased odds of exceeding mean LOS was observed among mild hypoalbuminemic, normal, and hyperalbuminemic patients compared to patients with baseline marked hypoalbuminemia. CONCLUSION Preoperative hypoalbuminemia is an independent risk factor for increased LOS and mortality among DFFs, controlling for confounding factors. Prospective investigation of albumin risk stratification is warranted to differentiate contributable effects of chronic malnutrition and traumatic inflammatory albumin downregulation among geriatric trauma patients. LEVEL OF EVIDENCE Prognostic Level III.
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Affiliation(s)
- Eric H Tischler
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, 450 Clarkson Avenue, Box 30, Brooklyn, NY, 11203, USA
| | - Jake R McDermott
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, 450 Clarkson Avenue, Box 30, Brooklyn, NY, 11203, USA
| | - Shivasuryan Vummidi
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, 450 Clarkson Avenue, Box 30, Brooklyn, NY, 11203, USA
| | - Samer A Mahmoud
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, 450 Clarkson Avenue, Box 30, Brooklyn, NY, 11203, USA
| | - Jonathan M Gross
- Department of Orthopaedic Surgery, Northwell Health -Staten Island University Hospital, 375 Seguine Avenue, Staten Island, NY, 10309, USA
| | - Aden N Malik
- Department of Orthopaedic Surgery, Lincoln Hospital, 234 East 149th Street, Bronx, NY, 10451, USA
| | - Nishant Suneja
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, Massachusetts, 02115, USA.
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Wilson JM, Kukowski NR, Staley CA, Bariteau JT. Role of Hypoalbuminemia as an Independent Predictor of 30-Day Postoperative Complications Following Surgical Fixation of Ankle Fractures. Foot Ankle Int 2020; 41:303-312. [PMID: 31868015 DOI: 10.1177/1071100719895222] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Malnutrition is known to be negatively associated with outcomes after multiple orthopedic procedures. We hypothesized that admission albumin levels, as a marker for malnutrition, would correlate with postoperative outcomes. The purpose of this study was to investigate this relationship following surgery for ankle fracture. METHODS This is a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients undergoing operative fixation of an ankle fracture were identified. A total of 6138 patients with albumin available for analysis were identified. Baseline patient information, preoperative serum albumin levels, 30-day postoperative complications, readmission, reoperation, and length of stay data were then collected. Poisson regression with robust error variance was performed to assess the effect of preoperative serum albumin level on postoperative outcomes. RESULTS The mean albumin level was 3.86 g/dL and 20.3% (1246/6138) of patients with available albumin levels were hypoalbuminemic. Multivariate analysis revealed that an albumin level <3.5 g/dL was an independent risk factor for complications (relative risk [RR], 1.42; 95% confidence interval [CI], 1.13-1.78; P = .002) and readmission (RR, 1.54; 95% CI, 1.13-2.08; P = .006). Additionally, when analyzed as a continuous variable, albumin level was negatively correlated with risk of mortality (RR, 0.37; 95% CI, 0.19-0.72; P = .003). Patients with hypoalbuminemia also had significantly longer lengths of stay (4.5 vs 2.1 days; P < .001). CONCLUSION While complication rates after fixation of ankle fractures remain low, hypoalbuminemia was a predictor of postoperative course. Malnutrition, therefore, may help inform the decision between surgical and conservative management of patients with ankle fractures potentially amenable to nonoperative management. Additionally, hypoalbuminemia should trigger heightened awareness and prophylactic therapy where appropriate. LEVEL OF EVIDENCE Level III, comparative study.
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Affiliation(s)
- Jacob M Wilson
- Department of Orthopedic Surgery, School of Medicine, Emory University, Atlanta, GA, USA
| | - Nathan R Kukowski
- Department of Orthopedic Surgery, School of Medicine, Emory University, Atlanta, GA, USA
| | - Christopher A Staley
- Department of Orthopedic Surgery, School of Medicine, Emory University, Atlanta, GA, USA
| | - Jason T Bariteau
- Department of Orthopedic Surgery, School of Medicine, Emory University, Atlanta, GA, USA
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Hypoalbuminemia Is an Independent Risk Factor for 30-Day Mortality, Postoperative Complications, Readmission, and Reoperation in the Operative Lower Extremity Orthopaedic Trauma Patient. J Orthop Trauma 2019; 33:284-291. [PMID: 30720559 DOI: 10.1097/bot.0000000000001448] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Malnutrition, as indicated by hypoalbuminemia, is known to have detrimental effects on outcomes after arthroplasty, geriatric hip fractures, and multiple general surgeries. Hypoalbuminemia has been examined in the critically ill but has largely been ignored in the orthopaedic trauma literature. We hypothesized that admission albumin levels would correlate with postoperative course in the nongeriatric lower extremity trauma patient. METHODS Patients with lower extremity (including pelvis and acetabulum) fracture who underwent operative intervention were collected from the ACS-NSQIP database. Patients younger than 65 years were included. Patient demographic data, complications, length of stay, reoperation rate, and readmission rate were collected, and patient modified frailty index scores were calculated. Poisson regression with robust error variance was then conducted, controlling for potential confounders. RESULTS Five thousand six hundred seventy-three patients with albumin available were identified, and 29.6% had hypoalbuminemia. Hypoalbuminemic patients had higher rates of postoperative complications [9.3% vs. 2.6%; relative risk (RR) 1.63] including increased rates of: mortality (3.2% vs. 0.4%; RR 4.86, 95% confidence interval 2.66-8.87), sepsis (1.5% vs. 0.5%, RR 2.35), and reintubation (2.3% vs. 0.4%; RR 3.84). Reoperation (5.5% vs. 2.6%, RR 1.74) and readmission (11.4% vs. 4.1%; RR 2.53) rates were also higher in patients with low albumin. CONCLUSION Hypoalbuminemia is a powerful predictor of acute postoperative course and mortality after surgical fixation in nongeriatric, lower extremity orthopaedic trauma patients. Admission albumin should be a routine part of the orthopaedic trauma workup. Further study into the utility of supplementation is warranted, as this may represent a modifiable risk factor. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Li G, Li P, Chen Q, Thu HE, Hussain Z. Current Updates on Bone Grafting Biomaterials and Recombinant Human Growth Factors Implanted Biotherapy for Spinal Fusion: A Review of Human Clinical Studies. Curr Drug Deliv 2019; 16:94-110. [PMID: 30360738 DOI: 10.2174/1567201815666181024142354] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 08/01/2018] [Accepted: 10/18/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Owing to their great promise in the spinal surgeries, bone graft substitutes have been widely investigated for their safety and clinical potential. By the current advances in the spinal surgery, an understanding of the precise biological mechanism of each bone graft substitute is mandatory for upholding the induction of solid spinal fusion. OBJECTIVE The aim of the present review is to critically discuss various surgical implications and level of evidence of most commonly employed bone graft substitutes for spinal fusion. METHOD Data was collected via electronic search using "PubMed", "SciFinder", "ScienceDirect", "Google Scholar", "Web of Science" and a library search for articles published in peer-reviewed journals, conferences, and e-books. RESULTS Despite having exceptional inherent osteogenic, osteoinductive, and osteoconductive features, clinical acceptability of autografts (patient's own bone) is limited due to several perioperative and postoperative complications i.e., donor-site morbidities and limited graft supply. Alternatively, allografts (bone harvested from cadaver) have shown great promise in achieving acceptable bone fusion rate while alleviating the donor-site morbidities associated with implantation of autografts. As an adjuvant to allograft, demineralized bone matrix (DBM) has shown remarkable efficacy of bone fusion, when employed as graft extender or graft enhancer. Recent advances in recombinant technologies have made it possible to implant growth and differentiation factors (bone morphogenetic proteins) for spinal fusion. CONCLUSION Selection of a particular bone grafting biotherapy can be rationalized based on the level of spine fusion, clinical experience and preference of orthopaedic surgeon, and prevalence of donor-site morbidities.
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Affiliation(s)
- Guanbao Li
- Department of Minimally Invasive Spine Surgery, Yulin City Orthopaedic Hospital of Traditional Chinese Medicine and Western Medicine, NO.597, Jiaoyu Road, Yulin, Guangxi, 537000, China
| | - Pinquan Li
- Department of Minimally Invasive Spine Surgery, Yulin City Orthopaedic Hospital of Traditional Chinese Medicine and Western Medicine, NO.597, Jiaoyu Road, Yulin, Guangxi, 537000, China
| | - Qiuan Chen
- Department of Minimally Invasive Spine Surgery, Yulin City Orthopaedic Hospital of Traditional Chinese Medicine and Western Medicine, NO.597, Jiaoyu Road, Yulin, Guangxi, 537000, China
| | - Hnin Ei Thu
- Department of Pharmacology and Dental Therapeutics, Faculty of Dentistry, Lincoln University College, Jalan Stadium, SS 7/15, Kelana Jaya, 47301 Petaling Jaya, Selangor, Malaysia
| | - Zahid Hussain
- Department of Pharmaceutics, Faculty of Pharmacy, Universiti Teknologi MARA (UiTM), Puncak Alam Campus, Bandar Puncak Alam 42300, Selangor, Malaysia
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Fernandez de Grado G, Keller L, Idoux-Gillet Y, Wagner Q, Musset AM, Benkirane-Jessel N, Bornert F, Offner D. Bone substitutes: a review of their characteristics, clinical use, and perspectives for large bone defects management. J Tissue Eng 2018; 9:2041731418776819. [PMID: 29899969 PMCID: PMC5990883 DOI: 10.1177/2041731418776819] [Citation(s) in RCA: 441] [Impact Index Per Article: 63.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 04/24/2018] [Indexed: 12/13/2022] Open
Abstract
Bone replacement might have been practiced for centuries with various materials of natural origin, but had rarely met success until the late 19th century. Nowadays, many different bone substitutes can be used. They can be either derived from biological products such as demineralized bone matrix, platelet-rich plasma, hydroxyapatite, adjunction of growth factors (like bone morphogenetic protein) or synthetic such as calcium sulfate, tri-calcium phosphate ceramics, bioactive glasses, or polymer-based substitutes. All these substitutes are not suitable for every clinical use, and they have to be chosen selectively depending on their purpose. Thus, this review aims to highlight the principal characteristics of the most commonly used bone substitutes and to give some directions concerning their clinical use, as spine fusion, open-wedge tibial osteotomy, long bone fracture, oral and maxillofacial surgery, or periodontal treatments. However, the main limitations to bone substitutes use remain the management of large defects and the lack of vascularization in their central part, which is likely to appear following their utilization. In the field of bone tissue engineering, developing porous synthetic substitutes able to support a faster and a wider vascularization within their structure seems to be a promising way of research.
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Affiliation(s)
- Gabriel Fernandez de Grado
- INSERM (French National Institute of Health and Medical Research), “Regenerative Nanomedicine” laboratory, http://www.regmed.fr, UMR 1260, Faculté de Médecine, FMTS, F-67085 Strasbourg Cedex
- Université de Strasbourg, Faculté de Chirurgie Dentaire, 8 rue Ste Elisabeth, F-67000 Strasbourg
- Hôpitaux Universitaires de Strasbourg, 1 Place de l’Hôpital, F-67000 Strasbourg
| | - Laetitia Keller
- INSERM (French National Institute of Health and Medical Research), “Regenerative Nanomedicine” laboratory, http://www.regmed.fr, UMR 1260, Faculté de Médecine, FMTS, F-67085 Strasbourg Cedex
- Université de Strasbourg, Faculté de Chirurgie Dentaire, 8 rue Ste Elisabeth, F-67000 Strasbourg
| | - Ysia Idoux-Gillet
- INSERM (French National Institute of Health and Medical Research), “Regenerative Nanomedicine” laboratory, http://www.regmed.fr, UMR 1260, Faculté de Médecine, FMTS, F-67085 Strasbourg Cedex
- Université de Strasbourg, Faculté de Chirurgie Dentaire, 8 rue Ste Elisabeth, F-67000 Strasbourg
| | - Quentin Wagner
- INSERM (French National Institute of Health and Medical Research), “Regenerative Nanomedicine” laboratory, http://www.regmed.fr, UMR 1260, Faculté de Médecine, FMTS, F-67085 Strasbourg Cedex
- Université de Strasbourg, Faculté de Chirurgie Dentaire, 8 rue Ste Elisabeth, F-67000 Strasbourg
| | - Anne-Marie Musset
- INSERM (French National Institute of Health and Medical Research), “Regenerative Nanomedicine” laboratory, http://www.regmed.fr, UMR 1260, Faculté de Médecine, FMTS, F-67085 Strasbourg Cedex
- Université de Strasbourg, Faculté de Chirurgie Dentaire, 8 rue Ste Elisabeth, F-67000 Strasbourg
- Hôpitaux Universitaires de Strasbourg, 1 Place de l’Hôpital, F-67000 Strasbourg
| | - Nadia Benkirane-Jessel
- INSERM (French National Institute of Health and Medical Research), “Regenerative Nanomedicine” laboratory, http://www.regmed.fr, UMR 1260, Faculté de Médecine, FMTS, F-67085 Strasbourg Cedex
- Université de Strasbourg, Faculté de Chirurgie Dentaire, 8 rue Ste Elisabeth, F-67000 Strasbourg
| | - Fabien Bornert
- INSERM (French National Institute of Health and Medical Research), “Regenerative Nanomedicine” laboratory, http://www.regmed.fr, UMR 1260, Faculté de Médecine, FMTS, F-67085 Strasbourg Cedex
- Université de Strasbourg, Faculté de Chirurgie Dentaire, 8 rue Ste Elisabeth, F-67000 Strasbourg
- Hôpitaux Universitaires de Strasbourg, 1 Place de l’Hôpital, F-67000 Strasbourg
| | - Damien Offner
- INSERM (French National Institute of Health and Medical Research), “Regenerative Nanomedicine” laboratory, http://www.regmed.fr, UMR 1260, Faculté de Médecine, FMTS, F-67085 Strasbourg Cedex
- Université de Strasbourg, Faculté de Chirurgie Dentaire, 8 rue Ste Elisabeth, F-67000 Strasbourg
- Hôpitaux Universitaires de Strasbourg, 1 Place de l’Hôpital, F-67000 Strasbourg
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Drosos GI, Touzopoulos P, Ververidis A, Tilkeridis K, Kazakos K. Use of demineralized bone matrix in the extremities. World J Orthop 2015; 6:269-277. [PMID: 25793167 PMCID: PMC4363809 DOI: 10.5312/wjo.v6.i2.269] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 07/07/2014] [Accepted: 10/16/2014] [Indexed: 02/06/2023] Open
Abstract
Autologous bone graft is considered as the gold standard for all indications for bone grafting procedures but the limited availability and complications in donor site resulted in seeking other options like allografts and bone graft substitutes. Demineralized bone matrix (DBM) is an allograft product with no quantity limitation. It is an osteoconductive material with osteoinductive capabilities, which vary among different products, depending on donor characteristics and differences in processing of the bone. The purpose of the present review is to provide a critical review of the existing literature concerning the use of DBM products in various procedures in the extremities. Clinical studies describing the use of DBM alone or in combination with other grafting material are available for only a few commercial products. The Level of Evidence of these studies and the resulting Grades of Recommendation are very low. In conclusion, further clinical studies of higher quality are required in order to improve the Recommendation Grades for or against the use of DBM products in bone grafting procedures.
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Tilkeridis K, Touzopoulos P, Ververidis A, Christodoulou S, Kazakos K, Drosos GI. Use of demineralized bone matrix in spinal fusion. World J Orthop 2014; 5:30-37. [PMID: 24649412 PMCID: PMC3952692 DOI: 10.5312/wjo.v5.i1.30] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 09/17/2013] [Accepted: 11/03/2013] [Indexed: 02/06/2023] Open
Abstract
Spinal fusion remains the gold-standard treatment for several pathological spine conditions. Although, autologous Iliac Crest Bone Grafting is considered the gold-standard graft choice to promote spinal fusion; however, it is associated with significant donor site morbidity and a limited graft quantity. Therefore, several bone graft alternatives have been developed, to augment arthrodesis. The purpose of this review is to present the results of clinical studies concerning the use of demineralized bone matrix (DBM), alone or as a composite graft, in the spinal fusion. A critical review of the English-language literature was conducted on Pubmed, using key word “demineralized bone matrix”, “DBM”, “spinal fusion”, and “scoliosis”. Results had been restricted to clinical studies. The majority of clinical trials demonstrate satisfactory fusion rates when DBM is employed as a graft extender or a graft enhancer. Limited number of prospective randomized controlled trials (4 studies), have been performed comparing DBM to autologous iliac crest bone graft in spine fusion. The majority of the clinical trials demonstrate comparable efficacy of DBM when it used as a graft extender in combination with autograft, but there is no clinical evidence to support its use as a standalone graft material. Additionally, high level of evidence studies are required, in order to optimize and clarify the indications of its use and the appropriate patient population that will benefit from DBM in spine arthrodesis.
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Zou X, Zou L, Foldager C, Bendtsen M, Feng W, Bünger CE. Different mechanisms of spinal fusion using equine bone protein extract, rhBMP-2 and autograft during the process of anterior lumbar interbody fusion. Biomaterials 2008; 30:991-1004. [PMID: 19046765 DOI: 10.1016/j.biomaterials.2008.10.061] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Accepted: 10/27/2008] [Indexed: 10/21/2022]
Abstract
To elucidate the molecular mechanisms of spinal fusion with different graft materials during an anterior lumbar interbody fusion, we examined the gene-expression profiles after implantation of equine bone protein extract, rhBMP-2 and autograft using microarray technology and data analysis, including hierarchical clustering, self-organizing maps (SOM), KEGG pathway and Biological process GO analyses in a porcine model. The results suggest that equine bone protein extract exhibited a more similar expression pattern with autograft than that of rhBMP-2. rhBMP-2 recruits progenitor cells, proliferation and differentiation possibly by inducing various factors including PGHS-2, IFGBP-2, VEGF and chemokines and then leads to preferable membranous ossification and bone remodeling. Conversely, equine bone protein extract results in endochondral ossification via upregulation of cartilage-related genes. Ossification by inducing direct osteoblastic differentiation and obviating the cartilaginous intermediate phases may increase spinal fusion rate.
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Affiliation(s)
- Xuenong Zou
- Department of Spine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
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Drosos GI, Kazakos KI, Kouzoumpasis P, Verettas DA. Safety and efficacy of commercially available demineralised bone matrix preparations: a critical review of clinical studies. Injury 2007; 38 Suppl 4:S13-21. [PMID: 18224733 DOI: 10.1016/s0020-1383(08)70005-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Demineralised bone matrix (DBM), a form of allograft, possesses the properties of osteoinductivity and osteoconductivity. A large body of data obtained from extensive preclinical studies have clearly supported the utility of DBM in human clinical settings. However, it is now recognized that various DBM configurations may differ considerably with regard to their bone inductive activity. Several factors could account for such variability, including the biologic properties of the graft, the host environment, and the methods of allograft preparation. The differing efficacy of DBM products may also depend on differences in particle size and shape, donor selection criteria, protocols for collection and storage, as well as DBM carrier materials. Several comparative studies have confirmed the differences in the osteoinductive potential of various DBM preparations. The purpose of the present review is to provide a critical overview of the current applications of DBM in a clinical setting.
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Affiliation(s)
- Georgios I Drosos
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100 Alexandroupolis, Greece.
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