The Effects of Different Nutritional Measurements on Delayed Wound Healing After Hip Fracture in the Elderly

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Background

It has been well recognized that malnutrition causes wounds to heal inadequately and incompletely. Malnutrition is often observed in the elderly, and it appears to be more severe in patients with hip fracture than in the general aging population. Few prospective studies give a detailed account of the identification and classification of nutritional status in the elderly. The objective of this study was to evaluate the effects of different nutritional measurements on wound healing status after hip fracture in the elderly.

Methods

From September 2002 to December 2007, 207 hip fracture patients older than 60 y treated surgically were reviewed for preoperative nutritional status. There were 81 males and 126 females with an average age of 75.93 y (62–91 y); 131 cases with femoral neck fractures, 76 cases with intertrochanteric fractures. Parameters indicative of nutritional status (serum albumin, serum transferrin, serum pre-albumin, and total lymphocyte count levels) at the time of admission were assessed, along with anthropometric measurements, Rainey MacDonald nutritional index, and MNA tool. Suture removal was performed on postoperative day 14.

Results

Delayed wound healing complicated 46 (22.2%) of the 207 cases. The preoperative serum transferring total lymphocyte count levels, MNA total score, and Rainey MacDonald nutritional index were significantly lower for patients who subsequently had delayed wound healing. When all variables were subjected to multivariate analysis, only total lymphocyte count levels and MNA total score showed significant value in predicting which patients would have delayed wound healing. Through prophylactic antibiotics and adherence to strict aseptic precautions, on follow-up, wound healing was normal in all patients.

Conclusions

Patients at risk for delayed wound healing problems after hip fracture can be identified using relatively inexpensive laboratory test such as TLC and MNA tool. The clinician must be aware of the risk values of both measurements. We believe this information is particularly important before planning procedures of hip fractures in the elderly.

Introduction

In the population older than 60 y, fracturing of a hip is one of the commonest reasons for being admitted to a hospital. Age-related changes increase the risk of perioperative complications. Many authors have demonstrated that there is a significant incidence of malnutrition in the elderly, and poorer outcomes after surgical procedures in patients with hip fractures 1, 2, 3, 4, 5, 6. The relationship between retarded wound healing and malnourishment is well documented and confirmed by clinical and experimental studies 1, 2, 7, 8. The delayed wound healing is devastating for the elder patients undergoing internal fixation of hip fracture.

However, the identification and classification of nutritional status in the elderly is a difficult phenomenon to study as no gold standard methodologies exist, although several different approaches have been used [9]. Various preoperative parameters and nutritional equations have been used to predict postoperative wound-healing status 1, 2, 3, 6, 7, 9, 10, 11, 12, 14. The hematological parameters most commonly used to assess the nutritional status are the serum albumin level and the total lymphocyte count. These are practical and reproducible tests that are available in most surgical patients. A negative Rainey MacDonald nutritional index (RMNI) was reported to be significantly associated with longer hospitalization and higher rates of complications [12]. The efficacy and validity of these parameters or equation have not been established. Mini-nutritional assessment (MNA) is a useful diagnostic tool for the identification of elderly patients at risk from malnutrition and those who are already malnourished in this hospital setting [9].

Nutritional evaluation and the impact of malnutrition in the orthopedic surgical patients have not received serious attention, especially in some developing countries. We undertook a prospective study to better define the role of preoperative nutritional status on postoperative wound healing in the elder patients undergoing joint surgery. The study determined the correlation between different nutritional parameters and wound healing status, the use and the validity of RMNI, and MNA in elderly hip fracture patients.

Section snippets

Patients Selection

Two hundred seven hip fracture patients older than 60 y treated surgically between September 2002 and December 2007 at the Medical Center of Soochow University were included in the study. All these fractures were isolated trauma to the hip. All patients were identified at the time of hospital admission and entered into the prospective database. The study was approved by the local Research Ethics Committees and all subjects gave written consent to participate. Patients with pathological

Results

There were 81 males and 126 females with an average age of 75.93 ± 6.89 y (62–91 y); 131 cases with femoral neck fractures, 76 cases with intertrochanteric fractures. Patients with cervical fractures were treated with arthroplasty. Patients with trochanteric fractures were treated with plates and sliding screws.

There were 46 (22.2%) cases of delayed wound healing; 13 (28.3%) of these cases had superficial wound infections. They were successfully treated with intravenous antibiotics. There were no

Discussion

Malnutrition is a serious problem and malnourished patients could have prolonged hospital stays complicated by increased incidence of infection, wasting of skeletal muscle mass, and generalized weakness. Furthermore, a malnourished state in an orthopaedic patient is likely to be exacerbated because fractures are associated with increased rates of catabolism 1, 2, 3, 4, 5, 6, 7, 13. Klein et al. [13] undertook a study to better understand the impact of perioperative nutritional status on

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