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OBJECTIVES:Distal femur fractures (DFF) are serious injuries that frequently affect older, medically complex patients. Malnutrition worsens outcomes in elective orthopaedic surgery, but its impact in urgent DFF fixation, where preoperative optimization time is limited, remains unclear. This study evaluated whether preoperative malnutrition predicts 90-day morbidity after DFF fixation and whether implant choice modifies risk among malnourished patients. METHODS:Adults undergoing operative DFF fixation from 2005 to 2025 were identified in the TriNetX US Collaborative Network. Malnutrition was defined as serum albumin ≤3.5 g/dL or leukocyte count ≤1.5 × 10³/µL within one year before surgery. After 1:1 propensity matching for demographics and comorbidities, outcomes were compared between 13,924 malnourished and 13,924 non-malnourished patients. A secondary matched analysis compared plate versus intramedullary nail fixation in malnourished patients (n = 662). Ninety-day postoperative complications, readmission, and opioid-related outcomes were assessed. RESULTS:Malnourished patients had significantly higher rates of nearly all 90-day complications, including sepsis (risk ratio [RR] 3.55), surgical site infection (RR 3.05), wound disruption (RR 3.38), pulmonary embolism (RR 2.09), pneumonia (RR 2.45), renal failure (RR 2.53), anemia (RR 1.97), and transfusion (RR 2.52) (all p < 0.001). Ninety-day readmission and opioid-related outcomes were also substantially increased. Among malnourished patients, overall complication rates were similar between plate and nail fixation, with the exception of lower pneumonia rates in the plate cohort (p = 0.045). CONCLUSIONS:Preoperative malnutrition is a strong, independent predictor of postoperative morbidity after DFF fixation, and complication risk remains high regardless of implant choice. Routine nutritional screening with simple laboratory markers and targeted perioperative optimization should be integrated into trauma workflows to improve outcomes in this vulnerable population.
INTRODUCTION:Distal femoral periprosthetic fractures following TKA are increasingly common in elderly patients. Surgical management most commonly involves either open reduction and internal fixation (ORIF) or distal femoral replacement (DFR); however, comparative data regarding short-term and long-term complications remain limited. As such, this study compared complications between ORIF and DFR in elderly patients with distal femoral periprosthetic fractures following TKA. METHODS:A retrospective cohort study was performed using the TriNetX Research Network. Patients aged ≥65 years with distal femoral periprosthetic fractures were identified and categorized by operative treatment. Propensity score matching was performed to balance cohorts. Short-term complications were assessed at 90 days, and long-term complications were evaluated at 1 and 5 years. Complications were compared using risk differences and risk ratios with 95% confidence intervals, and Kaplan-Meier survival methods. RESULTS:After matching, 698 patients remained in each cohort. Most 90-day complications were similar between groups. However, DFR was associated with higher rates of wound disruption (7.6% vs 2.7%, RR 2.79 [95% CI 1.67-4.66], p<0.001) and transfusion (17.5% vs 13.0%, RR 1.34 [1.04-1.72], p=0.021). At 5-year follow-up, DFR demonstrated higher risks of periprosthetic joint infection (22.5% vs 5.3%, RR 4.24 [3.01-5.98], p<0.001), revision TKA (15.5% vs 3.3%, RR 4.70 [3.03-7.27], p<0.001), and subsequent knee procedures (24.4% vs 14.9%, RR 1.64 [1.31-2.04], p<0.001). Conversely, repeat periprosthetic fractures were more frequent following ORIF (55.3% vs 44.8%), with DFR demonstrating a lower relative risk (RR 0.81 [0.73-0.90], p<0.001). Similarly, additional fixation procedures occurred more often after ORIF (4.9% vs 1.6%), while DFR was associated with a reduced relative risk (RR 0.32 [0.17-0.63], p<0.001). Mortality was similar between approaches at both 30 days (2.2% vs 2.2%, RR 1.00 [0.48-2.08], p=1.00) and 5 years (16.0% vs 15.4%, RR 1.04 [0.81-1.33], p=0.764). CONCLUSION:Short-term systemic complication rates were comparable between approaches, although DFR was associated with greater perioperative morbidity. Over longer follow-up, DFR demonstrated higher implant-related infection and revision risks, whereas ORIF carried higher risks of refracture and secondary fixation. These findings highlight a tradeoff between the immediate stability and mobilization of DFR and longer-term implant-related complications, supporting individualized treatment selection based on patient-specific risk factors.
BACKGROUND:Malnutrition is a potentially modifiable risk factor that may influence perioperative complications and fracture healing. This study evaluated the association between preoperative laboratory-defined malnutrition and short-term complications and 2-year outcomes following operative fixation of tibial shaft fractures. METHODS:Using the TriNetX Research Network (112 healthcare organizations), adults (≥18 years) undergoing operative management for tibial shaft fracture were identified. Preoperative malnutrition was defined as albumin ≤3.5 g/dL and/or leukocytes ≤1.5 × 10³/µL within 1 year prior to the index event. Cohorts were propensity score matched 1:1 on demographics and comorbidities. Outcomes were assessed from day 1 post-index through 90 days (medical/surgical complications) and 730 days (healing-related and limb outcomes). Risk ratios (RR) and hazard ratios (HR) with 95% confidence intervals (CI) were reported. RESULTS:After matching, 44,780 patients were included in each cohort (89,560 total), with good balance across covariates (all SMDs <0.10). At 90 days, malnutrition was associated with higher risk of acute respiratory failure/mechanical ventilation (13.9% vs 3.4%; RR 4.10 [95% CI 3.88-4.33].; HR 4.32 [4.09-4.57].), sepsis (5.2% vs 1.2%; RR 4.35 [3.97-4.77].; HR 4.47 [4.07-4.91].), postoperative infection (5.7% vs 1.8%; RR 3.14 [2.90-3.39].; HR 3.23 [2.99-3.50].), acute kidney injury (8.6% vs 3.0%; RR 2.90 [2.73-3.08].; HR 2.99 [2.81-3.18].), and DVT/PE (6.5% vs 2.7%; RR 2.36 [2.21-2.52].; HR 2.42 [2.26-2.59].) (all p < 0.001). At 2 years, malnutrition was associated with increased nonunion (4.4% vs 1.6%; RR 2.69 [2.47-2.92].; HR 2.85 [2.62-3.10].), chronic osteomyelitis (12.5% vs 3.9%; RR 3.19 [3.02-3.36].; HR 3.50 [3.32-3.69].), hardware removal (10.1% vs 6.0%; RR 1.68 [1.61-1.76].; HR 1.83 [1.74-1.92].), and amputation (1.4% vs 0.4%; RR 3.47 [2.95-4.08].; HR 3.59 [3.05-4.23].) (all p < 0.001). Revision fixation did not differ (8.4% vs 8.1%; p = 0.096). CONCLUSIONS:Preoperative laboratory-defined malnutrition was independently associated with substantially higher 90-day morbidity and increased 2-year nonunion and limb-complication risk following operative tibial shaft fracture management. These findings support preoperative nutritional risk stratification and targeted optimization efforts in this population.
