CORR Insights: Low Albumin Levels, More Than Morbid Obesity, Are Associated With Complications After TKA.

T he current study by Nelson and colleagues tries to bring greater clarity to the debate as to whether morbid obesity and malnutrition actually increase the risk of mortality and major complications following elective, primary TKA. These topics are important. As our healthcare system shifts to a qualitybased model, providers must accept responsibility for rates of complications, poor outcomes, and total cost per episode of care. Since TKA is one of the most commonly performed surgical procedure in the United States, it is the procedure garnering the most interest. Although the quality indicators that will be used to judge outcomes after TKA are still being developed, it is clear that complications that prolong length of stay and require readmission, reoperation, and even transfer to a rehab or skilled nursing facility, must be avoided because they add substantially to the total cost per episode of care. The quality-driven system of care forces us to evaluate candidates for elective surgery carefully and obligates us to attempt to prepare them such that all avoidable morbidity and mortality is prevented. The authors have chosen to focus on two familiar conditions: Morbid obesity (BMI > 40 kg/M) and malnutrition. Nelson and colleagues question whether these two conditions could be corrected prior to elective surgery. According to the authors, there is little likelihood that morbid obesity can be corrected in any meaningful manner and seem to favor the idea that malnutrition may be a better target for preoperative assessment. The authors have analyzed data from the National Surgical Quality Improvement Program (NSQIP) database to attempt to answer their research questions. They use the large data sample to perform a multivariate regression analysis in anattempt to definewhat the impact of these two conditions are on mortality, and major and minor complications. With respect to morbid obesity, their findings reaffirm many other studies. Morbid obesity increases the risk of both superficial and deep infection, but does not appear to increase risk of major cardiac or thromboembolic complications. On the other hand, malnutrition— defined as serum albumin < 3.5gm/dl —does appear to be associated with an increased risk of mortality and major This CORR Insights is a commentary on the article ‘‘Low Albumin Levels, More Than Morbid Obesity, Are Associated With Complications After TKA’’ by Nelson and colleagues available at: DOI: 10.1007/ s11999-015-4333-7. The author certifies that he, or a member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or the Association of Bone and Joint Surgeons. This CORR Insights comment refers to the article available at DOI: 10.1007/s11999015-4333-7. C. N. Cornell MD (&) The Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA e-mail: cornellc@hss.edu CORR Insights Published online: 5 June 2015 The Association of Bone and Joint Surgeons1 2015