Ageing is a persistent, irreversible, and inevitable process of transformations from birth to senescence. Today, 13% of the world population is old, and it is increasing by approximately 3% every year and will double by 2050. India's elderly population has also grown significantly, from 77 million in 2001 to 104 million in 2011, and will triple by 2050. Population ageing is accompanied by health and welfare problems, and undernutrition is a serious problem. Older patients are commonly subjected to surgical interventions, and these require higher nutritional needs, and therefore malnutrition is an essential issue [1, 5].

Malnutrition results from imbalances in nutrient intake, either deficiencies or excesses. Malnutrition manifests as undernutrition, leading to weight loss and micronutrient deficiency, or overnutrition, leading to obesity and related diseases. Malnutrition is characterized by the World Health Organization (WHO) as deficiencies, excesses, or imbalances in energy and nutrient intake, affecting general health. Ageing affects nutrient requirements, and the majority of older individuals do not have sufficient protein, vitamins, and essential minerals. Evidence shows that malnutrition is linked with higher mortality, longer hospital stay, higher risk of infection, impaired wound healing, and higher healthcare costs. Malnourished patients experience muscle weakness, falls, fractures, and longer recovery, which enhances dependence on daily living and institutional care [2].

The relation between nutrition and wound healing has been well-studied, and studies have indicated that well-nourished patients heal faster than patients with malnutrition. Carbohydrates, lipids, and proteins are necessary for tissue repair, and amino acids glutamine and arginine have an essential function in collagen production and immunity. Vitamins A, C, and K support healing and immunity, and minerals iron and zinc enable the transportation of oxygen and DNA production. Malnutrition impedes the body's recovery after surgery and increases postoperative complications. Nutrition develops the immune system and boosts the body's resistance to infection [3].

Nutritional status can be assessed by anthropometric indices, biochemical markers, clinical evaluation, and functional status. Anthropometric indices like triceps skinfold thickness (TSF), mid-upper arm circumference (MUAC), and body mass index (BMI) are body composition indices, whereas biochemical markers like haemoglobin, serum albumin, and total lymphocyte counts (TLC) are markers of nutrient stores and immune status. Hypoalbuminemia, a common condition among malnourished patients, is related to increased postoperative morbidity and mortality. Anaemia, another important parameter, worsens tissue oxygenation, prolongs the recovery period, and carries infection risk. Early identification and treatment of anaemia by nutritional intervention or medical therapy could improve surgical recovery.

Osteoporosis, a disorder of reduced bone mineral density, has a close association with malnutrition. Lack of calcium and vitamin D leads to bone weakening and enhances fracture risks. Micronutrients such as magnesium, phosphorus, and vitamin K are important in bone metabolism. Nutrition for the prevention of osteoporosis and the prevention of fracture risks implies the significance of proper intake of diet for maintaining bone health. Physical, psychological, and social changes with age also increase the risk of malnutrition [4].

Hip fractures in the elderly are on the rise, leading to increased mortality, disability, and dependence. Postoperative recovery would typically be hindered by metabolic changes that occur due to trauma and surgery collectively known as Acute Phase Reactants (APR). These changes create increased nutrient requirements, prolonged catabolism, and loss of muscle mass, which compromise recovery. Malnutrition exacerbates these effects, leading to poor functional outcomes. Evidence indicates that 25% to 60% of the elderly patients do not recover to pre-fracture functional status within a year. Prevention of malnutrition before surgery using nutritional supplementation can enhance recovery, reduce complications, and overall outcomes.

Organizational guidelines such as those of the European Society for Clinical Nutrition and Metabolism (ESPEN) highlight the pivotal position of enteral nutrition in enhancing surgical outcome. Malnutrition, nevertheless, is a prevalent condition among elderly inpatients, and it can lead to adverse post-surgical recovery. Preoperative nutritional supplementation has been demonstrated to decrease complications and enhance functional recovery. Furthermore, comorbid conditions of diabetes, cardiovascular disease, and cognitive impairment complicate nutritional care, further impeding recovery. Adequate preoperative evaluation needs to be done to maximize nutritional status and enhance the surgical outcome in hip-fracture elderly patients. Evidence has revealed that early nutritional support has a positive effect on recovery following hip fracture surgery. The research indicates the benefits of nutritional support in preventing complications and attaining faster rehabilitation. Understanding the perioperative role of nutrition assists clinicians in preventing and managing complications in the optimal manner and enhancing patient outcomes. Treatment of malnutrition through multidisciplinary approaches could enhance surgical outcomes, reduce the cost of care, and enhance the quality of life in hip fracture surgery in elderly patients.

Study Design and Setting

This hospital-based prospective observational study was performed in the Department of Orthopaedics, Assam Medical College & Hospital, Dibrugarh. The study was carried out for one year, from March 1, 2023, to February 29, 2024, on the surgical outcome of geriatric hip fracture patients according to nutritional status.

Study Population and Sample Selection

The study population included elderly patients aged 60 years and above who were admitted to the Orthopaedics department for hip fracture surgery. Patients who were managed conservatively, had polytrauma or multiple fractures, presented with pathological fractures, had terminal illnesses with a life expectancy of less than six months, or were mentally incapable of understanding and consenting to the study were excluded. A total of 70 participants were selected using a consecutive sampling method. The sample size was determined considering a 60% prevalence of undernutrition among geriatric hip fracture patients, with a relative precision of 20% and a 95% confidence interval.

Ethical Issues

Ethical permission was sought from the Institutional Ethics Committee (H) of Assam Medical College prior to the initiation of the study. Informed written consent was obtained from all the participants prior to their recruitment. The Indian Council of Medical Research (ICMR) had developed the consent form in 2017 and the same was communicated to all the participants in their local language so that they were well informed.

Data Collection and Research Tools

All patients were also given a thorough assessment on admission, such as socio demographic profiling, medical history assessment, and thorough nutritional assessment. Sociodemographic details were documented on a proforma tool created by the Department of Orthopaedics. This included identification details of the patient, socioeconomic status according to the Modified Kuppuswamy Scale (2023), and relevant medical history.

Nutritional assessment involves anthropometric measurements, biochemical examination, and the Mini Nutritional Assessment (MNA) questionnaire. Anthropometric parameters were BMI, mid-upper arm circumference (MUAC), and triceps skinfold thickness (TSF) and were measured by standard procedure. BMI based on weight and height was calculated and values below 19.99 were taken as undernourished. MUAC below 23 cm and TSF below 12 mm were also indicative of malnutrition.

Biochemical indices like hemoglobin, TLC, serum albumin, and serum transferrin were determined by ELISA or spectrophotometric assays. Hemoglobin level was graded to quantify the severity of anemia. TLC was employed as a marker of immune status, and serum albumin and transferrin levels were determined as markers of protein-energy malnutrition.

Surgical Treatment and Postoperative Evaluation

After preoperative assessment, all the patients underwent surgery for hip fracture. Hospital stay was noted and postoperative wound status was followed closely. Wound infections were classified as superficial or deep. Superficial infections were treated with dressing and antibiotics, but deep infections needed surgical debridement and long-term antibiotic therapy.

Functional outcomes were recorded with the Harris Hip Score (HHS) on discharge, at six weeks, and at twelve weeks post-operatively. The HHS recorded a number of parameters, including pain, motion, ability to perform activities of daily living, and joint function, in order to measure general functional recovery. Radiographs at follow-up were also taken to determine fracture healing and detect any complications.

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using Statistical Package for Social Sciences (SPSS) software. Continuous data were expressed as mean ± standard deviation, while categorical data were expressed as frequency and percentage. Statistical significance was assessed using the Student's t-test and Chi-square test, where a p-value of < 0.05 was deemed significant. The final analysis examined the correlation between preoperative nutritional status and postoperative outcomes such as length of hospital stay, surgical site infection rate, fracture healing, and functional recovery.

Demographic and Clinical Profile

The study included 70 geriatric patients (mean age: 68.73 ± 8.26 years), predominantly aged 60–74 years (68.57%). Males constituted a slight majority (55.71%), and 74.29% sustained injuries from slips/falls. Most fractures involved the neck of the femur (50%) or trochanteric regions (44.29%). Socioeconomic disparities were evident, with 55.71% belonging to the lower class.

Nutritional Status and Biochemical Markers

Using the Mini Nutritional Assessment (MNA), 41.43% were malnourished, 27.14% at risk, and 31.43% well-nourished (Table 1). Malnutrition correlated strongly with anaemia, hypoalbuminemia, and low transferrin levels (Table 2).

Table 1: Nutritional Status (MNA Score)

Table 2: Association of Nutritional Status with Key Variables

Surgical Outcomes

Malnourished patients had longer stays in the hospital (>14 days: 51.72%), increased wound infection (51.72%), and poor functional outcomes (Table 3). 86.36% of well-nourished patients had excellent Harris Hip Scores (HHS) at 12 weeks compared with 0% of malnourished patients (Table 3).

Table 3: Association of Nutritional Status with Surgical Outcomes

Graphical Representations

Figure 1: Bar graph showing the distribution of nutritional status (MNA categories).

Figure 2: Line graph comparing HHS trends at 6 and 12 weeks across nutritional groups.

Figure 3: Pie chart illustrating socioeconomic class distribution.

Malnutrition in 41.43% of geriatric patients with hip fracture was closely related to negative surgical outcomes such as prolonged stay, wound complication, and late functional recovery. Hypoalbuminemia, anaemia, and low socio-economic status proved to be vital risk factors. Pre-emptive nutritional therapy would prevent such risks and favor surgical outcomes.

The findings of this study highlight the significant role of nutritional status in determining the surgical outcomes of elderly patients with hip fractures. Malnutrition is highly prevalent in this vulnerable population and has a direct impact on postoperative recovery, wound healing, and overall functional outcomes. Adequate nutritional support is crucial for minimizing complications, reducing hospital stays, and enhancing the rehabilitation process.

The sociodemographic profile of the study population was crucial in identifying the impact of different factors on nutritional status and postoperative outcomes. Increasing age was a key factor influencing wound healing and functional recovery. Physiological changes due to increasing age, such as decreased appetite, impaired nutrient utilization, and diminishing muscle mass, lead to malnutrition and contribute to frailty. Such findings have been made by Sinha et al. [5], who discovered that age was a significant risk factor for malnutrition in geriatric inpatients independent of other factors. But the study failed to find any significant correlation between gender or socioeconomic status and nutritional status, possibly due to the small sample size or other confounding variables.

The incidence of malnutrition among the participants in the study was high, with 41.43% classified as malnourished and 27.14% at risk of malnutrition based on the Mini Nutritional Assessment (MNA). This is consistent with other research, for example, conducted by Kaiser et al. [20], which discovered that around two-thirds of hospitalized older patients were at nutritional risk or malnourished. Foo et al. [19] also cited malnutrition rates ranging from 4.0% to 39.4%, highlighting the prevalence of undernutrition in elderly patients who are undergoing hip fracture surgery. Malnutrition's impact was seen in this study, as almost half of the patients had poor functional outcomes at the six-week follow-up, similar to other studies utilizing the Harris Hip Score (HHS).

Biochemical markers also supported the correlation of malnutrition with unfavorable surgical outcomes. Hypoalbuminemia was detected in 35.7% of the subjects, and these patients were at increased risk for postoperative complications, such as higher mortality and reoperation rates. Albumin is an established nutritional marker and is integral to wound healing, according to Cabrerizo et al. [18] Comparisons to previous research show differing prevalence rates of hypoalbuminemia, with Koval et al. [17] reporting 18%, Newman et al. [16] reporting 34%, and Bohl et al. [15] reporting 45.9% in larger patient samples. Anemia was also a significant predictor of negative surgical outcomes in this study. Around one-third of participants were anemic, and this was associated with greater wound healing complications and prolonged perioperative blood transfusions. These results are corroborated by Haddad et al. [14], who found anemia to be a significant predictor of increased mortality in hip fracture patients.

Upon further analysis, malnutrition was found to have a significant relationship with low levels of serum transferrin and reduced total lymphocyte counts. Benjamin and Assounga have previously shown that reduced levels of transferrin are highly related to malnutrition, a finding replicated in this study, wherein malnourished patients had significantly reduced transferrin levels. In the same way, Rocha et al. [13] found that decreased total lymphocyte count was predictive of greater postoperative complications, further validating the role of immune function as a predictor of nutrients. These biochemical markers together offer a rich picture of the systemic influence of malnutrition on postoperative recovery and infection risk.

The presence of comorbidities, especially diabetes mellitus, also affected surgical outcomes. 10.67% of patients in this study had diabetes, and these patients had increased rates of wound infection and worse functional recovery. The effect of diabetes on the outcome of surgery has been well described, with Lieberman et al. [12] finding decreased rehabilitation effectiveness in diabetic patients and Okonkwo et al. [11] describing the molecular mechanisms by which diabetes undermines wound healing. The augmented risk of infections in diabetic patients is due to impaired immunity and impaired angiogenesis, which slow tissue repair and enhance postoperative complications.

The duration of hospital stay was also a significant predictor associated with nutritional status and outcomes of recovery. In the current study, roughly one-third of the patients had a hospital stay of longer than 14 days, and those patients had poorer functional outcomes. Hospital stay duration is usually an indirect measure of illness severity and the general health status of the patient. Ek et al. [10] reported that the average hospital stay for hip fracture patients was 11.2 ± 5.9 days, with longer hospital stays linked to increased mortality. These results indicate that optimizing nutritional care and comorbidity management may help decrease hospital stays and enhance overall recovery rates.

Wound healing results were significantly poorer in malnourished patients and those at risk for malnutrition. Wound infections, in the current study, were much more common in undernourished patients (51.72%) and at-risk patients (73.68%), highlighting the importance of adequate nutrition to anesthetize the patient. Seth et al. [9] have earlier shown that preoperative nutritional supplementation was correlated with reduced hospital stay and fewer complications, whereas malnutrition resulted in more infections and delayed wound healing. Malnutrition impairs the immune response, retards collagen synthesis, and reduces tissue integrity, all of which result in an increased risk of wound complications.

Malnutrition also negatively impacted fracture healing, with 40% of patients showing poor callus formation at the six-week follow-up. Moreover, two screw back outs were observed at 12 weeks, further underlining the effects of nutritional deficiency on bone healing. Malnutrition has a strong correlation with osteoporosis, which makes patients prone to defective fracture union and higher hardware failure risk. Karpouzous et al. [8] highlighted the necessity of proper intake of key vitamins, including A and D, and minerals such as calcium for optimal bone health and fracture healing. The study's results reiterate the necessity of early nutritional interventions to promote bone regeneration and minimize the risk of implant-related complications.

Functional results were measured with the Harris Hip Score, and the results showed a distinct correlation between malnutrition and delayed postoperative recovery. Six weeks later, 89.66% of the malnourished patients showed poor functional results, and at 12 weeks, 41.38% were still in the poor category. These results confirm a recent study by Lan et al. [7], where significantly improved functional recovery was obtained in the well-nourished group as opposed to the malnourished group. The findings emphasize the significance of proper nutrition to ensure optimal post-fracture rehabilitation and overall mobility.

In spite of the valuable information derived from this research, some limitations need to be recognized. The comparably brief 90-day follow-up duration can not always catch up with the long-term influence of malnutrition on functional outcome. Peeters et al. [6] stated that patients who have fractures of the hip tend to exhibit improvement during the initial six months following surgery but can lose mobility and independence as found after more extended follow-ups. Moreover, being an observational study, the study is prone to various biases and confounders that may affect the results. Selection bias could also restrict the external validity of the findings to other populations, and the sample size could have undermined the statistical power to capture significant associations with some variables.

More randomized controlled trials are required to further strengthen the evidence for the connection between nutrition and surgical outcomes. Future studies should investigate the advantages of targeted nutritional supplementation in older hip fracture patients to assess whether enhanced preoperative and postoperative nutrition can safely reduce wound complications, improve functional recovery, and decrease hospital length of stay. Modifying malnutrition as a modifiable risk factor may be instrumental in enhancing outcomes for this vulnerable patient group.

The results of this research highlight the pivotal importance of nutritional status in predicting surgical outcome and recovery in elderly hip fracture patients. A high percentage of this group is either malnourished or at risk, as indicated by both the Mini Nutritional Assessment (MNA) and Body Mass Index (BMI) tests. Malnutrition was found to be highly related to extended length of hospital stays, more postoperative complications, wound healing difficulty, fracture delayed union, and poorer functional outcome. Biochemical markers like albumin, haemoglobin, transferrin, and total lymphocyte counts were major nutritional indicators and had strong correlations with surgical outcomes. Moreover, existing conditions such as diabetes added extra complication burden, and hence emphasis is laid on perioperative planning. The research underscores the importance of preoperative nutritional evaluations and prompt intervention to maximize healing, lower the healthcare burden, and enhance overall quality of life in elderly patients with hip fracture. Correction of nutritional deficiencies, in addition to medical and surgical treatment, needs to be the focus of geriatric fracture management to maximize recovery of function and reduce poor outcomes. Longer follow-up studies and randomized controlled trials are required in the future to make more definitive recommendations regarding nutritional supplementation and long-term outcomes in this high-risk group.

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