Articles | Volume 11, issue 2
https://doi.org/10.5194/jbji-11-139-2026
© Author(s) 2026. This work is distributed under
the Creative Commons Attribution 4.0 License.
the Creative Commons Attribution 4.0 License.
https://doi.org/10.5194/jbji-11-139-2026
© Author(s) 2026. This work is distributed under
the Creative Commons Attribution 4.0 License.
the Creative Commons Attribution 4.0 License.
Malnutrition affects infection rates and quality of life in patients undergoing primary hip and knee arthroplasty: a retrospective study
Domenico De Mauro
Department of Orthopedics and Geriatrics Sciences, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
Department of Orthopedics, Ageing and Rheumatological Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
Department of Public Health, Federico II University, 80131, Naples, Italy
Chiara Comisi
Department of Orthopedics and Geriatrics Sciences, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
Department of Orthopedics, Ageing and Rheumatological Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
Valeria Maccauro
Department of Medical and Surgical Sciences, Nutritional Disorders unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
Giovanni Balato
Department of Public Health, Federico II University, 80131, Naples, Italy
Sebastian Meller
Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
Martina Di Martino
Infectious Diseases Unit, Department of Health Management, AORN Antonio Cardarelli, Naples, Italy
Fabiana Arduini
Department of Chemical Science and Technologies, University of Rome “Tor Vergata”, via della Ricerca Scientifica, 00133, Rome, Italy
Giulio Maccauro
Department of Orthopedics and Geriatrics Sciences, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
Department of Orthopedics, Ageing and Rheumatological Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
Raffaele Vitiello
CORRESPONDING AUTHOR
Department of Orthopedics and Geriatrics Sciences, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
Department of Orthopedics, Ageing and Rheumatological Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
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Alessandro Singlitico, Daniele Grassa, Rami Kaplan, Alessandro Smimmo, Giulio Maccauro, and Raffaele Vitiello
J. Bone Joint Infect., 10, 85–92, https://doi.org/10.5194/jbji-10-85-2025, https://doi.org/10.5194/jbji-10-85-2025, 2025
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In this article we discuss how gut microbiota can affect the outcomes of a total joint arthroplasty. Total joint arthroplasty is a safe procedure for improving the quality of life in patients affected by arthrosis. Periprosthetic joint infection (PJI) is relatively rare but represents one of the most common causes of implant failure requiring revision surgery. Recently, there has been a major interest in the role of gut microbiome, in particular dysbiosis, as a risk factor for PJI.
Domenico De Mauro, Cesare Meschini, Giovanni Balato, Tiziana Ascione, Enrico Festa, Davide Bizzoca, Biagio Moretti, Giulio Maccauro, and Raffaele Vitiello
J. Bone Joint Infect., 9, 137–142, https://doi.org/10.5194/jbji-9-137-2024, https://doi.org/10.5194/jbji-9-137-2024, 2024
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This study investigates sex-related differences in periprosthetic Joint Infections (PJIs) after total joint arthroplasty. A systematic review of nine studies reveals a higher risk of infectious complications in males compared to females, as indicated by statistically significant findings in half of the studies. This underscores the need for ongoing sex-related analysis to enhance evidence and insights in the field of PJIs.
Cited articles
Azzolino, D. and Lucchi, T.: Malnutrition in older adults: a wider view, Lancet, 402, 1976, https://doi.org/10.1016/S0140-6736(23)01780-4, 2023.
Bala, A., Ivanov, D. V., Huddleston, J. I., Goodman, S. B., Maloney, W. J., and Amanatullah, D. F.: The Cost of Malnutrition in Total Joint Arthroplasty, J. Arthroplasty, 35, 926–932.e1, https://doi.org/10.1016/j.arth.2019.11.018, 2020.
Balato, G., Barbaric, K., Bićanić, G., Bini, S., Chen, J., Crnogaca, K., Kenanidis, E., Giori, N., Goel, R., Hirschmann, M., Marcacci, M., Amat Mateu, C., Nam, D., Shao, H., Shen, B., Tarabichi, M., Tarabichi, S., Tsiridis, E., and Tzavellas, A.-N.: Hip and Knee Section, Prevention, Surgical Technique: Proceedings of International Consensus on Orthopedic Infections, J. Arthroplasty, 34, S301–S307, https://doi.org/10.1016/j.arth.2018.09.015, 2019.
Blevins, K., Aalirezaie, A., Shohat, N., and Parvizi, J.: Malnutrition and the Development of Periprosthetic Joint Infection in Patients Undergoing Primary Elective Total Joint Arthroplasty, J. Arthroplasty, 33, 2971–2975, https://doi.org/10.1016/j.arth.2018.04.027, 2018.
Bohl, D. D., Shen, M. R., Kayupov, E., and Valle, C. J. D.: Hypoalbuminemia Independently Predicts Surgical Site Infection, Pneumonia, Length of Stay, and Readmission After Total Joint Arthroplasty, The Journal of Arthroplasty, 31, 15–21, https://doi.org/10.1016/j.arth.2015.08.028, 2016.
Bruun, L. I., Bosaeus, I., Bergstad, I., and Nygaard, K.: Prevalence of malnutrition in surgical patients: evaluation of nutritional support and documentation, Clin. Nutr., 18, 141–147, https://doi.org/10.1016/s0261-5614(99)80003-x, 1999.
Cederholm, T., Jensen, G. L., Correia, M. I. T. D., Gonzalez, M. C., Fukushima, R., Higashiguchi, T., Baptista, G., Barazzoni, R., Blaauw, R., Coats, A., Crivelli, A., Evans, D. C., Gramlich, L., Fuchs-Tarlovsky, V., Keller, H., Llido, L., Malone, A., Mogensen, K. M., Morley, J. E., Muscaritoli, M., Nyulasi, I., Pirlich, M., Pisprasert, V., Schueren, M. A. E. de van der, Siltharm, S., Singer, P., Tappenden, K., Velasco, N., Waitzberg, D., Yamwong, P., Yu, J., Gossum, A. V., Compher, C., Jensen, G. L., Charlene, C., Cederholm, T., Gossum, A. V., Correia, M. I. T. D., Gonzalez, M. C., Fukushima, R., Higashiguchi, T., Baptista, G., Barazzoni, R., Blaauw, R., Coats, A., Crivelli, A., Evans, D. C., Gramlich, L., Fuchs, V., Keller, H., Llido, L., Malone, A., Mogensen, K. M., Morley, J. E., Muscaritoli, M., Nyulasi, I., Pirlich, M., Pisprasert, V., Schueren, M. A. E. de van der, Siltharm, S., Singer, P., Tappenden, K., Velasco, N., Waitzberg, D., Yamwong, P., and Yu, J.: GLIM criteria for the diagnosis of malnutrition – A consensus report from the global clinical nutrition community, Clinical Nutrition, 38, 1–9, https://doi.org/10.1016/j.clnu.2018.08.002, 2019.
De Mauro, D., Rovere, G., Are, L., Smakaj, A., Aprato, A., Mezzadri, U., Bove, F., Casiraghi, A., Marino, S., Ciolli, G., Cerciello, S., Maccagnano, G., Noia, G., Massè, A., Maccauro, G., and Liuzza, F.: Spring Plates as a Valid Additional Fixation in Comminuted Posterior Wall Acetabular Fractures: A Retrospective Multicenter Study, J. Clin. Med., 12, 576, https://doi.org/10.3390/jcm12020576, 2023.
De Mauro, D., Balato, G., Festa, E., Di Cristo, A., Marasco, L., Loffredo, G., Di Lauro, P., Di Gennaro, D., Maccauro, G., and Rosa, D.: Role of bariatric surgery in reducing periprosthetic joint infections in total knee arthroplasty. A systematic review and meta-analysis, BMC Musculoskelet Disord, 25, 248, https://doi.org/10.1186/s12891-024-07288-2, 2024a.
De Mauro, D., Meschini, C., Balato, G., Ascione, T., Festa, E., Bizzoca, D., Moretti, B., Maccauro, G., and Vitiello, R.: Sex-related differences in periprosthetic joint infection research, J. Bone Joint Infect., 9, 137–142, https://doi.org/10.5194/jbji-9-137-2024, 2024b.
De Mauro, D., Comisi, C., Festa, E., Ascione, T., Mariconda, M., and Balato, G.: Total knee arthroplasty following previous hardware implantation: do hardware removal strategies influence periprosthetic joint infections? A systematic review and meta-analysis, EFORT Open Rev., 10, 95–103, https://doi.org/10.1530/EOR-24-0100, 2025.
Ellsworth, B. and Kamath, A. F.: Malnutrition and Total Joint Arthroplasty, J. Nat. Sci., 2, e179, https://doi.org/10.1530/EOR-23-0192, 2016.
Eminovic, S., Vincze, G., Eglseer, D., Riedl, R., Sadoghi, P., Leithner, A., and Bernhardt, G. A.: Malnutrition as predictor of poor outcome after total hip arthroplasty, International Orthopaedics, 45, 51, https://doi.org/10.1007/s00264-020-04892-4, 2021.
Festa, E., Ascione, T., De Mauro, D., Di Gennaro, D., Baldini, A., and Balato, G.: Can a 1.5-Stage Revision be an Effective Alternative for Chronic Periprosthetic Hip and Knee Infections? A Systematic Review and Meta-Analysis, J. Arthroplasty, S0883-5403(24)00962–8, https://doi.org/10.1016/j.arth.2024.09.024, 2024a.
Festa, E., Ascione, T., Di Gennaro, D., De Mauro, D., Mariconda, M., and Balato, G.: Synovial calprotectin in prosthetic joint infection. A systematic review and meta-analysis of the literature, Arch. Orthop. Trauma Surg., https://doi.org/10.1007/s00402-024-05416-0, 2024b.
Fu, M. C., D'Ambrosia, C., McLawhorn, A. S., Schairer, W. W., Padgett, D. E., and Cross, M. B.: Malnutrition Increases With Obesity and Is a Stronger Independent Risk Factor for Postoperative Complications: A Propensity-Adjusted Analysis of Total Hip Arthroplasty Patients, J. Arthroplasty, 31, 2415–2421, https://doi.org/10.1016/j.arth.2016.04.032, 2016.
Fu, M. C., McLawhorn, A. S., Padgett, D. E., and Cross, M. B.: Hypoalbuminemia Is a Better Predictor than Obesity of Complications After Total Knee Arthroplasty: a Propensity Score-Adjusted Observational Analysis, HSS Journal, 13, 66, https://doi.org/10.1007/s11420-016-9518-4, 2017.
Giesinger, J. M., Hamilton, D. F., Jost, B., Behrend, H., and Giesinger, K.: WOMAC, EQ-5D and Knee Society Score Thresholds for Treatment Success After Total Knee Arthroplasty, The Journal of Arthroplasty, 30, 2154–2158, https://doi.org/10.1016/j.arth.2015.06.012, 2015.
Golladay, G. J., Satpathy, J., and Jiranek, W. A.: Patient Optimization-Strategies That Work: Malnutrition, J. Arthroplasty, 31, 1631–1634, https://doi.org/10.1016/j.arth.2016.03.027, 2016.
Gu, A., Malahias, M.-A., Strigelli, V., Nocon, A. A., Sculco, T. P., and Sculco, P. K.: Preoperative Malnutrition Negatively Correlates With Postoperative Wound Complications and Infection After Total Joint Arthroplasty: A Systematic Review and Meta-Analysis, J. Arthroplasty, 34, 1013–1024, https://doi.org/10.1016/j.arth.2019.01.005, 2019.
Hersberger, L., Bargetzi, L., Bargetzi, A., Tribolet, P., Fehr, R., Baechli, V., Geiser, M., Deiss, M., Gomes, F., Kutz, A., Kägi-Braun, N., Hoess, C., Pavlicek, V., Schmid, S., Bilz, S., Sigrist, S., Brändle, M., Benz, C., Henzen, C., Nigg, M., Thomann, R., Brand, C., Rutishauser, J., Aujesky, D., Rodondi, N., Donzé, J., Stanga, Z., Mueller, B., and Schuetz, P.: Nutritional risk screening (NRS 2002) is a strong and modifiable predictor risk score for short-term and long-term clinical outcomes: secondary analysis of a prospective randomised trial, Clinical Nutrition, 39, 2720–2729, https://doi.org/10.1016/j.clnu.2019.11.041, 2020.
Hiesmayr, M., Schindler, K., Pernicka, E., Schuh, C., Schoeniger-Hekele, A., Bauer, P., Laviano, A., Lovell, A. D., Mouhieddine, M., Schuetz, T., Schneider, S. M., Singer, P., Pichard, C., Howard, P., Jonkers, C., Grecu, I., Ljungqvist, O., and NutritionDay Audit Team: Decreased food intake is a risk factor for mortality in hospitalised patients: the NutritionDay survey 2006, Clin. Nutr., 28, 484–491, https://doi.org/10.1016/j.clnu.2009.05.013, 2009.
Hill, G. L., Blackett, R. L., Pickford, I., Burkinshaw, L., Young, G. A., Warren, J. V., Schorah, C. J., and Morgan, D. B.: Malnutrition in surgical patients. An unrecognised problem, Lancet, 1, 689–692, https://doi.org/10.1016/s0140-6736(77)92127-4, 1977.
Ignacio de Ulíbarri, J., González-Madroño, A., de Villar, N. G. P., González, P., González, B., Mancha, A., Rodríguez, F., and Fernández, G.: CONUT: a tool for controlling nutritional status. First validation in a hospital population, Nutr. Hosp., 20, 38–45, 2005.
Ihle, C., Weiß, C., Blumenstock, G., Stöckle, U., Ochs, B. G., Bahrs, C., Nüssler, A., and Schreiner, A. J.: Interview based malnutrition assessment can predict adverse events within 6 months after primary and revision arthroplasty – a prospective observational study of 351 patients, BMC Musculoskelet. Disord., 19, 83, https://doi.org/10.1186/s12891-018-2004-z, 2018.
Jin, M., Zhu, S., and Hou, Y.: Insight on Serum Albumin: From Structure and Biological Properties to Functional Biomaterials for Bone Repair, ACS Biomater. Sci. Eng., 9, 2235–2250, https://doi.org/10.1021/acsbiomaterials.2c01553, 2023.
Khalatbari-Soltani, S. and Marques-Vidal, P.: The economic cost of hospital malnutrition in Europe; a narrative review, Clin. Nutr. ESPEN, 10, e89–e94, https://doi.org/10.1016/j.clnesp.2015.04.003, 2015.
Kondrup, J., Allison, S. P., Elia, M., Vellas, B., Plauth, M., and Educational and Clinical Practice Committee, European Society of Parenteral and Enteral Nutrition (ESPEN): ESPEN guidelines for nutrition screening 2002, Clin. Nutr., 22, 415–421, https://doi.org/10.1016/s0261-5614(03)00098-0, 2003.
Nwachukwu, B. U., McCormick, F., Provencher, M. T., Roche, M., and Rubash, H. E.: A comprehensive analysis of Medicare trends in utilization and hospital economics for total knee and hip arthroplasty from 2005 to 2011, J. Arthroplasty, 30, 15–18, https://doi.org/10.1016/j.arth.2014.08.025, 2015.
Pes, M., Pulino, A., Pisanu, F., and Manunta, A. F.: Why malnutrition in orthopaedic elective patient is still an issue? A recent review of the literature, European Journal of Orthopaedic Surgery & Traumatology, 33, 3723, https://doi.org/10.1007/s00590-023-03593-z, 2023.
Roche, M., Law, T. Y., Kurowicki, J., Sodhi, N., Rosas, S., Elson, L., Summers, S., Sabeh, K., and Mont, M. A.: Albumin, Prealbumin, and Transferrin May Be Predictive of Wound Complications following Total Knee Arthroplasty, J. Knee Surg., 31, 946–951, https://doi.org/10.1055/s-0038-1672122, 2018.
Rudasill, S. E., Ng, A., and Kamath, A. F.: Preoperative Serum Albumin Levels Predict Treatment Cost in Total Hip and Knee Arthroplasty, Clin. Orthop. Surg., 10, 398–406, https://doi.org/10.4055/cios.2018.10.4.398, 2018.
Schroer, W. C., LeMarr, A. R., Mills, K., Childress, A. L., Morton, D. J., and Reedy, M. E.: 2019 Chitranjan S. Ranawat Award: Elective joint arthroplasty outcomes improve in malnourished patients with nutritional intervention: a prospective population analysis demonstrates a modifiable risk factor, Bone Joint J., 101-B, 17–21, https://doi.org/10.1302/0301-620X.101B7.BJJ-2018-1510.R1, 2019.
von Elm, E., Altman, D. G., Egger, M., Pocock, S. J., Gøtzsche, P. C., Vandenbroucke, J. P., and STROBE Initiative: The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies, Lancet, 370, 1453–1457, https://doi.org/10.1016/S0140-6736(07)61602-X, 2007.
Walls, J. D., Abraham, D., Nelson, C. L., Kamath, A. F., Elkassabany, N. M., and Liu, J.: Hypoalbuminemia More Than Morbid Obesity is an Independent Predictor of Complications After Total Hip Arthroplasty, The Journal of Arthroplasty, 30, 2290–2295, https://doi.org/10.1016/j.arth.2015.06.003, 2015.
Wilson, J. M., Schwartz, A. M., Farley, K. X., Bradbury, T. L., and Guild, G. N.: Combined Malnutrition and Frailty Significantly Increases Complications and Mortality in Patients Undergoing Elective Total Hip Arthroplasty, J. Arthroplasty, 35, 2488–2494, https://doi.org/10.1016/j.arth.2020.04.028, 2020.
Yi, P. H., Frank, R. M., Vann, E., Sonn, K. A., Moric, M., and Della Valle, C. J.: Is potential malnutrition associated with septic failure and acute infection after revision total joint arthroplasty?, Clin. Orthop. Relat. Res., 473, 175–182, https://doi.org/10.1007/s11999-014-3685-8, 2015.
Short summary
This retrospective study analyzed 682 patients who underwent primary total hip or knee arthroplasty to evaluate the impact of malnutrition on post-operative outcomes. Malnutrition, as defined by the Nutritional Risk Screening 2002 (NRS-2002) and controlling nutritional status (CONUT) scores, was significantly associated with higher rates of post-operative infection and poorer quality-of-life scores. Early nutritional assessment may improve post-operative recovery and reduce complication rates.
This retrospective study analyzed 682 patients who underwent primary total hip or knee...