Successful healing of an orthopedic incision requires coordinated inflammation, tissue proliferation, collagen synthesis, and remodeling. Patients with fractures or degenerative joint disease often face additional physiological demands from trauma, immobility, and surgery. Dietary intake, protein stores, and micronutrient availability contribute to these processes. A review of wound biology describes the distinct nutritional requirements across healing phases and the clinical importance of identifying patients at nutritional risk [1]. Consequently, assessment before surgery offers a practical opportunity to identify a potentially modifiable factor associated with postoperative recovery. Nutritional impairment is challenging to define in orthopedic practice. Body weight and body mass index alone may fail to identify reduced muscle reserve or inadequate intake. Serum albumin is widely available, but its concentration is also influenced by inflammation, liver function, and fluid balance; therefore, it is better interpreted as a prognostic marker than as a standalone diagnostic measure of malnutrition. An orthopedic review recommends integrating clinical history with nutritional measures when assessing surgical risk [2]. Nutritional and vitamin deficiencies have also been documented among patients with orthopedic trauma, demonstrating that a single laboratory measure may not capture the entire spectrum of nutritional risk [3]. Earlier clinical observations have shown variable findings. Rai and colleagues described nutritional abnormalities in patients undergoing replacement arthroplasty but reported no delayed wound healing in their small cohort [4]. In contrast, a study among older adults undergoing hip fracture surgery found that several nutritional measures were associated with delayed wound healing [5]. A systematic review of total joint arthroplasty later reported associations between preoperative malnutrition indicators and wound complications or infection, although the definitions and patient populations varied across included studies [6]. Differences in procedure type, urgency, infection-prevention practices, and postoperative surveillance may influence observed event rates. Beyond arthroplasty, the clinical significance of an abnormal nutritional assessment may depend on comorbid diabetes, open fractures, tissue injury, wound management, and access to follow-up. Studies of total knee arthroplasty have examined albumin and total lymphocyte count as predictors while questioning whether either marker alone adequately represents nutritional status [7]. This uncertainty supports careful exposure and outcome assessment, transparent reporting of denominators, and consideration of competing clinical explanations. Local evidence may help determine the feasibility of incorporating nutritional screening and structured wound follow-up into routine orthopedic care in Telangana. The objective of this study was to assess the association between preoperative nutritional status and delayed postoperative wound healing by day 30 among adults undergoing orthopedic surgery at Prathima Institute of Medical Sciences, Nagunur, Karimnagar, Telangana, India, during January to July 2026.

Study Design and Setting A prospective observational study was conducted in the orthopedic surgical services of Prathima Institute of Medical Sciences, Nagunur, Karimnagar, Telangana, India, from 1 January to 31 July 2026. The study was reported with reference to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations [8]. Study Population The study population comprised adult patients undergoing orthopedic procedures with a surgical incision and planned postoperative follow-up. The clinical spectrum included patients undergoing fracture fixation and elective orthopedic procedures. Inclusion Criteria Patients aged 18 years or older who underwent orthopedic surgery during the study period, had a documented preoperative nutritional assessment, and were available for postoperative wound evaluation were included. Exclusion Criteria Patients with pre-existing infection at the operative site, procedures without a closable surgical incision, or absence of postoperative wound assessment were excluded. Sample Size and Sampling A total of 100 eligible patients were included during the study period. Consecutive sampling was used, with eligible patients enrolled before surgery and followed according to the planned postoperative assessment schedule. Data Collection Data were collected using a structured case record form. Variables included age, sex, diabetes mellitus, open-fracture status, surgical details, preoperative nutritional status, postoperative wound findings, and relevant postoperative treatment. Patients were classified into poor or adequate nutritional-status groups based on the preoperative clinical nutritional assessment used in routine care. Outcome Measures The primary outcome was delayed wound healing by postoperative day 30. Delayed healing was defined as incomplete epithelialization of the incision, persistent wound drainage, or clinically documented wound dehiscence at follow-up. Patients without these findings were categorized as having healed wounds. Surgical site infection was considered a separate clinical outcome and was not inferred solely from wound-healing status. Statistical Analysis Categorical variables were summarized as frequencies and percentages, and age was presented as mean ± standard deviation. The association between preoperative nutritional status and delayed wound healing was examined using a 2×2 contingency table. The unadjusted risk ratio (RR) with 95% confidence interval (CI), odds ratio (OR), and absolute risk difference were calculated. Fisher’s exact two-sided test was used to compare proportions between the two nutritional groups. A P value <0.05 was considered statistically significant. Ethical Considerations Necessary institutional permissions were obtained before commencement of the study. Patient confidentiality was maintained throughout data collection and analysis, and clinical information was used only for the stated research purpose.

Baseline Characteristics A total of 100 patients undergoing orthopedic surgery were included. The mean age was 46.8 ± 15.2 years; 62 patients were male and 38 were female. Diabetes mellitus was present in 24 patients, while 20 patients underwent surgery for an open fracture (Table 1). Table 1. Demographic and clinical characteristics of the study population (N=100) Characteristic Value Age, years, mean ± SD 46.8 ± 15.2 Male 62 (62.0%) Female 38 (38.0%) Diabetes mellitus 24 (24.0%) Open fracture 20 (20.0%) SD, standard deviation. Preoperative Nutritional Status and Wound Healing Preoperative nutritional assessment classified 30 patients as having poor nutritional status and 70 as having adequate nutritional status. Overall, 19 patients experienced delayed wound healing by postoperative day 30, whereas 81 achieved satisfactory wound healing (Table 2). Table 2. Preoperative nutritional status and postoperative wound-healing outcomes (N=100) Measure n (%) Preoperative nutritional status Poor 30 (30.0%) Adequate 70 (70.0%) Postoperative wound-healing outcome Delayed healing 19 (19.0%) Healed 81 (81.0%) n, number. Association Between Nutritional Status and Delayed Wound Healing Delayed wound healing occurred in 12 of 30 patients (40.0%) with poor nutritional status compared with 7 of 70 patients (10.0%) with adequate nutritional status. The unadjusted risk ratio was 4.00 (95% CI, 1.75–9.16), indicating a fourfold higher risk of delayed healing in the poor-nutrition group. The absolute risk difference was 30.0 percentage points. Fisher’s exact test showed a statistically significant association between nutritional status and delayed wound healing (P=0.0014) (Table 3). Table 3. Association between preoperative nutritional status and wound healing Nutritional status Delayed healing, n (%) Healed, n (%) Total Poor 12 (40.0%) 18 (60.0%) 30 Adequate 7 (10.0%) 63 (90.0%) 70 Total 19 (19.0%) 81 (81.0%) 100 Effect estimates: RR=4.00 (95% CI, 1.75–9.16); OR=6.00 (95% CI, 2.06–17.48); absolute risk difference=30.0 percentage points; Fisher’s exact P=0.0014. CI, confidence interval; OR, odds ratio; RR, risk ratio.

This study identified a clear association between poor preoperative nutritional status and delayed postoperative wound healing among patients undergoing orthopedic surgery. Delayed healing occurred in 40.0% of patients with poor nutritional status compared with 10.0% of those with adequate nutritional status. The observed fourfold increase in relative risk suggests that nutritional status may be an important marker of postoperative wound recovery in orthopedic practice. The direction of this association is consistent with previously published orthopedic evidence. Bohl and colleagues reported that hypoalbuminemia was independently associated with surgical site infection, pneumonia, prolonged hospitalization, and readmission after total joint arthroplasty [9]. Roche et al. found that low albumin, prealbumin, and transferrin values were associated with wound complications following total knee arthroplasty [10]. Similarly, preoperative malnutrition was associated with infectious and wound complications after posterior lumbar spinal fusion [11]. Although these populations differ from a mixed orthopedic cohort in terms of baseline morbidity, instrumentation, wound size, and postoperative care, the findings collectively support the relevance of preoperative nutritional assessment. Several biological mechanisms may explain the observed relationship. Adequate protein intake is required for fibroblast activity, collagen synthesis, angiogenesis, and tissue remodeling. Deficiencies of micronutrients may adversely affect epithelialization, immune function, and resistance to infection. At the same time, nutritional markers such as serum albumin are influenced by inflammation, trauma, hepatic function, and fluid balance. Thus, poor nutritional status may also coexist with frailty, chronic disease, delayed presentation, or socioeconomic barriers that independently affect wound recovery. A propensity-adjusted analysis in knee arthroplasty has similarly emphasized the importance of considering correlated clinical risk factors when interpreting hypoalbuminemia [12]. Wound assessment is another important consideration. Persistent drainage, wound dehiscence, and surgical site infection may overlap clinically but represent distinct postoperative outcomes. Jaberi et al. reported that prolonged wound drainage and malnutrition adversely affected outcomes after joint arthroplasty [13]. Standardized infection-prevention measures, including appropriate perioperative antibiotic prophylaxis and wound-care protocols, also influence healing independently of nutrition [14]. Therefore, future studies should record procedure type, antibiotic timing, fracture severity, glycemic control, duration of surgery, and postoperative wound-care practices in greater detail. From a clinical perspective, preoperative nutritional screening is simple, relatively inexpensive, and potentially actionable. Identifying patients at nutritional risk may allow timely dietetic review, protein and micronutrient optimization, better control of associated comorbidities, and intensified postoperative wound surveillance. Larger prospective studies using validated nutritional instruments and multivariable analysis are needed to determine whether targeted nutritional intervention can reduce wound-healing complications and improve orthopedic outcomes. Limitations This study was conducted at a single center with a sample size of 100 patients, which may limit generalizability. Nutritional status was analyzed as a binary clinical category, and detailed anthropometric, biochemical, and dietary measures were not incorporated into the present analysis. The number of delayed-healing events was relatively small, limiting multivariable adjustment for diabetes, open fractures, procedure type, and other potential confounders. Follow-up was limited to 30 days, and longer-term wound outcomes were not assessed.

Poor preoperative nutritional status was significantly associated with delayed postoperative wound healing among patients undergoing orthopedic surgery. Delayed healing occurred in 40.0% of patients with poor nutritional status compared with 10.0% of those with adequate nutritional status, corresponding to an unadjusted risk ratio of 4.00. Incorporating nutritional assessment into preoperative orthopedic evaluation may help identify high-risk patients and support early nutritional optimization and closer postoperative wound monitoring.

1. Ghaly P, Iliopoulos J, Ahmad M. The role of nutrition in wound healing: an overview. Br J Nurs. 2021;30(5):S38-S42. doi:10.12968/bjon.2021.30.5.S38. 2. Cross MB, Yi PH, Thomas CF, Garcia J, Della Valle CJ. Evaluation of malnutrition in orthopaedic surgery. J Am Acad Orthop Surg. 2014;22(3):193-199. doi:10.5435/JAAOS-22-03-193. 3. Handcox JE, Gutierrez-Naranjo JM, Salazar LM, Bullock TS, Griffin LP, Zelle BA. Nutrition and vitamin deficiencies are common in orthopaedic trauma patients. J Clin Med. 2021;10(21):5012. doi:10.3390/jcm10215012. 4. Rai J, Gill SS, Satish Kumar BRJ. The influence of preoperative nutritional status in wound healing after replacement arthroplasty. Orthopedics. 2002;25(4):417-421. doi:10.3928/0147-7447-20020401-17. 5. Guo JJ, Yang H, Qian H, Huang L, Guo Z, Tang T. The effects of different nutritional measurements on delayed wound healing after hip fracture in the elderly. J Surg Res. 2010;159(1):503-508. doi:10.1016/j.jss.2008.09.018. 6. Gu A, Malahias MA, Strigelli V, Nocon AA, Sculco TP, Sculco PK. Preoperative malnutrition negatively correlates with postoperative wound complications and infection after total joint arthroplasty: a systematic review and meta-analysis. J Arthroplasty. 2019;34(5):1013-1024. doi:10.1016/j.arth.2019.01.005. 7. Morey VM, Song YD, Whang JS, Kang YG, Kim TK. Can serum albumin level and total lymphocyte count be surrogates for malnutrition to predict wound complications after total knee arthroplasty? J Arthroplasty. 2016;31(6):1317-1321. doi:10.1016/j.arth.2015.12.004. 8. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med. 2007;4(10):e296. doi:10.1371/journal.pmed.0040296. 9. Bohl DD, Shen MR, Kayupov E, Della Valle CJ. Hypoalbuminemia independently predicts surgical site infection, pneumonia, length of stay, and readmission after total joint arthroplasty. J Arthroplasty. 2016;31(1):15-21. doi:10.1016/j.arth.2015.08.028. 10. Roche M, Law TY, Kurowicki J, Sodhi N, Rosas S, Elson L, et al. Albumin, prealbumin, and transferrin may be predictive of wound complications following total knee arthroplasty. J Knee Surg. 2018;31(10):946-951. doi:10.1055/s-0038-1672122. 11. Bohl DD, Shen MR, Mayo BC, Massel DH, Long WW, Modi KD, et al. Malnutrition predicts infectious and wound complications following posterior lumbar spinal fusion. Spine (Phila Pa 1976). 2016;41(21):1693-1699. doi:10.1097/BRS.0000000000001591. 12. Fu MC, McLawhorn AS, Padgett DE, Cross MB. Hypoalbuminemia is a better predictor than obesity of complications after total knee arthroplasty: a propensity score-adjusted observational analysis. HSS J. 2017;13(1):66-74. doi:10.1007/s11420-016-9518-4. 13. Jaberi FM, Parvizi J, Haytmanek CT, Joshi A, Purtill J. Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty. Clin Orthop Relat Res. 2008;466(6):1368-1371. doi:10.1007/s11999-008-0214-7. 14. Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152(8):784-791. doi:10.1001/jamasurg.2017.0904.