Association of albumin, ASA class, and time with mortality, Re-admission, and Re-operation after proximal femoral fracture fixation

Background: Femoral fractures are common, high-energy injuries associated with substantial morbidity. Although surgical fixation remains the mainstay of treatment, outcomes vary widely, and predictors of adverse events are not fully defined. This study aimed to identify clinical and perioperative factors associated with 30-day mortality, readmission, and re-operation after femoral fracture fixation. Methods: We performed a retrospective cohort analysis of adult patients undergoing femoral fracture fixation between 2018 and 2022 using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Outcomes included 30-day mortality, unplanned readmission, and re-operation. Predictors assessed included demographic, clinical, and perioperative variables such as age, ASA class, albumin, operative time, comorbidities, and laboratory values. Univariate associations were examined, followed by multivariate logistic regression to identify independent predictors. Odds ratios with 95 % confidence intervals and receiver operating characteristic (ROC) curves were reported. Results: Among 63,734 patients, 9499 experienced an adverse event. Thirty-day mortality occurred in 3543 patients (5.6 %), most strongly associated with advanced age, higher ASA class, lower preoperative albumin, cancer, COPD, CHF, renal failure, and male sex. Readmission (n = 4776) was predicted by low albumin, ASA class, COPD, cancer, CHF, diabetes, steroid use, and general anesthesia. Re-operation (n = 1180) was primarily associated with hypoalbuminemia and prolonged operative time. Multivariate modeling demonstrated that preoperative albumin, ASA class, and operative duration were the most consistent predictors across outcomes. Model performance was strongest for mortality (AUC 0.77) and more modest for readmission and re-operation (AUC ∼0.61). Conclusion: This large, national study highlights preoperative albumin, ASA class, and operative duration as central markers of postoperative mortality, readmission, and re-operation after femoral fracture fixation. These findings underscore the importance of optimizing nutritional status, recognizing physiologic reserve, and streamlining perioperative processes to mitigate risk and improve outcomes.