Malnutrition is linked to worse postoperative outcomes, while perioperative supplementation with amino acids and micronutrients can improve recovery and reduce complications

by | Sep 12, 2024 | Blog

Tedesco A, Sharma AK, Acharya N, et al. The Role of Perioperative Nutritional Status and Supplementation in Orthopaedic Surgery: A Review of Postoperative Outcomes. JBJS Rev. 2024;12(4). doi:10.2106/JBJS.RVW.23.00242

Abstracted by:

Lindsy Moore, PT, DPT, OCS, COMT Soldotna, Alaska – Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, Fellowship Director, IAOM-US Fellowship program.

 Research: The article focuses on the impact of perioperative nutritional status and supplementation on postoperative outcomes in orthopedic surgery. The aim of the study is to provide an overview of the current literature in each orthopedic subspecialty and provide optimization recommendations based on those studies.

Methods: Preoperative Screening: Routine identification of at-risk patients through detailed history, physical examination, and nutritional screening. Serologic Markers: Use of serum albumin, transferrin, and complete blood count (CBC) with total lymphocyte count (TLC) to assess nutritional status. Anthropometric Measures: Measurements of height, weight, BMI, circumference, and skinfold thickness to evaluate body size and composition. Screening Tools: Utilization of standardized tools like the Mini-Nutritional Assessment Short Form (MNA-SF) and the Perioperative Nutrition Screen (PONS) to quantitatively assess nutritional status.

Results: Routine screening for malnutrition should be part of the preoperative evaluation for all patients. Malnutrition is linked to worse postoperative outcomes, including increased hospital stay, sepsis, and mortality. Perioperative supplementation with amino acids and micronutrients can improve recovery and reduce complications. Various tools, such as the Mini-Nutritional Assessment Short Form (MNA-SF) and Perioperative Nutrition Screen (PONS), are effective in assessing nutritional status.

Conclusion: The hypermetabolic-catabolic state induced by injury and surgery can lead to acquired malnutrition during the postoperative period or worsen existing nutritional deficiencies. To identify at-risk patients, a detailed history, physical examination, serologic and anthropomorphic studies, and nutritional screening tools are necessary. Preoperative optimization is crucial when feasible, and postoperative monitoring for malnutrition development is essential for at-risk patients.

IAOM-US Comments:

Physical therapists should be aware of the importance of identifying malnourished patients, as malnutrition can significantly impact recovery and rehabilitation outcomes. Incorporating nutritional optimization strategies, such as amino acid and micronutrient supplementation, can enhance recovery in an improved postoperative outcome. Effective post-surgical care requires collaboration between physical therapists, dietitians, and other health care providers to address nutritional needs and optimize patient recovery. Utilizing screening tools to assess nutritional status can help therapists identify at risk patients and tailor rehabilitation plans accordingly.

The prevalence of malnutrition in patients undergoing orthopedic surgeries has been identified as 50% to 60% of hospitalized patients.1 Malnutrition is reversible and when addressed can help decrease risk with perioperative interventions.1 Any patient, including healthy can become malnourished throughout the postoperative course because of the hypermetabolic-catabolic state, which is induced by injury and surgery. 1 There is a surge in oxidative stress and inflammation, increased metabolic demands to facilitate tissue repair, and a balance of protein synthesis and catabolism to maintain gluconeogenesis.2 When metabolic reserves are depleted excessively there is impaired immunity, disputed healing, increased hospital length of stay, sepsis, mortality.3,4 During the perioperative period 50-90% orthopedic patients reported suboptimal intake of oral nutrients.5  Vitamin D levels <20 ng/ml should also be considered as low vitamin D levels have been associated with increased risk of surgical infection and poor surgical outcomes in a range of surgical patients.6

Cutoff values to determine malnutrition: Serum Albumin: <3.5 mg/dL, Transferrin: <200 mg/dL, Total Lymphocyte Count (TLC): <1,500 cells/mm3, Prealbumin <10-15 mg/dL, Hemoglobin <13 g/dL.7

 Impact of Malnutrition on Orthopedic Surgery

Trauma:  Trauma patients have 20% to 50% higher energy expenditure compared to elective surgical patients, leading to rapid nutritional deterioration up to 1.7-fold.1 Up to 40% of hospitalized hip fracture patients are malnourished, which negatively impacts recovery.1 Studies show that essential amino acid supplementation can decrease complications, preserve muscle mass, and improve recovery rates.1 High-protein, high-calorie supplements have been associated with better markers of sarcopenia and functional status.1

Arthroplasty: The number of knee and hip replacements is growing annually, with over 2.4 million joint replacements performed between 2012 and 2020.1 Hypoalbuminemia is a risk factor for postoperative complications such as surgical site infection and delayed wound healing.4 Malnutrition in arthroplasty patients ranges from 8.5% to 50%, affecting outcomes.1 Perioperative supplementation with essential amino acids, hydroxy-beta-methylbutyrate (HMB), arginine, omega-3 fatty acids, and glutamine can reduce muscle atrophy, pain, recovery time and infection complications.8 Routine preoperative nutrition screening and optimization can significantly reduce complications and improve surgical outcomes.1

Sports: Tendon and ligamentous injuries account for about 44% of musculoskeletal complaints and are slow to heal due to low blood supply and relative hypocellularity.1 Adequate nutritional intake can modulate tenocyte metabolism and facilitate healing.1 Tendinopathy noted to be 30-50% of all sports injuries and is partly rooted in lifestyle choices, including diet and nutrition.9 Nutritional supplementation facilitates tendon healing through two main mechanisms: supporting collagen, proteoglycan and glycosaminoglycan synthesis and reducing inflammation.1 Using multifaceted nutritional interventions have shown more promising benefits compared with single nutrient supplementation: Supplementation of Vitamin C, glucosamine/chondroitin sulfate, mucopolysaccharides, or type 1 collagen have shown to accelerate tendon healing and improved tensile strength in preclinical studies.1

Spine: Serum markers like albumin, prealbumin, total protein, and albumin/globin can predict adverse events after spine surgery.1 Studies show that high-protein supplements can improve outcomes, including better vertebral fusion, reduced pain, and fewer complications.10,11 The Enhanced Recovery After Surgery (ERAS) program recommends nutritional assessment and intervention for malnourished patients undergoing lumbar fusion.1 A randomized double-blind placebo-controlled trial demonstrated that high-protein supplementation two days preoperatively to one month postoperatively improved vertebral fusion and posterior spine fusion, decreased surgical site infection, and decreased postoperative pain.11 Another randomized control study demonstrated that 36 grams per day of whey protein supplementation significantly decreased paraspinal atrophy, reduced pain, and disability after spinal fusion surgery.10

Foot and ankle: Up to 20.3% of patients undergoing ankle Open Reduction and Internal Fixation are malnourished.1 Malnutrition significantly raises the risk of surgical site infections and longer hospital stays.1 Hypoalbuminemia is a critical factor, second only to anemia, in predicting surgical complications.4 Postoperative vitamin C supplementation has been shown to reduce pain and improve functional outcomes.1

Identifying malnourished patients or those at high risk is crucial for optimizing their health before surgery. Optimizing nutrition can reduce health care costs by decreasing post operative complications, hospital stays, readmissions, and chronic pain. Universal screening and treatment of malnutrition before surgeries like total knee arthroplasty are cost effective, improving patient outcomes and reducing overall health care expenses.1 With rising health care cost, focusing on nutritional optimization can enhance patient recovery, making them better candidates for same day surgeries and reducing the economic burden of suboptimal outcomes.1

Figure 1: Diagram of potential deterioration in nutritional status over the perioperative period. There are several peri-operative stages at which nutritional status could be compromised. 12

Perioperative Nutrition Screen (PONS)

Figure 2: Perioperative Nutrition Screen (PONS) assessment tool.13

Mini Nutritional Assessment


Figure 3: Mini Nutritional Assessment (From Société des Produits Nestlé S.A.)14

Figure 4: Duke Peri-operative Enhancement Team (POET) pathway: Pre-operative nutritional intervention plan from the POET clinic at Duke University. Any patient assessed as being at malnutrition risk is referred for Evaluation by a dietitian and receives nutrition care according to this pathway. ONS, Oral nutrition supplements.12

References:

  1. Tedesco A, Sharma AK, Acharya N, et al. The Role of Perioperative Nutritional Status and Supplementation in Orthopaedic Surgery: A Review of Postoperative Outcomes. JBJS Rev. 2024;12(4). doi:10.2106/JBJS.RVW.23.00242
  2. Desborough JP. The stress response to trauma and surgery. Br J Anaesth. 2000;85(1):109-117. doi:10.1093/bja/85.1.109
  3. Phen HM, Jones C, Kravets VG, et al. Impact of Frailty and Malnutrition on Outcomes After Surgical Fixation of Lower Extremity Fractures in Young Patients. J Orthop Trauma. 2021;35(4):e126-e133. doi:10.1097/bot.0000000000001952
  4. Jm W, Nr K, Ca S, Jt B. Role of Hypoalbuminemia as an Independent Predictor of 30-Day Postoperative Complications Following Surgical Fixation of Ankle Fractures. Foot Ankle Int. 2020;41(3). doi:10.1177/1071100719895222
  5. Briguglio M, Wainwright TW, Southern K, Riso P, Porrini M, Middleton RG. Healthy Eating for Elective Major Orthopedic Surgery: Quality, Quantity, and Timing. J Multidiscip Healthc. 2023;Volume 16:2081-2090. doi:10.2147/JMDH.S415116
  6. Williams DGA, Wischmeyer PE. Perioperative Nutrition Care of Orthopedic Surgery Patient. Tech Orthop Rockv Md. 2020;35(1):15-18. doi:10.1097/bto.0000000000000412
  7. Dubé MD, Rothfusz CA, Emara AK, et al. Nutritional Assessment and Interventions in Elective Hip and Knee Arthroplasty: a Detailed Review and Guide to Management. Curr Rev Musculoskelet Med. 2022;15(4):311-322. doi:10.1007/s12178-022-09762-7
  8. Gonçalves TJM, Gonçalves SEAB, Nava N, et al. Perioperative Immunonutrition in Elderly Patients Undergoing Total Hip and Knee Arthroplasty: Impact on Postoperative Outcomes. JPEN J Parenter Enteral Nutr. 2021;45(7):1559-1566. doi:10.1002/jpen.2028
  9. Noriega-González DC, Drobnic F, Caballero-García A, Roche E, Perez-Valdecantos D, Córdova A. Effect of Vitamin C on Tendinopathy Recovery: A Scoping Review. Nutrients. 2022;14(13):2663. doi:10.3390/nu14132663
  10. Khalooeifard R, Shariatpanahi ZV, Ahani A, et al. Effect of Protein Supplement on Paraspinal Muscles in Spine Fusion Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial. Int J Spine Surg. 2021;15(1):47-54. doi:10.14444/8005
  11. Khalooeifard R, Oraee-Yazdani S, Keikhaee M, Shariatpanahi ZV. Protein Supplement and Enhanced Recovery After Posterior Spine Fusion Surgery: A Randomized, Double-blind, Placebo-controlled Trial. Clin Spine Surg. 2022;35(3):E356. doi:10.1097/BSD.0000000000001222
  12. Gillis C, Wischmeyer PE. Pre-operative nutrition and the elective surgical patient: why, how and what? Anaesthesia. 2019;74(S1):27-35. doi:10.1111/anae.14506
  13. Wischmeyer PE, Carli F, Evans DC, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Nutrition Screening and Therapy Within a Surgical Enhanced Recovery Pathway. Anesth Analg. 2018;126(6):1883. doi:10.1213/ANE.0000000000002743
  14. https://www.mna-elderly.com/sites/default/files/2021-10/mna-mini-english.pdf