September 21, 2023
4 min reading
Source: Blevins K, et al. J Arthroplasty. 2018; doi:10.1016/j.arth.2018.04.027.
Disclosure: Romeo reports receiving royalties, being on the speakers bureau and a consultant for Arthrex, and doing contract research for Arthrex.
Surgical outcomes are influenced by key factors that orthopedic surgeons assess before and during an episode of care.
Our primary focus is surgical factors. However, we are also responsible for understanding the treatment process and guiding rehabilitation. Additional perioperative concerns include anesthesia, postoperative pain management, and preventive strategies such as routine antibiotic use and prevention of thrombosis.
Increasingly important, but often difficult to influence and manage, are patient-specific factors such as age, overall fitness of the patient, social determinants of health, lifestyle choices, and nutritional status. We provide realistic expectations of surgical care, which may also come with a sense of pessimism about achieving an ideal outcome given patient-specific factors. Some patient characteristics may not be modifiable and are beyond the surgeon’s control, which can significantly affect surgical outcomes. The general duty of surgeons is to prioritize patient health, which involves a comprehensive approach to achieving ideal outcomes, including preoperative interventions known to influence surgical outcomes.
The surgical team should include a complete preoperative assessment of the patient as well as request preoperative discharge from primary care providers and medical specialists as indicated. Factors such as age cannot be changed and affect a patient’s tolerance to the stress of surgery, ability to heal, and ability to adequately rehabilitate. Patient-specific factors also influence the choice of surgical intervention, such as soft tissue repair vs. arthroplasty.
Smoking and alcohol and drug use are modifiable social behaviors and should be discussed with patients. Unfortunately, the behavior takes months or years to resolve before it changes or has already resulted in permanent damage. Patients should be offered referrals to cessation programs that can provide a pathway to a healthier lifestyle.
Recent CDC data shows that 41.9% of the US population is obese (BMI 30 kg/m2), while 9.2% were considered severely obese (BMI 40 kg/m2). With more than 50% of the US adult population exceeding the recommended healthy weight, many patients have accepted being overweight as the norm despite its impact on health and surgical care.
Orthopedic surgeons do not need to be diet and nutrition experts, but we should have a basic understanding and appreciation of the impact of nutrition on surgical outcomes. Ultimately, we are responsible for results despite nutritional factors beyond our control. Concern for patients’ overall health should lead to discussion with overweight or obese patients. We should discuss the growing body of evidence on the importance of overall nutrition and be willing to participate in screening programs to assess nutritional status.
The risks of surgical procedures are influenced by malnutrition and should also be discussed in informed consent. For example, patients should be informed that the risk of postoperative infection, poor wound healing, and delayed recovery after surgery are associated with low albumin levels, and they can take steps to reduce their risk.
Start a dialogue
Respecting the autonomy of patients in making decisions that affect their health is essential for ethical treatment of patients. Establishing a dialogue about perioperative nutrition is time-consuming, but necessary to provide the highest standard of care during surgery.
We cannot assume that obese patients are well-nourished. Obesity is one side of the burden of poor nutrition and can coexist in malnourished patients. Before the orthopedic evaluation, the patient can complete simple screening tools such as the Subjective Global Assessment, a questionnaire that helps differentiate nutritional risks and screens for patients who would benefit from nutritional intervention. The Mini Nutritional Assessment has also been shown to be an effective screening tool for joint replacement patients.
Serum albumin is associated with outcomes after joint replacement and hip fractures. Serum prealbumin has a shorter half-life and reflects current nutritional status. Serum albumin levels less than 3.5 g/dL are indicative of malnutrition and predict a higher rate of complications.
A comprehensive laboratory panel to screen for malnutrition may include serum albumin, serum prealbumin, transferrin, and total lymphocyte count. Vitamin D deficiency is a common finding in less sun-exposed environments and can affect patients of all ages and can be considered as part of the preoperative screening for malnutrition. If any of these labs are abnormal, further evaluation of the patient’s nutritional status may be necessary.
Organize a healthy approach
Proper nutrition affects outcomes in every patient population. Proper nutrition is essential for tissue healing, minimizing inflammation, bone health, maintaining muscle function, the effectiveness of our immune system, and reducing the risk of infection and other complications. In addition, nutrition should be considered as part of a pain management program, starting with Enhanced Recovery After Surgery (ERAS) protocols to reduce patient stress, stabilize physiological control of blood glucose and electrolytes, and ensure rapid recovery from the effects of anesthesia. Nutraceuticals, such as omega-3 fatty acid supplements and other antioxidants, can reduce postoperative inflammation and benefit pain relief.
Orthopedists should have informative preoperative nutritional discussions with patients of all ages and orthopedic conditions. As part of our responsibility for the patient’s well-being, especially if surgery is being considered, we should help organize a healthy approach to nutrition. Appropriate groups of patients should be subjectively and objectively screened for malnutrition. Patients should be encouraged to follow a well-balanced diet and avoid smoking, alcohol and drug use.
Because of the stress of surgery and postoperative recovery, patients should be encouraged to increase their protein intake 2 to 4 weeks before surgery and continue for 2 to 4 weeks after surgery. Patients should be instructed on supplements agreed with the anesthesia team using the ERAS approach. Patients should take a complex multivitamin daily, which may be supplemented with other nutrients and nutraceuticals depending on the nutritional assessment.
Surgeons may suggest additional nutritional support with vitamin D and calcium for bone health, vitamin C for wound healing, iron for patients with anemia or expected blood loss, omega-3 fatty acids for anti-inflammatory support, and possibly collagen supplementation for joint, bone, and skin health. Proper sleep and daily exercise are other valuable recommendations. Providing this level of patient counseling helps develop the patient engagement needed to achieve the most favorable outcomes and the highest standard of care.
- Blevins K, et al. J Arthroplasty. 2018; doi:10.1016/j.arth.2018.04.027.
- Cross MB et al. J Am Acad Orthop Surg. 2014; doi:10.5435/JAAOS-22-03-193.
- Phillips JLH et al. J Am Acad Orthop Surg. 2023; doi:10.5435/JAAOS-D-22-01035.
- For more information:
- Anthony A. Romeo, MD, is the chief medical editor of Healio | Orthopedics today. He can be reached at Healio, 6900 Grove Road, Thorofare, NJ 08086; by e-mail: firstname.lastname@example.org.
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