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Maheshwari V, Choudhury AK, Yadav R, Dhingra M, Kant R, Kalia RB. Prevalence of Poor Nutrition in Knee Osteoarthritis Patients: A Hospital-Based Cohort Study in Indian Population. Indian J Orthop 2024; 58:298-307. [PMID: 38425822 PMCID: PMC10899134 DOI: 10.1007/s43465-023-01090-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/25/2023] [Indexed: 03/02/2024]
Abstract
Purpose Malnourished adults with knee osteoarthritis (OA) have a lower propensity for physical activities, leading to post-surgical stress and poorer clinic-functional outcomes. The study is aimed to propose an integrative screening procedure for patients and to identify a subset of patients who are undernourished or at risk of undernutrition in the Indian population. Methods A hospital-based cross-sectional study was conducted at a tertiary care, a university-level teaching hospital for seven months, which included knee OA patients above the age of 45 years, and the following criteria were evaluated anthropometric measurement and blood biochemical parameters and nutritional scoring system. Results The current study reports a high prevalence of malnutrition (69.5%) in patients with knee OA in the Indian population based on blood biochemical levels, and late presenters are associated with poor nutritional status of an individual. A single gold standard blood biochemical test, serum albumin alone, reports many malnourished individuals in the population, and the remaining blood biochemical parameters may not yield any additional information. Mini nutritional assessment, mid-arm circumference, and mid-calf circumference are poor predictors of malnutrition, and we need a revised cut-off for our group of patients. Conclusion In the cohort of OA Knee, the prevalence of malnutrition is high (69.5%) in the Indian population. Serum Albumin is the best parameter to detect the presence of malnutrition preoperatively, and MNS is not applicable to detect malnutrition in our subset of patients. The study recommends routinely measuring serum albumin levels in all patients to correct the nutritional abnormality preoperatively, resulting in better surgical outcomes and reduced post-operatively complications. Level of evidence IV.
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Affiliation(s)
- Vikas Maheshwari
- Department of Orthopeaedics, All India Institute of Medical Sciences, Rishikesh, India
| | | | - Robin Yadav
- Department of Orthopeaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Mohit Dhingra
- Department of Orthopeaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Ravi Kant
- Department of Orthopeaedics, All India Institute of Medical Sciences, Rishikesh, India
| | - Roop Bhushan Kalia
- Department of Orthopeaedics, All India Institute of Medical Sciences, Rishikesh, India
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Rakutt MJ, Eason TB, Boyle KK, Buller LT, Krueger CA, Jacobs CA, Duncan ST, Landy DC. Nutritional Laboratory Studies Prior to Total Knee Arthroplasty: Practice Versus Publication. J Bone Joint Surg Am 2023; 105:1947-1953. [PMID: 37769038 DOI: 10.2106/jbjs.23.00572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
BACKGROUND Recent emphasis has been placed on nutritional status assessment prior to total knee arthroplasty (TKA), including multiple American Academy of Orthopaedic Surgeons publications recommending specific laboratory studies; however, the frequency with which surgeons obtain these laboratory studies remains unclear. We sought to assess the incidence of ordering nutritional laboratory studies in the 90 days prior to TKA, utilizing data from a large administrative claims database. METHODS With use of the PearlDiver database, we identified 557,670 patients undergoing primary TKA from 2011 to 2020 with a metabolic panel or blood cell count claim within 90 days prior to TKA. We then determined the incidence of prealbumin, transferrin, vitamin D, and zinc laboratory tests claimed 90 days prior to TKA. Associations between claims and the year of surgery, patient demographics, and clinical characteristics were assessed by comparing proportions and chi-square testing. RESULTS Nutritional laboratory studies were infrequently claimed within 90 days prior to TKA, with studies for prealbumin being performed in 2.2% of patients; transferrin, 1.9%; vitamin D, 10.2%; and zinc, 0.2%. From 2011 to 2020, there was a moderate but steady increase in the proportion of patients with claims for prealbumin (change from 0.8% in 2011 to 3.4% in 2020; p < 0.001), transferrin (0.8% to 2.7%; p < 0.001), and vitamin D (7.6% to 9.4%; p < 0.001) laboratory tests but there was less of a change for zinc (0.1% to 0.2%; p < 0.001). There were weak-to-absent associations of age, gender, obesity, diabetes, and anemia with laboratory claims. CONCLUSIONS Despite multiple publications and recommendations, nutritional laboratory studies are infrequently ordered prior to TKA. Although there has been a slight increase in the use of nutritional laboratory studies over the past decade, patient factors such as gender and obesity were not associated with this increase. Understanding current practice patterns may help target future areas for improvement. LEVEL OF EVIDENCE Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Maxwell J Rakutt
- Department of Orthopaedic Surgery, University of Vermont, Burlington, Vermont
| | - Travis B Eason
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - K Keely Boyle
- Department of Orthopaedic Surgery, University of Buffalo School of Medicine, Buffalo, New York
| | - Leonard T Buller
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | - Chad A Krueger
- Department of Orthopedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Cale A Jacobs
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephen T Duncan
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - David C Landy
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
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Zink TM, Kent SE, Choudhary AN, Kavolus JJ. Nutrition in Surgery: An Orthopaedic Perspective. J Bone Joint Surg Am 2023; 105:1897-1906. [PMID: 37856576 DOI: 10.2106/jbjs.23.00259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
➤ Malnutrition is common among subsets of patients undergoing orthopaedic surgery and is associated with an increased risk of postoperative complications.➤ Serum proteins, in particular, albumin, may be used in the evaluation of nutritional status.➤ Anthropometric measurements and surveys also play a role in the evaluation of nutritional status.➤ Increased energy and nutrient requirements due to surgical procedures necessitate increased caloric and protein intake in the perioperative period, which may be achieved through diet or supplementation.➤ Evidence supports the use of protein-calorie, amino acid, and immunonutrition supplements. Vitamin D supplementation is an area of further consideration.➤ Diet restriction, activity alterations, pharmacotherapy, and bariatric surgery are all safe, effective approaches to weight loss, although the optimal timing and magnitude of preoperative weight loss require further investigation.
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Affiliation(s)
- Thomas M Zink
- Tufts Medical Center, Boston, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
| | - Suzanne E Kent
- Tufts Medical Center, Boston, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
| | | | - Joseph J Kavolus
- Tufts University School of Medicine, Boston, Massachusetts
- Newton-Wellesley Orthopedic Associates, Newton, Massachusetts
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Fernández Miró M, Cabrejo Gavidia V, Carrascosa Piquer O, Valero Lanau J, Toapanta Valencia M, Aguado Jodar A. Malnutrition is associated with postoperative complications in elderly patients undergoing total hip arthroplasty. ENDOCRINOL DIAB NUTR 2023; 70 Suppl 3:59-66. [PMID: 37640474 DOI: 10.1016/j.endien.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/13/2022] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Malnutrition in elderly patients with hip fracture has been described as a factor associated with poor outcomes. This evidence for elderly patients undergoing elective total hip arthroplasty (THA) for osteoarthritis is not well-established. METHODS We retrospectively studied a cohort of patients with an age ≥65 years admitted to the hospital for THA between January 2018 and December 2020. Demographic characteristics were collected. Albumin and total lymphocyte count were included in the pre-operative analysis and 24h postoperatively. Nutritional screening was carried out 24h postoperatively. GLIM criteria were applied for the diagnosis of malnutrition. RESULTS 25 patients out of the total cohort of 65 (38.4%) were malnourished. Five out of six patients (83.3%) with postoperative complications presented malnutrition compared with 20 of 59 patients (33.8%) without postoperative complications (P=0.028). Mean length of stay (LOS) was 3.49±0.88 days. Five out of six (83.3%) patients with postoperative complications presented LOS >3 days compared with one out of six patients (16.6%) with LOS ≤3 days (P=0.009). 26 patients (40%) were referred to a community health centre, no differences in diagnosis of malnutrition were detected compared with patients who were discharged home. Patients with a diagnosis of malnutrition were significantly older, had a lower body mass index (BMI), a lower preoperative and postoperative albumin and worse anthropometric parameters. CONCLUSIONS Malnutrition is associated with postoperative complications and longer LOS in elderly patients with elective THA. Risk factors for malnutrition are older age and low BMI.
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Affiliation(s)
- Mercè Fernández Miró
- Department of Endocrinology and Nutrition, Centre d'Atenció Integral Dos de Maig, Consorci Sanitari Integral, Barcelona, Spain.
| | - Vanessa Cabrejo Gavidia
- Department of Endocrinology and Nutrition, Centre d'Atenció Integral Dos de Maig, Consorci Sanitari Integral, Barcelona, Spain
| | - Olga Carrascosa Piquer
- Department of Hospital Pharmacy, Centre d'Atenció Integral Dos de Maig, Consorci Sanitari Integral, Barcelona, Spain
| | - Jose Valero Lanau
- Department of Orthopaedic Surgery, Centre d'Atenció Integral Dos de Maig, Consorci Sanitari Integral, Barcelona, Spain
| | - Martha Toapanta Valencia
- Department of Surgery, Centre d'Atenció Integral Dos de Maig, Consorci Sanitari Integral, Barcelona, Spain
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Phillips JLH, Ennis HE, Jennings JM, Dennis DA. Screening and Management of Malnutrition in Total Joint Arthroplasty. J Am Acad Orthop Surg 2023; 31:319-325. [PMID: 36812414 DOI: 10.5435/jaaos-d-22-01035] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/19/2023] [Indexed: 02/24/2023] Open
Abstract
Malnutrition is an increasingly prevalent problem in patients undergoing total joint arthroplasty (TJA). Increased risks associated with TJA in the setting of malnourishment have been well documented. Standardized scoring systems in addition to laboratory parameters such as albumin, prealbumin, transferrin, and total lymphocyte count have been developed to identify and evaluate malnourished patients. Despite an abundance of recent literature, there is no consensus on the best approach for screening TJA patients from a nutritional standpoint. Although there are a variety of treatment options, including nutritional supplements, nonsurgical weight loss therapies, bariatric surgery, and the involvement of dieticians and nutritionists, the effect of these interventions on TJA outcomes has not been well characterized. This overview of the most current literature aims to provide a clinical framework for approaching nutrition status in arthroplasty patients. A comprehensive understanding of the tools available for managing malnourishment will facilitate improved arthroplasty care.
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Affiliation(s)
- Jessica L H Phillips
- From the Colorado Joint Replacement (Phillips, Ennis, Jennings, and Dennis), the Department of Mechanical and Materials Engineering, University of Denver (Jennings and Dennis), the Department of Orthopaedics, University of Colorado School of Medicine (Dennis), Denver, CO, and the Department of Biomedical Engineering, University of Tennessee, Knoxville, TN (Dennis)
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Gong J, Zuo S, Zhang J, Li L, Yin J, Li X, Yu F, Hu W. Comparison of four nutritional screening tools in perioperative elderly patients: Taking orthopedic and neurosurgical patients as examples. Front Nutr 2023; 10:1081956. [PMID: 37063338 PMCID: PMC10090350 DOI: 10.3389/fnut.2023.1081956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/14/2023] [Indexed: 03/31/2023] Open
Abstract
Background and aimsMalnutrition is widely present in elderly surgical patients and is highly correlated with prognosis after surgery. However, studies comparing the effectiveness of comprehensive nutritional screening tools in geriatric surgical patients have not yet been published. The nutritional risk among elderly orthopedic and neurosurgical patients and their associated clinical indicators and outcomes was assessed using four screening tools. The aim of this study was to explore suitable tools for screening the nutritional status and identify their potential to act as prognostic indicators.MethodsThe Nutritional Risk Score 2002 (NRS2002), Mini Nutritional Assessment - Short Form (MNA-SF), Geriatric Nutritional Risk Index (GNRI), and Prognostic Nutritional Index (PNI) were all performed within two days of admission and before surgery. The relationships between nutritional risk classifications and conventional nutritional markers, complications and length of hospital stay (LOS) were evaluated.ResultsIn this study, a total of 167 orthopedic patients and 103 neurosurgical patients were evaluated. In neurosurgical patients, the rates of malnutrition or patients at risk of malnutrition according to the MNA-SF, GNRI, NRS2002 and PNI were 26.4, 24.6, 8.4, and 12.6%, respectively. According to the NRS2002 and PNI, the rates of old neurosurgical patients who were malnourished or at risk of malnutrition were 14.6 and 3.9%, respectively, which were lower than the results assessed by the MNA-SF (24.3%) and GNRI (15.5%). Multiple regression analysis revealed a significant relationship between the PNI (malnourished vs.well-nourished, OR = 5.39, 95% CI:1.11-26.18, P = 0.037), GNRI (at risk vs.no risk, OR = 3.96, 95% CI: 1.01-15.45, P = 0.048) and the complications in orthopedic patients. Only GNRI was significantly related to LOS > 7 days (at risk vs.no risk, OR = 4.01, 95% CI: 1.64-9.80, P = 0.002). For neurosurgical patients, an association between GNRI and LOS > 8 days was discovered (at risk vs.no risk, OR = 3.35, 95% CI: 1.03-10.86, P = 0.002).ConclusionAmong the four nutritional risk screening tools, the GNRI exhibited better predictive value for short-term outcomes in elderly perioperative orthopedic and neurosurgical patients, thereby suggesting that it might be a more suitable tool for nutritional risk screening. Additional studies are required to determine the applicability of GNRI in other surgical fields.
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Affiliation(s)
- Jie Gong
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, China
| | - Silu Zuo
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, China
| | - Jie Zhang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
| | - Li Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jie Yin
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, China
| | - XinYi Li
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, China
| | - Fengmei Yu
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, China
- Fengmei Yu,
| | - Wen Hu
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Wen Hu,
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Elliott Holbert S, Brennan JC, Johnson AH, Turcotte JJ, King PJ, MacDonald JH. The effects of hypoalbuminemia in obese patients undergoing total joint arthroplasty. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04786-1. [PMID: 36773048 DOI: 10.1007/s00402-023-04786-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 01/22/2023] [Indexed: 02/12/2023]
Abstract
INTRODUCTION Total joint arthroplasty (TJA) is a highly effective surgery. However, poor nutritional status has been associated with worse outcomes. In orthopedics, nutrition status is commonly evaluated using serum albumin. When albumin levels fall below 3.0 g/dL, wound healing ability becomes impaired. Typically, malnutrition is associated with low BMI, but malnourished patients can also be obese. The goals of this study were to investigate the relationship between malnourishment represented through albumin levels of obese patients and likelihood of postoperative complications. METHODS A retrospective review of patients undergoing primary TJA from 2016 to 2020 in the American College of Surgeons National Surgical Quality Improvement Program national database was performed. Patients with an albumin of < 3.5 g/dL were considered to have hypoalbuminemia and those with ≥ 3.5 g/dL were considered normal albumin. Univariate analysis was used to determine demographic and comorbidity differences between those with and without hypoalbuminemia. Outcomes of interest included length of stay, resource utilization, discharge disposition, and unplanned readmissions. Multivariate logistic regression examined albumin as a predictor of increased resource utilization and complications after controlling for possible confounding variables. RESULTS Of the 79,784 patients, 4.96% of patients had low albumin. Those with hypoalbuminemia were nearly 1.5 years older than those with normal albumin, were more likely to be black, female, and had an overall increased comorbidity burden as shown by percent of patients with ASA > 3 (all p < 0.001). After risk adjustment, those with hypoalbuminemia and a BMI of 35 + had greater risk of complications and increased resource utilization. CONCLUSION Our results demonstrated the prevalence of malnutrition increases as a patient's BMI increases. Further, hypoalbuminemia was associated with increased resource utilization and increased complication rates in all obese patients. We suggest screening albumin levels in obese patients preoperatively to give surgeons the best opportunity to optimize patient nutrition before undergoing surgery.
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Affiliation(s)
- S Elliott Holbert
- Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD, 21401, USA
| | - Jane C Brennan
- Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD, 21401, USA
| | - Andrea H Johnson
- Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD, 21401, USA
| | - Justin J Turcotte
- Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD, 21401, USA.
| | - Paul J King
- Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD, 21401, USA
| | - James H MacDonald
- Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD, 21401, USA
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8
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Shang J, Zhao G, Gong J, Su D, Wang Y, Wang L. Nutritional Risk Screening 2002 predicts surgical outcomes in 1532 patients undergoing total joint arthroplasty: A retrospective cohort study. Nutr Clin Pract 2022; 38:636-647. [PMID: 36446553 DOI: 10.1002/ncp.10934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 09/30/2022] [Accepted: 10/23/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Limited information exists about the predictive effect of Nutritional Risk Screening (NRS) 2002 on orthopedic surgery. The aim of the present study is to explore the role of NRS 2002 in postoperative complications and resource utilization in patients with total joint arthroplasty (TJA). METHODS We retrospectively collected the demographics and surgical results of nearly 2000 TJA patients admitted from 2016 to 2020 and assessed the differences in short- and long-term complications and resource utilization parameters. Multivariate linear, logistic regression, and subgroup analysis were subsequently used to control for potential confounders. Survival analysis was performed to further verify the cumulative incidence of postoperative complications. RESULTS We identified 1532 patients receiving TJA, 8.7% of which were at nutrition risk (NRS 2002 score ≥3 out of 7). Preoperative nutrition risk was associated with an increased risk of systemic complications, incisional complications, surgical site infection (SSI), incisional SSI, periprosthetic joint infection, dislocation, and periprosthetic fracture after TJA (odds ratio [OR], 3.62-31.99; all P < 0.05). Preoperative nutrition risk was further associated with an increased risk of cardiac complications, respiratory complications, urinary complications, and arthroplasty-related reoperation (OR, 3.16-12.29; all P < 0.01). Moreover, preoperative nutrition risk was associated with increased costs and length of stay, and increased risk of unplanned intensive care unit admission, arthroplasty-related readmission, infection-related readmission, and SSI-related readmission. CONCLUSIONS NRS 2002 is associated with an elevated risk of postoperative complications and increased resource utilization, following TJA. Thus, routine screening is recommended to identify nutrition risk statuses of patients undergoing elective TJA.
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Affiliation(s)
- Jingjing Shang
- Department of Pharmacy The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University Changzhou China
| | - Gongyin Zhao
- Department of Orthopedics The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University Changzhou China
| | - Jinhong Gong
- Department of Pharmacy The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University Changzhou China
| | - Dan Su
- Department of Pharmacy The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University Changzhou China
| | - Yuji Wang
- Department of Orthopedics The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University Changzhou China
| | - Liangliang Wang
- Department of Orthopedics The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University Changzhou China
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9
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MacMahon A, Rao SS, Chaudhry YP, Hasan SA, Epstein JA, Hegde V, Valaik DJ, Oni JK, Sterling RS, Khanuja HS. Preoperative Patient Optimization in Total Joint Arthroplasty-The Paradigm Shift from Preoperative Clearance: A Narrative Review. HSS J 2022; 18:418-427. [PMID: 35846267 PMCID: PMC9247589 DOI: 10.1177/15563316211030923] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background: Total joint arthroplasty (TJA) is one of the most common procedures performed in the United States. Outcomes of this elective procedure may be improved via preoperative optimization of modifiable risk factors. Purposes: We sought to summarize the literature on the clinical implications of preoperative risk factors in TJA and to develop recommendations regarding preoperative optimization of these risk factors. Methods: We searched PubMed in August 2019 with an update in September 2020 for English-language, peer-reviewed publications assessing the influence on outcomes in total hip and knee replacement of 7 preoperative risk factors-obesity, malnutrition, hypoalbuminemia, diabetes, anemia, smoking, and opioid use-and recommendations to mitigate them. Results: Sixty-nine studies were identified, including 3 randomized controlled trials, 8 prospective cohort studies, 42 retrospective studies, 6 systematic reviews, 3 narrative reviews, and 7 consensus guidelines. These studies described worse outcomes associated with these 7 risk factors, including increased rates of in-hospital complications, transfusions, periprosthetic joint infections, revisions, and deaths. Recommendations for strategies to screen and address these risk factors are provided. Conclusions: Risk factors can be optimized, with evidence suggesting the following thresholds prior to surgery: a body mass index <40 kg/m2, serum albumin ≥3.5 g/dL, hemoglobin A1C ≤7.5%, hemoglobin >12.0 g/dL in women and >13.0 g/dL in men, and smoking cessation and ≥50% decrease in opioid use by 4 weeks prior to surgery. Surgery should be delayed until these risk factors are adequately optimized.
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Affiliation(s)
- Aoife MacMahon
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sandesh S. Rao
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yash P. Chaudhry
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Syed A. Hasan
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeremy A. Epstein
- Department of Medicine, Johns Hopkins
University School of Medicine, Baltimore, MD, USA
| | - Vishal Hegde
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel J. Valaik
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Julius K. Oni
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert S. Sterling
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Harpal S. Khanuja
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA,Department of Orthopaedic Surgery,
Johns Hopkins Bayview Medical Center, Baltimore, MD, USA,Harpal S. Khanuja, MD, Department of
Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave.,
Baltimore, MD 21224-2780, USA.
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10
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Fernández Miró M, Cabrejo Gavidia V, Carrascosa Piquer O, Valero Lanau J, Toapanta Valencia M, Aguado Jodar A. Malnutrition is associated with postoperative complications in elderly patients undergoing total hip arthroplasty. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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11
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Emara AK, Hadad MJ, Dube M, Klika AK, Burguera B, Piuzzi NS. Team Approach: Nutritional Assessment and Interventions in Elective Hip and Knee Arthroplasty. JBJS Rev 2022; 10:01874474-202203000-00001. [PMID: 35230998 DOI: 10.2106/jbjs.rvw.21.00138] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Nutritional assessment is a critical element of routine preoperative assessment and should be approached by an interdisciplinary team that involves the primary care physician, dietitian, and orthopaedist. » Patients should be stratified on the basis of their nutritional risk, which influences downstream optimization and deficiency reversal. » The scientific literature indicates that nutritional supplementation affords protection against adverse outcomes and helps functional recovery, even among patients who are not at nutritional risk. » Published investigations recommend a sufficient preoperative interval (at least 4 weeks) to ensure an adequate nutritional intervention in malnourished patients as opposed to regarding them as nonsurgical candidates.
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Affiliation(s)
- Ahmed K Emara
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Matthew J Hadad
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Michael Dube
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.,Northeast Ohio Medical University, Rootstown, Ohio
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Bartolome Burguera
- Department of Endocrinology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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12
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Moore HG, Justen MA, Kirwin DS, Burroughs PJ, Rubin LE, Grauer JN. Does dehydration prior to primary total joint arthroplasty increase risk of perioperative complications? ARTHROPLASTY 2021; 3:34. [PMID: 35236481 PMCID: PMC8796573 DOI: 10.1186/s42836-021-00090-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prior studies have suggested that preoperative dehydration increases odds of perioperative complications in several areas of orthopedic surgery. This study aimed to evaluate whether preoperative hydration status is associated with the incidence of short-term complications after primary total joint arthroplasty. METHODS The 2012-2019 National Surgical Quality Improvement Program (NSQIP) database was used to explore the relationship between preoperative dehydration (ratio of preoperative BUN divided by preoperative Creatinine (BUN/Creatinine) > 20) and perioperative outcomes of total hip (THA) and total knee arthroplasty (TKA) patients. Univariate comparisons and multivariate regression analyses were conducted to identify specific complications that occurred more often in patients with preoperative dehydration. RESULTS Of 188,629 THA and 332,485 TKA patients, 46.3 and 47.0% had preoperative dehydration, respectively. After controlling for demographics and comorbidities, dehydrated THA patients were no more likely to experience a complication compared to their non-dehydrated counterparts (relative risk [RR] = 0.97, 99.7% Confidence Interval [CI]: 0.92-1.03, P = 0.138) nor increased risk of blood transfusion (RR = 1.02, CI = 0.96-1.08, P = 0.408). Similar to THA patients, dehydrated TKA patients were not more likely to have a complication after surgery (RR = 0.97, CI = 0.92-1.03, P = 0.138) and were at no greater risk of transfusion (RR = 1.02, CI = 0.96-1.07, P = 0.408). A sub-analysis covering only patients with BUN and Cr values determined within 24 h after surgery was performed and similarly found no significant increase in perioperative complications or transfusion. CONCLUSION Overall, preoperative dehydration in patients undergoing THA/TKA did not appear to increase risk of transfusion or other perioperative complications. Further research is needed to characterize the role of hydration prior to elective total joint arthroplasty.
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Affiliation(s)
| | | | | | | | - Lee E Rubin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06511, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06511, USA.
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