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Hameed D, Bains SS, Dubin JA, Shul C, Chen Z, Stein A, Nace J, Mont MA. Timing Matters: Optimizing the Timeframe for Preoperative Weight Loss to Mitigate Postoperative Infection Risks in Total Knee Arthroplasty. J Arthroplasty 2024; 39:1419-1423.e1. [PMID: 38135167 DOI: 10.1016/j.arth.2023.12.028] [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: 07/21/2023] [Revised: 11/21/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND We explore the incidence of periprosthetic infections post-total knee arthroplasty (TKA) in morbidly obese patients who achieved weight loss. Current American Academy of Orthopaedic Surgeons guidelines suggest a preoperative body mass index (BMI) below 40 for TKA. This study assesses infection risks in patients initially who had a BMI of 40-50 who reduced their BMI to under 35 at varying intervals prior to surgery. METHODS We reviewed a national, all-payer database, PearlDiver, for patients undergoing primary TKA. Patients were stratified based on initial BMI of 40 to 50 and reduction of BMI to less than 35 at 3 months (n = 1,932), 3 to 6 months (n = 794), 6 to 9 months (n = 2,233), and 9 to 12 months (n = 1,194) prior to TKA, as well as patients who had a BMI between 40 to 50 (n = 41,632) on the day of surgery. The nonobese group comprised of patients who had a BMI between 20 and 30 (n = 33,294). Multivariate analyses were performed at one-year follow-up. RESULTS We found an increased risk of PJI for patients who had achieved BMI reduction less than nine months prior to TKA, compared to the BMI 20 to 30 cohort at the one-year follow-up (P < .001). Patients who achieved BMI reduction nine to twelve months prior to TKA showed no significant difference in PJI risk compared to the matching nonobese cohort at one-year follow-up (P = .400). CONCLUSIONS In conclusion, our results suggest that weight loss should be achieved at least nine months before TKA to decrease infection risks. These findings have significant implications for surgical considerations in obese patients undergoing TKA.
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Affiliation(s)
- Daniel Hameed
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sandeep S Bains
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jeremy A Dubin
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Craig Shul
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Zhongming Chen
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Alexandra Stein
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - James Nace
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
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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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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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Early Outcome Trends of Unicompartmental Knee Arthroplasty in Patients With Morbid Obesity: A Potential for Outpatient Surgery. J Arthroplasty 2022; 37:2009-2013.e3. [PMID: 35483608 DOI: 10.1016/j.arth.2022.04.028] [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: 03/16/2022] [Revised: 04/13/2022] [Accepted: 04/20/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Elevated body mass index (BMI) was previously considered a contraindication to unicompartmental knee arthroplasty (UKA). This study sought to determine if outcomes following UKA in patients with elevated BMI have improved over the years. We hypothesized that operative times and length of stay (LOS) following UKA would significantly decrease, while discharge to home rates would increase across all BMI cohorts, especially those with a BMI > 40. METHODS Using the National Surgical Quality Improvement Program registry, surgical cases categorized using the Current Procedural Terminology code 27446 for UKA with a recorded height and weight were included. Three BMI cohorts were created: BMI I (BMI < 30), BMI II (30 ≤ BMI ≤ 40), and BMI III (BMI > 40). Each BMI group was subclassified temporally by year of operation: Years A (2006-2009), Years B (2010-2014), and Years C (2015-2019). RESULTS A total of 14,114 patients were included. For BMI III, both operative time (P < .001) and LOS (P < .001) significantly decreased over the Years cohorts. Discharge home rates increased from 88.3% to 94.4% in BMI III (P = .001). All BMI cohorts saw similar changes in discharge patterns, 30-day readmissions, and reoperations within 30 days in recent years. CONCLUSION This study found that operative times and LOS have decreased significantly in patients with morbid obesity over the past 14 years, while more patients are being discharged home without being readmitted or reoperated on in the first month. As surgeons continue to improve their operative and reconstructive techniques, this study suggests that patients with elevated BMI should be considered candidates to undergo UKA procedures in ambulatory surgery centers or in hospitals with a rapid recovery unit.
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Jaenisch M, Wirtz DC. [Patient optimization before hip revision arthroplasty: : How to handle comorbidities]. ORTHOPADIE (HEIDELBERG, GERMANY) 2022; 51:619-630. [PMID: 35759042 DOI: 10.1007/s00132-022-04273-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/03/2022] [Indexed: 06/15/2023]
Abstract
Preoperative optimization of the therapeutic regime of comorbidities can lead to an improvement of the postoperative outcome and has the potential to reduce the financial burden on the health care system in revision hip arthroplasty. Patient-related factors and an increasing incidence of comorbidities lead to a higher risk of implant failure and revision for all causes. Important and potentially modifiable risk factors like preoperative anemia, coagulopathy, infectious disease (dental status, urinary tract infections, colonization with staphylococcus), metabolic conditions (obesity, malnutrition, diabetes mellitus, osteoporosis), and smoking need to be addressed. To achieve an optimal preoperative condition a multidisciplinary approach should be applied.
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Affiliation(s)
- Max Jaenisch
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Venusberg Campus 1, 53129, Bonn, Deutschland.
| | - Dieter Christian Wirtz
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Venusberg Campus 1, 53129, Bonn, Deutschland
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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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Geng H, Wang S, Jin Y, Cheng N, Song B, Shu S, Li B, Han Y, Han Y, Gao L, Ding Z, Xu Y, Wang X, Ma Z, Sun Y. Nutritional Status and Body Composition in Wilson Disease: A Cross-Sectional Study From China. Front Nutr 2022; 8:790520. [PMID: 35036410 PMCID: PMC8759200 DOI: 10.3389/fnut.2021.790520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/24/2021] [Indexed: 12/01/2022] Open
Abstract
Background: Abnormal nutritional status is frequently seen in patients with chronic diseases. To date, no study has investigated the detailed characteristics of abnormal nutritional status among Wilson's disease (WD) patients in the Chinese cohort. This study aimed to describe the nutritional status of WD patients, with a particular focus on the differences between patients with different phenotypes. Methods: The study subjects comprised 119 healthy controls, 129 inpatients (hepatic subtype, n = 34; neurological subtype, n = 95) who were being treated at the affiliated hospital of the Institute of Neurology, Anhui University of Chinese Medicine. All of the subjects were assessed for body composition by using bioelectrical impedance analysis. All WD patients received anthropometry, nutritional risk screening 2002 (NRS2002), and laboratory test (hemocyte and serum biomarkers) additionally. Results: Compared with healthy controls, the fat mass and rate of total body and trunk were significantly higher in WD patients (P < 0.001), the muscle and skeletal muscle mass of total body and trunk were significantly lower in WD patients (P < 0.001). Compared with hepatic subtype patients, the fat mass and rate of total body, trunk, and limbs were significantly lower in neurological subtype patients (P<0.01); while there were no significant differences in muscle and skeletal muscle between these two subtypes. The overall prevalence of abnormal nutritional status in WD patients was 43.41% (56/129). The prevalence of high-nutritional risk and overweight in WD patients was 17.83% (23 of 129) and 25.58% (33 of 129), respectively. Compare with patients with high nutritional risk, macro platelet ratio, alkaline phosphatase, the basal metabolic rate (p < 0.05), creatinine, trunk fat rate (p < 0.01) and appendicular skeletal muscle mass (p < 0.001) were significantly higher in patients without nutritional risk (p < 0.001). Patients with a high nutritional risk tend to have a lower cholinesterase concentration (x2 = 4.227, p < 0.05). Conclusion: Both patients with H-subtype and N-subtype are prone to have an abnormal nutritional status. Longitudinal studies are required to investigate if nutritional status and body composition could reflect prognosis in WD patients, and which of these body composition indexes contribute to malnutrition and worse prognosis.
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Affiliation(s)
- Hao Geng
- Laboratory of Sports and Nutrition Information Technology, Institute of Intelligent Machine, Hefei Institutes of Physical Science, Chinese Academy of Sciences (CAS), Hefei, China.,Department of Biophysics, University of Science and Technology of China, Hefei, China.,Hospital Affiliated to the Institute of Neurology, Anhui University of Chinese Medicine, Hefei, China
| | - Shijing Wang
- Hospital Affiliated to the Institute of Neurology, Anhui University of Chinese Medicine, Hefei, China
| | - Yan Jin
- Hospital Affiliated to the Institute of Neurology, Anhui University of Chinese Medicine, Hefei, China
| | - Nan Cheng
- Hospital Affiliated to the Institute of Neurology, Anhui University of Chinese Medicine, Hefei, China
| | - Bin Song
- Hospital Affiliated to the Institute of Neurology, Anhui University of Chinese Medicine, Hefei, China
| | - Shan Shu
- Hospital Affiliated to the Institute of Neurology, Anhui University of Chinese Medicine, Hefei, China
| | - Bo Li
- Hospital Affiliated to the Institute of Neurology, Anhui University of Chinese Medicine, Hefei, China
| | - Yongsheng Han
- Hospital Affiliated to the Institute of Neurology, Anhui University of Chinese Medicine, Hefei, China
| | - Yongzhu Han
- Hospital Affiliated to the Institute of Neurology, Anhui University of Chinese Medicine, Hefei, China
| | - Lishen Gao
- Laboratory of Sports and Nutrition Information Technology, Institute of Intelligent Machine, Hefei Institutes of Physical Science, Chinese Academy of Sciences (CAS), Hefei, China.,Department of Biophysics, University of Science and Technology of China, Hefei, China
| | - Zenghui Ding
- Laboratory of Sports and Nutrition Information Technology, Institute of Intelligent Machine, Hefei Institutes of Physical Science, Chinese Academy of Sciences (CAS), Hefei, China.,Department of Biophysics, University of Science and Technology of China, Hefei, China
| | - Yang Xu
- Laboratory of Sports and Nutrition Information Technology, Institute of Intelligent Machine, Hefei Institutes of Physical Science, Chinese Academy of Sciences (CAS), Hefei, China.,Department of Biophysics, University of Science and Technology of China, Hefei, China
| | - Xun Wang
- Hospital Affiliated to the Institute of Neurology, Anhui University of Chinese Medicine, Hefei, China
| | - Zuchang Ma
- Laboratory of Sports and Nutrition Information Technology, Institute of Intelligent Machine, Hefei Institutes of Physical Science, Chinese Academy of Sciences (CAS), Hefei, China.,Department of Biophysics, University of Science and Technology of China, Hefei, China
| | - Yining Sun
- Laboratory of Sports and Nutrition Information Technology, Institute of Intelligent Machine, Hefei Institutes of Physical Science, Chinese Academy of Sciences (CAS), Hefei, China.,Department of Biophysics, University of Science and Technology of China, Hefei, China
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