Metabolic Therapies in Orthopedics, Second Edition

Ingrid Kohlstadt, Kenneth Cintron

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781351708654
• Edition: 2
• Topic: Medicine
• Subtopic: Alternative & Complementary Medicine

The first medical reference textbook to compile an unprecedented synthesis of evidence for regenerative orthopedics by key opinion leaders

Thirty-five authors address your clinical questions

What emerging technologies are right for my clinical practice? How can I strengthen my patients before their orthopedic surgery? Practically speaking, how can I leverage the latest metabolic therapies to safeguard my patients from toxins, medications, food and chronic diseases known to adversely affect the musculoskeletal system?

"Ask the Author" feature

Would you like to discuss a patient with a particular author? Now you can do so at www.betterorthopedics.com.

First to be second

Did you notice this book is the first book in regenerative orthopedics to publish a second edition? This diverse author team leads the growing field of regenerative orthopedics and offers the broadest and in-depth approach to leveraging metabolic therapies.

This book comprises the professional opinion of its authors. It does not claim to represent guidelines, recommendations, or the current standard of medical care.

Section III

Metabolic Therapies for Specific Orthopedic Conditions

17	Perioperative Metabolic Therapies in Orthopedics

Frederick T. Sutter MD, MBA

Introduction

The physiological stress of major surgical procedures has been thoroughly reviewed¹ and there have been robust studies of the influence of metabolic therapy in general surgical procedures, and outcome measures beyond the length of stay (LOS) and readmission rates are being evaluated in the current literature. Scientific literature at a meta-analysis level of recommendation^{2 , 3} demonstrates the interrelationship between nutritional status, as a major determinant, and achieving successful general surgical outcomes when compared in enhanced recovery after surgery (ERAS) protocols, even in normally nourished patients. This chapter hones the general surgery research to orthopedic application. It details clinical and immediate metabolic therapy strategies to support patients undergoing orthopedic surgery.

Physicians are personally consuming and recommending nutrients to their patients, with a majority in the orthopedic and cardiology specialties. It appears timely, then, that they consider the abundant literature on this topic and begin prescribing specific diet, nutrient and exercise regimens to benefit patient outcomes.⁴ Many of today’s orthopedic surgeries are elective, providing a generous preoperative (preop) window to prepare a willing patient to achieve the best result possible. The orthopedic surgical substrate of bone, muscle, and connective tissue represents the body’s stockpile of protein, pH buffering, and minerals. Metabolic intervention to support these tissues offers a strategic leverage point to improve outcomes.

Orthopedic procedures occur disproportionately among patients with preexisting deconditioning, sarcopenia, and/or obesity. Self-directed patient metabolic efforts can be focused by physician guidance in the perioperative period and could also reduce the use of dietary supplements that can create unwanted complications in the perioperative period as the use of supplemental nutrients frequently occurs unbeknownst to the treating physician despite detailed intake history.⁵

Clinical behavior changes slowly and implementation of perioperative nutrition support is compounded by the fact that most physicians have had little opportunity for training in the use of nutrient therapies. Orthopedic fast-track clinical pathways rarely include a detailed discussion on nutrition beyond identifying those who are malnourished. In today’s healthcare environment shortening hospital length of stay, limiting the use of opioids, and reducing readmission through an organizational, multimodal approach creates many challenges. The combination of patient interest in optimizing their personal outcome with an impending surgical event creates a superb opportunity to spark meaningful patient compliance in a perioperative metabolic therapy program.

Epidemiology

With the trends of increased outpatient surgeries, shortened inpatient surgical stays, rising prevalence of obesity and bariatric surgery, published surgical results for hospitals, and a greater reliance on the primary physician for follow-up care, there is great opportunity to expand the outcomes horizon beyond the challenges of surgical technique. Engaging the support of willing non-surgical clinicians to reduce perioperative risks can facilitate recovery and meaningfully improve outcomes.

The prevalence of obesity has more than doubled in the last 30 years. There has been a concurrent increase in total calories consumed primarily in the form of carbohydrates and a slight decrease in the amount of protein calories.⁶ Obesity has increased the incidence of arthritic conditions requiring orthopedic procedures in younger adults, with greater complication rates of wound infection, deep venous thrombosis, cardiac events, and anesthesia risks.^{7 – 10} Obesogenic sarcopenia increases these risks.¹¹ See Chapter 10 for detailed review.

Perioperative Metabolic Risks

The combination of years of nutrient depletion due to poor diet, polypharmacy¹², obesogenic sarcopenia, disease-related malnutrition, advanced age, and deconditioning creates a challenging perioperative landscape for the orthopedic patient. Even anticipation of the procedure increases stress and can interfere with sleep. Activity restriction and pain, particularly in the lower limbs commonly promotes deconditioning with secondary loss of lean body mass creating an additional risk in the form of sarcopenia, which is associated with unfavorable outcomes.¹³ With inactivity, the patient frequently has a significant decline in vitamin D levels negatively influencing bone healing. Joint disease and subsequent surgery increases demand on the contralateral limb, increasing the risk of additional surgery.¹⁴ The restriction of nutrients during the NPO period prior to surgery initiates catabolism of lean tissue and dehydration and sets the stage for postoperative insulin resistance and hyperglycemia in diabetics. Eliminating medications and nutrients targeted for pain management prior to this can increase pain, immobility, and the need for additional narcotic analgesia. Surgery induces major catabolic stress as an inflammatory response creating a hyperimmune state and the associated depletion of many conditionally essential nutrients. This is understandably followed by immunosuppression due to exhausted substrates, increasing the risk of infection¹⁵ and postoperative complications. This severe challenge to the exquisitely balanced TH1 and TH2 immune autoregulation system deserves further consideration as the contextual foundation for further research in perioperative metabolic therapy which has been elegantly reviewed by Smit, et al.¹⁶ The chronic pain of advanced osteoarthritis is associated with sleep complaints in 67%–88% of patients, both of which share additional co-morbidities such as obesity, type 2 diabetes, and depression.¹⁷ Frequently, the patient has myofascial pain, which several studies found to significantly impair sleep quality as well.¹⁸ The majority of potentially addictive prescription sleep medications actually decrease time spent in the restorative sleep stages 3 and 4. Use of these medications should be sparing and balanced with other sleep strategies to avoid long term dependence and challenging withdrawal symptoms. Non-pharmacological sleep treatments are preferable, which presents a major opportunity for perioperative pain management in this age of polypharmacy and opioid addiction.¹⁹

After surgery, post-anesthesia nausea and vomiting (PONV) and immobilization can advance catabolic wasting and limit nutrient intake. Wound healing and blood loss increase demand for many nutrients well in excess of normal dietary intake, so consuming a “regular diet” is highly unlikely to fully meet the metabolic demands for optimal healing.²⁰

Enhanced Recovery after Surgery Guidelines

ERAS protocols have been developed to provide multimodal clinical support pathways to address the challenges of the perioperative period and have been demonstrated worldwide to be cost-effective and improve outcomes for a variety of surgical procedures.²¹ This idea was pioneered 20 years ago²² as a method for treating patients following colonic surgery. The focus in orthopedics currently is on the high-volume procedures of total joint arthroplasty (nearly 1,000,000 knee and hip procedures in the US annually)²³ and more recently of spine surgery. ERAS protocols are grouped in three multidisciplinary guideline bundles: preoperative, intraoperative, and postoperative.

The preop phase includes education and management of patient expectations for outcomes and pain control before and after surgery as well as the ERAS process; physiotherapy functional and cardiopulmonary (6 min walk test) evaluations; dietary assessment [there are several that have been validated: Mini Nutrition Assessment (MNA®), Subjective Global Assessment (SGA), and Nutritional Risk Screening (NRS)] to identify nutritional deficiencies combined with preop enteral nutrition – even in normally nourished patients – and minimizing preop fasting period to 2 hours, unless there is documentation of gastroparesis. Preventive analgesia may include pharmacologic intervention with limited opioids, non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and non-pharmacologic interventions to include acupuncture, neuromuscular electrical stimulation for knee and hip arthroplasty (NMES),²⁴ pulsed electromagnetic fields therapy (PEMF)²⁵, and early use of metabolic therapies effective in pain management as outlined below.

Intraoperative (intraop) intervention would include minimally invasive surgery, a preference for neuraxial anesthesia, goal directed fluid management,²⁶ and active warming for the avoidance of hypothermia and nausea and vomiting prophylaxis. Postoperative (postop) guidelines include early physiotherapy and mobilization, aggressive managements of PONV, balanced pain control with careful attention to minimizing narcotic analgesics, gum chewing to facilitate peristalsis and early return to oral diet and nutrition support formulas for at least 7 days, early discharge to home, and dynamic postop rehab progression for early return to functional activities. Online patient education (PlanAgainstPain.com) regarding pain management with opioids has been developed by the Choices Matter campaign, recently launched in New York City. For greater detail regarding ERAS approaches, see Reader Resources.

Pharmacology

The use of non-steroidal anti-inflammatory drugs (NSAIDs), cyclo-oxygenase-2 inhibitors, disease-modifying anti-rheumatic drugs (DMARDs), and biologic agents (BAs) in the perioperative period should be evaluated given their impact on the wound healing process. Potential complications include wound dehiscence, infection, impaired collagen synthe...

Table of contents

• Cover
• Half-Title
• Title
• Copyright
• Contents
• Preface
• Acknowledgements
• Editors
• Contributors
• SECTION I Cross-Cutting Technologies
• SECTION II Clinical Approaches to Preventing and Treating Metabolic Dysfunction
• SECTION III Metabolic Therapies for Specific Orthopedic Conditions
• Index