Nutritional Assessment and Interventions in Elective Hip and Knee Arthroplasty: a Detailed Review and Guide to Management

The dynamics of perioperative serum albumin before and after total knee arthroplasty

Background

Previous studies have evaluated preoperative serum albumin (SA) for predicting postoperative complications of total knee arthroplasty (TKA). This study aimed to investigate the dynamics of perioperative SA and changes in SA (ΔSA) and identify any influential patient or surgical factors.

Methods

In total, 381 patients (483 knees) undergoing primary TKA were recruited. SA values preoperatively (SA0), 1 week postoperatively (SA1W), and 4 weeks postoperatively (SA4W) were investigated. SA values were converted to a percentage of SA0 and differences between timepoints were calculated and expressed as follows: ΔSA1W-0, ΔSA4W-1W, and ΔSA4W-0. Patient and surgical factors previously identified or with the potential to influence SA were evaluated.

Results

The median values of SA0, SA1W, and SA4W were 4.4, 3.8, and 4.2 g/dL, respectively; SA0 was significantly different between groups (p < 0.001). The incidence of low SA0 (<3.5 g/dL) was less than 1 %. Median ΔSA values were -13.7 %, 9.6 %, and -4.5 % for ΔSA1W-0, ΔSA4W-1W and ΔSA4W-0, respectively; ΔSA was significantly different between groups (p < 0.001). SA4W recovered to 95.5 % of SA0 with less than 2 % of patients having low SA4W (<3.5 g/dL). Multiple regression analyses showed SA concentration at each timepoint was significantly associated with the other SA timepoint values; age was significantly associated with SA4W and SA1W (all p < 0.001).

Conclusions

We identified SA0 and age as significant factors affecting SA dynamics in the perioperative period. Low SA (<3.5 g/dL) was uncommon both preoperatively and at 4 weeks postoperatively; therefore, conventional cutoff values and preventive measures for low SA may need reconsideration.

Improved outcomes with perioperative dietitian-led interventions in patients undergoing total joint arthroplasty: A systematic review

Background

Nutritional assessment is important for optimization of patients undergoing elective total joint arthroplasty (TJA). Preoperative nutritional intervention is a potentially modifiable optimization target, but the outcomes of such intervention are not well-studied. The purpose of this study is to assess the impact of nutritional interventions on elective TJA outcomes.

Methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized to perform a systematic review of the Ovid Medline, Embase, and Cochrane Library systems. Included studies were comprised of patients greater than 18 years of age undergoing a primary unilateral TJA who received a perioperative dietitian-led intervention. Data analyzed included nutritional intervention protocol, patient demographics, length of stay (LOS), postoperative labs and complications, among others.

Results

Our initial search identified a total of 1766 articles. Four studies representing 5006 patients met inclusion criteria. The studies utilized a protein-dominant diet, with or without a carbohydrate solution accompanied by dietitian assessment or education. The 4 studies found that the intervention group had significantly decreased LOS, fewer albumin infusions, less wound drainage, lower rates of hypocalcemia and hypokalemia, reduced C-reactive protein (CRP) values, improved time out of bed, and decreased overall costs.

Conclusion

The findings support the potential benefits of perioperative dietitian-led intervention on key outcomes for patients undergoing primary TJA. Surgeons should consider nutritional intervention in their preoperative optimization protocols. Future studies could help elucidate the optimum nutritional regimens and monitoring for idealized intervention and surgical timing.

Prospero registration number

CRD4202338494.

Malnutrition in total joint arthroplasty: what should the orthopaedic surgeon consider?

Total joint arthroplasty (TJA) is rising globally, with an associated increase in associated complications, necessitating increased efforts in prevention of these complications with pre-operative optimisation. Malnutrition has been highlighted as one of the most important pre-operative modifiable risk factors to be addressed in TJA, with the term malnutrition in orthopaedic surgery having a broad definition that encompasses a wide range of nutritional abnormalities from undernutrition to overnutrition contributing to the outcomes of TJA. Complications associated with malnutrition include periprosthetic joint infection (PJI), periprosthetic fracture, dislocations, aseptic loosening, anaemia, prolonged length of stay (LOS), increased mortality, and raised health care costs. Standardised nutritional scoring tools, anthropometric measurements, and serological markers are all options available in pre-operative nutritional assessment in TJA, but there is no consensus yet regarding the standardisation of what parameters to assess and how to assess them. Abnormal parameters identified using any of the assessment methods results in the diagnosis of malnutrition, and correction of these parameters of overnutrition or undernutrition have shown to improve outcomes in TJA. With the multiple nutritional parameters contributing to the success of total joint arthroplasty, it is imperative that orthopaedic surgeon has a thorough knowledge regarding nutritional peri-operative optimisation in TJA.

The Role of Perioperative Nutritional Status and Supplementation in Orthopaedic Surgery: A Review of Postoperative Outcomes

» Identification of malnourished and at-risk patients should be a standardized part of the preoperative evaluation process for every patient.» Malnourishment is defined as a disorder of energy, protein, and nutrients based on the presence of insufficient energy intake, weight loss, muscle atrophy, loss of subcutaneous fat, localized or generalized fluid accumulation, or diminished functional status.» Malnutrition has been associated with worse outcomes postoperatively across a variety of orthopaedic procedures because malnourished patients do not have a robust metabolic reserve available for recovery after surgery.» Screening assessment and basic laboratory studies may indicate patients' nutritional risk; however, laboratory values are often not specific for malnutrition, necessitating the use of prognostic screening tools.» Nutrition consultation and perioperative supplementation with amino acids and micronutrients are 2 readily available interventions that orthopaedic surgeons can select for malnourished patients.

Prevalence of Poor Nutrition in Knee Osteoarthritis Patients: A Hospital-Based Cohort Study in Indian Population

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.

Does the geriatric nutritional risk index predict complication rates and implant survivorship in revision total joint arthroplasty?

INTRODUCTION

Malnutrition is associated with poorer outcomes after revision total joint arthroplasty (rTJA), though no universal metric for assessing malnutrition in rTJA patients has been reported. This study sought to determine if malnutrition as defined by the Geriatric Nutritional Risk Index (GNRI) can independently predict short-term complication rates and re-revision risk in patients undergoing rTJA.

METHODS

All patients ≥ 65 years old undergoing rTJA from 2011 to 2021 at a single orthopaedic specialty hospital were identified. Preoperative albumin, height, and weight were used to calculate GNRI. Based on the calculated GNRI value, patients were stratified into three groups: normal nutrition (GNRI > 98), moderate malnutrition (GNRI 92-98), and severe malnutrition (GNRI < 92). Chi-squared and independent samples t-tests were used to compare groups.

RESULTS

A total of 531 rTJA patients were included. Patients with normal nutrition were younger (p < 0.001), had higher BMI (p < 0.001). After adjusting for baseline characteristics, patients with severe and moderate malnutrition had longer length of stay (p < 0.001), were less likely to be discharged home (p = 0.049), and had higher 90-day major complication (p = 0.02) and readmission (p = 0.005) rates than those with normal nutrition. 90-day revision rates were similar. In Kaplan-Meier analyses, patients with severe and moderate malnutrition had worse survivorship free of all-cause re-revision at 1-year (p = 0.001) and 2-year (p = 0.002) follow-up compared to those with normal nutrition.

CONCLUSION

Moderate and severe malnutrition, as defined by GNRI, independently predicted higher complication and revision rates in rTJA patients. This suggests that the GNRI may serve as an effective screening tool for nutritional status in patients undergoing rTJA.

Concomitant malnutrition and frailty are significant risk factors for poor outcome following two-stage revision for chronic periprosthetic joint infection

BACKGROUND

Two-stage revision remains the gold standard for periprosthetic joint infection (PJI) treatment. Although previous studies have examined malnutrition and frailty independently, their cumulative effects are not clear. Therefore, this study aimed to assess the individual and combined influence of malnutrition and frailty on the two-stage revision surgery.

METHODS

Patients with chronic PJI undergoing two-stage revision were retrospectively included. The definition of PJI is completely consistent with the evidence-based definition of PJI recorded by the MSIS in 2018. Preoperative serum albumin levels and 11-item modified frailty index scores were collected. Four cohorts were created: (1) Normal (N), (2) Frail (F), (3) Malnourished (M), and (4) Malnourished and frail (MF). Demographic data, comorbidities, and postoperative complications were collected and compared between the four cohorts.

RESULTS

A total of 117 consecutive patients were enrolled, 48% of patients were healthy (27.4% F, 16.2% M, and 9.4% MF). MF group showed lower scores on the physical composite scale of the 12-item short-form health survey (SF12-PCS), mental composite summary (SF12-MCS), Harris hip score (HHS), and knee society score (KSS) (P < 0.05). The incidence of reinfection in the MF group was higher than that in all other groups (MF vs. N; odds ratio [OR] 3.7, 95% confidence interval [CI] 1.37 - 8.82, P = 0.032). The incidence of complications in the MF group was higher than that in all other groups (MF vs. N; OR 4.81, 95% CI 1.58-9.26, P = 0.018). Postoperative transfusion events (OR 2.92, 95% CI 1.27-3.09, P = 0.021), readmission at 60 days after the operation (OR 4.91, 95% CI 1.82-13.80, P = 0.012) was higher in the MF patients. In addition, the extended length of stay after the operation was highest in the MF patients, with an OR of 5.78 (95% CI 2.16-12.04, P = 0.003).

CONCLUSION

The concurrent presence of concomitant malnutrition and frailty in patients with PJI is related to poor prognosis and may be a predictor of the efficacy of two-stage revision. Future research will be needed to describe the benefits of improving these risk factors for patients with PJI.

Taking a Deeper Dive into Malnutrition and Revision Arthroplasty: When do Nutritionists Get Involved?

BACKGROUND

Perioperative malnutrition is associated with increased complications and mortality following revision total joint arthroplasty (TJA). Nutritional consultations are useful in characterizing patient nutritional status, but are inconsistently utilized post-revision TJA. We sought to describe 1) the prevalence of nutritional consultations post revision TJA, 2) determine if septic revision TJA patients needed consultations more often, and if 3) a diagnosis of 'malnutrition' from the nutritionist conferred increased readmission rates.

METHODS

A retrospective study of 2,697 rTJAs performed in a single institution over a 4-year period was performed. Patient demographics, reasons for revision TJA, occurrences of nutritional consultation (indicated if body mass index (BMI)<20, Malnutrition Screening Tool (MST) score > 2, or poor oral intake postoperatively), specific nutritional diagnosis (according to 2020 Electronic Nutrition Care Process Terminology (eNCPT) and 90-day readmission rates were recorded and analyzed. Rates of consultations and adjusted logistic regressions were calculated.

RESULTS

There were 501 patients (18.6%) who required nutritional consultations, with 55 (11.0%) of these patients receiving a 'malnutrition' diagnosis. Septic rTJA patients required significantly more nutritional consultations (P<0.01) and were significantly more likely to have 'malnutrition' (P=0.49). A diagnosis of malnutrition was associated with highest odds of all-cause readmission (Odds Ratio (OR)=3.89, P=0.01), which was even higher than undergoing a septic revision TJA.

CONCLUSION

Nutritional consultations occur frequently following revision TJA. Patients who receive a diagnosis of 'malnutrition' through consultation are at significantly higher risk for re-admission and require close follow-up. Future efforts are needed to further characterize these patients in order to identify as well as optimize them preoperatively.

Universal Screening for Malnutrition Prior to Total Knee Arthroplasty Is Cost-Effective: A Markov Analysis

BACKGROUND

Patients undergoing total knee arthroplasty (TKA) who have malnutrition possess an increased risk of periprosthetic joint infection (PJI). Although malnutrition screening and intervention may decrease the risk of PJI, it utilizes healthcare resources. To date, no cost-effectiveness analyses have been performed on the screening and treatment of malnutrition prior to TKA.

METHODS

A Markov model projecting lifetime costs and quality-adjusted life years (QALYs) was built to determine the cost-effectiveness of malnutrition screening and intervention for TKA patients from a societal perspective. Costs, health state utilities, and state transition probabilities were obtained from previously published literature, hospital costs at our institution, and expert opinions. Two important assumptions included that 30% of patients would be malnourished and that a malnutrition intervention would be 50% effective. The primary outcome of this study was the incremental cost-effectiveness ratio, with a willingness-to-pay threshold of $100,000 per QALY. One-way and two-way sensitivity analyses were performed to evaluate model parameter assumptions.

RESULTS

When using the base case values, universal malnutrition screening and intervention was cost-effective compared to no malnutrition screening or intervention, with an incremental cost-effectiveness ratio of $6,454 per QALY. Universal screening and intervention remained cost-effective, provided the cost of screening remained less than $3,373, the cost of nutritional intervention remained less than $12,042, the prevalence of malnutrition among surgical candidates was higher than 2%, and the risk of PJI among patients with malnutrition was greater than 1%.

CONCLUSION

Universal preoperative malnutrition screening and intervention among TKA candidates is cost-effective at parameters encountered in clinical practice. Nutritional optimization programs should be considered to facilitate malnutrition screening and intervention and future studies should evaluate their efficacy at lowering PJI risk.

Moderate-to-Severe Malnutrition Identified by the Controlling Nutritional Status (CONUT) Score Is Significantly Associated with Treatment Failure of Periprosthetic Joint Infection

The prevalence and role of malnutrition in periprosthetic joint infection (PJI) remain unclear. This study aimed to use measurable nutritional screening tools to assess the prevalence of malnutrition in PJI patients during two-stage exchange arthroplasty and to explore the association between malnutrition and treatment failure. Our study retrospectively included 183 PJI cases who underwent 1st stage exchange arthroplasty and had available nutritional parameters, of which 167 proceeded with 2nd stage reimplantation. The recently proposed Musculoskeletal Infection Society (MSIS) Outcome Reporting Tool was used to determine clinical outcomes. The Controlling Nutritional Status (CONUT), Nutritional Risk Index (NRI), and Naples Prognostic Score (NPS) were used to identify malnutrition at 1st and 2nd stage exchange, respectively. Multivariate logistic regression analyses were performed to determine the association between malnutrition and treatment failure. Restricted cubic spline models were further used to explore the dose−response association. Additionally, risk factors for moderate-to-severe malnutrition were evaluated. Malnourished patients identified by CONUT, NPS, and NRI accounted for 48.1% (88/183), 98.9% (181/183), and 55.7% (102/183) of patients at 1st stage, and 9.0% (15/167), 41.9% (70/167), and 43.1% (72/167) at 2nd stage, indicating a significant improvement in nutritional status. We found that poorer nutritional status was a predictor of treatment failure, with CONUT performing best as a predictive tool. Moderate-to-severe malnutrition at 1st stage identified by CONUT was significantly related to treatment failure directly caused by PJI (odds ratio [OR] = 5.86), while the OR was raised to 12.15 at 2nd stage (OR = 12.15). The linear dose−response associations between them were also confirmed (P for nonlinearity at both 1st and 2nd stage > 0.05). As for total treatment failure, moderate-to-severe malnutrition as determined by CONUT was associated with a 1.96-fold and 8.99-fold elevated risk at the 1st and 2nd stages, respectively. Age ≥ 68 years (OR = 5.35) and an increased number of previous surgeries (OR = 2.04) may be risk factors for moderate-to-severe malnutrition. Overall, the prevalence of malnutrition in PJI patients is very high. Given the strong association between moderate-to-severe malnutrition identified by CONUT and PJI treatment failure, COUNT could be a promising tool to evaluate the nutritional status of PJI patients to optimize treatment outcomes.