Perioperative nutritional supplementation and skeletal muscle mass in older hip-fracture patients

Effect of Comprehensive Rehabilitation Training Based on Balance Function on Postoperative Recovery and Function of Hip Fracture in the Elderly: A Systematic Review and Meta-Analysis

Introduction

In China, the proportion of the elderly population is gradually increasing, followed by the increasing medical demands of elderly patients. Hip fracture is a common fracture in the elderly. The elderly are prone to serious postoperative complications, resulting in failure to restore normal hip function, which seriously affects patients' quality of life and further increases their mortality rate. Thus, hip fracture represents a remarkable public health issue within the realm of geriatric medical care.

Significance

This study systematically evaluated the impact of comprehensive rehabilitation training, with a focus on balance function, on elderly individuals with hip fractures' postoperative recovery and functional outcomes.

Result

Results showed a significant difference in BBS scores favoring comprehensive rehabilitation training based on balance function over conventional intervention. Similarly, AM-PAC scores favored the balance-focused training. TUTG meta-analysis indicated its adoption in comprehensive rehabilitation training. FIM scores showed improvement with balance-focused training. Harris score meta-analysis also favored this approach. A funnel plot analysis revealed potential publication bias, likely due to study heterogeneity and limited publications.

Conclusions

In conclusion, comprehensive rehabilitation training centered around balance function displayed clinical efficacy in enhancing postoperative hip joint function in elderly hip fracture patients. This approach improved balance, coordination, and posture control, facilitating lower limb function recovery and overall prognosis. It holds promise as a valuable treatment approach.

Nutrition, Vitamin D, and Calcium in Elderly Patients before and after a Hip Fracture and Their Impact on the Musculoskeletal System: A Narrative Review

Hip fractures are a major health issue considerably impacting patients' quality of life and well-being. This is particularly evident in elderly subjects, in which the decline in bone and muscle mass coexists and predisposes individuals to fall and fracture. Among interventions to be implemented in hip fractured patients, the assessment and management of nutritional status is pivotal, particularly in subjects older than 65. Nutrition plays a central role in both primary and secondary preventions of fracture. An adequate protein intake improves muscle mass and strength and the intestinal absorption of calcium. Other nutrients with recognized beneficial effects on bone health are calcium, vitamins D, K, and C, potassium, magnesium, folate, and carotenoids. With reference to calcium, results from longitudinal studies showed that the consumption of dairy foods has a protective role against fractures. Moreover, the most recent systematic reviews and meta-analyses and one umbrella review demonstrated that the combination of calcium and vitamin D supplementation significantly reduces hip fracture risk, with presumed higher efficacy in older and institutionalized subjects. Owing to these reasons, the adequate intake of calcium, vitamin D, protein, and other macro and micronutrients has been successfully implemented in the Fracture Liaison Services (FLSs) that represent the most reliable model of management for hip fracture patients. In this narrative review, papers (randomized controlled trials, prospective and intervention studies, and systematic reviews) retrieved by records from three different databases (PubMed, Embase, and Medline) have been analyzed, and the available information on the screening, assessment, and management of nutritional and vitamin D status and calcium intake in patients with hip fractures is presented along with specific prevention and treatment measures.

Malnutrition-Related Health Outcomes in Older Adults with Hip Fractures: A Systematic Review and Meta-Analysis

Hip fracture is a common condition in older adults, leading to disability and mortality. Several studies have demonstrated the association between nutritional status and the risk of a negative health outcome after fractures. In this systematic review, we evaluated the association between malnutrition and mortality, changes in mobility/living arrangements, and postoperative complications, such as delirium, in older patients with hip fractures. A literature search on the PubMed, Web of Science, and Scopus databases, up to September 2023, was conducted to identify all studies involving older subjects that reported an association between MNA/GNRI/PNI/CONUT and health outcome after hip fracture. Meta-analysis was performed by a random-effects model using risk values (RR, OR, and HR) extracted from the 14 eligible selected studies. Malnutrition significantly increased the risk of any analyzed adverse outcome by 70% at 1 month, and up to 250% at 1 year. Malnutrition significantly increased delirium risk by 275% (OR = 2.75; 95% CI 1.80-4.18; p ≤ 0.05), mortality risk by 342% (OR = 3.42; 95% CI 2.14-5.48; p ≤ 0.05), mortality hazard risk by 351% (HR = 3.51; 95% CI 1.63-7.55; p ≤ 0.05) at 1 month, and transfer-to-more-supported-living-arrangements risk by 218% (OR = 2.18; 95% CI 1.58-3.01; p ≤ 0.05), and declined mobility risk by 41% (OR = 1.41; 95% CI 1.14-1.75; p ≤ 0.05), mortality risk by 368% (OR = 3.68; 95% CI 3.00-4.52; p ≤ 0.05), and mortality hazard risk by 234% (HR = 2.34; 95% CI 1.91-2.87; p ≤ 0.05) at 1 year. Malnutrition of older patients increases the risk of death and worsens mobility and independence after hip fractures. The results of the present study highlight the importance of nutritional status evaluation of older subjects with hip fractures in order to prevent potential adverse outcomes (Registration No: CRD42023468751).

Ultrasound evaluation of gastric emptying time of standardized high-calorie liquid meals in healthy adults: A double-blind cross-over randomized study

BACKGROUND AND AIMS

Commercially available high-calorie drinks containing fat and protein can be used as dietary supplements in surgical patients. According to preoperative fasting guidelines, high-calorie drinks are non-clear fluids and should not be consumed 6 h before elective procedures. The aim of this study was to evaluate the gastric emptying time of commercially available high-calorie drink formulations in healthy adults using gastric ultrasound.

METHODS

25 healthy adult volunteers were included in this double-blind, cross-over prospective study. On three study sessions, fasted volunteers ingested one of the three study products: a solution of 75 g of glucose in 200 ml of water, a fat-free liquid meal, and a nutritionally complete liquid meal with equal volume and energy content. Gastric ultrasound examinations were performed to evaluate the gastric contents qualitatively and the volume of the gastric contents was calculated from the cross-sectional area of the gastric antrum measured in right lateral position by using a validated model. Repeated gastric ultrasounds were performed at baseline and half-hourly after ingesting the products in supine and right lateral position until the criteria for an empty stomach were met.

RESULTS

The glucose solution and the standard fat-free high-calorie drink with the same caloric content had a median gastric emptying time of 150 min. The nutritionally complete liquid meal had a median gastric emptying time of 180 min. Gastric emptying was complete in all participants before 6 h had elapsed since ingesting the study products.

CONCLUSIONS

High calorie liquid meals have a gastric emptying time longer than the recommended fasting time for clear fluids, but shorter than the recommended fasting time for solids in healthy adults.

Loss of Muscle Mass and Strength After Hip Fracture: an Intervention Target for Nutrition Supplementation

PURPOSEOF REVIEW

To summarize what is known about the deleterious effect of hip fracture on muscle mass and strength as well as the scientific evidence for post-surgical nutrition supplementation to maintain muscle and improve function.

RECENT FINDINGS

This review provides a discussion of the relationship between muscle mass, strength, and physical function following hip fracture, briefly describes the approaches to measuring lean mass, discusses prevalence of sarcopenia and malnutrition among older men and women with hip fracture, and reviews the effects of essential amino acids on muscle. Loss of muscle mass and strength following hip fracture is substantial with consequences for recovery of functional independence. EAA-based nutrition supplementation, which directly effects muscle, has potential to improve outcomes.

Modified Frailty Index Combined with a Prognostic Nutritional Index for Predicting Postoperative Complications of Hip Fracture Surgery in Elderly

Aim: There is currently no consensus on the best risk assessment technique for predicting complications after hip surgery in the elderly, which is hindering the accuracy of surgical risk assessment. The goal of this study was to build a risk assessment model and evaluate its predictive value using the modified frailty index (5-mFI) and the prognostic nutritional index (PNI).Methods: A retrospective investigation was undertaken on 150 patients (aged ≥60 years) who had hip fracture surgery. Using univariate and multivariate logistic regression models, the relationship between combined 5-mFI and PNI and the evaluation of postoperative unfavorable outcomes such as infection and unscheduled intensive care unit (ICU) admission was investigated. Finally, utilizing receiver operating characteristic (ROC) curve analysis, the model's predictive value for adverse outcomes following hip fracture surgery in elderly patients was assessed.Results: Univariate and multivariate logistic analyses revealed that preoperative PNI, 5-mFI, ASA, and gender acted as independent predictors of adverse outcomes after hip fracture surgery in the elderly. According to the ROC curve analysis, the predictive model demonstrated a high predictive value for total postoperative complications (AUC: 0.788; 95%CI: 0.715-0.860; p<0.01), infectious complications (AUC: 0.798; 95% CI: 0.727-0.868; P<0.001), and unplanned ICU admission (AUC: 0.783; 95% CI: 0.705-0.861; P<0.001).Conclusions: The multivariable evaluation model, which included 5-mFI and PNI, showed a high predictive value and can hence be applied to predict the adverse outcomes in elderly patients undergoing hip fracture surgery.

Mapping Knowledge Structure and Themes Trends of Post-operative Rehabilitation of Hip Fractures in the Elderly: A Bibliometrics and Visualization Study

Background

Hip fractures are a common type of fracture in the elderly and are characterized by many complications and high mortality. Many topics concerning postoperative rehabilitation of hip fracture in elderly people still remain controversial, and the global research trend in this field has not yet been well studied. The aim of the present study was to illustrate the overall knowledge structure, development trends, and research hot spots of postoperative rehabilitation of hip fracture in elderly people.

Methods

Articles and reviews regarding postoperative rehabilitation of hip fracture in elderly people from 2001 to 2021 were identified from the Web of Science database. An online bibliometric platform, CiteSpace, and VOSviewer software were used to generate visualization knowledge maps, including annual trends of publications, contributions of countries, institutions, authors, funding agencies, and journals, and clustering of keywords.

Results

A total of 1,724 publications were identified from Web of Science Core Collection (WoSCC). In the past 20 years, the number of published studies on the rehabilitation of hip fracture in the elderly has exhibited an overall upward trend. The USA was the leading contributor in this field, with the largest number of publications (354, 20.65%) and the most citations (13,786 times). The international cooperation map among relevant countries/regions indicated that the USA collaborated most closely with Canada and China. The University of Maryland and Professor Marcantonio were the most prolific institution and influential author, respectively. Injury: International Journal of the Care of the Injured was the most productive journal concerning the research of postoperative rehabilitation of hip fracture in elderly people. The keyword co-occurrence analysis identified six clusters: quality of life study, rehabilitation and outcomes study, cognitive impairment study, operative approaches study, mortality study, and osteoporosis study.

Conclusions

There will be an increasing number of publications on the research of postoperative rehabilitation of hip fracture in elderly people, and the United States will stay ahead in this field. Our findings could offer practical sources for scholars to understand the current status and trend of studies on rehabilitation of hip fracture in the elderly and provide references and suggestions for the development of related research in future.

Perioperative Nutritional Support: A Review of Current Literature

Since the beginning of the practice of surgery, the reduction of postoperative complications and early recovery have been two of the fundamental pillars that have driven the improvement of surgical techniques and perioperative management. Despite great advances in these fields, the rationalization of antibiotic prophylaxis, and other important innovations, postoperative recovery (especially in elderly patients, oncological pathology or digestive or head and neck surgery) is tortuous. This can be explained by several reasons, among which, malnutrition has a major role. Perioperative nutritional support, included within the ERAS (Enhanced Recovery After Surgery) protocol, has proven to be a main element and a critical step to achieve better surgical results. Starting with the preoperative nutritional assessment and treatment in elective surgery, we can improve nutritional status using oral supplements and immunomodulatory formulas. If we add early nutritional support in the postoperative scenario, we are able to significantly reduce infectious complications, need for intensive care unit (ICU) and hospital stay, costs, and mortality. Throughout this review, we will review the latest developments and the available literature.

Optimization of transdisciplinary management of elderly with femur proximal extremity fracture: A patient-tailored plan from orthopaedics to rehabilitation

Fractures of femur proximal extremity (FFPE) are the most common fragility fractures requiring hospitalization, with a high risk of mortality, low independence in the activities of daily living and severe consequences on health-related quality of life. Timing for surgery has a key role in the management of elderly patients with FFPE as recommended by the Australian and New Zealand guidelines and the National Institute for Health and Care Excellence guidelines. Early surgery (within 48 h from hospital admission) allows significant benefits in terms of lower rates of postoperative complications and risk of death and can provide better functional outcomes. Therefore, time for surgery could be considered as a comorbidity marker. The choice between conservative or surgical approach surprisingly seems to be still not strongly supported by available literature, but it seems that both 30 d and 1 year risk of mortality is higher with the conservative treatment rather than with surgery. In light of these considerations, the optimization of FFPE management care is mandatory to improve functional outcomes and to reduce sanitary costs. Albeit it is widely accepted that transdisciplinary approach to patients suffering from FFPE is mandatory to optimize both short-term and long-term outcomes, the feasibility of a comprehensive approach in clinical practice is still a challenge. In particular, the large variability of figures involved could be considered both a resource and an additional disadvantage taking into account the difficulty to coordinate multidisciplinary approach covering care in all settings. Therefore, the aim of the present article was to summarize current evidence supporting transdisciplinary management of patients with FFPE, highlighting the benefits, feasibility and limitations of this approach.

Feasibility and preliminary effect of anabolic steroids in addition to strength training and nutritional supplement in rehabilitation of patients with hip fracture: a randomized controlled pilot trial (HIP-SAP1 trial)

Background

Anabolic steroid has been suggested as a supplement during hip fracture rehabilitation and a Cochrane Review recommended further trials. The aim was to determine feasibility and preliminary effect of a 12-week intervention consisting of anabolic steroid in addition to physiotherapy and nutritional supplement on knee-extension strength and function after hip fracture surgery.

Methods

Patients were randomized (1:1) during acute care to: 1. Anabolic steroid (Nandrolone Decanoate) or 2. Placebo (Saline). Both groups received identical physiotherapy (with strength training) and a nutritional supplement. Primary outcome was change in maximal isometric knee-extension strength from the week after surgery to 14weeks. Secondary outcomes were physical performance, patient reported outcomes and body composition.

Results

Seven hundred seventeen patients were screened, and 23 randomised (mean age 73.4years, 78% women). Target sample size was 48. Main limitations for inclusion were not home-dwelling (18%) and cognitive dysfunction (16%). Among eligible patients, the main reason for declining participation was Overwhelmed and stressed by situation (37%). Adherence to interventions was: Anabolic steroid 87%, exercise 91% and nutrition 61%. Addition of anabolic steroid showed a non-significant between-group difference in knee-extension strength in the fractured leg of 0.11 (95%CI -0.25;0.48) Nm/kg in favor of the anabolic group. Correspondingly, a non-significant between-group difference of 0.16 (95%CI -0.05;0.36) Nm/Kg was seen for the non-fractured leg. No significant between-group differences were identified for the secondary outcomes. Eighteen adverse reactions were identified (anabolic=10, control=8).

Conclusions

Early inclusion after hip fracture surgery to this trial seemed non-feasible, primarily due to slow recruitment. Although inconclusive, positive tendencies were seen for the addition of anabolic steroid.

Trial registration

Clinicaltrials.gov NCT03545347.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02273-z.

Incidence, morbidity and mortality of hip fractures over a period of 20 years in a health area of Southern Spain

OBJECTIVE

To evaluate the incidence of osteoporotic hip fracture in the Macarena Health Area (Seville).

SETTING AND PARTICIPANTS

This was a prospective observational study that collected all osteoporotic hip fractures that occurred between March 2013 and February 2014 at the Clinical Unit of Traumatology and Orthopaedics. All cases collected during the first 6 months of the study were followed for 1 year after the occurrence of the event.

OUTCOME MEASURES

We evaluated the incidence of osteoporotic hip fractures in the Macarena Health Area (Seville) from 1 March 2013 to 28 February 2014, and we compared the incidence with that in 2 previous studies carried out with the same methodology in 1994 and 2006. Furthermore, we calculated the morbidity and degree of disability 1 year after the fracture occurred and determined mortality and the associated factors.

RESULTS

The overall incidence was 228 per 100 000 individuals/year (95% CI 204.5 to 251.6), and the incidence was higher in women than in men. In women, the incidence rate decreased in all age groups over time, while in men, the incidence rate increased. The mortality rate 1 year after the episode was 27.2%. The factors associated with overall mortality were a body mass index below 25 kg/m², renal failure and low plasma proteins.

CONCLUSIONS

Our results show a high incidence of osteoporotic hip fracture that is increasing in men, and in men it is associated with a higher mortality than in women. There is room to improve the modifiable factors associated with mortality and the available rehabilitation interventions to reduce the disability associated with these fractures.

Physical Activity and Diet Shape the Immune System during Aging

With increasing age, the immune system undergoes a remodeling process, termed immunosenescence, which is accompanied by considerable shifts in leukocyte subpopulations and a decline in various immune cell functions. Clinically, immunosenescence is characterized by increased susceptibility to infections, a more frequent reactivation of latent viruses, decreased vaccine efficacy, and an increased prevalence of autoimmunity and cancer. Physiologically, the immune system has some adaptive strategies to cope with aging, while in some settings, maladaptive responses aggravate the speed of aging and morbidity. While a lack of physical activity, decreased muscle mass, and poor nutritional status facilitate immunosenescence and inflammaging, lifestyle factors such as exercise and dietary habits affect immune aging positively. This review will discuss the relevance and mechanisms of immunoprotection through physical activity and specific exercise interventions. In the second part, we will focus on the effect of dietary interventions through the supplementation of the essential amino acid tryptophan, n-3 polyunsaturated fatty acids, and probiotics (with a special focus on the kynurenine pathway).

Role of dietary protein and exercise on biomarkers of immune activation in older patients during hospitalization

The aim of this study was to examine the effect of short-term protein supplementation (aiming to consume 1.2 g protein/kg body weight per day) combined with moderate resistance training on 3 days of the week on tryptophan-kynurenine metabolism in 40 older patients with hip fracture. Secondary outcomes for physical recovery were hand-grip strength and chair-rise score. Older patients with hip fracture exhibited higher degrees of immune activation, detected by increased neopterin and kynurenine to tryptophan levels compared with reference values for healthy elderly with no significant differences between those who received the exercise-protein intervention compared to the control. Increasing dietary protein intake during hospitalization did not alleviate the Th1-type immune response in the elderly patient. On the other hand, muscularity per se may affect immune activation responses following injury, as improvements in maximum hand-grip strength with the intervention were related to decreases in neopterin levels.