One of the most successful strategies for improved outcome, especially in arthroplasty, is to advise a patient to lose weight if needed; and to recommend exercise that will keep the involved muscles strong, flexible, and ready to endure the rehabilitation required post surgery. What is often not addressed is the nutritional status of the perioperative patient. A diet deficient in protein, vitamins, and minerals may impede tissue/bone repair and remodelling, and may negatively affect wound healing and result in a less than optimal surgical outcome.
A recent study reported in The Journal of Bone and Joint Surgery noted a vitamin D deficiency in 50 per cent of patients undergoing orthopedic surgery. Vitamin D is known to be crucial to bone healing and muscle function and also has a suggested role in immune function. It is essential to correct any deficiency of this nutrient prior to surgery. Depending on how deficient a person is, using 2,000 to 4,000IU daily should correct this deficiency in most cases. Most bone remodelling and bone tissue formation, as part of the healing process, occurs at two to four weeks post surgery. Therefore, this is a critical time when the body requires adequate vitamin D.
Other nutrients to consider for their role, specifically in tissue formation, bone remodelling and wound healing, include:
Vitamin A may enhance healing in the early inflammatory phase by activating monocytes and macrophages at the wound site. Vitamin A also improves epithelial formation, bone formation and cellular differentiation, and stimulates the immune response. Prior to surgery, patients who are known to be depleted in vitamin A, are immune compromised, have been treated with steroids,or have fractures, tendon damage or sepsis, may all benefit from vitamin A supplementation. Although there is some reluctance to supplement due to toxicity, most toxicity cases reported exceed dosing of 50,000 IU over a period of weeks to years. Using 25,000 international units (IU) for a short period of time, for most patients, does not appear to pose any risk of toxicity.
This is a key component in the cellular matrix of skin, bone, capillaries, and connective tissue and is an essential cofactor in collagen formation. Vitamin C stimulates neutrophil function, increases angiogenesis and acts as a powerful antioxidant. Supplementation of one to two grams may positively affect wound healing and collagen formation. Considering the safety profile of vitamin C, this dosing is conservative and may be increased based on the metabolic needs of the patient.
Copper is an important mineral cofactor for the enzymes involved in the cross linking of collagen and elastin. It is also imperative for repair and maintenance of bone formation and influences fracture healing time.
Plasma levels of copper drop rapidly after surgery. It is important to note both high levels of zinc and vitamin C can decrease copper absorption. The optimal ratio of zinc to copper is 10:1. In most cases if zinc is supplemented at 30 mg, copper would be dosed at 3 mg. Although copper toxicity is rare and 10 mg is considered safe, it can cause nausea at doses of 60 mg or higher. It is best for the average person to stay close to the 3 mg/day for supplementation.
Iron is in every cell of the body and is present in many enzymes, acting as a catalyst especially in energy production. It also plays a vital role in immune function. Deficiency interferes with wound healing due to tissue hypoxia and decreases the ability of leukocytes to kill bacteria, thus increasing the risk of wound infection. Restless leg syndrome is a common complaint in those with low iron levels. The population at greatest risk of iron deficiency includes the elderly. This can be due to poor dietary intake along with reduced absorption due to low hydrochloric acid. Iron toxicity is rare and intakes of up to 75 mg/day are in most cases safe. Due to the possible connection between heart disease and high serum iron, it is best to have blood levels checked, including ferritin levels. Supplementing with 30 mg twice daily is a safe and effective dose for bringing levels into the normal range.
This is a necessary cofactor in more than 300 enzyme reactions in the body. It is required for DNA synthesis, cell division, protein synthesis and immune function. Poor wound healing has been associated with zinc deficiency. Supplementation with 15-30 mg of zinc is a safe and effective perioperative strategy to ensure adequate zinc levels.
RECOMMENDING A MULTIVITAMIN
From the nutrients already discussed, it would seem prudent to recommend, at the very least, a good comprehensive multiple vitamin-mineral supplement be used a few weeks to months leading up to surgery.
There is a study in progress in the Netherlands addressing the nutrient status of elderly patients admitted for hip surgery. It is estimated that the prevalence of malnutrition is as high as 63 per cent in this population group. Poor nutrient status is associated with impaired muscle function, disability, prolonged rehabilitation time, and increased mortality. The study will investigate the outcome of dietary intervention, consisting of a combination of dietetic counselling and oral supplementation, upon admission for surgery and extending up to three months post discharge. The results from this study are expected in early 2011. The study is limited truly to the perioperative patient and does not address a long preparatory pre-surgical strategy for nutritional status. It would be very interesting to further assess the effects of supplementation six months prior to and post surgery, compared to a placebo group. The rate of postoperative infection, healing time and pain scale evaluation would be valuable outcome measures to consider.
THE POWER OF PROTEIN
Adequate protein intake is another very important macronutrient to consider in the surgical patient. Protein provides the keybuilding blocks for so many structures in the body. In order to support a range of mechanisms that includes wound healing, collagen formation, enzyme formation, function, and provision of tensile strength in wound healing, protein intake must be maximized. The increased metabolic stress of surgery alone can increase the need from the average 0.8g/kg/day by 10 per cent. Muscle strength and repair rely on adequate protein intake – this should be considered patients, who should be doing all they can to ensure muscle strength and mass are at optimal levels prior to surgery, as post-surgery muscle wasting is inevitable. Ensuring a good baseline going into surgery is prudent. Adding a quality source protein powder, such as whey, to the dietary regime to ensure protein intake is optimized is a good plan. Quality protein powders should also supply a beneficial amount of glutamine. This amino acid is lost from skeletal muscle with injury/surgery and needs to be replaced.
A possible complication from any surgery that is not necessarily discussed per se, often, is myocardial and cerebrovascular ischemia. Badner et al. discusses mitigating the negative effects of increased nitrous oxide induced postoperative plasma homocysteine. Elevated homocysteine increases a patient’s risk of these ischemias. This risk may be mitigated by preoperative vitamin B supplementation. This study evaluated patients undergoinghip/knee arthroplasty. The study group received a B vitamin containing folic acid, as well as B12, and B6 aimed at ensuring proper homocysteine management, and were compared to a placebo group. The results showed the supplemented group did not experience the increase in postoperative homocysteine compared to the placebo group. This result could be extrapolated to support the notion that vitamin B supplementation may reduce the risk of homocysteine-related ischemic events.
Glucosamine is the key rate-limiting ingredient in the production of hyaluronic acid, which is an important component of the extracellular matrix and main glycosaminoglycans in tissue repair. A study in The Lancet already has demonstrated the role of glucosamine in the management of pain and progression of osteoarthritis (OA) due to its effects in preservation of cartilage. This would support its use long term prior to surgical intervention. Supplementing with glucosamine pre and post surgery may increase hyaluronicacid production, and hence improve overall healing – therefore, it could be indicated as an element of perioperative nutritional preparation, even if the intent is not for OA management, as it is currently best known for.
REDUCINGTHE RISK OF CLOT FORMATION
Lastly, a common complication of surgeries, especially hip/knee athroplasty, is the risk of developing postsurgical venous thromboembolism (VTE) and deep vein thrombosis (DVT). These are noted to occur inapproximately 40-60 per cent and 10-30 percent of patients respectively seven and 14 days post surgery. It has become common protocol to recommend thromboprophylaxis after these surgeries. Although pharmaceuticals such as warfarin, and heparins are routinely used, there is the issue of bleeding complications and proper balance in using these medications along with patient compliance. To prevent these complications and reduce risk, it might be worth considering the positive hemodynamic effects of using vitamin E, essential fatty acids, and enzymes, such as Nattokinase, that may reduce the risk of clot formation. This, of course, as with all supplementation around the time of surgical procedure, should be discussed with the patient’s health care provider and surgeon.
Overall, it is clear that the nutritional status of any surgical patient must be considered to ensure the best possible outcome. Addressing common nutrient deficiencies well in advance of surgery is prudent and not only may enhance healing time, but may also prevent negative side effects that can be debilitating. The use of a good comprehensive multivitamin, B complex, and additional vitamin C, poses little risk yet offers a worthy insurance policy to consider. Adequate protein status is another important area that will improve overall health and healing. Nutritional recommendations along with ideal weight management, exercise and strength training especially in hip/knee replacements will improve overall outcome for the patient.