Surgeons tend to focus on the technical details in their efforts to optimize the results of shoulder arthroplasty. However, the outcome realized by the patient is critically dependent on the patient's ability to recover, heal, and resist infection after this major surgical intervention. Our colleagues Hafiz Kassam and Reza Jazayeri recently published an informative article, Shoulder Arthroplasty and Infection: Why Nutrition Matters.
They point out that, on one hand, shoulder arthroplasty presents a major challenge to the patient's metabolism and, on the other hand, many patients having arthroplasty are metabolically underpowered. They point out that surgery triggers a hypermetabolic-catabolic cascade "characterized by protein breakdown, insulin resistance, and sharply increased amino acid demands—requirements that more than 50% of patients fail to meet. Importantly, multiple studies demonstrate that perioperative nutritional optimization improves outcomes and lowers complication rates even in patients who appear “healthy” and are not overtly malnourished. Nutritional optimization is therefore emerging as best practice for all elective arthroplasty patients, not only those deemed high risk."Malnutrition in elective shoulder arthroplasty: a multi-institutional retrospective study of preoperative albumin and adverse outcome
The authors of The Role of Perioperative Nutritional Status and Supplementation in Orthopaedic Surgery: A Review of Postoperative Outcomes) suggest this easy to apply screening tool.
Common serologic markers of nutritional insufficiency include serum albumin, transferrin, and complete blood count (CBC) with total lymphocyte count (TLC). Most clinicians use the following cutoff values to define malnutrition: serum albumin <3.5 mg/dL, transferrin <200 mg/dL, and TLC <1,500 cells/mm3.
What to do about malnutrition?
Because nutrition can be complex, especially for patients with comorbidities, enlisting the partnership of the patient's primary provider and perhaps a dietician is advisable.
Here are some general thoughts.
(1) the “right” pre-operative protein dose depends on factors such as the patient’s nutritional status, underlying disease, renal function, degree of catabolism, and timing before surgery.
(2) a target of 1 gram of protein per day per pound of body weight is often suggested unless there are contraindications, such as impaired kidney or liver function.
(3) start this program one month prior to surgery and continue for a month after surgery.
(4) consider a modest protein-containing drink (or essential amino acids) up to some hours before surgery (within limits allowed by anesthetic fasting guidelines).
(5) hypothetical example of daily diet for a 150 lb patient:
breakfast (35 g): 3 eggs and yogurt
lunch (30 g): turkey sandwich with cheese
dinner (35 g): fish or meat and quinoa
snack (20 g): protein bar
(6) if this degree of diet enhancement is difficult, consider supplement of whey protein.
(7) while it is not the emphasis of this post, the concept of "prehabilitation" applies equally well to optimizing balance, strength, home safety, and family/friend support.
Bottom line: when the patient comes to the operating room, they should be in the best possible condition
Feeling good and ready to go
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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).
