Showing posts with label malnutrition. Show all posts

Sunday, September 28, 2025

The "Secret Sauce" for Optimizing Rotator Cuff Outcomes: Biologics or nutrition?

There is great current interest by industry and by some surgeons in the use of "biologics" to enhance outcomes of rotator cuff surgery.

At this point, however, the value of these interventions in terms of improvement in patient reported outcomes per unit cost is uncertain.

On the other hand a different type of biological intervention - nutrition - is of demonstrated value to the patient.

In our last post, Reza Jazayeri and Hafiz Kassam highlighted the growing recognition that perioperative nutritional optimization is a critical and modifiable factor in shoulder arthroplasty. Poorly nourished patients face double the risk of infection and revision, while even “healthy” patients often fail to meet the metabolic demands triggered by surgery. With elective arthroplasty, we have the opportunity to “prehabilitate” patients nutritionally, improving their resilience to the hypermetabolic-catabolic stress of surgery (Preoperative malnutrition is associated with increased risk of 90-day major medical complications and increased 2-year revision rates following total shoulder arthroplasty).

Reza and Hafiz prepared this post on the application of this approach to patients having cuff repair surgery.

Why rotator cuff repair is an even greater challenge

Unlike arthroplasty, rotator cuff repair (RCR) requires direct tendon-to-bone healing — a biologically demanding process with higher metabolic thresholds. Recent data underscore this reality.

Patients ≥65 undergoing RCR with a Geriatric Nutritional Risk Index <103 had a ~5.6× higher risk of retear compared to those ≥103, even after adjustment for confounders (Preoperative Nutrition Impacts Retear Rate After Arthroscopic Rotator Cuff Repair)
Notably, this >103 cutoff is higher than arthroplasty thresholds (>98), reflecting the greater biologic demand of tendon-to-bone healing.
Alarmingly, 66% of patients were not optimized, highlighting a major opportunity for intervention .

Nutrition education & dietary intervention

Meeting these elevated demands requires deliberate action. High-protein diets and patient education programs have been shown to be effective.

The winner of the 2019 Ranawat Award (Elective joint arthroplasty outcomes improve in malnourished patients with nutritional intervention: a prospective population analysis demonstrates a modifiable risk factor) showed that a high-protein/ anti-inflammatory diet can significantly reduce complication in joint arthroplasty and the 2023 Lui study demonstrated that structured nutrition education significantly improved recovery rates after rotator cuff repair (The Association between Dietary Habits and Rapid Postoperative Recovery of Rotator Cuff Repair).

Targeted supplementation: beyond diet

Diet alone is often insufficient to meet perioperative anabolic demands. Evidence supports the use of targeted supplementation, particularly in the immediate perioperative window spanning 1 week pre-op (priming phase) to 2 weeks post-op (hypermetabolic phase).(Pre- and Post-Surgical Nutrition for Preservation of Muscle Mass, Strength, and Functionality Following Orthopedic Surgery)

Essential amino acids (EAAs/BCAAs) — accelerate collagen synthesis and blunt muscle breakdown. ,
Have been demonstrated in multiple RCTs in arthroplasty, trauma and spine to decrease complications, preserve muscle mass and improve functional recovery. (Amino Acid Supplementation May Help Prevent Muscle Wasting After Orthopedic Surgery) (The Role of Amino Acid Supplementation in Orthopaedic Surgery)
Leucine = key EAA → activates mTOR, driving protein synthesis.

RCR (rat model): preserved supraspinatus mass, reduced atrophy
Sarcopenia (older adults, 5 g/meal): overcame anabolic resistance, boosted muscle protein synthesis
Impact: protects muscle in cuff healing + counters sarcopenia → stronger recovery potential. (Leucine attenuates muscle atrophy)

Creatine & HMB (Hydroxymethylbutyrate-a leucine metabolite) — both have been well studied in both sarcopenia and sports performance, shown to reduce muscle loss (anti-catabolic), enhance muscle protein synthesis, and improve strength are now being implemented in surgical recovery.
Conditionally essential amino acids (arginine, glutamine) — key substrates for collagen and bone synthesis, nitric oxide–mediated blood flow, and immune function. In a JBJS 2022 RCT of trauma patients, 2 weeks of postop supplementation led to significant reduction in complications, preservation of muscle mass and improved fracture union rates. (Conditionally Essential Amino Acid Supplementation Reduces Postoperative Complications and Muscle Wasting )

Advances in nutritional science and basic research are increasingly translating into clinical practice. Emerging data now support targeted supplementation strategies that can be implemented in orthopedic surgery to improve outcomes by providing the key substrates needed to meet the hypermetabolic demands of the surgical stress response.

It is exciting that we now have clinically formulated supplementation protocols—combining these select nutrients supported by clinical studies that can be used to provide meaningful support for our patients. (Selected Nutrients to Oppose Muscle Disuse Following Arthroscopic Orthopedic Surgery)

Nutrition should no longer be neglected as a variable in surgical recovery. We now have the practical resources and evidence-based strategies to address this critical determinant of patient outcomes.

General guidelines for patients having rotator cuff surgery

1. Protein: Foundation for Healing

Target intake: ~1.6–2.0 g/kg/day (≈0.7–0.9 g/lb/day), spread across meals.
For a 180 lb patient, that’s about 125–160 g/day.
Why: Adequate protein supplies amino acids for collagen synthesis and muscle preservation.
Sources: Lean poultry, fish, eggs, Greek yogurt, whey or collagen peptides, tofu, beans.

2. Collagen & Vitamin C

Collagen peptides (10–15 g/day) may support tendon healing when paired with vitamin C.
Vitamin C (at least 75–100 mg) helps activate collagen cross-linking.
Practical tip: Take collagen powder with a glass of orange juice about an hour before rehab exercises.

3. Anti-Inflammatory Support

Omega-3 fatty acids (EPA + DHA, 1–3 g/day): May reduce inflammation and pain. Found in fatty fish (salmon, sardines) or fish oil.
Fruits and vegetables: Rich in antioxidants and polyphenols (berries, leafy greens, peppers).
Spices: Turmeric and ginger have modest anti-inflammatory effects.

4. Micronutrients Critical for Recovery

Vitamin D: Supports bone, muscle, and immune health. Ensure serum levels are adequate; supplement if low (often 1000–2000 IU/day).
Calcium: 1000–1200 mg/day from diet (dairy, fortified alternatives, greens).
Zinc: Important for wound healing (found in meat, shellfish, nuts).
Magnesium: Aids in muscle and nerve function (nuts, seeds, whole grains).

5. Energy Balance

Adequate calories are essential.
- Too few: impaired wound and tendon healing.
- Too many: risk of fat gain during limited activity.
Emphasize nutrient-dense foods rather than empty calories.

6. Timing Around Surgery

Pre-op (2–4 weeks before): Focus on optimizing protein intake, correcting vitamin D deficiency, and ensuring good hydration and fiber for bowel health.
Immediate post-op: Small, protein-rich meals; hydration; avoid constipation from pain medications.
Rehab phase: Time protein (and collagen + vitamin C) before therapy sessions to support muscle protein synthesis and tendon adaptation.

Bottom line:
Patients undergoing rotator cuff repair can optimize nutrition by ensuring high-quality protein, collagen + vitamin C, omega-3s, vitamin D, and overall nutrient adequacy, while avoiding undernutrition. The goal is to fuel healing, preserve muscle, and support tendon/bone recovery.

What goes in your mouth has a lot to do with how you heal

Lewis' Woodpecker

Oak Creek Wildlife Feeding Center

2022

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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).

Saturday, September 27, 2025

The "secret sauce" for optimizing arthroplasty outcomes: nutrition

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."

We need to keep in mind that shoulder arthroplasty is almost always an elective procedure: the surgeon and the patient have time to "prehabilitate" the metabolic power necessary for robust healing.

Malnurished patients have twice the risk of infection and twice the risk of revision:

Preoperative Malnutrition and Risk of 90-day Complications and 2-Year Revision After TSA).

Malnutrition in elective shoulder arthroplasty: a multi-institutional retrospective study of preoperative albumin and adverse outcome

The geriatric nutritional risk index as a strong predictor of adverse outcomes following total shoulder arthroplasty

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

Ash-throated fly catcher

Tucson, Arizona

Friday, July 23, 2021

Adverse outcomes from total shoulder arthroplasty - the role of malnutrition

Examining the Effects of Modifiable Risk Factors on Postoperative Outcomes after Total Shoulder Arthroplasty

These authors collected data on 14,478 adult patients undergoing total shoulder arthroplasty from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) 2006-2016 database.

They found that malnutrition (defined as preoperative albumin level of <3.5g/dL) was associated with an approximately 3-time increased likelihood of non-routine discharge and 5-time increased likelihood of hematologic complications after TSA. Overall the prevalence of malnutrition found in this study was 7.9%.

Comment: This study emphasizes the prevalence and importance of hypoalbuminemia to the outcome of total should arthroplasty. While the authors identify malnutrition as a "modifiable" risk factor, they do not provide evidence on (1) how this risk factor can be effectively modified and (2) whether improving preoperative albumin levels reverses the ill effects of malnutrition. Until such evidence is available, it may be more accurate to refer to hypoalbuminemia simply as a risk factor.

How you can support research in shoulder surgery Click on this link.

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 total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

Follow on twitter: Frederick Matsen (@shoulderarth)

Saturday, May 1, 2021

Malnutrition and arthroplasty outcomes

Malnutrition in Elective Shoulder Arthroplasty: A Multi-Institutional Retrospective Study of Preoperative Albumin and Adverse Outcomes

These authors investigated the role of preoperative albumin levels in predicting common postoperative adverse outcomes in patients undergoing shoulder arthroplasty.

They found that the prevalence of malnutrition (albumin <3.5 g/dL) was twice as high in patients having revision compared to those having primary arthroplasty (36.6% vs. 19.5%).

Patients having primary reverse arthroplasty and higher ASA scores were more likely to be malnourished.

Patients who were malnourished had an increased incidence of extended length of stay and discharge to rehab/SNF.

These authors did not assess whether attempts to improve serum albumin preoperatively were effective in improving outcome of shoulder arthroplasty.

Other studies of the effect of malnutrition on arthroplasty outcomes can be found in this link and this link.

Each of these suggest the use of preoperative serum albumin as an important indication of nutritional status.

How you can support research in shoulder surgery Click on this link.

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).

Wednesday, February 5, 2020

Shoulder arthroplasty - malnutrition increases risk

Effects of Modifiable Risk Factors on Outcomes after Shoulder Arthroplasty

These authors collected data from the American College of Surgeons National Quality Improvement Program from 2006-2016 for adult patients having total shoulder arthroplasty.

Malnutrition was defined as a preoperative albumin <3.5. Hematologic complications included thromboembolic events, bleeding, sepsis, or septic shock. Non-routine discharge was defined as a discharge other than to the patient's home.

As can be seen below, malnutrition was associated with >3 times increased risk of non-routine discharge and almost 5 times the risk of hematologic complications.

Comment: A serum albumin is an inexpensive test to obtain preoperatively. Its relationship to adverse outcomes is of interest.

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How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages arthritis , total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Wednesday, October 21, 2015

Total shoulder arthroplasty and malnutrition - the 4P s

Malnutrition: a marker for increased complications, mortality, and length of stay after total shoulder arthroplasty.

These authors defined malnutrition as a preoperative albumin concentration of <3.5 g/dL. They queried the American College of Surgeons National Surgical Quality Improvement Program database for total shoulder cases from 2005 to 2013 and compared the rates of postoperative complications between normal and malnourished patients.

Of the 1681 patients with albumin measurements, 7.6% were malnourished. Malnutrition was significantly associated with postoperative transfusion (odds ratio, 2.49), extended LOS (odds ratio, 1.69), and death (odds ratio, 18.09). The prevalence of morbid obesity was greater in malnourished patients than in controls.

Comment: Here is a great example of the influence of the patient's health as a predictor of outcome. Serum albumin is an inexpensive, easy to obtain blood test that has been shown to influence the rates of complications for many different types of surgery. It remains to be seen whether preoperative nutritional interventions are successful in reducing this risk.

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