Energy Status and Protein Intake As Prognostic Indicators of Rehabilitative Outcomes

Clinical Significance: The clinical relevance of the proposed project is the eventual development of evidence-based rehabilitative nutrition practice guidelines for orthopedic patients. The scientific literature specific to the role of perioperative nutrition on rehabilitative outcomes in patients undergoing elective total joint procedures, total hip arthroplasty and total knee arthroplasty in particular, is limited.

Background and Study Rationale. Orthopedic procedures are commonly undergone to treat injuries and chronic conditions affecting the hip and knee. Primary arthroplasties represented 86% of the 1.9 million hip and knee arthroplasties performed in the United States from 2012-2019. Total hip and total knee replacement procedures are typical in older men and women and persistent muscle loss is a shared clinical presentation for young as well as older individuals undergoing elective orthopedic surgery procedures. Energy status energy status and protein intake, nutrition factors known to affect muscle mass and strength in orthopedic patients, has not been characterized prior to admission. Whether this aspect of nutritional status might predict recovery of muscle mass, strength, and function in the context of standard practice/post-operative rehabilitative treatment guidelines is not known.

Elective orthopedic surgery patients face major challenges in maintaining muscle mass and function during the perioperative period. Patients receiving protein or essential amino acid supplementation following total hip and total knee replacement, show improvements in protein balance, patient reported outcome measures, as well as muscle mass, strength, and function. Investigations of larger sample size and longer study duration where protein intake is adequately characterized prior to surgery are needed in these patient populations to further determine connections between routine protein intake and post-operative muscle specific outcomes. Perioperative nutrition screening and assessment measures specifically tailored to orthopedic patients that are attentive to energy status and protein intake are needed. The development and validation of the protein screener proposed in for this project is a unique approach to efficiently acquiring valuable perioperative dietary information. Including subjective, as well as functional, outcome measures may reveal associations between energy status and dietary protein intake pre-operatively and rehabilitative outcomes specific to muscle health to support routine assessment of these dietary factors as prognostic indicators for patient recovery following total hip and total arthroplasty. The proposed project is novel in its goal to establish a foundation for evidence-based rehabilitative nutrition guidelines to enhance perioperative patient care and improve post-operative rehabilitative outcomes specific to muscle health (i.e., strength and function) and quality of life in elective orthopedic surgery patients undergoing total joint replacement procedures.

Approach. Following approval of investigation by the Hartford Hospital Institution Review Board, data collection involved the inclusion of a research information sheet and a 3-day food record with instructions for the respective patient to complete prior to surgery. Recruitment was done in collaboration with the perioperative program staff. Eligible patients and a member of the research team met with patients to determine interest, review study requirements, and obtain written, informed consent for study enrollment. Dietary assessments (protein screener and 3-day food record) occurred before and after surgery per treatment guidelines for total hip and total knee replacement patients, respectively. The protein screener was designed to characterize protein intake and protein source and the respective 3-day food record for participants was used to validate patient responses on screener. Routine clinical assessments per treatment guidelines for respective patient populations were done.

Statistical Approach. Means and standard deviations were determined for outcome measures. Data was analyzed using a 3 factor (energy status, protein intake, and rehabilitative outcome measures) repeated measures over time analysis of variance. Post hoc tests were applied where statistical significance is noted; alpha-level was set at P< 0.05.