"Enhancing Patient Outcomes with Clinical Nutrition: The Effects of Supplementation in Orthopedics"

Alexa Abdelaziz*1, Ralph Venuto2, Ryan Stahl3, John Karl OPTA4 and Sheraz Syed5 1Nutritional & Metabolic Biology, Director of Research and Development at MEND, Columbia University, New York, USA 2Orthopedic Surgeon in Newport Beach, California 3PT, DPT, OCSIvy Rehab Physical Therapy 4EXOS XPS Sports Performance Specialist, CES, BMS Ivy Rehab Physical Therapy 5Physical Therapist Cert. MDT Triumph Physical Therapy


Introduction
Each year more than half of people over the age of 18 in the US will develop a musculoskeletal injury that lasts more than 3 months. This is roughly 18% of all clinical visits and represents enormous costs, ~5.7% of US GDP and 216 million lost workdays [1]. Tens of millions of patients each year turn to orthopedic surgeons and physical therapists to treat their injuries and return to normal function as quickly as possible. There is an urgent need to utilize all of the latest techniques, tools and technologies to improve outcomes and enhance patient recovery to lower the cost burden on the health system and improve economic output due to lost workdays. New innovations continue to enhance the field of musculoskeletal injury treatment and management. One area that is showing considerable promise is in targeted nutrition.

Nutrition and Healing
Science is increasingly showing just how critical nutrition is to healing and recovery. As we know during a state of trauma, such as injury or surgery, the body's nutritional needs increase: a) The body enters a higher metabolic state and requires more energy b) Trauma and lack of use leads to muscle atrophy, which prolongs recovery c) The immune system is weakened due to stress and shock d) Risk of wound infection is increased e) Persistent inflammation delays return of function f) Trauma and physiological stress lead to increased fatigue Nutritional deficiencies impede the natural progression of healing, including elevating the risk of infection and lengthening recovery periods. A patient that is nutritionally optimized will heal better and faster and have better long-term outcomes. One that isn't will heal more slowly and may have long-term complications.
Unfortunately, most Americans are overfed and undernourished, meaning most Americans are not at optimal nutritional status to prevent complications post-trauma. Hospital studies have shown that as many as 50% of patients are undernourished or malnourished [2]. These patients face greater complications than properly nourished patients, including longer hospital stays, greater risk of infection, and increased mortality. One study, published in the Journal of Nutrition, studied over 16,000 individuals and found that many are not meeting the minimum recommended thresholds for micronutrient intake ( Table 1)

Clinical Evidence -Nutrition as an Orthopedic Treatment Tool
The science of nutrition in orthopedics is advancing rapidly and a growing body of clinical trials are demonstrating convincingly that targeted nutrition can enhance outcomes, both for acute patients as well as for patients with chronic conditions. Wound healing, This study also found a reduced dependence to bed and related complications after an orthopedic operation [4,5]. A study by supplementation is safe and reduced the loss of muscle volume in older adults recovering from TKA [7]. These studies emphasize the importance of targeted nutritional supplements for muscle preservation and return to function -critical in any patient with a surgery that results in significant muscle atrophy such as ACL.
Certain key ingredients are crucial to include to help support recovery. Liberman et al. found that thirteen weeks of nutritional supplementation with Vitamin D and leucine-enriched whey protein may attenuate the progression of chronic low-grade inflammatory profile in older sarcopenic persons with mobility limitations [8].
Another key study by Kim et al. found that in surgical patients, the addition of glutamine supplementation reduced infection rates and shortened the length of hospital stay. Glutamine also decreased the production of pro-inflammatory cytokines in this population [9].
By lowering inflammation, the healing process is greatly enhanced.
β-hydroxy β-methylbutyrate (HMB) has been shown in many studies to promote wound healing and diminish muscle wasting Flakoll et al. found that elderly women treated with a nutritional supplement containing HMB, arginine, and lysine for 12 weeks had increased muscle mass and maximum strength [10]. HMB is also utilized and useful in combination therapies. This doubleblind controlled 12-month study by Rathmacher et al. found that HMB in combination with Vitamin D had a significant benefit on lean body mass and showed improvement in knee extension peak torque even with no exercise. Overall, their findings showed that even without exercise, the HMB+ Vitamin D supplemented group showed significant increases in functional outputs than those in controls [11]. Interestingly, HMB has also been shown to increase anabolic signaling [12].  [13]. in the Journal of Orthopedic Sports Medicine, revision costs in ACL patients range roughly in the $9K range [14]. Considering the sheer volume of orthopedic injuries and surgeries, we can extrapolate that there is billions of dollars of cost in the healthcare system that can be addressed through nutritional supplementation and optimization.

Conclusions
In summary, an increasing body of science suggests that targeted supplementation should be utilized in patient care. By doing so, we can improve patient outcomes and reduce healthcare costs.