Specialized Care for Orthopaedic Patients

Obesity is not only a risk factor for developing arthritis in the knees and hips.  It is also linked to less favorable outcomes after joint replacement surgery.  Obesity is associated with longer hospital stays, higher overall costs and higher failure rates, necessitating costly revision surgery.  A CoreLife partnership provides you, the orthopaedic surgeon, with a trusted resource for pre-surgical care and preparation, as well as post-operative care to aid them in achieving the best results.

Orthopaedic risks in people who carry too much weight

In orthopaedics, evidence is mounting that a high BMI can cause or exacerbate musculoskeletal conditions, such as osteoarthritis, and diminish treatment outcomes. For example, being overweight increases the risk of wound infection, pulmonary complications, deep vein thrombosis, pulmonary embolism, myocardial infarction  and other complications following orthopaedic surgery.

How can CoreLife help?

The forecast for surgical outcomes can be greatly improved, especially with regards to postoperative joint function, by having patients lose weight and reduce BMI before undergoing joint replacement surgery. Weight loss may potentially decrease the pain to the point where surgery will no longer be needed. Weight loss may also be able to delay the procedure for a number of years. Artificial joints need to be replaced every 15 years, on average, so delaying the surgery is a positive thing.

Care at CoreLife

The team-care approach at CoreLife is used to treat overweight and obese patients with hip and knee arthritis.  With our well-rounded approach, we can help the patient lose weight, improve their health, and optimize nutrition before joint replacement to maximize its benefits.

Specifics of Care

Joseph Stapleton MS, RD, LDN, CPT

With orthopedic patients, some special considerations need to be made when designing a plan, and these vary based on the stage of the orthopedic pipeline the patient is in. If the patient still needs to meet certain body composition goals to qualify for orthopedic surgery, then our prescription will be slow, steady weight loss (1-2 lb/wk) while ensuring proper relevant vitamin and mineral intake.  Supervised physical activity is encouraged within the guidelines provided by the patient’s orthopedic surgeon, so if applicable recommendation to one of our trainers will benefit the patient.

Typically, a certain BMI is required for surgery and this will be the patient’s stated goal. Our goal will be to provide realistic recommendations that put the patient in negative energy balance while maintaining positive nitrogen balance, adequate intake of calcium (>1000mg) and vitamin D (400 iu).

If there are no comorbidities that would cause further consideration, then this patient would benefit from a macronutrient ratio close to the CoreLife ideal ratio of 30% protein 30% fat, 40% carbohydrate. Throughout the different stages leading up to and after their surgery that ratio does not have to change in an ideal setting.  If there are no allergies, vitamin supplementation may be recommended to help eliminate the chance of a malnutritive state at the operation.

Once the patient has met their BMI threshold and schedules surgery the 2-3 weeks leading up to the surgery date need a different goal. During this time the patient’s total caloric goal should be increased to maintenance level calories (intake that would lead to no gain or loss of weight for the individual). Malnutrition is very common in orthopedic surgical patients, so to combat this proactively patients return to maintenance calories, replenish their glycogen and nutrient stores, and set themselves up for success post-op. Leading up to surgery the patient and RD will be planning on how the patient will get their calories in post-surgery when even more calories are needed but nausea and lack of hunger will be likely obstacles.  Malnutrition has also been linked to higher incidence of orthopedic infections, so it is especially important to maintain intake levels will operating under the surgeons recommended pre and post-operative diet. More calories are needed to heal the work done during surgery, and this needs to be the primary goal in the immediate weeks following the operation.

Post-surgery caloric recommendation will be increased over maintenance according to the specific surgery and its energy needs for healing. Patient will be encouraged to snack frequently as large meals will likely be difficult to consume. Maintaining positive energy balance in this way along with adequate intake of calcium, vitamin D, vitamin C (90mg), and zinc (15mg) will help hasten recovery.

Once the patient is cleared by their orthopedic surgeon we taper down the patient’s caloric goal over the next couple of weeks back to their intake to lose at the desired rate of 1-2 lb/week and resume working towards patient’s long-term goal.

Many of these recommendations are true for surgical patients of any type, not just orthopedic surgical patients. But with orthopedics we see a higher risk of malnutrition and higher need to maintain calcium and vitamin D intake. The calorie recommendations shift to meet the immediate health concerns of the patient at each step along the way.

Sources:

https://www.ncbi.nlm.nih.gov/pubmed/7142234 Nutrition in Orthopaedic Surgery,  JE Jensen et al, Journal Of Bone and Joint Surgery.
http://europepmc.org/abstract/med/1906591 Nutrition: Its Relationship to Orthopedic Infections, TK Smith. The Orthopedic Clinics of North America.
https://www.mymosh.com/theedge/orthopedics/pre-post-surgery-nutrition/ Midwest Orthopedic Hospital. Pre-Post-Surgery Nutrition.
http://midwestbonejoint.com/general/nutrition-and-surgery/ Midwest Bone and Joint Institute. Nutrition and Surgery.
http://www.eatright.org/resource/fitness/training-and-recovery/endurance-and-cardio/eating-for-strength-and-recovery Academy of Nutrition and Dietetics. Eating For Strength and Recovery.
https://orthoinfo.aaos.org/en/staying-healthy/calcium-nutrition-and-bone-health American Academy of Orthopedic Surgeons. Calcium Nutrition and Bone Health.
http://journals.lww.com/corr/Abstract/1987/09000/Prevention_of_Complications_in_Orthopedic_Surgery.13.aspxPrevention of Complications in Orthopedic Surgery Secondary to Nutritional Depletion, TK Smith. Clinical Orthopaedics & Related Research