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The Journa l o fB on e and Jo in t Surgery
A m erica n Vo lumeVoLUME 64-A , N o . 9 DECEM BER 1982
Copyr igh t 98 2 by Th e J o u r n a l of8o ne and J oin t S urg
e, In co rp ora ted
N u tritio n in O rthop aed ic Su rge ry*BY JA CK E . JENSEN , M
.D .t, TERR I G . JEN SEN , M .S ., R .D 4, TAY LOR K . SM ITH , M
.D 4 , D ENN IS A . JOHNSTON , P
AND STANLEY J. DUDR ICK , M .D .T , H OUSTON , T EXASFrom th e D
iv is io n of O rth op aed #{25 2 } Su rge ry , D epa rtm en t o f
Su rg e ry , U n ive rs ity o f T exa s M ed ic a l S choo l a t H
ou sto n , H o us ton
ABSTRACT : O ne hundred and tw en ty -n in e pa tien tsundergo
ing orthopaed ic su rg ica l p ro cedures w erefound to hav e an
average in cid ence o f c lin ica l and sub -c lin ica l m alnu
trit ion of 42 .4 p er cen t p er patien t. T helow est in c id
ence of nu tr itiona l d ep le tion w as id en tif iedin pa tien ts
undergo ing tota l h ip -rep la cem en t su rgery(28 .6 per cen t)
, fo llow ed by th e e lec tiv e su rg ica l group(35.3 per cen t)
and patien ts w ith m u ltip le traum a andfem oral fra ctu res
(586 per cen t) . T raum a and m ajorsu rgery w ere shown to induce
a sta te of m alnu tr itionand a lo ss of imm unocom peten ce . A
sign ifican t (p 10 lbss e ru m a t bum i n( 3 .4 g /d le ed w
ith
ott1ollow,?I presen t I
dm in i5 te r s e ve re m atn ut i n t r a v e n o usn te r al n
u tr it io n ype ra l imen ta t ion
NUTR I T ION IN O RTHO PA ED IC SU RG ERY 1271
V O L . 64 -A , N O . 9 . D EC EM BER 1982
L a ye i e c t i v e
o p e r a t i o nO b ta in c om p le te
n utritio na l a ss e ss m en t
De la y A re a n y o t th e to llo w in g m g /d lr e s e n t s
er um t ra n st er r, n< 1 50
suppor t . 0lective P ro c e ed w itpera t ion opera t ionr ov
id e n u tr it io na l M on ito r w eigh t.nutr ient i nt ak e. n
it ro g enba lance . s e ru m a lb um in .to ta l ly mphocy te c
oun t
F IG . 7F low -cha rt dep ic ting a ra tiona l sc re en ing
approach to iden tify p a tien ts who a re nu tritiona lly a t r
isk , u ti liz ing tests tha t a re read ily ava ilab lec l in ica
l s ituat ions
preoperat ive 0crash w eigh t-reduc tion d iet fo r these
pa-tien ts w hen they are ov erw eigh t is u ndoub ted ly d et-r im
en ta l an d co n tra ind icated .
T he prev en tion of in fec tion is o f p a ram oun t im
por-tance in orthop aed ic su rg ery612 14 #{176} . Perio pe ra
tive an dpost- traum atic i mm unodepres sion an d v isce ra l p ro
te ind ep letio n m ay se rve as se lectiv e g u id es fo r the in
itiatio n ofan tib io tic s and the dura tion of the ir adm in
istra tion . W ehave d ocum en ted a sta te o f p ostop e ra tive
imm unodepres-s ion and theor ize tha t th is is w hy s tu d ies
have sh ow n tha tp eriop era tive p ro phy lac tic an tib io tic s
app ea r to be o fb en efit. T he d ata also ind ica te the v a lue
o f a clo se r eva lua -tion of the ind isc rim ina te use of s
tero ids in th e im -m unodepressed , m ultip ly traum atized pa
tien t w ith an as-soc iated head in ju ry and in th e pa tien t w
ith rheum ato id ar-th ritis, as these drug s fu rthe r dep ress
imm unocom petence .Su stain ed p ro te in d ep le tion and nega
tive n itrogen ba lancew ere observed bo th in the e lec tive -su
rge ry g rou p and in
the traum a grou p . T he preven tion of th is ca tabo lism o
fsk ele ta l m uscle p ro te in m ay be of c r itica l im po rtance
du r-ing the in itiation of m usc le rehab ilita tion .
T h is s tudy of o rthopaed ic p atien ts con firm s reportsfrom
o th e r d isc ip line s th at dep re ssed nu trition a l ind ice
scan pred ic t su bsequ en t in fec tiou s com plica tions . T hep
reop e ra tive , po st-in ju ry , o r po stop era tive pa tien t w
ho isa t h igh nu tr itiona l r isk is m ore suscep tib le to in
fec tion .
P rov isio n of the best nu tritio na l the rapy is dep en den
to n the in te rest and m otiv atio ns o f the phy sic ian an d su
r-g eon , w ho a re capab le o f g iv ing th e sam e qua lity o f n
u tr i-tio na l and m e tabo lic sup port to pa tien ts a s th e q
ua lity o fsu ppo rt tha t they prov id e v ia sop h istica ted pha
rm aco log i-ca l, tech n ica l, and o pera tiv e th erap y . M o
reover, a ration alp rog ram of n u tritio na l a sse ssm en t an d
support can hav e asig n if ican t bene ficia l effec t o n the
risk :b en efit ra tio , thecost:b ene fit ra tio , and cost-e ffec
tiven ess , b y w h ich theq ua lity o f hea lth ca re is in
creasin g ly be ing eva lua ted .
Re fe re n c e s1 . BISTRIAN, B . R .; BLACKBURN , G . L .; HA L
L O W EL L , EDW A R D ; an d HEDD L E , R O BER T : Pro tein S ta
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Assn . . 23 0 : 858-860, 1974 .2. BISTRIAN, B . R .; B LAC KBURN
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