Prehabilitation and supplement combination may improve knee replacement surgery outcomes

The review, published in the journal Nutrients​, called for a multidimensional approach and collaboration among specialists to address knee osteoarthritis and sarcopenia in older people. Nutraceuticals such as vitamin D, amino acids, probiotics and glucosamine sulfate are highlighted as beneficial supplements pre-surgery. 

Sarcopenia is age-related progressive loss of muscle mass and strength and occurs in around 10% of people over age 60​ worldwide. People with sarcopenia needing surgery have more risk of complications and less favorable outcomes than those without the condition.  

Increasing protein intake through food or supplements and physical activity such as resistance training can attenuate muscle loss and improve strength in sarcopenia. The current review was the first to explore how nutritional adjustments and prehabilitation can improve surgical outcomes. 

Study details

The researchers analyzed 12 randomized controlled trials (RCTs) concerning nutritional supplementation before knee arthroplasty and 26 clinical trials plus one prospective study regarding prehabilitation before the surgery.

They noted a lack of studies combining prehabilitation and dietary supplementation and that the limited evidence when using the search term sarcopenia highlights a gap in knowledge and consideration of these aspects with regard to knee surgery. 

The results suggested that there are currently no standardized prehabilitation and/or dietary supplementation strategies specifically tailored for patients with sarcopenia. Also, the type and duration of intervention varied among studies.  

The authors commented that previous research shows that a patient's baseline characteristics, such as body mass index (BMI), physical function and stress can predict surgical outcomes. Therefore, enhancing the presurgical condition could lead to better outcomes following surgery.  

The results showed that specific supplements may support a better outcome for knee arthroplasty. These include vitamin D, essential amino acids (EAAs), iron, glucosamine sulfate and adenosine triphosphate.

Beneficial prehabilitation strategies include strength training, flexibility, aerobic exercise, endurance training, proprioceptive exercises, blood flow restriction exercises, neuromuscular and postural exercises, and acupuncture. 

Nutrition and sarcopenia

Sarcopenia develops during aging as a result of inadequate nutrition, a sedentary lifestyle, inflammation and hormonal and neurological alterations. People with knee osteoarthritis who have limited mobility are prone to succumbing to sarcopenia and may require surgery. 

Sarcopenic patients often have lower protein, vitamin D, and micronutrient intake, which negatively impacts muscle health. Therefore, managing sarcopenia requires a multimodal approach involving proper nutrition, anti-inflammatory and anabolic medications, and rehabilitation training.

Adequate protein is crucial to prevent muscle loss. The current review recommends that healthy individuals need 1 g to 1.2 g of protein per kilogram of body weight per day (g/kg/d), and people with illness or malnutrition require higher amounts of 1.2 g to 1.5 g.  

A 2013 study​ suggested that EAAs before and two weeks after knee arthroplasty attenuated muscle atrophy and accelerated the return of functional mobility.

The current review notes that probiotics may support muscle strength, but human research is lacking, and that a supplement combination of protein, leucine, vitamin D and n-3 polyunsaturated fats (PUFAs) before orthopedic surgery may prevent sarcopenia and functional deterioration. The researchers also highlight vitamin D's role in bone health and muscle strength.   

The researchers called for further investigations in older populations with sarcopenia to promote the development of personalized nutritional strategies. 

Source: Nutrients ​2024, 16(20), 3462; 
doi: 10.3390/nu16203462​
“Optimizing the preoperative preparation of sarcopenic older people: The role of prehabilitation and nutritional supplementation before knee arthroplasty.”
Authors: F. Pegreffi et al.