A Pilot Study of Nutritional Supplementation in Soft Tissue Sarcoma Patients.

Background: Wound healing is particularly important for sarcoma patients who undergo neoadjuvant radiation therapy. Previous studies have demonstrated wound complications in this population approaching 35%. With this high rate of wound healing issues, identifying treatment modalities to minimize these complications is of paramount importance. Methods: All patients with high grade bone and soft tissue sarcoma received 15 days of twice daily amino acid supplementation starting in the immediate post-operative period. We documented the healing status of the surgical wound, the primary outcome, at all follow up appointments until six months after surgery. Non-healing wounds were defined as any wound requiring 1) a return visit to the OR for debridement, 2) IV antibiotics (ABX), and 3) unhealed wounds at 6 months post-operatively.1 For each patient, we collected biometrics with lean body mass analysis at preoperative appointment, and two and six weeks postoperatively. The proportion with non-healing wounds was compared with a historical patient cohort using the chi-square test. In a subgroup of participants with body composition measurements, we also compared changes in mean fat mass, lean mass, and psoas index from pre-operative baseline to 6 months post-operative using generalized linear models. Results: A total of 33 consecutive patients were supplemented with a branched chain amino acid (BCAA) formulation. The historical cohort included 146 participants from the previous 7 years (2010-2017). 26% of patients in the historical cohort experienced wound complications compared to 30% in the supplemented group. (p=0.72) When focusing specifically on lower extremity sarcomas treated with neoadjuvant radiation therapy, 46% of patients in the supplemented group experienced wound healing complications compared to 39% in the non-supplemented group (p=0.68). BCAA supplementation was found to be protective with regards to decreasing muscle wasting with no difference in psoas index measurements throughout the study period compared to a 20% muscle loss in the historical cohort (p=0.02). Conclusion: In our limited sample size, there was no difference in wound healing complications between sarcoma patients who received postoperative BCAA supplementation compared to a historical cohort who were not supplemented. Patients who did not receive supplementation had a significant decline in post-operative psoas index following operative sarcoma removal. Level of Evidence: III.

What Is the Impact of Body Mass Index Cutoffs on Total Hip Arthroplasty Complications?

BACKGROUND: Body mass index (BMI) cutoffs are commonly utilized to decide whether to offer obese patients elective total hip arthroplasty (THA). However, weight loss goals may be unachievable for many, and some patients are thereby denied complication-free surgery. The purpose of this study was to assess the impact of varying BMI cutoffs on the rates of complication-free surgery after THA. METHODS: Patients undergoing THA between 2015 and 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Common Procedural Terminology code 27130. BMI and rates of 30-day complications were collected. BMI cutoffs of 30, 35, 40, 45, and 50 kg/m2 were applied to model the incidence of complications if THA would have been allowed to proceed based on BMI. RESULTS: A total of 192,394 patients underwent THA, and 13,970 (7%) of them had a BMI ≥40 kg/m2. With a BMI cutoff of 40 kg/m2, 178,424 (92.7%) patients would have proceeded with THA. From this set, 170,296 (95.4%) would experience complication-free surgery, and 11.8% of complications would be prevented. THA would proceed for 191,217 (99.3%) patients at a BMI cutoff of 50 kg/m2, of which 182,123 (95.2%) would not experience a complication, and 1.3% of complications would be prevented. Using 35 kg/m2 as the BMI cutoff would prevent 28.6% of complications and permit 75.9% of complication-free surgeries to proceed. CONCLUSION: Lower BMI cutoffs for THA can result in fewer complications although they will consequentially limit access to complication-free THA. Consideration of risks of obesity in THA may be best considered as part of a holistic assessment and shared decision-making when deciding on goals for weight reduction.

Conditionally Essential Amino Acid Supplementation Reduces Postoperative Complications and Muscle Wasting After Fracture Fixation: A Randomized Controlled Trial.

BACKGROUND: Postoperative complications and substantial loss of physical function are common after musculoskeletal trauma. We conducted a prospective randomized controlled trial to assess the impact of conditionally essential amino acid (CEAA) supplementation on complications and skeletal muscle mass in adults after operative fixation of acute fractures. METHODS: Adults who sustained pelvic and extremity fractures that were indicated for operative fixation at a level-I trauma center were enrolled. The subjects were stratified based on injury characteristics (open fractures and/or polytrauma, fragility fractures, isolated injuries) and randomized to standard nutrition (control group) or oral CEAA supplementation twice daily for 2 weeks. Body composition (fat-free mass [FFM]) was measured at baseline and at 6 and 12 weeks postoperatively. Complications were prospectively collected. An intention-to-treat analysis was performed. The relative risk (RR) of complications for the control group relative to the CEAA group was determined, and linear mixed-effects models were used to model the relationship between CEAA supplementation and changes in FFM. RESULTS: Four hundred subjects (control group: 200; CEAA group: 200) were enrolled. The CEAA group had significantly lower overall complications than the control group (30.5% vs. 43.8%; adjusted RR = 0.71; 95% confidence interval [CI] = 0.55 to 0.92; p = 0.008). The FFM decreased significantly at 6 weeks in the control subjects (-0.9 kg, p = 0.0205), whereas the FFM was maintained at 6 weeks in the CEAA subjects (-0.33 kg, p = 0.3606). This difference in FFM was not seen at subsequent time points. CONCLUSIONS: Our results indicate that CEAA supplementation has a protective effect against common complications and early skeletal muscle wasting after operative fixation of extremity and pelvic fractures. Given the potential benefits of this inexpensive, low-risk intervention, multicenter prospective studies in focused trauma populations are warranted. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Periarticular Local Infiltrative Anesthesia and Regional Adductor Canal Block Provide Equivalent Pain Relief After Anterior Cruciate Ligament Reconstruction.

PURPOSE: To compare postoperative pain and recovery after anterior cruciate ligament reconstruction (ACLR) in patients who received an adductor canal block (ACB) or periarticular local infiltrative anesthesia (LIA). METHODS: A retrospective review of a prospectively collected ACL registry was performed. Patients underwent ACLR at a single institution between January 2015 and September 2020 and received long-acting local anesthesia with a preoperative ultrasound-guided ACB or periarticular LIA after surgery. Visual analog scale (VAS) pain scores, milligram morphine equivalents (MME) consumed in the post-anesthesia care unit (PACU), and total hospital recovery time were compared. Univariate analysis was used to compare VAS pain and MME totals between overall groups and groups propensity score matched for age, sex, body mass index, graft type, and meniscal treatment. Results are presented as mean (95%CI) unless otherwise indicated. RESULTS: There were 265 knees (253 patients) included (LIA, 157 knees; ACB, 108 knees). Overall, VAS pain scores before hospital discharge (LIA: 2.6 [2.4-2.8] vs ACB: 2.4 [2.1-2.7]; P = .334) and total MMEs were similar (LIA: 17.6 [16.4-18.8] vs ACB: 18.5 [17.2-19.8] (MME); P =.134). Median time to discharge also did not significantly differ (LIA: 137.5 [IQR: 116-178] vs. ACB: 147 [IQR: 123-183] (min); P = .118). Matched subanalysis (LIA and ACB; n = 94) did not reveal significant differences in VAS pain before discharge (LIA: 2.4 [2.1-2.7] vs ACB: 2.7 [2.4-3.0]; P = .134) or total MMEs (LIA: 18.6 (17.2-20.0) vs ACB: 17.9 (16.4-19.4); P = .520). CONCLUSION: The use of ACB or LIA resulted in similar early pain levels, opioid consumption, and hospital recovery times after ACLR surgery. LEVEL OF EVIDENCE: III, retrospective comparison study.

Performance of PROMIS for Healthy Patients Undergoing Meniscal Surgery.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed as an extensive question bank with multiple health domains that could be utilized for computerized adaptive testing (CAT). In the present study, we investigated the use of the PROMIS Physical Function CAT (PROMIS PF CAT) in an otherwise healthy population scheduled to undergo surgery for meniscal injury with the hypotheses that (1) the PROMIS PF CAT would correlate strongly with patient-reported outcome instruments that measure physical function and would not correlate strongly with those that measure other health domains, (2) there would be no ceiling effects, and (3) the test burden would be significantly less than that of the traditional measures. METHODS: Patients scheduled to undergo meniscal surgery completed the PROMIS PF CAT, Knee injury and Osteoarthritis Outcome Score (KOOS), Marx Knee Activity Rating Scale, Short Form-36 (SF-36), and EuroQol-5 Dimension (EQ-5D) questionnaires. Correlations were defined as high (≥0.7), high-moderate (0.61 to 0.69), moderate (0.4 to 0.6), moderate-weak (0.31 to 0.39), or weak (≤0.3). If ≥15% respondents to a patient-reported outcome measure obtained the highest or lowest possible score, the instrument was determined to have a significant ceiling or floor effect. RESULTS: A total of 107 participants were analyzed. The PROMIS PF CAT had a high correlation with the SF-36 Physical Functioning (PF) (r = 0.82, p < 0.01) and KOOS Sport (r = 0.76, p < 0.01) scores; a high-moderate correlation with the KOOS Quality-of-Life (QOL) (r = 0.63, p < 0.01) and EQ-5D (r = 0.62, p < 0.01) instruments; and a moderate correlation with the SF-36 Pain (r = 0.60, p < 0.01), KOOS Symptoms (r = 0.57, p < 0.01), KOOS Activities of Daily Living (ADL) (r = 0.60, p < 0.01), and KOOS Pain (r = 0.60, p < 0.01) scores. The majority (89%) of the patients completed the PROMIS PF CAT after answering only 4 items. The PROMIS PF CAT had no floor or ceiling effects, with 0% of the participants achieving the lowest and highest score, respectively. CONCLUSIONS: The PROMIS PF CAT correlates strongly with currently used patient-reported outcome measures of physical function and demonstrates no ceiling effects for patients with meniscal injury requiring surgery. It may be a reasonable alternative to more burdensome patient-reported outcome measures.