Loss of Muscle Mass and Strength After Hip Fracture: an Intervention Target for Nutrition Supplementation.

PURPOSEOF REVIEW: To summarize what is known about the deleterious effect of hip fracture on muscle mass and strength as well as the scientific evidence for post-surgical nutrition supplementation to maintain muscle and improve function. RECENT FINDINGS: This review provides a discussion of the relationship between muscle mass, strength, and physical function following hip fracture, briefly describes the approaches to measuring lean mass, discusses prevalence of sarcopenia and malnutrition among older men and women with hip fracture, and reviews the effects of essential amino acids on muscle. Loss of muscle mass and strength following hip fracture is substantial with consequences for recovery of functional independence. EAA-based nutrition supplementation, which directly effects muscle, has potential to improve outcomes.

Substantial Loss of Skeletal Muscle Mass Occurs After Femoral Fragility Fracture.

BACKGROUND: Femoral fragility fractures in older adults can result in devastating loss of physical function and independence. Skeletal muscle atrophy likely contributes to disability. The purpose of this study was to characterize the change in skeletal muscle mass, investigate the relationship with malnutrition and physical function, and identify risk factors for skeletal muscle loss. METHODS: Adults ≥65 years of age who were treated with operative fixation of an isolated femoral fragility fracture were enrolled in this multicenter, prospective observational study. Skeletal muscle mass was assessed within 72 hours of admission using multifrequency bioelectrical impedance analysis, which was repeated at 6 weeks, 3 months, and 6 months. Sarcopenia was defined by sex-specific cutoffs for the appendicular skeletal muscle mass index. The Mini Nutritional Assessment was used to measure nutritional status at the time of injury. Physical function was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function domain. Linear mixed models were used to evaluate changes in skeletal muscle mass and PROMIS Physical Function scores over time and to evaluate factors associated with skeletal muscle mass changes. RESULTS: Ninety participants (74% female) with a mean age of 77.6 ± 9.0 years were enrolled. At the time of injury, 30 (33%) were sarcopenic and 44 (49%) were at risk for malnutrition or had malnutrition. Older age was associated with lower skeletal muscle mass (age of ≥75 versus <75 years: least squares mean [and standard error], -3.3 ± 1.6 kg; p = 0.042). From the time of injury to 6 weeks, participants lost an average of 2.4 kg (9%) of skeletal muscle mass (95% confidence interval [CI] = ‒3.0 to ‒1.8 kg; p < 0.001). This early loss did not recover by 6 months (1.8 kg persistent loss compared with baseline [95% CI = ‒2.5 to ‒1.1 kg]; p < 0.001). Participants with normal nutritional status lost more skeletal muscle mass from baseline to 6 weeks after injury compared with those with malnutrition (1.3 kg more loss [standard error, 0.6 kg]; p = 0.036). A 1-kg decrease in skeletal muscle mass was associated with an 8-point decrease in the PROMIS Physical Function (model parameter estimate, 0.12 [standard error, 0.04]; p = 0.002). CONCLUSIONS: We found that older adults with femoral fragility fractures lost substantial skeletal muscle mass and physical function. Participants with adequate baseline nutrition actually lost more muscle mass than those who were malnourished, indicating that future investigations of interventions to prevent muscle loss should focus on older adults regardless of nutritional status. LEVEL OF EVIDENCE: Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Technical improvements in preparing 3D printed anatomical models for comminuted fracture preoperative planning.

Preoperative planning of comminuted fracture repair using 3D printed anatomical models is enabling surgeons to visualize and simulate the fracture reduction processes before surgery. However, the preparation of such models can be challenging due to the complexity of certain fractures, particularly in preserving fine detail in bone fragments, maintaining the positioning of displaced fragments, and accurate positioning of multiple bones. This study described several key technical considerations for preparing 3D printed anatomical models for comminuted fracture preoperative planning. An optimized segmentation protocol was developed that preserves fine detail in bone fragments, resulting in a more accurate representation of the fracture. Additionally, struts were manually added to the digital model to maintain the positioning of displaced fragments after fabrication, reducing the likelihood of errors during printing or misrepresentation of fragment positioning. Magnets were also used to enable separation and visualization of accurate positioning of multiple bones, making it easier to visualize fracture components otherwise obscured by the anatomy. Finally, the infill for non-target structures was adjusted to minimize print time and material wastage. These technical optimizations improved the accuracy and efficiency of preparing 3D printed anatomical models for comminuted fracture preoperative planning, improving opportunities for surgeons to better plan surgical treatment in advance, reducing the likelihood of errors, with the goal of improving surgical outcomes.

What Are the Barriers to Incorporating Nutrition Interventions Into Care of Older Adults With Femoral Fragility Fractures?

Femoral fragility fractures cause substantial morbidity and mortality in older adults. Mortality has generally been approximated between 10-20% in the first year after fracture and among those who do survive, another 20-60% require assistance with basic activities within 1-2 years following fracture.1 Malnutrition is common and perpetuates these poor outcomes. Nutrition supplementation has potential to prevent post-injury malnutrition, preserve functional muscle mass, and improve outcomes in older adults with femoral fragility fractures, however high-quality evidence is lacking, thus limiting translation of interventions into clinical practice. This review article is designed to highlight gaps in the evidence investigating nutrition interventions in this population and identify barriers for translation to clinical practice. Our goal is to guide future nutrition intervention research in older adults with femoral fragility fractures. Level of Evidence: V.

Returning to Activity After Anterior Cruciate Ligament Revision Surgery: An Analysis of the Multicenter Anterior Cruciate Ligament Revision Study (MARS) Cohort at 2 Years Postoperative.

BACKGROUND: Patients with anterior cruciate ligament (ACL) revision report lower outcome scores on validated knee questionnaires postoperatively compared to cohorts with primary ACL reconstruction. In a previously active population, it is unclear if patient-reported outcomes (PROs) are associated with a return to activity (RTA) or vary by sports participation level (higher level vs. recreational athletes). HYPOTHESES: Individual RTA would be associated with improved outcomes (ie, decreased knee symptoms, pain, function) as measured using validated PROs. Recreational participants would report lower PROs compared with higher level athletes and be less likely to RTA. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: There were 862 patients who underwent a revision ACL reconstruction (rACLR) and self-reported physical activity at any level preoperatively. Those who did not RTA reported no activity 2 years after revision. Baseline data included patient characteristics, surgical history and characteristics, and PROs: International Knee Documentation Committee questionnaire, Marx Activity Rating Scale, Knee injury and Osteoarthritis Outcome Score, and the Western Ontario and McMaster Universities Osteoarthritis Index. A binary indicator was used to identify patients with same/better PROs versus worse outcomes compared with baseline, quantifying the magnitude of change in each direction, respectively. Multivariable regression models were used to evaluate risk factors for not returning to activity, the association of 2-year PROs after rACLR surgery by RTA status, and whether each PRO and RTA status differed by participation level. RESULTS: At 2 years postoperatively, approximately 15% did not RTA, with current smokers (adjusted odds ratio [aOR] = 3.3; P = .001), female patients (aOR = 2.9; P < .001), recreational participants (aOR = 2.0; P = .016), and those with a previous medial meniscal excision (aOR = 1.9; P = .013) having higher odds of not returning. In multivariate models, not returning to activity was significantly associated with having worse PROs at 2 years; however, no clinically meaningful differences in PROs at 2 years were seen between participation levels. CONCLUSION: Recreational-level participants were twice as likely to not RTA compared with those participating at higher levels. Within a previously active cohort, no RTA was a significant predictor of lower PROs after rACLR. However, among patients who did RTA after rACLR, approximately 20% reported lower outcome scores. Most patients with rACLR who were active at baseline improved over time; however, patients who reported worse outcomes at 2 years had a clinically meaningful decline across all PROs.

Cellular and morphological changes with EAA supplementation before and after total knee arthroplasty.

Investigate the underlying cellular basis of muscle atrophy (Placebo) and atrophy reduction (essential amino acid supplementation, EAAs) in total knee arthroplasty (TKA) patients by examining satellite cells and other key histological markers of inflammation, recovery, and fibrosis. Forty-one subjects (53-76 yr) scheduled for TKA were randomized into two groups, ingesting 20 g of EAAs or placebo, twice-daily, for 7 days before TKA and for 6 wk after surgery. A first set of muscle biopsies was obtained from both legs before surgery in the operating room, and patients were randomly assigned and equally allocated to have two additional biopsies at either 1 or 2 wk after surgery. Biopsies were processed for gene expression and immunohistochemistry. Satellite cells were significantly higher in patients ingesting 20 g of essential amino acids twice daily for the 7 days leading up to surgery compared with Placebo (operative leg P = 0.03 for satellite cells/fiber and P = 0.05 for satellite cell proportions for Type I-associated cells and P = 0.05 for satellite cells/fiber for Type II-associated cells.) Myogenic regulatory factor gene expression was different between groups, with the Placebo Group having elevated MyoD expression at 1 wk and EAAs having elevated myogenin expression at 1 wk. M1 macrophages were more prevalent in Placebo than the EAAs Group. IL-6 and TNF-α transcripts were elevated postsurgery in both groups; however, TNF-α declined by 2 wk in the EAAs Group. EAAs starting 7 days before surgery increased satellite cells on the day of surgery and promoted a more favorable inflammatory environment postsurgery.NEW & NOTEWORTHY Clinical studies by our group indicate that the majority of muscle atrophy after total knee arthroplasty (TKA) in older adults occurs rapidly, within the first 2 wks. We have also shown that essential amino acid supplementation (EAAs) before and after TKA mitigates muscle atrophy; however, the mechanisms are unknown. These results suggest that satellite cell numbers are elevated with EAA ingestion before surgery, and after surgery, EAA ingestion positively influences markers of inflammation. Combined, these data may help inform further studies designed to address the accelerated sarcopenia that occurs in older adults after major surgery.

Relationship Between Sports Participation After Revision Anterior Cruciate Ligament Reconstruction and 2-Year Patient-Reported Outcome Measures.

BACKGROUND: Anterior cruciate ligament (ACL) revision cohorts continually report lower outcome scores on validated knee questionnaires than primary ACL cohorts at similar time points after surgery. It is unclear how these outcomes are associated with physical activity after physician clearance for return to recreational or competitive sports after ACL revision surgery. HYPOTHESES: Participants who return to either multiple sports or a singular sport after revision ACL surgery will report decreased knee symptoms, increased activity level, and improved knee function as measured by validated patient-reported outcome measures (PROMs) and compared with no sports participation. Multisport participation as compared with singular sport participation will result in similar increased PROMs and activity level. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 1205 patients who underwent revision ACL reconstruction were enrolled by 83 surgeons at 52 clinical sites. At the time of revision, baseline data collected included the following: demographics, surgical characteristics, previous knee treatment and PROMs, the International Knee Documentation Committee (IKDC) questionnaire, Marx activity score, Knee injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A series of multivariate regression models were used to evaluate the association of IKDC, KOOS, WOMAC, and Marx Activity Rating Scale scores at 2 years after revision surgery by sports participation category, controlling for known significant covariates. RESULTS: Two-year follow-up was obtained on 82% (986 of 1205) of the original cohort. Patients who reported not participating in sports after revision surgery had lower median PROMs both at baseline and at 2 years as compared with patients who participated in either a single sport or multiple sports. Significant differences were found in the change of scores among groups on the IKDC (P < .0001), KOOS-Symptoms (P = .01), KOOS-Sports and Recreation (P = .04), and KOOS-Quality of Life (P < .0001). Patients with no sports participation were 2.0 to 5.7 times more likely than multiple-sport participants to report significantly lower PROMs, depending on the specific outcome measure assessed, and 1.8 to 3.8 times more likely than single-sport participants (except for WOMAC-Stiffness, P = .18), after controlling for known covariates. CONCLUSION: Participation in either a single sport or multiple sports in the 2 years after ACL revision surgery was found to be significantly associated with higher PROMs across multiple validated self-reported assessment tools. During follow-up appointments, surgeons should continue to expect that patients who report returning to physical activity after surgery will self-report better functional outcomes, regardless of baseline activity levels.

Essential Amino Acid Supplementation Mitigates Muscle Atrophy After Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Substantial muscle atrophy occurs after total knee arthroplasty (TKA), resulting in decreased strength and impaired mobility. We sought to determine whether perioperative supplementation with essential amino acids (EAA) would attenuate muscle atrophy following TKA and whether the supplements were safe for ingestion in an older surgical population. METHODS: We performed a double-blind, placebo-controlled, randomized trial of 39 adults (age range, 53 to 76 years) undergoing primary unilateral TKA who ingested 20 g of EAA (n = 19) or placebo (n = 20) twice daily for 7 days preoperatively and for 6 weeks postoperatively. At baseline and 6 weeks postoperatively, magnetic resonance imaging (MRI) scans were obtained to measure quadriceps and hamstrings muscle volume. Secondary outcomes included functional mobility and strength. Data on physical activity, diet, and patient-reported outcomes (Veterans RAND 12-Item Health Survey and Knee injury and Osteoarthritis Outcome Score) were collected. Safety was determined through blood tests evaluating blood urea nitrogen, creatinine, creatinine clearance, homocysteine, and renal and liver function. Laboratory values at baseline, on the day of surgery, and at 2 days, 2 weeks, and 6 weeks postoperatively were compared between treatment groups. Analysis of covariance models, with baseline values as covariates, were used to evaluate outcomes between treatment groups. P values were adjusted for multiple tests. RESULTS: Compared with baseline, the EAA group had significantly less decrease in mean quadriceps muscle volume compared with the placebo group in the involved leg (-8.5% ± 2.5% compared with -13.4% ± 1.9%; p = 0.033) and the contralateral leg (-1.5% ± 1.6% compared with -7.2% ± 1.4%; p = 0.014). The hamstrings also demonstrated a greater muscle-volume-sparing effect for the EAA group than for the placebo group in the involved leg (-7.4% ± 2.0% compared with -12.2% ± 1.4%; p = 0.036) and contralateral leg (-2.1% ± 1.3% compared with -7.5% ± 1.5%; p = 0.005). There were no differences between the groups in terms of functional measures or strength. Blood chemistry values varied significantly between assessments periods but did not statistically differ between groups. CONCLUSIONS: The results of the present study suggest that EAA supplementation is safe and reduces the loss of muscle volume in older adults recovering from TKA. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Injury Surveillance and Evaluation of Medical Services Utilized During the 2016 Track and Field Olympic Trials.

BACKGROUND: Injury surveillance systems have been implemented at world championships, yet no previous work has determined the burden of injuries during the United States Track and Field Olympic Trials. Additionally, the type of medical service providers utilized throughout the meet has not been reported, leaving it unclear whether optimal staffing needs are being met. PURPOSE: To describe the incidence of injuries presenting to the medical team at the 2016 US Track and Field Olympic Trials (Eugene, Oregon) by event type and competitor demographics. STUDY DESIGN: Descriptive epidemiology study. METHODS: A retrospective review was performed of all documented injuries and treatments recorded from June 28 through July 10, 2016. Descriptive statistics and the prevalence of newly incurred injuries were calculated for registered athletes and nonathlete (ie, support) staff. The incidence of acute injuries was analyzed for registered athletes, as stratified by athlete sex and event type. RESULTS: A total of 514 individuals were seen during the trials: 89% were athletes and 11% were supporting staff. Physicians treated 71 injuries and 14 illnesses. Of diagnosed injuries, 85% (n = 60) occurred among athletes, with hamstring strains (16.7%, n = 10) being the most prevalent. A mean of 124 medical services (median, 137; interquartile range, 65.5-179.5) were provided each day of the trials. Among medical services, 41.8% were attributed to massage therapists for athletes, while chiropractic services were the most utilized service (47.1%) by the support staff. There was an overall incidence of 59.7 injuries per 1000 registered athletes, with jumpers (109.4 per 1000) and long-distance athletes (90.4 per 1000) being the most commonly seen athletes. CONCLUSION: Throughout the trials, athletes participating in jumping and long-distance events were the most commonly seen by physicians, creating the potential need for an increase in staffing of physicians during meet periods when these events occur. The provided medical services appeared to follow the number of athletes competing during the trials and the need for recovery treatments after competition. Findings from this study should inform future strategy for staffing and policy development at Olympic Trials and other elite-level track and field events in the United States.

Mental health care among low-income pregnant women with depressive symptoms: facilitators and barriers to care access and the effectiveness of financial incentives for increasing care.

Access to mental health care is suboptimal for low-income pregnant women. Using in-depth interviews, we examined barriers and facilitators to accessing care among 42 low income pregnant women with depressive symptoms. To pilot whether financial incentives would increase utilization during pregnancy, half the women were randomized to receive $10 gift cards after mental health visits. Women reported external and internal barriers to accessing mental health care, and internal and interpersonal facilitators. Financial incentives did not impact how often the women visited mental health providers, suggesting that small incentives are not sufficient to catalyze mental health care use for this population.

Hepatitis A vaccine uptake in San Diego County: Hispanic children are better immunized.

BACKGROUND: Few studies have examined compliance with hepatitis A vaccination recommendations or factors likely to predict vaccination against hepatitis A virus. OBJECTIVES: To investigate hepatitis A coverage among 3- to 17.9-year-olds in San Diego County and examine predictors of child and adolescent hepatitis A immunization. DESIGN, SETTING, AND PARTICIPANTS: A total of 1455 participants completed a random-digit dial telephone survey that assessed hepatitis A immunization status of 3- to 17.9-year-old children from May 1 to June 24, 2003. Analysis was limited to the 983 respondents with available immunization records or verified immunization histories. MAIN OUTCOME MEASURES: Receipt of at least 1 hepatitis A vaccine administered on or after the child's second birthday and differences in the frequencies of vaccination based on vaccine availability, sex, ethnicity, type of health care provider, mother's highest level of education, and parental knowledge of the hepatitis A vaccine recommendation. RESULTS: Participant response rate was 77.1%. Among all respondents aged 3 to 17.9 years, 59% received at least 1 hepatitis A vaccine and 41% completed the 2-shot regimen. The adjusted odds that a child received at least 1 hepatitis A vaccine was 3.6 times greater among Hispanic children compared with non-Hispanic children. Other predictors of hepatitis A immunization included child's age, having a public health care provider, lower maternal education, and parental knowledge of the vaccine recommendation. CONCLUSIONS: Results challenge historical patterns of underimmunization among Hispanic children compared with white children. Public health education and community awareness should be sustained in Hispanic communities, but interventions are needed in non-Hispanic communities.