Scott Webb (Host): Today, I'm joined by Dr. Joseph Serino again. He's an Orthopedic Surgeon who specializes in hip and knee replacements. And today, he's here to talk about the importance of proper nutrition before and after surgery to help with healing and decrease the chances of complications.

 Welcome to A Bone to Fix from Orthopedic Associates of Central Maryland Division. I'm Scott Webb, and I've got A Bone to Fix with you. Doctor, it's nice to have you back on the podcast. We're going to talk today about optimizing nutrition, you know, before and after surgery and how you help patients. So, let's talk about that. Why is nutritional optimization important, and what does it mean to be malnourished?

Joseph Serino, MD: Thanks. Yeah. This is a topic that I'm particularly passionate about. I'm a big believer in optimizing patient's nutrition both before and after surgery. And really, it's a topic that until recently, got very little recognition. But what some recent studies have shown that about a quarter up to even a half of patients undergoing hip or knee replacement are actually malnourished to some degree, which can directly and negatively impact outcomes after surgery. And in our population, malnutrition is not typically caused by not getting enough food. It's usually more the quality of food or the lack of certain micronutrients or macronutrients or the presence of certain metabolic conditions like diabetes or prior abdominal surgery that can contribute to that as well. Being malnourished can directly increase the risk of infection and many other serious complications after surgery. It can prevent or delay wound healing, and it can also prolong recovery. So, I think these are relatively simple, easy things that we can work on with our patients to help improve their outcomes and recovery after surgery.

Host: Sure. Yeah, this is anecdotal at best, but just sort of looking around as you say, like, it's not that we're not eating enough food in America; it's that we're just not probably eating the right foods, getting the right nutrients. So, it's good to know that patients are in good hands in terms of, you know, before, after surgery. So then, what are some of the key nutrients that support bone and tissue repair during recovery?

Joseph Serino, MD: There's a few important ones to consider. Vitamin D is incredibly important. If it's deficient in a patient, it can increase their pain, it can increase the risk of failure of the surgery due to implant loosening or fracture or infection. It's an important aspect of wound healing. Vitamin C similarly, and zinc are both important micronutrients to have for wound healing. For patients that are diabetic, blood sugar is actually a huge part of wound healing. Having uncontrolled blood sugars can dramatically increase the risk of wound healing complications and infection after surgery. And that's something that I talk to all my patients about.

And then, lastly, which we can get into a little bit more, is protein. Every function in our body uses protein to work. It's not just about muscle mass or building muscle, but it's about healing and recovery and immune support, all of which are really important for recovery after surgery. So, getting adequate protein intake both before and after surgery is incredibly important.

Host: And I must confess, Doctor, that it never occurred to me that there really was a link between nutrition and recovery. I mean, it makes so much sense when I hear an expert say it but I go, "Why didn't I ever think of this before?" But I guess, why we have the experts, why we have these podcasts. So, I want to have you talk about like, let's say how poor nutrition might delay recovery or increase the risk of complications.

Joseph Serino, MD: Poor nutrition, whether it's a vitamin D deficiency, anemia, protein malnutrition, not getting enough protein and, like I mentioned, having uncontrolled blood sugars, all play a multifactorial role in recovery. If any one of those is abnormal, that's all things that you know, I talk to my patients about before surgery and try to correct to the degree that we can, but all of them contribute. And like I mentioned, the risk of increased pain, wound healing complications, infection, fracture, all things that we really want to avoid and you know, work our hardest to avoid can be at increased risk for patients with nutritional deficiency. Correcting it, I hope, can significantly improve their chance of a successful outcome.

And at the end of the day, there are just some factors that we can control, you know, certain diseases, the degree of arthritis in our knees, our range of motion, things like that. There are so many factors that affect our outcome and our risk for complications, that I think we should really focus on the ones that we can control and we can check for and improve.

Host: Right. Like, family history, genetics, there's just things in life we can't control. They just are what they are, right? So, how do you actually check nutrition of your patients before surgery?

Joseph Serino, MD: That's a controversial topic in the nutritional studies that get published, and there's really no good single test for it. But I get blood work on all my patients prior to surgery, and there are really four areas that we look at. The first is we look at their blood counts to look for anemia, which can indicate an iron deficiency.

We also directly test vitamin D levels since vitamin D deficiency is extremely common, but also extremely easy to correct. We also look at levels of a protein called albumin, which is produced by the liver and can indicate if a patient's getting enough protein in their diet. We also look at the amount of white blood cells, which are called lymphocytes in the blood, which can correlate to protein intake and that's also part of the reason why protein is so important for immunity and preventing infection, is it actually directly supports our immune system and our white blood cells.

And the last thing I check on my patients before surgery is their blood sugar levels, specifically a test called hemoglobin A1c, which looks at their blood sugar levels over the last three months.

Host: Yeah. Now, barring you coming over to people's houses and helping them prepare meals, I want to get a sense from you, like how do you help patients optimize their nutrition before surgery?

Joseph Serino, MD: For every patient, we'll sit down before surgery-- not the day of surgery-- you know, a couple weeks before, and we'll go through their lab work. We'll talk about any abnormalities that are there and how we can work to correct them. But just kind of some blanket advice that I think is helpful for every patient is first just taking a daily multivitamin to get key nutrients like zinc and vitamin C that are important for healing. Taking at least a thousand international units of vitamin D every day, which is often included in multivitamins, but can be taken as a separate supplement if needed.

Exercise, like we talked about in one of our prior podcasts, is really important to maintain healthy muscle, and having healthy amounts of muscle actually keeps your metabolism high. It improves your blood sugars for both diabetic and non-diabetic patients.

And lastly, I really stress the importance of protein intake for my patients. I think it's really one of the most important factors for recovery after surgery. The recommendation is actually a half a gram of protein for every pound of body weight. So if you weigh 180 pounds, the goal should be to get at least 90 grams of protein a day. I think most patients are falling way below that goal. Trying to reach that goal, just using diet alone can be very challenging. And of course, you know, we should all try to eat balanced, healthy meals as much as we can. But sometimes having protein supplementation, is really helpful to reach our protein goal. There's lots of options available at grocery stores, Costco, online pharmacies. I recommend looking for either protein powders or shakes that have at least 20 to 30 grams of protein, minimal sugars added, and ideally some enrichment with either vitamins, arginine, creatine, other helpful micronutrients.

And one option that I offer to all my patients before surgery is through an online company called Enroute. They make protein supplements specifically for surgical patients. They have both plant and dairy-based options. It's essentially a pack of 56 shakes that they take one pack twice a day for two weeks before surgery, and then two weeks after surgery, and then kind of an extra one the night before surgery. But it contains all the important micronutrients in addition to protein to help support recovery. And it's kind of just a quick way to make sure that you're getting everything you need.

Host: Right. Well, Doctor, it's been great having you back today. I've learned so much the three times we've been together, and I'm sure we'll be on again in the future. But for today, as we wrap up, when we think about after surgery, you know, postoperative, if you will. What foods or nutrients are most effective in promoting faster healing? We all want to heal faster.

Joseph Serino, MD: Yeah, great question. And thanks for having me again. Really, it's the same type of nutrition that we should all be trying to get before surgery because, you know, we don't quite know exactly what the time point is. You know, when we start intaking these nutrients, when do they really down the line start improving our ability to heal and recover? So, I recommend really starting to focus on this in the month before surgery and then the month after surgery. And it should be the same key things: vitamins, protein and, of course, good hydration. That's a big one after surgery. Between all the medications that you're getting, just the surgery itself, swelling, it's very easy to get dehydrated. So, I recommend drinking a healthy amount of water throughout the day.

Host: Yeah. As you say, if things are good for us before surgery, they're probably good for us after surgery. And it's always important to stay hydrated. All good stuff. Appreciate your expertise, your time over these podcasts that we've done. Thank you so much.

Joseph Serino, MD: Thank you.

Host: We now have online scheduling. Please visit mdbonedocs.com and click the new online scheduling button to instantly make an appointment. Find out more about us online at mdbonedocs.com. And please remember to share and subscribe to this podcast. And that's all for today. I'm Scott Webb, and that was A Bone That's Fixed.