SLR - October 2022 - Jacqueline C. Lucke, DPM
Reference: Hendrickson NR, Davison J, Glass NA, Wilson ES, Miller A, Leary S, Lorentzen W, Karam MD, Hogue M, Marsh JL, Willey MC. Conditionally Essential Amino Acid Supplementation Reduces Postoperative Complications and Muscle Wasting After Fracture Fixation: A Randomized Controlled Trial. J Bone Joint Surg Am. 2022 May 4;104(9):759-766. doi: 10.2106/JBJS.21.01014.Level of Evidence: Therapeutic Level I
Scientific Literature Review
Reviewed By: Jacqueline C. Lucke, DPM
Residency Program: University of Florida Health Jacksonville – Jacksonville, FL
Podiatric Relevance: Musculoskeletal trauma is often accompanied by significant loss of muscle mass and physical function in the postoperative recovery period. Prolonged periods of non-weight bearing and immobilization in lower extremity trauma such as pilon, talus, and calcaneus fractures further exacerbates this risk. The nutritional status of the patient is a commonly overlooked but modifiable risk factor that can improve healing potential. Malnutrition combined with postoperative appetite suppression can put trauma patients at greater risk for poor outcomes, therefore, nutritional optimization of these patients should be a top priority. The purpose of this study was to investigate the impact of Conditionally essential amino acid (CEAA) supplementation on clinical outcomes in the postoperative musculoskeletal trauma patient.
Methods: This was a prospective, single-blinded, randomized controlled trial at a Level 1 trauma center. Patients included were adults who sustained pelvic and extremity fractures undergoing operative fixation. Patients were classified based on injury type: open fractures/polytrauma, fragility fractures, and isolated injuries, and treatment was randomized to standard nutrition for the control group, and oral CEAA supplementation twice daily for 2 weeks for the treatment group. The primary outcome measure was overall complication rate, which included those related to the surgery and fracture healing, as well as medical complications, documented prospectively for 12 months. The secondary outcomes measured were body composition, or fat-free mass (FFM), and dominant hand grip strength. FFM was measured at time of injury and again at 6 and 12 weeks postoperatively.
Results: A total of 400 patients were enrolled, with 200 each randomized to the control and CEAA group. There were no significant differences in the two groups with regards to demographic data, baseline FFM, medical history, and injury characteristics. After adjustment for follow up duration and injury classification, The CEAA group was found to have significantly lower overall complication rate than the control group (30.5% versus 43.8%, RR 0.71), and specifically, a lower nonunion and mortality rate. No significant difference was seen with SSI occurrence, medical complications, or unplanned reoperation rate. The CEAA group saw no change in FFM at 6 and 12 weeks, whereas FFM in the control group decreased significantly at 6 weeks but recovered at 12 weeks. There were no significant differences in grip strength between the groups at any time point.
Conclusions: The results of this study show that 2 weeks of twice daily CEAA supplementation can potentially reduce early loss of muscle mass and overall complication rate after musculoskeletal trauma requiring surgery. The preservation of muscle mass at 6 weeks did not last at 12 weeks, suggesting the need for more than two weeks of supplementation for long lasting protection against muscle waste. Despite this, CEAA supplementation was found to be a safe intervention with no adverse events reported, and is said to be inexpensive, however the authors did not provide cost analysis. Further studies are needed to determine if similar promising results can be seen with high risk patients undergoing other types of nonelective foot and ankle surgery.