title: Total hip arthroplasty and perioperative oral carbohydrate treatment: a randomised, double-blind, controlled trial Preoperative oral carbohydrate treatment attenuates immediate postoperative insulin resistance. Oral nutrition or water loading before hip replacement surgery; a randomized clinical trial Multimodal perioperative care plus immunonutrition versus traditional care in total hip arthroplasty: a randomized pilot study Essential amino acid supplementation in patients following total knee arthroplasty. Effects of supplementation with a combination of β-hydroxy-β-methyl butyrate, L-arginine, and L-glutamine on postoperative recovery of quadriceps muscle strength after total knee arthroplasty. Preoperative oral carbohydrates and postoperative insulin resistance. Preoperative oral carbohydrate treatment attenuates endogenous glucose release 3 days after surgery. A carbohydrate-rich drink shortly before surgery affected IGF-I bioavailability after a total hip replacement. A double-blind placebo controlled study on 29 patients A whey protein-based multi-ingredient nutritional supplement stimulates gains in lean body mass and strength in healthy older men: A randomized controlled trial Effect of β-hydroxy-β-methylbutyrate (HMB) on lean body mass during 10 days of bed rest in older adults. Randomized clinical trial of the effect of preoperative oral carbohydrate treatment on postoperative whole‐body protein and glucose kinetics
abstract: Context Perioperative oral carbohydrate intake is beneficial to general surgery patients . Total hip arthroplasty is a common surgical procedure , and even a moderate improvement in patient outcome could have a significant effect on the re sources needed for these patients . However , few studies have focused on the effects of carbohydrate intake on orthopaedic patients . Objective The purpose of this study was to investigate if perioperative oral carbohydrate intake alters the postoperative course for patients undergoing total hip arthroplasty . The primary hypothesis was that pain scores would be lower in patients treated with carbohydrate . Design A r and omised , double-blind , controlled trial . Setting This study was carried out between September 2009 and April 2011 at a district Swedish hospital that specialises in orthopaedic surgery . Patients Sixty ASA physical status I – III patients scheduled for elective total hip arthroplasty were included . Exclusion criteria were obesity , diabetes , prior hip surgery to the same hip , ongoing infection , immunological deficiency or age less than 50 or more than 80 years . Interventions Patients were given 400 ml of either an oral 12.5 % carbohydrate solution or a placebo beverage ( flavoured water ) 1.5 h before and 2 h after surgery . Main outcome measures Visual analogue scales were used to score six discomfort parameters . Results Immediately prior to surgery , the carbohydrate-treated patients were less hungry ( median score 9.5 vs. 22 mm ) and experienced less nausea ( 0 vs. 1.5 mm ) ( P < 0.05 ) . Postoperatively , patients in the carbohydrate group experienced less pain at 12 , 16 and 20 h ( median scores 20 , 30 and 34 vs. 7 , 5 and 0 mm ; P < 0.05 ) . Conclusion This study shows that there is limited benefit from administering oral carbohydatre prior to total hip arthroplasty Postoperative insulin resistance is a well-characterized metabolic state that has been shown to correlate with the length of postoperative stay in hospital . Preoperative intravenous or oral carbohydrate treatment has been shown to attenuate the development of postoperative insulin resistance measured 1 day after surgery . To study the effects of preoperative oral carbohydrate treatment on postoperative changes in insulin resistance and substrate utilization , in the absence of postoperative confounding factors , 15 patients were double-blindly treated with either a carbohydrate-rich beverage ( 12.5 % ) ( n = 8) or placebo ( n = 7 ) before undergoing total hip replacement surgery .  Insulin sensitivity , endogenous glucose release , and substrate oxidation rates were measured before and immediately after surgery . Whole body insulin sensitivity decreased by 18 % in the treatment group vs. 43 % in the placebo group ( P < 0.05 , Student 's t-test for unpaired data ) . In both groups , the major mechanism of insulin resistance was an inhibition of insulin-induced nonoxidative glucose disposal after surgery . The better preservation of insulin sensitivity in the treatment group was attributable to a less reduced glucose disposal in peripheral tissues and increased glucose oxidation rates Background Surgery induces insulin resistance that might be alleviated by a nutritional drink given preoperatively . The authors hypothesized that some of the beneficial effects of the drink could be attributed to the volume component ( approximately 1 L ) rather than to the nutrients . Methods Sixty patients scheduled for elective total hip replacement under spinal anesthesia were recruited to a clinical trial , and r and omly allocated to preoperative fasting , to oral ingestion of tap water , or to oral ingestion of a carbohydrate drink . An intravenous glucose tolerance test calculated glucose clearance and insulin sensitivity on the day before surgery , in the postoperative ward , and on the day after surgery . Other parameters were stress ( cortisol in plasma and urine ) , muscle catabolism ( urinary 3-methylhistidine ) , and wellbeing . Results Fifty-seven patients completed the study . In the postoperative ward , the glucose clearance and the insulin response had decreased from the previous day by 23 % and 36 % , respectively . Insulin sensitivity did not decrease until the next morning ( −48 % ) and was due to an increased insulin response ( + 51 % ) . Cortisol excretion was highest on the day of surgery , while 3-methylhistidine increased 1 day later . Follow-up on the third postoperative day showed an average of 1.5 complications per patient . Wellbeing was better 2 weeks after than before the surgery . None of the measured parameters differed significantly between the study groups . Conclusions Preoperative ingestion of tap water or a nutritional drink had no statistically significant effect on glucose clearance , insulin sensitivity , postoperative complications , or wellbeing in patients undergoing elective hip surgery . Trial registration Registration number : NCT 01211184 ( http://www . clinical trials.gov Background Multimodal protocol s of perioperative care may enhance postoperative recovery . However , limited information is available on preoperative immune and carbohydrate (CHO)-enriched drinks in patients undergoing hip arthroplasty . We aim ed to investigate the effect of a multimodal protocol ( ACERTO protocol ) plus preoperative immune nutrition on the length of stay ( LOS ) and the postoperative acute phase response of patients undergoing total hip arthroplasty . Methods Thirty-two patients ( mean age , 58 years ; range , 26–85 years ; 16 males ) were r and omized to receive either the  ACERTO protocol  ( n = 15 , ACERTO Group ) , which consisted of 6 h preoperative fasting for solids , an oral drink ( 200 mL of 12.5 % maltodextrin ) up to 2 h before induction of anesthesia , restricted intravenous fluids ( only 1000 mL of crystalloid fluid after surgery ) and preoperative immune nutrition ( 600 mL/day of Impact - Nestlé , Brazil ) for five days prior to surgery , or traditional care ( n = 17 ; control group ) , which consisted of 6–8 h preoperative fasting , intravenous hydration until the 1st postoperative day and no preoperative immune supplementation . The main endpoint was LOS . C-reactive protein ( CRP ) was the secondary endpoint and was assessed during induction of anesthesia and on postoperative day 2 . Results Neither deaths nor postoperative complications occurred . The median LOS was 3 ( 2–5 ) days in the ACERTO group and 6 ( 3–8 ) days in controls ( P < 0.01 ) . Postoperative CRP was higher in the control group ( P < 0.01 ) . Conclusion The ACERTO multimodal protocol of perioperative care plus preoperative immune nutrition may decrease LOS and postoperative CRP levels in total hip arthroplasty . Trial registration Clinical Trials : BACKGROUND By the year 2030 , 3.48 million older U.S. adults are projected to undergo total knee arthroplasty ( TKA ) . Following this surgery , considerable muscle atrophy occurs , result ing in decreased strength and impaired functional mobility . Essential amino acids ( EAAs ) have been shown to attenuate muscle loss during periods of reduced activity and may be beneficial for TKA patients . METHODS We used a double-blind , placebo-controlled , r and omized clinical trial with 28 older adults undergoing TKA . Patients were r and omized to ingest either 20 g of EAAs ( n = 16 ) or placebo ( n = 12 ) twice daily between meals for 1 week before and 2 weeks after TKA . At baseline , 2 weeks , and 6 weeks after TKA , an MRI was performed to determine mid-thigh muscle and adipose tissue volume . Muscle strength and functional mobility were also measured at these times . RESULTS TKA patients receiving placebo exhibited greater quadriceps muscle atrophy , with a -14.3 ± 3.6 % change from baseline to 2 weeks after surgery compared with -3.4 ± 3.1 % for the EAA group ( F = 5.16 , P = 0.036 ) and a -18.4 ± 2.3 % change from baseline to 6 weeks after surgery for placebo versus -6.2 ± 2.2 % for the EAA group ( F = 14.14 , P = 0.001 ) . EAAs also attenuated atrophy in the nonoperated quadriceps and in the hamstring and adductor muscles of both extremities . The EAA group performed better at 2 and 6 weeks after surgery on functional mobility tests ( all P < 0.05 ) . Change in quadriceps muscle atrophy was significantly associated with change in functional mobility ( F = 5.78 , P = 0.021 ) . CONCLUSION EAA treatment attenuated muscle atrophy and accelerated the return of functional mobility in older adults following TKA . TRIAL REGISTRATION Clinical trials.gov NCT00760383 OBJECTIVES Total knee arthroplasty ( TKA ) performed in knee osteoarthritis patients is reported to be immediately followed by a decrease in quadriceps muscle strength . We investigated the effects of supplementation with a combination β-hydroxy-β-methyl butyrate , L-arginine , and L-glutamine ( HMB/Arg/Gln ) on the postoperative recovery of quadriceps muscle strength in patients after TKA . METHODS Study subjects were 23 patients ( 12 women ; mean age : 70.5 ) who underwent TKA . The patients were r and omly allocated into the control group or the group that consumed HMB/Arg/Gln supplementation ( HMB/Arg/Gln group ) . HMB/Arg/Gln supplementation or control food were consumed for 5 days before the surgery and for 28 days after the surgery , and maximal quadriceps strength was measured at 7 days before the surgery , and at 14 , 28 and 42 days after the surgery . During the study , total energy expenditure was measured using a lifestyle recording device . The two groups followed the rehabilitation in the same way . RESULTS The maximal quadriceps strength was 1.1±0.62 Nm/Kg before surgery and 0.7±0.9 Nm/Kg after surgery 14 days in the control group ( p=0.02 ) , and 1.1±0.3 Nm/Kg before surgery and 0.9±0.4 Nm/Kg after surgery 14 days in the HMB/Arg/Gln group . Although the control group experienced a significant loss of muscle strength after the surgery , the HMB/Arg/Gln group did not . There was no significant difference in total energy expenditure between the two groups . CONCLUSIONS Consuming HMB/Arg/Gln supplementation may suppress the loss of muscle strength after TKA . Intervention with exercise and nutrition appears to enable patients to maintain their quadriceps strength UNLABELLED Infusions of carbohydrates before surgery have been shown to reduce postoperative insulin resistance . Presently , we investigated the effects of a carbohydrate drink , given shortly before surgery , on postoperative insulin sensitivity . METHODS Insulin sensitivity and glucose turnover ( [ 6 , 6,(2)H(2)]-D-glucose ) were measured using hyper-insulinemic , normoglycemic clamps before and after elective surgery . Sixteen patients undergoing total hip replacement were r and omly assigned to preoperative oral carbohydrate administration ( CHO-H , n = 8) or the same amount of a placebo drink ( placebo , n = 8) before surgery . Insulin sensitivity was measured before and immediately after surgery . Patients undergoing elective colorectal surgery were studied before surgery and 24 h postoperatively ( CHO-C ( n = 7 ) , and fasted ( n = 7 ) , groups ) . The fasted group underwent surgery after an overnight fast . In both studies , the CHO groups received 800 ml of an isoosmolar carbohydrate rich beverage the evening before the operation ( 100 g carbohydrates ) , as well as another 400 ml ( 50 g carbohydrates ) 2 h before the initiation of anesthesia . RESULTS Immediately after surgery , insulin sensitivity was reduced 37 % in the placebo group ( P < 0.05 vs. preoperatively ) while no significant change was found in the CHO-H group ( -16 % , p = NS ) . During clamps performed 24h postoperatively , insulin sensitivity and whole-body glucose disposal was reduced in both groups , but the reduction was greater compared to that in the CHO-C group ( -49 + /- 6 % vs. -26 + /- 8 % , P > > 0.05 fasted vs. CHO-C ) . CONCLUSIONS Patients given a carbohydrate drink shortly before elective surgery displayed less reduced insulin sensitivity after surgery as compared to patients undergoing surgery after an overnight fast BACKGROUND & AIMS Postoperative metabolism is characterised by insulin resistance and a negative whole-body nitrogen balance . Preoperative carbohydrate treatment reduces insulin resistance in the first day after surgery . We hypothesised that preoperative oral carbohydrate treatment attenuates insulin resistance and improves whole-body nitrogen balance 3 days after surgery . METHODS Fourteen patients undergoing total hip replacement were double-blindly r and omised to preoperative oral carbohydrate treatment ( 12.5 % , 800 + 400 ml , n = 8) or placebo ( n = 6 ) . Glucose kinetics ( 6,6-D2-glucose ) , substrate utilisation ( indirect calorimetry ) and insulin sensitivity ( hyperinsulinaemic-euglycaemic clamp ) were measured preoperatively and on the third day after surgery . Nitrogen losses were monitored for 3 days after surgery . Values are mean ( SEM ) . Analysis of variance ( ANOVA ) statistics were used . RESULTS Endogenous glucose release during insulin infusion increased after surgery in the placebo group . Preoperative carbohydrate treatment , as compared to placebo , significantly attenuated postoperative endogenous glucose release ( 0.69 ( 0.07 ) vs. 1.21 (0.13)mg kg(-1 ) x min(-1 ) , P < 0.01 ) , while whole-body glucose disposal and nitrogen balance were similar between groups . CONCLUSIONS While insulin resistance in the first day after surgery has previously been characterised by reduced glucose disposal , enhanced endogenous glucose release was the main component of postoperative insulin resistance on the third postoperative day . Preoperative carbohydrate treatment attenuated endogenous glucose release on the third postoperative day Background and aims : In response to surgical stress , the body reacts with a change in metabolism to a catabolic state . This is further aggravated by the fasting state preoperatively . We aim ed to determine the effects on catabolism i.e. , body composition and IGF-I bioavailability as measured by the serum IGF-I/IGFBP-1 ratio , of a carbohydrate rich drink given shortly before surgery . Methods : Twenty-nine patients scheduled for a total hip replacement ( THR ) were r and omized in a double-blind placebo-controlled pilot study to a carbohydrate-rich drink or to placebo pre-operatively . The nutritional supplementation consisted of an iso-osmolar carbohydrate-rich drink ( 12.5 g carbohydrates/100 ml , pH 5.0 ) . Fasting blood sample s were collected before surgery and repeated after 5 days and after 2 months . IGF-I and IGFBP-1 were determined in serum by RIA . Body composition was determined by dual energy X-ray absorptiometry ( DXA ) . Results : Compared with placebo we found a relative increase in IGF-I bioavailability post-operatively after a carbohydrate-rich drink given shortly before surgery . There were no significant long-term differences in the changes in fat or lean body mass between groups , but , in a subgroup with late scheduled surgery , there was a tendency to a difference ( p=0.08 ) of fat loss after 2 months , with less fat loss in those who received another carbohydrate drink close to surgery . The pre-operative intake of a 200–200x2 ml carbohydrate drink was well tolerated and safe . There were no adverse events such as pulmonary aspiration before , during or after operation . Conclusions : A carbohydrate-rich drink given shortly before surgery increases IGF-I bioavailability post-operatively in patients undergoing a THR , but has no significant effects on body composition after 2 months in physically active people . We suggest that , if the operation is postponed for more than four hours on the same day , an additional carbohydrate drink should be given Protein and other compounds can exert anabolic effects on skeletal muscle , particularly in conjunction with exercise . The objective of this study was to evaluate the efficacy of twice daily consumption of a protein-based , multi-ingredient nutritional supplement to increase strength and lean mass independent of , and in combination with , exercise in healthy older men . Forty-nine healthy older men ( age : 73 ± 1 years [ mean ± SEM ] ; BMI : 28.5 ± 1.5 kg/m2 ) were r and omly allocated to 20 weeks of twice daily consumption of either a nutritional supplement ( SUPP ; n = 25 ; 30 g whey protein , 2.5 g creatine , 500 IU vitamin D , 400 mg calcium , and 1500 mg n-3 PUFA with 700 mg as eicosapentanoic acid and 445 mg as docosahexanoic acid ) ; or a control ( n = 24 ; CON ; 22 g of maltodextrin ) . The study had two phases . Phase 1 was 6 weeks of SUPP or CON alone . Phase 2 was a 12 week continuation of the SUPP/CON but in combination with exercise : SUPP + EX or CON + EX  . Isotonic strength ( one repetition maximum [ 1RM ] ) and lean body mass ( LBM ) were the primary outcomes . In Phase 1 only the SUPP group gained strength ( Σ1RM , SUPP : + 14 ± 4 kg , CON : + 3 ± 2 kg , P < 0.001 ) and lean mass ( LBM , + 1.2 ± 0.3 kg , CON : -0.1 ± 0.2 kg , P < 0.001 ) . Although both groups gained strength during Phase 2 , upon completion of the study upper body strength was greater in the SUPP group compared to the CON group ( Σ upper body 1RM : 119 ± 4 vs. 109 ± 5 kg , P = 0.039 ) . We conclude that twice daily consumption of a multi-ingredient nutritional supplement  increased muscle strength and lean mass in older men . Increases in strength were enhanced further with exercise training . Trial Registration : Clinical Trials.gov BACKGROUND Loss of muscle mass due to prolonged bed rest decreases functional capacity and increases hospital morbidity and mortality in older adults . OBJECTIVE To determine if HMB , a leucine metabolite , is capable of attenuating muscle decline in healthy older adults during complete bed rest . DESIGN A r and omized , controlled , double-blinded , parallel-group design study was carried out in 24 healthy ( SPPB ≥ 9 ) older adult subjects ( 20 women , 4 men ) , confined to complete bed rest for ten days , followed by resistance training rehabilitation for eight weeks . Subjects in the experimental group were treated with HMB ( calcium salt , 1.5 g twice daily - total 3 g/day ) . Control subjects were treated with an inactive placebo powder . Treatments were provided starting 5 days prior to bed rest till the end rehabilitation phase . DXA was used to measure body composition . RESULTS Nineteen eligible older adults ( BMI : 21 - 33 ; age : 60 - 76 year ) were evaluable at the end of the bed rest period ( Control n = 8 ; Ca-HMB n = 11 ) . Bed rest caused a significant decrease in total lean body mass ( LBM ) ( 2.05 ± 0.66 kg ; p = 0.02 , paired t-test ) in the Control group . With the exclusion of one subject , treatment with HMB prevented the decline in LBM over bed rest -0.17 ± 0.19 kg ; p = 0.23 , paired t-test ) . There was a statistically significant difference between treatment groups for change in LBM over bed rest ( p = 0.02 , ANOVA ) . Sub- analysis on female subjects ( Control = 7 , HMB = 8) also revealed a significant difference in change in LBM over bed rest between treatment groups ( p = 0.04 , ANOVA ) . However , differences in function parameters could not be observed , probably due to the sample size of the study . CONCLUSIONS In healthy older adults  , HMB supplementation preserves muscle mass during 10 days of bed rest . These results need to be confirmed in a larger trial Preoperative  oral carbohydrate ( CHO )  reduces postoperative insulin resistance . In this r and omized trial , the effect of CHO on postoperative whole‐body protein turnover was studied
target: Intake of a carbohydrate-containing fluid is reported to improve insulin-like growth factor levels , reduce hunger , nausea , and length of stay , and attenuate the decrease in whole-body insulin sensitivity and endogenous glucose release .
  Amino acid supplementation is reported to reduce muscle atrophy and accelerate return of functional mobility .
  There is limited evidence for nutritional supplementation in THR and TKR pathways ; however , the low risk profile and potential benefits to adjunctive treatment methods , such as exercise programs , suggest nutritional supplements may have a role .
  Optimizing nutritional status pre-operatively may help manage the surgical stress response , with a particular benefit for undernourished , frail , or elderly individuals
background: Nutritional supplements can influence outcomes for individuals undergoing major surgery , particularly in older persons whose functional reserve is limited .
  Accelerating recovery from total hip replacement ( THR ) and total knee replacement ( TKR ) may offer significant benefits .
  Therefore , we explored the role of nutritional supplements in improving recovery following THR and TKR .