Perioperative infections remain a significant concern in orthopaedic surgery, impacting patient outcomes, prolonging hospital stays, and increasing healthcare costs. Recent evidence underscores the pivotal role of nutritional status in modulating the risk of postoperative infections. This article synthesizes current findings, highlighting the association between malnutrition and perioperative infections, and provides evidence-based recommendations for nutritional interventions to enhance surgical outcomes.

Malnutrition and surgical infections
Malnutrition, characterized by inadequate intake or absorption of nutrients, adversely affects the immune system, wound healing, and the body’s ability to combat infections. In orthopaedic surgery, patients with malnutrition exhibit an increased risk of postoperative complications, including infections. A recent comprehensive review by Zink et al emphasized that malnutrition is common among patients undergoing orthopaedic procedures and linked to an elevated risk of postoperative complications. These findings are consistent with other studies reporting a significant association between malnutrition and higher rates of surgical site infections (SSIs) in total joint arthroplasty and spine surgery.

Assessment tools and interventions
Effective nutritional assessment is crucial for identifying at-risk patients. Serum proteins, including albumin, prealbumin, and transferrin, have been evaluated along with total lymphocyte count for their correlation to patient nutritional status and perioperative outcomes. Albumin levels in particular have been consistently associated with wound-healing complications and infections. Anthropometric measures and standardized screening tools such as the Nutritional Risk Screening and the Mini Nutritional Assessment also play a role in identifying malnutrition.

Optimizing nutritional status before surgery can mitigate the risk of perioperative infections. Protein-calorie supplementation and immunonutrition (e.g., arginine, omega-3 fatty acids, and nucleotides) to support the immune response and reduce infection rates should be considered. A meta-analysis by Weimann et al supports the inclusion of immunonutrition in perioperative care to improve outcomes and decrease the length of hospital stays. Vitamin D plays a crucial role in bone health and immune function. Hypovitaminosis D is associated with increased rates of medical complications and infections following orthopaedic surgery. Studies have shown that preoperative vitamin D supplementation can improve outcomes and reduce the risk of perioperative infections, although further research is needed to establish definitive recommendations.

Obesity and weight management
Obesity is a modifiable risk factor associated with increased perioperative complications, including infections. Weight-management strategies, including diet modifications and bariatric surgery, are potential interventions to reduce the risk of infections in obese patients undergoing orthopaedic surgery. However, the optimal timing and magnitude of preoperative weight loss remain topics for further investigation.

Nutritional status significantly influences the risk of perioperative infections in orthopaedic surgery. Identifying and addressing malnutrition through comprehensive nutritional assessments and targeted interventions can enhance patient outcomes. Implementing preoperative protein-calorie and immunonutrition supplementation, along with vitamin D optimization and weight-management strategies, holds promise for reducing infection rates. Continued research is essential to refine these recommendations and develop standardized protocols for nutritional care in orthopaedic surgery.

Andrew R. Merwin, MD, is an orthopaedic trauma fellow at UT Health San Antonio.

Boris A. Zelle, MD, FAAOS, FAOA, is vice chair of research and program director of the orthopaedic trauma fellowship in the Department of Orthopaedics at UT Health San Antonio. Dr. Zelle is a member of the AAOS Now Editorial Board.

References

1. Zink TM, Kent SE, Choudhary AN, et al: Nutrition in surgery: an orthopaedic perspective. J Bone Joint Surg Am 2023;105(23):1897-906.
2. Bohl DD, Shen MR, Kayupov E, et al: Hypoalbuminemia independently predicts surgical site infection, pneumonia, length of stay, and readmission after total joint arthroplasty. J Arthroplasty 2016;31(1):15-21.
3. Yi PH, Frank RM, Vann E, et al: Is potential malnutrition associated with septic failure and acute infection after revision total joint arthroplasty? Clin Orthop Relat Res 2015;473(1):175-82.
4. Koren-Hakim T, Weiss A, Hershkovitz A, et al: Comparing the adequacy of the MNA-SF, NRS-2002 and MUST nutritional tools in assessing malnutrition in hip fracture operated elderly patients. Clin Nutr 2016;35(5):1053-8.
5. Weimann A, Braga M, Carli F, et al: ESPEN practical guideline: clinical nutrition in surgery. Clin Nutr 2021;40(7):4745-61.
   Smith TO, Aboelmagd T, Hing CB, et al: Does bariatric surgery prior to total hip or knee arthroplasty reduce post-operative complications and improve clinical outcomes for obese patients? Systematic review and meta-analysis. Bone Joint J 2016;98-B(9):1160-6.