Abstract
Total hip arthroplasty (THA) is a highly effective technique for relieving pain and reconstructing joint structures. However, even several years after THA, the preexisting muscle weakness does not resolve to the level of healthy individuals. Since the 2000s, minimally invasive surgical procedures and fast-track rehabilitation have enabled early functional recovery, particularly in terms of walking ability, but solutions to these problems have not yet been established. The benefits of combined nutrition and exercise interventions for sarcopenia and frailty are gaining widespread acceptance. Elements of sarcopenia and frailty may be inherently present in patients who have undergone THA, and a combination of nutritional and exercise interventions may be useful in treating post-prosthetic muscle weakness and prolonged muscle atrophy. This chapter describes their usefulness and implementation for patients who have undergone THA.
Keywords
- nutritional support
- muscle atrophy
- nutritional physiology
- total hip arthroplasty
- muscle weakness
1. Introduction
Total hip arthroplasty (THA) is an excellent surgical technique to alleviate hip pain and improve activities of daily living (ADL) and quality of life (QOL) in patients with end-stage hip osteoarthritis, and the number of THAs performed worldwide has increased year after year [1]. Particularly, THA has helped achieve favorable long-term results due to innovations in prosthetic implants and surgical techniques in recent years [1, 2].
However, most patients undergoing THA develop muscle atrophy and weakness due to joint deformity and decreased physical activity [3, 4], require a prolonged postoperative functional recovery period [5, 6], and are at increased risk of serious complications, including falls [7], dislocations [8, 9], and infections [10]. In addition, prolonged muscle atrophy and weakness after surgery have negative consequences, such as a higher risk of frailty and care needs [11, 12], postoperative complications, and an increased strain on social resources [13]. Therefore, there is an urgent need to understand the factors associated with muscle atrophy and weakness in patients who have undergone THA and to implement more effective interventions.
2. Functional and physiological changes in muscles before arthroplasty
Osteoarthritis (OA) and rheumatoid arthritis, for which THA is most commonly performed, are chronic diseases associated with changes in muscle function and quality due to both the disease and limb disuse. End-stage hip OA is associated with increased atrophy and fatty infiltration of the gluteus minor [13, 14], gluteus medius [13], and gluteus maximus muscles [14] in comparison to healthy individuals. The muscle mass of the gluteus maximus, gluteus medius, and gluteus minimus muscles in patients with end-stage OA showed 11.5, 6.9, and 13.7% asymmetry, respectively, compared to corresponding muscles in healthy individuals [14]. In the advanced stage of OA, a 12% asymmetry of the gluteus medius muscles has been reported as compared to healthy controls [15]. In addition, muscle biopsies of the quadriceps muscle have demonstrated atrophy of both type 2A and 2B muscle fibers [16]. A recent systematic review noted that muscle mass loss in patients with hip OA varied widely from muscle to muscle, while fatty infiltration was identified in several muscles [17, 18]. Against the background of these muscle mass and qualitative changes, the strength of the abductor muscle group is reduced compared to healthy subjects [13, 14, 17]. In terms of muscle activity, the gluteus minimus muscle in patients with OA is more active during the stance phase of walking compared to healthy individuals, with the degree of overactivity increasing with severity, while the gluteus medius muscle exhibits no difference [19]. On the other hand, it has been reported that there is an overall delay in muscle activity during stepping tasks, as well as increased activity in the gluteus minimus muscle, similar to walking [20].
Selective muscle atrophy of the vastus medialis muscle is observed in the early stages of knee OA [21]. Reduced quadriceps muscle strength is a risk factor for the progression of OA [22] and is 16–49% lower than in healthy older adults [21, 23, 24]. Clinical symptoms such as pain [25] and arthrogenic muscle inhibition (AMI) associated with joint edema [26] affect quadriceps muscle strength. Quadriceps muscle in knee OA patients exhibits more pronounced atrophy of type II fibers than type I fibers [27] and an increased proportion of non-contractile tissue within the muscle, such as fatty and connective tissue [21, 23, 24]. Maly et al. [28] found that females with advanced knee OA exhibit a greater percentage of fatty infiltration in the quadriceps muscle. Wada et al. [29] also reported that a one-kilogram increase in lower limb muscle mass for the joint protective effect could be expected to increase by 7.3 Nm in patients with early-stage knee OA, whereas it only increased by 3.8 Nm in end-stage knee OA. These reports confirm that changes in quadriceps muscle quality with the progression of knee OA affect muscle strength independently of muscle atrophy.
3. Dietary guidance and characteristics of dietary intake in patients with osteoarthritis
Dietary guidance for weight loss is widely used as a part of lifestyle guidance for osteoarthritis patients. However, obesity and metabolic syndrome are not risk factors for the progression of osteoarthritis [30, 31]. In contrast, Messier et al. [32, 33] reported that weight loss by restricting energy intake reduced joint pain and mechanical joint loading in knee OA patients; however, difficulties in maintaining energy intake restrictions have been noted for compliance and the long-term sustainability of weight loss. In addition, a recent scoping review suggested that the assessment for sarcopenic obesity should be included in osteoarthritis patients, as it is a risk factor for muscle weakness, loss of muscle mass, and post-prosthetic complications [34], and the risk of developing knee OA has been reported to increase approximately twofold [35]. With respect to necessary levels of protein, vitamins C, E, and omega-3 fatty acids, insufficient protein intake was observed to be more prevalent in older individuals with hip and knee osteoarthritis [36]. de Zwart et al. [37] also noted insufficient protein intake in most patients with knee OA. Additionally, there are also reports that a high intake of red meat is effective in reducing the need for THA [38]. Furthermore, adherence rates for the Mediterranean diet and dietary quality were significantly worse in OA patients [39], which suggests that a diet focused on anti-inflammatory effects may be beneficial [40].
4. Decrease in muscle mass at the perioperative period
The decrease in muscle mass after surgical procedures is partly due to accelerated catabolism caused by the surgical invasion and partly attributable to the muscle atrophy caused by rest. Surgical techniques for joint arthroplasty have developed rapidly, with mini-incision surgery techniques becoming more common since the 2000s, and surgical invasion and associated blood loss could be controlled [41]. Prevention of postoperative anemia is important because preoperative serum hemoglobin (Hb) is affected during the hospital stay after THA [42], and Hb decline after surgery affects lower limb muscle strength [43]. However, it was shown that moderate anemia had a limited impact on functional recovery [44].
In contrast, the effect of bed rest has been reported in patients with ankle fractures, where 7 days of bed rest with unloading resulted in a 6–16% reduction in the cross-sectional area of the quadriceps femoris muscle, whereas inpatients admitted to an intensive treatment unit experienced a 1.0–8.7% reduction over 3 days and an 8.8–13.7% reduction over 5 days [45]. In patients with hip fractures, type I muscle fibers did not differ among younger patients, while type II muscle fibers exhibited significant muscle atrophy compared to healthy older adults [46].
Enhanced Recovery After Surgery (ERAS) programs and early mobilization have become widespread in recent years and have been applied early in the area of arthroplasty. However, a systematic review [47] reported that employing ERAS after THA has no impact on functional improvement or complication prevention. This point should be considering Dreyer et al.’s [48] report of a decrease in muscle mass on both limbs on the operative and non-operative side after Total Knee Arthroplasty (TKA). Because patients requiring THA exhibit gluteal muscle atrophy before surgery, an assessment of postoperative muscle atrophy must also take into account the effects of increased bedrest, decreased loading of the lower limb that cannot be compensated by ERAS, selective atrophy of type II muscle fibers, and anemia due to blood loss.
5. Factors associated with medium- and long-term recovery in muscle strength and mass after THA
What will be the degree of functional improvement after early recovery and discharge by the ERAS program or fast-track surgery? Fukumoto et al. [49] found it to be lower than that of healthy controls [49, 50], although it did not reach preoperative levels at 1 month, but improved compared to preoperative values at 4 to 6 months, and hip abductor muscle strength was still affected by preoperative values at 6 months postoperatively. One year after THA, Judd et al. [51] reported that hip flexion and knee extension muscle strength were significantly lower in OA patients than in healthy individuals of the comparable age, whereas hip extension, abduction, and adduction muscle strength improved to the same level as healthy individuals of the same age. Recovery in muscle strength and mass up to 1 year after THA shows differences for each muscle group, reflecting differences in the site of muscle atrophy and fatty infiltration before THA (para 1). Furthermore, regarding the long-term course, it has also been reported that patients up to 6 years after THA did not achieve the level of healthy individuals of the comparable age [52], and similarly, hip abductor muscle strength remained significantly lower than in healthy individuals [53] after 10 years after THA.
Previous studies have shown that the hip and knee periprosthetic muscle strength after THA initially decreases compared to the level of preoperative strength up to about 1 month postoperatively but exceeds preoperative values at about 6 months postoperatively. Improvement thereafter is slower, and values are still lower than those of healthy individuals of comparable age more than 2 years after surgery. In other words, it can be inferred that in patients who have undergone THA, the hip and knee periprosthetic muscle weakness persists during the mid-to-long-term postoperative period. However, no consensus has been reached due to differences in surgical technique, femoral offset, and postoperative rehabilitation programs [54]. Furthermore, further research is needed on the medium- to long-term recovery of periprosthetic hip muscle strength and related factors, as there are few reports on patients who are more than 2 years postoperative.
Several observational studies on changes in skeletal muscle mass after THA have been published, supporting reports of prolonged muscle weakness over the medium and long term. Reports up to 2 years after surgery show that the muscle mass of the affected side does not improve to the level of the healthy side in the whole gluteus muscle group [55, 56], while it has been reported that there is no difference in the ratio of its muscle mass between the healthy and affected side 1 year after surgery when limited to the gluteus medius muscle. Isshiki et al. [57] found that in patients with posterior lateral THA over 8 years postoperatively, the muscle cross-sectional area of the affected side did not improve to the level of the healthy side throughout the entire preoperative, 3-year, and 8-year postoperative periods (Figure 1). These findings suggest that atrophy of the periprosthetic hip muscle, mainly the gluteus medius muscle, in patients who have undergone THA patients may persist in the mid-to-long-term postoperatively. However, this is debatable due to differences in age, surgical technique, and postoperative rehabilitation [58, 59, 60]. Further studies are needed to adjust for influencing factors such as surgical technique and postoperative rehabilitation.
6. Sarcopenia-frail as a comorbidity after THA
Sarcopenia as a comorbidity has received increased attention in recent years. Regarding the prevalence of sarcopenia, Chang et al. [61] reported that of the 307,678 patients who underwent THA, 1319 patients (0.43%) had a prior diagnosis of sarcopenia, while Koto et al. [62] found it to be 8%, with differences in both reports, these prevalence ratios were less than the 47.3% of proximal femur fractures [63]. However, preoperative physical function was impaired in patients with concomitant sarcopenia [64], and they are at an increased risk of complications due to implant-related dislocation in the first year postoperatively [61]. Additionally, a higher incidence of falls and fragility fractures is observed [61, 65], resulting in higher readmission rates and healthcare costs [61]. At 1-year follow-up, patients with concomitant sarcopenia who had undergone THA were 62% more likely to fall and 77% more likely to develop fragility fractures [41], which suggests that falls and fragility fractures not only reduce the QOL but also increase patient mortality [65].
Frailty after THA has been reported to increase the incidence of postoperative complications, revision surgery, readmission, and mortality, as well as prolong hospital stays, as with sarcopenia, and ultimately increase healthcare costs [66, 67, 68, 69, 70]. Therefore, early diagnosis and prevention of frailty in patients who have received THA are urgent issues. We investigated the prevalence of frailty and associated factors in community-dwelling elderly patients 1 year following THA and found a prevalence of 11.2% for frailty and 51.0% for pre-frailty [11]. The results showed a higher percentage compared to the prevalence in Japanese community-dwelling older adults (frail: 8.7%, pre-frail: 40.8%). In addition, the history of falls, maximum leg circumference, hip abductor strength, knee extensor strength, and performance on the Timed up & go test were significantly associated with frailty in patients who had undergone THA. These findings suggest that improving muscle mass and dynamic balance capacity as well as increasing muscle strength, particularly hip abductor and knee extensor strength, may be important to prevent frailty after THA. However, there are few reports on the coexistence of osteoarthritis and frailty [71, 72], and the causal relationship with frailty is also unclear [73].
7. Consensus on therapeutic interventions for sarcopenia and frailty
Research on sarcopenia has progressed dramatically in the last decade, and in recent years’ guidelines [74], consensus papers [75, 76], and position papers [77] have been successively published. The common view shared by these publications is that treatments can improve muscle strength and mass when combined with exercise and nutritional therapy. Muscle mass loss can occur under any of the conditions of sarcopenia, malnutrition, and cachexia [76], but each of these factors needs to be taken into account, as they are exacerbated by one another [77]. The recommended exercise intensity is 50% of 1 repetition maximum (1RM) and 80% of 1RM for muscle hypertrophy if feasible [78]. For nutritional therapy, a protein intake of 1–1.5 g per kg body weight per day is recommended, and there is insufficient evidence regarding the effectiveness of vitamin D [77]. The International Clinical Practice Guidelines for Sarcopenia [74] also note the importance of exercise therapy and protein-rich diet or supplementation, as well as education on these treatments.
Sarcopenia is also encompassed within the concept of frailty and overlaps with physical frailty in many aspects [79]. As with sarcopenia, several guidelines [80, 81] and recommendations [82] have been reported. As with sarcopenia, a combination of exercise and nutritional therapy is recommended, with exercise therapy encompassing resistance training and nutritional therapy consisting of protein and caloric supplementation [80, 81, 82]. In addition, vitamin D is recommended only in Asian regions [75], and cognitive or problem-solving therapy is not recommended [81]. Also, a recent recommendation has proposed screening for frailty in inpatients over 70 years of age [82].
8. Fast-track surgery and rehabilitation in THA
Fast-track surgery is a multimodal effort involving a multidisciplinary team of anesthetists, physiotherapists, and nurses in addition to the surgeon. Enhanced recovery requires a combination of preoperative education, stress reduction, pain relief, early ambulation and mobilization, drain and tube management and their removal to enable mobility, as well as fluid and nutritional therapy [83]. Fast-track surgery in THA, together with minimally invasive techniques, facilitates early functional recovery and discharge through multimodal pain management [84] and clinical nursing pathways [85]. This fast-track initiative was also reported to have no problems in terms of medical safety [86]. Compared to conventional perioperative management, fast-track surgery has been reported to reduce hospital stay [87], which is becoming more prevalent in patients undergoing THA, although there is less emphasis on nutritional support.
The main outcomes of fast-track surgery in THA are early mobility and discharge from the hospital. As described in the previous paragraphs, patients who have undergone THA exhibit the following characteristics: the preoperative presence of disuse changes in muscle function and qualitative aspects of physiology (par. 1), poor protein intake and adherence rate (par. 2), increased bedrest and decreased loading of the lower limb that cannot be compensated for even with the ERAS program, and selective atrophy of type II muscle fibers (par. 3). Additionally, prolonged muscle weakness in the mid-to-long-term postoperative period (par. 4) and the coexistence of frailty and sarcopenia in patients who received THA (par. 5) have also been identified, which have not been adequately addressed by initiatives such as fast-track surgery and rehabilitation. As the consensus for the combination of exercise and nutritional therapy as a therapeutic intervention in frailty and sarcopenia grows, initiatives to incorporate nutritional therapy into the fast-track component of THA are emerging.
9. Combination of exercise and nutritional interventions and their effects before surgery
Resistance training in combination with high protein intake for patients with OA has been suggested in systematic reviews to be potentially useful in improving lower limb muscle strength and motor function [88]. In one of the reviews, Ikeda et al. [89] randomly provided 6 g of branched-chain amino acid (BCAA) for 4 weeks to patients with end-stage hip OA scheduled for THA. An improvement in hip abductor muscle strength on the healthy side was observed (Figure 2), but they reported no difference in the affected side’s muscle strength compared to the placebo. One reason for this is that resistance exercise in combination with nutritional therapy has been reported to have no significant effect on improving muscle mass, muscle strength, and physical functions in healthy older people [90, 91]. In other words, the additional effect of nutritional supplementation is unlikely to be observed or limited in older people who were able to obtain sufficient amounts of nutrition, including protein, from their daily diet. As common challenges in OA patients, inadequate protein intake [36], and poor adherence to a Mediterranean diet are prevalent [39]. Future large-scale studies are needed to assess confounding factors such as age, nutritional status, daily diet, and physical activity of the participants and to adjust for these factors.
10. Combination of exercise and nutritional interventions and their effects after THA
In recent years, patients have been able to attain early mobility following THA, from the day of surgery due to remarkable advances in prosthetic implants and surgical techniques, which have also enabled the reduction of healthcare costs and hospital stays [92, 93, 94]. However, it has also been noted that approximately 70% of elderly inpatients for THA were discharged with the same degree of physical function as before surgery [95] and that prolonged functional decline is associated with muscle atrophy and weakness. Most of the patients who underwent THA exhibit inadequate nutritional intake preoperatively [36, 37]. This malnutrition not only prolongs functional recovery but also increases the incidence of postoperative complications, readmission rates, and hospital stays [61, 96]. In short, we believe that exercise therapy in combination with nutritional interventions, rather than exercise therapy alone, can maximize the induction of muscle protein synthesis, reduce muscle atrophy, and lead to a more efficient and early functional recovery.
Two randomized controlled trials (RCTs) in patients who underwent TKA and two in those who received THA have examined the influence of dietary intake on functional recovery following arthroplasty. In perioperative TKA patients, Ueyama et al. [97] conducted an RCT in which 3 g of essential amino acids (EAA) was provided three times daily from 1 week before to 2 weeks after surgery and investigated quadriceps muscle atrophy, knee extension muscle strength, and ADL ability up to 4 weeks after TKA. The authors reported that the intervention group showed significantly reduced postoperative muscle atrophy and early improvement in ADL functions. In addition, Dreyer et al. [48] conducted an RCT in perioperative patients planned for TKA and who were administered 20 g of EAA twice daily from 1 week before to 6 weeks after surgery to investigate quadriceps muscle atrophy and knee extensor strength up to 6 weeks after TKA. They reported significantly reduced postoperative muscle atrophy in the intervention group but no significant difference in knee extensor strength.
Ninomiya and Ikeda [98] compared 29 perioperative THA patients who were administered a high protein dietary supplement containing 3.4 g BCAA twice daily from 4 weeks before surgery to 8 weeks after surgery (BCAA group) with 29 patients who were administered a regular program (control group). They compared hip abductor strength and knee extensor strength between both groups for up to 8 weeks after surgery. The strength of hip abductors on the affected side did not differ between the two groups, whereas the strength of hip abductors on the healthy side and bilateral knee extensors was considerably greater in the BCAA group. In a study of patients who underwent THA and were in the convalescent rehabilitation period, Ikeda et al. [99] compared 18 patients (the BCAA group) who were provided with 3.4 g BCAA once daily for 1 month in conjunction with physiotherapy twice daily and 13 patients (the control group) who were provided with 1.2 g placebo with physiotherapy twice daily. They found that the BCAA prevented a decrease in skeletal muscle mass and reported significantly higher values for the knee extensor muscles on the operated side (Figures 3 and 4). However, no significant difference was observed in bilateral hip abduction muscle strength between both groups. These reports suggest that adequate nutritional intake in patients requiring THA or TKA may prevent postoperative muscle atrophy and have a limited effect on muscle strength and functional recovery, although this is debatable. This is because (1) AMI due to swelling and pain is associated with early postoperative muscle strength [26, 100, 101, 102]; (2) the effects of nutritional intake may be synergistic when combined with resistance training [103, 104], and additionally, the type, amount, and timing of nutrient intake may play a role. Future studies are needed to examine the effect of nutritional intake on functional recovery in patients undergoing THA after adjusting for these factors.
11. Problems in preventing prolonged muscle weakness after THA
We have previously reported that limb muscle strength and motor function in patients 10 years after THA were significantly lower, and the incidence of falls was 2.8 times higher than in healthy individuals of comparable age [53]. The incidence of fractures resulting from falls was reported to be about twice as high as the incidence of implant-related postoperative complications (dislocation and wear) [105]. While THA in recent years has undergone dramatic advancements in prosthetic implants that have reduced the incidence of revision surgery due to dislocation and wear and increased implant survival rates, patients are likely to be at increased risk of requiring care due to functional decline associated with age-related loss of muscle mass and strength. Currently, physiotherapy for patients undergoing THA includes exercise therapy and patient education with a focus on resistance training, with outcomes of improved lower limb muscle strength, walking ability, ADL functions, and QOL [106, 107]. However, recent studies have reported that physiotherapy after THA is as effective as independent training [108], pointing to the need to reconsider intervention methods. We reported that protein intake was associated with muscle strength in patients 1 year after THA [109]. Ueyama et al. [110] also reported that nutritional interventions were associated with enhanced muscle mass and strength in patients 2 years after THA. Therefore, to maintain and improve muscle mass, strength, and motor function in patients in the mid-to long-term following THA, it may be necessary not only to use exercise therapy but also to monitor the nutritional status of the patient and to use nutritional supplementation in combination (Figure 5).
12. Conclusion
Postoperative outcomes in patients undergoing THA have been highly successful in terms of early postoperative functional recovery and implant survival. We had assumed that the prolonged muscle weakness following THA would resolve with time. However, recent findings have indicated a situation that worsens with time. Fast-track rehabilitation, which focuses on a combination of exercise and nutritional therapy as a strategy to address preexisting muscle atrophy, fatty infiltration, and postoperative challenges, is a new technique that may provide a new tool for mitigating the problem of prolonged postoperative muscle weakness, which has remained unresolved for 20 years.
Acknowledgments
This book chapter writing was funded by Showa University Research Administration Center (Grant Number: 13000157).
Conflict of interest
The authors declare no conflict of interest.
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