Movement Is Life—Optimizing Patient Access to Total Joint Arthroplasty: Malnutrition Disparities : JAAOS - Journal of the American Academy of Orthopaedic Surgeons

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Movement Is Life—Optimizing Patient Access to Total Joint Arthroplasty: Malnutrition Disparities

O'Connor, Mary I. MD; Bernstein, Jenna MD; Huff, Tamara MD

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Journal of the American Academy of Orthopaedic Surgeons: November 1, 2022 - Volume 30 - Issue 21 - p 1007-1010
doi: 10.5435/JAAOS-D-21-00415
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Although an uncommon problem in American adults,1 malnutrition can markedly affect outcomes in total hip and knee arthroplasty, collectively referred to as total joint arthroplasty (TJA).2-7 It is important to diagnose and treat malnutrition before TJA and recognize where inequities exist in malnutrition and food security.

Malnutrition can be classified under two different umbrellas: undernutrition and overweight. Undernutrition includes stunting, wasting, low body mass index (BMI), and vitamin and mineral deficiencies.8,9 The focus here will be undernutrition (overweight is addressed in the obesity articles in this publication). Currently, 1.9% of American women and 0.6% of American men are considered underweight (defined as BMI < 18.5).1 Albumin, vitamin D, transferrin, and total lymphocyte count (TLC) are important benchmarks of a patient's nutrition status and can reflect malnutrition at any BMI.10 Food security plays an important and complex role in nutritional status. Currently, 10.5% of American households are food insecure.11

Rates of undernutrition and food insecurity are not equitably spread within the American population. Rates of food insecurity are two times higher in Hispanic and African Americans,12 as compared with their non-Hispanic White counterparts. Rates of food insecurity are also higher for women,13 those of lower socioeconomic status,11 and those in rural areas.14 Many individuals and families lack the means (eg, financial, transportation, and geographic) to procure healthy, nutritious foods such as fresh fruits and vegetables.11 This lack of access is exacerbated in rural areas.14 The food environment (e.g., food deserts, food swamps, and access to physical activity–promoting recreational areas) has been shown to play an important role in nutrition status15 and is not equitably distributed. Food swamps (neighborhoods with fast food/junk food outlets and liquor stores outnumbering healthy food stores) and food deserts (neighborhood that lack access to affordable, healthy foods) are more likely to be in geographic areas that are of low income, have high levels of unemployment, have low levels of public transportation, and have high proportions of people of color.15,16 There is a paradox of food insecurity in rural areas because a large portion of fresh food is grown in these regions, but many rural communities are still classified as food deserts or swamps.17 Communities of color in rural locations that are already marginalized in the American society face the greatest burden of malnutrition and have the greatest barriers to address this nutritional gap.12,15,17

Rates of osteoarthritis and its subsequent management with TJA also have notable disparities which mirror the areas of most predominant malnutrition. Rates of osteoarthritis are disproportionately higher in communities of color, specifically individuals who identify as African American or Hispanic18-21 and women of all races and ethnicities.22 However, it has been shown that TJA is underutilized by African American and Hispanic individuals,19,23 women,24,25 and those of low socioeconomic status.26 In addition, undernutrition disproportionately affects the elderly community, a demographic with a high burden of osteoarthritis and notable need for TJA.6 Therefore, the elderly, women, and communities of color are more likely to be malnourished and considered inappropriate surgical candidates for elective TJA procedures. These patients may not receive the benefit of TJA, which is known to dramatically improve quality of life,27,28 further exacerbating current disparities.

Clinical Implications of Malnutrition Related to Total Hip/Knee Arthroplasty

Malnutrition plays a role in a complex pattern of perioperative complications. Under its two buckets—undernutrition and overweight—malnutrition is associated with many postoperative complications.2-7 Because it pertains specifically to undernutrition, one study by the US department of Veterans' Affairs found that serum albumin (<3 g/dL) was the single most valuable predictor of poor surgical outcomes and increased morbidity.5 In addition, patients with low BMI were found to have increased length of stay and eightfold increased 2-year mortality after TJA.6 Although there are no strictly imposed universal cutoffs for nutrition status, the observed wide variability in institutional guidelines may restrict access to surgery for groups who already have shown underutilization of this quality-of-life improving procedure. Preoperative optimization of nutritional status for patients is a unique opportunity to improve postoperative outcomes.

Strategies to Optimize

Various proposals for preoperative assessment and management of malnutrition are currently being conducted by experts in the field of arthroplasty. We conducted 10 qualitative interviews with 14 members of the orthopaedic surgical care team across seven institutions: New York University, OrthoVirginia, Hospital for Special Surgery, Yale New Haven Health, Louisiana State University, Brigham and Women's Hospital, and Penn Medicine. These institutions and individuals were chosen because of their national reputations and peer-reviewed publications focused on improving access for vulnerable populations. They provided both evidenced-based and individualized optimization protocols. Importantly, there was wide variability in optimization protocols and members of the surgical care team, both within and across institutions.

Strategies for optimization begin with a holistic assessment of the patient's nutritional status. Patients should have a BMI >18.5 kg/m2, vitamin D level >30 ng/dL, albumin level >3.5 g/dL, transferrin level >200 mg/dL, and TLC of >1,500 cells/mm3. Even one abnormal metric of malnutrition can predispose a patient to poor perioperative outcomes.10 Patient screening can be accomplished by a nurse navigator, or any member of the care team, depending on institutional ability. Identifying patients with malnutrition should be accomplished early because levels of these key nutrients may take weeks to rise markedly.29 Patients who are identified as having any concerns for malnutrition should immediately be followed up with screening for food security, including geographic and resource-oriented ability to procure healthy food. Depending on institutional ability, patients with identified undernutrition should be referred to a nutritionist or weight management specialist. Ideally, this referral would be intrainstitutional, accept all forms of insurance including Medicaid, and be able to tailor highly individualized plans to surgical candidates with differing levels of food security. In those who have identified food insecurity, social work should be consulted to incorporate community partners to leverage available mechanisms for access to healthy food. These include, but are not limited to, government support programs (eg, Supplemental Nutrition Assistance Program); local organizations, such as churches, local nonprofits, and neighborhood management teams; local food shelters; Meals on Wheels; and the Medicaid Escalation Unit. In addition, identified malnourished surgical candidates can be instructed to take preoperative supplements of omega-3 fatty acids and arginine and protein shakes. These have been shown to decrease infectious morbidity, length of stay, and hospital-related expenses30-32 (Table 1).

Table 1 - Malnutrition Optimization Strategies
Optimization Strategy
Screening personnel
 Surgical care team, such as Nurse navigators
  Physician associates
  State-wide case managers
  Social workers
  Orthopaedic surgeon
 BMI < 18.5 kg/m2
 Nutrition status
  Albumin (<3.5 g/dL)
  Vitamin D (<30 ng/dL)
  Transferrin (<200 mg/dL)
 TLC (<1,500 cells/mm3)
 Food security
 Resources (eg, finances and transportation) to access healthy food
 Social support system
 Ability to exercise
 Nutritionist consult
 Weight loss programs
 Social work
Community partners
 Institutional funding for food procurement
 Meals on Wheels
 Local food shelters
 Government social support programs (eg, SNAP)
 Local organizations (eg, churches, community organizations, and neighborhood management teams)
 Medicaid Escalation Unit (if available in your state)
Short-term preoperative options
 Well-balanced meals
 Preoperative supplementation with omega-3 fatty acids and arginine and protein shakes
BMI = body mass index, SNAP = Supplemental Nutrition Assistance Program, TLC = total lymphocyte count

Across the seven institutions interviewed, there was no consistent approach toward optimization or retesting malnourished patients. Most consistent across institutions was monitoring albumin level and proceeding with elective TJA when albumin was in the normal range.

Summary Take-home Message

We recommend that orthopaedic surgeons screen for malnutrition for all elective total hip/knee arthroplasty patients with blood tests (albumin, vitamin D, transferrin, and TLC). Malnutrition can occur at any BMI and is an important reversible risk factor for postoperative complications.


This article is part of a series on optimizing underserved patients for total hip and knee arthroplasty. The series was coordinated in collaboration with Movement is Life, a group of healthcare professions focused on the elimination of musculoskeletal health disparities. The authors thank Daniel H. Wiznia, MD, Assistant Professor of Orthopaedics and Rehabilitation at Yale University and member of the Movement is Life Steering Committee, as well as Kelsey Rankin, BA, Yale University medical student, for their assistance in preparing the background for this article.


References printed in bold type are those published within the past 5 years.

1. Country Nutrition Profiles—Global Nutrition Report. 2021.
2. D'Apuzzo MR, Novicoff WM, Browne JA: The John Insall Award: Morbid obesity independently impacts complications, mortality, and resource use after TKA. Clin Orthop Relat Res 2015;473:57-63.
3. De Jong A, Verzilli D, Chanques G, et al.: Preoperative risk and perioperative management of obese patients [French]. Rev Mal Respir 2019;36:985-1001.
4. George J, Klika AK, Navale SM, et al.: Obesity epidemic: Is its impact on total joint arthroplasty underestimated? An analysis of national trends. Clin Orthop Relat Res 2017;475:1798-1806.
5. Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF: Preoperative serum albumin level as a predictor of operative mortality and morbidity: Results from the National VA Surgical Risk Study. Arch Surg 1999;134:36-42.
6. Katakam A, Melnic CM, Bragdon CR, Sauder N, Collins AK, Bedair HS: Low body mass index is a predictor for mortality and increased length of stay following total joint arthroplasty. J Arthroplasty 2021;36:72-77.
7. Sloan M, Sheth N, Lee GC: Is obesity associated with increased risk of deep vein thrombosis or pulmonary embolism after hip and knee arthroplasty? A large database study. Clin Orthop Relat Res 2019;477:523-532.
8. World Health Organization: Malnutrition. 2020.
9. World Health Organization: Malnutrition Q&A. 2020.
10. 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;473:175-182.
11. United States Department of Agriculture Economic Research Service: Food Security Status of US Households in 2019. 2019.
12. Odoms-Young A, Bruce MA: Examining the impact of structural racism on food insecurity: Implications for addressing racial/ethnic disparities. Fam Community Health 2018;41(suppl 2, Food Insecurity and Obesity):S3-S6.
13. United States Department of Agriculture Economic Research Service: Food Security in the US. 2021.
14. Food Research & Action Center: Rural Hunger. 2021.
15. Bower KM, Thorpe RJ, Rohde C, Gaskin DJ: The intersection of neighborhood racial segregation, poverty, and urbanicity and its impact on food store availability in the United States. Prev Med 2014;58:33-39.
16. United States Department of Agriculture: Characteristics and Influential Factors of Food Deserts. Economic Research Service, 2012.
17. Rural Health Information Hub: Rural Hunger and Access to Healthy Food. 2019.
18. Dillon CF, Rasch EK, Gu Q, Hirsch R: Prevalence of knee osteoarthritis in the United States: Arthritis data from the Third National Health and Nutrition Examination Survey 1991-94. J Rheumatol 2006;33:2271-2279.
19. MacFarlane LA, Kim E, Cook NR, et al.: Racial variation in total knee replacement in a diverse nationwide clinical trial. J Clin Rheumatol 2018;24:1-5.
20. Nelson AE, Braga L, Renner JB, et al.: Characterization of individual radiographic features of hip osteoarthritis in African American and White women and men: The Johnston County Osteoarthritis Project. Arthritis Care Res (Hoboken) 2010;62:190-197.
21. Sowers M, Lachance L, Hochberg M, Jamadar D: Radiographically defined osteoarthritis of the hand and knee in young and middle-aged African American and Caucasian women. Osteoarthritis Cartilage 2000;8:69-77.
22. Quintana JM, Arostegui I, Escobar A, Azkarate J, Goenaga JI, Lafuente I: Prevalence of knee and hip osteoarthritis and the appropriateness of joint replacement in an older population. Arch Intern Med 2008;168:1576-1584.
23. Singh JA, Lu X, Rosenthal GE, Ibrahim S, Cram P: Racial disparities in knee and hip total joint arthroplasty: An 18-year analysis of national Medicare data. Ann Rheum Dis 2014;73:2107-2115.
24. Hawker GA, Wright JG, Coyte PC, et al.: Differences between men and women in the rate of use of hip and knee arthroplasty. N Engl J Med 2000;342:1016-1022.
25. Parsley BS, Bertolusso R, Harrington M, Brekke A, Noble PC: Influence of gender on age of treatment with TKA and functional outcome. Clin Orthop Relat Res 2010;468:1759-1764.
26. Agabiti N, Picciotto S, Cesaroni G, et al.: The influence of socioeconomic status on utilization and outcomes of elective total hip replacement: A multicity population-based longitudinal study. Int J Qual Health Care 2007;19:37-44.
27. Molloy J, Kennedy J, Jenkins C, Mellon S, Dodd C, Murray D: Obesity should not be considered a contraindication to medial Oxford UKA: Long-term patient-reported outcomes and implant survival in 1000 knees. Knee Surg Sports Traumatol Arthrosc 2019;27:2259-2265.
28. Yates AJ, Kerr JM, Froimson MI, Della Valle CJ, Huddleston JI: The unintended impact of the removal of total knee arthroplasty from the Center for Medicare and Medicaid Services inpatient-only list. J Arthroplasty 2018;33:3602-3606.
29. Levitt DG, Levitt MD: Human serum albumin homeostasis: A new look at the roles of synthesis, catabolism, renal and gastrointestinal excretion, and the clinical value of serum albumin measurements. Int J Gen Med 2016;9:229-255.
30. Braga M, Gianotti L, Nespoli L, Radaelli G, Di Carlo V: Nutritional approach in malnourished surgical patients: A prospective randomized study. Arch Surg 2002;137:174-180.
31. Braga M, Gianotti L, Vignali A, Schmid A, Nespoli L, Di Carlo V: Hospital resources consumed for surgical morbidity: Effects of preoperative arginine and omega-3 fatty acid supplementation on costs. Nutrition 2005;21:1078-1086.
32. Gianotti L, Braga M, Nespoli L, Radaelli G, Beneduce A, Di Carlo V: A randomized controlled trial of preoperative oral supplementation with a specialized diet in patients with gastrointestinal cancer. Gastroenterology 2002;122:1763-1770.
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