Download Fracture

Focused Nutrition
and the Injured Athlete
Accelerated Recovery Through Focused Nutrition
Kirt M. Kimball, MD
Orthopedic Surgeon
Team Physician, Brigham Young University
Disclosures/Bio
• Orthopedic Surgeon: Revere Health, Provo, Utah
• Team Orthopedic Surgeon: Brigham Young University
• Fellow AAOS, AOSSM, CAQ Orthopedic Sports Medicine
• Medical Director, Intermountain Health Care, Musculoskeletal, South Region
• Surgical Consultant/ Advisory Board: ConforMis Total Joints
• Chief Medical Officer: Forté Elements
• Medical Director, Timpanogas Regional HCA Hospital, Total Joint Division
• Consultant: Summit Home Health
• Medical Director: I-Works Home Health
Today’s focus
• Today I will discuss how you, as a Certified Athletic
Trainer can, in conjunction with your medical staff,
• Support, and in some cases
• Augment recovery
from many of the acute and chronic
injuries/conditions you deal with every day.
• You can improve your outcomes by aggressively
employing focused nutritional elements you are
all familiar with.
Patient: D1 Football Player -- FX L3
Treatment: Brace; Time …..healing
Conditions of physical stress
Recovery impacted by Nutritional elements
• Major Trauma or Surgery
• Fracture
• Elective Surgery
• Nerve/Brain Injury
• Joint/Cartilage Injury
• Chronic Bone injury
Fracture Healing
Energy Demand and Consumption Increases
Energy
• Long bone fracture
• Normal caloric adult intake
2,500 cal. per day
• Fracture can increase daily
need to 6,000 cal. per day.
Fracture Healing and Protein
Protein
• By volume 50% of bone is protein
• When fracture occurs, protein building
blocks needed to synthesize new bone.
• 15-20 gram increase in daily amino
acids significantly increases rate of
fracture healing.
• Protein deficiency leads “rubbery” callus
and delayed healing.
Fracture Healing and Amino Acids
Amino Acids
• Lysine, Arginine, Proline, Glycine, Cystine
and Glutamine
• Especially important in fracture healing
• Lysine known to:
- Enhance calcium absorption
- Increase amount of Calcium absorbed in bone
matrix
- Aids in tissue regeneration
Protein and IGF-1
• IGF-1
• Insulin –like growth factor-1
• Polypeptide exerts a positive effect on skeletal
integrity, muscle strength, immune response and
bone renewal.
• Protein supplementation increases
endogenous IGF-1
Fracture Healing
Anti-inflammatory nutrients
• Trauma of fracture creates a burst of
pro-oxidants (free radicals) causing
oxidative stress that can overwhelm the
bodies antioxidant reserves.
• Tightly bound collagen strands running
through the mineral phase of bone are
forcefully broken.
• Ruptured collagen strands interact with
oxygen-yielding oxygen radical
metabolites (Free-radicals)
Free Radicals
• Create Inflammation
• Further breakdown bone collagen
• Lead to excessive bone turnover
• Free radical production can overwhelm
natural anti-oxidant defense mechanisms.
• Antioxidants shown to be effective in
suppressing destructive effect of free
radicals thus improving fracture healing.
Anti-oxidants effective
in canceling out free radicals
• Vitamin E
• Vitamin C
• Lycopene
• Alpha-lipoic acid
• Selenium acts as an antioxidant on its
own but it is particularly effective when
combined with vitamin E.
Inflammation
Essential to healing
• Involves Cyclooxygenase (Cox) enzymes (Cox-1 and Cox-2)
enzymes – important part of inflammatory cascade
• Many standard non-steroidal anti-inflammatory drugs act by
inhibiting COX-1 and COX-2 enzymes – relieves the pain,
but also delays healing.
NSAID’s NOT Recommended after Fracture
 aspirin
 ibuprofen
 indomethacin
 etodolac(Lodine)
 Naproxen ( Anaprox, Naprosyn, Aleve)
 Nabumetone (Relafen)
 meloxicam (Mobic)
Reduce inflammation naturally
• 328 wrist fracture patients
– modest 500 mg/day supplementation with vitamin C
– reduced by more than 4‐ fold the incidence of
post‐fracture complex regional pain syndrome.
• Quercitin,
- used in doses of 2–3 g per day
- has a synergistic effect with vitamin C, amplifying the
pain‐relief benefits
• Omega‐3 fatty acids
- reduce inflammation without inhibiting the COX‐1 and
COX‐2 enzymes
Reducing Inflammation
Naturally soothe the inflammatory process and
speed healing.
• Vitamin C,
• bioflavonoids,
• flavonols such as quercitin and
proanthrocydins
• omega-3 fatty acids
• Bromelain and Trypsin
Mineral Intake
Bone is 70% mineral by weight
• Fracture healing requires minerals
• Most of us “under-consume” minerals
• Stealing “from Peter to pay Paul” to get
adequate minerals for fracture healing
Fracture Minerals
• Zinc
- 200 enzymes require zinc for their
functioning
• Copper
- Important in formation of bone
collagen.
- Demand for copper and zinc increase
with severity of trauma.
• Calcium:
- Important in fracture healing however
skeletal sources and diet are
adequate.
- High calcium intake does NOT speed
fracture healing
• Phosphorus:
- Most have plenty in diet. Supplement
not necessary
• Silicon:
- Important in bone collagen synthesis.
- Studies show that bioactive silicon
enhances the effects of calcium and
vitamin D3 on new bone formation.
Enhanced Vitamin needs for Fracture Healing
Some vitamins need to be present in “therapeutic”
dosage to maximize fracture healing
• Vitamin C
• Vitamin D
• Vitamin K
• Vitamin B6
Vitamin C
• Essential for proper synthesis of bone
collagen protein matrix
• Important antioxidant
• Important anti-inflammatory
• Aggressive Vitamin C support leads to
faster and stronger fracture callus and
healing
Vitamin D
• Primary regulator of calcium
absorption
• Many studies demonstrate low vitamin
D leads to suboptimal fracture healing.
• Vitamin D in conjunction with Vitamin
K stimulates the transformation of
fracture site stem cells to bone
building osteoblasts.
• Vitamin D levels are an independent
predictor of recovery after major
fracture.
Prevalence of Vitamin D Deficiency
• Nearly 1/3 of the population and more than 50% of
general medicine patients are vitamin D deficient.
• We use sun-block, hats, long sleeves leads to less
Vit D
• Majority of patients undergoing orthopedic surgery
are deficient in vitamin D.
• Studies show accelerated muscle recovery with Vit D
Sources
• Holick MF. High prevalence of vitamin D inadequacy and implications for health. Mayo Clin Proce 2006;81:353-373
• Stoker GE, et al. Preoperative vitamin D status of adults undergoing surgical spine fusion. Spine 2013;38(6):507-515.
13. Fisher A, et al.
Hip fracture type: important role of parathyroid hormone (PTH) response to hypovitaminosis D. Bone 2010;47(2):400-407.
Vitamin K
• Essential in binding calcium to bone
• Helps preserve calcium by reducing the loss
of calcium in the urine
• Well established that it is beneficial to fracture
healing
• Vit. K is noted to be sequestered at the
fracture site and circulating vit K levels are
influenced by the severity of the fracture.
Vitamin B6
• Linked to fracture healing
• B6 modulates the effects of vitamin K
on bone through complex biochemical
pathways.
Optimum Fracture healing
• Bone is a complex tissue that requires many nutrients
• 20 Key bone-building nutrients needed for optimum
fracture healing
• Several studies have found multi-nutrient therapy to
reduce complication rates and accelerate fracture
healing.
• 2006 Swedish hip fracture study given complex
supplementation 15% complication rate vs 70% in non
treated group
An Example
• Male, age 21
• Offensive line
• Fractured both-bones forearm 21 months
into a 2 year missionary assignment in
South America.
• Surgical Repair in Chile.
• 3 months later completed missionary service
and returned to BYU to play football.
March 4, 2015
• Patient suffers sub trochanteric femur fracture
• Post intra-medullary rod placement
August 17, 2015
5 Months Post Fracture
September 21, 2015
6 Months Post Injury
• Still non-union
• Status post secondary surgical
correction – rod removed, plate and
screws
• Salvage attempt with bone graft
November 2, 2015
8 Months Post
• 2 months post secondary surgical correction
• Salvage attempt with bone graft not working
• Still non-union
January 4, 2016
10 Months Post Fracture
• 4 months post secondary surgical correction
• 4 months post bone graft
• Bone graft failing
• Continued non-union
Added Intense Focused Nutrition
Forté Fracture
®
February, 2016
11 Months Post Injury
• 5 months post secondary surgical correction, 5 months
post bone graft
• Continued non-union
Patient begins supplementing with Forté
Fracture
®
intense nutritional supplement
April 11, 2016
13 Months Post
2 Months Post Nutritional Intervention
• After 2 months of supplementation with Focused
Nutritional supplementation
• Healing occurs
Comprehensive Therapy
• Swedish hip fracture study (2006)
• 15% complication rate vs 70% rate in group without
supplemental therapy.
• Swedish meta-analysis of 17 hip fx studies reported oral multinutritional supplements reduced deaths and complications by
50%!
Tibia Fracture healing
• Multi-nutrient study reduced healing time of tibia fractures by
approximately two weeks
• 33% healed in 10 weeks compared to 11% in placebo group.
Conditions of physical stress
Recovery impacted by Nutritional elements
• Major Trauma or Surgery
• Fracture
• Elective Surgery
• Nerve/Brain Injury
• Joint/Cartilage Injury
• Chronic Bone injury
Questions?
• For copy of Slides or questions:
• [email protected]