so clearly there's an enormous body of data to support the role of nutrition interventions to improve outcomes reduce mortality reduce complications in general surgery there was also significant data to show that nutrition interventions in the perioper period around the time of surgery can significantly improve outcomes in orthopedic surgery particularly outcomes that relate to muscle function and the ability of the patient to do their activities of daily life and and do the things they want to do as they recover from these Orthopedic surgeries and I think one of the very best and most important trials ever done in surgical nutrition was actually done examining essential amino acids in patients having total knee arthroplasty or or TKA and this was done by Dr H drer and his group it was an NIH funded study and and was ultimately published in one of the very best journals in the world the journal of clinical investigation so this was a premier highlevel study and again one of the very best in all of our surgical clinical nutrition data and it showed that patients who received essential amino acids around the time of surgery had significant improvements in muscle mass muscle strength and in functional testing or their ability to do activities and function in the world that they lived in after surgery and so I think this is really exceptional data to show the incredible effect a simple intervention like essential amino acids like those that are in men's repair and recover and other key joint formulas that men makes these data really show how critical it is that all of our patients be receiving this simple inexpensive and highly effective intervention before and after their time when they undergo knee Replacements I think you could also think about this data in the hip replacement group patients with hip fractures knee injuries I think broadly in Orthopedics this data is so compelling and and I think what really makes it remarkable again is this was NIH funded data this is not industry funded data this is NIH reviewed and funded data published in a premier Journal that that really only takes the very best and the very most exceptional research in our fields of nutrition and clinical research so as we begin to think about how nutrition and essential amino acids benefit our patients around the time of orthopedic surgery or perhaps other surgeries as well a really seminal paper was done by Dr drer and his group where they looked at biopsies muscle biopsies of patients undergoing knee replacement surgeries and they found some really exceptional findings they found that patients who were receiving essential amino acids before their knee surgery had increase in the satellite cell numbers of the muscle and satellite cells are critical to Muscle Recovery and to muscle repair and so even before the operation getting essential amino acids will set the patient up to have a better ch CH for recovery and repair and we can even begin to understand the mechanism this study also found that there was reduced inflammation in the muscles of the patients who received the essential amino acids around the time of surgery so I think again that is a critical finding as well because inflammation in the muscle obviously leads to poor Muscle Recovery poor muscle repair and and all the things that slow our patients ability to get back to the life that they came to us to restore to them and so think not only do we have the clinical outcome data the the the patient function data the muscle mass and muscle size data but we have mechanistic data that helps us explain how essential amino acids and nutrition interventions help preserve muscle mass muscle function and patients quality of life which I really think really completes the circle of what we need to make this a standard of care intervention in all of our patients having any major Orthopedic surgeries amazing what's even more impressive about the data that Dr drer and his group had done showing improvements of muscle strength and muscle benefit is is this data has been replicated in many other sites and centers and most notably in a study in Japan where they actually brought the patients into the hospital 30 days before the knee surgery operation and actually controlled every aspect of their diet and other care other than one group got a essential amino acids and one group did not and again they were able to replicate the findings of improved muscle mass and muscle function in the patients even under these highly controlled settings and then a group in Japan went further with this research and they actually followed patients out to two years and what they found is the patients that got essential amino acids had better muscle mass and muscle function muscle strength two years after they underwent this Sur surgery and that the benefit of essential amino acids not only benefits the patient in the weeks following surgery but appears to benefit the patient for years following the surgery and so I think this is quite remarkable and one may ask gosh how how is this possible that an intervention we do around the time of surgery for not a very long period of time can have such an incredible effect on outcomes even years later well we have seen this before for those of you that are familiar with the enhanced recovery the eras Pathways that we use in many different surgical Specialties there's remarkable data in that area in that field showing that patients who undergo surgery for cancer Surgical Oncology patients who get at least 70% of the key eras components around the time of surgery have significant improvements in their fiveyear survival they have more than a 40% increase in survival 5 years later based on the key interventions that are done around the time of surgery and two key interventions that make up enhanced recovery Pathways were found to be responsible for this mortality benefit and the primary one that led to this benefit was early feeding after surgery so again it was a nutritional intervention that was one of the two main drivers of the benefit of eras pathways on mortality 5 years after the operation that's just incredible data and it really shows that how we deal and treat our patients nutrition needs around the time of surgery not only affects what happens to them in the weeks or months following surgery but appears to affect clearly what happens to them both in their muscle mass their muscle function and even their survival years later out to five years later and it's a significantly large Improvement and outcome that I think cannot be ignored and I think now really should drive every Surgical Specialty but particularly in Orthopedics to make this a standard of care for all their patients and if you're a patient having an orthopedic surgery this is something you should be asking for and this is something you should be taking because it's again it's inexpensive it's safe and it's going to improve your function and your outcomes for not just weeks after your surgery but for years after your surgery which is what we all want for all of our patients as they come for these operations to improve their lives I think it's key to realize that the data that I've just talked to you about in the essential amino acid literature is not the only data supporting the role of nutrition interventions and key amino acids in improving outcomes in orthopedic surgery I think another nutrient that is really key and has significant evidence in the orthopedic literature is hmbb hydroxy methylate which we've talked a little bit about in in in other discussions we've had of course but hmb is a key nutrient that improves muscle mass by stimulating the mour pathway and reduces inflammation that leads to muscle breakdown so it really enhances our ability to recover muscle mass and some of these key studies looked at patients with hip fractures who received hmbb plus protein which is very similar to repair and recover and in this study what they found was the patients who had hip fractures had reduced loss of muscle mass which we know is one of the main killers of patients who have hip fractures we know patients who have hip fractures can lose a lot of muscle mass from the fracture itself and the bed rest it requires and it often leads to life-threatening or life-ending complications things like pneumonia and blood clots and other complications that often lead to the end of the life of of our patients with hip fractures and so I think it's really remarkable that hmb and these protein combinations can prevent that muscle loss which really is is perhaps the worst part of having the hip fracture for the patient long term and then there's also data in the total knee population much like for essential amino acids hmb has also been shown to reduce the loss of muscle mass that we see and we know occurs after a knee replacement surgery or uh and and I think that's again more evidence showing that nutrition is really critical to prevent this muscle loss and prevent the weakness and improve recovery for our knee replacement patients and then finally in patients with pelvic and extremity fractures receiving hmb around the time of that injury just after that injury reduce the complications those patients saw and reduce their loss of fat-free mass or muscle mass um and they were better able to preserve their muscle mass and fat-free Mass so again I think in a wide body of Orthopedic patients this data continues to show that essential amino acids and other specialized amino acids like hmb should be St standard of care for our patients undergoing orthopedic surgery whether it be elective knee replacement or hip replacement or for patients who have hip fractures or knee injuries or other Orthopedic injuries that require surgery I think for all patients having these operations or having these injuries this is a chance that you can improve your recovery and your outcome from them and for the surgeons and the surgical teams that do this this is a simple inexpensive and safe way you can really improve your patient outcome and improve their qualities of Life which I think this is a huge opportunity that cannot be ignored