Accurate Education - Module 1: PRE-Operative Dietary & Nutritional Management

Peri-operative Pain Management:

Module 1:

PRE-Operative Dietary & Nutritional Management

This section covers Module 1 of the Peri-operative Pain Protocol — the Pre-operative Dietary & Nutritional Management Protocol — as part of a comprehensive approach to the management of pain associated with upcoming planned surgical procedures. These procedures include those for the management of chronic joint, neck and back pain such as spinal fusions, artificial disc replacements, total joint replacements as well as less invasive procedures.

Perioperative – Before, During and After Surgery
Preoperative – Before Surgery
Postoperative – After Surgery

This guide is not intended to replace appropriate nutritional guidance that should be provided by a dietitian regarding perioperative dietary management. Please consult with your surgeon for dietary guidance including referral to a dietitian.

See:

Peri-Operative Pain Management (P-OPM)

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Definitions and Terms Related to Pain

Module 1:

Pre-operative Dietary & Nutritional Management

Introduction – The Peri-operative Pain Management Protocol

The goal of the peri-operative pain protocol is to manage pain starting with the pre-operative period (4–6 weeks before surgery) through the post-operative period (up to 12 weeks after surgery. This protocol includes dietary & nutritional management as well as the use of nutraceuticals during both the pre-operative and post-operative periods. It is designed to reduce not only post-operative pain, but importantly, to also reduce the transitioning of post-operative pain from becoming chronic pain.

This peri-operative pain management protocol applies the principles of the 4-D chronic pain management protocols described here.The 4-D protocols engage lifestyle management as well as the use of prescription medications and therapeutic nutraceuticals based on the anti-inflammatory diet.

Strategic Framework for Protocol Development – A Modular Approach

Protocol Structure and Development Sequence

The peri-operative protocol is divided into the pre-operative period (4–6 weeks before surgery) and the post-operative period ((0–12 weeks after surgery). The pre-operative and post-operative protocols are each divided into two modules (1) Dietary & Nutritional Management and (2) Nutraceutical Management.

The four modules are presented in this order, as each builds on the prior:

Pre-operative Management (4–6 weeks before surgery)

Module 1: Dietary and Nutritional Management
Module 2: Nutraceutical Management

Post-operative Management (0–12 weeks after surgery)

Module 3: Dietary and Nutritional Management
Module 4: Nutraceutical Management

Outlined in the protocol are breakdowns of the responsibilities for both the surgical team and the pain management team regarding the assessment and management of the patient’s pain. Topics include pre-operative and post-operative dietary & nutritional management and recommended nutraceutical management.

Peri-operative Considerations for Patients on Chronic Opioid Management

Of note, this protocol has been established to facilitate appropriate and effective peri-operative pain management specifically directed at those pain patients who have been taking opioids chronically for their pain. Both the presence of chronic pain, as well as the long-term use of opioids, introduces significant variables that impact appropriate choices for managing the patient’s pain. An additional section is forthcoming for the management of peri-operative pain management directed at those patients with acute pain and/or non-opioid dependent pain.

Module 1

Module 1 – Pre-operative Dietary & Nutritional Management – is designed to integrate with the 4-D Protocol’s existing biomarker panel while adding perioperative-specific nutritional screening. It is grounded in the American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) Joint Consensus Statements, AAOS/JBJS orthopaedic nutrition reviews, and the GLIM malnutrition criteria. The evidence supporting each component is cited throughout.

The ASER and POQI Joint Consensus Statements strongly recommends that an individualized multimodal analgesia strategy be used, especially for patients on preoperative opioids, with routine use of nonopioid options and nonpharmacological treatments (GRADE A evidence).

OVERVIEW AND RATIONALE

This module establishes a structured pre-operative dietary & nutritional assessment protocol designed to be initiated at the first preoperative visit (ideally 4–6 weeks before surgery) and completed by the time of surgery.

The rationale is three-fold:

1. Preoperative malnutrition affects 8.5–50% of total joint arthroplasty patients and is an independent predictor of prolonged length of stay, increased re-operation rates, infection, and mortality.[1]

2. Chronic opioid use compounds nutritional risk through endocrine disruption (hypogonadism, adrenal suppression), metabolic derangements (elevated triglycerides, insulin resistance, hyperglycemia), gastrointestinal dysfunction (constipation, impaired absorption), and dietary patterns characterized by excess sugar/fat intake with inadequate fruits, vegetables, and protein.[1][2][3]

3. Exercise and nutritional prehabilitation are the individual components most likely to improve all critical surgical outcomes, including reduced complications and shorter length of stay, based on a 2025 BMJ network meta-analysis of 186 RCTs.[4]

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SECTION 1: NUTRITIONAL SCREENING

1A. Clinical Screening Tools

Administer at the initial preoperative visit (4–6 weeks before surgery). Use one or both of the following validated instruments:

Mini Nutritional Assessment–Short Form (MNA-SF): 6-item tool, <5 minutes to administer. Validated in degenerative spine surgery populations where it was significantly associated with infectious complications, nonhome discharge, prolonged postoperative length of stay, and delayed ambulation. Score ≤11 indicates risk of malnutrition; score ≤7 indicates malnutrition.[5]
“ACS Strong for Surgery Screening” (screening tools): Recommended by the American College of Surgeons. Screen positive if any of the following are present:[6]

1. BMI <19
2. Unintentional weight loss >8 lbs in the last 3 months
3. Poor appetite (eating less than half of meals or fewer than 2 meals per day)
4. Unable to take food orally

If either of the above screening tools is positive, referral to a registered dietitian is recommended for comprehensive evaluation to initiate the interventions described below.[6][7]

1B. Anthropometric Assessment

Body weight, height, BMI
Mid-arm muscle circumference (if available)
Unintentional weight loss assessment (% weight change over prior 3–6 months)
Handgrip strength (if dynamometer available — functional marker of sarcopenia)

1C. Dietary History

24-hour dietary recall or food frequency questionnaire
Assess current protein intake (g/kg/day)
Assess fruit/vegetable intake (servings/day)
Assess processed food and added sugar intake
Screen for opioid-related dietary patterns: preference for sweet/convenient foods, decreased vegetable/fruit/grain intake, constipation-related appetite suppression[1]

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SECTION 2: LABORATORY BIOMARKER PANEL

The following panel integrates standard perioperative nutritional markers with the 4-D Protocol’s existing biomarker assessments. Many of these labs will already be available from the patient’s ongoing 4-D Protocol monitoring; those that are not should be ordered at the initial preoperative visit.

2A. Macronutritional Status / Surgical Risk Markers

These markers are best understood as indicators of inflammatory/nutritional risk rather than pure nutritional status, per the ASPEN position paper.[8] However, they remain the most widely validated predictors of postoperative complications in orthopedic surgery.[1][8]

Marker

Normal

Mild Depletion

Moderate Depletion

Severe Depletion

Action Threshold

Serum Albumin

≥3.5

g/dL

3.0–3.5

g/dL

2.5–3.0

g/dL

<2.5

g/dL

<3.5 g/dL: initiate protein supplementation;

<3.0 g/dL: consider delaying surgery per ESPEN [1]

Prealbumin (Transthyretin)

18–45 mg/dL

10–18

mg/dL

5–10

mg/dL

<18 mg/dL: initiate supplementation;

<10 mg/dL: aggressive repletion [1]

Transferrin

200–360 mg/dL

150–200

mg/dL

100–150

mg/dL

<100

mg/dL

<200 mg/dL: assess iron status and protein intake [1], [2]

Total Lymphocyte Count

>1,500

/mm³

1,200–1,500

/mm³

800–1,20

/mm³

<800

/mm³

<1,500/mm³: immunocompromised state; optimize nutrition [1], [2]

Clinical interpretation note:

Albumin (half-life ~20 days) reflects chronic nutritional/inflammatory status and is the most validated predictor of postoperative complications in TJA — patients with albumin <3.5 g/dL have a 2.2-fold increased risk of postoperative wound complications.[8]

Prealbumin (half-life ~2 days) is more responsive to acute changes and is useful for monitoring response to nutritional intervention over the preoperative period.[8]

2B. Micronutrient Panel (Key: TJA = Total Joint Arthroplasty/replacement)

Marker	Target Level	Deficiency Threshold	Clinical Relevance	Repletion Protocol
25(OH) Vitamin D	≥30 ng/mL (optimal: 40–60 ng/mL)	<30 ng/mL (deficiency: <20 ng/mL)	Deficiency in 13–63% of TJA patients; associated with increased complications, impaired functional scores, higher infection risk [1], [2]	If <30 ng/mL: 50,000 IU D3 weekly × 4 weeks, then 2,000 IU/day maintenance (Corrects 73% of patients vs. 42% with low-dose daily) [3]
Magnesium (serum or RBC)	Serum: 1.8–2.4 mg/dL; RBC Mg: 4.2–6.8 mg/dL	Serum <1.8 mg/dL	Supports vitamin D activation, analgesia, collagen stability; deficiency common in chronic pain patients [1]	Magnesium glycinate 400–800 mg/day (elemental Mg)
Vitamin C	0.6–2.0 mg/dL	<0.6 mg/dL	Improves collagen synthesis, decreases inflammatory markers, reduces pain, lowers CRPS incidence after surgery [1]	500–1,000 mg/day starting 2–4 weeks preoperatively
Omega-Check	≥5.5% (optimal)	<3.5% (high risk)	Anti-inflammatory; reduces DVT/PE risk postoperatively; SPAQI consensus supports continuation perioperatively [4], [5]	EPA/DHA 2–4 g/day (continue through surgery per SPAQI)
Omega-3 Index	≥8% (optimal)	<4% (high risk)	Anti-inflammatory; reduces DVT/PE risk postoperatively; SPAQI consensus supports continuation perioperatively [4], [5]	EPA/DHA 2–4 g/day (continue through surgery per SPAQI)
Vitamin B12	>400 pg/mL	<200 pg/mL (deficiency); 200–400 pg/mL (borderline)	Neuroprotection; relevant to neuroinflammation domain of 4D Protocol	Per 4D Protocol repletion guidelines
Folate	>7 ng/mL	<3 ng/mL	Methylation support; homocysteine metabolism	Per 4D Protocol
Iron studies (ferritin, TIBC)	Ferritin: 30–300 ng/mL	Ferritin <30 ng/mL	Preoperative anemia optimization; relevant to surgical blood loss	Iron supplementation if deficient
Homocysteine	<10 µmol/L	>15 µmol/L (elevated)	Inflammatory marker; methylation status; 4D Protocol biomarker	B12/folate/B6 repletion With activated B9/B12

2C. 4D Protocol Domain Markers (Already in Existing 4-D Panel)

These markers from the 4-D Protocol’s standard biomarker panel provide additional perioperative context:

hs-CRP (systemic inflammation domain): Elevated levels indicate heightened inflammatory state entering surgery; target <3.0 mg/L preoperatively if possible

IL-6 (if available): Correlates with surgical stress response magnitude

CoQ10 levels (mitochondrial domain): Relevant to perioperative energy metabolism;

Note: CoQ10 supplementation should be held 2 weeks preoperatively per SPAQI[10]

Kynurenine pathway metabolites (neuroinflammation domain): Baseline assessment informs postoperative neuroinflammation risk (if available)

SECTION 3: DIETARY INTERVENTIONS

3A. Anti-Inflammatory Dietary Pattern

Initiate at the first preoperative visit (4–6 weeks before surgery). The goal is to shift the Dietary Inflammatory Index (DII) score toward anti-inflammatory values. Higher DII scores (pro-inflammatory diets) are associated with increased odds of chronic pain (OR 2.51 in the highest quartile for women), and shifting toward a lower DII is associated with reduced pain incidence over subsequent years.[12][13]

Core dietary principles:

Increase consumption of omega-3-rich foods (fatty fish ≥2 servings/week, walnuts, flaxseed)
Increase colorful fruits and vegetables (≥5 servings/day) — sources of flavonoids, polyphenols, and vitamin C
Emphasize whole grains over refined carbohydrates
Include ginger in cooking where tolerable
Reduce processed foods, added sugars, and refined seed oils (pro-inflammatory)
Reduce red and processed meat intake
Include fermented foods (yogurt, kefir, sauerkraut) for gut microbiome support — particularly relevant given opioid-induced gut dysbiosis[1]

This pattern aligns with the Mediterranean dietary pattern, which has the strongest evidence base for anti-inflammatory effects and is associated with lower odds of chronic pain across multiple dietary indices.[4]

3B. Protein Optimization

Protein delivery is more important than total calorie delivery in the perioperative period.[3]

Target: 1.2–1.5 g protein/kg/day (ESPEN recommendation for surgical patients)[14][5]
For a 70 kg patient, this equals 84–105 g protein/day
Emphasize high-quality protein sources: lean poultry, fish, eggs, dairy, legumes
Whey protein supplementation (20–40 g/day) if dietary intake is insufficient — whey protein increases intracellular glutathione (GSH), which neutralizes reactive oxygen species and blunts surgical stress-induced inflammation[14].
Essential amino acid (EAA) supplementation: Evidence supports preservation of quadriceps muscle mass, improved strength recovery, and accelerated return to ADLs after TJA[8]
See: Perioperative Protein Supplementation

3C. Immunonutrition Considerations

For patients undergoing major surgery (spinal fusion, TJA) who screen positive for malnutrition:

Consider immunonutrition formulas containing arginine, glutamine, omega-3 fatty acids, and nucleotides for 5–7 days preoperatively
WHO guidelines suggest multiple nutrient-enhanced nutritional formulas reduce SSI incidence (OR 0.53; 95% CI 0.30–0.91) compared with standard nutrition in malnourished patients undergoing major surgery[15]
HMB (β-hydroxy-β-methylbutyrate) combined with arginine and glutamine may suppress postoperative quadriceps strength loss after TKA[16]

3D. Carbohydrate Loading

Preoperative carbohydrate loading (complex carbohydrate drink 2–3 hours before surgery) mitigates postoperative insulin resistance[8][14]
This is a standard component of Enhanced Recovery After Surgery (ERAS) protocols
Coordinate with the surgical team regarding their ERAS carbohydrate loading protocol

3E. Opioid-Specific Dietary Considerations

Chronic opioid use creates specific nutritional challenges that should be addressed preoperatively:

Constipation management: Increase fiber intake (25–35 g/day), adequate hydration (≥64 oz/day), consider prebiotic foods
Metabolic syndrome risk: Opioid users demonstrate elevated triglycerides, insulin levels, and fasting glucose compared to non-users; the 4-D protocol addresses these derangements[2]

Endocrine effects: Long-term opioids affect the hypothalamic-pituitary-gonadal axis, potentially causing osteoporosis, fatigue, and metabolic dysfunction; ensure vitamin D and calcium adequacy[3]; (the 4-D protocol addresses these concerns)

Gut microbiome disruption: Opioids alter gut microbiota composition; Mediterranean dietary patterns and fermented foods may partially restore microbial diversity[1] (The 4-D protocol addresses these derangements with foundational recommendations for Synbiotics).

—

SECTION 4: PRE-OPERATIVE ASSESSMENT TIMELINE

Visit 1: Initial Pre-operative Assessment (6-8 weeks before surgery)

Administer MNA-SF (Mini Nutritional Assessment – Short Form) and/or ACS Strong for Surgery screening
Obtain anthropometric measurements
Perform dietary history
Order laboratory panel (Section 2) — integrate with 4-D Protocol labs already scheduled
Initiate anti-inflammatory dietary pattern education
Begin protein optimization (See: Peri-operative Protein Supplementation)
Begin vitamin D repletion if deficient (50,000 IU/week × 4 weeks)
Begin vitamin C supplementation (500–1,000 mg/day)
Continue omega-3 supplementation (will continue through surgery per SPAQI)
Refer to registered dietitian if screening positive for malnutrition[6][7]

Visit 2: Follow-up (2–4 weeks before surgery, or telehealth)

Review lab results; adjust interventions based on biomarker response
Check prealbumin (if initially low) as a responsive marker of nutritional improvement
Reinforce dietary adherence
Transition vitamin D to maintenance dose (2,000 IU/day) if loading complete
Coordinate with surgical team regarding:
ERAS carbohydrate loading protocol
Nutraceutical hold schedule (detailed in Module 2)
Surgeon communication regarding opioid management (companion document)

Pre-Surgical Day

Carbohydrate loading per ERAS protocol (if surgeon’s protocol includes this)
Continue vitamin C, omega-3, vitamin D maintenance
Hold nutraceuticals per Module 2 schedule

—

SECTION 5: INTEGRATION WITH THE 4D PROTOCOL

The pre-operative nutritional assessment engages the 4-D Protocol’s approach. The patients 4 Domain profile identifies the dominant contributing domains to a patient’s underlying contributory risks and nutraceutical supplementation emphasis is based on the patient’s 4-D profile.

The following integration points should be noted:

Systemic Inflammation (Domain 1): The anti-inflammatory dietary pattern and omega-3 optimization directly target this domain. Preoperative hs-CRP provides a baseline for monitoring the surgical inflammatory response postoperatively.
Neuroinflammation (Domain 2): Adequate B-vitamin status, magnesium, and protein intake support neurotransmitter synthesis and kynurenine pathway balance. Surgical stress activates neuroinflammatory cascades; preoperative optimization of these substrates may attenuate the response.
Oxidative Stress (Domain 3): Vitamin C, whey protein (via glutathione synthesis), and the polyphenol-rich anti-inflammatory diet directly support antioxidant defenses against surgical oxidative stress.[14]
Mitochondrial Dysfunction(Domain 4 ): Adequate CoQ10 status (assessed but supplementation held 2 weeks preoperatively per SPAQI), magnesium, and B-vitamin adequacy support mitochondrial bioenergetics during the metabolic stress of surgery.[10]

—

SECTION 6: DOCUMENTATION AND COMMUNICATION

At the completion of the preoperative nutritional assessment, generate a summary document for the patient’s surgical record that includes:

1. Nutritional screening score (MNA-SF or Strong for Surgery result)

2. Baseline biomarker values with flagged deficiencies

3. Interventions initiated and duration

4. Current nutraceutical/supplement list with hold dates (from Module 2)

5. Dietary modifications implemented

6. Baseline 4-D domain profile scores for postoperative comparison

This document serves as the foundation for the surgeon communication and for postoperative reassessment at the first post-surgical clinic visit.

Evidence Summary and Key Considerations

The protocol above synthesizes evidence from multiple authoritative sources. The ASER/POQI Joint Consensus Statement provides the strongest guideline-level recommendations for routine preoperative nutrition screening and protein-prioritized nutritional support.[3] The biomarker thresholds are drawn from a systematic review and meta-analysis of 20 studies confirming that albumin <3.5 g/dL carries a 2.2-fold increased risk of wound complications after TJA, and the ASPEN position paper clarifying that visceral proteins are best understood as inflammatory/risk markers rather than pure nutritional markers.[8]

The vitamin D repletion protocol is based on a comparative study showing that a loading dose of 50,000 IU weekly × 4 weeks corrected deficiency in 73% of patients versus only 42% with daily low-dose supplementation.[9] A separate multicenter study demonstrated that preoperative vitamin D optimization reduced total complications (8.6% vs. 4.3%, p = 0.005), superficial wound infections, and postoperative cellulitis.[1] Vitamin D deficiency affects 13–63% of TJA patients, making screening essentially universal in this population.[8]

The protein target of 1.2–1.5 g/kg/day is endorsed by ESPEN for surgical patients, and essential amino acid supplementation has demonstrated preservation of quadriceps muscle mass and accelerated functional recovery after TJA.[14][5][8] The immunonutrition evidence (arginine + glutamine + omega-3 + nucleotides) is supported by WHO guidelines showing a 47% reduction in surgical site infections with multi-nutrient formulas.[15]

A particularly important consideration for this patient population is the compounding effect of chronic opioid use on nutritional status. Patients taking opioids chronically tend to have significantly elevated triglycerides, insulin, and fasting glucose compared to non-users, and long-term opioid therapy causes endocrine disruption affecting bone health, metabolism, and immune function.[2][3] The dietary patterns associated with chronic pain — preference for sweet, convenient foods with decreased vegetable and grain intake — directly oppose the anti-inflammatory dietary pattern recommended here.[1] This makes the dietary intervention component not merely supplementary but essential for this population.

The DII framework from the 4D Protocol provides a validated method for quantifying the inflammatory potential of the patient’s diet and tracking improvement over the preoperative period.[12][13]

Regarding the surgeon communication component on opioid management — this is noted as a priority and will be developed as a companion document. The ASER/POQI consensus provides strong evidence that multimodal analgesia is “even more relevant for the population taking chronic opioids” and that the primary objective is to treat acute pain while preventing withdrawal and avoiding persistent opioid escalation beyond baseline dose.[3]

References

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Management of Patients on Preoperative Opioid Therapy. Edwards DA, Hedrick TL, Jayaram J, et al. Anesthesia and Analgesia. 2019;129(2):553-566. doi:10.1213/ANE.0000000000004018.
Non-Opioid Analgesics for the Prevention of Chronic Postsurgical Pain: A Systematic Review and Network Meta-Analysis. Doleman B, Mathiesen O, Sutton AJ, et al. British Journal of Anaesthesia. 2023;130(6):719-728. doi:10.1016/j.bja.2023.02.041.
American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Nutrition Screening and Therapy Within a Surgical Enhanced Recovery Pathway. Wischmeyer PE, Carli F, Evans DC, et al. Anesthesia and Analgesia. 2018;126(6):1883-1895. doi:10.1213/ANE.0000000000002743.
Nutritional Assessment and Interventions in Elective Hip and Knee Arthroplasty: A Detailed Review and Guide to Management. Dubé MD, Rothfusz CA, Emara AK, et al. Current Reviews in Musculoskeletal Medicine. 2022;15(4):311-322. doi:10.1007/s12178-022-09762-7.
Perioperative Nutritional Optimization in Total Joint Arthroplasty: From Screening to Supplementation. Siddiqi A, Yousuf KM, Chen AF, Jacob PB, Wickline A. The Journal of Arthroplasty. 2026;:S0883-5403(26)00313-X. doi:10.1016/j.arth.2026.03.088.
Preoperative Nutrition in Orthopaedic Surgery. Aepala MR, Chandler AJ, Orbeta L, Confino J, Wong SE. JB & JS Open Access. 2025 Oct-Dec;10(4):e25.00066. doi:10.2106/JBJS.OA.25.00066.
Relative Efficacy of Prehabilitation Interventions and Their Components: Systematic Review With Network and Component Network Meta-Analyses of Randomised Controlled Trials. McIsaac DI, Kidd G, Gillis C, et al. BMJ (Clinical Research Ed.). 2025;388:e081164. doi:10.1136/bmj-2024-081164.
Preoperative Management of Surgical Patients Using Dietary Supplements: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement. Cummings KC, Keshock M, Ganesh R, et al. Mayo Clinic Proceedings. 2021;96(5):1342-1355. doi:10.1016/j.mayocp.2020.08.016.
A Case Illustrating the Practical Application of the AAOS Clinical Practice Guideline: Pharmacologic, Physical, and Cognitive Pain Alleviation for Musculoskeletal Extremity/Pelvis Surgery. Patzkowski JC, Patzkowski MS. The Journal of the American Academy of Orthopaedic Surgeons. 2022;30(18):e1161-e1164. doi:10.5435/JAAOS-D-22-00048.
AAOS/METRC Clinical Practice Guideline Summary: Pharmacologic, Physical, and Cognitive Pain Alleviation for Musculoskeletal Extremity/Pelvis Surgery. Patzkowski JC, Patzkowski MS. The Journal of the American Academy of Orthopaedic Surgeons. 2022;30(18):e1152-e1160. doi:10.5435/JAAOS-D-22-00047.
Management of Antithrombotic Therapy in Patients Undergoing Invasive Procedures. Baron TH, Kamath PS, McBane RD. The New England Journal of Medicine. 2013;368(22):2113-24. doi:10.1056/NEJMra1206531.
Perioperative Management of Antithrombotic Medications: Guidelines From the American College of Chest Physicians. du Breuil AL. American Family Physician. 2023;108(2):208-211.
Geriatric Surgery Verification Program Standards. JoAnn Coleman, Emily Finlayson, Mark Katlic, et al. American College of Surgeons (2019).
Comparison of Four Nutritional Screening Tools for Predicting Postoperative Adverse Events Following Degenerative Spinal Deformity Surgery. Wang SK, Li J, Wang P, et al. Spine. 2024;49(8):536-546. doi:10.1097/BRS.0000000000004933.
Presurgery Exercise-Based Conditioning Interventions (Prehabilitation) in Adults Undergoing Lower Limb Surgery for Peripheral Arterial Disease. Palmer J, Pymer S, Smith GE, et al. The Cochrane Database of Systematic Reviews. 2020;9:CD013407. doi:10.1002/14651858.CD013407.pub2.
Nutrition in Surgery: An Orthopaedic Perspective. Zink TM, Kent SE, Choudhary AN, Kavolus JJ. The Journal of Bone and Joint Surgery. American Volume. 2023;105(23):1897-1906. doi:10.2106/JBJS.23.00259.

Emphasis on Education

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