Vitamin C in orthopedic practices: Current concepts, novel ideas, and future perspectives

Preoperative and postoperative administration of vitamin C in cardiac surgery patients - settings, dosages, duration, and clinical outcomes: a narrative review

Vitamin C or ascorbic acid is a water-soluble vitamin capable of directly donating electrons to reactive oxygen species, attenuating electrical remodeling, and cardiac dysfunction in patients undergoing cardiac surgery (CS), considered one of the most effective defenses against free radicals in the blood, thus being one of the first antioxidants consumed during oxidative stress. The aim of this review is to assess the effects of perioperative administration of vitamin C in CS patients. A comprehensive literature search was conducted in order to identify prospective cohort studies and/or randomized controlled trials reporting on the perioperative effects of vitamin C among adult patients undergoing CS. Studies published between January 1980 to December 2022 were included in our search, resulting in a total of 31 articles that met all our inclusion criteria. There seems to be a beneficial effect of vitamin C supplementation in arrhythmias such as in postoperative atrial fibrillation, reduction of ICU length of stay, and hospital length of stay, reduction in postoperative ventilation time, in inotropic demand, and in postoperative fatigue. Vitamin C can act as a scavenger of free radicals to decrease the peroxidation of the lipids present in the cell membrane, and to protect the myocardium postoperatively from ischemia/reperfusion injury, thus attenuating oxidative stress and inflammation. It represents a readily available and cost-effective strategy that could improve the outcome of patients undergoing CS, by reducing the risk of serious cardiovascular adverse events, both perioperatively and postoperatively.

Exploring Ascorbic Acid's Role in Orthopedic Practices: Present Theories, Innovative Approaches, and Prospects

In the human body, ascorbic acid (AA) is known for its potent antioxidant and reducing properties and also plays a vital role in supporting the growth of bones and cartilage. It has been used extensively in orthopedic surgery. Ongoing studies under the umbrella of ascorbic acid research investigate its impact on bone and tendon physiology, as well as its influence on joint replacement and postoperative pain. The majority of both laboratory and human studies link the usage of ascorbic acid to enhanced bone health and improved tendon healing. Recent literature suggest that ascorbic acid administration may have a positive impact on the outcome of orthopedic procedures. On the other hand, controversy exists regarding the efficacy of ascorbic acid in reducing the incidence of complex regional pain syndrome. In brief, the effectiveness of ascorbic acid in enhancing orthopedic procedure outcomes remains a subject of ongoing investigation. Although certain studies have hinted at the potential positive influence of ascorbic acid on these outcomes, further research is required to validate its effectiveness and ascertain the ideal dosage and method of administration for maximizing its anticipated advantages. To establish the efficacy of ascorbic acid in improving orthopedic procedure outcomes, rigorous human trials of high quality are imperative. The aim of this review was to provide an overview of ascorbic acid's utilization in orthopedic practices and to pinpoint prospective areas for future research.

Evaluating osteogenic effects associated with the incorporation of ascorbic acid in mineralized collagen scaffolds

Current treatments for craniomaxillofacial (CMF) defects motivate the design of instructive biomaterials that can promote osteogenic healing of complex bone defects. We report methods to promote in vitro osteogenesis of human mesenchymal stem cells (hMSCs) within a model mineralized collagen scaffold via the incorporation of ascorbic acid (vitamin C), a key factor in collagen biosynthesis and bone mineralization. An addition of 5 w/v% ascorbic acid into the base mineralized collagen scaffold significantly changes key morphology characteristics including porosity, macrostructure, and microstructure. This modification promotes hMSC metabolic activity, ALP activity, and hMSC-mediated deposition of calcium and phosphorous. Additionally, the incorporation of ascorbic acid influences osteogenic gene expression (BMP-2, RUNX2, COL1A2) and delays the expression of genes associated with osteoclast activity and bone resorption (OPN, CTSK), though it reduces the secretion of OPG. Together, these findings highlight ascorbic acid as a relevant component for mineralized collagen scaffold design to promote osteogenic differentiation and new bone formation for improved CMF outcomes.

Comparative effect of triamcinolone/lidocaine ultrasonophoresis and injection on pain, disability, quality of life in patients with acute rotator cuff related shoulder pain: a double blinded randomized controlled trial

BACKGROUND

Alleviating inflammation should be considered as one of the first steps of the treatment plan in patients with acute rotator cuff related shoulder pain (RCRSP).

OBJECTIVE

To compare the effects of triamcinolone/lidocaine ultrasonophoresis, injection on pain, disability, and quality of life in patients with acute RCRSP.

METHODS

A total of 28 acute RCRSP patients were randomly allocated into two groups of ultrasonophoresis and injection. Both groups received vitamin C and shoulder care education for 10 days and then were subjected to therapeutic interventions. Ultrasonophoresis group received triamcinolone (16 mg) and lidocaine (2mg) using ultrasonophoresis (frequency: 3 MHz, intensity: 1.50 W/Cm2), while the injection group received a single subacromial injection of triamcinolone (80 mg) and lidocaine (10 mg). The main outcomes measures were pain assessed by two scales (visual analog scale), and shoulder pain and disability index (SPADI), disability (SPADI), and quality of life (Western Ontario rotator cuff questionnaire).

RESULTS

Although the main effect of time was statistically significant for all dependent variables (P< 0.01), no significant interaction was found between group and time (P-value (0.12-0.55)). The ultrasonophoresis effect, size for pain, disability, and quality of life were 2.58, 1.43, 1.78, and 1.35, respectively. The injection effect, size for pain, disability, and quality of life were 1.98, 2.02, 1.40, and 1.60, respectively.

CONCLUSIONS

Triamcinolone/lidocaine ultrasonophoresis demonstrated similar outcomes to injection in reducing pain, improving disability, and enhancing quality of life in patients with acute RCRSP in short time. According to our findings, ultrasonophoresis with triamcinolone/lidocaine cream is as effective as triamcinolone/lidocaine injection and can be proposed as a potential adjunctive treatment for patients with acute RCRSP.

Low levels of serum vitamin C in children with limb fractures: a case-control study

Introduction

The role of vitamin C in pediatric fractures has not received much attention, although it is known to be a factor in osteoporotic fractures in the elderly. This case-control study aimed to investigate the changes in serum vitamin C levels among children with limb fractures.

Methods

We recruited 325 children with and 316 children without limb fractures hospitalized between January 2021 and December 2021. Following admission, basic demographic data of all participants were collected, and fasting serum vitamin C levels were determined using ultra-high-performance liquid chromatography-tandem mass spectrometry.

Results

The mean age of the fracture group was 5.1 years (95% CI, 4.83-5.33). The serum vitamin C levels in the fracture group (4.48 µg/ml) were significantly lower than those in the control group (8.38 µg/ml) (p < 0.0001). Further subgroup analysis of the fracture group revealed that serum vitamin C levels decreased significantly after 4 years of age and there was a significant difference in the duration after injury between <6 and >6 h (p = 0.0224). Spearman's rank correlation coefficient suggested that age and vitamin C levels were negatively correlated in the fracture group.

Conclusion

In general, children with limb fractures had lower serum vitamin C levels, especially those aged 4 years and over.

Anti-Inflammatory Effect of Vitamin C during the Postoperative Period in Patients Subjected to Total Knee Arthroplasty: A Randomized Controlled Trial

Vitamin C, a potent reducing and antioxidant agent, plays an important role in the body, aiding in the growth of cartilage and bones. It is also involved in mechanisms that help reduce inflammation and its effects on the body. In addition, vitamin C decreases pro-inflammatory cytokines, such as IL-6, which produce acute-phase proteins such as CRP and influence inflammatory markers such as ESR. We carried out a study with 110 patients who underwent total knee replacement surgery. We divided the patients into two groups, in which the intervention group received 15 g of parenteral vitamin C during the immediate postoperative period while the control group did not. Patients who received 15 g of vitamin C after total knee replacement surgery had decreased inflammatory markers, specifically CRP and ESR. Overall, administering vitamin C in the post-surgical period results in improved management of inflammation, as evidenced by a decrease in CRP and ESR values. This leads to faster recovery and better healing outcomes for patients undergoing total knee replacement surgery. Furthermore, the beneficial effects of vitamin C in reducing proinflammatory cytokines, reducing the need for opioid analgesics, and its mild adverse effects make it a promising adjuvant in managing postoperative recovery.

Molecules Inducing Dental Stem Cells Differentiation and Bone Regeneration: State of the Art

Teeth include mesenchymal stem cells (MSCs), which are multipotent cells that promote tooth growth and repair. Dental tissues, specifically the dental pulp and the dental bud, constitute a relevant source of multipotent stem cells, known as dental-derived stem cells (d-DSCs): dental pulp stem cells (DPSCs) and dental bud stem cells (DBSCs). Cell treatment with bone-associated factors and stimulation with small molecule compounds are, among the available methods, the ones who show excellent advantages promoting stem cell differentiation and osteogenesis. Recently, attention has been paid to studies on natural and non-natural compounds. Many fruits, vegetables, and some drugs contain molecules that can enhance MSC osteogenic differentiation and therefore bone formation. The purpose of this review is to examine research work over the past 10 years that has investigated two different types of MSCs from dental tissues that are attractive targets for bone tissue engineering: DPSCs and DBSCs. The reconstruction of bone defects, in fact, is still a challenge and therefore more research is needed; the articles reviewed are meant to identify compounds useful to stimulate d-DSC proliferation and osteogenic differentiation. We only consider the results of the research which is encouraging, assuming that the mentioned compounds are of some importance for bone regeneration.

Impact of vitamin C on the reduction of opioid consumption after an emergency department visit for acute musculoskeletal pain: a double-blind randomised control trial protocol

INTRODUCTION

Recent evidence has shown that vitamin C has some analgesic properties in addition to its antioxidant effect and can, therefore, reduce opioid use during recovery time. Vitamin C analgesic effect has been explored mostly during short-term postoperative context or in disease-specific chronic pain prevention, but never after acute musculoskeletal injuries, which are often seen in the emergency department (ED). The protocol's primary aim is to compare the total morphine 5 mg pills consumed during a 2-week follow-up between patients receiving vitamin C or a placebo after ED discharge for an acute musculoskeletal pain complaint.

METHODS AND ANALYSIS

We will conduct a two-centre double-blind randomised placebo-controlled trial with 464 participants distributed in two arms, one group receiving 1000 mg of vitamin C two times a day for 14 days and another one receiving a placebo. Participants will be ≥18 years of age, treated in ED for acute musculoskeletal pain present for less than 2 weeks and discharged with an opioid prescription for home pain management. Total morphine 5 mg pills consumed during the 2-week follow-up will be assessed via an electronic (or paper) diary. In addition, patients will report their daily pain intensity, pain relief, side effects and other types of pain medication or other non-pharmacological approach used. Three months after the injury, participants will also be contacted to evaluate chronic pain development. We hypothesised that vitamin C, compared with a placebo, will reduce opioid consumption during a 14-day follow-up for ED discharged patients treated for acute musculoskeletal pain.

ETHICS AND DISSEMINATION

This study has received approval from the Ethics Review Committee from the 'Comité d'éthique de la recherche du CIUSSS du Nord-de-l'Île-de-Montréal (No 2023-2442)'. Findings will be disseminated through scientific conferences and peer-reviewed journal publication. The data sets generated during the study will be available from the corresponding author on reasonable request.

TRIAL REGISTRATION NUMBER

NCT05555576 ClinicalTrials.Gov PRS.

The association between dietary vitamin C intake and periodontitis: result from the NHANES (2009-2014)

Background

The purpose of this study was to investigate whether periodontitis is associated with dietary vitamin C intake, using data from The National Health and Nutrition Examination Survey (NHANES) 2009–2014.

Methods

The study included 5145 adults (age ≥ 30 years) with periodontitis as a dichotomous variable and daily intake of vitamin C as a continuous variable. Multiple sets of covariates, such as age, sex, number of flossing, etc., were selected. Using EmpowerStats version 3.0, multivariate logistic regression analysis and hierarchical analysis were performed on the data, and curve fitting graphs were made.

Results

There were no statistically significant differences (P > 0.05) between the four dietary vitamin C intake groups (quartiles, Q1–Q4) and covariates (drinking alcohol and hypertension). The low VC intake group (Q1) was more prone to periodontitis than Q2, Q3, and Q4 (all OR < 1.00). A threshold nonlinear association was found between vitamin C (mg) log10 transformation and periodontitis in a generalized additive model (GAM) (P = 0.01).

Conclusion

The relationship between dietary vitamin C intake and the likelihood of periodontitis was non-linear. The smallest periodontitis index occurred when dietary vitamin C intake was 158.49 mg. Too little or too much vitamin C intake increases periodontitis.

Effect of Perioperative Vitamin C on the Incidence of Complex Regional Pain Syndrome: A Systematic Review and Meta-Analysis

Complex regional pain syndrome type 1 (CRPS-I) is a complex complication that occurs after limb extremity surgeries. Controversy exists regarding the effectiveness of vitamin C in reducing that condition. Therefore, we conducted this systematic review and meta-analysis to assess the role of vitamin C on CRPS-I and functional outcomes after distal radius, wrist, foot, and ankle surgeries. We searched Medline (via PubMed), Embase, the Cochrane Library, Clinicaltrial.gov, and Google Scholar for relevant studies comparing perioperative vitamin C versus placebo after distal radius, wrist, foot, and ankle surgeries from infinity to May 2021. Continuous data such as functional outcomes and pain scores were pooled as mean differences, while dichotomous variables such as the incidence of complex regional pain syndrome and complications were pooled as odds ratios, with 95% confidence interval, using R software (meta package, version 4.9-0) for Windows. Eight studies were included. The timeframe for vitamin C administration in each study ranged from 42 to 50 days postinjury and/or surgical fixation. The effect size showed that vitamin C was associated with a decreased rate of CRPS-1 than placebo (odds ratio 0.33, 95% confidence interval [0.17, 0.63]). No significant difference was found between vitamin C and placebo in terms of complications (odds ratio 1.90, 95% confidence interval [0.99, 3.65]), functional outcomes (mean difference 6.37, 95% confidence interval [-1.40, 14.15]), and pain scores (mean difference -0.14, 95% confidence interval [-1.07, 0.79]). Overall, vitamin C was associated with a decreased rate of CRPS-I than placebo, while no significant difference was found regarding complications, functional outcomes, and pain scores. These results hold true when stratifying fracture type (distal radius, ankle, and foot surgeries) and vitamin C dose (500 mg or 1 g).

The Impact of General Anesthesia on Redox Stability and Epigenetic Inflammation Pathways: Crosstalk on Perioperative Antioxidant Therapy

Worldwide, the prevalence of surgery under general anesthesia has significantly increased, both because of modern anesthetic and pain-control techniques and because of better diagnosis and the increased complexity of surgical techniques. Apart from developing new concepts in the surgical field, researchers and clinicians are now working on minimizing the impact of surgical trauma and offering minimal invasive procedures due to the recent discoveries in the field of cellular and molecular mechanisms that have revealed a systemic inflammatory and pro-oxidative impact not only in the perioperative period but also in the long term, contributing to more difficult recovery, increased morbidity and mortality, and a negative financial impact. Detailed molecular and cellular analysis has shown an overproduction of inflammatory and pro-oxidative species, responsible for augmenting the systemic inflammatory status and making postoperative recovery more difficult. Moreover, there are a series of changes in certain epigenetic structures, the most important being the microRNAs. This review describes the most important molecular and cellular mechanisms that impact the surgical patient undergoing general anesthesia, and it presents a series of antioxidant therapies that can reduce systemic inflammation.

3rd generation MICA with the "K-wires-first technique" - a step-by-step instruction and preliminary results

BACKGROUND

Minimally-invasive techniques for hallux valgus correction are becoming increasingly popular. In the last decades, multiple techniques for minimally-invasive hallux valgus correction have been described. MICA (Minimally-invasive Chevron & Akin), representing the 3rd generation of minimally-invasive hallux valgus correction, combines the advantages of an extraarticular osteotomy, stable internal fixation, and high potential for correction. This report aims to provide a step-by-step instruction of the surgical technique with the "K-wires-first" MICA modification, illustrated by detailed imaging of both intraoperative fluoroscopy and clinical imaging as well as corresponding sawbone models for each step. Preliminary results including radiological outcome and complications of the first 50 cases will be discussed.

METHODS

Between May 2018 and May 2021, 50 consecutive MICAs in 47 patients were performed with the K-wires-first technique. There were 40 women and 7 men with an average of 57.4y (range 25-78). The mean preoperative IMA was 16.2° (range 11.0-21.5), the HVA 30.6° (range 21.8-42.1).

RESULTS

There was one intraoperative conversion to an open surgical bunion correction corresponding to a 2% conversion rate respectively (1/50). On 3 feet (2 patients), removal of the Chevron screws was performed after 7, 9, and 12 months due to prominent and disturbing screw heads at the level of the medial cortex, accounting for a revision rate of 6% (3/50). There were no other secondary revision surgeries. The IMA decreased after MICA by a mean of 10.8° from 16.2° to 5.4° and the HVA by a mean of 22.1° from 30.6° to 8.5°, demonstrating MICA's high potential for correction.

CONCLUSIONS

Compared to other MICA techniques, the K-wires-first modification helps to reduce hardware malpositioning and the risk of conversion to open surgery. Furthermore, our preliminary results demonstrate a high potential for correction even for severe hallux deformities.

TRIAL REGISTRATION

Retrospectively registered, swissethics BASEC-ID 2021-01537, July 16th, 2021 ( www.raps.swissethics.ch ).

Association of Recurrent Tear After Arthroscopic Rotator Cuff Repair and Superoxide-Induced Oxidative Stress

BACKGROUND

Recurrent tears after arthroscopic rotator cuff repair (ARCR) remain a significant clinical problem. Oxidative stress contributes to the degeneration of the rotator cuff, and a degenerative rotator cuff can lead to recurrent tear after ARCR. However, the correlation between oxidative stress and retear after ARCR is unclear.

PURPOSE

To investigate the correlation between superoxide-induced oxidative stress and recurrent tear after ARCR.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A total of 68 patients who underwent ARCR using a suture-bridge technique participated in this study. Specimens were collected from the edge of the torn tendon during surgery. The modified Bonar score was used to evaluate degeneration of the rotator cuff on histological specimens, and fluorescence intensity on dihydroethidium (DHE) staining was used to detect oxidative stress. Superoxide dismutase (SOD) enzyme activity was also measured. The following were used for clinical evaluation: age, tear size on magnetic resonance imaging (MRI) before surgery, Goutallier classification on MRI before surgery, and Japanese Orthopaedic Association score before and 6 months after surgery. After the repaired rotator cuffs were evaluated on MRI 6 months after surgery, the patients were divided into groups: those with a healed rotator cuff (healed group; n = 46) and those with a recurrent tear (retear group; n = 22). The significant differences between the groups were determined with regard to clinical evaluation, modified Bonar score, DHE intensity, and SOD activity. In addition, multivariate logistic regression analysis was performed to investigate risk factors for recurrent tear.

RESULTS

Age, tear size, Goutallier classification, modified Bonar score, DHE intensity, and SOD activity were significantly greater in the retear group than in the healed group, although the Japanese Orthopaedic Association score was not significantly different. Multiple logistic regression analysis demonstrated that age, tear size, and SOD activity were significantly correlated with recurrent tear.

CONCLUSION

In addition to tear size and age, superoxide-induced oxidative stress may be an exacerbating factor for retear after ARCR.