Vitamin D insufficiency in the elderly orthopaedic patient: an epidemic phenomenon

Prevalence and Associated Risk Factors for Hypovitaminosis D in Patients Scheduled for Primary Total Knee Arthroplasty in Germany

OBJECTIVE

Several studies have reported a high prevalence of hypovitaminosis D in orthopedic patients. The purpose of this prospective observational study was to report on the prevalence of hypovitaminosis D in patients scheduled for elective primary total knee arthroplasty (TKA) and its associated risk factors.

METHODS

In this monocentric cohort study, 25(OH) vitamin D serum levels were measured in 687 consecutive patients undergoing primary total knee arthroplasty (TKA) over a period of twelve months. Vitamin D levels were classified into deficiency (<20 ng/mL), insufficiency (20-29 ng/mL), and sufficiency (≥30 ng/mL). The study assessed the association of vitamin D levels with demographic and clinical factors, including age, sex, BMI, smoking status, and season of measurement. Statistical analyses included chi-square tests, correlation analyses, and multiple linear regression to identify significant predictors of vitamin D levels.

RESULTS

The cohort had a mean age of 67.70 ± 8.95 years and a mean BMI of 31.00 ± 5.71 kg/m2. Collectively, 33.9% of patients were vitamin D deficient, a further 32.9% were insufficient, and only 33.2% were sufficient. Vitamin D levels varied significantly with the season and were associated with obesity and smoking. Specifically, there was a small significant inverse correlation between BMI and vitamin D levels (r = -0.17, p < 0.01). Furthermore, regular nicotine abuse was linked to lower vitamin D levels (r = 0.14, p < 0.01). Multiple linear regression analysis reveals that age, BMI, nicotine abuse, and season were small significant predictors of preoperative vitamin D levels (R2 = 0.15, adjusted R2 = 0.12). A total of 121 (17.61%) patients reported routine vitamin D intake prior to surgery. Supplementing patients had a significantly higher mean serum vitamin D level and a significant reduction in the mean length of in-hospital stay (p < 0.01).

CONCLUSIONS

The prevalence of vitamin D insufficiency and deficiency in patients undergoing elective primary TKA is alarmingly high. In ongoing efforts to optimize the efficacy and outcome of the TKA procedure, orthopedic surgeons should be advised to strongly implement the role of perioperative vitamin D levels in their routine practice.

Prevalence and Risk Factors of Vitamin D Deficiency in Patients Scheduled to Undergo Revision Arthroplasty of the Hip, Knee and Shoulder-Data from a Single-Centre Analysis

Vitamin D is crucial for ideal bone health and good muscle function, both essential requirements for successful joint arthroplasty. Hence, vitamin D deficiency has recently been identified as a predictor of poorer outcomes in patients scheduled to undergo total joint arthroplasty (TJA). Moreover, there is ample evidence today that vitamin D deficiency is associated with periprosthetic joint infection. Yet, vitamin D deficiency seems to be frequent in patients who are scheduled to undergo TJA. However, the prevalence of hypovitaminosis D in patients who require revision arthroplasty (rTJA) is largely unknown. Further, risk factors of vitamin D deficiency in these patients remain to be elucidated. For this reason, the primary objective of this study was to assess the vitamin D status of patients scheduled to undergo rTJA of the hip, knee and shoulder. The secondary objective was to identify potential risk factors for hypovitaminosis D in these patients. Serum vitamin D [25(OH)D] levels of 249 patients who were scheduled for rTJA were assessed over a period of twelve months at a high-volume TJA centre. Collectively, 23% of patients reported a routine intake of vitamin D supplements (58/249). Notably, 81% of patients (155/191) who did not report a routine vitamin D intake presented with insufficient vitamin D levels (below 30 ng/mL), while only 19% of patients (36/191) had sufficient vitamin D levels. Of those who reported a routine vitamin D intake, 75% (43/58) had sufficient vitamin D levels, while 25% (15/58) showed insufficient vitamin D status. Patients who did not routinely take any vitamin D supplements had significantly lower vitamin D levels compared to patients who reported regular vitamin D intake (19.91 ng/mL vs. 40.66 ng/mL). Further, BMI and nicotine abuse were identified as potential risk factors for hypovitaminosis D in patients without vitamin D supplementation. Moreover, the season of spring seems to be a risk factor in patients with vitamin D supplementation, while age itself did not appear to be a significant risk factor for low vitamin D levels. In conclusion, we found an alarmingly high rate of vitamin D deficiency in patients scheduled to undergo rTJA. Notably, reported routine vitamin D supplementation showed significantly increased serum vitamin D levels compared to patients with no reported supplementation. Due to the high prevalence of vitamin D deficiency, we believe that vitamin D status should routinely be assessed in patients who are scheduled to undergo rTJA.

Association between Vitamin D Deficiency and Prognosis after Hip Fracture Surgery in Older Patients in a Dedicated Orthogeriatric Care Pathway

OBJECTIVES

Vitamin D deficiency is common in patients undergoing hip fracture surgery (HFS) and has been found to be associated with poor post-operative outcome in other settings. This study aimed to analyze the association between vitamin D status and prognosis after HFS.

DESIGN

Observational, prospective, single-center study.

SETTING AND PARTICIPANTS

All patients admitted in a peri-operative geriatric unit between 2009 and 2020 for HFS were included.

MEASUREMENTS

A moderate vitamin D deficiency was defined by a vitamin D level between 25 and 75 nmol/l and a severe deficiency by a vitamin D level <25 nmol/l. Primary endpoint was mortality 6 months after surgery. Secondary endpoints were bacterial infections and delirium during hospitalization. Odds ratio (OR) and 95% confidence interval (95%CI) were computed using logistic regression models with adjustment for confounders.

RESULTS

1197 patients were included (median age 87 years, IQR [82-91]). Median vitamin D level was 55 nmol/l (IQR [30-75 nmol/l]). Moderate and severe vitamin D deficiencies were reported in 53% and 21% of patients, respectively. There was no significant association between moderate or severe vitamin D deficiencies and 6-month mortality (OR 0.91, 95%CI [0.59-1.39], and OR 1.31, 95%CI [0.77-2.22], respectively), bacterial infection (OR 0.89, 95%CI [0.60-1.31] and OR 1.55, 95%CI [0.99-2.41], respectively), nor delirium (OR 1.03, 95%CI [0.75-1.40], and OR 1.05, 95%CI [0.70-1.57], respectively).

CONCLUSION

Vitamin D deficiency was not associated with mortality, bacterial infection or delirium after HFS. Our results suggest that comorbidities, functional status and post-operative complications are the main determinants of post-operative outcome after HFS.

The role of vitamin D and vitamin D deficiency in orthopaedics and traumatology-a narrative overview of the literature

Vitamin D is considered to play an important role in musculoskeletal health. It’s classical function is the regulation of calcium and phosphate homeostasis, thus ensuring a balanced bone metabolism that is characterised by an equal amount of bone resorption and bone formation. In the past decades, a plethora of pre-clinical and clinical studies reporting on potential health-beneficial properties of vitamin D have emerged. Moreover, there is an abundance of reports highlighting vitamin D deficiency and insufficiency in patients with almost innumerable diseases. Further, it is estimated that more than one billion people globally are affected by insufficient vitamin D levels. As such, research on vitamin D has been particularly popular over the past years. In orthopaedics and traumatology, most studies describe favourable effects of vitamin D in general. However, the relative importance of vitamin D is oftentimes debated. In this narrative review of the literature, we consider first, the properties of vitamin D and how vitamin D, vitamin D deficiency and the vitamin D receptor (VDR) impact on musculoskeletal health. Secondly, we provide an overview of studies reporting the prevalence of vitamin D deficiency in traumatology and diverse orthopaedic diseases including bone oncology. Lastly, we emphasise recent findings and touch on future perspectives in vitamin D research.

Vitamin D Supplementation Improves the Effects of the Rehabilitation Program on Balance and Pressure Distribution in Patients after Anterior Cervical Interbody Fusion-Randomized Control Trial

STUDY DESIGN

A double-blinded, randomized controlled trial.

BACKGROUND

Surgery is effective in reducing pain intensity in patients with cervical disc disease. However, functional measurements demonstrated that the results have been not satisfactory enough. Thus, rehabilitation programs combined with the supplementation of vitamin D could play an essential role.

METHODS

The study recruited 30 patients, aged 20 to 70 years, selected for anterior cervical interbody fusion (ACIF). The patients were randomly divided into the placebo (Pl) and vitamin D (3200 IU D3/day) supplemented groups. The functional tests limits of stability (LOS), risk of falls (RFT), postural stability (PST), Romberg test, and foot pressure distribution were performed before supplementation (BS-week 0), five weeks after supplementation (AS-week 5), four weeks after surgery (BSVR-week 9), and 10 weeks after supervising rehabilitation (ASVR-week 19).

RESULTS

The concentration of 25(OH)D3 in the serum, after five weeks of supplementation, was significantly increased, while the Pl group maintained the same. The RFT was significantly reduced after five weeks of vitamin D supplementation. Moreover, a further significant decrease was observed following rehabilitation. In the Pl group, no changes in the RFT were observed. The overall postural stability index (OSI), LOS, and the outcomes of the Romberg test significantly improved in both groups; however, the effects on the OSI were more pronounced in the D3 group at the end of the rehabilitation program.

CONCLUSIONS

Our data suggest that vitamin D supplementation positively affected the rehabilitation program in patients implemented four weeks after ACIF by reducing the risk of falls and improving postural stability.

Bone Marrow Foot Oedema in Adolescents: The Role of Vitamin D

Background

Bone marrow oedema (BMO) in children/adolescents is a rare clinical condition without an etiologic cause. It is associated with typical increased signal intensity on T2-weighted magnetic resonance images (MRI) and an increase in bone turnover in which vitamin D plays a pivotal role. No treatment guidelines for these young patients are to date available.

Methods

We performed a retrospective study in a pediatric setting of 13 patients with diagnosis of primary BMO of the foot on the basis of clinical and radiological findings. Data collection included sex, age, patient history, symptoms at presentation, clinical examination, laboratory bone turnover markers, vitamin D levels, MRI, treatment, and outcome.

Results

Vitamin D deficiency or insufficiency was found in 76.9% of cases. All patients were treated with adequate vitamin D daily intake, a short course of analgesic therapy, physical therapy, avoiding detrimental feet and ankle immobilization. All fully recovered in 3-month lag period.

Conclusions

Our data highlight that environmental factors, such as underestimated articular or bone microtraumatisms, as well as joint hyper mobility, in a bone turnover milieu of vitamin D deficiency could be the cause of this clinical conditions. Adequate vitamin D supplementation, associated with physical and analgesic therapy, is crucial in the management of BMO.

Functional outcomes and mortality in geriatric and fragility hip fractures-results of an integrated, multidisciplinary model experienced by the "Florence hip fracture unit"

PURPOSE

The aim of this study was to evaluate the outcomes of an integrated multidisciplinary hip fracture unit through the following parameters: time to surgery, mortality, return to activities of daily living, adherence to re-fractures prevention programs.

METHODS

Six hundred seventy-seven consecutive patients with hip fracture were included in the study. We calculated the time to surgery as the time in hours from admission until surgery. The in-hospital mortality was calculated as the number of deaths that occurred before discharge. Each patient was then evaluated post-operatively at six weeks, three months, and one year. We studied basic activity of daily living (BADL) and the New Mobility Scale (NMS). Adherence to re-fractures prevention programs was also evaluated.

RESULTS

88.9% of patients underwent surgery within two calendar days from admission. In-hospital mortality was 2.4%, and the overall mortality at one year from the intervention was 18.7%. Full mobility status or a low impairment of the mobility status was reached in 32.1% of the patients at one year and a level ≥ 3 of autonomy in BADL was reached in 62.4% (338/542) of patients. Three hundred forty-two patients were prescribed a specific therapy for secondary prevention of re-fracture.

CONCLUSIONS

An integrated, multidisciplinary model for the treatment of hip fragility fractures was effective in reducing time to surgery and mortality, increasing the level autonomy and mobility status and promoting adherence to re-fracture therapy.

The significance of the vitamin D metabolism in the development of periprosthetic infections after THA and TKA: a prospective matched-pair analysis of 240 patients

Background

The importance of the vitamin D homeostasis in infections is already known. However, its significance in periprosthetic infections (PPIs) after total hip arthroplasty and total knee arthroplasty is largely unexplored. The aim of the study is to precisely analyze the vitamin D balance in patients with PPIs after total hip arthroplasty and total knee arthroplasty. Here, cases with primary endoprosthesis implants and aseptic loosening are used as comparison groups.

Materials and methods

In this prospective matched-pair analysis, patients with PPI at the hip and knee joints were included in the study group (SG). The control groups (CGs) consisted of patients with primary implants (CG I) and who underwent replacement surgery due to aseptic loosening (CG II). In addition to 25 OH vitamin D3 and calcium, bone mineral and protein parameters were determined. An osteoporosis-specific questionnaire was collected.

Results

There are no significant differences in the 25 OH-vitamin D levels between the SG (17.9±8.9) and both CGs (CG I: 16.8±6.90; CG II: 19.7±7.90). However, compared with the SG, significantly higher levels of calcium (Ca) and bone-specific alkaline phosphatase were found in both CGs in comparison with the SG. Significantly lower values concerning the protein balance in PPI were conspicuous. Acute PPI showed a significant reduction in 25 OH vitamin D3 compared with chronic infections (8.3±5.98 vs 21.6±8.40, P=0.002). Calcium and protein balance were also significantly reduced in acute PPIs.

Conclusion

Acute PPIs of the hip and knee joints show a significantly reduced calcium and 25 OH vitamin D3 levels as well as lowered proteins (albumin and total protein) compared with chronic infections as well as primary endoprostheses and aseptic replacement operations. Substitution of vitamin D3 and calcium with simultaneous adaptation of the protein balance is recommended in all PPIs, especially in the acute PPI.

High prevalence and seasonal variation of hypovitaminosis D in patients scheduled for lower extremity total joint arthroplasty

Background

High rates of vitamin D insufficiency and deficiency have been demonstrated in various patient populations, including patients undergoing total joint arthroplasties (TJA). However, the risk factors associated with this condition and its seasonal variation is still to be determined in patients scheduled for elective TJA.

Methods

We retrospectively identified 226 (116 hips, 120 knees) patients who underwent primary TJA, and had a vitamin D measurement, at a single institution (latitude, 41° 30' N) from 2006 to 2016. Demographics, comorbidities, and perioperative data were collected from electronic medical records. Patients were stratified into vitamin D sufficient (≥30 ng/mL), insufficient (<30 ng/mL), and deficient group (<20 ng/mL). Multivariate regression analyses were used to study the risk factors for vitamin D insufficiency and deficiency.

Results

There were 99/226 (43.8%) patients in the vitamin D sufficient group, 137/226 patients (60.6%) in the insufficient group, of which 61/226 (26.9%) were in the deficient group. On multivariate analysis, an American Society of Anesthesiologists' (ASA) score ≥3 was a risk factor for vitamin D insufficiency (P<0.001), while ASA ≥3 (P<0.001) and younger age (P=0.002) were risk factors for vitamin D deficiency. Vitamin D levels varied between the quarters with lowest level seen in quarter 1 (P=0.015).

Conclusions

There was an overall high prevalence of vitamin D insufficiency (60%) and deficiency (27%). Due to higher risk of hypovitaminosis D, particular attention should be placed in patients with an ASA score ≥3, and patients scheduled during winter season.

High Prevalence of Vitamin D Deficiency in Patients with Bone Tumors

The aim of this study was to evaluate the prevalence of vitamin D deficiency in patients with different types of bone tumors and to elucidate whether or not there are differences in prediagnostic vitamin D levels in patients with malignant compared to benign bone tumors. Prediagnostic serum 25(OH)D levels of 105 consecutive patients that presented with bone tumors and tumor-like lesions to two Orthopedic Level I University Centers in Germany between 2011 and 2016 were measured on admission. We found an alarming and widespread rate of vitamin D deficiency in patients with bone tumors. Specifically, 83% of all patients had low vitamin D levels with a mean 25(OH)D level of 19.82 ng/ml. Notably, patients diagnosed with malignant bone tumors had significantly lower vitamin D levels compared to patients with benign bone lesions (p = 0.0008). In conclusion, it is essential to assess vitamin D levels in patients with tumors involving bone. In addition, there might be an association between vitamin D deficiency and the onset or course of primary malignant bone tumors.

High Prevalence of Vitamin D Deficiency in Patients With Bone Marrow Edema Syndrome of the Foot and Ankle

BACKGROUND

Bone marrow edema syndrome (BMOS) is a phenomenon primarily affecting the lower extremity. It is characterized by a sudden onset of pain and an ill-defined osseous hyperintense signal in magnetic resonance imaging. The main cause of BMOS is still largely unknown. Its pathophysiology is presumably multifactorial and it has recently been demonstrated that it usually involves an increase in bone turnover and alterations within the bone microenvironment. Vitamin D plays a pivotal role in maintaining a healthy and well-balanced bone microenvironment. However, to date only limited information has been reported on vitamin D status in patients with BMOS. Moreover, it is still uncertain whether hypovitaminosis D is associated with the etiology and course of the disease. For this reason, the aim of this study was to determine serum vitamin D levels (25(OH)D) of patients diagnosed with BMOS of the foot and ankle.

METHODS

Patients were identified and laboratory results collected by retrospective review of the medical records between year 2011 and 2015. Diagnosis was based on clinical examination, the existence of prolonged foot pain, the presence of abnormal bone marrow signal intensity in T1- and T2-weighted magnetic resonance imaging, and the patient's medical history. All patients who demonstrated other concomitant diagnoses were excluded from the study.

RESULTS

Overall, 31 patients were affected by BMOS with a mean age of 44.4 (range, 18-76) years. Notably, 84% of patients (26/31) had low vitamin D levels with a mean 25(OH)D level of 19.03 ng/mL. Specifically, 61% of patients (19/31) were vitamin D deficient, 23% (7/31) vitamin D insufficient, and only 5 patients (16%) had sufficient vitamin D levels. Statistical analysis showed no significant difference comparing vitamin D levels with patient age, sex, and time of diagnosis. Moreover, there was no correlation between vitamin D status and the number of bony foci or location of BMOS.

CONCLUSION

We found a widespread rate of vitamin D deficiency in patients presenting with BMOS of the foot and ankle. Comparing these data to the vitamin D status of the general population in Germany and to patients living in comparable latitudes, this raises the possibility that BMOS might be associated with low vitamin D status.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Circulating interleukin-6 is not altered while γ-tocopherol is increased in subjects scheduled for knee surgery with low vitamin D

The purpose of this study was to identify if circulating interleukin (IL)-6 and γ-tocopherol (γT) fluctuate with vitamin D status in subjects with an underlying knee joint injury or disease. We hypothesized that low vitamin D associates with an increase in plasma γT while serum IL-6 remains unchanged in subjects with an underlying knee joint trauma or disease. Fifty-four subjects scheduled to undergo primary, unilateral anterior cruciate ligament reconstructive surgery (ACL; n=27) or total knee arthroplasty (TKA; n=27) were studied. Circulating γT, α-tocopherol (αT), lipids (cholesterol and triglycerides), IL-6, and 25-hydroxyvitamin D (25(OH)D) were measured in fasting blood samples obtained prior to surgery. Subjects were classified as vitamin D deficient, insufficient, or sufficient if they had a serum 25(OH)D concentration <50, 50-75, or >75nM, respectively. The majority (57%) of the subjects possessed a serum 25(OH)D less than 50nM. Circulating cholesterol, triglycerides, and IL-6 were not significantly (all p>0.05) different between vitamin D status groups. However, lipid corrected αT was significantly (p<0.05) decreased and both lipid- and non-lipid-corrected plasma γT concentrations were significantly (both p<0.05) increased with low serum 25(OH)D (i.e., <50nM). A significant (p<0.05) multi-variate analysis revealed that an increase in plasma γT per lipids was significantly (p<0.05) predicted by a decrease in serum 25(OH)D but not by a decrease in plasma αT per lipids. We conclude that low vitamin D associates with an increase in plasma γT but not IL-6 in subjects with an underlying joint injury or disease.

Is there an association between low serum 25-OH-D levels and the length of hospital stay in orthopaedic patients after arthroplasty?

Background

The purpose of this observational study was to evaluate serum levels of 25-OH-D in patients scheduled to undergo elective hip or knee arthroplasty. We hypothesised that 25-OH-D level is an independent risk factor for length of stay in orthopaedic patients after elective hip or knee arthoplasty.

Materials and methods

25-OH-D levels were measured in 1083 patients admitted to an orthopaedic surgery department to undergo elective hip or knee arthroplasty. Comparisons were performed using Chi square or Student’s t test, followed by univariate and multiple linear regression analysis examining the correlation between the length of stay in the orthopaedic department and 25-OH-D level while adjusting for possible confounders.

Results

Overall, 86 % of patients had insufficient serum levels of 25-OH-D, and over 60 % were vitamin D deficient. The mean length of stay was 13.2 ± 8.3 days. In patients with hypovitaminosis D, the length of stay was significantly longer compared to patients with normal serum 25-OH-D levels (15.6 ± 7.2 compared to 11.3 ± 7.9 days, P = 0.014). In univariate analyses, serum 25-OH-D level was inversely related to the length of stay in our orthopaedic department compared to patients with normal vitamin D levels (r = −0.16; P = 0.008). In multivariate analyses, the length of stay remained significantly associated with low 25-OH-D levels (P = 0.002), indicating that low vitamin D levels increase the length of stay.

Conclusions

We found a high frequency of hypovitaminosis D among orthopaedic patients scheduled to undergo elective arthroplastic surgery. Low vitamin D levels showed a significant inverse association to the length of stay in our orthopaedic department. Patients with vitamin D levels in the target range were hospitalised 4.3 days less than patients with hypovitaminosis D.

Level 3 of evidence according to “The Oxford 2011 levels of evidence”.

Vitamin D Status in an Elective Orthopedic Surgical Population

BACKGROUND

Adequate vitamin D availability is required for normal bone metabolism. Hypovitaminosis D is highly prevalent in latitudes above 30 degrees. The goal of this prospective study was to determine the prevalence of hypovitaminosis D in an unselected population of patients undergoing major ankle or hindfoot arthrodesis in Burlington, Vermont (latitude 44.5° N).

METHODS

One hundred eighteen patients undergoing a major ankle, hindfoot, or midfoot arthrodesis between May 2012 and February 2014 were eligible for the study, of which 81 participated. All clinical data, including comorbidities, demographics, and lab values, were obtained from the comprehensive electronic medical record system that encompassed all inpatient and outpatient care. Based on the recommendations published by the Vitamin D Task Force Committee of the Endocrine Society, vitamin D levels above 30 ng/mL were considered normal. Statistical analyses were performed using a significance level of P <.05.

RESULTS

Of 81 patients tested, 54 (67%) had low serum vitamin D. Older patients had lower risk for hypovitaminosis D (RR = 0.953, CI = 0.908, 0.999, P = .046), whereas a Charlson Index ≥3 had increased risk (RR = 16.8, CI = 1.5, 192.3, P = .023). Of the 16 patients retested after vitamin supplementation, only 9 (56%) corrected to normal.

CONCLUSIONS

In an unselected population in Vermont undergoing hindfoot and ankle arthrodesis, there was a high prevalence of hypovitaminosis D, even in patients without predisposing risk factors. Consequently, routine testing or presumptive high-dose vitamin D replenishment therapy should be considered for all patients scheduled for such surgery, primarily to promote adequate skeletal calcium metabolism.

LEVEL OF EVIDENCE

Level II, prospective study.