Is supplementation of vitamin d beneficial for fracture healing? A short review of the literature

The Ankle Joint: Revision Ankle Fusion Options, Nonunion, Malunion, Protocol for Best Outcome

Ankle arthrodesis has been a time-tested procedure for osteoarthritis, avascular necrosis of the talus, deformity correction, and significant trauma of the ankle. Technique guides have created dissection pearls, ease of fixation, and arthroscopic techniques to mitigate complications of the procedure. Major complications, such as nonunion, malunion, or implant infection are the most worrisome and cumbersome complications to handle. The aim of this article is to provide the practicing surgeon evidence to provide innovative management techniques for nonunion, malunion, and infection following primary ankle arthrodesis.

Vitamin D for prevention of sternotomy healing complications: REINFORCE-D trial

Background

Most cardiac surgery patients undergo median sternotomy during open heart surgery. Sternotomy healing is an arduous, very complex, and multifactorial process dependent on many independent factors affecting the sternum and the surrounding soft tissues. Complication rates for median sternotomy range from 0.5 to 5%; however, mortality rates from complications are very variable at 7–80%. Low calcidiol concentration below 80 nmol/L results in calcium absorptive impairment and carries a risk of bone loss, which is considered as a risk factor in the sternotomy healing process. The primary objective of this clinical trial is to compare the incidence of all postoperative sternotomy healing complications in two parallel patient groups administered cholecalciferol or placebo. The secondary objectives are focused on general patient recovery process: sternal bone healing grade at the end of the trial, length of hospitalization, number of days spent in the ICU, number of days spent on mechanical lung ventilation, and number of hospital readmissions for sternotomy complications.

Methods

This clinical trial is conducted as monocentric, randomized, double-blind, placebo-controlled, with planned enrollment of 600 patients over 4 years, approximately 300 in the placebo arm and 300 in the treatment arm. Males and females from 18 to 95 years of age who fulfill the indication criteria for undergoing cardiac surgery with median sternotomy can be included in this clinical trial, if they meet the eligibility criteria.

Discussion

REINFORCE-D is the first monocentric trial dividing patients into groups based on serum calcidiol levels, and with dosing based on serum calcidiol levels. This trial may help to open up a wider range of postoperative healing issues.

Trial registration

EU Clinical Trials Register, EUDRA CT No: 2016-002606-39. Registered on September 8, 2016.

Pleiotropic actions of Vitamin D in composite musculoskeletal trauma

Composite tissue injuries are the result of high energy impacts caused by motor vehicle accidents, gunshot wounds or blasts. These are highly traumatic injuries characterized by wide-spread, penetrating wounds affecting the entire musculoskeletal system, and are generally defined by frank volumetric muscle loss with concomitant segmental bone defects. At the tissue level, the breadth of damage to multiple tissue systems, and potential for infection from penetration, have been shown to lead to an exaggerated, often chronic inflammatory response with subsequent dysregulation of normal musculoskeletal healing mechanisms. Aside from the direct effects of inflammation on myogenesis and osteogenesis, frank muscle loss has been shown to directly impair fracture union and ultimately contribute to failed wound regeneration. Care for these injuries requires extensive surgical intervention and acute care strategies. However, often these interventions do not adequately mitigate inflammation or promote proper musculoskeletal injury repair and force amputation of the limb. Therefore, identification of factors that can promote tissue regeneration and mitigate inflammation could be key to restoring wound healing after composite tissue injury. One such factor that may directly affect both inflammation and tissue regeneration in response to these multi-tissue injuries may be Vitamin D. Beyond traditional roles, the pleiotropic and localized actions of Vitamin D are increasingly being recognized in most aspects of wound healing in complex tissue injuries - e.g., regulation of inflammation, myogenesis, fracture callus mineralization and remodeling. Conversely, pre-existing Vitamin D deficiency leads to musculoskeletal dysfunction, increased fracture risk or fracture non-unions, decreased strength/function and reduced capacity to heal wounds through increased inflammation. This Vitamin D deficient state requires acute supplementation in order to quickly restore circulating levels to an optimal level, thereby facilitating a robust wound healing response. Herein, the purpose of this review is to address the roles and critical functions of Vitamin D throughout the wound healing process. Findings from this review suggest that careful monitoring and/or supplementation of Vitamin D may be critical for wound regeneration in composite tissue injuries.

Osteoporosis, osteomalacia, and hip fracture: A case study from the Terry collection

OBJECTIVE

This case study describes a perimortem hip fracture in a documented individual from the Robert J. Terry Skeletal Collection. The purpose of this paper is to comprehend how co-occurring conditions contributed to fracture risk and to understand the effect of the injury on this individual.

MATERIALS AND METHODS

A 73-year-old female from the Terry Collection with a fracture of the left proximal femur was assessed macroscopically, and images were taken with a Keyence VHX-2000 digital microscope. Documentation concerning the individual's history and contemporary treatment of hip fractures was explored.

RESULTS

Assessment demonstrated impaction of fractured elements occurred as a result of the inferior displacement of the femoral head into the femoral neck. Eburnation and hinge fractures are present on the fracture margins. Bending deformities of the sacrum, sternum, and ribs indicate underlying osteomalacia. No evidence of surgical intervention was observed.

CONCLUSIONS

Both osteomalacia and osteoporosis contributed to overall fracture risk in this case, which demonstrates how complex underlying factors can interact to increase the probability of fracture, and influence post-fracture mortality.

SIGNIFICANCE

This report is the first case study, to date, of a healing hip fracture in which the circumstances of the fracture and the medical history of the individual are known.

LIMITATIONS

To fully investigate osteoporosis, bone mineral density for this individual should be compared with others in the collection.

SUGGESTIONS FOR FURTHER RESEARCH

The effect of co-occurring conditions on fracture risk should be explored in the wider Terry Collection, and in other skeletal collections.

Preclinical safety and efficacy of 24R,25-dihydroxyvitamin D3 or lactosylceramide treatment to enhance fracture repair

Background/Objective

Cyp24a1-null mice deficient in 24,25(OH)₂D₃ display impaired callus formation during the endochondral phase of bone fracture repair. The 24,25(OH)₂D₃ metabolite acted by binding to the TLC domain containing 3B isoform 2 (TLCD3B2, previously named FAM57B2) effector protein, which then synthesizes lactosylceramide (LacCer). Treatment with 24,25(OH)₂D₃ or LacCer restored callus size and mechanical properties in Cyp24a1-null mice.

Methods

To assess the safety of these molecules and test their efficacy for bone healing in wild-type, non-genetically modified mice, we treated 12-week-old, osteotomized C57BL/6 female mice with each compound for up to 21 days post-osteotomy. Control cohorts were injected with vehicle.

Results

Neither compound was found to exhibit any nephro- nor hepato-toxicity. Calcemia remained stable throughout the experiment and was unaffected by either treatment. Supplementation with 24,25(OH)₂D₃ increased circulating levels of this metabolite about 8-fold, decreased 1,25(OH)₂D₃ levels, and significantly increased circulating 1,24,25(OH)₃D₃ levels, suggesting 1?-hydroxylation of 24,25(OH)₂D₃. TLCD3B2 was found to be expressed in fracture callus at the surface of unmineralized or pre-mineralized cartilage on day 10 and day 12 post-osteotomy and to progressively recede to become undetectable by day 18. Treatment with 24,25(OH)₂D₃ or LacCer reduced the number of TLCD3B2-positive cells. Both treatments also significantly increased stiffness and elastic modulus of the healing bone callus.

Conclusion

Exogenous administration of 24,25(OH)₂D₃ or LacCer improved the biomechanical properties of repaired bones in wild-type animals without affecting circulating calcium levels or other blood parameters, demonstrating preclinical safety and efficacy.

Translational potential

Our data suggest the use of 24R,25-dihydroxyvitamin D₃ or lactosylceramide for ameliorating fracture healing in clinical practice.

Fixation using alternative implants for the treatment of hip fractures (FAITH-2): design and rationale for a pilot multi-centre 2 × 2 factorial randomized controlled trial in young femoral neck fracture patients

BACKGROUND

Femoral neck fractures in patients ≤ 60 years of age are often very different injuries compared to low-energy, hip fractures in elderly patients and are difficult to manage because of inherent problems associated with high-energy trauma mechanisms and increased functional demands for recovery. Internal fixation, with multiple cancellous screws or a sliding hip screw (SHS), is the most common treatment for this injury in young patients. However, there is no clinical consensus regarding which surgical technique is optimal. Additionally, there is compelling rationale to use vitamin D supplementation to nutritionally optimize bone healing in young patients. This pilot trial will determine feasibility and provide preliminary clinical data for a larger definitive trial.

METHODS

We will conduct a multicenter, concealed randomized controlled pilot study, using a 2 × 2 factorial design in 60 patients aged 18-60 years with a femoral neck fracture. Eligible patients will be randomized in equal proportions to one of four groups: 1) SHS and vitamin D supplementation (4000 international units (IU) daily dose) for 6 months, 2) cancellous screws and vitamin D supplementation (4000 IU daily dose) for 6 months, 3) SHS and placebo, and 4) cancellous screws and placebo. Participants will be followed for 12 months post-fracture. Feasibility outcomes include initiation of clinical sites, recruitment, follow-up, data quality, and protocol adherence. Clinical outcomes, for both the pilot and planned definitive trials, include a composite of patient-important outcomes (re-operation, femoral head osteonecrosis, severe femoral neck malunion, and nonunion), health-related quality of life and patient-reported function, fracture healing complications, and radiographic fracture healing. A priori success criteria have been established. If the pilot study is deemed successful, study participants will be included in the definitive trial and clinical outcomes for the pilot will not be analyzed. If the pilot study is not deemed successful, clinical outcome data will be analyzed.

DISCUSSION

Results of this study will inform the feasibility of a definitive trial. If clinical outcome data are analyzed, they will be disseminated through a publication and presentations.

TRIAL REGISTRATION

The FAITH-2 trial, described as a definitive trial, was registered at ClinicalTrials.gov (NCT01908751) prior to enrollment of the first participant.

Surgical Considerations for Osteoporosis in Ankle Fracture Fixation

As the geriatric population and associated ankle fractures continues to increase, fracture surgeons should be prepared to surgically manage osteoporotic ankle fractures. There are abundant challenges in management, soft tissue care, and fixation of ankle fractures with poor bone quality especially in elderly patients who have difficulty limiting weight bearing. This article summarizes several different surgical techniques that can be used to optimize outcomes of these fractures.

American College of Foot and Ankle Surgeons® Clinical Consensus Statement: Perioperative Management

A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.

Atypical periprosthetic acetabular fracture in long-term alendronate therapy

Bisphosphonates have been commonly used in the treatment of osteoporosis, demonstrating its efficacy in fracture risk reduction. However, even if are generally safe and well tolerated, concerns have emerged about atypical fractures related to its prolonged use. Although atypical femoral fracture are more common, case reports demonstrated that even other skeletal areas can be involved by unusual pattern of fracture. We report a atypical acetabular periprosthetic fracture in a 83-year-old female patient after prolonged alendronate treatment for osteoporosis and isolated acetabular revision surgery. The patient underwent to clinical, bioumoral and radiological evaluation and all the history cases were fully reported. We believe this periprosthetic fracture, according to the available data, may have similar underlying pathology to atypical femoral fractures. Awareness of symptoms, in addition to a regular radiographic survey may facilitate early diagnosis and possible prevention of spontaneous periprosthetic fractures, in patients receiving bisphosphonate therapy beyond 5 years. The treatment of this atypical periprosthetic fracture should include both surgical than pharmacological therapy to obtained bone healing.

Economic Benefit of Calcium and Vitamin D Supplementation: Does It Outweigh the Cost of Nonunions?

OBJECTIVES

The purpose was to evaluate economic benefit of calcium and vitamin D supplementation in orthopaedic trauma patients. We hypothesized that reduced nonunion rates could justify the cost of supplementing every orthopaedic trauma patient.

DESIGN

Retrospective, economic model.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Adult patients over 3 consecutive years presenting with acute fracture.

INTERVENTION

Operative or nonoperative fracture management.

MAIN OUTCOME MEASUREMENTS

Electronic medical records were queried for ICD-9 code for diagnosis of nonunion and for treatment records of nonunion for fractures initially treated within our institution.

RESULTS

In our hospital, a mean of 92 (3.9%) fractures develop nonunion annually. A 5% reduction in nonunion risk from 8 weeks of vitamin D supplementation would result in 4.6 fewer nonunions per year. The mean estimate of cost for nonunion care is $16,941. Thus, the projected reduction in nonunions after supplementation with vitamin D and calcium would save $78,030 in treatment costs per year. The resulting savings outweigh the $12,164 cost of supplementing all fracture patients during the first 8 weeks of fracture healing resulting in a net savings of $65,866 per year.

CONCLUSIONS

Vitamin D and calcium supplementation of orthopaedic trauma patients for 8 weeks after fracture seems to be cost effective. Supplementation may also reduce the number of subsequent fractures, enhance muscular strength, improve balance in the elderly, elevate mood leading to higher functional outcome scores, and diminish hospital tort liability by reducing the number of nonunions.

LEVEL OF EVIDENCE

Economic Level V. See Instructions for Authors for a complete description of levels of evidence.

The use of augmentation techniques in osteoporotic fracture fixation

There are an increasing number of fragility fractures, which present a surgical challenge given the reduced bone quality of underlying osteoporosis. Particularly in aged patients, there is a need for early weight bearing and mobilization to avoid further complications such as loss of function or autonomy. As an attempt to improve fracture stability and ultimate healing, the use of biomaterials for augmentation of osseous voids and fracture fixation is a promising treatment option. Augmentation techniques can be applied in various locations, and fractures of the metaphyseal regions such as proximal humerus, femur, tibia and the distal radius remain the most common areas for its use. The current review, based on the available mechanical and biological data, provides an overview of the relevant treatment options and different composites used for augmentation of osteoporotic fractures.

Nonunion of the Femur and Tibia: An Update

Delayed union and nonunion of tibial and femoral shaft fractures are common orthopedic problems. Numerous publications address lower extremity long bone nonunions. This review presents current trends and recent literature on the evaluation and treatment of nonunions of the tibia and femur. New studies focused on tibial nonunion and femoral nonunion are reviewed. A section summarizing recent treatment of atypical femoral fractures associated with bisphosphonate therapy is also included.

Vitamin D and bone fracture healing

AIM: To examine whether vitamin D is of potential relevance in the healing process of fractures.

METHODS: The present narrative review examined the bulk of the evidence based literature on the topic of vitamin D and bone healing in key electronic data bases from 1980 onwards using the terms vitamin D and bone healing, callus, fracture healing. All data were examined carefully and categorized according to type of study. A summary of the diverse terms and approaches employed in the research, as well as the rationale for hypothesizing vitamin D has a role in fracture healing was detailed.

RESULTS: The results show very few human studies have been conducted to examine if vitamin D is effective at promoting post fracture healing, and the different animal models that have been studied provide no consensus on this topic. The terms used in the related literature, as well as the methods used to arrive at conclusions on this clinical issue are highly diverse, there is no standardization of either of these important terms and methodologies, hence no conclusive statements or clinical guidelines can be forthcoming. There is a strong rational for continuing to examine if vitamin D supplements should be administered post-fracture, and ample evidence vitamin D is an essential hormone for functioning in general, as well as bone health and muscle as this relates to bone density.

CONCLUSION: Whether those with low vitamin D levels can benefit from supplements if their nutritional practices do not cover recommended daily amounts, remains in question.

Vitamin D and skeletal health in infancy and childhood

During growth, severe vitamin D deficiency in childhood can result in symptomatic hypocalcaemia and rickets. Despite the suggestion from some studies of a secular increase in the incidence of rickets, this observation may be driven more by changes in population demographics than a true alteration to age, sex and ethnicity-specific incidence rates; indeed, rickets remains uncommon overall and is rarely seen in fair-skinned children. Additionally, the impact of less severe vitamin D deficiency and insufficiency has received much interest in recent years, and in this review, we consider the evidence relating vitamin D status to fracture risk and bone mineral density (BMD) in childhood and adolescence. We conclude that there is insufficient evidence to support the suggestion that low serum 25-hydroxyvitamin D [25(OH)D] increases childhood fracture risk. Overall, the relationship between 25(OH)D and BMD is inconsistent across studies and across skeletal sites within the same study; however, there is evidence to suggest that vitamin D supplementation in children with the lowest levels of 25(OH)D might improve BMD. High-quality randomised trials are now required to confirm this benefit.

Effect of vitamin D in fracture healing in a child: case report

In this report, we describe the effect of vitamin D and calcium supplementation on fracture healing in a young boy with a hypovitaminosis D who had a radius refracture. The radiographic evaluation of the callus formation shows a clear effect of vitamin D on fracture healing in absence of additional variables.

INTRODUCTION

Fracture healing restores the tissue to its original physical and mechanical properties and it involves a complex multistep process that involves response to injury, intramembranous bone formation, chondrogenesis, endochondral bone formation, and bone remodeling. All this process is influenced by a variety of systemic and local factors. It is generally assumed that vitamin D plays an intimate role in healing fractures; however, very little data exists on how it does.

CASE REPORT

In this report, the authors describe the effect of vitamin D and calcium supplementation on fracture healing in a young boy with a hypovitaminosis D who had a radius refracture.

CONCLUSIONS

Our case report suggests that the hypovitaminosis D is a possible cause of inadequate fracture healing and refracture in children and it shows a clear effect of vitamin D supplementation on callus formation in the absence of additional variables.