Vitamin D deficiency in patients with osteoarthritis undergoing total hip replacement: a cause for concern?

VDR Gene Polymorphisms (BsmI, FokI, TaqI, ApaI) in Total Hip Arthroplasty Outcome Patients

A total hip arthroplasty (THA) can improve quality of life, but loosening of the hip prosthesis is a complex problem in which vitamin D may also play a role. The Vitamin D Receptor (VDR) is involved in the response of cells to the action of vitamin D, and its genetic variability raises the question of whether individual differences could influence the risk of prosthesis loosening. The aim of this study was to investigate the relationship between VDR single nucleotide polymorphisms (SNPs) (ApaI, BsmI, FokI and TaqI) and the serum VDR and 25(OH)D levels in three groups of patients: (1) arthroscopy patients after THA without loosening of the prosthesis (CA-Control Arthroplasty), (2) patients after THA with loosened hip prostheses (L-Loosening) and (3) the control group (C-Control). Our results suggest that the genotypes tt of TaqI, BB of BsmI, and FF of FokI may influence the VDR effect in patients with loosened protheses. Our results showed that the ACAC haplotype (AtBF) was over two times more frequent in the L group than in CA + C: OR =2.35 [95% CI 1.44-3.83; p = 0.001]. There was no significant correlation between the VDR and serum 25(OH)D levels, but there were differences between studied groups.

Preventive strategies to reduce the rate of periprosthetic infections in total joint arthroplasty; a comprehensive review

The increasing frequency of total hip (THA) and knee arthroplasties (TKA) is marred by the rise in periprosthetic joint infections (PJIs) and surgical site infections (SSIs), with PJIs incurring costs over $1.62 billion as of 2020 and individual case management averaging $90,000. SSIs additionally burden the U.S. healthcare economy with billions in expenses annually. PJI prevalence in primary THA and TKA ranges from 0.5% to 2.4%, spiking to 20% in revisions and representing 25% of TKA revision causes. Projections estimate up to 270,000 annual PJI cases by 2030. Often caused by gram-positive bacteria, particularly methicillin-resistant staphylococci, these infections demand preventive measures. This review dissects PJI prevention across preoperative, intraoperative, and perioperative phases, aligning with evidence-based CDC and WHO guidelines. Preoperative measures include managing diabetes, obesity, tobacco use, Staphylococcus aureus screening and nasal decolonization, nutritional optimization, and management of inflammatory arthropathies. Intraoperatively, antibiotic prophylaxis, skin preparation, operative room environmental controls, surgical technique precision, and irrigation options are scrutinized. Perioperative concerns focus on anticoagulation, blood management, and infection risk mitigation. Integrating these strategies promotes a patient-centric care model, aiming to reduce PJI incidence, improve patient outcomes, and increase care cost-effectiveness in joint arthroplasty.

Adjuvant Vitamin D Injection in Elderly Patients Before Intertrochanteric Fracture Surgery: A Randomised Controlled Trial

Background

There are multiple recommended protocols for Vitamin D (VitD) supplementation in elderly; however, only a few studies achieved to examine the role of VitD supplements before intertrochanteric fracture surgery on mortality and complications after surgery.

Methods

This single-center block-randomized double-blinded trial was conducted on 80 patients with intertrochanteric fractures and a sufficient level of 25 (OH) VitD. The intervention group received an intramuscular 300,000 IU VitD ampule before surgery. The primary outcome was a 6-month mortality rate, and the secondary outcomes were 1- and 2-year mortality rates and Harris Hip Score (HHS) in 6, 12, and 24 months after surgery. Chi-square, t-test, repeated measure ANOVA, and Cox regression survival model was used for statistical analysis.

Results

40 patients were allocated to each group. Demographic, clinical characteristics, and preoperative evaluations were not significantly different between the groups. Mortality rate 6-month after the surgery was 7.5% and 10% for the intervention and placebo groups respectively (P value = .71), 15% and 12.5% at 1-year (P value = .83), and 25% and 27.5% at 2-year (P value = .98). Based on the Cox regression model, only age was significantly associated with mortality (HR = 1.229, P value <.001). Significant HHS changes from baseline through 24 months after surgery were observed within both groups; however, mean differences were not significantly different between groups.

Conclusions

A single preoperative 300,000 IU VitD did not significantly impact 2-year survival and HHS in patients with intertrochanteric fractures and sufficient serum VitD level.

Comparative Clinical Effects and Risk Factors Associated With Vitamin D in Foot and Ankle Fracture and Arthrodesis Healing

Vitamin D deficiency in relation to bone metabolism and healing has been controversial and not well studied. However, hypovitaminosis has been widely identified within the orthopedic patient population. The current best evidence suggests a lack of data on this important topic. The ability to assess patients for optimum bone healing and metabolism is still in question due to lack of a suitable reliable biomarker and multiple other unknown variables affecting bone metabolism. To compound this effect, popular dermatological precautions in the last 20 to 30 years of avoiding sunlight also have the effect of further reducing serum vitamin D production in the skin. As a proof of concept, we performed a preliminary comparative observational retrospective review of orthopedic patients undergoing fracture and arthrodesis osseous healing to determine how serum vitamin D levels are associated with bone healing along with their confounding comorbidities. Based on our review, the current accepted vitamin D levels (≥20 ng/mL) are low and insufficient for fractures and for arthrodesis osseous healing due to observed high rates (>35%) of delayed unions, and an increased (>90%) in the number of multiple confounding comorbidities affecting bone healing process that are often not mentioned or captured in this type of study in previous literature. Obesity and diabetes are significant contributory risks factors, and the preliminary findings suggest that the current accepted adequate levels may not be enough for osseous healing. These low vitamin D levels appear to affect bone healing and prolong treatment, with worsening trends with diabetes and obesity comorbidities.

The Role of Vitamin D in the Development and Progression of Osteoarthritis

"Low levels of vitamin D in patients with osteoarthritis (ΟΑ) rather adversely affect the structure and function of articular cartilage. Low levels of vitamin D are also associated with joint pain, limited physical activity, quality of life, as well as decreased muscle strength, primarily in the lower extremities with adverse OA progression. A high percentage of low vitamin D levels was found in patients with OA and joint arthroplasty as well as a less satisfactory postoperative follow-up in patients with low vitamin D levels. The administration of vitamin D supplementation in patients with knee osteoarthritis has been associated with improved articular cartilage architecture, and reduced joint pain, combined with improved functionality and quality of life in patients with OA. "

Vitamin D Metabolic Pathway Components in Orthopedic Patientes-Systematic Review

Vitamin D takes part in the functioning of many processes that ensure the homeostasis of the body. In orthopedics, it is indicated as an inseparable element ensuring proper bone growth and functioning, and its deficiencies are indicated in various diseases, mainly in the proper structure and function of the skeleton. In this review, we focus on the most important components of the vitamin D metabolic pathway, in correlation with selected orthopedic conditions. Records were obtained from the PubMed database in a timeline of 2010-2022. The keywords were as follows: vitamin D/cholesterol/vitamin D binding protein/ VDBP/Cytochrome/CYP24A1/CYP 27B1/Vitamin D receptor/VDR/ + diseases (ACL reconstruction, rotator cuff, arthroplasty knee/hip/shoulder). The recent original studies were analyzed, discussed, and the most important data were shown. The vast majority of articles concern the metabolite of vitamin D (25(OH)D), which is measured as a standard in diagnostic laboratories. Even though there is a lot of valuable information in the literature, we believe that the other elements of the vitamin D pathway also deserve attention and suggest their research in correlation with orthopedic disorders to supplement the missing knowledge on this topic.

Relationship between distal radius fracture severity and 25-hydroxyvitamin-D level among perimenopausal and postmenopausal women

AIMS

Low-energy distal radius fractures (DRFs) are the most common upper arm fractures correlated with bone fragility. Vitamin D deficiency is an important risk factor associated with DRFs. However, the relationship between DRF severity and vitamin D deficiency is not elucidated. Therefore, this study aimed to identify the correlation between DRF severity and serum 25-hydroxyvitamin-D level, which is an indicator of vitamin D deficiency.

METHODS

This multicentre retrospective observational study enrolled 122 female patients aged over 45 years with DRFs with extension deformity. DRF severity was assessed by three independent examiners using 3D CT. Moreover, it was categorized based on the AO classification, and the degree of articular and volar cortex comminution was evaluated. Articular comminution was defined as an articular fragment involving three or more fragments, and volar cortex comminution as a fracture in the volar cortex of the distal fragment. Serum 25-hydroxyvitamin-D level, bone metabolic markers, and bone mineral density (BMD) at the lumbar spine, hip, and wrist were evaluated six months after injury. According to DRF severity, serum 25-hydroxyvitamin-D level, parameters correlated with bone metabolism, and BMD was compared.

RESULTS

The articular comminuted group (n = 28) had a significantly lower median serum 25-hydroxyvitamin-D level than the non-comminuted group (n = 94; 13.4 ng/ml (interquartile range (IQR) 9.8 to 17.3) vs 16.2 ng/ml (IQR 12.5 to 20.4); p = 0.005). The AO classification and volar cortex comminution were not correlated with the serum 25-hydroxyvitamin-D level. Bone metabolic markers and BMD did not significantly differ in terms of DRF severities.

CONCLUSION

Articular comminuted DRF, referred to as AO C3 fracture, is significantly associated with low serum 25-hydroxyvitamin-D levels. Therefore, vitamin D3 supplementation for vitamin D deficiency might prevent articular comminuted DRFs. Nevertheless, further studies must be conducted to validate the results of the current study. Cite this article: Bone Jt Open 2022;3(3):261-267.

High-Dose Vitamin D Supplementation Can Correct Hypovitaminosis D Prior to Total Knee Arthroplasty

BACKGROUND

Vitamin D deficiency in the perioperative surgical period is associated with inferior surgical outcomes. There are no established preoperative supplementation regimens in the orthopedic literature. The purpose of this study is to compare the efficacy between 2 different supplementation regimens of vitamin D prior to total knee arthroplasty.

METHODS

We conducted a retrospective analysis of 174 patients identified as vitamin D deficient (25(OH)D < 30 ng/mL) who received one of 2 vitamin D supplementation protocols: (1) daily supplementation with D3 on a sliding scale from 1000 to 6000 IU or (2) a loading dose of 50,000 IU D3 weekly for 4 weeks then 2000 IU/d. Serum vitamin D levels were measured at 3 months and 1 month preoperatively.

RESULTS

Mean patient age was 65.5(±8.6) years, and 54.6% were female. Deficiency was corrected in 73.3% of patients in the loading dose group and 42.4% of patients in the daily, low-dose group [χ² (1, N = 174) = 16.53, P < .001]. Patients in the loading dose group also achieved a greater average correction in vitamin D levels.

CONCLUSION

This is the first study to compare preoperative vitamin D supplementation protocols. A loading dose regimen of 50,000 IU weekly for 4 weeks followed by a maintenance dose of 2000 IU/d more effectively corrects vitamin D deficiency compared to a low-dose, daily regimen among total knee arthroplasty patients. We recommend this regimen for deficiency correction in patients who have been screened to be deficient in vitamin D preoperatively.

Nutraceutical Approach to Chronic Osteoarthritis: From Molecular Research to Clinical Evidence

Osteoarthritis (OA) is a degenerative inflammatory condition of the joint cartilage that currently affects approximately 58 million adults in the world. It is characterized by pain, stiffness, and a reduced range of motion with regard to the arthritic joints. These symptoms can cause in the long term a greater risk of overweight/obesity, diabetes mellitus, and falls and fractures. Although the current guidelines for the treatment of OA suggest, as the gold standard for this condition, pharmacological treatment characterized by non-steroidal anti-inflammatory drugs (NSAID), opioids, and cyclooxygenase (COX)-2-specific drugs, a great interest has been applied to nutraceutical supplements, which include a heterogeneous class of molecules with great potential to reduce inflammation, oxidative stress, pain, and joint stiffness and improve cartilage formation. The purpose of this review is to describe the potential application of nutraceuticals in OA, highlighting its molecular mechanisms of actions and data of efficacy and safety (when available).

How can the orthopedic surgeon ensure optimal vitamin D status in patients operated for an osteoporotic fracture?

In this narrative review, the role of vitamin D deficiency in the pathophysiology, healing of fragility fractures, and rehabilitation is discussed. Vitamin D status can be assessed by measuring serum 25(OH)-vitamin D level with standardized assays. There is a high prevalence of vitamin D insufficiency (25(OH)D < 50 nmol/l (i.e., 20 ng/mL)) or deficiency (25(OH)D < 25 nmol/l (i.e., 10 ng/mL)) in patients with fragility fractures and especially in those with a hip fracture. The evidence on the effects of vitamin D deficiency and/or vitamin D supplementation on fracture healing and material osseointegration is still limited. However, it appears that vitamin D have a rather positive influence on these processes. The fracture liaison service (FLS) model can help to inform orthopedic surgeons, all caregivers, and fractured patients about the importance of optimal vitamin D status in the management of patients with fragility fractures. Therefore, vitamin D status should be included in Capture the Fracture® program as an outcome of FLS in addition to dual-energy X-ray absorptiometry (DXA) and specific antiosteoporosis medication. Vitamin D plays a significant role in the pathophysiology and healing of fragility fractures and in rehabilitation after fracture. Correction of vitamin D deficiency should be one of the main outcomes in fracture liaison services.

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.

Preoperative optimization to prevent periprosthetic joint infection in at-risk patients

Periprosthetic joint infection (PJI) remains an important complication with devastating consequences after total joint arthroplasties. With the increasing number of arthroplasties worldwide, the number of PJI will increase correspondingly with a significant economic burden to our healthcare system. It is likely impossible to completely eradicate PJI; hence, assessment and optimization of its risk factors to preventing such a disastrous complication will be the key. There are many strategies to prevent PJI in the preoperative, intraoperative, or postoperative phases. The preoperative assessment provides a unique opportunity to screen and diagnose underlying comorbidities and optimize modifiable risk factors before elective surgeries. In this review, we will focus on current literature in preoperative assessment of various modifiable risk factors and share the experience and practical approach in our institution in preoperative optimization to reduce PJI in total joint arthroplasties.

Evaluation of Serum 25-Hydroxyvitamin D3 and Bone Mineral Density in 268 Patients with Hip Fractures

Objective

The aim of the present study was to evaluate the relationship among vitamin D nutritional status, bone mineral density, and other factors in elderly patients with brittle hip fractures.

Methods

The present study was a retrospective analysis of 268 patients, 102 men (38.06%) and 166 women (61.94%), with brittle hip fractures admitted to the Hip Joint Center of Tianjin Hospital from February 2016 to June 2018. The median age of the patients was 74 years (range, 50–93 years). The patients were divided into three groups based on age: ≤69 years, 70–79 years, and ≥80 years. Serum 25‐hydroxyvitamin D₃ (25(OH) D₃), parathyroid hormone (PTH), body mass index (BMI), and bone mineral density (BMD) of the lumbar spine, femoral neck, and hip were measured and statistically analyzed.

Results

The median serum 25(OH)D₃ level of patients was 9.90 (range, 2.60–42.70) ng/mL; the proportion of deficiency was 89.18% and the deficiency was severe in 136 cases (49.25%). The proportion of vitamin D deficiency was significantly lower in men than in women (P = 0.013). With the increase of age, 25(OH)D₃ levels gradually decreased (P = 0.044) and PTH levels gradually increased (P < 0.001). There was significantly negative correlation (P < 0.001) between the levels of serum 25(OH)D₃ and PTH. There were 200 cases (74.63%) in which T‐values of BMD were less than −2.5 in any part of the lumbar vertebrae, femoral neck, and hip. T‐values in 74 cases (27.61%) were less than −2.5 in all three parts. The T‐values of BMD in men were significantly higher than those in men (P < 0.001). With the increase of age, the femoral neck BMD in men gradually decreased (P = 0.016), and the femoral neck and hip BMD in female gradually decreased (P‐value was 0.001 and 0.003, respectively). Multivariate analysis suggested that gender and BMI were independent risk factors for BMD, and vitamin D deficiency affected BMD.

Conclusion

Vitamin D deficiency is common in patients with brittle hip fractures, especially in women. With the increase of age, vitamin D continues to decrease and PTH increases. The decrease of BMD in patients with hip fractures is the result of a combination of age, gender, BMI, and vitamin D content.

Vitamin D deficiency and total shoulder arthroplasty complications

INTRODUCTION

The primary objective of this study was to examine the relationship between vitamin D deficiency and implant-related and medical complications following total shoulder arthroplasty.

METHODS

Using the PearlDiver database, patients who underwent total shoulder arthroplasty from 2005 to 2016 with vitamin D deficiency were identified. These were compared to a 3:1 control group matched by age, sex, and presence of a concomitant osteoporosis diagnosis. Primary outcome measures were implant-related complications (loosening, periprosthetic fracture, periprosthetic joint infection, and revision total shoulder arthroplasty) in addition to medical complications within 90 days of surgery. A multivariable logistic regression analysis was utilized to control for patient demographics and comorbidities.

RESULTS

One thousand and six hundred and seventy-four patients with vitamin D deficiency were identified and compared to 5022 controls. There was a significantly higher rate of revision total shoulder arthroplasty in the vitamin D deficient patients compared to controls (2.3% versus 0.8%, odds ratio 3.3, p < 0.0001). After controlling for confounding variables, there were no significant differences in any of the remaining implant-related or medical complications with the exception of higher rates of urinary tract infections in patients with vitamin D deficiency.

CONCLUSIONS

Vitamin D deficiency is associated with a higher rate of all-cause revision total shoulder arthroplasty but not medical complications compared to controls.Level of evidence: Level III case control study.

Outcome of total hip and total knee arthroplasty and vitamin D homeostasis

BACKGROUND

Low levels of vitamin D are common in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), but it is still unclear whether the outcome of such surgery is related to vitamin D levels.

SOURCES OF DATA

Publicly available electronic databases were systematically reviewed to update knowledge about the role of vitamin D in THA and TKA patients, and to appraise the correlation between vitamin D levels before surgery and post-surgical outcomes. Eight studies were included in our review: six employed prospective observational designs, two reported retrospective database interrogations. Six prospective observational studies and two retrospective database interrogations matched inclusion and exclusion criteria.

AREAS OF AGREEMENT

Patients undergoing THA and TKA have a high prevalence of hypovitaminosis D. Five of eight studies (62.5%) report a statistically significant association between low vitamin D status and worse outcomes after THA and TKA.

AREAS OF CONTROVERSY

Different explanations have been proposed for vitamin D insufficiency, but some authors have questioned the correctness of the methods used to measure the vitamin D levels.

GROWING POINTS

A trial focusing on the role of vitamin D supplementation on safety and outcomes of patients undergoing THA and TKA with low vitamin D status is ongoing.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further studies should explore the possible causal relationship between vitamin D status and outcomes of THA and TKA and verify the laboratory methods to analyse it.

The Effect of Perioperative Vitamin D Levels on the Functional, Patient-Related Outcome Measures and the Risk of Infection Following Hip and Knee Arthroplasty: A Systematic Review

Introduction

The aim of this study was to evaluate the effect of perioperative vitamin D levels in terms of functional results, patient-related outcome measures (PROMs) and infection risk after hip or knee replacement.

Materials and Methods

A systematic search in PubMed, Cochrane library, ScienceDirect and ClinicalTrials.gov was conducted according to the PRISMA guidelines from inception to January 2020.

Results

Eighteen studies with more than 8000 knee and 1500 hip joint arthroplasties were included. The mean follow-up ranged from 6 weeks to 1 year and mean patients’ age from 59.4 to 76 years. Hypovitaminosis was diagnosed in 26.7% of cases. Most studies did not find significant differences in pre- and postoperative functional results, PROMs and length of hospital stay between hypovitaminosis and euvitaminosis groups. Deficient patients may be at higher risk of postoperative joint stiffness. Patients suffering from hip and knee periprosthetic joint infection seem to have lower vitamin D levels compared to those with aseptic loosening of implants.

Conclusion

The necessity of pre-operative correction of vitamin D levels to achieve better functional results and minimize the risk of infection following hip and knee arthroplasty remains inconclusive. Extend of exposure to low vitamin D levels and comparison between outliers needs further evaluation.

Hypovitaminosis D in lower extremity Joint Arthroplasty: A systematic review and meta-analysis

The purpose of the current systematic review was to identify the prevalence of hypovitaminosis-D in LE-TJA patients; and outline the association between pre-operative hypovitaminosis and post-operative outcomes. A search of PubMed-Medline and the Cochrane-Library databases was performed for literature published before November 27th, 2019. The eighteen studies analyzed had a pooled prevalence for vitamin D insufficiency (20 - <30 ng/mL) and deficiency (<20 ng/mL) of 53.4% and 39.4%, respectively. Hypovitaminosis-D was associated with higher complication rates (p = 0.043), and a greater prevalence among septic versus aseptic revisions (p = 0.016). Therefore, pre-operative screening for hypovitaminosis-D can be beneficial in patients undergoing LE-TJA.

LEVEL OF EVIDENCE

Systematic Review (Level III).

Hypovitaminosis D in the Greek Elderly Population Doesn't Concern Only Patients with Hip Fracture

Introduction

Vitamin D (VD) deficiency seems to be an underestimated public health issue, especially in countries with a significant duration of sunlight throughout the year, as in this sunny Mediterranean region where this cross-sectional observational study was held. This study was conducted to assess the hypothesis that a higher prevalence of hypovitaminosis D exists in the elderly population with a hip fracture as compared with patients with knee/hip osteoarthritis or lumbar spondylosis in a south-western Mediterranean region.

Methods

This study included 61 consecutive patients with a mean age of 83 years who sustained a hip fracture (Group A). Sixty patients, with an average age of 73 years, who suffered from degenerative hip/knee osteoarthritis or lumbar spondylosis were subsequently selected as the control group (Group B). Parathyroid hormone (PTH) and 25-hydroxy VD blood levels were measured.

Results

Ninety-six point seven percent (96.7%; 59/61) of the individuals with hip fracture and 81.7% (49/60) in the controls were found with abnormal VD values (<30 ng/ml). The comparison of vitamin D values between the total samples of group A and B revealed a statistically significant difference (unpaired t-test, p<0.0001) while both male (p=0.0049) and female (p<0.0001) individuals in group A also showed statistically significant lower VD levels than their counterparts did. In addition, increased levels of parathormone were observed in women of group A (p=0.0016) and, therefore, for group A in the total sample (p=0.0004) while no statistical significance was observed in males (p=0.7712). Age was found to be an independent risk factor for VD deficiency in both groups (Group A p=0.04, Group B p=0.043). It is noteworthy that only four patients from group B (6, 67%) and none from group A had undergone blood tests for VD and PTH evaluation before hospital admission.

Conclusions

Τhe results confirmed the initial hypothesis of the study. Although VD hypovitaminosis concerns the majority of elderly living in this south-western Mediterranean region, the authors suggest VD and PTH measurements regardless of annual insolation, to identify and counsel the elderly with an increased risk of hip fracture and to avoid perioperative complications in patients who undergo elective orthopedic surgeries.

Malnutrition in Orthopaedic Sports Medicine: A Review of the Current Literature

CONTEXT

Malnutrition is well-studied in various aspects of the orthopaedic literature, most commonly in relation to arthroplasty, spine surgery, and trauma. However, the management of nutritional deficiencies is commonly overlooked among orthopaedic sports medicine providers. The purpose of this article is to analyze the available sports medicine literature to review the associations between malnutrition and the management of orthopaedic sports medicine patients from a treatment and performance standpoint.

EVIDENCE ACQUISITION

PubMed was searched for relevant articles published from 1979 to 2019.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Few studies exist on the implications of macronutrient deficiencies specific to orthopaedic sports medicine procedures. Interestingly, micronutrient disorders-namely, hypovitaminosis D and iron deficiency-have been well studied and may lead to worse postoperative outcomes, injury rates, and athletic performance. Nutritional supplementation to correct such deficiencies has been shown to mitigate these effects, though further study is required.

CONCLUSION

Nutritional deficiencies are highly prevalent in orthopaedic sports medicine patients, and practitioners should be aware of their potential effects on treatment and performance outcomes. Management of such deficiencies and their effect on surgical patients remain an area of potential future research. Future studies are warranted in order to explore the potential therapeutic role of nutritional supplementation to prevent complications after common orthopaedic sports medicine procedures, improve athletic performance, and reduce injury rates.

Preoperative Vitamin D Repletion in Total Knee Arthroplasty: A Cost-Effectiveness Model

BACKGROUND

Recent studies have identified vitamin D deficiency (serum 25-hydroxyvitamin D [25(OH)D] < 20 ng/L) as a potentially modifiable risk factor for prosthetic joint infection (PJI) in arthroplasty. The purpose of this study is to determine whether implementation of preoperative 25(OH)D repletion is cost-effective for reducing PJI following total knee arthroplasty (TKA).

METHODS

A cost estimation predictive model was generated to determine the utility of both selective and nonselective 25(OH)D repletion in primary TKA to prevent PJI. Input data on the incidence of 25(OH)D deficiency, relative complication rates, and costs of serum 25(OH)D repletion and 2-stage revision for PJI were derived from previously published literature identified using systematic review and publicly available data from Medicare reimbursement schedules. Mean, lower, and upper bounds of 1-year cost savings were computed for nonselective and selective repletion relative to no repletion.

RESULTS

Selective preoperative 25(OH)D screening and repletion were projected to result in $1,504,857 (range, $215,084-$4,256,388) in cost savings per 10,000 cases. Nonselective 25(OH)D repletion was projected to result in $1,906,077 (range, $616,304-$4,657,608) in cost savings per 10,000 cases. With univariate adjustment, nonselective repletion is projected to be cost-effective in scenarios where revision for PJI costs ≥$10,636, incidence of deficiency is ≥1.1%, and when repletion has a relative risk reduction ≥4.2%.

CONCLUSION

This predictive model supports the potential role of 25(OH)D repletion as a cost-effective mechanism of reducing PJI risk in TKA. Given the low cost of 25(OH)D repletion relative to serum laboratory testing, nonselective repletion appears to be more cost-effective than selective repletion. Further prospective investigation to assess this modifiable risk factor is warranted.

Effect of preoperative vitamin D deficiency on functional outcomes after high tibial osteotomy: a retrospective case control study

Background

This study aimed to evaluate the effects of vitamin D deficiency on the functional outcomes following a high tibial osteotomy (HTO).

Methods

Clinical data of 209 patients (327 knees) who underwent HTO done by a single surgeon were retrospectively registered for the study. Ninety-four patients (94 knees) who underwent HTO were analyzed. Patients were assigned into two groups according to their preoperative serum vitamin D levels (D- Deficiency and S- Sufficient); < 20 ng/ml (group D, N = 48) and ≥ 20 ng/ml (group S, N = 46) respectively. A subjective form of International Knee Documentation Committee (IKDC) score, mechanical alignment, and cartilage status before and 1 year following HTO were studied between groups.

Results

The mean postoperative IKDC score was significantly higher in group S (p = 0.012). Moreover, the difference of IKDC score between pre- and post- HTO was also significantly higher in group S (p = 0.006). Preoperative vitamin D level and IKDC score did not show a significant correlation. Serum vitamin D level was found to be moderately correlated to postoperative IKDC score (r = 0.342 and, p = 0.001). A moderately positive correlation between serum vitamin D level and improvement of IKDC score following osteotomy was appreciated (r = 0.381 and, p < 0.001).

Conclusion

Patients with vitamin D deficiency had less satisfactory functional outcomes within 1 year from HTO surgery. Our results suggest that preoperative serum vitamin D level is one of the factors affecting the outcome after HTO. We recommended analyzing serum vitamin D levels as part of the routine workup in patients undergoing HTO.

Association between serum Vitamin D deficiency and Knee Osteoarthritis

Objective:

Levels of Vitamin D may influence the development of knee osteoarthritis (OA), which is one of the most common joint diseases. The aim of this study was to investigate the association between serum Vitamin D deficiency and knee OA in Ardabil and Iran.

Methods:

One hundred fifty-eight consecutive patients referred to rheumatology clinic of Ardabil City Hospital were recruited in the study. All the participants underwent x-rays in two anterior-posterior and side views of the knees. Staging of knee OA was done according to Kellgren-Lawrence criteria. Seventy-nine individuals with clinical and radiographic signs of knee OA were defined as the case group, and those without clinical and radiographic signs of the disease were defined as a control group. Haematology and biochemical profile including measurement of 25-hydroxyvitamin D serum level was performed in the participants.

Results:

The mean age of patients and controls were 54.12 ± 4.67 and 55.37 ± 5.12 years, respectively. The average serum vitamin D in OA patients and controls were 26.8±6.2 ng/ml and 28.1±5.3ng/ml, respectively (p=0.36). There was a significant association between serum vitamin D and staging of knee OA (p=0.001). Based on vitamin D levels, most of patients with vitamin D deficiency were in stages III and IV.

Conclusion:

The findings of the study suggest that vitamin D deficiency should be considered in patients with OA and treated accordingly.

Surgical Considerations for Vitamin D Deficiency in Foot and Ankle Surgery

Vitamin D deficiency affects nearly one-sixth of the world's population and is common in patients undergoing foot and ankle surgery. Vitamin D is critical for calcium homeostasis and plays an important role in the maintenance of bone health. Patients undergoing foot and ankle procedures can be evaluated preoperatively with vitamin D level testing, and deficiencies can be addressed with either preoperative or postoperative supplementation. Current data suggest that patients with adequate vitamin D levels may have better outcomes, but the details are not yet clear. Vitamin D supplementation is well tolerated with rare side effects.

Current concepts in vitamin D and orthopaedic surgery

INTRODUCTION

Vitamin D plays an important role in the musculoskeletal system of the human body. Here, we review the most current literature on vitamin D as it relates to orthopaedic surgery and the musculoskeletal system, focusing largely on non-fracture applications.

MATERIALS AND METHODS

A literature review was performed on the basic science of vitamin D metabolism, epidemiology of vitamin D levels, role of vitamin D within the musculoskeletal system, and the correlation of vitamin D with injuries and orthopaedic surgical outcomes.

RESULTS

The existing literature suggests vitamin D plays multiple roles in the musculoskeletal system. Recent research has shed light on the importance of vitamin D in the setting of soft tissue healing and recovery in addition to affecting postoperative outcomes after common orthopaedic procedures.

CONCLUSIONS

Given the widespread prevalence of vitamin D deficiency, orthopaedic surgeons should be aware of the current evidence regarding clinical implications in patients with musculoskeletal complaints.

Vitamin D and Vitamin D Receptor Gene in Osteoarthritis

Osteoarthritis is a degenerative, painful and irreversible disease that affects millions of people worldwide. The causes and mechanisms of osteoarthritis have not been fully understood. Vitamin D is an essential factor in bone metabolism. Its actions are mediated by the vitamin D receptor, a transcription factor that controls gene expression, thus maintaining calcium and phosphate homeostasis. Vitamin D has been hypothesized to play essential role in a number of musculoskeletal diseases including osteoarthritis, and its deficiency is prevalent among osteoarthritis patients. A large number of studies have been done regarding the effects of vitamin D in pathogenesis and progression of osteoarthritis, as well as its use a therapeutic agent. Up to date, studies have provided controversial results, and no consensus concerning this matter was achieved. With this review, we aim to explore current data on the possible role of vitamin D and its receptor in pathogenesis of osteoarthritis and assess the efficiency of vitamin D supplementation as a therapeutic strategy.

Association Between Preoperative Vitamin D Status and Short-Term Physical Performance after Total Hip Arthroplasty: A Prospective Study

BACKGROUND

Insufficient serum vitamin D concentrations (50-75 nmol/L) are prevalent in 40-65% of patients who require total hip arthroplasty (THA). This could impair physical recovery after surgery. This study investigated the association between preoperative vitamin D status and physical performance after THA. Additionally, postoperative changes in vitamin D concentrations were measured.

METHODS

We included 87 patients scheduled for elective THA and aged ≥65 years. Three groups were recruited: patients classified as vitamin D deficient (< 50 nmol/L, n = 23), insufficient (50-75 nmol/L, n = 32), or sufficient (> 75 nmol/L, n = 32). Serum 25-hydroxyvitamin D3 (25[OH]D3) concentration and physical performance were measured perioperatively. Linear mixed models were used to examine differences between groups.

RESULTS

Change in physical performance over time was not affected by preoperative vitamin D status. In contrast, for physical activity, both vitamin D (p = 0.021) and time (p < 0.001) effect was seen: from 80.2 ± 25.8 to 58.1 ± 17.8 min/day in the deficient group, 143.7 ± 19.8 to 92.9 ± 11.5 min/day in the insufficient group, and 108.1 ± 20.9 to 62.3 ± 12.9 min/day in the sufficient group. The Chair Stand Test, Timed Up and Go test, and 10-Meter Walking Test also improved significantly over time, but independent of vitamin D status. An increase in 25(OH)D3 concentration 6 weeks postoperatively was correlated with improved hip function (Pearson's r = -0.471, p = 0.018). Overall, serum 25(OH)D3 declined with 32% one day after surgery (p < 0.001), to nearly return to baseline values 6 weeks later in all groups.

CONCLUSION

Vitamin D status did not appear to affect physical recovery after THA. The drop in vitamin D after surgery deserves further investigation, but could possibly be explained by hemodilution.

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.

Preoperative Vitamin D Deficiency Is Associated With Higher Postoperative Complication Rates in Total Knee Arthroplasty

The purpose of this study was to determine the relative incidence of postoperative complications in 25-hydroxyvitamin D (25D)-deficient and -sufficient patients undergoing total knee arthroplasty (TKA). Patients who were either serum 25D deficient (25D <20 ng/mL) or 25D sufficient (25D ≥20 ng/mL) 90 days prior to primary TKA from 2007 to 2016 were identified using the Humana administrative claims registry. The incidence of postoperative medical and surgical complications was determined by querying for relevant International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes. Risk-adjusted odds ratios (ORs) were calculated using multivariate logistic regression with age, sex, and Charlson Comorbidity Index as covariates. In total, 868 of 6593 patients who underwent TKA from 2007 to 2016 were 25D deficient, corresponding to a 13.2% prevalence rate. On adjustment for age, sex, and Charlson Comorbidity Index, 25D-deficient patients had a higher incidence of postoperative stiffness requiring manipulation under anesthesia (OR, 1.69; 95% confidence interval [CI], 1.39-2.04; P<.001), surgical site infection requiring irrigation and debridement (OR, 1.76; 95% CI, 1.25-2.48; P=.001), and prosthesis explantation (OR, 2.97; 95% CI, 2.04-4.31; P<.001) at 1 year. Patients who were 25D deficient also had higher rates of postoperative deep venous thrombosis (OR, 1.80; 95% CI, 1.36-2.38; P<.001), myocardial infarction (OR, 2.11; 95% CI, 1.41-3.15; P<.001), and cerebrovascular accident (OR, 1.73; 95% CI, 1.17-2.57; P=.006). Thus, serum 25D levels below 20 ng/mL are associated with a higher incidence of postoperative complications and may be a perioperative modifiable risk factor in TKA. [Orthopedics. 2018; 41(4):e489-e495.].

Prevalence of Vitamin D Deficiency in Patients With Talar Osteochondral Lesions

BACKGROUND

Vitamin D deficiency affects over 1 billion people worldwide and is common in foot and ankle patients. The prevalence in those with osteochondral lesions of the talus (OLTs) is unknown. This study identified the prevalence and risk factors for hypovitaminosis D in patients with an OLT.

METHODS

Serum 25(OH)D levels were obtained from patients presenting with an OLT from May to November during 2007 to 2016. Hypovitaminosis D was defined as 25(OH)D less than 30 ng/mL (75 nmol/L). Patients presenting with an acute ankle sprain (AS) during the same months served as a control group. Specific medical risk factors for hypovitaminosis D were recorded. The final OLT population included 46 patients (31 women [67.4%]; mean [SD] age 43.6 [14.8] years). The comparison AS group had 40 patients (32 women [80.0%]; mean [SD] age 56.2 [13.0] years).

RESULTS

The mean (SD) 25(OH)D in the OLT and AS cohorts were 31.2 (12.6) ng/mL and 37.1 (13.5) ng/mL, respectively ( P = .039). Hypovitaminosis D was identified in 54% of the OLT population and 28% of the AS population ( P = .012).

CONCLUSION

Hypovitaminosis D is intimately related to decreased bone mineral density. This study identified a significantly higher rate of hypovitaminosis D in patients with an OLT compared to a cohort of AS patients. These findings suggest that when patients present with an OLT, health care providers should consider evaluating for and treating hypovitaminosis D.

LEVEL OF EVIDENCE

Level III, comparative study.

VASO (Vitamin D and Arthroplasty Surgery Outcomes) study - supplementation of vitamin D deficiency to improve outcomes after total hip or knee replacement: study protocol for a randomised controlled feasibility trial

BACKGROUND

Vitamin D deficiency has been linked to poor outcomes after total hip replacement (THR) or total knee replacement (TKR), including lower patient-reported outcome measures (PROMs), peri-prosthetic infection and longer hospital stay. We present a randomised feasibility trial protocol designed to prospectively investigate the influence of vitamin D testing, and subsequent supplementation for deficiency, prior to THR/TKR.

METHODS/DESIGN

One hundred adult patients undergoing primary THR/TKR for osteoarthritis at two NHS hospital trusts in North East England will be recruited. Exclusion criteria include lack of mental capacity, revision surgery, participants already taking vitamin D/calcium supplements, or a known contraindication to vitamin D treatment. Participants will be ineligible for the trial if they have an estimated glomerular filtration rate < 30 ml/minute. We will measure patients' vitamin D levels at baseline, and those identified as deficient (vitamin D < 50 nmol/L) will be randomised to receive either vitamin D supplementation or no supplementation prior to, and for 6 months following, surgery. Patients with a normal vitamin D level (≥50 nmol/L) will receive no supplementation. Vitamin D levels will be rechecked on the day of surgery and again at 6 months. Patients will also complete a lifestyle questionnaire, as well as the Oxford hip or knee and EQ-5D-3 L PROM questionnaires, at baseline and at 6 months following surgery. The aims are to determine the feasibility of the methodology and to gather data to inform the conduct of a future, larger trial to investigate if supplementation with vitamin D, in those who are deficient, prior to THR/TKR improves outcomes as measured by PROM scores.

DISCUSSION

Previous reports have measured vitamin D levels and correlated this to outcome, but we can find no randomised trial in which researchers investigated the effect of supplementation. The aim of this trial is to determine if vitamin D deficiency is a modifiable risk factor for poor outcome after THR/TKR.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN14533082 . Registered on 3 April 2017.

Vitamin D deficiency adversely affects early post-operative functional outcomes after total knee arthroplasty

PURPOSE

Vitamin D has received considerable attention in recent years owing to the increasing evidence of its importance in muscle function and physical performance. The present study attempted to determine whether patients with low serum vitamin D levels had impairment in early functional outcomes following total knee arthroplasty (TKA).

METHODS

This was a prospective cohort study that included 92 patients. Patients were divided into two groups according to their vitamin D levels as assessed at the preoperative visit: (1) vitamin D-deficient group, serum 25-hydroxyvitamin D₃ (25(OH)D) levels <12 ng/mL; (2) vitamin D non-deficient group, serum 25(OH)D levels ≥12 ng/mL. American Knee Society Score (KSS) and four other performance tests including the alternative step test (AST), six-metre walk test (SMT), sit-to-stand test (STS), and timed up and go test (TUGT) were used for assessment of post-operative function. All assessments were performed one day before and three months after TKA.

RESULTS

Of the 92 patients included in the study, 87 patients performed all required assessments. The mean post-operative functional KSS was significantly lesser in the vitamin D-deficient group than in the vitamin D non-deficient group (67.2 vs. 73.4, p = 0.031). The mean values of time taken for post-operative AST (16.6 vs. 14.6 s, p = 0.033) and SMT (8.8 vs. 7.7 s, p = 0.012) were significantly longer in the vitamin D-deficient group than in the vitamin D non-deficient group. Post-operative STS and TUGT demonstrated higher values for mean time taken in the vitamin D-deficient group than in the vitamin D non-deficient group, but these were not statistically significant (13.6 vs. 12.4 s, not significant (n.s.); 12.7 vs. 11.7 s, n.s., respectively).

CONCLUSION

Early post-operative functional outcomes following TKA appear to be adversely affected by vitamin D deficiency.

LEVEL OF EVIDENCE

Prospective cohort study, Level II.

Fewer Complications Following Revision Hip and Knee Arthroplasty in Patients With Normal Vitamin D Levels

BACKGROUND

Surgeons and hospitals increasingly face penalty for complications and readmission following total joint arthroplasty; therefore, optimization of modifiable risk factors is paramount. Literature associates low vitamin D with risk of periprosthetic joint infection, and we hypothesized low vitamin D to be predictive of increased rate of complications and readmissions.

METHODS

A retrospective review of 126 revision total joint arthroplasty patients between 2010 and 2014 was performed.

RESULTS

Low vitamin D was not associated with risk of 30-day readmission but was found to be associated with an increased risk of 90-day complications as well as periprosthetic joint infection as the reason for revision surgery.

CONCLUSION

Preoperative vitamin D level should be considered a modifiable risk factor for complications following revision arthroplasty.

Hypovitaminosis D in Patients Undergoing Shoulder Arthroplasty: A Single-Center Analysis

Vitamin D is recognized as an essential component in bone health, muscle function, and immune system regulation. This study sought to characterize the prevalence of hypovitaminosis D in patients undergoing total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RSA), and shoulder hemiarthroplasty (HA). Between September 2013 and December 2014, a total of 218 patients undergoing TSA, RSA, and HA by a single surgeon were screened for hypovitaminosis D and retrospectively reviewed. Demographic variables and risk factors were recorded. Overall, 93 shoulder arthroplasty patients (43%) were vitamin D insufficient (<30 ng/mL) and 24 patients (11%) were vitamin D deficient (<20 ng/mL). Body mass index (BMI) had a significant effect on vitamin D levels; BMI of 30 kg/m(2) or greater was associated with lower vitamin D levels (31.5±12.1 ng/mL) compared with patients with a BMI of less than 30 kg/m(2) (36.2±15.7 ng/mL, P ≤.01). The absence of supplementation with vitamin D and calcium prior to serum testing was the most significant risk factor for hypovitaminosis D (odds ratio [OR], 8.234, P<.001). Age, gender, race, smoking status, American Society of Anesthesiologists (ASA) score, procedure, and surgical indication were not significant. This is the largest cohort of shoulder arthroplasty patients screened for hypovitaminosis D. Almost half (43%) of the study population was insufficient, and both the absence of supplementation prior to serum testing and BMI of 30 kg/m(2) or greater were found to be predictive of lower serum 25-hydroxyvitamin D levels. Given the extent of vitamin D involvement in normal musculoskeletal physiology, routine preoperative evaluation is merited. [Orthopedics. 2016; 39(4):e651-e656.].

Vitamin D insufficiency and deficiency in patients with fractures of the fifth metatarsal

INTRODUCTION

The fifth metatarsal is a common site for both acute and stress fractures in the foot. They are usually isolated low-energy or stress fractures. Vitamin D deficiency has been associated with fragility fractures in many parts of the body. We believe that low Vitamin D could be a significant aetiological factor in fractures of the fifth metatarsal.

METHODOLOGY

A prospective study of patients with fractures of the fifth metatarsal was conducted. Patients presenting to fracture clinic with these fractures had their vitamin D and calcium levels measured. We also conducted a literature review of studies of vitamin D levels in the Northern Hemisphere between 1990 and 2014.

RESULTS

Forty patients with fifth metatarsal fractures were studied (22 metatarsal base fractures, 6 shaft fractures, and 2 stress fractures). The average patient age was 49 (range 22-83). 12 patients (30%) had a Vitamin D level consistent with deficiency, and a further 14 (35%) had a level consistent with insufficiency. Average Vitamin D levels in winter fractures were significantly lower (52.23nmol/L) than for those sustained in summer (76.73nmol/L).

CONCLUSIONS

Hypovitaminosis D was common in patients with fifth metatarsal fractures. Vitamin D supplementation has been shown in animal studies to improve fracture healing rates, and in humans to decrease the risk of fragility fracture. It should be part of regular practice to check Vitamin D levels in these patients, and supplement where necessary.

Effect of Preoperative Vitamin D Levels on Functional Performance after Total Knee Arthroplasty

Background

Low vitamin D levels affects muscle function. Vitamin D and calcium deficiency cause osteomalacic myopathy and poor functional recovery after hip fractures. The relationship of vitamin D and functional performance after total knee arthroplasty (TKA) is not previously reported.

Methods

Influence of vitamin D on functional performance before and after TKA was reviewed retrospectively in 120 patients. Of these, 64 had vitamin D deficiency (25-hydroxy vitamin D < 30 ng/mL) preoperatively. All 120 patients received vitamin D oral supplementation postoperatively. Functional parameters including Western Ontario and McMaster Osteoarthritis Index (WOMAC), Short-Form Health Survey questionnaire, and Knee Society Score were assessed pre- and postoperatively at 3 months.

Results

Preoperative function was significantly lower in osteoarthritic patients with vitamin D deficiency (WOMAC score; p = 0.040), but at 3 months all functional scores were similar.

Conclusions

We concluded that vitamin D deficiency has a negative effect on function in knee osteoarthritic patients. However, postoperative vitamin D supplementation can lead to functional recovery in these patients. Thus, TKA should not be delayed in vitamin D deficient patients; rather supplementation in the postoperative period is preferable to achieve comparable functional outcome at 3 months to patients with vitamin D sufficiency.

Perioperative vitamin D levels correlate with clinical outcomes after ankle fracture fixation

INTRODUCTION

Hypovitaminosis D is common in patients undergoing orthopaedic trauma surgery. While previous studies have shown that vitamin D levels correlate with functional outcome after hip fracture surgery, the significance of vitamin D levels on outcomes after surgery in other orthopaedic trauma patients is unknown. The purpose of this study was to determine if vitamin D levels correlated with outcomes in ankle fracture patients.

MATERIALS AND METHODS

We reviewed a prospective registry of patients who underwent operative treatment for ankle fractures from 2003 to 2012. Preoperative serum 25-hydroxyvitamin D (25[OH]D) levels were measured, and the primary and secondary outcomes included foot and ankle outcome scores (FAOS) and ankle range of motion. Data were also collected on patient comorbidities, articular malreductions, and wound complications. Included patients had at least 12 months of clinical outcome data.

RESULTS

Ninety-eight patients operatively treated for ankle fractures met our inclusion criteria. Of these 98 patients, 36 (37%) were deficient in vitamin D (<20 ng/ml) and 31 (32%) had vitamin D insufficiency (<30 ng/ml, ≥20 mg/ml). Patients with vitamin D deficiency were similar with regard to age, gender, and comorbidities compared to patients with vitamin D levels ≥20. Univariate analysis revealed that patients with vitamin D deficiency had significantly worse FAOS with regard to symptoms (P = 0.017) and quality of life (P = 0.040) domains than patients with vitamin D levels ≥20. Multivariate regression analysis suggested that vitamin D deficiency was a factor in inferior FAOS with regard to symptoms, activities of daily living, and quality of life.

CONCLUSIONS

In our group of patients with operative treated ankle fractures, preoperative vitamin D deficiency correlated with inferior clinical outcomes at a minimum of 1 year follow-up. Our study suggests that deficient vitamin D levels may result in worse outcomes in orthopaedic trauma patients recovering from fracture fixation.

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.

Patient-related medical risk factors for periprosthetic joint infection of the hip and knee

Despite advancements and improvements in methods for preventing infection, periprosthetic joint infection (PJI) is a significant complication following total joint arthroplasty (TJA). Prevention is the most important strategy to deal with this disabling complication, and prevention should begin with identifying patient-related risk factors. Medical risk factors, such as morbid obesity, malnutrition, hyperglycemia, uncontrolled diabetes mellitus, rheumatoid arthritis (RA), preoperative anemia, cardiovascular disorders, chronic renal failure, smoking, alcohol abuse and depression, should be evaluated and optimized prior to surgery. Treating patients to get laboratory values under a specified threshold or cessation of certain modifiable risk factors can decrease the risk of PJI. Although significant advances have been made in past decades to identify these risk factors, there remains some uncertainty regarding the risk factors predisposing TJA patients to PJI. Through a review of the current literature, this paper aims to comprehensively evaluate and provide a better understanding of known medical risk factors for PJI after TJA.

Vitamin D status and surgical outcomes: a systematic review

The importance of vitamin D for musculoskeletal health has long been recognized, and awareness of significant extra-skeletal effects in health and disease is rapidly emerging. Although it has been possible for many decades to quantify serum markers of vitamin D deficiency, and to correct deficiency at low cost and with high safety, the influence of vitamin D status on post-surgical outcomes has only recently been identified as a research topic of interest. To the present, these data have not been the subject matter of formal review. Accordingly, we conducted a systematic review to assess the association between perioperative vitamin D status and outcomes after surgery. The databases of PubMed, Ovid MEDLINE, EMBASE, AMED, CINAHL (EBSCOHost), The Cochrane Databases of Systematic Review, and PROSPERO were searched through December, 2014 for studies relating to vitamin D and surgery. The initial search yielded 90 manuscripts. After applying exclusion criteria, 31 studies were eligible for inclusion. Fifteen studies employed prospective observational designs, 3 used prospective randomized protocols, and 13 report retrospective database interrogations. The main finding of the present review is that 26 of 31 studies (84%) report at least one statistically significant worse outcome in patients with low vitamin D status. Five of 31 studies (16%) found no association. In conclusion, this review supports the hypothesis that hypovitaminosis D is associated with adverse outcomes after diverse surgical procedures. Future studies should focus on additional surgeries and outcomes, and on the role of vitamin D supplementation in the improvement of patient safety in participants with low vitamin D status at the time of surgery.

Role of Vitamin D in Osteoarthritis: Molecular, Cellular, and Clinical Perspectives

Osteoarthritis is a debilitating and degenerative disease which affects millions of people worldwide. The causes and mechanisms of osteoarthritis remain to be fully understood. Vitamin D has been hypothesised to play essential roles in a number of diseases including osteoarthritis. Many cell types within osteoarthritic joints appear to experience negative effects often at increased sensitivity to vitamin D. These findings contrast clinical research which has identified vitamin D deficiency to have a worryingly high prevalence among osteoarthritis patients. Randomised-controlled trial is considered to be the most rigorous way of determining the effects of vitamin D supplementation on the development of osteoarthritis. Studies into the effects of low vitamin D levels on pain and joint function have to date yielded controversial results. Due to the apparent conflicting effects of vitamin D in knee osteoarthritis, further research is required to fully elucidate its role in the development and progression of the disease as well as assess the efficacy and safety of vitamin D supplementation as a therapeutic strategy.

Vitamin D status in patients with knee or hip osteoarthritis in a Mediterranean country

Background

Vitamin D plays an important role in bone mineralization, remodeling, and maintenance and therefore its deficiency may be implicated in the pathogenesis of osteoarthritis (OA). Vitamin D status was evaluated in patients with knee or hip OA scheduled for joint replacement. The impact of anthropometric parameters such as gender, age, and body mass index on vitamin D levels was also examined. The study was conducted in a Mediterranean country (Greece).

Materials and methods

We included 164 patients with knee or hip OA scheduled for joint replacement in this study. Serum levels of 25-hydroxyvitamin D (vitamin D) were measured in routine blood samples taken from the patients at their pre-admission visit, a week before the operation, using radioimmunoassay.

Results

The majority of patients were vitamin D deficient (81.7 %); 15.2 % of them were vitamin D insufficient (hypovitaminosis). Only 3 % of patients were vitamin D sufficient. There was a significantly positive association between vitamin D levels and male gender.

Conclusion

These findings indicate a large percentage of vitamin D deficient patients with knee or hip OA, which is unexpected considering the high annual insolation in northern Greece. Many other possible predisposing factors for OA should be taken into consideration. Whether treatment with vitamin D supplements may provide beneficial effects to these patients and the stage of disease in which this treatment should commence remains an issue for further scientific investigation.

Level of evidence

Level IV.

[Endoprosthetic treatment of osteoporosis-related coxarthrosis : aspects of safe patient treatment]

BACKGROUND

With increasing life expectancy the prevalence of osteoarthritis is also substantially rising. Patients aged between 65 and 75 years scheduled for total joint arthroplasty suffer from undetected osteoporosis in 20-25% of cases.

OBJECTIVES

How to determine osteoporosis during preoperative workup? Which conclusions can be drawn for the operation treatment and the postoperative course?

METHODS

The literature dealing with the prevalence of osteoporosis, perioperative complications of total hip arthroplasty, selected register informations, guidelines for diagnostics and treatment of osteoporosis and for the postoperative treatment are summarized and discussed.

RESULTS

The fracture risk is determined according to the guidelines of the Dachverband Osteologie (DVO, Governing Body on Osteology). The implant and the anchorage are selected based on the risk of suffering from osteoporosis. An intraoperative fracture and early aseptic loosening are the main operative risk factors. For the postoperative course in addition to education about arthroplasty, adequate support for prevention of falls is mandatory. Continuous physiotherapy with muscular strengthening is advisable. The long-term medication should be checked for risks in the PRISCUS list of potentially inappropriate medication in the elderly and non-steroidal anti-inflammatory drugs (NSAIDs) should not be prescribed in patients with cardiac comorbidities. Patients with confirmed osteoporosis should be treated with antiresorptive agents.

Vitamin D insufficiency in patients with THA: prevalence and effects on outcome

BACKGROUND

The consequences of vitamin D insufficiency in the elderly remain controversial. The prevalence and potential effects of its chronic insufficiency on quality of life and physical function in patients undergoing THA have received little attention.

QUESTION/PURPOSES

We determined (1) prevalence of preoperative vitamin D insufficiency in patients undergoing THA and (2) relationships of insufficiency to patient-perceived outcomes (PPOs) and hip scores.

METHODS

We retrospectively reviewed 62 consecutive patients who underwent 66 primary THAs. We excluded two patients with missing data and the second hip of bilateral THAs, leaving 60 patients (60 hips) for final inclusion. Based on preoperative plasma 25-hydroxyvitamin-D3 levels, patients were retrospectively assigned into a normal or insufficient group. We used two different thresholds (20 and 30 ng/mL) to define insufficiency; groups were set twice. We compared demographics, BMI, American Society of Anesthesiologists score, Charlson Comorbidity Index; albumin, transferrin, calcium levels; and total lymphocyte count between groups. The insufficient group had a higher mean BMI with the 20-ng/mL cutoff but not with the 30-ng/mL cutoff. We compared the 20-ng/mL cutoff groups (adjusting for BMI) and the 30-ng/mL cutoff groups in terms of preoperative and postoperative Quality of Well-being Scale, SF-36, WOMAC, Harris hip, and Merle d'Aubigné-Postel scores. Mean followup was 11 months (range, 3-24 months).

RESULTS

The prevalence of vitamin D insufficiency was 30% (using 20 ng/mL) and 65% (using 30 ng/mL). Preoperative and postoperative Harris hip and Merle d'Aubigné-Postel scores were lower in patients with insufficiency using 30 ng/mL. No differences in PPOs or hip scores were found using 20 ng/mL.

CONCLUSIONS

Hypovitaminosis D was common in patients with THA and associated with lower hip scores. Standardization of the definition of hypovitaminosis D is urgently needed so that further studies can properly evaluate its real prevalence, potential negative effects on function, and therapeutic effects of reversing insufficiency before THA.

Prevalence of vitamin D deficiency in patients with foot and ankle injuries

BACKGROUND

Vitamin D deficiency has been identified as one of the most common causes of fragility fractures and poor fracture healing. Although rates of vitamin D deficiency have been delineated in various orthopaedic populations, little is known about the prevalence of vitamin D deficiency in patients with foot and ankle disorders. The goal of this study was to identify the prevalence of vitamin D deficiency in patients with a low energy fracture of the foot or ankle.

METHODS

Over a 6-month period, a serum 25-OH vitamin D level was obtained from consecutive patients with a low energy ankle fracture, fifth metatarsal base fracture, or stress fracture of the foot or ankle. For comparative purposes, vitamin D levels in patients with an ankle sprain and no fracture were also examined.

RESULTS

The study cohort included 75 patients, of which 21 had an ankle fracture, 23 had a fifth metatarsal base fracture, and 31 had a stress fracture. The mean age was 52 (range, 16-80) years. Thirty-five of the fracture patients (47%) had an insufficient vitamin D level (below the recommended level of 30 ng/mL), and 10 of the patients (13%) had a level that was deficient (< 20 ng/mL). Vitamin D levels were significantly lower in those with a fracture than in those with an ankle sprain (P = .02). In the fracture cohort, the factors significantly associated with vitamin D insufficiency in the multivariate analysis were smoking (P = .03), obesity (P = .003), and other medical risk factors for vitamin D deficiency (P = .03).

CONCLUSION

Hypovitaminosis D was common among patients with a foot or ankle injury seen at our institution. Patients with a low energy fracture of the foot or ankle were at particular risk for low vitamin D, especially if they smoked, were obese, or had other medical risk factors. Given that supplementation with vitamin D (± calcium) has been shown to reduce the risk of fragility fractures and improve fracture healing, monitoring of 25-OH vitamin D and supplementation should be considered in patients with fractures.

LEVEL OF EVIDENCE

Level III, prospective case control.

High prevalence of vitamin D deficiency in elderly patients with advanced osteoarthritis scheduled for total knee replacement associated with poorer preoperative functional state

Vitamin D deficiency has been reported previously in patients with osteoarthritis undergoing total hip arthroplasty. We found a high prevalence of vitamin D deficiency in elderly patients with advanced knee osteoarthritis scheduled for total knee replacement and also a significant association with a lower preoperative functional state. A review of the literature is given on vitamin D deficiency in patients with knee osteoarthritis and the association with lower outcome scores after arthroplasty is discussed.