The prevalence of vitamin D deficiency in patients with vertebral fragility fractures

The association of combined vitamin C and D deficiency with bone mineral density and vertebral fracture

PURPOSE

Both vitamin C and D deficiencies are extremely common in clinical practice, especially in elderly population. Unfortunately, the role of vitamin C deficiency in osteoporosis related consequences is often neglected. The aim of the present study is to analyse if combined vitamin C and D deficiency would have an association with bone mineral density (BMD) and osteoporotic vertebral fracture (OVF).

METHODS

Ninety-nine post-menopausal female patients admitted in the department of spine surgery of third affiliated hospital of Sun Yat-sen University were enrolled in the study. The participants were divided into four groups; vitamin D deficiency alone (comparator group), vitamin C deficiency alone and combined vitamin C and D deficiency as experimental group. The levels of vitamin C, vitamin D, calcium, phosphorous, BMD and condition of OVF were analysed.

RESULTS

There were statistically significant differences between the groups in terms of vitamin C and D levels. In terms of lumbar BMD, significant differences were observed between vitamin D deficiency alone and combined vitamin C and D deficiency. Only the combined vitamin C and D deficiency had a significant negative association with lumbar BMD and T-score. Similarly, combined vitamin C and D deficiency had a significant positive association with lumbar osteoporosis. None of the groups had any significant association with OVF. Combined vitamin C and D deficiency was found to be significantly associated with lower lumbar BMD and osteoporosis.

CONCLUSION

Combined vitamin C and D deficiency results in lower bone mineral density and higher risk of osteoporosis. We believe that existence of deficiencies of both vitamins could have a synergistic effect. Therefore, we recommend that vitamin C and D should be routinely measured in clinical practice.

Comparison of the Efficacy of Zoledronate and Denosumab in Patients with Acute Osteoporotic Vertebral Compression Fractures: A Randomized Controlled Trial

Background: The comparison of the efficacy of zoledronate and denosumab for treating osteoporosis is controversial, and few randomized controlled trials have compared these two drugs in practical patients with acute osteoporotic vertebral compression fractures (OVCFs). We conducted a randomized controlled study to compare the efficacy of zoledronate and denosumab in patients with acute OVCF, with a focus on the occurrence of new OVCF. Methods: We enrolled 206 subjects who had their first acute OVCF, without any previous history of osteoporosis medication. The patients were randomly assigned to receive either intravenous zoledronate once a year or subcutaneous denosumab twice a year. We investigated the OVCF recurrence, clinical outcome, bone mineral density (BMD), and bone turnover markers over 12 months. Results: The final cohort comprised 89 participants (mean age of 75.82 ± 9.34 years, including 74 women [83.15%]) in the zoledronate group and 86 patients (mean age of 75.53 ± 10.23 years, including 71 women [82.56%]) in the denosumab group. New OVCFs occurred in 8 patients (8.89%) in the zoledronate group and 11 patients (12.79%) in the denosumab group (odds ratio, 1.485 [95% confidence interval, 0.567-3.891], p = 0.419). No significant difference was observed in the survival analysis between the two groups (p = 0.407). The clinical outcome, including the visual analog scale score for pain and simple radiographic findings, did not differ between the two groups. The changes in BMD and bone turnover markers were also not significantly different between the two groups. Additionally, drug-related adverse events did not differ between the groups in terms of safety. Conclusions: The efficacy of zoledronate was comparable to that of denosumab in terms of the occurrence of new OVCFs, as well as of the overall clinical course in patients with their first acute OVCF. Notably, this study represents the first comparison of these two drugs in patients with acute OVCF. However, further research with large-scale and long-term follow-up is necessary.

Vitamin D Deficiency in Patients With Low-Energy Hip Fractures in Accordance With the Mediterranean Paradox

Introduction Vitamin D deficiency (VDD) is considered one of the leading causes of poor bone quality. It may also be related to severe muscular weakness, especially in the elderly, which leads to frequent falls. Thus, VDD might be associated with fragility fractures of the hip, wrist, and spine in this age category. In this cross-sectional study, our goal was to present vitamin D levels in an elderly Mediterranean population with hip fractures and to assess whether its levels are related to the incidence or prevention of such injuries. Methods Between January and December 2021, 140 patients aged 65 years or older were hospitalized in our department with a fracture involving the hip joint. Serum calcium and vitamin D level control was performed upon admission, as well as recording whether anti-osteoporosis medication had been prescribed. Only patients with low-energy fractures were included, whereas oncologic patients and those with high-energy trauma were excluded. Results Thirty-eight men and 102 women, with a mean age of 83.12 and 84.88 years, respectively, participated in our study. Intertrochanteric fractures were the most common injuries (50.72%). Low vitamin D levels (<30 ng/mL) were observed in 132 patients (94.28%). A bone density scan during the last year had been conducted by only seven patients (5%), whereas in 136 patients (97.14%), no anti-osteoporotic medication was given. Conclusion There is an excessive percentage of aged patients with hip fractures in Greece, demonstrating a significant vitamin D insufficiency despite the high annual frequency of sunny days in this Mediterranean region. Presumably, most of these patients neither perform the routine bone density scan nor do they take any kind of preventive pharmaceutical treatment, which might reveal devaluation of osteoporosis from this age group due to contingent comorbidities.

Association of overweight and obesity with vertebral fractures: a systematic review and meta-analysis

INTRODUCTION

Over the past decade, there has been increasing interest in exploring the relationship between overweight, obesity and vertebral fractures. Nonetheless, available data from studies on the relationship between overweight, obesity and vertebral fractures remains controversial.

EVIDENCE ACQUISITION

A systematic search was performed in the PubMed and Cochrane Library databases. We selected relevant literature by using these keywords: fracture, vertebral fracture, vertebral compression fracture, overweight, obese, obesity. The retrieval mainly collected publicly published observational studies on the correlation between overweight, obesity and vertebral fractures, excluding the literature that did not meet the inclusion criteria. Meta-analysis for the data extracted from all the included literatures was performed by STATA 12.0 (StataCorp LLC, College Station, TX, USA) to summarize test performance with forest plots and assess the heterogeneity.

EVIDENCE SYNTHESIS

Ten studies, including 1,024,181 subjects satisfied the predefined eligibility criteria. The results showed that the overweight (25.0≤ Body Mass Index [BMI] ≤29.9 kg/m2) and obesity (BMI≥30.0kg/m2) were associated with a decreased risk of vertebral fractures, respectively. The pooled RR is 0.86 (95% CI: 0.79, 0.95) and 0.81(95% CI:0.74-0.90) with no evidence of statistical heterogeneity. However, the relationship between overweight/obesity (BMI≥25 kg/m2) and vertebral fractures is not statistically significant.

CONCLUSIONS

This study showed that overweight and obesity might decrease the risk of vertebral fractures, respectively. However, we did not observe a significant association between overweight/obesity (BMI≥25 kg/m2) and vertebral fractures.

Vitamin D status, including serum levels and sun exposure are associated or correlated with bone mass measurements diagnosis, and bone density of the spine

BACKGROUND

Osteoporosis is a health complication worldwide, especially in developing countries. The prevalence was reported to be 18.3% globally. While the effect of biochemical factors on fracture risk/odds has been documented, the association/correlation between serum 25(OH)D levels, vitamin D dietary intake, and sun exposure with bone mineral density (BMD) remains controversial. This study aimed to evaluate the association and correlation between vitamin D status, including serum levels, dietary intakes, and sun exposure with BMD. We hypothesized that vitamin D-related factors would have different correlations/associations with BMD, which would help better evaluate future studies' results.

METHODS

A total of 186 individuals were included in this study (winter 2020). BMD was measured by Dual-energy X-ray absorptiometry. Blood serum levels of 25(OH)D, phosphorus, calcium, parathyroid hormone (PTH), and calcitonin were tested using standard lab tests. Valid and reliable questionnaires were used for sun exposure assessment and dietary intakes.

RESULTS

There was a significant protective association between spine BMD (classifications, two groups) (OR = 0.69, 95%CI: 0.50-0.94; p-value = 0.023), BMD diagnosis (classifications, two groups) (OR = 0. 69, 95%CI: 0.49-0.87; p-value = 0.036) and sun exposure. There was a significant and moderate correlation between Spine measurements (Spine BMD: Pearson correlation coefficient = 0.302, p-value = 0.046; Spine T-score: Pearson correlation coefficient = 0.322, p-value = 0.033, Spine Z-score: Pearson correlation coefficient = 0.328, p-value = 0.030) and serum 25(OH)D. In addition, participants with osteopenia and osteoporosis significantly consume a higher amount of soluble fiber than the normal BMD group. There was no significant correlation between vitamin D intake and BMD.

CONCLUSION

In conclusion, serum 25(OH)D levels and sun exposure are correlated and associated with BMD. However, prospective studies are needed to investigate the association between dietary vitamin D intake and BMD.

The Effect of Vitamin D Supplementation for Bone Healing in Fracture Patients: A Systematic Review

While most literature on vitamin D supplementation in fracture patients focuses on fracture prevention, the effect of vitamin D on bone healing is a much less studied concept. The primary aim of this systematic review was to assess whether vitamin D supplementation in fracture patients improves clinical or radiological union complications. The secondary aims were to assess supplementation effect on patient functional outcome scores and bone mineral density (BMD). A systematic search of all relevant articles was performed using the following databases: MEDLINE, Embase, Google Scholar, and Web of Science. The population selection included human patients with a fresh fracture treated conservatively or operatively. The intervention included any form of vitamin D supplementation, compared to no supplementation or a placebo. The primary outcomes assessed were clinical or radiological union rates or complications arising from the nonunion. The secondary outcomes assessed were functional outcome scores, BMD scores after treatment, and pain scores. A total of fourteen studies, assessing a total of 2734 patients, were included. Eight studies assessed the effect of vitamin D on clinical or radiological union. Five studies reported no significant difference in complication rates when supplementing fracture patients. Alternatively, three studies reported a positive effect with supplementation between the groups. One of these studies found a difference only for early orthopaedic complications (<30 days), but no differences in late complications. The other two studies found significant differences in clinical union; however, no changes were observed in radiological union. Six studies investigated functional outcome scores after supplementation. Four of these studies found no significant differences between most functional outcome scores. Only three studies reported BMD outcomes, one of which found limited effect on total hip BMD. The overall findings are that vitamin D alone does little to influence fracture healing and subsequent union rates or functional outcome. The studies suggestive of a positive effect were generally of a lower quality. Further high quality RCTs are needed to justify routine supplementation at the time of fracture.

Vitamin D Supplementation and Its Impact on Different Types of Bone Fractures

Vitamin D helps to balance the levels of calcium and phosphorus to maintain proper bone structure. It is also involved in essential biological roles and displays a wide spectrum of potential benefits in the human body. Since there are many types of fractures that occur at specific ages and due to different circumstances, the influence of vitamin D on the frequency of a particular fracture may differ. Thus, the authors investigated the possible preventive effect of vitamin D on the risks of vertebral fractures, hip fractures, stress fractures and pediatric fractures. Additional aspects of vitamin D, especially on recuperation after injures and its impact on the severity of particular fractures, were also discussed. It was suggested that vitamin D supplementation may contribute to a reduction in hip fracture risk due to reduced bone turnover, decreased frequency of falls and improved muscle function. Furthermore, vitamin D appears to lower the risk of stress fractures in athletes and military recruits. Due to a nonunified protocol design, presented investigations show inconsistencies between vitamin D supplementation and a decreased risk of vertebral fractures. However, a vitamin D preventive effect on pediatric fractures seems to be implausible.

High prevalence of missed information related on bone health in orthogeriatric patients with fragility fractures of the pelvis-an institutional register-based analysis

This is the first study that highlighted the amount of missed information related on bone health in orthogeriatric patients suffering fragility fractures of the pelvis and also evaluated its prevalence and differing etiology in the assessed patients, regarding osteoporosis and/or osteomalacia, based on laboratory and instrumental measurements. This evaluation should become a standardized procedure in the treatment of orthogeriatric patients presenting with a FFP.

INTRODUCTION

Fragility fractures of the pelvis (FFP) are common in orthogeriatric patients. Secondary fracture prevention regarding evaluation and treatment of an underlying osteoporosis or osteomalacia is still often neglected. The purpose of this study was to evaluate the amount of missed information related on bone health in older adult FFP patients, the prevalence of vitamin D deficiency in assessed patients, and if fracture type-dependent distribution patterns could be observed.

METHODS

A retrospective analysis of prospectively collected data of an institutional register was performed. Patients aged 80 years and older (n = 456) admitted with a FFP from 01/2003 until 12/2019 to a level I trauma center were included.

RESULTS

In 456 patients, FFP type II were leading (66.7%). Diagnostics were conducted in 37.1% of the patients regarding measurement of vitamin D levels and 21.7% regarding DXA measurements; vitamin D deficiency was observed in 62.7%, indicators for an underlying osteomalacia in 45.8%, and an osteoporosis in 46.5% of the assessed patients.

CONCLUSION

Although FFP are common and will increase, there is still a lack of secondary fracture prevention, starting with information related on bone health. In the assessed patients, a high prevalence of vitamin D deficiency was present, but no significant correlation between vitamin D level and type of fracture was observed. Ongoing education for varying etiology and specific treatment of these fractures is necessary, as surgical treatment was unified, but drug therapy remains different.

The Prevalence of Vitamin D Deficiency in Patients Undergoing Total Knee Arthroplasty: A Propensity Score Matching Analysis

PURPOSE

We investigated and compared the serum 25-OH vitamin D [25(OH)D] level and prevalence of vitamin D deficiency (VDD) between patients who underwent total knee arthroplasty (TKA) and healthy participants through a matched analysis.

METHODS

The unmatched case group consisted of 824 patients who underwent TKA and the unmatched control group 2,794 healthy participants examined at our institution. The control group was matched on the various characteristics-sex, age, weight, body mass index (BMI), blood chemistry, and season of sampling-through propensity score matching (PSM). After PSM, 501 and 721 patients were matched in the case and control group, respectively. Levels of blood chemistry including 25(OH)D were examined and VDD was defined as < 20 ng/mL.

RESULTS

The average serum 25(OH)D level was significantly lower in the OA group (15.3 ng/mL) than that in the control group (19.9 ng/mL, p < 0.001). When categorized using a 20 ng/mL cutoff, the VDD prevalence was 75.0% in the OA group and 59.4% in the control group. The prevalence of vitamin D insufficiency was 18.4% in the OA group and 24.5% in the control group. The prevalence of vitamin D sufficiency was 6.8% in the OA group and 15.9% in the control group (p < 0.001).

CONCLUSIONS

The patients who underwent TKA had lower serum 25(OH)D level and higher VDD prevalence compared to the healthy participants who matched using PSM. There were no differences in VDD rates by sex or obesity and the VDD prevalence was more than 70% during all season. Therefore, in patients undergoing TKA, general attention to VDD is required regardless of sex, obesity, and season. Serum 25-OH vitamin D [25(OH)D] level and vitamin D deficiency (VDD) prevalence were compared between patients undergoing total knee arthroplasty and healthy individuals. The differences in serum 25(OH)D level and VDD prevalence were significant between the two groups after propensity score matching.

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.

Asymptomatic morphometric vertebral fractures and its associated factors: A cross-sectional study among adults in a selected urban area in Selangor, Malaysia

Objective

This study aimed to determine the prevalence of vertebral fractures (VF) in a selected urban population in Malaysia and to explore possible variables associated with VF in the study population.

Methods

A cross-sectional study involving community-living, healthy subjects aged between 45–90 years from the state of Selangor, Malaysia, were invited to attend a bone health check-up. Subjects with diseases known to affect bone metabolism or were on treatment for osteoporosis (OP) were excluded. Bone mineral density (BMD) was measured using dual energy X-ray absorptiometry (DXA). Lateral and antero-posterior view lumbar spine x-rays were performed and VF was determined by the semi-quantitative Genant method.

Results

A total of 386 subjects were studied. Asymptomatic morphometric VF were found in 44 (11.4%) subjects. T12 was the most common vertebrae to be fractured. The prevalence of VF was significantly higher in menopausal women (12.4%) compared to non-menopausal women, in those above the age of 60 (18.5%), in those of Chinese ethnicity (16.5%), in those with a low body fat percentage (17.1%) and among those with OP (27.0%). The mean (standard deviation) 25-hydroxyvitamin D [25(OH)D] levels were significantly higher in those with VF compared to those without VF, 67.64 (23.50) and 57.47 (21.71) nmol/L, respectively. However, after multiple regression analysis, age over 60 years and OP on DXA BMD measurement were the only significant associated factors for VF.

Conclusion

Overall, 11.4% of a selected Malaysian urban population had asymptomatic morphometric VF. Age over 60 years and OP on DXA BMD measurement, but not 25(OH)D levels, were associated with VF.

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

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

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

STUDY DESIGN

A double-blinded, randomized controlled trial.

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Vitamin D and the athlete-patient: state of the art

Vitamin D deficiency is common in athletes. The conventional measurement of vitamin D levels provides a general indicator of body stores. However, there are nuances in its interpretation as values of 25(OH)D do not correlate absolutely with the amount of 'bioavailable' vitamin to the cells. Vitamin D should be regarded as a hormone and influences between 5% and 10% of our total genome. Determining the precise effect of the vitamin, isolated from the actions of other cofactors, is not straightforward and restricts our complete understanding of all of its actions. Deficiency has harmful effects on not only bone and muscle but also wider areas, including immunity and respiratory and neurological activities. More caution should be applied regarding the ability of supranormal vitamin D levels to elevate athletic performance. Hopefully, future research will shed more light on optimal levels of vitamin D and supplementation regimes, and improved understanding of its intracellular control of our genetic mechanisms and how extrinsic influences modify its activity.

Free vitamin D correlate better with bone mineral density and thoracolumbar junction osteoporotic vertebral fractures than serum vitamin D

Background

Vitamin D deficiency has long been studied as a risk factor for osteoporosis. However, the association between serum vitamin D status, bone mineral density (BMD) and the incidence of vertebral fractures (OVFs) remain controversial. It is believed that free portion of the circulating vitamin D carries the metabolic activities of vitamin D. Therefore, the aim of the present study is to analyse if free vitamin D correlates with BMD and osteoporotic fragile vertebral fractures in the elderly population.

Methods

A total of 90 consecutive patients, including 81 female and 9 male patients, aged > 48 years, were included in this cross sectional study between March and July of 2018. Total vitamin D (total 25(OH)D), free vitamin D (free 25(OH)D), calcium and phosphorus were measured. BMD was measured using dual energy X-ray absorptiometry (DEXA) and osteoporotic vertebral fracture was assessed using plain radiograph. Multiple linear regression was performed to find out the association between total vitamin D, free vitamin D and BMD at various sites. To evaluate the association with osteoporotic vertebral multivariate logistic regression model was used.

Results

The mean total vitamin D and free vitamin D were 25.1 ± 10.2 and 6.1 ± 1.7 respectively. Free vitamin D had a linear correlation with total vitamin D (R² = 0.69). While free vitamin D had a positive correlation with lumbar BMD roles (p < 0.05), total vitamin D didn’t have any association with BMD at any site. Of the total patients, 62 patients (68.9%) had thoracolumbar junction OVFs. Free vitamin D level correlated with the prevalence of OVFs as well as lumbar osteoporosis (p < 0.05). However, there was no statistical correlation between serum vitamin D status and the OVFs.

Conclusions

Free vitamin D was significantly related to the occurrence of thoracolumbar junction OVFs and lumbar BMD, which assumed to be a positive predictor for fracture and osteoporosis prevention. However, total serum vitamin D levels did not have any association with BMD at different sites as well as fragile vertebral fracture.

Trial registration

The study is registered at clinicaltrials.gov NCT03605173.

Vitamin D Deficiency/Insufficiency Is Associated with Risk of Osteoporotic Thoracolumbar Junction Vertebral Fractures

Background

The association between serum vitamin D level and vertebral fracture (VFx) remains controversial. The purpose of this study was to determine whether serum 25-hydroxy vitamin D (25(OH)D) level is associated with osteoporotic thoracolumbar junction VFx in elderly patients.

Material/Methods

From Jan 2013 to Dec 2017, this retrospective case-control study included 534 patients with primary osteoporotic thoracolumbar junction VFx (T10–L2) and 569 elderly orthopedic patients with back pain (without osteoporotic VFx) as controls. Serum 25(OH)D levels were measured and the association with osteoporotic VFx was analyzed. Other clinical data, including BMI, comorbidities, and bone mineral density (BMD), were also collected and compared between these 2 groups.

Results

It was shown that 25(OH)D levels were significantly lower in patients with T10–L2 VFx than in control patients. Among 534 VFx patients, 417 (78.1%) patients showed grade 2–3 fracture. Serum 25(OH)D levels were significantly related to affected vertebral numbers and VFx severities. The VFx risk was 28% lower (OR=0.72, 95% CI 0.62–0.83) per increased SD in serum 25(OH)D. Compared with the 1^st quartile (mean 25(OH)D: 29.67±6.18 nmol/L), the VFx risk was significantly lower in the 3^rd (mean 25(OH)D: 60.91±5.12nmol/L) and 4^th quartiles (mean 25(OH)D: 103.3±44.21nmol/L), but not in the 2^nd quartile (mean 25(OH)D: 45.40±3.95 nmol/L). In contrast, the VFx risk was significantly increased in the 1^st quartile (OR=1.87, 95% CI 1.42–2.45) compared with the 2^nd–4^th quartiles.

Conclusions

Vitamin D deficiency/insufficiency was associated with risk of osteoporotic thoracolumbar junction vertebral fractures in elderly patients.

Vitamin D Deficiency in Patients With Idiopathic and Traumatic Osteochondritis Dissecans of the Talus

BACKGROUND

Low vitamin D levels are common in patients with foot and ankle disorders. We have previously demonstrated that juveniles diagnosed with osteochondritis dissecans (OCD) have a high prevalence of vitamin D deficiency. Moreover, there is evidence that OCD might be related to vitamin D deficiency in general. However, whether or not hypovitaminosis D is associated with OCD of the talus has yet to be elucidated.

METHODS

The aim of this study was to determine serum vitamin D levels [25(OH)D] of patients diagnosed with traumatic and idiopathic OCD of the talus. The vitamin D status of patients was measured and correlated to age, sex, season, etiology, laterality, degree of disease, and nicotine abuse. Moreover, parathyroid hormone and serum calcium levels of patients were obtained to assess for severe vitamin D deficiency and secondary hyperparathyroidism. Between January 2015 and December 2017, 65 patients with a mean age of 38.9 years and a total of 68 lesions were identified.

RESULTS

In total, 75.4% of patients had low vitamin D levels with a mean overall 25(OH)D level of 24.2 ng/mL. Specifically, 35.4% of patients were vitamin D deficient; another 40% were vitamin D insufficient, and only 24.6% of patients presented with sufficient vitamin D levels. Statistical analysis showed no significant difference comparing vitamin D levels of patients with idiopathic OCD to patients with traumatic OCD.

CONCLUSION

We could not find any significant differences in the vitamin D status of patients with OCD of the talus compared with patients with foot and ankle disorders in general. However, we found that vitamin D deficiency was frequent in patients presenting with traumatic and idiopathic OCD of the talus. We believe it might be beneficial to routinely assess and treat the vitamin D status of patients.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Is There a Correlation Between Preoperative or Postoperative Vitamin D Levels with Pseudarthrosis, Hardware Failure, and Revisions After Lumbar Spine Fusion?

BACKGROUND

Vitamin D deficiency is a well-known cause of postoperative complications in patients undergoing orthopedic surgery. Orthopedic complications seen in vitamin D deficiency include nonunion, pseudarthrosis, and hardware failure. We seek to investigate the relationship between vitamin D deficiency and outcomes after lumbar spinal fusions.

METHODS

A retrospective patient chart review was conducted at a single center for all patients who underwent lumbar spinal fusions from January 2015 to September 2017 with preoperative or postoperative vitamin D laboratory values. We recorded demographics, social history, medications, pre-existing medical conditions, bone density (dual-energy x-ray absorptiometry) T-scores, procedural details, 1-year postoperative Visual Analog Score (VAS), documented pseudarthrosis, revisions, and hardware failure. A total of 150 patients were initially included in the cohort for analysis.

RESULTS

Overall, preoperative and postoperative vitamin D levels were not significantly associated with a vast majority of the patient characteristics studied, including comorbidities, medications, or surgical diagnoses (P > 0.05). Age at surgery was significantly associated with vitamin D levels; older patients had higher serum levels of vitamin D both preoperatively (P = 0.03) and postoperatively (P = 0.01). Those with a higher average body mass index had lower vitamin D in both groups (P = 0.02). Vitamin D levels were not significantly associated with rates of postoperative pseudarthrosis, revision, or hardware complications (P > 0.05). VAS pain score at 1 year and smoking status preoperatively or postoperatively were not associated with vitamin D levels (P > 0.05).

CONCLUSIONS

Both preoperative and postoperative vitamin D levels were not significantly associated with an increased or decreased risk of pseudarthrosis, revision surgery, hardware failure, or 1-year VAS pain score after lumbar spine fusion surgery.

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.

Chronic kidney disease predicts a lower probability of improvement in patient-reported experience measures among patients with fractures: a prospective multicenter cohort study

Patient-reported experience measures (PREMs) are integral component of care for fracture patients. Using a multicenter cohort, we showed that the presence of chronic kidney disease (CKD) attenuated the probability of PREM improvement in fracture patients.

INTRODUCTION

Assessing PREM can assist physicians in improving patients' experiences. Patients with CKD are at an increased risk of exhibiting poor PREM and developing fractures. We aimed to assess whether CKD influences the probability of PREM improvement during follow-up among patients with fractures.

METHODS

We prospectively enrolled patients with hip or vertebral fractures from different institutes into a fracture liaison service program. After registering clinical histories, they received a baseline PREM assessment based on EuroQol group-5 dimension content, including self-care, daily activity, and pain severity using a 5-point Likert scale. A follow-up PREM assessment was arranged 4 months later, and we evaluated whether baseline CKD was predictive of PREM improvement.

RESULTS

Among 593 fracture patients (18% with CKD), 37.3% and 62.7% presented with hip and vertebral fractures, respectively. Self-care, daily activity, and pain severity improved after follow-up in 32%, 27%, and 43% participants; those with CKD exhibited worse self-care ability and daily activity than those without. Multivariate logistic regression analyses showed that baseline CKD was significantly associated with lower possibility of improvement in daily activity (odds ratio [OR] 0.58, p = 0.049) and pain severity (OR 0.52, p = 0.01), and an insignificant change in the possibility of improvement in self-care ability (OR 0.61, p = 0.09).

CONCLUSIONS

The presence of CKD predicts a significantly lower probability of PREM improvement among fracture patients. An early emphasis on renal function during fracture care should be considered.

Organic Gallium Treatment Improves Osteoporotic Fracture Healing Through Affecting the OPG/RANKL Ratio and Expression of Serum Inflammatory Cytokines in Ovariectomized Rats

This study aimed to investigate the impact of organic gallium (OG) on osteoporotic fracture healing in ovariectomized female Sprague-Dawley rats, as well as study the mechanisms of OG on osteoporotic fracture healing. Forty-five female Sprague-Dawley rats were divided into three groups: sham operation group (Sxas control group), ovariectomized group (Ovx), and Ovx treated with OG group (Ovx + OG). Rat femoral fractures were studied using a standardized fracture-healing model utilizing bone fixation with an intramedullary pin. Six weeks later, analyses of micro-CT, histomorphometric, RNA extraction, RT-qPCR, and serum were performed following sacrifice of all mice. In comparison with Ovx group, OG can significantly increase bone volume (BV), tissue volume (TV), BV/TV radio, bone strength, callus bony area, and as similar to BMP-2 expression. OG treatment elevated OPG messenger RNA (mRNA) and inhibited RANKL mRNA, and showed an effect on OPG/RANKL ratio. OG treatment can inhibit the expression of TNF-α and IL-6. In conclusion, current study results indicate that organic OG can positively affect the OPG/RANKL ratio and inhibit the expression of serum inflammatory cytokines; thus, it can improve osteoporotic fracture healing.

Treatment of Hypovitaminosis D in an Orthopaedic Trauma Population

OBJECTIVES

To determine the incidence of hypovitaminosis D and to evaluate a supplementation intervention. We hypothesized that patients would exhibit high adherence with a free sample, and levels would become sufficient.

DESIGN

Prospective observational study.

SETTING

Level 1 trauma center.

PATIENTS

One hundred forty-four consecutive, skeletally mature patients treated for acute fractures.

INTERVENTION

All were provided 600 mg calcium and 800 IU vitamin D3 capsules twice daily.

MAIN OUTCOME MEASUREMENTS

Serum 25(OH) D levels were obtained on presentation and after supplementation. Patient surveys determined adherence, vitamin D intake, and sun exposure.

RESULTS

Ninety-one men and 53 women, mean age 45 years, mean body mass index 28.1, were studied. Mean baseline 25(OH) D level was 20.2 ng/mL, including 9 patients taking vitamin D supplements before injury. All others (mean baseline 16.9 ng/mL) were prescribed calcium and vitamin D and were offered free supplements when discharged. Seventy-seven patients completed surveys, and mean 25(OH) D level was 36.7 ng/mL after a mean of 7.0 weeks of supplementation (P < 0.0001). Seventy-nine percent reported adherence to supplement recommendations. All adherent patients achieved normal levels. Sixteen patients were nonadherent, with 10 who forgot to take the supplement, 4 choosing not to use it, 1 choosing to sell the sample, and 1 losing the sample.

CONCLUSION

Hypovitaminosis D was present in 97% of orthopaedic trauma patients who were not already taking supplements. The intervention was effective in reducing hypovitaminosis D within several weeks, with all supplemented patients achieving normal levels. Seventy-nine percent of patients adhered to recommendations. Further study to determine the long-term cost-effectiveness of this strategy seems warranted.

LEVEL OF EVIDENCE

Therapeutic, Level II. See Instructions for Authors for a complete description of levels of evidence.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Osteoporosis associated vertebral fractures-Health economic implications

Introduction

Osteoporosis-associated vertebral fractures represent an increasing clinical and public health problem, one with important socioeconomic effects within western countries.

The purpose of this study was to analyse demographic, medical, gender and socioeconomic aspects of osteoporotic vertebral fractures of the thoracic or lumbar spine over a period of at least 10-years.

Material and methods

Included for analysis were 694 patients who had suffered a vertebral fracture due to primary or secondary osteoporosis, and who were treated at our Level-I trauma center between 2000 and 2013. Collected data included demographic, medical and socioeconomic aspects.

Results

Clinical results revealed that 669 patients (96%) were treated conservatively. The remaining 25 patients (4%) underwent surgical therapy: 4 were treated with vertebroplasty, 15 with kyphoplasty and 6 patients with posterior stabilization. The mean age was 75.6 years (range: 50–98), with the vast majority of patients being female (n = 515). A statistically significant demographic difference (i.e., increase) in fractures was observed between the age groups 60–69 and 70–79 (p = 0.041). Concerning socioeconomic aspects, statistical analysis showed that the number of sick leaves and the need for professional domestic help was higher in female patients. Concerning treatment costs, statistical analysis did not reveal any significant differences between female and male patients.

Conclusion

Significant gender differences–to the detriment of the female population–could be demonstrated within this study. A regrettably low rate of adequate treatment after diagnosis of osteoporosis and its associated fractures–specifically relating to primary and secondary prevention–could also be identified. To prospectively avoid complications and consequential cost increases, more awareness of the necessity for prevention, early diagnosis and adequate treatment of osteoporosis and its related fractures should be considered.

Validity of height loss as a predictor for prevalent vertebral fractures, low bone mineral density, and vitamin D deficiency

Many osteoporosis-related vertebral fractures are unappreciated but their detection is important as their presence increases future fracture risk. We found height loss is a useful tool in detecting patients with vertebral fractures, low bone mineral density, and vitamin D deficiency which may lead to improvements in patient care.

INTRODUCTION

This study aimed to determine if/how height loss can be used to identify patients with vertebral fractures, low bone mineral density, and vitamin D deficiency.

METHODS

A hospital database search in which four patient groups including those with a diagnosis of osteoporosis-related vertebral fracture, osteoporosis, osteopenia, or vitamin D deficiency and a control group were evaluated for chart-documented height loss over an average 3 1/2 to 4-year time period. Data was retrieved from 66,021 patients (25,792 men and 40,229 women).

RESULTS

A height loss of 1, 2, 3, and 4 cm had a sensitivity of 42, 32, 19, and 14% in detecting vertebral fractures, respectively. Positive likelihood ratios for detecting vertebral fractures were 1.73, 2.35, and 2.89 at 2, 3, and 4 cm of height loss, respectively. Height loss had lower sensitivities and positive likelihood ratios for detecting low bone mineral density and vitamin D deficiency compared to vertebral fractures. Specificity of 1, 2, 3, and 4 cm of height loss was 70, 82, 92, and 95%, respectively. The odds ratios for a patient who loses 1 cm of height being in one of the four diagnostic groups compared to a patient who loses no height was higher for younger and male patients.

CONCLUSIONS

This study demonstrated that prospective height loss is an effective tool to identify patients with vertebral fractures, low bone mineral density, and vitamin D deficiency although a lack of height loss does not rule out these diagnoses. If significant height loss is present, the high positive likelihood ratios support a further workup.

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.

Serum levels of the bone turnover markers dickkopf-1, sclerostin, osteoprotegerin, osteopontin, osteocalcin and 25-hydroxyvitamin D in Swedish geriatric patients aged 75 years or older with a fresh hip fracture and in healthy controls

BACKGROUND

Bone turnover markers have a potential clinical use in describing bone remodeling and in predicting fractures.

AIMS

In an elderly population ≥75 years with a fresh hip fracture, and in healthy controls, investigate bone turnover markers and their relation to each other, to vitamin D status and to bone mineral density (BMD).

METHODS

In a cross-sectional study serum levels of dickkopf-1 (DKK-1), sclerostin (SOST), osteoprotegerin (OPG), osteopontin (OPN), osteocalcin, 25-hydroxyvitamin D (25(OH)D) were analyzed in 89 Swedish patients with a fresh hip fracture and in 82 healthy volunteers. Serum levels of bone markers were determined by Luminex technique.

RESULTS

S-25-hydroxyvitamin D (S-25(OH)D) was decreased in patients compared to controls (48 ± 21 vs. 76 ± 25 nmol/L, p < 0.001). SOST, but none of the other bone turnover markers correlated with BMD (r = 0.50, p < 0.001). Compared with controls, higher levels of OPG (488 ± 1.4 vs. 191 ± 1.4 ng/L, p < 0.001), OPN (69 ± 1.7 vs. 19 ± 1.4 µg/L, p < 0.001), DKK-1 (273 ± 1.7 vs. 168 ± 1.7 ng/L, p < 0.001), and lower levels of osteocalcin (5.8 ± 3.5 vs. 9.5 ± 3.6 µg/L, p < 0.001), were found in the fracture group. Levels of OPG, DKK-1 and SOST in both groups were positively associated. S-25(OH)D concentration was not found to be strongly associated with any of the bone markers.

CONCLUSIONS

In contrast to findings in other studies, we found no strong correlation between 25(OH)D and the investigated bone markers. Both in patients with a fresh hip fracture and in healthy elderly, DKK-1, SOST and OPG appear to be associated. This suggests a relevance in these relationships meriting further investigation.

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

Background

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

Materials and methods

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

Results

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

Conclusions

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

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

High prevalence of radiological vertebral fractures in adult patients with Ehlers-Danlos syndrome

Previous studies have reported an increased prevalence of osteoporosis in Ehlers–Danlos syndrome (EDS), but these were limited by a small number of patients and lack of information on fragility fractures. In this crosssectional study, we evaluated the prevalence of radiological vertebral fractures (by quantitative morphometry) and bone mineral density (BMD, at lumbar spine, total hip and femoral neck by dual-energy X-ray absorptiometry) in 52 consecutive patientswith EDS (10 males, 42 females; median age 41 years, range: 21–71; 12with EDS classic type, 37 with EDS hypermobility type, 1 with classic vascular-like EDS, and 2 without specific classification) and 197 control subjects (163 females and 34 males; median age 49 years, range: 26–83) attending an outpatient bone clinic. EDS patients were also evaluated for back pain by numeric pain rating scale (NRS- 11).Vertebral fractures were significantly more prevalent in EDS as compared to the control subjects (38.5% vs. 5.1%; p b 0.001) without significant differences in BMD at either skeletal sites. In EDS patients, the prevalence of vertebral fractures was not significantly (p = 0.72) different between classic and hypermobility types. BMD was not significantly different between fractured and non-fractured EDS patients either at lumbar spine (p = 0.14), total hip (p=0.08), or femoral neck (p=0.21). Severe back pain(≥7 NRS)was more frequent in EDS patients with vertebral fractures as compared to thosewithout fractures (60% vs. 28%; p=0.04). Inconclusion, this is the first study showing high prevalence of vertebral fractures in a relatively large population of EDS patients. Vertebral fractures were associated with more severe back pain suggesting a potential involvement of skeletal fragility in determining poor quality of life. The lack of correlation between vertebral fractures and BMD is consistent with the hypothesis that bone quality may be impaired in EDS.