Deficiency Rampant in Patients for Orthopedic Surgery, Damaging Recovery
People undergoing procedures
involving bone or muscle should correct their vitamin D if they want an
earlier faster, better, result
Oct. 6, 2010 -
Almost 50 percent of patients undergoing orthopedic surgery have vitamin
D deficiency that should be corrected before surgery to improve patient
outcomes, based on a study by researchers at Hospital for Special
Surgery (HSS) in New York City. Vitamin D is essential for bone healing
and muscle function and is critical for a patient's recovery.
appears in the October issue of The Journal of Bone and Joint Surgery.
"In the perfect
world, test levels, fix and then operate," said Joseph Lane, M.D.,
professor of Orthopedic Surgery and chief of the Metabolic Bone Disease
Service at HSS, who led the study.
"If you put
people on 2,000-4,000 [milligrams] of vitamin D based on what their
deficient value was, you can usually get them corrected in four to six
weeks, which is when you are really going to need the vitamin D. If you
are really aggressive right before surgery, you can correct deficient
levels quickly, but you have to correct it, measure it, and then act on
According to Dr.
Lane, bone remodeling or bone tissue formation, a part of the healing
process, occurs about two to four weeks after surgery. This is the
critical stage when your body needs vitamin D.
For their study,
investigators conducted a retrospective chart review of 723 patients who
were scheduled for orthopedic surgery between January 2007 and March
2008 at HSS. They examined the vitamin D levels, which had been measured
in all patients before their surgery, and found that 43 percent had
insufficient vitamin D and 40 percent had deficient levels.
inadequacy was defined as <32 ng/mL, vitamin D insufficiency was defined
as 20 to <32 ng/mL, and vitamin D deficiency was defined at <20 ng/mL.
more prevalent in younger patients, men and individuals with dark
skin—blacks and Hispanic.
levels of deficiency were seen in patients in the trauma service, where
66 percent of patients had insufficient levels and 52 percent had
Of the patients
undergoing foot and ankle surgery, 34 percent had inadequate levels and
of patients undergoing hand surgery, 40 percent had insufficient levels.
In the Sports
Medicine Service, 52.3 percent had insufficient levels and of these,
one-third of these or 17 percent of the total had deficient levels.
see stress fractures in the Sports Medicine Service and if you want to
heal, you have to fix the calcium and vitamin D," Dr. Lane said.
Arthroplasty Service, which conducts hip and knee replacements, 38
percent had inadequate levels and 48 percent had deficient levels.
arthroplasty, there is a certain number of patients that when you put in
the prothesis, it breaks the bone adjacent to the protheses, which can
really debilitate patients," he added.
This could be
prevented or minimized by rectifying vitamin D levels. Dr. Lane also
explained that they now perform procedures where they grow a bone into a
prosthesis without using cement.
people, it would be an advantage to have adequate vitamin D, because it
matures the bone as it grows in, it is really healing into the
prosthesis," he said.
"The take home
message is that low vitamin D has an implication in terms of muscle and
fracture healing, it occurs in about 50 percent of people coming in for
orthopedic surgery, and it is eminently correctable," Dr. Lane said.
that people undergoing a procedure that involves the bone or the muscle
should correct their vitamin D if they want to have an earlier faster,
better, result. What we are saying is 'wake up guys, smell the coffee;
half of your patients have a problem, measure it, and if they are low,
then fix it.'"
In recent years,
vitamin D deficiency has been recognized as a common phenomenon and is
caused by many factors. It is difficult to get from foods, except, for
example, cod liver oil and fish. Until recently, the recommended daily
allowance was set too low so foods were not supplemented with adequate
doses. And third, while people can absorb vitamin D from sunlight,
people these days often work long hours and often use sunscreen that
impedes vitamin D intake.
The study was
funded, in part, by the Charles Cohn Foundation of Rockville Centre,
Other authors of
the study, all from Hospital of Special Surgery, are Ljiljana Bogunovic,
M.D., Abraham D. Kim, B.A., Brandon S. Beamer, B.A., and Joseph Nguyen,
About Hospital for
Special Surgery (Provided by hospital)
Founded in 1863,
Hospital for Special Surgery (HSS) is a world leader in orthopedics,
rheumatology and rehabilitation. HSS is nationally ranked No. 1 in
orthopedics, No. 3 in rheumatology, No. 16 in neurology and No. 18 in
geriatrics by U.S. News & World Report (2010-11), and has received
Magnet Recognition for Excellence in Nursing Service from the American
Nurses Credentialing Center, and has one of the lowest infection rates
in the country. From 2007 to 2010, HSS has been a recipient of the
HealthGrades Joint Replacement Excellence Award. A member of the New
York-Presbyterian Healthcare System and an affiliate of Weill Cornell
Medical College, HSS provides orthopedic and rheumatologic patient care
at New York-Presbyterian Hospital at New York Weill Cornell Medical
Center. All Hospital for Special Surgery medical staff are on the
faculty of Weill Cornell Medical College. The hospital's research
division is internationally recognized as a leader in the investigation
of musculoskeletal and autoimmune diseases. Hospital for Special Surgery
is located in New York City and online at
Vitamins and Minerals: About Vitamin D
Vitamins are organic
substances (made by plants or animals), minerals are inorganic
elements that come from the earth; soil and water and are
absorbed by plants. Animals and humans absorb minerals from the
plants they eat. Vitamins and minerals are nutrients that your
body needs to grow and develop normally.
Vitamins and minerals have a
unique role to play in maintaining your health. For example
Vitamin D helps your body absorb the amount of calcium (a
mineral) it needs to form strong bones. A deficiency in vitamin
D can result in a disease called rickets (softening of the bones
caused by the bodies inability to absorb the mineral calcium.)
The body cannot produce calcium; therefore, it must be absorbed
through our food.
Other minerals like
chromium, copper, iodine, iron, selenium, and zinc are called
trace minerals because you only need very small amounts of them
each day. The best way to get enough vitamins is to eat a
balanced diet with a variety of foods. You can usually get all
your vitamins from the foods you eat.
About Vitamin D
Vitamin D is a fat-soluble
vitamin that is naturally present in very few foods, added to
others, and available as a dietary supplement. It is also
produced endogenously when ultraviolet rays from sunlight strike
the skin and trigger vitamin D synthesis. Vitamin D obtained
from sun exposure, food, and supplements is biologically inert
and must undergo two hydroxylations in the body for activation.
The first occurs in the
liver and converts vitamin D to 25-hydroxyvitamin D [25(OH)D],
also known as calcidiol. The second occurs primarily in the
kidney and forms the physiologically active
1,25-dihydroxyvitamin D [1,25(OH)2D], also known as calcitriol.
Vitamin D is essential for
promoting calcium absorption in the gut and maintaining adequate
serum calcium and phosphate concentrations to enable normal
mineralization of bone and prevent hypocalcemic tetany.
It is also needed for bone
growth and bone remodeling by osteoblasts and osteoclasts.
Without sufficient vitamin D, bones can become thin, brittle, or
misshapen. Vitamin D sufficiency prevents rickets in children
and osteomalacia in adults.
Together with calcium,
vitamin D also helps protect older adults from osteoporosis.
Vitamin D has other roles in
human health, including modulation of neuromuscular and immune
function and reduction of inflammation. Many genes encoding
proteins that regulate cell proliferation, differentiation, and
apoptosis are modulated in part by vitamin D. Many
laboratory-cultured human cells have vitamin D receptors and
some convert 25(OH)D to 1,25(OH)2D. It remains to be determined
whether cells with vitamin D receptors in the intact human carry
out this conversion.