New York City—October 6, 2010
“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 it.”
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.
Vitamin D 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. Problems were more prevalent in younger patients, men and individuals with dark skin—blacks and Hispanic.
The highest levels of deficiency were seen in patients in the trauma service, where 66 percent of patients had insufficient levels and 52 percent had deficient levels. 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. “We frequently 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.
In the Arthroplasty Service, which conducts hip and knee replacements, 38 percent had inadequate levels and 48 percent had deficient levels. “With 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.” 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. “In those 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. “We recommend 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, N.Y..
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, MPH.