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October 12, 2010

Correct vitamin D deficiency before surgery, orthopedist recommends

Correct vitamin D deficiency before surgery, orthopedist recommends

The October 6, 2010 issue of The Journal of Bone and Joint Surgery reports that nearly half of orthopedic surgery patients are deficient in vitamin D, a condition that impairs bone healing, muscle function and surgery recovery.

Professor of Orthopedic Surgery and chief of the Metabolic Bone Disease Service at New York's Hospital for Special Surgery Joseph Lane, MD and colleagues reviewed the charts of 723 men and women scheduled for orthopedic surgery from January, 2007 to March, 2008. Forty-three percent of the patients had insufficient preoperative vitamin D levels, defined as 20 to 32 nanograms per milliliter, and 40 percent had deficient levels of less than 20 nanograms per milliliter. Younger individuals, men, and those with dark skin were likeliest to be low in vitamin D.

Dr Lane explained that healing of bony tissue takes place two to four weeks following bone surgery, and sufficient vitamin D is needed for this process. "In the perfect world, test levels, fix and then operate," Dr Lane stated. "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."

Sixty percent of trauma service patients had insufficient levels and 52 percent were deficient. A high percentage of vitamin D insufficiency was also observed in Sports Medicine and Arthroplasty (hip and knee replacement) services. "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 noted. "With arthroplasty, there is a certain number of patients that when you put in the prosthesis, it breaks the bone adjacent to the prostheses, which can really debilitate patients.

"This study should serve as a wake-up call to orthopedists that vitamin D deficiency is widespread, not necessarily tied to age, sex or background and screening for it should be part of routine presurgical care for adults," Dr Lane stated. "Meanwhile, patients who are planning to undergo any orthopedic procedure can request a screening (specifically, a blood test called the 25 hydroxyvitamin D test) or ask to be placed on a medically supervised vitamin D supplement regimen prior to surgery."

"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," he concluded. "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.'"

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Surgical preparation

Assuring that the body is replete with antioxidants is one easy and powerful way to avoid the antioxidant depletion that occurs during the surgical procedure (Pechan I et al 2004). Maximizing the anti-inflammatory status and boosting immune function to achieve the proper balance of host defense against infection while minimizing the exaggerated inflammatory response to surgery is another. And, of course, ensuring adequate protein intake prior to surgery is an important way of providing the soon-to-be-healing body with the building blocks of new tissue. All of these effects can be achieved with a reasonable program of supplementation in the weeks prior to surgery.

Amino acids are the building blocks of proteins, which are themselves the chief components of structural tissue. The enzymes that catalyze all biological processes are also proteins. Surgery dramatically increases the daily requirement of protein, particularly if there is substantial blood loss; and supplements containing amino acids or whole proteins have been shown both in animal models and human clinical trials to enhance the outcomes of surgical procedures (Collins CE et al 2005; MacKay D et al 2003; Scholl D et al 2001). Supplements may improve wound healing (Collins CE et al 2005), reduce the rate and severity of pressure ulcers (Frias SL et al 2004; Bourdel-Marchasson I et al 2000; Breslow RA et al 1993), and improve fat mass (a good thing following surgery; de Luis DA et al 2005).

Almost all of the known vitamins are essential in each of the phases of surgery, either as vital cofactors in protein or nucleic acid synthesis for rapidly healing tissue or as potent antioxidants that can minimize tissue damage and the heightened inflammatory response caused by surgery. Blood levels of many of the vitamins are markedly reduced during surgery, and there is good evidence for both pre- and postoperative supplementation.

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