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Hypovitaminosis D in Patients Scheduled to Undergo Orthopaedic SurgeryA Single-Center Analysis
Ljiljana Bogunovic, MD1; Abraham D. Kim, MD1; Brandon S. Beamer, MD1; Joseph Nguyen, MPH1; Joseph M. Lane, MD1
1 Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for J.M. Lane: LaneJ@hss.edu
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Cohn Foundation and the Weill-Cornell Clinical Translation Science Center (UL1 RR024996-01). In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from commercial entities (Eli Lilly, Procter and Gamble, Novartis, and Zimmer).

Investigation performed at the Hospital for Special Surgery, New York, NY

Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Oct 06;92(13):2300-2304. doi: 10.2106/JBJS.I.01231
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Vitamin D is essential for optimal bone health and muscle function. An alarmingly high rate of vitamin-D deficiency in the general population has been reported recently. The purpose of the present study was to characterize the extent of low serum levels of vitamin D among orthopaedic surgery patients.


We performed a retrospective chart review of 723 patients who were scheduled for orthopaedic surgery between January 2007 and March 2008. Preoperative serum 25-hydroxyvitamin D (25[OH]D) levels were measured. The prevalence of normal (=32 ng/mL), insufficient (<32 ng/mL), and deficient (<20 ng/mL) vitamin-D levels was determined. Logistic regression was used to assess risk factors for insufficient (<32 ng/mL) 25(OH)D levels.


Overall, 43% of all patients had insufficient serum vitamin-D levels, and, of these, 40% had deficient levels. Among the orthopaedic services, the highest rates of low serum vitamin-D levels were seen in the trauma and sports services, in which the rates of abnormal (insufficient and deficient) vitamin-D levels were 66% and 52%, respectively. The lowest rate of abnormal vitamin-D levels was seen in the metabolic bone disease service. Patients between the ages of fifty-one and seventy years were 35% less likely to have low vitamin-D levels than patients between the ages of eighteen and fifty years (p = 0.018). The prevalence of low vitamin-D levels was significantly higher in men (p = 0.006). Individuals with darker skin tones (blacks and Hispanics) were 5.5 times more likely to have low vitamin-D levels when compared with those with lighter skin tones (whites and Asians) (p < 0.001).


The prevalence of low serum levels of vitamin D among patients undergoing orthopaedic surgery is very common. Given the importance of vitamin D in musculoskeletal health, such low levels may negatively impact patient outcomes.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Joseph M. Lane, MD
    Posted on March 19, 2011
    Dr. Lane responds to Dr. Arya and colleagues
    Hospital for Special Surgery, New York, New York

    Dr. Arya has confirmed the widespread extent of hypovitaminosis D. In his letter he reports a marked level of insufficiency and deficiency in a relatively healthy population in India. The ciritcal message related to the letter is that hypovitaminosis D occurs in tropical and subtropical areas in spite of extensive sun exposure. The darker skin pigmentation, the effort to avoid the sunlight and the inability to find high natural nutritional sources of Vitamin D have contributed to this observation. Consequently worldwide attention to Vitamin D levels are needed. At this time the corrective dose of Vitamin D is patient specific and requires monitoring to avoid excesses. This author supports the reports from Dr. Arya and thanks him for extending the observations internationally.

    Subhash C. Arya
    Posted on February 11, 2011
    Hypovitaminosis D3 in Patients for Knee Transplant Surgery in Delhi
    Sant Parmanand Hospital, Delhi Institute of Trauma and Orthopedics, Delhi, India

    To the Editor:

    We substantiate the hypovitaminosis D3 data from Bogunovic et al. in, "Hypovitaminosis D in Patients Scheduled to Undergo Orthopaedic Surgery: A Single-Center Analysis" (2010;92:2300-4) from the Hospital for Special Surgery, New York, NY with vitamin D3 status in patients undergoing knee transplant surgery in the Indian capital metropolis.

    During the interval between June to October 2010, 63 patients, 54 females and 9 males who underwent knee transplant surgery, 51 bilateral and 12 unilateral, were evaluated at the Delhi Institute of Trauma and Orthopedics located at the Sant Parmanand Hospital, Delhi. Their mean age, standard deviation was 64±7.8 years, with age ranging between 49 to 81 years. Vitamin D3 levels were evaluated locally using the 25(OH)-Vitamin D direct Elisa Kit (Immunodiagnostik, Bensheim), based on a competitive ELISA technique with a selected monoclonal antibody that recognizes 25(OH)-vitamin D. The results were expressed, after point-to-point calculation, as nmol/l (with 1 nmol/L being equivalent to 2.5 ng/mL). In six patients, 5 for bilateral and one for unilateral surgery, vitamin D3 levels were ≥ 80nmol/L.

    Nine patients, 6 for bilateral and 3 for unilateral, had levels between 50-80 nmol/L, while 48 patients, 40 for bilateral and 8 for unilateral, showed vitamin D3 levels lower than 50 nmol/L. There was no significant difference in vitamin D3 values between male and female patients or between cases undergoing unilateral or bilateral surgery. Approximately three-fourth of the local patients undergoing knee transplant surgery with vitamin D3 levels < 50 nmol/l, were vitamin D deficient. That vitamin D3 deficiency far exceeds the 40% deficiency in patients scheduled for orthopedic surgery in New York, NY. Intake of a vitamin D3 rich diet is poor and Vitamin D3 fortified food is not available in India. With plenty of sunshine around, affluent women, constituting the vast majority of the present series, prefer minimum exposures to direct sunlight and use umbrella/protective shields outdoors and thick curtains indoors. We would address vitamin D3 deficiency status in among the local cases in the post-operative phase by vitamin D3 supplementations. The post-supplementation vitamin D3 levels would also be monitored to detect any non-responders. A daily supplementation by vitamin D3 1000 IU, might fail to achieve the vitamin D3 level ≥ 75 nmol/l in 20-30 percent cases (1).


    1. Schwalfenberg GK. A step in the right direction. CMAJ. 2010;182:1763.

    Joseph M. Lane, MD
    Posted on November 10, 2010
    Dr. Lane and colleagues respond to Dr. Barker
    Hospital for Special Surgery, New York, New York

    Dr. Tyler Barker has identified critical issues that are always present in retrospective studies. We agree with these concerns and did note similar limitations within the manuscript. In this case there was no detailed information in the records of the dietary supplements utilized by the cohort in question. We postulate that the lower vitamin D levels in the younger individuals represent the greater lack of concern for their mineral status. Elderly patients are well aware of osteoporosis and both these individuals and their physicians routinely discuss the need for appropriate calcium and vitamin D support. These patients will more likely be taking some supplements. Unfortunately the RDA for vitamin D has been set at 400 international units per day. This level apparently is far too low and is under modification currently. The major result of the study under discussion is the broad level of inadequate vitamin D in the orthopedic community. Finally, the more distant the patient is from the classical osteoporotic stereotype the greater the chance for vitamin deficiency. Our authors view this retrospective study more as a hypothesis developing study. We agree with Dr. Barker that a carefully constructed prospective study is now appropriate to discern the true causes for the low vitamin D levels so that corrective strategies can be established.

    Tyler Barker
    Posted on October 25, 2010
    Vitamin D and Orthopaedic Research
    The Orthopedic Specialty Hospital, Murray, Utah

    To the Editor:

    In a recent issue of The Journal of Bone and Joint Surgery, Bogunovic et al. illustrated the prevalence of vitamin-D inadequacy in patients undergoing diverse orthopedic surgeries in the article entitled, "Hypovitaminosis D in Patients Scheduled to Undergo Orthopaedic Surgery: A Single-Center Analysis" (2010;92:2300-4). Serum 25-hydroxyvitamin D [25(OH)D total] concentrations were measured in preoperative blood samples obtained from 723 patients. Of the patients, 43% were vitamin-D insufficient (serum 25(OH)D 20 to 32 ng/mL), of which, 40% were deficient (serum 25(OH)D < 20 ng/mL). Approximately 50% of the anterior cruciate ligament (ACL) and/or meniscal repair patients possessed inadequate (insufficiency or deficiency) vitamin-D levels. This is provocative because the prevalence rate in vitamin-D inadequacy was higher than those receiving arthroplasty services, a population generally older. Vitamin-D inadequacy was also more prevalent in a younger (18 to 50 year olds) compared to older cohorts (51 to 70 year olds or more than 70 years old), which is surprising when considering the predisposition to low vitamin-D with aging.

    Despite the overall clinical relevance and significance, there are a couple of limitations that require attention in addition to those already discussed by Bogunovic et al. First, the authors stated that patients were categorized into several age groups to account for differences in dietary habits. However, dietary habits vary within age groups, and therefore, merely grouping by age does not protect against this potential confounding influence. Second, and importantly, it is plausible that some of the patients (and speculative moreso in the older cohorts based on the lower vitamin-D inadequacy prevalence rates) were supplementing with vitamin-D alone or with a supplement(s) that contains vitamin-D (e.g., a multi-vitamin). Although the aforementioned limitations presented herein are difficult to address in a retrospective and cross-sectional study design without considering a priori, future micronutrient (i.e., vitamin-D) studies in orthopaedics are encouraged to provide pertinent background data regarding patient-reported supplement use. Nevertheless, these shortcomings do not detract from the overall significance or the potential impact of the study by Bogunovic et al.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

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