Who Needs Vitamin D Supplementation? A Case Series Highlighting a Standard Protocol for Preoperative Health Assessment Troy Boffeli, DPM, FACFAS; Rachel Collier, DPM, AAFAS; Sam Gervais, DPM Regions Hospital / HealthPartners Institute for Education and Research - Saint Paul, MN

STATEMENT OF PURPOSE: resulted in of the talonavicular joint. Subsequent revision talonavicular joint Table 1. Classification and Treatment Recommendations Based on Serum Figure 3. Case 2 – Progressive Flatfoot Deformity Vitamin D plays a critical role in bone health by facilitating the absorption of fusion failed to heal however the patient’s left foot is asymptomatic (Figure 5a).

and phosphate and increasing the bioavailability of these chemicals for bone 25(OH)D levels

metabolism. Deficiency in vitamin D has been implicated in pathologic fractures, Vitamin D Status Serum 25(OH)D Value Treatment The patient presented at initial clinic encounter requesting similar surgical intervention on , delayed fracture healing and non-union after arthrodesis or osteotomy right foot. Plain radiographs demonstrated calcaneal navicular coalition as well as procedures. Optimization of bone health in patients presenting with traumatic foot and significant degeneration of the talonavicular and calcaneocuboid joints (Figure 5b). Sufficient >30 ng/ml <70 yo: 600 IU D3 daily ankle injuries as well as patients undergoing elective surgery is critical for successful Operative plan included coalition resection, talonavicular fusion, and calcaneocuboid outcomes. Identifying patients with sub-optimal vitamin D levels requires a >70 yo: 800 IU D3 daily fusion. Thorough preoperative bone health screening was performed given history of standardized protocol to ensure appropriate management is initiated. The purpose of Insufficient 20-29 ng/ml 1000-2000 IU D3 daily nonunion following multiple surgeries. No prior evaluation of vitamin D deficiency was this case series is to present a standardized, cost-efficient protocol for peri-operative identified. optimization of vitamin D levels in patients undergoing both elective and non-elective Deficient <20 ng/ml 50,000 IU D2 weekly x12 weeks plus 1500- A 56 year old Asian female presented with worsening pain foot and ankle procedures. Case examples are presented to highlight that it is not and progressive flatfoot deformity as demonstrated by plain 2000 IU D3 daily Serum levels of 25(OH)D demonstrated deficiency at 13.0 ng/ml. He was treated with necessary to delay surgical intervention if vitamin D supplementation is implemented radiographs. Darker pigmented skin has been identified as a 50,000 IU D2 weekly for 12 weeks with an additional 2000 IU D3 daily. Surgery was not in a timely and appropriate dosage during bone healing. risk factor for vitamin D deficiency. No other risk factors were delayed while serum levels normalized. The patient was kept non-weight bearing for 12 identified. Preoperative serum 25(OH)D levels were 17.3 Table 2. Bone Health Screening Protocol weeks and used an external bone stimulator throughout the recovery. Osseous fusion ng/ml. LITERATURE REVIEW: was demonstrated on 12 week postoperative plain radiographs (Figure 6). The patient

The role of vitamin D in calcium and bone health has been well has returned to normal activities and has not had problems or additional treatment 10 established. Vitamin D increases intestinal absorption of calcium and phosphate. In Figure 4. Case 2 – 10 Week Status Post Multiple Joint Arthrodesis months later. the absence of vitamin D only 10-15% of dietary calcium is absorbed. Vitamin D can increase the efficiency of calcium absorption to 30-80% (1,2). When serum calcium levels are suboptimal, will act on the kidneys to increase vitamin RESULTS: D production as well as increase renal reabsorption of calcium. Additionally, Risk factors for vitamin D deficiency were identified in each of the presented cases. parathyroid hormone will activate to mobilize calcium stores from bone. In Suboptimal vitamin D levels were treated immediately using a standard treatment conditions of chronic low vitamin D levels, excessive mobilization of bone calcium protocol. Surgery was not delayed while waiting for serum vitamin D levels to normalize stores will lead to and osteoporosis. Several studies have identified an and all patients progressed to osseous healing. Post treatment vitamin D levels are not alarmingly high rate of vitamin D deficiency in the general population. It is estimated routinely obtained however this should be considered for patients who demonstrate that over one billion people worldwide have suboptimal levels of vitamin D (1-4). In a delayed healing or patients receiving weekly injections of 50,000 IU D2 for deficiency as recent study evaluating 75 patients presenting with low-energy ankle fractures, fifth some patients need a second course of treatment. Patients are told to remain on long metatarsal fractures, or stress fractures, 47% had serum 25(OH)D levels below 30 50,000 IU D3 weekly for 12 weeks along with 2000 IU D3 term daily supplementation and to discuss overall bone health with their primary ng/dl (5). daily was initiated. Surgery was not delayed waiting for provider.

serum 25(OH)D levels to normalize. Osseous bridging is The Endocrine Society categorizes vitamin D status into sufficient, insufficient, and noted at 10 weeks postoperatively. deficient levels. Sufficient levels are >30 ng/ml; insufficient levels are 21-29 ng/ml; Figure 1. Case 1 – Painful End Stage Hallux Limitus and deficient levels are <20 ng/ml. Treatment recommendations utilizing DISCUSSION: supplementation with vitamin D2 or D3 is based on vitamin D status (Table 1) Figure 5. Case 3 – Midfoot DJD and Tarsal Coalition with History of Prior Optimization of bone health before osseous procedures or when treating fractures is (6). Proper supplementation is crucial for optimizing bone health, and consequently, critical to set the stage for a desirable outcome. Vitamin D plays an integral role in bone good surgical outcomes. Risk factors for Vitamin D deficiency include conditions Nonunion of Arthrodesis health and deficient levels can lead to decreased . It is known that causing reduced skin synthesis, such as season, latitude, sunscreen use, and skin a b osteoporosis may lead to poor union rates and unfavorable surgical outcomes. Thus, if pigment. People with darker pigmented skin are at risk as melanin absorbs UV chronic Vitamin D deficiency can lead to osteopenia and osteoporosis, a heightened radiation, which can decrease vitamin D production by as much as 90-99% (2). awareness for this common vitamin deficiency is necessary in the preoperative workup Studies have shown that above 35 degrees latitude, little to no vitamin D is produced for patients with recent fractures or those undergoing elective osteotomy or fusion. A during the winter months (1-3). Other risk factors for deficiency include pregnancy, standard protocol for identifying risk factors, testing serum vitamin D levels when malabsorption syndromes, decreased oral intake, disease, liver disease, indicated, and treating deficient levels appropriately would be a valuable tool for the obesity, age, smoking, history of nonunion or pathologic fractures, and certain surgeon. Not all patients need serum levels checked or supplementation, but patients medications (1-4). Plain radiographs of a 70 year old female demonstrating severe with recent fractures or those undergoing elective osteotomy or fusion would benefit from degeneration of the first metatarsophalangeal joint and diffuse a standard pretreatment bone health assessment. Literature investigating the effect of vitamin D on orthopedic surgical outcomes is A 65 year old male with bilateral congenital tarsal coalition presented with worsening decrease in bone density. Arthrodesis was recommended. limited. In a study investigating metabolic abnormalities in patient’s presenting with right foot pain. Prior surgical history of left TNJ fusion and revision surgery resulted in Preoperative bone health assessment identified age and family Preoperative patients need to be carefully screened for suboptimal bone health. Patient nonunion following any orthopedic surgery not explained by other causes, vitamin D nonunion as seen on CT imaging (a). Plain radiograph of right foot demonstrate severe history of osteoporosis as risk factors with no prior vitamin D questionnaires should focus on risk factors for vitamin D deficiency, osteopenia, and deficiency was the most common newly diagnosed metabolic abnormality. TNJ and CCJ degeneration (b). No prior vitamin D assessment identified with assessment. Serum 25(OH)D levels were 20.7 ng/ml indicating osteoporosis. Risk factors for vitamin D deficiency to consider when screening may 25/37(68%) patients with were found to have vitamin D deficiency in the preoperative bone health assessment. 25(OH)D levels were 13.0 ng/ml. insufficiency. include: age, skin pigmentation, obesity, smoking, decreased oral intake, malabsorption workup postoperatively for nonunion (7). A recent article evaluating fusion rates in syndromes, kidney disease, liver disease, history of nonunion or pathologic fractures. spine surgery demonstrated a significantly longer time to fusion in patients with Our routine is to screen for bone health risk factors in all new patients using a vitamin D deficiency. Additionally, there was an association between vitamin D Figure 6. Case 3 – 12 Weeks Status Post Coalition Resection and standardized intake history form. The shared medical record is also helpful from this deficiency and nonunions (8). Although limited evidence exists, suboptimal vitamin D Figure 2. Case 1 – 6 Week Status Post Arthrodesis for Hallux Limitus Midtarsal Joint Arthrodesis regard. Additional screening is instituted at key points in the continuum of care including levels have been shown to be a potential contributor of poor surgical outcomes. when surgery is being scheduled, as part of our fracture triage process and at

preoperative visits. One population that needs extra attention involves those who enter Given the high prevalence of vitamin D deficiency, and the consequence of sub- the system on an emergency basis and undergo surgery without the usual preoperative optimal serum levels on bone health, screening 25(OH)D levels has been advocated. work up afforded to elective surgery patients. These patients need special attention to However, measuring 25(OH)D levels is expensive and there is a lack of studies bone health assessment during hospital admission or at an early postoperative visit. We supporting universal screening (3,4). Screening should be reserved for at-risk have a low threshold for testing patients with risk factors if osseous procedures or patients (1-4). A standardized preoperative bone health assessment designed to fracture care is planned. identify patients who are at risk of suboptimal vitamin D levels is desired to optimize

surgical outcomes however this is not commonplace in the foot and ankle surgical The patient was treated for deficient vitamin D levels immediately with 50,000 IU D2 Patients with suboptimal vitamin D levels are treated based on recommended practice. Table 2 provides a structured bone health assessment protocol based on weekly for 12 weeks along with 2000 IU D3 daily. Surgery was not delayed. The supplementation guidelines. This case series highlights our protocol for vitamin D history and chart review. Patient with identified risk factors should be tested and postoperative course included 12 weeks of non-weight bearing as well as am external supplementation in patients with suboptimal levels undergoing elective foot and ankle treated appropriately, ideally during the course of fracture healing. The patient was treated with 2000 IU D3 daily immediately bone stimulator. Plain radiographs demonstrate osseous fusion. Lifelong daily procedures or fracture care. Our routine is to proceed with surgical intervention rather

following abnormal lab testing. Surgery was not delayed and supplementation with 2000 IU D3 was recommended. At 10 months, no further than delaying surgery while waiting for serum levels to normalize. Interestingly, we have

osseous fusion is demonstrated at 6 week postoperative treatment has been required. Retesting of 25(OH)D levels could be considered at this anecdotally noted a high rate of union with concomitant surgery and treatment of vitamin

CASE SERIES: radiographs. Lifetime daily supplementation was recommended. level of deficiency as a second round of therapy is sometimes needed. D deficiency. This case series is intended to highlight our current practice yet further A case series is presented to illustrate a standardized protocol for evaluating and research is needed to evaluate the consequence of vitamin D deficiency on osseous managing vitamin D levels peri-operatively. Bone health screening questions and Preoperative bone health screening identified no prior vitamin D assessment. Identified procedures and fracture healing of the foot and ankle. chart review is a routine component of preparing patients for surgery involving D deficiency. Preoperative 25(OH)D level was 20.7 ng/md indicating insufficient status. risk factors included darker skin pigmentation, which increases risk of vitamin D osteotomy, fracture repair of joint fusion. Non-operative care of fractures should also Supplementation with a daily dose of 2000 IU D3 was initiated and surgery was not deficiency due to absorption of UV radiation by melanin. 25(OH)D level identified delayed waiting for serum vitamin D levels to normalize. 6 week postoperative radiographs involve bone health screening. Serum 25-hydroxyvitamin D levels are obtained when deficiency at 17.3 ng/ml. She was treated with 50,000 IU D2 weekly for a duration of 12 REFERENCES: indicated based on risk factor assessment and anticipated treatment. demonstrated osseous fusion and the patient has not had problems now 12 months later weeks in addition to 2000 IU D3 daily which was started preoperatively and continued for 1. Hollick MF. Vitamin D Deficiency. N Engl J Med 357:266-81, 2007. 2. Hollick MF. Optimal Vitamin D Status for the Prevention and Treatment of Osteoporosis. Drugs Aging 24(12):1017-1029, 2007. (Figure 2). Lifetime daily supplementation was recommended and no further vitamin D a lifetime without plans for further monitoring. Surgery was not delayed and 10 week assessment is indicated. 3. Binkley N, Ramamurthy R, Krueger D. Low vitamin D Status: Definition, Prevalence, Consequences, and Correction. Endocrinol Case #1: plain radiographs demonstrated osseous union at both fusion sites (Figure 4). She has Metab Clin N Am 39:287-301, 2010. not had problems or additional treatment now 12 months later. 4. Kennel KA, Drake MT, Hurley DL. Vitamin D Deficiency in Adults: When to Test and How to Treat. Mayo Clin Proc 85(8):752-758, A 70 year old healthy female presented to clinic with worsening right first 2010. metatarsophalangeal joint (MPJ) pain. Periarticular osteophytes and decreased range Case #2: 5. Smith JT, Halim K, Palms DA, Okike K, Bluman EM, Chiodo CP. Prevalence of Vitamin D Deficiency in Patients with Foot and Ankle of motion was noted upon physical exam. Plain radiographs demonstrated advanced A 56 year old Asian female presented to clinic with progressive pain associated with flatfoot Case #3: Injuries. Foot and Ankle International 35(1):8-13, 2014. deformity and posterior tibial tendon dysfunction. Conservative care had been exhausted 6. The Endocrine Society. Evaluation, Treatment, and Precention of Vitamin D Deficiency: An Endocrine Society Clinical Practice degeneration of the first MPJ as well as diffuse decrease in bone density (Figure 1). A 65 year old male presented to clinic with right foot pain. Detailed history revealed Guideline. Journal of Clinical Endcorinology and Metabolism 96(7):1911-1930, 2011. Given the clinical and radiographic findings, first MPJ arthrodesis was recommended. without adequate relief of symptoms. Plain radiographs demonstrated flatfoot deformity congenital bilateral calcaneal-navicular coalition with associated talonavicular joint and 7. Brinker MR, O’Connor DP, Monla YT, Earthman TP. Metabolic and Endocrine Abnormalities in Patients with Nonunions. J Orthop Preoperative bone health screening identified no prior vitamin D assessment. Family with apex of medial column collapse located at the naviculo-cuneiform joint (Figure 3). calcaneocuboid joint arthritis. Previous left foot surgery, including resection of the Trauma 21(8):557-570, 2007. Operative plan included subtalar joint fusion and naviculo-cuneiform joint fusion. 8. Ravindra VM, Godzik J, Dailey AT, Schmidt MH, Bisson EF, Hood RS, Cutler A, Ray WZ. Vitamin D Levels and 1-Year Fusion history was significant for osteoporosis. Age was an additional risk factor for vitamin coalition with talonavicular joint fusion, attempted two years prior by an outside provider Outcomes in Elective Spine Surgery: A Prospective Observational Study. Spine 2015; 40(19):1536-41