The Effect of Perioperative Vitamin D Levels on the Functional, Patient-Related Outcome Measures and the Risk of Infection Following Hip and Knee Arthroplasty: A Systematic Review

Effect of Vitamin D Deficiency on Periprosthetic Joint Infection and Complications after Primary Total Joint Arthroplasty

INTRODUCTION

Vitamin D deficiency is a global problem, and 13 to 75% of patients undergoing total joint arthroplasty (TJA) have vitamin D deficiency. Several studies have shown that low preoperative vitamin D levels may increase the risk of postoperative complications, including periprosthetic joint infection (PJI), in patients undergoing primary TJA. However, most of the studies are underpowered. This study aimed to investigate the relationship between vitamin D deficiency and surgical and medical complications after primary TJA, with a specific focus on PJI.

METHODS

Prospectively collected institutional multicenter arthroplasty databases were reviewed to identify patients who underwent primary total knee and hip arthroplasty between 2019 and 2022. The study group was defined as patients whose vitamin D level is < 30 ng/dl and who received a single oral dose of 7.5 mg (300,000 IU) D3 within two weeks before index surgery (n = 488; mean age 63 years). Patients in the control group were those whose preoperative vitamin D levels were unknown and who did not receive vitamin D supplementation (n = 592, mean age 66). Demographics, comorbidities, and 90-day postoperative surgical and medical complications were recorded. The groups were compared regarding 90-day medical and surgical complications, including PJI, mortality, and readmission rates.

RESULTS

The total number of complications (8.6 and 4.3%; respectively; P = 0.005), superficial wound infection (2.5 and 0.2%, respectively; P < 0.001), and postoperative cellulitis (2.2 and 0% respectively; P < 0.001) were statistically significantly higher in the patient group who did not receive vitamin D supplementation. However, 90-day mortality (P = 0.524), PJI (P = 0.23), and readmission rate (P = 0.683) were similar between the groups.

CONCLUSION

This study demonstrated that preoperative optimization of vitamin D levels may be beneficial in reducing postoperative complications, including superficial wound infection and postoperative cellulitis. Administering an oral 300,000 U single-dose vitamin D regimen to correct vitamin D deficiency can positively impact outcomes following primary TJA.

Cyclic cryotherapy with vitamin D facilitates early rehabilitation after total knee arthroplasty

Objective

This study aimed to evaluate the efficacy of cyclic cryotherapy and vitamin D administration on early rehabilitation after total knee arthroplasty (TKA), as its efficacy remains unclear.

Methods

We divided 150 patients (three groups) who underwent TKA into those treated with or without cyclic cryotherapy and vitamin D.

Results

Compared with patients who did not receive cyclic cryotherapy, those who received postoperative cyclic cryotherapy and vitamin D supplementation had significantly higher American Knee Society Scores (AKSS) on postoperative day (POD) 7 and at 1 month postoperatively; higher visual analogue scale (VAS) values on POD1-3 and POD7; reduced thigh swelling on POD3 and POD7; increased range of motion (ROM) on POD3, POD7, and at 1 month postoperatively; and reduced postoperative length of stay (PLOS). However, no significant difference in patient satisfaction was observed between the patient groups. At 1 and 3 months postoperatively, patients administered cyclic cryotherapy and vitamin D had significantly higher AKSS, ROM, and vitamin D levels than those who did not receive vitamin D. No perioperative complications such as surgical site infection, skin frostbite, or vitamin D intoxication were observed.

Conclusion

Cyclic cryotherapy post-TKA had short-term advantages in terms of AKSS, VAS, thigh swelling, ROM, PLOS, and accelerated rehabilitation, but did not improve patient satisfaction. Cyclic cryotherapy combined with vitamin D improved AKSS and ROM at 1 and 3 months postoperatively.

Vitamin D Deficiency Leads to Poorer Health Outcomes and Greater Length of Stay After Total Knee Arthroplasty and Supplementation Improves Outcomes: A Systematic Review and Meta-Analysis

BACKGROUND

Vitamin D deficiency is increasingly identified as a predictor of poorer outcomes in musculoskeletal disease affecting as many as 1 in 4 people. This study aimed to evaluate the effect of vitamin D supplementation on outcomes after primary total knee arthroplasty (TKA).

METHODS

A targeted search of terms related to vitamin D and TKA outcomes was performed in PubMed, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, American Academy of Orthopaedic Surgeons, and British Orthopaedic Association databases. The results were analyzed using forest plots with I2 heterogeneity statistics and pooled effects with 95% confidence intervals (CIs) and p values. A p < 0.05 was considered statistically significant.

RESULTS

A total of 146,054 patients with 150,107 TKRs were analyzed in 10 studies that complied with the inclusion criteria, of which 3 were suitable for meta-analysis. Of these, 4 of the 10 studies showed that vitamin D deficiency resulted in poorer functional outcome scores (Western Ontario and McMasters Universities Osteoarthritis Index, Knee Society Scoring System, and American Knee Society scores), as well as increased risk of revision surgery, incidence of joint infection, and postoperative stiffness. Meta-analysis of length of hospital stay (LOS) demonstrated a significant increase in LOS in patients with vitamin D deficiency (standardized mean difference, -0.54, 95% CI, -0.69 to -0.38, p < 0.00001). Furthermore, outcomes were improved with vitamin D supplementation in 6 of 10 studies.

CONCLUSION

Vitamin D deficiency results in poorer outcomes of primary TKA, with improved outcomes after supplementation. Further studies should examine the role of preoperative vitamin D screening and/or perioperative supplementation in primary TKA and standardize outcome measures to assess their effect.

LEVEL OF EVIDENCE

Level I/II. See Instructions for Authors for a complete description of levels of evidence.

Influence of vitamin D levels on outcomes and nosocomial COVID-19 infection in patients undergoing total knee arthroplasty- a cohort study

Purpose

This study aimed to audit the effects of vitamin D3 on the early functional outcomes, the incidence of nosocomial COVID-19 infection and complications in patients undergoing elective Total Knee Arthroplasty (TKA).

Methods

This was a retrospective study involving patients undergoing primary unilateral TKA between January 2020 to May 2021 operated by a single surgeon using a single implant. Participants were divided into two cohorts, Deficient-vitamin D3 level <20 ng/ml and Sufficient-vitamin D3 level ≥20 ng/ml. Assessment for Knee Society Score and Oxford Knee Score (OKS) was done preoperatively and one year after TKA. Nosocomial COVID-19 infection rate, 30-day re-admissions and complications were noted during the study.

Results

235 patients were divided into 2 cohorts matched by age, gender and ASA grades. 74 patients belonged to the deficient group and 161 belonged to the sufficient group. The mean preoperative scores in the sufficient group were higher than the deficient group (OKS = 15.74 vs 12.95; KSS = 88.91vs 85.62). Similarly, the one-year postoperative scores in the sufficient group were significantly higher (OKS = 36.54 vs 35.16; KSS = 164.01 vs 161.22). A linear correlation was present between preoperative score (r = 0.273) & post-operative scores (r = 0.141) with serum vitamin D3 levels. Vitamin D3 deficient individuals had higher nosocomial COVID-19 infection rate (10.81% vs 4.96%,p = 0.16). The incidence of complications like DVT, embolism, stroke, infection and fracture were not statistically different in the two groups.

Conclusion

Vitamin D positively influences the outcomes of TKA and protects against nosocomial COVID-19 infection in patients undergoing elective TKA.