When A Vitamin D Deficiency Complicates Bunion Surgery
With a look at the current research, this author offers insights on addressing the bone healing issues resulting from vitamin D deficiency in a 19-year-old patient with bunions.
The importance of vitamin D in bone health has long been established.1 Consequently, a lack of vitamin D in the diet or lack of sun exposure may lead to serious health problems such as osteomalacia, rickets, certain cancers, diabetes, heart disease and even mortality risk in women. Unfortunately, vitamin D deficiency and its known consequences are a global concern.2 Studies have implicated sedentary lifestyles, climate, sunscreen/protective clothing and other factors as causative.1,2
Bone healing in healthy middle-aged and younger people does not frequently come to mind when planning foot and ankle surgery, unless there are documented reasons for this to occur. These reasons include smoking, a prior history of delayed or nonunion, a prior history of vitamin D deficiency/insufficiency, documented non-adherence or osteogenesis imperfecta.
In more recent years, there have been studies regarding the screening of vitamin D levels preoperatively not only in adults but also in children.3,4 With our profession’s many years of collective surgical experience in bone and joint surgery, it is astounding that only recently is so much attention focusing on a seemingly simple issue.
In the fall of 2011, I attended the Texas Podiatric Medical Association Conference in Frisco, Texas, at which Laurence Rubin, DPM, presented a lecture on the screening of patients prior to osseous foot and ankle surgery.4 This workup included a 25(OH) vitamin D level and a 24-hour urine calcium level as well as the possibility of hormone testing. This was not the first occasion I had either discussed or listened to discussions on vitamin D importance, but this was the first time I had noted it extrapolating to podiatry.
Based upon this sound advice, I had started to screen patients who were more likely to be at risk for Vitamin D deficiency including women who were post-menopausal, post-hysterectomy or older. For young healthy individuals with no prior history, it seemed a waste of resources to test for this preoperatively just as it is not necessary to have a preoperative chest X-ray or electrocardiography in young, healthy individuals per anesthesia algorithms. There are not standardized criteria in place for bone health testing in foot and ankle surgery.
A Closer Look At The Patient Presentation And Treatment
A 19-year-old female presented to my office for long-term complaints of bunion pain on her left foot. She had been using wide shoes, accommodative padding and sandals to avoid the pain. The patient had reached the point where her foot was painful with walking, even in open-toed shoes. This prompted her to seek surgical consultation for correction. Her past medical and surgical histories were unremarkable for significant pathology. The patient denied any smoking, alcohol or illicit substance abuse. Family history and review of systems were non-contributory to her chief complaint.
The physical examination demonstrated a significantly increased intermetatarsal angle and hallux abductus angle. The proximal articular set angle was greater as was the tibial sesamoid position. The range of motion at the first metatarsophalangeal joint (MPJ) was restricted with track-bound range of motion and palpation tenderness. Radiographs confirmed the gross findings. There was no evidence of osteopenia or osteoporosis on radiograph.
My plan for this patient was a closing base wedge osteotomy with Juvara angular modification to correct/prevent elevatus. It was also possible that a double osteotomy may be needed to correct the proximal articular set angle intraoperatively.