When A Vitamin D Deficiency Complicates Bunion Surgery

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Author(s): 
Matthew Claxton, DPM

   In this case, there were some warning signs that we missed. These signs were pale skin color, a sedentary lifestyle and a lack of exposure to sunlight through exercise or physical activity. Also, she stated that she used sunscreen or wore long sleeves when going outside for longer periods of time.

   Over the past year, in addition to this case, I have now had several other young patients with similar bone healing issues including a 21-year-old with delayed union of a bone graft and a multitude of teenagers and 20-year-olds with delayed fracture healing or the appearance of stress fractures, which would not be expected in this population. There was also a 12-year-old with a stress fracture who had a vitamin D level of 12 ng/mL.

   The debate/argument with dermatologists is ongoing about how much sun exposure is “safe.” Currently, the best recommendations are for 30 minutes of exposure each day without sunscreen between the hours of 10 a.m. and 3 p.m. Unfortunately, during times of work, school and winter months, this much exposure might not be possible. One study at Boston College showed a prevalence of vitamin D insufficiency/deficiency in college students to be as high as 67 percent at the end of winter months. Therefore, it is recommended that all people over age 30 take 600 IU/day of vitamin D plus calcium. Elderly individuals over age 70 need an average of 800 to 1,000 IU/day.8

In Closing

Based upon the mounting research, there is a need for prospective studies on Vitamin D deficiency in foot and ankle surgery. Unfortunately, since the problem is so widespread, institutional review boards would have significant issues in approving studies to prospectively test bone healing in individuals as once physicians have proven a deficiency preoperatively, it would be negligent not to treat the condition. The long-term concern for standardized pre-op screening would be whether insurance companies would cover the lab cost without level 1 evidence to support its need.9 The best recommendation at this time is that all patients undergoing osseous surgery should have preoperative screenings for Vitamin D deficiency or insufficiency.

   Dr. Claxton practices in O’Fallon, Ill.

References
1. Holick MF. Vitamin D deficiency. N Engl J Med. 2007; 37(3):266-81.
2. Holick MF, Chen TC. Vitamin D deficiency: a worldwide problem with health consequences. Am J Clin Nutrition 2008; 87(4):1080S-086S.
3. Bogunovic L, Kim AD, Beamer BS, et al. Hypovitaminosis D in patients scheduled to undergo orthopaedic surgery: a single-center analysis. J Bone Joint Surg. 2010; 92(13):2300-2304.
4. Parry J, Sullivan E, Scott, Cooper A. Vitamin D sufficiency screening in preoperative pediatric orthopaedic patients. J Pediatr Orthopaedics. 2011; 31(3):331–333.
5. Rubin L. Vitamin D and calcium deficiencies: From Mount Rushmore and Lady Liberty to my operative patient. Presented at the 2011 Southwest Foot and Ankle Conference, Frisco, TX. Sept. 16, 2011.
6. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2011; 96(7):1911-1930.
7. Ross AC, Manson JE, Abrams SA, et al. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J Clin Endocrinol Metab. 2011; 96(1):53-58.
8. Consensus Report, Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. November 30, 2010.
9. Rollins G. Vitamin D Testing – What’s the Right Answer. Clinical Laboratory News. 2009; 35(7). Available at http://www.aacc.org/publications/cln/2009/july/Pages/CovStory1July09.aspx# . Published 2009. Accessed June 25, 2012.

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