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Patients presenting with fractures are likely to be vitamin D deficient: are we getting enough sun? Tyler C. Mow, Christopher M. Stokes and Alasdair G. Sutherland Warrnambool Campus, Deakin University Medical School, Geelong, Victoria, Australia
Key words deficiency, internal fixation, fracture force. Correspondence Dr Tyler C. Mow, Deakin University Medical School, Warrnambool Campus, 8/14 Albert Street, Northcote, Geelong, Vic. 3070, Australia. Email: [email protected] T. C. Mow MBBS, BSci; C. M. Stokes MBBS, BMedSci, PGDipSurgAnat; A. G. Sutherland MD (Hons), FRCSEd (Tr&Orth), FRACS Orth, FAOrthA. Accepted for publication 24 April 2015. doi: 10.1111/ans.13190
Abstract Background: 25-Hydroxyvitamin D serves a crucial role in bone metabolism through its role on osteoclast and osteoblastic function. To assess the implication of vitamin D and its relationship to bone fracture and fracture force, we have examined vitamin D levels in patients requiring inpatient fracture management. Methods: We performed serological testing of vitamin D levels, calcium, parathyroid hormone and liver function tests on patients admitted to our rural institution in southeastern Australia for inpatient fracture management. All participants completed a questionnaire designed to screen for potential contributing factors to bony fragility. Demographic data were also obtained including age, gender and body mass index. Fracture location and the type of inpatient management as well as the force of injury were included in our analysis. Results: We recruited 100 patients to the study, with a median age of 72 (range 22–98) of whom 66 were women. Most had low-energy fractures (79%), treated by internal fixation (73%) or arthroplasty (9%) with 18 treated non-operatively. The majority of the patients were at best vitamin D insufficient, 65 nmol/L reduced fracture risk by up to 20%.10 Levels up to 75 nmol/L and above have been suggested as optimal,11–13 which would require higher dose supplementation.13 We wished to examine the prevalence of vitamin D deficiency in a prospective cohort of patients presenting for inpatient treatment of fractures in a rural population in southeastern Australia (living at 38° south). We were also interested in the relationship between vitamin levels and the type of fractures sustained and type of treatment required.
Methods
electrolytes, creatinine, calcium, magnesium, phosphate, liver function tests and parathyroid hormone levels were taken.
Statistical analysis Based on observations of emergency department fracture presentations, we determined that a sample size of 100 patients would be appropriate to assess vitamin D status within our rural population. As this was a cohort study of vitamin D levels, no formal power calculation was undertaken. Patients were assigned a study number and data were stored and analysed anonymously. Vitamin D levels were the primary outcome measure and were recorded as absolute values and also categorized: (i) vitamin D deficiency (75 nmol/L). Secondary outcomes included the relationship between vitamin D levels and force of injury, type of treatment and sun exposure. Analysis used Statistical Package for Social Sciences v22 (IBM, Melbourne, Victoria, Australia). Statistical significance was set at a P-value of 60 nmol/L for the prevention of fracture.26 This study has demonstrated that the prevalence of vitamin D insufficiency and deficiency are high in those presenting with fractures and represents both behavioural factors as well as engrained sun smart policies.
References 1. Patton C, Powell A. Vitamin D in orthopaedics. J. Am. Acad. Orthop. Surg. 2012; 20: 123–9. 2. Suda T, Shinki T. The role of vitamin D in bone and intestinal cell differentiation. Annu. Rev. Nutr. 1990; 10: 195–211. 3. Daly RM, Gagnon C, Lu ZX et al. Prevalence of vitamin D deficiency and its determinants in Australian adults aged 25 years and older: a national, population-based study. Clin. Endocrinol. (Oxf) 2012; 77: 26–35.
© 2015 Royal Australasian College of Surgeons
Vitamin D and patients with fractures
4. Van Der Mei IA, Dore D, Winzenberg L, Blizzard L, Jones G. Vitamin D deficiency in Tasmania: a whole life perspective. Intern. Med. J. 2012; 42: 1137–44. 5. Van Der Mei IA, Ponsonby AL, Engelson O et al. The high prevalence of vitamin D insufficiency across Australian Populations is only partly explained by season and latitude. Environ. Health Perspect. 2007; 115: 1132–9. 6. Cancer Council Australia. Risks and benefits of sun exposure position statement. 2007. 7. Nowson CA, Diamond TH, Pasco JA et al. Vitamin D in Australia. Issues and recommendations. Aust. Fam. Physician 2004; 33: 133–8. 8. Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB et al. Fall prevention with supplemental and active forms of vitamin D: a metaanalysis of randomised controlled trials. BMJ 2009; 339: b3692. 9. Bischoff-Ferrari HA, Willett WC, Wong JB et al. Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a metaanalysis of randomized controlled trials. Arch. Intern. Med. 2009; 169: 551–61. 10. Dawson-Hughes B. What is the optimal dietary intake of vitamin D for reducing fracture risk. Calcif. Tissue Int. 2013; 92: 184–90. 11. Dawson-Hughes B, Heaney RP, Holick MF, Lips P, Meunier PJ, Veith R. Estimates of optimal vitamin D status. Osteoporos. Int. 2005; 16: 713–6. 12. Hollis BW. Circulating 25-hydroxyvitamin D sufficiency: implications for establishing a new effective dietary intake recommendation for vitamin D. J. Nutr. 2005; 135: 317–22. 13. Bischoff-Ferrari HA, Shao A, Dawson-Hughes B, Hathcock J, Giovannucci E, Willett WC. Benefit-risk assessment of vitamin D supplementation. Osteoporos. Int. 2010; 21: 1121–32. 14. Joshi D, Center JR, Eisman JA. Vitamin D deficiency in adults. Aust. Perscr. 2010; 33: 103–6. 15. Department of Health. Victorian Health Monitor Vitamin D Survey. Melbourne: Department of Health, 2013.
© 2015 Royal Australasian College of Surgeons
769
16. Bischoff-Ferrari HA, Willett WC, Wong JB, Giovannucci E, Dietrich T, Dawson-Hughes B. Fracture prevention with vitamin D supplementation a meta-analysis of randomized controlled trials. JAMA 2011; 293: 2257– 64. 17. Nowson CA, McGrath JJ, Ebeling PR et al. Vitamin D and health in adults in Australia and New Zealand: a position statement. Med. J. Aust. 2012; 196: 686–7. 18. Diamanatopoulos AP, Rhode G, Johnsrud I, Skoie IM, Hochberg M, Haugeberg G. The epidemiology of low- and high-energy distal radial fracture in middle-aged and elderly men and women in Southern Norway. PLoS ONE 2012; 7: E42267. 19. Krappinger D, Kammerlander C, Hak DJ, Blauth M. Low-energy osteoporotic fractures. Arch. Orthop. Trauma Surg. 2010; 130: 1167–75. 20. 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: 1911– 30. 21. Rigel DS. Cutaneous ultraviolet exposure and its relationship to the development of skin cancer. J. Am. Acad. Dermatol. 2008; 58: s129–32. 22. Feelisch M, Kold-Bachofen V, Liu D et al. Is sunlight good for our heart? Eur. Heart J. 2010; 31: 1041–5. 23. Liu D, Fernandez BO, Hamilton A et al. UVA irradiation of human skin vasodilates arterial vasculature and lowers blood pressure independently of nitric oxide synthase. J. Invest. Dermatol. 2014; 134: 1839–46. 24. Holick MF. Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers and cardiovascular disease. Am. J. Clin. Nutr. 2004; 80 (Suppl.): 1678S–88S. 25. Bischoff-Ferrari HA, Willett WC, Orav EJ et al. A pooled analysis of vitamin D dose requirements for fracture prevention. N. Engl. J. Med. 2012; 367: 40–9. 26. Working Group of the Australian and New Zealand Bone and Mineral Society, Endocrine Society of Australia and Osteoporosis Australia. Vitamin D and adult bone health in Australia and New Zealand: a position statement. Med. J. Aust. 2005; 182: 281–5.
Patients presenting with fractures are likely to be vitamin D deficient: are we getting enough sun? Tyler C. Mow, Christopher M. Stokes and Alasdair G. Sutherland Warrnambool Campus, Deakin University Medical School, Geelong, Victoria, Australia
Key words deficiency, internal fixation, fracture force. Correspondence Dr Tyler C. Mow, Deakin University Medical School, Warrnambool Campus, 8/14 Albert Street, Northcote, Geelong, Vic. 3070, Australia. Email: [email protected] T. C. Mow MBBS, BSci; C. M. Stokes MBBS, BMedSci, PGDipSurgAnat; A. G. Sutherland MD (Hons), FRCSEd (Tr&Orth), FRACS Orth, FAOrthA. Accepted for publication 24 April 2015. doi: 10.1111/ans.13190
Abstract Background: 25-Hydroxyvitamin D serves a crucial role in bone metabolism through its role on osteoclast and osteoblastic function. To assess the implication of vitamin D and its relationship to bone fracture and fracture force, we have examined vitamin D levels in patients requiring inpatient fracture management. Methods: We performed serological testing of vitamin D levels, calcium, parathyroid hormone and liver function tests on patients admitted to our rural institution in southeastern Australia for inpatient fracture management. All participants completed a questionnaire designed to screen for potential contributing factors to bony fragility. Demographic data were also obtained including age, gender and body mass index. Fracture location and the type of inpatient management as well as the force of injury were included in our analysis. Results: We recruited 100 patients to the study, with a median age of 72 (range 22–98) of whom 66 were women. Most had low-energy fractures (79%), treated by internal fixation (73%) or arthroplasty (9%) with 18 treated non-operatively. The majority of the patients were at best vitamin D insufficient, 65 nmol/L reduced fracture risk by up to 20%.10 Levels up to 75 nmol/L and above have been suggested as optimal,11–13 which would require higher dose supplementation.13 We wished to examine the prevalence of vitamin D deficiency in a prospective cohort of patients presenting for inpatient treatment of fractures in a rural population in southeastern Australia (living at 38° south). We were also interested in the relationship between vitamin levels and the type of fractures sustained and type of treatment required.
Methods
electrolytes, creatinine, calcium, magnesium, phosphate, liver function tests and parathyroid hormone levels were taken.
Statistical analysis Based on observations of emergency department fracture presentations, we determined that a sample size of 100 patients would be appropriate to assess vitamin D status within our rural population. As this was a cohort study of vitamin D levels, no formal power calculation was undertaken. Patients were assigned a study number and data were stored and analysed anonymously. Vitamin D levels were the primary outcome measure and were recorded as absolute values and also categorized: (i) vitamin D deficiency (75 nmol/L). Secondary outcomes included the relationship between vitamin D levels and force of injury, type of treatment and sun exposure. Analysis used Statistical Package for Social Sciences v22 (IBM, Melbourne, Victoria, Australia). Statistical significance was set at a P-value of 60 nmol/L for the prevention of fracture.26 This study has demonstrated that the prevalence of vitamin D insufficiency and deficiency are high in those presenting with fractures and represents both behavioural factors as well as engrained sun smart policies.
References 1. Patton C, Powell A. Vitamin D in orthopaedics. J. Am. Acad. Orthop. Surg. 2012; 20: 123–9. 2. Suda T, Shinki T. The role of vitamin D in bone and intestinal cell differentiation. Annu. Rev. Nutr. 1990; 10: 195–211. 3. Daly RM, Gagnon C, Lu ZX et al. Prevalence of vitamin D deficiency and its determinants in Australian adults aged 25 years and older: a national, population-based study. Clin. Endocrinol. (Oxf) 2012; 77: 26–35.
© 2015 Royal Australasian College of Surgeons
Vitamin D and patients with fractures
4. Van Der Mei IA, Dore D, Winzenberg L, Blizzard L, Jones G. Vitamin D deficiency in Tasmania: a whole life perspective. Intern. Med. J. 2012; 42: 1137–44. 5. Van Der Mei IA, Ponsonby AL, Engelson O et al. The high prevalence of vitamin D insufficiency across Australian Populations is only partly explained by season and latitude. Environ. Health Perspect. 2007; 115: 1132–9. 6. Cancer Council Australia. Risks and benefits of sun exposure position statement. 2007. 7. Nowson CA, Diamond TH, Pasco JA et al. Vitamin D in Australia. Issues and recommendations. Aust. Fam. Physician 2004; 33: 133–8. 8. Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB et al. Fall prevention with supplemental and active forms of vitamin D: a metaanalysis of randomised controlled trials. BMJ 2009; 339: b3692. 9. Bischoff-Ferrari HA, Willett WC, Wong JB et al. Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a metaanalysis of randomized controlled trials. Arch. Intern. Med. 2009; 169: 551–61. 10. Dawson-Hughes B. What is the optimal dietary intake of vitamin D for reducing fracture risk. Calcif. Tissue Int. 2013; 92: 184–90. 11. Dawson-Hughes B, Heaney RP, Holick MF, Lips P, Meunier PJ, Veith R. Estimates of optimal vitamin D status. Osteoporos. Int. 2005; 16: 713–6. 12. Hollis BW. Circulating 25-hydroxyvitamin D sufficiency: implications for establishing a new effective dietary intake recommendation for vitamin D. J. Nutr. 2005; 135: 317–22. 13. Bischoff-Ferrari HA, Shao A, Dawson-Hughes B, Hathcock J, Giovannucci E, Willett WC. Benefit-risk assessment of vitamin D supplementation. Osteoporos. Int. 2010; 21: 1121–32. 14. Joshi D, Center JR, Eisman JA. Vitamin D deficiency in adults. Aust. Perscr. 2010; 33: 103–6. 15. Department of Health. Victorian Health Monitor Vitamin D Survey. Melbourne: Department of Health, 2013.
© 2015 Royal Australasian College of Surgeons
769
16. Bischoff-Ferrari HA, Willett WC, Wong JB, Giovannucci E, Dietrich T, Dawson-Hughes B. Fracture prevention with vitamin D supplementation a meta-analysis of randomized controlled trials. JAMA 2011; 293: 2257– 64. 17. Nowson CA, McGrath JJ, Ebeling PR et al. Vitamin D and health in adults in Australia and New Zealand: a position statement. Med. J. Aust. 2012; 196: 686–7. 18. Diamanatopoulos AP, Rhode G, Johnsrud I, Skoie IM, Hochberg M, Haugeberg G. The epidemiology of low- and high-energy distal radial fracture in middle-aged and elderly men and women in Southern Norway. PLoS ONE 2012; 7: E42267. 19. Krappinger D, Kammerlander C, Hak DJ, Blauth M. Low-energy osteoporotic fractures. Arch. Orthop. Trauma Surg. 2010; 130: 1167–75. 20. 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: 1911– 30. 21. Rigel DS. Cutaneous ultraviolet exposure and its relationship to the development of skin cancer. J. Am. Acad. Dermatol. 2008; 58: s129–32. 22. Feelisch M, Kold-Bachofen V, Liu D et al. Is sunlight good for our heart? Eur. Heart J. 2010; 31: 1041–5. 23. Liu D, Fernandez BO, Hamilton A et al. UVA irradiation of human skin vasodilates arterial vasculature and lowers blood pressure independently of nitric oxide synthase. J. Invest. Dermatol. 2014; 134: 1839–46. 24. Holick MF. Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers and cardiovascular disease. Am. J. Clin. Nutr. 2004; 80 (Suppl.): 1678S–88S. 25. Bischoff-Ferrari HA, Willett WC, Orav EJ et al. A pooled analysis of vitamin D dose requirements for fracture prevention. N. Engl. J. Med. 2012; 367: 40–9. 26. Working Group of the Australian and New Zealand Bone and Mineral Society, Endocrine Society of Australia and Osteoporosis Australia. Vitamin D and adult bone health in Australia and New Zealand: a position statement. Med. J. Aust. 2005; 182: 281–5.
