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Vitamin D and foot and ankle trauma: An individual or societal problem
Abstract
Background:
Vitamin D deficiency is a worldwide health concern. Hypovitaminosis D may adversely affect recovery from bone injury. The authors aimed to perform an audit of the Vitamin D status of patients in three centres in the United Kingdom presenting with foot and ankle osseous damage.
Methods:
Serum 25-hydroxyvitamin-D (vitamin D) levels were obtained in patients presenting with imaging confirmed foot and ankle osseous trauma. Variables including age, gender, ethnicity, location, season, month, anatomical location and type of bone injury were recorded.
Results:
308 patients were included from three different centres. 66.6% were female. The average age was 47.7 (range; 10-85). The mean hydroxyvitamin-D levels were 52.0 nmol/L (SD 28.5). 18.8% were grossly deficient, 23.7% deficient, 34.7% insufficient and 22.7% within normal range. 351 separate bone injuries were identified of which 104 were categorised as stress reactions, 134 as stress fractures, 105 as fractures and 8 non-unions. Age, gender, anatomical location and fracture type did not statistically affect vitamin D levels. Ethnicity did affect Vitamin D levels: non-Caucasians mean levels were 32.4 nmols/L compared to Caucasian levels of 53.2 nmol/L (p=0.0026).
Conclusion:
Only 18.8% of our trauma patients had a normal Vitamin D level and 22.7% were grossly deficient. Patient age, gender, anatomical location and injury type did not statistically affect vitamin D levels. No difference between trauma and elective patients were found. Hypovitaminosis D is a problem of society in general rather than specific to certain foot and ankle injury patterns or particular patient groups sustaining trauma.
Level of evidence:
2b.
... Severe deficiency was notably prevalent in cases with multiple fractures (five cases, 15.2%), hip fractures (three cases, 20%), and spine fractures (one case, 12.5%). However, Ribbans et al. [18] found no significant link between vitamin D levels and the anatomical location of the injury in their study. In a literature review by Maier et al. [3], it was found that numerous studies reported a high incidence of vitamin D deficiency in women with hip and vertebral fractures. ...
Background
Vitamin D deficiency is prevalent globally, with potential consequences for bone health and trauma outcomes. This study aimed to assess the prevalence of vitamin D deficiency in orthopedic trauma patients and investigate its correlation with various demographic and injury-related factors.
Methodology
A cross-sectional investigation was undertaken at a tertiary care center. An evaluation of serum 25-hydroxyvitamin D3 levels was conducted on 124 individuals, aged 20 to 70 years, who were hospitalized with orthopedic injuries. Demographic information, the injury method, the bone involvement pattern, and socioeconomic status were documented. Statistical analysis was employed to evaluate the correlations between vitamin levels D and these variables.
Results
The overall prevalence of vitamin D deficiency was 54 (43.6%) cases, with nine (7.3%) cases exhibiting severe deficiency and 45 (36.3%) cases exhibiting moderate deficiency. Higher rates of deficiency were associated with lower socioeconomic status (p = 0.044) and low-velocity trauma (p = 0.037). No significant association was found with age, sex, or residence. Interestingly, patients with multiple fractures were more prone to deficiency compared to those with single fractures.
Conclusions
This survey revealed a significant vitamin D deficiency among orthopedic trauma patients. Factors such as socioeconomic status and the nature of the injury emerged as significant risk factors. While conducting routine vitamin D assessments might pose challenges in developing nations, consistent supplementation could prove advantageous in enhancing fracture healing and overall health outcomes among this demographic. There is a call for future research to delve deeper into the role of vitamin D in trauma management and refine supplementation strategies.
... Junto a isso, a redução da exposição aos raios ultravioleta B (UVB) da luz solar faz com que se desenvolva uma deficiência que tem se tornado um problema de saúde pública. A população não caucasiana é a mais afetada pela hipovitaminose D. Já no que se refere às estações do ano, os meses de inverno são os que mais apresentam níveis da vitamina abaixo do ideal, assim como as regiões de alta latitude (Ribbans et al., 2019). Além disso, algumas comorbidades como Doença Celíaca e Tumor Mesenquimal Fosfatúrico, em conjunto com o tabagismo e a obesidade, estão fortemente correlacionadas com a deficiência da vitamina na população (Smith et al., 2014). ...
Objetivos: Revisar a literatura disponível sobre a relação entre a hipovitaminose D e as patologias de pé e tornozelo, com enfoque no sistema osteomuscular e na prevalência de fraturas, a fim de investigar os prejuízos dos baixos níveis da 25-hidroxivitamina D (25(OH)D) para a saúde humana. Metodologia: Trata-se de uma revisão integrativa. Foram selecionados artigos da plataforma PubMed, publicados até 2023, obtidos pela combinação dos descritores “Deficiência de vitamina D”, “Patologias”, "Fraturas”, “Pé” e “Tornozelo”, que respondiam à pergunta norteadora: “Hipovitaminose D e patologias do pé e tornozelo, há relação?”. Resultados: Foram incluídos 22 artigos publicados entre 2009 e 2023 e deles foram extraídos os dados sobre a relação da hipovitaminose D com patologias em pés e tornozelos, sendo os achados agrupados em manifestações nos sistemas osteoarticular, muscular e vascular. As manifestações osteoarticulares foram predominantes, sendo que menores taxas de consolidação de fratura óssea, maior tempo para cicatrização e maior índice de refratura foram as principais relações apresentadas. As manifestações musculares incluíram a redução da força muscular relacionada à hipovitaminose, apesar de 1 dos estudos não ter encontrado essa relação. Os achados vasculares relacionaram a insuficiência de vitamina D com a doença arterial periférica. Foram abordados o raquitismo e a osteomalácia secundários ao tumor mesenquimal fosfatúrico de tecidos moles do pé, condição rara que desencadeia a hipovitaminose D. Conclusão: A hipovitaminose D estabelece relação de causa e de consequência com patologias de pé e tornozelo, sendo os sistemas osteoarticular, muscular e vascular os principais acometidos.
... However, one series demonstrated no difference in the spectrum of vitamin D deficiency in a foot and ankle trauma group compared with a presurgical nontrauma group sampled simultaneously in the UK. 48 Stress fractures are common in young, active individuals. Much research in this area has been undertaken in the military. ...
Vitamin D deficiency is common in athletes. The conventional measurement of vitamin D levels provides a general indicator of body stores. However, there are nuances in its interpretation as values of 25(OH)D do not correlate absolutely with the amount of 'bioavailable' vitamin to the cells. Vitamin D should be regarded as a hormone and influences between 5% and 10% of our total genome. Determining the precise effect of the vitamin, isolated from the actions of other cofactors, is not straightforward and restricts our complete understanding of all of its actions. Deficiency has harmful effects on not only bone and muscle but also wider areas, including immunity and respiratory and neurological activities. More caution should be applied regarding the ability of supranormal vitamin D levels to elevate athletic performance. Hopefully, future research will shed more light on optimal levels of vitamin D and supplementation regimes, and improved understanding of its intracellular control of our genetic mechanisms and how extrinsic influences modify its activity.
Bone stress injuries (BSIs) are a frequent finding in athletes, particularly of the foot and ankle. A BSI is caused by recurring microtrauma to the cortical or trabecular bone exceeding the repair capacity of normal bone. The most frequent fractures at the ankle are low risk, characterized by a low risk for nonunion. These include the posteromedial tibia, the calcaneus, and the metatarsal diaphysis. High-risk stress fractures have a higher risk for nonunion and need more aggressive treatment. Examples are the medial malleolus, navicular bone, and the base of the second and fifth metatarsal bone.
Imaging features depend on the primary involvement of cortical versus trabecular bone. Conventional radiographs may remain normal up to 2 to 3 weeks. For cortical bone, early signs of BSIs are a periosteal reaction or the “gray cortex sign,” followed by cortical thickening and fracture line depiction. In trabecular bone, a sclerotic dense line may be seen. Magnetic resonance imaging enables early detection of BSIs and can differentiate between a stress reaction and a fracture. We review typical anamnestic/clinical findings, epidemiology and risk factors, imaging characteristics, and findings at typical locations of BSIs at the foot and ankle that may help guide treatment strategy and patient recovery.
Background:
Vitamin D deficiency is a global concern impacting upon large communities and certain disease populations. It can adversely affect the outcome of orthopaedic operations. We aimed to perform an audit of the Vitamin D status of patients in two centres in the United Kingdom undergoing elective foot and ankle surgery.
Methods:
Serum 25-hydroxyvitamin-D (vitamin D) levels were obtained prospectively in 577 consecutive elective patients undergoing elective foot and ankle surgery between October 2014 and March 2017 (29 months). Variables including age, gender, ethnicity, location, season, month and procedure type were recorded.
Results:
577 patients were included over the study period. 62.0% were female. Mean age was 53.2 (median 54.5, range 16.7-86.6). 300 patients were treated in Northampton and 277 in Leicester. The serum 25-hydroxyvitamin-D levels for the patient group were normally distributed. The mean was 52.3nmol/L (SD 28.0; range 7.5-175) and the median 47.5nmol/L. 21.7% were grossly deficient, 31.9% deficient, 28.9% insufficient and 17.5% within normal range. Age, gender and procedure type did not statistically affect vitamin D levels (p=0.5, t-test). Ethnicity, location and Winter season did affect Vitamin D levels (p<0.05). August was the most significant month with levels significantly higher than January, February, March, April, June, November and December (p<0.05, one-way ANOVA).
Conclusions:
Only 1 in 5.7 patients had a normal Vitamin D level and 1 in 4.6 were grossly deficient. Ethnicity and patient location significantly affected Vitamin D results. Summer months were noted to demonstrate significantly the highest levels and August the highest. We did not find that age or gender affected Vitamin D levels in our cohort.
Low levels of serum vitamin D have been linked to numerous musculoskeletal and nonmusculoskeletal conditions. Vitamin D deficiency appears relatively high among various patient subpopulations, including patients with fracture nonunion. We conducted a retrospective study to determine the prevalence of vitamin D deficiency and insufficiency in a large population of patients with orthopedic trauma. The study included all patients who were over age 18 years, had no risk factors for vitamin D deficiency, and were treated for an acute fracture at a Level 1 trauma center. Between January 2009 and September 2010, 889 trauma patients had recorded serum 25-hydroxyvitamin D levels. Overall prevalence of combined vitamin D deficiency/insufficiency was 77%; prevalence of vitamin D deficiency alone was 39%. There were no statistically significant (P < .05) age or sex differences among the population. There did not appear to be a seasonal difference. Vitamin D deficiency and insufficiency in acute orthopedic trauma patients appear very common. Further investigation is needed to fully understand the clinical significance.
Mounting evidence from observational and clinical trials indicates that optimal vitamin D reduces the risk of many diseases. We used observational studies and recent data on 25-hydroxyvitamin D [25(OH)D] concentrations of Canadians from Cycle 3 of the Canadian Health Measures Survey to estimate the reduction in disease incidence, mortality rates, and the total economic burden (direct plus indirect) of disease if 25(OH)D concentrations of all Canadians were raised to or above 100 nmol/L. Recently, the mean 25(OH)D concentration of Canadians varied depending on age and season (51–69 nmol/L), with an overall mean of 61 nmol/L. The diseases affected by 25(OH)D concentration included cancer, cardiovascular disease, dementia, diabetes mellitus, multiple sclerosis, respiratory infections, and musculoskeletal disorders. We used 25(OH)D concentration–health outcome relations for breast cancer and cardiovascular disease and results of clinical trials with vitamin D for respiratory infections and musculoskeletal disorders to estimate the reductions in disease burden for increased 25(OH)D concentrations. If all Canadians attained 25(OH)D concentrations>100 nmol/L, the calculated reduction in annual economic burden of disease was $12.5±6 billion on the basis of economic burdens for 2016 and a reduction in annual premature deaths by 23,000 (11,000–34,000)on the basis of rates for 2011. However, the effects on disease incidence, economic burden, and mortality rate would be phased in gradually over several years primarily because once a chronic disease is established, vitamin D affects its progression only modestly. Nevertheless, national policy changes are justified to improve vitamin D status of Canadians through promotion of safe sun exposure messages, vitamin D supplement use, and/or facilitation of food fortification.
Background:
The aim of the study was to evaluate the effects of the using bisphosphonate, vitamin D, and a combination of bisphosphonate and vitamin D on fracture healing, by comparison of radiological and histological findings of the study groups and a control group.
Methods:
A total of 24 rats were randomly divided into 4 groups. A mid-third fracture was created in the femur of all rats. Saline was administered to Group A, bisphosphonate (Alendronate) to Group B, bisphosphonate (Alendronate) + vitamin D (Calcitriol) to Group C and vitamin D (Calcitriol) to Group D. All preparations were administered orally for 28 days.
Results:
No statistically significant difference was determined between the groups in respect of the effect on fracture healing according to radiological findings. The histological findings of fracture healing showed Groups B and C to be significantly more advanced than Group A (p = 0.017, p = 0.009). However no significant difference was found in Group D comparison with Group A (p = 0.224).
Conclusion:
According to the histological findings, advanced fracture healing was seen in the groups administered with bisphosphonate or combined bisphosphonate and vitamin D compared to the use of vitamin D alone and the control group. It was concluded that bisphosphonate treatment combined with vitamin D can be used safely without any negative effect on fracture healing.
Previous national nutrition surveys in Irish adults did not include blood samples; thus, representative serum 25-hydroxyvitamin D (25(OH)D) data are lacking. In the present study, we characterised serum 25(OH)D concentrations in Irish adults from the recent National Adult Nutrition Survey, and determined the impact of vitamin D supplement use and season on serum 25(OH)D concentrations. Of the total representative sample (n 1500, aged 18+ years), blood samples were available for 1132 adults. Serum 25(OH)D was measured via immunoassay. Vitamin D-containing supplement use was assessed by questionnaire and food diary. Concentrations of serum 25(OH)D were compared by season and in supplement users and non-users. Year-round prevalence rates for serum 25(OH)D concentration < 30, < 40, < 50 and < 75 nmol/l were 6·7, 21·9, 40·1 and 75·6 %, respectively (11·1, 31·1, 55·0 and 84·0 % in winter, respectively). Supplement users had significantly higher serum 25(OH)D concentrations compared to non-users. However, 7·5 % of users had winter serum 25(OH)D < 30 nmol/l. Only 1·3 % had serum 25(OH)D concentrations >125 nmol/l. These first nationally representative serum 25(OH)D data for Irish adults show that while only 6·7 % had serum 25(OH)D < 30 nmol/l (vitamin D deficiency) throughout the year, 40·1 % had levels considered by the Institute of Medicine as being inadequate for bone health. These prevalence estimates were much higher during winter time. While vitamin D supplement use has benefits in terms of vitamin D status, at present rates of usage (17·5 % of Irish adults), it will have only very limited impact at a population level. Food-based strategies, including fortified foods, need to be explored.
Musculoskeletal pain affects nearly half of all adults, most of whom are vitamin D deficient. Previous findings demonstrated that putative nociceptors ("pain-sensing" nerves) express vitamin D receptors (VDRs), suggesting responsiveness to 1,25-dihydroxyvitamin D. In the present study, rats receiving vitamin D-deficient diets for 2-4 weeks showed mechanical deep muscle hypersensitivity, but not cutaneous hypersensitivity. Muscle hypersensitivity was accompanied by balance deficits and occurred before onset of overt muscle or bone pathology. Hypersensitivity was not due to hypocalcemia and was actually accelerated by increased dietary calcium. Morphometry of skeletal muscle innervation showed increased numbers of presumptive nociceptor axons (peripherin-positive axons containing calcitonin gene-related peptide), without changes in sympathetic or skeletal muscle motor innervation. Similarly, there was no change in epidermal innervation. In culture, sensory neurons displayed enriched VDR expression in growth cones, and sprouting was regulated by VDR-mediated rapid response signaling pathways, while sympathetic outgrowth was not affected by different concentrations of 1,25-dihydroxyvitamin D. These findings indicate that vitamin D deficiency can lead to selective alterations in target innervation, resulting in presumptive nociceptor hyperinnervation of skeletal muscle, which in turn is likely to contribute to muscular hypersensitivity and pain.
The goal of this work is to estimate the reduction in mortality rates for six geopolitical regions of the world under the assumption that serum 25-hydroxyvitamin D (25(OH)D) levels increase from 54 to 110 nmol/l.
This study is based on interpretation of the journal literature relating to the effects of solar ultraviolet-B (UVB) and vitamin D in reducing the risk of disease and estimates of the serum 25(OH)D level-disease risk relations for cancer, cardiovascular disease (CVD) and respiratory infections. The vitamin D-sensitive diseases that account for more than half of global mortality rates are CVD, cancer, respiratory infections, respiratory diseases, tuberculosis and diabetes mellitus. Additional vitamin D-sensitive diseases and conditions that account for 2 to 3% of global mortality rates are Alzheimer's disease, falls, meningitis, Parkinson's disease, maternal sepsis, maternal hypertension (pre-eclampsia) and multiple sclerosis. Increasing serum 25(OH)D levels from 54 to 110 nmol/l would reduce the vitamin D-sensitive disease mortality rate by an estimated 20%.
The reduction in all-cause mortality rates range from 7.6% for African females to 17.3% for European females. Reductions for males average 0.6% lower than for females. The estimated increase in life expectancy is 2 years for all six regions.
Increasing serum 25(OH)D levels is the most cost-effective way to reduce global mortality rates, as the cost of vitamin D is very low and there are few adverse effects from oral intake and/or frequent moderate UVB irradiance with sufficient body surface area exposed.
The objective was to provide guidelines to clinicians for the evaluation, treatment, and prevention of vitamin D deficiency with an emphasis on the care of patients who are at risk for deficiency.
The Task Force was composed of a Chair, six additional experts, and a methodologist. The Task Force received no corporate funding or remuneration.
Consensus was guided by systematic reviews of evidence and discussions during several conference calls and e-mail communications. The draft prepared by the Task Force was reviewed successively by The Endocrine Society's Clinical Guidelines Subcommittee, Clinical Affairs Core Committee, and cosponsoring associations, and it was posted on The Endocrine Society web site for member review. At each stage of review, the Task Force received written comments and incorporated needed changes.
Considering that vitamin D deficiency is very common in all age groups and that few foods contain vitamin D, the Task Force recommended supplementation at suggested daily intake and tolerable upper limit levels, depending on age and clinical circumstances. The Task Force also suggested the measurement of serum 25-hydroxyvitamin D level by a reliable assay as the initial diagnostic test in patients at risk for deficiency. Treatment with either vitamin D(2) or vitamin D(3) was recommended for deficient patients. At the present time, there is not sufficient evidence to recommend screening individuals who are not at risk for deficiency or to prescribe vitamin D to attain the noncalcemic benefit for cardiovascular protection.
Objectives:
To identify participants' characteristics that influence the anti-fracture efficacy of vitamin D or vitamin D plus calcium with respect to any fracture, hip fracture, and clinical vertebral fracture and to assess the influence of dosing regimens and co-administration of calcium.
Design:
Individual patient data analysis using pooled data from randomised trials.
Data sources:
Seven major randomised trials of vitamin D with calcium or vitamin D alone, yielding a total of 68 517 participants (mean age 69.9 years, range 47-107 years, 14.7% men).
Study selection:
Studies included were randomised studies with at least one intervention arm in which vitamin D was given, fracture as an outcome, and at least 1000 participants.
Data synthesis:
Logistic regression analysis was used to identify significant interaction terms, followed by Cox's proportional hazards models incorporating age, sex, fracture history, and hormone therapy and bisphosphonate use.
Results:
Trials using vitamin D with calcium showed a reduced overall risk of fracture (hazard ratio 0.92, 95% confidence interval 0.86 to 0.99, P=0.025) and hip fracture (all studies: 0.84, 0.70 to 1.01, P=0.07; studies using 10 microg of vitamin D given with calcium: 0.74, 0.60 to 0.91, P=0.005). For vitamin D alone in daily doses of 10 microg or 20 microg, no significant effects were found. No interaction was found between fracture history and treatment response, nor any interaction with age, sex, or hormone replacement therapy.
Conclusion:
This individual patient data analysis indicates that vitamin D given alone in doses of 10-20 microg is not effective in preventing fractures. By contrast, calcium and vitamin D given together reduce hip fractures and total fractures, and probably vertebral fractures, irrespective of age, sex, or previous fractures.
Osteomalacia is an uncommon cause of muscle weakness. Our objectives were to describe features of myopathy associated with Vitamin D deficiency and examine the contributing factors leading to osteomalacic myopathy in our region.
Patients identified retrospectively for the six year period ending in December 2006 with the diagnosis of osteomalacia and/or Vitamin D deficiency associated proximal muscle weakness were included. They were followed in three major centers in western Saudi Arabia. Clinical, biochemical, radiological, and electrophysiological findings were collected before and after Vitamin D treatment by chart review.
Forty seven female patients aged 13-46 years (mean 23.5, SD 4.5) were included. All were veiled and covered heavily when outside the house for social and cultural reasons. Only eight (17%) had adequate varied diet with daily milk ingestion. All patients presented with progressive proximal muscle weakness lasting 6-24 months (mean 14) prior to our evaluation. The weakness was severe in six (13%) patients leading to wheel chair bound states. Associated musculoskeletal pain involving the back, hips, or lower limbs was common (66%). Osteomalcia was the referral diagnosis in only 11 patients and the remaining 36 (77%) patients were misdiagnosed. All patients had metabolic and radiological profiles suggestive of osteomalacia. Remarkable recovery was documented in all patients following oral cholecalciferol and calcium supplementation.
Vitamin D deficiency is an important treatable cause of osteomalacic myopathy in Saudi Arabia. The diagnosis is frequently delayed or missed. Screening for Vitamin D deficiency in patients with acquired myopathy is needed to identify this treatable disorder.
The reduced capacity of older skin to synthesize vitamin D(3) under the influence of ultraviolet light makes older persons at risk of vitamin D deficiency. The risk could even be increased in institutionalized persons owing to their lower sunshine exposure. It has been reported that an inadequate vitamin D level is associated with secondary hyperparathyroidism, increased bone turnover, and bone loss, which increase fracture risk. The objective of this study was to assess the prevalence of inadequate serum vitamin D levels in institutionalized, postmenopausal, osteoporotic women. Assessment of 25-hydroxyvitamin D [25(OH)D] was performed in 445 institutionalized, osteoporotic women from nine countries (Australia, Belgium, France, Germany, Hungary, Italy, Poland, Spain and UK). For each institutionalized woman, three age-matched, noninstitutionalized, osteoporotic controls were also included. Four cutoffs of 25(OH)D inadequacy were fixed: less than 80, less than 75, less than 50 and less than 30 nmol/l. Mean age was 79.7 years (standard deviation [SD] = 5.8) for the institutionalized women and 79.5 years (SD = 5.5) for the noninstitutionalized women (p = 0.45). Significantly fewer institutionalized women received vitamin D supplements (13.2 vs 24.0%; p < 0.0001). In women without vitamin D supplements, the level of 25(OH)D was significantly lower in institutionalized women (56.9 [SD = 23.9] nmol/l) compared with noninstitutionalized women (63.2 [SD = 22.0] nmol/l; p < 0.0001). In institutionalized women (without vitamin D supplements), the prevalence of 25(OH)D inadequacy was 10.4, 41.2, 80.3 and 84.2% when considering cutoffs of 80, 75, 50 and 30 nmol/l, respectively. In the control group, the prevalence was 2.7, 22.9, 74.4 and 81.7%, respectively. The prevalence of vitamin D inadequacy was significantly higher in institutionalized women when considering the 75, 50 and 30 nmol/l cutoffs but not when considering the 80 nmol/l cutoff. This study highlights a high prevalence of vitamin D inadequacy in institutionalized, osteoporotic women. Compared with age-matched osteoporotic controls, the prevalence of severe vitamin D inadequacy was substantially more important in institutionalized women. We believe that a greater awareness of the importance of vitamin D inadequacy is needed in order to address this public health problem.
Low vitamin D levels may contribute to hip fractures in women, although limited data are available on vitamin D levels in US women admitted with acute hip fractures.
To determine whether postmenopausal women with hip fractures have low vitamin D and high parathyroid hormone levels compared with nonosteoporotic and osteoporotic women admitted for elective joint replacement.
Comparative case series conducted between January 1995 and June 1998.
Ninety-eight postmenopausal community-dwelling women with no secondary causes of bone loss admitted for hip replacement, of whom 30 women had acute hip fractures and 68 women were admitted for elective joint replacement. Of the women admitted for elective joint replacement, 17 had osteoporosis and 51 did not. Women with comorbid conditions or who were taking medications that affect bone density and turnover were excluded.
Primary measures were levels of vitamin D and parathyroid hormone; secondary measures were body composition and markers of bone turnover.
Women with hip fractures had lower levels of 25-hydroxyvitamin D than women without osteoporosis admitted for elective joint replacement (P = .02) and than women with osteoporosis admitted for elective joint replacement (P = .01) (medians, 32.4, 49.9, and 55.0 nmol/L, respectively; comparisons adjusted for age and estrogen intake). Parathyroid hormone levels were higher in women with fractures than women in the nonosteoporotic control group (P<.001) or than elective osteoporotic women (P = .001) (medians, 5.58, 3.26, and 3.79 pmol/L, respectively; comparisons adjusted for age and estrogen intake). Fifteen patients (50.0%) with hip fractures had deficient vitamin D levels (< or =30.0 nmol/L) and 11 (36.7%) had a parathyroid hormone level greater than 6.84 pmol/L. Levels of N-telopeptide, a marker of bone resorption, were greater in the women with hip fractures than in the elective nonosteoporotic controls (P = .004).
Postmenopausal community-living women who presented with hip fracture showed occult vitamin D deficiency. Repletion of vitamin D and suppression of parathyroid hormone at the time of fracture may reduce future fracture risk and facilitate hip fracture repair. Because vitamin D deficiency is preventable, heightened awareness is necessary to ensure adequate vitamin D nutrition, particularly in northern latitudes.
The purpose of our study was to investigate possible risk factors and mechanisms for the development of pelvic stress fractures in female Navy recruits. We used a case-control retrospective study of female Navy recruits undergoing basic military training. We compared anthropometric and activity data between recruits with pelvic stress fractures (N = 25) and female recruits who completed training without injury (N = 61). Recruits developing pelvic stress fractures were significantly (p < 0.05) shorter and lighter and were more frequently Asian or Hispanic than recruits without stress fractures. In addition, recruits with pelvic stress fractures reported marching in the back of their training division, were road guards, and felt that their stride was too long during training activities more often than recruits without injury. Self-reported fitness, activities before recruit training, or a history of amenorrhea was not found to be associated with the development of a pelvic stress fracture in our population.
Stress fractures account for substantial morbidity for young women undergoing U.S. Marine Corps basic training.
Certain pretraining characteristics identify women at increased risk of stress fractures during boot camp.
Cohort study; Level of evidence, 2.
Data collected included baseline performance on a timed run (a measure of aerobic fitness), anthropometric measurements, and a baseline questionnaire highlighting exercise and menstrual status among 2962 women undergoing basic training at the Marine Corps Recruit Depot, Parris Island, in 1995 and 1996.
One hundred fifty-two recruits (5.1%) had 181 confirmed lower extremity stress fractures, with the most common sites being the tibia (25%), metatarsals (22%), pelvis (22%), and femur (20%). Logistic regression models revealed that having low aerobic fitness (a slower time on the timed run) and no menses during the past year were significantly associated with the occurrence of any stress fracture and with pelvic or femoral stress fracture during boot camp.
These findings suggest that stress fractures may be reduced if women entering Marine Corps Recruit Depot training participated in pretraining activities designed to improve aerobic fitness. Furthermore, women reporting no menses during the previous year may need additional observation during training.
Consistent with previous studies, we found that low aerobic fitness was the only modifiable risk factor associated with stress fractures during boot camp.
Background
Recruits undergoing military training experience a particularly high incidence of stress fractures. The role of combined calcium and vitamin D (25-OHD) deficiency and subsequent supplementation has been well described in the literature, but the role of 25-OHD deficiency alone is less well understood, particularly its influence on recovery once a stress fracture has been incurred.
Methods
Retrospective data of recruits who had incurred stress fractures were collected (n=37). Independent-samples t-tests were conducted in Microsoft Excel to investigate the association between serum-25 OHD and the time taken to recover.
Results
Significant differences (p<0.05) were found in the mean time taken to recover from stress fractures when participants were grouped according to serum 25-OHD level. Sufficient levels of serum 25-OHD (>50 nmol/L) at the time of injury resulted in shorter recovery times than all other groups.
Conclusion
The study demonstrated an association between serum 25-OHD level and the time taken to recover from a stress fracture. The sample population of this study was too small to contribute to the discussion about whether a minimum serum 25-OHD status should be met before entering British Army training, but a larger prospective study should be able to provide the data required for a cost benefit analysis to be conducted and a decision made.
The purpose of this study was to explore factors associated with increased stress fractures in collegiate cross country runners. Participants in this study were 42 male and female cross country runners at a Division I university. Each athlete completed a questionnaire regarding smoking status, vitamin/mineral intake, previous stress fracture history, birth control usage, menstrual status, and demographic information. Nutritional assessment via a 3-day food record and measurements of whole body, lumbar spine, and hip bone mineral densities (BMD) were also conducted on each athlete. Results indicated that 40% of the female and 35% of the male runners reported a history of stress fracture, and that all of these did not meet the recommended daily energy intake or adequate intakes for calcium or Vitamin D required for their amount of training. Two-tailed t-test found statistically higher incidences of lumbar spine BMD in males and females whose daily calcium and Vitamin D intakes were below minimum requirements as well as for women whose caloric intake was below the required level. When data on the lumbar spine was evaluated, 31% of participants (31.8% of the male and 30% of the female runners) were identified as having osteopenia and 4.8% with osteoporosis. Results warrant a need for future longitudinal studies.
Aims:
To evaluate the effect of a single early high-dose vitamin D supplement on fracture union in patients with hypovitaminosis D and a long bone fracture.
Patients and methods:
Between July 2011 and August 2013, 113 adults with a long bone fracture were enrolled in a prospective randomised double-blind placebo-controlled trial. Their serum vitamin D levels were measured and a total of 100 patients were found to be vitamin D deficient (< 20 ng/ml) or insufficient (< 30 ng/mL). These were then randomised to receive a single dose of vitamin D3 orally (100 000 IU) within two weeks of injury (treatment group, n = 50) or a placebo (control group, n = 50). We recorded patient demographics, fracture location and treatment, vitamin D level, time to fracture union and complications, including vitamin D toxicity. Outcomes included union, nonunion or complication requiring an early, unplanned secondary procedure. Patients without an outcome at 15 months and no scheduled follow-up were considered lost to follow-up. The t-test and cross tabulations verified the adequacy of randomisation. An intention-to-treat analysis was carried out.
Results:
In all, 100 (89%) patients had hypovitaminosis D. Both treatment and control groups had similar demographics and injury characteristics. The initial median vitamin D levels were 16 ng/mL (interquartile range 5 to 28) in both groups (p = 0.885). A total of 14 patients were lost to follow-up (seven from each group), two had fixation failure (one in each group) and one control group patient developed an infection. Overall, the nonunion rate was 4% (two per group). No patient showed signs of clinical toxicity from their supplement.
Conclusions:
Despite finding a high level of hypovitaminosis D, the rate of union was high and independent of supplementation with vitamin D3. Cite this article: Bone Joint J 2017;99-B:1520-5.
Vitamin D insufficiency and deficiency can be diagnosed with measurements of serum 25-hydroxyvitamin D (25OHD). Most vitamin D is derived from sunlight (80%), so serum 25OHD levels are lowest in late winter and early spring. Dietary vitamin D in North America is small, about 100 to 200 IU daily. A recent review of the literature shows many association studies relating vitamin D deficiency and insufficiency to several diseases. Large randomized trials of vitamin D are underway and soon there may be answers as to whether vitamin D is clinically effective and what level of serum 25OHD is necessary.
One hundred years ago, vitamin D was identified as the cause and cure of osteomalacia. This role remains firmly established. Vitamin D influences skeletal mineralization principally through the regulation of intestinal calcium absorption. It has been proposed that vitamin D has direct beneficial effects on bone (besides the prevention of osteomalacia), but these have been difficult to establish in clinical trials. Meta-analyses of vitamin D trials show no effects on bone density or fracture risk when the baseline 25-hydroxyvitamin D is >40 nmol/L. A daily dose of 400 to 800 IU vitamin D3 is usually adequate to correct such deficiency.
Postoperative nonunion is not uncommon in the lower extremity, and significant morbidity can be associated with nonunion of the foot and ankle after surgical reconstruction. For the purposes of the present study, we retrospectively reviewed and compared a cohort of patients who had undergone elective foot and ankle reconstruction to better assess the modifiable risk factors associated with postoperative nonunion. We hypothesized that the presence of endocrine and metabolic abnormalities are often associated with nonunion after foot and ankle surgical reconstruction. We formulated a matched case-control study that included 29 patients with nonunion and a control group of 29 patients with successful fusion to assess the prevalence of certain modifiable risk factors known to have an association with nonunion after foot and ankle arthrodesis. The modifiable risk factors assessed included body mass index, tobacco use, diabetes mellitus, vitamin D abnormality, thyroid dysfunction, and parathyroid disease. A statistically significant (p < .05) difference was found between the 2 groups for endocrine and metabolic disease diagnoses in the medical records of the 58 patients identified. Thus, 76% versus 26% (p < .05) of patients experienced nonunion in the endocrine disease group versus the nonendocrine disease group, respectively. Patients with vitamin D deficiency or insufficiency were 8.1 times more likely to experience nonunion (95% confidence interval 1.996 to 32.787). No statistically significant differences were found between the groups in terms of age, sex, tobacco use, body mass index, or procedure selection (p = .56, p = .43, p = .81, p = .28, and p = 1.0, respectively). A greater prevalence of endocrine abnormalities, in particular, vitamin D deficiency and insufficiency, was associated with nonunion after elective foot and ankle reconstruction. Patients with such abnormalities appear to have a greater risk of developing nonunion after arthrodesis procedures.
Introduction:
In the literature, there is conflicting data regarding the relationship between vitamin D and fractures. Reports on the effects of vitamin D levels on pathologies of the foot and ankle are limited. The purpose of this study is to assess the prevalence of vitamin D insufficiency in patients who have sustained low-energy metatarsal fractures compared to foot or ankle sprains without osseous involvement.
Methods:
Between May 2012 and August 2014, vitamin D levels and demographic data were collected prospectively in a total of 99 patients; 71 with metatarsal fractures and 28 with sprains, both from a low-energy mechanism of injury. Data between the metatarsal fracture group and sprain group were compared through univariate and multivariate analyses.
Results:
Mean vitamin D in the fracture group was 26.9 ng/mL (range = 78.0-4.3), and in the sprain group it was 27.1 ng/mL (range = 64.1-8.3; P = .93). Vitamin D insufficiency (<30 ng/mL) was present in 47 (66%) of fracture patients and 20 (71%) of sprain patients ( P = .81).
Conclusion:
A high incidence of hypovitaminosis D was seen in all foot and ankle patients. There was no difference in mean vitamin D level or incidence of vitamin D insufficiency between patients with metatarsal fractures or sprains resulting from similar low-energy mechanisms.
Levels of evidence:
Level III: Prospective, case-control study.
The claim that large proportions of North American and other populations are deficient in vitamin D is based on misinterpretation and misapplication of the Institute of Medicine reference values for nutrients — misunderstandings that can adversely affect patient care.
Importance
Vitamin D deficiency has been associated with poor physical performance.Objective
To determine the effectiveness of high-dose vitamin D in lowering the risk of functional decline.Design, Setting, and Participants
One-year, double-blind, randomized clinical trial conducted in Zurich, Switzerland. The screening phase was December 1, 2009, to May 31, 2010, and the last study visit was in May 2011. The dates of our analysis were June 15, 2012, to October 10, 2015. Participants were 200 community-dwelling men and women 70 years and older with a prior fall.Interventions
Three study groups with monthly treatments, including a low-dose control group receiving 24 000 IU of vitamin D3 (24 000 IU group), a group receiving 60 000 IU of vitamin D3 (60 000 IU group), and a group receiving 24 000 IU of vitamin D3 plus 300 μg of calcifediol (24 000 IU plus calcifediol group).Main Outcomes and Measures
The primary end point was improving lower extremity function (on the Short Physical Performance Battery) and achieving 25-hydroxyvitamin D levels of at least 30 ng/mL at 6 and 12 months. A secondary end point was monthly reported falls. Analyses were adjusted for age, sex, and body mass index.Results
The study cohort comprised 200 participants (men and women ≥70 years with a prior fall). Their mean age was 78 years, 67.0% (134 of 200) were female, and 58.0% (116 of 200) were vitamin D deficient (<20 ng/mL) at baseline. Intent-to-treat analyses showed that, while 60 000 IU and 24 000 IU plus calcifediol were more likely than 24 000 IU to result in 25-hydroxyvitamin D levels of at least 30 ng/mL (P = .001), they were not more effective in improving lower extremity function, which did not differ among the treatment groups (P = .26). However, over the 12-month follow-up, the incidence of falls differed significantly among the treatment groups, with higher incidences in the 60 000 IU group (66.9%; 95% CI, 54.4% to 77.5%) and the 24 000 IU plus calcifediol group (66.1%; 95% CI, 53.5%-76.8%) group compared with the 24 000 IU group (47.9%; 95% CI, 35.8%-60.3%) (P = .048). Consistent with the incidence of falls, the mean number of falls differed marginally by treatment group. The 60 000 IU group (mean, 1.47) and the 24 000 IU plus calcifediol group (mean, 1.24) had higher mean numbers of falls compared with the 24 000 IU group (mean, 0.94) (P = .09).Conclusions and Relevance
Although higher monthly doses of vitamin D were effective in reaching a threshold of at least 30 ng/mL of 25-hydroxyvitamin D, they had no benefit on lower extremity function and were associated with increased risk of falls compared with 24 000 IU.Trial Registration
clinicaltrials.gov Identifier: NCT01017354
Introduction:
The fifth metatarsal is a common site for both acute and stress fractures in the foot. They are usually isolated low-energy or stress fractures. Vitamin D deficiency has been associated with fragility fractures in many parts of the body. We believe that low Vitamin D could be a significant aetiological factor in fractures of the fifth metatarsal.
Methodology:
A prospective study of patients with fractures of the fifth metatarsal was conducted. Patients presenting to fracture clinic with these fractures had their vitamin D and calcium levels measured. We also conducted a literature review of studies of vitamin D levels in the Northern Hemisphere between 1990 and 2014.
Results:
Forty patients with fifth metatarsal fractures were studied (22 metatarsal base fractures, 6 shaft fractures, and 2 stress fractures). The average patient age was 49 (range 22-83). 12 patients (30%) had a Vitamin D level consistent with deficiency, and a further 14 (35%) had a level consistent with insufficiency. Average Vitamin D levels in winter fractures were significantly lower (52.23nmol/L) than for those sustained in summer (76.73nmol/L).
Conclusions:
Hypovitaminosis D was common in patients with fifth metatarsal fractures. Vitamin D supplementation has been shown in animal studies to improve fracture healing rates, and in humans to decrease the risk of fragility fracture. It should be part of regular practice to check Vitamin D levels in these patients, and supplement where necessary.
Vitamin D is an essential, fat-soluble nutrient that is a key modulator of bone health. Despite the gaining popularity throughout published medical studies, no consensus has been reached regarding a serum vitamin D level that will guarantee adequate skeletal health in a patient with an increased functional demand. The purpose of the present investigation was to examine the serum concentrations of vitamin D in patients with confirmed stress fractures. A total of 124 patients were included in our retrospective cohort study. Of the 124 patients, 53 had vitamin D levels measured within 3 months of diagnosis. An association was seen in patients with a stress fracture and vitamin D level measured, as 44 (83.02%) of the 53 patients had a serum 25-hydroxyvitamin D level <40 ng/mL. Although an association was seen at our institution in patients with stress fractures and a serum vitamin D concentration <40 ng/mL, a larger and prospective investigation is warranted to further understand the effect of vitamin D level and stress fracture prevention in an active, nonmilitary population.
To determine the prevalence of hypovitaminosis D in primary care outpatients with persistent, nonspecific musculoskeletal pain syndromes refractory to standard therapies.
In this cross-sectional study, 150 patients presented consecutively between February 2000 and June 2002 with persistent, nonspecific musculoskeletal pain to the Community University Health Care Center, a university-affiliated inner city primary care clinic in Minneapolis, Minn (45 degrees north). Immigrant (n = 83) and nonimmigrant (n = 67) persons of both sexes, aged 10 to 65 years, from 6 broad ethnic groups were screened for vitamin D status. Serum 25-hydroxyvitamin D levels were determined by radioimmunoassay.
Of the African American, East African, Hispanic, and American Indian patients, 100% had deficient levels of vitamin D (< or = 20 ng/mL). Of all patients, 93% (140/ 150) had deficient levels of vitamin D (mean, 12.08 ng/mL; 95% confidence interval, 11.18-12.99 ng/mL). Nonimmigrants had vitamin D levels as deficient as immigrants (P = .48). Levels of vitamin D in men were as deficient as in women (P = .42). Of all patients, 28% (42/150) had severely deficient vitamin D levels (< or = 8 ng/mL), including 55% of whom were younger than 30 years. Five patients, 4 of whom were aged 35 years or younger, had vitamin D serum levels below the level of detection. The severity of deficiency was disproportionate by age for young women (P < .001), by sex for East African patients (P < .001), and by race for African American patients (P = .006). Season was not a significant factor in determining vitamin D serum levels (P = .06).
All patients with persistent, nonspecific musculoskeletal pain are at high risk for the consequences of unrecognized and untreated severe hypovitaminosis D. This risk extends to those considered at low risk for vitamin D deficiency: nonelderly, nonhousebound, or nonimmigrant persons of either sex. Nonimmigrant women of childbearing age with such pain appear to be at greatest risk for misdiagnosis or delayed diagnosis. Because osteomalacia is a known cause of persistent, nonspecific musculoskeletal pain, screening all outpatients with such pain for hypovitaminosis D should be standard practice in clinical care.
Vitamin D deficiency has been identified as one of the most common causes of fragility fractures and poor fracture healing. Although rates of vitamin D deficiency have been delineated in various orthopaedic populations, little is known about the prevalence of vitamin D deficiency in patients with foot and ankle disorders. The goal of this study was to identify the prevalence of vitamin D deficiency in patients with a low energy fracture of the foot or ankle.
Over a 6-month period, a serum 25-OH vitamin D level was obtained from consecutive patients with a low energy ankle fracture, fifth metatarsal base fracture, or stress fracture of the foot or ankle. For comparative purposes, vitamin D levels in patients with an ankle sprain and no fracture were also examined.
The study cohort included 75 patients, of which 21 had an ankle fracture, 23 had a fifth metatarsal base fracture, and 31 had a stress fracture. The mean age was 52 (range, 16-80) years. Thirty-five of the fracture patients (47%) had an insufficient vitamin D level (below the recommended level of 30 ng/mL), and 10 of the patients (13%) had a level that was deficient (< 20 ng/mL). Vitamin D levels were significantly lower in those with a fracture than in those with an ankle sprain (P = .02). In the fracture cohort, the factors significantly associated with vitamin D insufficiency in the multivariate analysis were smoking (P = .03), obesity (P = .003), and other medical risk factors for vitamin D deficiency (P = .03).
Hypovitaminosis D was common among patients with a foot or ankle injury seen at our institution. Patients with a low energy fracture of the foot or ankle were at particular risk for low vitamin D, especially if they smoked, were obese, or had other medical risk factors. Given that supplementation with vitamin D (± calcium) has been shown to reduce the risk of fragility fractures and improve fracture healing, monitoring of 25-OH vitamin D and supplementation should be considered in patients with fractures.
Level III, prospective case control.
The incidence and distribution of stress fractures were evaluated prospectively over 12 months in 53 female and 58 male competitive track and field athletes (age range, 17 to 26 years). Twenty athletes sustained 26 stress fractures for an overall incidence rate of 21.1%. The incidence was 0.70 for the number of stress frac tures per 1000 hours of training. No differences were observed between male and female rates (P > 0.05). Twenty-six stress fractures composed 20% of the 130 musculoskeletal injuries sustained during the study. Although there was no difference in stress fracture incidence among athletes competing in different events (P > 0.05), sprints, hurdles, and jumps were associated with a significantly greater number of foot fractures; middle- and long-distance running were as sociated with a greater number of long bone and pelvic fractures (P < 0.05). Overall, the most common sites of bone injuries were the tibia with 12 injuries (46%), followed by the navicular with 4 injuries (15%), and the fibula with 3 injuries (12%). The high incidence of stress fractures in our study suggests that risk factors in track and field athletes should be identified.
Vitamin D is an important component in musculoskeletal development, maintenance, and function. Adequate levels of vitamin D correlate with greater bone mineral density, lower rates of osteoporotic fractures, and improved neuromuscular function. Debate exists about both adequate levels required and intake requirements needed to prevent deficiency of vitamin D. Epidemiologic data have identified an increasing number of orthopaedic patients at risk for vitamin D deficiency, with potentially widespread consequences for bone healing, risk of fracture, and neuromuscular function.
Vitamin D is essential for optimal bone health and muscle function. An alarmingly high rate of vitamin-D deficiency in the general population has been reported recently. The purpose of the present study was to characterize the extent of low serum levels of vitamin D among orthopaedic surgery patients.
We performed a retrospective chart review of 723 patients who were scheduled for orthopaedic surgery between January 2007 and March 2008. Preoperative serum 25-hydroxyvitamin D (25[OH]D) levels were measured. The prevalence of normal (≥32 ng/mL), insufficient (<32 ng/mL), and deficient (<20 ng/mL) vitamin-D levels was determined. Logistic regression was used to assess risk factors for insufficient (<32 ng/mL) 25(OH)D levels.
Overall, 43% of all patients had insufficient serum vitamin-D levels, and, of these, 40% had deficient levels. Among the orthopaedic services, the highest rates of low serum vitamin-D levels were seen in the trauma and sports services, in which the rates of abnormal (insufficient and deficient) vitamin-D levels were 66% and 52%, respectively. The lowest rate of abnormal vitamin-D levels was seen in the metabolic bone disease service. Patients between the ages of fifty-one and seventy years were 35% less likely to have low vitamin-D levels than patients between the ages of eighteen and fifty years (p = 0.018). The prevalence of low vitamin-D levels was significantly higher in men (p = 0.006). Individuals with darker skin tones (blacks and Hispanics) were 5.5 times more likely to have low vitamin-D levels when compared with those with lighter skin tones (whites and Asians) (p < 0.001).
The prevalence of low serum levels of vitamin D among patients undergoing orthopaedic surgery is very common. Given the importance of vitamin D in musculoskeletal health, such low levels may negatively impact patient outcomes.
Osteoporosis is a major health problem characterized by compromised bone strength that predisposes patients to an increased risk of fracture, more and more investigations are focusing on the treatment of osteoporotic fracture healing. However, there are few studies elucidating the efficacy of vitamin D, 1,25-dihydroxy vitamin D(3) (1,25(OH)(2)D(3)), on osteoporotic fracture healing. In the present study we have established an osteoporotic fracture rat model to evaluate the effects of 1,25(OH)(2)D(3) on fracture healing. Female SD rats of six-month-old (n=40) allocated randomly into two groups were given ovariectomy. Bilateral midshaft femoral osteotomy was performed 12 weeks post-ovariectomy. Then treatment was begun at the second day after osteotomy and continued until sacrifice at 6 and 16 weeks post-fracture with middle chain triglyceride (MCT) vehicle and 1,25(OH)(2)D(3) at 0.1 microg/kg/day by oral gavage. Fracture callus was evaluated by soft X-ray radiography, micro-computed tomography (micro-CT), biomechanical testing and histology. Soft X-ray radiography, at 6 weeks post-fracture, showed a less distinct fracture line in the 1,25(OH)(2)D(3) group compared with the MCT-vehicle group, however, the fracture line was invisible in both groups at 16 weeks post-fracture. Micro-CT based histomorphometric data, at 6 weeks post-fracture, showed that the total volume of callus (TV) was approximately 23% higher in the 1,25(OH)(2)D(3) group than that in the MCT-vehicle group (P<0.001), and the new bone volume (BV), BV/TV, the trabecular number (Tb.N), and density of TV also showed the same trend. At 16 weeks post-fracture, the increment still existed as shown by Tb.Th and density of TV (P<0.001, vs control). Biomechanical testing data, at 6 weeks post-fracture, showed that the ultimate load at failure and energy absorption of the 1,25(OH)(2)D(3) group were nearly one fold higher than that of the MCT-vehicle group (P<0.001). At 16 weeks post-fracture, the ultimate load and energy absorption were also higher with the treatment of 1,25(OH)(2)D(3) (P<0.01 vs control). Histology showed that the fracture callus in the 1,25(OH)(2)D(3) group was remodeled better compared to the control group. In conclusion, 1,25(OH)(2)D(3) could promote fracture healing by improving the histomorphometric parameters, mechanical strength and tendency to increase transformation of woven bone into lamellar bone in an ovariectomized rat model.
Vitamin D has important benefits in reducing the risk of many conditions and diseases. Those diseases for which the benefits are well supported and that have large economic effects include many types of cancer, cardiovascular diseases, diabetes mellitus, several bacterial and viral infections, and autoimmune diseases such as multiple sclerosis. Europeans generally have low serum 25-hydroxyvitamin D [25(OH)D] levels owing to the high latitudes, largely indoor living, low natural dietary sources of vitamin D such as cold-water ocean fish, and lack of effective vitamin D fortification of food in most countries. Vitamin D dose-disease response relations were estimated from observational studies and randomized controlled trials. The reduction in direct plus indirect economic burden of disease was based on increasing the mean serum 25(OH)D level to 40 ng/mL, which could be achieved by a daily intake of 2000-3000 IU of vitamin D. For 2007, the reduction is estimated at euro187,000 million/year. The estimated cost of 2000-3000 IU of vitamin D3/day along with ancillary costs such as education and testing might be about euro10,000 million/year. Sources of vitamin D could include a combination of food fortification, supplements, and natural and artificial UVB irradiation, if properly acquired. Additional randomized controlled trials are warranted to evaluate the benefits and risks of vitamin D supplementation. However, steps to increase serum 25(OH)D levels can be implemented now based on what is already known.
Athletes from 20 Division I AA collegiate varsity sports and 1 club sport were followed carefully for the development of stress fractures during the 1990 to 1991 and the 1991 to 1992 academic years. During this period, among 914 athletes, 34 stress fractures were sustained. Seven of these, or 20.6%, were of the femoral shaft. This represents a much higher incidence than previously observed in athletes. A new clinical test is described that significantly aids in the early diagnosis and follow-up treatment of femoral shaft stress fractures.
It is widely acknowledged that musculoskeletal injuries occur as a result of vigorous physical activity and exercise, but little quantitative documentation exists on the incidence of or risk factors for these injuries. This study was conducted to assess the incidence, types, and risk factors for training-related injuries among young men undergoing Army infantry basic training. Prior to training we evaluated 303 men (median age 19 yr), utilizing questionnaires and measurements of physical fitness. Subjects were followed over 12 wk of training. Physical training was documented on a daily basis, and injuries were ascertained by review of medical records for every trainee. We performed univariate and multivariate analyses of the data. Cumulative incidence of subjects with one or more lower extremity training-related injury was 37% (80% of all injuries). The most common injuries were muscle strains, sprains, and overuse knee conditions. A number of risk factors were identified, including: older age, smoking, previous injury (sprained ankles), low levels of previous occupational and physical activity, low frequency of running before entry into the Army, flexibility (both high and low), low physical fitness on entry, and unit training (high running mileage).
In a previous ultrastructural study, the benefit of a single high dose of vitamin D3 on fracture healing in a healthy animal model was demonstrated. This study examined the biomechanical consequences of applying a single high dose of vitamin D3 in a healthy rabbit model subsequent to femoral fracture. The fracture load, the values of energy absorbed until fracture and the flexural rigidity values of the vitamin D group were significantly higher than the corresponding ones of the control group in the case of fracture. On the other hand, for intact bones, those values did not differ significantly between the two groups. It was concluded that single high-dose vitamin D3 application had positive effects on fracture healing in a healthy animal model, as far as the parameters related to mechanical strength are concerned.
The purpose of this study was to identify rates of diagnosis-specific musculoskeletal injuries in U.S. Marine Corps recruits and to examine the association between patterns of physical training and these injuries.
Subjects were 1,296 randomly selected male Marine recruits, ages 17 to 28 yr, who reported to Marine Corps Recruit Depot San Diego for boot camp training between January 12 and September 14, 1993. Recruits were followed prospectively through 12 wk of training for injury outcomes. Injury patterns were examined in relation to weekly volumes and types of vigorous physical training.
The overall injury rate was 39.6% (number of recruits injured/population at risk), with 82% of injuries occurring in the lower extremities. Overuse injuries accounted for 78% of the diagnoses. The most frequent site of injury was the ankle/foot region (34.3% of injuries), followed by the knee (28.1%). Ankle sprains (6.2%, N = 1,143), iliotibial band syndrome (5.3%, N = 1,143), and stress fractures (4.0%, N = 1,296) were the most common diagnoses. Injury rates were highest during the weeks with high total volumes of vigorous physical training and the most hours of running and marching. Weekly injury rates were significantly correlated with hours of vigorous physical training (overuse injuries r = 0.667, P = 0.018; acute injuries r = 0.633, P = 0.027).
The results of this controlled epidemiological investigation indicate that volume of vigorous physical training may be an etiologic factor for exercise-related injuries. The findings also suggest that type of training, particularly running, and abrupt increases in training volume may further contribute to injury risk.
The purpose of this study was to (1) quantify the healing process of the human osteoporotic proximal humerus fracture (PHF) expressed in terms of callus formation over the fracture region using BMD scanning, and (2) quantify the impact of medical intervention with vitamin D3 and calcium on the healing process of the human osteoporotic fracture. The conservatively treated PHF was chosen in order to follow the genuine fracture healing without influence of osteosynthetic materials or casts. Thirty women (mean age = 78 years; range = 58-88) with a PHF, osteoporosis or osteopenia (based on a hip scan, WHO criteria), and not taking any drugs related to bone formation, including calcium or vitamin D supplementation, were randomly assigned to either oral 800 IU vitamin D3 plus 1 g calcium or placebo, in a double-blind prospective study. We measured biochemical, radiographic, and bone mineral density effect parameters to evaluate the impact on the healing process. Scanning procedures of the fractured shoulder included use of a fixation device to obtain the highest possible precision. Double scans of the fractured shoulder revealed a coefficient of variation (CV) on BMD measurements that improved from 2.8% immediately after fracture occurrence to 1.7% at 12 weeks (P = 0.003) approaching the 1.2% levels observed over the healthy shoulder. BMD was similar in the two groups at baseline (active 0.534 g/cm2 vs. placebo 0.518 g/cm2), and both increased over the 12-week observation period, with peak levels in week 6. By week 6 BMD levels were higher in the active group (0.623 g/cm2) compared with the placebo group (0.570 g/cm2, P = 0.006). Thirty seven percent of the patients presented with vitamin D levels below 30 nmol/l, indicative of mild vitamin D insufficiency. In conclusion, we have demonstrated that it is possible to quantify callus formation of the PHF with sufficiently high precision to demonstrate the positive influence of vitamin D3 and calcium over the first 6 weeks after fracture. Whether this results in more stable fractures, extends to other fracture types, or applies to other osteogenic bone agents such as bisphosphonates remains to be examined.
The purpose of this prospective study was to examine rates and risk factors for overuse injuries among 824 women during Marine Corps Recruit Depot basic training at Parris Island, SC, in 1999.
Data collected included training day exposures (TDE), baseline performance on a standardized 1.5-mile timed run, and a pretraining questionnaire highlighting exercise and health habits. The women were followed during training for occurrence of stress fracture and other lower-extremity overuse injury.
There were 868 lower-extremity overuse injuries for an overall injury rate of 12.6/1000 TDE. Rates for initial and subsequent injury were 8.7/1000 and 20.7/1000 TDE, respectively. There were 66 confirmed lower-extremity stress fractures among 56 (6.8%) women (1.0/1000 TDE). Logistic regression modeling indicated that low aerobic fitness (a slower time on the timed run (> 14.4 min)), no menses in six or more consecutive months during the past year, and less than 7 months of lower-extremity weight training were significantly associated with stress fracture incidence. Self-rated fair-poor fitness at baseline was the only variable significantly associated with other non-stress fracture overuse injury during basic training.
Among this sample of women, the risk of lower-extremity overuse injury was high, with a twofold risk of subsequent injury. The results suggest that stress fracture injury might be decreased if women entered training with high aerobic fitness and participated frequently in lower-extremity strength training. Furthermore, women reporting a history of menstrual irregularity at their initial medical exam may require closer observation during basic training.
To determine whether patients with unexplained nonunions, patients with a history of multiple low-energy fractures with at least one progressing to a nonunion, and patients with a nonunion of a nondisplaced pubic rami or sacral ala fracture would have an underlying metabolic or endocrine abnormality that had not been previously diagnosed.
Case series.
Tertiary referral center.
From a larger series of 683 consecutive patients with nonunion seen by us between January 1998 and December 2005, 37 patients were referred to 1 of 2 clinically practicing endocrinologists to undergo an evaluation for metabolic and endocrine abnormalities. The screening criteria were: 1) an unexplained nonunion that occurred despite adequate reduction and stabilization (and debridement in initially infected cases) without obvious technical error and without any other obvious etiology; 2) a history of multiple low-energy fractures with at least one progressing to a nonunion; or 3) a nonunion of a nondisplaced pubic rami or sacral ala fracture.
In all, 31 of the 37 patients (83.8%, 95% CI: 71.3% to 93.8%) who met our screening criteria had one or more new diagnoses of metabolic or endocrine abnormalities. The most common newly diagnosed abnormality was vitamin D deficiency (25 of 37 patients; 68%). Other newly diagnosed abnormalities included calcium imbalances, central hypogonadism, thyroid disorders, and parathyroid hormone disorders. All newly diagnosed abnormalities were treated medically. Eight patients who underwent no operative intervention following the diagnosis and treatment of a new metabolic or endocrine abnormality achieved bony union in an average of 7.6 months (range, 3 to 12 months) following their first visit to the endocrinologist.
Although our study does not prove a causal link between metabolic and endocrine abnormalities and either the development or healing of nonunions, 84% of the patients who met our screening criteria were found to have metabolic or endocrine abnormalities, and eight of our patients achieved bony union following medical treatment alone. All patients with nonunion who meet our screening criteria should be referred to an endocrinologist for evaluation because they are likely to have undiagnosed metabolic or endocrine abnormalities that may be interfering with bone healing.
Stress fractures (SFx) are one of the most common and debilitating overuse injuries seen in military recruits, and they are also problematic for nonmilitary athletic populations. The goal of this randomized double-blind, placebo-controlled study was to determine whether a calcium and vitamin D intervention could reduce the incidence of SFx in female recruits during basic training.
We recruited 5201 female Navy recruit volunteers and randomized them to 2000 mg calcium and 800 IU vitamin D/d or placebo. SFx were ascertained when recruits reported to the Great Lakes clinic with symptoms. All SFx were confirmed with radiography or technetium scan according to the usual Navy protocol.
A total of 309 subjects were diagnosed with a SFx resulting in an incidence of 5.9% per 8 wk. Using intention-to-treat analysis by including all enrolled subjects, we found that the calcium and vitamin D group had a 20% lower incidence of SFx than the control group (5.3% versus 6.6%, respectively, p = 0.0026 for Fisher's exact test). The per protocol analysis, including only the 3700 recruits who completed the study, found a 21% lower incidence of fractures in the supplemented versus the control group (6.8% versus 8.6%, respectively, p = 0.02 for Fisher's exact test).
Generalizing the findings to the population of 14,416 women who entered basic training at the Great Lakes during the 24 mo of recruitment, calcium and vitamin D supplementation for the entire cohort would have prevented approximately 187 persons from fracturing. Such a decrease in SFx would be associated with a significant decrease in morbidity and financial costs.
Dietary vitamin D intake for the elderly population: update on the recommended dietary allowance for vitamin D
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EIS Position Stand on the testing and interpretation of vitamin D levels and prescription of vitamin D supplements in Elite Sport
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