Journal of Limb Lengthening & Reconstruction

: 2021  |  Volume : 7  |  Issue : 2  |  Page : 110--113

Prevalence of vitamin D deficiency in adult limb lengthening and deformity correction patients

Oliver Charles Sax1, Nequesha Mohamed2, Jessica C Rivera3, Philip K McClure1, John E Herzenberg1,  
1 International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
2 Department of Orthopaedic Surgery, Medical Center Boulevard, Wake Forest Baptist Health, Winston-Salem, NC, USA
3 Department of Orthopaedic Surgery, Louisiana State University School of Medicine, New Orleans, LA, USA

Correspondence Address:
Dr. Philip K McClure
International Center for Limb Lengthening, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, Maryland 21215


Introduction: Limb lengthening and deformity correction surgery (LLDC) requires adequate bone metabolism for distraction osteogenesis. Low Vitamin D is a common nutritional deficit that places bone health at risk and has been associated with fracture. It is currently unknown what the Vitamin D levels are among patients undergoing elective osteotomy. The goal of this research is to determine the prevalence of Vitamin D deficiency in adult patients undergoing lower extremity osteotomies for LLDC. Materials and Methods: A retrospective review was performed for adult patients (≥18 years old) who underwent an osteotomy surgery at a single institution between 2014 and 2018. The primary outcome measure was perioperative 25(OH)D serum level. Of 139 subjects identified as undergoing a lower extremity osteotomy surgery, 96 (69%) underwent perioperative Vitamin D testing. Deficiency and insufficiency were defined as a 25(OH)D value of <20 ng/mL and between 20 and 30 ng/mL, respectively. Results: Patients undergoing external fixator placement for length and/or deformity correction were most likely to have this laboratory assessed (88%) versus acute correction patients (65%) and intramedullary lengthening patients (62%), (P = 0.033). The mean Vitamin D level was 29.5 ± 17.8 ng/mL (range: 5.7–95.9 ng/mL). A total of 63% of patients had low perioperative Vitamin D: 33.3% deficient, 30.2% insufficient. Conclusion: The majority of adult LLDC patients have deficient or insufficient Vitamin D levels perioperatively. Vitamin D “prehabilitation” whereby testing and repleting before limb lengthening surgery should be highly considered as standard practice.

How to cite this article:
Sax OC, Mohamed N, Rivera JC, McClure PK, Herzenberg JE. Prevalence of vitamin D deficiency in adult limb lengthening and deformity correction patients.J Limb Lengthen Reconstr 2021;7:110-113

How to cite this URL:
Sax OC, Mohamed N, Rivera JC, McClure PK, Herzenberg JE. Prevalence of vitamin D deficiency in adult limb lengthening and deformity correction patients. J Limb Lengthen Reconstr [serial online] 2021 [cited 2022 Oct 7 ];7:110-113
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Full Text


Vitamin D (25-hydroxyvitamin D; 25[OH]D) deficiency and insufficiency are ubiquitous, afflicting more than one billion adults and children globally.[1],[2] Estimated prevalence of deficiency and insufficiency in the United States is 28.9% and 41.4%, respectively, with adults who are African American, of low socioeconomic class, obese, and physically inactive at greater risk.[3] Vitamin D plays an essential role in bone metabolism, and low levels can predispose patients to risk of fracture, poor bone healing, nonunion, or possibly refracture.[4] For limb lengthening and deformity correction surgery (LLDC), success is largely dependent on proper bone formation and healing.[5] Thus, these patients may be at risk, but literature is scarce regarding Vitamin D prevalence among these patients.

Multiple laboratory and clinical studies highlight the cellular role of Vitamin D in hard callus formation and bone remodeling.[6],[7] Specifically, it has been demonstrated to regulate growth factor and cytokine synthesis in addition to alter growth factor signaling to maintain overall bone mass.[7],[8] These principles can be applied to regenerate bone healing in the distraction phase of osteogenesis and bone lengthening. Distraction osteogenesis is comprised of three phases: latency (initial hematoma and inflammation), distraction (stretching of callus), and consolidation (remodeling and healing).[5],[9] As such, reduced mineral content of newly formed bone should warrant a Vitamin D screen, along with other “prehabilitation” practices such as smoking cessation and medication reconciliation.

Despite the importance of Vitamin D in fracture healing and bone formation, there is a paucity of literature outlining its role in the setting of LLDC surgery. Therefore, the purpose of this study is to retrospectively examine the incidence of Vitamin D insufficiency and deficiency among adults undergoing LLDC surgery at a single institution. We hypothesize that the incidence is similar to the general adult population.

 Materials and Methods

Patient selection

This retrospective study analyzed adult patients 18 years and older undergoing correction osteotomy or limb lengthening at a single referral center between January 1, 2014, and December 31, 2018. Patients were identified by screening case logs for osteotomy procedures followed by acute deformity correction and fixation, placement of a circular external fixator, or insertion of an intramedullary lengthening nail. We identified 139 patients. But excluded 43 as they lacked perioperative 25(OH)D levels, resulting in a total of 96 LLDC patients. This retrospective study did not receive any funding and was exempt from institutional review board approval.


Variables collected were age, sex, race, diagnosis, location of long bone treated, and perioperative 25(OH)D levels. Vitamin D levels were measured either the day before or the day of surgery. In accordance with the Endocrine Society,[10] patients with serum 25(OH)D levels ≥30 ng/mL were considered adequate for bone health; levels from 29 to 20 ng/mL were considered insufficient; levels <20 ng/mL were considered deficient. Testing for Vitamin D was done intraoperatively or immediately postoperatively on all patients. Supplementation with over-the-counter dosages (2000–4000 international units daily) was done routinely. Deficient patients are treated with repletion dosaging (50,000 international units per day).

Statistical analysis

Data were summarized with descriptive statistics, including means and standard deviations for continuous variables and the number of subjects and percent in each category for categorical variables. Statistical analyses were performed using IBM SPSS Statistics for Windows, version 25.0 (IBM Corporation, Armonk, New York, United States).


Patient demographics

The studied patients were predominantly male (55%), caucasian (60%), with a mean age of 33.3 ± 15.4 years [Table 1]. Idiopathic disorders comprised 29% of LLDC patients, followed by posttraumatic deformity (19%) and congenital limb deficiency (13%). Most patients underwent a unilateral, single femur, or tibia osteotomy (79%).{Table 1}

Vitamin D Levels

Among all LLDC patients, the mean Vitamin D level was 29.5 ± 17.8 ng/mL (range: 5.7–95.9) [Table 2]. Patients with deficient levels (<20 ng/mL) totaled 33% (32/96); patients with insufficient levels (20–29 ng/mL) totaled 30% (29/96); patients with adequate levels (30 ng/ml or greater) totaled 37% (35/96). Patients with external fixator placement for length and/or deformity correction were most likely to have Vitamin D levels assessed (88%), compared to acute correction (65%) and intramedullary lengthening patients (62%) (P = 0.033).{Table 2}


Hypovitaminosis D continues to pose a global health risk in the United States.[1],[2] Literature clearly demonstrates its association with increased fracture risk and poor bone health;[3],[4],[6] however, little is known about its incidence in patients undergoing LLDC surgery. This population is arguably at greater risk than the general population because of the postoperative bone healing and remodeling demands required for bone consolidation.[5],[9] Therefore, we sought to examine the incidence rate of Vitamin D deficiency and insufficiency among adults in the setting of LLDC surgery. We found that 63% had below-normal levels; 33% of adults had deficiency, and 30% had insufficiency. Patients corrected with external fixation were more likely to have been screened preoperatively.

This study has several limitations. Despite identifying 139 patients who had undergone osteotomy procedures, several patients were excluded due to the absence of preoperative Vitamin D levels during chart review. Fortunately, this was a small proportion of study patients, and therefore, we feel that the included patients comprised an accurate representation of adult LLDC population. Further, this study only assessed the perioperative Vitamin D status of our adult patients, and the levels were not followed over time during subsequent office or hospital visits. Testing for Vitamin D status well in advance of surgery may have provided an opportunity for possible early detection and mitigation of hypovitaminosis D sequela. However, this is not routinely screened in the preoperative setting. Our study was intended to quantify perioperative levels of Vitamin D to highlight the ubiquity of Vitamin D deficiencies and insufficiencies in adult LLDC patients. These results were obtained from the patient population of a single institution and may not be generalizable to or representative of true Vitamin D incidence rates across the country. Arguably the most limiting factor of this study is the small sample size. However, our institution serves as a referral center as it is one of a handful of centers that specialize in LLDC, and the presented data include a relatively large cohort given the focus of the study. We sought to identify the hypovitaminosis D incidence in this population and can serve as a catalyst for future examination of bone health in the setting of LLDC.

The overall percentage of hypovitaminosis D in our study totaled 63%; 33% were deficient and 30% were insufficient. These levels are consistent with reported Vitamin D levels among the general U.S. adult population. In reviews of the National Health and Nutrition Examination Survey, Forrest and Stuhldreher[11] and Liu et al.[3] found an overall prevalence rate of Vitamin D insufficiency in adults to be about 42% with close to an additional 29% with a deficiency. These studies also used 20 ng/mL as a threshold between deficient (less than) and insufficient (more than). Despite these similarities, comparison of our study results to other populations is difficult considering the multifarious implications in hypovitaminosis D, including but not limited to: geographic location, time of year, time spent indoors, and ethnicity. Given the musculoskeletal and extra-skeletal dependence on Vitamin D, supplementation may be considered for low levels and standard practices are generally followed. The International Osteoporosis Foundation[12] recommends a serum Vitamin D level above 30 ng/mL or 800–1000 IU/day for all elderly men and women. Importantly, they note that efficacy above this level to prevent fracture has insufficient evidence for a recommendation to be made. The American Geriatrics Society[13] also recommends a daily supplement of at least 1000 IU/day to reduce the risk of fracture and falls, and routine testing is not necessary before supplementation. These recommendations provide support to our study conclusion that all patients undergoing LLDC surgery should be screened before surgery and provided with supplementation in the postoperative setting to facilitate fracture healing.

Although literature is scant concerning the prevalence of Vitamin D among LLDC patients, it is widely known that it mitigates fracture risk through bone metabolism effects.[4],[5],[7],[6],[14] The impact of supplementation in the adult population, especially the elderly, has been well documented. In a randomized control trial, Bischoff-Ferrari et al.[15] demonstrated that oral Vitamin D supplementation between 700 and 800 IU/day reduces the risk of hip and nonvertebral fractures in elderly individuals. Hypovitaminosis D has been comparably implicated in high and low-energy fractures. Lee and Kim[16] reviewed postmenopausal women with fractures and found Vitamin D deficiency and insufficiency rates of 61.8% and 14.7%, respectively. Steele et al.[17] reviewed 44 orthopedic trauma inpatients with nonvertebral fractures. They found a Vitamin D insufficiency (<32 ng/mL) of 59.1% comprised primarily of elderly women and recommended screening in all trauma patients. Hypovitaminosis in the young adult population has demonstrated similar findings. Ferrari et al.[18] reviewed osteoporosis in the young adult (ages 20–50 years) highlighted the role of Vitamin D deficiency. Tangpricha et al.[19] assessed Vitamin D levels among healthy volunteers across all age groups and concluded that young adults have an equal to greater risk of Vitamin D insufficiency that older adults. Given the known deleterious effects from low Vitamin D in conjunction with insufficiency among young adults, it is imperative for providers to screen for Vitamin D in the perioperative setting. Moreover, patients who undergo LLDC surgery have additional bone healing demands and it may be even more prudent to screen these patients before their surgical procedures. This raises the concept of “prehabilitation,” optimizing as many preoperative factors as possible. Identification of Vitamin D status has been argued to play an important factor in patient optimization.[20] Vitamin D testing and replenishment should be incorporated alongside smoking cessation, medication reconciliation, etc., to mitigate any potential bone healing-related complications in the postoperative setting.

Despite advances in medicine, adult patients continue to suffer from low Vitamin D levels in the United States. These results highlight a similar prevalence of Vitamin D insufficiency and deficiency among LLDC patients compared to the general population, but the risks may be greater in the former group given the bone healing requirements. Therefore, we recommend screening all patients undergoing LLDC in the preoperative setting. Further research is warranted to clarify long-term effects of low vitamin levels and fracture risk in this patient population.

Financial support and sponsorship

PKM is a consultant for DePuy Synthes Companies, Novadip, Orthofix, and Smith+Nephew. JEH is a clinical advisor for Bonus BioGroup and a consultant for NuVasive Specialized Orthopedics, Orthofix, OrthoPediatrics, OrthoSpin, Smith+Nephew, and WishBone Medical. The following organizations supported the institution of OCS, PKM, and JEH: Biocomposites, DePuy Synthes Companies, MHE Coalition, Orthofix, OrthoPediatrics, Pega Medical, Smith+Nephew, Stryker, and Zimmer Biomet.

Conflicts of interest

There are no conflicts of interest.


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