Joint Surgery: Another Vitamin D Dilemma

Studies suggest taking a vitamin D supplement may help prevent infection, fractures, and other complications following hip or knee replacement surgery. But the evidence is murky, and physicians do not routinely recommend the practice in the perioperative period.

Existing guidelines on the use of vitamin D do not address the potential benefits of supplementation for improving outcomes after arthroplasty. The topic has become more important, as the number of patients undergoing joint replacement is growing. According to the American College of Rheumatology, about 790,000 total knee replacements and 549,000 hip replacements are performed each year in the United States. One study projected that by 2060, the number of these surgeries would grow to nearly 3 million and 2 million, respectively.

Claudette M. Lajam, MD, professor of orthopedic surgery and system chief of orthopedic safety and quality at NYU Grossman School of Medicine, New York City, said emerging research shows vitamin D deficiency may correlate with poorer outcomes after elective total joint replacement. Several randomized trials conducted over the past 5 years compared outcomes of people who were given a supplement with the outcomes of those who had surgery in the past and may or may not have had low vitamin D levels. The results are conflicting.

One study found supplementation on the day of knee replacement failed to demonstrate statistical significant differences in function or complications in the early postoperative period compared with placebo. Another study found the total number of complications, superficial wound infection, and postoperative cellulitis were greater in people who did not receive vitamin D supplementation prior to surgery.

“The rub is that we can’t show for sure that managing vitamin D deficiency helps with outcomes after hip and knee replacement. But if your levels are low, it’s a good idea to consider supplementation before elective surgery,” Lajam, who is also a spokesperson for the American Academy of Orthopaedic Surgeons, said. “If there is a potential benefit and there’s no real harm, why wouldn’t you do it?”

The Endocrine Society issued guidelines in 2024 that recommend healthy adults younger than 75 years to not take vitamin D supplements at doses higher than the daily dietary intakes recommended by the Institute of Medicine.

The US Preventive Services Task Force (USPSTF) is in the process of updating its 2018 recommendation statement on vitamin D supplementation, with or without calcium, to prevent fractures in community-dwelling adults. The 2018 document does not address vitamin D use in joint replacements.

The result is a gap in guidance that might leave clinicians confused about what to tell otherwise healthy patients considering joint replacement, some experts said.

Linda Russell, MD, director of Perioperative Medicine at the Hospital for Special Surgery (HSS) in New York City, said HSS does not assess vitamin D status in all patients as part of preoperative lab testing, in part because of cost considerations. But she said she thinks doing so is wise.

Vitamin D helps the body absorb calcium, which strengthens bones, and may reduce inflammation, both of which are factors in recovering from joint replacement surgery.

Periprosthetic fracture above or below the orthopedic implant is another concern for which vitamin D status may be important. The proportion of patients who experience a perioprosthetic fracture within five years of total hip arthroplasty is 0.9% and after total knee arthroplasty is 0.6%.

Russell said many patients have osteoporosis and are susceptible to a periprosthetic fracture if they fall. HSS recommends postmenopausal women and men older than 70 years who are undergoing arthroplasty receive a bone density test if they have not had one in the past 2 years to determine if they have osteoporosis, she said. If they do, their vitamin D levels are tested, and they are treated for any vitamin D deficiency.

“It makes a lot of sense that if you’re going to have an orthopedic procedure, if you’re going to have a joint replacement, you would like to ensure that the patient’s getting sufficient calcium and vitamin D preoperatively, both to promote bone and muscle health, because you don’t want patients to fall postoperatively. And vitamin D level has been tied to an increased rate of falls” if it is low, she said.

Literature Meta-analyses

Nicolas Piuzzi, MD, associate professor of orthopedic surgery and co-director of the Musculoskeletal Research Center at Cleveland Clinic in Cleveland, said he often recommends measuring vitamin D levels as part of preoperative testing even if doing so is not standard of care. “We need to look at a lot of factors, and vitamin D is one of those that is relevant because it affects so many aspects of the surgery, specifically bone health,” he said.

Piuzzi co-authored a 2020 review and meta-analysis that found a pooled prevalence of vitamin D insufficiency of 53.4% and vitamin D deficiency of 39.4% among patients undergoing total joint arthroplasty.

The authors said although some studies reported higher rates of complications in patients with vitamin D deficiency, there was wide heterogeneity among the studies, which made it difficult to make definite conclusions about the role of vitamin D on complications after joint replacement. They concluded that there is insufficient literature to conclusively establish an association between vitamin D and adverse outcomes, including infection and stiffness. Nevertheless, they said that due to the high prevalence of vitamin D deficiency and the plausible association with poor outcomes, routine preoperative screening of vitamin D levels should be considered in patients undergoing lower extremity total joint arthroplasty.

As for prevalence in community-dwelling people, one study found nearly 20% of noninstitutional middle-aged and older adults in the United States were vitamin D deficient, which was correlated to increased mortality risk.

Another study, published in EFORT Open Reviews in May 2022, found only three studies that have reported on the perioperative administration of vitamin D and its effect on a measured outcome following total knee replacement surgery. In one randomized controlled trial, compared with the administration of placebo, the administration of a multivitamin significantly modulated the postoperative response, as indicated by a reduction in the measure of inflammation. But the authors were unable to attribute that finding directly to vitamin D.

They recommended further adequately powered randomized controlled trials using vitamin D supplementation and patient-reported outcome measures to assess if preoperative vitamin D insufficiency is a modifiable risk factor to improve outcomes following total hip and total knee replacement.

A more recent literature review and meta-analysis of 10 studies, published in The Journal of Bone and Joint Surgery in 2024, found that in four of the studies, vitamin D deficiency resulted in poorer outcomes, including increased risk for revision surgery, joint infection, and postoperative stiffness. The authors found that outcomes improved with vitamin D supplementation in six of the studies and that there was a significant increase in the length of hospital stays for patients with vitamin D deficiency.

Optimizing Patient Care

The National Institutes of Health’s Office of Dietary Supplements says screening for vitamin D levels is becoming more common in routine laboratory bloodwork ordered by primary care physicians. The USPSTF concluded in 2021 that evidence is insufficient to assess the benefits and harms of screening for vitamin De deficiency in asymptomatic adults.

Patients may not follow their physician’s recommendation to take a vitamin D supplement if their levels are low. Lajam said when faced with having a hip or knee replacement surgery, patients who have ignored or procrastinated managing their health conditions may be motivated to take steps to improve their health.

“We tell patients that if they don’t tune things up, they could have a disastrous problem. And then their ears prick up and they think, ‘I’d better do this,’” she said. “Maybe there is some lasting effect of the intervention we do as surgeons to get people ready for surgery. If we can encourage folks to get vitamin D levels under control, maybe that will stick with them afterward.”

Lajam was senior author of a 2023 study that assessed improvement in preoperative levels of A1c in patients with diabetes following total joint arthroplasty. The retrospective analysis found patients with higher preoperative A1c were more likely to have clinically meaningful decreases in A1c postoperatively.

The authors said their findings show that multifactorial and personalized intervention can improve glycemic control and complications from diabetes. They concluded their results, whether due to focused optimization, improved postoperative mobility, or a combination of these factors, provide hope that undergoing total joint replacement can have a positive impact on overall health.

Piuzzi’s advice for physicians is that whoever sees a patient first, whether it is a primary care physician or an orthopedic surgeon, take the time for comprehensive optimization of patient care, which involves managing their diabetes, obesity, nutrition, and vitamin D status.

“How can we improve health overall so that if the patient ends up reaching the point where they need a joint replacement, we already can make use of those several years or months of optimization?” he said. By optimizing care, we can “expect to have better outcomes.”

Piuzzi is a paid consultant or speaker for Stryker Corporation. He has consulted for and received compensation or royalties from Pacira Pharmaceuticals, Inc., but instructed the company to donate all compensation to not-for-profit causes or to Cleveland Clinic to support research and education. The other sources reported no relevant financial conflicts of interest.

Brenda Sandburg is a freelance journalist who has written about US Food and Drug Administration policies, the biopharmaceutical industry, and legal issues for the Pink Sheet and American Lawyer Media.