The Effect of Perioperative Vitamin D Levels on the Functional, Patient-Related Outcome Measures and the Risk of Infection Following Hip and Knee Arthroplasty: A Systematic Review

Figures & data

Figure 1 PRISMA flowchart illustrating the search strategy.

Table 1 Descriptive Characteristics of the Included Studies

Author	Study Design	Study Type	No of Patients	Male (%)^a	Mean Age of Involved Groups	Follow-Up	Type of Surgery	Vitamin D Sufficiency Cut Off Level	Patients with Hypovitaminosis (%)^a
Hedge et al^Citation17	R	CS	6593	1599 (24.2)	I: 65 S:70	12 m	KA	≥20 ng/mL	868 (13.2)
Janssen et al^Citation15	R	CS	138	57 (41.3)	I: 69.9 S: 72.8	6m	KA	>40 ng/mL	33 (23.9)
Allain et al^Citation14	P	C	92	38 (41.3)	W: 75.1 M:73.6	6 m	KA (9 RKA)	≥50 ng/mL	33 (36)
Maniar et al^Citation12	R	CS	120	23 (19.1)	I: 67 S:69	3m	KA	≥30 ng/mL	64 (53.3)
Lee et al^Citation13	P	C	191	38 (19.8)	I:68 S:67	3m	KA	> 50 nmol/L	84 (44)
Jansen et al^Citation25	R	CS	139	58 (42)	71,4	6m	KA	>40 ng/mL	23 (22.5)
Shin et al^Citation11	P	C	87	NA (10.3)	I:70.7 S:72.4	3m	KA	≥12 ng/mL	44 (50.5)
Maier et al^Citation23	R	CS	1083	516 (47.5)	76	NA	HA, KA	≥30 ng/mL	681 (62.8)
Traven et al^Citation27	R	CC	126	56 (44.4)	65.4	3m	64 RKA 62 RHA	≥30 ng/mL	69 (54.7)
Maier et al^Citation26	R	CS	190	84 (44.2)	PA:65, PJI:68, AL:68,4	NA	HA, KA SA	≥30 ng/mL	129 (68)
Zajonz et al^Citation16	P	CC	240	113 (47)	PA:71, PJI:74, AL:70	NA	HA, KA	> 30 ng/mL	203 (84.5)
Visser et al^Citation18	P	C	87	21 (24.1)	74	6w	HA	≥75ng/mL	55 (63.2)
Signori et al^Citation24	R	CS	42	9 (21.4)	PJI:63.5, AL:59.4	NA	21 RHA 21 RKA	>20mg/dl	NA
De Cuhna et al^Citation28	P	C	93	48 (51.6)	59.7	3m	HA	NA	77 (82.8)
Lavernia et al^Citation19	R	CS	60	12 (20)	70	11m	HA	20 or 30 ng/mL	39 (65)
Unnanuntana et al^Citation21	P	C	219	93 (42.5)	I:65 S:69.3	6w	HA	>30 ng/mL	102 (46.6)
Unnanuntana et al^Citation22	R	CS	200	88 (44)	66.5	NA	HA	32 ng/mL	79 (39.5)
Nawabi et al^Citation20	R	CS	62	23 (37)	71	6m	HA	40nmol/l	15 (24.2)

Notes: ^aValues are given as raw numbers with percentages in parentheses.

Abbreviations: R, retrospective; P, prospective; HA, hip arthroplasty; KA, knee arthroplasty; SA, shoulder arthroplasty; RHA, revision hip arthroplasty; RKA, revision knee arthroplasty; NA, non available; C, cohort; CC, case–control; CS, case series; m, months; w, weeks; S, sufficiency group; I, insufficiency group; PJI, periprosthetic joint infection; AL, aseptic loosening; PA, primary arthroplasty; W, women; M, men.

Table 2 Effect of Vitamin D in Functional Outcomes in Patients Undergoing Knee Arthroplasty

Author	Mean Vitamin D Level (ng/mL)^a	Scores Evaluated	Groups Compared	Main Clinical Findings
Hedge et al^Citation17	NA	NA	D <20 ng/mL S ≥20 ng/mL	Deficient patients: higher incidence of postoperative stiffness requiring manipulation under anesthesia (OR,1.69; 95% CI, 1.39–2.04)
Janssen et al^Citation15	D:32 S:65	WOMAC	D <40 ng/mL S >40 ng/mL	Deficient patients: worse functional outcome after eight years (p=0.04)
Allain et al^Citation14	NA	WOMAC, ABC	D <30 ng/mL I: 30–49 ng/mL S ≥50 ng/mL	No differences in preoperative and postoperative total scores between groups Deficient patients: significantly less postoperative improvement in WOMAC stiffness score
Maniar et al^Citation12	NA	SF-12, KSS, WOMAC	D <30 ng/mL S ≥30 ng/mL	No differences in preoperative total scores except WOMAC (p = 0.04) No differences in postoperative total scores between groups
Lee et al^Citation13	NA	WOMAC, QoR, EQ-5D	I< 50 nmol/L (Severe <12.5, Moderate 12.5–29, Mild 30–49) S > 50 nmol/L	Moderate-to severe hypovitaminosis D group: lower preoperative WOMAC function score No differences in postoperative total scores between groups
Jansen et al^Citation25	58.9	KSS	D <40 ng/mL S >40 ng/mL	Deficient patients: significantly lower mean preoperative KSS Deficient patients: not statistically significant lower mean postoperative KSS at six months
Shin et al^Citation11	D:9.1 S:18.3	KSS, AST, SMT, STS, TUGT	D <12 ng/mL S ≥12 ng/mL	No differences in preoperative total scores between groups No differences in postoperative mean time of STS and TUGT Deficient patients: significantly lesser post-operative functional KSS (p=0.045) Deficient patients: significantly longer mean time taken for post-operative AST (p = 0.033) and SMT (p = 0.012)

Notes: ^aMean vitamin D level is given for the whole group or for separate groups accordingly.

Abbreviations: NA, non available; D, deficient; I, insufficient; S, sufficient; OR, odds ratio; CI, 95% confidence interval; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; SF-12, 12-Item Short Form Survey; KSS, Knee Society Score; AST, alternative step test; TUGT, timed up and go test; SMT, six meter walk test; STS, sit to stand test; ABC, Activities-specific Balance Confidence Scale; QoR, Quality of Recovery; EQ-5D, European Quality of Life-5 Dimensions; 25-(OH)D, 25-hydroxyvitamin D.

Table 3 Effect of Vitamin D in Functional Outcomes in Patients Undergoing Hip Arthroplasty

Author	Mean Vitamin D Level^a	Scores	Groups Compared	Main Clinical Findings
Visser et al^Citation18	68.1 nmol/l	WOMAC, HGS, CST, TUGT, 10-MWT, LAPAQ	D <50 ng/mL I: 50–75 ng/mL S ≥75ng/mL	No differences in preoperative total scores between groups No differences in postoperative HGS, CST, 10-MWT, WOMAC Insufficient patients: higher postoperative LAPAQ score
Cuhna et al^Citation28	13.8 ng/mL	Gait Analysis	NA	Baseline Vitamin D levels: weak correlation with change in peak extension (p = 0.017) and peak power generation (p = 0.04) Vitamin D levels: no effect in change of gait pattern
Lavernia et al^Citation19	NA	WOMAC, HHS, PMA, QWB-7, SF-36	I <20 or 30 ng/mL S >20 or 30 ng/mL	No differences in preoperative and postoperative total scores between groups when the threshold was set in 20 ng/mL No differences in preoperative and postoperative total scores of WOMAC, QWB-7 and SF-36 between groups when the threshold was set in 30 ng/mL Significant differences in preoperative and postoperative total scores of HHS and Merle d’Aubigne’-Postel score between groups when the threshold was set in 30 ng/mL favoring sufficient group
Unnanuntana et al^Citation22	D:15.7 ng/mL I:26.7 ng/mL S:43.8 ng/mL	Transferring in and out of bed, ability to walk with assisting devices and ability to ascend/descent stairs	I <32 ng/mL S>32 ng/mL	No association between vitamin D level and the attainment of in hospital functional milestones
Nawabi et al^Citation20	58 nmol/l	HHS	S >40nmol/l D <40nmol/l	Sufficient patients: significantly higher preoperative HHS (p = 0.018) Sufficient patients: non-significantly higher postoperative HHS at 6 months (p = 0.067) Deficient patients: significantly less likely to attain an excellent outcome (p = 0.038)
Unnanuntana et al^Citation21	NA	WOMAC, SF-36, TUGT, Two-min walk test	S>30 ng/mL I<30 ng/mL	No differences in preoperative scores between groups No differences in postoperative WOMAC and SF-36 between groups Deficient patients: significantly improved TUGT postoperatively

Notes: ^aMean vitamin D level is given for the whole group or for separate groups accordingly.

Abbreviations: CST, Chair Stand Test; TUGT, timed up and go test; 10-MWT, 10-meter walking test; NA, non available; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; HHS, Harris Hip Score; SF-36, 36-Item Short Form Survey; HGS, hand grip strength; LAPAQ, LASA Physical Activity Questionnaire; QWB-7, Quality of Well-being Scale; 25-(OH)D3, 25-hydroxyvitamin D₃; D, deficient; S, sufficient; I, insufficient; PMA, Merle d’Aubigne’-Postel.

Table 4 Length of Hospital Stay Based on the Vitamin D Level of Groups of Patients

Author	Deficient (Range)	Insufficient	Sufficient (Range)	p
Maier et al^Citation26,a	15.6 (7.2)	NA	11.3 (7.9)	0.014
Traven et al^Citation27,b	5	NA	3.6	0.097
Lee et al^Citation13	10 (8–15)^c	9^b	10^b	0.76
Janssen et al^Citation15,c	7 (2–28)	NA	7 (2–19)	0.03
Unnanuntana et al^Citation22,b	4	3.8	3.7	0.724

Notes: ^aValues are given as mean with the standard deviation in parentheses. ^bValues are given as mean. ^cValues are given as mean with the range in parentheses.

Abbreviation: NA, non available.

Table 5 Comparison of Vitamin D Levels Between Groups of Patients Undergoing Revision for Periprosthetic Join Infection or Aseptic Loosening or Primary Arthroplasty

Author	Number of Patients			Vitamin D Level (ng/mL)^a			p-value
	PJI	PA	AL	PJI	PA	AL	PJI vs AL	PJI vs PA	PA vs AL
Zajonz et al^Citation16	80	80	80	17.9 (8.9)	16.8 (6.9)	19.7 (7.9)	0.771	0.846	NA
Maier et al^Citation26	50	109	31	13.29 (6.5)	19.46 (9.4)	20.5 (9.1)	<0.001	<0.001	0.58
Signori et al^Citation24	23	NA	19	18.5  (6.5)	NA	13.6 (9.4)	< 0.05	NA	NA

Note: ^aValues are given as mean with standard deviation in parentheses.

Abbreviations: PJI, periprosthetic joint infection; NA, non available; PA, primary arthroplasty; AL, aseptic loosening.

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