Association of Frailty and Preoperative Vitamin D Status with Postoperative Outcomes After Fragility Hip Fracture Surgery
Article Sidebar
Main Article Content
Abstract
OBJECTIVES: This study aimed to evaluate the associations of preoperative vitamin D status with postoperative outcomes in geriatric hip fracture patients managed within an integrated orthogeriatric pathway.
MATERIALS AND METHODS: This retrospective observational cohort study included 549 patients (aged ≥ 60 years) who underwent surgery for fragility hip fractures at Bangkok Hospital Headquarters between 2016 and 2025. A sub-analysis was conducted on 334 patients with available preoperative serum 25-hydroxyvitamin D (25(OH)D) levels. Key variables included age, Charlson Comorbidity Index (CCI), and prefracture frailty assessed using the Clinical Frailty Scale (CFS). The primary outcome was overall postoperative complications.
RESULTS: The mean age was 79.9 years, and 69.0% of participants were female. Frailty assessment showed that 48.8% were fit (CFS ≤ 3), 31.1% were vulnerable (CFS 4–5), and 20.0% were frail (CFS ≥ 6). Among 334 patients with available preoperative 25(OH)D measurements, vitamin D deficiency (VDD; < 20 ng/mL) was present in 46.4%. Overall postoperative complications occurred in 184 patients (55.1%), including 93/155 (60.0%) in the VDD group and 91/179 (50.8%) in the non-deficient group (p = 0.117). Lower vitamin D levels were significantly associated with higher comorbidity burden (p = 0.033) and greater frailty (p = 0.012), but not with overall postoperative complications or delirium (all p > 0.05).
CONCLUSION: While frailty remains an important clinical consideration in early postoperative vulnerability, preoperative vitamin D status may serve as a biochemical marker of underlying physiological vulnerability. The lack of association between VDD and short-term outcomes in this cohort suggests that vitamin D status alone may not predict acute postoperative outcomes. Nevertheless, routine assessment and correction of vitamin D remain important for long-term musculoskeletal health, mobility recovery, and secondary fracture prevention within the Fracture Liaison Service (FLS) framework.
Article Details
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
This article is published under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND 4.0). You may copy and redistribute the material for noncommercial purposes, provided that appropriate credit is given and a link to the license is included. Modified versions may not be distributed under this license.
License: https://creativecommons.org/licenses/by-nc-nd/4.0/
References
Rojviroj S, Visutipol B, Jisarojito S, et al. Geriatric hip fracture pathway in private hospital: early results. J SEA Ortho [Internet]. 2014 [cited 2026 March 15];38(3-4):57-62. Available from: https://www.jseaortho.org/index.php/jsao/article/view/103
Bischoff-Ferrari HA. Fragility fractures: the future epidemic and its challenges. Skeletal Radiol. 2013;42(11):1-2. doi: 10.1007/s00256-012-1549-4.
Royal College of Physicians. A broken hip—three steps to recovery: the 2024 National Hip Fracture Database report on 2023 [Internet]. London: Royal College of Physicians; 2024 [cited 2026 March 15]. Available from: https://www.nhfd.co.uk/reportopen/NHFD-2024%2BAnnual%2BReport
Rockwood K, Theou O. Clinical frailty scale. In: Ruiz JG, Theou O, editors. Frailty: a multidisciplinary approach to assessment, management, and prevention. Cham: Springer; 2024. p. 121-3. doi: 10.1007/978-3-031-57361-3_16
Ikram A, Norrish AR, Marson BA, et al. Can the Clinical Frailty Scale on admission predict 30-day survival, postoperative complications, and institutionalization in patients with fragility hip fracture? A cohort study of 1,255 patients. Bone Joint J. 2022;104-B(8):980–6. doi: 10.1302/0301-620X.104B8.BJJ-2020-1835.R2.
Seong YJ, Shin WC, Moon NH, et al. Timing of hip-fracture surgery in elderly patients: literature review and recommendations. Hip Pelvis. 2020;32(1):11-6. doi: 10.5371/hp.2020.32.1.11.
Yang Q, Fu J, Pan X, et al. A retrospective analysis of the incidence of postoperative delirium and the importance of database selection for its definition. BMC Psychiatry. 2023;23(1):88. doi: 10.1186/s12888-023-04576-4.
Wimalawansa SJ. Vitamin D: what clinicians need to know. Sri Lanka J Diabetes Endocrinol Metab. 2012;2(2):73-88. doi: 10.4038/sjdem.v2i2.4776
Winzenberg T, van der Mei I, Mason RS, et al. Vitamin D and the musculoskeletal health of older adults. Aust Fam Physician. 2012;41(3):92-99.
Cherniack EP, Levis S, Troen BR. Hypovitaminosis D: a widespread epidemic. Geriatrics. 2008;63(4):24-30.
Kruavit A, Chailurkit L, Thakkinstian A, et al. Prevalence of vitamin D insufficiency and low bone mineral density in elderly Thai nursing home residents. BMC Geriatr. 2012;12:49. doi: 10.1186/1471-2318-12-49.
Thai Osteoporosis Foundation. Clinical practice guide for the care of osteoporosis. Bangkok: Chulalongkorn University Press; 2022.
Bischoff-Ferrari HA. Vitamin D in geriatric patients. Internist (Berl). 2020;61(6):535-40. doi: 10.1007/s00108-020-00803-2.
Holick MF. Vitamin D deficiency. N Engl J Med. 2007;357:266– 81. doi: 10.1056/NEJMra070553.
Pilz S, März W, Cashman KD, et al. Rationale and Plan for Vitamin D Food Fortification: A Review and Guidance Paper. Front Endocrinol (Lausanne). 2018;9:373. doi: 10.3389/fendo.2018.00373
Hill TR, Aspray TJ. The role of vitamin D in maintaining bone health in older people. Ther Adv Musculoskelet Dis. 2017;9(4):89–95. doi: 10.1177/1759720X17692502.
Giustina A, Bouillon R, Dawson-Hughes B, et al. Vitamin D in the older population: a consensus statement. Endocrine. 2023;79(1):31-44. doi: 10.1007/s12020-022-03208-3.
Amphansap T, Wongthanakitcharoen P, Stitkitti N, et al. Prevalence and risk factors of vitamin D inadequacy among Thai elderly patients with osteoporotic hip fracture. J Southeast Asian Med Res. 2022.
Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489–95. doi: 10.1503/cmaj.050051.
Lv Q-B, Gao X, Liu X, et al. Vitamin D status and sitespecific fracture pattern associations in older adults with fragility fractures: a cross-sectional analysis of 2543 patients. Front Nutr. 2026;13:1810545. doi: 10.3389/fnut.2026.1810545.
Dauny V, Thietart S, Cohen-Bittan J, et al. Association between vitamin D deficiency and prognosis after hip fracture surgery in older patients in a dedicated orthogeriatric care pathway. J Nutr Health Aging. 2022;26(4):324-31. doi: 10.1007/s12603-022-1762-3.
Charlson M, Szatrowski TP, Peterson J, et al. Validation of a combined comorbidity index. J Clin Epidemiol. 1994;47:1245-51. doi: 10.1016/0895-4356(94)90129-5.
Ingstad F, Solberg LB, Nordsletten L, et al. Vitamin D status and complications, readmissions, and mortality after hip fracture. Osteoporos Int. 2021;32(5):873-81. doi: 10.1007/s00198-020-05739-9.
Fink A, Puchwein P, Fahrleitner-Pammer A, et al. Increased early postoperative complication rate after osteoporotic hip fracture in patients with low 25(OH) vitamin D levels. Nutrients. 2024;16(12):1917. doi:10.3390/nu16121917.
Komasara P, Szwarc T, Kałwik M, et al. The impact of vitamin D3 levels on recovery and rehabilitation following surgical treatment of femoral neck fractures: a narrative review. Int J Innov Technol Soc Sci. 2025;3(47). doi: 10.31435/ijitss.3(47).2025.3562.
Di Monaco M, Castiglioni C, Di Carlo S, et al. Classes of vitamin D status and functional outcome after hip fracture: a prospective, short-term study of 1350 inpatients. Eur J Phys Rehabil Med. 2019;55(3):361-7. doi: 10.23736/S1973-9087.18.05191-2.
Guerra MTE, Wagner MB, Vargas A, et al. Low serum levels of vitamin D significantly increase the risk of death in older adults with hip fractures: a prospective cohort. Rev Col Bras Cir. 2022 Apr 1;49:e20223054. doi: 10.1590/0100-6991e-20223054.
Bayram JM, Kanesan H, Clement ND. Vitamin D deficiency in hip fracture patients is associated with an increased mortality risk. Eur J Orthop Surg Traumatol. 2024;35(1):33. doi: 10.1007/s00590-024-04162-8.
Bischoff-Ferrari HA. Vitamin D: its role in health and disease in older people. In: Michel JP, Beattie BL, Martin FC, et al., editors. Oxford textbook of geriatric medicine. 3rd ed. Oxford: Oxford University Press; 2017. doi: 10.1093/med/9780198701590.003.0061.
Capatina C, Carsote M, Poiana C, et al. Vitamin D deficiency and musculoskeletal function in the elderly. Strength Cond J. 2015;37(1):24-9. doi: 10.1519/SSC.0000000000000115.
Lips P. Vitamin D deficiency and secondary hyperparathyroidism in the elderly: consequences for bone loss and fractures and therapeutic implications. Endocr Rev. 2001;22(4):477–501. doi: 10.1210/edrv.22.4.0437.
Chevalley T, Brandi ML, Cavalier E, et al. How can the orthopedic surgeon ensure optimal vitamin D status in patients operated for an osteoporotic fracture? Osteoporos Int. 2021;32(10):1921-35. doi:10.1007/s00198-021-05957-9.
Wijnen H, Jansen M, Stalpers-Konijnenburg S, et al. Vitamine D-deficiëntie bij patiënten met een heupfractuur. Ned Tijdschr Traumatol. 2011;19(6):150-6. doi: 10.1007/s12506-011-0043-2.
Cianferotti L, Bifolco G, Caffarelli C, et al. Nutrition, Vitamin D, and Calcium in Elderly Patients before and after a Hip fracture and Their Impact on the Musculoskeletal System: A Narrative Review. Nutrients. 2024;16(11):1773. doi: 10.3390/nu16111773.
