Association of Vitamin D Deficiency With Adverse Postoperative Outcomes Following Hallux Valgus Correction

Abstract

Background:

Hallux valgus (HV) is a common forefoot deformity treated surgically. Vitamin D is essential for bone and soft tissue health, but its role in postoperative outcomes after HV is unclear. This study evaluated whether low preoperative vitamin D is associated with increased complications.

Methods:

Adults undergoing HV correction were analyzed retrospectively using the TriNetX Research Network. Patients were categorized as vitamin D deficient (≤20 ng/mL), subsufficient (≤30 ng/mL), or sufficient (≥30 ng/mL). Secondary analyses examined outcomes by surgical setting (inpatient vs ambulatory) and procedure type among subsufficient patients. Propensity score matching controlled for demographics and comorbidities. Ninety-day outcomes included wound complications, health care visits, opioid use, and thromboembolic events. Significance was set at P <.05.

Results:

After matching, 7041 deficient and 8150 subsufficient patients were compared with equal numbers of sufficient controls. Vitamin D deficiency and subsufficiency were associated with higher rates of wound dehiscence, postoperative infection, inpatient consultation/admission, emergency department (ED) visits, and opioid use (all P < .05). In secondary analyses, 1286 inpatient and 6346 ambulatory subsufficient and sufficient patients were matched. Vitamin D subsufficiency was associated with higher ED visits in inpatients and increased wound dehiscence, inpatient encounters, ED visits, and opioid use in ambulatory patients (all P < .05). Among 3600 vitamin D-subsufficient patients per cohort, metatarsophalangeal (MTP) fusion had higher wound dehiscence than HV correction (P = .033).

Conclusion:

Low preoperative vitamin D is associated with increased postoperative complications after HV, including wound dehiscence, infection, health care utilization, and opioid use. Subsufficient vitamin D was linked to higher ED visits in inpatients and increased wound dehiscence, inpatient encounters, ED visits, and opioid use in ambulatory patients. Among subsufficient patients, MTP fusion had higher wound dehiscence than HV correction, likely due to greater soft tissue disruption. These findings highlight that both vitamin D status and procedure type are associated with postoperative complications; however, given the modest absolute risk differences, preoperative vitamin D screening should be viewed as a possible risk-stratification tool.

Level of Evidence:

Level III, cohort study.

Keywords

hallux valgus vitamin D deficiency wound complications postoperative outcomes opioid use

Introduction

Hallux valgus is a progressive angular deformity of the forefoot that affects up to 22% of the worldwide adult population.¹ This deformity can result in significant discomfort for patients, as a medial prominence, or “bunion,” arises from malalignment of the first metatarsophalangeal joint. Given the high prevalence of hallux valgus, surgical correction is routinely performed when nonoperative treatment fails to reduce pain and restore function for patients.^2,3 Continued investigation is still warranted to identify patients at risk of complications following hallux valgus correction.

Vitamin D plays a crucial role in promoting the intestinal absorption of calcium and phosphorus.⁴ Current evidence suggests that up to 32% of the American population and 1 billion individuals worldwide experience vitamin D deficiency. In orthopaedic surgery, vitamin D deficiency or insufficiency is prevalent and affects approximately 47% to 85% of the patient population.^5
-8 Deficiency in vitamin D has been linked to decreased bone mineral density, increasing susceptibility to orthopaedic complications such as osteoporosis and fractures.⁹

Given the role of vitamin D in mineral metabolism, patients who have low serum levels of 25-hydroxyvitamin D often develop low bone mineral density and osteopenia.¹⁰ Vitamin D deficiency has also been shown to be associated with major postoperative complications after orthopaedic surgery, including both medical (acute kidney failure, deep vein thrombosis, pulmonary embolism, pneumonia) and surgical (periprosthetic joint infection, aseptic loosening, readmission) events. However, these results have largely been limited to the arthroplasty and trauma literature.^11
-14 No study to date has examined the relationship between preoperative vitamin D status and postoperative outcomes following hallux valgus corrective procedures.

Given the high prevalence of both hallux valgus and Vitamin D deficiency, we sought to evaluate whether patients who had suboptimal vitamin D levels were at elevated risk of complications following hallux valgus correction. We also sought to assess whether this relationship differs among patients undergoing surgery in the inpatient or ambulatory setting. Consistent with results in the orthopaedic surgery literature, we hypothesized that patients with suboptimal vitamin D levels would demonstrate increased medical and surgical complications within 90 days postoperatively.

Methods

This retrospective cohort study used data from the TriNetX US Research Network, which aggregated deidentified electronic health records from 106 participating health care organizations. Because of the deidentified nature of the data set, institutional review board (IRB) approval was not required.

The study population included adult patients (aged 18 years and older) who underwent surgical correction of hallux valgus within the past 20 years. Surgical procedures were identified using the following Current Procedural Terminology (CPT) codes: 28292, 28295, 28296, 28297, 28298, and 28299. Patients were also included if they had an arthrodesis of their great toe at the metatarsophalangeal joint (CPT: 28750, First MTP Fusion) and a history of hallux valgus prior (International Classification of Diseases, Tenth Revision [ICD-10]: M21.61, M20.10). Patients whose corrective surgery occurred more than 20 years before the data collection period were excluded from the analysis to ensure temporal relevance.

Patients were first stratified into deficient, subsufficient, and sufficient cohorts based on their vitamin D status. Those classified as vitamin D deficient had either a serum or plasma 25-hydroxyvitamin D₂ and/or D₃ concentration ≤20.00 ng/mL (as identified by LOINC codes: 62292-8, 1989-3, 46269-7, 35365-6), or a documented diagnosis of vitamin D deficiency using ICD-10 code E55. The vitamin D-subsufficient cohort had either a serum or plasma 25-hydroxyvitamin D₂ and/or D₃ concentration ≤30.00 ng/mL or a documented diagnosis of vitamin D deficiency. The vitamin D-sufficient cohort had either a serum or plasma 25-hydroxyvitamin D₂ and/or D₃ concentration ≥30.00 ng/mL and no documented diagnosis of vitamin D deficiency.

For the primary analysis, 2 demographic and outcomes comparisons were made: (1) deficient vs sufficient patients, and (2) subsufficient vs sufficient patients. Secondary analyses (subsufficient vs sufficient) evaluated whether associations between vitamin D status and postoperative outcomes differed by surgical setting (inpatient vs ambulatory). Inpatient and ambulatory procedures were identified by linking the “Inpatient Encounter” and “Ambulatory” visit types to procedural codes occurring on the same day within the TriNetX platform. Additionally, within the vitamin D-subsufficient cohort, we conducted a separate analysis comparing patients who underwent joint-sparing hallux valgus correction with those who underwent joint-sacrificing first metatarsophalangeal (MTP) fusion to evaluate whether postoperative outcomes differed by surgical procedure type.

To minimize potential confounding in both analyses, propensity score matching (PSM) was performed using 1:1 greedy nearest-neighbor matching without replacement. Matching was conducted on a set of demographic and clinical variables present before the index surgical event. These included current age, age at time of surgery, race, ethnicity, gender, and comorbidities such as diabetes mellitus (ICD-10: E08-E13), overweight/obesity or other hyperalimentation disorders (E65-E68), inflammatory polyarthropathies (M05-M14), alcohol-related disorders (F10), nicotine dependence (F17), health hazards related to socioeconomic or psychosocial circumstances (Z55-Z65), and lipoprotein metabolism disorders and other lipidemias (E78). All propensity score matching and statistical analyses were conducted using the TriNetX Analytics platform.

Clinical outcomes were assessed at 90 days postoperatively to capture early postoperative complications and relevant medical outcomes, which commonly manifest within this period following orthopaedic surgical interventions (Supplemental Table 1). Statistical analyses used either Student t tests or χ² tests, as appropriate. A 2-tailed P value of <.05 was set as the threshold for statistical significance. A standard difference of >0.1 indicated a significant clinical imbalance. Absolute risk differences (ARDs) with 95% confidence intervals and risk ratios (RRs) for each outcome was calculated to quantify absolute and relative differences between cohorts based on vitamin D status. Because multiple postoperative outcomes within a related hypothesis family were evaluated, these analyses were considered exploratory and hypothesis-generating; P values were interpreted descriptively without formal adjustment for multiple comparisons. Subgroup analyses by surgical setting and procedure type were also exploratory.

Results

Demographic and clinical characteristics before and after propensity score matching for the vitamin D-deficient compared to the vitamin D-sufficient cohort are presented in Supplemental Table 2. Before matching, the vitamin D-sufficient cohort included 62 204 surgical patients, whereas the deficient cohort comprised 7120 patients with documented deficiency. Following 1:1 propensity score matching, both cohorts consisted of 7041 patients. Baseline characteristics were well balanced across all included covariates. Although some demographic differences between cohorts remained statistically significant, the corresponding standardized mean differences were below 0.1, which indicated no meaningful clinical imbalance.

Ninety-day postoperative outcomes are summarized in Table 1. The vitamin D-deficient cohort demonstrated a significantly higher incidence of wound dehiscence within 90 days of surgery compared with the sufficient cohort (P < .001). Inpatient consultation or admission was also more frequently observed in the deficient group (P = .040). Additionally, emergency department utilization during the 90-day postoperative period was significantly higher among patients with vitamin D deficiency (P < .001). Lastly, the deficient group was more likely to receive prescriptions for opioid analgesics within 90 days following surgery (P < .001).

Table 1.

Ninety-Day Postoperative Outcomes Following Hallux Valgus Correction in Patients with Vitamin D Deficiency Compared With Patients Vitamin D Sufficient.

Complications	Vitamin D Sufficient, n (%)	Vitamin D Deficient, n (%)	Absolute Risk Difference (95% CI)	Risk Ratio Sufficient/Deficient (95 % CI)	P Value
Sepsis	23 (0.3)	16 (0.2)	−0.1 (−0.3, 0.1)	1.4 (0.8, 2.7)	.262
Infection following procedure	99 (1.4)	121 (1.7)	0.3 (0.0, 0.6)	0.8 (0.6, 1.1)	.135
Wound dehiscence	151 (2.1)	227 (3.2)	1.1 (0.7, 1.5)	0.7 (0.5, 0.8)	<.001*
Pulmonary embolism	27 (0.4)	43 (0.6)	0.2 (0.0, 0.5)	0.6 (0.4, 1.02)	.055
Deep vein thrombosis	87 (1.2)	90 (1.3)	0.0 (−0.3, 0.4)	1.0 (0.7, 1.3)	.821
Acute myocardial infarction	23 (0.3)	15 (0.2)	−0.1 (−0.3, 0.1)	1.5 (0.8, 2.9)	.194
Inpatient consultation or admission	26 (0.4)	43 (0.6)	0.2 (0.0, 0.5)	0.6 (0.4, 1.0)	.040*
Pneumonia	45 (0.6)	57 (0.8)	0.2 (−0.1, 0.4)	0.8 (0.5, 1.2)	.233
Emergency department visit	471 (6.7)	587 (8.3)	1.6 (1.0, 2.3)	0.8 (0.7, 0.9)	<.001*
Opioid analgesic use	6488 (92.1)	6633 (94.2)	2.1 (1.4, 2.8)	1.0 (0.97, 0.99)	<.001*

Significant P values (P < .05).

Demographic and clinical characteristics before and after propensity score matching for the vitamin D-subsufficient compared to the vitamin D-sufficient cohort are presented in Supplemental Table 3. Prior to matching, the sufficient cohort included 62 204 surgical patients, whereas the subsufficient cohort comprised 8267 patients. Following 1:1 propensity score matching, both cohorts consisted of 8150 patients. Baseline characteristics were well balanced across all included covariates. Again, although select demographic differences between cohorts remained statistically significant, the corresponding standardized mean differences below the 0.1 threshold indicated no meaningful clinical imbalance.

Ninety-day postoperative outcomes are summarized in Table 2. The subsufficient cohort demonstrated a significantly higher incidence of infection (P = .036) and wound dehiscence (P < .001) within 90 days of surgery compared with the sufficient cohort. Inpatient consultation or admission was also more frequently observed in the subsufficient cohort (P = .036). Additionally, emergency department utilization during the 90-day postoperative period was significantly higher among patients with subsufficient levels of vitamin D (P < .001). Lastly, the subsufficient cohort was more likely to receive prescriptions for opioid analgesics within 90 days following surgery (P < .001).

Table 2.

Ninety-Day Postoperative Outcomes Following Hallux Valgus Correction in Patients With Vitamin D Deficiency or Insufficiency (Subsufficient) Compared With Patients Vitamin D Sufficient.

Complications	Vitamin D Sufficient, n (%)	Vitamin D Subsufficient, n (%)	Absolute Risk Difference (95% CI)	Risk Ratio Sufficient/Subsufficient (95 % CI)	P Value
Sepsis	28 (0.3)	18 (0.2)	−0.1 (−0.3, 0.1)	1.6 (0.9, 2.8)	.140
Infection following procedure	116 (1.4)	150 (1.8)	0.4 (0.0, 0.8)	0.8 (0.6, 0.98)	.036*
Wound dehiscence	171 (2.1)	253 (3.1)	1.0 (0.7, 1.4)	0.7 (0.6, 0.8)	<.001*
Pulmonary embolism	42 (0.5)	47 (0.6)	0.1 (−0.1, 0.3)	0.9 (0.6, 1.4)	.595
Deep vein thrombosis	116 (1.4)	105 (1.3)	−0.1 (−0.4, 0.2)	1.1 (0.9, 1.4)	.456
Acute myocardial infarction	23 (0.3)	18 (0.2)	−0.1 (−0.3, 0.1)	1.3 (0.7, 2.4)	.434
Inpatient consultation or admission	28 (0.3)	46 (0.6)	0.3 (0.0, 0.5)	0.6 (0.4, 0.97)	.036*
Pneumonia	48 (0.6)	60 (0.7)	0.1 (−0.1, 0.3)	0.8 (0.5, 1.2)	.247
Emergency department visit	534 (6.6)	669 (8.2)	1.6 (1.1, 2.1)	0.8 (0.7, 0.9)	<.001*
Opioid analgesic use	7468 (91.6)	7657 (94.0)	2.4 (1.8, 3.0)	1.0 (0.97, 0.98)	<.001*

Significant P values (P < .05).

Demographic and clinical characteristics before and after propensity score matching for inpatient and ambulatory vitamin D-subsufficient vs sufficient cohorts are shown in Supplemental Tables 4 and 5. Before matching, the inpatient cohorts included 4574 sufficient and 1331 subsufficient patients, and the ambulatory cohorts included 39 752 sufficient and 6437 subsufficient patients. After 1:1 matching, each inpatient cohort comprised 1286 patients, and each ambulatory cohort comprised 6346 patients. Baseline characteristics were well balanced across covariates.

Postoperative outcomes within 90 days for inpatient and ambulatory HV cohorts are summarized in Table 3. The subsufficient cohort had a higher incidence of emergency department (ED) visits (P = .018). Among ambulatory patients, wound dehiscence (P = .020), inpatient consultation or admission (P = .026), ED visits (P < .001), and opioid use (P = .002) were more frequent in the subsufficient cohort than in the sufficient cohort.

Table 3.

Ninety-Day Postoperative Outcomes After Hallux Valgus Correction by Surgical Setting in Vitamin D Subsufficient Compared With Sufficient Patients.

Complications	Vitamin D Sufficient, n (%)	Vitamin D Subsufficient, n (%)	Absolute Risk Difference (95% CI)	Risk Ratio Sufficient/Subsufficient (95 % CI)	P Value
Inpatient
Sepsis	<10 (0.8)	<10 (0.8)	0.0 (NA)	NA	NA
Infection following procedure	22 (1.7)	25 (1.9)	0.2 (−0.5, 0.9)	0.9 (0.5, 1.5)	.659
Wound dehiscence	34 (2.6)	41 (3.2)	0.6 (0.0, 1.2)	0.8 (0.5, 1.3)	.412
Pulmonary embolism	<10 (0.8)	<10 (0.8)	0.0 (NA)	NA	NA
Deep vein thrombosis	23 (1.8)	20 (1.6)	−0.2 (−0.8, 0.4)	1.2 (0.6, 2.1)	.645
Acute myocardial infarction	<10 (0.8)	<10 (0.8)	0.0 (NA)	NA	NA
Inpatient consultation or admission	<10 (0.8)	<10 (0.8)	0.0 (NA)	NA	NA
Pneumonia	<10 (0.8)	<10 (0.8)	0.0 (NA)	NA	NA
Emergency department visit	96 (7.5)	130 (10.1)	2.6 (1.3, 3.9)	0.7 (0.6, 0.95)	.018*
Opioid analgesic use	1276 (99.2)	1274 (99.1)	−0.1 (−0.5, 0.3)	1.002 (1.0, 1.0)	.669
Ambulatory
Sepsis	23 (0.4)	15 (0.3)	−0.1 (−0.3, 0.1)	1.5 (0.8, 2.9)	.194
Infection following procedure	95 (1.5)	109 (1.7)	0.2 (−0.1, 0.5)	0.9 (0.7, 1.1)	.323
Wound dehiscence	162 (2.6)	206 (3.2)	0.6 (0.3, 0.9)	0.8 (0.6, 0.96)	.020*
Pulmonary embolism	33 (0.5)	44 (0.7)	0.2 (0.0, 0.4)	0.5 (0.5, 1.2)	.209
Deep vein thrombosis	70 (1.1)	86 (1.4)	0.3 (0.0, 0.6)	0.8 (0.6, 1.1)	.197
Acute myocardial infarction	19 (0.3)	20 (0.3)	0.0 (−0.1, 0.1)	1.0 (0.5, 1.8)	.873
Inpatient consultation or admission	18 (0.3)	34 (0.5)	0.2 (0.0, 0.4)	0.5 (0.3, 0.9)	.026*
Pneumonia	42 (0.7)	49 (0.8)	0.1 (0.0, 0.3)	0.9 (0.6, 1.3)	.462
Emergency department visit	331 (5.2)	489 (7.7)	2.5 (2.0, 3.1)	0.7 (0.6, 0.8)	<.001*
Opioid analgesic use	5922 (93.3)	6006 (94.6)	1.3 (0.5, 2.1)	0.98 (0.98, 0.99)	.002*

Significant P values (P < .05).

Demographic and clinical characteristics for vitamin D-subsufficient patients undergoing HV correction vs first MTP fusion are summarized in Supplemental Table 6. Before matching, the HV cohort comprised 14704 patients, whereas the MTP fusion cohort included 3602 patients. Following 1:1 propensity score matching, each cohort contained 3600 patients, with strong covariate balance achieved across all baseline characteristics. Ninety-day postoperative outcomes are reported in Table 4. Overall, outcomes were comparable between groups, except for a higher rate of wound dehiscence in the MTP fusion cohort (P = .033).

Table 4.

Ninety-Day Postoperative Outcomes Following Hallux Valgus Correction vs First MTP Fusion in Vitamin D Subsufficient Patients.

Complications	Vitamin D Sufficient, n (%)	Vitamin D Subsufficient, n (%)	Absolute Risk Difference (95% CI)	Risk Ratio Sufficient/Subsufficient (95 % CI)	P Value
Sepsis	14 (0.4)	15 (0.4)	0.0 (−0.3, 0.3)	0.9 (0.5, 1.9)	.852
Infection following procedure	70 (1.9)	75 (2.1)	0.2 (−0.3, 0.7)	0.9 (0.7, 1.3)	.675
Wound dehiscence	93 (2.6)	124 (3.4)	0.8 (0.2, 1.4)	0.8 (0.6, 0.98)	.033*
Pulmonary embolism	15 (0.4)	25 (0.7)	0.3 (0.0, 0.6)	0.6 (0.3, 1.1)	.113
Deep vein thrombosis	49 (1.4)	55 (1.5)	0.1 (−0.4, 0.6)	0.9 (0.6, 1.3)	.553
Acute myocardial infarction	19 (0.5)	13 (0.4)	−0.1 (−0.5, 0.3)	1.5 (0.7, 3.0)	.288
Inpatient consultation or admission	<10 (0.3)	<10 (0.3)	0.0 (NA)	NA	NA
Pneumonia	26 (0.7)	41 (1.1)	0.4 (0.0, 0.8)	0.6 (0.4, 1.0)	.066
Emergency department visit	280 (7.8)	311 (8.6)	0.8 (0.0, 1.6)	0.9 (0.8, 1.1)	.183
Opioid analgesic use	3420 (95.0)	3426 (95.2)	0.2 (−0.7, 1.1)	1.0 (1.0, 1.0)	.744

Significant P values (P < .05).

Discussion

This study examined the association between vitamin D deficiency and postoperative complications following hallux valgus (HV) correction surgery. Given the exploratory design and evaluation of multiple related outcomes, the observed associations should be interpreted cautiously and viewed as hypothesis-generating rather than confirmatory. Patients presenting with either vitamin D deficiency or subsufficient levels exhibited higher rates of wound dehiscence, postoperative infection, inpatient consultation or admission, emergency department utilization, and postoperative opioid use within 90 days of HV surgery. Several of these associations remained significant in the ambulatory-only analysis. Additionally, wound dehiscence occurred more frequently following MTP fusion compared with HV surgery alone. In contrast, vitamin D status was not associated with differences in postoperative pulmonary embolism or deep vein thrombosis. These findings suggest that suboptimal vitamin D levels may be relevant to wound-healing and health care utilization outcomes after HV correction, whereas their impact on short-term venous thromboembolism risk appears negligible.

A significantly elevated risk of wound dehiscence within 90 days post-surgery was observed in patients with vitamin D deficiency or subsufficient levels compared with vitamin D-sufficient patients. This association persisted when analyses were restricted to ambulatory patients. However, a separate examination of inpatients failed to identify an association between vitamin D status and wound dehiscence. This discrepancy may reflect a variation in baseline risk, perioperative care, or sample size, as inpatients present with more comorbidities and typically receive closer monitoring and wound care. Predictors of wound dehiscence in HV surgery are poorly characterized, and prior work has not examined vitamin D status in this context.¹⁵ Evidence from other orthopaedic procedures suggests that vitamin D deficiency can impair wound healing.^16
-20 In our procedure-specific analysis limited to vitamin D-subsufficient patients, first MTP fusion was associated with higher rates of dehiscence than joint-sparing HV correction. Because this comparison was restricted to subsufficient patients, the difference likely reflects procedural factors and does not elucidate whether subsufficiency increases wound risk relative to sufficiency. Overall, these results suggest that both preoperative vitamin D status and procedure type may influence wound-healing risk, thereby supporting the consideration of vitamin D assessment as a potential adjunct in preoperative optimization strategies.

Suboptimal vitamin D levels were also associated with higher utilization outcomes, including inpatient consultation/admission, ED visits, and postoperative opioid use. These associations remained significant in the ambulatory cohort; however, the opioid relationship did not persist among inpatients. This attenuation may be attributable to standardized inpatient pain protocols that minimize variability in postoperative opioid prescribing and the fact that the 90-day window primarily reflects immediate postoperative management rather than long-term opioid dependency. Prior literature associates vitamin D deficiency with greater postoperative pain and opioid requirements.²¹ Given the risks associated with opioid exposure—particularly in the context of the ongoing opioid crisis—identifying modifiable predictors of increased analgesic needs is critical. Preoperative vitamin D screening may serve as a low-risk, cost-effective strategy to enhance postoperative pain management and potentially mitigate long-term opioid dependence. Prior studies have discussed the association between vitamin D deficiency and increased postoperative pain following procedures such as knee arthroplasty.²² Although it is unclear whether the ED visits in this study were specifically pain-related, the observed associations highlight the necessity for further research on how vitamin D status may influence postoperative pain experience and health care utilization following HV surgery.

Vitamin D status was not associated with an altered risk of pulmonary embolism (PE) or deep vein thrombosis (DVT), and this finding remained consistent across inpatient and ambulatory sub-analyses. Although prior studies in total shoulder arthroplasty have reported a higher incidence of PE in vitamin D-deficient patients compared to nondeficient patients, our findings suggest that, in the context of HV correction, routine vitamin D deficiency may not substantially affect short-term thromboembolic risk.¹³ The observed incidence of DVT (~4%) and PE (0.15%-0.2%) aligns with previously reported rates following foot and ankle procedures, supporting the consistency of thromboembolic outcomes in this surgical population.^23
-25

The present study identified an association between vitamin D deficiency and wound dehiscence; however, no significant association was observed with postoperative sepsis. Interestingly, patients in the vitamin D-subsufficient group had higher rates of postoperative infection following HV correction compared to patients who were vitamin D-sufficient. Prior studies have linked vitamin D deficiency to increased rates of infection, sepsis, and mortality across surgical populations, particularly in hip and knee arthroplasty where suboptimal levels have been associated with periprosthetic joint and surgical site infections.^18,19 In contrast, our findings suggest that although low vitamin D status may impair local wound healing and increase susceptibility to superficial infection, its influence on the progression to systemic infection in the hallux valgus population may be limited. This distinction underscores the possibility that the immunomodulatory effects of vitamin D vary based on surgical site and tissue type involved.

This study represents the first comprehensive evaluation of postoperative outcomes in HV patients stratified by suboptimal vs sufficient vitamin D levels. Nonetheless, several important limitations warrant consideration. First, this study was exploratory in nature and evaluated multiple outcomes without formal correction for multiplicity, increasing the potential for type I error. Although propensity score matching was applied to mitigate confounding, residual bias is likely. Matching techniques cannot perfectly balance all covariates, and the observed differences may reflect underlying differences in patient health status rather than causal effects of suboptimal vitamin D levels. Moreover, the analysis was limited to complications occurring within 90 days postoperatively, precluding assessment of longer-term outcomes. Another notable limitation is the absence of data pertaining to hardware selection, failure, or nonunion-a particularly pertinent concern in the context of vitamin D deficiency. Given the critical role of vitamin D in bone mineralization, future prospective studies incorporating radiographic data are essential to bridge this information gap that administrative databases cannot address. A subset of surgeries lacked classification as inpatient or outpatient, leading to reduced totals in the sub-analysis and the potential underestimation of values for these specific cohorts. Furthermore, in our procedure-specific analysis limited to vitamin D-subsufficient patients, first MTP fusion demonstrated higher wound dehiscence than joint-sparing HV correction, though interpretation is limited by the absence of a subsufficient vs sufficient comparison. Given that this study is dependent on administrative data, the potential for misclassification, coding inaccuracies, or incomplete capture of outcomes cannot be excluded. Finally, although some differences reached statistical significance, absolute risk differences were generally small; however, the large sample size and well-balanced cohorts after propensity score matching support the robustness of these exploratory associations.

Conclusion

Suboptimal levels of vitamin D prior to HV correction demonstrated statistically significant, though clinically modest, associations with higher rates of wound dehiscence, infection following the procedure, inpatient consultation or admission, emergency department utilization, and postoperative opioid prescribing within the first 90 days, particularly among ambulatory patients. When stratified by surgical setting, subsufficiency was linked to increased ED visits in inpatients and higher wound dehiscence, ED visits, and opioid use in ambulatory patients. Among vitamin D-subsufficient patients, first MTP fusion had higher wound dehiscence than HV correction, likely reflecting greater soft tissue disruption. These findings highlight that both vitamin D status and procedure type influence postoperative risk and support consideration of preoperative vitamin D assessment to potentially reduce complications and improve recovery.

Supplemental Material

sj-pdf-1-fao-10.1177_24730114261422228 – Supplemental material for Association of Vitamin D Deficiency With Adverse Postoperative Outcomes Following Hallux Valgus Correction

Supplemental material, sj-pdf-1-fao-10.1177_24730114261422228 for Association of Vitamin D Deficiency With Adverse Postoperative Outcomes Following Hallux Valgus Correction by Eve R. Glenn, David Ryu, Eric Mao, Daniel Badin, Nigel Hsu, John M. Thompson and Amiethab Aiyer in Foot & Ankle Orthopaedics

Footnotes

Appendix

Supplemental Table 6.

Comparison of Baseline Demographic and Clinical Characteristics Before and After Propensity Score Matching in Vitamin D Subsufficient Hallux Valgus and First MTP Fusion Cohorts.

	Hallux Valgus (n = 14 704)			First MTP Fusion (n = 3602)				Standardized Mean Difference
	Mean ± SD	Patients	% of Cohort	Mean ± SD	Patients	% of Cohort	P Value	Standardized Mean Difference
Current age	61.5 ± 14.0	14704	100	67.1 ± 14.0	3602	100	<.001*	0.4
Age at index	56.5 ± 13.7	14704	100	62.5 ± 11.8	3602	100	<.001*	0.5
Male		1679	11.4		642	17.82	<.001*	0.2
Female		12716	86.5		2959	82.15	<.001*	0.1
Hispanic or Latino		956	6.5		187	5.19	.004	0.1
Not Hispanic or Latino		11090	75.4		3006	83.45	<.001*	0.2
White		10309	70.1		2787	77.37	<.001*	0.2
Black or African American		2687	18.3		574	15.94	.001	0.1
Asian		296	2.0		44	1.22	.002	0.1
American Indian or Alaska Native		74	0.5		12	0.33	.181	0.0
Native Hawaiian or Other Pacific Islander		27	0.2		10	0.28	.260	0.0
Disorders of lipoprotein metabolism and other lipidemias		8055	54.8		2454	68.13	<.001*	0.3
Overweight, obesity and other hyperalimentation		5380	36.6		1485	41.23	<.001*	0.1
Inflammatory polyarthropathies		3406	23.2		1459	40.51	<.001*	0.4
Diabetes mellitus		2740	18.6		841	23.35	<.001*	0.1
Nicotine dependence		2249	15.3		678	18.82	<.001*	0.1
Persons with potential health hazards related to socioeconomic and psychosocial circumstances		854	5.8		285	7.91	<.001*	0.1
Alcohol-related disorders		752	5.1		291	8.08	<.001*	0.1
	Hallux Valgus (n = 3600)			First MTP Fusion (n = 3600)				Standardized Mean Difference
	Mean ± SD	Patients	% of Cohort	Mean ± SD	Patients	% of Cohort	P Value	Standardized Mean Difference
Current age	67.3 ± 11.5	3600	100	67.0 ± 11.9	3600	100	.391	0.0
Age at index	62.8 ± 11.3	3600	100	62.4 ± 11.8	3600	100	.187	0.0
Male		595	16.5		640	17.8	.159	0.0
Female		3002	83.4		2959	82.2	.179	0.0
Hispanic or Latino		157	4.4		187	5.2	.097	0.0
Not Hispanic or Latino		3053	84.8		3004	83.4	.114	0.0
White		2865	79.6		2785	77.4	.022	0.05
Black or African American		526	14.6		574	15.9	.116	0.0
Asian		36	1		44	1.2	.368	0.0
American Indian or Alaska Native		10	0.3		12	0.3	.669	0.0
Native Hawaiian or Other Pacific Islander		10	0.3		10	0.3	1.000	0.0
Disorders of lipoprotein metabolism and other lipidemias		2517	69.9		2452	68.1	.098	0.0
Overweight, obesity and other hyperalimentation		1468	40.8		1484	41.2	.701	0.0
Inflammatory polyarthropathies		1384	38.4		1457	40.5	.078	0.0
Diabetes mellitus		831	23.1		841	23.4	.780	0.0
Nicotine dependence		662	18.4		678	18.8	.628	0.0
Persons with potential health hazards related to socioeconomic and psychosocial circumstances		270	7.5		283	7.9	.565	0.0
Alcohol-related disorders		255	7.1		291	8.1	.109	0.0

Significant P values (P < .05).

ORCID iDs

Eve R. Glenn, ScB,

Nigel Hsu, MD,

Amiethab Aiyer, MD,

Ethical Considerations

Institutional Review Board (IRB) approval was not required for this study.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

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