Fracture healing in older people is a multifactorial biological process greatly influenced by systemic nutritional, metabolic, and hormonal factors. Changes in bone turnover and mineral metabolism with aging lead to decreased bone mass and loss of structural integrity, which predispose individuals to fragility fractures [1]. Of these, fractures of the hip, wrist, and vertebrae are more prevalent with substantial morbidity, mortality, and cost-associated effects [2]. The older adult population is growing rapidly in India and globally, likely leading to an increased prevalence of osteoporotic fractures needing surgery [3]. The recovery following fracture fixation in elderly patients is usually protracted, so geriatric fractures rarely reach normal function, which is mainly due to age-related comorbidities, poor bone quality, and nutritional deficiencies, of which vitamin D deficiency is now increasingly recognized as a key factor [4]. Vitamin D is crucial for the regulation of calcium and phosphate metabolism and bone remodeling, as it enhances osteoblast differentiation and deposition of bone matrix[5]. Thus, it may seriously affect osteogenesis of the callus, delay the process of joining, and influence functional recovery after orthopedic surgery [6].

Vitamin D, which is predominantly synthesized in the skin upon exposure to ultraviolet B (UVB) radiation, has a few dietary sources, including fortified milk, fatty fish, and egg yolk [7]. Even in the tropical conditions, hypovitaminosis is disturbingly common, mainly because of lifestyle factors and lack of exposure to sunlight due to traditional clothing and poor dietary intake. Studies have shown that 70-90% of older people in India have suboptimal serum 25-hydroxyvitamin D levels (<30 ng/mL), leading to decreased calcium absorption and secondary hyperparathyroidism [8]. This ongoing inadequacy diminishes cortical bone and further disrupts trabecular bone microarchitecture, making the skeleton susceptible to low-impact fractures [9]. The sufficiency of vitamin D in post operative orthopaedics, Societal needs, and the trapped population. In addition to bone consolidation, through muscle recovery and functional rehabilitation, the sufficiency of vitamin D in postoperative patients also plays a vital role. Skeletal muscle tissue contains vitamin D receptors that affect muscle protein synthesis, balance, and neuromuscular coordination, variables essential to the resumption of mobility in elderly patients with a fracture [10]. Consequently, low serum vitamin D concentrations can be associated with prolonged immobilization, a greater risk of falling, delayed ambulation, and worse QoL [11].

Combined with delayed fracture healing, the role of vitamin D deficiency has come to light, especially in recent years. Experimental trials demonstrated that vitamin D supplementation promotes callus formation, increases alkaline phosphatase activity, and accelerates endochondral ossification [12]. Clinical studies have also reported a favorable association between vitamin D status and radiographic union rate, indicating that the micronutrient may serve as a biochemical cofactor in bone metabolism and the control of inflammation through the healing cascade [13]. On the other hand, its deficiency results in decreased angiogenesis, reduced collagen synthesis, and less mineral deposition at the fracture site. Crucially, these risks are increased in the elderly; age-related hormonal changes and diminished renal hydroxylation of vitamin D all contribute to reduced effects. The reported prevalence of vitamin D deficiency in elderly fracture patients scheduled for fixation ranges from 50% to 80% across Indian tertiary care hospitals, pointing to the scale of the problem. Furthermore, the heterogeneity in the type of fracture, comorbidity burden, and postoperative presents more challenges to identify a recovery trajectory for this age group [14]. Thus, measuring and adjusting vitamin D status at the early stage may be a modifiable factor to promote postoperative recovery and prevent functional impairment [15].

Notwithstanding the growing evidence linking vitamin D deficiency to orthopaedics, there are still no systematic studies addressing this issue in rural populations, which include malnutrition and limited access to healthcare services. The rural community of Maharashtra, Loni, is a population-based study area with agricultural occupation and, consequently, low dietary diversity among the elderly with chronic diseases (CDDEs) [16]. As natural sunlight exposure is the primary source of vitamin D, it is worth noting that seasonal differences, clothing behaviour, and decreased post-fracture mobility are additional limitations in these patients. Additionally, economic constraints often result in delayed diagnosis and postoperative rehabilitation with consequent suboptimal outcomes. Therefore, research into the relationship between vitamin D levels and functional recovery in this type of environment may further support regional preventive intervention or therapeutic guidance. Earlier international studies have revealed the potential advantages of vitamin D optimization for fracture healing and functional independence; however, direct evidence from the Indian rural population is scarce.

In the above context, this study entitled “Evaluation of Vitamin D Status and its Correlation with Functional Recovery following Fracture Fixation in Elderly Patients” was carried out in the Department of Orthopaedics, Rural Medical College, PMT-Loni, Maharashtra, India. The main objective was to assess the vitamin D status in elderly patients undergoing surgical fracture fixation and to correlate it with postoperative outcomes and rehabilitation. This study is proposed to explore the biochemical or functional interactions, address the gaps in the existing literature, and provide potential guidance for clinical application. The results would help the orthopedic surgeons in formulating an evidence-based approach to standardize nutritional management and improve patient outcomes, which eventually translates into lowering complications and better quality of life of the geriatric Indian population [17].

OBJECTIVE

The primary objective of this study was to evaluate the serum vitamin D status among elderly patients undergoing surgical fracture fixation and to establish a correlation between serum 25-hydroxyvitamin D levels and postoperative functional recovery outcomes. The research aimed to determine how varying degrees of vitamin D deficiency or sufficiency affect fracture healing time, radiological union, and physical rehabilitation following internal fixation procedures. By analyzing these associations, the study sought to elucidate whether preoperative vitamin D levels could serve as a predictive biomarker for postoperative recovery and mobility outcomes among geriatric orthopedic patients. The intent was to explore vitamin D not merely as a nutritional factor but as a biological determinant of healing efficiency, muscle function, and overall postoperative recovery trajectory.

The secondary objectives were multifaceted. First, to assess the prevalence and severity of vitamin D deficiency in elderly fracture patients admitted to the Department of Orthopaedics at Rural Medical College, PMT, Loni, Maharashtra, India. Second, to examine the influence of vitamin D status on functional outcome scores specifically the Harris Hip Score (HHS) for lower limb fractures and the Disabilities of Arm, Shoulder and Hand (DASH) score for upper limb fractures over a defined follow-up period of six months. Third, to determine whether vitamin D deficiency contributes to delayed fracture healing, increased postoperative complications, or prolonged rehabilitation duration. Furthermore, the study sought to identify demographic and clinical factors (such as age, gender, comorbidities, or fracture site) that might influence vitamin D status and thereby affect recovery outcomes. Ultimately, this research aimed to generate evidence-based recommendations supporting routine vitamin D screening and correction protocols in elderly fracture patients to optimize functional recovery, minimize postoperative morbidity, and enhance quality of life through comprehensive orthopedic care.

Study Design and Setting

This prospective observational study was conducted in the Department of Orthopaedics, Rural Medical College, Pravara Institute of Medical Sciences (PMT), Loni, Maharashtra, India, over a period of 13 months from April 2024 to May 2025. The study was designed to evaluate the relationship between serum vitamin D levels and functional recovery outcomes following surgical fracture fixation in elderly patients. Ethical approval for the study was obtained from the Institutional Ethics Committee, and the research was performed in accordance with the principles of the Declaration of Helsinki (2013 revision). Prior to enrollment, all participants provided written informed consent, with detailed explanations regarding study objectives, potential benefits, and confidentiality assurances.

The sample size was determined using statistical power analysis based on previously published studies evaluating the correlation between vitamin D deficiency and fracture healing [1,2]. Assuming a medium effect size of 0.35, power of 0.8, and a 5% level of significance, a minimum of 70 participants was required. To account for potential dropouts, the final target sample was fixed at 75 participants. Eligible patients were recruited consecutively from the inpatient orthopedic wards and outpatient trauma services of the hospital.

All surgeries were performed by experienced orthopedic surgeons following standard fixation protocols using appropriate implants (e.g., dynamic hip screw, intramedullary nail, plate fixation). Postoperative care and rehabilitation were standardized to minimize confounding variables. Physiotherapy sessions were initiated according to the patient’s tolerance and fracture type. Follow-up assessments were carried out at 6 weeks, 12 weeks, and 6 months postoperatively to evaluate radiological healing and functional outcomes.

Inclusion Criteria

1. Elderly patients aged 60 years and above.
2. Individuals with acute fractures of long bones (femur, tibia, humerus, or radius/ulna) managed by internal fixation.
3. Patients presenting within 7 days of injury and scheduled for elective surgical fixation.
4. Patients providing informed written consent and willing to attend all follow-up visits.

Exclusion Criteria

1. Patients with pathological fractures secondary to malignancy or metabolic bone disease other than osteoporosis.
2. Individuals with chronic liver disease, renal insufficiency, or endocrine disorders affecting calcium metabolism.
3. Patients receiving vitamin D or calcium supplementation within three months prior to the study.
4. Polytrauma cases, open fractures, or fractures requiring external fixation.
5. Bedridden or cognitively impaired patients unable to participate in rehabilitation assessment.

These criteria were designed to ensure homogeneity of the study population and minimize confounding variables that could influence bone metabolism or recovery outcomes.

Data Collection Procedure

Data were collected using a pretested structured proforma designed by the research team. It included patient demographics (age, sex, occupation), clinical details (fracture site, type, mechanism of injury), comorbidities (diabetes, hypertension, osteoporosis), and anthropometric measurements (height, weight, BMI).

Blood Sampling and Biochemical Assessment:

Venous blood samples were collected from each patient within 24 hours of admission and prior to surgery. Samples were analyzed for serum 25-hydroxyvitamin D [25(OH)D] levels using the chemiluminescent immunoassay (CLIA) method on an automated analyzer (Abbott Architect i2000SR). The intra- and inter-assay coefficient of variation for the test was <8%. The following classification was adopted based on Endocrine Society clinical guidelines [3]:

• Deficient: <20 ng/mL
• Insufficient: 20–30 ng/mL
• Sufficient: >30 ng/mL

Additionally, serum calcium, phosphate, and alkaline phosphatase were measured to assess bone turnover markers. Patients were categorized into vitamin D status groups for comparative analysis.

Surgical and Postoperative Protocol:

All fracture fixations were performed under regional or general anesthesia following aseptic precautions. The fixation technique was chosen according to fracture morphology and surgeon preference. Postoperatively, all patients received routine antibiotics, thromboprophylaxis, and analgesia. Early mobilization was encouraged as per pain tolerance, and supervised physiotherapy was initiated from postoperative day two. Patients were discharged once stable and instructed for scheduled follow-up.

Follow-up and Functional Assessment:

Follow-up evaluations were carried out at 6 weeks, 12 weeks, and 24 weeks (6 months).

• Radiological Healing: evaluated through X-rays using Cortical Bridging Index (CBI) and Radiological Union Score for Tibia (RUST) where applicable. Fracture union was defined as visible bridging callus formation across ≥3 cortices with no visible fracture line [4].
• Functional Outcome Measures:
• For lower limb fractures: Harris Hip Score (HHS) assessing pain, function, range of motion, and deformity.
• For upper limb fractures: Disabilities of Arm, Shoulder, and Hand (DASH) Score, quantifying physical disability and symptoms.

Both scoring systems were administered at each follow-up visit, and improvement trends were analyzed. Functional recovery was categorized as excellent, good, fair, or poor based on score thresholds.

Quality Control:

All biochemical analyses were performed in the institutional central laboratory accredited by NABL. Two trained research assistants independently entered data to minimize transcription errors. Inter-observer variation in radiographic assessment was reduced by consensus evaluation between two orthopedic consultants.

Statistical Data Analysis

Data were entered and analyzed using IBM SPSS Statistics version 26.0 (Armonk, NY, USA). Descriptive statistics were computed for all variables:

• Continuous data were presented as mean ± standard deviation (SD).
• Categorical data were expressed as frequencies and percentages.

Before inferential testing, normality of continuous variables was assessed using the Shapiro–Wilk test.

Comparative Analyses:

• Differences between vitamin D status groups (deficient, insufficient, sufficient) were analyzed using one-way Analysis of Variance (ANOVA) for continuous variables such as healing time and functional scores.
• The Chi-square test was applied to categorical variables like sex distribution and comorbidities.
• Post-hoc Tukey tests were conducted for pairwise comparisons of means when ANOVA indicated significant differences.

Correlation Analyses:

• The relationship between serum vitamin D levels and outcome measures (HHS and DASH scores) was examined using the Pearson correlation coefficient (r).
• A positive correlation indicated improved functional recovery with increasing vitamin D concentration.

Regression Analysis:

To adjust for confounding variables (age, BMI, comorbidities, and fracture site), multivariate linear regression models were used. Vitamin D level served as the independent predictor variable, while healing time and functional scores were dependent outcome variables.

Statistical Significance:

A p-value < 0.05 was considered statistically significant. The confidence interval (CI) was set at 95% for all tests. Graphical representations (bar charts, line graphs, and pie charts) were generated to illustrate key findings and group distributions.

Ethical Considerations and Confidentiality

The study adhered to ethical standards for biomedical research involving human participants. The Institutional Ethics Committee approval ensured compliance with ethical guidelines. Each participant was assigned a unique identification code to maintain anonymity. Patient records and laboratory reports were stored securely with restricted access to research staff. Data sharing was limited to aggregated findings for publication purposes only. No financial incentives were provided to participants, and vitamin D results were communicated to all patients for further medical management when necessary.

Operational Definitions

• Functional Recovery: improvement in mobility, pain relief, and limb function measured by validated scales (HHS/DASH) six months postoperatively.
• Fracture Healing: radiological evidence of bone union and absence of tenderness or abnormal movement at the fracture site.
• Vitamin D Deficiency: serum 25(OH)D <20 ng/mL, following the Endocrine Society’s classification.

Summary

In summary, this study utilized a prospective, analytical observational design with standardized biochemical, radiological, and functional evaluation parameters. By categorizing patients based on vitamin D status and monitoring their postoperative recovery longitudinally, this methodology ensured a robust assessment of the relationship between micronutrient deficiency and fracture healing dynamics in the elderly. The integration of biochemical markers, imaging evaluation, and validated scoring systems provided a comprehensive framework to understand the multifaceted role of vitamin D in bone and functional restoration following surgical fixation.

Demographic and Clinical Characteristics of the Study Population

A total of 75 elderly patients who underwent surgical fracture fixation were included in the study. The mean age of participants was 67.8 ± 5.4 years, with an age range of 60–84 years. There was a female predominance (60%) compared to males (40%), reflecting the higher incidence of osteoporotic fractures among postmenopausal women. The majority of fractures were caused by low-energy falls (76%), followed by road traffic accidents (20%) and other causes such as direct trauma (4%).

Common fracture sites included the proximal femur (hip) in 40% of cases, distal radius in 25%, humerus in 20%, and tibia/fibula in 15%. A significant proportion of patients (68%) had one or more comorbidities, such as hypertension (42%), diabetes mellitus (28%), and osteoporosis (22%), which were carefully controlled during the study period.

Table 1 summarizes the demographic and clinical characteristics of the study participants.

Table 1: Demographic Distribution of the Study Population

This table presents the baseline demographic and clinical characteristics of the 75 elderly participants who underwent fracture fixation. It includes mean age, gender distribution, body mass index (BMI), fracture site, mechanism of injury, and comorbidity prevalence. The majority of patients were female (60%), with an average age of 67.8 ± 5.4 years, and low-energy falls constituted the predominant mechanism of injury (76%). The table establishes the general comparability of patient subgroups in terms of demographic and clinical parameters.

Serum Vitamin D Status

The mean serum 25(OH)D concentration among all participants was 18.6 ± 7.4 ng/mL, indicating an overall low level of vitamin D in this elderly population.

Out of the 75 participants:

• 48 (64%) were classified as vitamin D deficient (<20 ng/mL)
• 17 (22.7%) were vitamin D insufficient (20–30 ng/mL)
• 10 (13.3%) had sufficient vitamin D (>30 ng/mL)

These findings highlight a high prevalence (86.7%) of suboptimal vitamin D status, consistent with prior reports from Indian rural populations [1,2]. The distribution of vitamin D categories is presented in Table 2 and visually depicted in Figure 1 (Pie Chart).

Table 2: Distribution of Participants Based on Vitamin D Status

This table summarizes the serum 25-hydroxyvitamin 25(OH)D concentrations of the study participants, classified into three categories deficient (<20 ng/mL), insufficient (20–30 ng/mL), and sufficient (>30 ng/mL) according to Endocrine Society guidelines. The majority (64%) were found to be deficient, 22.7% insufficient, and only 13.3% sufficient. Mean serum 25(OH)D levels are presented for each category, reflecting the high prevalence of hypovitaminosis D in the elderly population studied.

Figure 1: Distribution of participants by vitamin D status

This pie chart illustrates the proportion of elderly fracture fixation patients categorized by serum 25(OH)D levels. A significant majority (64%) were vitamin D deficient (<20 ng/mL), 22.7% were insufficient (20–30 ng/mL), and only 13.3% had sufficient vitamin D (>30 ng/mL). The figure highlights the high prevalence of vitamin D deficiency in the study cohort, underscoring the clinical need for routine preoperative screening and supplementation among elderly orthopedic patients.

Radiological and Functional Recovery Outcomes

Fracture healing and functional recovery were evaluated at 6 weeks, 12 weeks, and 6 months postoperatively. Patients with sufficient vitamin D levels demonstrated earlier callus formation and shorter healing times compared to those who were deficient.

The mean fracture healing time was:

• 14.2 ± 1.8 weeks in vitamin D–deficient patients,
• 12.6 ± 1.5 weeks in the insufficient group, and
• 10.4 ± 1.3 weeks among those with sufficient vitamin D levels (p = 0.018).

The difference was statistically significant, as confirmed by one-way ANOVA testing.

Table 3: Correlation Between Vitamin D Levels and Healing Time

This table shows the relationship between serum vitamin D status and mean fracture healing duration, expressed in weeks. Healing time decreased progressively with higher vitamin D levels: deficient patients averaged 14.2 ± 1.8 weeks, insufficient patients 12.6 ± 1.5 weeks, and sufficient patients 10.4 ± 1.3 weeks. The observed difference was statistically significant (p = 0.018, one-way ANOVA), confirming that vitamin D sufficiency accelerates bone healing following surgical fixation.

This finding indicates that vitamin D sufficiency contributes to faster bone regeneration, likely due to enhanced calcium absorption and osteoblastic activity [3].

Functional Outcomes (Harris Hip Score and DASH Score)

Functional outcomes were assessed at the 6-month follow-up using the Harris Hip Score (HHS) for lower limb fractures and the DASH score for upper limb fractures. Patients with sufficient vitamin D levels achieved higher mean HHS (82.1 ± 9.2) compared to the deficient group (58.3 ± 7.1) and insufficient group (72.2 ± 8.3). Similarly, the DASH score where lower values indicate better function was significantly lower in the sufficient group (35.6 ± 4.8) compared to the deficient (62.4 ± 6.5) and insufficient (48.9 ± 5.6) groups. These differences were statistically significant (p = 0.011).

Table 4: Comparison of Mean Functional Scores by Vitamin D Status

This table compares postoperative functional outcomes using the Harris Hip Score (HHS) and the Disabilities of the Arm, Shoulder, and Hand (DASH) score at six months across the three vitamin D categories. Patients with sufficient vitamin D demonstrated significantly higher HHS (82.1 ± 9.2) and lower DASH (35.6 ± 4.8) scores, indicating superior recovery. Statistical analysis (p = 0.011) confirmed the positive correlation between vitamin D sufficiency and better musculoskeletal function.

Figure 2: Comparison of Mean Harris Hip and DASH Scores by Vitamin D Category

This bar chart compares postoperative functional outcomes measured by the Harris Hip Score (HHS) and Disabilities of the Arm, Shoulder, and Hand (DASH) score across vitamin D status groups. Patients with sufficient vitamin D levels (>30 ng/mL) achieved markedly higher HHS values (82.1 ± 9.2) and lower DASH scores (35.6 ± 4.8), indicating better functional recovery. In contrast, vitamin D–deficient patients (<20 ng/mL) demonstrated delayed recovery and poorer functional outcomes. The chart demonstrates a clear, positive correlation between higher vitamin D levels and improved rehabilitation performance following fracture fixation.

Correlation and Regression Analysis

Pearson’s correlation analysis revealed a strong positive correlation between serum 25(OH)D and Harris Hip Score (r = 0.72, p < 0.01), indicating that higher vitamin D levels are significantly associated with improved lower-limb function. A similarly strong negative correlation with DASH score (r = –0.68, p < 0.01) was observed, confirming that functional disability decreased as vitamin D increased.

To further control for confounders such as age, gender, BMI, fracture type, and comorbidities, multivariate regression analysis was performed. The results confirmed that serum vitamin D was an independent predictor of functional recovery, even after adjusting for covariates (β = 0.56, 95% CI 0.32–0.74, p = 0.004).

Table 5: Summary of Key Statistical Findings

The data collectively suggest that vitamin D status strongly influences both biological and functional aspects of fracture recovery.

This table consolidates the major statistical results of the study, presenting the relationships between vitamin D status, healing time, and functional outcomes. It includes the statistical test applied (ANOVA, Pearson correlation, and multivariate regression), p-values, correlation coefficients (r), and regression coefficients (β). The data confirm that serum vitamin D concentration is an independent predictor of both faster bone healing and improved postoperative functional recovery (β = 0.56, p = 0.004).

Comparative Observations

When stratified by gender, females showed slightly lower mean vitamin D levels (17.9 ± 6.8 ng/mL) compared to males (19.7 ± 7.6 ng/mL), but this difference was not statistically significant (p = 0.32). However, functional outcomes tended to be poorer among women, potentially due to higher osteoporosis prevalence and reduced muscle mass [4]. Patients with comorbidities such as diabetes or hypertension had significantly lower Harris Hip Scores (mean 65.4 ± 8.7) compared to those without comorbidities (75.2 ± 7.3), suggesting a possible interaction between systemic disease and recovery speed.

Fracture site also played a role in outcome variation: hip fractures required longer healing durations (average 13.8 ± 1.6 weeks) compared to upper limb fractures (11.7 ± 1.4 weeks). Nevertheless, vitamin D status remained a consistent predictor of improved outcomes across all anatomical fracture types.

Summary of Findings

1. Vitamin D deficiency was prevalent in 64% of elderly fracture patients.
2. Healing time decreased significantly as vitamin D levels increased (p = 0.018).
3. Functional scores (HHS, DASH) improved progressively with higher vitamin D concentrations (p = 0.011).
4. Strong positive correlation (r = 0.72) existed between vitamin D and functional recovery.
5. Vitamin D was an independent predictor of postoperative recovery in regression analysis.

These findings collectively support the hypothesis that maintaining optimal vitamin D status enhances both the biological healing process and functional rehabilitation following fracture fixation in elderly individuals.

The present study demonstrates a strong and statistically significant correlation between serum vitamin D levels and postoperative functional recovery among elderly patients undergoing fracture fixation. Our findings revealed that vitamin D deficiency was highly prevalent (64%) in the study population, a result consistent with prior research from both Indian and international cohorts [18]. Elderly individuals, particularly in rural India, are predisposed to low vitamin D status due to multiple risk factors such as inadequate sunlight exposure, poor dietary intake, and reduced skin synthesis associated with aging [19]. The study observed that patients with sufficient vitamin D levels (>30 ng/mL) exhibited superior radiological healing, higher Harris Hip Scores, and lower DASH disability scores compared to those with deficient or insufficient levels. This suggests that vitamin D plays a critical role not only in osteogenesis but also in neuromuscular recovery following fracture fixation. These results align with the findings of [4, 5], who reported that optimal vitamin D concentrations are associated with accelerated bone union and improved functional scores in elderly fracture patients. Vitamin D, through its active metabolite calcitriol, stimulates calcium absorption in the intestines, promotes osteoblastic activity, and regulates the expression of osteocalcin and type I collagen all essential components of bone matrix formation [20]. Additionally, its anti-inflammatory effects contribute to modulating the bone healing cascade, facilitating the transition from inflammatory to reparative phases more efficiently [32].

Comparatively, vitamin D-deficient patients in this study exhibited delayed callus formation, prolonged fracture healing time, and lower mobility restoration. This finding mirrors the results of [9], who reported that patients with hypovitaminosis D required extended rehabilitation and experienced delayed functional milestones following hip fracture fixation. Biologically, this delay can be attributed to impaired mineralization, reduced calcium-phosphate homeostasis, and suboptimal chondrocyte differentiation during endochondral ossification [22]. Moreover, vitamin D deficiency leads to increased parathyroid hormone (PTH) levels, which in turn accelerate bone resorption and compromise bone strength [23]. Several meta-analyses have corroborated that vitamin D supplementation reduces fracture risk and improves postoperative recovery outcomes among elderly populations [24]. The present study supports these conclusions and further emphasizes the practical need for preoperative screening and correction of vitamin D levels. In the rural Indian context, this becomes even more vital given the high burden of undiagnosed deficiency and limited awareness regarding supplementation. Moreover, the neuromuscular benefits of vitamin D extend beyond bone metabolism. It enhances muscle contractility and strength through activation of vitamin D receptors in skeletal muscle fibers, thereby improving balance and reducing the likelihood of recurrent falls during rehabilitation [25]. This dual mechanism promoting both bone healing and muscle recovery makes vitamin D a pivotal determinant in postoperative functional restoration. In our cohort, the observed improvement in DASH and Harris Hip Scores among vitamin D–sufficient individuals underscores this synergistic effect [27].

The results of this study are consistent with earlier Indian and international investigations emphasizing the clinical relevance of vitamin D optimization in orthopedic patients. Cauley, J. A., et al. and Avenell, A., et al. observed that vitamin D deficiency negatively impacted fracture union and increased the risk of non-union, particularly in long bone fractures. In contrast, supplementation protocols led to a 20–30% improvement in functional outcomes, highlighting the therapeutic potential of vitamin D correction. Similarly, Avenell, A., et al. [21] found that vitamin D–sufficient patients showed earlier radiographic healing and superior limb function within 12 weeks postoperatively. From a pathophysiological standpoint, vitamin D modulates osteoprotegerin (OPG) and receptor activator of nuclear factor kappa-B ligand (RANKL) pathways, maintaining a balance between bone formation and resorption [25]. Furthermore, vitamin D plays an indirect role in angiogenesis by upregulating vascular endothelial growth factor (VEGF), which is crucial for callus vascularization and tissue remodeling. This comprehensive influence extends across molecular, cellular, and biomechanical levels of the healing process. The improvement in Harris Hip and DASH scores observed in our study supports the hypothesis that adequate vitamin D not only accelerates biological healing but also enhances postoperative rehabilitation outcomes through improved musculoskeletal function [26]. Notably, the recovery curve among vitamin D–sufficient patients was steeper during the first three postoperative months, indicating that the early postoperative phase is particularly sensitive to nutritional status. This finding corresponds to the study by Kim, S. H., et al. [25], who highlighted that early correction of deficiency improves muscle mass and reduces rehabilitation duration in orthopedic patients [28].

In the context of rural healthcare, the implications of this study are particularly significant. Despite the high prevalence of vitamin D deficiency, routine screening before orthopedic surgery is not widely practiced in rural hospitals due to cost constraints and limited diagnostic resources. The findings suggest that simple, cost-effective screening and supplementation protocols could yield substantial benefits by reducing hospital stay duration and improving functional independence among elderly fracture patients. Additionally, this approach aligns with the preventive healthcare model emphasized by the World Health Organization (WHO), which advocates addressing modifiable risk factors to optimize postoperative outcomes in aging populations. Our results further resonate with the work of [29], who emphasized that vitamin D optimization reduces postoperative complications such as delayed union, malunion, and muscle weakness [31]. It is also noteworthy that while fracture fixation techniques and postoperative rehabilitation protocols contribute significantly to patient outcomes, nutritional and hormonal factors like vitamin D serve as essential biological catalysts for recovery [30]. Thus, orthopedic care should adopt a holistic approach that integrates surgical precision with metabolic optimization. Implementing standardized vitamin D supplementation protocols, patient education on dietary sources, and encouragement of safe sunlight exposure could potentially improve long-term outcomes in elderly patients recovering from fractures [33].

The current study’s findings, therefore, reinforce the emerging paradigm that vitamin D is not merely a vitamin but a pro-hormone with extensive effects on bone, muscle, and neural tissues. Ensuring optimal serum levels pre- and post-surgery can enhance tissue regeneration, minimize complications, and improve mobility outcomes in elderly fracture patients. Considering India’s high burden of vitamin D deficiency, particularly in rural regions, incorporating vitamin D testing into routine orthopedic protocols may represent a cost-effective intervention with high clinical impact. Future studies should focus on randomized controlled trials evaluating dose-dependent effects of supplementation, interaction with calcium intake, and long-term outcomes such as bone mineral density and quality of life measures [34]. Moreover, public health initiatives should address nutritional literacy among older adults to combat widespread vitamin D deficiency. Overall, the evidence from this and previous studies collectively underscores the multifaceted role of vitamin D in promoting bone health, supporting neuromuscular function, and facilitating efficient functional recovery after orthopedic interventions [35].

LIMITATIONS OF THE STUDY

While this study provides valuable insights into the relationship between vitamin D status and postoperative functional recovery among elderly patients undergoing fracture fixation, several limitations must be acknowledged to ensure a balanced interpretation of the findings.

Firstly, the sample size of 75 participants, although statistically adequate for detecting moderate correlations, remains relatively small for establishing generalizable conclusions across diverse populations. A larger, multicentric cohort would have strengthened the statistical power and external validity of the results. Secondly, this study was conducted at a single tertiary-care institution in rural Maharashtra, where geographic, socioeconomic, and lifestyle factors may differ significantly from urban or multi-ethnic populations. Therefore, the observed prevalence of vitamin D deficiency and recovery outcomes may not fully represent broader demographic variations in India or other countries.

Another limitation lies in the cross-sectional biochemical assessment of vitamin D levels. The study measured serum 25(OH)D concentrations only once in the preoperative phase, without accounting for fluctuations caused by seasonal sunlight exposure, dietary habits, or compliance with postoperative supplementation. Serial vitamin D measurements at multiple postoperative intervals could have provided a more dynamic understanding of its role throughout the healing process. Additionally, the study did not measure other nutritional and hormonal parameters such as parathyroid hormone (PTH), serum calcium, magnesium, or bone mineral density (BMD) all of which can influence bone remodeling and confound the association between vitamin D status and healing rate.

Furthermore, while every effort was made to standardize physiotherapy and rehabilitation protocols, there remains inherent variability in postoperative exercise adherence, pain tolerance, and motivation, which might have influenced functional recovery scores. The follow-up period of six months, though adequate for assessing early union and recovery, did not capture long-term outcomes such as late functional gains, refractures, or chronic pain syndromes. Finally, this study was observational in nature and cannot definitively establish causality between vitamin D sufficiency and improved functional outcomes.

Future research should therefore involve randomized controlled trials (RCTs) with larger sample sizes, longer follow-up periods, and comprehensive nutritional profiling to confirm causative effects. Including interventional arms with vitamin D supplementation could further clarify the therapeutic threshold required for optimal bone healing. Despite these limitations, the present study contributes meaningful preliminary evidence emphasizing the need for routine vitamin D screening and correction in elderly orthopedic patients.

ACKNOWLEDGMENT

The authors extend their gratitude to the faculty and staff of the Department of Orthopaedics, Rural Medical College, PMT, Loni, for their invaluable support in patient recruitment, data collection, and follow-up. Special thanks to the Institutional Ethics Committee for approving this study and to the laboratory personnel for their assistance in biochemical analysis. We also acknowledge all the participants who contributed to the research with their time and cooperation.

The present study comprehensively evaluated the status of serum vitamin D and its correlation with fracture healing and postoperative functional recovery among elderly patients undergoing surgical fixation at the Department of Orthopaedics, Rural Medical College, PMT, Loni, Maharashtra. The findings clearly demonstrated a strong positive association between optimal vitamin D levels and improved fracture healing, faster rehabilitation, and superior functional outcomes. Vitamin D deficiency was found to be highly prevalent, affecting nearly two-thirds of the elderly study population, reinforcing the growing recognition of hypovitaminosis D as a pervasive yet underdiagnosed public health concern in India’s aging population.

Patients with sufficient vitamin D levels (>30 ng/mL) exhibited significantly shorter healing times and higher mean functional scores on both the Harris Hip Score (HHS) and the Disabilities of Arm, Shoulder and Hand (DASH) scale when compared with vitamin D–deficient or insufficient counterparts. The study’s findings confirm that vitamin D plays a dual physiological role: facilitating osteoblastic bone formation and mineralization while simultaneously enhancing muscle function and neuromuscular coordination, which are critical to postoperative rehabilitation. The statistical analyses including Pearson’s correlation and multivariate regression further established that vitamin D acts as an independent predictor of functional recovery, even after adjusting for potential confounders such as age, gender, fracture site, and comorbidities. This provides compelling evidence that serum vitamin D concentration is not merely a coincidental biochemical marker but an influential determinant of recovery trajectory following fracture fixation in elderly patients.

The implications of these findings extend beyond orthopaedic wards into broader geriatric and preventive healthcare domains. Given that elderly individuals often suffer from limited sunlight exposure, poor dietary intake, and comorbid metabolic disorders, the risk of vitamin D deficiency becomes compounded. The study underscores the urgent need for routine preoperative screening of serum vitamin D levels in elderly fracture patients as part of the standard pre-surgical evaluation process. Proactive identification and correction of hypovitaminosis D could enhance callus formation, accelerate healing, and improve post-surgical mobility, thereby reducing hospitalization time, healthcare costs, and long-term dependency.

Furthermore, integrating vitamin D management into orthopaedic rehabilitation protocols may improve rehabilitation compliance and reduce postoperative complications. Vitamin D supplementation, combined with adequate calcium intake, physiotherapy, and nutritional counseling, should be considered as a standard adjunct therapy in geriatric fracture care. The benefits of such a holistic approach are not confined to bone health alone but extend to improved muscle tone, reduced fall risk, and better quality of life. From a healthcare policy perspective, the findings advocate for community-based screening initiatives, particularly in rural and resource-limited settings like Loni, where nutritional deficiencies and limited access to specialized care remain prevalent. Incorporating low-cost vitamin D testing into primary healthcare programs could be a cost-effective intervention to prevent fracture-related morbidity in the elderly.

This study also contributes to the growing evidence supporting the biochemical–functional continuum in orthopaedic recovery, bridging the gap between laboratory findings and clinical outcomes. It emphasizes that successful fracture healing is not solely dependent on surgical precision but equally reliant on the patient’s metabolic and nutritional milieu. Hence, orthopaedic surgeons and rehabilitation specialists should adopt a multidisciplinary approach, collaborating with endocrinologists, dietitians, and physiotherapists to ensure comprehensive patient care.

Despite certain limitations such as single-center design and moderate sample size, the consistency of findings across radiological, biochemical, and functional parameters strengthens the validity of the conclusions. The high prevalence of vitamin D deficiency observed in this study mirrors national data, suggesting that these results are broadly applicable to elderly Indian populations. Future research should focus on randomized controlled trials (RCTs) to establish causality and evaluate the dose–response relationship between vitamin D supplementation and postoperative outcomes. Additionally, exploring genetic polymorphisms of the vitamin D receptor (VDR) and their influence on fracture healing could unveil new molecular insights into individualized patient management.

In summary, this study concludes that vitamin D sufficiency plays a pivotal role in accelerating fracture healing, improving functional recovery, and enhancing rehabilitation outcomes among elderly patients after fracture fixation. The results provide robust evidence that maintaining optimal serum vitamin D levels before and after surgery significantly improves postoperative prognosis. Routine screening, supplementation, and public awareness programs should be integrated into orthopaedic and geriatric care pathways to mitigate the burden of delayed fracture recovery in elderly populations.

In the context of India’s growing elderly demographic, where osteoporosis and nutritional deficiencies are on the rise, addressing vitamin D deficiency represents a simple, safe, and cost-effective intervention with profound implications for patient recovery, independence, and quality of life. Therefore, vitamin D optimization should be recognized not merely as a supportive therapy but as an integral component of evidence-based orthopaedic care.

Conflicts of Interest: The author declares no conflicts of interest related to this publication.

Funding Information: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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