Advertisement

Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 27, Issue 4, pp 1182–1188 | Cite as

Vitamin C demand is increased after total knee arthroplasty: a double-blind placebo-controlled-randomized study

  • Henrik BehrendEmail author
  • Harald Lengnick
  • Vilijam Zdravkovic
  • Andreas Ladurner
  • Diana Rudin
  • Matthias Erschbamer
  • Markus Joerger
  • Markus Kuster
Knee
  • 318 Downloads

Abstract

Purpose

This study was designed to determine whether perioperative supplementation of vitamin C (VC) improves range of motion (ROM) and reduces the risk of arthrofibrosis (AF) following total knee arthroplasty (TKA).

Methods

Ninety-five patients undergoing TKA were randomized to either oral VC (1000 mg daily) or placebo for 50 days (48 VC group, 47 placebo group). The effect of VC supplementation was tested on ROM, AF, WOMAC, FJS-12, and VC plasma concentrations (VCc). VCc were analyzed in both patient groups before surgery, 4 and 7 days after surgery.

Results

ROM at 1 year was not different between study groups. The prevalence of AF was 5 of 48 (10.4%) in the VC group compared to 11 of 47 (23.4%) in the placebo group (p = 0.09). VCc decreased post-operatively in the placebo group (49–12 µmol/l on day 7, p < 0.001), but not in the VC group (53–57 µmol/l). Patients with a perioperative drop of VCc ≥ 30 µmol/l developed significantly more AF at 1 year compared to patients with a VCc drop of < 30 µmol/l (p = 0.007).

Conclusions

TKA results in VC depletion. Perioperative VC supplementation prevents VCc drop in most patients undergoing TKA and may lower the incidence of AF. The clinical relevance of this study is that VC supplementation seems to be a cheap and safe adjunct to improve functional outcome after TKA.

Level of evidence

I.

Trial registry

The study was registered at the ISRCTN registry with study ID ISRCTN40250576.

Keywords

Vitamin C plasma levels Arthrofibrosis Forgotten Joint Score-12 Total Knee Arthroplasty (TKA) Total Knee Replacement (TKR) 

Notes

Funding

This study was funded by a special grant: “Entschädigung, Innovation und Entwicklung” of Cantonal Hospital St. Gallen number: 100111.

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in the study were in accordance with the ethical standards of the international research committee and with the 1964 Helsinki declaration and its amendments or comparable ethical standards. The approval of the ethics committee of Canton St. Gallen: EKSG 10/098 was obtained.

Informed consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Alcantara-Martos T, Delgado-Martinez AD, Vega MV, Carrascal MT, Munuera-Martinez L (2007) Effect of vitamin C on fracture healing in elderly osteogenic disorder Shionogi rats. J Bone Jt Surg Br 89:402–407CrossRefGoogle Scholar
  2. 2.
    Ballmer PE, Reinhart WH, Jordan P (1994) Depletion of plasma vitamin C but not of vitamin E in response to cardiac operations. J Thorac Cardiovasc Surg 108(2):311–320PubMedGoogle Scholar
  3. 3.
    Bartlett MK, Jones CM, Ryan AE (1940) Vitamin C studies on surgical patients. Ann Surg 111:1–26CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Behrend H, Giesinger K, Giesinger JM, Kuster MS (2012) The “forgotten joint” as the ultimate goal in joint arthroplasty: validation of a new patient-reported outcome measure. J Arthroplasty 27:430–436CrossRefPubMedGoogle Scholar
  5. 5.
    Bellamy N, Buchanan WW (1986) A preliminary evaluation of the dimensionality and clinical importance of pain and disability in osteoarthritis of the hip and knee. Clin Rheumatol 5:231–241CrossRefPubMedGoogle Scholar
  6. 6.
    Berger MM (2005) Can oxidative damage be treated nutritionally? Clin Nutr 24:172–183CrossRefPubMedGoogle Scholar
  7. 7.
    Carr AC, McCall C (2017) The role of vitamin C in the treatment of pain: new insights. J Transl Med 15(1):77CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Carr AC, Pullar JM, Bozonet SM, Vissers MCM (2016) Marginal ascorbate status (hypovitaminosis C) results in an attenuated response to vitamin C supplementation. Nutrients 8 (6)Google Scholar
  9. 9.
    Carr AC, Rosengrave PC, Bayer S, Chambers S, Mehrtens J, Shaw GM (2017) Hypovitaminosis C and vitamin C deficiency in critically ill patients despite recommended enteral and parenteral intakes. Crit Care 21(1):300CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Conway FJS, Talwar D, McMillan DC (2015) The relationship between acute changes in the systemic inflammatory response and plasma ascorbic acid, alpha-tocopherol and lipid peroxidation after elective hip arthroplasty. Clin Nutr 34(4):642–646CrossRefPubMedGoogle Scholar
  11. 11.
    de Grooth H-J, Geenen IL, Girbes AR, Vincent J-L, Parienti J-J, Oudemans-van Straaten HM (2017) SOFA and mortality endpoints in randomized controlled trials: a systematic review and meta-regression analysis. Crit Care 21(1):38CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Donaldson JR, Tudor F, Gollish J (2016) Revision surgery for the stiff total knee arthroplasty. Bone Jt J 98-B(5):622–627CrossRefGoogle Scholar
  13. 13.
    Freeman TA, Parvizi J, Valle Della CJ, Steinbeck MJ (2009) Reactive oxygen and nitrogen species induce protein and DNA modifications driving arthrofibrosis following total knee arthroplasty. Fibrogenesis Tissue Repair 2(1):5CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Fukushima R, Yamazaki E (2010) Vitamin C requirement in surgical patients. Curr Opin Clin Nutr Metab Care 13(6):669–676CrossRefPubMedGoogle Scholar
  15. 15.
    Giladi AM, Dossett LA, Fleming SB, Abumrad NN, Cotton BA (2011) High-dose antioxidant administration is associated with a reduction in post-injury complications in critically ill trauma patients. Injury 42(1):78–82CrossRefPubMedGoogle Scholar
  16. 16.
    Gollwitzer H, Burgkart R, Diehl P, Gradinger R, Bühren V (2006) Therapy of arthrofibrosis after total knee arthroplasty. Orthopade 35(2):143–152CrossRefPubMedGoogle Scholar
  17. 17.
    Guo R-F, Ward PA (2007) Role of oxidants in lung injury during sepsis. Antioxid Redox Signal 9(11):1991–2002CrossRefPubMedGoogle Scholar
  18. 18.
    Kalson NS, Borthwick LA, Mann DA, Deehan DJ, Lewis P, Mann C, Mont MA, Morgan-Jones R, Oussedik S, Williams FMK, Toms A, Argenson JN, Bellemans J, Bhave A, Furnes O, Gollwitzer H, Haddad FS, Hofmann S, Krenn V (2016) International consensus on the definition and classification of fibrosis of the knee joint. Bone Jt J 98:1479–1488CrossRefGoogle Scholar
  19. 19.
    Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16(4):494–502CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Long CL, Maull KI, Krishnan RS, Laws HL, Geiger JW, Borghesi L, Franks W, Lawson TC, Sauberlich HE (2003) Ascorbic acid dynamics in the seriously ill and injured. J Surg Res 109(2):144–148CrossRefPubMedGoogle Scholar
  21. 21.
    Magit D, Wolff A, Sutton K, Medvecky MJ (2007) Arthrofibrosis of the knee. J Am Acad Orthop Surg 15(11):682–694CrossRefPubMedGoogle Scholar
  22. 22.
    Nguyen TT, Cox CS, Traber DL, Gasser H, Redl H, Schlag G, Herndon DN (1993) Free radical activity and loss of plasma antioxidants, vitamin E, and sulfhydryl groups in patients with burns: the 1993 Moyer Award. J Burn Care Rehabil 14(6):602–609CrossRefPubMedGoogle Scholar
  23. 23.
    Olmedilla B, Granado F, Southon S, Wright AJ, Blanco I, Gil-Martinez E, Berg H, Corridan B, Roussel AM, Chopra M, Thurnham DI (2001) Serum concentrations of carotenoids and vitamins A, E, and C in control subjects from five European countries. Br J Nutr 85(2):227–238CrossRefPubMedGoogle Scholar
  24. 24.
    Padayatty SJ, Sun H, Wang Y, Riordan HD, Hewitt SM, Katz A, Wesley RA, Levine M (2004) Vitamin C pharmacokinetics: implications for oral and intravenous use. Ann Intern Med 140(7):533–537CrossRefPubMedGoogle Scholar
  25. 25.
    Parihar A, Parihar MS, Milner S, Bhat S (2008) Oxidative stress and anti-oxidative mobilization in burn injury. Burns 34(1):6–17CrossRefPubMedGoogle Scholar
  26. 26.
    Sarisözen B, Durak K, Dinçer G, Bilgen OF (2002) The effects of vitamins E and C on fracture healing in rats. J Int Med Res 30(3):309–313CrossRefPubMedGoogle Scholar
  27. 27.
    Stephenson CM, Levin RD, Spector T, Lis CG (2013) Phase I clinical trial to evaluate the safety, tolerability, and pharmacokinetics of high-dose intravenous ascorbic acid in patients with advanced cancer. Cancer Chemother Pharmacol 72(1):139–146CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Stephenson JJ, Quimbo RA, Gu T (2010) Knee-attributable medical costs and risk of re-surgery among patients utilizing non-surgical treatment options for knee arthrofibrosis in a managed care population. Curr Med Res Opin 26(5):1109–1118CrossRefPubMedGoogle Scholar
  29. 29.
    Tanaka H, Lund T, Wiig H, Reed RK, Yukioka T, Matsuda H, Shimazaki S (1999) High dose vitamin C counteracts the negative interstitial fluid hydrostatic pressure and early edema generation in thermally injured rats. Burns 25(7):569–574CrossRefPubMedGoogle Scholar
  30. 30.
    Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW (2007) Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study. J Bone Jt Surg Am 89(7):1424–1431Google Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Authors and Affiliations

  1. 1.Department of Orthopaedic Surgery and TraumatologyCantonal Hospital, St. GallenSt. GallenSwitzerland
  2. 2.Department of Medical Oncology and HaematologyCantonal HospitalSt. GallenSwitzerland
  3. 3.Department of Orthopaedic Surgery, Royal Perth HospitalUniversity of Western AustraliaPerthAustralia

Personalised recommendations