Bone Mineral Density in the Proximal Tibia and Calcaneus Before and After Arthroscopic Reconstruction of the Anterior Cruciate Ligament

doi:10.1016/j.arthro.2005.12.004

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 22, Issue 3, March 2006, Pages 265-269

https://doi.org/10.1016/j.arthro.2005.12.004 Get rights and content

Purpose: To monitor changes in bone mineral density (BMD) of the proximal tibia and the calcaneus in patients with anterior cruciate ligament (ACL) rupture before and after arthroscopic reconstruction of the ligament, related to clinical data. Type of Study: A 2-year prospective cohort study with assessment of patient evaluation of knee performance, clinical scoring of surgical results, and measurement of BMD in the tibia and calcaneus. Methods: Eighteen patients with a unilateral ACL rupture underwent an autogenous bone–patellar tendon–bone graft ACL reconstruction. The patients were examined before surgery and after 4, 12, and 24 months. BMD was assessed bilaterally in the proximal tibia and calcaneus using dual-photon absorptiometry and converted to a Z-score by use of BMD values from a group of healthy controls. Clinical evaluation included determination of Lysholm score, quantitative Lachman test, pivot-shift test, and the patients’ self-reported highest level of activity and knee performance in sports and daily activities. Results: There were significant declines in Z-score of the proximal tibia of the operated leg during the first year after surgery, whereas there was no change in the calcaneus and contralateral leg. In the lateral tibia, the Z-score was significantly lower at 24 months follow-up, compared with both controls and the noninjured side, whereas BMD of the medial tibia had returned to near normal levels. There were significant improvements in Lysholm score, highest level of activity, and knee performance in daily activities and sports. The patients’ evaluation of improvement in knee performance in sports activities at 24 months follow-up was associated with an increase in Z-score of the injured leg. Conclusions: We found a partially reversible decline in BMD of the proximal tibia after arthroscopic ACL reconstruction. Improvement in knee performance in sports activities was associated with an increase in BMD of the injured leg. BMD of the calcaneus remained unaffected in both legs. Level of Evidence: Level III, therapeutic case control study.

Section snippets

Methods

This was a Level III, therapeutic, case control study of 21 patients (15 men and 6 women) with chronic ACL insufficiency and 41 healthy control subjects (18 men and 23 women). The healthy controls were recruited from among participants in a previous study on BMD and ultrasound values of the calcaneus in normal Danish adults.⁹ Only controls matching the relevant age groups of patients were included. Inclusion criteria for the patients were symptoms of instability and clinical evidence of ACL

Results

Eighteen patients completed all follow-up examinations at 4, 12, and 24 months. One had emigrated and the remaining 2 did not wish to complete the set of tests. Preoperative data on quantitative Lachman test and drawer test results for 3 of the patients were lost because of a computer malfunction. Anthropomorphometric data are presented in Table 1. The controls matched the patient group except that the male control subjects were slightly younger than the patients. The time interval between

Discussion

This study showed that there is a considerable localized decline in BMD of the proximal tibia during the first postoperative year after reconstruction of the ACL. The bone loss was most pronounced below the lateral subchondral plate whereas the uninjured leg remained unaffected. In a study by Leppälä et al.,¹¹ the decline in BMD after ACL reconstruction was primarily found to be associated with surgical intervention, whereas conservatively treated patients had near normal BMD in the injured

Conclusions

Our study shows that there is a tendency for BMD of the proximal tibia to return to near normal levels 2 years after surgery. There are also indications that there is an association between changes in BMD of the injured leg and the performance level of the injured knee in sports activities after arthroscopic ACL reconstruction.

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Cited by (19)

Subchondral and epiphyseal bone remodeling following surgical transection and noninvasive rupture of the anterior cruciate ligament as models of post-traumatic osteoarthritis
2016, Osteoarthritis and Cartilage
Citation Excerpt :
In addition to the acute joint trauma from ACL injury, chronic joint destabilization causes adverse, non-anatomic tissue loading, which is a major proposed contributor to chronic inflammation and the perpetuation of OA1. Bony remodeling, including loss of subchondral and epiphyseal bone and decreased epiphyseal bone mineral density (BMD), is known to occur following ACL injury11–14 and as part of the chronic OA cascade11–17. However, clinical studies outlining longitudinal morphological changes in subchondral and epiphyseal bone following ACL injury are, to date, lacking.
Animal models are frequently used to study post-traumatic osteoarthritis (PTOA). A common anterior cruciate ligament (ACL) injury model is surgical transection, which may introduce confounding factors from surgery. Noninvasive models could model human injury more closely. The purpose of this study was to compare subchondral and epiphyseal trabecular bone remodeling after surgical transection and noninvasive rupture of the ACL.
Thirty-six rats were randomized to an uninjured control, surgical transection (Transection), or noninvasive rupture (Rupture). Animals were randomized to 4 or 10 week time points (n = 6 per group). Micro computed tomography (μCT) imaging was performed with an isotropic voxel size of 12 μm. Subchondral and epiphyseal bone was segmented semi-automatically, and morphometric analysis was performed.
Transection caused a greater decrease in subchondral bone volume fraction (BV/TV) than Rupture in the femur and tibia. Rupture had greater subchondral bone tissue mineral density (TMD) at 4 and 10 weeks in the femur and tibia. Subchondral bone thickness (SCB.Th) was decreased in the femur in Transection only. Epiphyseal BV/TV was decreased in Transection only, and Rupture exhibited increased femoral epiphyseal TMD compared to both Control and Transection. Rupture exhibited greater femoral epiphyseal trabecular thickness (Tb.Th.) compared to Control and Transection at 4 weeks, and both Rupture and Transection had increased femoral epiphyseal Tb.Th. at 10 weeks. Epiphyseal trabecular number (Tb.N) was decreased in both injury groups at both time points. Femoral and tibial epiphyseal structure model index (SMI) increased in both groups.
The two injury models cause differences in post-injury bone morphometry, and surgical transection may be introducing confounding factors that affect downstream bony remodeling.
Anterior cruciate ligament reconstruction reduces bone mineral areal mass
2013, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
In the present study, there was no correlation between the change in Tegner activity level before and after surgery and the BMA loss in the calcaneus and the proximal femur. This is in contrast to the study of Zerahn et al.,7 who found that a BMA increase during rehabilitation was associated with an increase in knee performance during sports activities at the 2-year follow-up. The patients in the present study reported a significant improvement in HRQoL according to the self-reported EQ-5D questionnaire.
The aim of this study was to prospectively follow bone mineral areal mass (BMA) changes in the calcaneii, hips, and lumbar spine after anterior cruciate ligament (ACL) reconstruction using hamstring tendon autografts.
Patients with a unilateral ACL injury scheduled for reconstruction were included in the study. The BMA mass was measured in both calcaneii, the hips, and the lumbar spine using the dual-energy x-ray absorptiometry (DEXA) technique. Quality of life was estimated using the EQ-5D questionnaire, and activity was measured using the Tegner activity score. The patients were assessed before surgery and after 6, 18, 36, and 60 months.
Forty-eight patients (21 female and 27 male patients), median age 31 years (17 to 64 years), participated in the study for 5 years. After 5 years, the female patients had lost 9.5% (P < .001) and 10.1% (P < .001) of their BMA in the calcaneus on the operated and nonoperated sides, respectively. Correspondingly, the male patients had lost 6.5% (P = .004) and 8.5% (P < .001) on the operated and nonoperated sides, respectively. In the hips, the female patients had lost 4.0% (P < .001) and 2.7% (P < .001) on the operated and the nonoperated sides, respectively. Among the male patients, the BMA loss was 3.4% (P = .002) and 4.8% (P < .001) in the hips on the operated and the nonoperated sides, respectively. The EQ-5D index was a mean (standard deviation [SD]) of 0.72 (0.23) before surgery and 0.86 (0.17) (P < .001) after 5 years. The preinjury Tegner activity level was a median (range) 7.5 (1 to 10). The preoperative Tegner activity level was 2.5 (0 to 9) and increased to 4 (1 to 9) (P = .002) after 5 years.
Both female and male patients had a significant decrease in BMA in both calcaneii and both hips during the 5-year study period compared with a reference population of Swedish healthy women and men. The patients increased their Tegner activity level and improved their EQ-5D index during the 5-year follow-up period.
Level II, prognostic prospective study.
Tibial subchondral bone mineral density: Sources of variability and reproducibility
2013, Osteoarthritis and Cartilage
It has been shown that subchondral bone mineral density (sBMD) measurement may be a relevant parameter of osteoarthritis (OA) progression. However, factors implicating the reproducibility and contributing to the variability of the measurement have not been fully described. Thus, the aim of this study was to explore the reproducibility of sBMD by Dual energy X-ray Absorptiometry (DXA) and to further examine its sources of variability.
In this study, short-term, intra and inter-observer reproducibility of sBMD was examined on knee images obtained on DXA scans. The influence of software (lumbar spine and forearm modes), knee positioning (flexion or extension), site and size of regions of interest (ROI) and use of rice, on both lateral and medial tibial sBMD, were assessed. Root mean square coefficient of variation (RMS CV) and least significant changes (LSC) were calculated.
The short-term precision of sBMD ranged between 2.24% and 5.12% for RMS CV and between 0.053 and 0.135 g/cm² for LSC. Good intra-observer precision was found for knee flexion conditions whatever the software used (RMS CV ranging from 0.43 to 1.41%). The reproducibility was dependant from the ROI size (the ROI including joint space exhibiting better precision results than ROI including solely the subchondral plate). For a constant size of the ROI, the precision results were site-dependant. Inter-observer RMS CV results ranged from 0.59 to 5.01% according to ROI and software used. For the specific task of monitoring medial sBMD in the ROI including solely subchondral plate, forearm flexion condition produced the highest intra-observer and short-term precision (respectively RMS CV: 0.45% and 2.77%; LSC: 0.013 and 0.080 g/cm²).
Taking account into the excellent precision of the sBMD measurements expressed as RMS CV with the protocol proposed in the present study, clinical application of these measurements might be envisaged.
Effectiveness of low-profile supplemental fixation in anterior cruciate ligament reconstructions with decreased bone mineral density
2013, Arthroscopy - Journal of Arthroscopic and Related Surgery
The purpose of this study was to compare anterior cruciate ligament (ACL) fixation using a bioabsorbable interference screw (BIS) and a supplemental low-profile suture anchor (PushLock 4.5-mm polyetheretherketone anchor; Arthrex, Naples, FL) with a standard BIS fixation to determine if fixation methods were dependent on tibial bone mineral density (BMD).
Ten matched pairs of fresh-frozen human female knee specimens (20 total) were harvested with specimen ages ranging from 40 to 65 years. The BMD for each specimen was determined with a dual-energy x-ray absorptiometry scanner. The specimens were divided into 2 groups, 1 with a BIS and the other with a BIS plus a PushLock. Tibial-sided ACL fixation with hamstring tendon grafts was performed on all the specimens. Then, load to failure and stiffness were biomechanically tested.
The BIS-plus-PushLock specimens had a significantly higher mean yield load compared with specimens with the BIS alone (702 N v 517 N, P = .047). However, in samples with lower bone density, there was no statistically significant difference in failure loads between fixation techniques (P = .8566 at BMD of 0.5 g/cm²). As the bone density of the samples increased, the failure loads increased for both techniques (P < .0001 for PushLock and P = .0057 for BIS). This BMD-associated increase was greater for the PushLock (P = .0148), resulting in a statistically significant difference in failure load at the upper range tested (P = .0293 at BMD of 0.9 g/cm²).
Supplemental fixation of ACL reconstructions with a PushLock is beneficial in persons with a normal BMD of the proximal tibia, but at a lower BMD, there was no difference in our study.
Individuals with normal BMDs may benefit from this supplemental fixation. However, caution should be used in postmenopausal women or individuals with chronic ACL injuries when using this fixation strategy.
Anterior cruciate ligament rupture in athletes: Impact on knee bone mineral density
2013, Science and Sports
Les traumatismes du genou consécutifs à une pratique sportive favorisent la survenue d’une gonarthrose. L’objectif de cette étude était d’évaluer la densité minérale osseuse (DMO) au genou pour analyser le retentissement sur l’os épiphysaire d’une lésion du ligament croisé antérieur (LCA) opérée. Huit sujets sportifs des deux sexes ont été recrutés. La durée médiane après ligamentoplastie du LCA était de 19,8 (9,2–75,7) mois. Une ostéodensitométrie a été réalisée au corps entier et aux épiphyses fémoro-tibiales afin de déterminer la composition corporelle et la DMO. Les DMO du tibia proximal et du fémur distal étaient significativement plus faibles du côté lésé vs non lésé, respectivement 1,230 ± 0,292 vs 1,307 ± 0,339 g/cm², au tibia et 1,487 ± 0,393 vs 1,587 ± 0,371 g/cm², au fémur. Aucune différence significative n’a été observée entre la DMO des membres inférieurs entiers (lésés 1,377 ± 0,200 vs non lésés 1,413 ± 0,190 g/cm², p = 0,12). Nos résultats témoignent des relations os épiphysaire et blessure ligamentaire au genou. Les modifications observées pourraient être le reflet précoce des modifications physiopathologiques qui conduisent à la gonarthrose post-traumatique.
Severe knee injuries occurring in sports are known to lead to early osteoarthritis. The aim of this study was to characterize the epiphyseal bone mineral density (BMD) on the knee in order to analyze the potential impact of anterior cruciate ligament (ACL) rupture on epiphyseal bone. Eight competitive athletes (men and women) were recruited with unilateral ACL rupture and a median time since surgery of 19.8 months (9.2–75.7). Dual Energy X-ray Absorptiometry (DXA) was used to determine the body composition and the BMD at the whole body and at the knee epiphysis. Proximal tibia and distal femur BMD epiphysis were significantly lower in the injured leg compared to uninjured leg, respectively 1.230 ± 0.292 vs. 1.307 ± 0.339 g/cm², at the tibia and 1.487 ± 0.393 vs. 1.587 ± 0.371 g/cm² at the femur. Moreover, injured and uninjured whole legs BMD were not statistically different (injured 1.377 ± 0.200 vs. uninjured 1.413 ± 0.190 g/cm², P = 0.12). Our results indicate a relationship between epiphyseal bone and knee injury. Changes observed could be early physiopathological changes involved in post-traumatic osteoarthritis at the knee.
A randomized controlled trial comparing bone mineral density changes of three different ACL reconstruction techniques
2012, Knee
Citation Excerpt :
We reported significant positive correlation between BMD at the distal femur and the single-leg hop distance at 1 year, suggesting that BMD at the distal femur might positively affect the stability of the knee joint after reconstruction. Several authors reported that BMD correlated significantly with the functional scores of the injured knee after reconstruction [3,6]. Significant bone loss and decreased mechanical properties in the first 21 days after flexor tendon insertion site injury and repair were also reported in animal study, supporting the relationship between bone loss and strength [1,2].
This study aimed to compare the changes in bone mineral density (BMD) of three different ACL reconstruction (ACLR) techniques and its association with early clinical and functional outcomes.
Sixty-two male adult patients undergoing primary ACLR were prospectively parallel randomized to bone–patellar tendon–bone graft (BPTB), single-bundle (HT-SB) or double-bundle (HT-DB) hamstring graft. BMD (primary outcome) at the proximal tibia, distal femur, femoral neck and trochanteric region was measured blindly at day 1, 3 months, 5 months and 1 year after surgery. KT-1000, Lysholm, IKDC, one-leg hop test and Lachman test were performed blindly at baseline and 1 year post-reconstruction.
There was a significant bone loss at the injured knee and hip at 3 and 5 months which was reversible at the knee, but not at the hip, at 1 year post-operation. There was a significant improvement of early clinical and functional outcomes at 1 year. No significant differences in bone loss was detected among different surgical techniques, except BMD loss at the femoral neck, though a trend of greater BMD loss in the HT-SB group at 5 months after reconstruction was observed. There was a significant positive correlation between BMD at the distal femur and the single-leg hop distance at 1 year.
In conclusion, the three surgical techniques were similar in transient bone loss at the knee region, irreversible bone loss at the hip, early clinical and functional outcomes up to 1 year post-reconstruction. BMD at the distal femur was positively associated with the single-leg hop distance at 1 year post-reconstruction.

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Original articleBone Mineral Density in the Proximal Tibia and Calcaneus Before and After Arthroscopic Reconstruction of the Anterior Cruciate Ligament

Section snippets

Methods

Results

Discussion

Conclusions

Bone

Bone

Arthroscopy

Arthroscopy

Bone mineral loss after lower extremity trauma. 62 cases followed for 15-38 years

Acta Orthop Scand

BMC assessed by dual photon absorptiometry in the proximal tibiaNormative data and measurements in orthopedic conditions

Eur J Exp Musculoskel Res

Effects of immobilization, three forms of remobilization, and subsequent deconditioning on bone mineral content and density in rat femora

J Bone Miner Res

Bone loss after hip fracture is correlated to the postoperative degree of mobilisation

Arch Orthop Trauma Surg

A cruciate ligament injury produces considerable, permanent osteoporosis in the affected knee

J Bone Miner Res

Original article
Bone Mineral Density in the Proximal Tibia and Calcaneus Before and After Arthroscopic Reconstruction of the Anterior Cruciate Ligament