Bone density loss following ankle fusion persists at long-term follow-up

Document Type : Original Article


1 Department of Trauma Surgery, Medizinische Hochschule Hannover, Hanover, Germany

2 Department of Radiology, Klinikum Dortmund, Dortmund, Germany

3 Orthopaedic and Spine Centre, Mater Private Hospital, Cork, Ireland



Introduction: The aim of ankle fusion is to create a stable and pain-free hind foot. A decrease in bone density secondary to postoperative immobilization is well established. It is commonly accepted that bone density is restored toward normal values when normal weight bearing is permitted. To the current authors' knowledge, this restoration of bone density has not been definitively established via clinical studies. Subjects and Methods: Patients who underwent an isolated ankle fusion between January 1998 and March 2015, to address advanced degenerative or posttraumatic osteoarthrosis or rheumatoid arthritis were included. Clinical and radiological examination, Foot Function Index (FFI), and American Orthopedic Foot and Ankle Society-Score (AOFAS) scoring systems were utilized. Pain intensity was calculated using the Visual analogue scale (VAS). We use semiquantitative ultrasound osteodensitometry to measure bone density. Results: Bone density was determined in 60 patients, at an average follow-up of 9 years following ankle fusion. The mean T-score for bone density of the calcaneus was significantly lower in the treated foot compared to the contralateral side (−1.4 vs.−0.4; P = 0.001). With the numbers available, a reduction in bone density was found without a significant difference in the AOFAS score (P = 0.875), FFI (P = 0.655), VAS (P = 0.804), and body mass index (P = 0.272). Seven (12%) developed a nonunion. Conclusions: These results demonstrate that a reduction in bone density as a consequence of immobilization while bone union was achieved did not completely return to baseline values even at 10 years postoperative. This persistent reduction in bone density does not correlate in a statistically significant way with higher pain scores, inferior AOFAS scores or nonunion rates. Postoperative partial weight bearing should be instigated as soon as possible to minimize bone loss.


Bloch B, Srinivasan S, Mangwani J. Current concepts in the management of ankle osteoarthritis: A Systematic Review. J Foot Ankle Surg 2015;54:932-9.  Back to cited text no. 1
Malerba F, Benedetti MG, Usuelli FG, Milani R, Berti L, Champlon C, et al. Functional and clinical assessment of two ankle arthrodesis techniques. J Foot Ankle Surg 2015;54:399-405.  Back to cited text no. 2
Thomas RH, Daniels TR. Ankle arthritis. J Bone Joint Surg Am 2003;85-A: 923-36.  Back to cited text no. 3
Gaedke IE, Wiebking U, O'Loughlin PF, Krettek C, Gaulke R. Clinical and radiological mid- to long-term outcomes following ankle fusion. In Vivo 2018;32:1463-71.  Back to cited text no. 4
Pluskiewicz W, Drozdzowska B, Lyssek-Boroń A, Bielecki T, Adamczyk P, Sawaryn P, et al. Densitometric and quantitative ultrasound measurements and laboratory investigations in wheelchair-bound patients. J Clin Densitom 2006;9:78-83.  Back to cited text no. 5
Drysdale IP, Collins AL, Walters NJ, Bird D, Hinkley HJ. Potential benefits of marathon training on bone health as assessed by calcaneal broadband ultrasound attenuation. J Clin Densitom 2007;10:179-83.  Back to cited text no. 6
Jirkovská A, Kasalický P, Boucek P, Hosová J, Skibová J. Calcaneal ultrasonometry in patients with Charcot osteoarthropathy and its relationship with densitometry in the lumbar spine and femoral neck and with markers of bone turnover. Diabet Med 2001;18:495-500.  Back to cited text no. 7
Klos K, Windolf M, Schwieger K, Kuhn P, Hänni M, Gueorguiev B, et al. Intraoperative mechanical bone strength determination in tibiotalocalcaneal fusion: A biomechanical investigation. Foot Ankle Int 2009;30:1183-9.  Back to cited text no. 8
Franck H, Gottwalt J. Associations with subregional BMD-measurements in patients with rheumatoid arthritis. Rheumatol Int 2008;29:47-51.  Back to cited text no. 9
Sritara C, Thakkinstian A, Ongphiphadhanakul B, Pornsuriyasak P, Warodomwichit D, Akrawichien T, et al. Work- and travel-related physical activity and alcohol consumption: Relationship with bone mineral density and calcaneal quantitative ultrasonometry. J Clin Densitom 2015;18:37-43.  Back to cited text no. 10
Nakamura Y, Uchiyama S, Kamimura M, Komatsu M, Ikegami S, Kato H. Bone alterations are associated with ankle osteoarthritis joint pain. Sci Rep 2016;6:18717.  Back to cited text no. 11
Leumann A, Valderrabano V, Hoechel S, Gopfert B, Muller-Gerbl M. Mineral density and penetration strength of the subchondral bone plate of the talar dome: High correlation and specific distribution patterns. J Foot Ankle Surg 2015;54:17-22.  Back to cited text no. 12
Muehleman C, Berzins A, Koepp H, Eger W, Cole AA, Kuettner KE, et al. Bone density of the human talus does not increase with the cartilage degeneration score. Anat Rec 2002;266:81-6.  Back to cited text no. 13
Coster MC, Rosengren BE, Karlsson C, Schevelow T von, Magnusson H, Brudin L, et al. Bone mass and anthropometry in patients with osteoarthritis of the foot and ankle. Foot Ankle Surg 2014;20:52-6.  Back to cited text no. 14
Hoppe S, Uhlmann M, Schwyn R, Suhm N, Benneker LM. Intraoperative mechanical measurement of bone quality with the DensiProbe. J Clin Densitom 2015;18:109-16.  Back to cited text no. 15
Bauer DC, Glüer CC, Cauley JA, Vogt TM, Ensrud KE, Genant HK, et al. Broadband ultrasound attenuation predicts fractures strongly and independently of densitometry in older women. A prospective study. Study of Osteoporotic Fractures Research Group. Arch Intern Med 1997;157:629-34.  Back to cited text no. 16
Collinge CA, Lebus G, Gardner MJ, Gehrig L. A comparison of quantitative ultrasound of the calcaneus with dual-energy x-ray absorptiometry in hospitalized orthopaedic trauma patients. J Orthop Trauma 2010;24:176-80.  Back to cited text no. 17
Hans D, Dargent-Molina P, Schott AM, Sebert JL, Cormier C, Kotzki PO, et al. Ultrasonographic heel measurements to predict hip fracture in elderly women: The EPIDOS prospective study. Lancet 1996;348:511-4.  Back to cited text no. 18
Haugeberg G, Ørstavik RE, Uhlig T, Falch JA, Halse JI, Kvien TK. Comparison of ultrasound and X-ray absorptiometry bone measurements in a case control study of female rheumatoid arthritis patients and randomly selected subjects in the population. Osteoporos Int 2003;14:312-9.  Back to cited text no. 19
Sawyer A, Moore S, Fielding KT, Nix DA, Kiratli J, Bachrach LK. Calcaneus ultrasound measurements in a convenience sample of healthy youth. J Clin Densitom 2001;4:111-20.  Back to cited text no. 20
Wang Q, Nicholson PH, Timonen J, Alen M, Moilanen P, Suominen H, et al. Monitoring bone growth using quantitative ultrasound in comparison with DXA and pQCT. J Clin Densitom 2008;11:295-301.  Back to cited text no. 21
Medilink. Quantitative Ultrasound Device Pegasus – User Manual. Mauguio, France: Medilink; 2014.  Back to cited text no. 22
Consensus development conference: Diagnosis, prophylaxis, and treatment of osteoporosis. Am J Med 1993;94:646-50.  Back to cited text no. 23
Latt LD, Glisson RR, Adams SB Jr., Schuh R, Narron JA, Easley ME. Biomechanical comparison of external fixation and compression screws for transverse tarsal joint arthrodesis. Foot Ankle Int 2015;36:1235-42.  Back to cited text no. 24
Bouguecha A, Weigel N, Behrens BA, Stukenborg-Colsman C, Waizy H. Numerical simulation of strain-adaptive bone remodelling in the ankle joint. Biomed Eng Online 2011;10:58.  Back to cited text no. 25
Messina C, Usuelli FG, Maccario C, Di Silvestri CA, Gitto S, Cortese MC, et al. Precision of bone mineral density measurements around total ankle replacement using dual energy x-ray absorptiometry. J Clin Densitom 2020;23:656-63.  Back to cited text no. 26
Wetke E, Zerahn B, Kofoed H. Prospective analysis of a first MTP total joint replacement. Evaluation by bone mineral densitometry, pedobarography, and visual analogue score for pain. Foot Ankle Surg 2012;18:136-40.  Back to cited text no. 27
Lee SM, Seo JS, Kwak SH, Shin WC, Bae JY, Woo SH. Bone density of the calcaneus correlates with radiologic and clinical outcomes after calcaneal fracture fixation. Injury 2020;51:1910-8.  Back to cited text no. 28
Klos K, Mückley T, Wähnert D, Zwipp H, Gueorguiev BG, Schwieger K, et al. The use of DensiProbe™ in hindfoot arthrodesis. Can fusion failure be predicted by mechanical bone strength determination? Z Orthop Unfall 2011;149:206-11.  Back to cited text no. 29
Schreiber JJ, McQuillan TJ, Halilaj E, Crisco JJ, Weiss AP, Patel T, et al. Changes in local bone density in early thumb carpometacarpal joint osteoarthritis. J Hand Surg Am 2018;43:33-8.  Back to cited text no. 30
Xu Y, Guo B, Gong J, Xu H, Bai Z. The correlation between calcaneus stiffness index calculated by QUS and total body BMD assessed by DXA in Chinese children and adolescents. J Bone Miner Metab 2014;32:159-66.  Back to cited text no. 31
International Society for Clinical Densitometry, Inc. Official Position Statement. Available from: [Last accessed on 2019 May 28].  Back to cited text no. 32