Archives of Orthopaedic and Trauma Surgery

, Volume 138, Issue 12, pp 1653–1657 | Cite as

Bone density correlates with clinical outcomes after ankle fracture fixation

  • Stephen J. WarnerEmail author
  • Matthew R. Garner
  • Peter D. Fabricant
  • Dean G. Lorich
Orthopaedic Surgery



Osteoporosis and decreased bone density are known to increase fracture incidence and severity. Although much is known regarding the effects of bone density on fracture risk and the treatment options for prevention of fragility fractures, whether bone quality alters clinical outcomes after fracture fixation is unknown. The purpose of this study was to determine whether bone quality correlates with clinical outcomes after fracture fixation.

Materials and methods

A prospective database of all operatively treated ankle fractures by a single surgeon from 2003 to 2013 was used to identify patients. All patients included in the study had preoperative computed tomography (CT) imaging of the injured ankle and postoperative CT imaging of the contralateral ankle. Hounsfield unit (HU) measurement values were determined by placing an elliptical region of interest confined to the cancellous metaphyseal region of the distal tibia and fibula. The primary and secondary clinical outcomes included Foot and Ankle Outcome Scores (FAOS) and ankle range of motion (ROM). Included patients had at least 12 months of clinical outcome data.


Sixty-four patients met the inclusion criteria. Comparison of HU values from the injured and contralateral side demonstrated almost perfect agreement (ICC(2,1) = 0.938), suggesting that HU values can be accurately measured in the setting of a fracture. Increased HU values of the injured distal tibia and fibula significantly correlated with improved outcomes in four of five FAOS domains, including pain, activities of daily living, sports, and quality of life (beta = 0.285–0.344; P ≤ 0.05 for all). Range of motion outcomes did not significantly correlate with HU values.


Our results suggest that decreased bone quality, as measured using preoperative CT, significantly correlates with inferior short-term clinical outcomes. These results have significant implications for integrating bone quality into treatment algorithms for fracture patients.


Ankle fracture Outcomes Bone density Hounsfield units CT 



There is no funding source.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Stephen J. Warner
    • 1
    Email author
  • Matthew R. Garner
    • 2
  • Peter D. Fabricant
    • 3
  • Dean G. Lorich
    • 4
  1. 1.Orthopaedic Trauma ServiceUniversity of Texas Health Science Center at HoustonHoustonUSA
  2. 2.Orthopaedic Trauma ServicePennsylvania State UniversityHersheyUSA
  3. 3.Pediatric Orthopaedic ServiceHospital for Special SurgeryNew YorkUSA
  4. 4.Orthopaedic Trauma ServiceHospital for Special Surgery and Weill Cornell Medical College, New York Presbyterian HospitalNew YorkUSA

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