Abstract
Introduction: Bone loss occurs in the regional bone following tibial shaft fracture. An earlier cross-sectional study showed that measurements made at the metaphyseal region of the tibia using peripheral quantitative computed tomography (pQCT) and the ultradistal region of the tibia using dual-energy X-ray absorptiometry (DXA) were the most responsive at monitoring this bone loss. Biochemical markers of bone turnover enable us to assess the activity of bone formation and resorption during fracture healing. The aim of this longitudinal study was to determine the pattern and distribution of bone loss and bone turnover following a tibial shaft fracture treated with either plaster cast or intramedullary nail. Methods: Eighteen subjects underwent bone mass measurements using DXA at the tibia and hip and quantitative ultrasound (QUS) at the tibia and calcaneus of both limbs at 2 weeks, 8 weeks, 12 weeks and 24 weeks following fracture, with hip and tibia DXA measurements also performed at 52 weeks. Nine of the patients treated with plaster cast had pQCT measurements at the tibia at 24 weeks. We measured three bone formation markers, bone alkaline phosphatase (bone ALP), osteocalcin (OC) and procollagen type 1 N-terminal peptide (PINP), a marker of bone resorption, serum C-telopeptides of type 1 collagen (β-CTX) and a marker of collagen III turnover, procollagen type III N-terminal peptide (PIIINP) at 1 day, 3 days and 7 days and at 2, 4, 8, 12, 16 and 24 weeks following fracture. The greatest bone losses were observed at the ultradistal region of the tibia using DXA (28%, p <0.001) and the metaphyseal region of the tibia using pQCT (26–31%, p <0.001) at 24 weeks. In the hip, the greatest loss was in the trochanter region at 24 weeks (10%, p <0.001). The greatest loss at the calcaneus measured using QUS was for broadband ultrasound attenuation (BUA) measured using CUBA Clinical at 24 weeks (13%, p =0.01). Results: At 1 year, there was a small recovery in bone loss (ultradistal tibia DXA, 20%, p <0.01; trochanter DXA 9%, p <0.001). Bone turnover increased following fracture (PINP +72±21%, p <0.0001, bone ALP +199±22%, p =0.004, β-CTX +105±23%, p <0.0001, all at 24 weeks). There was a smaller +33±10% increase in osteocalcin at 24 weeks. PIIINP concentration peaked at week 8 (+57±9%, p <0.0001). The bone resorption marker β-CTX showed an earlier rise (week 2, 139±33%) than the bone formation markers. Conclusions: We conclude that: (1) bone loss following tibial shaft fracture occurs both proximal and distal to the fracture; (2) the decreased BMD is largest for trabecular bone in the tibia with similar measurements using DXA and pQCT; (3) there is limited recovery of bone lost at the hip and tibia at 1 year; (4) tibial speed of sound (SOS) demonstrated a greater decrease than calcaneal SOS when comparing z -scores; (5) BUA is the QUS variable that shows the biggest decrease of bone mass at the calcaneus; (6) increase in bone turnover occurs following fracture with an earlier increase in bone resorption markers and a later rise in bone formation markers.
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References
Bickerstaff DR, Kanis JA (1994) Algodystrophy: an under-recognized complication of minor trauma. Br J Rheumatology 33:240–248
Cattermole HC, Cook JE, Fordham JN, Muckle DS, Cunningham JL (1997) Bone mineral changes during tibial fracture healing. Clin Orthop 339:190–196
Drysdale IP, Hinkley HJ, Shale ML (1998) Bilateral variation of calcaneal broadband ultrasound attenuation [abstract]. Bone 23 [Suppl]:S523
Emami A, Larsson S, Hellquist E, Mallmin H (2001) Limited bone loss in the hip and heel after reamed intramedullary fixation and early weight-bearing of tibial fractures. J Orthop Trauma 15:560–565
Eyres KS, Kanis JA (1995) Bone loss after tibial fracture. Evaluated by dual-energy X-ray absorptiometry. J Bone Joint Surg Br 77:473–478
Findlay SC, Eastell R, Ingle BM (2002) Measurement of bone adjacent to tibial shaft fractures. Osteoporos Int 13:980–989
Finsen V, Haave O (1987) Changes in bone mass after tibial shaft fracture. Acta Orthop Scand 58:369–371
Ingle BM, Hay SM, Bottjer HM, Eastell R (1999) Changes in bone mass and bone turnover following ankle fracture. Osteoporos Int 10:408–415
Ingle BM, Hay SM, Bottjer HM, Eastell R (1999) Changes in bone mass and bone turnover following distal forearm fracture. Osteoporos Int 10:399–407
Kannus P, Jarvinen M, Sievanen H, Oja P, Vuori I (1994) Osteoporosis in men with a history of tibial fracture. J Bone Miner Res 9:423–429
Karlsson MK, Nilsson BE, Obrant KJ (1993) Bone mineral loss after lower extremity trauma. 62 cases followed for 15–38 years. Acta Orthop Scand 64:362–364
Lilley J, Walters BG, Heath DA, Drolc Z (1991) Comparison and investigation of bone mineral density in opposing femora by dual-energy X-ray absorptiometry. Osteoporos Int 2:274–278
Muller ME, Nazarian S, Koch P, Schatzker J (1990) The comprehensive classification of fractures of long bones. Springer, Berlin Heidelberg New York
Mundy GR (1990) Bone remodelling. In: Favus MJ (ed) Primer on the metabolic bone diseases and disorders of mineral metabolism. Lippincott, Philadelphia, pp 30–38
Obrant KJ (1984) Tetracycline double-labelling in post-traumatic osteopenia in man. Arch Orthop Trauma Surg 103:81–82
Obrant KJ (2004) Trabecular bone changes in the greater trochanter after fracture of the femoral neck. Acta Orthop Scand 55:78–82
Sarangi PP, Ward AJ, Smith EJ, Staddon GE, Atkins RM (1993) Algodystrophy and osteoporosis after tibial fractures. J Bone Joint Surg Br 75:450–452
Ulivieri FM, Bossi E, Azzoni R, Ronzani C, Trevisan C, Montesano A, Ortolani S (1990) Quantification by dual photon absorptiometry of local bone loss after fracture. Clin Orthop 250:291–296
van der Poest Clement E, van der Wiel H, Patka P, Roos JC, Lips P (1999) Long-term consequences of fracture of the lower leg: cross-sectional study and long-term follow-up of bone mineral density in the hip after fracture of the lower leg. Bone 24:131–134
Van der Wiel HE, Lips P, Nauta J, Patka P, Haarman HJ, Teule GJ (1994) Loss of bone in the proximal part of the femur following unstable fractures of the leg. J Bone Joint Surg Am 76:230–236
Veitch SW, Findlay SC, Ingle BM, Ibbotson CJ, Hamer AJ, Eastell R (2004) Accuracy and precision of peripheral quantitative computed tomography measurements at the tibial metaphysis. J Clin Densitom 7:209–217
Weinreb M, Rodan GA, Thompson DD (1989) Osteopenia in the immobilized rat hind limb is associated with increased resorption and decreased bone formation. Bone 10:187–194
Yang RS, Tsai KS, Chieung PU, Liu TK (1997) Symmetry of bone mineral density at the proximal femur with emphasis on the effect of side dominance. Calcif Tissue Int 61:189–191
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The authors would like to acknowledge Mr. Mick Denison (M.D.) and Dr. Sarah Gowlett (S.G.) for reviewing X-rays.
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Veitch, S.W., Findlay, S.C., Hamer, A.J. et al. Changes in bone mass and bone turnover following tibial shaft fracture. Osteoporos Int 17, 364–372 (2006). https://doi.org/10.1007/s00198-005-2025-y
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DOI: https://doi.org/10.1007/s00198-005-2025-y