Lower Bone Density on Preoperative Computed Tomography Predicts Periprosthetic Fracture Risk in Total Ankle Arthroplasty

The effect of bone mineral density (BMD) on outcomes from total ankle arthroplasty (TAA) has not been studied. BMD can be estimated by measuring Hounsfield units (HU) on standard computed tomography (CT), which is frequently performed prior to TAA. We aimed to identify whether tibial and talar HU measured from preoperative CT scans were associated with periprosthetic fracture or revision risk in patients undergoing TAA. A prospectively collected database was used to retrospectively screen all patients undergoing primary TAA. Only patients with a preoperative CT within 1 year of surgery were included. Primary outcomes were periprosthetic fracture and prosthetic revision. HU were measured on axial CT cuts in the distal tibia and talus. Additional patient factors analyzed included age, sex, weight, body mass index (BMI), tobacco use, presence of rheumatoid arthritis, and preoperative deformity. A total of 198 ankles were included, with a mean 2.4 years of follow-up. There were 7 intraoperative and 9 postoperative periprosthetic fractures (3.5% and 4.5%, respectively). Seven patients (3.5%) underwent prosthetic removal or revision. Lower tibial and talar HU, lower weight, and lower BMI were associated with periprosthetic fractures (P < .05). After controlling for age, sex, and weight, only tibial HU was significantly associated with periprosthetic fracture (P = .018). All intraoperative fractures occurred in patients with tibial HU less than 200. None of the patient factors analyzed were associated with revision. Lower tibial HU on preoperative CT was strongly associated with periprosthetic fracture risk with TAA. In patients with tibial HU less than 200, surgeons may consider prophylactic internal fixation of the medial malleolus. Level III, retrospective cohort study