Osseous deficits after anterior cruciate ligament injury and reconstruction: a systematic literature review with suggestions to improve osseous homeostasis.
OBJECTIVE
This systematic review was performed to improve our understanding of the current evidence regarding the influence of anterior cruciate ligament (ACL) injury and reconstruction on involved lower extremity apparent bone mineral density, bone content, or bone area mass (bone integrity).


METHODS
Two independent reviewers performed a Medline search from 1966 to January 2010 using the terms "anterior cruciate ligament" or "ACL" combined with "wound" or "injury" and "bone density" or "osteoporosis." Study inclusion criteria were English-language human studies. Reference sections of selected studies were also reviewed.


RESULTS
Ten studies were identified that met our inclusion criteria. Eight studies performed ACL reconstruction with bone-patellar tendon-bone autografts and interference screw fixation. One study performed ACL reconstruction by use of Achilles tendon allografts with interference screw and staple fixation. Two ACL injury studies either did not involve ACL reconstruction or attempted primary repair with sutures. All studies reported varying levels of decreased bone mineral density, bone content, or bone area mass (bone integrity) at the involved lower extremity after ACL injury that did not return to premorbid levels even with ACL reconstruction and rehabilitation. Sites of reduced bone integrity included the proximal and distal femur, proximal tibia, patella, and calcaneus. Bone loss was increased with limited weight bearing and prolonged disuse or immobilization; however, significant improvements were not observed with accelerated rehabilitation. Some studies reported relations between Lysholm, Tegner, International Knee Documentation Committee survey, or function scores and bone integrity, whereas others reported no or poor relations.


CONCLUSIONS
Involved lower extremity bone integrity is decreased after ACL injury. Current evidence suggests that premorbid bone integrity is not re-established after ACL reconstruction even when accelerated rehabilitation is performed. Recommendations to improve osseous homeostasis and bone health after ACL injury and reconstruction are provided.
Nyland
John
J
Department of Orthopaedic Surgery, University of Louisville, Kentucky 40202, USA. john.nyland@louisville.edu
Fisher
Brent
B
Brand
Emily
E
Krupp
Ryan
R
Caborn
David N M
DN
D000125:Achilles Tendon / Q000637:transplantation; D000328:Adult; D016118:Anterior Cruciate Ligament / Q000601:surgery*; D000070598:Anterior Cruciate Ligament Injuries; D015519:Bone Density; D050071:Bone Density Conservation Agents / Q000627:therapeutic use; D001863:Bone Screws; D050376:Bone-Patellar Tendon-Bone Grafting / Q000534:rehabilitation; D002111:Calcaneus / Q000473:pathology*; D003131:Combined Modality Therapy; D005260:Female; D005269:Femur / Q000473:pathology* / Q000601:surgery; D006706:Homeostasis; D006801:Humans; D007103:Immobilization / Q000009:adverse effects; D008297:Male; D010024:Osteoporosis / Q000178:diet therapy / Q000209:etiology* / Q000517:prevention & control / Q000628:therapy; D010329:Patella / Q000473:pathology*; D011183:Postoperative Complications / Q000209:etiology* / Q000517:prevention & control; D055070:Resistance Training; D017792:Surgical Stapling; D013536:Suture Techniques; D013977:Tibia / Q000473:pathology* / Q000601:surgery; D014945:Wound Healing; D014947:Wounds and Injuries / Q000534:rehabilitation
D050071:Bone Density Conservation Agents