Research Article| Volume 62, ISSUE 1, P120-124, January 2023

Assessment of Bone Mineral Density in the Distal Tibia Using Quantitative Hounsfield Samples From Computer Tomography


      The distal tibia bone quality is of paramount importance for ankle fractures, total ankle implants, ankle fusions, and osteotomy procedures. Despite this fact relatively little is known regarding the overall bone quality for this section of the tibia. Previous literature suggest that there is a statistically significant decrease in bone mineral density within the distal 5% to 10% segment of the tibia medullary canal. This segment of medullary bone is considerable in size and thus valuable for fixation constructs as it is oftentimes utilized for medial malleolar fractures, distal tibia fractures, total ankle replacements, ankle fusions, and other procedures. This study assessed bone attenuation between the distal 5% and 10% mark of the tibia in 1% slices via Hounsfield unit measurements on CT scans based on previously established correlation between Hounsfield units and bone mineral density found on DEXA scans. One hundred five distal tibia segments were assessed with an average interval in percentile slices of 3.8 mm. As expected there was a gradual decrease in bone attenuation noted with each proximal percentile segment. There exists a statistically significant difference in bone attenuation among males versus females as well as those older than 60 years versus younger than 60 years. The findings suggest fixation constructs in the tibia medullary canal may find limited benefit proximal from 7% segment in females ≥60, or 26.1 mm from tibial plafond. Fixation constructs in tibia medullary canal may find limited benefit proximal from 8% segment in males <60, or 32.3 mm from tibial plafond.

      Level of Clinical Evidence


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Foot and Ankle Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Capozza RF
        • Feldman S
        • Mortarino P
        • Reina PS
        • Schiessl H
        • Rittweger J
        • Ferretti JL
        • Cointry GR.
        Structural analysis of the human tibia by tomographic (pQCT) serial scans.
        J. Anat. 2010; 4: 470-481
        • Scheyerer MJ
        • Ullrich B
        • Osterhoff G
        • Spiegl UA
        • Schnake KJ.
        Arbeitsgruppe Osteoporotische Frakturen der Sektion Wirbelsäule der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie. [Hounsfield units as a measure of bone density-applications in spine surgery].
        Unfallchirurg. 2019; 8: 654-661
        • Johnson CC
        • Gausden EB
        • Weiland AJ
        • Lane JM
        • Schreiber JJ.
        Using hounsfield units to assess osteoporotic status on wrist computed tomography scans: comparison with dual energy X-Ray absorptiometry.
        J Hand Surg Am. 2016; 41: 767-774
        • Narayanan A
        • Cai A
        • Xi Y
        • Maalouf NM
        • Rubin C
        • Chhabra A.
        CT bone density analysis of low-impact proximal femur fractures using Hounsfield units.
        Clin Imaging. 2019; 57: 15-20
        • Patel SP
        • Lee JJ
        • Hecht GG
        • Holcombe SA
        • Wang SC
        • Goulet JA.
        Normative vertebral Hounsfield unity values and correlation with bone mineral density.
        J Clin Exp Orthop. 2016; 2: 1-7
        • Lee SY
        • Kwon SS
        • Kim HS
        • Yoo JH
        • Kim J
        • Kim JY
        • Min BC
        • Moon SJ
        • Sung KH.
        Reliability and validity of lower extremity computed tomography as a screening tool for osteoporosis.
        Osteoporos Int. 2015; 26: 1387-1394
        • Cody EA
        • Lachman JR
        • Gausden EB.
        Lower bone density on preoperative computed tomography predicts periprosthetic fracture risk in total ankle arthroplasty.
        Foot Ankle Int. 2018; 40: 1-8
        • Stowers JM
        • Black AT
        • Kavanagh AM
        • Mata K
        • Bohm A
        • Katchis SD
        • Weiner LS
        • Spielfogel W
        • Rahnama A.
        Predicting nonunions in ankle fractures using quantitative tibial hounsfield samples from preoperative computed tomography: a multicenter matched case control study.
        J Foot Ankle Surg. 2021; (S1067-2516(21)00395-1Epub ahead of print. PMID: 34819267)
        • Banerjee M
        • Samanta C
        • Sangram S
        • Hota M
        • Kundu P
        • Mondal M
        • Ghosh R
        • Majumdar S.
        Estimation of human height from the length of tibia.
        Indian J Basic Appl Med Res. 2015; 5: 30-47
        • Schreiber JJ
        • Hughes AP
        • Taher F
        • Girardi FP.
        An association can be found between Hounsfield units and success of lumbar spine fusion.
        HSS J. 2014; 1: 25-29