Beware of the Bone Bruise
Abstract & Commentary
Synopsis: Patients with a geographic bone bruise in association with an ACL rupture have larger effusions and require a longer time to obtain normal knee range of motion and gait pattern after an ACL tear when compared to patients who sustain an ACL rupture without a bone bruise.
Source: Johnson DL, et al. The effect of a geographic lateral bone bruise on knee inflammation after acute anterior cruciate ligament rupture. Am J Sports Med 2000;28:152-155.
This is a prospective study of patients with acute anterior cruciate ligament (ACL) ruptures that compares those with and without a geographic bone bruise. The exclusion criteria eliminated all patients with multiple ligament injuries and/or a reticular or linear bone bruise pattern on magnetic resonance imaging (MRI).
The bone bruise group comprised 20 patients (7 men, 13 women) with an average age of 18 years. Six injuries were contact related and 14 were noncontact. The group without a bone bruise comprised 20 patients, with an average age of 19. The mechanism of injury was contact in 11 and noncontact in nine. Gender was not specified for this group. At weekly physician and physical therapist visits, the size of effusion, range of motion, ambulation, and knee pain on a visual analogue scale were recorded. Physicians and therapists were not blinded as to patient group.
The results showed that patients with a bone bruise required a longer time for the knee effusion to dissipate, to regain a normal gait, and to equalize knee range of motion. In addition, patients with bone bruises had higher visual analogue pain scores.
Comment by James R. Slauterbeck, MD
Bone bruises are associated with articular cartilage injury. Unfortunately, many articular cartilage injuries have little ability to recover. Therefore, the bone bruises may have a significantly poor prognostic factor in the early and late outcomes after ACL reconstruction. To date, it is not known what the long-term effect of a bone bruise has on the overall function of the knee.
This study showed that a bone bruise may delay the time needed for a patient to recover after the initial injury. It also implies that one should consider waiting a longer than normal period before surgery is undertaken. In addition, this article sites unpublished data by Garrit demonstrating that patients with bone bruises and ACL ruptures have more pain and complications after ACL reconstructions. Maybe the arthritic changes following ACL reconstruction identified by Daniels represent a subset of patients with more extensive bone bruises.
Although this article recommends waiting 2-4 weeks before ACL reconstruction, this may not be the best recommendation for all patients. It is my opinion and practice to clinically assess the injured knee and to delay surgery until a normal gait, a mild or absent effusion, and a full range of motion are established. Patients who are slow to recover after ACL injury may benefit from a MRI to identify if a bone bruise is present. This may assist the surgeon in predicting the time to perform an ACL reconstruction and may help to predict which patients may be at risk for poorer outcomes. These data help define that all patients with isolated ACL ruptures are not the same and those with bone bruises may require longer time periods before reconstruction.
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