Change in bone mineral density after cemented and uncemented knee arthroplasty with an asymmetrical tibial component: secondary analysis of a randomized study using dual-energy X-ray absorptiometry
DOI:
https://doi.org/10.2340/17453674.2026.45944Keywords:
Arthroplasty, Bone Mineral Density, Knee, Osteoarthrosis, Radiological imagingAbstract
Background and purpose: Total knee arthroplasties (TKA) affect the mechanical loading of the knee joint and may be associated with changes in bone mineral density (BMD). We aimed to evaluate adaptive periprosthetic BMD after cemented and uncemented TKA.
Methods: This is a secondary report of an earlier published RCT. Patients receiving cemented (n = 31) or uncemented (n = 32) TKA were included in a randomized controlled trial (RCT) with a 1:1 allocation. BMD was measured using Dual-energy X-ray Absorptiometry (DEXA) at 1 week and 3, 6, 12, and 24 months postoperatively in 3 regions of interest (ROI) in the femur and tibia. Changes in BMD were assessed using a paired t-test, and between-groups differences using an unpaired t-test. Time-related changes were analyzed using ANOVA. The study was registered at clinicaltrials.gov (NCT03563131) before enrolment.
Results: Femoral components: Over 2 years, BMD in ROI I decreased by 33% in the uncemented group and 21% in the cemented group, with a between-group difference of 12.2 percentage points (95% confidence interval [CI] 5.3–19.1; significant). In ROI II, the decrease was 19% vs 13%, with a between-group difference of 6.1 percentage points (CI –1.2 to 13.5; not significant). In ROI III, decreases were 6% vs 7%, with a between-group difference of –0.6 percentage points (CI –4.3 to 3.3; not significant). Tibial components: Changes were small (-4.7 to 3.3%), with significant decreases only in ROI I in the cemented group over 24 months. No significant between-group differences were observed.
Conclusion: The periprosthetic BMD after TKA decreased both around cemented and uncemented components, particularly in ROI I after using an uncemented femoral component, whereas the decrease under the tibial components was small and of uncertain clinical significans.
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Van Dooren B-J, Bos P, Peters R M, Van Steenbergen L N, De Visser E, Brinkman J M, et al. Time trends in case-mix and risk of revision following hip and knee arthroplasty in public and private hospitals: a cross-sectional analysis based on 476,312 procedures from the Dutch Arthroplasty Register. Acta Orthop 2024; 95: 307-18. doi: 10.2340/17453674.2024.40906. DOI: https://doi.org/10.2340/17453674.2024.40906
Minoda Y, Kobayashi A, Ikebuchi M, Iwaki H, Inori F, Nakamura H. Porous tantalum tibial component prevents periprosthetic loss of bone mineral density after total knee arthroplasty for five years: a matched cohort study. J Arthroplasty 2013; 28: 1760-4. doi: 10.1016/j.arth.2013.03.031. DOI: https://doi.org/10.1016/j.arth.2013.03.031
Martin J R, Watts C D, Levy D L, Miner T M, Springer B D, Kim R H. Tibial tray thickness significantly increases medial tibial bone resorption in cobalt-chromium total knee arthroplasty implants. J Arthroplasty 2017; 32: 79-82. doi: 10.1016/j.arth.2016.06.007. DOI: https://doi.org/10.1016/j.arth.2016.06.007
Hvid I, Jensen N C, Bünger C, Sølund K, Djurhuus J C. Bone mineral assay: its relation to the mechanical strength of cancellous bone. Eng Med 1985; 14: 79-83. doi: 10.1243/emed_jour_1985_014_016_02. DOI: https://doi.org/10.1243/EMED_JOUR_1985_014_016_02
Soininvaara T A, Miettinen H J, Jurvelin J S, Suomalainen O T, Alhava E M, Kröger H P. Periprosthetic tibial bone mineral density changes after total knee arthroplasty: one-year follow-up study of 69 patients. Acta Orthop Scand 2004; 75: 600-5. doi: 10.1080/00016470410001493. DOI: https://doi.org/10.1080/00016470410001493
Andersen M R, Winther N S, Lind T, Schrøder H M, Mørk Petersen M. Bone remodeling of the distal femur after uncemented total knee arthroplasty: a 2-year prospective DXA study. J Clin Densitom 2018; 21: 236-43. doi: 10.1016/j.jocd.2017.05.001. DOI: https://doi.org/10.1016/j.jocd.2017.05.001
van Loon C J, de Waal Malefijt M C, Buma P, Verdonschot N, Veth R P. Femoral bone loss in total knee arthroplasty: a review. Acta Orthop Belg 1999; 65: 154-63.
Soininvaara T A, Miettinen H J, Jurvelin J S, Suomalainen O T, Alhava E M, Kröger H P. Periprosthetic femoral bone loss after total knee arthroplasty: 1-year follow-up study of 69 patients. Knee 2004; 11: 297-302. doi: 10.1016/j.knee.2003.09.006. DOI: https://doi.org/10.1016/j.knee.2003.09.006
Yilmaz M, Holm C E, Lind T, Flivik G, Odgaard A, Petersen M M. Bone remodeling and implant migration of uncemented femoral and cemented asymmetrical tibial components in total knee arthroplasty: DXA and RSA evaluation with 2-year follow up. Knee Surg Relat Res 2021; 33: 25. doi: 10.1186/s43019-021-00111-5. DOI: https://doi.org/10.1186/s43019-021-00111-5
Soininvaara T, Kröger H, Jurvelin J S, Miettinen H, Suomalainen O, Alhava E. Measurement of bone density around total knee arthroplasty using fan-beam dual energy X-ray absorptiometry. Calcif Tissue Int 2000; 67: 267-72. doi: 10.1007/s002230001111. DOI: https://doi.org/10.1007/s002230001111
Martin J R, Watts C D, Levy D L, Kim R H. Medial Tibial stress shielding: a limitation of cobalt chromium tibial baseplates. J Arthroplasty 2017; 32: 558-62. doi: 10.1016/j.arth.2016.07.027. DOI: https://doi.org/10.1016/j.arth.2016.07.027
Rathsach Andersen M, Winther N, Lind T, Schrøder H M, Petersen M M. Bone remodeling of the proximal tibia after uncemented total knee arthroplasty: secondary endpoints analyzed from a randomized trial comparing monoblock and modular tibia trays-2 year follow-up of 53 cases. Acta Orthop 2019; 90: 479-83. doi: 10.1080/17453674.2019.1637178. DOI: https://doi.org/10.1080/17453674.2019.1637178
Hvid I, Bentzen S M, Jørgensen J. Remodeling of the tibial plateau after knee replacement: CT bone densitometry. Acta Orthop Scand 1988; 59: 567-73. doi: 10.3109/17453678809148787. DOI: https://doi.org/10.3109/17453678809148787
Karbowski A, Schwitalle M, Eckardt A, Heine J. Periprosthetic bone remodelling after total knee arthroplasty: early assessment by dual energy X-ray absorptiometry. Arch Orthop Trauma Surg 1999; 119: 324-6. doi: 10.1007/s004020050419. DOI: https://doi.org/10.1007/s004020050419
Altun M Y, Flivik G, Lind T, Odgaard A, Holm C E, Petersen M M. Migration of cemented and uncemented implants in total knee arthroplasty with an asymmetrical tibial component. J Bone Joint Surg 2025; 107: 1926-39. doi: 10.2106/JBJS.24.00835. DOI: https://doi.org/10.2106/JBJS.24.00835
Winther N S. Early changes in BMD after insertion of the uncemented Vanguard® TKA (porous plasma spray coated) and the influence of a novel porous titanium surface (Regenerex®) on tibial component migration and adaptive bone remodeling of the proximal tibia. PhD Thesis, Faculty of Health and Medical Sciences University of Copenhagen, 2014, Denmark.
Petersen M M, Lauritzen J B, Pedersen J G, Lund B. Decreased bone density of the distal femur after uncemented knee arthroplasty: a 1-year follow-up of 29 knees. Acta Orthop Scand 1996; 67: 339-44. doi: 10.3109/17453679609002327. DOI: https://doi.org/10.3109/17453679609002327
Liu T K, Yang R S, Chieng P U, Shee B W. Periprosthetic bone mineral density of the distal femur after total knee arthroplasty. Int Orthop 1995; 19: 346-51. doi: 10.1007/bf00178346. DOI: https://doi.org/10.1007/BF00178346
Järvenpää J, Soininvaara T, Kettunen J, Miettinen H, Kröger H. Changes in bone mineral density of the distal femur after total knee arthroplasty: a 7-year DEXA follow-up comparing results between obese and nonobese patients. Knee 2014; 21: 232-5. doi: 10.1016/j.knee.2013.03.004. DOI: https://doi.org/10.1016/j.knee.2013.03.004
Christensen R, Ranstam J, Overgaard S, Wagner P. Guidelines for a structured manuscript: statistical methods and reporting in biomedical research journals. Acta Orthop 2023; 94: 243-9. doi: 10.2340/17453674.2023.11656. DOI: https://doi.org/10.2340/17453674.2023.11656
Petersen M M, Jensen N C, Gehrchen P M, Nielsen P K, Nielsen P T. The relation between trabecular bone strength and bone mineral density assessed by dual photon and dual energy X-ray absorptiometry in the proximal tibia. Calcif Tissue Int 1996; 59: 311-14. doi: 10.1007/s002239900131. DOI: https://doi.org/10.1007/s002239900131
Khan M, Osman K, Green G, Haddad F S. The epidemiology of failure in total knee arthroplasty. Bone Joint J 2016; 98-B: 105-12. doi: 10.1302/0301-620X.98B1.36293. DOI: https://doi.org/10.1302/0301-620X.98B1.36293
Levine B R, Springer B D, Golladay G J. Highlights of the 2019 American Joint Replacement Registry Annual Report. Arthroplasty Today 2020; 6: 998-1000. doi: 10.1016/j.artd.2020.09.010. DOI: https://doi.org/10.1016/j.artd.2020.09.010
Levitz C L, Lotke P A, Karp J S. Long-term changes in bone mineral density following total knee replacement. Clin Orthop Relat Res 1995: 68-72. PMID: 7497687. DOI: https://doi.org/10.1097/00003086-199512000-00010
Madsen O R, Schaadt O, Bliddal H, Egsmose C, Sylvest J. Bone mineral distribution of the proximal tibia in gonarthrosis assessed in vivo by photon absorption. Osteoarthritis Cartilage 1994; 2: 141-7. doi: 10.1016/S1063-4584(05)80064-0. DOI: https://doi.org/10.1016/S1063-4584(05)80064-0
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Copyright (c) 2026 Müjgan Yilmaz Altun, Gunnar Flivik, Thomas Lind, Anders Odgaard, Michael Mørk Petersen
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