Advertisement

Osteoporosis International

, Volume 30, Issue 2, pp 383–390 | Cite as

DXA evaluation of femoral bone mineral density and cortical width in patients with prior total knee arthroplasty

  • T. Blaty
  • D. Krueger
  • R. Illgen
  • M. Squire
  • B. Heiderscheit
  • N. BinkleyEmail author
  • P. Anderson
Original Article
  • 132 Downloads

Abstract

Summary

Periprosthetic fractures after total knee arthroplasty (TKA) have devastating consequences. Osteoporosis increases periprosthetic fracture risk, but distal femur bone mineral density (BMD) is not measured post-TKA. This study measured distal femur BMD and cortical width; both were lower in the TKA compared to the non-operated leg. BMD measurement reproducibility was good. Standardized DXA regions of interest are proposed.

Introduction

Periprosthetic fractures following total knee arthroplasty (TKA) are not rare. We hypothesized that TKA is associated with low BMD, potentially increasing periprosthetic fracture risk. However, distal femur dual energy x-ray (DXA) measurement is virtually never performed after TKA due to lack of standardized approaches. Thus, this study’s aims were to develop standard DXA femur regions of interest (ROIs), assess cortical width, and determine measurement reproducibility in TKA patients.

Methods

Thirty adults (15 M/15 F) age 59–80 years with unilateral, primary TKA within 2–5 years had femoral DXA scans performed in duplicate using a Lunar iDXA densitometer. In prior work, we established that femur BMD was lowest in the distal metaphysis and highest in mid-shaft. Thus, BMD and cortical width were measured at 15%, 25%, and 60% of the femur length measured from the distal notch. Femur BMD and cortical width were compared between limbs (TKA vs. non-operated side) by paired t test.

Results

BMD was 3.2–9.9% lower (p < 0.001) in the operated femur at all custom ROIs; substantial between individual differences existed with some up to 30% lower. Cortical width was lower (p < 0.05) at the 25% ROI on the TKA side. BMD reproducibility was excellent; CV 0.85–1.33%.

Conclusions

Distal femur BMD can be reproducibly measured using DXA and is ~ 10% lower on the TKA leg. Similarly, medial and lateral cortices are thinner at the 25% ROI. These bone changes likely increase periprosthetic fracture risk. Further work to define and mitigate periprosthetic fracture risk after TKA is needed.

Keywords

Bone mineral density (BMD) Cortical width Dual energy x-ray absorptiometry (DXA) Total knee arthroplasty (TKA) 

Notes

Compliance with ethical standards

The protocol was approved by the University of Wisconsin Health Sciences Institutional Review Board and conducted in compliance with Federal and local regulations.

Conflicts of interest

None.

References

  1. 1.
    Kurtz S, Ong K, Lau E, Mowat F, Halpern M (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 89:780–785Google Scholar
  2. 2.
    Maradit Kremers H, Larson DR, Crowson CS, Kremers WK, Washington RE, Steiner CA, Jiranek WA, Berry DJ (2015) Prevalence of total hip and knee replacement in the United States. J Bone Joint Surg Am 97:1386–1397CrossRefGoogle Scholar
  3. 3.
    Yoo JD, Kim NK (2015) Periprosthetic fractures following total knee arthroplasty. Knee Surg Relat Res 27:1–9CrossRefGoogle Scholar
  4. 4.
    Sarmah SS, Patel S, Reading G, El-Husseiny M, Douglas S, Haddad FS (2012) Periprosthetic fractures around total knee arthroplasty. Ann R Coll Surg Engl 94:302–307CrossRefGoogle Scholar
  5. 5.
    Della Rocca GJ, Leung KS, Pape HC (2011) Periprosthetic fractures: epidemiology and future projections. J Orthop Trauma 25(Suppl 2):S66–S70CrossRefGoogle Scholar
  6. 6.
    Meek RM, Norwood T, Smith R, Brenkel IJ, Howie CR (2011) The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement. J Bone Joint Surg (Br) 93:96–101CrossRefGoogle Scholar
  7. 7.
    Hoffmann MF, Jones CB, Sietsema DL, Koenig SJ, Tornetta P 3rd (2012) Outcome of periprosthetic distal femoral fractures following knee arthroplasty. Injury 43:1084–1089CrossRefGoogle Scholar
  8. 8.
    Platzer P, Schuster R, Aldrian S, Prosquill S, Krumboeck A, Zehetgruber I, Kovar F, Schwameis K, Vecsei V (2010) Management and outcome of periprosthetic fractures after total knee arthroplasty. J Trauma 68:1464–1470CrossRefGoogle Scholar
  9. 9.
    Reeves RA, Schairer WW, Jevsevar DS (2018) Costs and risk factors for hospital readmission after periprosthetic knee fractures in the United States. J Arthroplast 33(324–330):e321Google Scholar
  10. 10.
    Lizaur-Utrilla A, Miralles-Munoz FA, Sanz-Reig J (2013) Functional outcome of total knee arthroplasty after periprosthetic distal femoral fracture. J Arthroplast 28:1585–1588CrossRefGoogle Scholar
  11. 11.
    Ruder JA, Hart GP, Kneisl JS, Springer BD, Karunakar MA (2017) Predictors of functional recovery following periprosthetic distal femur fractures. J Arthroplast 32:1571–1575CrossRefGoogle Scholar
  12. 12.
    Whitehouse MR, Mehendale S (2014) Periprosthetic fractures around the knee: current concepts and advances in management. Curr Rev Musculoskelet Med 7:136–144CrossRefGoogle Scholar
  13. 13.
    Head J (2017) Periprosthetic distal femur fractures: review of current treatment options. Reconstructive Review 7:NO4Google Scholar
  14. 14.
    Labuda A, Papaioannou A, Pritchard J, Kennedy C, DeBeer J, Adachi JD (2008) Prevalence of osteoporosis in osteoarthritic patients undergoing total hip or total knee arthroplasty. Arch Phys Med Rehabil 89:2373–2374CrossRefGoogle Scholar
  15. 15.
    Chang CB, Kim TK, Kang YG, Seong SC, Kang SB (2014) Prevalence of osteoporosis in female patients with advanced knee osteoarthritis undergoing total knee arthroplasty. J Korean Med Sci 29:1425–1431CrossRefGoogle Scholar
  16. 16.
    Lingard EA, Mitchell SY, Francis RM, Rawlings D, Peaston R, Birrell FN, McCaskie AW (2010) The prevalence of osteoporosis in patients with severe hip and knee osteoarthritis awaiting joint arthroplasty. Age Ageing 39:234–239CrossRefGoogle Scholar
  17. 17.
    Zhu Y, Chen W, Sun T, Zhang X, Liu S, Zhang Y (2015) Risk factors for the periprosthetic fracture after total hip arthroplasty: a systematic review and meta-analysis. Scand J Surg 104:139–145CrossRefGoogle Scholar
  18. 18.
    Gazdzik TS, Gajda T, Kaleta M (2008) Bone mineral density changes after total knee arthroplasty: one-year follow-up. J Clin Densitom 11:345–350CrossRefGoogle Scholar
  19. 19.
    Windisch C, Windisch B, Kolb W, Kolb K, Grutzner P, Roth A (2012) Osteodensitometry measurements of periprosthetic bone using dual energy X-ray absorptiometry following total knee arthroplasty. Arch Orthop Trauma Surg 132:1595–1601CrossRefGoogle Scholar
  20. 20.
    Soininvaara TA, Miettinen HJ, Jurvelin JS, Suomalainen OT, Alhava EM, Kroger HP (2004) Periprosthetic femoral bone loss after total knee arthroplasty: 1-year follow-up study of 69 patients. Knee 11:297–302CrossRefGoogle Scholar
  21. 21.
    Minoda Y, Ikebuchi M, Kobayashi A, Iwaki H, Inori F, Nakamura H (2010) A cemented mobile-bearing total knee replacement prevents periprosthetic loss of bone mineral density around the femoral component: a matched cohort study. J Bone Joint Surg (Br) 92:794–798CrossRefGoogle Scholar
  22. 22.
    Jaroma A, Soininvaara T, Kroger H (2016) Periprosthetic tibial bone mineral density changes after total knee arthroplasty. Acta Orthop 87:268–273CrossRefGoogle Scholar
  23. 23.
    Rockoff SD, Sweet E, Bleustein J (1969) The relative contribution of trabecular and cortical bone to the strength of human lumbar vertebrae. Calcif Tissue Res 3:163–175CrossRefGoogle Scholar
  24. 24.
    Holzer G, von Skrbensky G, Holzer LA, Pichl W (2009) Hip fractures and the contribution of cortical versus trabecular bone to femoral neck strength. J Bone Miner Res 24:468–474CrossRefGoogle Scholar
  25. 25.
    Edmondson CP, Schwartz EN (2017) Non-BMD DXA measurements of the hip. Bone 104:73–83CrossRefGoogle Scholar
  26. 26.
    van de Laarschot DM, Smits AAA, Buitendijk SKC, Stegenga MT, Zillikens MC (2017) Screening for atypical femur fractures using extended femur scans by DXA. J Bone Miner Res 32(8):1632–1639CrossRefGoogle Scholar
  27. 27.
    Baim S, Wilson C, Lewiecki EM, Luckey MM, Downs RW, Lentle BC (2006) Precision assessment and radiation safety for dual-energy x-ray absorptiometry: position paper of the International Society for Clinical Densitometry. J Clin Densitom 8:371–378CrossRefGoogle Scholar
  28. 28.
    Genant HK, Wu CY, Van Kuijk C, Nevitt MC (1993) Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res 8:1137–1148CrossRefGoogle Scholar
  29. 29.
    Thomas B, Binkely N, Anderson PA, Krueger D (2018) DXA measured distal femur bone mineral density in patients after total knee arthroplasty: method development and reproducibility. J Clin Densitom In PressGoogle Scholar
  30. 30.
    Bohr H, Schaadt O (1985) Bone mineral content of the femoral neck and shaft: relation between cortical and trabecular bone. Calcif Tissue Int 37:340–344CrossRefGoogle Scholar
  31. 31.
    Shepherd JA, Lu Y, Wilson K, Fuerst T, Genant H, Hangartner TN, Wilson C, Hans D, Leib ES (2006) Cross-calibration and minimum precision standards for dual-energy X-ray absorptiometry: the 2005 ISCD Official Positions. J Clin Densitom 9:31–36CrossRefGoogle Scholar
  32. 32.
    Mau-Moeller A, Behrens M, Felser S, Bruhn S, Mittelmeier W, Bader R, Skripitz R (2015) Modulation and predictors of periprosthetic bone mineral density following total knee arthroplasty. Biomed Res Int 2015:418168CrossRefGoogle Scholar
  33. 33.
    Gundry M, Hopkins S, Knapp K (2017) A review on bone mineral density loss in total knee replacements leading to increased fracture risk. Clin Rev Bone Miner Metab 15:162–174CrossRefGoogle Scholar
  34. 34.
    Seki T, Omori G, Koga Y, Suzuki Y, Ishii Y, Takahashi HE (1999) Is bone density in the distal femur affected by use of cement and by femoral component design in total knee arthroplasty? J Orthop Sci 4:180–186CrossRefGoogle Scholar
  35. 35.
    Au AG, James Raso V, Liggins AB, Amirfazli A (2007) Contribution of loading conditions and material properties to stress shielding near the tibial component of total knee replacements. J Biomech 40:1410–1416CrossRefGoogle Scholar
  36. 36.
    Moon YW, Kim HJ, Ahn HS, Lee DH (2016) Serial changes of quadriceps and hamstring muscle strength following total knee arthroplasty: a meta-analysis. PLoS One 11:e0148193CrossRefGoogle Scholar
  37. 37.
    Stevens JE, Mizner RL, Snyder-Mackler L (2003) Quadriceps strength and volitional activation before and after total knee arthroplasty for osteoarthritis. J Orthop Res 21:775–779CrossRefGoogle Scholar
  38. 38.
    Naili JE, Iversen MD, Esbjornsson AC, Hedstrom M, Schwartz MH, Hager CK, Brostrom EW (2017) Deficits in functional performance and gait one year after total knee arthroplasty despite improved self-reported function. Knee Surg Sports Traumatol Arthrosc 25:3378–3386CrossRefGoogle Scholar
  39. 39.
    Lee A, Park J, Lee S (2015) Gait analysis of elderly women after total knee arthroplasty. J Phys Ther Sci 27:591–595CrossRefGoogle Scholar
  40. 40.
    Schneider U, Schmidt-Rohlfing B, Knopf U, Breusch SJ (2002) Effects upon bone metabolism following total hip and total knee arthroplasty. Pathobiology 70:26–33CrossRefGoogle Scholar
  41. 41.
    Kenanidis EI, Potoupnis ME, Papavasillioul KA, Sayegh FE, Petsatodis GE, Kapetanos GA (2010) Serum levels of bone turnover markers following total joint arthroplasty. J Orthop Surg (Hong Kong) 18:290–295CrossRefGoogle Scholar
  42. 42.
    Rand T, Seidl G, Kainberger F, Resch A, Hittmair K, Schneider B, Gluer CC, Imhof H (1997) Impact of spinal degenerative changes on the evaluation of bone mineral density with dual energy x-ray absorptiometry (DXA). Calcif Tissue Int 60:430–433CrossRefGoogle Scholar
  43. 43.
    Abdel MP, Watts CD, Houdek MT, Lewallen DG, Berry DJ (2016) Epidemiology of periprosthetic fracture of the femur in 32 644 primary total hip arthroplasties: a 40-year experience. Bone Joint J 98-B:461–467CrossRefGoogle Scholar
  44. 44.
    Abdel MP, Houdek MT, Watts CD, Lewallen DG, Berry DJ (2016) Epidemiology of periprosthetic femoral fractures in 5417 revision total hip arthroplasties: a 40-year experience. Bone Joint J 98-B:468–474CrossRefGoogle Scholar
  45. 45.
    Teng S, Yi C, Krettek C, Jagodzinski M (2015) Bisphosphonate use and risk of implant revision after total hip/knee arthroplasty: a meta-analysis of observational studies. PLoS One 10:e0139927CrossRefGoogle Scholar
  46. 46.
    Jaroma AV, Soininvaara TA, Kroger H (2015) Effect of one-year post-operative alendronate treatment on periprosthetic bone after total knee arthroplasty. A seven-year randomised controlled trial of 26 patients. Bone Joint J 97-B:337–345CrossRefGoogle Scholar
  47. 47.
    Suzuki T, Sukezaki F, Shibuki T, Toyoshima Y, Nagai T, Inagaki K (2018) Teriparatide administration increases periprosthetic bone mineral density after total knee arthroplasty: a prospective study. J Arthroplast 33:79–85CrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2018

Authors and Affiliations

  1. 1.Osteoporosis Clinical Research ProgramUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA
  2. 2.Department of Orthopedics and RehabilitationUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA

Personalised recommendations