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



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.


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.


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.


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%.


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.


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


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



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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

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