Creating Perforations in the Sclerotic Region of the Proximal Tibia During Total Knee Arthroplasty to Enhance Prosthesis Stability

Abstract

Objective: In patients with varus deformity of the knee, the redistribution of the subchondral bone mineral density (BMD) of the tibia leads to sclerotic zones that may cause osteoarthritis. Drilling the sclerotic area of the tibia prior to cementing during total knee arthroplasty is advisable practice. However, the extent of the sclerotic area and the effect of drilling on the tibial component are not well defined. We aimed to quantify the BMD and sclerotic bone distribution of the knee to clarify the effect of drilling on the stability of the prosthesis.

Methods: Our retrospective cohort study enrolled a total of 97 patients from December 2018 to December 2019, categorized into drilled and nondrilled groups, with their computed tomography (CT) knee joint images documented. The proximal tibia image was divided into nine regions, the BMD of each region calculated, and CT values compared between the affected and normal sides. We established finite element models to analyze the drilling and stress distribution. The differences in CT values were assessed using the paired t test and Wilcoxon signed-rank test.

Results: The mean thickness of sclerotic bone was 7.7 ± 1.4 mm, and the surface area was 441.9 ± 89.4 mm². The CT values of the affected anteromedial, anterolateral, mediomedial, mediolateral, posteromedial, posteromedian, and posterolateral tibial areas were significantly higher than their normal counterparts. Stress concentration around the boreholes in all finite element models is minimal, with stress values ranging from 0.01 to 3.73 MPa, markedly lower than the 13.93 MPa observed in the undrilled model.

Conclusion: Abnormal stress in the proximal tibia alters the distribution pattern of BMD, and drilling in the sclerotic area is associated with improved prosthesis stability.

Keywords

bone density / finite element analysis / osteoarthritis / stress distribution / total knee arthroplasty

References

[1] J. N. Katz, K. R. Arant, and R. F. Loeser, “Diagnosis and Treatment of Hip and Knee Osteoarthritis: A Review,” JAMA 325, no. 6 (2021): 568-578.

[2] L. Sharma and C. G. Solomon, “Osteoarthritis of the Knee,” New England Journal of Medicine 384, no. 1 (2021): 51-59.

[3] J. Sewell and A. Östör, “Emerging Injectable Therapies for Osteoarthritis,” Expert Opinion on Emerging Drugs 27, no. 3 (2022): 311-320.

[4] A. C. Gelber, “Knee Osteoarthritis,” Annals of Internal Medicine 177, no. 9 (2024): ITC129-ITC144.

[5] H. Ma, W. Zhang, J. Shi, D. Zhou, and J. Wang, “The Efficacy and Safety of Extracorporeal Shockwave Therapy in Knee Osteoarthritis: A Systematic Review and Meta-Analysis,” International Journal of Surgery 75 (2020): 24-34.

[6] B. E. Øiestad, C. B. Juhl, A. G. Culvenor, B. Berg, and J. B. Thorlund, “Knee Extensor Muscle Weakness is a Risk Factor for the Development of Knee Osteoarthritis: An Updated Systematic Review and Meta-Analysis Including 46 819 Men and Women,” British Journal of Sports Medicine 56, no. 6 (2022): 349-355.

[7] P. A. Hernandez, J. C. Bradford, P. Brahmachary, et al., “Unraveling Sex-Specific Risks of Knee Osteoarthritis Before Menopause: Do Sex Differences Start Early in Life?,” Osteoarthritis and Cartilage 32, no. 9 (2024): 1032-1044.

[8] C. Xu, T. Liu, J. B. Driban, T. McAlindon, C. B. Eaton, and B. Lu, “Dietary Patterns and Risk of Developing Knee Osteoarthritis: Data From the Osteoarthritis Initiative,” Osteoarthritis and Cartilage 29, no. 6 (2021): 834-840.

[9] T. Oláh, J. Reinhard, M. W. Laschke, et al., “Axial Alignment Is a Critical Regulator of Knee Osteoarthritis,” Science Translational Medicine 14, no. 629 (2022): eabn0179.

[10] Y. H. Gao, Y. M. Qi, P. H. Huang, X. Y. Zhao, and X. Qi, “Distribution of Coronal Plane Alignment of the Knee Classification in Chinese Osteoarthritic and Healthy Population: A Retrospective Cross-Sectional Observational Study,” International Journal of Surgery 110, no. 5 (2024): 2583-2592.

[11] S. J. MacDessi, W. Griffiths-Jones, I. A. Harris, J. Bellemans, and D. B. Chen, “Coronal Plane Alignment of the Knee (CPAK) Classification,” Bone and Joint Journal 103-b, no. 2 (2021): 329-337.

[12] G. Cai, P. Otahal, F. Cicuttini, et al., “The Association of Subchondral and Systemic Bone Mineral Density With Osteoarthritis-Related Joint Replacements in Older Adults,” Osteoarthritis and Cartilage 28, no. 4 (2020): 438-445.

[13] L. Fang, C. Xia, H. Xu, et al., “Defining Disease Progression in Chinese Mainland People: Association Between Bone Mineral Density and Knee Osteoarthritis,” Journal of Orthopaedic Translation 26 (2021): 39-44.

[14] Y. J. Hu, Y. E. Yu, H. J. Cooper, et al., “Mechanical and Structural Properties of Articular Cartilage and Subchondral Bone in Human Osteoarthritic Knees,” Journal of Bone and Mineral Research 39, no. 8 (2024): 1120-1131.

[15] K. A. Knurr, S. A. Kliethermes, C. R. Haack, et al., “Changes in Bone Mineral Density of the Femur and Tibia Before Injury to 2 Years After Anterior Cruciate Ligament Reconstruction in Division I Collegiate Athletes,” American Journal of Sports Medicine 50, no. 9 (2022): 2410-2416.

[16] J. H. Ahn, S. H. Jeong, and S. H. Lee, “The Effect of Multiple Drilling on a Sclerotic Proximal Tibia During Total Knee Arthroplasty,” International Orthopaedics 39, no. 6 (2015): 1077-1083.

[17] C. Zheng, H. Y. Ma, Y. Q. Du, et al., “Finite Element Assessment of the Screw and Cement Technique in Total Knee Arthroplasty,” BioMed Research International 2020 (2020): 3718705.

[18] D. Zhao, S. A. Banks, D. D. D'Lima, C. W. Colwell, and B. J. Fregly, “In Vivo Medial and Lateral Tibial Loads During Dynamic and High Flexion Activities,” Journal of Orthopaedic Research 25, no. 5 (2007): 593-602.

[19] K. D. Allen, L. M. Thoma, and Y. M. Golightly, “Epidemiology of Osteoarthritis,” Osteoarthritis and Cartilage 30, no. 2 (2022): 184-195.

[20] J. Wu, Y. Pan, Y. Yu, et al., “Axial Compressive Loading Attenuates Early Osteoarthritis by Reducing Subchondral Bone Remodeling,” American Journal of Sports Medicine 51, no. 7 (2023): 1752-1764.

[21] R. Heiss, J. D. Laredo, W. Wirth, et al., “Quantitative CT of the Knee in the IMI-APPROACH Osteoarthritis Cohort: Association of Bone Mineral Density With Radiographic Disease Severity, Meniscal Coverage and Meniscal Extrusion,” Bone 168 (2023): 116673.

[22] P. Omoumi, H. Babel, B. M. Jolles, and J. Favre, “Quantitative Regional and Sub-Regional Analysis of Femoral and Tibial Subchondral Bone Mineral Density (sBMD) Using Computed Tomography (CT): Comparison of Nonosteoarthritic (OA) and Severe OA Knees,” Osteoarthritis and Cartilage 25, no. 11 (2017): 1850-1857.

[23] S. Miyamura, K. Oka, S. Abe, et al., “Altered Bone Density and Stress Distribution Patterns in Long-Standing Cubitus Varus Deformity and Their Effect During Early Osteoarthritis of the Elbow,” Osteoarthritis and Cartilage 26, no. 1 (2018): 72-83.

[24] B. Javaheri, H. Razi, S. Gohin, et al., “Lasting Organ-Level Bone Mechanoadaptation Is Unrelated to Local Strain,” Science Advances 6, no. 10 (2020): eaax8301.

[25] L. Hutchison, J. Grayson, C. Hiller, N. D'Souza, S. Kobayashi, and M. Simic, “Relationship Between Knee Biomechanics and Pain in People With Knee Osteoarthritis: A Systematic Review and Meta-Analysis,” Arthritis Care and Research 75, no. 6 (2023): 1351-1361.

[26] R. F. Pinto, T. B. Birmingham, H. T. Philpott, et al., “Changes and Associations Between Gait Biomechanics and Knee Inflammation After Aspiration and Glucocorticoid Injection for Knee Osteoarthritis,” Arthritis Care and Research 75, no. 8 (2023): 1764-1772.

[27] J. R. Rodríguez-Collell, D. Mifsut, A. Ruiz-Sauri, L. Rodríguez-Pino, E. M. González-Soler, and A. A. Valverde-Navarro, “Improving the Cementation of the Tibial Component in Knee Arthroplasty: A Study of Four Techniques in the Cadaver,” Bone Joint Res 10, no. 8 (2021): 467-473.

[28] A. M. Refsum, U. V. Nguyen, J. E. Gjertsen, et al., “Cementing Technique for Primary Knee Arthroplasty: A Scoping Review,” Acta Orthopaedica 90, no. 6 (2019): 582-589.

[29] S. Jaeger, M. Eissler, M. Schwarze, M. Schonhoff, J. P. Kretzer, and R. G. Bitsch, “Does Tibial Design Modification Improve Implant Stability for Total Knee Arthroplasty? An Experimental Cadaver Study,” Bone Joint Res 11, no. 4 (2022): 229-238.

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2025 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.