Knee-specific bone quality assessment for cementless total knee arthroplasty candidate selection: a narrative review

Cementless total knee arthroplasty (TKA) has regained attention in younger, active, and obese patients, supported by advances in implant design, porous coating, and 3D printing technologies. However, the success of cementless fixation depends on adequate initial mechanical stability and subsequent osseointegration, making the assessment of bone quality at the implant-bone interface essential. Although central dual-energy X-ray absorptiometry (DXA) is useful for evaluating systemic bone health, it has been reported to inadequately reflect the localized peripheral bone quality of the distal femur and proximal tibia. Therefore, cementless TKA candidate selection requires direct evaluation of the bone quality around the knee joint, particularly at the bone resection site. This narrative review summarizes the preoperative and intraoperative methods available for knee-specific bone quality assessment in the context of cementless TKA selection. Various X-ray-based methods are accessible but limited by two-dimensional projection and protocol variability. Peripheral DXA allows localized bone mineral density measurement but lacks standardization and remains two-dimensional. Magnetic resonance imaging (MRI) has potential for assessing marrow composition and trabecular microarchitecture, but evidence supporting its use in cementless TKA selection remains limited. By contrast, computed tomography (CT)-based assessment is considered the most practical modality, offering three-dimensional evaluation and region-specific analysis. Hounsfield unit analysis on conventional CT can be readily integrated into the routine preoperative workflow, while quantitative CT and dual-energy CT provide more quantitative evaluation through volumetric bone mineral density measurement. Intraoperative assessment has the advantage of directly evaluating the implant bed; however, conventional tactile assessment remains subjective, and visual grading systems and device-based assessments have been proposed to overcome this limitation. Nevertheless, no standardized method has yet been established, and further research is needed. CT-based assessment is the most practical current modality, and intraoperative assessment is gaining objectivity. The integration of these methods with artificial intelligence-driven multi-modal assessment is expected to enable more precise and patient-specific cementless TKA candidate selection.