BMD T-score discriminates trochanteric fractures from unfractured controls, whereas geometry discriminates cervical fracture cases from unfractured controls of similar BMD

Pulkkinen, Pasi; Partanen, Juha; Jalovaara, P.; Jämsä, Timo

doi:10.1007/s00198-009-1070-3

Cited by 18 publications

(7 citation statements)

References 31 publications

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“…Failure load was predicted less well in the stance configuration than in the side configuration. Our results are in agreement with those in several publications (23)(24)(25), some of which indicate a closer association of trochanteric fractures with low BMD than with cervical fractures, for which geometric parameters play a greater role. In our multivariate analyses, adding radiography variables to areal BMD in the total hip as measured with DXA increased the predictive performance from 73% to 80% in the stance configuration and from 82% to 84% in the side configuration.…”

Section: Descriptive Statistics and Analysessupporting

confidence: 93%

Prediction of Hip Failure Load: In Vitro Study of 80 Femurs Using Three Imaging Methods and Finite Element Models—The European Fracture Study (EFFECT)

Pottecher¹,

Engelke²,

Duchemin³

et al. 2016

Radiology

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Purpose To evaluate the performance of three imaging methods (radiography, dual-energy x-ray absorptiometry [DXA], and quantitative computed tomography [CT]) and that of a numerical analysis with finite element modeling (FEM) in the prediction of failure load of the proximal femur and to identify the best densitometric or geometric predictors of hip failure load. Materials and Methods Institutional review board approval was obtained. A total of 40 pairs of excised cadaver femurs (mean patient age at time of death, 82 years ± 12 [standard deviation]) were examined with (a) radiography to measure geometric parameters (lengths, angles, and cortical thicknesses), (b) DXA (reference standard) to determine areal bone mineral densities (BMDs), and (c) quantitative CT with dedicated three-dimensional analysis software to determine volumetric BMDs and geometric parameters (neck axis length, cortical thicknesses, volumes, and moments of inertia), and (d) quantitative CT-based FEM to calculate a numerical value of failure load. The 80 femurs were fractured via mechanical testing, with random assignment of one femur from each pair to the single-limb stance configuration (hereafter, stance configuration) and assignment of the paired femur to the sideways fall configuration (hereafter, side configuration). Descriptive statistics, univariate correlations, and stepwise regression models were obtained for each imaging method and for FEM to enable us to predict failure load in both configurations. Results Statistics reported are for stance and side configurations, respectively. For radiography, the strongest correlation with mechanical failure load was obtained by using a geometric parameter combined with a cortical thickness (r(2) = 0.66, P < .001; r(2) = 0.65, P < .001). For DXA, the strongest correlation with mechanical failure load was obtained by using total BMD (r(2) = 0.73, P < .001) and trochanteric BMD (r(2) = 0.80, P < .001). For quantitative CT, in both configurations, the best model combined volumetric BMD and a moment of inertia (r(2) = 0.78, P < .001; r(2) = 0.85, P < .001). FEM explained 87% (P < .001) and 83% (P < .001) of bone strength, respectively. By combining (a) radiography and DXA and (b) quantitative CT and DXA, correlations with mechanical failure load increased to 0.82 (P < .001) and 0.84 (P < .001), respectively, for radiography and DXA and to 0.80 (P < .001) and 0.86 (P < .001) , respectively, for quantitative CT and DXA. Conclusion Quantitative CT-based FEM was the best method with which to predict the experimental failure load; however, combining quantitative CT and DXA yielded a performance as good as that attained with FEM. The quantitative CT DXA combination may be easier to use in fracture prediction, provided standardized software is developed. These findings also highlight the major influence on femoral failure load, particularly in the trochanteric region, of a densitometric parameter combined with a geometric parameter. (©) RSNA, 2016 Online supplemental material is available for this article.

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Section: Descriptive Statistics and Analysessupporting

confidence: 93%

Prediction of Hip Failure Load: In Vitro Study of 80 Femurs Using Three Imaging Methods and Finite Element Models—The European Fracture Study (EFFECT)

Pottecher¹,

Engelke²,

Duchemin³

et al. 2016

Radiology

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“…This is in line with the findings in this and other studies (50)(51)(52) that patients with extracapsular fracture are generally older and have lower hip BMD than patients with intracapsular fracture, which lead to lower elastic modulus and yield stress of bone in our FE model. It has been shown that the current BMD-based clinical assessment procedure is adequate to predict extracapsular fracture, (53) but may underdiagnose intracapsular fracture, (54) because women with intracapsular fracture tend to have a much more complex risk profile such as longer FN length, wider neck-shaft angle, and narrower neck width than in the controls or patients with extracapsular fracture. (41)(42)(43)46,50,55) The estimated strength in this study is independently associated with both intracapsular and extracapsular fractures, its association is stronger than TH BMD and many HSA variables, and it predicts intracapsular and extracapsular fractures significantly better than TH BMD.…”

Section: Discussionmentioning

confidence: 99%

Prediction of Incident Hip Fracture with the Estimated Femoral Strength by Finite Element Analysis of DXA Scans in the Study of Osteoporotic Fractures

Yang

Palermo

Black

et al. 2014

Journal of Bone and Mineral Research

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A bone fractures only when loaded beyond its strength. The purpose of this study was to determine the association of femoral strength, as estimated by finite element (FE) analysis of DXA scans, with incident hip fracture in comparison to hip BMD, FRAX® and hip structure analysis (HSA) variables. This prospective case-cohort study included a random sample of 1941 women and 668 incident hip fracture cases (295 in the random sample) during a mean±SD follow-up of 12.8±5.7 yrs from the Study of Osteoporotic Fractures (n=7860 community-dwelling women ≥67 yr of age). We analyzed the baseline DXA scans (Holgoic 1000) of the hip using a validated plane-stress, linear-elastic finite element (FE) model of the proximal femur and estimated the femoral strength during a simulated sideways fall. Cox regression accounting for the case-cohort design assessed the association of estimated femoral strength with hip fracture. The age-BMI-adjusted hazard ratio (HR) per SD decrease for estimated strength (2.21, 95% CI 1.95–2.50) was greater than that for TH BMD (1.86, 95% CI 1.67–2.08; p<0.05), FN BMD (2.04, 95% CI 1.79–2.32; p>0.05), FRAX® scores (range 1.32–1.68; p<0.0005) and many HSA variables (range 1.13–2.43; p<0.005), and the association was still significant (p<0.05) after further adjustment for hip BMD or FRAX® scores. The association of estimated strength with incident hip fracture was strong (Harrell's C index 0.770), significantly better than TH BMD (0.759, p<0.05) and FRAX® scores (0.711–0.743, p<0.0001) but not FN BMD (0.762, p>0.05) Similar findings were obtained for intra- and extra-capsular fractures. In conclusion, the estimated femoral strength from FE analysis of DXA scans is an independent predictor and performs at least as well as FN BMD in predicting incident hip fracture in postmenopausal women.

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“…There was no difference in FN BMD, bone strength, or LSR according to type of fracture (neck of femur or trochanteric). Some studies have suggested that trochanteric and femoral neck fractures are associated with different geometrical and density measures 37–41. Because the FE model integrates bone mass distribution and geometry information embedded in DXA scans with the loading condition known to cause hip fracture, these subtle differences are incorporated into the FE analysis model but may be canceling each other out in estimating the whole bone strength.…”

Section: Discussionmentioning

confidence: 99%

Use of DXA-based finite element analysis of the proximal femur in a longitudinal study of hip fracture

Naylor

McCloskey

Eastell

et al. 2012

Journal of Bone and Mineral Research

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Bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA) is used for clinical assessment of fracture risk; however, measurements that incorporate bone strength could improve predictive ability. The aim of this study was to determine whether bone strength derived from finite element (FE) analysis was associated with hip fracture risk in a longitudinal study. We studied 728 women (mean age 82 years), 182 with subsequent hip fracture. FE models were generated from baseline DXA scans of the hip to determine femoral bone strength and load-to-strength ratio (LSR). The baseline LSR was significantly higher in fracture cases (median 1.1) compared with controls (0.7, p < 0.0001). Femoral strength and BMD were also significantly lower in cases (median 1820 N, 0.557 g/cm 2 ) compared with controls (2614 N, 0.618 g/cm 2 ) both p < 0. In conclusion, the DXA-based FE model was able to discriminate incident hip fracture cases from controls in this longitudinal study independently from FN BMD, prior fracture, VFA, and FRAX score. Such an approach may provide a useful tool for better assessment of bone strength to identify patients at high risk of hip fracture who may benefit from treatment to reduce fracture risk. ß

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BMD T-score discriminates trochanteric fractures from unfractured controls, whereas geometry discriminates cervical fracture cases from unfractured controls of similar BMD

Cited by 18 publications

References 31 publications

Prediction of Hip Failure Load: In Vitro Study of 80 Femurs Using Three Imaging Methods and Finite Element Models—The European Fracture Study (EFFECT)

Prediction of Hip Failure Load: In Vitro Study of 80 Femurs Using Three Imaging Methods and Finite Element Models—The European Fracture Study (EFFECT)

Prediction of Incident Hip Fracture with the Estimated Femoral Strength by Finite Element Analysis of DXA Scans in the Study of Osteoporotic Fractures

Use of DXA-based finite element analysis of the proximal femur in a longitudinal study of hip fracture

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