Micro-structural basis for particular vulnerability of the superolateral neck trabecular bone in the postmenopausal women with hip fractures

Milovanović, Petar; Djonić, Danijela; Marshall, Robert P.; Hahn, Michael; Nikolić, Slobodan; Živković, Vladimir; Amling, Michael; Djurić, Marija

doi:10.1016/j.bone.2011.09.044

Cited by 60 publications

(43 citation statements)

References 41 publications

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“…In contrast, BS/BV, TbTh, TbSp, TbN, and TMD values were significantly different between the two groups. When compared to other literature, the average values for BV/TV, BS/BV, v BMD, TbSp and TbN presented in this study are within the same range as those previously reported; while for TbTh values presented in this paper are slightly lower, and DA, SMI and TMD are higher than the literature (Green et al, 2011, Ulrich et al, 1999, Perilli et al, 2008, Wu et al, 2013, Thomsen et al, 2015, Link et al, 1998, Ding and Hvid, 2000, Macdonald et al, 2011, Liu et al, 2010b, Milovanovic et al, 2012, Meunier and Boivin, 1997, Humbert et al, 2012). However, our population are exclusively osteoporotic and the aforementioned values have shown a trend one way or another with the progress of the disease.…”

Section: Resultssupporting

confidence: 89%

“…The present SMI values are significantly greater than those previously reported in one study for femoral head specimens (Wu et al, 2013). They are however, lower than those values reported for specimens taken from the supralateral neck (Milovanovic et al, 2012) and trochanter (Wu et al, 2013). On the whole more than 70% of the present data has values greater than the max SMI previously reported.…”

Section: Discussioncontrasting

confidence: 74%

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The micro-architecture of human cancellous bone from fracture neck of femur patients in relation to the structural integrity and fracture toughness of the tissue

et al. 2015

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Osteoporosis is clinically assessed from bone mineral density measurements using dual energy X-ray absorption (DXA). However, these measurements do not always provide an accurate fracture prediction, arguably because DXA does not grapple with ‘bone quality’, which is a combined result of microarchitecture, texture, bone tissue properties, past loading history, material chemistry and bone physiology in reaction to disease. Studies addressing bone quality are comparatively few if one considers the potential importance of this factor. They suffer due to low number of human osteoporotic specimens, use of animal proxies and/or the lack of differentiation between confounding parameters such as gender and state of diseased bone. The present study considers bone samples donated from patients (n = 37) who suffered a femoral neck fracture and in this very well defined cohort we have produced in previous work fracture toughness measurements (FT) which quantify its ability to resist crack growth which reflects directly the structural integrity of the cancellous bone tissue. We investigated correlations between BV/TV and other microarchitectural parameters; we examined effects that may suggest differences in bone remodelling between males and females and compared the relationships with the FT properties. The data crucially has shown that TbTh, TbSp, SMI and TbN may provide a proxy or surrogate for BV/TV. Correlations between FT critical stress intensity values and microarchitecture parameters (BV/TV, BS/TV, TbN, BS/BV and SMI) for osteoporotic cancellous tissue were observed and are for the first time reported in this study. Overall, this study has not only highlighted that the fracture model based upon BMD could potentially be improved with inclusion of other microarchitecture parameters, but has also given us clear clues as to which of them are more influential in this role.

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Section: Resultssupporting

confidence: 89%

Section: Discussioncontrasting

confidence: 74%

The micro-architecture of human cancellous bone from fracture neck of femur patients in relation to the structural integrity and fracture toughness of the tissue

et al. 2015

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“…This adds considerable support to data indicating that trabecular bone is an important determinant of hip fracture [37], [38], [39], [40]. Deficient trabecular bone in the hip [41], [42], [43] has been implicated in increased fracture risk due to anisotropy leading to inability to cope with loading from an unexpected direction as in a sideways fall [44]. Since cortical thinning reduces the hip's capacity to absorb energy imparted by a fall [7], it follows that trabecular bone loss adds to this effect.…”

Section: Discussionsupporting

confidence: 71%

Focal osteoporosis defects play a key role in hip fracture

Poole

Skingle

Gee

et al. 2017

Bone

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BackgroundHip fractures are mainly caused by accidental falls and trips, which magnify forces in well-defined areas of the proximal femur. Unfortunately, the same areas are at risk of rapid bone loss with ageing, since they are relatively stress-shielded during walking and sitting. Focal osteoporosis in those areas may contribute to fracture, and targeted 3D measurements might enhance hip fracture prediction. In the FEMCO case-control clinical study, Cortical Bone Mapping (CBM) was applied to clinical computed tomography (CT) scans to define 3D cortical and trabecular bone defects in patients with acute hip fracture compared to controls. Direct measurements of trabecular bone volume were then made in biopsies of target regions removed at operation.MethodsThe sample consisted of CT scans from 313 female and 40 male volunteers (158 with proximal femoral fracture, 145 age-matched controls and 50 fallers without hip fracture). Detailed Cortical Bone Maps (c.5580 measurement points on the unfractured hip) were created before registering each hip to an average femur shape to facilitate statistical parametric mapping (SPM). Areas where cortical and trabecular bone differed from controls were visualised in 3D for location, magnitude and statistical significance. Measures from the novel regions created by the SPM process were then tested for their ability to classify fracture versus control by comparison with traditional CT measures of areal Bone Mineral Density (aBMD). In women we used the surgical classification of fracture location (‘femoral neck’ or ‘trochanteric’) to discover whether focal osteoporosis was specific to fracture type. To explore whether the focal areas were osteoporotic by histological criteria, we used micro CT to measure trabecular bone parameters in targeted biopsies taken from the femoral heads of 14 cases.ResultsHip fracture patients had distinct patterns of focal osteoporosis that determined fracture type, and CBM measures classified fracture type better than aBMD parameters. CBM measures however improved only minimally on aBMD for predicting any hip fracture and depended on the inclusion of trabecular bone measures alongside cortical regions. Focal osteoporosis was confirmed on biopsy as reduced sub-cortical trabecular bone volume.ConclusionUsing 3D imaging methods and targeted bone biopsy, we discovered focal osteoporosis affecting trabecular and cortical bone of the proximal femur, among men and women with hip fracture.

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“…However, there is no such information in their paper, and we can only guess, or infer from 3D images of a similar publication of theirs, that the slices were quite thin, maybe one to three trabecular strut lengths [2]. For accurate analysis, certain 3D parameters-in particular, DA, SMI and Tb.Sp-require a minimum bone volume in order to provide an accurate description in 3D.…”

mentioning

confidence: 99%

On local micro-architecture analysis of trabecular bone in three dimensions

Tassani

Perilli

2013

International Orthopaedics (SICOT)

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We read with great interest the article by Djuric et al.[1] on 3D micro-computed tomography (micro-CT) analysis of trabecular bone from femoral neck ( Fig. 1 in their paper) of osteoarthritic (OA, n=9) patients compared with a control group (CTL, n=13). The excised bone sections show a trend towards increased bone volume fraction (BV/TV), significantly higher connectivity density (Conn.D), lower structure model index (SMI) and reduced degree of anisotropy (DA) in OA compared with CTL.We would like to emphasise the importance of specifying the physical thickness of the bone slice they analysed, which is related to the maximum volume of interest (VOI) available for analysis, and thus to the reported results in 3D. However, there is no such information in their paper, and we can only guess, or infer from 3D images of a similar publication of theirs, that the slices were quite thin, maybe one to three trabecular strut lengths [2]. For accurate analysis, certain 3D parameters-in particular, DA, SMI and Tb.Sp-require a minimum bone volume in order to provide an accurate description in 3D.The reported anisotropy findings were indeed opposite to those of Tassani et al. [3], who found a significant increase in 3D orientation along the z axis and therefore in anisotropy, of the trabecular framework in OA (n=30) compared with CTL (n=30). In Tassani et al., the specimen comprised a cylindrical volume of 19.5 mm in height and 9 mm in diameter (main compressive region, femoral head). DA is calculated by dividing the principal axes of an ellipsoid describing the orientation of the trabecular micro-architecture [4], calculated as a regression of mean intercept length (MIL) points in space and based on the assumption of orthotropy. If the selected trabecular VOI is too thin (narrow), or unbalanced in size among the three dimensions (1-2 mm in one direction, capturing maybe two trabeculae, vs. 10-20 mm in another), the ellipsoid might be (misleadingly) squashed because of the choice of the thin VOI, rather than representing the spatial arrangement of the trabeculae in 3D. Moreover, the coefficient of determination of the ellipsoid regression might also be small, revealing a suboptimal fit and hence the possibly an unsuitable MIL analysis over that volume. For instance, the difference in anisotropy findings compared with those by Tassani et al. might also be due to the thin VOI used by Djuric et al. and linked to the thin bone slice used in the 3D examination by Djuric et al.In order to enable better interpretations of the 3D results of Djuric et al.'s study and comparisons with the published literature, we suggest the authors to indicate the dimensions of the bone slice and VOI used, of the MIL values along the three axes used to compute the DA, and possibly of the coefficients of determination (R 2 ) of the fitted ellipsoid. We understand that this last parameter in particular is often ignored and is almost never reported in the scientific literature; however, in cases in which large disproportions in VOI dimensions may exist, a...

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Micro-structural basis for particular vulnerability of the superolateral neck trabecular bone in the postmenopausal women with hip fractures

Cited by 60 publications

References 41 publications

The micro-architecture of human cancellous bone from fracture neck of femur patients in relation to the structural integrity and fracture toughness of the tissue

The micro-architecture of human cancellous bone from fracture neck of femur patients in relation to the structural integrity and fracture toughness of the tissue

Focal osteoporosis defects play a key role in hip fracture

On local micro-architecture analysis of trabecular bone in three dimensions

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