Liver Fat Content Measurement with Quantitative CT Validated against MRI Proton Density Fat Fraction: A Prospective Study of 400 Healthy Volunteers.

Background Although chemical shift-encoded (CSE) MRI proton density fat fraction (PDFF) is the current noninvasive reference standard for liver fat quantification, the liver is more frequently imaged with CT. Purpose To validate quantitative CT measurements of liver fat against the MRI PDFF reference standard. Materials and Methods In this prospective study, 400 healthy participants were recruited between August 2015 and July 2016. Each participant underwent same-day abdominal unenhanced quantitative CT with a calibration phantom and CSE 3.0-T MRI. CSE MRI liver fat measurements were used to calibrate an equation to adjust CT fat measurements and put them on the PDFF measurement scale. CT and PDFF liver fat measurements were plotted as histograms, medians, and interquartile ranges compared; scatterplots and Bland-Altman plots obtained; and Pearson correlation coefficients calculated. Receiver operating characteristic curves including areas under the curve were evaluated for mild (PDFF, 5%) and moderate (PDFF, 14%) steatosis thresholds for both raw and adjusted CT measurements. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated. Results Four hundred volunteers (mean age, 52.6 years ± 15.2; 227 women) were evaluated. MRI PDFF measurements of liver fat ranged between 0% and 28%, with 41.5% (166 of 400) of participants with PDFF greater than 5%. Both raw and adjusted quantitative CT values correlated well with MRI PDFF (r2 = 0.79; P < .001). Bland-Altman analysis of adjusted CT values showed no slope or bias. Both raw and adjusted CT had areas under the receiver operating characteristic curve of 0.87 and 0.99, respectively, to identify participants with mild (PDFF, >5%) and moderate (PDFF, >14%) steatosis, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value for unadjusted CT was 75.9% (126 of 166), 85.0% (199 of 234), 78.3% (126 of 161), and 83.3% (199 of 239), respectively, for PDFF greater than 5%; and 84.8% (28 of 33), 98.4% (361 of 367), 82.4% (28 of 34), and 98.6% (361 of 366), respectively, for PDFF greater than 14%. Results for adjusted CT were mostly identical. Conclusion Quantitative CT liver fat exhibited good correlation and accuracy with proton density fat fraction measured with chemical shift-encoded MRI. © RSNA, 2019 Online supplemental material is available for this article.

Direct Comparison of Unenhanced and Contrast-Enhanced CT for Opportunistic Proximal Femur Bone Mineral Density Measurement: Implications for Osteoporosis Screening.

OBJECTIVE: For patients undergoing contrast-enhanced CT examinations that include the proximal femur, an opportunity exists for concurrent screening bone mineral density (BMD) measurement. We investigated the effect of IV contrast enhancement on CT-derived x-ray absorptiometry areal BMD measurement. MATERIALS AND METHODS: Our cohort included 410 adults (mean age, 65.3 ± 10.0 years; range, 49-95 years) who underwent split-bolus CT urography at 120 kVp. Areal femoral neck BMD in g/cm(2) was measured on both unenhanced and contrast-enhanced CT series with asynchronous phantom calibration. Constant offset and multiplicative factor corrections for the contrast-enhanced series were derived from the Bland-Altman plot linear regression slopes. RESULTS: Mean unenhanced and contrast-enhanced areal femoral neck BMD values were 0.681 ± 0.118 and 0.713 ± 0.123 g/cm(2), respectively. The SD of the distribution of residuals for the constant offset and multiplicative model corrections were 0.0232 and 0.0231, respectively. The constant offset correction associated with contrast enhancement was 0.032 ± 0.023 g/cm(2), which corresponds to 0.29 ± 0.21 T-score units using the CT-derived x-ray absorptiometry young normal areal femoral neck BMD reference SD of 0.111 g/cm(2). CONCLUSION: For the purposes of opportunistic osteoporosis screening, contrast-enhanced abdominopelvic CT studies are equivalent to unenhanced CT and can therefore be used for femoral neck BMD assessment. This measure could greatly enhance osteoporosis screening.

Marrow Adipose Tissue Quantification of the Lumbar Spine by Using Dual-Energy CT and Single-Voxel (1)H MR Spectroscopy: A Feasibility Study.

PURPOSE: To test the performance of dual-energy computed tomography (CT) in the assessment of marrow adipose tissue (MAT) content of the lumbar spine by using proton (hydrogen 1 [(1)H]) magnetic resonance (MR) spectroscopy as a reference standard and to determine the influence of MAT on the assessment of bone mineral density (BMD). MATERIALS AND METHODS: This study was institutional review board approved and complied with HIPAA guidelines. Written informed consent was obtained. Twelve obese osteopenic but otherwise healthy subjects (mean age ± standard deviation, 43 years ± 13) underwent 3-T (1)H MR spectroscopy of the L2 vertebra by using a point-resolved spatially localized spectroscopy sequence without water suppression. The L2 vertebra was scanned with dual-energy CT (80 and 140 kV) by using a dual-source multi-detector row CT scanner with a calibration phantom. Mean basis material composition relative to the phantom was estimated in the L2 vertebra. Volumetric BMD was measured with and without correction for MAT. Bland-Altman 95% limits of agreement and Pearson correlation coefficients were calculated. RESULTS: There was excellent agreement between (1)H MR spectroscopy and dual-energy CT, with a mean difference in fat fraction of -0.02 between the techniques, with a 95% confidence interval of -0.24, 0.20. There was a strong correlation between marrow fat fraction obtained with (1)H MR spectroscopy and that obtained with dual-energy CT (r = 0.91, P < .001). The presence of MAT led to underestimation of BMD, and this bias increased with increasing MAT content (P < .001). CONCLUSION: Dual-energy CT can be used to assess MAT content and BMD of the lumbar spine in a single examination and provides data that closely agree and correlate with (1)H MR spectroscopy data.

Negative Impact of Aromatase Inhibitors on Proximal Femoral Bone Mass and Geometry in Postmenopausal Women with Breast Cancer.

Aromatase inhibitors (AIs), the standard therapy for estrogen receptor- or progesterone receptor-positive breast cancer in postmenopausal women, lead to increased hip fractures in breast cancer patients. To investigate the mechanism of increased incidence of hip fractures in breast cancer patients treated with AIs, we evaluated bone mineral density (BMD) in the cortical and trabecular compartments and assessed femoral geometry using quantitative computed tomography (QCT) in breast cancer patients. In total, 249 early breast cancer patients who underwent QCT in their fifties (mean age 54.3 years) were retrospectively analyzed. Proximal femoral BMD and geometrical parameters were compared. In all regions of the proximal femur, cortical areal BMDs were lower in the AI group than in the non-AI group (p < 0.05). Cortical thickness of the femoral neck, trochanter, and total hip was significantly lower in the AI group compared with the non-AI group (p < 0.05). Analysis of the narrowest section of the femoral neck showed significantly thinner cortical bone and smaller cortical area in the AI group than in the non-AI group (p < 0.05), especially in the superoposterior quadrant. Bone strength parameters in the femoral neck, such as the section modulus and cross-sectional moment of inertia, were significantly lower in the AI group than in the non-AI group (p < 0.05). In conclusion, AI treatment in breast cancer patients is associated with deterioration of femoral cortical BMD and geometry, which could contribute in site-specific weakened bone strength and increased incidence of hip fractures.

Comparison of femoral neck BMD evaluation obtained using Lunar DXA and QCT with asynchronous calibration from CT colonography.

For patients undergoing screening computed tomography colonography (CTC), an opportunity exists for bone mineral density (BMD) screening without additional radiation exposure using quantitative computed tomography (QCT). This study investigated the use of dual-energy X-ray absorptiometry (DXA)-equivalent QCT Computed Tomography X-Ray Absorptiometry (CTXA) analysis at the hip obtained using CTC examinations using a retrospective asynchronous calibration of patient scans. A cohort of 33 women, age 61.3 (10.6) yr (mean [standard deviation]), had routine CTC using various GE LightSpeed CT scanner models followed after 0-9 mo by a DXA hip BMD examination using a GE Lunar Prodigy machine. Areal bone mineral density (aBMD) and T-scores of the proximal femur were measured from either prone or supine CTC examinations using Mindways QCT Pro software following standard workflow except that the CT scanners were asynchronously calibrated by phantoms scanned retrospectively of the CTC examination without the subject present. CTXA and DXA aBMD were highly correlated (R2=0.907) with a linear relationship of DXA_BMD=1.297*CTXA_BMD+0.048. The standard error of estimate (SEE) on the linear fit was 0.053 g/cm2. CTXA and DXA T-scores showed a linear relationship of DXA_T-score=1.034*CTXA_T-score+0.3 and an SEE of 0.379 T-scores. CTXA and DXA aBMD and T-score measurements showed good correlation despite asynchronous scan acquisition and retrospective QCT calibration. The SEE of 0.053 g/cm2 is on par with the literature comparing Hologic and Lunar DXA devices. The observed relationship between CTXA and Lunar DXA aBMD matches predictions from published cross-calibrations relating CTXA to DXA aBMD measurement. Thus, opportunistic use of CTXA T-scores obtained at the time of CTC could enhance osteoporosis screening.

Aortic calcification and bone metabolism: the relationship between aortic calcification, BMD, vertebral fracture, 25-hydroxyvitamin D, and osteocalcin.

The aim of this study was to investigate the relationship between aortic calcification (AC) and low bone mineral density (BMD), 25(OH)D, C-terminal telopeptide (CTx), and osteocalcin levels in Asian women. We also tried to find the association between AC and the risk of vertebral fracture. We included 769 patients in this study. All patients underwent QCT. Aortic calcium score (ACS) was quantified by the Agatston scoring method. Spinal fracture was defined by lumbar spine radiography. Among 769 subjects, 96 had at least one vertebral fracture and 345 had AC. ACS positively correlated with age. Osteocalcin, CTx, 25(OH)D, total-hip trabecular BMD (tBMD), femoral neck tBMD, and vertebral tBMD were inversely related with ACS. However, cortical BMD (cBMD) did not correlate with ACS. Among these parameters, only osteocalcin significantly correlated with ACS, even after adjusting for age. We divided the subjects into two groups based on the presence of AC to determine the association between AC and vertebral fracture. Multivariate logistic regression analysis showed that age, tBMD of each site, and AC were associated with vertebral fractures. After adjusting for confounding factors, patients with AC had more than a threefold increased risk of vertebral fracture (OR = 3.29-3.57, P < 0.05 according to site). This study suggests that high ACS is related to low tBMD but not cBMD. Furthermore, our findings indicate that this relationship is definitely age-dependent. Finally, we found that AC is significantly associated with the prevalence of vertebral fracture in Asian women.

The combined effects of age and HIV on the anatomic distribution of cortical and cancellous bone in the femoral neck among men and women.

OBJECTIVE: To investigate HIV-related and age-related differences in hip bone structure in men and women. DESIGN: Cross sectional study of bone structure and HIV serostatus. METHODS: We used Quantitative Computed Tomography (QCT) data from the Multicenter AIDS Cohort Study (MACS) and Women's Interagency HIV Study (WIHS) to examine cortical thickness (CT) and cortical (CBMD), trabecular (TBMD), and integral (IBMD) bone mineral density across anatomic quadrants of the femoral neck in older adult MSM and women with (PWH) and without (PWOH) HIV infection. The percentage difference (%diff) in the means for CT and BMD overall and by quadrant between PWH and PWOH were estimated. RESULTS: Among 322 MSM (median age 60 years) with bone measures, distributions were similar between HIV serostatus groups with %diff in the quadrant means ranging from -7 to -1% for CT and from -1 to 4% for BMD, and overall lower hip cortical thickness than expected. In contrast, in 113 women (median age 51 years), PWH had lower CT, IBMD and TBMD consistently across all quadrants, with differences ranging from -10 to -20% for CT, -6 to -11% for IBMD and -3 to -6% for TBMD. Estimates reached statistical significance in superoanterior quadrant for CT and IBMD and inferoposterior for CT. CONCLUSION: Among women, PWH appear to have a thinner cortex and less dense integral bone compared with PWOH, particularly in the superior quadrants whereas MSM overall had a thinner than expected hip cortex.

The measurement of liver fat from single-energy quantitative computed tomography scans.

BACKGROUND: Studies of soft tissue composition using computed tomography (CT) scans are often semi-quantitative and based on Hounsfield units (HU) measurements that have not been calibrated with a quantitative CT (QCT) phantom. We describe a study to establish the water (H2O) and dipotassium hydrogen phosphate (K2HPO4) basis set equivalent densities of fat and fat-free liver tissue. With this information liver fat can be accurately measured from any abdominal CT scan calibrated with a suitable phantom. METHODS: Liver fat content was measured by comparing single-energy QCT (SEQCT) HU measurements of the liver with predicted HU values for fat and fat-free liver tissue calculated from their H2O and K2HPO4 equivalent densities and calibration data from a QCT phantom. The equivalent densities of fat were derived from a listing of its constituent fatty acids, and those of fat-free liver tissue from a dual-energy QCT (DEQCT) study performed in 14 healthy Chinese subjects. This information was used to calculate liver fat from abdominal SEQCT scans performed in a further 541 healthy Chinese subjects (mean age 62 years; range, 31-95 years) enrolled in the Prospective Urban Rural Epidemiology (PURE) Study. RESULTS: The equivalent densities of fat were 941.75 mg/cm3 H2O and -43.72 mg/cm3 K2HPO4, and for fat-free liver tissue 1,040.13 mg/cm3 H2O and 21.34 mg/cm3 K2HPO4. Liver fat in the 14 subjects in the DEQCT study varied from 0-17.9% [median: 4.5%; interquartile range (IQR): 3.0-7.9%]. Liver fat in the 541 PURE study subjects varied from -0.3-29.9% (median: 4.9%; IQR: 3.4-6.9%). CONCLUSIONS: We have established H2O and K2HPO4 equivalent densities for fat and fat-free liver tissue that allow a measurement of liver fat to be obtained from any abdominal CT scan acquired with a QCT phantom. Although radiation dose considerations preclude the routine use of QCT to measure liver fat, the method described here facilitates its measurement in patients having CT scans performed for other purposes. Further studies comparing the results with magnetic resonance (MR) measurements of liver fat are required to validate the method as a useful clinical tool.

Opportunistic Quantitative CT Bone Mineral Density Measurement at the Proximal Femur Using Routine Contrast-Enhanced Scans: Direct Comparison With DXA in 355 Adults.

For patients undergoing routine contrast-enhanced CT examinations, an opportunity exists for concurrent osteoporosis screening without additional radiation exposure or patient time using proximal femur CT X-ray absorptiometry (CTXA). We investigated the effect of i.v. contrast enhancement on femoral neck CTXA T-score measurement compared with DXA. This cohort included 355 adults (277 female; mean age, 59.7 ± 13.3 years; range, 21 to 90 years) who underwent standard contrast-enhanced CT assessment at 120 kVp over an 8-year interval, as well as DXA BMD assessment within 100 days of the CT study (mean 46 ± 30 days). Linear regression and a Bland-Altman plot were performed to compare DXA and CTXA results. CTXA diagnostic sensitivity and specificity was evaluated with DXA as the reference standard. There was good correlation between DXA and CTXA (r2 = 0.824 for both areal BMD and T-scores) and the SD of the distribution of residuals was 0.063 g/cm2 or 0.45 T-score units. There was no trend in differences between the two measurements and a small bias was noted with DXA T-score +0.18 units higher than CTXA. CTXA had a sensitivity for discriminating normal from low bone mineral density of 94.9% (95% CI, 90.6% to 97.4%). For opportunistic osteoporosis screening at routine post-contrast abdominopelvic CT scans, CTXA produces T-scores similar to DXA. Because femoral neck CTXA BMD measurement is now included in the WHO Fracture Risk Assessment Tool (FRAX) tool, this opportunistic method could help to increase osteoporosis screening because it can be applied regardless of the clinical indication for CT scanning. © 2016 American Society for Bone and Mineral Research.

Effect of Low-Magnitude Mechanical Stimuli on Bone Density and Structure in Pediatric Crohn's Disease: A Randomized Placebo-Controlled Trial.

Pediatric Crohn's Disease (CD) is associated with low trabecular bone mineral density (BMD), cortical area, and muscle mass. Low-magnitude mechanical stimulation (LMMS) may be anabolic. We conducted a 12-month randomized double-blind placebo-controlled trial of 10 minutes daily exposure to LMMS (30 Hz frequency, 0.3 g peak-to-peak acceleration). The primary outcomes were tibia trabecular BMD and cortical area by peripheral quantitative CT (pQCT) and vertebral trabecular BMD by QCT; additional outcomes included dual-energy X-ray absorptiometry (DXA) whole body, hip and spine BMD, and leg lean mass. Results were expressed as sex-specific Z-scores relative to age. CD participants, ages 8 to 21 years with tibia trabecular BMD <25th percentile for age, were eligible and received daily cholecalciferol (800 IU) and calcium (1000 mg). In total, 138 enrolled (48% male), and 121 (61 active, 60 placebo) completed the 12-month trial. Median adherence measured with an electronic monitor was 79% and did not differ between arms. By intention-to-treat analysis, LMMS had no significant effect on pQCT or DXA outcomes. The mean change in spine QCT trabecular BMD Z-score was +0.22 in the active arm and -0.02 in the placebo arm (difference in change 0.24 [95% CI 0.04, 0.44]; p = 0.02). Among those with >50% adherence, the effect was 0.38 (95% CI 0.17, 0.58, p < 0.0005). Within the active arm, each 10% greater adherence was associated with a 0.06 (95% CI 0.01, 1.17, p = 0.03) greater increase in spine QCT BMD Z-score. Treatment response did not vary according to baseline body mass index (BMI) Z-score, pubertal status, CD severity, or concurrent glucocorticoid or biologic medications. In all participants combined, height, pQCT trabecular BMD, and cortical area and DXA outcomes improved significantly. In conclusion, LMMS was associated with increases in vertebral trabecular BMD by QCT; however, no effects were observed at DXA or pQCT sites. © 2016 American Society for Bone and Mineral Research.

Quantitative computed tomography and opportunistic bone density screening by dual use of computed tomography scans.

Central dual-energy X-ray absorptiometry (DXA) of the lumbar spine and proximal femur is the preferred method for bone mineral density (BMD) testing. Despite the fracture risk statistics, osteoporosis testing with DXA remains underused. However, BMD can also be assessed with quantitative computed tomography (QCT) that may be available when access to DXA is restricted. For patients undergoing a primary CT study of the abdomen or pelvis, a potential opportunity exists for concurrent BMD screening by QCT without the need for any additional imaging, radiation exposure, or patient time.

CTXA hip--an extension of classical DXA measurements using quantitative CT.

Bone mineral density (BMD) estimates for the proximal femur using Dual Energy X-ray Absorptiometry (DXA) are currently considered the standard for making a diagnosis of osteoporosis in an individual patient using BMD alone. We have compared BMD results from a commercial Quantitative CT (QCT) BMD analysis system, "CTXA Hip", which provides clinical data for the proximal femur, to results from DXA. We have also used CTXA Hip to determine cortical and trabecular contributions to total BMD. Sixty-nine patients were scanned using 3D QCT and DXA. CTXA Hip BMD measurements for Total Hip and Femoral Neck were compared to DXA results. Twenty-two women were scanned at 0, 1, 2 years and CTXA Hip and DXA results analyzed for long-term reproducibility. Long-term reproducibility calculated as root-mean-square averages of SDs in vivo was 0.012 g/cm2 (CV = 1.8%) for CTXA Total Hip and 0.011 g/cm2 (CV = 2.0%) for CTXA Femoral Neck compared to 0.014 g/cm2 (CV = 2.0%) and 0.016 g/cm2 (CV = 2.7%), respectively, for DXA. The correlation of Total Hip BMD CTXA vs. DXA was R = 0.97 and for Femoral Neck was R = 0.95 (SEE 0.044 g/cm2 in both cases). Cortical bone comprised 62±5% (mean ± SD) of total hipbone mass in osteoporotic women. CTXA Hip provides substantially the same clinical information as conventional DXA and in addition provides estimates of BMD in separate cortical and trabecular bone compartments, which may be useful in evaluation of bone strength.

Simulated increases in body fat and errors in bone mineral density measurements by DXA and QCT.

Major alterations in body composition, such as with obesity and weight loss, have complex effects on the measurement of bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA). The effects of altered body fat on quantitative computed tomography (QCT) measurements are unknown. We scanned a spine phantom by DXA and QCT before and after surrounding with sequential fat layers (up to 12 kg). In addition, we measured lumbar spine and proximal femur BMD by DXA and trabecular spine BMD by QCT in 13 adult volunteers before and after a simulated 7.5 kg increase in body fat. With the spine phantom, DXA BMD increased linearly with sequential fat layering at the normal (p < 0.01) and osteopenic (p < 0.01) levels, but QCT BMD did not change significantly. In humans, fat layering significantly reduced DXA spine BMD values (mean ± SD: -2.2 ± 3.7%, p = 0.05) and increased the variability of measurements. In contrast, fat layering increased QCT spine BMD in humans (mean ± SD: 1.5 ± 2.5%, p = 0.05). Fat layering did not change mean DXA BMD of the femoral neck or total hip in humans significantly, but measurements became less precise. Associations between baseline and fat-simulation scans were stronger for QCT of the spine (r(2)= 0.97) than for DXA of the spine (r(2)= 0.87), total hip (r(2) = 0.80), or femoral neck (r(2)= 0.75). Bland-Altman plots revealed that fat-associated errors were greater for DXA spine and hip BMD than for QCT trabecular spine BMD. Fat layering introduces error and decreases the reproducibility of DXA spine and hip BMD measurements in human volunteers. Although overlying fat also affects QCT BMD measurements, the error is smaller and more uniform than with DXA BMD. Caution must be used when interpreting BMD changes in humans whose body composition is changing.

Estimation of bone mineral density in children from diagnostic CT images: a comparison of methods with and without an internal calibration standard.

We investigated the feasibility and potential limitations of estimating bone mineral density (BMD) from standard diagnostic computed tomography (dCT). We analyzed three sets of BMD measurements for L1 and L2, each performed by a novice and an expert, for intra- and interobserver variance (n=43 studies from 38 patients; median age, 13.2 years) using one BMD quantification system with (conventional quantitative computed tomography (QCT)) and two without (QCT and dCT) an external calibration phantom. Using ANOVA model, means of three sets of BMD measurements analyzed by the expert differed by 2.5mg/cm(2); for the novice, by less than 1mg/cm(2). Variation of measurement differences was less for the expert. Mean intra- and interobserver absolute standardized differences (ASD) were 1.77% and 1.8%, respectively. The mean ASD between phantom and phantom-less methods of QCT studies were 3.3%; mean ASD of phantom QCT versus phantom-less dCT was 14.3%. Regression modeling suggested compensation for sources of dCT BMD measurement bias can reduce the mean ASD of phantom QCT versus phantom-less dCT to 6.5%. Thus, phantom-less QCT of dCT adds clinically useful BMD information not typically attained from dCT, thereby augmenting patient care and presenting important possibilities for research without need for additional study.

Changing structure of the femoral neck across the adult female lifespan.

The anatomic distribution of cortical and cancellous bone in the femoral neck may be critical in determining resistance to fracture. We investigated the effects of aging on femoral neck bone in women. In this cross-sectional study, we used clinical multidetector computed tomography (MDCT) of the hips to investigate aging effects in 100 female volunteers aged 20 to 90 years. We developed a clinically efficient protocol to measure cortical thickness (C.Th) and cortical, trabecular, and integral bone mineral density (CtBMD, TrBMD, and iBMD in mg/cm(3)) in anatomic quadrants of the femoral neck. We used a nested ANOVA to evaluate their associations with height, weight, location in the femoral neck, and age of the subject. Age was the principal determinant of both cortical thickness and BMD. Age had significantly different effects within the anatomic quadrants; compared with young women, elderly subjects had relative preservation of the inferoanterior (IA) quadrant but strikingly reduced C.Th and BMD superiorly. A model including height, weight, and region of interest (and their interactions) explained 83% of the measurement variance (p < .0001). There were marked C.Th and BMD differences between age 25 and age 85 in the already thin superior quadrants. At 25 years the predicted C.Th of the superoposterior quadrant was 1.63 mm, whereas at 85 years it was 0.33 mm [-1.33 mm, 95% confidence interval (CI) of difference over 60 years -1.69 to -0.95]. By contrast, at 25 years mean C.Th of the IA quadrant was 3.9 mm, whereas at 85 years it was 3.3 mm (-0.6 mm, 95% CI -0.83 to -0.10). CtBMD of the IA region was equivalent at 25 and 85 years. In conclusion, elderly women had relative preservation of IA femoral neck bone over seven decades compared with young women but markedly lower C.Th and BMD in the other three quadrants. The IA quadrant transmits mechanical load from walking. Mechanical theory and laboratory tests on cadaveric femurs suggest that localized bone loss may increase the risk of fracture in elderly fallers. It remains to be determined whether this MDCT technique can provide better prediction of hip fracture than conventional clinical dual X-ray absorptiometry (DXA).