Hip Fracture Risk Assessment Tools for Adults Aged 80 Years and Older.

Importance: While adults aged 80 years and older account for 70% of hip fractures in the US, performance of fracture risk assessment tools in this population is uncertain. Objective: To compare performance of the Fracture Risk Assessment Tool (FRAX), Garvan Fracture Risk Calculator, and femoral neck bone mineral density (FNBMD) alone in 5-year hip fracture prediction. Design, Setting and Participants: Prognostic analysis of 3 prospective cohort studies including participants attending an index examination (1997 to 2016) at age 80 years or older. Data were analyzed from March 2023 to April 2024. Main Outcomes and Measures: Participants contacted every 4 or 6 months after index examination to ascertain incident hip fractures and vital status. Predicted 5-year hip fracture probabilities calculated using FRAX and Garvan models incorporating FNBMD and FNBMD alone. Model discrimination assessed by area under receiver operating characteristic curve (AUC). Model calibration assessed by comparing observed vs predicted hip fracture probabilities within predicted risk quintiles. Results: A total of 8890 participants were included, with a mean (SD) age at index examination of 82.6 (2.7) years; 4906 participants (55.2%) were women, 866 (9.7%) were Black, 7836 (88.1%) were White, and 188 (2.1%) were other races and ethnicities. During 5-year follow-up, 321 women (6.5%) and 123 men (3.1%) experienced a hip fracture; 818 women (16.7%) and 921 men (23.1%) died before hip fracture. Among women, AUC was 0.69 (95% CI, 0.67-0.72) for FRAX, 0.69 (95% CI, 0.66-0.72) for Garvan, and 0.72 (95% CI, 0.69-0.75) for FNBMD alone (FNBMD superior to FRAX, P = .01; and Garvan, P = .01). Among men, AUC was 0.71 (95% CI, 0.66-0.75) for FRAX, 0.76 (95% CI, 0.72-0.81) for Garvan, and 0.77 (95% CI, 0.72-0.81) for FNBMD alone (P < .001 Garvan and FNBMD alone superior to FRAX). Among both sexes, Garvan greatly overestimated hip fracture risk among individuals in upper quintiles of predicted risk, while FRAX modestly underestimated risk among those in intermediate quintiles of predicted risk. Conclusions and Relevance: In this prognostic study of adults aged 80 years and older, FRAX and Garvan tools incorporating FNBMD compared with FNBMD alone did not improve 5-year hip fracture discrimination. FRAX modestly underpredicted observed hip fracture probability in intermediate-risk individuals. Garvan markedly overpredicted observed hip fracture probability in high-risk individuals. Until better prediction tools are available, clinicians should prioritize consideration of hip BMD, life expectancy, and patient preferences in decision-making regarding drug treatment initiation for hip fracture prevention in late-life adults.

Longitudinal changes of the femoral bone mineral density from first to third trimester of pregnancy: bone health assessment by means of non-ionizing REMS technology.

BACKGROUND: Throughout the pregnancy, there is a substantial transfer of calcium from the maternal skeleton to the fetus, which leads to a transient net reduction of the maternal bone mineral density. AIMS: To assess longitudinally the changes in the bone mineral density at the femoral neck between the first and third trimester of pregnancy in a cohort of healthy participants using Radiofrequency Echographic Multi Spectrometry (REMS) technology. METHODS: Prospective, cohort study conducted at the University hospital of Parma, Italy between July 2022 and February 2023. We recruited healthy participants with an uncomplicated singleton pregnancy before 14 completed weeks of gestation. All included participants were submitted to a sonographic examination of the femoral neck to assess the bone mineral density (and the corresponding Z-score values) using REMS at 11-13 and 36-38 weeks of pregnancy. The primary outcome was the change in the bone mineral density values at the maternal femoral neck between the first and third trimester of pregnancy. RESULTS: Over a period of 7 months, a total of 65 participants underwent bone mineral density measurement at the femoral neck at first and third trimester of the pregnancy using REMS. A significant reduction of the bone mineral density at the femoral neck (0.723 ± 0.069 vs 0.709 ± 0.069 g/cm2; p < 0.001) was noted with a mean bone mineral density change of - 1.9 ± 0.6% between the first and third trimester of pregnancy. At multivariable linear regression analysis, none of the demographic or clinical variables of the study population proved to be independently associated with the maternal bone mineral density changes at the femoral neck. CONCLUSIONS: Our study conducted on a cohort of healthy participants with uncomplicated pregnancy demonstrates that there is a significant reduction of bone mineral density at femoral neck from early to late gestation.

An Imaging Assessment of the Femoral Neck-shaft Angle in Adult Bengali Bangladeshi Population.

Most orthopaedics implants were designed and manufactured based on data from the Western population whose skeletal dimensions are different from the Bengali Bangladeshi population. This study aims to determine the value of the femoral neck-shaft angle of the adult Bengali Bangladeshi population for adequate planning, preparation and pre-operative selection of orthopaedic implants for surgeries involving the femoral neck and stocking of orthopaedic implants. This was a cross-sectional analytical study which involved measuring the femoral neck-shaft angle (NSA) from the pelvic radiographs anterior-posterior view of adult patients reported "normal study" by the registered radiologist. This study was carried out in the Department of Anatomy, Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh from March 2019 to February 2020. A total of 200 femoral neck-shaft angles were analyzed from 100 patients' radiographs comprising 50 males and 50 females. The average NSA of adult Bengali Bangladeshi is 128.74°±5.83° with a mean value of 128.68°±6.20° for the right and 128.81°±5.66° for the left. The mean value of NSA is 129.64°±5.90° and 127.85°±5.64° in adult males and females respectively. The femoral neck-shaft angle in adult Bengali Bangladeshi males was significantly higher than the females.

Fracture Toughness: Bridging the Gap Between Hip Fracture and Fracture Risk Assessment.

PURPOSE OF REVIEW: This review surveys recent literature related to cortical bone fracture mechanics and its application towards understanding bone fragility and hip fractures. RECENT FINDINGS: Current clinical tools for hip fracture risk assessment have been shown to be insensitive in some cases of elevated fracture risk leading to the question of what other factors account for fracture risk. The emergence of cortical bone fracture mechanics has thrown light on other factors at the tissue level that are important to bone fracture resistance and therefore assessment of fracture risk. Recent cortical bone fracture toughness studies have shown contributions from the microstructure and composition towards cortical bone fracture resistance. A key component currently overlooked in the clinical evaluation of fracture risk is the importance of the organic phase and water to irreversible deformation mechanisms that enhance the fracture resistance of cortical bone. Despite recent findings, there is an incomplete understanding of which mechanisms lead to the diminished contribution of the organic phase and water to the fracture toughness in aging and bone-degrading diseases. Notably, studies of the fracture resistance of cortical bone from the hip (specifically the femoral neck) are few, and those that exist are mostly consistent with studies of bone tissue from the femoral diaphysis. Cortical bone fracture mechanics highlights that there are multiple determinants of bone quality and therefore fracture risk and its assessment. There is still much more to learn concerning the tissue-level mechanisms of bone fragility. An improved understanding of these mechanisms will allow for the development of better diagnostic tools and therapeutic measures for bone fragility and fracture.

[Assessment of the local blood supply when femoral neck fracture occurs:advances in the anatomy research and its clinical application].

The stability of internal fixation of femoral neck fractures can be obtained through surgical techniques, the configuration of screws and bone grafting, etc. However, the blood supply injury caused by fractures could not be completely reversed by the current medical management. Hence, the comprehensive evaluation of the residual blood supply of the femoral neck, to perioperatively avoid further iatrogenic injury, has become a hotspot. The anatomy of the extraosseous blood supply of the femoral neck has been widely reported, while its clinical application mostly involved the assessment of the medial circumflex femoral artery and retinacular arteries. However, further studies are needed to explore the prognosis of patients with these artery injuries, with different degrees, caused by femoral neck fractures. Direct observations of nutrient foramina in vivo are not possible with current clinical technologies, but it is possible to make reasonable preoperative planning to avoid subsequent femoral head necrosis based on the distribution features of nutrient foramina. The anatomy and clinical application studies of the intraosseous blood supply focused on the junction area of the femoral head and neck to probe the mechanism of femoral head necrosis. Thus, the intraosseous blood supply of other regions in the femoral neck remains to be further investigated. In addition, a blood supply evaluation system based on a three-level structure, extraosseous blood vessels, nutrient foramina, and intraosseous vascular network, could be explored to assist in the treatment of femoral neck fractures.

Application of intelligent X-ray image analysis in risk assessment of osteoporotic fracture of femoral neck in the elderly.

The paper focuses on establishing a risk assessment model of femoral neck osteoporotic fracture (FNOF) in the elderly population and improving the screening efficiency and accuracy of such diseases in specific populations. In literature research, the main risk factors of femoral neck osteoporosis (FNOP) in the elderly were studied and analyzed; the femur region of interest (ROI) and the hard bone edge segmentation model were selected from the X-ray digital image by using the image depth learning method. On this basis, the femoral trabecular score and femoral neck strength (FNS) in the set region were selected as the main evaluation elements, and the quantitative analysis method was established; an X-ray image processing method was applied to the feasibility study of FNOP and compared with dual-energy X-ray absorptiometry measurements of bone mineral density; Finally, the main risk factors of FNOP were selected and the prediction model of FNOP in the elderly population was established based on medical image processing, machine learning model construction and other methods. Some FNOP health records were selected as test samples for comparative analysis with traditional manual evaluation methods. The paper shows the risk assessment model of FNOF in the elderly population, which is feasible in testing. Among them, the artificial neural network model had a better accuracy (95.83%) and recall rate (100.00%), and the support vector machine prediction model had high specificity (62.50%). With the help of a machine learning method to establish the risk assessment model of FNOF for the elderly, one can provide decision support for the fracture risk assessment of the elderly and remind the clinic to give targeted interventions for the above high-risk groups in order to reduce the fracture risk.

Assessment of the genetic and clinical determinants of hip fracture risk: Genome-wide association and Mendelian randomization study.

Hip fracture is the clinically most important fracture, but the genetic architecture of hip fracture is unclear. Here, we perform a large-scale hip fracture genome-wide association study meta-analysis and Mendelian randomization study using five cohorts from European biobanks. The results show that five genetic signals associate with hip fractures. Among these, one signal associates with falls, but not with bone mineral density (BMD), while four signals are in loci known to be involved in bone biology. Mendelian randomization analyses demonstrate a strong causal effect of decreased femoral neck BMD and moderate causal effects of Alzheimer's disease and having ever smoked regularly on risk of hip fractures. The substantial causal effect of decreased femoral neck BMD on hip fractures in both young and old subjects and in both men and women supports the use of change in femoral neck BMD as a surrogate outcome for hip fractures in clinical trials.

Radiofrequency echographic multispectrometry (REMS): an innovative technique for the assessment of bone status in young women with anorexia nervosa.

PURPOSE: Reduced bone mineral density (BMD) and increase risk of fragility fracture are common complication of anorexia nervosa (AN). BMD by dual-energy X-ray absorptiometry (DXA) present several limits in subjects with AN. This study aimed to evaluate the usefulness of the new Radiofrequency echographic multispectrometry (REMS) technique in the assessment of bone status in young women with AN. METHODS: In a cohort of 50 subjects with restrictive AN and in 30 healthy controls, we measured BMD at the lumbar spine (LS-BMD), at femoral neck (FN-BMD) and total hip (TH-BMD) using both DXA and REMS technique. RESULTS: BMD evaluated by DXA and REMS technique at all measurement sites were all significantly (p < 0.01) lower in subjects suffering from AN subjects than in controls. Good correlations were detected between BMD by DXA and BMD by REMS measurements at LS (r = 0.64, p < 0.01) at FN (r = 0.86, p < 0.01) and at TH (r = 0.84, p < 0.01) in subjects suffering from AN. Moreover, Bland-Altman analysis confirmed the good agreement between the two techniques. The subjects suffering from AN with previous vertebral fragility fractures presented lower values of both BMD-LS and BMD-TH by DXA and by REMS with respect to those without fractures; however, the difference was significant only for BMD-TH by REMS (p < 0.05). CONCLUSIONS: Our data suggest that REMS technique due to its characteristic of precision and reproducibility may represent an important tool for the evaluation of the changes in bone status in AN young women, especially during the fertile age and in case of pregnancy and breastfeeding. LEVEL OF EVIDENCE: Level of evidence: level III cohort study.

Assessment of bone mineral density and bone metabolism in young men with obstructive sleep apnea: a cross-sectional study.

BACKGROUND: Hypoxia in obstructive sleep apnea (OSA) patients during sleep may have an effect on bone metabolism. Few data regarding evaluation of bone metabolism in young individuals diagnosed with OSA. In this study, we aim to identify the association between bone mineral density and OSA in young men (≤ 40 years old of age). METHODS: Consecutive male subjects who underwent polysomnography were enrolled. Serum calcium, 25-hydroxyvitamin-D3, ß-isomerized form C-terminal telopeptide of type I collagen, osteocalcin and procollagen type 1 N-propeptide were measured in all participants, and bone mineral density (BMD) at lumbar spine (L1-L4), femoral neck and hip total were determined by dual energy X-ray absorption (DXA). RESULTS: The population consisted of 85 subjects (mean age 35.53 years). The BMD at lumbar spine (L1-L4) in moderate OSA patients was higher than control and severe OSA group significantly (p = 0.036). After adjustment for confounding factors, stepwise multiple linear regression analyses showed LaSO2 (ß = 0.340, p = 0.008) as an independent explanatory variable for Lumbar L1-L4 BMD, LaSO2 (ß = 0.304, p = 0.037), BMI (ß = 0.393, p = 0.008) for femur neck BMD and BMI (ß = 0.720, p = 0.002) for hip total BMD. CONCLUSIONS: Our finding indicated that there was a relationship between OSA and bone metabolism in younger men, and moderate OSA-related hypoxia positively related with BMD. This study also showed that different degrees of recurrent hypoxia had different effects on bone metabolism, a finding that required further investigation.

The outcome of an automated assessment of trabecular pattern in intraoral radiographs as a fracture risk predictor.

OBJECTIVES: This study aims to investigate if automated analyses of the trabecular pattern in intraoral radiographs independently contribute to fracture risk assessment when other risk factors incorporated in the Fracture Risk Assessment Tool (FRAX) are taken into account. A secondary aim is to explore the correlation between the automated trabecular pattern assessment in intraoral radiographs and Trabecular Bone Score (TBS). METHODS: A total of 567 intraoral radiographs from older females participating in a large population-based study (SUPERB) based in Gothenburg, Sweden, were selected to analyse trabecular pattern using semi-automated and fully automated software. Associations between trabecular pattern analysis and incident fractures were studied using Cox proportional hazard model, unadjusted and adjusted for FRAX risk factors (previous fracture, family history of hip fracture, smoking, corticosteroids, rheumatoid arthritis, without and with bone mineral density (BMD) of the femoral neck). In addition, the correlation between trabecular pattern analysis and TBS of the lumbar spine was investigated using Pearson correlation analysis. RESULTS: Neither the unadjusted nor the adjusted trabecular pattern analysis in intraoral radiographs was significantly associated with any fracture or major osteoporotic fracture (MOF). A weak correlation was found between semi-automated trabecular pattern analysis and TBS. No correlation was found between the fully automated trabecular pattern analysis and TBS. CONCLUSIONS: The present study shows that semi-automated and fully automated digital analyses of the trabecular pattern in intraoral radiographs do not contribute to fracture risk prediction. Furthermore, the study shows a weak correlation between semi-automated trabecular pattern analysis and TBS.

In Vivo Comparison of Backscatter Techniques for Ultrasonic Bone Assessment at the Femoral Neck.

Ultrasonic techniques are being developed to detect changes in cancellous bone caused by osteoporosis. The goal of this study was to test the relative in vivo performance of eight backscatter parameters developed over the last several years for ultrasonic bone assessment: apparent integrated backscatter (AIB), frequency slope of apparent backscatter (FSAB), frequency intercept of apparent backscatter (FIAB), normalized mean of the backscatter difference (nMBD), normalized slope of the backscatter difference (nSBD), normalized intercept of the backscatter difference (nIBD), normalized backscatter amplitude ratio (nBAR) and backscatter amplitude decay constant (BADC). Backscatter measurements were performed on the left and right femoral necks of 80 adult volunteers (age = 25 ± 11 y) using an imaging system equipped with a convex array transducer. For comparison, additional ultrasonic measurements were performed at the left and right heel using a commercially available heel-bone ultrasonometer that measured the stiffness index. Six of the eight backscatter parameters (all but nSBD and nIBD) exhibited similar and highly significant (p < 0.000001) left-right correlations (0.51 ≤ R ≤ 0.68), indicating sensitivity to naturally occurring variations in bone tissue. Left-right correlations for the stiffness index measured at the heel (R = 0.75) were not significantly better than those produced by AIB, FSAB and FIAB. The short-term precisions of AIB, nMBD, nBAR and BADC (7.8%-11.7%) were comparable to that of the stiffness index measured with the heel-bone ultrasonometer (7.5%).

Does hip structural analysis confer additional benefit to routine BMD assessment in postmenopausal women with hip fracture? A study from a tertiary center in southern India.

This study from southern India showed that proximal hip geometry was significantly impaired in postmenopausal women with femoral neck fracture. The trabecular bone score (TBS), which is reflective of bone microarchitecture, was also significantly impaired in patients with fracture. INTRODUCTION: There is limited information with regard to comprehensive bone health in Indian postmenopausal women with neck of femur fracture. We studied the bone mineral density (BMD), trabecular bone score (TBS), proximal hip geometry, and bone mineral biochemistry in postmenopausal women with and without femoral neck fractures. METHODS: This was a cross-sectional study conducted at a tertiary care center in South India. BMD, TBS, and hip structural analysis (HSA) were assessed using a dual-energy X-ray absorptiometry (DXA) scanner. Bone mineral biochemical profiles were also studied. RESULTS: A total of 90 postmenopausal women with acute femoral neck fracture with mean (SD) age of 63.2 (6.1) years and 90 age-matched controls were included. The prevalence of osteoporosis was higher among cases as compared to controls (83.3% vs 47.8%; P < 0.001). Degraded bone microarchitecture (TBS value < 1.200) was more frequent among women with hip fracture as compared to controls (46.7% vs 31.1%; P = 0.032). Cross-sectional moment of inertia (CSMI) was significantly lower at the narrow neck (NN) and inter-trochanteric (IT) region in cases (P < 0.05) and buckling ratio (BR) was significantly higher at all three sites in postmenopausal women with femoral neck fracture as compared controls. Multivariate logistic regression analysis showed that femoral neck osteoporosis, low CSMI at NN and high BR at NN and femoral shaft emerged as factors significantly associated with femoral neck fractures. CONCLUSION: This study highlights that impaired parameters of proximal hip geometry and a low trabecular bone score may be significantly associated with femoral neck fractures in postmenopausal women.

Assessment of total and regional bone mineral density using bioelectrical impedance vector analysis in elderly population.

This study aimed to investigate the relationship between bone mineral density (BMD) and height-adjusted resistance (R/H), reactance (Xc/H) and phase angle (PhA). A total of 61 male and 64 female subjects aged over 60 years were recruited from middle Taiwan. The R and Xc were measured using Bodystat Quadscan 4000 at a frequency of 50 kHz. BMD at the whole body, L2-L4 spine, and dual femur neck (DFN), denoted as BMDTotal, BMDL2-L4, and BMDDFN, were calculated using a Hologic DXA scanner. The R-Xc graph was used to assess vector shift among different levels of BMD. BMD was positively correlated with Xc/H and negatively correlated with R/H (p < 0.001). The General Linear Model (GLM) regression results were as follows: BMDTotal = 1.473-0.002 R/H + 0.007 Xc/H, r = 0.684; BMDL2-L4 = 1.526-0.002 R/H + 0.012 Xc/H, r = 0.655; BMDDFN = 1.304-0.002 R/H + Xc/H, r = 0.680; p < 0.0001. Distribution of vector in the R-Xc graph was significantly different for different levels of BMDTotal, BMDL2-L4 and BMDDFN. R/H and Xc/H were correlated with BMD in the elderly. The linear combination of R/H and Xc/H can effectively predict the BMD of the whole body, spine and proximal femur, indicating that BIVA may be used in clinical and home-use monitoring tool for screening BMD in the elderly in the future.

Assessment of Bone Mineral Density in Patients Undergoing Hemodialysis; An Iranian Population-Based Study.

BACKGROUND: End-stage renal disease (ESRD) is a condition in which bone turnover and metabolism is impaired; thus, osteoporosis and low bone density are subsequently inevitable. We aimed to determine bone mineral density (BMD) and biochemical markers, and associated factors in hemodialysis (HD) patients. METHODS: Patients aged 30-70 years undergoing HD between 2015 to 2019 were enrolled in this cross-sectional study. BMD measured by dual energy x-ray absorptiometry (DEXA) and biochemical laboratory tests were assessed in 200 patients undergoing HD. Statistical analysis was based on t test, Pearson, regression and Mann-Whitney tests using SPSS 16. RESULTS: Two hundred patients were investigated. Sixty percent of the patients were female. Mean ± SD of participants' age was 58.6 (±11.63) years and mean ± SD for duration of HD was 45.69 (± 43.76) months. Osteoporosis was found in 48% (n=96) and low bone density in 36% (n=76) of our patients. General osteoporosis was more frequent in those undergoing HD for more than 3 years, although not significantly (P=0.093, odds ratio [OR]=0.37). However, regional osteoporosis in hip and femoral neck, but not spine vertebrae, were significantly higher after three years of HD (P=0.036, OR=0.27; P=0.042, OR=0.27; and P=0.344, OR=0.56, respectively). Increased body mass index (BMI) correlated negatively with osteoporosis (P=0.050). CONCLUSION: With increasing age and duration of HD, BMD decreases. Higher BMI was associated with higher bone mass density. Bone density assessment seems to be necessary in patients undergoing HD.

Spine-Hip Discordance and FRAX assessment Fracture Risk in Postmenopausal Women with Osteopenia from Concordant Diagnosis Between Lumbar Spine and Femoral Neck.

The diagnostic criteria proposed by the World Health Organization did not consider the discrepancy in diagnosis between lumbar spine (LS) and femoral neck (FN) and the clinical implications is unclear. Therefore, this retrospective study evaluated the probability of fracture risk in postmenopausal women with lumbar spine (LS)-femoral neck (FN) bone mineral density (BMD) discordance or not Patients included 1066 healthy postmenopausal women (median age 55.5 years) who visited our hospital for a health check-up between May 2013 and April 2017. Discordance was defined as a difference of one or two degrees between LS BMD and FN BMD. TBS was calculated from dual energy absorptiometry (DXA) images. Fracture risk was assessed using the Fracture Risk Assessment Tool (FRAX), including TBS-adjusted FRAX Seven hundred and two patients (65.9%) showed concordant LS and FN results, whereas 364 patients (34.1%) exhibited discordance. Normal BMD was found in 519 concordant patients (73.9%). Concordant patients showed significantly higher FRAX scores, including TBS-adjusted FRAX results, than discordant patients with low LS or FN. Furthermore, FRAX results in concordant osteopenia patients were similar to that of osteoporosis patients with osteopenia or a normal result at one site. FRAX and TBS-adjusted FRAX results in concordant osteopenia patients were comparable to that of discordant osteoporosis patients We concluded that patients with colncordant osteopenia in both the FN and LS should be managed in a similar way to patients with discordant osteoporosis.

Bone Material Strength Index as Measured by Impact Microindentation is Low in Patients with Primary Hyperparathyroidism.

CONTEXT: In primary hyperparathyroidism (PHPT) bone mineral density (BMD) is typically decreased in cortical bone and relatively preserved in trabecular bone. An increased fracture rate is observed however not only at peripheral sites but also at the spine, and fractures occur at higher BMD values than expected. We hypothesized that components of bone quality other than BMD are affected in PHPT as well. OBJECTIVE: To evaluate bone material properties using impact microindentation (IMI) in PHPT patients. METHODS: In this cross-sectional study, the Bone Material Strength index (BMSi) was measured by IMI at the midshaft of the tibia in 37 patients with PHPT (28 women), 11 of whom had prevalent fragility fractures, and 37 euparathyroid controls (28 women) matched for age, gender, and fragility fracture status. RESULTS: Mean age of PHPT patients and controls was 61.8 ±â€…13.3 and 61.0 ±â€…11.8 years, respectively, P = .77. Calcium and PTH levels were significantly higher in PHPT patients but BMD at the lumbar spine (0.92 ±â€…0.15 vs 0.89 ±â€…0.11, P = .37) and the femoral neck (0.70 ±â€…0.11 vs 0.67 ±â€…0.07, P = .15) were comparable between groups. BMSi however was significantly lower in PHPT patients than in controls (78.2 ±â€…5.7 vs 82.8 ±â€…4.5, P < .001). In addition, BMSi was significantly lower in 11 PHPT patients with fragility fractures than in the 26 PHPT patients without fragility fractures (74.7 ±â€…6.0 vs 79.6 ±â€…5.0, P = .015). CONCLUSION: Our data indicate that bone material properties are altered in PHPT patients and most affected in those with prevalent fractures. IMI might be a valuable additional tool in the evaluation of bone fragility in patients with PHPT.

Vertebral Fracture Assessment in Postmenopausal Women With Postsurgical Hypoparathyroidism.

CONTEXT: Hypoparathyroidism is a rare endocrine disorder whose skeletal features include suppression of bone turnover and greater volume and width of the trabecular compartment. Few and inconsistent data are available on the prevalence of vertebral fractures (VF). OBJECTIVE: To evaluate the prevalence of VF assessed by vertebral fracture assessment (VFA) in postmenopausal women with chronic postsurgical hypoparathyroidism. DESIGN: Cross-sectional study. SETTING: Ambulatory referral center. PATIENTS OR OTHER PARTICIPANTS: Fifty postmenopausal women (mean age 65.4 ± 9 years) with chronic postsurgical hypoparathyroidism and 40 age-matched healthy postmenopausal women (mean age 64.2 ± 8.6). MAIN OUTCOME MEASURES: Lumbar spine, femoral neck, and total hip bone mineral density were measured by dual X-ray absorptiometry (Hologic Inc., USA) in all subjects. Site-matched spine trabecular bone score was calculated by TBS iNsight (Medimaps, Switzerland). Assessment of VF was made by VFA (iDXA, Lunar GE, USA) using the semiquantitative method and the algorithm-based qualitative assessment. RESULTS: All-site BMD values were higher in the hypoparathyroid vs the control group. By VFA, we observed a 16% prevalence of VF in hypoparathyroid women vs 7.5% in control subjects. Among those with hypoparathyroidism who fractured, 5 (62.5%) had grade 1 wedge, 2 (25%) had grade 2 wedge, and 1 (12.5%) had grade 2 wedge and grade 2 biconcave VF. In the hypoparathyroid group, 57% with VFs and 32% without VFs had symptoms of hypoparathyroidism. CONCLUSION: We demonstrate for the first time that in postmenopausal women with chronic postsurgical hypoparathyroidism, VFs are demonstrable by VFA despite normal BMD.

Assessment of femoral neck strength and bone mineral density changes following exercise using 3D-DXA images.

Physical exercise induces spatially heterogeneous bone changes in the proximal femur. Recent advances have enabled 3D dual-energy X-ray Absorptiometry (DXA)-based finite element (FE) models to estimate bone strength. However, its ability to detect exercise-induced BMD and strength changes is unclear. The aim of this study was to quantify the repeatability of vBMD and femoral neck strength obtained from 3D-DXA images and determine the changes due an exercise intervention. The DXA scans included pairs of same-day repeated scans from ten healthy females and pre- and post-exercise intervention scans of 26 males. FE models with element-by-element correspondence were generated by morphing a template mesh to each bone. BMD and femoral strength under single-leg-stance and sideways fall loading configurations were obtained for both groups and compared. In the repeated images, the total hip vBMD difference was 0.5 ± 2.5%. Element-by-element BMD differences reached 30 ± 50%. The strength difference in single-leg stance was 2.8 ± 13% and in sideways fall was 4.5% ± 19%. In the exercise group, strength changes were 6 ± 19% under single-leg stance and 1 ± 18% under sideways fall. vBMD parameters were weakly correlated to strength (R2 < 0.31). The exercise group had a mean bone accrual exceeding repeatability values in the femoral head and cortical regions. The case with the highest vBMD change (6.4%) caused 18% and -7% strength changes under single-leg stance and sideways fall. 3D-DXA technology can assess the effect of exercise interventions in large cohorts but its validity in individual cases should be interpreted with caution.

Statistical quantification of hip radiograph assessment using Shenton line femur neck length ratio.

INTRODUCTION: Identification of a poorly positioned hip radiograph often requires a subjective assessment by the radiographer, which, due to the observer dependency of this method, may have conflicting opinions between radiographers. A quantitative approach may be a better personnel independent approach for assessing an optimally positioned hip radiograph. A Shenton line length femur neck length ratio (SLFLR) could be used to achieve this, which is the aim of this study. METHODS: Seventy-three (48 digital and 25 analog) optimally positioned non-pathological hip radiographs of asymptomatic patients aged between 20 and 59 years and reported by the consultant radiologist as normal were conveniently selected. Three different radiographers, each blinded to the results of the other two, measured the Shenton line length and the femur neck length with the aid of flexible and straight meter rules for the analog images and inbuilt electronic calipers for the digital images. Bland-Altman method of agreement was used to assess for reproducibility and reliability of the measurements while the 5th, 25th, 75th, and 95th percentiles of the SLFLR were computed. RESULTS: The mean ± SD SLFLR for both genders were 1.07 ± 0.08 cm (females: 1.06 ± 0.09 and males: 1.08 ± 1.07 cm). The measurements demonstrated high reproducibility and reliability between (interclass correlation coefficient: 0.993) and within (intraclass correlation coefficient: 0.998) radiographers. The 5th, 25th, 75th, and 95th percentile values of the SLFLR are 0.90, 1.03, 1.12, and 1.18. CONCLUSION: For a hip radiograph to be reported as optimal for patients aged 20-59 years, the SLFLR should be between 0.90 and 1.18. This method is highly reproducible and repeatable and could be adopted for quantitative assessment of radiographs. IMPLICATIONS FOR PRACTICE: The SLFLR could be used as an additional tool by the radiographer to quantitatively assess for a well-positioned hip radiograph.

In Vivo Assessment of Age- and Loading Configuration-Related Changes in Multiscale Mechanical Behavior of the Human Proximal Femur Using MRI-Based Finite Element Analysis.

BACKGROUND: MRI-based finite element analysis (MRI-FEA) is the only method able to assess microstructural and whole-bone mechanical properties of the hip in vivo. PURPOSE: To examine whether MRI-FEA is capable of discriminating age-related changes in whole-bone mechanical performance and micromechanical behavior of the proximal femur, particularly considering the most common hip fracture-related sideways fall loading. STUDY TYPE: Retrospective. SUBJECTS: A total of nine younger (27 ± 3.2 years) and nine elderly (61 ± 3.9 years) healthy volunteers. FIELD STRENGTH/SEQUENCE: 3T; 3D fast field echo sequence. ASSESSMENT: The left proximal femurs were scanned and FE models created. FEA was performed to simulate sideways fall and stance loading for each femoral model. Apparent stiffness and high-risk (90th percentile) tensile and compressive strains of the proximal femur as well as the average strains within cubic regions of the femoral neck and greater trochanter were assessed. STATISTICAL TESTS: Paired and unpaired t-tests. RESULTS: Compared to the young group, the femoral stiffness of the elderly decreased by 39% and 40% (both P < 0.05) under the sideways fall and stance conditions, respectively. Accordingly, the high-risk tensile and compressive stains were elevated with aging (40% and 23% for sideways fall, 23% and 11% for stance conditions; all P < 0.05). However, the loading configuration-induced difference was only observed in the elderly group for the high-risk strains (22% for tension and 12% for compression; both P < 0.05). Additionally, compared to the stance condition, the sideways fall increased the average tensile (young: 108%, elderly: 123%; both P < 0.05) and compressive strains (young: 631%, elderly: 617%, both P < 0.05) within the greater trochanter rather than the femoral neck region. DATA CONCLUSION: In vivo MRI-FEA is capable of capturing age-related changes in both apparent-level stiffness and tissue-level micromechanical behavior of the proximal femur. However, the effect of sideways fall loading might be better reflected by tissue-level micromechanics rather than apparent stiffness. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE: 1.