Perspectives on the non-invasive evaluation of femoral strength in the assessment of hip fracture risk

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Bouxsein, M. L.¹; Zysset, P.²; Glüer, C. C.³; McClung, M.^4,5; Biver, E.⁶; Pierroz, D. D.⁷; Ferrari, S. L.⁸

Perspectives on the non-invasive evaluation of femoral strength in the assessment of hip fracture risk

Osteoporos Int. March 2020;31(3):393-408

©2020 International Osteoporosis Foundation and National Osteoporosis Foundation

Affiliations

¹Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, and Department of Orthopedic Surgery, Harvard Medical School, Boston, USA

²ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland

³Section of Biomedical Imaging, Department of Radiology and Neuroradiology, University Medical Center of Schleswig-Holstein, Kiel, Germany

⁴Oregon Osteoporosis Center, Portland, USA

⁵Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia

⁶Division of Bone Disease, Department of Internal Medicine Specialties, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland

⁷International Osteoporosis Foundation (IOF), Nyon, Switzerland
Abstract and keywords

Summary: We reviewed the experimental and clinical evidence that hip bone strength estimated by BMD and/or finite element analysis (FEA) reflects the actual strength of the proximal femur and is associated with hip fracture risk and its changes upon treatment.

Introduction: The risk of hip fractures increases exponentially with age due to a progressive loss of bone mass, deterioration of bone structure, and increased incidence of falls. Areal bone mineral density (aBMD), measured by dual-energy X-ray absorptiometry (DXA), is the most used surrogate marker of bone strength. However, age-related declines in bone strength exceed those of aBMD, and the majority of fractures occur in those who are not identified as osteoporotic by BMD testing. With hip fracture incidence increasing worldwide, the development of accurate methods to estimate bone strength in vivo would be very useful to predict the risk of hip fracture and to monitor the effects of osteoporosis therapies.

Methods: We reviewed experimental and clinical evidence regarding the association between aBMD and/orCT-finite element analysis (FEA) estimated femoral strength and hip fracture risk as well as their changes with treatment.

Results: Femoral aBMD and bone strength estimates by CT-FEA explain a large proportion of femoral strength ex vivo and predict hip fracture risk in vivo. Changes in femoral aBMD are strongly associated with anti-fracture efficacy of osteoporosis treatments, though comparable data for FEA are currently not available.

Conclusions: Hip aBMD and estimated femoral strength are good predictors of fracture risk and could potentially be used as surrogate endpoints for fracture in clinical trials. Further improvements of FEA may be achieved by incorporating trabecular orientations, enhanced cortical modeling, effects of aging on bone tissue ductility, and multiple sideway fall loading conditions.

Keywords: Bone mineral density (BMD); Bone strength; Finite element analysis (FEA); Hip fracture
Links

DOI: 10.1007/s00198-019-05195-0

PubMed: 31900541

WoS: 000519860900001
History

Received: 2019-08-23

Accepted: 2019-10-04

Online: 2020-01-03

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