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Prado M, Khosla S, Giambini H. Vertebral Fracture Risk Thresholds from Phantom-Less Quantitative Computed Tomography-Based Finite Element Modeling Correlate to Phantom-Based Outcomes. J Clin Densitom 2024; 27:101465. [PMID: 38183962 DOI: 10.1016/j.jocd.2023.101465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 01/08/2024]
Abstract
INTRODUCTION Osteoporosis indicates weakened bones and heightened fracture susceptibility due to diminished bone quality. Dual-energy x-ray absorptiometry is unable to assess bone strength. Volumetric bone mineral density (vBMD) from quantitative computed tomography (QCT) has been used to establish guidelines as equivalent measurements for osteoporosis. QCT-based finite element analysis (FEA) has been implemented using calibration phantoms to establish bone strength thresholds based on the established vBMD. The primary aim was to validate vertebral failure load thresholds using a phantom-less approach with previously established thresholds, advancing a phantom-free approach for fracture risk prediction. METHODOLOGY A controlled cohort of 108 subjects (68 females) was used to validate sex-specific vertebral fracture load thresholds for normal, osteopenic, and osteoporotic subjects, obtained using a QCT/FEA-based phantom-less calibration approach and two material equations. RESULTS There were strong prediction correlations between the phantom-less and phantom-based methods (R2: 0.95 and 0.97 for males, and R2: 0.96 and 0.98 for females) based on the two equations. Bland Altman plots and paired t-tests showed no significant differences between methods. Predictions for bone strengths and thresholds using the phantom-less method matched those obtained using the phantom calibration and those previously established, with ≤4500 N (fragile) and ≥6000 N (normal) bone strength in females, and ≤6500 N (fragile) and ≥8500 N (normal) bone strength in males. CONCLUSION Phantom-less QCT-based FEA can allow for prospective and retrospective studies evaluating incidental vertebral fracture risk along the spine and their association with spine curvature and/or fracture etiology. The findings of this study further supported the application of phantom-less QCT-based FEA modeling to predict vertebral strength, aiding in identifying individuals prone to fractures. This reinforces the rationale for adopting this method as a comprehensive approach in predicting and managing fracture risk.
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Affiliation(s)
- Maria Prado
- Department of Biomedical Engineering and Chemical Engineering, One UTSA Circle, University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Sundeep Khosla
- Kogod Center on Aging and Division of Endocrinology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hugo Giambini
- Department of Biomedical Engineering and Chemical Engineering, One UTSA Circle, University of Texas at San Antonio, San Antonio, TX 78249, USA.
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Yan C, Lynch AC, Alemi MM, Banks JJ, Bouxsein ML, Anderson DE. Validity of evaluating spinal kinetics without participant-specific kinematics. J Biomech 2023; 161:111821. [PMID: 37805384 DOI: 10.1016/j.jbiomech.2023.111821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 09/12/2023] [Accepted: 09/26/2023] [Indexed: 10/09/2023]
Abstract
Musculoskeletal models are commonly used to estimate in vivo spinal loads under various loading conditions. Typically, participant-specific measured kinematics (PSMK) are coupled with participant-specific models, but obtaining PSMK data can be costly and infeasible in large studies or clinical practice. Thus, we evaluated two alternative methods to estimate spinal loads without PSMK: 1) ensemble average kinematics (EAK) based on kinematics from all participants; and 2) using separately measured individual kinematics (SMIK) from multiple other participants as inputs, then averaging the resulting loads. This study compares the dynamic spine loading patterns and peak loads in older adults performing five lifting tasks using PSMK, EAK and SMIK. Median root mean square errors of EAK and SMIK methods versus PSMK ranged from 18 to 72% body weight for compressive loads and from 2 to 25% body weight for shear loads, with median cross-correlations ranging from 0.931 to 0.991. The root mean square errors and cross-correlations between repeated PSMK trials fell within similar ranges. Compressive peak loads evaluated by EAK and SMIK were not different than PSMK in 12 of 15 cases, while by comparison repeated PSMK trials were not different in 13 of 15 cases. Overall, the resulting spine loading magnitudes and profiles using EAK or SMIK were not notably different than using a PSMK approach, and differences were not greater than between two PSMK trials. Thus, these findings indicate that these approaches may be used to make reasonable estimates of dynamic spinal loading without direct measurement of participant kinematics.
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Affiliation(s)
- Chenxi Yan
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, United States
| | - Andrew C Lynch
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Mohammad Mehdi Alemi
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, United States
| | - Jacob J Banks
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, United States
| | - Mary L Bouxsein
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, United States
| | - Dennis E Anderson
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, United States.
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Keaveny TM, Adams AL, Fischer H, Brara HS, Burch S, Guppy KH, Kopperdahl DL. Increased risks of vertebral fracture and reoperation in primary spinal fusion patients who test positive for osteoporosis by Biomechanical Computed Tomography analysis. Spine J 2023; 23:412-424. [PMID: 36372353 DOI: 10.1016/j.spinee.2022.10.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/29/2022] [Accepted: 10/31/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND CONTEXT While osteoporosis is a risk factor for adverse outcomes in spinal fusion patients, diagnosing osteoporosis reliably in this population has been challenging due to degenerative changes and spinal deformities. Addressing that challenge, biomechanical computed tomography analysis (BCT) is a CT-based diagnostic test for osteoporosis that measures both bone mineral density and bone strength (using finite element analysis) at the spine; CT scans taken for spinal evaluation or previous care can be repurposed for the analysis. PURPOSE Assess the effectiveness of BCT for preoperatively identifying spinal fusion patients with osteoporosis who are at high risk of reoperation or vertebral fracture. STUDY DESIGN Observational cohort study in a multi-center integrated managed care system using existing data from patient medical records and imaging archives. PATIENT SAMPLE We studied a randomly sampled subset of all adult patients who had any type of primary thoracic (T4 or below) or lumbar fusion between 2005 and 2018. For inclusion, patients with accessible study data needed a preop CT scan without intravenous contrast that contained images (before any instrumentation) of the upper instrumented vertebral level. OUTCOME MEASURES Reoperation for any reason (primary outcome) or a newly documented vertebral fracture (secondary outcome) occurring up to 5 years after the primary surgery. METHODS All study data were extracted using available coded information and CT scans from the medical records. BCT was performed at a centralized lab blinded to the clinical outcomes; patients could test positive for osteoporosis based on either low values of bone strength (vertebral strength ≤ 4,500 N women or 6,500 N men) and/or bone mineral density (vertebral trabecular bone mineral density ≤ 80 mg/cm3 both sexes). Cox proportional hazard ratios were adjusted by age, presence of obesity, and whether the fusion was long (four or more levels fused) or short (3 or fewer levels fused); Kaplan-Meier survival was compared by the log rank test. This project was funded by NIH (R44AR064613) and all physician co-authors and author 1 received salary support from their respective departments. Author 6 is employed by, and author 1 has equity in and consults for, the company that provides the BCT test; the other authors declare no conflicts of interest. RESULTS For the 469 patients analyzed (298 women, 171 men), median follow-up time was 44.4 months, 11.1% had a reoperation (median time 14.5 months), and 7.7% had a vertebral fracture (median time 2.0 months). Overall, 25.8% of patients tested positive for osteoporosis and no patients under age 50 tested positive. Compared to patients without osteoporosis, those testing positive were at almost five-fold higher risk for vertebral fracture (adjusted hazard ratio 4.7, 95% confidence interval = 2.2-9.7; p<.0001 Kaplan-Meier survival). Of those positive-testing patients, those who tested positive concurrently for low values of both bone strength and bone mineral density (12.6% of patients overall) were at almost four-fold higher risk for reoperation (3.7, 1.9-7.2; Kaplan-Meier survival p<.0001); the remaining positive-testing patients (those who tested positive for low values of either bone strength or bone mineral density but not both) were not at significantly higher risk for reoperation (1.6, 0.7-3.7) but were for vertebral fracture (4.3, 1.9-10.2). For both clinical outcomes, risk remained high for patients who underwent short or long fusion. CONCLUSION In a real-world clinical setting, BCT was effective in identifying primary spinal fusion patients aged 50 or older with osteoporosis who were at elevated risks of reoperation and vertebral fracture.
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Affiliation(s)
- Tony M Keaveny
- Departments of Mechanical Engineering and Bioengineering, University of California, Berkeley, CA, USA.
| | - Annette L Adams
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Heidi Fischer
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Harsimran S Brara
- Department of Neurosurgery, Southern California Permanente Medical Group, Los Angeles, CA, USA
| | - Shane Burch
- Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
| | - Kern H Guppy
- Department of Neurosurgery, Kaiser Permanente Medical Group, Sacramento, CA, USA
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Yamada J, Akeda K, Takegami N, Fujiwara T, Nishimura A, Sudo A. Change in prevalence of vertebral fractures over two decades: a Japanese medical examination-based study. J Bone Miner Metab 2023; 41:124-130. [PMID: 36416974 PMCID: PMC9684763 DOI: 10.1007/s00774-022-01385-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 11/03/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Although remarkable progress has been made in osteoporosis treatment over the last two decades, no study has reported the change in the prevalence of vertebral fractures (VFs) during this time. This study aimed to compare the prevalence and pattern of VFs at three time points from 1997 to 2019 in a Japanese medical examination-based study. MATERIALS AND METHODS The participants of this study were inhabitants of a typical Japanese mountain village who participated in these surveys at three time points: 1997 (group A), 2009 or 2011 (group B), and 2019 (group C). The age- and sex-adjusted groups were defined as groups A', B', and C', respectively (39 men and 85 women; mean age 73.6-74.0 years old). The type and extent of deformities of the prevalent fractures from T4 to L4 on the lateral thoracic and lumbar spine radiographs were semiquantitatively evaluated. RESULTS The prevalence of VFs has significantly decreased over the past two decades. In group A, the percentages of thoracic level, biconcave type, and severe deformity of VFs were significantly higher than expected. The bone mineral density of the participants increased significantly over time. The treatment rate for osteoporosis in participants with osteoporosis has improved over the past two decades. CONCLUSION This study demonstrated that the prevalence of VFs has decreased, and the pattern of VFs has changed over the last two decades in a typical Japanese mountain village due to multifactorial improvements in skeletal fragility, including improvement in osteoporosis treatment rate.
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Affiliation(s)
- Junichi Yamada
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Koji Akeda
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan.
| | - Norihiko Takegami
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Tatsuhiko Fujiwara
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Akinobu Nishimura
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie, 514-8507, Japan
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Trabecular bone score in the hip: a new method to examine hip bone microarchitecture-a feasibility study. Arch Osteoporos 2022; 17:126. [PMID: 36125566 DOI: 10.1007/s11657-022-01168-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 09/09/2022] [Indexed: 02/03/2023]
Abstract
Our study found, in older adults who are residents of long-term care facilities, assessing hip microarchitecture with DXA-derived bone texture score may serve as a supplement to bone mineral density to improve fracture prediction and to facilitate decision-making for pharmacological management. PURPOSE Many patients with high fragility fracture risk do not have a sufficiently low bone mineral density (BMD) to become eligible for osteoporosis treatment. They often have deteriorated bone microarchitecture despite a normal or only mildly abnormal BMD. We sought to examine the beta version of the trabecular bone score (TBS) algorithm for the hip: TBS Hip, an indirect index of bone microarchitecture, and assess if TBS Hip brings complementary information to other bone quality indices such as BMD and bone turnover markers (BTMs) to further improve identifying individuals who are at high risk for fractures. METHODS In this analysis, we considered baseline TBS Hip at total hip, femoral neck, and greater trochanter, TBS at lumbar spine, BMD at all of these skeletal sites, and BTMs in 132 postmenopausal women who were residents of long-term care (LTC) facilities enrolled in a randomized placebo-controlled osteoporosis clinical trial. RESULTS On average, participants were 85.2 years old and had a BMI of 26.9 kg/m2. The correlation coefficient between BMD and TBS Hip at total hip, femoral neck, and greater trochanter was 0.50, 0.32, and 0.39 respectively (all p < 0.0001). The correlation coefficient between BMD and lumbar spine TBS was 0.52 (p < 0.0001). There was no statistically significant correlation between BTMs with TBS at lumbar spine or TBS Hip at total hip, femoral neck, and greater trochanter. CONCLUSION Among older women residing in LTC facilities, there was a moderate correlation between measures of BMD and TBS Hip at total hip, femoral neck, and greater trochanter, suggesting TBS Hip may provide complementary information to BMD .
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Anderson DE, Groff MW, Flood TF, Allaire BT, Davis RB, Stadelmann MA, Zysset PK, Alkalay RN. Evaluation of Load-To-Strength Ratios in Metastatic Vertebrae and Comparison With Age- and Sex-Matched Healthy Individuals. Front Bioeng Biotechnol 2022; 10:866970. [PMID: 35992350 PMCID: PMC9388746 DOI: 10.3389/fbioe.2022.866970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/01/2022] [Indexed: 11/13/2022] Open
Abstract
Vertebrae containing osteolytic and osteosclerotic bone metastases undergo pathologic vertebral fracture (PVF) when the lesioned vertebrae fail to carry daily loads. We hypothesize that task-specific spinal loading patterns amplify the risk of PVF, with a higher degree of risk in osteolytic than in osteosclerotic vertebrae. To test this hypothesis, we obtained clinical CT images of 11 cadaveric spines with bone metastases, estimated the individual vertebral strength from the CT data, and created spine-specific musculoskeletal models from the CT data. We established a musculoskeletal model for each spine to compute vertebral loading for natural standing, natural standing + weights, forward flexion + weights, and lateral bending + weights and derived the individual vertebral load-to-strength ratio (LSR). For each activity, we compared the metastatic spines' predicted LSRs with the normative LSRs generated from a population-based sample of 250 men and women of comparable ages. Bone metastases classification significantly affected the CT-estimated vertebral strength (Kruskal-Wallis, p < 0.0001). Post-test analysis showed that the estimated vertebral strength of osteosclerotic and mixed metastases vertebrae was significantly higher than that of osteolytic vertebrae (p = 0.0016 and p = 0.0003) or vertebrae without radiographic evidence of bone metastasis (p = 0.0010 and p = 0.0003). Compared with the median (50%) LSRs of the normative dataset, osteolytic vertebrae had higher median (50%) LSRs under natural standing (p = 0.0375), natural standing + weights (p = 0.0118), and lateral bending + weights (p = 0.0111). Surprisingly, vertebrae showing minimal radiographic evidence of bone metastasis presented significantly higher median (50%) LSRs under natural standing (p < 0.0001) and lateral bending + weights (p = 0.0009) than the normative dataset. Osteosclerotic vertebrae had lower median (50%) LSRs under natural standing (p < 0.0001), natural standing + weights (p = 0.0005), forward flexion + weights (p < 0.0001), and lateral bending + weights (p = 0.0002), a trend shared by vertebrae with mixed lesions. This study is the first to apply musculoskeletal modeling to estimate individual vertebral loading in pathologic spines and highlights the role of task-specific loading in augmenting PVF risk associated with specific bone metastatic types. Our finding of high LSRs in vertebrae without radiologically observed bone metastasis highlights that patients with metastatic spine disease could be at an increased risk of vertebral fractures even at levels where lesions have not been identified radiologically.
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Affiliation(s)
- Dennis E. Anderson
- Department of Orthopedic Surgery, Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Michael W. Groff
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, United States
| | - Thomas F. Flood
- Department of Radiology, Brigham and Women’s Hospital, Boston, MA, United States
| | - Brett T. Allaire
- Department of Orthopedic Surgery, Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Roger B. Davis
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Marc A. Stadelmann
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Philippe K. Zysset
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Ron N. Alkalay
- Department of Orthopedic Surgery, Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
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Letter to the Editor concerning "Best Practice Guidelines for Assessment and Management of Osteoporosis in Adult Patients Undergoing Elective Spinal Reconstruction". Spine (Phila Pa 1976) 2022; 47:E466-E467. [PMID: 35066536 DOI: 10.1097/brs.0000000000004323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Dieckmeyer M, Löffler MT, El Husseini M, Sekuboyina A, Menze B, Sollmann N, Wostrack M, Zimmer C, Baum T, Kirschke JS. Level-Specific Volumetric BMD Threshold Values for the Prediction of Incident Vertebral Fractures Using Opportunistic QCT: A Case-Control Study. Front Endocrinol (Lausanne) 2022; 13:882163. [PMID: 35669688 PMCID: PMC9165054 DOI: 10.3389/fendo.2022.882163] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/08/2022] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To establish and evaluate the diagnostic accuracy of volumetric bone mineral density (vBMD) threshold values at different spinal levels, derived from opportunistic quantitative computed tomography (QCT), for the prediction of incident vertebral fractures (VF). MATERIALS AND METHODS In this case-control study, 35 incident VF cases (23 women, 12 men; mean age: 67 years) and 70 sex- and age-matched controls were included, based on routine multi detector CT (MDCT) scans of the thoracolumbar spine. Trabecular vBMD was measured from routine baseline CT scans of the thoracolumbar spine using an automated pipeline including vertebral segmentation, asynchronous calibration for HU-to-vBMD conversion, and correction of intravenous contrast medium (https://anduin.bonescreen.de). Threshold values at T1-L5 were calculated for the optimal operating point according to the Youden index and for fixed sensitivities (60 - 85%) in receiver operating characteristic (ROC) curves. RESULTS vBMD at each single level of the thoracolumbar spine was significantly associated with incident VFs (odds ratio per SD decrease [OR], 95% confidence interval [CI] at T1-T4: 3.28, 1.66-6.49; at T5-T8: 3.28, 1.72-6.26; at T9-T12: 3.37, 1.78-6.36; and at L1-L4: 3.98, 1.97-8.06), independent of adjustment for age, sex, and prevalent VF. AUC showed no significant difference between vertebral levels and was highest at the thoracolumbar junction (AUC = 0.75, 95%-CI = 0.63 - 0.85 for T11-L2). Optimal threshold values increased from lumbar (L1-L4: 52.0 mg/cm³) to upper thoracic spine (T1-T4: 69.3 mg/cm³). At T11-L2, T12-L3 and L1-L4, a threshold of 80.0 mg/cm³ showed sensitivities of 85 - 88%, and specificities of 41 - 49%. To achieve comparable sensitivity (85%) at more superior spinal levels, resulting thresholds were higher: 114.1 mg/cm³ (T1-T4), 92.0 mg/cm³ (T5-T8), 88.2 mg/cm³ (T9-T12). CONCLUSIONS At all levels of the thoracolumbar spine, lower vBMD was associated with incident VFs in an elderly, predominantly oncologic patient population. Automated opportunistic osteoporosis screening of vBMD along the entire thoracolumbar spine allows for risk assessment of imminent VFs. We propose level-specific vBMD threshold at the thoracolumbar spine to identify individuals at high fracture risk.
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Affiliation(s)
- Michael Dieckmeyer
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- *Correspondence: Michael Dieckmeyer,
| | - Maximilian Thomas Löffler
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Radiology, University Medical Center, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Malek El Husseini
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Anjany Sekuboyina
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bjoern Menze
- Image-Based Biomedical Modeling, Department of Computer Science, Technical University of Munich, Munich, Germany
- Department of Quantitative Biomedicine, Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Nico Sollmann
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | - Maria Wostrack
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Thomas Baum
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jan Stefan Kirschke
- Department of Diagnostic and Interventional Neuroradiology, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- TUM-Neuroimaging Center, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Liu A, Liu Y, Su KJ, Greenbaum J, Bai Y, Tian Q, Zhao LJ, Deng HW, Shen H. A transcriptome-wide association study to detect novel genes for volumetric bone mineral density. Bone 2021; 153:116106. [PMID: 34252604 PMCID: PMC8478845 DOI: 10.1016/j.bone.2021.116106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/17/2021] [Accepted: 07/05/2021] [Indexed: 01/02/2023]
Abstract
Transcriptome-wide association studies (TWAS) systematically investigate the association of genetically predicted gene expression with disease risk, providing an effective approach to identify novel susceptibility genes. Osteoporosis is the most common metabolic bone disease, associated with reduced bone mineral density (BMD) and increased risk of osteoporotic fractures, whereas genetic factors explain approximately 70% of the variance in phenotypes associated with bone. BMD is commonly assessed using dual-energy X-ray absorptiometry (DXA) to obtain measurements (g/cm2) of areal BMD. However, quantitative computed tomography (QCT) measured 3D volumetric BMD (vBMD) (g/cm3) has important advantages compared with DXA since it can evaluate cortical and trabecular microstructural features of bone quality, which can be used to directly predict fracture risk. Here, we performed the first TWAS for volumetric BMD (vBMD) by integrating genome-wide association studies (GWAS) data from two independent cohorts, namely the Framingham Heart Study (FHS, n = 3298) and the Osteoporotic Fractures in Men (MrOS, n = 4641), with tissue-specific gene expression data from the Genotype-Tissue Expression (GTEx) project. We first used stratified linkage disequilibrium (LD) score regression approach to identify 12 vBMD-relevant tissues, for which vBMD heritability is enriched in tissue-specific genes of the given tissue. Focusing on these tissues, we subsequently leveraged GTEx expression reference panels to predict tissue-specific gene expression levels based on the genotype data from FHS and MrOS. The associations between predicted gene expression levels and vBMD variation were then tested by MultiXcan, an innovative TWAS method that integrates information available across multiple tissues. We identified 70 significant genes associated with vBMD, including some previously identified osteoporosis-related genes such as LYRM2 and NME8, as well as some novel loci such as DNAAF2 and SPAG16. Our findings provide novel insights into the pathophysiological mechanisms of osteoporosis and highlight several novel vBMD-associated genes that warrant further investigation.
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Affiliation(s)
- Anqi Liu
- Tulane Center for Biomedical Informatics and Genomics, Deming Department of Medicine, School of Medicine, Tulane University, New Orleans, LA, USA
| | - Yong Liu
- Center for System Biology, Data Sciences, and Reproductive Health, School of Basic Medical Science, Central South University, Yuelu, Changsha, Hunan Province, PR China
| | - Kuan-Jui Su
- Tulane Center for Biomedical Informatics and Genomics, Deming Department of Medicine, School of Medicine, Tulane University, New Orleans, LA, USA
| | - Jonathan Greenbaum
- Tulane Center for Biomedical Informatics and Genomics, Deming Department of Medicine, School of Medicine, Tulane University, New Orleans, LA, USA
| | - Yuntong Bai
- Tulane Center for Biomedical Informatics and Genomics, Deming Department of Medicine, School of Medicine, Tulane University, New Orleans, LA, USA; Department of Biomedical Engineering, Tulane University, New Orleans, LA, USA
| | - Qing Tian
- Tulane Center for Biomedical Informatics and Genomics, Deming Department of Medicine, School of Medicine, Tulane University, New Orleans, LA, USA
| | - Lan-Juan Zhao
- Tulane Center for Biomedical Informatics and Genomics, Deming Department of Medicine, School of Medicine, Tulane University, New Orleans, LA, USA
| | - Hong-Wen Deng
- Tulane Center for Biomedical Informatics and Genomics, Deming Department of Medicine, School of Medicine, Tulane University, New Orleans, LA, USA; Center for System Biology, Data Sciences, and Reproductive Health, School of Basic Medical Science, Central South University, Yuelu, Changsha, Hunan Province, PR China
| | - Hui Shen
- Tulane Center for Biomedical Informatics and Genomics, Deming Department of Medicine, School of Medicine, Tulane University, New Orleans, LA, USA.
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Spiegl UJ, Scheyerer MJ, Osterhoff G, Grüninger S, Schnake KJ. Osteoporotic mid-thoracic vertebral body fractures: what are the differences compared to fractures of the lumbar spine?-a systematic review. Eur J Trauma Emerg Surg 2021; 48:1639-1647. [PMID: 34590172 PMCID: PMC9192434 DOI: 10.1007/s00068-021-01792-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 09/17/2021] [Indexed: 11/24/2022]
Abstract
Purpose The aim of this systematically review is to detect differences between fractures located at the mid-thoracic spine compared to fractures of the thoracolumbar junction (TLJ) and the lumbar spine in osteoporotic vertebral body fractures. Methods This review is based on articles retrieved by a systematic search in the PubMed and Web of Science database for publications regarding osteoporotic fractures of the thoracolumbar spine with respect to the fracture location. Differences in prevalence, cause of fracture, fracture healing, and outcomes between the mid-thoracic spine and the TLJ and the lumbar spine were considered. Results Altogether, 238 articles could be retrieved from the literature search. A total of 222 articles were excluded. Thus, 16 remaining original articles were included in this systematic review comprising the topics prevalence, bone mineral density and regional blood flow, biomechanics, subsequent fractures, and outcome, respectively. The overall level of evidence of the vast majority of studies was moderate to low. Conclusion Several differences between osteoporotic fractures of the mid-thoracic spine compared to the TLJ and the lumbar spine could be identified. Thereby, osteoporotic mid-thoracic fractures seem to be particularly more related to frailty without a history of traumatic injury compared to osteoporotic fractures of the TLJ and the lumbar spine. Additionally, the presence of severe mid-thoracic fractures predicts subsequent fractures of the hip. In contrast, subsequent fractures of the spine are less likely.
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Affiliation(s)
- Ulrich Josef Spiegl
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
| | - Max Joseph Scheyerer
- Department of Orthopedics and Trauma Surgery, University Hospital of Cologne, Cologne, Germany
| | - Georg Osterhoff
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Sebastian Grüninger
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | - Klaus John Schnake
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany.,Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
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11
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Driessen JHM, van Dort MJ, Romme EAPM, Wouters EFM, Smeenk FWJM, van Rietbergen B, van den Bergh JPW, Geusens P. Associations between bone attenuation and prevalent vertebral fractures on chest CT scans differ with vertebral fracture locations. Osteoporos Int 2021; 32:1869-1877. [PMID: 33594489 PMCID: PMC8387252 DOI: 10.1007/s00198-020-05719-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 10/27/2020] [Indexed: 01/31/2023]
Abstract
UNLABELLED Vertebral fracture (VF) locations are bimodally distributed in the spine. The association between VF and bone attenuation (BA) measured on chest CT scans varied according to the location of VFs, indicating that other factors than only BA play a role in the bimodal distribution of VFs. INTRODUCTION Vertebral fractures (VFs) are associated with low bone mineral density but are not equally distributed throughout the spine and occur most commonly at T7-T8 and T11-T12 ("cVFs") and less commonly at T4-T6 and T9-T10 ("lcVF"). We aimed to determine whether associations between bone attenuation (BA) and VFs vary between subjects with cVFs only, with lcVFs only and with both cVFs and lcVFs. METHODS Chest CT images of T4-T12 in 1237 smokers with and without COPD were analysed for prevalent VFs according to the method described by Genant (11,133 vertebrae). BA (expressed in Hounsfield units) was measured in all non-fractured vertebrae (available for 10,489 vertebrae). Linear regression was used to compare mean BA, and logistic regression was used to estimate the association of BA with prevalent VFs (adjusted for age and sex). RESULTS On vertebral level, the proportion of cVFs was significantly higher than of lcVF (5.6% vs 2.0%). Compared to subjects without VFs, BA was 15% lower in subjects with cVFs (p < 0.0001), 25% lower in subjects with lcVFs (p < 0.0001) and lowest in subjects with cVFs and lcVFs (- 32%, p < 0.0001). The highest ORs for presence of VFs per - 1SD BA per vertebra were found in subjects with both cVFs and lcVFs (3.8 to 4.6). CONCLUSIONS The association between VFs and BA differed according to VF location. ORs increased from subjects with cVFs to subjects with lcVFs and were highest in subjects with cVFs and lcVFs, indicating that other factors than only BA play a role in the bimodal VF distribution. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT00292552.
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Affiliation(s)
- J H M Driessen
- Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+ (MUMC+), Postbus 5800, 6202, AZ, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre+ (MUMC+), Postbus 5800, 6202, AZ, Maastricht, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+ (MUMC+), Postbus 5800, 6202, AZ, Maastricht, The Netherlands
| | - M J van Dort
- Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+ (MUMC+), Postbus 5800, 6202, AZ, Maastricht, The Netherlands.
| | - E A P M Romme
- Department of Respiratory Medicine, Rijnstate Hospital, Postbus 9555, 6800, TA, Arnhem, The Netherlands
| | - E F M Wouters
- Department of Respiratory Diseases, Maastricht University Medical Centre+ (MUMC+), Postbus 5800, 6202, AZ, Maastricht, The Netherlands
| | - F W J M Smeenk
- Department of Respiratory Medicine, Catharina Hospital, Postbus 1350, 5602, ZA, Eindhoven, The Netherlands
- School of Health Professions Education, Faculty of Health Medicine and Life Sciences, Maastricht University Medical Centre+ (MUMC+), Postbus 5800, 6202, AZ, Maastricht, The Netherlands
| | - B van Rietbergen
- Faculty of Biomedical Engineering, Section Orthopaedic Biomechanics, Eindhoven University of Technology, Postbus 513, 5600, MB, Eindhoven, The Netherlands
| | - J P W van den Bergh
- Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+ (MUMC+), Postbus 5800, 6202, AZ, Maastricht, The Netherlands
- Department of Internal Medicine/Rheumatology, Maastricht University Medical Centre+ (MUMC+), Postbus 5800, 6202, AZ, Maastricht, The Netherlands
- Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands
| | - P Geusens
- Department of Internal Medicine/Rheumatology, Maastricht University Medical Centre+ (MUMC+), Postbus 5800, 6202, AZ, Maastricht, The Netherlands
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12
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Dual-Energy Computed Tomography Virtual Noncalcium Technique in Diagnosing Osteoporosis: Correlation With Quantitative Computed Tomography. J Comput Assist Tomogr 2021; 45:452-457. [PMID: 34297514 PMCID: PMC8132909 DOI: 10.1097/rct.0000000000001168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective The aim of this study was to evaluate dual-energy computed tomography (CT) virtual noncalcium (VNCa) technique as a means of quantifying osteoporosis. Methods Dual-energy CT scans were obtained prospectively, targeting lumbar regions of 55 patients with chronic low back pain. A standard quantitative CT (QCT) phantom was positioned at the waist during each procedure, using proprietary software (QCT Pro; Mindways, Tex) to measure bone mineral density (BMD) in each vertebral body. Vendor dual-energy analytic software was altered with a specially modified configuration file to produce a “Virtual Non Calcium” or “VNCa” output, as such output variables were remapped to produce the following calcium values rather than iodine, yielding the following QCT parameters: CT value of calcium (originally “contrast media” [CM]), CT value of mixed energy imaging (regular CT value [rCT]), calcium density (originally “contrast agent density” [CaD]), and fat fraction (FF). Pearson test served to assess correlations between BMD and these parameters. Multiple linear regression analysis was applied to construct an equation for generating regressive BMD (rBMD) values. In gauging diagnostic accuracies, the criterion-standard BMD cutoff point (<80 mg/cm3) was adopted for QCT, whereas the rBMD threshold was defined by receiver operating characteristic curve. Results Contrast media, rCT, CaD, and FF values (reflecting CT value of calcium, regular CT value, calcium density, and fat fraction, respectively) significantly correlated with BMD (r values: 0.885, 0.947, 0.877, and 0.492, respectively; all P < 0.01). Contrast media, CaD, and FF showed independent associations with BMD; the regressive equation was formulated as follows: rBMD = 54.82 − 0.19 × CM + 20.03 × CaD − 1.24 × FF. The area under the curve of rBMD in diagnosing osteoporosis was 0.966 ± 0.009 (P < 0.01). At an rBMD threshold of less than 81.94 mg/cm3, sensitivity and specificity were 90.0% and 92.0%, respectively. Conclusions Dual-energy CT VNCa technique may constitute a valid alternative method for quantifying the mineral content and marrow fat composition of bone in diagnostic assessments of osteoporosis.
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13
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Mokhtarzadeh H, Anderson DE, Allaire BT, Bouxsein ML. Patterns of Load-to-Strength Ratios Along the Spine in a Population-Based Cohort to Evaluate the Contribution of Spinal Loading to Vertebral Fractures. J Bone Miner Res 2021; 36:704-711. [PMID: 33253414 PMCID: PMC8383210 DOI: 10.1002/jbmr.4222] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 11/12/2020] [Accepted: 11/19/2020] [Indexed: 12/20/2022]
Abstract
Vertebral fractures (VFx) are common among older adults. Epidemiological studies report high occurrence of VFx at mid-thoracic and thoracolumbar regions of the spine; however, reasons for this observation remain poorly understood. Prior reports of high ratios of spinal loading to vertebral strength in the thoracolumbar region suggest a possible biomechanical explanation. However, no studies have evaluated load-to-strength ratios (LSRs) throughout the spine for a large number of activities in a sizeable cohort. Thus, we performed a cross-sectional study in a sample of adult men and women from a population-based cohort to: 1) determine which activities cause the largest vertebral LSRs, and 2) examine patterns of LSRs along the spine for these high-load activities. We used subject-specific musculoskeletal models of the trunk to determine vertebral compressive loads for 109 activities in 250 individuals (aged 41 to 90 years, 50% women) from the Framingham Heart Study. Vertebral compressive strengths from T4 to L4 were calculated from computed tomography-based vertebral size and bone density measurements. We determined which activities caused maximum LSRs at each of these spinal levels. We identified nine activities that accounted for >95% of the maximum LSRs overall and at least 89.6% at each spinal level. The activity with the highest LSR varied by spinal level, and three distinct spinal regions could be identified by the activity producing maximum LSRs: lateral bending with a weight in one hand (upper thoracic), holding weights with elbows flexed (lower thoracic), and forward flexion with weight (lumbar). This study highlights the need to consider a range of lifting, holding, and non-symmetric activities when evaluating vertebral LSRs. Moreover, we identified key activities that produce higher loading in multiple regions of the spine. These results provide the first guidance on what activities to consider when evaluating vertebral load-to-strength ratios in future studies, including those examining dynamic motions and the biomechanics of VFx. © 2020 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Hossein Mokhtarzadeh
- Department of Biomedical Engineering, Melbourne School of Engineering, The University of Melbourne, Melbourne, Australia
| | - Dennis E Anderson
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA
| | - Brett T Allaire
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mary L Bouxsein
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA.,Harvard-MIT Health Sciences and Technology Program, Cambridge, MA, USA
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14
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Johannesdottir F, Allaire B, Kopperdahl DL, Keaveny TM, Sigurdsson S, Bredella MA, Anderson DE, Samelson EJ, Kiel DP, Gudnason VG, Bouxsein ML. Bone density and strength from thoracic and lumbar CT scans both predict incident vertebral fractures independently of fracture location. Osteoporos Int 2021; 32:261-269. [PMID: 32748310 PMCID: PMC8265597 DOI: 10.1007/s00198-020-05528-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 06/30/2020] [Indexed: 01/01/2023]
Abstract
UNLABELLED In a population-based study, we found that computed tomography (CT)-based bone density and strength measures from the thoracic spine predicted new vertebral fracture as well as measures from the lumbar spine, suggesting that CT scans at either the thorax or abdominal regions are useful to assess vertebral fracture risk. INTRODUCTION Prior studies have shown that computed tomography (CT)-based lumbar bone density and strength measurements predict incident vertebral fracture. This study investigated whether CT-based bone density and strength measurements from the thoracic spine predict incident vertebral fracture and compared the performance of thoracic and lumbar bone measurements to predict incident vertebral fracture. METHODS This case-control study of community-based men and women (age 74.6 ± 6.6) included 135 cases with incident vertebral fracture at any level and 266 age- and sex-matched controls. We used baseline CT scans to measure integral and trabecular volumetric bone mineral density (vBMD) and vertebral strength (via finite element analysis, FEA) at the T8 and L2 levels. Association between these measurements and vertebral fracture was determined by using conditional logistic regression. Sensitivity and specificity for predicting incident vertebral fracture were determined for lumbar spine and thoracic bone measurements. RESULTS Bone measurements from T8 and L2 predicted incident vertebral fracture equally well, regardless of fracture location. Specifically, for predicting vertebral fracture at any level, the odds ratio (per 1-SD decrease) for the vBMD and strength measurements at L2 and T8 ranged from 2.0 to 2.7 (p < 0.0001) and 1.8 to 2.8 (p < 0.0001), respectively. Results were similar when predicting fracture only in the thoracic versus the thoracolumbar spine. Lumbar and thoracic spine bone measurements had similar sensitivity and specificity for predicting incident vertebral fracture. CONCLUSION These findings indicated that like those from the lumbar spine, CT-based bone density and strength measurements from the thoracic spine may be useful for identifying individuals at high risk for vertebral fracture.
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Affiliation(s)
- F Johannesdottir
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, RN115, 330 Brookline Avenue, Boston, MA, 02215, USA.
- Harvard Medical School, Boston, MA, USA.
| | - B Allaire
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, RN115, 330 Brookline Avenue, Boston, MA, 02215, USA
| | | | - T M Keaveny
- Department of Mechanical Engineering, University of California, Berkeley, CA, USA
- Department of Bioengineering, University of California, Berkeley, CA, USA
| | | | - M A Bredella
- Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - D E Anderson
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, RN115, 330 Brookline Avenue, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - E J Samelson
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - D P Kiel
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - V G Gudnason
- Icelandic Heart Association, Kopavogur, Iceland
- Department of Medicine, University of Iceland, Reykjavik, Iceland
| | - M L Bouxsein
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, RN115, 330 Brookline Avenue, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
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15
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Prado M, Rezaei A, Giambini H. Density-Dependent Material and Failure Criteria Equations Highly Affect the Accuracy and Precision of QCT/FEA-Based Predictions of Osteoporotic Vertebral Fracture Properties. Ann Biomed Eng 2020; 49:663-672. [PMID: 32820381 DOI: 10.1007/s10439-020-02595-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/11/2020] [Indexed: 11/25/2022]
Abstract
About 700,000 vertebral fractures occur in the US as a result of bone loss. Quantitative computed tomography (QCT)-based finite element analysis (FEA) is a promising tool for fracture risk prediction that is becoming attractive in the clinical setting. The goals of this study were (1) to perform individual and pooled specimen optimization using inverse QCT/FEA modeling to obtain ash density-elastic modulus equations incorporating the whole vertebral body and accounting for all variables used during FE modeling, and (2) to determine the effect of material equations and failure criteria on the accuracy and precision of mechanical properties. Fifty-four (54) human vertebrae were used to optimize material equations based on experimental outcomes and, together with a previously proposed material equation, were implemented in our models using three different failure criteria to obtain fracture loads. Our robust QCT/FEA approach predicted 78% of the failure loads. Material equations resulted in poor accuracy in the predicted stiffness, yet yielded good precision and, more importantly, strong correlations with fracture loads. Both material and fracture criterion equations are equally important in estimating accurate and precise QCT/FEA predictions. Results suggest that both elastic modulus and fracture criterion equations should be validated against experimental outcomes to better explain the response of the tissue under various conditions.
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Affiliation(s)
- Maria Prado
- Department of Biomedical and Chemical Engineering, The University of Texas at San Antonio, San Antonio, TX, 78249, USA
| | - Asghar Rezaei
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
| | - Hugo Giambini
- Department of Biomedical and Chemical Engineering, The University of Texas at San Antonio, San Antonio, TX, 78249, USA.
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16
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Geusens P, Kendler DL, Fahrleitner-Pammer A, López-Romero P, Marin F. Distribution of Prevalent and Incident Vertebral Fractures and Their Association with Bone Mineral Density in Postmenopausal Women in the Teriparatide Versus Risedronate VERO Clinical Trial. Calcif Tissue Int 2020; 106:646-654. [PMID: 32157334 DOI: 10.1007/s00223-020-00683-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 01/17/2020] [Indexed: 10/24/2022]
Abstract
Vertebral fractures (VFx) occur most frequently in the mid-thoracic and thoraco-lumbar regions, which experience the highest mechanical loading along the spine. The prevalence and incidence of VFx by their location and severity, and their relationship with bone mineral density (BMD), are seldom reported in randomized clinical trial cohorts. The VERO trial randomized 1360 postmenopausal women with at least two moderate or one severe VFx to receive either teriparatide or risedronate for up to 24 months. In this post hoc analysis, we describe the centrally read distribution and severity of prevalent and incident VFx, and the association of their location with the baseline BMD. At baseline, 21.4% of all evaluable vertebral bodies had a prevalent VFx; most commonly at L1, T12, L2 and T11 (38.5%, 37.4%, 25.3% and 23.5% of patients, respectively). Patients with prevalent VFx only at T12/L1 showed a higher baseline BMD compared to patients with VFx at other levels. At month 24, 100 patients had 126 incident VFx (teriparatide: 35; risedronate: 91). The most frequent incident VFx occurred at T12 (n = 17, 1.6% of patients), followed by L1 and T11 (n = 14, 1.3% both). The frequency of incident VFx was lower at all vertebral levels in patients given teriparatide. These results confirm prior reports that VFx occurs more frequently at mid-thoracic and thoraco-lumbar regions of the spine. Patients with these VFx locations have higher BMD than those who fracture at other sites, suggesting a role for mechanical stress in the etiology of VFx. Teriparatide is superior to risedronate in the prevention of VFx at these common fracture locations.Trial registration ClinicalTrials.gov Identifier: NCT01709110.
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Affiliation(s)
- Piet Geusens
- Department of Internal Medicine, Subdivision of Rheumatology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
| | - David L Kendler
- Department of Medicine (Endocrinology), University of British Columbia, Vancouver, BC, V5Z 4E1, Canada
| | - Astrid Fahrleitner-Pammer
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Pedro López-Romero
- Department of Medical Research, Eli Lilly and Company, Avda. de la Industria 30, 28108, Alcobendas (Madrid), Spain
| | - Fernando Marin
- Department of Medical Research, Eli Lilly and Company, Avda. de la Industria 30, 28108, Alcobendas (Madrid), Spain
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17
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Keaveny TM, Clarke BL, Cosman F, Orwoll ES, Siris ES, Khosla S, Bouxsein ML. Biomechanical Computed Tomography analysis (BCT) for clinical assessment of osteoporosis. Osteoporos Int 2020; 31:1025-1048. [PMID: 32335687 PMCID: PMC7237403 DOI: 10.1007/s00198-020-05384-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 03/09/2020] [Indexed: 12/12/2022]
Abstract
The surgeon general of the USA defines osteoporosis as "a skeletal disorder characterized by compromised bone strength, predisposing to an increased risk of fracture." Measuring bone strength, Biomechanical Computed Tomography analysis (BCT), namely, finite element analysis of a patient's clinical-resolution computed tomography (CT) scan, is now available in the USA as a Medicare screening benefit for osteoporosis diagnostic testing. Helping to address under-diagnosis of osteoporosis, BCT can be applied "opportunistically" to most existing CT scans that include the spine or hip regions and were previously obtained for an unrelated medical indication. For the BCT test, no modifications are required to standard clinical CT imaging protocols. The analysis provides measurements of bone strength as well as a dual-energy X-ray absorptiometry (DXA)-equivalent bone mineral density (BMD) T-score at the hip and a volumetric BMD of trabecular bone at the spine. Based on both the bone strength and BMD measurements, a physician can identify osteoporosis and assess fracture risk (high, increased, not increased), without needing confirmation by DXA. To help introduce BCT to clinicians and health care professionals, we describe in this review the currently available clinical implementation of the test (VirtuOst), its application for managing patients, and the underlying supporting evidence; we also discuss its main limitations and how its results can be interpreted clinically. Together, this body of evidence supports BCT as an accurate and convenient diagnostic test for osteoporosis in both sexes, particularly when used opportunistically for patients already with CT. Biomechanical Computed Tomography analysis (BCT) uses a patient's CT scan to measure both bone strength and bone mineral density at the hip or spine. Performing at least as well as DXA for both diagnosing osteoporosis and assessing fracture risk, BCT is particularly well-suited to "opportunistic" use for the patient without a recent DXA who is undergoing or has previously undergone CT testing (including hip or spine regions) for an unrelated medical condition.
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Affiliation(s)
- T M Keaveny
- Departments of Mechanical Engineering and Bioengineering, University of California, Berkeley, CA, USA.
| | - B L Clarke
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - F Cosman
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - E S Orwoll
- Bone and Mineral Unit, Oregon Health and Science University, Portland, OR, USA
| | - E S Siris
- Toni Stabile Osteoporosis Center, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - S Khosla
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - M L Bouxsein
- Orthopedic Biomechanics Laboratory, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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18
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Kaiser J, Allaire B, Fein PM, Lu D, Adams A, Kiel DP, Jarraya M, Guermazi A, Demissie S, Samelson EJ, Bouxsein ML, Morgan EF. Heterogeneity and Spatial Distribution of Intravertebral Trabecular Bone Mineral Density in the Lumbar Spine Is Associated With Prevalent Vertebral Fracture. J Bone Miner Res 2020; 35:641-648. [PMID: 31886907 PMCID: PMC7145746 DOI: 10.1002/jbmr.3946] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 12/12/2019] [Accepted: 12/14/2019] [Indexed: 01/25/2023]
Abstract
The spatial heterogeneity in trabecular bone density within the vertebral centrum is associated with vertebral strength and could explain why volumetric bone mineral density (vBMD) exhibits low sensitivity in identifying fracture risk. This study evaluated whether the heterogeneity and spatial distribution of trabecular vBMD are associated with prevalent vertebral fracture. We examined the volumetric quantitative computed tomography (QCT) scans of the L3 vertebra in 148 participants in the Framingham Heart Study Multidetector CT study. Of these individuals, 37 were identified as cases of prevalent fracture, and 111 were controls, matched on sex and age with three controls per case. vBMD was calculated within 5-mm contiguous cubic regions of the centrum. Two measures of heterogeneity were calculated: (i) interquartile range (IQR); and (ii) quartile coefficient of variation (QCV). Ratios in the spatial distributions of the trabecular vBMD were also calculated: anterior/posterior, central/outer, superior/mid-transverse, and inferior/mid-transverse. Heterogeneity and spatial distributions were compared between cases and controls using Wilcoxon rank sum tests and t tests and tested for association with prevalent fractures with conditional logistic regressions independent of integral vBMD. Prevalent fracture cases had lower mean ± SD integral vBMD (134 ± 38 versus165 ± 42 mg/cm3 , p < .001), higher QCV (0.22 ± 0.13 versus 0.17 ± 0.09, p = .003), and lower anterior/posterior rBMD (0.65 ± 0.13 versus 0.78 ± 0.16, p < .001) than controls. QCV was positively associated with increased odds of prevalent fracture (OR 1.61; 95% CI, 1.04 to 2.49; p = .034), but this association was not independent of integral vBMD (p = .598). Increased anterior/posterior trabecular vBMD ratio was associated with decreased odds of prevalent fracture independent of integral vBMD (OR 0.38; 95% CI, 0.20 to 0.71; p = .003). In conclusion, increased trabecular vBMD in the anterior versus posterior centrum, but not trabecular vBMD heterogeneity, was associated with decreased risk of prevalent fracture independent of integral vBMD. Regional measurements of trabecular vBMD could aid in determining the risk and underlying mechanisms of vertebral fracture. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Jarred Kaiser
- Department of Mechanical Engineering, Boston University, Boston, MA, USA
| | - Brett Allaire
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Paul M Fein
- Department of Mechanical Engineering, Boston University, Boston, MA, USA
| | - Darlene Lu
- Department of Biostatistics, Boston University, Boston, MA, USA
| | - Alexander Adams
- Department of Mechanical Engineering, Boston University, Boston, MA, USA
| | - Douglas P Kiel
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Roslindale, MA, USA
| | - Mohamed Jarraya
- Department of Radiology, Boston University School of Medicine, Boston, MA, USA
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ali Guermazi
- Department of Radiology, Boston University School of Medicine, Boston, MA, USA
| | | | - Elizabeth J Samelson
- Department of Biostatistics, Boston University, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Roslindale, MA, USA
| | - Mary L Bouxsein
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA
| | - Elise F Morgan
- Department of Mechanical Engineering, Boston University, Boston, MA, USA
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19
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Hsu YH, Estrada K, Evangelou E, Ackert-Bicknell C, Akesson K, Beck T, Brown SJ, Capellini T, Carbone L, Cauley J, Cheung CL, Cummings SR, Czerwinski S, Demissie S, Econs M, Evans D, Farber C, Gautvik K, Harris T, Kammerer C, Kemp J, Koller DL, Kung A, Lawlor D, Lee M, Lorentzon M, McGuigan F, Medina-Gomez C, Mitchell B, Newman A, Nielson C, Ohlsson C, Peacock M, Reppe S, Richards JB, Robbins J, Sigurdsson G, Spector TD, Stefansson K, Streeten E, Styrkarsdottir U, Tobias J, Trajanoska K, Uitterlinden A, Vandenput L, Wilson SG, Yerges-Armstrong L, Young M, Zillikens C, Rivadeneira F, Kiel DP, Karasik D. Meta-Analysis of Genomewide Association Studies Reveals Genetic Variants for Hip Bone Geometry. J Bone Miner Res 2019; 34:1284-1296. [PMID: 30888730 PMCID: PMC6650334 DOI: 10.1002/jbmr.3698] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 01/29/2019] [Accepted: 02/07/2019] [Indexed: 12/14/2022]
Abstract
Hip geometry is an important predictor of fracture. We performed a meta-analysis of GWAS studies in adults to identify genetic variants that are associated with proximal femur geometry phenotypes. We analyzed four phenotypes: (i) femoral neck length; (ii) neck-shaft angle; (iii) femoral neck width, and (iv) femoral neck section modulus, estimated from DXA scans using algorithms of hip structure analysis. In the Discovery stage, 10 cohort studies were included in the fixed-effect meta-analysis, with up to 18,719 men and women ages 16 to 93 years. Association analyses were performed with ∼2.5 million polymorphisms under an additive model adjusted for age, body mass index, and height. Replication analyses of meta-GWAS significant loci (at adjusted genomewide significance [GWS], threshold p ≤ 2.6 × 10-8 ) were performed in seven additional cohorts in silico. We looked up SNPs associated in our analysis, for association with height, bone mineral density (BMD), and fracture. In meta-analysis (combined Discovery and Replication stages), GWS associations were found at 5p15 (IRX1 and ADAMTS16); 5q35 near FGFR4; at 12p11 (in CCDC91); 11q13 (near LRP5 and PPP6R3 (rs7102273)). Several hip geometry signals overlapped with BMD, including LRP5 (chr. 11). Chr. 11 SNP rs7102273 was associated with any-type fracture (p = 7.5 × 10-5 ). We used bone transcriptome data and discovered several significant eQTLs, including rs7102273 and PPP6R3 expression (p = 0.0007), and rs6556301 (intergenic, chr.5 near FGFR4) and PDLIM7 expression (p = 0.005). In conclusion, we found associations between several genes and hip geometry measures that explained 12% to 22% of heritability at different sites. The results provide a defined set of genes related to biological pathways relevant to BMD and etiology of bone fragility. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Yi-Hsiang Hsu
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Harvard Medical School, Boston, MA
- Broad Institute, Cambridge, MA
| | - Karol Estrada
- Broad Institute, Cambridge, MA
- Department of Internal Medicine, Erasmus MC, 3000 CA Rotterdam, the Netherlands
- Department of Epidemiology, Erasmus MC, 3000 CA Rotterdam, the Netherlands
| | - Evangelos Evangelou
- Department of Hygiene and Epidemiology, University of Ioannina Medical School, Ioannina 45110, Greece
| | - Cheryl Ackert-Bicknell
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester, Rochester, New York, USA
| | - Kristina Akesson
- Department of Clinical Sciences Malmö, Lund University, Sweden
- Department of Orthopedics, Skåne University Hospital, S-205 02 Malmö, Sweden
| | - Thomas Beck
- Beck Radiological Innovations, Baltimore, MD
| | - Suzanne J Brown
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Terence Capellini
- Department of Human Evolutionary Biology, Harvard University, Cambridge, MA
| | - Laura Carbone
- Department of Medicine at the Medical College of Georgia at Augusta University, Augusta, GA
| | - Jane Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Ching-Lung Cheung
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Steven R Cummings
- California Pacific Medical Center Research Institute, San Francisco, CA
| | | | - Serkalem Demissie
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Michael Econs
- Department of Medicine and Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Daniel Evans
- California Pacific Medical Center Research Institute, San Francisco, CA
| | - Charles Farber
- Public Health Sciences, University of Virginia, Charlottesville, VA
| | - Kaare Gautvik
- Lovisenberg Diakonale Hospital, Unger-Vetlesen Institute, and University of Oslo, Institute of Basic Medical Sciences, Oslo, Norway
| | - Tamara Harris
- Laboratory of Epidemiology and Population Sciences, Intramural Research Program, NIA, Bethesda, MD
| | - Candace Kammerer
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - John Kemp
- University of Queensland Diamantina Institute, Translational Research Institute, Brisbane, Queensland, Australia
- MRC Integrative Epidemiology Unit, University of Bristol, UK
| | - Daniel L Koller
- Department of Medicine and Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Annie Kung
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Debbie Lawlor
- MRC Integrative Epidemiology Unit, University of Bristol, UK
| | - Miryoung Lee
- University of Texas, School of Public Health at Bronwsville, TX
| | - Mattias Lorentzon
- Department of Internal Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, SE-413 45 Gothenburg, Sweden
| | - Fiona McGuigan
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester, Rochester, New York, USA
- Department of Clinical Sciences Malmö, Lund University, Sweden
| | | | - Braxton Mitchell
- Program in Personalized and Genomic Medicine, and Department of Medicine, Division of Endocrinology, Diabetes and Nutrition, University of Maryland School of Medicine, and Geriatric Research and Education Clinical Center - Veterans Administration Medical Center, Baltimore, MD
| | - Anne Newman
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | | | - Claes Ohlsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, SE-413 45 Gothenburg, Sweden
| | - Munro Peacock
- Department of Medicine and Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Sjur Reppe
- Lovisenberg Diakonale Hospital, Unger-Vetlesen Institute, and University of Oslo, Institute of Basic Medical Sciences, Oslo, Norway
- Oslo University Hospital, Department of Medical Biochemistry, Oslo, Norway
| | - J Brent Richards
- Department of Human Genetics, McGill University, and Lady Davis Institute, Jewish General Hospital, McGill University, Montréal, Québec, Canada
| | - John Robbins
- Department of Medicine, University California at Davis, Sacramento, CA
| | | | - Timothy D Spector
- Department of Twin Research and Genetic Epidemiology, King’s College London, St Thomas’ Campus, London, UK
| | | | - Elizabeth Streeten
- Program in Personalized and Genomic Medicine, and Department of Medicine, Division of Endocrinology, Diabetes and Nutrition, University of Maryland School of Medicine, and Geriatric Research and Education Clinical Center - Veterans Administration Medical Center, Baltimore, MD
| | | | | | | | - André Uitterlinden
- Department of Internal Medicine, Erasmus MC, 3000 CA Rotterdam, the Netherlands
- Department of Epidemiology, Erasmus MC, 3000 CA Rotterdam, the Netherlands
| | - Liesbeth Vandenput
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, SE-413 45 Gothenburg, Sweden
| | - Scott G Wilson
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Australia
- Department of Twin Research and Genetic Epidemiology, King’s College London, St Thomas’ Campus, London, UK
- School of Biomedical Sciences, University of Western Australia, Nedlands, Australia
| | | | - Mariel Young
- Department of Human Evolutionary Biology, Harvard University, Cambridge, MA
| | - Carola Zillikens
- Department of Internal Medicine, Erasmus MC, 3000 CA Rotterdam, the Netherlands
- Department of Epidemiology, Erasmus MC, 3000 CA Rotterdam, the Netherlands
| | - Fernando Rivadeneira
- Department of Internal Medicine, Erasmus MC, 3000 CA Rotterdam, the Netherlands
- Department of Epidemiology, Erasmus MC, 3000 CA Rotterdam, the Netherlands
| | - Douglas P Kiel
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Harvard Medical School, Boston, MA
- Broad Institute, Cambridge, MA
| | - David Karasik
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
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20
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López Picazo M, Humbert L, Di Gregorio S, González Ballester MA, Del Río Barquero LM. Discrimination of osteoporosis-related vertebral fractures by DXA-derived 3D measurements: a retrospective case-control study. Osteoporos Int 2019; 30:1099-1110. [PMID: 30770938 DOI: 10.1007/s00198-019-04894-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 02/08/2019] [Indexed: 01/30/2023]
Abstract
UNLABELLED A retrospective case-control study assessing the association of DXA-derived 3D measurements with osteoporosis-related vertebral fractures was performed. Trabecular volumetric bone mineral density was the measurement that best discriminates between fracture and control groups. INTRODUCTION The aim of the present study was to evaluate the association of DXA-derived 3D measurements at the lumbar spine with osteoporosis-related vertebral fractures. METHODS We retrospectively analyzed a database of 74 postmenopausal women: 37 subjects with incident vertebral fractures and 37 age-matched controls without any type of fracture. DXA scans at the lumbar spine were acquired at baseline (i.e., before the fracture event for subjects in the fracture group), and areal bone mineral density (aBMD) was measured. DXA-derived 3D measurements, such as volumetric BMD (vBMD), were assessed using a DXA-based 3D modeling software (3D-SHAPER). vBMD was computed at the trabecular, cortical, and integral bone. Cortical thickness and cortical surface BMD were also measured. Differences in DXA-derived measurements between fracture and control groups were evaluated using unpaired t test. Odds ratio (OR) and area under the receiver operating curve (AUC) were also computed. Subgroup analyses according to fractured vertebra were performed. RESULTS aBMD of fracture group was 9.3% lower compared with control group (p < 0.01); a higher difference was found for trabecular vBMD in the vertebral body (- 16.1%, p < 0.001). Trabecular vBMD was the measurement that best discriminates between fracture and control groups, with an AUC of 0.733, against 0.682 for aBMD. Overall, similar findings were observed within the subgroup analyses. The L1 vertebral fractures subgroup had the highest AUC at trabecular vBMD (0.827), against aBMD (0.758). CONCLUSION This study showed the ability of cortical and trabecular measurements from DXA-derived 3D models to discriminate between fracture and control groups. Large cohorts need to be analyzed to determine if these measurements could improve fracture risk prediction in clinical practice.
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Affiliation(s)
- M López Picazo
- Musculoskeletal Unit, Galgo Medical, Barcelona, Spain.
- BCN Medtech, Universitat Pompeu Fabra, Barcelona, Spain.
| | - L Humbert
- Musculoskeletal Unit, Galgo Medical, Barcelona, Spain
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21
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Digital Tomosynthesis and Fractal Analysis Predict Prevalent Vertebral Fractures in Patients With Multiple Myeloma: A Preliminary In Vivo Study. AJR Am J Roentgenol 2019; 213:W38-W44. [PMID: 30973772 DOI: 10.2214/ajr.18.20700] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE. The objective of this study was to investigate the association of fractal-derived bone microstructural parameters with vertebral fracture status using in vivo digital tomosynthesis images of the spine. MATERIALS AND METHODS. Digital tomosynthesis images of the thoracic and lumbar spine from T1 to L5 were acquired from 36 patients with newly diagnosed multiple myeloma or monoclonal gammopathy of uncertain significance (age range, 39-85 years old). Scans were performed with patients in the supine position with reconstructed planes formed in the coronal direction. Bone mineral density (BMD) was recorded for 10 patients who had recently undergone dual x-ray absorptiometry. Vertebral fracture and lytic lesion status was determined by a radiologist from digital radiographs. Radiologist interpretation was reviewed to identify levels with a minimum number of fractures or lesions. For fractal analysis, the largest possible cuboid volume of interest within the cancellous bone was cropped from T7 and T11 images. Mean and SD of fractal variables between slices of fractal dimension (FD, a measure of self-similarity in the texture), mean lacunarity (λ, a measure of heterogeneity) and the slope of lacunarity versus box size relationship (Sλ, a measure of sensitivity of heterogeneity to size scale) were calculated using a box-counting method. A generalized estimating equation (GEE) platform was used to examine fractal variables as predictors of fracture status. RESULTS. Fracture status was not significantly associated with sex, race, age, stage of myeloma, presence of lesion in the spine, or BMD. In light of these results, no correction was made for these variables in further analyses of fractal variables. No interaction was found between vertebral level and any of the fractal variables (p = 0.12-0.77). Therefore, vertebral level was not considered further as an independent variable. Logistic regression analysis within GEE indicated that probability of fracture decreased with increasing mean FD (p = 0.02). In contrast, probability of fracture increased with increasing mean λ (p = 0.03). Although not to a statistically significant degree, probability of fracture increased with increasing mean Sλ (p = 0.08), SD of FD (p = 0.07), SD of λ (p = 0.07), and SD of Sλ (p = 0.06). CONCLUSION. We found FD and lacunarity calculated within the cancellous centrum of T7 and T11 vertebrae to be significantly associated with the presence of a vertebral fracture in this cohort. The decreased probability of fracture with increasing fractal dimension and increased probability of fracture with increasing lacunarity are consistent with the idea that cancellous bone with a better organized trabecular architecture is mechanically more competent. To our knowledge, this is the first in vivo evidence that fractal analysis of vertebral bone from tomosynthesis images may be useful in assessing vertebral fracture risk in patients with multiple myeloma.
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22
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Allaire BT, Lu D, Johannesdottir F, Kopperdahl D, Keaveny TM, Jarraya M, Guermazi A, Bredella MA, Samelson EJ, Kiel DP, Anderson DE, Demissie S, Bouxsein ML. Prediction of incident vertebral fracture using CT-based finite element analysis. Osteoporos Int 2019; 30:323-331. [PMID: 30306225 PMCID: PMC6450770 DOI: 10.1007/s00198-018-4716-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 09/19/2018] [Indexed: 01/24/2023]
Abstract
UNLABELLED Prior studies show vertebral strength from computed tomography-based finite element analysis may be associated with vertebral fracture risk. We found vertebral strength had a strong association with new vertebral fractures, suggesting that vertebral strength measures identify those at risk for vertebral fracture and may be a useful clinical tool. INTRODUCTION We aimed to determine the association between vertebral strength by quantitative computed tomography (CT)-based finite element analysis (FEA) and incident vertebral fracture (VF). In addition, we examined sensitivity and specificity of previously proposed diagnostic thresholds for fragile bone strength and low BMD in predicting VF. METHODS In a case-control study, 26 incident VF cases (13 men, 13 women) and 62 age- and sex-matched controls aged 50 to 85 years were selected from the Framingham multi-detector computed tomography cohort. Vertebral compressive strength, integral vBMD, trabecular vBMD, CT-based BMC, and CT-based aBMD were measured from CT scans of the lumbar spine. RESULTS Lower vertebral strength at baseline was associated with an increased risk of new or worsening VF after adjusting for age, BMI, and prevalent VF status (odds ratio (OR) = 5.2 per 1 SD decrease, 95% CI 1.3-19.8). Area under receiver operating characteristic (ROC) curve comparisons revealed that vertebral strength better predicted incident VF than CT-based aBMD (AUC = 0.804 vs. 0.715, p = 0.05) but was not better than integral vBMD (AUC = 0.815) or CT-based BMC (AUC = 0.794). Additionally, proposed fragile bone strength thresholds trended toward better sensitivity for identifying VF than that of aBMD-classified osteoporosis (0.46 vs. 0.23, p = 0.09). CONCLUSION This study shows an association between vertebral strength measures and incident vertebral fracture in men and women. Though limited by a small sample size, our findings also suggest that bone strength estimates by CT-based FEA provide equivalent or better ability to predict incident vertebral fracture compared to CT-based aBMD. Our study confirms that CT-based estimates of vertebral strength from FEA are useful for identifying patients who are at high risk for vertebral fracture.
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Affiliation(s)
- B T Allaire
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, RN 115, Boston, MA, 02215, USA
| | - D Lu
- Boston University, Boston, MA, USA
| | - F Johannesdottir
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, RN 115, Boston, MA, 02215, USA
- Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA
| | | | - T M Keaveny
- Department of Mechanical Engineering, University of California, Berkeley, CA, USA
- Department of Bioengineering, University of California, Berkeley, CA, USA
| | - M Jarraya
- Department of Radiology, Mercy Catholic Medical Center, Darby, PA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - A Guermazi
- Boston University School of Medicine, Boston, MA, USA
| | - M A Bredella
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - E J Samelson
- Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - D P Kiel
- Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - D E Anderson
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, RN 115, Boston, MA, 02215, USA
- Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA
| | | | - M L Bouxsein
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, RN 115, Boston, MA, 02215, USA.
- Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA.
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23
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Johannesdottir F, Allaire B, Bouxsein ML. Fracture Prediction by Computed Tomography and Finite Element Analysis: Current and Future Perspectives. Curr Osteoporos Rep 2018; 16:411-422. [PMID: 29846870 DOI: 10.1007/s11914-018-0450-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW This review critiques the ability of CT-based methods to predict incident hip and vertebral fractures. RECENT FINDINGS CT-based techniques with concurrent calibration all show strong associations with incident hip and vertebral fracture, predicting hip and vertebral fractures as well as, and sometimes better than, dual-energy X-ray absorptiometry areal biomass density (DXA aBMD). There is growing evidence for use of routine CT scans for bone health assessment. CT-based techniques provide a robust approach for osteoporosis diagnosis and fracture prediction. It remains to be seen if further technical advances will improve fracture prediction compared to DXA aBMD. Future work should include more standardization in CT analyses, establishment of treatment intervention thresholds, and more studies to determine whether routine CT scans can be efficiently used to expand the number of individuals who undergo evaluation for fracture risk.
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Affiliation(s)
- Fjola Johannesdottir
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, RN 120, Boston, MA, 02215, USA.
- Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA.
| | - Brett Allaire
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, RN 120, Boston, MA, 02215, USA
| | - Mary L Bouxsein
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, RN 120, Boston, MA, 02215, USA
- Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA
- Endocrine Unit, Massachusetts General Hospital, Boston, MA, USA
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24
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van Dort MJ, Geusens P, Driessen JH, Romme EA, Smeenk FW, Wouters EF, van den Bergh JP. High Imminent Vertebral Fracture Risk in Subjects With COPD With a Prevalent or Incident Vertebral Fracture. J Bone Miner Res 2018; 33:1233-1241. [PMID: 29572955 DOI: 10.1002/jbmr.3429] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 03/08/2018] [Accepted: 03/16/2018] [Indexed: 01/08/2023]
Abstract
Subjects with chronic obstructive pulmonary disease (COPD) have an increased risk of vertebral fractures (VFs); however, VF incidence is largely unknown. Therefore, the aim of our study was to determine the incidence of new and/or worsening VF in subjects with COPD. Smokers and subjects with COPD (GOLD II-IV) from the ECLIPSE study with complete set of chest CT scans (baseline and 1- and 3-year follow-up) to evaluate vertebrae T1 down to L1 were included. If a VF was diagnosed on the last scan, detailed VF assessment of the previous scans was performed. VFs were scored according to the method of Genant as mild, moderate, or severe. Main outcome measure was the cumulative incidence of new and/or worsening VF at subject level, within 1 and 3 years. Of 1239 subjects (mean age 61 years, 757 males [61%], 999 subjects with COPD), 253 (20.5%) had ≥1 prevalent VF. The cumulative incidence of VFs was 10.1% within 1 year and 24.0% within 3 years. After adjustment for age, sex, body mass index (BMI), pack-years, and smoking status, prevalence and incidence were similar between smokers and COPD GOLD stages. Within 1 year, 29.2% of the subjects with a prevalent VF had an incident VF, compared with 5.1% in absence of prevalent VF (hazard ratio [HR] = 5.1; 95% confidence interval [CI] 3.6-7.4) and 58.5% versus 15.0% within 3 years (HR = 3.6; 95% CI 2.9-4.6). The incidence of VF was higher with increasing number and severity of prevalent VFs. Among subjects having an incident VF within the first year, 57.3% had a subsequent VF within the next 2 years. In this study, more than half of the smokers and subjects with COPD with a prevalent VF or an incident VF within the first year sustained a subsequent VF within 3 years. The 3-year risk was even higher in the presence of multiple or severe prevalent VFs. © 2018 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals Inc.
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Affiliation(s)
- Mayke J van Dort
- Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+ (MUMC+), Maastricht, the Netherlands
| | - Piet Geusens
- Department of Internal Medicine/Rheumatology, Maastricht University Medical Centre+ (MUMC+), Maastricht, the Netherlands
| | - Johanna Hm Driessen
- Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+ (MUMC+), Maastricht, the Netherlands.,CAPHRI Care and Public Health Research Institute, Maastricht University Medical Centre+ (MUMC+), Maastricht, the Netherlands.,Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+ (MUMC+), Maastricht, the Netherlands
| | - Elisabeth Apm Romme
- Department of Respiratory Medicine, Catharina Hospital, Eindhoven, the Netherlands
| | - Frank Wjm Smeenk
- Department of Respiratory Medicine, Catharina Hospital, Eindhoven, the Netherlands
| | - Emiel Fm Wouters
- Department of Respiratory Diseases, Maastricht University Medical Centre+ (MUMC+), Maastricht, the Netherlands
| | - Joop Pw van den Bergh
- Department of Internal Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+ (MUMC+), Maastricht, the Netherlands.,Department of Internal Medicine, VieCuri Medical Centre, Venlo, the Netherlands
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25
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Choksi P, Jepsen KJ, Clines GA. The challenges of diagnosing osteoporosis and the limitations of currently available tools. Clin Diabetes Endocrinol 2018; 4:12. [PMID: 29862042 PMCID: PMC5975657 DOI: 10.1186/s40842-018-0062-7] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 04/27/2018] [Indexed: 02/07/2023] Open
Abstract
Dual-energy X-ray absorptiometry (DXA) was the first imaging tool widely utilized by clinicians to assess fracture risk, especially in postmenopausal women. The development of DXA nearly coincided with the availability of effective osteoporosis medications. Although osteoporosis in adults is diagnosed based on a T-score equal to or below − 2.5 SD, most individuals who sustain fragility fractures are above this arbitrary cutoff. This incongruity poses a challenge to clinicians to identify patients who may benefit from osteoporosis treatments. DXA scanners generate 2 dimensional images of complex 3 dimensional structures, and report bone density as the quotient of the bone mineral content divided by the bone area. An obvious pitfall of this method is that a larger bone will convey superior strength, but may in fact have the same bone density as a smaller bone. Other imaging modalities are available such as peripheral quantitative CT, but are largely research tools. Current osteoporosis medications increase bone density and reduce fracture risk but the mechanisms of these actions vary. Anti-resorptive medications (bisphosphonates and denosumab) primarily increase endocortical bone by bolstering mineralization of endosteal resorption pits and thereby increase cortical thickness and reduce cortical porosity. Anabolic medications (teriparatide and abaloparatide) increase the periosteal and endosteal perimeters without large changes in cortical thickness resulting in a larger more structurally sound bone. Because of the differences in the mechanisms of the various drugs, there are likely benefits of selecting a treatment based on a patient’s unique bone structure and pattern of bone loss. This review retreats to basic principles in order to advance clinical management of fragility fractures by examining how skeletal biomechanics, size, shape, and ultra-structural properties are the ultimate predictors of bone strength. Accurate measurement of these skeletal parameters through the development of better imaging scanners is critical to advancing fracture risk assessment and informing clinicians on the best treatment strategy. With this information, a “treat to target” approach could be employed to tailor current and future therapies to each patient’s unique skeletal characteristics.
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Affiliation(s)
- Palak Choksi
- 1Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
| | - Karl J Jepsen
- 2Departments of Orthopaedic Surgery and Biomedical Engineering, University of Michigan, Ann Arbor, MI USA
| | - Gregory A Clines
- 1Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA.,Endocrinology Section, Ann Arbor VA Medical Center, 2215 Fuller Road, Research 151, Ann Arbor, MI 48105-2399 USA
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26
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Salvatore G, Berton A, Giambini H, Ciuffreda M, Florio P, Longo UG, Denaro V, Thoreson A, An KN. Biomechanical effects of metastasis in the osteoporotic lumbar spine: A Finite Element Analysis. BMC Musculoskelet Disord 2018; 19:38. [PMID: 29402261 PMCID: PMC5799979 DOI: 10.1186/s12891-018-1953-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 01/22/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Cancer patients are likely to undergo osteoporosis as consequence of hormone manipulation and/or chemotherapy. Little is known about possible increased risk of fracture in this population. The aim of this study was to describe the biomechanical effect of a metastatic lesion in an osteoporotic lumbar spine model. METHODS A finite element model of two spinal motion segments (L3-L5) was extracted from a previously developed L3-Sacrum model and used to analyze the effect of metastasis size and bone mineral density (BMD) on Vertebral bulge (VB) and Vertebral height (VH). VB and VH represent respectively radial and axial displacement and they have been correlated to burst fracture. A total of 6 scenarios were evaluated combining three metastasis sizes (no metastasis, 15% and 30% of the vertebral body) and two BMD conditions (normal BMD and osteoporosis). RESULTS 15% metastasis increased VB and VH by 178% and 248%, respectively in normal BMD model; while VB and VH increased by 134% and 174% in osteoporotic model. 30% metastasis increased VB and VH by 88% and 109%, respectively, when compared to 15% metastasis in normal BMD model; while VB and VH increased by 59% and 74% in osteoporotic model. CONCLUSION A metastasis in the osteoporotic lumbar spine always leads to a higher risk of vertebral fracture. This risk increases with the size of the metastasis. Unexpectedly, an increment in metastasis size in the normal BMD spine produces a greater impact on vertebral stability compared to the osteoporotic spine.
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Affiliation(s)
- Giuseppe Salvatore
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128 Trigoria, Rome, Italy
| | - Alessandra Berton
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128 Trigoria, Rome, Italy
| | - Hugo Giambini
- Biomechanics Laboratory, Division of Orthopaedic Research, Mayo Clinic, Rochester, MN, USA
| | - Mauro Ciuffreda
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128 Trigoria, Rome, Italy
| | - Pino Florio
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128 Trigoria, Rome, Italy
| | - Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128 Trigoria, Rome, Italy.
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128 Trigoria, Rome, Italy
| | - Andrew Thoreson
- Biomechanics Laboratory, Division of Orthopaedic Research, Mayo Clinic, Rochester, MN, USA
| | - Kai-Nan An
- Biomechanics Laboratory, Division of Orthopaedic Research, Mayo Clinic, Rochester, MN, USA
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Lee DC, Hoffmann PF, Kopperdahl DL, Keaveny TM. Phantomless calibration of CT scans for measurement of BMD and bone strength-Inter-operator reanalysis precision. Bone 2017; 103:325-333. [PMID: 28778598 PMCID: PMC5636218 DOI: 10.1016/j.bone.2017.07.029] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 06/01/2017] [Accepted: 07/21/2017] [Indexed: 01/22/2023]
Abstract
Patient-specific phantomless calibration of computed tomography (CT) scans has the potential to simplify and expand the use of pre-existing clinical CT for quantitative bone densitometry and bone strength analysis for diagnostic and monitoring purposes. In this study, we quantified the inter-operator reanalysis precision errors for a novel implementation of patient-specific phantomless calibration, using air and either aortic blood or hip adipose tissue as internal calibrating reference materials, and sought to confirm the equivalence between phantomless and (traditional) phantom-based measurements. CT scans of the spine and hip for 25 women and 15 men (mean±SD age of 67±9years, range 41-86years), one scan per anatomic site per patient, were analyzed independently by two analysts using the VirtuOst software (O.N. Diagnostics, Berkeley, CA). The scans were acquired at 120kVp, with a slice thickness/increment of 3mm or less, on nine different CT scanner models across 24 different scanners. The main parameters assessed were areal bone mineral density (BMD) at the hip (total hip and femoral neck), trabecular volumetric BMD at the spine, and vertebral and femoral strength by finite element analysis; other volumetric BMD measures were also assessed. We found that the reanalysis precision errors for all phantomless measurements were ≤0.5%, which was as good as for phantom calibration. Regression analysis indicated equivalence of the phantom- versus phantomless-calibrated measurements (slope not different than unity, R2≥0.98). Of the main parameters assessed, non-significant paired mean differences (n=40) between the two measurements ranged from 0.6% for hip areal BMD to 1.1% for mid-vertebral trabecular BMD. These results indicate that phantom-equivalent measurements of both BMD and finite element-derived bone strength can be reliably obtained from CT scans using patient-specific phantomless calibration.
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Affiliation(s)
| | | | | | - Tony M Keaveny
- Department of Mechanical Engineering, University of California, Berkeley, CA, USA; Department of Bioengineering, University of California, Berkeley, CA, USA.
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28
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Keaveny TM, Crittenden DB, Bolognese MA, Genant HK, Engelke K, Oliveri B, Brown JP, Langdahl BL, Yan C, Grauer A, Libanati C. Greater Gains in Spine and Hip Strength for Romosozumab Compared With Teriparatide in Postmenopausal Women With Low Bone Mass. J Bone Miner Res 2017; 32:1956-1962. [PMID: 28543940 DOI: 10.1002/jbmr.3176] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 05/09/2017] [Accepted: 05/22/2017] [Indexed: 12/18/2022]
Abstract
Romosozumab is a monoclonal antibody that inhibits sclerostin and has been shown to reduce the risk of fractures within 12 months. In a phase II, randomized, placebo-controlled clinical trial of treatment-naïve postmenopausal women with low bone mass, romosozumab increased bone mineral density (BMD) at the hip and spine by the dual effect of increasing bone formation and decreasing bone resorption. In a substudy of that trial, which included placebo and teriparatide arms, here we investigated whether those observed increases in BMD also resulted in improvements in estimated strength, as assessed by finite element analysis. Participants received blinded romosozumab s.c. (210 mg monthly) or placebo, or open-label teriparatide (20 μg daily) for 12 months. CT scans, obtained at the lumbar spine (n = 82) and proximal femur (n = 46) at baseline and month 12, were analyzed with finite element software (VirtuOst, O.N. Diagnostics) to estimate strength for a simulated compression overload for the spine (L1 vertebral body) and a sideways fall for the proximal femur, all blinded to treatment assignment. We found that, at month 12, vertebral strength increased more for romosozumab compared with both teriparatide (27.3% versus 18.5%; p = 0.005) and placebo (27.3% versus -3.9%; p < 0.0001); changes in femoral strength for romosozumab showed similar but smaller changes, increasing more with romosozumab versus teriparatide (3.6% versus -0.7%; p = 0.027), and trending higher versus placebo (3.6% versus -0.1%; p = 0.059). Compartmental analysis revealed that the bone-strengthening effects for romosozumab were associated with positive contributions from both the cortical and trabecular bone compartments at both the lumbar spine and hip. Taken together, these findings suggest that romosozumab may offer patients with osteoporosis a new bone-forming therapeutic option that increases both vertebral and femoral strength within 12 months. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
| | | | | | | | - Klaus Engelke
- Bioclinica, Hamburg, Germany, and Institute of Medical Physics, University of Erlangen, Erlangen, Germany
| | | | - Jacques P Brown
- CHU de Québec Research Centre and Laval University, Québec City, QC, Canada
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Oei L, Koromani F, Rivadeneira F, Zillikens MC, Oei EHG. Quantitative imaging methods in osteoporosis. Quant Imaging Med Surg 2016; 6:680-698. [PMID: 28090446 DOI: 10.21037/qims.2016.12.13] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Osteoporosis is characterized by a decreased bone mass and quality resulting in an increased fracture risk. Quantitative imaging methods are critical in the diagnosis and follow-up of treatment effects in osteoporosis. Prior radiographic vertebral fractures and bone mineral density (BMD) as a quantitative parameter derived from dual-energy X-ray absorptiometry (DXA) are among the strongest known predictors of future osteoporotic fractures. Therefore, current clinical decision making relies heavily on accurate assessment of these imaging features. Further, novel quantitative techniques are being developed to appraise additional characteristics of osteoporosis including three-dimensional bone architecture with quantitative computed tomography (QCT). Dedicated high-resolution (HR) CT equipment is available to enhance image quality. At the other end of the spectrum, by utilizing post-processing techniques such as the trabecular bone score (TBS) information on three-dimensional architecture can be derived from DXA images. Further developments in magnetic resonance imaging (MRI) seem promising to not only capture bone micro-architecture but also characterize processes at the molecular level. This review provides an overview of various quantitative imaging techniques based on different radiological modalities utilized in clinical osteoporosis care and research.
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Affiliation(s)
- Ling Oei
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Fjorda Koromani
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Fernando Rivadeneira
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Edwin H G Oei
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Nielson CM, Liu CT, Smith AV, Ackert-Bicknell CL, Reppe S, Jakobsdottir J, Wassel C, Register TC, Oei L, Alonso N, Oei EH, Parimi N, Samelson EJ, Nalls MA, Zmuda J, Lang T, Bouxsein M, Latourelle J, Claussnitzer M, Siggeirsdottir K, Srikanth P, Lorentzen E, Vandenput L, Langefeld C, Raffield L, Terry G, Cox AJ, Allison MA, Criqui MH, Bowden D, Ikram MA, Mellstrom D, Karlsson MK, Carr J, Budoff M, Phillips C, Cupples LA, Chou WC, Myers RH, Ralston SH, Gautvik KM, Cawthon PM, Cummings S, Karasik D, Rivadeneira F, Gudnason V, Orwoll ES, Harris TB, Ohlsson C, Kiel DP, Hsu YH. Novel Genetic Variants Associated With Increased Vertebral Volumetric BMD, Reduced Vertebral Fracture Risk, and Increased Expression of SLC1A3 and EPHB2. J Bone Miner Res 2016; 31:2085-2097. [PMID: 27476799 PMCID: PMC5477772 DOI: 10.1002/jbmr.2913] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 06/22/2016] [Accepted: 07/08/2016] [Indexed: 12/26/2022]
Abstract
Genome-wide association studies (GWASs) have revealed numerous loci for areal bone mineral density (aBMD). We completed the first GWAS meta-analysis (n = 15,275) of lumbar spine volumetric BMD (vBMD) measured by quantitative computed tomography (QCT), allowing for examination of the trabecular bone compartment. SNPs that were significantly associated with vBMD were also examined in two GWAS meta-analyses to determine associations with morphometric vertebral fracture (n = 21,701) and clinical vertebral fracture (n = 5893). Expression quantitative trait locus (eQTL) analyses of iliac crest biopsies were performed in 84 postmenopausal women, and murine osteoblast expression of genes implicated by eQTL or by proximity to vBMD-associated SNPs was examined. We identified significant vBMD associations with five loci, including: 1p36.12, containing WNT4 and ZBTB40; 8q24, containing TNFRSF11B; and 13q14, containing AKAP11 and TNFSF11. Two loci (5p13 and 1p36.12) also contained associations with radiographic and clinical vertebral fracture, respectively. In 5p13, rs2468531 (minor allele frequency [MAF] = 3%) was associated with higher vBMD (β = 0.22, p = 1.9 × 10-8 ) and decreased risk of radiographic vertebral fracture (odds ratio [OR] = 0.75; false discovery rate [FDR] p = 0.01). In 1p36.12, rs12742784 (MAF = 21%) was associated with higher vBMD (β = 0.09, p = 1.2 × 10-10 ) and decreased risk of clinical vertebral fracture (OR = 0.82; FDR p = 7.4 × 10-4 ). Both SNPs are noncoding and were associated with increased mRNA expression levels in human bone biopsies: rs2468531 with SLC1A3 (β = 0.28, FDR p = 0.01, involved in glutamate signaling and osteogenic response to mechanical loading) and rs12742784 with EPHB2 (β = 0.12, FDR p = 1.7 × 10-3 , functions in bone-related ephrin signaling). Both genes are expressed in murine osteoblasts. This is the first study to link SLC1A3 and EPHB2 to clinically relevant vertebral osteoporosis phenotypes. These results may help elucidate vertebral bone biology and novel approaches to reducing vertebral fracture incidence. © 2016 American Society for Bone and Mineral Research.
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Affiliation(s)
- Carrie M Nielson
- School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - Ching-Ti Liu
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Albert V Smith
- Icelandic Heart Association, Kopavogur, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | | | - Sjur Reppe
- Department of Medical Biochemistry, Oslo University Hospital, Ullevål, Oslo, Norway
- Lovisenberg Diakonale Hospital, Oslo, Norway
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | | | - Christina Wassel
- Department of Pathology and Laboratory Medicine, University of Vermont College of Medicine, Burlington, VT, USA
| | - Thomas C Register
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Ling Oei
- Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
- Netherlands Genomics Initiative (NGI)-sponsored Netherlands Consortium for Healthy Aging (NCHA), Leiden, The Netherlands
| | - Nerea Alonso
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, Scotland, UK
| | - Edwin H Oei
- Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Neeta Parimi
- California Pacific Medical Center Research Institute, San Francisco, CA, USA
| | - Elizabeth J Samelson
- Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
| | - Mike A Nalls
- National Institute on Aging (NIA), National Institutes of Health, Bethesda, MD, USA
| | - Joseph Zmuda
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Thomas Lang
- Department of Radiology, University of California, San Francisco (UCSF) School of Medicine, San Francisco, CA, USA
| | - Mary Bouxsein
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Harvard University Medical School, Boston, MA, USA
| | | | - Melina Claussnitzer
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University Medical School, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Technical University Munich, Munich, Germany
| | | | - Priya Srikanth
- School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - Erik Lorentzen
- Department of Bioinformatics, Gothenburg University, Gothenburg, Sweden
| | - Liesbeth Vandenput
- Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Carl Langefeld
- Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Laura Raffield
- Center for Human Genomics, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Center for Diabetes Research, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Greg Terry
- Department of Radiology & Radiological Sciences, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN, USA
| | - Amanda J Cox
- Center for Diabetes Research, Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Matthew A Allison
- Department of Family Medicine and Public Health, University of California, San Diego (UCSD), La Jolla, CA, USA
| | - Michael H Criqui
- Department of Family Medicine and Public Health, University of California, San Diego (UCSD), La Jolla, CA, USA
| | - Don Bowden
- Center for Diabetes Research, Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Internal Medicine/Endocrinology, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Center for Genomics and Personalized Medicine Research, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - M Arfan Ikram
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Dan Mellstrom
- Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus K Karlsson
- Department of Orthopaedics and Clinical Sciences, Malmo University Hospital, Lund University, Malmo, Sweden
| | - John Carr
- Department of Radiology & Radiological Sciences, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN, USA
| | - Matthew Budoff
- Los Angeles Biomedical Research Institute, Torrance, CA, USA
| | - Caroline Phillips
- National Institute on Aging (NIA), National Institutes of Health, Bethesda, MD, USA
| | - L Adrienne Cupples
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Wen-Chi Chou
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | | | - Stuart H Ralston
- Rheumatic Diseases Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, Scotland, UK
| | - Kaare M Gautvik
- Lovisenberg Diakonale Hospital, Oslo, Norway
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Peggy M Cawthon
- California Pacific Medical Center Research Institute, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Steven Cummings
- California Pacific Medical Center Research Institute, San Francisco, CA, USA
| | - David Karasik
- Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Fernando Rivadeneira
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Vilmundur Gudnason
- Icelandic Heart Association, Kopavogur, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Eric S Orwoll
- Division of Endocrinology, Oregon Health & Science University, Portland, OR, USA
| | - Tamara B Harris
- National Institute on Aging (NIA), National Institutes of Health, Bethesda, MD, USA
| | - Claes Ohlsson
- Centre for Bone and Arthritis Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Douglas P Kiel
- Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University Medical School, Boston, MA, USA
| | - Yi-Hsiang Hsu
- Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Molecular and Integrative Physiological Sciences, Harvard School of Public Health, Boston, MA, USA
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Lee DC, Varela A, Kostenuik PJ, Ominsky MS, Keaveny TM. Finite Element Analysis of Denosumab Treatment Effects on Vertebral Strength in Ovariectomized Cynomolgus Monkeys. J Bone Miner Res 2016; 31:1586-95. [PMID: 27149403 DOI: 10.1002/jbmr.2830] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 03/01/2016] [Accepted: 03/04/2016] [Indexed: 01/22/2023]
Abstract
Finite element analysis has not yet been validated for measuring changes in whole-bone strength at the hip or spine in people after treatment with an osteoporosis agent. Toward that end, we assessed the ability of a clinically approved implementation of finite element analysis to correctly quantify treatment effects on vertebral strength, comparing against direct mechanical testing, in cynomolgus monkeys randomly assigned to one of three 16-month-long treatments: sham surgery with vehicle (Sham-Vehicle), ovariectomy with vehicle (OVX-Vehicle), or ovariectomy with denosumab (OVX-DMAb). After treatment, T12 vertebrae were retrieved, scanned with micro-CT, and mechanically tested to measure compressive strength. Blinded to the strength data and treatment codes, the micro-CT images were coarsened and homogenized to create continuum-type finite element models, without explicit porosity. With clinical translation in mind, these models were then analyzed for strength using the U.S. Food and Drug Administration (FDA)-cleared VirtuOst software application (O.N. Diagnostics, Berkeley, CA, USA), developed for analysis of human bones. We found that vertebral strength by finite element analysis was highly correlated (R(2) = 0.97; n = 52) with mechanical testing, independent of treatment (p = 0.12). Further, the size of the treatment effect on strength (ratio of mean OVX-DMAb to mean OVX-Vehicle, as a percentage) was large and did not differ (p = 0.79) between mechanical testing (+57%; 95% CI [26%, 95%]) and finite element analysis (+51% [20%, 88%]). The micro-CT analysis revealed increases in cortical thickness (+45% [19%, 73%]) and trabecular bone volume fraction (+24% [8%, 42%]). These results show that a preestablished clinical finite element analysis implementation-developed for human bone and clinically validated in fracture-outcome studies-correctly quantified the observed treatment effects of denosumab on vertebral strength in cynomolgus monkeys. One implication is that the treatment effects in this study are well explained by the features contained within these finite element models, namely, the bone geometry and mass and the spatial distribution of bone mass. © 2016 American Society for Bone and Mineral Research.
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Affiliation(s)
| | - Aurore Varela
- Charles River Laboratories Inc., Montréal, QC, Canada
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Giambini H, Dragomir-Daescu D, Huddleston PM, Camp JJ, An KN, Nassr A. The Effect of Quantitative Computed Tomography Acquisition Protocols on Bone Mineral Density Estimation. J Biomech Eng 2016; 137:114502. [PMID: 26355694 DOI: 10.1115/1.4031572] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 09/09/2015] [Indexed: 11/08/2022]
Abstract
Osteoporosis is characterized by bony material loss and decreased bone strength leading to a significant increase in fracture risk. Patient-specific quantitative computed tomography (QCT) finite element (FE) models may be used to predict fracture under physiological loading. Material properties for the FE models used to predict fracture are obtained by converting grayscale values from the CT into volumetric bone mineral density (vBMD) using calibration phantoms. If there are any variations arising from the CT acquisition protocol, vBMD estimation and material property assignment could be affected, thus, affecting fracture risk prediction. We hypothesized that material property assignments may be dependent on scanning and postprocessing settings including voltage, current, and reconstruction kernel, thus potentially having an effect in fracture risk prediction. A rabbit femur and a standard calibration phantom were imaged by QCT using different protocols. Cortical and cancellous regions were segmented, their average Hounsfield unit (HU) values obtained and converted to vBMD. Estimated vBMD for the cortical and cancellous regions were affected by voltage and kernel but not by current. Our study demonstrated that there exists a significant variation in the estimated vBMD values obtained with different scanning acquisitions. In addition, the large noise differences observed utilizing different scanning parameters could have an important negative effect on small subregions containing fewer voxels.
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Prevalence of Poor Bone Quality in Women Undergoing Spinal Fusion Using Biomechanical-CT Analysis. Spine (Phila Pa 1976) 2016; 41:246-52. [PMID: 26352741 DOI: 10.1097/brs.0000000000001175] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective, cross-sectional analysis of vertebral bone quality in spine-fusion patients at a single medical center. OBJECTIVE To characterize the prevalence of osteoporosis and fragile bone strength in a spine-fusion population of women with an age range of 50 years to 70 years. Fragile bone strength is defined as the level of vertebral strength below which a patient is at as high a risk of future vertebral fracture as a patient having bone density-defined osteoporosis. SUMMARY OF BACKGROUND DATA Poor bone quality--defined here as the presence of either osteoporosis or fragile bone strength--is a risk factor for spine-fusion patients that often goes undetected but can now be assessed preoperatively by additional postprocessing of computed tomography (CT) scans originally ordered for perioperative clinical assessment. METHODS Utilizing such perioperative CT scans for a cohort of 98 women (age range: 51-70 yr) about to undergo spine fusion, we retrospectively used a phantomless calibration technique and biomechanical-CT postprocessing analysis to measure vertebral trabecular bone mineral density (BMD) (in mg/cm³) and by nonlinear finite element analysis, vertebral compressive strength (in Newtons, N) in the L1 or L2 vertebra. Preestablished validated threshold values were used to define the presence of osteoporosis (trabecular BMD of 80 mg/cm³ or lower) and fragile bone strength (vertebral strength of 4500 N or lower). RESULTS Fourteen percent of the women tested positive for osteoporosis, 27% tested positive for fragile bone strength, and 29% were classified as having poor bone quality (either osteoporosis or fragile bone strength). Over this narrow age range, neither BMD nor vertebral strength were significantly correlated with age, weight, height, or body mass index (P values 0.14-0.97 for BMD; 0.13-0.51 for strength). CONCLUSION Poor bone quality appears to be common in women between ages 50 years and 70 years undergoing spinal fusion surgery. LEVEL OF EVIDENCE 3.
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Tan J, Fu X, Sun CG, Liu C, Zhang XH, Cui YY, Guo Q, Ma T, Wang H, Du GH, Yin X, Liu ZJ, Leng HJ, Xu YS, Song CL. A single CT-guided percutaneous intraosseous injection of thermosensitive simvastatin/poloxamer 407 hydrogel enhances vertebral bone formation in ovariectomized minipigs. Osteoporos Int 2016. [PMID: 26223190 DOI: 10.1007/s00198-015-3230-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
UNLABELLED The ultimate goal of osteoporosis treatment is prevention of fragile fracture. Local treatment targeting specific bone may decrease the incidence of osteoporotic fractures. We developed an injectable, thermosensitive simvastatin/poloxamer 407 hydrogel; a single CT-guided percutaneous intraosseous injection augmented vertebrae in ovariectomized minipigs. INTRODUCTION The greatest hazard associated with osteoporosis is local fragility fractures. An adjunct, local treatment might be helpful to decrease the incidence of osteoporotic fracture. Studies have found that simvastatin stimulates bone formation, but the skeletal bioavailability of orally administered is low. Directly delivering simvastatin to the specific bone that is prone to fractures may reinforce the target bone and reduce the incidence of fragility fractures. METHODS We developed an injectable, thermosensitive simvastatin/poloxamer 407 hydrogel, conducted scanning electron microscopy, rheological, and drug release analyses to evaluate the delivery system; injected it into the lumbar vertebrae of ovariectomized minipigs via minimally invasive CT-guided percutaneous vertebral injection. Three months later, BMD, microstructures, mineral apposition rates, and strength were determined by DXA, micro-CT, histology, and biomechanical test; expression of VEGF, BMP2, and osteocalcin were analyzed by immunohistochemistry and Western blots. RESULTS Poloxamer 407 is an effective controlled delivery system for intraosseous-injected simvastatin. A single injection of the simvastatin/poloxamer 407 hydrogel significantly increased BMD, bone microstructure, and strength; the bone volume fraction and trabecular thickness increased nearly 150 %, bone strength almost doubled compared with controls (all P < 0.01); and induced higher expression of VEGF, BMP2, and osteocalcin. CONCLUSIONS CT-guided percutaneous vertebral injection of a single simvastatin/poloxamer 407 thermosensitive hydrogel promotes bone formation in ovariectomized minipigs. The underlying mechanism appears to involve the higher expression of VEGF and BMP-2.
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MESH Headings
- Absorptiometry, Photon/methods
- Animals
- Bone Density/drug effects
- Bone Morphogenetic Protein 2/metabolism
- Chemistry, Physical
- Drug Combinations
- Drug Delivery Systems
- Drug Evaluation, Preclinical/methods
- Female
- Hydrogel, Polyethylene Glycol Dimethacrylate
- Injections, Spinal
- Lumbar Vertebrae/diagnostic imaging
- Lumbar Vertebrae/metabolism
- Lumbar Vertebrae/physiopathology
- Microscopy, Electron, Scanning
- Osteogenesis/drug effects
- Osteoporosis/diagnostic imaging
- Osteoporosis/drug therapy
- Osteoporosis/physiopathology
- Ovariectomy
- Poloxamer/administration & dosage
- Poloxamer/chemistry
- Poloxamer/pharmacology
- Poloxamer/therapeutic use
- Radiography, Interventional
- Rheology
- Simvastatin/administration & dosage
- Simvastatin/pharmacology
- Simvastatin/therapeutic use
- Swine
- Swine, Miniature
- Tomography, X-Ray Computed
- Vascular Endothelial Growth Factor A/metabolism
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Affiliation(s)
- J Tan
- Department of Orthopedics, Peking University Third Hospital, Beijing, 100191, China
| | - X Fu
- Department of Orthopedics, Peking University Third Hospital, Beijing, 100191, China
| | - C G Sun
- Department of Orthopedics, Peking University Third Hospital, Beijing, 100191, China
- Beijing Key Laboratory of Spinal Diseases, Beijing, 100191, China
| | - C Liu
- Department of Radiology, Peking University Third Hospital, Beijing, 100191, China
| | - X H Zhang
- Department of Pharmacology, Peking University Third Hospital, Beijing, 100191, China
| | - Y Y Cui
- Department of Orthopedics, Peking University Third Hospital, Beijing, 100191, China
| | - Q Guo
- Department of Neurology, Peking University Third Hospital, Beijing, 100191, China
| | - T Ma
- Department of Orthopedics, Peking University Third Hospital, Beijing, 100191, China
| | - H Wang
- Department of Orthopedics, Peking University Third Hospital, Beijing, 100191, China
- Beijing Key Laboratory of Spinal Diseases, Beijing, 100191, China
| | - G H Du
- Department of Orthopedics, Peking University Third Hospital, Beijing, 100191, China
- Beijing Key Laboratory of Spinal Diseases, Beijing, 100191, China
| | - X Yin
- Department of Orthopedics, Peking University Third Hospital, Beijing, 100191, China
- Beijing Key Laboratory of Spinal Diseases, Beijing, 100191, China
| | - Z J Liu
- Department of Orthopedics, Peking University Third Hospital, Beijing, 100191, China
- Beijing Key Laboratory of Spinal Diseases, Beijing, 100191, China
| | - H J Leng
- Department of Orthopedics, Peking University Third Hospital, Beijing, 100191, China
- Beijing Key Laboratory of Spinal Diseases, Beijing, 100191, China
| | - Y S Xu
- Department of Neurology, Peking University Third Hospital, Beijing, 100191, China
| | - C L Song
- Department of Orthopedics, Peking University Third Hospital, Beijing, 100191, China.
- Beijing Key Laboratory of Spinal Diseases, Beijing, 100191, China.
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Abraham AC, Agarwalla A, Yadavalli A, McAndrew C, Liu JY, Tang SY. Multiscale Predictors of Femoral Neck In Situ Strength in Aging Women: Contributions of BMD, Cortical Porosity, Reference Point Indentation, and Nonenzymatic Glycation. J Bone Miner Res 2015; 30:2207-14. [PMID: 26060094 PMCID: PMC4673035 DOI: 10.1002/jbmr.2568] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 05/21/2015] [Accepted: 06/02/2015] [Indexed: 02/05/2023]
Abstract
The diagnosis of fracture risk relies almost solely on quantifying bone mass, yet bone strength is governed by factors at multiple scales including composition and structure that contribute to fracture resistance. Furthermore, aging and conditions such as diabetes mellitus alter fracture incidence independently of bone mass. Therefore, it is critical to incorporate other factors that contribute to bone strength in order to improve diagnostic specificity of fracture risk. We examined the correlation between femoral neck fracture strength in aging female cadavers and areal bone mineral density, along with other clinically accessible measures of bone quality including whole-bone cortical porosity (Ct.Po), bone material mechanical behavior measured by reference point indentation (RPI), and accumulation of advanced glycation end-products (AGEs). All measurements were found to be significant predictors of femoral neck fracture strength, with areal bone mineral density (aBMD) being the single strongest correlate (aBMD: r = 0.755, p < 0.001; Ct.Po: r = -0.500, p < 0.001; RPI: r = -0.478, p < 0.001; AGEs: r = -0.336, p = 0.016). RPI-derived measurements were not correlated with tissue mineral density or local cortical porosity as confirmed by micro-computed tomography (μCT). Multiple reverse stepwise regression revealed that the inclusion of aBMD and any other factor significantly improve the prediction of bone strength over univariate predictions. Combining bone assays at multiple scales such as aBMD with tibial Ct.Po (r = 0.835; p < 0.001), tibial difference in indentation depth between the first and 20th cycle (IDI) (r = 0.883; p < 0.001), or tibial AGEs (r = 0.822; p < 0.001) significantly improves the prediction of femoral neck strength over any factor alone, suggesting that this personalized approach could greatly enhance bone strength and fracture risk assessment with the potential to guide clinical management strategies for at-risk populations.
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Affiliation(s)
- Adam C Abraham
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Avinesh Agarwalla
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA
| | - Aditya Yadavalli
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA
| | - Christopher McAndrew
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Jenny Y Liu
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Simon Y Tang
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA.,Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA.,Department of Mechanical Engineering and Materials Science, Washington University in St. Louis, St. Louis, MO, USA
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36
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Fidler JL, Murthy NS, Khosla S, Clarke BL, Bruining DH, Kopperdahl DL, Lee DC, Keaveny TM. Comprehensive Assessment of Osteoporosis and Bone Fragility with CT Colonography. Radiology 2015. [PMID: 26200602 DOI: 10.1148/radiol.2015141984] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE To evaluate the ability of additional analysis of computed tomographic (CT) colonography images to provide a comprehensive osteoporosis assessment. MATERIALS AND METHODS This Health Insurance Portability and Accountability Act-compliant study was approved by our institutional review board with a waiver of informed consent. Diagnosis of osteoporosis and assessment of fracture risk were compared between biomechanical CT analysis and dual-energy x-ray absorptiometry (DXA) in 136 women (age range, 43-92 years), each of whom underwent CT colonography and DXA within a 6-month period (between January 2008 and April 2010). Blinded to the DXA data, biomechanical CT analysis was retrospectively applied to CT images by using phantomless calibration and finite element analysis to measure bone mineral density and bone strength at the hip and spine. Regression, Bland-Altman, and reclassification analyses and paired t tests were used to compare results. RESULTS For bone mineral density T scores at the femoral neck, biomechanical CT analysis was highly correlated (R(2) = 0.84) with DXA, did not differ from DXA (P = .15, paired t test), and was able to identify osteoporosis (as defined by DXA), with 100% sensitivity in eight of eight patients (95% confidence interval [CI]: 67.6%, 100%) and 98.4% specificity in 126 of 128 patients (95% CI: 94.5%, 99.6%). Considering both the hip and spine, the classification of patients at high risk for fracture by biomechanical CT analysis--those with osteoporosis or "fragile bone strength"--agreed well against classifications for clinical osteoporosis by DXA (T score ≤-2.5 at the hip or spine), with 82.8% sensitivity in 24 of 29 patients (95% CI: 65.4%, 92.4%) and 85.7% specificity in 66 of 77 patients (95% CI: 76.2%, 91.8%). CONCLUSION Retrospective biomechanical CT analysis of CT colonography for colorectal cancer screening provides a comprehensive osteoporosis assessment without requiring changes in imaging protocols.
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Affiliation(s)
- Jeff L Fidler
- From the Department of Radiology (J.L.F., N.S.M.), Division of Endocrinology (S.K., B.L.C.), and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, 200 1st Ave SW, Rochester, MN 55902; O.N. Diagnostics, Berkeley, Calif (D.L.K., D.C.L., T.M.K.); and Departments of Mechanical Engineering and Bioengineering, University of California-Berkeley, Berkeley, Calif (T.M.K.)
| | - Naveen S Murthy
- From the Department of Radiology (J.L.F., N.S.M.), Division of Endocrinology (S.K., B.L.C.), and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, 200 1st Ave SW, Rochester, MN 55902; O.N. Diagnostics, Berkeley, Calif (D.L.K., D.C.L., T.M.K.); and Departments of Mechanical Engineering and Bioengineering, University of California-Berkeley, Berkeley, Calif (T.M.K.)
| | - Sundeep Khosla
- From the Department of Radiology (J.L.F., N.S.M.), Division of Endocrinology (S.K., B.L.C.), and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, 200 1st Ave SW, Rochester, MN 55902; O.N. Diagnostics, Berkeley, Calif (D.L.K., D.C.L., T.M.K.); and Departments of Mechanical Engineering and Bioengineering, University of California-Berkeley, Berkeley, Calif (T.M.K.)
| | - Bart L Clarke
- From the Department of Radiology (J.L.F., N.S.M.), Division of Endocrinology (S.K., B.L.C.), and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, 200 1st Ave SW, Rochester, MN 55902; O.N. Diagnostics, Berkeley, Calif (D.L.K., D.C.L., T.M.K.); and Departments of Mechanical Engineering and Bioengineering, University of California-Berkeley, Berkeley, Calif (T.M.K.)
| | - David H Bruining
- From the Department of Radiology (J.L.F., N.S.M.), Division of Endocrinology (S.K., B.L.C.), and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, 200 1st Ave SW, Rochester, MN 55902; O.N. Diagnostics, Berkeley, Calif (D.L.K., D.C.L., T.M.K.); and Departments of Mechanical Engineering and Bioengineering, University of California-Berkeley, Berkeley, Calif (T.M.K.)
| | - David L Kopperdahl
- From the Department of Radiology (J.L.F., N.S.M.), Division of Endocrinology (S.K., B.L.C.), and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, 200 1st Ave SW, Rochester, MN 55902; O.N. Diagnostics, Berkeley, Calif (D.L.K., D.C.L., T.M.K.); and Departments of Mechanical Engineering and Bioengineering, University of California-Berkeley, Berkeley, Calif (T.M.K.)
| | - David C Lee
- From the Department of Radiology (J.L.F., N.S.M.), Division of Endocrinology (S.K., B.L.C.), and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, 200 1st Ave SW, Rochester, MN 55902; O.N. Diagnostics, Berkeley, Calif (D.L.K., D.C.L., T.M.K.); and Departments of Mechanical Engineering and Bioengineering, University of California-Berkeley, Berkeley, Calif (T.M.K.)
| | - Tony M Keaveny
- From the Department of Radiology (J.L.F., N.S.M.), Division of Endocrinology (S.K., B.L.C.), and Division of Gastroenterology and Hepatology (D.H.B.), Mayo Clinic, 200 1st Ave SW, Rochester, MN 55902; O.N. Diagnostics, Berkeley, Calif (D.L.K., D.C.L., T.M.K.); and Departments of Mechanical Engineering and Bioengineering, University of California-Berkeley, Berkeley, Calif (T.M.K.)
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