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Bonaccorsi G, Sciavicco G, Rinaudo L, Brigato A, Fiorella G, Carnevale A, Ulivieri FM, Messina C. Usefulness of DXA-based bone strain index in postmenopausal women with type 2 diabetes mellitus. Arch Osteoporos 2024; 19:54. [PMID: 38926167 PMCID: PMC11208269 DOI: 10.1007/s11657-024-01411-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 06/11/2024] [Indexed: 06/28/2024]
Abstract
Bone Strain Index (BSI) is a new dual-energy x-ray absorptiometry (DXA)-based index. We retrospectively evaluated data from 153 postmenopausal women with a history of type 2 diabetes mellitus (T2DM). Lumbar spine and femoral Bone Strain Index (BSI) were sensitive to skeletal impairment in postmenopausal women suffering from T2DM. PURPOSE Bone Strain Index (BSI) is a new dual-energy X-ray absorptiometry (DXA)-based measurement. We evaluated the performance of BSI in predicting the presence of fragility fractures in type 2 diabetes mellitus (T2DM) postmenopausal women. METHODS We retrospectively evaluated data from a case-control study of 153 postmenopausal women with a history of at least 5 years of T2DM (age from 40 to 90 years). For each subject, we assessed the personal or familiar history of previous fragility fractures and menopause age, and we collected data about bone mineral density (BMD), BSI, and Trabecular Bone Score (TBS) measurements. Statistical analysis was performed having as outcome the history of fragility fractures. RESULTS Out of a total of 153 subjects, n = 22 (14.4%) presented at least one major fragility fracture. A negative correlation was found between lumbar BSI and lumbar BMD (r = - 0.49, p < 0.001) and between total femur BSI and total femur BMD (r = - 0.49, p < 0.001). A negative correlation was found between femoral neck BSI and femoral neck BMD (r = - 0.22, p < 0.001). Most DXA-based variables were individually able to discriminate between fractured and non-fractured subjects (p < 0.05), and lumbar BSI was the index with the most relative difference between the two populations, followed by femoral BSI. CONCLUSION Lumbar spine and femoral BSI are sensitive to skeletal impairment in postmenopausal women suffering from T2DM. The use of BSI in conjunction with BMD and TBS can improve fracture risk assessment.
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Affiliation(s)
- Gloria Bonaccorsi
- Department of Translational Medicine, Menopause and Osteoporosis Center, University of Ferrara, Ferrara, Italy
| | - Guido Sciavicco
- Department of Mathematics and Computer Science, University of Ferrara, Ferrara, Italy
| | - Luca Rinaudo
- Tecnologie Avanzate T.A. S.R.L, Lungo Dora Voghera 36/A, Turin, Italy
| | - Andrea Brigato
- Department of Mathematics and Computer Science, University of Ferrara, Ferrara, Italy
| | - Giuliana Fiorella
- Tecnologie Avanzate T.A. S.R.L, Lungo Dora Voghera 36/A, Turin, Italy
| | - Aldo Carnevale
- Department of Translational Medicine - Section of Radiology, University of Ferrara, Ferrara, Italy
| | | | - Carmelo Messina
- U.O.C. Radiodiagnostica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, 20122, Milan, Italy.
- Dipartimento Di Scienze Biomediche Per La Salute, Università Degli Studi Di Milano, Via Pascal, 36, Milan, Italy.
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Roux JP, Duboeuf F, Sornay-Rendu E, Rinaudo L, Ulivieri FM, Wegrzyn J, Chapurlat R. The relationship between bone strain index, bone mass, microarchitecture and mechanical behavior in human vertebrae: an ex vivo study. Osteoporos Int 2024; 35:1069-1075. [PMID: 38520505 DOI: 10.1007/s00198-024-07066-9] [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: 10/24/2023] [Accepted: 02/22/2024] [Indexed: 03/25/2024]
Abstract
The aim of this study was to determine whether the Bone Strain Index (BSI), a recent DXA-based bone index, is related to bone mechanical behavior, microarchitecture and finally, to determine whether BSI improves the prediction of bone strength and the predictive role of BMD in clinical practice. PURPOSE Bone Strain Index (BSI) is a new DXA-based bone index that represents the finite element analysis of the bone deformation under load. The current study aimed to assess whether the BSI is associated with 3D microarchitecture and the mechanical behavior of human lumbar vertebrae. METHODS Lumbar vertebrae (L3) were harvested fresh from 31 human donors. The anteroposterior BMC (g) and aBMD (g/cm2) of the vertebral body were measured using DXA, and then the BSI was automatically derived. The trabecular bone volume (Tb.BV/TV), trabecular thickness (Tb.Th), degree of anisotropy (DA), and structure model index (SMI) were measured using µCT with a 35-µm isotropic voxel size. Quasi-static uniaxial compressive testing was performed on L3 vertebral bodies under displacement control to assess failure load and stiffness. RESULTS The BSI was significantly correlated with failure load and stiffness (r = -0.60 and -0.59; p < 0.0001), aBMD and BMC (r = -0.93 and -0.86; p < 0.0001); Tb.BV/TV and SMI (r = -0.58 and 0.51; p = 0.001 and 0.004 respectively). After adjustment for aBMD, the association between BSI and stiffness, BSI and SMI remained significant (r = -0.51; p = 0.004 and r = -0.39; p = 0.03 respectively, partial correlations) and the relation between BSI and failure load was close to significance (r = -0.35; p = 0.06). CONCLUSION The BSI was significantly correlated with the microarchitecture and mechanical behavior of L3 vertebrae, and these associations remained statistically significant regardless of aBMD.
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Affiliation(s)
| | | | | | | | | | - Julien Wegrzyn
- Univ Lyon, INSERM, UMR 1033, 69008, Lyon, France
- Department of Orthopedic Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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3
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Jaafar S, Cristofolini G, Morenghi E, Rinaudo L, Birtolo MF, Sala E, Ferrante E, Mungari R, Lavezzi E, Leonardi L, Ragucci P, Ulivieri FM, Balzarini L, Mantovani G, Lania AG, Mazziotti G. DXA-derived lumbar bone strain index corrected for kyphosis is associated with vertebral fractures and trabecular bone score in acromegaly. Endocrine 2024:10.1007/s12020-024-03863-8. [PMID: 38809345 DOI: 10.1007/s12020-024-03863-8] [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: 04/09/2024] [Accepted: 05/04/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE The bone strain index (BSI) is a marker of bone deformation based on a finite element analysis inferred from dual X-ray absorptiometry (DXA) scans, that has been proposed as a predictor of fractures in osteoporosis (i.e., higher BSI indicates a lower bone's resistance to loads with consequent higher risk of fractures). We aimed to investigate the association between lumbar BSI and vertebral fractures (VFs) in acromegaly. METHODS Twenty-three patients with acromegaly (13 males, mean age 58 years; three with active disease) were evaluated for morphometric VFs, trabecular bone score (TBS), bone mineral density (BMD) and BSI at lumbar spine, the latter being corrected for the kyphosis as measured by low-dose X-ray imaging system (EOS®-2D/3D). RESULTS Lumbar BSI was significantly higher in patients with VFs as compared to those without fractures (2.90 ± 1.46 vs. 1.78 ± 0.33, p = 0.041). BSI was inversely associated with TBS (rho -0.44; p = 0.034), without significant associations with BMD (p = 0.151), age (p = 0.500), BMI (p = 0.957), serum IGF-I (p = 0.889), duration of active disease (p = 0.434) and sex (p = 0.563). CONCLUSIONS Lumbar BSI corrected for kyphosis could be proposed as integrated parameter of spine arthropathy and osteopathy in acromegaly helping the clinicians in identifying patients with skeletal fragility possibly predisposed to VFs.
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Affiliation(s)
- Simona Jaafar
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Endocrinology, Diabetology and Andrology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giacomo Cristofolini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Endocrinology, Diabetology and Andrology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Emanuela Morenghi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Biostatistics Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - Maria Francesca Birtolo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Endocrinology, Diabetology and Andrology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Elisa Sala
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrinology Unit, Milan, Italy
| | - Emanuele Ferrante
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrinology Unit, Milan, Italy
| | - Roberta Mungari
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrinology Unit, Milan, Italy
| | - Elisabetta Lavezzi
- Endocrinology, Diabetology and Andrology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Lorenzo Leonardi
- Department of Radiology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Pasquala Ragucci
- Department of Radiology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Fabio M Ulivieri
- Bone Metabolic Unit, Casa di Cura la Madonnina Milan, Milan, Italy
| | - Luca Balzarini
- Department of Radiology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giovanna Mantovani
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Endocrinology Unit, Milan, Italy
- University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy
| | - Andrea G Lania
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
- Endocrinology, Diabetology and Andrology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
| | - Gherardo Mazziotti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Endocrinology, Diabetology and Andrology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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Rinaudo L, Cuttone S, Messina C, Magni V, Capra D, Sconfienza LM, Sardanelli F, Ulivieri FM. Generation and Validation of Normative, Age-Specific Reference Curves for Bone Strain Index in Women. Diagnostics (Basel) 2024; 14:1046. [PMID: 38786344 PMCID: PMC11120451 DOI: 10.3390/diagnostics14101046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/07/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024] Open
Abstract
Bone Strain Index (BSI), based on dual-energy X-ray absorptiometry (DXA), is a densitometric index of bone strength of the femur and lumbar spine. Higher BSI values indicate a higher strain applied to bone, predisposing to higher fracture risk. This retrospective, multicentric study on Italian women reports the BSI normative age-specific reference curves. A cohort of Caucasian Italian women aged 20 to 90 years was selected from three different clinical centres. Bone mineral density (BMD) and BSI measurements were obtained for the lumbar spine vertebrae (L1-L4) and for the femur (neck, trochanter and intertrochanter) using Hologic densitometers scans. The data were compared with BMD normative values provided by the densitometer manufacturer. Then, the age-specific BSI curve for the femur and lumbar spine was generated. No significant difference was found between the BMD of the subjects in this study and BMD reference data provided by Hologic (p = 0.68 for femur and p = 0.90 for lumbar spine). Spine BSI values (L1-L4) increase by 84% between 20 and 90 years of age. The mean BSI of the total femur increases about 38% in the same age range. The BSI age-specific reference curve could help clinicians improve osteoporosis patient management, allowing an appropriate patient classification according to the bone resistance to the applied loads and fragility fracture risk assessment.
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Affiliation(s)
- Luca Rinaudo
- Tecnologie Avanzate T.A. srl, Lungo Dora Voghera 36/A, 10153 Torino, Italy
| | - Sofia Cuttone
- Tecnologie Avanzate T.A. srl, Lungo Dora Voghera 36/A, 10153 Torino, Italy
| | - Carmelo Messina
- IRCCS Istituto Ortopedico Galeazzi, 20157 Milano, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20122 Milano, Italy
| | - Veronica Magni
- Postgraduate School in Radiodiagnostics, Università degli Studi di Milano, 20122 Milano, Italy
| | - Davide Capra
- Postgraduate School in Radiodiagnostics, Università degli Studi di Milano, 20122 Milano, Italy
| | - Luca Maria Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, 20157 Milano, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20122 Milano, Italy
| | - Francesco Sardanelli
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20122 Milano, Italy
- IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Italy
| | - Fabio Massimo Ulivieri
- Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milano, Italy
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Gazzotti S, Sassi R, Aparisi Gómez MP, Moroni A, Brizola E, Miceli M, Bazzocchi A. Imaging in osteogenesis imperfecta: Where we are and where we are going. Eur J Med Genet 2024; 68:104926. [PMID: 38369057 DOI: 10.1016/j.ejmg.2024.104926] [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: 09/27/2023] [Revised: 01/02/2024] [Accepted: 02/16/2024] [Indexed: 02/20/2024]
Abstract
Osteogenesis imperfecta (OI) is a rare phenotypically and genetically heterogeneous group of inherited skeletal dysplasias. The hallmark features of OI include bone fragility and susceptibility to fractures, bone deformity, and diminished growth, along with a plethora of associated secondary features (both skeletal and extraskeletal). The diagnosis of OI is currently made on clinical grounds and may be confirmed by genetic testing. However, imaging remains pivotal in the evaluation of this disease. The aim of this article is to review the current role played by the various radiologic techniques in the diagnosis and monitoring of OI in the postnatal setting as well as to discuss recent advances and future perspectives in OI imaging. Conventional Radiography and Dual-energy X-ray Absorptiometry (DXA) are currently the two most used imaging modalities in OI. The cardinal radiographic features of OI include generalized osteopenia/osteoporosis, bone deformities, and fractures. DXA is currently the most available technique to assess Bone Mineral Density (BMD), specifically areal BMD (aBMD). However, DXA has important limitations and cannot fully characterize bone fragility in OI based on aBMD. Novel DXA-derived parameters, such as Trabecular Bone Score (TBS), may provide further insight into skeletal changes induced by OI, but evidence is still limited. Techniques like Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) can be useful as problem-solvers or in specific settings, including the evaluation of cranio-cervical abnormalities. Recent evidence supports the use of High-Resolution peripheral Quantitative Computed Tomography (HR-pQCT) as a promising tool to improve the characterization of bone fragility in OI. However, HR-pQCT remains a primarily research technique at present. Quantitative Computed Tomography (QCT) is an alternative to DXA for the determination of BMD at central sites, with distinct advantages but considerably higher radiation exposure. Quantitative Ultrasound (QUS) is a portable, inexpensive, and radiation-free modality that may complement DXA evaluation, providing information on bone quality. However, evidence of usefulness of QUS in OI is poor. Radiofrequency Echographic Multi Spectrometry (REMS) is an emerging non-ionizing imaging method that holds promise for the diagnosis of low BMD and for the prediction of fracture risk, but so far only one published study has investigated its role in OI. To conclude, several different radiologic techniques have proven to be effective in the diagnosis and monitoring of OI, each with their own specificities and peculiarities. Clinicians should be aware of the strategic role of the various modalities in the different phases of the patient care process. In this scenario, the development of international guidelines including recommendations on the role of imaging in the diagnosis and monitoring of OI, accompanied by continuous active research in the field, could significantly improve the standardization of patient care.
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Affiliation(s)
- S Gazzotti
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - R Sassi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - M P Aparisi Gómez
- Department of Radiology, Te Toka Tumai Auckland (Auckland District Health Board), Auckland, New Zealand; Department of Anatomy and Medical Imaging, Faculty of Medical and Health Sciences, Waipapa Taumata Rau | University of Auckland, Auckland, New Zealand; Department of Radiology, IMSKE, Valencia, Spain
| | - A Moroni
- Department of Rare Skeletal Disorders, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - E Brizola
- Department of Rare Skeletal Disorders, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - M Miceli
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - A Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
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Valls-Pascual E, Orenes-Vera AV, Sendra-García A, Martínez-Ferrer À, Montolío-Chiva L, Vázquez-Gómez I, Flores-Fernández E, Ybáñez-García D, Vega-Martínez M, García-Ferrer L, Graells-Ferrer M, Alegre-Sancho JJ. Relationship between trabecular bone score, bone mineral density and vertebral fractures in patients with axial spondyloarthritis. BMC Musculoskelet Disord 2023; 24:316. [PMID: 37087414 PMCID: PMC10122358 DOI: 10.1186/s12891-023-06431-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 04/13/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND In patients with axial spondyloarthritis, vertebral fracture risk is elevated and not always correlated with bone mineral density (BMD). Trabecular bone score (TBS) may offer some advantages in the assessment of vertebral fracture risk in these patients. The primary objective of this study was to compare TBS and BMD between axial spondyloarthritis patients depending on their vertebral fracture status. Secondary objectives were to estimate the prevalence of morphometric vertebral fractures, and to explore factors associated with fracture, as well as the interference of syndesmophytes on BMD and TBS. METHODS A cross-sectional study was conducted. Data were collected on demographic and clinical characteristics, lab results, imaging findings and treatment. Statistical analysis was performed using SPSS v.13 statistical software. RESULTS Eighty-four patients (60 men and 24 women; mean age of 59 years) were included. Nearly half (47.6%) of them had lumbar syndesmophytes. The rate of morphometric fracture was 11.9%. TBS showed a higher area under the curve (0.89) than total hip, femoral neck and lumbar BMD (0.80, 0.78, and 0.70 respectively) for classifying patients regarding their fracture status. Nonetheless, the differences did not reach statistical significance. Syndesmophytes affected lumbar spine BMD (p < 0.001), but not hip BMD or TBS. Fractures were associated with TBS, total hip BMD, erythrocyte sedimentation rate and C-reactive protein levels. CONCLUSIONS We identified decreased TBS and total hip BMD, as well as increased erythrocyte sedimentation rate and C-reactive protein levels as factors associated with morphometric vertebral fractures. Unlike lumbar spine BMD, TBS is not affected by the presence of syndesmophytes.
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Affiliation(s)
- Elia Valls-Pascual
- Rheumatology Department, Doctor Peset University Hospital, Valencia, Spain.
| | | | - Ana Sendra-García
- Pharmacy Department, Doctor Peset University Hospital, Valencia, Spain
| | | | - Lydia Montolío-Chiva
- Rheumatology Department, University General Hospital of Castellón, Castellón de La Plana, Spain
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Tabacco G, Naciu AM, Messina C, Sanson G, Rinaudo L, Cesareo R, Falcone S, Napoli N, Ulivieri FM, Palermo A. DXA-based bone strain index in normocalcemic primary hyperparathyroidism. Osteoporos Int 2023; 34:999-1003. [PMID: 36640186 DOI: 10.1007/s00198-023-06669-y] [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: 02/03/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023]
Abstract
UNLABELLED The trabecular and cortical bone assessed by bone strain index seems not to be significantly affected in NHPT. INTRODUCTION The natural history and bone involvement of normocalcemic hyperparathyroidism (NHPT) are not fully clarified yet. The bone strain index (BSI) is a deformation index based on the finite element method and can be applied to DXA scans. In this study, we aim to assess BSI in subjects with NHPT. METHOD A case-control study included 170 subjects: 40 subjects with NHPT, 50 subjects with primary hypercalcemic hyperparathyroidism (PHPT), and 80 controls (age- and sex-matched with the NPTH group). RESULTS Lumbar spine (LS) bone mineral density (BMD), femoral neck (FN) BMD, total hip (TH) BMD, and TBS were similar between NHPT and both PHPT and controls. FN-BSI was lower in NHPT compared to PHPT (1.52 ± 0.31 vs 1.72 ± 0.42 p = 0.031) while there were no differences between NHPT and controls. TH-BSI was lower in NHPT compared to PHPT (1.36 ± 0.23 vs 1.52 ± 0.34, p = 0.030), while there were no differences between NHPT and controls. LS-BSI was not different between NHPT and both PHPT and controls. CONCLUSION The trabecular and cortical bones assessed by BSI seem not to be significantly impaired in NHPT. Further prospective studies are needed to confirm these findings and to give an insight into the natural history of NHPT to improve knowledge and management of this condition.
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Affiliation(s)
- Gaia Tabacco
- Unit of Metabolic Bone and Thyroid Diseases, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy.
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University of Rome, Rome, Italy.
| | - Anda Mihaela Naciu
- Unit of Metabolic Bone and Thyroid Diseases, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University of Rome, Rome, Italy
| | - Carmelo Messina
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - Gianfranco Sanson
- School of Nursing, Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | | | - Roberto Cesareo
- UOS Malattie Metaboliche, Santa Maria Goretti Hospital, Latina, Italy
| | - Stefania Falcone
- Unit of Endocrinology and Metabolic Diseases, CTO A. Alesini Hospital, University Tor Vergata, Rome, Italy
| | - Nicola Napoli
- Unit of Metabolic Bone and Thyroid Diseases, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University of Rome, Rome, Italy
| | | | - Andrea Palermo
- Unit of Metabolic Bone and Thyroid Diseases, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University of Rome, Rome, Italy
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8
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Pedersini R, Cosentini D, Rinaudo L, Zamparini M, Ulivieri FM, di Mauro P, Maffezzoni F, Monteverdi S, Vena W, Laini L, Amoroso V, Simoncini EL, Farina D, Mazziotti G, Berruti A. Assessment of DXA derived bone quality indexes and bone geometry parameters in early breast cancer patients: A single center cross-sectional study. Bone Rep 2023; 18:101654. [PMID: 36700242 PMCID: PMC9868326 DOI: 10.1016/j.bonr.2023.101654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 01/03/2023] [Accepted: 01/06/2023] [Indexed: 01/12/2023] Open
Abstract
Background Bone mineral density (BMD) lacks sensitivity in individual fracture risk assessment in early breast cancer (EBC) patients treated with aromatase inhibitors (AIs). New dual-energy X-ray absorptiometry (DXA) based risk factors are needed. Methods Trabecular bone score (TBS), bone strain index (BSI) and DXA parameters of bone geometry were evaluated in postmenopausal women diagnosed with EBC. The aim was to explore their association with morphometric vertebral fractures (VFs). Subjects were categorized in 3 groups in order to evaluate the impact of AIs and denosumab on bone geometry: AI-naive, AI-treated minus (AIDen-) or plus (AIDen+) denosumab. Results A total of 610 EBC patients entered the study: 305 were AI-naive, 187 AIDen-, and 118 AIDen+. In the AI-naive group, the presence of VFs was associated with lower total hip BMD and T-score and higher femoral BSI. As regards as bone geometry parameters, AI-naive fractured patients reported a significant increase in femoral narrow neck (NN) endocortical width, femoral NN subperiosteal width, intertrochanteric buckling ratio (BR), intertrochanteric endocortical width, femoral shaft (FS) BR and endocortical width, as compared to non-fractured patients. Intertrochanteric BR and intertrochanteric cortical thickness significantly increased in the presence of VFs in AIDen- patients, not in AIDen+ ones. An increase in cross-sectional area and cross-sectional moment of inertia, both intertrochanteric and at FS, significantly correlated with VFs only in AIDen+. No association with VFs was found for either lumbar BSI or TBS in all groups. Conclusions Bone geometry parameters are variably associated with VFs in EBC patients, either AI-naive or AI treated in combination with denosumab. These data suggest a tailored choice of fracture risk parameters in the 3 subgroups of EBC patients.
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Key Words
- AI, aromatase inhibitor
- AIDen+, aromatase inhibitor with denosumab
- AIDen-, aromatase inhibitor without denosumab
- Aromatase inhibitors
- BMD, bone mineral density
- BMI, body-mass index
- BR, buckling ratio
- BSI, bone strain index
- Bone strain index
- CSA, cross-sectional area
- CSMI, cross-sectional moment of inertia
- DXA, dual-energy X-ray absorptiometry
- Dual-energy X-ray absorptiometry
- EBC, early breast cancer
- FS, femoral shaft
- HAL, hip axis length
- HR, hormone receptor
- HSA, Hip Structure Analysis
- IT, intertrochanteric
- NN, narrow neck
- NSA, neck shaft angle
- PS, propensity score
- ROC, receiver operator characteristic
- TBS, trabecular bone score
- VF, vertebral fracture
- Vertebral fractures
- Z, modulus
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Affiliation(s)
- Rebecca Pedersini
- Medical Oncology, ASST Spedali Civili, Brescia, Italy
- Breast Unit, ASST Spedali Civili, Brescia, Italy
- Corresponding author at: Oncologia Medica, ASST Spedali Civili di Brescia, Piazzale Spedali Civili 1, 20123, Brescia, Italy.
| | - Deborah Cosentini
- Medical Oncology, ASST Spedali Civili, Brescia, Italy
- Breast Unit, ASST Spedali Civili, Brescia, Italy
| | | | | | | | | | | | | | - Walter Vena
- Endocrinology, Diabetology and Medical Andrology Unit, Metabolic Bone Diseases and Osteoporosis Section, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - Lara Laini
- Medical Oncology, ASST Spedali Civili, Brescia, Italy
| | - Vito Amoroso
- Medical Oncology, ASST Spedali Civili, Brescia, Italy
| | | | - Davide Farina
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Medical Oncology, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Gherardo Mazziotti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
- Endocrinology, Diabetology and Medical Andrology Unit, Metabolic Bone Diseases and Osteoporosis Section, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
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9
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Bazzocchi A, Isaac A, Dalili D, Fotiadou A, Kariki EP, Kirschke JS, Krestan CR, Messina C, Oei EHG, Phan CM, Prakash M, Sabir N, Tagliafico A, Aparisi F, Baum T, Link TM, Guglielmi G, Aparisi Gómez MP. Imaging of Metabolic Bone Diseases: The Spine View, Part I. Semin Musculoskelet Radiol 2022; 26:478-490. [PMID: 36103889 DOI: 10.1055/s-0042-1754340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Metabolic bone diseases comprise a wide spectrum. Of them, osteoporosis is the most frequent and the most commonly found in the spine, with a high impact on health care systems and on morbidity due to vertebral fractures (VFs).This article discusses state-of-the-art techniques on the imaging of metabolic bone diseases in the spine, from the well-established methods to the latest improvements, recent developments, and future perspectives.We review the classical features of involvement of metabolic conditions involving the spine. Then we analyze the different imaging techniques for the diagnosis, characterization, and monitoring of metabolic bone disease: dual-energy X-ray absorptiometry (DXA) and DXA-based fracture risk assessment applications or indexes, such as the geometric parameters, Bone Strain Index, and Trabecular Bone Score; quantitative computed tomography; and magnetic resonance and ultrasonography-based techniques, such as radiofrequency echographic multi spectrometry. We also describe the current possibilities of imaging to guide the treatment of VFs secondary to metabolic bone disease.
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Affiliation(s)
- Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Amanda Isaac
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Danoob Dalili
- Academic Surgical Unit, South West London Elective Orthopaedic Centre (SWLEOC), Epsom, London, United Kingdom.,Department of Diagnostic and Interventional Radiology, Epsom and St. Helier University Hospitals NHS Trust, London, United Kingdom
| | | | - Eleni P Kariki
- Manchester University NHS Foundation Trust, Manchester, United Kingdom.,Division of Informatics, Imaging & Data Sciences, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Jan S Kirschke
- Interventional und Diagnostic Neuroradiology, School of Medicine, Technical University Munich, Munich, Germany
| | | | | | - Edwin H G Oei
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Catherine M Phan
- Service de Radiologie Ostéo-Articulaire, APHP, Nord-Université de Paris, Hôpital Lariboisière, Paris, France
| | - Mahesh Prakash
- Department of Radiodiagnosis & Imaging, PGIMER, Chandigarh, India
| | - Nuran Sabir
- Department of Radiology, Pamukkale University School of Medicine, Denizli, Turkey
| | - Alberto Tagliafico
- DISSAL, University of Genova, Genoa, Italy.,Ospedale Policlinico San Martino, Genova, Italy
| | - Francisco Aparisi
- Department of Radiology, Hospital Vithas Nueve de Octubre, Valencia, Spain
| | - Thomas Baum
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Thomas M Link
- Department of Radiology and Biomedical Imaging, University of California at San Francisco, San Francisco, California
| | | | - Maria Pilar Aparisi Gómez
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand.,Department of Radiology, IMSKE, Valencia, Spain
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10
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Ulivieri FM, Rinaudo L. The Bone Strain Index: An Innovative Dual X-ray Absorptiometry Bone Strength Index and Its Helpfulness in Clinical Medicine. J Clin Med 2022; 11:jcm11092284. [PMID: 35566410 PMCID: PMC9102586 DOI: 10.3390/jcm11092284] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/06/2022] [Accepted: 04/14/2022] [Indexed: 12/27/2022] Open
Abstract
Bone strain Index (BSI) is an innovative index of bone strength that provides information about skeletal resistance to loads not considered by existing indexes (Bone Mineral Density, BMD. Trabecular Bone Score, TBS. Hip Structural Analysis, HSA. Hip Axis Length, HAL), and, thus, improves the predictability of fragility fractures in osteoporotic patients. This improved predictability of fracture facilitates the possibility of timely intervention with appropriate therapies to reduce the risk of fracture. The development of the index was the result of combining clinical, radiographical and construction-engineering skills. In fact, from a physical point of view, primary and secondary osteoporosis, leading to bone fracture, are determined by an impairment of the physical properties of bone strength: density, internal structure, deformation and fatigue. Dual X-ray absorptiometry (DXA) is the gold standard for assessing bone properties, and it allows measurement of the BMD, which is reduced mainly in primary osteoporosis, the structural texture TBS, which can be particularly degraded in secondary osteoporosis, and the bone geometry (HSA, HAL). The authors recently conceived and developed a new bone deformation index named Bone Strain Index (BSI) that assesses the resistance of bone to loads. If the skeletal structure is equated to engineering construction, these three indexes are all considered to determine the load resistance of the construct. In particular, BSI allows clinicians to detect critical information that BMD and TBS cannot explain, and this information is essential for an accurate definition of a patient’s fracture risk. The literature demonstrates that both lumbar and femoral BSI discriminate fractured osteoporotic people, that they predict the first fragility fracture, and further fragility fractures, monitor anabolic treatment efficacy and detect patients affected by secondary osteoporosis. BSI is a new diagnostic tool that offers a unique perspective to clinical medicine to identify patients affected by primary and, specially, secondary osteoporosis. This literature review illustrates BSI’s state of the art and its ratio in clinical medicine.
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Affiliation(s)
- Fabio Massimo Ulivieri
- Centro per la Diagnosi e la Terapia dell’Osteoporosi, Casa di Cura La Madonnina, Via Quadronno 29, 20122 Milan, Italy
- Correspondence:
| | - Luca Rinaudo
- Tecnologie Avanzate T.A. Srl, Lungo Dora Voghera 36, 10153 Torino, Italy;
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11
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Sornay-Rendu E, Duboeuf F, Ulivieri FM, Rinaudo L, Chapurlat R. The bone strain index predicts fragility fractures. The OFELY study. Bone 2022; 157:116348. [PMID: 35121211 DOI: 10.1016/j.bone.2022.116348] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/25/2022] [Accepted: 01/28/2022] [Indexed: 02/07/2023]
Abstract
Recently, the bone strain index (BSI), a new index of bone strength based on a finite element model (FEA) from dual X-ray absorptiometry (DXA), has been developed. BSI represents the average equivalent strain inside the bone, assuming that a higher strain level (high BSI) indicates a condition of higher risk. Our study aimed to analyze the relationship between BSI and age, BMI and areal BMD in pre- and postmenopausal women and to prospectively investigate fracture prediction (Fx) by BSI in postmenopausal women. Methods. At the 14th annual follow-up of the OFELY study, BSI was measured at spine (Spine BSI) and femoral scans (Neck and Total Hip BSI), in addition to areal BMD with DXA (Hologic QDR 4500) in 846 women, mean (SD) age 60 yr (15). The FRAX® (fracture risk assessment tool) for major osteoporotic fractures (MOF) was calculated with FN areal BMD (aBMD) at baseline; incident fragility fractures were annually registered until January 2016. Results. In premenopausal women (n = 261), Neck and Total Hip BSI were slightly negatively correlated with age (Spearman r = -0.13 and -0.15 respectively, p = 0.03), whereas all BSIs were positively correlated with BMI (r = +0.20 to 0.37, p < 0.01) and negatively with BMD (r = -0.69 to -0.37, p < 0.0001). In postmenopausal women (n = 585), Neck and Total Hip BSI were positively correlated with age (Spearman r = +0.26 and +0.31 respectively, p < 0.0001), whereas Spine BSI was positively correlated with BMI (r = +0.22, p < 0.0001) and all BSIs were negatively correlated with BMD (r = -0.81 to -0.60, p < 0.0001). During a median [IQ] 9.3 [1.0] years of follow-up, 133 postmenopausal women reported an incident fragility Fx, including 80 women with a major osteoporotic Fx (MOF) and 26 women with clinical vertebral Fx (VFx). Each SD increase of BSI value was associated with a significant increase of the risk of all fragility Fx with an age-adjusted HR of 1.23 for Neck BSI (p = 0.02); 1.27 for Total Hip BSI (p = 0.004) and 1.35 for Spine BSI (p < 0.0001). After adjustment for FRAX®, the association remained statistically significant for Total Hip BSI (HR 1.24, p = 0.02 for all fragility Fx; 1.31, p = 0.01 for MOF) and Spine BSI (HR 1.33, p < 0.0001 for all fragility Fx; 1.33, p = 0.005 for MOF; 1.67, p = 0.002 for clinical VFx). In conclusion, spine and femur BSI, an FEA DXA derived index, predict incident fragility fracture in postmenopausal women, regardless of FRAX®.
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Affiliation(s)
| | - François Duboeuf
- INSERM UMR 1033 and Université Claude Bernard-Lyon 1, Hôpital E Herriot, Lyon, France.
| | | | - Luca Rinaudo
- Technologic Srl, Lungo Dora Voghera 34/36A, 10153 Torino, Italy.
| | - Roland Chapurlat
- INSERM UMR 1033 and Université Claude Bernard-Lyon 1, Hôpital E Herriot, Lyon, France.
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12
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Buccino F, Colombo C, Duarte DHL, Rinaudo L, Ulivieri FM, Vergani LM. 2D and 3D numerical models to evaluate trabecular bone damage. Med Biol Eng Comput 2021; 59:2139-2152. [PMID: 34471983 PMCID: PMC8440311 DOI: 10.1007/s11517-021-02422-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 08/05/2021] [Indexed: 12/25/2022]
Abstract
The comprehension of trabecular bone damage processes could be a crucial hint for understanding how bone damage starts and propagates. Currently, different approaches to bone damage identification could be followed. Clinical approaches start from dual X-ray absorptiometry (DXA) technique that can evaluate bone mineral density (BMD), an indirect indicator of fracture risk. DXA is, in fact, a two-dimensional technology, and BMD alone is not able to predict the effective risk of fractures. First attempts in overcoming this issue have been performed with finite element (FE) methods, combined with the use of three-dimensional high-resolution micro-computed tomographic images. The purpose of this work is to evaluate damage initiation and propagation in trabecular vertebral porcine samples using 2D linear-elastic FE models from DXA images and 3D linear FE models from micro-CT images. Results show that computed values of strains with 2D and 3D approaches (e.g., the minimum principal strain) are of the same order of magnitude. 2D DXA-based models still remain a powerful tool for a preliminary screening of trabecular regions that are prone to fracture, while from 3D micro-CT-based models, it is possible to reach details that permit the localization of the most strained trabecula.
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Affiliation(s)
- Federica Buccino
- Department of Mechanical Engineering, Politecnico Di Milano, Via La Masa 1, 20156, Milan, Italy
| | - Chiara Colombo
- Department of Mechanical Engineering, Politecnico Di Milano, Via La Masa 1, 20156, Milan, Italy
| | | | - Luca Rinaudo
- TECHNOLOGIC S.R.L. Hologic Italia, Lungo Dora Voghera, 34/36A, 10153, Turin, Italy
| | - Fabio Massimo Ulivieri
- Nuclear Medicine-Bone Metabolic Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, via Francesco Sforza 75, 20122, Milan, Italy
| | - Laura Maria Vergani
- Department of Mechanical Engineering, Politecnico Di Milano, Via La Masa 1, 20156, Milan, Italy.
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13
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Tabacco G, Naciu AM, Messina C, Sanson G, Rinaudo L, Cesareo R, Falcone S, Manfrini S, Napoli N, Bilezikian JP, Ulivieri FM, Palermo A. DXA-Based Bone Strain Index: A New Tool to Evaluate Bone Quality in Primary Hyperparathyroidism. J Clin Endocrinol Metab 2021; 106:2304-2312. [PMID: 33963754 PMCID: PMC8599893 DOI: 10.1210/clinem/dgab317] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Primary hyperparathyroidism (PHPT) is associated with impaired bone quality and increased fracture risk. Reliable tools for the evaluation of bone quality parameters are not yet clinically available. Bone Strain Index (BSI) is a new metric for bone strength based on Finite Element Analysis from lumbar spine and femoral neck dual-energy x-ray absorptiometry (DXA) images. OBJECTIVE To assess the lumbar spine (LS), femoral neck (FN), and total hip (TH) BSI in PHPT patients compared with controls and to investigate the association of BSI with vertebral fractures (VFs) in PHPT. METHODS This case-control study enrolled 50 PHPT patients and 100 age- and sex-matched control subjects from an outpatient clinic. The main outcome measures were LS-BSI, FN-BSI, and TH-BSI. RESULTS FN bone mineral density (BMD) and one-third distal radius BMD were lower in the PHPT group than in controls (FN 0.633 ± 0.112 vs 0.666 ± 0.081, P = 0.042; radius 0.566 ± 0.07 vs 0.625 ± 0.06, P < 0.001). PHPT group has significant lower TBS score compared with controls (1.24 ± 0.09 vs 1.30 ± 0.10, P < 0.001). BSI was significantly higher at LS (2.28 ± 0.59 vs 2.02 ± 0.43, P = 0.009), FN (1.72 ± 0.41 vs 1.49 ± 0.35, P = 0.001), and TH (1.51 ± 0.33 vs 1.36 ± 0.25, P = 0.002) in PHPT. LS-BSI showed moderate accuracy for discriminating VFs (AUC 0.667; 95% CI, 0.513-0.820). LS-BSI ≥ 2.2 and was a statistically significant independent predictor of VFs, with an adjusted odds ratio ranging from 5.7 to 15.1. CONCLUSION BSI, a DXA-derived bone quality index, is impaired in PHPT and may help to identify PHPT subjects at high risk of fractures.
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Affiliation(s)
- Gaia Tabacco
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University of Rome, Rome, Italy
| | - Anda M Naciu
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University of Rome, Rome, Italy
| | - Carmelo Messina
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milano, Italy
| | - Gianfranco Sanson
- School of Nursing, Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | | | - Roberto Cesareo
- UOS Malattie Metaboliche, Santa Maria Goretti Hospital, Latina, Italy
| | - Stefania Falcone
- Unit of Endocrinology and Metabolic Diseases, CTO A. Alesini Hospital, University Tor Vergata, Rome, Italy
| | - Silvia Manfrini
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University of Rome, Rome, Italy
| | - Nicola Napoli
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University of Rome, Rome, Italy
| | - John P Bilezikian
- Department of Medicine, Division of Endocrinology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York 10032, USA
| | - Fabio M Ulivieri
- U.O. Medicina Nucleare, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Andrea Palermo
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University of Rome, Rome, Italy
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14
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Ulivieri FM, Rinaudo L. Beyond Bone Mineral Density: A New Dual X-Ray Absorptiometry Index of Bone Strength to Predict Fragility Fractures, the Bone Strain Index. Front Med (Lausanne) 2021; 7:590139. [PMID: 33521014 PMCID: PMC7843921 DOI: 10.3389/fmed.2020.590139] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 12/17/2020] [Indexed: 12/12/2022] Open
Abstract
For a proper assessment of osteoporotic fragility fracture prediction, all aspects regarding bone mineral density, bone texture, geometry and information about strength are necessary, particularly in endocrinological and rheumatological diseases, where bone quality impairment is relevant. Data regarding bone quantity (density) and, partially, bone quality (structure and geometry) are obtained by the gold standard method of dual X-ray absorptiometry (DXA). Data about bone strength are not yet readily available. To evaluate bone resistance to strain, a new DXA-derived index based on the Finite Element Analysis (FEA) of a greyscale of density distribution measured on spine and femoral scan, namely Bone Strain Index (BSI), has recently been developed. Bone Strain Index includes local information on density distribution, bone geometry and loadings and it differs from bone mineral density (BMD) and other variables of bone quality like trabecular bone score (TBS), which are all based on the quantification of bone mass and distribution averaged over the scanned region. This state of the art review illustrates the methodology of BSI calculation, the findings of its in reproducibility and the preliminary data about its capability to predict fragility fracture and to monitor the follow up of the pharmacological treatment for osteoporosis.
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Affiliation(s)
- Fabio Massimo Ulivieri
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Unità Operativa (UO) Medicina Nucleare, Milan, Italy
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