Femoral geometry, bone mineral density, and the risk of hip fracture in premenopausal women: a case control study

Are there associations between hip geometry and bone quality? An analysis on 3074 adults from a general population

INTRODUCTION

Patients with reduced bone mineral density and altered hip geometry are susceptible for hip pathologies. Knowledge on associations between bone properties and hip geometric parameters might facilitate identification of patients at risk for hip pathologies. The aim of the present study was to identify associations of bone properties assessed by quantitative ultrasound (QUS) at the heel and hip geometric parameters like center-edge angle (CE), neck-shaft angle (NSA) and alpha angle.

MATERIALS AND METHODS

Hip geometric parameters (CE, NSA and alpha angle) of 3074 participants from the population-based Study of Health in Pomerania were assessed on magnetic resonance imaging. QUS was performed on both calcanei providing broadband ultrasound attenuation (BUA), speed of sound (SOS) and stiffness-index. Based on the stiffness-index the individual osteoporotic fracture risk (low, moderate or high) was determined. Associations between QUS-based and hip geometric parameters were calculated in linear regression models adjusted for age, sex, body height and weight. Interactions of QUS markers with age and sex on hip geometric parameters were tested.

RESULTS

Significant inverse associations between BUA (β = - 0.068), SOS (β = - 0.024) as well as stiffness-index (β = - 0.056) and CE were present, while fracture risk was positively associated with CE (β for high = 1.28 and moderate = 2.54 vs. low fracture risk). Interactions between BUA and sex as well as between SOS and age were detected in the models for CE. Furthermore, there was an inverse relation between fracture risk and NSA that was restricted to the moderate risk (β for moderate vs. low fracture risk = - 0.60). There were no significant associations between QUS parameters and alpha angle.

CONCLUSIONS

In the general population, several associations between QUS-based bone properties or fracture risk and hip geometry are present. Less dysplastic hips had a lower stiffness-index and a higher fracture risk, whereas more valgus hips had a lower fracture risk.

Proximal femur geometry: a major predictor of proximal femur fracture subtypes

INTRODUCTION

Proximal femur geometry (PFG) represents an important risk factor for the occurrence of hip fractures. There are currently few studies regarding the correlation between PFG and the occurrence of a specific fracture subtype, and those that exist have small cohorts and present with different methodologies and contradictory results. Therefore, there is no consensus in the literature regarding this topic. The present study aimed to establish the contribution of the PFG in the occurrence of different subtypes of proximal femur fractures (PFF): intertrochanteric, neck and subtrochanteric.

METHODS

Analysis of 1022 plain anteroposterior pelvic radiographs of patients consecutively admitted to the emergency room of a Level 1 Trauma Centre between 2013 and 2019 after low energy trauma who presented with PFF and underwent surgical treatment. Patients were analysed considering age, gender and subtype of PFF (intertrochanteric, neck or subtrochanteric). Radiological parameters including cervicodiaphyseal angle (CDA), horizontal offset (HO), femoral neck width (FNW), femoral neck length (FNL), great trochanter-pubic symphysis distance (GTPSD), acetabular teardrop distance (ATD) and width of the intertrochanteric region (WIR) were measured and compared between the different subtypes of fractures (7154 measurements). Statistical analysis was conducted recurring to absolute measurements and measurements ratios. The correlation was assessed using t-test.

RESULTS

There were statistically significant differences in proximal femur geometry between the different subtypes of fractures. Patients presenting with femoral neck fractures had greater CDA (132.5 ± 6.9 vs. 130.0 ± 7.3; p < 0.001) and lower HO (45.8 ± 7.4 vs. 49.0 ± 8.0; p < 0.001), HO/ATD (0.34 ± 0.068 vs. 0.37 ± 0.072; p < 0.001) and HO/GTPSD (0.26 ± 0.049 vs. 0.28 ± 0.039; p < 0.001) than patients with intertrochanteric/subtrochanteric fractures.

CONCLUSIONS

PFG represents an important contributor to the occurrence of different fracture subtypes. Femoral neck fractures are associated with greater CDA and lower HO, HO/ATD and HO/GTPSD when compared to intertrochanteric or subtrochanteric fractures.

Racial and ethnic difference in the risk of fractures in the United States: a systematic review and meta-analysis

This systematic review and meta-analysis examined the association between race and ethnicity and fracture risk in the United States. We identified relevant studies by searching PubMed and EMBASE for studies published from the databases' inception date to December 23, 2022. Only observational studies conducted in the US population that reported the effect size of racial-ethnic minority groups versus white people were included. Two investigators independently conducted literature searches, study selection, risk of bias assessment, and data abstraction; discrepancies were resolved by consensus or consultation of a third investigator. Twenty-five studies met the inclusion criteria, and the random-effects model was used to calculate the pooled effect size due to heterogeneity between the studies. Using white people as the reference group, we found that people of other races and ethnic groups had a significantly lower fracture risk. In Black people, the pooled relative risk (RR) was 0.46 (95% confidence interval (CI), 0.43-0.48, p < 0.0001). In Hispanics, the pooled RR was 0.66 (95% CI, 0.55-0.79, p < 0.0001). In Asian Americans, the pooled RR was 0.55 (95% CI, 0.45-0.66, p < 0.0001). In American Indians, the pooled RR was 0.80 (95% CI, 0.41-1.58, p = 0.3436). Subgroup analysis by sex in Black people revealed the strength of association was greater in men (RR = 0.57, 95% CI = 0.51-0.63, p < 0.0001) than in women (RR = 0.43, 95% CI = 0.39-0.47, p < 0.0001). Our findings suggest that people of other races and ethnic groups have a lower fracture risk than white people.

Risk factors for prolonged preoperative waiting time of intertrochanteric fracture patients undergoing operative treatment

Purpose

Intertrochanteric fracture is a common fracture in older adults. We observed the case characteristics of intertrochanteric fracture and analyzed the risk factors for prolonged preoperative waiting time based on patient data from a 6 year period. Investigate the post-admission treatment of intertrochanteric fracture.

Methods

We retrospectively reviewed the medical records from July 2015 to July 2021 of patients hospitalized for intertrochanteric fracture who had undergone internal fixation surgery in the orthopedic ward of the Affiliated Hospital of Shandong University of Traditional Chinese Medicine. Data regarding gender, age, AO/OTA classification, preoperative waiting time, preoperative medical comorbidities, and complicated deep venous thrombosis (DVT) of lower limbs were collected. Statistical tests were used to evaluate the factors influencing preoperative preparation time and DVT.

Results

A total of 1812 cases were retrospectively analyzed, 1258 patients (69.43%) had three or more medical comorbidities. The average preoperative waiting time was 5.09 ± 3.27 days. Advanced age, more preoperative medical comorbidities and DVT led to longer preoperative waiting times, and preoperative medical comorbidities were an independent risk factor. Patients with advanced age and preoperative medical comorbidities were more likely to have DVT.

Conclusion

Age and preoperative medical comorbidities are risk factors for DVT and prolonged preoperative preparation time in intertrochanteric fracture patients. Preoperative medical comorbidities are an independent risk factors affecting the preoperative waiting time, and a combination of multiple comorbidities almost predicts the delay of the operation time.

Age Related Trends in Structural Indices of Proximal Femur in Women Aged 20-70 in Southern Sri Lanka

Age related trends of the indices of hip structure help understanding how bone strength changes with age and the increased bone fragility in old age. Community-dwelling women aged 20-70years (n = 419) were selected by stratified random method and divided into age categories; 20-29years (n-69), 30-39years (n = 60), 40-49years (n = 69), 50-59years (n = 107) and 60-70years (n = 114). All subjects underwent dual energy x-ray absorptiometry (DXA) and hip structure analysis using Hologic Discovery scanner (Hologic Inc, Bedford, USA). Measured indices included hip axis length (HAL) and neck shaft angle (NSA) of the proximal femur. Cross sectional area (CSA), cross sectional moment of inertia (CSMI), section modulus (SM), cortical thickness (CT), buckling ration (BR) of three regions of interest; narrow neck, intertrochanteric region and femoral shaft, were also measured. Age related trends of all indices were studied with Locally Weighted Scatterplot Smoothing lines (LOESS) and ANOVA. Mean HAL and NSA values were not different between age categories. CSA, CSMI, SM and CT in three different regions showed curvilinear relationships with age. These indices gradually increased with age between 20-50 years and the maximum values were seen in the 40-49years age category and they declined afterwards. The decline of these indices was more rapid in the narrow neck and intertrochanter regions when compared with femoral shaft and the lowest mean CSA, CSMI, SM and CT in these two regions were seen in the 60-70 age category. BR showed a gradual decrease with age between 20-50 years and the lowest mean value was seen in the 40-49 age category. BR increased afterwards and the maximum mean value was seen in the 60-70 age category. This study demonstrates the dynamics of structural properties of proximal femur in the three selected cross sections of community-dwelling women aged 20-70 years and the increased bone fragility in old age.

Serum vitamin K1 (phylloquinone) is associated with fracture risk and hip strength in post-menopausal osteoporosis: A cross-sectional study

PURPOSE

Vitamin K may play a potential role in bone metabolism, although further evidence is needed. The mechanisms behind its skeletal effects and optimum intake for maintaining bone health remain poorly defined. To elucidate these two issues, we investigated the association between circulating vitamin K₁ (phylloquinone) concentrations with fracture risk, bone mineral density (BMD), hip geometry and plasma dephospho-uncarboxylated-Matrix Gla Protein (dp-ucMGP), an extra-hepatic vitamin K dependent protein (VKDP), in post-menopausal osteoporosis (PMO).

METHODS

We studied 374 women aged (mean [SD]) 68.7[12.3] years with PMO. Information including demographics, lifestyle habits and previous fractures was captured through a questionnaire. Serum was analysed for vitamin K₁. BMD at the lumbar spine (LS), total hip (TH) and femoral neck (FN) (n = 277) and hip structural analysis (HSA) parameters (n = 263) were derived from DXA scans. VKDPs including undercarboxylated prothrombin (PIVKA-II) and dp-ucMGP were measured in a sub-group (n = 130).

RESULTS

Serum vitamin K₁ was significantly lower in the group with fractures (prevalent fractures: 0.53 [0.41], no fractures; 0.65 [0.66] μg/L, p = 0.04) and independently associated with fracture risk. The adjusted odds ratio (95% CI) per μg/L increase in vitamin K₁ was 0.550 (0.310-0.978, p = 0.042). Among the HSA parameters, serum vitamin K₁ was positively associated with cross-sectional area (CSA) (p = 0.02), cross sectional moment of inertia (CSMI) (p = 0.028) and section modulus (Z) (p = 0.02) at the narrow neck (NN) of femur. Dp-ucMGP was detectable in 97 (75%) participants with serum vitamin K₁ of 0.26 [0.15] μg/L, whilst PIVKA-II was above the clinical threshold in only 3.8%.

CONCLUSIONS

Our data suggest that the positive effect of vitamin K on fracture risk may be related to its effects on bone strength. Higher concentrations of serum vitamin K₁ may be required for vitamin K's skeletal effects compared to coagulation. Further prospective or interventional studies are needed for confirmation and should include measures of bone quality.

Radiofrequency echographic multi-spectrometry for the in-vivo assessment of bone strength: state of the art-outcomes of an expert consensus meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)

PURPOSE

The purpose of this paper was to review the available approaches for bone strength assessment, osteoporosis diagnosis and fracture risk prediction, and to provide insights into radiofrequency echographic multi spectrometry (REMS), a non-ionizing axial skeleton technique.

METHODS

A working group convened by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis met to review the current image-based methods for bone strength assessment and fracture risk estimation, and to discuss the clinical perspectives of REMS.

RESULTS

Areal bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA) is the consolidated indicator for osteoporosis diagnosis and fracture risk assessment. A more reliable fracture risk estimation would actually require an improved assessment of bone strength, integrating also bone quality information. Several different approaches have been proposed, including additional DXA-based parameters, quantitative computed tomography, and quantitative ultrasound. Although each of them showed a somewhat improved clinical performance, none satisfied all the requirements for a widespread routine employment, which was typically hindered by unclear clinical usefulness, radiation doses, limited accessibility, or inapplicability to spine and hip, therefore leaving several clinical needs still unmet. REMS is a clinically available technology for osteoporosis diagnosis and fracture risk assessment through the estimation of BMD on the axial skeleton reference sites. Its automatic processing of unfiltered ultrasound signals provides accurate BMD values in view of fracture risk assessment.

CONCLUSIONS

New approaches for improved bone strength and fracture risk estimations are needed for a better management of osteoporotic patients. In this context, REMS represents a valuable approach for osteoporosis diagnosis and fracture risk prediction.

Automatic hip geometric feature extraction in DXA imaging using regional random forest

BACKGROUND

Hip fracture is considered one of the salient disability factors across the global population. People with hip fractures are prone to become permanently disabled or die from complications. Although currently the premier determiner, bone mineral density has some notable limitations in terms of hip fracture risk assessment.

OBJECTIVES

To learn more about bone strength, hip geometric features (HGFs) can be collected. However, organizing a hip fracture risk study for a large population using a manual HGFs collection technique would be too arduous to be practical. Thus, an automatic HGFs extraction technique is needed.

METHOD

This paper presents an automated HGFs extraction technique using regional random forest. Regional random forest localizes landmark points from femur DXA images using local constraints of hip anatomy. The local region constraints make random forest robust to noise and increase its performance because it processes the least number of points and patches.

RESULTS

The proposed system achieved an overall accuracy of 96.22% and 95.87% on phantom data and real human scanned data respectively.

CONCLUSION

The proposed technique's ability to measure HGFs could be useful in research on the cause and facts of hip fracture and could help in the development of new guidelines for hip fracture risk assessment in the future. The technique will reduce workload and improve the use of X-ray devices.

Non-BMD DXA measurements of the hip

Hip fracture is one of the most serious complications of osteoporosis. More than 50% of hip and other fractures occur in patients without densitometric osteoporosis. Therefore, areal bone mineral density (aBMD) may not be the best way to assess fracture risk. In order to improve assessment of fracture risk, many other approaches have been taken. At the present time, the Fracture Risk Algorithm (FRAX©) is one of the most notable ways to improve assessment of fracture risk. However, since early in the initiation of the dual energy x-ray absorptiometry (DXA) era, several non-BMD DXA approaches to the assessment of hip fracture risk have been proposed. This review will cover some of those methodologies, including hip-axis length (HAL), hip-structural analysis (HSA), finite element analysis (FEA) by DXA, and body composition of the thigh by DXA (BCT). These methods have been utilized in models of hip fracture occurrence and in pharmacological clinical trials. How they should be used in clinical practice or if they should be used in clinical practice is more of an issue. In addition, we will discuss the recent proposal of the use of Long Femur Scan Field in the effort to diagnose atypical femoral fractures.

Muscle mass is a strong correlation factor of total hip BMD among Korean premenopausal women

Objectives

This study was to investigate mean Z-score of BMD of Korean premenopausal women and also to investigate the relationship between BMD and body composition, such as skeletal muscle (SM) mass, body fat mass, and abdominal adiposity among healthy Korean premenopausal women in their forties.

Methods

A total of 2711 premenopausal women in her forties (40-49 years) who had taken dual energy X-ray absorptiometry (DXA) for BMD screening and body composition analyser (InBody J10^®) from 2012 to 2013 at health promotion center of Ewha Womans university Mokdong hospital were analyzed retrospectively. Demographic data such as body mass index (BMI), waist circumference (WC), hip circumference (HC), waist hip ratio (WHR), SM mass, body fat mass, and serum lipid profile were included in this study. The Pearson's correlation coefficient (CC) was used to identify co-efficiency between BMD and other parameters.

Results

The mean age was 44.2 ± 4.44 (years) and mean BMI was 22.43 ± 2.99 (kg/m²). Mean Z-score of BMD-lumbar 1-4 (BMD-L) and BMD-femur total hip (BMD-F) was 0.33 ± 1.14 and -0.19 ± 0.85. Mean of BMD-L and BMD-F were 1.18 ± 0.16 (g/cm²) and 0.96 ± 0.12 (g/cm²). Skeletal muscle mass showed a strong significant correlation coefficient (CC) only with BMD-F (CC = 0.13, p-value = 4.78 × 10^-11). However serum lipid profile, body fat mass, and WHR did not show significant CC with mean Z-score of BMD-F and BMD-L.

Conclusions

Skeletal muscle mass measured by body composition analyzer of BIA method is a strong correlation factor for BMD especially of hip bone among healthy Korean premenopausal women in their forties.