New quantitative ultrasound techniques for bone analysis at the distal radius in hip fracture cases: differences between femoral neck and trochanteric fractures.

The spatial differences in bone mineral density and hip structure between low-energy femoral neck and trochanteric fractures in elderly Chinese using quantitative computed tomography.

The ability of bone mineral density (BMD) to discriminate cervical and trochanteric hip fractures was studied. Since the majority of fractures occur among people who are not diagnosed as having osteoporosis, we also examined this population to elucidate whether geometrical risk factors can yield additional information on hip fracture risk beside BMD. The study showed that the T-score criterion was able to discriminate fracture patients from controls in the cases of trochanteric fractures, whereas geometrical measures may discriminate cervical fracture cases in patients with T-score >-2.5. Low bone mineral density (BMD) is a well-established risk factor for hip fracture. However, majority of fractures occur among people not diagnosed as having osteoporosis. We studied the ability of BMD to discriminate cervical and trochanteric hip fractures. Furthermore, we examined whether geometrical measures can yield additional information on the assessment of hip fracture risk in the fracture cases in subjects with T-score >-2.5. Study group consisted of postmenopausal females with non-pathologic cervical (n = 39) or trochanteric (n = 18) hip fracture (mean age 74.2 years) and 40 age-matched controls. BMD was measured at femoral neck, and femoral neck axis length, femoral neck and shaft cortex thicknesses (FNC and FSC), and femoral neck-shaft angle (NSA) were measured from radiographs. BMD T-score threshold of -2.5 was able to discriminate trochanteric fractures from controls (p < 0.001). Seventeen out of 18 trochanteric fractures occurred in individuals with T-score <or=-2.5. However, the T-score criterion was not able to discriminate cervical fractures. Twenty of these fractures (51.3%) occurred in individuals with BMD in osteoporotic range and 19 (48.7%) in individuals with T-score >-2.5. Within these non-osteoporotic cervical fracture patients (N = 19) and non-osteoporotic controls (N = 35), 83.3% were classified correctly based on a model including NSA and FNC (p < 0.001), area under the receiver operating characteristics curve being 0.85 for the model, while it was only 0.56 for BMD alone. The study suggests that the risk of trochanteric fractures could be discriminated based on a BMD T-score <-2.5 criterion, whereas cervical fracture cases would remain under-diagnosed if solely using this criterion. Instead, geometrical risk factors are able to discriminate cervical fracture cases even among individuals with T-score >-2.5. For cervical and trochanteric fractures combined, BMD and geometric measures independently contributed to hip fracture discrimination. Our data support changing from T-score <-2.5 to a more comprehensive assessment of hip fracture etiology, in which fracture type is also taken into account. The findings need to be confirmed with a larger sample, preferably in a prospective study.

The aim of this study was to assess the influence of bone mineral density and hip geometry on the fragility fracture of femoral neck and trochanteric region. There were 95 menopausal females of age ≥ 50 years with fragility fracture of hip, including 55 cases of femoral neck fracture and 40 cases of trochanteric fracture. Another 63 non-fractured females with normal bone mineral density (BMD) were chosen as control. BMD, hip axis length, neck-shaft angle and structural parameters including cross surface area, cortical thickness and buckling ratio were detected and compared. Compared with control group, the patients with femoral neck fracture or trochanteric fractures had significantly lower BMD of femoral neck, as well as lower cross surface area and cortical thickness and higher buckling ratio in femoral neck and trochanteric region. There were no significant differences of BMD and structural parameters in the femoral neck fracture group and intertrochanteric fracture group. Hip axis length and neck-shaft angle were not significantly different among three groups. The significant changes of BMD and proximal femur geometry were present in the fragility fracture of femoral neck and trochanteric region. The different types of hip fractures cannot be explained by these changes.

We studied 43 patients with ipsilateral femoral shaft and femoral neck fractures who had dynamic hip screw fixation alone or in combincation with dynamic compression plate. All patients except two were diagnosed early; 37 patients had other associated injuries. There were 41 males and two females. The follow-up ranged from eight months to four years (mean 2-1/2 years). Six patients were lost to follow-up. Fracture of the neck of the femur healed in all 37 patients. Four patients had delayed union and two patients developed nonunion of the shaft of the femur. The aim of this paper is to show our experience and results using one technique for the treatment of such fractures.

ObjectiveTo assess the differences in bone mineral density (BMD) and hip geometry in trochanteric and cervical hip fractures in elderly Chinese patients.MethodsA consecutive series of 196 hip fracture patients aged over 50 years was recruited from November 2013 to October 2015, including 109 cases of cervical fractures (36 males and 73 females) and 87 cases of trochanteric fractures (34 males and 53 females). All patients were evaluated through dual‐energy X‐ray absorptiometry, and baseline characteristics, BMD and structural parameters were collected and reviewed.ResultsThere were statistically significant differences in age, height, and body mass index between patients with each type of fracture, and patients with trochanteric fractures were older than those with cervical fractures, especially in women. The BMD in trochanteric fractures was markedly lower than in cervical fractures in all five sites of the hip by an approximate reduction of 10%, in both men and women. The cross‐sectional area, cross‐sectional moment of inertia, and the cortical thickness in the cervical fracture group were significantly higher than in the trochanteric fracture group. However, the buckling ratio of both the femoral neck and trochanteric region were significantly lower in the cervical fracture group. Age (/10 years), cross‐sectional moment of inertia in femoral neck and buckling ratio in trochanteric region were significant risk factors for trochanteric fractures compared with cervical fractures.ConclusionsCompared with cervical hip fractures, patients with trochanteric fractures were older, had a lower BMD, and had less bone mechanical strength, especially in female patients. Age, femoral neck cross‐sectional moment of inertia (FNCSMI), and trochanteric region buckling ratio (ITBR) were stronger risk factors for trochanteric hip fractures than for cervical fractures.

Some proximal femur geometry (PFG) parameters, measured by dual-energy X-ray absorptiometry (DXA), have been reported to discriminate subjects with hip fracture. Relatively few studies have tested their ability to discriminate femoral neck fractures from those of the trochanter. To this end we performed a cross-sectional study in a population of 547 menopausal women over 69 years of age with femoral neck fractures (n = 88), trochanteric fractures (n = 93) or controls (n = 366). Hip axis length (HAL), neck-shaft angle (NSA), femoral neck diameter (FND) and femoral shaft diameter (FSD) were measured by DXA, as well as the bone mineral density (BMD) of the nonfractured hip at the femoral neck, trochanter and Ward's triangle. In fractured subjects, BMD was lower at each measurement site. HAL was longer and NSA wider in those with femoral neck fractures. With logistic regression the age-adjusted odds ratio (OR) for a 1 standard deviation (SD) decrease in BMD was significantly associated at each measurement site with femoral neck fracture (femoral neck BMD: OR 1.9, 95% confidence interval (95% CI): 1.4-2.5; trochanter BMD: OR 1.6, 95% CI 1.2-2.0; Ward's triangle BMD: OR 1.7, 95% CI 1.3-2.2) and trochanteric fracture (femoral neck BMD: OR 2.6, 95% CI 1.9-3.6; trochanter BMD: OR 3.0, 95% CI 2.2-4.1; Ward's triangle BMD: OR 1.8, 95% CI 1.4-2.3). Age-adjusted OR for 1 SD increases in NSA (OR 2.2, 95% CI 1.7-2.8) and HAL (OR 1.3, 95% CI 1.1-1.6) was significantly associated with the fracture risk only for femoral neck fracture. In the best predictive model the strongest predictors were site-matched BMD for both fracture types and NSA for neck fracture. Trochanteric BMD had the greatest area (0.78, standard error (SE) 0.02) under the receiver operating characteristic curve in trochanteric fractures, whereas for NSA (0.72, SE 0.03) this area was greatest in femoral neck fractures. These results confirm the association of BMD with proximal femur fracture and support the evidence that PFG plays a significant role only in neck fracture prediction, since NSA is the best predictive parameter among those tested.

Relation entre la densité minérale osseuse du fémur proximal et l’instabilité des fractures fémorales proximales : étude rétrospective

Relationship between site-specific bone mineral density in the proximal femur and instability of proximal femoral fractures: A retrospective study

There is little knowledge about the spatial distribution differences in volumetric bone mineral density and cortical bone structure at the proximal femur between femoral neck fractures and trochanteric fractures. In this case-control study, a total of 93 women with fragility hip fractures, 72 with femoral neck fractures (mean ± SD age: 70.6 ± 12.7 years) and 21 with trochanteric fractures (75.6 ± 9.3 years), and 50 control subjects (63.7 ± 7.0 years) were included for the comparisons. Differences in the spatial distributions of volumetric bone mineral density, cortical bone thickness, cortical volumetric bone mineral density, and volumetric bone mineral density in a layer adjacent to the endosteal surface were investigated using voxel-based morphometry (VBM) and surface-based statistical parametric mapping (SPM). We compared these spatial distributions between controls and both types of fracture, and between the two types of fracture. Using VBM, we found spatially heterogeneous volumetric bone mineral density differences between control subjects and subjects with hip fracture that varied by fracture type. Interestingly, femoral neck fracture subjects, but not subjects with trochanteric fracture, showed significantly lower volumetric bone mineral density in the superior aspect of the femoral neck compared with controls. Using surface-based SPM, we found that compared with controls, both fracture types showed thinner cortices in regions in agreement with the type of fracture. Most outcomes of cortical and endocortical volumetric bone mineral density comparisons were consistent with VBM results. Our results suggest: 1) that the spatial distribution of trabecular volumetric bone mineral density might play a significant role in hip fracture; 2) that focal cortical bone thinning might be more relevant in femoral neck fractures; and 3) that areas of reduced cortical and endocortical volumetric bone mineral density might be more relevant for trochanteric fractures in Chinese women. © 2017 American Society for Bone and Mineral Research.

The goals of this retrospective study were to assess the clinical and radiographic outcomes in dogs with proximal femoral fractures, other than capital physeal fractures, treated via total hip arthroplasty. Medical records as well as pre-operative, immediate post-operative and 2 to 3 months post-operative radiographs of 14 dogs with femoral head and neck fractures treated via total hip arthroplasty were reviewed. A Liverpool Osteoarthritis in Dogs questionnaire was completed by owners to assess long-term outcomes. Seven femoral head fractures, and seven femoral neck fractures were included. Four of the femoral head fractures were acute in nature, the three remaining femoral head fractures and all seven femoral neck fracture cases were chronic fractures. Malorientation of the femoral stem was more common in the chronic femoral fracture cases when compared to the acute femoral fracture cases. Two of the acute fracture cases and five chronic fracture cases experienced a change in femoral stem position post-operatively. One femoral fissure fracture occurred and was repaired intraoperatively. One case had a post-operative complication that resulted in implant removal. All dogs had good to excellent owner-perceived outcome. Femoral head and neck fractures, and in particular the chronic cases, represented a challenging subset of cases presenting for total hip arthroplasty, resulting in suboptimal stem alignment in many cases. However, clinical outcomes were considered good to excellent in all dogs in the study, indicating that total hip arthroplasty is a viable treatment option for these types of fractures.

[Extract] Osteoporosis is characterized by reduced bone strength caused by microstructural deterioration of the trabecular bone, increase in cortical porosity, and cortical thinning.1 Neither of these microstructural changes can be specifically assessed using dual‐energy X‐ray absorptiometry (DXA) commonly used and recommended to diagnose osteoporosis and bone fragility. However, the relationship between DXA‐derived areal bone mineral density (BMD) at the hip and risk of fracture has been well established. Every standard deviation decrease in BMD increases the risk of incident hip fracture by nearly three times.2 Fracture risk is not only dependent on bone fragility but also on general frailty, which becomes more prevalent with aging, poor balance, and other factors intricately connected to increased risk of falls.3 Incorporation of falls history and measures of physical function and muscle mass are most likely necessary to improve fracture risk prediction by capturing the falls risk dimension of fracture etiology. Because fracture risk also depends on clinical risk factors, of which some are independent of BMD, the use of risk calculators, such as FRAX, incorporating clinical risk factors, has been shown to improve the sensitivity to identify patients with incident fractures.4 As a result, many guidelines consider both BMD and fracture risk when proposing intervention thresholds.5 Using only the osteoporosis diagnosis6 to predict fractures has poor sensitivity and the majority of patients having fractures do not have osteoporosis.7 Therefore, much can be gained by attempting to account for clinical risk factors, falls risk, and developing enhanced methods to characterize skeletal fragility in order to improve the ability to detect risk patients before they fracture. Recently, results from a large meta‐analysis of prospective studies of women and men who had their bones measured with high‐resolution peripheral computed tomography (HRpQCT) identified several bone microstructural traits, including failure load and trabecular volumetric BMD, associated with incident fracture, although the HRpQCT indices only increased the area under the curve slightly in addition to femoral neck BMD and clinical risk factors

BackgroundMuscle weakness is a key factor in the increase risk of falls and might also play a significant role in the increase of risk of hip fracture. Computed tomography‐measured muscle size and muscle density are well‐established imaging biomarkers used in studies of physical function, frailty or cancer, but limited to hip fracture. In particular, it is warranted to have a better understanding of the performance of muscle size and density in the discrimination of acute hip fractures. We also aim to determine age‐related differences of muscle size and density in healthy controls and hip fracture patients.MethodsFour hundred thirty‐eight low‐energy acute hip fracture cases and 316 healthy controls from the China Action on Spine and Hip Status study were included in the study. Muscle cross‐sectional area and density were measured for the gluteus maximus and gluteus medius and minimus. Areal bone mineral density (aBMD) of the femoral neck and total hip was measured. Using propensity score matching, we generated three samples with cases and controls matched for age, body mass index, and gender: femoral neck fracture (FNF), intertrochanteric fracture (ITF), and any hip fracture vs. controls, respectively.ResultsHandgrip strength, gluteus muscle area and density, and bone parameters of the matched hip fracture groups were lower than those of the correspondence control groups, respectively (P < 0.05). The univariate analysis showed that associations of aBMD with FNF and with ITF were significantly weaker than associations between fracture and muscle parameters. Gluteus medius and minimus muscle density showed the highest areas under the curve (AUC) with FNF (0.88, 95% confidence interval, 0.85–0.92) and trochanteric fracture (0.95, 95% confidence interval, 0.92–0.97). The model including all muscle and bone parameters provided the highest AUC (FNF: AUC 0.912; ITF: AUC 0.958), and AUC results of another selected model without muscle density showed that association with fracture significantly dropped (FNF: AUC 0.755; ITF: AUC 0.858). Separate results for the two age groups younger and older than 70 years showed no age‐related significant differences in discriminate models.ConclusionsMuscle density performs better than aBMD from hip computed tomography X‐ray absorptiometry and muscle size in discrimination of hip fracture. Combination of aBMD and muscle density provided the best discrimination. The integration of muscle assessments may trigger a paradigm shift in hip fracture prediction. Gluteus muscle density should also be evaluated as treatment outcome.

Hip fractures can be separated into femoral neck (cervical or intracapsular) or trochanteric (extracapsular). Trochanteric fractures have been associated with up to twice the short-term mortality of cervical fractures in the elderly. Fracture type may be influenced by the fall direction and local differences in proximal femur strength properties. We previously demonstrated that fall characteristics and body habitus, in addition to femoral bone mineral density, play a dominant role in the prediction of hip fracture in elderly fallers. To examine the association of these determinants with hip fracture type, we assessed fall characteristics, body habitus, and site-specific bone mineral density measurements in 112 elderly hip fracture patients (85 women and 27 men, mean age 85 years) 1 week after an acute hip fracture. Trochanteric BMD was 13% lower in women and 11% lower in men for patients with trochanteric fracture than in those with femoral neck fracture (p < 0.01). A stepwise multiple logistic regression indicated that trochanteric BMD (decrease of 1.0 SD, adjusted OR 4.6, 95% Cl 2.0-9.5, p < 0.0001) and femoral neck BMD (increase of 1.0 SD, adjusted OR 3.0, 95% Cl 1.6-5.9, p = 0.0003) were independently associated with trochanteric fracture. Fall characteristics, body habitus, gender, and age were not associated with hip fracture type. We conclude that a relatively low trochanteric BMD or a high femoral neck BMD was associated with a trochanteric hip fracture and that site-specific trochanteric BMD determinations should be measured when assessing risk of trochanteric hip fractures in the elderly.

Quantitative ultrasound parameters as well as bone mineral density are better predictors of trochanteric than cervical hip fractures in elderly women. Results from the EPIDOS study

Based on engineering principles, geometric measurements of femoral size should be related to femoral strength and the risk for hip fracture. To evaluate whether a simple measurement of femoral geometry is associated with hip fracture risk, we obtained dual x-ray absorptiometry scans of the proximal femur on 8074 white women age 67 or older. During an average of 1.6 years of follow-up, 64 participants suffered hip fractures. In all fracture cases and in a random sample of 134 women who did not subsequently suffer a hip fracture, we measured hip axis length (the distance from greater trochanter to inner pelvic brim), neck width, and the neck/shaft angle on the scan printout, with the observer blinded to subsequent fracture status of the participant. Results were analyzed using multiple logistic models, and odds ratios were determined. After adjustment for age, each standard deviation decrease in femoral neck bone mineral density increased hip fracture risk 2.7-fold (95% confidence interval 1.7, 4.3), and each standard deviation increase in hip axis length nearly doubled the risk of hip fracture (odds ratio = 1.8; 95% CI 1.3, 2.5). The relationship between hip axis length and fracture risk persisted even after adjustment for age, femoral neck density, height, and weight. A longer hip axis length was associated with an increased risk of both femoral neck (OR = 1.9; 95% CI 1.3, 3.0) and trochanteric fractures (1.6; 1.0, 2.4). We found no significant association between the neck width (1.1; 0.8, 1.5) or the neck/shaft angle (1.4; 0.9, 2.2) and risk of hip fracture.(ABSTRACT TRUNCATED AT 250 WORDS)