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Quantifying the material and structural determinants of bone strength

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The ability of a bone to resist fracture depends on the amount of bone present, the spatial distribution of the bone mass as cortical and trabecular bone and the intrinsic properties of the bone material. Whereas low areal bone mineral density (aBMD) predicts fractures, its sensitivity and specificity is low, as over 50% of fractures occur in persons without osteoporosis by BMD testing and most women with osteoporosis do not sustain a fracture. New non-invasive imaging techniques, including three-dimensional (3D) assessments of bone density and geometry, microarchitecture and integrated measurements of bone strength such as finite element analysis (FEA), provide estimates of bone strength that can be used to increase the sensitivity and specificity of fracture risk assessment. Initial observations have shown that these techniques provide information that will improve our understanding of the pathophysiology of skeletal fragility and suggest that these techniques are likely to have a role in the clinical management of individuals at risk for fracture.

Section snippets

Criteria for evaluating new technologies

Imaging technologies must be accurate and precise and must have established quality control procedures, standardised data acquisition and analysis, as well as methods for cross-calibration of devices at different clinical centres [16]. Data that help define the clinical utility of a new imaging technique include: (1) sex- and age-specific reference data; (2) assessment of disease severity; (3) associations with fracture risk in untreated subjects; and (4) changes in the measurement with

Dual-energy X-ray absorptiometry (DXA) and aBMD

Introduced about 25 years ago, dual-energy X-ray absorptiometry (DXA) provides a quantitative assessment of mineralised bone mass at the axial and appendicular skeleton in vivo. This technique measures the attenuation of photons of two different energies during radiation transmission. Bone mineral content (BMC, g) and aBMD (g cm–2) of a region of interest are obtained. As low aBMD is a strong risk factor for fractures [17], this technique provided the basis for the World Health Organization

Conclusions

Novel non-invasive techniques for assessment of the structural determinants of bone strength are available. These techniques quantify the macro- and microstructure of bone such as bone size, shape, cortical thickness, cortical density, a surrogate of cortical porosity, trabecular number, thickness and separation. FE analysis, by combining bone geometry with material characteristics, provides good estimates of whole bone strength. Whether these strength and/or morphological features singly or

Acknowledgements

We thank Drs. Sharmala Majumdar, Claus Glüer, Thomas Lang and David Kopperdahl for generously providing images.

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