Osteoporosis treatment prevents hip fracture similarly in both sexes: the FOCUS observational study.

Randomized trials have not been performed, and may never be, to determine if osteoporosis treatment prevents hip fracture in men. Addressing that evidence gap, we analyzed data from an observational study of new hip fractures in a large integrated healthcare system to compare the reduction in hip fractures associated with standard-of-care osteoporosis treatment in men versus women. Sampling from 271 389 patients age ≥ 65 who had a hip-containing computed tomography scan during care between 2005-2018, we selected all who subsequently had a first hip fracture (cases) after the CT scan (start of observation) and a sex-matched equal number of randomly selected patients. From those, we analyzed all who tested positive for osteoporosis (DXA-equivalent hip bone mineral density T-score ≤ -2.5, measured from the CT scan using VirtuOst). We defined "treated" as at least six months of any osteoporosis medication by prescription fill data during follow up; "not-treated" was no prescription fill. Sex-specific odds ratios of hip fracture for treated versus not-treated patients were calculated by logistic regression; adjustments included age, BMD T-score, a BMD-treatment interaction, body mass index, race/ethnicity, and seven baseline clinical risk factors. At two-year follow-up, 33.9% of the women (750/2211 patients) and 24.0% of the men (175/728 patients) were treated, primarily with alendronate; 51.3% and 66.3%, respectively, were not-treated; and 721 and 269, respectively, had a first hip fracture since the CT scan. Odds ratio of hip fracture for treated versus not-treated was 0.26 (95% confidence interval: 0.21-0.33) for women and 0.21 (0.13-0.34) for men; the ratio of these odds ratios (men:women) was 0.81 (0.47-1.37), indicating no significant sex effect. Various sensitivity and stratified analyses confirmed these trends, including results at five-year follow-up. Given these results and considering the relevant literature, we conclude that osteoporosis treatment prevents hip fracture similarly in both sexes.

Much evidence suggests that osteoporosis treatment should prevent hip fracture similarly in both sexes. However, because of their expense, randomized clinical trials to demonstrate that definitively have not been performed and may never be. As a result, osteoporosis testing and treatment is not as widely adopted for men as it is for women. Addressing that evidence gap, we analyzed data from over 250 000 patients in the Kaiser Permanente healthcare system in Southern California. Sampling a subset of all patients over a 13-year period who had had a computed tomography (CT or CAT) scan as part of their medical care for any reason, we measured bone mineral density from the CT scans to identify all patients who had osteoporosis at the hip and then used data from the electronic health records to determine statistically the risk of a future hip fracture for those who were treated for osteoporosis versus those who were not treated. We found that the reduction in risk of hip fracture associated with treatment did not differ between the sexes. These results demonstrate that treating osteoporosis in patients at high risk of hip fracture should reduce the risk of hip fracture similarly in both sexes.

Validation of Biomechanical Computed Tomography for Fracture Risk Classification in Metastatic Hormone-sensitive Prostate Cancer.

BACKGROUND: Guidelines recommend dual-energy x-ray absorptiometry (DXA) screening to assess fracture risk and benefit from antiresorptive therapy in men with metastatic hormone-sensitive prostate cancer (mHSPC) on androgen deprivation therapy (ADT). However, <30% of eligible patients undergo DXA screening. Biomechanical computed tomography (BCT) is a radiomic technique that measures bone mineral density (BMD) and bone strength from computed tomography (CT) scans. OBJECTIVE: To evaluate the (1) correlations between BCT- and DXA-assessed BMD, and (2) associations between BCT-assessed metrics and subsequent fracture. DESIGN, SETTING, AND PARTICIPANTS: A multicenter retrospective cohort study was conducted among patients with mHSPC between 2013 and 2020 who received CT abdomen/pelvis or positron emission tomography/CT within 48 wk before ADT initiation and during follow-up (48-96 wk after ADT initiation). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We used univariate logistic regression to assess the associations between BCT measurements and the primary outcomes of subsequent pathologic and nonpathologic fractures. RESULTS AND LIMITATIONS: Among 91 eligible patients, the median ([interquartile range) age was 67 yr (62-75), 44 (48.4%) were White, and 41 (45.1%) were Black. During the median follow-up of 82 wk, 17 men (18.6%) developed a pathologic and 15 (16.5%) a nonpathologic fracture. BCT- and DXA-assessed femoral-neck BMD T scores were strongly correlated (R2 = 0.93). On baseline CT, lower BCT-assessed BMD (odds ratio [OR] 1.80, 95% confidence interval or CI [1.10, 3.25], p = 0.03) was associated with an increased risk of a pathologic fracture. Lower femoral strength (OR 1.63, 95% CI [0.99, 2.71], p = 0.06) was marginally associated with an increased risk of a pathologic fracture. Neither BMD (OR 1.52, 95% CI [0.95, 2.63], p = 0.11) nor strength (OR 1.14, 95% CI [0.75, 1.80], p = 0.57) was associated with a nonpathologic fracture. BCT identified nine (9.9%) men eligible for antiresorptive therapy, of whom four (44%) were not treated. Limitations include low fracture numbers resulting in lower power to detect fracture associations. CONCLUSIONS: Among men diagnosed with mHSPC, BCT assessments were strongly correlated with DXA, predicted subsequent pathologic fracture, and identified additional men indicated for antiresorptive therapy. PATIENT SUMMARY: We assess whether biomechanical computer tomography (BCT) from routine computer tomography (CT) scans can identify fracture risk among patients recently diagnosed with metastatic prostate cancer. We find that BCT and dual-energy x-ray absorptiometry-derived bone mineral density are strongly correlated and that BCT accurately identifies the risk for future fracture. BCT may enable broader fracture risk assessment and facilitate timely interventions to reduce fracture risk in metastatic prostate cancer patients.

Radiation-induced changes in load-sharing and structure-function behavior in murine lumbar vertebrae.

In this study, we used micro-CT-based finite element analysis to investigate the biomechanical effects of radiation on the microstructure and mechanical function of murine lumbar vertebrae. Specifically, we evaluated vertebral microstructure, whole-bone stiffness, and cortical-trabecular load sharing in the L5 vertebral body of mice exposed to ionizing radiation 11 days post exposure (5 Gy total dose; n = 13) and controls (n = 14). Our findings revealed the irradiated group exhibited reduced trabecular bone volume and microstructure (p < 0.001) compared to controls, while cortical bone volume remained unchanged (p = 0.91). Axially compressive loads in the irradiated group were diverted from the trabecular centrum and into the vertebral cortex, as evidenced by a higher cortical load-fraction (p = 0.02) and a higher proportion of cortical tissue at risk of initial failure (p < 0.01). Whole-bone stiffness was lower in the irradiated group compared to the controls, though the difference was small and non-significant (2045 ± 142 vs. 2185 ± 225 vs. N/mm, irradiated vs. control, p = 0.07). Additionally, the structure-function relationship between trabecular bone volume and trabecular load fraction differed between groups (p = 0.03), indicating a less biomechanically efficient trabecular network in the irradiated group. We conclude that radiation can decrease trabecular bone volume and result in a less biomechanically efficient trabecular structure, leading to increased reliance on the vertebral cortex to resist axially compressive loads. These findings offer biomechanical insight into the effects of radiation on structure-function behavior in murine lumbar vertebrae independent of possible tissue-level material effects.

Relative Effects of Radiation-Induced Changes in Bone Mass, Structure, and Tissue Material on Vertebral Strength in a Rat Model.

The observed increased risk of fracture after cancer radiation therapy is presumably due to a radiation-induced reduction in whole-bone strength. However, the mechanisms for impaired strength remain unclear, as the increased fracture risk is not fully explained by changes in bone mass. To provide insight, a small animal model was used to determine how much of this whole-bone weakening effect for the spine is attributable to changes in bone mass, structure, and material properties of the bone tissue and their relative effects. Further, because women have a greater risk of fracture after radiation therapy than men, we investigated if sex had a significant influence on bone's response to irradiation. Fractionated in vivo irradiation (10 × 3 Gy) or sham irradiation (0 Gy) was administered daily to the lumbar spine in twenty-seven 17-week-old Sprague-Dawley rats (n = 6-7/sex/group). Twelve weeks after final treatment, animals were euthanized, and lumbar vertebrae (L4 and L5 ) were isolated. Using a combination of biomechanical testing, micro-CT-based finite element analysis, and statistical regression analysis, we separated out the effect of mass, structural, and tissue material changes on vertebral strength. Compared with the sham group (mean ± SD strength = 420 ± 88 N), the mean strength of the irradiated group was lower by 28% (117 N/420 N, p < 0.0001). Overall, the response of treatment did not differ with sex. By combining results from both general linear regression and finite element analyses, we calculated that mean changes in bone mass, structure, and material properties of the bone tissue accounted for 56% (66 N/117 N), 20% (23 N/117 N), and 24% (28 N/117 N), respectively, of the overall change in strength. As such, these results provide insight into why an elevated clinical fracture risk for patients undergoing radiation therapy is not well explained by changes in bone mass alone. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Biomechanical structure-function relations for human trabecular bone - comparison of calcaneus, femoral neck, greater trochanter, proximal tibia, and vertebra.

MicroCT-based finite element models were used to compute power law relations for uniaxial compressive yield stress versus bone volume fraction for 78 cores of human trabecular bone from five anatomic sites. The leading coefficient of the power law for calcaneus differed from those for most of the other sites (p < 0.05). However, after normalizing by site-specific mean values, neither the leading coefficient (p > 0.5) nor exponent (p > 0.5) differed among sites, suggesting that a given percentage deviation from mean bone volume fraction has the same mechanical consequence for all sites investigated. These findings help explain the success of calcaneal x-ray and ultrasound measurements for predicting hip fracture risk.

Prevalence of osteoporosis in older male veterans receiving hip-containing computed tomography scans: opportunistic use of biomechanical computed tomography analysis (BCT).

Osteoporosis care in men is suboptimal due to low rates of testing and treatment. Applying biomechanical computed tomography (BCT) analysis to existing CT scans, we found a high proportion of men with osteoporosis have never been diagnosed or treated. BCT may improve identification of patients at high risk of fracture. PURPOSE: Osteoporosis care in men is suboptimal due to low rates of DXA testing and treatment. Biomechanical computed tomography analysis (BCT) can be applied "opportunistically" to prior hip-containing CT scans to measure femoral bone strength and hip BMD. METHODS: In this retrospective, cross-sectional study, we used BCT in male veterans with existing CT scans to investigate the prevalence of osteoporosis, defined by hip BMD (T-score ≤ - 2.5) or fragile bone strength (≤ 3500 N). 577 men, age ≥ 65 with abdominal/pelvic CTs performed in 2017-2019, were randomly selected for BCT analysis. Clinical data were collected via electronic health records and used with the femoral neck BMD T-score from BCT to estimate 10-year hip fracture risks by FRAX. RESULTS: Prevalence of osteoporosis by BCT increased with age (13.5% age 65-74; 18.2% age 75-84; 34.3% age ≥ 85), with an estimated overall prevalence of 18.3% for men age ≥ 65. In those with osteoporosis (n = 108/577), only 38.0% (41/108) had a prior DXA and 18.6% (7/108) had received osteoporosis pharmacotherapy. Elevated hip fracture risk by FRAX (≥ 3%) did not fully capture those with fragile bone strength. In a multivariate logistic regression model adjusted for age, BMI, race, and CT location, end stage renal disease (odds ratio 7.4; 95% confidence interval 2.3-23.9), COPD (2.2; 1.2-4.0), and high-dose inhaled corticosteroid use (3.7; 1.2-11.8) were associated with increased odds of having osteoporosis by BCT. CONCLUSION: Opportunistic BCT in male veterans provides an additional avenue to identify patients who are at high risk of fractures.

Effects of four-year cyclic versus two-year daily teriparatide treatment on volumetric bone density and bone strength in postmenopausal women with osteoporosis.

PURPOSE: To evaluate the effects of cyclic vs daily teriparatide treatment (TPTD) on volumetric bone mineral density (vBMD) and bone strength at the hip and spine in women who were previously untreated. METHODS: A total of 86 women were randomized to a 24-month open label treatment of either daily TPTD (20 µg daily) or cyclic TPTD (20 µg daily for 3 months followed by 3 months off). During a 2-year extension, women in the daily TPTD group were switched to alendronate (ALN) and those in the cyclic TPTD group continued on cyclic TPTD (without any ALN). QCT images were acquired at baseline, 2-years (n = 54) and 4-years (n = 35) and analyzed for volumetric integral, cortical and trabecular bone mineral density (vBMD) and bone strength (by finite element analysis) at the hip and spine. The primary analysis presented here compared the responses across equal total TPTD doses (2 years daily vs 4 years cyclic). RESULTS: In the spine, integral vBMD and strength increased substantially after 2 years daily and 4 years cyclic TPTD, with no significant differences (vBMD +12 % vs +11 %, respectively, p = 0.70; spine strength +21 % vs +16 %, respectively, p = 0.35). At the hip, the gains were smaller, but again no significant differences were detected between the groups for the increases in either vBMD (+2 % in both groups, p = 0.97) or hip strength (3 % vs 3 %, p = 0.91). In the spine, the vBMD increment was about twice as large in the trabecular vs peripheral compartment; in the hip, significant vBMD gain was seen only in the trabecular compartment. CONCLUSIONS: The gains in volumetric BMD and bone strength for an equivalent dose of TPTD did not depend on whether it was administered every day over two years or cyclically over four years.

Increased risks of vertebral fracture and reoperation in primary spinal fusion patients who test positive for osteoporosis by Biomechanical Computed Tomography analysis.

BACKGROUND CONTEXT: While osteoporosis is a risk factor for adverse outcomes in spinal fusion patients, diagnosing osteoporosis reliably in this population has been challenging due to degenerative changes and spinal deformities. Addressing that challenge, biomechanical computed tomography analysis (BCT) is a CT-based diagnostic test for osteoporosis that measures both bone mineral density and bone strength (using finite element analysis) at the spine; CT scans taken for spinal evaluation or previous care can be repurposed for the analysis. PURPOSE: Assess the effectiveness of BCT for preoperatively identifying spinal fusion patients with osteoporosis who are at high risk of reoperation or vertebral fracture. STUDY DESIGN: Observational cohort study in a multi-center integrated managed care system using existing data from patient medical records and imaging archives. PATIENT SAMPLE: We studied a randomly sampled subset of all adult patients who had any type of primary thoracic (T4 or below) or lumbar fusion between 2005 and 2018. For inclusion, patients with accessible study data needed a preop CT scan without intravenous contrast that contained images (before any instrumentation) of the upper instrumented vertebral level. OUTCOME MEASURES: Reoperation for any reason (primary outcome) or a newly documented vertebral fracture (secondary outcome) occurring up to 5 years after the primary surgery. METHODS: All study data were extracted using available coded information and CT scans from the medical records. BCT was performed at a centralized lab blinded to the clinical outcomes; patients could test positive for osteoporosis based on either low values of bone strength (vertebral strength ≤ 4,500 N women or 6,500 N men) and/or bone mineral density (vertebral trabecular bone mineral density ≤ 80 mg/cm3 both sexes). Cox proportional hazard ratios were adjusted by age, presence of obesity, and whether the fusion was long (four or more levels fused) or short (3 or fewer levels fused); Kaplan-Meier survival was compared by the log rank test. This project was funded by NIH (R44AR064613) and all physician co-authors and author 1 received salary support from their respective departments. Author 6 is employed by, and author 1 has equity in and consults for, the company that provides the BCT test; the other authors declare no conflicts of interest. RESULTS: For the 469 patients analyzed (298 women, 171 men), median follow-up time was 44.4 months, 11.1% had a reoperation (median time 14.5 months), and 7.7% had a vertebral fracture (median time 2.0 months). Overall, 25.8% of patients tested positive for osteoporosis and no patients under age 50 tested positive. Compared to patients without osteoporosis, those testing positive were at almost five-fold higher risk for vertebral fracture (adjusted hazard ratio 4.7, 95% confidence interval = 2.2-9.7; p<.0001 Kaplan-Meier survival). Of those positive-testing patients, those who tested positive concurrently for low values of both bone strength and bone mineral density (12.6% of patients overall) were at almost four-fold higher risk for reoperation (3.7, 1.9-7.2; Kaplan-Meier survival p<.0001); the remaining positive-testing patients (those who tested positive for low values of either bone strength or bone mineral density but not both) were not at significantly higher risk for reoperation (1.6, 0.7-3.7) but were for vertebral fracture (4.3, 1.9-10.2). For both clinical outcomes, risk remained high for patients who underwent short or long fusion. CONCLUSION: In a real-world clinical setting, BCT was effective in identifying primary spinal fusion patients aged 50 or older with osteoporosis who were at elevated risks of reoperation and vertebral fracture.

Vertebral Bone Mineral Density, Vertebral Strength, and Syndesmophyte Growth in Ankylosing Spondylitis: The Importance of Bridging.

OBJECTIVE: To examine the relationship between vertebral trabecular bone mineral density (tBMD), vertebral strength, and syndesmophytes in patients with ankylosing spondylitis (AS) using quantitative computed tomography (QCT). METHODS: We performed QCT of the spine to measure syndesmophytes and tBMD in 5 vertebrae (T11-L3) in 61 patients with AS. Finite element analysis was performed to measure vertebral strength in compressive overload, including in trabecular and cortical compartments. In cross-sectional analyses, we examined associations of syndesmophyte height with tBMD and vertebral strength in each vertebra. In 33 patients followed up for 2 years, we investigated whether baseline tBMD and vertebral strength predicted syndesmophyte growth in the same vertebra, and vice versa. RESULTS: In the cross-sectional analyses, 126 vertebrae had bridging, 77 vertebrae had nonbridging syndesmophytes, and 83 vertebrae had no syndesmophytes. There were strong inverse associations between syndesmophyte height and tBMD, total strength, and trabecular strength only among bridged vertebrae. In the longitudinal analysis, nonbridged vertebrae with low tBMD (adjusted ß = -0.01 [95% confidence interval (95% CI) -0.019, -0.0012]) and low strength (adjusted ß = -0.0003 [95% CI -0.0004, -0.0002]) had more syndesmophyte growth over time. Similar associations were absent among bridged vertebrae. Conversely, vertebrae with bridging at baseline had a significant loss in percent tBMD over time (adjusted ß = -0.001 [95% CI -0.0017, -0.0004]). CONCLUSION: Associations between syndesmophytes and vertebral density and strength in AS differ between bridged and nonbridged vertebrae. Among nonbridged vertebrae, low tBMD and strength are associated with syndesmophyte growth. Bridging is associated with large subsequent losses in tBMD, possibly due to mechanical offloading.

Relations Between Bone Quantity, Microarchitecture, and Collagen Cross-links on Mechanics Following In Vivo Irradiation in Mice.

Humans are exposed to ionizing radiation via spaceflight or cancer radiotherapy, and exposure from radiotherapy is known to increase risk of skeletal fractures. Although irradiation can reduce trabecular bone mass, alter trabecular microarchitecture, and increase collagen cross-linking, the relative contributions of these effects to any loss of mechanical integrity remain unclear. To provide insight, while addressing both the monotonic strength and cyclic-loading fatigue life, we conducted total-body, acute, gamma-irradiation experiments on skeletally mature (17-week-old) C57BL/6J male mice (n = 84). Mice were administered doses of either 0 Gy (sham), 1 Gy (motivated by cumulative exposures from a Mars mission), or 5 Gy (motivated by clinical therapy regimens) with retrieval of the lumbar vertebrae at either a short-term (11-day) or long-term (12-week) time point after exposure. Micro-computed tomography was used to assess trabecular and cortical quantity and architecture, biochemical composition assays were used to assess collagen quality, and mechanical testing was performed to evaluate vertebral compressive strength and fatigue life. At 11 days post-exposure, 5 Gy irradiation significantly reduced trabecular mass (p < 0.001), altered microarchitecture (eg, connectivity density p < 0.001), and increased collagen cross-links (p < 0.001). Despite these changes, vertebral strength (p = 0.745) and fatigue life (p = 0.332) remained unaltered. At 12 weeks after 5 Gy exposure, the trends in trabecular bone persisted; in addition, regardless of irradiation, cortical thickness (p < 0.01) and fatigue life (p < 0.01) decreased. These results demonstrate that the highly significant effects of 5 Gy total-body irradiation on the trabecular bone morphology and collagen cross-links did not translate into detectable effects on vertebral mechanics. The only mechanical deficits observed were associated with aging. Together, these vertebral results suggest that for spaceflight, irradiation alone will likely not alter failure properties, and for radiotherapy, more investigations that include post-exposure time as a positive control and testing of both failure modalities are needed to determine the cause of increased fracture risk. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research. This article has been contributed to by US Government employees and their work is in the public domain in the USA.

Romosozumab improves lumbar spine bone mass and bone strength parameters relative to alendronate in postmenopausal women: results from the Active-Controlled Fracture Study in Postmenopausal Women With Osteoporosis at High Risk (ARCH) trial.

The Active-Controlled Fracture Study in Postmenopausal Women With Osteoporosis at High Risk (ARCH) trial (NCT01631214; https://clinicaltrials.gov/ct2/show/NCT01631214) showed that romosozumab for 1 year followed by alendronate led to larger areal bone mineral density (aBMD) gains and superior fracture risk reduction versus alendronate alone. aBMD correlates with bone strength but does not capture all determinants of bone strength that might be differentially affected by various osteoporosis therapeutic agents. We therefore used quantitative computed tomography (QCT) and finite element analysis (FEA) to assess changes in lumbar spine volumetric bone mineral density (vBMD), bone volume, bone mineral content (BMC), and bone strength with romosozumab versus alendronate in a subset of ARCH patients. In ARCH, 4093 postmenopausal women with severe osteoporosis received monthly romosozumab 210 mg sc or weekly oral alendronate 70 mg for 12 months, followed by open-label weekly oral alendronate 70 mg for ≥12 months. Of these, 90 (49 romosozumab, 41 alendronate) enrolled in the QCT/FEA imaging substudy. QCT scans at baseline and at months 6, 12, and 24 were assessed to determine changes in integral (total), cortical, and trabecular lumbar spine vBMD and corresponding bone strength by FEA. Additional outcomes assessed include changes in aBMD, bone volume, and BMC. Romosozumab caused greater gains in lumbar spine integral, cortical, and trabecular vBMD and BMC than alendronate at months 6 and 12, with the greater gains maintained upon transition to alendronate through month 24. These improvements were accompanied by significantly greater increases in FEA bone strength (p < 0.001 at all time points). Most newly formed bone was accrued in the cortical compartment, with romosozumab showing larger absolute BMC gains than alendronate (p < 0.001 at all time points). In conclusion, romosozumab significantly improved bone mass and bone strength parameters at the lumbar spine compared with alendronate. These results are consistent with greater vertebral fracture risk reduction observed with romosozumab versus alendronate in ARCH and provide insights into structural determinants of this differential treatment effect. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

The Role of Vertebral Porosity and Implant Loading Mode on Bone-Tissue Stress in the Human Vertebral Body Following Lumbar Total Disc Arthroplasty.

STUDY DESIGN: Micro-computed tomography- (micro-CT-) based finite element analysis of cadaveric human lumbar vertebrae virtually implanted with total disc arthroplasty (TDA) implants. OBJECTIVE: (1) Assess the relationship between vertebral porosity and maximum levels of bone-tissue stress following TDA; (2) determine whether the implant's loading mode (axial compression vs. sagittal bending) alters the relationship between vertebral porosity and bone-tissue stress. SUMMARY OF BACKGROUND DATA: Implant subsidence may be related to the bone biomechanics in the underlying vertebral body, which are poorly understood. For example, it remains unclear how the stresses that develop in the supporting bone tissue depend on the implant's loading mode or on typical inter-individual variations in vertebral morphology. METHODS: Data from micro-CT scans from 12 human lumbar vertebrae (8 males, 4 females; 51-89 years of age; bone volume fraction [BV/TV] = 0.060-0.145) were used to construct high-resolution finite element models (37 µm element edge length) comprising disc-vertebra-implant motion segments. Implants were loaded to 800 N of force in axial compression, flexion-, and extension-induced impingement. For comparison, the same net loads were applied via an intact disc without an implant. Linear regression was used to assess the relationship between BV/TV, loading mode, and the specimen-specific change in stress caused by implantation. RESULTS: The increase in maximum bone-tissue stress caused by implantation depended on loading mode (P < 0.001), increasing more in bending-induced impingement than axial compression (for the same applied force). The change in maximum stress was significantly associated with BV/TV (P = 0.002): higher porosity vertebrae experienced a disproportionate increase in stress compared with lower porosity vertebrae. There was a significant interaction between loading mode and BV/TV (P = 0.002), indicating that loading mode altered the relationship between BV/TV and the change in maximum bone-tissue stress. CONCLUSION: Typically-sized TDA implants disproportionately increase the bone-tissue stress in more porous vertebrae; this affect is accentuated when the implant impinges in sagittal bending.Level of Evidence: N/A.

Change in vertebral strength and bone mineral density in men and women over the year post-hip fracture: a subgroup analysis.

This study examines changes in bone density and strength in the spine over the year after hip fracture to see if there are differences in the changes between men and women. Results show losses in the spine that may increase the risk of subsequent vertebral fractures, particularly for women. PURPOSE: Compare changes over the first year post-hip fracture in vertebral bone mineral density (BMD) and compressive strength, measured from quantitative computed tomography (QCT) scans of the spine (T12-L1), between women and men. METHODS: QCT scans were performed on 37 participants (21 men and 16 women) at 2 and 12 months post-hip fracture as part of an ancillary observational study of hip fracture recovery in older community-dwelling men and women. Vertebral BMD and compressive strength were calculated using VirtuOst® (O.N. Diagnostics, Berkeley, CA). Unpaired t-tests were used to compare men and women with respect to baseline demographics, measurements of BMD and bone strength for the whole vertebra and the cortical and trabecular compartments, and any changes in these parameters between months 2 and 12. RESULTS: At 2 months post-fracture, there were no significant sex differences in any measurements of vertebral strength or BMD. Between months 2 and 12, vertebral strength decreased significantly in women (- 3.8%, p < 0.05) but not in men (- 2.3%, p < 0.20), vertebral trabecular BMD decreased similarly in both sexes (- 5.7% women; - 6.0% men), but cortical BMD did not change for either sex. CONCLUSION: Despite the small sample size, these findings suggest that appreciable loss of vertebral trabecular bone can occur for both sexes in the year following hip fracture, which may increase the risk of subsequent vertebral fracture, particularly for women.

Triple-Phase Computed Tomography May Replace Dual-Energy X-ray Absorptiometry Scan for Evaluation of Osteoporosis in Liver Transplant Candidates.

Assessment of bone density is an important part of liver transplantation (LT) evaluation for early identification and treatment of osteoporosis. Dual-energy X-ray absorptiometry (DXA) is currently the standard clinical test for osteoporosis; however, it may contribute to the appointment burden on LT candidates during the cumbersome evaluation process, and there are limitations affecting its accuracy. In this study, we evaluate the utility of biomechanical analysis of vertebral images obtained during dual-energy abdominal triple-phase computed tomography (TPCT) in diagnosing osteoporosis among LT candidates. We retrospectively reviewed cases evaluated for LT between January 2017 and March 2018. All patients who underwent TPCT within 3 months of DXA were included. The biomechanical computed tomography (BCT) analysis was performed at a centralized laboratory (O.N. Diagnostics, Berkeley, CA) by 2 trained analysts blinded to the DXA data. DXA-based osteoporosis was defined as a T score ≤-2.5 at the hip or spine. BCT-based osteoporosis was defined as vertebral strength ≤4500 N for women or ≤6500 N for men or trabecular volumetric bone mineral density ≤80 mg/cm3 . Comparative data were available for 91 patients who had complete data for both DXA and BCT: 31 women and 60 men, age 54 ± 11 years (mean ± standard deviation), mean body mass index 28 ± 6 kg/m2 . Using DXA as the clinical reference, sensitivity of BCT to detect DXA-defined osteoporosis was 83.3% (20/24 patients) and negative predictive value was 91.7%; specificity and positive predictive value were 65.7% and 46.5%, respectively. BCT analysis of vertebral images on triple-phase computed tomography, routinely obtained during transplant evaluation, can reliably rule out osteoporosis in LT candidates. Patients with suspicion of osteoporosis on TPCT may need further evaluation by DXA.

Opportunistic Computed Tomography and Spine Surgery: A Narrative Review.

STUDY DESIGN: Narrative review. OBJECTIVE: This article seeks to provide a narrative review regarding the ability of opportunistic information available from computed tomography (CT) scans to guide decisions in spine surgery related to patient bone quality. METHODS: A review of the literature (limited to human and English language) was performed via PubMed and Google Scholar using the search terms; "osteoporosis" AND "opportunistic" AND "computed tomography" AND "spine surgery." The titles and then abstracts of all identified citations were reviewed for inclusion by 2 of the authors (MS, BAF). Relevant articles were then studied in full text. RESULTS: A review of the literature found 25 articles that were selected for inclusion in this narrative review. These articles were broadly divided into 4 subcategories: (1) opportunistic CT (oCT) and osteoporosis detection, (2) oCT data and the quality of screw fixation, (3) utilization of Hounsfield units to assess clinical and/or radiographic outcomes following spine fusion, and (4) virtual stress testing in spine surgery. CONCLUSION: The literature on oCT, as well as associated virtual stress-testing techniques, demonstrate the potential to enhance spine surgery outcomes by preoperatively identifying at-risk patients in need of bone health optimization and informing best techniques for performing spinal fusion surgery on patients with diminished bone quality. While our narrative summary of the limited literature to date suggests a promising future for oCT data, significant additional research and/or radiographic workflow standardization is needed to validate these methods for clinical use.

Comparison of Vertebral and Femoral Strength Between White and Asian Adults Using Finite Element Analysis of Computed Tomography Scans.

Given non-optimal testing rates for dual-energy X-ray absorptiometry (DXA) and the high use of computed tomography (CT) in some Asian countries, biomechanical computed tomography analysis (BCT)-based bone strength testing, which utilizes previously taken clinical CT scans, may improve osteoporosis testing rates. However, an understanding of ethnic differences in such bone strength measurements between Whites and Asians is lacking, which is an obstacle to clinical interpretation. Using previously taken CT and DXA scans, we analyzed bone strength and bone mineral density (BMD) at the hip and spine in two sex- and age-matched community-based cohorts, aged 40 to 80 years: Whites (Rochester, MN, USA) and Koreans (Seoul, South Korea). For both the spine and femur, the age dependence of bone strength was similar for both groups, White (n = 371; women n = 202, 54.5%) and Korean (n = 396; women n = 199, 50.3%). For both sexes, mean spine strength did not differ between groups, but femur strength was 9% to 14% higher in Whites (p ≤ 0.001), an effect that became non-significant after weight adjustment (p = 0.375). For Koreans of both sexes, the fragile bone strength thresholds for classifying osteoporosis, when derived from regional DXA BMD T-score references, equaled the clinically validated thresholds for Whites (in women and men, femoral strength, 3000 N and 3500 N; vertebral strength 4500 N and 6500 N, respectively). Using these thresholds, classifications for osteoporosis for Koreans based on bone strength versus based on DXA BMD T-scores were consistent (89.1% to 94.4% agreement) at both the hip and spine and for both sexes. The BCT-based, clinically validated bone strength thresholds for Whites also applied to Koreans, which may facilitate clinical interpretation of CT-based bone strength measurements for Koreans. © 2020 American Society for Bone and Mineral Research (ASBMR).

Effect of variations in tissue-level ductility on human vertebral strength.

Although the ductility of bone tissue is a unique element of bone quality and varies with age and across the population, the extent to which and mechanisms by which typical population-variations in tissue-level ductility can alter whole-bone strength remains unclear. To provide insight, we conducted a finite element analysis parameter study of whole-vertebral (monotonic) compressive strength on six human L1 vertebrae. Each model was generated from micro-CT scans, capturing the trabecular micro-architecture in detail, and included a non-linear constitutive model for the bone tissue that allowed for plastic yielding, different strengths in tension and compression, large deformations, and, uniquely, localized damage once a specified limit in tissue-level ultimate strain was exceeded. Those strain limits were based on reported (mean ± SD) values from cadaver experiments (8.8 ± 3.7% strain for trabecular tissue and 2.2 ± 0.9% for cortical tissue). In the parameter study, the strain limits were varied by ±1 SD from their mean values, for a combination of nine analyses per specimen; bounding values of zero and unlimited post-yield strain were also modeled. The main outcomes from the finite element analysis were the vertebral compressive strength and the amount of failed (yielded or damaged) tissue at the overall structure-level failure. Compared to a reference case of using the mean values of ultimate strain, we found that varying both trabecular and cortical tissue ultimate strains by ±1 SD changed the computed vertebral strength by (mean ± SD) ±6.9 ± 1.1% on average. Mechanistically, that modest effect arose because the proportion of yielded tissue (without damage) was 0.9 ± 0.3% of all the bone tissue across the nine cases and the proportion of damaged tissue (i.e. tissue exceeding the prescribed tissue-level ultimate strain) was 0.2 ± 0.1%. If the types of variations in tissue-level ductility investigated here accurately represent real typical variations in the population, the consistency of our results across specimens and the modest effect size together suggest that typical variations in tissue-level ductility only have a modest impact on vertebral compressive strength, in large part because so few trabeculae are damaged at the load capacity of the bone.

Load-transfer in the human vertebral body following lumbar total disc arthroplasty: Effects of implant size and stiffness in axial compression and forward flexion.

Adverse clinical outcomes for total disc arthroplasty (TDA), including subsidence, heterotopic ossification, and adjacent-level vertebral fracture, suggest problems with the underlying biomechanics. To gain insight, we investigated the role of size and stiffness of TDA implants on load-transfer within a vertebral body. Uniquely, we accounted for the realistic multi-scale geometric features of the trabecular micro-architecture and cortical shell. Using voxel-based finite element analysis derived from a micro-computed tomography scan of one human L1 vertebral body (74-µm-sized elements), a series of generic elliptically shaped implants were analyzed. We parametrically modeled three implant sizes (small, medium [a typical clinical size], and large) and three implant materials (metallic, E = 100 GPa; polymeric, E = 1 GPa; and tissue-engineered, E = 0.01 GPa). Analyses were run for two load cases: 800 N in uniform compression and flexion-induced anterior impingement. Results were compared to those of an intact model without an implant and loaded instead via a disc-like material. We found that TDA implantation increased stress in the bone tissue by over 50% in large portions of the vertebra. These changes depended more on implant size than material, and there was an interaction between implant size and loading condition. For the small implant, flexion increased the 98th-percentile of stress by 32 ± 24% relative to compression, but the overall stress distribution and trabecular-cortical load-sharing were relatively insensitive to loading mode. In contrast, for the medium and large implants, flexion increased the 98th-percentile of stress by 42 ± 9% and 87 ± 29%, respectively, and substantially re-distributed stress within the vertebra; in particular overloading the anterior trabecular centrum and cortex. We conclude that TDA implants can substantially alter stress deep within the lumbar vertebra, depending primarily on implant size. For implants of typical clinical size, bending-induced impingement can substantially increase stress in local regions and may therefore be one factor driving subsidence in vivo.