Peripheral quantitative computed tomography (pQCT)–based finite element analysis provides enhanced diagnostic performance in identifying non-vertebral fracture patients compared with dual-energy X-ray absorptiometry

  • H. Jiang
  • D.L. Robinson
  • C.J. Yates
  • P.V.S. Lee
  • J.D. WarkEmail author
Original Article



Due to limitations of the predominant clinical method for diagnosing osteoporosis, an engineering model based on a dedicated CT scanner for bone density and structure was applied in fracture patients and controls. Improved diagnostic performance was observed, which supports its potential use in future research and clinical practice.


Dual-energy X-ray absorptiometry (DXA), the predominant clinical method for diagnosing osteoporosis, has limitations in identifying individuals with increased fracture risk. Peripheral quantitative computed tomography (pQCT) provides additional information and can be used to generate finite element (FE) models from which bone strength properties can be estimated. We investigated the ability of pQCT-FE properties to distinguish peripheral low-trauma fracture patients from healthy controls, by comparison with DXA and standard pQCT.


One hundred and eight fracture patients (77 females aged 67.7 ± 7.9 years, 31 males aged 69.7 ± 8.9 years) were recruited from a hospital fracture liaison service. One hundred and twenty healthy community controls (85 females aged 69.8 ± 8.5 years, 35 males aged 68.9 ± 7.2 years) were recruited.


Significant differences between groups were observed in pQCT-FE properties, especially at the 4% tibia site. Fracture odds increased most per standard deviation decrease in pQCT-FE at this location [shear stiffness estimate, kshear, in females, OR = 10.34, 95% CI (1.91, 43.98); bending stiffness estimate, kbend, in males, OR = 8.32, 95% CI (4.15, 33.84)]. Area under the receiver operating characteristics curve (AUROC) was observed to be highest with pQCT-FE properties at 4% the tibia site. In females, this was 0.83 for the pQCT-FE variable kshear, compared with 0.72 for DXA total hip bone density (TH aBMD) and 0.76 for pQCT tibia trabecular density (Trb vBMD); in males, this was 0.81 for the pQCT-FE variable kbend at the 4% tibia site, compared with 0.62 for TH aBMD and 0.71 for Trb vBMD. There were significant differences in AUROC between DXA and pQCT-FE variables in both females (p = 0.02) and males (p = 0.03), while no difference was observed in AUROC between primary pQCT and pQCT-FE variables.


pQCT-FE modeling can provide enhanced diagnostic performance compared with DXA and, given its moderate cost, may be useful in clinical settings.


AUROC bone strength fracture status finite element modeling pQCT 



The authors would like to thank all subjects for their participation in this study and the University of the Third Age for providing assistance in participant recruitment. We acknowledge Dr Ashwini Kale for performing DXA and pQCT scans, Mr Richard Farrugia for coordinating the fracture liaison service from which all fracture patients were recruited and Associate Professor Andrew Bucknill for his strong support of recruitment at the fracture liaison service.

Funding information

HJ is funded with a joint PhD scholarship by China Scholarship Council (funding reference: CSC201608240003) and the University of Melbourne.

Compliance with ethical standards

Verbal and written informed consents were obtained from each participant after they were provided with detailed information about the study. This study was approved by Melbourne Health Human Research Ethics Committee (ethics approval number MH 2014.143).

Conflicts of interest


Supplementary material

198_2019_5213_MOESM1_ESM.docx (29 kb)
ESM 1 (DOCX 29 kb)


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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2019

Authors and Affiliations

  • H. Jiang
    • 1
  • D.L. Robinson
    • 2
  • C.J. Yates
    • 1
    • 3
    • 4
  • P.V.S. Lee
    • 2
  • J.D. Wark
    • 1
    • 3
    • 4
    Email author
  1. 1.Department of MedicineRoyal Melbourne Hospital, University of MelbourneMelbourneAustralia
  2. 2.Department of Biomedical EngineeringUniversity of MelbourneMelbourneAustralia
  3. 3.Bone and Mineral MedicineRoyal Melbourne HospitalMelbourneAustralia
  4. 4.Department of Diabetes and EndocrinologyRoyal Melbourne HospitalMelbourneAustralia

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