Fracture Prediction by Computed Tomography and Finite Element Analysis: Current and Future Perspectives
- 293 Downloads
Purpose of Review
This review critiques the ability of CT-based methods to predict incident hip and vertebral fractures.
CT-based techniques with concurrent calibration all show strong associations with incident hip and vertebral fracture, predicting hip and vertebral fractures as well as, and sometimes better than, dual-energy X-ray absorptiometry areal biomass density (DXA aBMD). There is growing evidence for use of routine CT scans for bone health assessment.
CT-based techniques provide a robust approach for osteoporosis diagnosis and fracture prediction. It remains to be seen if further technical advances will improve fracture prediction compared to DXA aBMD. Future work should include more standardization in CT analyses, establishment of treatment intervention thresholds, and more studies to determine whether routine CT scans can be efficiently used to expand the number of individuals who undergo evaluation for fracture risk.
KeywordsQuantitative computed tomography (QCT) Finite element analysis (FEA) Computational anatomy Hip fracture Vertebral fracture Opportunistic CT
This article was supported by NHI fund. Grant Number: R01 AR053986, PI:Mary L. Bouxsein.
Compliance with Ethical Standards
Conflict of Interest
Fjola Johannesdottir, Brett Allaire, and Mary Bouxsein declare no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 15.• Bredbenner TL, Mason RL, Havill LM, Orwoll ES, Nicolella DP, for the Osteoporotic Fractures in Men (MrOS) Study. Fracture risk predictions based on statistical shape and density modeling of the proximal femur. J Bone Miner Res. 2014;29(9):2090–100. Statistical shape and density modeling predicted incident hip fracture better than DXA aBMD among men in MrOS. PubMedPubMedCentralGoogle Scholar
- 16.• Carballido-Gamio J, Harnish R, Saeed I, Streeper T, Sigurdsson S, Amin S, et al. Proximal femoral density distribution and structure in relation to age and hip fracture risk in women. J Bone Miner Res. 2013;28(3):537–46. Older Icelandic women who sustain incident hip fracture had deficits in the superior and inferior femoral neck cortex and the trabecular bone regions at the superior aspect of the femoral neck and the intertrochanteric region. This structural phenotype cannot be described as an accelerated pattern of normal age-related bone loss. PubMedPubMedCentralGoogle Scholar
- 18.• Chalhoub D, Orwoll ES, Cawthon PM, Ensrud KE, Boudreau R, Greenspan S, et al. Areal and volumetric bone mineral density and risk of multiple types of fracture in older men. Bone. 2016;92:100–6. Lower aBMD and vBMD in the hip and spine were associated with increased fracture risk in the hip and spine, respectively, in 3301 men from the MrOS study. AUC analysis showed FN aBMD predicted hip fracture better than FN vBMD (0.76 vs. 0.72), but spine vBMD had better predictability of spine fracture than spine aBMD (0.79 vs. 0.72). PubMedPubMedCentralGoogle Scholar
- 21.Johannesdottir F, Poole KES, Reeve J, Siggeirsdottir K, Aspelund T, Mogensen B, et al. Distribution of cortical bone in the femoral neck and hip fracture: a prospective case-control analysis of 143 incident hip fractures; the AGES-REYKJAVIK Study. Bone. 2011;48(6):1268–76.PubMedPubMedCentralGoogle Scholar
- 22.• Treece, G.M., Gee A.H., Tonkin C., Ewing S.K., Cawthon P.M., Black D.M., Poole K.E.S., for the Osteoporotic Fractures in Men (MrOS) Study, Predicting hip fracture type with cortical bone mapping (CBM) in the osteoporotic fractures in men (MrOS) study. J Bone Miner Res, 2015. 30(11): p. 2067–2077. Using cortical bone mapping, they identified focal regions of thin cortical bone and larger trabecular bone defects that predicted incident hip fracture in men. The fracture prediction performance was slightly better than DXA aBMD. Google Scholar
- 25.Falcinelli C, Schileo E, Balistreri L, Baruffaldi F, Bordini B, Viceconti M, et al. Multiple loading conditions analysis can improve the association between finite element bone strength estimates and proximal femur fractures: a preliminary study in elderly women. Bone. 2014;67(Supplement C):71–80.PubMedGoogle Scholar
- 49.Adams, J.E., Quantitative computed tomography. Eur J Radiol. 71(3): 415–424, 2009.Google Scholar
- 53.Helgason, B., Perilli E., Schileo E., Taddei F., Brynjólfsson S., Viceconti M., Mathematical relationships between bone density and mechanical properties: a literature review. Clin Biomech (Bristol, Avon), 2008. 23(2): p. 135–146.Google Scholar
- 54.Engelke K, Adams JE, Armbrecht G, Augat P, Bogado CE, Bouxsein ML, et al. Clinical use of quantitative computed tomography and peripheral quantitative computed tomography in the management of osteoporosis in adults: the 2007 ISCD Official Positions. J Clin Densitom. 2008;11(1):123–62.PubMedGoogle Scholar
- 56.Zysset P, Qin L, Lang T, Khosla S, Leslie WD, Shepherd JA, et al. Clinical use of quantitative computed tomography–based finite element analysis of the hip and spine in the management of osteoporosis in adults: the 2015 ISCD Official Positions—part II. J Clin Densitom. 2015;18(3):359–92.PubMedGoogle Scholar
- 59.Anderson DE, Demissie S, Allaire BT, Bruno AG, Kopperdahl DL, Keaveny TM, et al. The associations between QCT-based vertebral bone measurements and prevalent vertebral fractures depend on the spinal locations of both bone measurement and fracture. Osteoporos Int. 2014;25(2):559–66.PubMedGoogle Scholar
- 61.Rianon NJ, Lang TF, Siggeirsdottir K, Sigurdsson G, Eiriksdottir G, Sigurdsson S, et al. Fracture risk assessment in older adults using a combination of selected quantitative computed tomography bone measures: a subanalysis of the Age, Gene/Environment Susceptibility-Reykjavik Study. J Clin Densitom. 2014;17(1):25–31.PubMedGoogle Scholar
- 68.Napoli N, et al. Vertebral fracture risk in diabetic elderly men: the MrOS study. J Bone Miner Res. 2017;Google Scholar
- 70.Brett AD, Brown JK. Quantitative computed tomography and opportunistic bone density screening by dual use of computed tomography scans. Journal of Orthopaedic Translation. 2015;3(4):178–84.Google Scholar
- 72.• Pickhardt PJ, Bodeen G, Brett A, Brown JK, Binkley N. Comparison of femoral neck BMD evaluation obtained using lunar DXA and QCT with asynchronous calibration from CT colonography. J Clin Densitom. 2015;18(1):5–12. QCT-based aBMD by CTXA was highly correlated ( R 2 =0.91) with DXA aBMD in females who underwent computed tomography colonography with asynchronous QCT calibration, evidence that CTXA T -scores may be an option for opportunistic osteoporosis screening in scans without contrast. PubMedGoogle Scholar
- 75.• Lee DC, Hoffmann PF, Kopperdahl DL, Keaveny TM. Phantomless calibration of CT scans for measurement of BMD and bone strength-inter-operator reanalysis precision. Bone. 2017;103:325–33. Reanalysis precision errors for all phantomless (internal calibration) measurements were as good as or better than those from phantom calibration. Differences in absolute measurements between phantom and phantomless were less than 1%, indicating bone measurements can be obtained from CT scans without calibration phantoms. PubMedGoogle Scholar
- 79.• Lee SJ, Anderson PA, Pickhardt PJ. Predicting future hip fractures on routine abdominal CT using opportunistic osteoporosis screening measures: a matched case-control study. AJR Am J Roentgenol. 2017;209(2):395–402. Asynchronously calibrated lumbar spine attenuation and CT-derived FN T-score were associated with future hip fracture in a cohort of 204 hip fracture cases and 204 age-sex matched controls with previous abdominopelvic CT scans. PubMedGoogle Scholar
- 82.• Pompe E, Willemink MJ, Dijkhuis GR, Verhaar HJJ, Hoesein FAAM, de Jong PA. Intravenous contrast injection significantly affects bone mineral density measured on CT. Eur Radiol. 2015;25(2):283–9. Contrast injection has a significant influence on direct CT-derived attenuation in the spine, which may lead to an underestimation of osteoporosis—adjustment for injection phase or internal calibration is necessary to account for IV contrast. PubMedGoogle Scholar
- 83.• Ziemlewicz TJ, Maciejewski A, Binkley N, Brett AD, Brown JK, Pickhardt PJ. Opportunistic quantitative CT bone mineral density measurement at the proximal femur using routine contrast-enhanced scans: direct comparison with DXA in 355 adults. J Bone Miner Res. 2016;31(10):1835–40. Showed high correlation ( r 2 =0.82) between DXA and CTXA in contrast-enhanced CT scans in both men and women. CTXA provided similar T -scores as DXA, which may allow for identification of patients at risk for fracture. PubMedGoogle Scholar
- 90.Lee, SJ, Graffy PM, Zea RD, Ziemlewicz TJ, Pickhardt PJ. Future osteoporotic fracture risk related to lumbar vertebral trabecular attenuation measured at routine body CT. J Bone Miner Res, 2018;33(5):860–7.Google Scholar
- 91.• Adams A, Fischer H, Kopperdahl DL. The Fracture, Osteoporosis, and CT Utilization Study (FOCUS)—utilizing pre-existing CT to assess risk of hip fracture in a large real-world clinical setting. J Bone Miner Res. 2017;32(Suppl 1) https://doi.org/10.1002/jbmr.3423. The Fracture, Osteoporosis, and CT Utilization Study showed that finite element analysis of previously obtained routine CT scans could predict hip fracture as well as DXA aBMD.
- 92.• Shepstone L, Lenaghan E, Cooper C, Clarke S, Fong-Soe-Khioe R, Fordham R, et al. Screening in the community to reduce fractures in older women (SCOOP): a randomised controlled trial. Lancet. 2018;391:741–7. https://doi.org/10.1016/S0140-6736(17)32640-5. This study reported that community-based osteoporosis screening of fracture risk in older women in the UK is feasible and could be effective in reducing the incidence of hip fractures. PubMedGoogle Scholar
- 94.Helgason B, Gilchrist S, Ariza O, Vogt P, Enns-Bray W, Widmer RP, et al. The influence of the modulus-density relationship and the material mapping method on the simulated mechanical response of the proximal femur in side-ways fall loading configuration. Med Eng Phys. 2016;38(7):679–89.PubMedGoogle Scholar
- 97.Allison SJ, Poole KES, Treece GM, Gee AH, Tonkin C, Rennie WJ, et al. The influence of high-impact exercise on cortical and trabecular bone mineral content and 3D distribution across the proximal femur in older men: a randomized controlled unilateral intervention. J Bone Miner Res. 2015;30(9):1709–16.PubMedGoogle Scholar
- 110.Sarvi MN, Luo Y. A two-level subject-specific biomechanical model for improving prediction of hip fracture risk. Clin Biomech (Bristol, Avon). 2015;30(8):881–7.Google Scholar