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Reference values and clinical predictors of bone strength for HR-pQCT-based distal radius and tibia strength assessments in women and men



Reference values for radius and tibia strength using multiple-stack high-resolution peripheral quantitative computed tomography (HR-pQCT) with homogenized finite element analysis are presented in order to derive critical values improving risk prediction models of osteoporosis. Gender and femoral neck areal bone mineral density (aBMD) were independent predictors of bone strength.


The purpose was to obtain reference values for radius and tibia bone strength computed by using the homogenized finite element analysis (hFE) using multiple stacks with a HR-pQCT.


Male and female healthy participants aged 20–39 years were recruited at the University Hospital of Bern. They underwent interview and clinical examination including hand grip, gait speed and DXA of the hip. The nondominant forearm and tibia were scanned with a double and a triple-stack protocol, respectively, using HR-pQCT (XCT II, SCANCO Medical AG). Bone strength was estimated by using the hFE analysis, and reference values were calculated using quantile regression. Multivariable analyses were performed to identify clinical predictors of bone strength.


Overall, 46 women and 41 men were recruited with mean ages of 25.1 (sd 5.0) and 26.2 (sd 5.2) years. Sex-specific reference values for bone strength were established. Men had significantly higher strength for radius (mean (sd) 6640 (1800) N vs. 4110 (1200) N; p < 0.001) and tibia (18,200 (4220) N vs. 11,970 (3150) N; p < 0.001) than women. In the two multivariable regression models with and without total hip aBMD, the addition of neck hip aBMD significantly improved the model (p < 0.001). No clinical predictors of bone strength other than gender and aBMD were identified.


Reference values for radius and tibia strength using multiple HR-pQCT stacks with hFE analysis are presented and provide the basis to help refining accurate risk prediction models. Femoral neck aBMD and gender were significant predictors of bone strength

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The authors would like to thank all the participants who graciously devoted time to participate in the study. We thank Furkan Gazozcu for scan acquisition and participant recruitment, and collaborators of the Department of Osteoporosis at the University Hospital Bern for DXA measurements and performance of quality protocols.


This work was in part supported by the „Forschungsfonds der Geriatrischen Universitätsklinik“, Bern/Switzerland. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Correspondence to K. Lippuner.

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The present study was conducted with the approval no. 2017-00882 of the ethics committee of the canton of Bern, Switzerland. All participants provided written informed consent.

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Stuck, A.K., Schenk, D., Zysset, P. et al. Reference values and clinical predictors of bone strength for HR-pQCT-based distal radius and tibia strength assessments in women and men. Osteoporos Int 31, 1913–1923 (2020).

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  • Bone strength
  • Clinical predictors
  • Failure load
  • Finite element analysis
  • HR-pQCT
  • Multiple stacks
  • Reference values