Introduction. Precision error (PE) in Dual Energy X-Ray Absorptiometry (DXA) is important for accurate monitoring of changes in Bone-Mineral-Density (BMD). It has been demonstrated that BMD PE increases with increasing BMI. In vivo PE for the Trabecular-Bone-Score (TBS) has not been reported. This study aimed to evaluate the short-term PE (STPE)) of BMD and TBS and to investigate the effect of obesity on DXA PE. Method. DXA lumbar spine scans (L1–L4) were performed using GE Lunar Prodigy. STPE was measured in 91 women (Group A) at a single visit by duplicating scans with repositioning in-between. PE was calculated as the percentage coefficient of variation (%CV). Group A was sub-divided into four groups based on BMI (A.1. <25kg/m2, A.2. 25–29.9kg/m2, A.3. 30–35kg/m2 and A.4. >35kg/m2) to assess the effect of obesity on STPE. Abnormally different vertebrae were excluded from the analysis in accordance with The International Society for Clinical Densitometry (ISCD) recommendations. Results. The Group A STPE was 1.26 % for BMD and 2.04% for TBS. Short-term PE for BMD and TBS respectively in the BMI subgroups was: A.1. 1.07% and 1.82%, A.2. 1.34% and 2.26%, A.3. 1.25% and 2.35%, A.4. 1.68% and 1.82%. Conclusion. The results show that STPE is higher for TBS than for BMD. Short-term PE for both BMD and TBS are adversely affected by increasing BMI but this effect is mitigated in the highest BMI category where use of the ‘thick’ scanning mode improves signal to noise ratio

Osteoporosis is a common disorder characterized by low bone mass and reduced bone quality that affects the bone strength negatively and leads to increased risk of fracture. Bone mineral density (BMD) has been the standard instrument for the diagnosis of osteoporosis and the determination of fracture risk. Despite the approximation of the bone mass, BMD does not provide information about the bone structure. Trabecular bone score (TBS), which provides an indirect evaluation of skeletal microarchitecture, is calculated from dual X-ray absorptiometry and a simple and noninvasive method that may contribute to the prediction of osteoporotic fractures in addition to the measure of bone density. The goal of this study was to determine the mean TBS values in healthy postmenopausal women and the overall association between TBS and demographic features, bone mineral density of the lumbar spine and femoral neck and bone mineral density to body mass index ratio (BMD/BMI) of the lumbar spine. Fifty-three postmenopausal healthy women participated. The bone mineral density of the lumbar spine and femoral neck were measured dual X-ray absorptiometry. Anteroposterior lumbar spine acquisitions were used to calculate TBS for L1-L4. Age, height, weight, BMI and the ratio of BMD to BMI, which was considered to be a simple tool for assessing fracture risk in especially obese individuals, were calculated. The relationship between TBS and other variables was examined using Spearman's rank correlation coefficients. Mean BMD of the lumbar spine and the femoral neck were 0.945 ± 0.133 and 0.785 ± 0.112 g/cm2, respectively (Table 1). Mean TBS was 1.354 ± 0.107. There was a significant positive moderate correlation between TBS and total lumbar BMD/BMI ratio (r=0.595, pTBS values of postmenopausal women were negatively correlated with age and BMI and positively with bone mineral density and BMD/BMI ratio. The ratio between lumbar BMD and BMI presented a stronger correlation with TBS than that of BMD with TBS. Because of the better correlation, the BMD/BMI ratio may be used as a simple tool for the assessment of the risk of fractures. Further investigation may be needed to evaluate the factors influencing exercise intervention on TBS on this population of patients

Abstract. Objective. This study assesses the prevalence of major and minor discordance between hip and spine T scores using Radiofrequency Echographic Multi-spectrometry (REMS). REMS is a novel technology that uses ultrasound and radiofrequency analysis to measure bone density and bone fragility at the hip and lumbar spine. The objective was to compare the results with the existing literature on Dual-Energy X-ray Absorptiometry (DEXA) the current “gold standard” for bone densitometry. REMS and DEXA have been shown to have similar diagnostic accuracy, however, REMS has less human input when carrying out the scan, therefore the rates of discordance might be expected to be lower than for DEXA. Discordance poses a risk of misclassification of patients’ bone health status, causing diagnostic ambiguity and potentially sub-optimal management decisions. Reduction of discordance rates therefore has the potential to significantly improve treatment and patient outcomes. Methods. Results from 1,855 patients who underwent REMS investigations between 2018 and 2022 were available. Minor discordance is defined as a difference of one World Health Organisation (WHO) diagnostic classification (Normal / Osteopenia or Osteopenia / Osteoporosis). Major discordance is defined as a difference of two WHO diagnostic classifications (Normal / Osteoporosis). The results were compared with reported DEXA discordance rates. Results. 1,732 individuals had both hip and spine T scores available for analysis. There were 267 cases of discordance. No instances of major discordance were observed. The minor discordance rate was 15.4%. 6.5% of the REMS scans with minor discordance showed > 1.0 standard deviation (SD) difference between the T scores of the hip and spine. 19.4% had differences of between 0.6 SD and 1.0 SD while 73.9% had ≤ 0.5 SD or less. In 24.5% of the cases of REMS discordance the hip T scores were greater than the spine and in 75.5% of cases the spine T score was greater than the hip. Conclusions. The current analysis is the largest of its kind. It demonstrates that REMS has an overall lower rate of discordance than reported DEXA rates. Major discordance rates with DEXA range from 2–17%, but REMS avoids many of the positioning problems and post-processing errors inherent in DEXA scanning, which might account for the absence of major discordance. Rates of minor discordance in DEXA scans range between 38–51%. The REMS minor discordance rate being much lower than these rates suggests that it has the potential to enhance diagnostic accuracy considerably. Most REMS discordance results showed ≤ 0.5 SD variance between the T scores of the two sites, indicating close correlation in the bone densitometry analysis. Most studies of DEXA discordant results confirm that spinal T scores are more often higher than at the hip. The REMS results concur with this observation. Considering the comparable accuracy rates that have been shown between REMS and DEXA, with its much lower discordance rate, REMS can potentially improve current medical practice and enhance patient care. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Objectives. The aim of the current study was to assess whether calcaneal broadband ultrasound attenuation (BUA) can predict whole body and regional dual-energy x-ray absorptiometry (DXA)-derived bone mass in healthy, Australian children and adolescents at different stages of maturity. Methods. A total of 389 boys and girls across a wide age range (four to 18 years) volunteered to participate. The estimated age of peak height velocity (APHV) was used to classify children into pre-, peri-, and post-APHV groups. BUA was measured at the non-dominant heel with quantitative ultrasonometry (QUS) (Lunar Achilles Insight, GE), while bone mineral density (BMD) and bone mineral content (BMC) were examined at the femoral neck, lumbar spine and whole body (DXA, XR-800, Norland). Associations between BUA and DXA-derived measures were examined with Pearson correlations and linear regression. Participants were additionally ranked in quartiles for QUS and DXA measures in order to determine agreement in rankings. Results. For the whole sample, BUA predicted 29% of the study population variance in whole body BMC and BMD, 23% to 24% of the study population variance in lumbar spine BMC and BMD, and 21% to 24% of the variance in femoral neck BMC and BMD (p < 0.001). BUA predictions were strongest for the most mature participants (pre-APHV R. 2. = 0.03 to 0.19; peri-APHV R. 2. = 0.05 to 0.17; post-APHV R. 2. = 0.18 to 0.28) and marginally stronger for girls (R. 2. = 0.25-0.32, p < 0.001) than for boys (R. 2. = 0.21-0.27, p < 0.001). Agreement in quartile rankings between QUS and DXA measures of bone mass was generally poor (27.3% to 38.2%). Conclusion. Calcaneal BUA has a weak to moderate relationship with DXA measurements of bone mass in children, and has a tendency to misclassify children on the basis of quartile rankings. Cite this article: B. K. Weeks, R. Hirsch, R. C. Nogueira, B. R. Beck. Is calcaneal broadband ultrasound attenuation a valid index of dual-energy x-ray absorptiometry-derived bone mass in children? Bone Joint Res 2016;5:538–543. DOI: 10.1302/2046-3758.511.BJR-2016-0116.R1

Introduction and Objective. Geriatric patients with a fragility fracture of the hip (FFH) are especially prone to sarcopenia with poor functional outcomes and quality of life. We assessed the prevalence of sarcopenia in older South African patients with FFH. Risk factors for sarcopenia were also investigated. Materials and Methods. From August 1 to November 30, 2018, all older patients with FFH were invited to participate. Sarcopenia was diagnosed based on the revised criteria of the European Working Group on Sarcopenia in Older People (EWGSOP2). Handgrip strength (HGS) and muscle strength were assessed. Muscle quantity was determined by dual-energy X-ray absorptiometry. Demographic information was collected, and 25-hydroxyvitamin D (25[OH]D) status was determined. Results. Of the 100 hip fracture cases, 65 were enrolled, and 52% (34/65) were sarcopenic (women: 62%; men: 38%). HGS accurately identified sarcopenia (sensitivity and specificity: 100%). Patients >80 years of age had a prevalence of sarcopenia twice (18/21 [83%]) that of younger patients (18/44 [36%]). Women with sarcopenia were smaller than those without (weight: p < 0.001; height: p < 0.001; body mass index: p¼0.018). Low 25(OH)D was almost universally present, with median 25(OH)D levels significantly lower in the patients with sarcopenia (27 nmol/L [interquartile range {IQR}: 20–39] vs. 40 nmol/L [IQR: 29–53]). Several risk factors, including advanced age; female sex; a smaller body size, especially among women; limited physical activity; and low 25(OH)D levels, were identified. Conclusions. The accuracy of HGS testing in this cohort underscores EWGSOP2's recommendation that muscle strength is key to sarcopenia. Further study and follow-up are required to determine the clinical relevance of sarcopenia among FFH patients. The prevalence of sarcopenia in our FFH population is high. Sarcopenia is associated with poor patient outcomes following surgical intervention. Orthopaedic surgeons should therefore be cognisant of the presentation and associated risk of sarcopenia as our patient populations age

Background. Although there are predictive equations that estimate the total fat mass obtained from multiple-site ultrasound (US) measurements, the predictive equation of total fat mass has not been investigated solely from abdominal subcutaneous fat thickness. Therefore, the aims of this study were; (1) to develop regression-based prediction equations based on abdominal subcutaneous fat thickness for predicting fat mass in young- and middle-aged adults, and (2) to investigate the validity of these equations to be developed. Methods. The study was approved by the Local Research Ethics Committee (Decision number: GO 19/788). Twenty-seven males (30.3 ± 8.7 years) and eighteen females (32.4 ± 9.5 years) were randomly divided into two groups as the model prediction group (19 males and 12 females) and the validation group (8 males and 6 females). Total body fat mass was determined by dual-energy X-ray absorptiometry (DXA). Abdominal subcutaneous fat thickness was measured by US. The predictive equations for total fat mass from US were determined as fat thickness (in mm) × standing height (in m). Statistical analyses were performed using R version 4.0.0. The association between the total fat mass and the abdominal subcutaneous fat thickness was interpreted using the Pearson test. The linear regression analysis was used to predict equations for total body fat mass from the abdominal subcutaneous fat thickness acquired by US. Then these predictive equations were applied to the validation group. The paired t-test was used to examine the difference between the measured and the predicted fat masses, and Lin's concordance correlation coefficient (CCC) was used as a further measure of agreement. Results. There was a significant positive moderate correlation between the total fat mass and the abdominal subcutaneous fat thickness × height in the model prediction group of males (r = 0.588, p = 0.008), whereas significant positive very strong correlation was observed in the model prediction group of females (r = 0.896, p < 0.001). Predictive equations for DXA-measured total body fat mass from abdominal subcutaneous fat thickness using US were as follows: for males “Fat mass-DXA = 0.276 × (Fat thickness-US × Height) + 17.221” (R. 2. = 0.35, SEE = 3.6, p = 0.008); for females “Fat mass-DXA = 0.694 x (Fat thickness-US × Height) + 7.085” (R. 2. = 0.80, SEE = 2.8, p < 0.001). When fat mass prediction equations were applied to the validation groups, measured- and estimated-total fat masses in males and females were found similar (p = 0.9, p = 0.5, respectively). A good level of agreement between measurements in males and females was attained (CCC = 0.84, CCC = 0.76, respectively). Conclusion. We developed and validated prediction equations that are convenient for determining total fat masses in young- and middle-aged adults using abdominal subcutaneous fat thickness obtained from the US. The abdominal subcutaneous fat thickness obtained from a single region by US might provide a noninvasive quick and easy evaluation not only in clinical settings but also on the field

Objectives. Bisphosphonates (BP) are the first-line treatment for preventing fragility fractures. However, concern regarding their efficacy is growing because bisphosphonate is associated with over-suppression of remodelling and accumulation of microcracks. While dual-energy X-ray absorptiometry (DXA) scanning may show a gain in bone density, the impact of this class of drug on mechanical properties remains unclear. We therefore sought to quantify the mechanical strength of bone treated with BP (oral alendronate), and correlate data with the microarchitecture and density of microcracks in comparison with untreated controls. Methods. Trabecular bone from hip fracture patients treated with BP (n = 10) was compared with naïve fractured (n = 14) and non-fractured controls (n = 6). Trabecular cores were synchrotron scanned and micro-CT scanned for microstructural analysis, including quantification of bone volume fraction, microarchitecture and microcracks. The specimens were then mechanically tested in compression. Results. BP bone was 28% lower in strength than untreated hip fracture bone, and 48% lower in strength than non-fractured control bone (4.6 MPa vs 6.4 MPa vs 8.9 MPa). BP-treated bone had 24% more microcracks than naïve fractured bone and 51% more than non-fractured control (8.12/cm. 2. vs 6.55/cm. 2. vs 5.25/cm. 2. ). BP and naïve fracture bone exhibited similar trabecular microarchitecture, with significantly lower bone volume fraction and connectivity than non-fractured controls. Conclusion. BP therapy had no detectable mechanical benefit in the specimens examined. Instead, its use was associated with substantially reduced bone strength. This low strength may be due to the greater accumulation of microcracks and a lack of any discernible improvement in bone volume or microarchitecture. This preliminary study suggests that the clinical impact of BP-induced microcrack accumulation may be significant. Cite this article: A. Jin, J. Cobb, U. Hansen, R. Bhattacharya, C. Reinhard, N. Vo, R. Atwood, J. Li, A. Karunaratne, C. Wiles, R. Abel. The effect of long-term bisphosphonate therapy on trabecular bone strength and microcrack density. Bone Joint Res 2017;6:602–609. DOI: 10.1302/2046-3758.610.BJR-2016-0321.R1

SL-PLUS MIA stem (Smith & Nephew Orthopaedics AG) is a modified implant of Zweymuller type SL-PLUS standard stem (Smith & Nephew Orthopaedics AG). We constructed finite element (FE) models and analysed equivalent stresses in the femur. In addition, we measured bone mineral density (BMD) in the femur by dual-energy X-ray absorptiometry (DEXA) after THA. The purpose of this study was to investigate the equivalent stress and to compare the results of the FE analyses with changes in BMD after THA. Twenty-one patients (18 women and 3 men) who underwent primary cementless THA with SL-PLUS MIA or SL-PLUS formed the basis of this study. Eleven patients received SL-PLUS MIA and ten patients received SL-PLUS. Zones were defined according to Gruen's system (zones 1∼7). Computed-tomography (CT) images of the femur were taken before and at 1 week after THA. FE models of the femur and prosthesis were obtained from CT data by Mechanical Finder (Research Center of Computational Mechanics Inc., Tokyo, Japan), software that creates FE models showing individual bone shape and density distribution. Equivalent stresses were analysed in zones 1 to 7 and compared to the DEXA data. FE studies revealed that there was no significant difference in equivalent stress between SL-PLUS MIA and SL-PLUS. BMD was maintained after THA in zones 3, 4, and 5, whereas BMD decreased in zones 2, 6, and 7. In zone 1, BMD decreased in SL-PLUS MIA stem group by 14%, while BMD was maintained in SL-PLUS standard stem

Objectives. To assess the sensitivity and specificity of self-reported osteoporosis compared with dual energy X-ray absorptiometry (DXA) defined osteoporosis, and to describe medication use among participants with the condition. Methods. Data were obtained from a population-based longitudinal study and assessed for the prevalence of osteoporosis, falls, fractures and medication use. DXA scans were also undertaken. Results. Overall 3.8% (95% confidence interval (CI) 3.2 to 4.5) of respondents and 8.8% (95% CI 7.5 to 10.3) of those aged ≥ 50 years reported that they had been diagnosed with osteoporosis by a doctor. The sensitivity (those self-reporting osteoporosis and having low bone mineral density (BMD) on DXA) was low (22.7%), although the specificity was high (94.4%). Only 16.1% of those aged ≥ 50 years and with DXA-defined osteoporosis were taking bisphosphonates. Conclusions. The sensitivity of self-reporting to identify osteoporosis is low. Anti-osteoporotic medications are an important part of osteoporosis treatment but opportunities to use appropriate medications were missed and inappropriate medications were used

Aims. Osteoporosis and abnormal bone metabolism may prove to be significant factors influencing the outcome of arthroplasty surgery, predisposing to complications of aseptic loosening and peri-prosthetic fracture. We aimed to investigate baseline bone mineral density (BMD) and bone turnover in patients about to undergo arthroplasty of the hip and knee. Methods. We prospectively measured bone mineral density of the hip and lumbar spine using dual-energy X-ray absorptiometry (DEXA) scans in a cohort of 194 patients awaiting hip or knee arthroplasty. We also assessed bone turnover using urinary deoxypyridinoline (DPD), a type I collagen crosslink, normalised to creatinine. Results. The prevalence of DEXA proven hip osteoporosis (T-score ≤ -2.5) among hip and knee arthroplasty patients was found to be low at 2.8% (4 of 143). Spinal osteoporosis prevalence was higher at 6.9% (12 of 175). Sixty patients (42% (60 of 143)) had osteopenia or osteoporosis of either the hip or spine. The mean T-score for the hip was -0.34 (. sd. 1.23), which is within normal limits, and the mean hip Z-score was positive at 0.87 (. sd. 1.17), signifying higher-than-average BMD for age. The median urinary DPD/creatinine was raised in both female patients at 8.1 (interquartile range (IQR) 6.6 to 9.9) and male patients at 6.2 (IQR 4.8 to 7.5). Conclusions. Our results indicate hip and knee arthroplasty patients have higher BMD of the hip and spine compared with an age-matched general population, and a lower prevalence of osteoporosis. However, untreated osteoporotic patients are undergoing arthroplasty, which may negatively impact their outcome. Raised DPD levels suggest abnormal bone turnover, requiring further investigation. Cite this article: Bone Joint Res 2014;3:14–19

The shape of the vertebral bodies from L1 to L4 was assessed from lateral dual-energy x-ray absorptiometry (DXA) images using an active shape model. The output from the model was compared to measurements of areal bone mineral density in L1 to L4 (aBMD) using a stepwise linear regression model. A significant relationship was found between aBMD and vertebral shape that suggests that the method may be useful for correcting artefacts such as osteophytes

Summary Statement. It is now possible to diagnose osteoporosis using incidental CT scans; this approach has been used to objectively demonstrate the role of osteoporosis in fracture in ankylosing spondylitis patients. Background. In advanced disease, Ankylosing Spondylitis (AS) is frequently associated with a reduction in bone mineral density (BMD), this contributes to pain and predisposes to fractures. Quantifying this reduction in BMD is complicated by the simultaneous processes occurring, in which there is both an overgrowth of bone (syndesmophytes) and a concurrent loss of trabecular bone. Traditional methods such as dual-energy X-ray absorptiometry (DXA) struggle to generate accurate estimates for BMD in these patients. It has recently become possible to diagnose osteoporosis, with a high sensitivity and specificity, using incidental CT scans of the L1 vertebra. The purpose of this study was to evaluate the use of opportunistic CT screening in the diagnosis of osteoporosis in patients with AS who had sustained vertebral fractures. Patients & Methods. Following Institutional review board approval, patients with AS who presented, with acute fractures of the spine, to our facility between 2004 and 2013 were reviewed to assess whether or not they had a Computed Tomography (CT) scan of the abdomen on admission or in the 6 months before or after injury. In addition, patients were also required to have signs of advanced AS such as the presence of syndesmophytes and syndesmophyte bridging; patients with fractures through L1 were excluded. Of those fitting the criteria, a region of Interest (ROI) was generated over the body of L1, Hounsfield unit (HU) were then measured. Results. Of the 42 patients reviewed, a total of 17 AS patients fit the above criteria. 15 were male and 2 were female, mean age of the whole cohort was 69.9years (range 22–85; SD 15.9). Using a threshold balanced for sensitivity and specificity (<135 HU) which differentiates between osteopenia and osteporosis, 14 (82%) patients were found to have a BMD less than 135HU; a higher threshold (<160 HU) with 90 % sensitivity for differentiating osteoporosis from osteopenia was applied to the group, and 15 patients (88%) were found to be osteoporotic. Of note all the females in the study were osteoporotic. Discussion and Conclusion. This study demonstrates, for the first time, using opportunistic CT screening, that a high proportion of AS patients who sustain fractures have osteoporosis; this overcomes the difficulties that have been encountered with the use of DXA in this unique group of patients. This simple and accessible method saves on excess cost and exposure to radiation. With a high sensitivity, patients identified using this method can then be managed more proactively. We believe these data have the potential to significantly impact the day to day management of patients with spondyloarthropathies

We studied the reliability of the Singh classification of trabecular bone structure in the proximal femur as a measure of osteoporosis, using kappa statistics. Radiographs of fractures of the femoral neck or trochanteric region in 80 consecutive patients were assessed by six observers. The interobserver variation was large; only three of 72 radiographs were given the same classification by all six observers and the kappa values ranged from 0.15 to 0.54. The intraobserver variation showed substantial strength of agreement; kappa values ranged from 0.63 to 0.88. In 77 patients dual-energy X-ray absorptiometry was used to measure bone mineral density. The results were compared with those of the Singh classification: we found no correlation

Weight-bearing is a known stimulus for bone remodelling and a reduction in weight-bearing is associated with reduced bone mineral density (BMD) in affected limbs post lower limb fracture. This study investigated short and long-term precision of a method for measuring relative left/right weight-bearing using two sets of identical calibrated scales. The effect of imbalance on BMD at the hip and on lower limb lean tissue mass (LLTM) was also assessed. 46 postmenopausal women, with no history of leg or ankle fracture, were measured three times whilst standing astride two scales (Seca, Germany). 34 of the participants were re-measured after 6 months by the same method. Bilateral hip and total body dual x-ray absorptiometry measurements were performed using a GE Lunar Prodigy (Bedford, MA). Precision errors in weight-bearing measures were calculated using the root mean square coefficient of variation (RMSCV%). The correlations at the first visit between left/right differences in weight-bearing and differences in BMD and LLTM were calculated. The short-term RMSCV% for left and right weights were 4.20% and 4.25% respectively and the long-term RMSCV% were 6.91% and 6.90%. Differences in left/right weight-bearing ranged from 0 to 24% (SD 8.63%) at visit 1 and 0 to 30% (SD 10.71%) at visit 2. Using data from visit 1, the relationship between hip BMD differences and left/right weight-bearing differences were investigated, with no significant correlations found. However, a weak, but statistically significant correlation of r=0.35 (p=0.02) was found for differences in LLTM and left/right weight-bearing differences. In conclusion, left/right weight-bearing measured using two scales is a precise method for evaluating differences in weight-bearing in the short and long-term. Differences in left/right weight-bearing in this population varied by up to 30%. Participants showed a high degree of consistency in their long-term balance in a natural standing posture. Inequalities in left/right weight-bearing did not correlate significantly with BMD at the hip, but demonstrated a weak but statistically significant correlation with lean tissue mass

In a prospective study of 14 patients undergoing total hip replacement we have used dual-energy X-ray absorptiometry (DEXA) to investigate remodelling of the bone around two different designs of cementless femoral prosthesis. The bone mineral density (BMD) was measured at 12-weekly intervals for a year. Eight patients (group A) had a stiff, collarless implant and six (group B) a flexible isoelastic implant. Patients in group A showed a decrease in BMD from 14 weeks after operation. By 12 months, the mean loss in BMD was 27%, both medially and laterally to the proximal part of the implant. Those in group B showed an overall increase in BMD which reached a mean of 12.6% on the lateral side of the distal portion of the implant. Our results support the current concepts of the effects of stem stiffness and flexibility on periprosthetic remodelling

The operative treatment of fractures of the proximal humerus can be complicated by poor bone quality. Our aim was to evaluate a new method which allows prediction of the bone quality of the proximal humerus from radiographs. Anteroposterior radiographs were taken of 19 human cadaver humeri. The cortical thickness was measured at two levels of the proximal humeral diaphysis. The bone mineral density (BMD) was determined for the humeral head (HH), the surgical neck (SN), the greater tuberosity (GT) and lesser tuberosity (LT) using dual-energy x-ray absorptiometry. The mean cortical thickness was 4.4 ± 1.0 mm. Specimens aged 70 years or less had a significantly higher cortical thickness than those aged over 70 years. A significant positive correlation was found between cortical thickness and the BMD for each region of interest. The cortical thickness of the proximal diaphysis is a reliable predictor of the bone quality of the proximal humerus

Summary. At the clinical CT image resolution level, there is no influence of the image voxel size on the derived finite element human cancellous bone models. Introduction. Computed tomography (CT)-based finite element (FE) models have been proved to provide a better prediction of vertebral strength than dual-energy x-ray absorptiometry [1]. FE models based on µCTs are able to provide the golden standard results [2], but due to the sample size restriction of the µCT and the XtremeCT machines, the clinical CT-based FE models is still the most promising tool for the in vivo prediction of vertebrae's strength. It has been found [3] that FE predicted Young's modulus of human cancellous bone increases as the image voxel size increases at the µCT resolution level [3]. However, it is still not clear whether the image voxel size in the clinical range has an impact on the predicted mechanical behavior of cancellous bone. This study is designed to answer this question. Methods. For this study, 6 thoracolumbar vertebrae (Th12) obtained from the female donors were scanned in the non-dissected cadavers under 2 different resolutions – group A: 120 kVp, 100 mAs, with a resolution of 0.29×0.29×1.3 mm. 3. ; group B: 120 kVp, 360 mAs, with a resolution of 0.18×0.18×0.6 mm. 3. A solid calibration phantom (QRM-BDC) was placed beneath the cadavers during the scans. Cuboids with the size of 12.3×12.3×14.3 mm. 3. were cropped from the center of each vertebral body. The FE model was created by converting each image voxel into hexahedron (C3D8). Inhomogeneous material property was defined for the cuboid [4], i.e. the image greyscale value were firstly calibrated into the bone mineral density (BMD), then the Young's modulus and yield stress were calculated from the BMD [5] for each element. Statistical analysis was performed to compare the FE predicted mechanical properties between the groups and the significance level was set to 95% (α=0.05). Results. The trabecular structure is more clearly mimicked in the models from group B than those from group A. The modulus (mean ± SE) in group A is 5.9% higher than that in group B (193.33 ± 31.67 MPa vs. 182.50 ± 27.07 MPa). The yield strength (mean ± SE) in group A is 6.4% higher than that in group B (0.99 ± 0.21MPa vs. 0.93 ± 0.17MPa). However, the paired t-test shows there is no significant difference of the mechanical properties in the two groups (p=0.109 for the modulus and p=0.234 for the yield strength). Discussion. This study shows that there is no influence of the voxel size on the clinical CT derived FE cancellous bone models. This finding can help choose a better, less invasive CT protocol for the patient when creating a clinical CT image based FE model. Acknowledgements. This study is financially supported by the Federal Ministry of Education and Research and the state of Hamburg, Germany

Background and objectives. Local bone-related adverse events occur more frequently following metal-on metal hip resurfacing (MOMHR) versus convention total hip arthroplasty (THA). High local tissue levels of cobalt and chromium may contribute to impaired bone health, however the systemic effects on bone of exposure to elevated metal levels after MOMHR are unknown. Methods. In this cross-sectional study we compared whole body bone mineral density (WB-BMD) and biochemical markers of bone turnover in 31 healthy male subjects at a mean of 8 years after MOMHR versus 31 individually age and time since surgery matched male subjects after conventional THA. All subjects had well-functioning prostheses and were in good self-reported health as assessed by Oxford Hip Score and EQ-5D questionnaire. WB-BMD was measured by dual energy x-ray absorptiometry and adjusted for pre-morbid osteoporosis risk factors using the FRAX tool, and for the presence of the metal prostheses using identical exclusion regions. Bone turnover markers were measured on fasting morning serum or 24hr urine collection by electro-chemiluminescent assay. Cobalt and chromium were measured by ICP-MS. Results. The subject pairs were similar for all matching criteria (P>0.05, all comparisons). Cobalt and chromium were elevated in the MOMHR versus THA group (P<0.05, all comparisons). WB-BMD was 7% higher in the MOMHR versus THA subjects (1.05 versus 0.98 g/cm2, P= 0.002). Bone formation, measured by serum osteocalcin, was 17% lower in the MOMHR versus THA subjects (18.2 versus 21.1ng/mL, P= 0.02) and osteoclast number measured by TRAP 5b, was 23% lower (3.4 versus 3.9U/L, P= 0.008). Systemic levels of bone formation and resorption markers were inversely correlated with systemic cobalt, but not chromium levels (Spearman, P<0.05). Conclusion. Subjects 8 years after MOMHR versus THA have higher WB-BMD and lower bone turnover measured by some markers, and marker activity inversely correlate to systemic cobalt levels. These data suggest that this metal has a systemic suppressive effect on bone turnover. The difference in BMD may be due to a reduction in age-related bone loss since surgery, although the measured BMD might also be due, in part, to diffuse metal deposition within the skeleton

Summary Statement. Proximal femoral bony deficits present a surgical and biomechanical challenge to implant longevity in revision hip arthroplasty. This work finds comparable primary stability when a distally fixing tapered fluted stem was compared with a conical design in cadaveric tests. Introduction. Proximal bony deficits complicate revision hip surgery and compromise implant survival. Longer distally fixing stems which bypass such defects are therefore required to achieve stability compatible with bony ingrowth and implant longevity. Aims. It is hypothesised that a tapered stem will provide superior rotational stability to a conical design. This work therefore aims to compare the primary stability and biomechanical properties of a new design of tapered fluted modular femoral stem (Redapt®, Smith & Nephew) with that of a conical fluted stem (Restoration®, Stryker). Materials & Methods. 7 Pairs of cadaveric femora were obtained according to strict inclusion/exclusion criteria. Each underwent dual energy x-ray absorptiometry and calibration plain-film radiographs were taken. Digital templating was performed using TraumaCad (Voyant Health, Brainlab) to determine implant sizing. Both stems are fluted, modular and manufactured from titanium. The control stem (Restoration) featured a straight conical design and the investigation stem (Redapt) a straight tapered design. Implantation was performed by a revision arthroplasty surgeon familiar with both systems. Proximal bone deficiency was reproduced using an extended trochanteric osteotomy with removal of metaphyseal bone before reattaching the osteotomy. Primary stability in the axial, sagittal and coronal planes was assessed using micromotion transducers (HBM, Darmstadt, Germany) and also by Radiostereometric Analysis (RSA). RSA employs simultaneous biplanar radiographs to measure relative movement. Two 1mm tantalum beads were mounted on the prosthesis with the centre of the femoral head taken as the third reference point. Beads were placed proximally in the surrounding bone as rigid body markers. Each bone was potted according to the ISO standard for fatigue testing and cyclically loaded at 1Hz for at least 3 increments (750–350N, 1000–350N, 1500–350N) for 1000 cycles. RSA radiographs were taken at baseline and on completion of each cycle. A strain analysis was concurrently performed using a PhotoStress® (Vishay Precision Group, Raleigh, USA) photoelastic coating on the medial femoral cortex. Each bone was loaded intact and then with the prosthesis in-situ at 500N increments until strain fringes were identified. Once testing was completed, the stems were sectioned at the femoral isthmus and data is presented on the cross-sectional fit and fill observed. Results. Both stem designs showed comparable primary stability with all stems achieving clinically acceptable micromotion (<150 μm) when loaded at body weight. A larger proportion of the control stems remained stable as loading increased to x2-3 body weight. Transducer-recorded migration appeared greatest in the axial plane (y axis) with negligible distal movement in the coronal or sagittal planes. Point motion analysis (RSA) indicated most movement to be in the coronal plane (x-axis) whereas segment motion analysis showed rotation about the long axis of the prosthesis to be largest. Photoelastic strain patterns were transferred more distally in both designs, however substantial stress shielding was also observed. Discussion/Conclusion. Both designs achieved adequate distal fixation and primary stability under representative clinical loading conditions. This work supports the continued use of this novel stem design for revision surgery in the presence of extensive proximal bone loss

Summary Statement. It is now possible to diagnose osteoporosis using incidental abdominal CT scans; applying this approach to fractures of the cervical spine demonstrates levels of osteoporosis in patients over 65. Introduction. Recently published data now makes it possible to screen for osteoporosis in patients who, in the course of their hospital stay, have had Computed Tomography (CT) scans of their abdomen for reasons other than direct imaging. This is as a result of CT derived bone mineral density (BMD) in the first lumbar vertebra (L1) being correlated BMD derived from Dual-energy X-ray absorptiometry (DEXA) scans. The advantage of this is the reduction in both cost and radiation exposure. Although age has a detrimental effect on BMD, relatively few patients have formal DEXA studies. The aims of this study were to evaluate the utility of this new technique in a cohort of patients with acute fractures of the cervical spine and to compare relative values for BMD in patients aged over 65 with those aged under 65, and thus define the role of osteoporosis in these injuries. Methods & Patients. Following Institutional review board approval, we performed a retrospective study of patients who presented to a level I trauma center with acute fractures of the cervical spine between 2010 and 2013; patients also had to have had a CT scan of their L1 vertebra either during the admission or within 6 months of their admission (for any other clinical reason). Using a picture archiving and communication (PACS) system, we generated regions of interest (ROI) of similar size in the body of L1 (excluding the cortex), in line with the publication by Pickhardt et al., and computed the mean values for Hounsfield units (HU). These values were compared against established threshold values which differentiate between osteoporosis and osteopenia; for a balanced sensitivity and specificity, <135 HU is the threshold and for 90% sensitivity a HU threshold of <160 HU is set. Comparisons were also performed between age stratified groups. Results. A total of 187 patients were reviewed for eligibility, 91 patients met the criteria with 53 patients aged 64 years or younger (range 23–64) and 38 patients aged above 65 years (range 65–98). In the younger cohort, 6/53 (11% were osteoporotic, using the lower threshold, while the higher threshold indicated 5/53 (17%) of patients under 65 years were osteoporotic; mean HU for the group was 195.8 (SD 43.3). In the older cohort, 24/38 (63%) were osteoporotic using the lower threshold, whereas 34/38 (89%) were osteoporotic using the higher threshold. Mean HU for the cohort aged over 65 years was 118.7 (SD 38.4). Age based comparison of the mean values, regardless of threshold, was statistically significant (p<0.001) in both cases. Discussion and Conclusions. This study demonstrates, for the first time in the cervical spine (including C2), the role of age related osteoporosis in acute fractures of the cervical spine. This new technique harnessing the presence of opportunistic CT scans of the abdomen saves on the extra cost and radiation exposure that may be associated with DEXA scanning. In younger patients, the higher threshold indicated 17% were osteoporotic – in the setting of an opportunistic scan, this may afford them the opportunity to commence prophylactic treatment to prevent future fractures. We believe these result have the potential to significantly impact future clinical practice