Automated 3D trabecular bone structure analysis of the proximal femur—prediction of biomechanical strength by CT and DXA

The standard diagnostic technique for assessing osteoporosis is dual X-ray absorptiometry (DXA) measuring bone mass parameters. In this study, a combination of DXA and trabecular structure parameters (acquired by computed tomography [CT]) most accurately predicted the biomechanical strength of the proximal femur and allowed for a better prediction than DXA alone. An automated 3D segmentation algorithm was applied to determine specific structure parameters of the trabecular bone in CT images of the proximal femur. This was done to evaluate the ability of these parameters for predicting biomechanical femoral bone strength in comparison with bone mineral content (BMC) and bone mineral density (BMD) acquired by DXA as standard diagnostic technique. One hundred eighty-seven proximal femur specimens were harvested from formalin-fixed human cadavers. BMC and BMD were determined by DXA. Structure parameters of the trabecular bone (i.e., morphometry, fuzzy logic, Minkowski functionals, and the scaling index method [SIM]) were computed from CT images. Absolute femoral bone strength was assessed with a biomechanical side-impact test measuring failure load (FL). Adjusted FL parameters for appraisal of relative bone strength were calculated by dividing FL by influencing variables such as body height, weight, or femoral head diameter. The best single parameter predicting FL and adjusted FL parameters was apparent trabecular separation (morphometry) or DXA-derived BMC or BMD with correlations up to r = 0.802. In combination with DXA, structure parameters (most notably the SIM and morphometry) added in linear regression models significant information in predicting FL and all adjusted FL parameters (up to R adj = 0.872) and allowed for a significant better prediction than DXA alone. A combination of bone mass (DXA) and structure parameters of the trabecular bone (linear and nonlinear, global and local) most accurately predicted absolute and relative femoral bone strength

Simulation of fracture strength improvements of a human proximal femur using finite element analysis.

The most common hip fracture in the elderly occurs as a result of a fall to the side with impact over the greater trochanter resulting in a fracture of the proximal femur. The fracture usually involves the femoral neck or the intertrochanteric region. It has recently been determined that the fracture crack of a hip fracture typically initiates on the superior-lateral cortex of the femoral neck and then propagates across the femoral neck, resulting in a complete fracture. The strength of the superior-lateral cortex of the femoral neck is likely determined by the combined properties of the generally thin cortex (outer layer) and the underlying trabecular bone in this region. The objective of this study was to determine the relative effects of increasing or decreasing the thickness of these bone tissues on the overall failure strength of the proximal femur. The clinical significance of this work relates to hip fracture risk with various potential treatment options to improve either cortical or trabecular bone quality. A human femur obtained from a 68 year old female donor was scanned using computed tomography at 60-micron voxel resolution and a series of high-resolution finite element models were generated. The models were constructed with a base-element dimension of 120 microns and models included a basic model with cortical and trabecular thicknesses representative of the cadaver specimen from the original scan. Other models used a standardized algorithm to either dilate or erode the trabecular and cortical bone compartments of the femoral neck so that a total of nine models were created including the basic model. Each model was used to simulate a fall-to-the-side loading condition with appropriate boundary and loading conditions as used in previous models and experiments. An experimental test of the cadaver femur was also performed with three strain gauges placed on the proximal femur: on the superior-lateral cortex, on the inferior-medial cortex, and on the medial cortex positioned distal to the lesser trochanter. This femur was loaded at a rate of 100 mm/s until fracture of the femoral neck using a standard fall-to-the-side setup and the applied load and gauge strains were recorded. The femur neck fractured at a load of 2140 N. To validate the basic finite element model, the strain gauge strains at the load levels of 1000 N and 2000 N were compared to the calculated strains from the basic model at the same loads and same location as the gauge on the cadaver femur. After the basic model was validated, a failure criterion was determined as the volume percentage of the elements in the model that had exceeded 7000 µε at the failure load corresponding to the load at which the cadaver femur failed. Subsequently, this failure criterion was applied to the other eight models as a parametric analysis to estimate the increase or decrease in failure strength caused by the changes in cortical and trabecular thickness. The validation test results showed that the basic finite element model calculated strain on the superolateral cortex was within 2.1% of the experimentally measured strain at 1000 N loading. The validated basic model was then used to determine that the percentage of finite elements (by volume of the model) in excess of 7000 µε at the failure load was 4.2%. This failure criterion was then used to estimate the failure load for the other eight models with different combinations of either thicker (+120 µm) or thinner (-120 µm) cortex and trabeculae in the femoral neck. The calculated failure loads ranged from 324 N for the model with thinned cortex and thinned trabeculae to 3336 N for the model with thickened cortex and thickened trabeculae. The model with normal cortex and thickened trabeculae had a failure load of 3242 N, which is only 2.8% less than the strongest case. The largest single parameter effect on proximal femoral strength is realized by an increase in trabecular thickness. This is somewhat surprising considering that cortical bone is typically stronger than cancellous bone. However, the spatial arrangement of trabecular bone and the buttress support it provides to the thin cortex apparently plays an important role in the ability of a global increase in thickness to have a significant beneficial effect

Generation of 3D shape, density, cortical thickness and finite element mesh of proximal femur from a DXA image

Areal bone mineral density (aBMD), as measured by dual-energy X-ray absorptiometry (DXA), predicts hip fracture risk only moderately. Simulation of bone mechanics based on DXA imaging of the proximal femur, may help to improve the prediction accuracy. Therefore, we collected three (1-3) image sets, including CT images and DXA images of 34 proximal cadaver femurs (set1, including 30 males, 4 females), 35 clinical patient CT images of the hip (set 2, including 27 males, 8 females) and both CT and DXA images of clinical patients (set 3, including 12 female patients). All CT images were segmented manually and landmarks were placed on both femurs and pelvises. Two separate statistical appearance models (SAMs) were built using the CT images of the femurs and pelvises in sets 1 and 2, respectively. The 3D shape of the femur was reconstructed from the DXA image by matching the SAMs with the DXA images. The orientation and modes of variation of the SAMs were adjusted to minimize the sum of the absolute differences between the projection of the SAMs and a DXA image. The mesh quality and the location of the SAMs with respect to the manually placed control points on the DXA image were used as additional constraints. Then, finite element (FE) models were built from the reconstructed shapes. Mean point-to-surface distance between the reconstructed shape and CT image was 1.0mm for cadaver femurs in set 1 (leave-one-out test) and 1.4mm for clinical subjects in set 3. The reconstructed volumetric BMD showed a mean absolute difference of 140 and 185mg/cm3 for set 1 and set 3 respectively. The generation of the SAM and the limitation of using only one 2D image were found to be the most significant sources of errors in the shape reconstruction. The noise in the DXA images had only small effect on the accuracy of the shape reconstruction. DXA-based FE simulation was able to explain 85% of the CT-predicted strength of the femur in stance loading. The present method can be used to accurately reconstruct the 3D shape and internal density of the femur from 2D DXA images. This may help to derive new information from clinical DXA images by producing patient-specific FE models for mechanical simulation of femoral bone mechanics

ToScA North America (6 – 8 June 2017, The University of Texas, Austin, TX) Program

ToScA North America will address key areas of science, including Multi-modal Imaging, Geosciences, Forensics, Increasing Contrast, Educational Outreach, Data, Materials Science and Medical and Biological Science.University of Texas High-Resolution X-ray CT Facility (UTCT); Jackson School of Geosciences, The University of Texas at Austin; Natural History Museum (London); Royal Microscopical Society (Oxford, UK)Geological Science

Hip fractures : A biomechanical analysis of fracture strength prediction, prevention, and repair

Due to the aging population, hip fracture incidence has been increasing over the past decades. Measurements of bone mineral density with dual energy X-ray absorptiometry are the gold standard for hip fracture risk assessment, where patients with a low bone density have a high risk of fracture. However, many people that are not diagnosed to be at risk, still fracture their hip. Calculations of bone strength using subject-specific finite element (FE) models, can improve fracture risk prediction, but further improvement is required.Patients with a high fracture risk are often prescribed pharmaceutical treatment in order to increase bone density systemically. As systemic response to treatment is limited, other options to prevent fractures by improving the bone strength are investigated. One of those options is the injection of biomaterials in the femoral neck. In case of a hip fracture due to a low-energy fall, total hip replacement is generally preferred over joint-preserving methods like fixation using a dynamic hip screw. Screw fixation comes with a risk of screw instability, especially in low-density bone. Bone cements can be used to improve fixation of orthopaedic implants and fracture fixation devices. Calcium sulphate/hydroxyapatite (CaS/HA) is an injectable biomaterial that has been used, for example, to reinforce collapsed vertebrae and to stabilize wrist fractures. The work presented in the thesis aims to improve fracture risk prediction, and fracture prevention and repair methods with use of CaS/HA. This is achieved through a combination of experimental mechanical tests at organ and tissue scale, and development and thorough validation of FE models of the proximal femur.In the first part of this thesis, 12 cadaveric femora were used in an experiment where the bones were loaded until fracture in a configuration developed to replicate a fall to the side. During loading, high-speed cameras were used to image both the medial and lateral side of the femoral neck allowing for full-field strain measurements using digital image correlation. The femora were imaged with clinical CT before and micro-CT before and after mechanical testing. Using the acquired CT images, FE models were developed at two different resolutions to determine their ability to capture the fracture force, fracture location and surface strains. The FE models based on the clinical CT images were able to accurately capture the fracture force and identify regions where the bone would fracture. These models could also capture the strains with high accuracy. However, the strains were not predicted as accurately in regions with high surface irregularity. The models based on the micro-CT images could show with higher accuracy how the strains were distributed around local porosity (e.g., due to vascularization) in the femoral neck and how these influenced the fracture pattern.The thesis continues with an investigation of fracture prevention and repair methods through the use of CaS/HA. The ability of CaS/HA to increase the fracture strength of the proximal femur for fracture prevention and its ability to stabilize a dynamic hip screw used for fracture repair was investigated. The increase in fracture strength was investigated using FE models. These models showed that CaS/HA can increase the fracture strength of the femur approximately 20% when injected close to the cortex in the lateral neck. Pullout tests using a dynamic hip screw were performed on synthetic bone blocks and femoral heads from hip fracture patients. In the synthetic blocks, CaS/HA significantly increased the pullout strength. However, in the human bone the stability of the screw was not improved, because the cement could not easily spread into the threads of the screws. The mechanical behaviour of CaS/HA and bone was further investigated using high-resolution synchrotron X-ray tomography. Cylindrical trabecular bone specimens with and without CaS/HA were imaged with tomography during in-situ loading of the samples. The images revealed that CaS/HA reinforced the bone, and that CaS/HA is a brittle material that will crack before the bone.To conclude, in this thesis FE models are presented showing accurate prediction of fracture strength, which can be used for improved fracture risk assessments. Furthermore, the work provides insight in how CaS/HA behaves mechanically and how it can be used to increase the fracture strength and to stabilize fixation devices in the femur, improving fracture prevention and fracture repair methods