The measurement of areal bone mineral density (aBMD) by dual x-ray absorptiometry (DXA) has been the mainstay for the diagnosis of osteoporosis for at least two decades. The sensitivity and specificity of this test, however, remains suboptimal. For example, more than 50% of postmenopausal women with fragility fracture are not identified with DXA. A great deal of research has been performed recently to develop alternative or complementary imaging techniques to overcome DXA predictive limitations. These techniques are based on the non invasive analysis of bone microarchitecture and estimation of bone strength by finite element analysis (FEA).
Texture analysis uses mathematical models based on fractal analysis to evaluate bone microarchitecture using various types of bone images. The trabecular bone score (TBS) has emerged as an approach that may improve fracture risk prediction. The TBS is based on the texture analysis of the DXA lumbar spine image to quantify bone microarchitecture. Several cohort studies have shown that a subset of individuals could be reclassified with TBS. A meta-analysis results have allowed for incorporation of the TBS in the FRAX score calculation, that is widely available.
The measurement of volumetric BMD with quantitative computerized tomography (QCT) at the hip has been shown to predict fracture risk. These images can also be used to perform FEA that may increase the fracture risk prediction. The additional value of this technique compared with DXA remains to be established in a clinical setting.
Bone microarchitecture can also be assessed at peripheral sites such as the distal radius and tibia using high resolution peripheral quantitative tomography (HRpQCT). Numerous cross-sectional and case-control studies have shown a significant association between prevalent fracture and bone microarchitecture and estimated bone strength assessed with FEA. The bone parameters measured at distal sites are also associated with fractures at distant sites, e.g., the vertebrae and the femoral neck. In a recent prospective study, bone microarchitecture at the distal radius - especially the trabecular vBMD - has been associated with incident osteoporotic fracture. The FEA models were also predictive of fragility fracture. The best models and the most appropriate architectural parameters - whether they are trabecular of cortical - remain to be dissected out and their comparative diagnostic value with aBMD by DXA remains to be established.
The measurement of the TBS may allow for reclassification of a subset of postmenopausal women at higher risk for fracture whereas they display a moderately reduced aBMD. Hip QCT and HRpQCT may also improve the prediction for fracture, but they are still research techniques.
Disclosure of Interest None declared