Bone texture analysis on direct digital radiographic images: precision study and relationship with bone mineral density at the os calcis

Reliability of Using Texture Analysis of Periapical Radiographs Obtained Using Radiovisiography for Assessing Bone Quality in Dental Implant Planning: A Cross-Sectional Study

Background Pre-prosthetic implant radiographic imaging helps in the quantitative and qualitative analysis of the bone structure and also enables the evaluation of the relationship between critical structures and potential implant sites. Purpose The aim of the study was to define the reliability of utilizing the analysis of textures from the periapical radiographic images obtained through Radiovisiography (RVG) in order to better plan for dental implantations. Methods A cross-sectional study was conducted using 50 intraoral periapical radiographs which were obtained through RVG performed prior to the placement of implants. The radiographs were segregated based on anatomical locations i.e. 12 for the anterior maxilla, nine for the posterior maxilla, seven for the anterior mandible, and 22 for the posterior mandible. Each of the radiographs was visually assessed by four experienced examiners, namely a Prosthodontist E1, Periodontist E2, Oral surgeon E3, and Oral radiologist E4, which was then compared to an experienced operator's tactile perception during a pilot drill for implant placement. As a reference, the Lekholm and Zarb classification was provided to all the examiners for them to qualitatively assess the bone structure in the radiographs. Results The examiners' results were correlated with the assessment provided by the experienced operator. E1 and E4 successfully assessed 42% of the radiographs while E2 had the least success with only 26%. Of the 12 anterior maxillary radiographs, only eight were accurately assessed by E1. With respect to the posterior maxilla, all examiners correctly assessed four radiographs each. Of the seven anterior mandibular radiographs, except for E2, the rest correctly assessed three radiographs each. Of the 22 posterior mandibular radiographs, only nine were accurately assessed by E4. Conclusion Intraoral periapical radiographs obtained through RVG did not meet the desired parameters for assessing the bone quality during the planning stage for implants.

Comparison of the Classification Results Accuracy for CT Soft Tissue and Bone Reconstructions in Detecting the Porosity of a Spongy Tissue

The aim of the study was to compare the accuracy of the classification pertaining to the results of two types of soft tissue and bone reconstructions of the spinal CT in detecting the porosity of L1 vertebral body spongy tissue. The dataset for each type of reconstruction (high-resolution bone reconstruction and soft tissue reconstruction) included 400 sponge tissue images from 50 healthy patients and 50 patients with osteoporosis. Texture feature descriptors were calculated based on the statistical analysis of the grey image histogram, autoregression model, and wavelet transform. The data dimensional reduction was applied by feature selection using nine methods representing various approaches (filter, wrapper, and embedded methods). Eleven methods were used to build the classifier models. In the learning process, hyperparametric optimization based on the grid search method was applied. On this basis, the most effective model and the optimal subset of features for each selection method used were determined. In the case of bone reconstruction images, four models achieved a maximum accuracy of 92%, one of which had the highest sensitivity of 95%, with a specificity of 89%. For soft tissue reconstruction images, five models achieved the highest testing accuracy of 95%, whereas the other quality indices (TPR and TNR) were also equal to 95%. The research showed that the images derived from soft tissue reconstruction allow for obtaining more accurate values of texture parameters, which increases the accuracy of the classification and offers better possibilities for diagnosing osteoporosis.

Safety and efficacy of Wharton's jelly-derived mesenchymal stem cells with teriparatide for osteoporotic vertebral fractures: A phase I/IIa study

Osteoporotic vertebral compression fractures (OVCFs) are serious health problems. We conducted a randomized, open-label, phase I/IIa study to determine the feasibility, safety, and effectiveness of Wharton's jelly-derived mesenchymal stem cells (WJ-MSCs) and teriparatide (parathyroid hormone 1-34) in OVCFs. Twenty subjects with recent OVCFs were randomized to teriparatide (20 μg/day, daily subcutaneous injection for 6 months) treatment alone or combined treatment of WJ-MSCs (intramedullary [4 × 107 cells] injection and intravenous [2 × 108 cells] injection after 1 week) and teriparatide (20 μg/day, daily subcutaneous injection for 6 months). Fourteen subjects (teriparatide alone, n = 7; combined treatment, n = 7) completed follow-up assessment (visual analog scale [VAS], Oswestry Disability Index [ODI], Short Form-36 [SF-36], bone mineral density [BMD], bone turnover measured by osteocalcin and C-terminal telopeptide of type 1 collagen, dual-energy x-ray absorptiometry [DXA], computed tomography [CT]). Our results show that (a) combined treatment with WJ-MSCs and teriparatide is feasible and tolerable for the patients with OVCFs; (b) the mean VAS, ODI, and SF-36 scores significantly improved in the combined treatment group; (c) the level of bone turnover markers were not significantly different between the two groups; (d) BMD T-scores of spine and hip by DXA increased in both control and experimental groups without a statistical difference; and (e) baseline spine CT images and follow-up CT images at 6 and 12 months showed better microarchitecture in the combined treatment group. Our results indicate that combined treatment of WJ-MSCs and teriparatide is feasible and tolerable and has a clinical benefit for fracture healing by promoting bone architecture. Clinical trial registration: https://nedrug.mfds.go.kr/, MFDS: 201600282-30937.

Texture Analysis and Genetic Algorithms for Osteoporosis Diagnosis

Early diagnosis of osteoporosis can efficiently predict fracture risk. There is a great demand to prevent this disease. The goal of this study was to distinguish osteoporotic cases from healthy controls on 2D bone radiograph images, using texture analysis and genetic algorithms (GAs). Gray Level Co-occurrence Matrix (GLCM), Run length Matrix (RLM) and Binarized Statistical Image Features (BSIF) were used for texture analysis. Features are numerous and parameter-dependent. The related experts can pick out the useful input features for the classifier. It however remains a difficult task and may be inefficient or even harmful as the data pattern is not clear. In this paper, GAs were used to optimize the two parameters of the co-occurrence matrix (distance parameter or pixel separation, orientation or direction) and the number of gray levels used in the preprocessing quantification step. GAs were also used to select the best combination of features extracted from GLCM and RLM matrices. Experiments were conducted on two populations composed of Osteoporotic Patients and Control Subjects. Results show that GAs combined with GLCM and BSIF features can improve the classification rates (ACC = 87.50%) obtained using GLCM (ACC = 77.8%) alone.

Evaluation of bone texture imaging parameters on panoramic radiographs of patients with Sheehan's syndrome: a STROBE-compliant case-control study

Sheehan's syndrome (SHS) is a rare condition related to the risk of osteoporosis and evaluation of bone texture imaging features on panoramic radiographs would be suitable for this condition, which was the aim of the present study. Fractal dimension, lacunarity, and trabecular morphologic aspects were significantly altered in these patients.

INTRODUCTION

SHS is an important public health problem particularly in developing countries. It is characterized as postpartum hypopituitarism secondary to obstetric complications-related ischemic pituitary necrosis that shows significant systemic metabolic repercussions. Thus, this study aimed to evaluate bone texture parameters in digital panoramic radiographs of patients with SHS.

METHODS

A case-control study was conducted with 30 SHS patients from an Endocrinology and Diabetology Service of reference in Brazil, and 30 age- and sex-matched healthy controls. A custom computer program measured fractal dimension, lacunarity, and some morphologic features in the following mandibular regions of interest (50 × 50 pixels): below the mental foramen (F1), between the first and second molars (M1), and at the center of the mandibular ramus (R1).

RESULTS

The fractal analysis showed a statistically significant difference between the studied groups in all regions of interest. The fractal dimension in F1 (p = 0.016), M1 (p = 0.043), and R1 (p = 0.028) was significantly lower in SHS group, as well as lacunarity in R1 (p = 0.008). Additionally, several morphologic features were statistically significant in the SHS group (p < 0.05).

CONCLUSION

Therefore, individuals with SHS showed altered imaging texture parameters on panoramic radiographs, which reflect a smaller spatial organization of the bone trabeculae and, possibly, a state of reduced mineral bone density.

Mandibular bone effects of botulinum toxin injections in masticatory muscles in adult

OBJECTIVE

Botulinum toxin (BTX) is injected into masticatory muscles to treat various conditions. Animal studies have demonstrated bone loss at the condylar and alveolar regions of the mandible after BTX injection into masticatory muscles. The aim of the present study was to investigate mandibular bone changes in patients who received BTX injections in masticatory muscles.

STUDY DESIGN

Twelve adult patients who received BTX injections into masticatory muscles were included in this study. Cone beam computed tomography (CBCT) was performed before and 12 months after the injection. The condylar and alveolar regions of the mandible were analyzed by using texture analysis of the CBCT images with the run length method. Condylar cortical thickness was measured, and 3-dimensional analysis of the mandible was also performed. Six patients who did not receive BTX injections were used as controls.

RESULTS

A run length parameter (gray level nonuniformity) was found to be increased in condylar and alveolar bones. A significant cortical thinning was found at the anterior portion of the right condyle. Three-dimensional analysis showed significant changes in the condylar bone and at the digastric fossa. No changes in mandibular angles were found.

CONCLUSIONS

This study identified mandibular bone changes in adult patients who received BTX injection into masticatory muscles.

The QUALYOR (QUalité Osseuse LYon Orléans) study: a new cohort for non invasive evaluation of bone quality in postmenopausal osteoporosis. Rationale and study design

The diagnostic performance of densitometry is inadequate. New techniques of non-invasive evaluation of bone quality may improve fracture risk prediction. Testing the value of these techniques is the goal of the QUALYOR cohort.

INTRODUCTION

The bone mineral density (BMD) of postmenopausal women who sustain osteoporotic fracture is generally above the World Health Organization definition for osteoporosis. Therefore, new approaches to improve the detection of women at high risk for fracture are warranted.

METHODS

We have designed and recruited a new cohort to assess the predictive value of several techniques to assess bone quality, including high-resolution peripheral quantitative computerized tomography (HRpQCT), hip QCT, calcaneus texture analysis, and biochemical markers. We have enrolled 1575 postmenopausal women, aged at least 50, with an areal BMD femoral neck or lumbar spine T-score between - 1.0 and - 3.0. Clinical risk factors for fracture have been collected along with serum and blood samples.

RESULTS

We describe the design of the QUALYOR study. Among these 1575 women, 80% were aged at least 60. The mean femoral neck T-score was - 1.6 and the mean lumbar spine T-score was -1.2. This cohort is currently being followed up.

CONCLUSIONS

QUALYOR will provide important information on the relationship between bone quality variables and fracture risk in women with moderately decreased BMD.

Classification of the trabecular bone structure of osteoporotic patients using machine vision

Osteoporosis is a common bone disease which often leads to fractures. Clinically, the major challenge for the automatic diagnosis of osteoporosis is the complex architecture of bones. The clinical diagnosis of osteoporosis is conventionally done using Dual-energy X-ray Absorptiometry (DXA). This method has specific limitations, however, such as the large size of the instrument, a relatively high cost and limited availability. The method proposed here is based on the automatic processing of X-ray images. The bone X-ray image was statistically processed and strategically reformed to extract discriminatory statistical features of different orders. These features were used for machine learning for the classification of two populations composed of osteoporotic and healthy subjects. Four classifiers - support vector machine (SVM), k-nearest neighbors, Naïve Bayes and artificial neural network - were used to test the performance of the proposed method. Tests were performed on X-ray images of the calcaneus bone collected from the hospital of Orleans. The results are significant in terms of accuracy and time complexity. Experimental results indicate a classification rate of 98% using an SVM classifier which is encouraging for automatic osteoporosis diagnosis using bone X-ray images. The low time complexity of the proposed method makes it suitable for real time applications.

HIGH-IMPACT DROP EXERCISE ALTERS MECHANICAL PROPERTIES IN OSTEOPENIC BONE

ABSTRACT Introduction: Osteopenia is a reversible condition and precedes osteoporosis. Physical activity and mechanical loading appear to play an important role in the regulation of bone homeostasis, without the side effects of targeted drug therapy. However, there is controversy as to which type of stimulus promotes more effective adaptations with respect to mechanical properties of bones. Objective: To investigate the effects of high-impact drop training on bone structure after ovariectomy-induced osteopenia in 40 10-week-old female Wistar rats. Methods: Twenty female rats (prevention program) were randomly assigned into two groups (n=10): Ovariectomized sedentary (OVXs), and OVX trained (OVX+Dropt). OVX+Dropt animals began training 3 days after surgery. Another twenty female rats (treatment program) were randomly assigned to two other groups (n=10): Ovariectomized sedentary (OVXs), and OVX trained (OVX+Dropt). OVX+Dropt animals began training 60 days after surgery. The rats in the trained groups were dropped from 40 cm height 20 times/day, 5 days/week over a period of 12 weeks period. At the end, the biomechanical tests were analyzed. Results: The final load and stiffness of the left tibia in the trained groups were higher than in the sedentary groups (p<0.05). Conclusions: Dropping exercise induced favorable changes in bone mechanical properties. High-impact drop exercise is effective to prevent bone loss after ovariectomy even when osteopenia is already established.

Jumping exercise preserves bone mineral density and mechanical properties in osteopenic ovariectomized rats even following established osteopenia

The effects of jump training on bone structure before and after ovariectomy-induced osteopenia in rats were investigated. Jumping exercise induced favorable changes in bone mineral density, bone mechanical properties, and bone formation/resorption markers. This exercise is effective to prevent bone loss after ovariectomy even when osteopenia is already established.

INTRODUCTION

The present study investigated the effects of jump training on bone structure before and after ovariectomy-induced osteopenia in 80 10-week-old Wistar rats.

METHODS

Forty rats (prevention program) were randomly allocated to one of four equal groups (n = 10): sham-operated sedentary (SHAM-SEDp), ovariectomized (OVX) sedentary (OVX-SEDp), sham-operated exercised (SHAM-EXp), and OVX exercised (OVX-EXp). SHAM-EXp and OVX-EXp animals began training 3 days after surgery. Another 40 rats (treatment program) were randomly allocated into another four groups (n = 10): sham-operated sedentary (SHAM-SEDt), OVX sedentary (OVX-SEDt), sham-operated exercised (SHAM-EXt), and OVX exercised (OVX-EXt). SHAM-EXt and OVX-EXt animals began training 60 days after surgery. The rats in the exercised groups jumped 20 times/day, 5 days/week, to a height of 40 cm for 12 weeks. At the end of the experimental period, serum osteocalcin, follicle-stimulating hormone (FSH) dosage, dual X-ray absorptiometry (DXA), histomorphometry, and biomechanical tests were analyzed.

RESULTS

The OVX groups showed higher values of FSH and body weight (p < 0.05). DXA showed that jump training significantly increased bone mineral density of the femur and fifth lumbar vertebra (p < 0.05). The stiffness of the left femur and fifth lumbar vertebra in the exercised groups was greater than that of the sedentary groups (p < 0.05). Ovariectomy induced significant difference in bone volume (BV/TV, percent), trabecular separation (Tb.Sp, micrometer), and trabecular number (Tb.N, per millimeter) (p < 0.05) compared to sham operation. Jump training in the OVX group induced significant differences in BV/TV, Tb.Sp, and Tb.N and decreased osteoblast number per bone perimeter (p < 0.05) compared with OVX nontraining, in the prevention groups. Osteocalcin dosage showed higher values in the exercised groups (p < 0.05).

CONCLUSIONS

Jumping exercise induced favorable changes in bone mineral density, bone mechanical properties, and bone formation/resorption markers. Jump training is effective to prevent bone loss after ovariectomy even when osteopenia is already established.

Clinical Evaluation of Bone Strength and Fracture Risk

PURPOSE OF REVIEW

This paper seeks to evaluate and compare recent advances in the clinical assessment of the changes in bone mechanical properties that take place as a result of osteoporosis and other metabolic bone diseases and their treatments.

RECENT FINDINGS

In addition to the standard of DXA-based areal bone mineral density (aBMD), a variety of methods, including imaging-based structural measurements, finite element analysis (FEA)-based techniques, and alternate methods including ultrasound, bone biopsy, reference point indentation, and statistical shape and density modeling, have been developed which allow for reliable prediction of bone strength and fracture risk. These methods have also shown promise in the evaluation of treatment-induced changes in bone mechanical properties. Continued technological advances allowing for increasingly high-resolution imaging with low radiation dose, together with the expanding adoption of DXA-based predictions of bone structure and mechanics, as well as the increasing awareness of the importance of bone material properties in determining whole-bone mechanics, lead us to anticipate substantial future advances in this field.

Intraoral radiographs texture analysis for dental implant planning

BACKGROUND AND OBJECTIVES

Computer vision extracts features or attributes from images improving diagnosis accuracy and aiding in clinical decisions. This study aims to investigate the feasibility of using texture analysis of periapical radiograph images as a tool for dental implant treatment planning.

METHODS

Periapical radiograph images of 127 jawbone sites were obtained before and after implant placement. From the superimposition of the pre- and post-implant images, four regions of interest (ROI) were delineated on the pre-implant images for each implant site: mesial, distal and apical peri-implant areas and a central area. Each ROI was analysed using Matlab® software and seven image attributes were extracted: mean grey level (MGL), standard deviation of grey levels (SDGL), coefficient of variation (CV), entropy (En), contrast, correlation (Cor) and angular second moment (ASM). Images were grouped by bone types-Lekholm and Zarb classification (1,2,3,4). Peak insertion torque (PIT) and resonance frequency analysis (RFA) were recorded during implant placement. Differences among groups were tested for each image attribute. Agreement between measurements of the peri-implant ROIs and overall ROI (peri-implant + central area) was tested, as well as the association between primary stability measures (PIT and RFA) and texture attributes.

RESULTS

Differences among bone type groups were found for MGL (p = 0.035), SDGL (p = 0.024), CV (p < 0.001) and En (p < 0.001). The apical ROI showed a significant difference from the other regions for all attributes, except Cor. Concordance correlation coefficients were all almost perfect (ρ > 0.93), except for ASM (ρ = 0.62). Texture attributes were significantly associated with the implant stability measures.

CONCLUSION

Texture analysis of periapical radiographs may be a reliable non-invasive quantitative method for the assessment of jawbone and prediction of implant stability, with potential clinical applications.

Analysis of fracture healing in osteopenic bone caused by disuse: experimental study

Osteoporosis has become a serious global public health issue. Hence, osteoporotic fracture healing has been investigated in several previous studies because there is still controversy over the effect osteoporosis has on the healing process. The current study aimed to analyze two different periods of bone healing in normal and osteopenic rats. Sixty, 7-week-old female Wistar rats were randomly divided into four groups: unrestricted and immobilized for 2 weeks after osteotomy (OU2), suspended and immobilized for 2 weeks after osteotomy (OS2), unrestricted and immobilized for 6 weeks after osteotomy (OU6), and suspended and immobilized for 6 weeks after osteotomy (OS6). Osteotomy was performed in the middle third of the right tibia 21 days after tail suspension, when the osteopenic condition was already set. The fractured limb was then immobilized by orthosis. Tibias were collected 2 and 6 weeks after osteotomy, and were analyzed by bone densitometry, mechanical testing, and histomorphometry. Bone mineral density values from bony calluses were significantly lower in the 2-week post-osteotomy groups compared with the 6-week post-osteotomy groups (multivariate general linear model analysis, P<0.000). Similarly, the mechanical properties showed that animals had stronger bones 6 weeks after osteotomy compared with 2 weeks after osteotomy (multivariate general linear model analysis, P<0.000). Histomorphometry indicated gradual bone healing. Results showed that osteopenia did not influence the bone healing process, and that time was an independent determinant factor regardless of whether the fracture was osteopenic. This suggests that the body is able to compensate for the negative effects of suspension.

Influence of treadmill training on bone structure under osteometabolic alteration in rats subjected to high-fat diet

Nutrition and physical training have important roles in the accumulation and maintenance of bone mass. The aim of this study was to evaluate, in ovariectomized rats (OVX), the effects of treadmill training (T) with high-fat diet (F) on weight gain and bone tissue properties with eight groups (n = 10) for 12 weeks: OVX SC (OVX, sedentary lifestyle, diet control); OVX SF; OVX TC; OVX TF; SH SC (SHAM, sedentary lifestyle, diet control); SH SF; SH TC; and SH TF. Weekly weight gain and final body composition were assessed. After euthanasia, tibiae were analyzed. The trained animals had higher body weight (P = 0.001), bone mineral density (P < 0.001), and trabecular bone (P < 0.001). The animals with a high-fat diet showed higher global fat (P < 0.001), percentage of global fat (P < 0.001) and deformation at impact (P = 0.031) and reduced tibial bone mineral content (P = 0.036). Physical training improves bone microarchitecture, without presenting an increase in impact resistance, and a high-fat diet increases body fat and impairs bone mineralization.

High-impact exercise in rats prior to and during suspension can prevent bone loss

High-impact exercise has been considered an important method for treating bone loss in osteopenic experimental models. In this study, we investigated the effects of osteopenia caused by inactivity in femora and tibiae of rats subjected to jump training using the rat tail suspension model. Eight-week-old female Wistar rats were divided into five groups (n=10 each group): jump training for 2 weeks before suspension and training during 3 weeks of suspension; jump training for 2 weeks before suspension; jump training only during suspension; suspension without any training; and a control group. The exercise protocol consisted of 20 jumps/day, 5 days/week, with a jump height of 40 cm. The bone mineral density of the femora and tibiae was measured by double energy X-ray absorptiometry and the same bones were evaluated by mechanical tests. Bone microarchitecture was evaluated by scanning electron microscopy. One-way ANOVA was used to compare groups. Significance was determined as P<0.05. Regarding bone mineral density, mechanical properties and bone microarchitecture, the beneficial effects were greater in the bones of animals subjected to pre-suspension training and subsequently to training during suspension, compared with the bones of animals subjected to pre-suspension training or to training during suspension. Our results indicate that a period of high impact exercise prior to tail suspension in rats can prevent the installation of osteopenia if there is also training during the tail suspension.

Decreased Bone Formation Explains Osteoporosis in a Genetic Mouse Model of Hemochromatosiss

Osteoporosis may complicate iron overload diseases such as genetic hemochromatosis. However, molecular mechanisms involved in the iron-related osteoporosis remains poorly understood. Recent in vitro studies support a role of osteoblast impairment in iron-related osteoporosis. Our aim was to analyse the impact of excess iron in Hfe-/- mice on osteoblast activity and on bone microarchitecture. We studied the bone formation rate, a dynamic parameter reflecting osteoblast activity, and the bone phenotype of Hfe-/- male mice, a mouse model of human hemochromatosis, by using histomorphometry. Hfe-/- animals were sacrificed at 6 months and compared to controls. We found that bone contains excess iron associated with increased hepatic iron concentration in Hfe-/- mice. We have shown that animals with iron overload have decreased bone formation rate, suggesting a direct impact of iron excess on active osteoblasts number. For bone mass parameters, we showed that iron deposition was associated with bone loss by producing microarchitectural impairment with a decreased tendency in bone trabecular volume and trabecular number. A disorganization of trabecular network was found with marrow spaces increased, which was confirmed by enhanced trabecular separation and star volume of marrow spaces. These microarchitectural changes led to a loss of connectivity and complexity in the trabecular network, which was confirmed by decreased interconnectivity index and increased Minkowski's fractal dimension. Our results suggest for the first time in a genetic hemochromatosis mouse model, that iron overload decreases bone formation and leads to alterations in bone mass and microarchitecture. These observations support a negative effect of iron on osteoblast recruitment and/or function, which may contribute to iron-related osteoporosis.

Fracture discrimination by combined bone mineral density (BMD) and microarchitectural texture analysis

The use of bone mineral density (BMD) for fracture discrimination may be improved by considering bone microarchitecture. Texture parameters such as trabecular bone score (TBS) or mean Hurst parameter (H) could help to find women who are at high risk of fracture in the non-osteoporotic group. The purpose of this study was to combine BMD and microarchitectural texture parameters (spine TBS and calcaneus H) for the detection of osteoporotic fractures. Two hundred and fifty five women had a lumbar spine (LS), total hip (TH), and femoral neck (FN) DXA. Additionally, texture analyses were performed with TBS on spine DXA and with H on calcaneus radiographs. Seventy-nine women had prevalent fragility fractures. The association with fracture was evaluated by multivariate logistic regressions. The diagnostic value of each parameter alone and together was evaluated by odds ratios (OR). The area under curve (AUC) of the receiver operating characteristics (ROC) were assessed in models including BMD, H, and TBS. Women were also classified above and under the lowest tertile of H or TBS according to their BMD status. Women with prevalent fracture were older and had lower TBS, H, LS-BMD, and TH-BMD than women without fracture. Age-adjusted ORs were 1.66, 1.70, and 1.93 for LS, FN, and TH-BMD, respectively. Both TBS and H remained significantly associated with fracture after adjustment for age and TH-BMD: OR 2.07 [1.43; 3.05] and 1.47 [1.04; 2.11], respectively. The addition of texture parameters in the multivariate models didn't show a significant improvement of the ROC-AUC. However, women with normal or osteopenic BMD in the lowest range of TBS or H had significantly more fractures than women above the TBS or the H threshold. We have shown the potential interest of texture parameters such as TBS and H in addition to BMD to discriminate patients with or without osteoporotic fractures. However, their clinical added values should be evaluated relative to other risk factors.

Tibial subchondral bone mineral density: sources of variability and reproducibility

OBJECTIVES

It has been shown that subchondral bone mineral density (sBMD) measurement may be a relevant parameter of osteoarthritis (OA) progression. However, factors implicating the reproducibility and contributing to the variability of the measurement have not been fully described. Thus, the aim of this study was to explore the reproducibility of sBMD by Dual energy X-ray Absorptiometry (DXA) and to further examine its sources of variability.

METHODS

In this study, short-term, intra and inter-observer reproducibility of sBMD was examined on knee images obtained on DXA scans. The influence of software (lumbar spine and forearm modes), knee positioning (flexion or extension), site and size of regions of interest (ROI) and use of rice, on both lateral and medial tibial sBMD, were assessed. Root mean square coefficient of variation (RMS CV) and least significant changes (LSC) were calculated.

RESULTS

The short-term precision of sBMD ranged between 2.24% and 5.12% for RMS CV and between 0.053 and 0.135 g/cm(2) for LSC. Good intra-observer precision was found for knee flexion conditions whatever the software used (RMS CV ranging from 0.43 to 1.41%). The reproducibility was dependant from the ROI size (the ROI including joint space exhibiting better precision results than ROI including solely the subchondral plate). For a constant size of the ROI, the precision results were site-dependant. Inter-observer RMS CV results ranged from 0.59 to 5.01% according to ROI and software used. For the specific task of monitoring medial sBMD in the ROI including solely subchondral plate, forearm flexion condition produced the highest intra-observer and short-term precision (respectively RMS CV: 0.45% and 2.77%; LSC: 0.013 and 0.080 g/cm(2)).

CONCLUSION

Taking account into the excellent precision of the sBMD measurements expressed as RMS CV with the protocol proposed in the present study, clinical application of these measurements might be envisaged.

Radiographical texture analysis improves the prediction of vertebral fracture: an ex vivo biomechanical study

STUDY DESIGN

Compression biomechanical tests using fresh cadaveric thoracolumbar motion segments.

OBJECTIVE

The purpose of this study was to determine if the combination of bone texture parameters using bone microarchitecture, and bone mineral density (BMD) measurement by dual-energy x-ray absorptiometry provided a better prediction of vertebral fracture than BMD evaluation alone.

SUMMARY OF BACKGROUND DATA

Bone strength is routinely evaluated using BMD, as measured by dual-energy x-ray absorptiometry. Currently, there is an ongoing debate about the strengths and limitations of bone densitometry in clinical practice. To assess the fracture risk properly, other factors are important to be taken into account such as the macro- and microarchitecture of the bone. Recently, a new high-resolution x-ray device with direct digitization, named bone microarchitecture (BMA, D3A Medical Systems), has been developed to provide a better precision of texture parameters than those previously obtained on digitized films.

METHODS

Twenty-seven 3-level thoracolumbar motion segments (T11, T12, L1, and L2, L3, L4) of excised spines, obtained at the Anatomy Department of Marseille, were studied using bone microarchitecture to estimate 3 textural parameters: fractal parameter Hmean, co-occurrence matrix, and run-length matrix, dual-energy x-ray absorptiometry to measure BMD, and mechanical compression tests to failure. All specimens were examined by computed tomography before and after compression. The prediction of the vertebral failure load was evaluated using multiple regression analyses.

RESULTS

Twenty-seven vertebral fractures were observed with a mean failure load of 2636.3 N (standard deviation, 996 N). Fractal parameter Hmean, co-occurrence matrix, and run-length matrix were each significantly correlated with BMD (P< 0.01) and bone strength (P< 0.01). Combining bone texture parameters and BMD significantly improved the fracture load prediction from adjusted r = 0.701 to adjusted r = 0.806 (P< 0.01).

CONCLUSION

In these excised vertebrae, the combination of bone texture parameters with BMD demonstrated a better performance in the failure load prediction than that of BMD alone.

LEVEL OF EVIDENCE

N/A.

Bone mineral density, hip bone geometry, and calcaneus trabecular bone texture in obese and normal-weight children

Our study aimed at comparing bone mineral density (BMD), geometric indices of hip bone strength, and indices of trabecular bone texture at the calcaneus in obese and normal-weight children. Fifty-three obese children (10.3 ± 1.4 yr) and 24 normal-weight children (10.4 ± 1.5 yr) participated in this study. Body composition, bone mineral content, and BMD at whole body (WB), lumbar spine (L2-L4), total forearm, and proximal femur (total hip [TH] and femoral neck [FN]) were measured by dual-energy X-ray absorptiometry (DXA). Bone geometry of the hip was evaluated by the hip structure analysis (HSA) program. DXA scans were analyzed at the FN at its narrowest region and the femoral shaft (FS) by the HSA program. Cross-sectional area (CSA) and section modulus (Z) were measured from hip BMD profiles. Texture analysis was performed on digitized radiographs of the calcaneus to assess trabecular bone microarchitecture, and the result was expressed as Hmean. WB BMD, L2-L4 BMD, TH BMD, and FN BMD were significantly higher in obese children compared with normal-weight peers (p < 0.05). FN Z and FS Z were not significantly different between the 2 groups, whereas Hmean parameter was significantly lower in obese children compared with normal-weight peers (p < 0.001). After adjustment for body weight, obese children displayed lower WB BMD, FN CSA, FN Z, FS CSA, and FS Z compared with normal-weight children. This study suggests that BMD of WB and geometric indices of hip bone strength are not adapted to the increased body weight in obese children.

Prospective assessment of bone texture parameters at the hand in rheumatoid arthritis

OBJECTIVE

Fractal bone analysis (Hmean) is a texture parameter reflecting bone microarchitecture. The BMA device (D3A™ Medical Systems, Orléans, France) is a high-resolution X-ray device that allows assessment of bone texture analysis. We aimed to measure Hmean in rheumatoid arthritis patients at the second and third metacarpal bones, at baseline and after 1 year of follow-up, and to assess the relationship of Hmean and rheumatoid arthritis disease parameters.

METHODS

Patients with rheumatoid arthritis according to ACR criteria were included. They were assessed over 1 year, in the context of a prospective study conducted in Maastricht. For this substudy, activity of the disease was assessed by erythrocyte sedimentation rate, C-reactive protein and Disease Activity Score 28 performed at each visit. Radiographic bone damage was assessed using hand and feet radiographs at baseline and on a 1-year basis. The bone texture parameters were evaluated on the second and third metacarpal heads of the left hand using BMA device.

RESULTS

One hundred and sixty-five rheumatoid arthritis patients were included in this study. At baseline, Hmean was negatively correlated with age [r=-0.22 (P=0.013)] and erythrocyte sedimentation rate [r=-0.16 (P=0.039)]. No significant correlation was found between Hmean and Disease Activity Score, disease activity Visual Analog Scale, daily corticosteroid dose and C-reactive protein. There was a significant increase in Hmean of second and third metacarpal bones over 1 year (1.6% and 1.3%, P<0.01) except in patients with local second and third metacarpal bones erosion.

CONCLUSION

The bone texture parameter Hmean is influenced by age, inflammation and local erosions in rheumatoid arthritis.

Bone texture analysis is correlated with three-dimensional microarchitecture and mechanical properties of trabecular bone in osteoporotic femurs

Fracture of the proximal femur is a major public health problem in elderly persons. It has recently been suggested that combining texture analysis and bone mineral density measurement improves the failure load prediction in human femurs. In this study, we aimed to compare bone texture analysis with three-dimensional (3D) microarchitecture and mechanical properties of trabecular bone in osteoporotic femurs. Eight femoral heads from osteoporotic patients who fractured their femoral neck provided 31 bone cores. Bone samples were studied using a new high-resolution digital X-ray device (BMA™, D3A Medical Systems) allowing for texture analysis with fractal parameter H (mean), and were examined using micro-computed tomography (microCT) for 3D microarchitecture. Finally, uniaxial compression tests to failure were performed to estimate failure load and apparent modulus of bone samples. The fractal parameter H (mean) was strongly correlated with bone volume fraction (BV/TV) (r = 0.84) and trabecular thickness (Tb.Th) (r = 0.91) (p < 0.01). H (mean) was also markedly correlated with failure load (r = 0.84) and apparent modulus (r = 0.71) of core samples (p < 0.01). Bone volume fraction (BV/TV) and trabecular thickness (Tb.Th) demonstrated significant correlations with failure load (r = 0.85 and 0.72, respectively) and apparent modulus (r = 0.72 and 0.64, respectively) (p < 0.01). Overall, the best predictors of failure load were H (mean), bone volume fraction, and trabecular thickness, with r (2) coefficients of 0.83, 0.76, and 0.80 respectively. This study shows that the fractal parameter H (mean) is correlated with 3D microCT parameters and mechanical properties of femoral head bone samples, which suggests that radiographic texture analysis is a suitable approach for trabecular bone microarchitecture assessment in osteoporotic femurs.

[Microarchitecture assessment of human trabecular bone: description of methods]

Trabecular bone microarchitecture changes in relation to mechanical stress, effects of age, osteoporosis and anti-osteoporotic drugs. In vivo, these anomalies can be evaluated using textural parameters on high resolution radiographs and images of DXA. It is possible to extract morphological and topological parameters: apparent on MRI images and 3D with a dedicated device called High resolution peripheral quantitative computed tomography (HR-pQCT) with a resolution close to the size of the trabeculae. In vitro, it is possible to obtain on bone samples a 2D analysis by histomorphometry and a 3D analysis from 10 µm images obtained by synchrotron radiation or conventional micro-CT.

The consequences of chronic kidney disease on bone metabolism and growth in children

Growth retardation, decreased final height and renal osteodystrophy (ROD) are common complications of childhood chronic kidney disease (CKD), resulting from a combination of abnormalities in the growth hormone (GH) axis, vitamin D deficiency, hyperparathyroidism, hypogonadism, inadequate nutrition, cachexia and drug toxicity. The impact of CKD-associated bone and mineral disorders (CKD-MBD) may be immediate (serum phosphate/calcium disequilibrium) or delayed (poor growth, ROD, fractures, vascular calcifications, increased morbidity and mortality). In 2012, the clinical management of CKD-MBD in children needs to focus on three main objectives: (i) to provide an optimal growth in order to maximize the final height with an early management with recombinant GH therapy when required, (ii) to equilibrate calcium/phosphate metabolism so as to obtain acceptable bone quality and cardiovascular status and (iii) to correct all metabolic and clinical abnormalities that can worsen bone disease, growth and cardiovascular disease, i.e. metabolic acidosis, anaemia, malnutrition and 25(OH)vitamin D deficiency. The aim of this review is to provide an overview of the mineral, bone and vascular abnormalities associated with CKD in children in terms of pathophysiology, diagnosis and clinical management.

Bone texture analysis of human femurs using a new device (BMA™) improves failure load prediction

We measured bone texture parameters of excised human femurs with a new device (BMA™). We also measured bone mineral density by DXA and investigated the performance of these parameters in the prediction of failure load. Our results suggest that bone texture parameters improve failure load prediction when added to bone mineral density.

INTRODUCTION

Bone mineral density (BMD) is a strong determinant of bone strength. However, nearly half of the fractures occur in patients with BMD which does not reach the osteoporotic threshold. In order to assess fracture risk properly, other factors are important to be taken into account such as clinical risk factors as well as macro- and microarchitecture of bone. Bone microarchitecture is usually assessed by high-resolution QCT, but this cannot be applied in routine clinical settings due to irradiation, cost and availability concerns. Texture analysis of bone has shown to be correlated to bone strength.

METHODS

We used a new device to get digitized X-rays of 12 excised human femurs in order to measure bone texture parameters in three different regions of interest (ROIs). We investigated the performance of these parameters in the prediction of the failure load using biomechanical tests. Texture parameters measured were the fractal dimension (Hmean), the co-occurrence matrix, and the run length matrix. We also measured bone mineral density by DXA in the same ROIs as well as in standard DXA hip regions.

RESULTS

The Spearman correlation coefficient between BMD and texture parameters measured in the same ROIs ranged from -0.05 (nonsignificant (NS)) to 0.57 (p = 0.003). There was no correlation between Hmean and co-occurrence matrix nor Hmean and run length matrix in the same ROI (r = -0.04 to 0.52, NS). Co-occurrence matrix and run length matrix in the same ROI were highly correlated (r = 0.90 to 0.99, p < 0.0001). Univariate analysis with the failure load revealed significant correlation only with BMD results, not texture parameters. Multiple regression analysis showed that the best predictors of failure load were BMD, Hmean, and run length matrix at the femoral neck, as well as age and sex, with an adjusted r (2) = 0.88. Added to femoral neck BMD, Hmean and run length matrix at the femoral neck (without the effect of age and sex) improved failure load prediction (compared to femoral neck BMD alone) from adjusted r (2) = 0.67 to adjusted r (2) = 0.84.

CONCLUSION

Our results suggest that bone texture measurement improves failure load prediction when added to BMD.

Combination of texture analysis and bone mineral density improves the prediction of fracture load in human femurs

Twenty-one excised femurs were studied using (1) a high-resolution digital X-ray device to estimate three textural parameters, (2) dual-energy X-ray absorptiometry (DXA) to measure bone mineral density (BMD), and (3) mechanical tests to failure. Textural parameters significantly correlated with BMD (p < 0.05) and bone strength (p < 0.05). Combining texture parameters and BMD significantly improved the fracture load prediction from adjusted r(2) = 0.74 to adjusted r(2) =0.82 (p < 0.05).

INTRODUCTION

The purpose of this study is to determine if the combination of bone texture parameters using a new high-resolution X-ray device and BMD measurement by DXA provided a better prediction of femoral failure load than BMD evaluation alone.

METHODS

The proximal ends of 21 excised femurs were studied using (1) a high-resolution digital X-ray device (BMA, D3A Medical Systems) to estimate three textural parameters: fractal parameter Hmean, co-occurrence, and run-length matrices, (2) DXA to measure BMD, and (3) mechanical tests to failure in a side-impact configuration. Regions of interest in the femoral neck, intertrochanteric region, and greater trochanter were selected for DXA and bone texture analysis. Every specimen was scanned twice with repositioning before mechanical testing to assess reproducibility using intraclass correlation coefficient (ICC) with 95% confidence interval. The prediction of femoral failure load was evaluated using multiple regression analysis.

RESULTS

Thirteen femoral neck and 8 intertrochanteric fractures were observed with a mean failure load of 2,612 N (SD, 1,382 N). Fractal parameter Hmean, co-occurrence, and run-length matrices each significantly correlated with site-matched BMD (p < 0.05) and bone strength (p < 0.05). The ICC of the textural parameters varied between 0.65 and 0.90. Combining bone texture parameters and BMD significantly improved the fracture load prediction from adjusted r(2) =0.74 to adjusted r(2) = 0.82 (p < 0.05).

CONCLUSION

In these excised femurs, the combination of bone texture parameters with BMD demonstrated a better performance in the failure load prediction than that of BMD alone.

Assessment of hand trabecular bone texture with high resolution direct digital radiograph in rheumatoid arthritis: a case control study

OBJECTIVES

Rheumatoid arthritis is characterized by an early inflammatory related periarticular osteopenia. A new high resolution direct digital X-ray device has been recently developed to provide bone texture analysis which is designed to assess changes in trabecular bone architecture. For the first time, we have evaluated trabecular bone texture impairment in rheumatoid arthritis patients compared to healthy controls.

METHODS

In this cross-sectional study, the reproducibility was assessed by three separate digital X-rays of the right hand, with repositioning in 14 late rheumatoid arthritis patients and 14 healthy subjects. Then, trabecular bone texture of the MCP2 and MCP3 from patients enrolled in a prospective cohort of 78 rheumatoid arthritis patients was compared with that of 50 healthy subjects, using three texture parameters: Hmean, co-occurrence and run-length.

RESULTS

The coefficients of variation of the high resolution direct digital X-ray measurements ranged from 0.5 to 1.8%. Only the Hmean parameter was significantly decreased in rheumatoid arthritis patients compared to healthy subjects at MCP2 (0.637±0.040 vs. 0.654±0.032, P<0.05) and at MCP3 (0.646±0.044 vs. 0.665±0.037, P<0.05). This reduction was significantly correlated to disease activity.

CONCLUSIONS

This study demonstrated both the good reproducibility of the high resolution digital X-ray measurements and the trabecular bone texture impairment at MCP joints in rheumatoid arthritis patients. In addition to provide a high resolution hand radiograph, this technique may represent an interesting tool to easily quantify periarticular osteopenia with a low radiation dose.

Osteoimmunology and osteoporosis

The concept of osteoimmunology is based on growing insight into the links between the immune system and bone at the anatomical, vascular, cellular, and molecular levels. In both rheumatoid arthritis (RA) and ankylosing spondylitis (AS), bone is a target of inflammation. Activated immune cells at sites of inflammation produce a wide spectrum of cytokines in favor of increased bone resorption in RA and AS, resulting in bone erosions, osteitis, and peri-inflammatory and systemic bone loss. Peri-inflammatory bone formation is impaired in RA, resulting in non-healing of erosions, and this allows a local vicious circle of inflammation between synovitis, osteitis, and local bone loss. In contrast, peri-inflammatory bone formation is increased in AS, resulting in healing of erosions, ossifying enthesitis, and potential ankylosis of sacroiliac joints and intervertebral connections, and this changes the biomechanical competence of the spine. These changes in bone remodeling and structure contribute to the increased risk of vertebral fractures (in RA and AS) and non-vertebral fractures (in RA), and this risk is related to severity of disease and is independent of and superimposed on background fracture risk. Identifying patients who have RA and AS and are at high fracture risk and considering fracture prevention are, therefore, advocated in guidelines. Local peri-inflammatory bone loss and osteitis occur early and precede and predict erosive bone destruction in RA and AS and syndesmophytes in AS, which can occur despite clinically detectable inflammation (the so-called 'disconnection'). With the availability of new techniques to evaluate peri-inflammatory bone loss, osteitis, and erosions, peri-inflammatory bone changes are an exciting field for further research in the context of osteoimmunology.

Bone assessment in children with chronic kidney disease: data from two new bone imaging techniques in a single-center pilot study

Bone damage in children with chronic kidney disease (CKD) is a challenge for pediatric nephrologists. Areal measurements of bone mineral density (BMD) by dual x-ray absorptiometry (DXA) have been routinely performed to assess bone mass but recent international guidelines have concluded that DXA was of less value in CKD. The aim of this study is to evaluate bone quality in CKD children using new bone imaging techniques in a pilot cross-sectional single-center study. We performed bone imaging (high-resolution peripheral quantitative computed tomography, HR-pQCT, XtremeCT, Scanco Medical AG, Switzerland), to assess compartmental volumetric BMD and trabecular microarchitecture in 22 CKD children and 19 controls. In seven younger patients (i.e., under 10 years of age), we performed bone texture analysis (BMA, D3A Medical Systems, France) in comparison to 15 healthy prepubertal controls. Among older children, CKD patients had significantly lower height and body weight without significant impairment of BMD and microarchitecture than healthy controls. In univariate analysis, there were significant correlations between cortical BMD and glomerular filtration rate (r= -0.46), age (r=0.60) and body mass index (r=0.67). In younger children, bone texture parameters were not different between patients and controls. Our results did not show significant differences between healthy controls and CKD children for compartmental bone densities and microarchitecture, but the small sample size and the heterogeneity of the CKD group require caution in the interpretation. Novel bone imaging techniques seem feasible in children, and further longitudinal studies are required to thoroughly explore long-term cardiovascular and bone consequences of phosphate-calcium metabolism deregulation during CKD.

Comparison of radiograph-based texture analysis and bone mineral density with three-dimensional microarchitecture of trabecular bone

PURPOSE

Hip fracture is a serious health problem and textural methods are being developed to assess bone quality. The authors aimed to perform textural analysis at femur on high-resolution digital radiographs compared to three-dimensional (3D) microarchitecture comparatively to bone mineral density.

METHODS

Sixteen cadaveric femurs were imaged with an x-ray device using a C-MOS sensor. One 17 mm square region of interest (ROI) was selected in the femoral head (FH) and one in the great trochanter (GT). Two-dimensional (2D) textural features from the co-occurrence matrices were extracted. Site-matched measurements of bone mineral density were performed. Inside each ROI, a 16 mm diameter core was extracted. Apparent density (Dapp) and bone volume proportion (BV/TV(Arch)) were measured from a defatted bone core using Archimedes' principle. Microcomputed tomography images of the entire length of the core were obtained (Skyscan 1072) at 19.8 microm of resolution and usual 3D morphometric parameters were computed on the binary volume after calibration from BV/TV(Arch). Then, bone surface/bone volume, trabecular thickness, trabecular separation, and trabecular number were obtained by direct methods without model assumption and the structure model index was calculated.

RESULTS

In univariate analysis, the correlation coefficients between 2D textural features and 3D morphological parameters reached 0.83 at the FH and 0.79 at the GT. In multivariate canonical correlation analysis, coefficients of the first component reached 0.95 at the FH and 0.88 at the GT.

CONCLUSIONS

Digital radiographs, widely available and economically viable, are an alternative method for evaluating bone microarchitectural structure.

Assessment of bone microarchitecture in chronic kidney disease: a comparison of 2D bone texture analysis and high-resolution peripheral quantitative computed tomography at the radius and tibia

Bone microarchitecture can be studied noninvasively using high-resolution peripheral quantitative computed tomography (HR-pQCT). However, this technique is not widely available, so more simple techniques may be useful. BMA is a new 2D high-resolution digital X-ray device, allowing for bone texture analysis with a fractal parameter (H(mean)). The aims of this study were (1) to evaluate the reproducibility of BMA at two novel sites (radius and tibia) in addition to the conventional site (calcaneus), (2) to compare the results obtained with BMA at all of those sites, and (3) to study the relationship between H(mean) and trabecular microarchitecture measured with an in vivo 3D device (HR-pQCT) at the distal tibia and radius. BMA measurements were performed at three sites (calcaneus, distal tibia, and radius) in 14 healthy volunteers to measure the short-term reproducibility and in a group of 77 patients with chronic kidney disease to compare BMA results to HR-pQCT results. The coefficient of variation of H(mean) was 1.2, 2.1, and 4.7% at the calcaneus, radius, and tibia, respectively. We found significant associations between trabecular volumetric bone mineral density and microarchitectural variables measured by HR-pQCT and H(mean) at the three sites (e.g., Pearson correlation between radial trabecular number and radial H(mean) r = 0.472, P < 0.001). This study demonstrated a significant but moderate relationship between 2D bone texture and 3D trabecular microarchitecture. BMA is a new reproducible technique with few technical constraints. Thus, it may represent an interesting tool for evaluating bone structure, in association with biological parameters and DXA.

Prediction of femoral fracture load: cross-sectional study of texture analysis and geometric measurements on plain radiographs versus bone mineral density

PURPOSE

To use standard radiographs to determine which combination of co-occurrence textural parameters, geometric measurements, and cortical thickness measurements from femur radiographs provided the best estimate of femoral failure load and to compare these with total hip dual-energy x-ray absorptiometry bone mineral density (BMD) evaluation.

MATERIALS AND METHODS

Digital radiographs of 40 pairs of excised femurs (24 women, 16 men; mean age, 82 years + or - 12 [standard deviation]) were obtained. Regions of interest in the femoral neck, greater trochanter, intertrochanteric area, and femoral head were then selected. Three textural parameters derived from a co-occurrence matrix were estimated with imaging software. Neck-shaft angle, femoral neck axis length, calcar femorale thickness, and internal and external femoral shaft thickness were assessed. The femurs were randomly allocated to single-stance (femoral neck fracture) or side-impact (intertrochanteric fracture) configurations for failure load measurement.

RESULTS

Textural parameters correlated significantly with site-matched BMD. Stepwise regression analysis was performed, and total hip BMD explained 73% and 78% of the failure load in single-stance and side-impact configurations, respectively. Combining internal femoral shaft thickness with one or two textural parameters explained 72%-79% of failure load variance in the single-stance configuration and 63%-76% of failure load variance in the side-impact configuration.

CONCLUSION

In these excised femurs, combining textural parameters with cortical thickness measurements had a performance comparable to that of BMD alone in the explanation of femoral failure load.

Radiographic texture analysis of densitometric calcaneal images: relationship to clinical characteristics and to bone fragility

Osteoporotic fractures are related not only to bone mineral density (BMD) but also to bone structure or microarchitecture, which is not assessed routinely with currently available methods. We have developed radiographic texture analysis (RTA) for calcaneal images from a peripheral densitometer as an easy, noninvasive method for assessing bone structure. We conducted a cross-sectional study of the relationship between RTA and prevalent vertebral fractures (n = 148) among 900 subjects (ages 19 to 99 years, 94 males) referred for bone densitometry as part of their routine medical care. RTA features were derived from Fourier-based image analysis of the radiographic texture pattern (including root mean square, first moment, and power spectral analyses). RTA features were associated with age, weight, gender, and race, as well as glucocorticoid use. When controlling for clinical risk factors and BMD (or a summary measure calculated using FRAX algorithms), RTA features were significantly different for subjects with and without prevalent vertebral fractures [adjusted odds ratio (OR) = 1.5 per 1 standard deviation (SD) decrease in RTA feature beta, 95% confidence interval (CI) 1.2-1.8, p = .001]. Gender and use of pharmacologic therapy for osteoporosis did not significantly affect this association, suggesting that RTA can be applied to a wide range of densitometry patients. We conclude that RTA obtained using a portable instrument has a potential as a noninvasive method to enhance identification of patients at increased risk of osteoporotic fractures.

Using Radon transform of standard radiographs of the hip to differentiate between post-menopausal women with and without fracture of the proximal femur

Texture features based on the Radon transform were extracted from clinical radiographs of the hip in post-menopausal women. The novel algorithm allowed us to identify patients with fracture of the proximal femur and may provide an alternative to measuring bone mineral density in predicting the fracture-risk in osteoporosis, especially where densitometry is regionally unavailable.

INTRODUCTION

The aim of this study is to introduce an algorithm for differentiation between patients with and without fracture of the hip using parameters based on the Radon transform (RT) and applied to standard radiographs of the proximal femur and to compare the results with bone mineral density (BMD).

METHODS

The study comprised 50 post-menopausal women (78.6 +/- 11.5 years of age), including 25 patients with hip fracture and 25 age-matched controls. We obtained lumbar and femoral BMD and standard femoral radiographs. In the radiographs we analysed trabecular patterns of the hip in a region-of-interest of 57 x 29 mm using the RT. From the histogram-representation of the RT, we extracted several characteristic parameters. By ROC and discriminant-analysis, we assessed the statistical power of both methods.

RESULTS

For correct differentiation between fracture and non-fracture cases by femoral BMD, area-under-the-curve (AUC) was 0.78; AUC for the RT-based parameters ranged from 0.73 to 0.8. By combination of densitometric and textural information in a multivariate model the fracture status of 84% of subjects was predicted correctly, identification of fracture cases rose to 88%.

CONCLUSION

Identification of fracture patients by RT applied to femoral radiographs was feasible and seemed to have a discriminative potential comparable to that of standard densitometry. In the future, the new method may provide an alternative to DXA or in conjunction with conventional densitometry may enhance the detection of patients with elevated risk of hip fracture.

[The challenges of the bone micro-architecture]

Osteoporosis is a bone disorder that leads to increased fracture risk. It was defined by the World Health Organisation as a decrease of bone mass and a deterioration of bone quality. In clinical practice, the diagnosis of osteoporosis is based on bone mineral density (BMD) measurements assessed by dual energy X-ray absorptiometry. However, BMD assessment is not the only factor that influences bone strength. The main objective is that clinicians can use a combination of risk factors that are easily assessable, for a better prediction of osteoporosis risk fracture. Bone strength reflects both bone density and bone quality. One of the most important determinants of bone quality is the trabecular bone micro-architecture as suggested by the definition of osteoporosis. Moreover, various studies have concluded to the potential clinical interest of the bone micro-architecture. The aim of this article was to review the challenges of bone micro-architecture, characterization tools (morphological analysis, topology, texture) and imaging techniques (X-ray imaging, scanning and MRI) to assess trabecular bone micro-architecture.

Clinical interest of bone texture analysis in osteoporosis: a case control multicenter study

We demonstrate the clinical interest of bone texture analysis with a new high resolution X-ray device. We have found that the combination of BMD and texture parameter values provided a better assessment of the fracture risk than that obtainable solely by BMD measurement.

INTRODUCTION

Osteoporosis is characterized by BMD and trabecular bone microarchitecture. We have developed a new high-resolution X-ray device with direct digitization. The aim of this study was to demonstrate in a multicenter case control study the clinical interest of bone texture analysis with this new device.

METHODS

In this cross-sectional multicenter case-control population study in post-menopausal women, 159 osteoporotic fractures were compared with 219 control cases. Images were obtained on calcaneus with a direct digital X-ray device (BMA, D3A Medical Systems). Co-occurrence, run-length matrices and the fractal parameter Hmean were evaluated. BMD was measured at the lumbar spine (LS), femoral neck (FN) and total hip (TH) by DXA.

RESULTS

The three texture parameters were significantly lower in osteoporotic fracture cases than in control cases. These differences persisted after adjustment for TH BMD. Receiver operating characteristic curves were used to compare the discriminant capacity of texture parameters and BMD measurements for fracture. The highest areas under curve (AUC) were 0.721 for TH BMD and 0.706 for Hmean (AUC THBMD vs. AUC Hmean, p = NS). We determined the threshold between high and low Hmean parameter values and then the odds ratios (OR) of fracture for low Hmean, for BMD < or =2.5 SD in the T-score and for combinations of both parameters. The OR of fracture for low H was 2.72 (95% CI, 1.36-5.4). For a FN BMD < or = -2.5 SD, the OR of 4.78 (2.19-10.43) shifted to 14.06 (4.41-44.85) adding H.

CONCLUSIONS

These data confirmed the clinical interest of the combination of BMD and texture parameters to improve the assessment of the risk of fracture other that obtainable by the sole BMD measurement.

Laws' masks descriptors applied to bone texture analysis: an innovative and discriminant tool in osteoporosis

OBJECTIVE

The objective of this study was to explore Laws' masks analysis to describe structural variations of trabecular bone due to osteoporosis on high-resolution digital radiographs and to check its dependence on the spatial resolution. Laws' masks are well established as one of the best methods for texture analysis in image processing and are used in various applications, but not in bone tissue characterisation. This method is based on masks that aim to filter the images. From each mask, five classical statistical parameters can be calculated.

MATERIALS AND METHODS

The study was performed on 182 healthy postmenopausal women with no fractures and 114 age-matched women with fractures [26 hip fractures (HFs), 29 vertebrae fractures (VFs), 29 wrist fractures (WFs) and 30 other fractures (OFs)]. For all subjects radiographs were obtained of the calcaneus with a new high-resolution X-ray device with direct digitisation (BMA, D3A, France). The lumbar spine, femoral neck, and total hip bone mineral density (BMD) were assessed by dual-energy X-ray absorptiometry.

RESULTS

In terms of reproducibility, the best results were obtained with the TRE5E5 mask, especially for three parameters: "mean", "standard deviation" and "entropy" with, respectively, in vivo mid-term root mean square average coefficient of variation (RMSCV)%= 1.79, 4.24 and 2.05. The "mean" and "entropy" parameters had a better reproducibility but "standard deviation" showed a better discriminant power. Thus, for univariate analysis, the difference between subjects with fractures and controls was significant (P<10(-3)) and significant for each fracture group independently (P<10(-4) for HF, P=0.025 for VF and P< 10(-3) for OF). After multivariate analysis with adjustment for age and total hip BMD, the difference concerning the "standard deviation" parameter remained statistically significant between the control group and the HF and VF groups (P<5 x 10(-5), and P=0.04, respectively). No significant correlation between these Laws' masks parameters and BMD was obtained. In addition, this study showed the dependence of Laws' masks parameters on image resolution, which confirms the necessity to perform Laws' textural measurement on high-resolution images.

CONCLUSION

The reproducibility and discriminant power of the Laws' masks analysis has been demonstrated on bone images; thus, this method constitutes a promising routine technique for the determination of osteoporosis fracture risk from radiographs.

Temporal radiographic texture analysis in the detection of periprosthetic osteolysis

Periprosthetic osteolysis is one of the most serious long-term problems in total hip arthroplasty. It has been primarily attributed to the body's inflammatory response to submicron polyethylene particles worn from the hip implant, and it leads to bone loss and structural deterioration in the surrounding bone. It was previously demonstrated that radiographic texture analysis (RTA) has the ability to distinguish between osteolysis and normal cases at the time of clinical detection of the disease; however, that analysis did not take into account the changes in texture over time. The goal of this preliminary analysis, however, is to assess the ability of temporal radiographic texture analysis (tRTA) to distinguish between patients who develop osteolysis and normal cases. Two tRTA methods were used in the study: the RTA feature change from baseline at various follow-up intervals and the slope of the best-fit line to the RTA data series. These tRTA methods included Fourier-based and fractal-based features calculated from digitized images of 202 total hip replacement cases, including 70 that developed osteolysis. Results show that separation between the osteolysis and normal groups increased over time for the feature difference method, as the disease progressed, with area under the curve (AUC) values from receiver operating characteristic analysis of 0.65 to 0.72 at 15 years postsurgery. Separation for the slope method was also evident, with AUC values ranging from 0.65 to 0.76 for the task of distinguishing between osteolysis and normal cases. The results suggest that tRTA methods have the ability to measure changes in trabecular structure, and may be useful in the early detection of periprosthetic osteolysis.

Radiographic texture analysis in the characterization of trabecular patterns in periprosthetic osteolysis

RATIONALE AND OBJECTIVES

Periprosthetic osteolysis is a disease attributed to the body's reaction to fine polyethylene wear debris shed from total hip replacements. The purpose of this preliminary study was to investigate the ability of radiographic texture analysis (RTA) to characterize the trabecular texture patterns on pelvic images for osteolysis and normal total hip arthroplasty (THA) cases.

MATERIALS AND METHODS

Fourier-based and fractal-based texture features were calculated for a database of digitized radiographs from 202 THA cases, 70 of which developed osteolysis. The features were calculated from regions of interest selected at two time points: less than 1 month after surgery, and at the first clinical indication of osteolysis (or randomly selected follow-up time for normal cases). Receiver operating characteristic (ROC) analysis was used to compare feature performance at baseline and follow-up for osteolysis and normal cases.

RESULTS

Separation between the RTA features for osteolysis and normal cases was negligible at baseline and increased substantially for the follow-up images. The directional Fourier-based feature provided the best separation with an A(z) value from ROC analysis of 0.75 for the follow-up images, in the task of distinguishing between normal and osteolytic cases.

CONCLUSIONS

The results from this preliminary analysis indicate that qualitative changes in trabecular patterns from immediately after surgery to the eventual detection of osteolysis correspond to quantitative changes in RTA features. It therefore appears that RTA provides information that could potentially be useful to aid in the detection of this disease.