Value of Measuring Bone Microarchitecture in Fracture Discrimination in Older Women with Recent Hip Fracture: A Case-control Study with HR-pQCT

Majority of hip fragility fractures among older people can be predicted by a DXA examination: an updated analysis of literature results and empirical Chinese data with a focus on the validation of the newly proposed osteofrailia criterion for men

Background

How different gender-specific bone mineral density cutpoint T-scores are associated with different hip fragility fracture (FFx) prediction sensitivity has not been well studied. This article presents an updated analysis of hip FFx prediction among older people by a dual-energy X-ray absorptiometry (DXA) measure, using literature results and our own Chinese data.

Methods

We systematically searched literature reports on DXA T-score results measured at the timepoint of a hip FFx. With osteoporotic fractures in women (MsOS) and in men (MrOS) Hong Kong studies, at baseline 2,000 Chinese women (mean: 72.5 years) and 2,000 Chinese men (mean: 72.3 years) were recruited. Female participants were followed up for 8.8±1.5 years, and 69 FFx were recorded. Male participants were followed up for 9.9±2.8 years, and 63 hip FFx were recorded.

Results

Ten articles published femoral neck (FN) and/or total hip (TH) T-score at the timepoint of a hip FFx with separated females' or males' T-score data. We estimated that, if a DXA exam were taken shortly before the FFx accident, females' FN, females' TH, males' FN, or males' TH T-scores on average predicted 66.9%, 70.4%, 66.5%, and 67.8% of the hip FFx. For the MsOS and MrOS Hong Kong studies, a combination of baseline FN and TH T-score predicted >50% of the cases with a follow-up hip FFx. A combination of baseline FN T-score, TH T-score, lumbar spine T-score, and spine fracture-like deformity assessment predicted 68.1% of the female cases with a follow-up hip FFx, and 63.4% of the male cases with a follow-up hip FFx.

Conclusions

If a DXA scan is regularly performed, approximately 70% of the hip FFx incidents can be predicted for older women and men.

For older women, the majority of hip fragility fractures and radiographic vertebral fragility fractures occur among the densitometrically osteoporotic population: a literature analysis

It has been frequently cited that 'the majority of fragility fractures (FF) occur at non-osteoporotic bone mineral density (BMD)'. For the reports with T-score measured around the time of a hip fracture, we conducted a systematic literature search in December 2022, and resulted in 10 studies with five for Caucasian women and five for East Asian women. Femoral neck (FN) T-score was reported in five Caucasian studies and three East Asian studies, three of five Caucasian studies had a mean T-score ≤-2.5, and one study had the majority of their patients measuring a mean T-score ≤-2.5. All three East Asian studies reported a mean FN T-score ≤-2.7. Total hip T-score was reported in two Caucasian studies and three East Asian studies, the two Caucasian studies both had a mean T-score ≤-2.5, and all three East Asian studies had a mean T-score ≤-2.6. A new literature search conducted in April 2024 results in additional three studies, with results being consistent with the data described above. A trend was noted that 'younger' patients suffer from hip fractures at a 'higher' T-score. For the highly cited articles where the notion the majority of FF occur at non-osteoporotic BMD was derived from, authors reported prospective epidemiological studies where BMD was not measured at the timepoint of hip fracture, instead, BMD was measured at the study baseline. These epidemiological studies suggest that >50% of hip fractures likely occur in women with an osteoporotic FN or hip T-score. However, a pattern was seen that older men suffer from hip fracture at a notably higher T-score than older women. For the cases of radiographic vertebral FF, despite varying criteria being used to classify these FFs, the majority of female patients had spine densitometric osteoporosis. Literature shows, compared with the cases of hip fracture, distal forearm fracture occurs at a 'younger' age and 'higher' BMD, suggesting distal forearm fracture is more likely associated with a 'higher' trauma energy level.

Hip Fractures in Older Adults Are Associated With the Low Density Bone Phenotype and Heterogeneous Deterioration of Bone Microarchitecture

Femoral neck areal bone mineral density (FN aBMD) is a key determinant of fracture risk in older adults; however, the majority of individuals who have a hip fracture are not considered osteoporotic according to their FN aBMD. This study uses novel tools to investigate the characteristics of bone microarchitecture that underpin bone fragility. Recent hip fracture patients (n = 108, 77% female) were compared with sex- and age-matched controls (n = 216) using high-resolution peripheral quantitative computed tomography (HR-pQCT) imaging of the distal radius and tibia. Standard morphological analysis of bone microarchitecture, micro-finite element analysis, and recently developed techniques to identify void spaces in bone microarchitecture were performed to evaluate differences between hip fracture patients and controls. In addition, a new approach for phenotyping bone microarchitecture was implemented to evaluate whether hip fractures in males and females occur more often in certain bone phenotypes. Overall, hip fracture patients had notable deterioration of bone microarchitecture and reduced bone mineral density compared with controls, especially at weight-bearing sites (tibia and femoral neck). Hip fracture patients were more likely to have void spaces present at either site and had void spaces that were two to four times larger on average when compared with non-fractured controls (p < 0.01). Finally, bone phenotyping revealed that hip fractures were significantly associated with the low density phenotype (p < 0.01), with the majority of patients classified in this phenotype (69%). However, female and male hip fracture populations were distributed differently across the bone phenotype continuum. These findings highlight how HR-pQCT can provide insight into the underlying mechanisms of bone fragility by using information about bone phenotypes and identification of microarchitectural defects (void spaces). The added information suggests that HR-pQCT can have a beneficial role in assessing the severity of structural deterioration in bone that is associated with osteoporotic hip fractures. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Meta-analyses of the quantitative computed tomography data in dialysis patients show differential impacts of renal failure on the trabecular and cortical bones

Dialysis patients have compromised bone health that increases their fracture risk due to low bone mass and deterioration in bone microarchitecture. Through meta-analyses of published studies, we conclude that dialysis patients suffer from impaired compartmental bone parameters compared with healthy controls.

INTRODUCTION

We performed meta-analyses to determine the effect of chronic kidney disease (CKD) patients under dialysis on the trabecular and cortical parameters of radius and tibia.

METHODS

This is a meta-analysis of cross-sectional and prospective clinical studies. PubMed, Web of Science, Google Scholar, and Scopus were searched using various permutation combinations. Dialysis patients were compared with non-CKD healthy controls using quantitative computed tomography. High-resolution peripheral quantitative computed tomography (HR-pQCT) and pQCT data of dialysis patients were dissected from eligible studies for pooled analysis of each parameter.

RESULTS

Ten studies met the inclusion criteria that included data from 457 dialysis patients and 2134 controls. Pooled analysis showed a significant decrease (a) in total vBMD at distal radius [standard deviation of the mean (SDM) = -0.842, p = 0.000] and tibia (SMD = -0.705, p = 0.000) and (b) in cortical vBMD (SDM = -1.037, p = 0.000) at radius of dialysis patients compared with control. There were strong correlations between total vBMD and microarchitecture parameters at tibia in dialysis patients.

CONCLUSIONS

At radius and tibia, bone mass, microarchitecture, and geometry at trabecular and cortical envelopes displayed impairments in dialysis patients compared with control. Tibial vBMD may have diagnostic value in dialysis. HR-pQCT and pQCT may be used to further understand the compartmental bones response to CKD-induced loss at different stages of CKD.

HR-pQCT for the Evaluation of Muscle Quality and Intramuscular Fat Infiltration in Ageing Skeletal Muscle

Myosteatosis is the infiltration of fat in skeletal muscle during the onset of sarcopenia. The quantification of intramuscular adipose tissue (IMAT) can be a feasible imaging modality for the clinical assessment of myosteatosis, important for the early identification of sarcopenia patients and timely intervention decisions. There is currently no standardized method or consensus for such an application. The aim of this study was to develop a method for the detection and analysis of IMAT in clinical HR-pQCT images of the distal tibia to evaluate skeletal muscle during the ageing process, validated with animal and clinical experimentation. A pre-clinical model of ovariectomized (OVX) rats with known intramuscular fat infiltration was used, where gastrocnemii were scanned by micro-computed tomography (micro-CT) at an 8.4 μm isotropic voxel size, and the images were analyzed using our modified IMAT analysis protocol. IMAT, muscle density (MD), and muscle volume (MV) were compared with SHAM controls validated with Oil-red-O (ORO) staining. Furthermore, the segmentation and IMAT evaluation method was applied to 30 human subjects at ages from 18 to 81 (mean = 47.3 ± 19.2). Muscle-related parameters were analyzed with functional outcomes. In the animal model, the micro-CT adipose tissue-related parameter of IMAT% segmented at −600 HU to 100 HU was shown to strongly associate with the ORO-positively stained area (r = 0.898, p = 0.002). For the human subjects, at an adjusted threshold of −600 to −20 HU, moderate positive correlations were found between MV and MD (r = 0.642, p < 0.001), and between MV and IMAT volume (r = 0.618, p < 0.01). Moderate negative correlations were detected between MD and IMAT% (r = −0.640, p < 0.001). Strong and moderate associations were found between age and MD (r = −0.763, p < 0.01), and age and IMAT (r = 0.559, p < 0.01). There was also a strong correlation between IMAT% and chair rise time (r = 0.671, p < 0.01). The proposed HR-pQCT evaluation protocol for intramuscular adipose-tissue produced MD and IMAT results that were associated with age and physical performance measures, and were of good predictive value for the progression of myosteatosis or sarcopenia. The protocol was also validated on animal skeletal muscle samples that showed a good representation of histological lipid content with positive correlations, further supporting the clinical application for the rapid evaluation of muscle quality and objective quantification of skeletal muscle at the peripheral for sarcopenia assessment.

Gait speed and spasticity are independently associated with estimated failure load in the distal tibia after stroke: an HR-pQCT study

This HR-pQCT study was conducted to examine bone properties of the distal tibia post-stroke and to identify clinical outcomes that were associated with these properties at this site. It was found that spasticity and gait speed were independently associated with estimated failure load in individuals with chronic stroke.

PURPOSE

(1) To examine the influence of stroke on distal tibia bone properties and (2) the association between these properties and clinical outcomes in people with chronic stroke.

METHODS

Sixty-four people with stroke (age, 60.8 ± 7.7 years; time since stroke, 5.7 ± 3.9 years) and 64 controls (age: 59.4 ± 7.8 years) participated in this study. High-resolution peripheral quantitative computed tomography (HR-pQCT) was used to scan the bilateral distal tibia, and estimated failure load was calculated by automated finite element analysis. Echo intensity of the medial gastrocnemius muscle and blood flow of the popliteal artery were assessed with ultrasound. The 10-m walk test (10MWT), Fugl-Meyer Motor Assessment (FMA), and Composite Spasticity Scale (CSS) were also administered.

RESULTS

The percent side-to-side difference (%SSD) in estimated failure load, cortical area, thickness, and volumetric bone mineral density (vBMD), and trabecular and total vBMD were significantly greater in the stroke group than their control counterparts (Cohen's d = 0.48-1.51). Isometric peak torque and echo intensity also showed significant within- and between-groups differences (p ≤ 0.01). Among HR-pQCT variables, the %SSD in estimated failure load was empirically chosen as one example of the strong discriminators between the stroke group and control group, after accounting for other relevant factors. The 10MWT and CSS subscale for ankle clonus remained significantly associated with the %SSD in estimated failure load after adjusting for other relevant factors (p ≤ 0.05).

CONCLUSION

The paretic distal tibia showed more compromised vBMD, cortical area, cortical thickness, and estimated failure load than the non-paretic tibia. Gait speed and spasticity were independently associated with estimated failure load. As treatment programs focusing on these potentially modifiable stroke-related impairments are feasible to administer, future studies are needed to determine the efficacy of such intervention strategies for improving bone strength in individuals with chronic stroke.

Best Performance Parameters of HR-pQCT to Predict Fragility Fracture: Systematic Review and Meta-Analysis

Osteoporosis is a systemic skeletal disease characterized by low bone mass and bone structural deterioration that may result in fragility fractures. Use of bone imaging modalities to accurately predict fragility fractures is always an important issue, yet the current gold standard of dual-energy X-ray absorptiometry (DXA) for diagnosis of osteoporosis cannot fully satisfy this purpose. The latest high-resolution peripheral quantitative computed tomography (HR-pQCT) is a three-dimensional (3D) imaging device to measure not only volumetric bone density, but also the bone microarchitecture in a noninvasive manner that may provide a better fracture prediction power. This systematic review and meta-analysis was designed to investigate which HR-pQCT parameters at the distal radius and/or distal tibia could best predict fragility fractures. A systematic literature search was conducted in Embase, PubMed, and Web of Science with relevant keywords by two independent reviewers. Original clinical studies using HR-pQCT to predict fragility fractures with available full text in English were included. Information was extracted from the included studies for further review. In total, 25 articles were included for the systematic review, and 16 articles for meta-analysis. HR-pQCT was shown to significantly predict incident fractures and/or major osteoporotic fractures (MOFs). Of all the HR-pQCT parameters, our meta-analysis revealed that cortical volumetric bone mineral density (Ct.vBMD), trabecular thickness (Tb.Th), and stiffness were better predictors. Meanwhile, HR-pQCT parameters indicated better performance in predicting MOFs than incident fractures. Between the two standard measurement sites of HR-pQCT, the non-weight-bearing distal radius was a more preferable site than distal tibia for fracture prediction. Furthermore, most of the included studies were white-based, whereas very few studies were from Asia or South America. These regions should build up their densitometric databases and conduct related prediction studies. It is expected that HR-pQCT can be used widely for the diagnosis of osteoporosis and prediction of future fragility fractures. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Mechanical metric for skeletal biomechanics derived from spectral analysis of stiffness matrix

A new metric for the quantitative and qualitative evaluation of bone stiffness is introduced. It is based on the spectral decomposition of stiffness matrix computed with finite element method. The here proposed metric is defined as an amplitude rescaled eigenvalues of stiffness matrix. The metric contains unique information on the principal stiffness of bone and reflects both bone shape and material properties. The metric was compared with anthropometrical measures and was tested for sex sensitivity on pelvis bone. Further, the smallest stiffness of pelvis was computed under a certain loading condition and analyzed with respect to sex and direction. The metric complements anthropometrical measures and provides a unique information about the smallest bone stiffness independent from the loading configuration and can be easily computed by state-of-the-art subject specified finite element algorithms.

A new approach for quantifying localized bone loss by measuring void spaces

The application of high resolution peripheral quantitative computed tomography (HR-pQCT) for the study of bone health has provided valuable insight into the role bone microarchitecture has in determining bone strength and fracture risk. However, conventional density and morphological parameters struggle to distinguish whether localized bone loss is present, visible as heterogeneous deterioration in the trabecular network. This is because current HR-pQCT parameters quantify a global average of properties in the cortical or trabecular compartment. This study proposes a new metric we term "void space" that segments volumes of localized deterioration in the trabecular bone network from HR-pQCT scans and quantifies void space as the void space to total volume ratio (VS/TV, %). A simple and fully automated protocol for segmenting and quantifying void space in HR-pQCT scans is presented, along with the assessment of accuracy, precision, and cross-calibration between generations of HR-pQCT systems. Finally, prevalence of void space and the association with standard HR-pQCT parameters is demonstrated using a large population-based cohort (n = 1236). Void space detection was found to be highly reproducible (accuracy >95%, least significant change <1.76% VS/TV) and correlation between scanner generations was strong (R² = 0.87), although the first generation system struggled to identify small voids. Assessment of void space prevalence in the population-based cohort revealed that void spaces were more common in females than males, prevalence increased with age, and void spaces were typically systemic (occurring at both scan sites rather than only one). A comparison of group-wise differences between participants with and without void space demonstrated that individuals with void spaces had significantly worse trabecular properties for both sexes and at both scan sites. Specifically, the median trabecular bone mineral density, bone volume fraction, and trabecular number were below the 25th percentile of the population, while trabecular separation and inhomogeneity were above the 75th percentile of the population in participants with void spaces. Cortical bone characteristics did not differ between participants with and without void spaces. When the void space region was excluded from morphological analysis so that only the remaining "functional bone" was considered, trabecular properties of participants with void spaces were greatly improved, especially for those who were the greatest outliers. Void space is an intuitive morphological parameter that captures localized deterioration in the trabecular bone network, and has the potential to provide valuable insight into the assessment of bone fragility.

Performance of HR-pQCT, DXA, and FRAX in the discrimination of asymptomatic vertebral fracture in postmenopausal Chinese women

Volumetric bone density (vBMD) and trabecular microarchitecture measured by high-resolution peripheral quantitative computed tomography (HR-pQCT) can discriminate the patients with high risk of asymptomatic vertebral fracture (VF) in postmenopausal Chinese women. These findings suggested that HR-pQCT could provide additional information on bone quality of the patients with asymptomatic VF.

INTRODUCTION

Although there were several studies using HR-pQCT to investigate asymptomatic VF, it remains uncertain if HR-pQCT parameters can discriminate asymptomatic VF patients, especially in Chinese population. The purpose of this study was to investigate whether bone quality measured by HR-pQCT could discriminate asymptomatic VF independent of hip areal bone mineral density (aBMD) measured by dual-energy x-ray absorptiometry (DXA) and fracture risks evaluated using built-in Fracture Risk Assessment Tool (FRAX_BMD).

METHODS

This is a nested case-control study. One hundred seventy-five ambulatory Chinese postmenopausal women aged 60-79 years were retrieved from Normative Reference Standards (NRS) cohort in Hong Kong. DXA was used to identify VF from lateral spine images (VFA) using Genant's semi-quantitative method. Major osteoporotic fracture risk was calculated using FRAX tool. HR-pQCT was used to assess vBMD, microarchitecture, and estimated strength at both distal radius and tibia. Comparison of HR-pQCT parameters between asymptomatic VF and control was performed using covariance analysis. Logistic regression analysis was performed for calculating the adjusted odds ratio (OR) with 95% confidence intervals (CI) of fracture status as per SD decrease in HR-pQCT parameters.

RESULTS

Women with asymptomatic VF were older than those of the control in our NRS cohort. Nevertheless, after adjusted for covariance, asymptomatic VF showed significantly lower trabecular vBMD (Tb.vBMD) at radius but higher SMI at tibia as compared with those of the control. Tb.vBMD at radius yielded the highest value of area under the curve (AUC) as compared with total hip aBMD and FRAX_BMD. However, no significant difference was found among each other.

CONCLUSION

Tb.vBMD at the radius and SMI at the tibia provided by HR-pQCT can discriminate asymptomatic VF independent of hip aBMD and FRAX_BMD by DXA in postmenopausal women.

Efficacy of low-magnitude high-frequency vibration (LMHFV) on musculoskeletal health of participants on wheelchair: a study protocol for a single-blinded randomised controlled study

BACKGROUND

Osteoporosis is an age-related disease with progressive loss of bone, leading to fragile bone. It is one of the major health issues in older adults and causes medical, social and economic impacts globally. Patients with osteoporosis have high risk of osteoporotic fractures. Low-magnitude high-frequency vibration (LMHFV) is a non-invasive biophysical intervention providing whole-body mechanical stimulation. Previous studies showed that LMHFV is beneficial to muscle strength, postural control, balancing ability, new bone formation, spinal bone mineral density (BMD) and blood circulation. During the LMHFV treatment, older adults need to stand upright on the platform for 20 min/day. However, some physically weak elderlies with poor musculoskeletal ability cannot stand for a long period. Therefore, the design of vibration platform is modified for the disabled patients to treat at sitting position and the efficacy of LMHFV on this group of elderlies will be verified. It is hypothesised that new design of LMHFV is beneficial to wheelchair users in terms of vertebral BMD, muscle health and musculoskeletal functions.

METHODS

This study is a single-blinded randomised controlled trial to investigate the effect of LMHFV on vertebral BMD, muscle health, balancing ability and functional ability in wheelchair users (mainly on wheelchair for outdoor activities). Healthy elderlies aged 65 years or above with walking difficulties and using wheelchair are eligible. Exclusion criteria are those: (1) who cannot stand and walk independently, (2) who have vibration treatment before, (3) with malignancy, (4) with acute fractures or severe osteoarthritis, (5) with cardiovascular concern such as with pacemaker in situ, (6) with chronic inflammatory conditions known to affect muscle metabolism such as rheumatoid arthritis and (7) with high frequency of physical activities, such as participants who participated in regular exercise five times a week or more. Recruited participants will be randomised to either LMHFV or control group. Participant assigned to LMHFV group will receive LMHFV (35 Hz, 0.3g (g=gravitational acceleration), 20 min/day, at least three times/week) for 6 months. The primary outcome is BMD at the lumbar spine to be assessed by dual-energy X-ray absorptiometry that is clinically recommended for the diagnosis of osteoporosis. All primary and secondary outcome assessments for all groups will be performed in the investigators' institute at baseline and 6 months post treatment.

DISCUSSION

This study aims to investigate the effects of LMHFV on wheelchair users. The findings of this study will help to confirm the efficacy of LMHFV on vertebral BMD, muscle health, balancing ability and functional outcomes in wheelchair using elderlies. LMHFV therapy is an intervention strategy that is easy to implement at the community healthcare level or individually at home that has previously been proven to reduce fall risk and muscle strength at the lower limb. The ultimate goal is to improve their bone and muscle quality of wheelchair users, as well as enhancing their quality of life.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT04180267).

HR-pQCT Measures of Bone Microarchitecture Predict Fracture: Systematic Review and Meta-Analysis

High-resolution peripheral quantitative computed tomography (HR-pQCT) is a noninvasive imaging modality for assessing volumetric bone mineral density (vBMD) and microarchitecture of cancellous and cortical bone. The objective was to (1) assess fracture-associated differences in HR-pQCT bone parameters; and (2) to determine if HR-pQCT is sufficiently precise to reliably detect these differences in individuals. We systematically identified 40 studies that used HR-pQCT (39/40 used XtremeCT scanners) to assess 1291 to 3253 and 3389 to 10,687 individuals with and without fractures, respectively, ranging in age from 10.9 to 84.7 years with no comorbid conditions. Parameters describing radial and tibial bone density, microarchitecture, and strength were extracted and percentage differences between fracture and control subjects were estimated using a random effects meta-analysis. An additional meta-analysis of short-term in vivo reproducibility of bone parameters assessed by XtremeCT was conducted to determine whether fracture-associated differences exceeded the least significant change (LSC) required to discern measured differences from precision error. Radial and tibial HR-pQCT parameters, including failure load, were significantly altered in fracture subjects, with differences ranging from -2.6% (95% confidence interval [CI] -3.4 to -1.9) in radial cortical vBMD to -12.6% (95% CI -15.0 to -10.3) in radial trabecular vBMD. Fracture-associated differences reported by prospective studies were consistent with those from retrospective studies, indicating that HR-pQCT can predict incident fracture. Assessment of study quality, heterogeneity, and publication biases verified the validity of these findings. Finally, we demonstrated that fracture-associated deficits in total and trabecular vBMD and certain tibial cortical parameters can be reliably discerned from HR-pQCT-related precision error and can be used to detect fracture-associated differences in individual patients. Although differences in other HR-pQCT measures, including failure load, were significantly associated with fracture, improved reproducibility is needed to ensure reliable individual cross-sectional screening and longitudinal monitoring. In conclusion, our study supports the use of HR-pQCT in clinical fracture prediction. © 2019 American Society for Bone and Mineral Research.

Ultrasound-Based Estimates of Cortical Bone Thickness and Porosity Are Associated With Nontraumatic Fractures in Postmenopausal Women: A Pilot Study

Recent ultrasound (US) axial transmission techniques exploit the multimode waveguide response of long bones to yield estimates of cortical bone structure characteristics. This pilot cross-sectional study aimed to evaluate the performance at the one-third distal radius of a bidirectional axial transmission technique (BDAT) to discriminate between fractured and nonfractured postmenopausal women. Cortical thickness (Ct.Th) and porosity (Ct.Po) estimates were obtained for 201 postmenopausal women: 109 were nonfractured (62.6 ± 7.8 years), 92 with one or more nontraumatic fractures (68.8 ± 9.2 years), 17 with hip fractures (66.1 ± 10.3 years), 32 with vertebral fractures (72.4 ± 7.9 years), and 17 with wrist fractures (67.8 ± 9.6 years). The areal bone mineral density (aBMD) was obtained using DXA at the femur and spine. Femoral aBMD correlated weakly, but significantly with Ct.Th (R = 0.23, p < 0.001) and Ct.Po (R = -0.15, p < 0.05). Femoral aBMD and both US parameters were significantly different between the subgroup of all nontraumatic fractures combined and the control group (p < 0.05). The main findings were that (1) Ct.Po was discriminant for all nontraumatic fractures combined (OR = 1.39; area under the receiver operating characteristic curve [AUC] equal to 0.71), for vertebral (OR = 1.96; AUC = 0.84) and wrist fractures (OR = 1.80; AUC = 0.71), whereas Ct.Th was discriminant for hip fractures only (OR = 2.01; AUC = 0.72); there was a significant association (2) between increased Ct.Po and vertebral and wrist fractures when these fractures were not associated with any measured aBMD variables; (3) between increased Ct.Po and all nontraumatic fractures combined independently of aBMD neck; and (4) between decreased Ct.Th and hip fractures independently of aBMD femur. BDAT variables showed comparable performance to that of aBMD neck with all types of fractures (OR = 1.48; AUC = 0.72) and that of aBMD femur with hip fractures (OR = 2.21; AUC = 0.70). If these results are confirmed in prospective studies, cortical BDAT measurements may be considered useful for assessing fracture risk in postmenopausal women. © 2019 American Society for Bone and Mineral Research.