Quantitative Analysis of Primary Compressive Trabeculae Distribution in the Proximal Femur of the Elderly

Abstract

Objective: As osteoporosis progresses, the primary compressive trabeculae (PCT) in the proximal femur remains preserved and is deemed the principal load-bearing structure that links the femoral head with the femoral neck. This study aims to elucidate the distribution patterns of PCT within the proximal femur in the elderly population, and to assess its implications for the development and optimization of internal fixation devices used in hip fracture surgeries.

Methods: This is a retrospective cohort study conducted from March 2022 to April 2023. A total of 125 patients who underwent bilateral hip joint CT scans in our hospital were enrolled. CT data of the unaffected side of the hip were analyzed. Key parameters regarding the PCT distribution in the proximal femur were measured, including the femoral head’s radius (R), the neck-shaft angle (NSA), the angle between the PCT-axis and the head–neck axis (α), the distance from the femoral head center to the PCT-axis (δ), and the lengths of the PCT’s bottom and top boundaries (L-bottom and L-top respectively). The impact of gender differences on PCT distribution patterns was also investigated. Student’s t-test or Mann–Whitney U test were used to compare continuous variables between genders. The relationship between various variables was investigated through Pearson’s correlation analysis.

Results: PCT was the most prominent bone structure within the femoral head. The average NSA, α, and δ were 126.85 ± 5.85°, 37.33 ± 4.23°, and 0.39 ± 1.22 mm, respectively, showing no significant gender differences (p > 0.05). Pearson’s correlation analysis revealed strong correlations between α and NSA (r = –0.689, p < 0.001), and R and L-top (r = 0.623, p < 0.001), with mild correlations observed between δ and NSA (r = –0.487, p < 0.001), and R and L-bottom (r = 0.427, p < 0.001). Importantly, our study establishes a method to accurately localize PCT distribution in true anteroposterior (AP) radiographs of the hip joint, facilitating precise screw placement in proximal femur fixation procedures.

Conclusion: Our study provided unprecedented insights into the distribution patterns of PCT in the proximal femur of the elderly population. The distribution of PCT in the proximal femur is predominantly influenced by anatomical and geometric factors, such as NSA and femoral head size, rather than demographic factors like gender. These insights have crucial implications for the design of internal fixation devices and surgical planning, offering objective guidance for the placement of screws in hip fracture treatments.

Keywords

CT imaging / hip fracture / PCT / primary compressive trabeculae / proximal femur

References

[1] Viganò M, Pennestrì F, Listorti E, Banfi G. Proximal hip fractures in 71, 920 elderly patients: incidence, epidemiology, mortality and costs from a retrospective observational study. BMC Public Health. 2023; 23: 1963.

[2] Wang PW, Yao XD, Zhuang HF, Li YZ, Xu H, Lin JK, et al. Mortality and related risk factors of fragile hip fracture. Orthop Surg. 2022; 14: 2462–2469.

[3] Parfitt AM. Implications of architecture for the pathogenesis and prevention of vertebral fracture. Bone. 1992; 13(Suppl 2): S41–S47.

[4] Barak MM, Black MA. A novel use of 3d printing model demonstrates the effects of deteriorated trabecular bone structure on bone stiffness and strength. J Mech Behav Biomed Mater. 2018; 78: 455–464.

[5] Park J, Sutradhar A, Shah JJ, Paulino GH. Design of complex bone internal structure using topology optimization with perimeter control. Comput Biol Med. 2018; 94: 74–84.

[6] Van Rietbergen B, Huiskes R, Eckstein F, Ruegsegger P. Trabecular bone tissue strains in the healthy and osteoporotic human femur. J Bone Miner Res. 2003; 18: 1781–1788.

[7] Ries C, Boese CK, Sturznickel J, Koehne T, Hubert J, Pastor MF, et al. Age-related changes of micro-morphological subchondral bone properties in the healthy femoral head. Osteoarthr Cartil. 2020; 28: 1437–1447.

[8] Taghizadeh E, Chandran V, Reyes M, Zysset P, Buchler P. Statistical analysis of the inter-individual variations of the bone shape, volume fraction and fabric and their correlations in the proximal femur. Bone. 2017; 103: 252–261.

[9] Passi N, Gefen A. Trabecular bone contributes to strength of the proximal femur under mediolateral impact in the avian. J Biomech Eng. 2005; 127: 198–203.

[10] Reznikov N, Alsheghri AA, Piche N, Gendron M, Desrosiers C, Morozova I, et al. Altered topological blueprint of trabecular bone associates with skeletal pathology in humans. Bone Rep. 2020; 12: 100264.

[11] Elke RP, Cheal EJ, Simmons C, Poss R. Three-dimensional anatomy of the cancellous structures within the proximal femur from computed tomography data. J Orthop Res. 1995; 13: 513–523.

[12] Mayhew PM, Thomas CD, Clement JG, Loveridge N, Beck TJ, Bonfield W, et al. Relation between age, femoral neck cortical stability, and hip fracture risk. Lancet. 2005; 366: 129–135.

[13] Bot RB, Chirla R, Hozan CT, Cavalu S. Mapping the spatial evolution of proximal femur osteoporosis: a retrospective cross-sectional study based on CT scans. Int J Gen Med. 2024; 17: 1085–1100.

[14] Lv H, Zhang L, Yang F, Li M, Yin P, Su X, et al. A novel 3d-printed device for localization and extraction of trabeculae from human femoral heads: a comparison with traditional visual extraction. Osteoporos Int. 2015; 26: 1791–1799.

[15] Carballido-Gamio J, Harnish R, Saeed I, Streeper T, Sigurdsson S, Amin S, et al. Proximal femoral density distribution and structure in relation to age and hip fracture risk in women. J Bone Miner Res. 2013; 28: 537–546.

[16] Chiba K, Burghardt AJ, Osaki M, Majumdar S. Heterogeneity of bone microstructure in the femoral head in patients with osteoporosis: an ex vivo hr-pqct study. Bone. 2013; 56: 139–146.

[17] Lu Y, Wang L, Hao Y, Wang Z, Wang M, Ge S. Analysis of trabecular distribution of the proximal femur in patients with fragility fractures. BMC Musculoskelet Disord. 2013; 14: 130.

[18] Stiehl JB, Jacobson D, Carrera G. Morphological analysis of the proximal femur using quantitative computed tomography. Int Orthop. 2007; 31: 287–292.

[19] Nawathe S, Nguyen BP, Barzanian N, Akhlaghpour H, Bouxsein ML, Keaveny TM. Cortical and trabecular load sharing in the human femoral neck. J Biomech. 2015; 48: 816–822.

[20] Chon CS, Kim JW, Sohn HS, Jung GH. Computational simulation of cephalomedullary nailing in the osteoporotic asian femur and clinical implications. Injury. 2021; 53: 1177–1183.

[21] Gao J, Gong H, Zhang R, Zhu D. Age-related regional deterioration patterns and changes in nanoscale characterizations of trabeculae in the femoral head. Exp Gerontol. 2015; 62: 63–72.

[22] Munemoto M, Kido A, Sakamoto Y, Inoue K, Yokoi K, Shinohara Y, et al. Analysis of trabecular bone microstructure in osteoporotic femoral heads in human patients: in vivo study using multidetector row computed tomography. BMC Musculoskelet Disord. 2016; 17: 13.

[23] Jenkins PJ, Ramaesh R, Pankaj P, Patton JT, Howie CR, Goffin JM, et al. A micro-architectural evaluation of osteoporotic human femoral heads to guide implant placement in proximal femoral fractures. Acta Orthop. 2013; 84: 453–459.

[24] Zhang R, Wang L, Lin Y, Yang M, Guo Z, Xia W, et al. A novel method for estimating nail-tract bone density for intertrochanteric fractures. J Orthop Translat. 2019; 18: 40–47.

[25] Ciarelli TE, Fyhrie DP, Schaffler MB, Goldstein SA. Variations in three-dimensional cancellous bone architecture of the proximal femur in female hip fractures and in controls. J Bone Miner Res. 2000; 15: 32–40.

[26] Li J, Zhang L, Zhang H, Yin P, Lei M, Wang G, et al. Effect of reduction quality on post-operative outcomes in 31-a2 intertrochanteric fractures following intramedullary fixation: a retrospective study based on computerised tomography findings. Int Orthop. 2019; 43: 1951–1959.

[27] Yang L, Udall WJ, Mccloskey EV, Eastell R. Distribution of bone density and cortical thickness in the proximal femur and their association with hip fracture in postmenopausal women: a quantitative computed tomography study. Osteoporos Int. 2014; 25: 251–263.

[28] Pontzer H, Lieberman DE, Momin E, Devlin MJ, Polk JD, Hallgrimsson B, et al. Trabecular bone in the bird knee responds with high sensitivity to changes in load orientation. J Exp Biol. 2006; 209: 57–65.

[29] Zhang J, Li H, Zhou Y, Chen S, Rong Q. An analysis of trabecular bone structure based on principal stress trajectory. Bioengineering (Basel). 2023; 10: 1224.

[30] Kim J, Chun BJ, Kim JJ. Quantitative load dependency analysis of local trabecular bone microstructure to understand the spatial characteristics in the synthetic proximal femur. Biology (Basel). 2023; 12: 170.

[31] Wang J, Zhou B, Parkinson I, Thomas CD, Clement JG, Fazzalari N, et al. Trabecular plate loss and deteriorating elastic modulus of femoral trabecular bone in intertrochanteric hip fractures. Bone Res. 2013; 1: 346–354.

[32] Liu XS, Sajda P, Saha PK, Wehrli FW, Bevill G, Keaveny TM, et al. Complete volumetric decomposition of individual trabecular plates and rods and its morphological correlations with anisotropic elastic moduli in human trabecular bone. J Bone Miner Res. 2008; 23: 223–235.

[33] Albareda-Albareda J, Redondo-Trasobares B, Calvo-Tapies J, Blanco-Baiges E, Torres-Campos A, Gomez-Vallejo J, et al. Salvage of cephalomedullary nail cutout with the variable angle proximal femoral plate. Injury. 2021; 52(Suppl 4): S37–S41.

[34] Greenwood C, Clement J, Dicken A, Evans P, Lyburn I, Martin RM, et al. Age-related changes in femoral head trabecular microarchitecture. Aging Dis. 2018; 9: 976–987.

RIGHTS & PERMISSIONS

2024 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.