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Physical determinants of three dimensional femoral neck structure and strength in older postmenopausal women
ABSTRACTS / Bone 43 (2008) S38–S75
A78 Is regular table tennis activity associated with increased bone and muscle strength and improved balance in older Asian men and women Lan Li 1, John Wark 1, Keith Hill 2, Peter Wong 3, Nigel Kwok 1 1 Department of Medicine, RMH, The University of Melbourne, Parkville, Victoria, Australia 2 Prevention and Public Health Division, NARI, The University of Melbourne, Parkville, Victoria, Australia 3 Department of Rheumatology, RMH, The University of Melbourne, Parkville, Victoria, Australia Background: Physical activity programs benefit bone health and lower falls risk in the elderly. However, there are no published studies of the effects of table tennis (TT) on fracture risk. Aims: To investigate the association of regular TT(N1 hour/week for over 1 year) in older Asian Australians with measures of fracture risk, by comparing areal bone mineral density(aBMD), bone geometry and strength, lower limb strength and balance function, comparing TT players with non- players. Methods: 77 healthy ambulatory men and women of Chinese descent, living in Melbourne, age 50-80y, were recruited. ABMD was measured at the femoral neck(FN), total hip(TH), lumbar spine(LS) and distal 1/3 radius(FA) [cross-sectional independent t-test was used, and results adjusted for age, height and weight]; and peripheral quantitative computed tomography(pQCT) of both forearms(4%,30% sites) and tibia(4%,33% sites). Validated tests of balance and strength were performed: Kinetic Communicator dynamometer (KIN-COM), Nicholas Manual Muscle Tester(NMMT). Chattecx Balance System (CBS), Neurocom and Lord's balance test(LBT)(for postural stability). Results: Significant mean differences in adjusted aBMD were seen: for TT-player (n = 45) vs non-TT-players (n = 32), FN: +0.052 g/cm2, p = 0.003, TH: +0.057 g/cm2, p = 0.006 and LS: +0.084 g/cm2, p = 0.007. There was no significant FA difference between players and nonplayers. The mean cortical area of distal 33% radius in players' dominant arm was 3.2 ± 3.5 mm2 (p = 0.007)greater than their nondominant arm. Isometric knee extensor and hip abductor strength was 44 ± 44 Nm (p = 0.03) and 1.42 ± 1.58 kg (p = 0.048) greater among TT players in 11 matched player/non-player pairs. Conclusion: TT players had significantly greater adjusted aBMD than non-players at clinically-relevant sites, which may reduce fracture risk in this population. Prospective studies of the skeletal benefits of table tennis are warranted. doi:10.1016/j.bone.2008.08.080
A79 Disparate decrease of blood perfusion among femoral head, femoral neck and femoral shaft in patients with decreased bone mineral density Yi-Xiang Wang, James F. Griffith, Anthony Kwok, David K.W. Yeung, Jason Leung, Heather T. Ma, Ping Chung Leung The Chinese University of Hong Kong, HK, China Introduction: Decreased bone mineral density (BMD) is associated with fractures, among them, hip fractures consist a major socioeconomic problem. MRI-derived parameters of bone marrow blood perfusion are decreased in osteoporotic subjects. We investigated the decrease of blood perfusion of proximal femur in patients with osteoponia and osteoporosis as it may influence the incidence and its consequent healing of hip fractures. Subjects and methods: There were 179 volunteers, including 39 females and 26 males with normal BMD; 47 females and 27 males
S67
with osteoponia; 34 females and 6 males with osteoporosis. The institutional ethics review board approved the study and signed consent was obtained. MRI was performed on a 1.5 T Philips scanner. For dynamic contrast enhanced MRI, images were obtained in a coronal plane aligned along the central portion of the proximal femur, using a short T1W gradient echo sequence. A total of 160 images were obtained at 540 msec/ acquisition after a bolus of Gd-DOTA (0.15 mmol/kg) at 2.5 mL/sec. ROIs separately encompassing the marrow cavity of the head, neck, shaft of proximal femur were drawn manually, and maximum enhancement (ME) and enhancement slope (ES) were derived. Results: MRI data showed femoral shaft was better perfused while femoral head had the less blood perfusion. In volunteers with normal BMD, ME of femoral head and femoral neck represent 26.5% and 83.5% of that of femoral shaft; ES of femoral head and femoral neck represent 28% and 91.1% of that of femoral shaft. In both osteoponia and osteoporosis patients, ME and ES decreased among the three femoral regions, and to the greater extent with the osteoporosis patients. Compared with normal BMD volunteers, femoral neck had the biggest percentage decrease in blood perfusion. Specifically, in osteoponia patients, ME and ES decreased 16.2% and 25.3% for femoral head, 37.7% and 38.7% for femoral neck, and 19.5% and 5.1% for femoral shaft. In osteoporosis patients, ME and ES decreased 34.5% and 48.3% for femoral head, 52.3% and 53.8% for femoral neck, and 41.5% and 31.9% for femoral shaft. Conclusion: A disparate decrease of blood perfusion among femoral head, neck and shaft in patients with decreased bone mineral density was observed, with femoral neck demonstrating the biggest percentage decrease in blood perfusion associated with BMD decrease. doi:10.1016/j.bone.2008.08.081
A80 Physical determinants of three dimensional femoral neck structure and strength in older postmenopausal women Richard Prince 1, Kun Zhu 2, Marie Pollock 1, Vincent Low 3 1 School of Medicine and Pharmacology, University of Western Australia, Perth, Australia 2 Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Perth, Australia 3 Department of Radiology, Sir Charles Gairdner Hospital, Perth, Australia Aims: Both height and weight are determinants of areal BMD. However, the relative importance of body mass and stature to true three dimensional bone structure and strength remains uncertain. This study examines the relationship between body mass and size to femoral neck (FN) structure measured using quantitative computed tomography (QCT) and the bone strength calculated from engineering principles. Methods: The study subjects were 186 women aged 73.6 ± 8.2 years. Potential physical determinants were height, weight and calf girth. Bone structure was measured by QCT (Phillips Brillance CT) with patients lying on top of the QCT Pro™ calibration phantom and analysed with Mindways QCT Pro software. Linear regression analysis of the determinants of FN structure and strength variables was undertaken using the independent variables age, height, weight and calf girth. Results: Both height and weight accounted for some of the variance of areal FN BMD (R2 Height 5.8%, Weight 5.8%, P b 0.01) but not true volumetric FN BMD although there were strong independent correlations of height and weight with FN mass (R2 Height 15.1%,
S68
ABSTRACTS / Bone 43 (2008) S38–S75
Weight 8.9%, P b 0.01) and volume (R2 Height 13.4%, Weight 6.7%, P b 0.01). In multiple regression the only significant predictor of total and trabecular FN cross-sectional bone area, related to bone strength in compression, was height accounting for 16% and 7.4% of the variation, respectively. Regarding FN section modulus, a measure of FN strength in bending, both in plane and out of plane measures were related to height at 19.7% and 16.3% of variation, respectively. Conclusions: These results show that in elderly postmenopausal women true three dimensional volumetric FN BMD is not related to body size. This is because although both FN mass and volume are body size dependent, this dependency is proportional and cancels out in the calculation of true BMD. However, FN bone strength in compression and vending is related to stature presumably because of the bone size dependency of these measurements.
doi:10.1016/j.bone.2008.08.082
A81 Peripheral quantitative computed tomography shows changes in radial bone structure in elderly women: A two year cohort study Simon Scott 1, Kun Zhu 2, Richard Prince 1 1 School of Medicine and Pharmacology, University of Western Australia, Perth, Australia 2 Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Perth, Australia Aims: Peripheral quantitative computed tomography (pQCT) is a powerful tool for examining bone structure as it allows 3D determination of bone size and therefore strength. This study aimed to examine the change in bone structure and strength as determined by pQCT in a cohort of 768 community-dwelling Australian women aged 80 ± 2.5 yr at baseline. Methods: Radial bone structure was measured at baseline and two years later at the 4% trabecular site using a XCT-2000 (Norland-Stratec, Germany) pQCT machine. 510 subjects had the structure measured at the 15% cortical site. SSI, measures of bone resistance to torsion (Polar) and bending (x and y direction) were computed. Results: At both sites there was a significant increase in bone volume, which in theory may increase bone strength, but a decrease in bone density associated with a fall in SSI. Total vBMD (mg/cm3)
Total Volume (mm3)
SSI Polar
SSI x
SSI y
4% radius Baseline 24 months Change %
296 ± 70 285 ± 70⁎⁎ -3.1 ± 0.4⁎⁎
283 ± 55 288 ± 65⁎⁎ +2.6 ± 0.6⁎⁎
194 ± 74 167 ± 76⁎⁎ -12 ± 1.0⁎⁎
106 ± 38 92 ± 40⁎⁎ -11.6 ± 1.0⁎⁎
128 ± 54 112 ± 55⁎⁎ -11.1 ± 1.1⁎⁎
15% radius Baseline 24 months Change %
642 ± 109 616 ± 114⁎⁎ -4.0 ± 0.3⁎⁎
117 ± 19 120 ± 22⁎⁎ +2.5 ± 0.4⁎⁎
218 ± 48 215 ± 50⁎⁎ -1.4 ± 0.4⁎⁎
108 ± 24 107 ± 25⁎ -0.8 ± 0.7⁎
147 ± 34 145 ± 35⁎⁎ -1.2 ± 0.4⁎⁎
⁎ P b 0.01cf baseline; ⁎⁎ P b 0.001cf baseline.
Conclusions: The study of radial bone structure by pQCT demonstrates that although the bone has become larger, the type of changes after only two years have made the bone weaker.
doi:10.1016/j.bone.2008.08.083
A83 Effectiveness of lifestyle intervention on BMD in postmenopausal osteopenia women Hua Lin, Xin Chen, Xiu-feng Zhu The Center of Research for Metabolic Bone Disease, The Affiliated Drum Tower Hospital of Medical School, Nanjing University, Nanjing, China Objective: The purpose of this study was to evaluate the clinical effectiveness of lifestyle intervention on BMD in postmenopausal osteopenia women. Methods: Two hundred and forty postmenopausal osteopenia women aged 48–65 years were randomly divided into two groups: Group A—lifestyle intervention, that includes healthy and balanced diet, exposure to sunlight (30m-2h/d, and more than 8h/w), and respect to physical fitness (30m-1h/d, and more than 3-5times/w). All participants were received calcium 600 mg and VitD 125IU daily. Group B—non-intervention controls. During one year of intervention, Bone mineral density (BMD) was measured by DXA on lumbar spine and proximal femur at pre- intervention, 6 months and 12months after intervention. Results: After 6 months of intervention, There are no significant difference of BMD in two groups, but the changes of BMD on lumbar spine has significant difference between two groups (0.010 ± 0.033/-0.008 ± 0.041, p = 0.0439). After 12 months of intervention. There is a significant difference of BMD on lumbar spine in two groups (0.890 ±0.142 g/cm2/0.855 ± 0.138 g/cm2, p = 0.0459), and a significant difference of the changes of BMD on lumbar spine (0.025 ± 0.069/-0.003± 0.095, p = 0.0016) and total hip (0.015 ± 0.105/-0.004 ± 0.096, p = 0.0217) in two groups. Conclusions: Over a period of 1 year lifestyle intervention includes healthy and balanced diet, calcium and vitamin D supplementation, exposure to sunlight, and respect to physical fitness is successful to maintain bone mineral density at the spine and hip in postmenopausal osteopenia women. doi:10.1016/j.bone.2008.08.085
A84 The use of Micro Ct in osteoporosis Banu Kalpakcioglu Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey Osteoporosis can be defined as a metabolic disorder characterized by a loss of bone mineral and characterized by the occurrence of atraumatic fractures of the vertebrae, fall-related hip fractures, and Colles fractures of the distal radius. It is characterized by low bone mass and deterioration of skeletal architecture causing increased bone fragility .Based on this definition bone mineral density (BMD) as assessed by dual energy x-ray absorptometry and based on T-scores provide the operational definition of osteoporosis as a gold standard. But, as BMD is assessed as a key component of osteoporosis diagnosis and assessment, it is being realized that BMD alone has a poor sensitivity. Both BMC and BMD, as measured by areal projectional techniques, such as DXA, are strongly influenced by body size, and populations of smaller frame, such as those in the Far East and Africa, have lower bone mineral values than Western populations but do not have higher rates of osteoporotic fracture . Although currently DXA is the gold standard for diagnosis many studies indicate that BMD only partly explains bone strength.There is only a modest relationship between change in bone mass in the individual and reduction of fracture risk. There are numerous methods of noninvasive and/or nondestructive techniques that can provide structural information about bone, beyond simple bone densitometry. Assessment of macro-
A78 Is regular table tennis activity associated with increased bone and muscle strength and improved balance in older Asian men and women Lan Li 1, John Wark 1, Keith Hill 2, Peter Wong 3, Nigel Kwok 1 1 Department of Medicine, RMH, The University of Melbourne, Parkville, Victoria, Australia 2 Prevention and Public Health Division, NARI, The University of Melbourne, Parkville, Victoria, Australia 3 Department of Rheumatology, RMH, The University of Melbourne, Parkville, Victoria, Australia Background: Physical activity programs benefit bone health and lower falls risk in the elderly. However, there are no published studies of the effects of table tennis (TT) on fracture risk. Aims: To investigate the association of regular TT(N1 hour/week for over 1 year) in older Asian Australians with measures of fracture risk, by comparing areal bone mineral density(aBMD), bone geometry and strength, lower limb strength and balance function, comparing TT players with non- players. Methods: 77 healthy ambulatory men and women of Chinese descent, living in Melbourne, age 50-80y, were recruited. ABMD was measured at the femoral neck(FN), total hip(TH), lumbar spine(LS) and distal 1/3 radius(FA) [cross-sectional independent t-test was used, and results adjusted for age, height and weight]; and peripheral quantitative computed tomography(pQCT) of both forearms(4%,30% sites) and tibia(4%,33% sites). Validated tests of balance and strength were performed: Kinetic Communicator dynamometer (KIN-COM), Nicholas Manual Muscle Tester(NMMT). Chattecx Balance System (CBS), Neurocom and Lord's balance test(LBT)(for postural stability). Results: Significant mean differences in adjusted aBMD were seen: for TT-player (n = 45) vs non-TT-players (n = 32), FN: +0.052 g/cm2, p = 0.003, TH: +0.057 g/cm2, p = 0.006 and LS: +0.084 g/cm2, p = 0.007. There was no significant FA difference between players and nonplayers. The mean cortical area of distal 33% radius in players' dominant arm was 3.2 ± 3.5 mm2 (p = 0.007)greater than their nondominant arm. Isometric knee extensor and hip abductor strength was 44 ± 44 Nm (p = 0.03) and 1.42 ± 1.58 kg (p = 0.048) greater among TT players in 11 matched player/non-player pairs. Conclusion: TT players had significantly greater adjusted aBMD than non-players at clinically-relevant sites, which may reduce fracture risk in this population. Prospective studies of the skeletal benefits of table tennis are warranted. doi:10.1016/j.bone.2008.08.080
A79 Disparate decrease of blood perfusion among femoral head, femoral neck and femoral shaft in patients with decreased bone mineral density Yi-Xiang Wang, James F. Griffith, Anthony Kwok, David K.W. Yeung, Jason Leung, Heather T. Ma, Ping Chung Leung The Chinese University of Hong Kong, HK, China Introduction: Decreased bone mineral density (BMD) is associated with fractures, among them, hip fractures consist a major socioeconomic problem. MRI-derived parameters of bone marrow blood perfusion are decreased in osteoporotic subjects. We investigated the decrease of blood perfusion of proximal femur in patients with osteoponia and osteoporosis as it may influence the incidence and its consequent healing of hip fractures. Subjects and methods: There were 179 volunteers, including 39 females and 26 males with normal BMD; 47 females and 27 males
S67
with osteoponia; 34 females and 6 males with osteoporosis. The institutional ethics review board approved the study and signed consent was obtained. MRI was performed on a 1.5 T Philips scanner. For dynamic contrast enhanced MRI, images were obtained in a coronal plane aligned along the central portion of the proximal femur, using a short T1W gradient echo sequence. A total of 160 images were obtained at 540 msec/ acquisition after a bolus of Gd-DOTA (0.15 mmol/kg) at 2.5 mL/sec. ROIs separately encompassing the marrow cavity of the head, neck, shaft of proximal femur were drawn manually, and maximum enhancement (ME) and enhancement slope (ES) were derived. Results: MRI data showed femoral shaft was better perfused while femoral head had the less blood perfusion. In volunteers with normal BMD, ME of femoral head and femoral neck represent 26.5% and 83.5% of that of femoral shaft; ES of femoral head and femoral neck represent 28% and 91.1% of that of femoral shaft. In both osteoponia and osteoporosis patients, ME and ES decreased among the three femoral regions, and to the greater extent with the osteoporosis patients. Compared with normal BMD volunteers, femoral neck had the biggest percentage decrease in blood perfusion. Specifically, in osteoponia patients, ME and ES decreased 16.2% and 25.3% for femoral head, 37.7% and 38.7% for femoral neck, and 19.5% and 5.1% for femoral shaft. In osteoporosis patients, ME and ES decreased 34.5% and 48.3% for femoral head, 52.3% and 53.8% for femoral neck, and 41.5% and 31.9% for femoral shaft. Conclusion: A disparate decrease of blood perfusion among femoral head, neck and shaft in patients with decreased bone mineral density was observed, with femoral neck demonstrating the biggest percentage decrease in blood perfusion associated with BMD decrease. doi:10.1016/j.bone.2008.08.081
A80 Physical determinants of three dimensional femoral neck structure and strength in older postmenopausal women Richard Prince 1, Kun Zhu 2, Marie Pollock 1, Vincent Low 3 1 School of Medicine and Pharmacology, University of Western Australia, Perth, Australia 2 Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Perth, Australia 3 Department of Radiology, Sir Charles Gairdner Hospital, Perth, Australia Aims: Both height and weight are determinants of areal BMD. However, the relative importance of body mass and stature to true three dimensional bone structure and strength remains uncertain. This study examines the relationship between body mass and size to femoral neck (FN) structure measured using quantitative computed tomography (QCT) and the bone strength calculated from engineering principles. Methods: The study subjects were 186 women aged 73.6 ± 8.2 years. Potential physical determinants were height, weight and calf girth. Bone structure was measured by QCT (Phillips Brillance CT) with patients lying on top of the QCT Pro™ calibration phantom and analysed with Mindways QCT Pro software. Linear regression analysis of the determinants of FN structure and strength variables was undertaken using the independent variables age, height, weight and calf girth. Results: Both height and weight accounted for some of the variance of areal FN BMD (R2 Height 5.8%, Weight 5.8%, P b 0.01) but not true volumetric FN BMD although there were strong independent correlations of height and weight with FN mass (R2 Height 15.1%,
S68
ABSTRACTS / Bone 43 (2008) S38–S75
Weight 8.9%, P b 0.01) and volume (R2 Height 13.4%, Weight 6.7%, P b 0.01). In multiple regression the only significant predictor of total and trabecular FN cross-sectional bone area, related to bone strength in compression, was height accounting for 16% and 7.4% of the variation, respectively. Regarding FN section modulus, a measure of FN strength in bending, both in plane and out of plane measures were related to height at 19.7% and 16.3% of variation, respectively. Conclusions: These results show that in elderly postmenopausal women true three dimensional volumetric FN BMD is not related to body size. This is because although both FN mass and volume are body size dependent, this dependency is proportional and cancels out in the calculation of true BMD. However, FN bone strength in compression and vending is related to stature presumably because of the bone size dependency of these measurements.
doi:10.1016/j.bone.2008.08.082
A81 Peripheral quantitative computed tomography shows changes in radial bone structure in elderly women: A two year cohort study Simon Scott 1, Kun Zhu 2, Richard Prince 1 1 School of Medicine and Pharmacology, University of Western Australia, Perth, Australia 2 Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Perth, Australia Aims: Peripheral quantitative computed tomography (pQCT) is a powerful tool for examining bone structure as it allows 3D determination of bone size and therefore strength. This study aimed to examine the change in bone structure and strength as determined by pQCT in a cohort of 768 community-dwelling Australian women aged 80 ± 2.5 yr at baseline. Methods: Radial bone structure was measured at baseline and two years later at the 4% trabecular site using a XCT-2000 (Norland-Stratec, Germany) pQCT machine. 510 subjects had the structure measured at the 15% cortical site. SSI, measures of bone resistance to torsion (Polar) and bending (x and y direction) were computed. Results: At both sites there was a significant increase in bone volume, which in theory may increase bone strength, but a decrease in bone density associated with a fall in SSI. Total vBMD (mg/cm3)
Total Volume (mm3)
SSI Polar
SSI x
SSI y
4% radius Baseline 24 months Change %
296 ± 70 285 ± 70⁎⁎ -3.1 ± 0.4⁎⁎
283 ± 55 288 ± 65⁎⁎ +2.6 ± 0.6⁎⁎
194 ± 74 167 ± 76⁎⁎ -12 ± 1.0⁎⁎
106 ± 38 92 ± 40⁎⁎ -11.6 ± 1.0⁎⁎
128 ± 54 112 ± 55⁎⁎ -11.1 ± 1.1⁎⁎
15% radius Baseline 24 months Change %
642 ± 109 616 ± 114⁎⁎ -4.0 ± 0.3⁎⁎
117 ± 19 120 ± 22⁎⁎ +2.5 ± 0.4⁎⁎
218 ± 48 215 ± 50⁎⁎ -1.4 ± 0.4⁎⁎
108 ± 24 107 ± 25⁎ -0.8 ± 0.7⁎
147 ± 34 145 ± 35⁎⁎ -1.2 ± 0.4⁎⁎
⁎ P b 0.01cf baseline; ⁎⁎ P b 0.001cf baseline.
Conclusions: The study of radial bone structure by pQCT demonstrates that although the bone has become larger, the type of changes after only two years have made the bone weaker.
doi:10.1016/j.bone.2008.08.083
A83 Effectiveness of lifestyle intervention on BMD in postmenopausal osteopenia women Hua Lin, Xin Chen, Xiu-feng Zhu The Center of Research for Metabolic Bone Disease, The Affiliated Drum Tower Hospital of Medical School, Nanjing University, Nanjing, China Objective: The purpose of this study was to evaluate the clinical effectiveness of lifestyle intervention on BMD in postmenopausal osteopenia women. Methods: Two hundred and forty postmenopausal osteopenia women aged 48–65 years were randomly divided into two groups: Group A—lifestyle intervention, that includes healthy and balanced diet, exposure to sunlight (30m-2h/d, and more than 8h/w), and respect to physical fitness (30m-1h/d, and more than 3-5times/w). All participants were received calcium 600 mg and VitD 125IU daily. Group B—non-intervention controls. During one year of intervention, Bone mineral density (BMD) was measured by DXA on lumbar spine and proximal femur at pre- intervention, 6 months and 12months after intervention. Results: After 6 months of intervention, There are no significant difference of BMD in two groups, but the changes of BMD on lumbar spine has significant difference between two groups (0.010 ± 0.033/-0.008 ± 0.041, p = 0.0439). After 12 months of intervention. There is a significant difference of BMD on lumbar spine in two groups (0.890 ±0.142 g/cm2/0.855 ± 0.138 g/cm2, p = 0.0459), and a significant difference of the changes of BMD on lumbar spine (0.025 ± 0.069/-0.003± 0.095, p = 0.0016) and total hip (0.015 ± 0.105/-0.004 ± 0.096, p = 0.0217) in two groups. Conclusions: Over a period of 1 year lifestyle intervention includes healthy and balanced diet, calcium and vitamin D supplementation, exposure to sunlight, and respect to physical fitness is successful to maintain bone mineral density at the spine and hip in postmenopausal osteopenia women. doi:10.1016/j.bone.2008.08.085
A84 The use of Micro Ct in osteoporosis Banu Kalpakcioglu Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey Osteoporosis can be defined as a metabolic disorder characterized by a loss of bone mineral and characterized by the occurrence of atraumatic fractures of the vertebrae, fall-related hip fractures, and Colles fractures of the distal radius. It is characterized by low bone mass and deterioration of skeletal architecture causing increased bone fragility .Based on this definition bone mineral density (BMD) as assessed by dual energy x-ray absorptometry and based on T-scores provide the operational definition of osteoporosis as a gold standard. But, as BMD is assessed as a key component of osteoporosis diagnosis and assessment, it is being realized that BMD alone has a poor sensitivity. Both BMC and BMD, as measured by areal projectional techniques, such as DXA, are strongly influenced by body size, and populations of smaller frame, such as those in the Far East and Africa, have lower bone mineral values than Western populations but do not have higher rates of osteoporotic fracture . Although currently DXA is the gold standard for diagnosis many studies indicate that BMD only partly explains bone strength.There is only a modest relationship between change in bone mass in the individual and reduction of fracture risk. There are numerous methods of noninvasive and/or nondestructive techniques that can provide structural information about bone, beyond simple bone densitometry. Assessment of macro-