title: Contribution of trochanteric soft tissues to fall force estimates, the factor of risk, and prediction of hip fracture risk.
abstract: We compared trochanteric soft tissue thickness, femoral aBMD, and the ratio of fall force to femoral strength (i.e., factor of risk) in 21 postmenopausal women with incident hip fracture and 42 age-matched controls. Reduced trochanteric soft tissue thickness, low femoral aBMD, and increased ratio of fall force to femoral strength (i.e., factor of risk) were associated with increased risk of hip fracture.
  
  
  BACKGROUND
  The contribution of trochanteric soft tissue thickness to hip fracture risk is incompletely understood. A biomechanical approach to assessing hip fracture risk that compares forces applied to the hip during a sideways fall to femoral strength may by improved by incorporating the force-attenuating effects of trochanteric soft tissues.
  
  
  METHODS
  We determined the relationship between femoral areal BMD (aBMD) and femoral failure load in 49 human cadaveric specimens, 53-99 yr of age. We compared femoral aBMD, trochanteric soft tissue thickness, and the ratio of fall forces to bone strength (i.e., the factor of risk for hip fracture, phi), before and after accounting for the force-attenuating properties of trochanteric soft tissue in 21 postmenopausal women with incident hip fracture and 42 age-matched controls.
  
  
  RESULTS
  Femoral aBMD correlated strongly with femoral failure load (r2 = 0.73-0.83). Age, height, and weight did not differ; however, women with hip fracture had lower total femur aBMD (OR = 2.06; 95% CI, 1.19-3.56) and trochanteric soft tissue thickness (OR = 1.82; 95% CI, 1.01, 3.31). Incorporation of trochanteric soft tissue thickness measurements reduced the estimates of fall forces by approximately 50%. After accounting for force-attenuating properties of trochanteric soft tissue, the ratio of fall forces to femoral strength was 50% higher in cases than controls (0.92 +/- 0.44 versus 0.65 +/- 0.50, respectively; p = 0.04).
  
  
  CONCLUSIONS
  It is possible to compute a biomechanically based estimate of hip fracture risk by combining estimates of femoral strength based on an empirical relationship between femoral aBMD and bone strength in cadaveric femora, along with estimates of loads applied to the hip during a sideways fall that account for thickness of trochanteric soft tissues. Our findings suggest that trochanteric soft tissue thickness may influence hip fracture risk by attenuating forces applied to the femur during a sideways fall and provide rationale for developing improved measurements of trochanteric soft tissue and for studying a larger cohort to determine whether trochanteric soft tissue thickness contributes to hip fracture risk independently of aBMD.
authors.affiliation: Orthopedic Biomechanics Laboratory, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts 02215, USA. mbouxsei@bidmc.harvard.edu
authors.forename: Mary L
authors.initials: ML
authors.lastname: Bouxsein
authors.forename: Pawel
authors.initials: P
authors.lastname: Szulc
authors.forename: Fracoise
authors.initials: F
authors.lastname: Munoz
authors.forename: Erica
authors.initials: E
authors.lastname: Thrall
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Sornay-Rendu
authors.forename: Pierre D
authors.initials: PD
authors.lastname: Delmas
mesh_terms: D000058:Accidental Falls; D000368:Aged; D000369:Aged, 80 and over; D001696:Biomechanical Phenomena; D001835:Body Weight; D015519:Bone Density / Q000502:physiology; D005260:Female; D005269:Femur / Q000737:chemistry / Q000502:physiology; D005272:Femur Neck / Q000737:chemistry / Q000293:injuries; D006620:Hip Fractures / Q000209:etiology* / Q000378:metabolism / Q000503:physiopathology; D006801:Humans; D016015:Logistic Models; D010384:Pelvic Bones / Q000737:chemistry / Q000293:injuries; D017698:Postmenopause; D018570:Risk Assessment / Q000379:methods; D012307:Risk Factors; D012737:Sex Factors; D013314:Stress, Mechanical; D013848:Thigh / Q000033:anatomy & histology*; D014947:Wounds and Injuries / Q000150:complications