Bone, 14, 231-242, (1993) 8756-3282193 $6.00 + .

OO
Printed in the USA. All rights reserved. Copyright 0 1993 Pergamon Press Ltd.

STRUCTURAL AND CELLULAR ASSESSMENT OF

BONE QUALITY OF PROXIMAL FEMUR

Lawrence D. Dorr, MD*, Marie-Claude Faugere, MD**, Audley M. Mackel, MD***, Thomas
A. Gruen, MD* ***, Benedek Bognar, MD* * and Hartmut H. Malluche, MD* *
*The Center for Arthritis and Joint Implant Surge University of Southern California;
**Division of Nephrology, Bone and Mineral Metaboz ‘km, University of Kentucky;***11201
Shaker Blvd., Cleveland, Ohio; ****; Institute for Bone & Joint Disorders, Phoenix, AZ

INTRODUCIION
Bone quality of the femoral bone represents a major determinant in the choice of therapeutic
options and durability of total hip re lacement. Several x-ray classifi#ons have been proposed
to help in the assessment of trabecu Par and/or cortical bone quality. 3 Recently, it was shown
that bone quality is inadequately assessed by the two most common used roentgenogra hit
indices, i.e. the Smgh and Engh indices and it was postulated that iliac crest bone biopsies w! ich
provide information on the systemic (iliac) bone status, offer a more precise index of bone
quality.17 in a previous study we examined both systemic iliac) and local femoral) bone
abnormalities in patients undergoing total hip replacement. 4 Even though tI, ere was good
overall agreement between bone remodelhng activrties measured at th two sites, local changes
seemed to predict, somewhat better, patients at risk of complications. 2 Nonetheless, in all the
above mentioned approaches aimed at assessing bone quality, the shape of the proximal femoral
bone has not been taken into consideration. The purpose of the present study was (1) to
investigate whether different roentgenographic patterns of proximal femoral bones can be
identified and quantitatively validated takin into account shape and cortical thicknesses and if
so, (2) to reconcile those patterns with c!emographic characteristics, biochemical data and
histologic parameters of femoral bone structure and cellular activities.

PATIENTS AND MBTHODS

Patients: Fifty-two consecutive patients who underwent total hip replacement were enrolled in
the study after informed consent was obtained. All patients had climcal and roentgenographical
evidence of osteoarthritis. The mean age of the patients was 622 2 years (range 34-81 years).
There were 33 men and 19 women. Prior to surgery, radiographs of the pelvis with proximal
femur and Lauenstein laterals of the proximal femur were performed in all patrents for
qualitative and quantitative assessment of bone es. At time of surgery, blood samples were
drawn for determination of serum calcium parat!i? oid hormone and 1,25(OH)2D and femoral
bone samples were obtained for mineralized bone l7istology and histomorphometry.
Roentgenographic evaluation: The roentgenographic evaluation was performed on antero-
ostenor radiogra hs of the pelvis which include the proximal l/3 to l/2 of the femur and
& uenstein later ap views. All radiographs were reviewed without prior knowled e of the
patient’s clinical status. The thickness and shape of the medial, lateral, anterior an d posterior
cortices were assessed both qualitatively and quantitatively. Qualitative examinations of all the
patients’ x-rays were independently performed by two observers twice. Roentgen0 raphic
measurements were done using a digitizing tablet interfaced with an IBM-PC mo f el AT
computer (IBM Corp., Armok, NY) through the RS 232 serial port. The program was written in
C-programming language and a cursor was used to pick the points at desired locations. Although
the measurements can be made manually, the use of a computerized method allows a gain in
time and precision. The following parameters were measured and calculated (Figure 1).
231
232 L. D. Dorr et al.: Bone quality of proximal femur

(a) The cortical index: A reference line through the mid lesser trochanter and perpendicular to
the long axis of the femur was first delineated. A second line arallel to the reference line was
then drawn 10 cm below. Intercept points were identified at tEe endosteal (x-x) and periosteal
(z-z) surfaces at this level (Figure 1). The intramedullary canal diameter (the distance between
the two endosteal points x-x, MD) was measured as well as the femoral diaphyseal diameter (the
distance between the two periosteal intercepts z-z, FD). The cortical index (CI) was calculated
as the ratio of the femoral dia hyseal diameter minus the intramedullary canal diameter over the
femoral diaphyseal diameter PCI =FD-MD/FD). the cortical index reflects, thus, the thickness of
cortical bone at this level. A high cortical ratio indicates a thick bone. Calculations of the
medio-lateral and antero-posterior cortical indices were done from measurements obtained from
antero-posterior and Lauenstein lateral views respectively.
(b) The canal to calcar isthmus ratio (CC ratio): This measurement was determined on the
antero-posterior radiogra h. The CC ratio was calculated as the fraction of the intramedullary
canal isthmus over the caPcar isthmus dimension. A reference line representing the level of the
calcar isthmus was drawn from the apex of the lesser trochanter. Two points on the endosteal
margin of the femur are identified 3 cm below the reference line (mid-lesser trochanteric line).
From roentgenographic and cadaver analysis, the 3 cm point was chosen since we found it to be
the most surtable for determination of the proximal endosteal surface. Lines joining the distal
(10 cm) and proximal (3 cm) endosteal points (Figure 1) were drawn on the lateral and medial
side. These two longitudinal lines intercept the mid-lesser trochanteric line at two points; the
distance between these two points represents the proximal (metaphyseal) calcar isthmus
diameter. The CC ratio is therefore a measure of the relative size at two levels of the proximal
femur. A small ratio indicates a large calcar isthmus relative to the diaphyseal intramedullary
canal, resultin in a funnel shaped proximal femur. With a widening distal intramedullar canal,
the ratio is higa er and the femur becomes more cylindrical.

Bone Biopsy and Histomophometry:

Bone biopsies were obtained at the time of total hip replacement from the mid posterior neck
just proximal to the intertrochanteric ridge.

f
Tetracycline double-labelling was given to all patients rior to the biopsy.10 This was done with
a ten day interval between oral doses of tetracyc ine (500 mg t.i.d. for four days) and
DeclomycinR (300 mg t.i.d. for two days). Biopsies were taken with an electric drill of five
millimeter inner diameter.8

All bone samples were recessed undecalcified. After ethanol fixation, they were dehydrated
and embedded in methy Pmethacrylate. Three micrometer and seven micrometer-thick sections
were cut using a Reichert-Jung microtome (Model 1140; Buffalo, NY). The three micrometer-
thick sections were stained usin the modified Masson-Goldner stainfi which allowed good
discrimination between calcified \ one and osteoid and gives excellent cellular detail.10 Seven
micrometer-thick unstained sections were pre ared fro phase contrast and fluorescent light
microscopy. Static and dynamic parameters oP bone structure, formation and resorption were
evaluated using the Osteoplan II System (Zeiss; Thornwood, NY)12 This semi-automatic
technique uses a Zeiss universal microscope (Zeiss; Thornwood, NY) and printer (Data Plus,
Data Products; Woodhill, CA). The measurements are performed by counting bone cells and
tracing lengths of individual features and circuiting areas. As each histologic structure is
measured, rts image is transferred to the printer, which documents all measurements. The
obtained data are stored on a disc and calculation of three-dimensional static and d amic
parameters of bone structure, formation, and resorption are made by the computer from tK” e two-
dimensional measured histologic features.
The following histomorphometric parameters of bone in the femur were evaluated:

a) Cortical thickness (mm).

b) Cortical porosi (%).
c) Wall thickness m , i.e. mean thickness of a completed osteon.
d) Osteoid surface (% , i.e. percentage of cortical or Haversian surface covered by osteoid.
L. D. Dorr et al.: Bone quality of proximal femur 233

e) Osteoid thickness @m).

f) Osteoblast surface (%), i.e., the percentage of cortical surface covered by active
osteoblasts.
g) Osteoblast number (#/lo0 mm), i.e. the number of osteoblasts per 100 mm cortical
boundary length.
h) Erosion surface (%), i.e. percentage of cortical Haversian surface exhibiting erosion
lacunae with or without osteoclasts.
Osteoclast surface (%), i.e. percentage of cortical surface covered by osteoclasts.
J*j Osteoclast number (#/lo0 mm), i.e. the number of osteoclasts per 100 mm cortical or
Haversian canals boundary len h.
k) Mineral apposition rate @rn Pday), i.e. mean distance between double labels/days of
labelling free interval.
1) Osteoid maturation time (Omt, days).
m) Formation period (FP, days).

All parameters comply with the nomenclature and according to the ASBMR histomorphometry
nomenclature committee.lT
Serum Biochemistry: Serum calcium was measured by atomic absorption spectrophotometry
(Model 5000, Perkin-Elmer Corp.; Norwalk, CT). Serum levels of parathyrold hormone were
measured by radioimmunoassa reco ‘zing the N-Terminal fragment (Nicholas Institute; San
Juan Capistrano, CA) and 1,2P(OH2 K was measured by high pressure liquid chromatography
(HPLC) (Nichols Institute, San Juan Capistrano, CA).

Statistical Analysis: Statistical evaluation for differences between groups was done using
anal sis of variance and subsequent Duncan’s multiple range test with an overall test significance
leve Yof 5%. Student’s t-test was performed to evaluate differences between men and women.
For cate o&al variables (i.e. bone type, sex), the statistical significance of associations was
evaluate d: using the Chi-square test. Regression analyses were performed and correlation
coefficients were calculated. Stepwise multiple linear regression analysis was used to determine
factors associated with the bone typin . All computations were erformed with SPSS+ Software
Package, (SPSS V3.0, Inc.; Chicago, I&) em loymg an IBM-PS K ode1 60 computer (IBM Corp.
Armock, NY). Results are given as mean vaPues f standard error of the mean.

RESULTS

Roentgenographic evaluation:
Qualitative Assessment: Three distinct patterns of shape and bone structure of the femur were
qualitatively identified from roentgenographs between the metaphysis and the dia hyseal
isthmus. In classifying the x-rays, the inter-observer variation was less than 20% at tKe first
reading and less than 5% at the second viewing. The inter-observer variation was less than 5%.
The three groups were labelled as Type A, B, and C.
Type A bone (Figure 2) has thick cortices seen on the anterior-posterior radiograph and a large
posterior cortex seen on the lateral view. The medial and posterior cortices begin at the distal
end of the lesser trochanter and immediate1 are quite thick. They create a narrow diaphyseal
canal. Thick dia hyseal cortices also pro (ruce a funnel shape to the proximal femur. The
cortical bone has a istinct edges and the roentgenographic appearance is dense.
Type B (Figure 3a, 6) exhibits bone loss from the medial and especially posterior cortices. The
most proximal portion of the posterior cortex is thinned or absent which accounts for an
increased width of the intramedullary canal. The posterior endosteal surface is irregular and
niay be scalloped or show striations (Figure 3b, c).
Type C bone (figure 4a, 6) has virtually lost the medial and posterior cortices. The anterior and

R
osterior cortices may also be dramatically thinned so that the bone on the lateral radiograph
as a fuzzy appearance. The intramedullary canal diameter is usually very Hrlde on the lateral
radiographs and, thus, Type C bone is best differentiated from Type B on the lateral radiographs.
234 L. D. Dorr et al.: Bone quality of proximal femur

Quantitative Results: Measurements of the medio-lateral and antero-posterior cortical indices

were statistically significantly different between the three types ~~0.01) (Table 1). Cortical
indices were higher in Type A than Type B and hi er in Type B th an in Type C (Table 1). The
canal to calcar ratio (CC ratio) was si ‘ficantpy lower in Type A than Type C (p ~0.05).
However, Type B was not significantly dif!m erent from Types A and C (Table 1).

In addition, when all patients were considered together, the medio-lateral cortical index was
si ‘ficantly greater than the antero-posterior corncal index @<O.OOl). This was also found
wEmen men and women were analyzed separately. The antero-posterior cortical index was greater
in men than women (p c O.Ol), but no difference was observed between sex for the values of the
medio-lateral cortical index or the CC ratio. The cortical indices on the lateral and antero-
posterior views were positively correlated (r =0.78, p < 0.0001). There was a negative relationship
between CC ratio and medio-lateral (r =-0.56, p < 0.001) and antero-posterior cortical index (r = -
0.48, p < 0.002).
Clinical results: The demo raphic results are listed in Table 2. There was no difference in
prevalence of Type A (36.5%‘I, Type B (32.7%) and Type C (30.8%) among the patients studied.
However, the dtstribution of bone type between men and women was statistically different
(p < 0.005 : 90% of Type A patients were men, 65% of Type B and 30% of Type C. Analysis of
variance t)or all bone types revealed that patients with Type C were significantly older than those
with Type A(p ~0.05). This was also found when men and women were analyzed separately.
Overall, women were significantly older than men (p < 0.002).
Patients with Type A bone (both men and women) were heavier than patients with Type B or C
(p < O.OOS),and, as expected, men were heavier than women (p ~0.001).

Serum Biochemistry (Table 3): Results of serum calcium parathyroid hormone and
1,25(OH)2D were in the normal range. There were no statistically significant differences in any
of the measured biochemical parameters between the three bone types.
Histomorphometry Results (Table 4) :Cortical thickness was significantly different between the
~0.05). Patients from T e A had thicker cortices than those from Type B
patients from Type B exhirpited significant higher values than patients from Type
C (p < 0.05, Figure 5). Cortical porosity was si ‘ficantly higher in Type B bone than in A or C
er in cortical porosity. The mean wall thickness
(p < 0.05, Figure 6). Types A and C did not di Eni
of corn leted osteons was smaller in Type C than in Type A. Osteoid volume, osteoid surface,
osteob Past surface, osteoblast number as well as osteoclast surface and number of osteoclasts
were significantly higher in Type C bone than in A and B bone (pcO.0). No difference in the
latter parameters, indicative of bone turnover as seen between Type A and B. There was a trend
toward a lower mineral apposition rate in Type C, but this did not reach statistical significance.
However, the mean formation period of osteons was significantly prolonged in Type C compared
to A and B bone (~~0.05). There was no difference in osteoid thickness and osteon maturation
time between the various types of bone.
When all patients were considered together, there were positive relationships between cortical
thickness measured by histomorphomet and the medio-lateral and antero-posterior cortical
indices and osteoid surface (~~0.05r as well as cortical thickness calculated from
roentgenographic measurements (r = 0.58, p c 0.001 and r = 0.48, p c 0.01) respectively.
DISCUSSION
The present results allow the proposal of a new classification of bone changes of the proximal
femur identified on roentgenographs and validated by histomorphometry.
Type A bone is found more frequently in men than in women and more often in younger and
heavier patients. The histologic signs of thicker cortices and less porosity are in good agreement
with the x-ray findin of lower CC ratio and higher cortical indices. Histologically no evidence
of osteoblastic insu 8”iciency is seen. Type A bone has radiologically a good structural funnel
shape and narrow lateral diaphyseal canal isthmus which permits good fixation with a cemented
L. D. Dorr et al.: Bone quality of proximal femur 235

or noncemented femoral stem.

Type B bone is also more prevalent in men than in women. It is histologically characterized by
thinner cortices than Type A bone. Cortical porosity is highest in Type B bone and this active
resorption is reflected in the irregular endosteal surface. Type B bone shows loss from the
proximal cortex of bone, as shown by the relatively higher intramedullary canal diameter and
cortical index on the lateral radiograph. As documented by minor changes in the CC ratio, the
funnel shape of the canal remains good so that implant fixation is not a problem.

Type C bone is found predominantly in women of older ages and lower body weight. It has both
structural and cellular compromise. Cortices are thin with corn lete loss of the medial and
posterior cortices resulting in a “stovepipe”13 shape of the intrame Bullary canal. The statistically
significant decrease in cortical indices, and the increase in CC ration reflects these structural
changes.

These structural changes, in combination with cellular abnormalities created a less favorable
environment for implant fixation. Furthermore, these bone changes could hinder internal
fixation and healing of a femoral neck fracture. The high osteoid volume, osteoid surface, bone
osteoblast and bone osteoclast interface as well as high numbers of bone forming and resorbing
cells in combination with the prolonged mean formation period of osteons 1s indicative of
cellular insufficiency. This combination of increase bone cell number with a decrease in activity
is also seen in the postmenopausal state and in experimental animals with cessation of ovarian
fnnction.6s11 It might be related to the fact that this group comprises mainly older
postmenopausal women. Type C bone has the thinnest cortical thickness but less porosity than
.
group B. This indicates that cortical cancellization resulting in porosity takes place at the inner
FX
cortical surface and progresses towards the peri he Once a major portion of the cortex has
been resorbed this process appears to cease and ew t in less porous outer lamellae remain.
The implications of this bone typing of the proximal bone morphology include both research and
clinical a lication. The low incidence of osteopenia associated with osteoarthritis7 is not
supporte 8 y previous and present studies. We have previously reported that in a series of 97
patients undergoin total high replacement for arthritis, all the patients exhibited osteopenia on
iliac crest biopsies 8. The present study shows that striking structural with or without cellular
signs of femoral osteopenia were seen in close to two-thirds of the patients.
Clinically, the analysis of the outcome of patients under oing total hip arthroplasty, using a give3
device, could benefit from evaluating the results actor c!ing to the proposed bone typing. Engh
has reported that the results of bone ingrowth total hip replacements are less favorable in
women over 60 years of age, which correspond to the Type C population. Ruthjen, et al,
evaluated the results of the PCA hip stem (Porous Coated Anoticrm, Howmedica, Rutherford,
NJ) and found no correlation to bone type. 15 This series had only three patients with type C
bone. Faris and his colleagues reported on bone remodelling changes of a bone ingrowth stem
and found no correlation to bone types. 5 This stud was of only one year; results and definitive
bone remodelling changes are not apparent at this sBort follow-up time.133
We observed statistically significant relationships of bone type to thigh ain up to two years,
prosthetic fill in the bone, the incidence of radiolucent lines of both tKe stem and cup and
adaptive bone remodelling.1 At four years the clinical results were equal between all bone types.
This stud was of one hundred consecutive APR (Anatomic Porous Replacement, Intermedics
Orthope Bits, Austin, Texas) total hip arthroplasties followed for four years. Thirty-ei ht hips
were Type A bone, forty-three Type B and nmeteen Type C. We suggest that the inci j ence of
prolonged thigh pain, adaptive bone remodelling, and less dense rosthetic support seen in T e
C bone reflects a prolonged healing time caused by the altere B cellular characteristics of ylY t is
bone. Our results show that patients with T e C bone will have clinical results equal to patients
with Type A or B bone but will require as Pong as two years to do this. We believe that future
use of bone es in long-term follow-up of arthroplasty results will help characterize results just
as separation?Yy patient factors such as weight, act&y levels and disease have in the past.
236 L. D. DOIT et al.: Bone quality of proximal femur

Table 1
Roentgenographic measurements in 52 osteoarthritic patients with different
roentgenographic bone types.

TYPE A TYPE B TYPE C

Medio-lateral cortical 0.58 lr O.OIA** 0.50 + o.oB 0.42 k 0.01’

index*(AP X-ray)

Anterior-posterior 0.48 + O.OiA 0.39 + O.OIB 0.30 + o.02c

cortical index
(lateral X-ray)

Canal to Calcar ratio 0.57 k 0.02A 0.59 ?I 0.02AB 0.64 + 0.02’

t
Results are given as mean f SEM.
**
Results with the same letter are not statistically different.

Table 2
Demographic results in 52 osteoarthritic patients with different
roentgenographic bone types.

TYPE A TYPE B TYPE C TOTAL

Number of patients

Men 17 11 5 33
Women 2 6 11 19
Total 19 17 16 52

Age (years)*

Men 53 ? 2A** 60 + 3AB 69 2 3’ 58 2 2’

Women 57 k 7A 64 + qAB 71 If: 28 67 2 2
Total 54 2 2A 62 k 3AB 704 lB 62 + 2

Body Weight (lb)*

Men 216 + 7A 185 + 8’ 183 + 5’ 201 f 5’

Women 223 + 18A 167 + 15’ 146 2 7’ 161 + 8
Total 217 + 7A 178 f 8’ 158 f 7B 186 -e 5

* Results are given as mean 2 SEM

** Results with the same letter are not statistically different.
’ Difference between men and women (~~0.05).
L. D. Dorr et al.: Bone quality of proximal femur 231

Table 3
Serum biochemical results in 52 osteoarthritic patients with
different roentgenographic bone types

TYPE A TYPE 6 TYPE C Normal Ranae

Calcium (mg/dl)* 9.5 t O.l*** 9.2 + 0.2* 9.7 -c O.l* 8.8 - 10.2

1,25 (OH)2D 22 ?I 2* 25 + 3* 28 + 2* 15-60

(pg/ml)

Parathyroid hormone 15 f 1* 16 + l* 17 + iA 8 - 24
(pg/ml)

* Results are given as mean + SEM.

** Results with the same letter are not statistically different.

Table 4
Histomorphometric results in 52 osteoarthritic patients with different
roentgenographic bone types

TYPE A TYPE I3 TYPE C

Cortical Thickness (mm)’ 1.70 + 0.29*** 0.95 + o.loB 0.50 2 o.08c

Cortical Porosity (%) 11.5 + 2.31A 25.7 2 3.82’ 14.3 + 2.35*
Wall Thickness @m) 112 ? 14* 96 2 13AB 70 + 8’
Osteoid Volume/Bone Volume 4.56 2 1.82* 6.57 2 1.95* 8.59 + 1.82B
(mm3/cm3)
Osteoid Surface/Bone Volume 8.81 f 1.13 14.52 + 2.76AB 22.97 + 4x8
(%)
Osteoid Thickness (Crm) 10.1 + 1.34* 9.72 f 1.18* 7.65 + 0.91*
Osteoblast Surface/Bone 1.54 4 0.13* 1.19 f o.29AB 1.57 f o.4gB
Surface (%)
Total Resorption Lacunae (%) 4.18 + 0.82* 9.04 f 2.38* 9.29 + 2.76*
Osteoclast Number (#/l OOmm) 17.6 f 5.73* 23.7 + 6.00* 66.2 + 19.6B
Mineral apposition rate @m/d) 0.86 + 0.18* 0.87 2 0.12* 0.74 f 0.17*
Osteoid maturation time (days) 14.81 + 2.66* 12.19 r 1.38* 18.52 f 6.33*
Formation period (davs) 173 * 37* 120 f 18* 231 r 93’
l

Results are given as mean + SEM.

l *
Results with the same letter are not statistically different.
238 L. D. Don et al.: Bone quality of proximal femur

REFERENCES

1. Dorr, L.D., et al. Seminars in Arthroplasty 1990 1:77-86, 1990.

Dorr, L.D., et al. Clin. Orthop. 259:114-121, 1990.
:. Engh, C.A. Clin. Orthop. 176:52-66, 1983.
4: Engh, CA., et al. Proceedings of the Twelfth Open Scientific Meeting of the Hip Society,
C.V. Mosby pp. 95-U!, 1984.
5. Faris, P.M. et al. Semmars in Arthroplas 1:57-63.
Faugere, M.C. et al. Am. J. Physiol. 13:37-38, 1986.
7”: Healy, J.H. et al. J. Bone Joint Surg. 67A:586,1985.
Malluche, H.H. Dialysis Transplantation Nephrology, Pitman Medical 112-115
;* Malluche, H.H. Orthopaedic Research Society Proceedings Feb., 1989.
lb. Malluche, H.H. et al. Atlas of Mineralized Bone Histology. Karger, Basel, New York,
1986.
Malluche, H.H. et al. Endocrinology 119:2643-2654, 1986.
::: Malluche, H.H. et al. Calcif. Tissue Int. 34:439-448, 1992.
Noble, P.C., et al. Clin. Orthop. 235:148-166, 1988.
::* Parfitt, A.M. et al. J. Bone Min. Res. 6:595-610, 1986.
15: Ruthjen, K.W. et al. Am. Acad. Orthop. Surg. Proceedings, 1990.
Sin h, M. et al. J. Bone Joint Surg. 52-a:457-467, 1970.
:4: Stu Bberg, B.N. et al. Clin. Orthop. 240:200-205, 1989.

Figure 1: Measurement of
CC ratio. Distal endosteal
points are 10 cm from mid-
lesser trochanter line;
proximal endosteal points
are marked on the
endosteal surface 3 cm
perpendicular to the mid-
lesser trochanter line. The
ratio is 50% and is the
diameter of the canal
isthmus X= 15 mm) over
the calcar isthmus (Y=30
mm). The cortical index is
measured at 10 cm from the
mid-lesser trochanter and is
0.5 (Cl =30-15/30).
L. D. Dorr et al.: Bone quality of proximal femur 239

Figure 2: Type A bone A x-ray, The arrows note the thick medial fin. The isthmus
intramedullary diameter is 1$mm on the AP x-ray and 13m.m on the lateral x-ray with a CC ratio
of 50%.

Figure 3a: Type B

bone Ap x-ray.
Medial cortex IS
thinned compared to
Type A bone but a
funnel shape is still
present.
 I_. D. Dot-r et al.: Bone quality of proximal femur

Fiire 3b: Type B bone lateral x-ray. Note loss of posterior cortex and irregular endoste
surface.

Figure 4a: Type C bone Ap x-ray which shows loss of cortical bone and a stovepipe shape of
proximal femur.
L. 13. Dorr et al.: Bone quality of proximal femur 241

Figure 4b: Type C bone lateral x-ray which shows thin cortices, wide intramedullary canal and
“fuzzy”appearance of bone.

200
Figure 5: cortical
thickness of femoral
bone in the three
I.50

1.00

0.50

0.00I
TYPEA TYPE0 TYPEC
242 L. D. Dorr et al.: Bone quality of proximal femur

Figure 6: Cortical
porosity of femoral
bone m the three
roentgenographic
Type B is
?ggr than e A
fj IO and C (p < 0.0Yp
).
i=

8
0
0 t

Figure 7: Osteoblast
number of femoral
bone in the three
roentgeno aphic
types. lgrype C is
significantly higher
than types A and B
(p < 0.05).

-90
E
8 72
Figure 8: Osteoclast
number of femoral
bone in the three
roentgeno raphic
types. I!ype C is
significantly higher
than types A and B
(p < 0.05).