A Novel DXA-Based Hip Failure Index Captures Hip Fragility Independent of BMD

Capability of a novel dual-energy X-ray absorptiometry (DXA)-based hip failure index (HiFI) to discriminate between hip fracture cases and controls was evaluated. Given the constraints of planar DXA, the femoral neck was assumed a foam-filled (∼trabecular bone), thin-walled (∼cortical bone) sandwich structure, while HiFI estimated the critical force sufficient to buckle the wall of such a structure. Proximal femur DXA data from 1379 women aged 65 yr and older, 268 with prior hip fracture were used. Comparison between standard areal bone mineral density (BMD), femur strength index (FSI), and HiFI was based on areas under receiver operatoring characteristic curves (AUC). The mean femoral neck BMD (SD) was 0.689 (0.109) g/cm2 among the cases and 0.768 (0.119) g/cm2 among the controls; the mean FSI 1.33 (0.36) and 1.54 (0.41), and the mean HiFI −0.28 (0.14) and −0.18 (0.15), respectively; all intergroup differences were highly significant (p < 0.001). The intergroup difference for HiFI remained significant (p < 0.002) after adjusting for age and BMD or FSI. The AUCs were 0.696 (95% confidence interval [CI]: 0.661-0.730) for BMD, 0.665 (0.630-0.700) for FSI, and 0.701 (0.666-0.736) for HiFI. In conclusion, HiFI may capture structural traits that account for femoral neck fragility independently of BMD or FSI. Obviously, the use of actual geometric and structural information from three-dimensional imaging of the femoral neck would help diminish the crude assumptions of the present DXA approach and reveal the true potential of the HiFI approach to gauge hip fragility and identify at-risk individuals for hip fractures.