Morphological Assessment of Proximal Femoral Radiography Prior to Subsequent Hip fracture in Elderly: Comparison between Femoral Neck and Intertrochanteric Fracture

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Witit Pothong
Nath Adulkasem


Background: Subsequent contralateral fragility hip fracture (SCHF) is a significant issue in aging population. Morphological assessment of proximal femoral radiography correlates with bone density before treatment or surgery.

Objective: To investigate the differences of radiographic morphologic parameters of proximal femur between subsequence contralateral fragility femoral neck fracture (FNF) and intertrochanteric fracture (ITF).

Material and methods: A retrospective cohort study was conducted among unilateral fragility hip fracture patients who underwent surgical treatment in Lamphun Hospital between January 2016 to December 2021 and had SCHF. Anteroposterior radiographs of both hips taken at the time of the initial hip fracture were used to determine the canal-calcar ratio (CCR), cortical thickness index (CTI), canal flare index (CFI) and morphological cortical index (MCI) of the non-fracture site. Baseline characteristics and radiographic morphologic parameters were compared between the subsequence contralateral FNF group and ITF group. Univariable logistic regression analysis was employed to determine the odds ratio of the morphologic parameters to predict the SCHF event.

Results: There were 424 patients enrolled in the study and 47 (11.1%) experienced SCHF. Among these, 33 cases (70.2%) were in ITF group and 14 cases (29.8%) were in FNF group. There was no significant difference between the two groups in any of the radiographic morphologic parameters. In patients who developed subsequent contralateral FNF, CFI <3.0 showed the highest odds ratio (OR 23.4, 95% CI 6.3–86.9). CTI <0.56 in male and <0.62 in male demonstrated the perfect prediction in all patients who sustained  subsequent contralateral ITF.

Conclusion: In elderly hip fractures, the radiologic morphologic parameters (CTI, CFI, CCR, MCI) had no difference between subsequent contralateral FNF and ITF. The parameter with the greatest odds ratio in patients with FNF was CFI <3.0. CTI 0.56 in males and 0.62 in males were the parameters seen in all patients with subsequent contralateral ITF.



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Pothong, W., & Adulkasem, N. . (2023). Morphological Assessment of Proximal Femoral Radiography Prior to Subsequent Hip fracture in Elderly: Comparison between Femoral Neck and Intertrochanteric Fracture. Lampang Medical Journal, 44(1), 1–8. Retrieved from
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Magaziner J, Simonsick EM, Kashner TM, Hebel JR,Kenzora JE. Survival experience of aged hip fracture patients. Am J Public Health. 1989;79(3):274–8.

Formiga F, Rivera A, Nolla JM, Coscujuela A, Sole A, Pujol R. Failure to treat osteoporosis and the risk of subsequent fractures in elderly patients with previous hip fracture: a five-year retrospec tive study. Aging ClinExp Res. 2005;17(2):96–9.

Schrøder H, Petersen KK, Erlandsen M. Occurrence and incidence of the second hip fracture. Clin Orthop Relat Res. 1993;289:166–9.

Robinson C, Royds M, Abraham A, McQueen M, Christie J. Refractures in patients at least forty- five years old: a prospective analysis of twenty-two thousand and sixty patients. J Bone Joint Surg Am. 2002;84(9):1528–33.

Ruan WD, Wang P, Ma XL, Ge RP, Zhou XH. Analysis on the risk factors of second fracture in osteoporosis-related fractures. Chin J Traumatol. 2011;14(2):74–8.

Toth E, Banefelt J, Akesson K, Spangeus A, Ortsater G, Libanati C. History of previous fracture and imminent fracture risk in Swedish women aged 55 to 90 years presenting with a fragility fracture. J Bone Miner Res. 2020;35(5):861–8.

Mitani S, Shimizu M, Abo M, Hagino H, Kurozawa Y. Risk factors for second hip fractures among elderly patients. J Orthop Sci. 2010;15(2):192–7.

Yamanashi A, Yamazaki K, Kanamori M, Mochizuki K, Okamoto S, Koide Y, et al. Assessment of risk factors for second hip fractures in Japanese elderly. Osteoporos Int. 2005;16(10):1239–46.

Jones G, Nguyen T, Sambrook P, Kelly P, Eisman J. Progressive loss of bone in the femoral neck in elderly people: longitudinal findings from the Dubbo osteoporosis epidemiology study. BMJ. 1994;309(6956):691–5.

Sah AP, Thornhill TS, LeBoff MS, Glowacki J. Correlation of plain radiographic indices of the hip with quantitative bone mineral density. Osteoporos Int. 2007;18(8):1119–26.

Baumgartner R, Heeren N, Quast D, Babst R, Brunner A. Is the cortical thickness index a valid parameter to assess bone mineral density in geriatric patients with hip fractures? Arch Orthop Trauma Surg. 2015;135(6):805–10.

Nguyen BN, Hoshino H, Togawa D, Matsuyama Y. Cortical thickness index of the proximal femur: A radiographic parameter for preliminary assessment of bone mineral density and osteoporosis status in the age 50 years and over population. Clin Orthop Surg. 2018;10(2):149–56.

Grevenstein D, Vidovic B, Baltin C, Eysel P, Spies CK, Unglaub F, et al. The proximal femoral bone geometry in plain radiographs. Arch Bone Jt Surg. 2020;8(6):675–81.

Kose O, Kilicaslan OF, Arik HO, Sarp U, Toslak IE, Ucar M. Prediction of osteoporosis through radiographic assessment of proximal femoral morphology and texture in elderly; is it valid and reliable? Turk J Osteoporos. 2015;21:46–52.

Yeung Y, Chiu KY, Yau WP, Tang WM, Cheung WY, Ng TP. Assessment of the proximal femoral morphology using plain radiograph-can it predict the bone quality? J Arthroplasty. 2006;21(4):50813.

Dorr LD. Total hip replacement using APR system. Techniques in Orthopaedics. 1986;1(3):22–34.

Dorr LD, Faugere M-C, Mackel AM, Gruen TA, Bognar B, Malluche HH. Structural and cellular assessment of bone quality of proximal femur. Bone. 1993;14(3):231–42.

Noble PC, Box GG, Kamaric E, Fink MJ, Alexander JW, Tullos HS. The effect of aging on the shape of the proximal femur. Clin Orthop Relat Res. 1995;316:31–44.

Spotorno L, Romagnoli S. The CLS uncemented total hip replacement system. Thun: Werbelinie AG; 1991.

Pothong W, Adulkasem N. Comparative evaluation of radiographic morphologic parameters for predicting subsequent contralateral fragility hip fracture. Int Orthop. 2023;47(7):1837–43.

Aghili AL, Hojjati MH, Goudarzi AM, Rabiee M, Aslan MH, Oral AY, et al. Stress analysis of human femur under different loadings. International Congress on Advances in Applied Physics and Materials Science; Antalya, Turkey: American Institute of Physics; 2011.

LI Y, Zhuang H, Cai S, Lin J, Yao X, Pan Y, et al. Correlation of canal flare index of the proximal femur with bone mineral density of the femoral neck. Chin J Tissue Eng Res. 2014;53:3178–83.