Purpose of review: Bone densitometry provides a two-dimensional projected areal apparent bone mineral density that fails to capture the heterogeneity of bone's material composition and macro-, micro-, and nano-structures critical to its material and structural strength. Assessment of the structural basis of bone fragility has focused largely on trabecular bone based on the common occurrence of fragility fractures at sites with substantial amounts of trabecular bone. This review focuses on the contribution of cortical bone to bone fragility throughout life.
Recent findings: Accurately differentiating cortical and trabecular bone loss has important implications in quantifying bone fragility as these compartments have differing effects on bone strength. Recent advances in imaging methodology have improved distinction of these two compartments by (i) recognition of a cortico-trabecular transitional zone and (ii) quantifying bone microstructure in a region of interest that is a percentage of bone length rather than a fixed point. Additionally, non-invasive three-dimensional imaging methods allow more accurate quantification of changes in the cortical, trabecular, and cortico-trabecular compartments during growth, aging, disease, and treatment. Over 75% of the skeleton is assembled as cortical bone. Of all fragility fractures, ~ 80% are appendicular and involve regions rich in cortical bone and ~ 70% of all age-related appendicular bone loss is cortical and is mainly due to unbalanced intracortical remodeling which increases cortical porosity. The failure to achieve the optimal peak bone microstructure during growth due to disease and the deterioration in cortical and trabecular bone produced by bone loss compromise bone strength. The loss of strength produced by microstructural deterioration is disproportionate to the bone loss producing this deterioration. The reason for this is that the loss of strength increases as a 7th power function of the rise in cortical porosity and a 3rd power function of the fall in trabecular density (Schaffler and Burr in J Biomech. 21(1):13-6, 1988), hence the need to quantify bone microstructure.
Keywords: Bone strength; Cortical porosity; Osteoporosis; Remodeling.