In vivo repeatability of homogenized finite element analysis based on multiple HR-pQCT sections for assessment of distal radius and tibia strength

Introduction: Micro finite element analysis (mu FE) is a widely applied tool in biomedical research for assessing in vivo mechanical properties of bone at measurement sites, including the ultra-distal radius and tibia. A finite element approach (hFE) based on homogenized constitutive models for trabecular bone offers an attractive alternative for clinical use, as it is computationally less expensive than traditional mu FE. The respective patient-specific models for in vivo bone strength estimation are usually based on standard clinical high-resolution peripheral quantitative CT (HR-pQCT) measurements. They include a scan region of roughly 10 mm in height and are referred to as single-sections. It has been shown, that these small peripheral bone sections don't reliably cover the fracture line in Colles' fractures and therefore the weakest region at the radius. Recently introduced multiple section (multiple adjacent single-sections) measurements might improve the evaluation of bone strength, but little is known about the repeatability of hFE estimations in general, and especially for multiple section measurement protocols. Accordingly, the aim of the present work is to quantify repeatability of clinical in vivo bone strength measurement by hFE on multiple section HR-pQCT reconstructions at the distal radius and tibia. Methods: Nineteen healthy Swiss women (43.6y +/- 17.8y) and twenty men (48.2y +/- 19.4y) were examined with HR-pQCT at 61 mu m isotropic voxel resolution. Each subject was first scanned three times using a double-section (336 slices) at the distal radius and then three times using a triple-section (504 slices) at the distal tibia. The multiple section HR-pQCT reconstructions were graded for motion artefacts and non-linear hFE models (radius and tibia) and linear mu FE models (only radius) were generated for estimation of stiffness and ultimate load. Then in vivo repeatability errors were computed in terms of root mean square coefficients of variation (CV). Results: In vivo repeatability errors of non-linear hFE stiffness (S) and ultimate load (F) were significantly higher at the radius (S: 2.71% and F: 2.97%) compared to the tibia (S: 1.21%, F: 1.45%). Multiple section linear mu FE at the radius resulted in substantially higher repeatability errors (S: 5.38% and F: 10.80%) compared to hFE. Discussion/conclusion: Repeatability errors of hFE outcomes based on multiple section measurements at the distal radius and tibia were generally lower compared to respective reported single-section mu FE repeatability errors. Therefore, hFE is an attractive alternative to today's gold standard of mu FE models and should especially be encouraged when analyzing multiple section measurements.