Finite element analysis for refracture risk assessment in elderly patients with osteoporosis: a feasibility study_West China Medical Journal

Authors：

YANG Ziqi , SONG Jie , CHEN Mengxia ,  GAO Yuan

Department of Nursing, First Medical Center, Chinese PLA General Hospital, Beijing 100853, P. R. China;

Corresponding?author：

GAO Yuan, Email: gaoyuanzd@163.com

Keywords：

Osteoporosis; second fracture; finite element analysis; fracture fragile site; fracture threshold

DOI：

10.7507/1002-0179.202606227

Video：

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Objective To construct and preliminarily validate a CT-based patient-specific finite element (FE) model for locating skeletal fragile sites and estimating safe impact thresholds in elderly patients with a second fracture, so as to provide a quantitative reference for individualized fracture prevention assessment by nurses. Methods Ten patients with a second fracture (7 hip and 3 distal radius fractures) admitted to Chinese PLA General Hospital between January 2024 and March 2026 were retrospectively enrolled. Three-dimensional FE models were reconstructed from contralateral CT images obtained at the first fracture to simulate the mechanical process of low-energy injury-induced fracture. Using the affected-side CT images obtained at the second fracture as the reference, agreement between model prediction and actual fracture was evaluated in three dimensions: number of fracture fragments, fracture classification, and key angles (Pauwels angle for the hip and ulnar deviation angle for the radius). High-risk stress concentration areas and fracture thresholds were also generated. This was designed as a feasibility study, and all statistical results were regarded as hypothesis-generating rather than confirmatory. Results The overall agreement for the number of fracture fragments was 9/10 (hip 7/7, distal radius 2/3), and that for fracture classification was 9/10. The mean absolute error of the Pauwels angle was (4.4±2.9)°, and the predicted values were positively correlated with the measured values (r=0.978, n=7); this correlation was exploratory. The mean absolute error of the ulnar deviation angle was (6.4±4.4)°. The model identified the most fragile site and the fracture threshold for each patient, and all fracture thresholds were lower than the corresponding estimated fall impact forces. Conclusions In this small sample, the FE model based on contralateral CT images showed preliminary feasibility in locating skeletal fragile sites and quantifying safe impact thresholds in elderly patients with a second fracture, which may provide a quantitative reference for individualized fracture prevention assessment by nurses. Given the limited sample size and retrospective design, these findings need to be confirmed in larger and experimental studies.

Citation： YANG Ziqi, SONG Jie, CHEN Mengxia, GAO Yuan. Finite element analysis for refracture risk assessment in elderly patients with osteoporosis: a feasibility study. West China Medical Journal, 2026, 41(9): 1433-1439. doi: 10.7507/1002-0179.202606227 Copy

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2.	Praveen AD, Aspelund T, Ferguson SJ, et al. Refracture and mortality risk in the elderly with osteoporotic fractures: the AGES-Reykjavik study[J]. Osteoporos Int, 2024, 35(7): 1231-1241.
3.	Williams SA, Daigle SG, Weiss R, et al. Economic burden of osteoporosis-related fractures in the US medicare population[J]. Ann Pharmacother, 2021, 55(7): 821-829.
4.	Wang C, Kim SM. The Otago Exercise Program’s effect on fall prevention: a systematic review and meta-analysis[J]. Front Public Health, 2025, 13: 1522952.
5.	Sheridan KJ. Osteoporosis in adults with cerebral palsy[J]. Dev Med Child Neurol, 2009, 51(Suppl 4): 38-51.
6.	Bugbird AR, Whittier DE, Burt LA, et al. Longitudinal associations between changes in bone mechanical strength and fracture risk estimated by μFRAC[J]. J Bone Miner Res, 2026, 41(2): 112-119.
7.	Kong SH, Shin CS. Applications of machine learning in bone and mineral research[J]. Endocrinol Metab (Seoul), 2021, 36(5): 928-937.
8.	Kim S, Goelz L, Münn F, et al. Detection of missed fractures of hand and forearm in whole-body CT in a blinded reassessment[J]. BMC Musculoskelet Disord, 2021, 22(1): 589.
9.	Nguy?n MV, Carlier C, Nich C, et al. Fracture risk of long bone metastases: a review of current and new decision-making tools for prophylactic surgery[J]. Cancers (Basel), 2021, 13(15): 3662.
10.	Revel M, Gardegaront M, Bermond F, et al. A credible homogenized finite element model to predict radius fracture in the case of a forward fall[J]. J Mech Behav Biomed Mater, 2022, 131: 105206.
11.	中華醫學會骨質疏松和骨礦鹽疾病分會. 原發性骨質疏松癥診療指南(2022)[J]. 中國全科醫學, 2023, 26(14): 1671-1691.
12.	Yang L, Zhang X, Zhong Z, et al. Patient-specific finite element analysis of four different fixation methods for transversely unstable radial head fractures[J]. Sci Rep, 2024, 14(1): 21134.
13.	Peng MJ, Chen HY, Hu Y, et al. Finite element analysis of porously punched prosthetic short stem virtually designed for simulative uncemented hip arthroplasty[J]. BMC Musculoskelet Disord, 2017, 18(1): 295.
14.	Guha I, Zhang X, rajapakse CS, et al. Finite element analysis of trabecular bone microstructure using CT imaging and continuum mechanical modeling[J]. Med Phys, 2022, 49(6): 3886-3899.
15.	Yosibash Z, Trabelsi N, Milgrom C. Reliable simulations of the human proximal femur by high-order finite element analysis validated by experimental observations[J]. J Biomech, 2007, 40(16): 3688-3699.
16.	Faulkner KG, Glüer CC, Grampp S, et al. Cross-calibration of liquid and solid QCT calibration standards: corrections to the UCSF normative data[J]. Osteoporos Int, 1993, 3(1): 36-42.
17.	Schileo E, Dall’Ara E, Taddei F, et al. An accurate estimation of bone density improves the accuracy of subject-specific finite element models[J]. J Biomech, 2008, 41(11): 2483-2491.
18.	Yosibash Z, Katz A, Milgrom C. Toward verified and validated FE simulations of a femur with a cemented hip prosthesis[J]. Med Eng Phys, 2013, 35(7): 978-987.
19.	Patel TK, Brodt MD, Silva MJ. Experimental and finite element analysis of strains induced by axial tibial compression in young-adult and old female C57Bl/6 mice[J]. J Biomech, 2014, 47(2): 451-457.
20.	Bouxsein ML, Szulc P, Munoz F, et al. Contribution of trochanteric soft tissues to fall force estimates, the factor of risk, and prediction of hip fracture risk[J]. J Bone Miner Res, 2007, 22(6): 825-831.
21.	Guitton TG, van der Werf HJ, Ring D. Quantitative three-dimensional computed tomography measurement of radial head fractures[J]. J Shoulder Elbow Surg, 2010, 19(7): 973-977.
22.	Adejuyigbe B, Gharpure M, Tilve R, et al. Revisiting the OTA-OFC: a systematic review of open fracture classification studies since 2010[J]. OTA Int, 2025, 8(2): e391.
23.	Liu F, Su P, Zhang L, et al. Preoperative computed tomography morphological characteristics of displaced femoral neck fractures[J]. Jt Dis Relat Surg, 2023, 34(2): 253-264.
24.	Tang Z, Zhang Y, Huang S, et al. Biomechanical study of a biplanar double support screw (BDSF) technique based on Pauwels angle in femoral neck fractures: finite element analysis[J]. Front Bioeng Biotechnol, 2024, 12: 1358181.
25.	Kitidumrongsook P, Luangjarmekorn P, Kuptniratsaikul V, et al. Measurement of radiological parameters of distal radius fracture using the ulnar axis compared with the radial axis[J]. J Hand Surg Asian Pac Vol, 2024, 29(2): 140-147.
26.	Galliker ES, Laing AC, Ferguson SJ, et al. The influence of fall direction and hip protector on fracture risk: FE model predictions driven by experimental data[J]. Ann Biomed Eng, 2022, 50(3): 278-290.
27.	Fung A, Fleps I, Cripton PA, et al. The efficacy of femoral augmentation for hip fracture prevention using ceramic-based cements: a preliminary experimentally-driven finite element investigation[J]. Front Bioeng Biotechnol, 2023, 11: 1079644.

1. Izquierdo-Avino R, Cebollada-Gadea L, Jordan-Jarque M, et al. Risk of osteoporotic fracture and refracture: the importance of index fracture site[J]. Arch Osteoporos, 2023, 18(1): 27.
2. Praveen AD, Aspelund T, Ferguson SJ, et al. Refracture and mortality risk in the elderly with osteoporotic fractures: the AGES-Reykjavik study[J]. Osteoporos Int, 2024, 35(7): 1231-1241.
3. Williams SA, Daigle SG, Weiss R, et al. Economic burden of osteoporosis-related fractures in the US medicare population[J]. Ann Pharmacother, 2021, 55(7): 821-829.
4. Wang C, Kim SM. The Otago Exercise Program’s effect on fall prevention: a systematic review and meta-analysis[J]. Front Public Health, 2025, 13: 1522952.
5. Sheridan KJ. Osteoporosis in adults with cerebral palsy[J]. Dev Med Child Neurol, 2009, 51(Suppl 4): 38-51.
6. Bugbird AR, Whittier DE, Burt LA, et al. Longitudinal associations between changes in bone mechanical strength and fracture risk estimated by μFRAC[J]. J Bone Miner Res, 2026, 41(2): 112-119.
7. Kong SH, Shin CS. Applications of machine learning in bone and mineral research[J]. Endocrinol Metab (Seoul), 2021, 36(5): 928-937.
8. Kim S, Goelz L, Münn F, et al. Detection of missed fractures of hand and forearm in whole-body CT in a blinded reassessment[J]. BMC Musculoskelet Disord, 2021, 22(1): 589.
9. Nguy?n MV, Carlier C, Nich C, et al. Fracture risk of long bone metastases: a review of current and new decision-making tools for prophylactic surgery[J]. Cancers (Basel), 2021, 13(15): 3662.
10. Revel M, Gardegaront M, Bermond F, et al. A credible homogenized finite element model to predict radius fracture in the case of a forward fall[J]. J Mech Behav Biomed Mater, 2022, 131: 105206.
11. 中華醫學會骨質疏松和骨礦鹽疾病分會. 原發性骨質疏松癥診療指南(2022)[J]. 中國全科醫學, 2023, 26(14): 1671-1691.
12. Yang L, Zhang X, Zhong Z, et al. Patient-specific finite element analysis of four different fixation methods for transversely unstable radial head fractures[J]. Sci Rep, 2024, 14(1): 21134.
13. Peng MJ, Chen HY, Hu Y, et al. Finite element analysis of porously punched prosthetic short stem virtually designed for simulative uncemented hip arthroplasty[J]. BMC Musculoskelet Disord, 2017, 18(1): 295.
14. Guha I, Zhang X, rajapakse CS, et al. Finite element analysis of trabecular bone microstructure using CT imaging and continuum mechanical modeling[J]. Med Phys, 2022, 49(6): 3886-3899.
15. Yosibash Z, Trabelsi N, Milgrom C. Reliable simulations of the human proximal femur by high-order finite element analysis validated by experimental observations[J]. J Biomech, 2007, 40(16): 3688-3699.
16. Faulkner KG, Glüer CC, Grampp S, et al. Cross-calibration of liquid and solid QCT calibration standards: corrections to the UCSF normative data[J]. Osteoporos Int, 1993, 3(1): 36-42.
17. Schileo E, Dall’Ara E, Taddei F, et al. An accurate estimation of bone density improves the accuracy of subject-specific finite element models[J]. J Biomech, 2008, 41(11): 2483-2491.
18. Yosibash Z, Katz A, Milgrom C. Toward verified and validated FE simulations of a femur with a cemented hip prosthesis[J]. Med Eng Phys, 2013, 35(7): 978-987.
19. Patel TK, Brodt MD, Silva MJ. Experimental and finite element analysis of strains induced by axial tibial compression in young-adult and old female C57Bl/6 mice[J]. J Biomech, 2014, 47(2): 451-457.
20. Bouxsein ML, Szulc P, Munoz F, et al. Contribution of trochanteric soft tissues to fall force estimates, the factor of risk, and prediction of hip fracture risk[J]. J Bone Miner Res, 2007, 22(6): 825-831.
21. Guitton TG, van der Werf HJ, Ring D. Quantitative three-dimensional computed tomography measurement of radial head fractures[J]. J Shoulder Elbow Surg, 2010, 19(7): 973-977.
22. Adejuyigbe B, Gharpure M, Tilve R, et al. Revisiting the OTA-OFC: a systematic review of open fracture classification studies since 2010[J]. OTA Int, 2025, 8(2): e391.
23. Liu F, Su P, Zhang L, et al. Preoperative computed tomography morphological characteristics of displaced femoral neck fractures[J]. Jt Dis Relat Surg, 2023, 34(2): 253-264.
24. Tang Z, Zhang Y, Huang S, et al. Biomechanical study of a biplanar double support screw (BDSF) technique based on Pauwels angle in femoral neck fractures: finite element analysis[J]. Front Bioeng Biotechnol, 2024, 12: 1358181.
25. Kitidumrongsook P, Luangjarmekorn P, Kuptniratsaikul V, et al. Measurement of radiological parameters of distal radius fracture using the ulnar axis compared with the radial axis[J]. J Hand Surg Asian Pac Vol, 2024, 29(2): 140-147.
26. Galliker ES, Laing AC, Ferguson SJ, et al. The influence of fall direction and hip protector on fracture risk: FE model predictions driven by experimental data[J]. Ann Biomed Eng, 2022, 50(3): 278-290.
27. Fung A, Fleps I, Cripton PA, et al. The efficacy of femoral augmentation for hip fracture prevention using ceramic-based cements: a preliminary experimentally-driven finite element investigation[J]. Front Bioeng Biotechnol, 2023, 11: 1079644.

West China Medical Journal

Finite element analysis for refracture risk assessment in elderly patients with osteoporosis: a feasibility study

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