In vivo mechanical assessment of cortical bone rigidity enhances fracture discrimination beyond DXA in postmenopausal women

Dual-energy x-ray absorptiometry (DXA)-derived areal bone mineral density (BMD) remains the clinical standard for assessing osteoporosis risk, yet it fails to identify over 75% of individuals who sustain fragility fractures. Direct in vivo mechanical assessment of cortical bone strength may address this diagnostic gap by capturing structural and material properties that govern whole-bone strength but are not reflected by BMD. We conducted a multicenter case-control study with cross-sectional exposure assessment to compare ulna flexural rigidity, a biomechanical property correlated with whole-bone strength (R2 ≈ 0.99), estimated using Cortical Bone Mechanics Technology (CBMT), with DXA-derived BMD for discriminating prior fragility fractures in postmenopausal women. A total of 372 women aged 50-80 years (109 with low-trauma fractures, 263 matched controls) were enrolled across four U.S. sites. Ulna flexural rigidity was assessed by dynamic vibrational analysis; BMD was measured at the spine, hip, and 1/3 radius. Women with prior fractures had significantly lower flexural rigidity than controls (absolute: 20.0 vs. 24.8 N·m2; 21% lower; weight-normalized: 0.29 vs. 0.36 N·m2/kg; 22% lower; both P < .001). CBMT demonstrated good discriminatory accuracy (AUC = 0.80 normalized; 0.76 absolute), with significantly better AUCs than DXA, which showed only fair to poor performance (AUC ≤ 0.63). In multivariable models including CBMT and DXA-derived BMD, CBMT remained independently associated with fracture status, whereas BMD did not. Subgroup analyses showed CBMT retained good performance in treatment-naïve women (AUC = 0.85) and in those with non-osteoporotic BMD (AUC = 0.80). Exploratory fracture-site analyses demonstrated that ulna EI discriminated upper and lower extremity fractures, including hip, whereas DXA-derived BMD generally showed fair to poor discrimination. Biomechanical assessment of bone rigidity provides clinically relevant information beyond areal BMD, including women not classified high risk. Direct in vivo assessment of cortical bone rigidity may enhance fracture risk stratification and enhance osteoporosis screening.