Experimental hip fracture load can be predicted from plain radiography by combined analysis of trabecular bone structure and bone geometry. 
Computerized analysis of the trabecular structure was used to test whether femur failure load can be estimated from radiographs.  The study showed that combined analysis of trabecular bone structure and geometry predicts in vitro failure load with similar accuracy as DXA.  Since conventional radiography is widely available with low imaging cost, it is of considerable interest to discover how well bone mechanical competence can be determined using this technology.  We tested the hypothesis that the mechanical strength of the femur can be estimated by the combined analysis of the bone trabecular structure and geometry.  The sample consisted of 62 cadaver femurs (34 females, 28 males).  After radiography and DXA, femora were mechanically tested in side impact configuration.  Fracture patterns were classified as being cervical or trochanteric.  Computerized image analysis was applied to obtain structure-related trabecular parameters (trabecular bone area, Euler number, homogeneity index, and trabecular main orientation), and set of geometrical variables (neck-shaft angle, medial calcar and femoral shaft cortex thicknesses, and femoral neck axis length).  Multiple linear regression analysis was performed to identify the variables that best explain variation in BMD and failure load between subjects.  In cervical fracture cases, trabecular bone area and femoral neck axis length explained 64% of the variability in failure loads, while femoral neck BMD also explained 64%.  In trochanteric fracture cases, Euler number and femoral cortex thickness explained 66% of the variability in failure load, while trochanteric BMD explained 72%.  Structural parameters of trabecular bone and bone geometry predict in vitro failure loads of the proximal femur with similar accuracy as DXA, when using appropriate image analysis technology.