Evidence for bone formation on the external "periosteal" surface of the femoral neck: a comparison of intracapsular hip fracture cases and controls

Age-related expansion of the external surface of the femoral neck in order to offset generalized bone loss is potentially an important mechanism whereby hip strength and hence resistance to hip fracture is maintained. However, it has been widely assumed that bone formation is precluded from this external interface due to the presence of a synovial membrane associated with the hip joint. In this study we have demonstrated histologically that bone formation does indeed occur on the outer "periosteal" surface of the proximal femoral neck. It was therefore hypothesized that an impairment or reduction in periosteal bone formation might be seen in cases of femoral neck fracture compared with age-matched controls. Qualitative analysis of whole femoral neck samples from female subjects and age- and sex-matched post-mortem controls demonstrated that these groups expressed similar distributions of the bone formation marker, alkaline phosphatase (AP), at the periosteal surface [whole biopsy mean % periosteal AP-positive surface: control=16.0 (range=0.5–43.0), fracture=13.4 (range=1.0–34.6), p=0.44]. In conclusion, despite a wide intersubject variation, bone formation at the femoral neck periosteum is a feature of elderly women even if they have had a hip fracture.