Toward accessible quantification of bone mineral density: feasibility of radiographic bone aluminum equivalence (RBAE) determined by digital radiography against DEXA and CT in translational sheep model.

BACKGROUND: The study aimed to explore an accessible quantification of bone mineral density (BMD) through Radiographic Bone Aluminium Equivalence (RBAE) as determined by Digital Radiography (DR), compared to dual-energy X-ray absorptiometry (DEXA) and computed tomography (CT) in ex vivo animal model. METHODS: Metacarpal and metatarsal bones (n = 24) from skeletally mature sheep were imaged using standard DR, DEXA, and CT protocols. DR-derived BMD values were calculated from calibrated greyscale intensities using an aluminum step-wedge and image-analysis workflow. Correlation and regression analyses were performed to evaluate the relationship between the different modalities, whereas the intraclass correlation coefficient (ICC) and Bland-Altman analyses were used to assess agreement between the measurement methods. RESULTS: DR-derived BMD as expressed as BRAE demonstrated strong linear correlation with DEXA (r = 0.779, p = 0.001) and moderate linear correlation with CT (r = 0.536, p = 0.04). Across all imaging modalities, metatarsal bones exhibited significantly higher BMD than metacarpal bones, with clear bilateral symmetry observed within each bone type. The consistency of results across modalities strengthens the validity of the findings and supports the reliability of each technique for detecting biologically meaningful differences in BMD. The agreement between DEXA, CT and digital radiography underscores the feasibility of using radiographic BMD to quantify BMD. CONCLUSION: Digital radiography, supported by standardized calibration and analysis, yields a reproducible BMD estimates that align closely with DEXA and CT measurements. These findings highlight DR as a cost-effective and accessible option for BMD assessment, while providing valuable baseline insight into normal mineral distribution. This information supports future research on pathological bone loss, imaging validation, and therapeutic strategies to improve bone quality.