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Current Medical Imaging

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REVIEW ARTICLE

A Review on Imaging Techniques and Artificial Intelligence Models for

Osteoporosis Prediction
S.Arun Inigo1,*, R. Tamilselvi1 and M.Parisa Beham1
1
Department of Electronics and Communication Engineering, Sethu Institute of Technology, Pulloor, Kariyapatti, India

Abstract:
Osteoporosis causes harmful influences on both men and women of all races. Bone mass, also referred to as “bone density,” is frequently used to
assess the health of bone. Humans frequently experience bone fractures as a result of trauma, accidents, metabolic bone diseases, and disorders of
bone strength, which are typically led by changes in mineral composition and result in conditions like osteoporosis, osteoarthritis, osteopenia, etc.
Artificial intelligence holds a lot of promise for the healthcare system. Data collection and preprocessing seem to be more essential for analysis, so
bone images from different modalities, such as X-ray, Computed Tomography (CT), and Magnetic Resonance Imaging (MRI), are taken into
consideration that help to recognize, classify, and evaluate the patterns in clinical images. This research presents a comprehensive overview of the
performance of various image processing techniques and deep learning approaches used to predict osteoporosis through image segmentation,
classification, and fault detection. This survey outlined the proposed domain-based deep learning model for image classification in addition to the
initial findings. The outcome identifies the flaws in the existing literature's methodology and lays the way for future work in the deep learning-
based image analysis model.

Keywords: Medical image, Bone mineral density (BMD), Image processing, Artificial intelligence, Dataset quality, Deep learning (DL).

Article History Received: March 16, 2023 Revised: April 29, 2023 Accepted: May 12, 2023

1. INTRODUCTION
A skeletal illness characterized as osteoporosis is defined
by the loss of bone mass and microstructural degradation of
bone tissue. Osteoporosis, which means “porous bone,” makes
bones more brittle and fracture-prone. Low-energy fractures
are linked to increased mortality and morbidity rates. Some
patients lose height as a result of it. Osteoporosis generally
causes a stooped or slumped posture when it affects vertebrae
or the bones of the spine. Mobility issues brought on by
osteoporosis can result in feelings of loneliness or melancholy.
With early diagnosis of the bone risk factor, life expectancy
and its quality can be increased. Human fractures pose a
substantial health concern and frequently result in significant
short- and long-term discomfort for those who sustain them.
Bones go through a cycle of renewal continuously. Remodeling
is the process when older bone tissue is replaced by freshly
generated bone tissue. The primary causes of fractures are age,
smoking, drinking, osteoporosis, diabetes, and gender. One in
two women over the age of 50 will get a fracture over her
lifetime, making women significantly more likely to experience
* Address correspondence to this author at the Department of Electronics and
Communication Engineering, Sethu Institute of Technology, Pulloor, Kariyapatti,
India; E-mail: aruninigo@sethu.ac.in
one than men. Bone density tends to increase when humans
seem to be young adults, typically between the ages of 25 and
30 (Fig. 1). After then, our bones gradually lose density as we
age. However, there are methods to stop this natural loss of
bone mass, including the use of vitamins, minerals, drugs like
hormonal therapy, and weight-bearing workouts [1].
Worldwide, one in three women over the age of 50 will
suffer an osteoporotic fracture. For men, this percentage drops,
with one in five people in the same age range reportedly
suffering from an osteoporosis-related fracture [2].
Artificial intelligence is the art of “teaching” machines to
act as they think and appear intelligent. Technically speaking,
artificial intelligence (AI) refers to a large class of algorithmic
technologies designed to imitate human reasoning. Artificial
intelligence's machine learning (ML) field uses statistical
techniques to spot empirical patterns in data. The data is
especially used by ML as examples to guide the learning
process towards a particular destination. Deep learning (DL), a
subset of machine learning, provides multilayered (“deep”)
model architectures that can manage complex non-linear
interactions between the input and output variables [3].
AI—which has the capacity to make machines that

DOI: 10.2174/1573405620666230608091911, 2024, 20, e080623217779

2 Current Medical Imaging, 2024, Volume 20
replicate human behavior—is poised to transform the
profession of medicine. AI is a complementary technology that
is intended to improve the human abilities of nurses, doctors,
and researchers in the medical field. AI in medicine is not
meant to replace doctors; rather, it is meant to enhance their
skills. Recently, it has become clear that machine learning,
particularly deep learning with artificial neural networks, holds
great promise for achieving human- or nearly human-level
performance in various difficult-to-automate highly complex
perceptual tasks, such as image classification and natural
language processing.
Fig. (1). Information on bone mass at various ages [2].
Fig. (2). Osteoporosis or low hip bone mass in women and men over 50 years of age: projected prevalence [5].
Inigo et al.
The doctor can identify the broken bone using the X-ray
image. The manual method for identifying fractures is time-
consuming and prone to error. Therefore, it is essential to
create an automated system to recognize the broken bone. Deep
Neural Networks are commonly used for power device
simulation (DNN). Recently, a deep neural network model was
developed to distinguish between broken and healthy bones. A
classifier of the deep learning model is produced by a little data
set. In order to increase data gathering, methodologies for data
augmentation have been designed [4].
Artificial Intelligence Models for Osteoporosis Prediction
Fig. (3). X-ray images of normal bone and osteoporosis bone.
The National Center for Health Statistics, a division of the
Centers for Disease Control and Prevention, conducts the
National Health and Nutrition Examination Survey
(NHANES). A sample of Americans that were nationally
representative was used for this poll. In the United States,
14,646 men and women over 20 years old had their hip bone
mineral density assessed as part of the NHANES from 1988 to
1994. The percentage of those over 50 who had osteoporosis
and poor bone mass was calculated by comparing these
numbers to the WHO definitions. These percentages were then
put on the whole population of men and women over the age of
50 to identify the exact number of males and females in the
United States with osteoporosis and poor bone mass.
Projections for 2010 and 2020 were based on population
predictions for those years; they are much higher than the
current values because of both the anticipated ageing of the
population in Fig. (2) and the anticipated rise in the overall
population. Normal and osteoporosis X-ray images of the knee
and Spine are presented (Fig. 3) [5]. For further procedures like
improvement, test/training, segmentation, and classification,
the dataset needs to be created. Clinical observation and patient
history are crucial components in determining the future
prospects for osteoporosis in its early stages.
1.1. Clinical Observations and Side Effects
Osteoporosis is the most common bone disease in humans,
and it is a major public health concern. It is more common in
women and the elderly. Similar to how hypertension raises the
risk of stroke, osteoporosis does the same for fractures.
Osteoporosis affects millions of people of all ages and cultures,
and its prevalence will rise as the population ages. It is a silent
disease until fractures occur, at which point it causes serious
secondary health issues and even death [5].
The 3 Most Common Causes of Osteoporosis are
Estrogen deficiencies in women. During menopause,
women typically experience estrogen deficiency.
Current Medical Imaging, 2024, Volume 20 3
A lack of calcium. Minerals are constantly lost and
replaced in the bones.
A sedentary way of life.
Four clinical covariate types, namely, age, gender, BMI
(Body mass index), and history of hip fracture, were chosen
from the clinical factors of patients with osteoporosis in the
study. The BMI was calculated by dividing the weight in
kilograms by the square of the height in meters (kg/m2). The
height and weight were measured at the same time as the
BMD. A history of hip fracture was also chosen as a patient
factor because hip fractures affect secondary fractures in
osteoporotic fractures [6].
1.2. Bone Mineral Density (BMD)
The World Health Organization (WHO) defines
osteoporosis as having a BMD criterion of less than -2.5,
normal BMD T-score between 0 to -1, and osteopenia between
T-scores -1 and -2.5 (Fig. 4) [7]. The benchmark test for
osteoporosis is dual-energy X-ray absorptiometry (DXA) in the
proximal femur, lumbar spine, and, in some scenarios, the
forearm. The BMD score for spine bone density (L2-L4) using
DEXA is given in Fig. (5). Here, the age and T-score are
considered to find osteoporosis [8]. Hsieh et al. focused on
BMD thresholds with a positive predictive value (PPV) of 95%
for classifying and a negative predictive value (NPV) of 95%
for excluding osteoporosis. Overall, the hip cohort had an
excellent PPV or NPV for osteoporosis, with 88.2% of the
predicted values, and the spine cohort had an excellent PPV or
NPV of 70.4%. In real-world tests, the actual rate of
radiographs that could be evaluated for BMD and fracture risk
is around 80% [9, 10].
Fathima et al.emphasized the assessment of BMD using
several benchmark image processing methods, such as image
enhancement, segmentation, and texture analysis on X-ray and
DEXA pictures for osteoporosis detection. DEXA's superior
qualities open the door for new medical applications and
research [11].
4 Current Medical Imaging, 2024, Volume 20
Fig. (4). BMD score range.
Fig. (5). Example BMD Score analysis using DEXA [8].
The rest of the paper is structured as follows: In Sections 2
and 3, existing survey works and research motivation are
discussed. Details on image acquisition and various image
processing methods for classification and segmentation details
are given in Section 4. Discussion on different deep learning
models for segmentation, classification of bone fracture risk
and osteoporosis detection is elaborated in Section 5. Section 6
highlights the study findings of this comprehensive survey.
Finally, Section 7 concludes and highlights the anticipated
improvements.
2. RELATED SURVEY WORK
Only a few numbers of reviews have been carried out in
the last 2 decades with an emphasis on model architecture and
performance in the domain of osteoporosis image analysis. The
majority of the survey's questions rely on various features to
represent anomaly patterns and classification classifiers. This
article is focused on recently published reviews in the fields of
medical image analysis and osteoporosis image analysis
Kavita et al. reviewed a study on CAD-system vision
based on automatic detection and diagnosis of osteoporosis,
including the survey on X-rays, DEXA scans, MRIs, and CT-
scan of vertebrae. The channel to detect osteoporosis includes
the acquisition of the image, pre-processing, segmenting with
respect to ROI, extracting features, and lastly, classifiers using
machine learning techniques [12]. Even though the gold
Inigo et al.
standard technique for the diagnosis of osteoporosis, DEXA, is
accurate and highly precise, it has certain limitations, such as
the high cost and low availability of DEXA in the low
economy. Diagnosis of osteoporosis by analysis of radiographs
can be a cost-effective alternative to DEXA. Since BMD
measures the bone quantity and not the bone structure, it is
insufficient to predict the risk of fragility fractures [13].
Various medical image segmentation models using deep
learning are discussed, i.e., CNN, FCNN, Unet, GAN, SegAN,
etc. Increasingly new methods are used to improve the
accuracy and robustness of segmentation continuously.
Diagnosing various diseases through artificial intelligence
realizes the idea of sustainable medical treatment. It has
become a powerful tool for clinicians. But it is still an open
problem to expect a series of innovations and research results.
This article presents a direct review of the current literature on
the use of artificial intelligence in the identification of groups
at risk of osteoporosis or fractures resulting from this disease.
The application of artificial intelligence has shown to be
adequate for the prognosis of the disease or fracture since there
is no need to provide a diagnostic rule to identify it [14].
The X-ray image of the bone structure was measurably
prepared and deliberately changed to remove unfair factual
highlights of various requests. These bone features were
analyzed through machine learning algorithms to categorize
them into two groups, one with osteoporosis and the other one
Artificial Intelligence Models for Osteoporosis Prediction Current Medical Imaging, 2024, Volume 20 5

as a healthy subject. The classifiers used for feature extraction
used in this study were artificial neural networks, Support
vector machines, K-nearest neighbor (KNN), and Naive Bayes
[15]. In the fast-moving world of genomics, including the field
of osteoporosis, hundreds of genetic markers have been
identified as associated with complex traits. As discussed
above, the GWAS findings have aided the discovery of several
novel osteoporosis drug targets. However, there is still an
overwhelming number of significant associations for which the
underlying biological mechanisms remain unknown, as the
functional characterization of the discovered genetic variants
has lagged far behind [16]. The use of AI-based systems in the
detection of osteoporosis requires additional validation through
more prospective research in multicenter scenarios with larger
random samples from all patient categories [17]. This survey
also covers works of general medical image analysis literature
to get further knowledge and insight and infer more specific
data about the use of deep learning models (Table 1).
3. RESEARCH MOTIVATION
The development of new methods for automatically
segmenting and classifying images will be very helpful to
rheumatologists and radiologists. Caution should be exercised
when comparing studies and reporting performance indicators
because they may also be assessed in distinct ways in addition
to utilizing different datasets for evaluation. Increased data and
model sharing will take the field even more and increase the
research's reliability.

Table 1. Existing Review Articles on Bone Fracture Risk and Osteoporosis Image Analysis in the Aspects of BMD (Bone
Mineral Density), IPT (Image Processing Techniques), ML/DMA (Machine Learning/Deep Model Architecture), DQ (Dataset
Quality), and DKDM (Domain Knowledge Inclusion in Deep Models).

ML/
References Description BMD IPT DQ DKDM
DMA
[35] A Review of Deep-Learning-Based Medical Image Segmentation Methods -
9 - - -
[58] Osteoporosis Prediction in Trabecular Bone Using Machine Learning: A Review
9 9 - - -
[12] Deep Neural Networks for Diagnosis of Osteoporosis: A Review
9 - 9 - -
[13] A comparative study on the detection of osteoporosis using deep learning methods: A review -
9 9 - -
[14] Current and Emerging Diagnostic Imaging-Based
Techniques for Assessment of Osteoporosis and
Fracture Risk
9 9 - - -

[15] Computer-aided diagnosis systems for osteoporosis detection:, a comprehensive survey

9 9 - - -
[16] Artificial intelligence on the identification of risk groups for osteoporosis, a general review - -
9 9 -
[17] The genetic architecture of osteoporosis and fracture risk
9 -
- - -
[65] Current Concepts Review - The Assessment of Fracture Risk
9 9 - - -
Survey on Bone Fracture Identification
[66]
Techniques using Quantitative and Learning Based Algorithms 9 9 9 - -

[3] Machine Learning Solutions for Osteoporosis—A Review -

9 9 9 -
This survey Imaging Techniques and Artificial Intelligence Models for Osteoporosis Prediction
9 9 9 - 9

Fig. (6). Flow chart for model development.

6 Current Medical Imaging, 2024, Volume 20
This work is focused on an organized assessment of the
literature on osteoporotic fracture risk image analysis using
Deep Learning Models and Image Processing techniques,
leading to the formulation of several research topics. Numerous
studies have been done over the past decades on osteoporosis
image analysis that takes into account custom feature analysis
methods. As a result, this survey has been narrowed to
concentrate on the most recent five years (2016-2022) of
published studies using deep learning and image processing
techniques in the field of osteoporosis and bone fracture risk
with the help of image analysis. By providing answers to the
following questions, the targeted study sets the path for
formulating the problem statements.
P1: How the image processing techniques are supported in
data set preparation?
Motivation: The aim is to improve dataset quality so that
deep models can utilize it for greater accuracy.
P2: What other options are there for image processing to
improve the dataset quality?
Motivation: To gain a deeper understanding of the
currently used imaging methods and propose strategies for the
improvement of training datasets in the future.
P3: Is using supervised deep models to train or learn
features if the datasets involved in the existing deep learning
study sufficient?
Motivation: To obtain an in-depth knowledge of the
present supervised learning system, it is suggested to employ
semi-supervised learning or unsupervised learning, which uses
training data that is unlabeled.
P4: How to improve model performance by incorporating
domain information into deep learning models?
Motivation: The necessity of domain or expert knowledge
should be incorporated into the deep models to get improved
performance.
P5: Which method learning from scratch or transfer
learning, can be used?
Motivation: Either create a new model or use existing
models for transfer learning.
P6: How many self-explanatory deep models are created to
increase model credibility?
Motivation: Create a clear and easy-to-use model to grasp
the fundamentals of the model's decision-making process and
adjust the model for better performance. The process for model
development mentioned in Fig. (6) is explained below:
3.1. Collect and Preprocess Medical Images
Collect medical images from various sources and
preprocess them to remove any artifacts and enhance the image
quality. This may involve resizing, normalization, and filtering.
Annotate the images with relevant labels, such as the region of
interest, segmentation masks, or disease diagnosis.
3.2. Split the Data into Training, Validation, and Testing
Sets
Split the annotated data into training, validation, and
Inigo et al.
testing sets. The training set is used to train the deep learning
model, while the validation set is used to evaluate the
performance of the model during training. The testing set is
used to evaluate the final performance of the model.
3.3. Model Selection
Select an appropriate deep learning architecture, such as
convolutional neural networks (CNNs) or recurrent neural
networks (RNNs), for the task at hand.
3.4. Training Model
Train the model using the training data and appropriate
optimization techniques, such as stochastic gradient descent
(SGD) or Adam optimizer.
3.5. Hyperparameter Tuning
Adjust the hyperparameters of the model, such as learning
rate, number of layers, and batch size, to optimize the model's
performance on the validation set.
3.6. Evaluate the Model
Evaluate the performance of the model on the testing set.
This involves calculating metrics, such as accuracy, sensitivity,
specificity, and area under the curve (AUC).
3.7. Interpretation and Visualization
Interpret the results of the model and visualize the
performance using techniques, such as confusion matrix and
ROC curves.
3.8. Deployment and Integration
Once the model is trained and validated, deploy the model
for real-world use. This may involve integrating the model into
an existing clinical workflow or developing a new application
for medical image analysis.
4. REVIEW ON SEVERAL IMAGE PROCESSING
TECHNIQUES
Image processing is a branch of computer science. It uses
computing techniques to convert the captured data of an
imaging process into meaningful information (Fig. 7). Image
processing techniques are used to process digital images, such
as for medical imaging or for computer vision. Techniques
include burning, bleaching, fixing, and resizing images to
varying levels of quality. For medical images, preprocessing is
an important step in the image processing pipeline. Medical
images are highly sensitive to noise and can benefit from
filtering to improve overall image quality. In order to diagnose
and represent anatomical features in humans, such as bone, X-
ray imaging technology is used. The image that is obtained is
then processed using various image processing techniques,
such as Computer-Aided Diagnosis, image enhancement,
filtering techniques, Edge Detection, and segmentation, which
are favorable for technicians. In a patient who is in pain, it
might be challenging and time-consuming to pinpoint the
fracture. Medical imaging modalities are now crucial to
research and diagnosis [18].
Artificial Intelligence Models for Osteoporosis Prediction
Fig. (7). Flow of image processing model [18].
(a)
Fig. (8). (a) Normal Bone, (b) Osteoporosis image, (c) Fracture bone.
4.1. Image Acquisition
Image acquisition is the process of collecting an image
from many imaging modalities that may be used in image
processing and computer vision. These hardware systems often
include cameras, X-ray, CT, and MRI scanners, sensors, and
cameras. Since an image is necessary for the system to perform
any meaningful processing, it serves as both the first and most
crucial stage in the workflow sequence. Typically, the
technology captures an entirely unprocessed image. In all
research efforts, data preparation is essential. For bone
pictures, we should create a dataset. Currently, digital photos
are predominated. They could go through computer-assisted
preprocessing before analysis.
4.2. Image Preprocessing
Pre-processing is generally used on data to guarantee that
the image quality is increased so that it will learn and analyze
more effectively. Data modifications, such as normalization,
image reshaping, pixel brightness, transformation/brightness
correction, geometric transformation, image filtering and
segmentation, Fourier transform, and image restoration, are all
included in preprocessing. Gray-scaling is the technique of
transforming a continuous-tone image into an editable image
by a computer. The process of turning a gray-scale image into a
black-and-white one is known as image binarization (Fig. 8).
The existence of noise and the dark background of images
are the two topics that Bin Guan et al. examined. For these two
concerns, we must undertake image preparation. Then, to
Current Medical Imaging, 2024, Volume 20 7
(b) (c)
process the gray scale image, the morphological opening
procedure with a 21 X 21 kernel is used Fig. (9). The major
region can be seen, while the isolated noise in the image can be
removed by the opening operation. Here, the area
encompassing all bones and fractures is referred to as the
image's primary areas [19].
The total variation (TV) noise reduction technique has
been designed and studied, as Kanghyen Seo et al. revealed.
This study's goal was to examine and compare the image
quality using simulations to determine the normalized noise
power spectrum (NNPS) and contrast-to-noise ratio (CNR).
The results showed that the TV noise-reducing methodology is
the best way to guarantee accurate noise removal in X-ray
imaging systems [20]. A new approach, termed SACEN
(Simultaneous Automatic Contrast adjustment, Edge
Enhancement, and Noise Removal) algorithm, is put forth by
Mahendran et al. It can simultaneously modify the contrast,
enhance edges, and remove noise from X-ray images [21].
In this published study, Kirti et al. discussed using a
modified Harris corner point detector to identify noisy pixels
and responsive median filtering the spatial domain to reduce
Poisson noise in X-ray images. This technique is a quick, clear
way to forecast noise [22]. An enhanced self-adaptive filtering
technique is provided by Zhu et al., in which the filtering
coefficient is generated using a linear decay function. Then, the
X-ray medical image preprocessing system based on the
improved self-adaptive filter is built and constructed using a
field programmable gate array (FPGA) and other peripherals
8 Current Medical Imaging, 2024, Volume 20 Inigo et al.

[23]. In the study conducted by Bekkanti et al., the system
receives an X-ray image as input, which is preprocessed first. It
is necessary to filter the images since the PSNR values of a few
sample X-ray images are evaluated at the beginning. The
PSNR value varies between being higher for some photos and
lower for others. As a result, a filtering strategy is used, and
M3 filtering provides a higher PSNR value, making it a better
filtering technique for the system that has been proposed.
Features of an image are extracted using the proposed Harris
corner technique [24].
To remove the noise included in the original image, filters
are applied by blurring or masking the image. This is the same
as a mean filter that exhibits a bell-shaped hump with a
different kernel. In two dimensions, Gaussian filters are very
often symmetric. For edge detection, employ Gaussian filters
for unsharp masking (Fig. 10), i.e., edge detection [24].

(a)Original Image

(b)Preprocessed Image

Fig. (9). Image Enhancement by 21 X 21 kernels.

(a) (b)
Fig. (10). (a) Original Image, (b) M3 filtering Image [24].
Artificial Intelligence Models for Osteoporosis Prediction
In preparation for further processing, filtering changes the
quality of an image by changing the pixel values. Applying
filters can produce a number of effects, including boosting
contrast and adding a range of distinctive effects to
photographs. Median, Gaussian, mean, and Weiner filters are
the most frequently used filters in image processing. By
replacing the center value with the median of all pixel values,
median filtering keeps crisp edges. The image noise is reduced
using a Wiener and Gaussian filter. The average of all pixel
values is substituted for the center value via a mean filter.
Segmentation algorithms will become more effective as a result
of this transformation of data attributes.
4.3. Image Segmentation & Feature Extraction
Image segmentation is a pixel identification problem that
divides an image into equivalent sections. Segmentation is used
in medical image analysis to determine the outline of an organ
or anatomical structure in images. It is a vital and challenging
step in the processing of images. It is currently a prominent
topic in the study of images.
The following phases can be used to categorize the
segmentation of medical images:
1. Obtain a data set for medical imaging that typically
consists of a training set, validation set, and test set.
2. Resize and remove noise in the image
3. Employ the proper medical image segmentation
technique
4. Performance review of estimates.
According to Isinkaye et al. discussed various image
segmentation techniques for bone X-ray images to determine
which were most effective for prompt medical diagnosis. The
X-ray bone segmentation results showed that, compared to
previous medical image segmentation techniques, the active
contour model utilizing the snake model performed the best at
identifying the boundaries and contours of regions of interest
Fig. (11). Canny edge detection and harris corner [24].
Current Medical Imaging, 2024, Volume 20 9
[25]. Modern computer-aided fracture detection systems help
orthopedic doctors and radiologists by giving prompt, accurate
results. Automated X-ray picture classification should be the
first step in order to detect fractures automatically. As a result,
an effort has been made. In this study, a system is presented
that uses five image processing phases, including statistical
feature extraction, enhancement using adaptive histogram
equalization, and denoising using a high boost filter [26].
Rohini et al. proposed a framework for the classification of X-
ray images to classify the automated explanation to provide
efficient and effective results to physicians and radiologists for
decision-making. This methodology entails images being
preprocessed using the M3 filter for denoising, segmentation
by K-means clustering, followed by statistical feature
extraction [27].
Bharodiya et al.proposed a much better algorithm for
segmenting human X-ray images based on a Gaussian filter
and adaptive thresholding classification technique. This
algorithm is known as adaptive thresholding classification
(ATC) segmentation. This algorithm's attained accuracy and
precision are 98.014% and 95.122%, respectively [28]. Hrosik
et al. proposed a method for brain image segmentation with the
aim of detecting different primary tumors. Brain images are
segmented by the firefly algorithm combined with the k-means
clustering method in order to emphasize anomalies like glioma,
metastatic adenocarcinoma, metastatic bronchogenic
carcinoma, and sarcoma [29].
Finding the ROI (Region of Interest) is the initial step in
locating the image's edges. Prewitt, Sobel, and Canny are three
edge detection methods that are used in this situation. When
compared to the other two edge detection strategies, the canny
edge detection methodology performs the best. For feature
extraction, the Harris corner detection technique is used. The
most important required features of an image are extracted
using the proposed Harris corner technique (Fig. 11). To
identify the corners in an image, Harris corner detection is
used, which acts as an operator [24].
10 Current Medical Imaging, 2024, Volume 20 Inigo et al.

The experimental findings were backed by Peruri et al.,
who noted that Canny Edge Detection is regarded as the best
edge detection operator available. Even in raucous images, it
effectively recognizes faint edges in addition and shows road
features. First, the image is smoothed out using a mathematical
filter before the clever edge detection algorithm begins to
discover a good variety of edges in the image [30].
The threshold segmentation method was employed by
Sahu et al. to assess the improved image and identify bone
fractures in medical X-ray images. In this study, the image was
used as the input, and after noise removal, the x-ray image of
the right hand and the image of a hairline bone fracture were
segmented using simple thresholding, multiple thresholding,
and optimal thresholding methods, and then the results were
compared to determine which method was the most effective
for threshold image segmentation [31]. In addition, SIFT and
improved Haar Wavelet Transform both significantly enhanced
the quality of the X-ray image. In addition, in this work, “Bag
of Words” approaches based on k-means clustering were
utilized to extract enhanced features from SIFT. This method's
classification phase includes a traditional back propagation
neural network with 1024 neurons and three layers [32].

Table 2. Summary of the fields of image preprocessing, image segmentation, and classification related to bone image analysis.

Image Image Segmentation

Image
References Fracture Bone Name Pre-Processing Methods /Classification Methods Remarks
Modality
Used Used
[19] Arm fracture detection X-rays 21 × 21 kernel Noise removal • To remove isolated noise in the
image
• Enhanced for a larger dataset with
higher-quality images
[20] Noise reduction in X-rays Total variation (TV) noise Noise removal • Guaranteed accurate noise removal
radio-magnetic bone reduction technique in the X-ray image
• Using NNPS frequency ranges and
CNR value
[24] General fracture bone X-ray M3 Filters are used, PSNR, Canny Edge Detection, ROI • Harris corner detection, along with
SNR and Harris corner detection M3 filtering, gives better accuracy.
technique are used.
[25] Segmentation of X-rays, Various Filters are used Active contour model • Active contour model utilizing the
medical bone image CT, MRI snake model to detect smooth shapes
in the image
• Thresholding, Edge-based, Region-
based techniques will solve simple
medical bone image segmentation
[24] Longer fracture bone X-ray Various Filters are used Edge Detection • Shorter bone fracture detection has
to improve further
[30] Bone image X-rays, Various Filters are used Threshold Image • Identifying the regions of interest.
segmentation CT, MRI Segmentation
[31] General fracture bone X-ray, CT, Haar Wavelet Transforms, k-means clustering, Back • Enhancement and feature
MRI Scale-Invariant Feature propagation neural network Extraction are done with X-ray
Transform (SIFT) images.
• More datasets can be used to
improve the accuracy
[32] Fractured bone X-ray Gaussian Filters Canny Edge Detection and • Harris Corner method performs
Harris corner detection better recognition rate and has to
technique check with real-time datasets
[62] Image segmentation X-rays, Harris Hawks Optimization K-means and the Fuzzy • Results in terms of quality,
CT, MRI IterAg consistency and accuracy

Table 3. Comparison of six imaging systems [34].

Imaging System Imaging Method Imaging Basis Advantage

CT Mathematics reconstruction Absorption coefficient High-density resolution
MRI Mathematics reconstruction A variety of parameters Multiple functions
US Mathematics reconstruction Acoustic impedance interface Safe, dynamic, and repetitive
OCT Mathematics reconstruction Based on the interferometer principle High resolution
PET Mathematics reconstruction Using positron radionuclide labeling Accurate location and high clinical value
X-Ray Transmission projection Density and thickness Strong penetrability
Artificial Intelligence Models for Osteoporosis Prediction
Fig. (12). Neural-network model architecture that ensembles image data and clinical covariates [6].
For improving medical images, various image processing
methods are investigated (Table 2), and some key factors, such
as quality, consistency, and accuracy, are inferred. The
application of computer-aided diagnosis to medical images has
been significantly hampered by this issue, a well-known fitting
problem in image processing techniques because of the lack of
datasets. It is possible to find a solution to the clustering issue
with more data, which would enhance the classification
performance. Another active field of research at the moment is
automation for medical image diagnosis or prediction. Recent
AI-based techniques can be used to segment and classify
medical images for computer-aided diagnosis.
5. MACHINE LEARNING AND DEEP LEARNING
TECHNIQUES FOR BONE IMAGE ANALYSIS
Artificial Intelligence is a technology that uses algorithms
to assist humans in tasks previously thought to be impossible.
The technology is currently being used for recognition and
analysis of medical images. AI-based image processing helps
in reducing the number of errors and improving the accuracy of
image processing. Modern approaches to medical image
processing often require multiple steps that span a wide range
of scales. This is due to the non-linear nature and the diversity
of numeric feature space. Deep learning, in particular, has
significant potential for solving complex problems involving
both image pixel manipulation and data transformation.
As per statistics, 20% of men and 50% of women over 50
will sustain an osteoporosis-related fracture, with hip fractures
being the most serious due to the associated mortality,
disability, and societal and personal costs. Dual-energy X-ray
absorptiometry (DEXA) is the gold standard for determining
bone mineral density (BMD) in the proximal femur and lumbar
spine in order to diagnose osteoporosis [33]. Early detection of
osteoporosis is crucial for the prevention of osteoporotic
fractures since therapeutic medication therapies are more
successful when administered before fractures have
Current Medical Imaging, 2024, Volume 20 11
manifested. Due to the quick growth of AI technology, the
application of AI technology to mine clinical data has emerged
as a major trend in the medical industry. In order to address
clinical problems, medical image analysis is performed by
examining the images obtained by medical imaging systems
(Table 3). The objective is to increase the quality of clinical
diagnosis and extract useful information [34].
In Image, the deep learning method operates directly on
raw pixels and learns features by itself. Image preprocessing is
the steps taken to format images before they are used for model
training and inference. DL has some special libraries for
preprocessing the image.
Deep learning libraries like Keras, Tensor Flow, numpy,
scipy, and matplotlib can be used for better results. Medical
images are different from natural images. There are differences
between different medical images. This difference also affects
the adaptability of the deep learning model during
segmentation. The noise and artifacts of medical images are
also a major problem in data preprocessing [35].
The Convolutional Neural Network (CNN) is a classic
model produced by the combination of deep learning and
image processing technologies. As one of the most
representative neural networks in the field of deep learning
technology, it has made many breakthroughs in the field of
image analysis and processing [35]. Even though a pre-trained
model minimizes the training time and the quantity of images
needed to produce an effective classifier, all CNNs were
employed for transfer learning with fine-tuning [36]. The
Python package PyTorch was used to carry out the DL process
[6]. Pickhardt et al. proposed a comparison of an older feature-
based image processing tool and a new deep learning technique
assessed for bone mineral density on heterogeneous CT
images. It was compared with manual reference standard to
design, test, and validate a deep learning (DL) tool that
upgrades a prior bone mineral density (BMD) technique for
12 Current Medical Imaging, 2024, Volume 20
processing feature-based CT images. It was concluded that the
new DL BMD tool gets a higher success rate than the older
feature-based image processing tool, and its outputs can be
targeted for higher specificity or sensitivity for osteoporosis
assessment [37].
The effectiveness of the ResNet18 [38], ResNet34 [39],
GoogleNet [40], EfficientNet b3 [41], and EfficientNet b4 is
known [41]. Among them, ResNet and GoogleNet were
previous champions of the ImageNet Large Scale Visual
Recognition Challenge, a contest between computer-based
image recognition models. Here it is applied in the latest CNN
model with EfficientNet (Fig. 12), which is smaller and faster
than the other CNN models [42]. The fracture risk that people
with diabetes and osteoporosis encounter has not been further
researched, according to Chen et al. The fracture risk of
patients with diabetes and osteoporosis is predicted using a
hybrid model that combines XGBoost and deep neural
networks. Additionally, the impact of the patient's
physiological parameters on fracture risk was examined [43].
U-net, one of CNN's most significant semantic segmentation
frameworks, is crucial to the study of medical images [44, 45].
Upsampling and downsampling make up the majority of the U-
net network. The U-net network's large number of feature
channels in the upsampling phase, which enables the network
to convey contextual information to higher resolution layers, is
a large asset.
Prior to feeding the grayscale DXA images as input for the
convolutional neural network, they are preprocessed and
automatically cropped to 150 X 150 pixels. Convolutional
layers (conv1–conv4) with pooling layers (pool1–pool4)
gradually reduce the size of the feature maps by extracting
features at various degrees of abstraction. A fully linked layer
sends the retrieved characteristics to classification for further
processing. A single neuron in the network's output layer
produces the categorization output value, which ranges from 0
to 1. Below each layer, the number of kernels is displayed,
along with the size of the resulting feature map (Fig. 13) [46].
Fig. (13). CNN architecture [9].
Inigo et al.
The following performance metrics were used to assess the
CNN models' performance in modality-specific transfer
learning with fine-tuning and ensemble learning: (1) accuracy,
(2) precision (positive predictive value (PPV), (3) recall
(sensitivity), (4) specificity, (5) negative predictive value
(NPV), (6) F1 score, and (7) AUC score [9].
Although deep learning-based models only had limited
datasets to validate them on, they offered a stronger correlation
between predicted and reference values [9, 47, 48]. An
accuracy of 82% was attained for the detection of osteoporosis
in bigger research examining the performance of simulated T-
scores on a larger dataset of 1843 CT-DXA sets [49]. This
method assessed individuals for osteoporosis at no additional
cost, time, or radiation exposure by using radiographs that had
already “been taken” for other therapeutic indications. For
instance, a number of research used metrics based on computed
tomography (CT) to calculate bone mineral density (BMD)
[48], classify osteoporosis, simulate DXA T-scores [49], and
forecast fracture outcomes [50].
The general object detection algorithm serves as an
inspiration for deep learning techniques for fracture
identification and detection. Both single-stage and two-stage
detectors have recently helped to popularize generic object
detection. R-CNN was the first to introduce two-stage
detectors, and as Fast R-CNN [51] and Faster R-CNN [52]
evolved, they furthered the improvements. In order to increase
the effectiveness of detectors and enable end-to-end training of
the detectors, the faster R-CNN developed a region proposal
network. Numerous techniques to improve Faster R-CNN from
many angles were introduced following this major moment.
For instance, FPN [53] used the architecture of a multiscale
feature pyramid to minimize the scale variance. Faster R-CNN
was expanded to a multistage detector by Cascade R-CNN
[54]. The most effective general object detection technique to
date has been two-stage detectors, which have been widely
utilized in many fields.
Artificial Intelligence Models for Osteoporosis Prediction
Fig. (14). Hip Osteoporosis prediction [58].
A framework for semi-supervised LA segmentation from
3D MRIs was proposed by Zhao et al. using Context-aware
Network (CA-Net). To learn the contextual information from
the 3D MRIs, the proposed framework incorporates
Transformers into the V-Net. Then modifies CNN's output to
ensure that Transformers and the original V-Net encoder are
effectively integrated into a new encoder because both the
input and output of V-Net are 3D images. The proposed CA-
Net produces segmentation results with dice scores of 88.14.
Backbone networks are used in the majority of object
detection techniques to extract feature maps from the raw
images. Guan et al. developed a unique backbone network
based on deep residual networks and dilated convolution to
extract thigh fracture information [55].
For radiologists, rib fracture detection is a time-consuming
and hard task. This study sought to introduce a unique deep
learning-based rib fracture detection method that can assist
radiologists in quickly and accurately diagnosing rib fractures
in chest computer tomography (CT) images. The training set,
the validation set, and the testing set each received 1507, 100,
and 100 patients, respectively, according to the examination
time. The sensitivity and false positives of the deep learning
system were assessed using a Free Response ROC analysis. To
assess the diagnostic effectiveness of this system against
radiologists, precision, recall, F1-score, negative predictive
value (NPV), and detection and diagnosis were used as
evaluation criteria [56].
Jang et al. discussed VGG16 equipped with a nonlocal
neural network and developed a deep neural network (DNN)
model. The confusion matrix was calculated, and the accuracy,
sensitivity, specificity, positive predictive value (PPV), and
negative predictive value (NPV) were evaluated (Fig. 14).
DNN model that could predict osteoporosis only from a single
hip radiograph with>80% accuracy and>90% sensitivity with
near 70% specificity based on VGG16 equipped with a
nonlocal neural network (NLNN) model was proposed by Jang
R et al. [57].
Current Medical Imaging, 2024, Volume 20 13
Dagan et al. developed CT-based prediction tools that
automatically calculated fracture risk scores based on data from
chest or abdomen CT scans. The tool was created by
integrating three bone imaging biomarkers generated by deep
learning algorithms and adding CT metadata of patient age and
sex. These three prediction tools (CT-based, FRAXnb, and
FRAXnb-CT) were compared for the two outcomes assessed
by the FRAXnb tool: hip fractures and major osteoporotic
fractures [50]. In addition, the fracture risk of patients with
diabetes and osteoporosis has not been further studied. In this
paper, a hybrid model combining XGBoost with a deep neural
network was used to predict the fracture risk of patients with
diabetes and osteoporosis and investigate the effect of patients’
physiological factors on fracture risk [43].
Based on the U-Net, our pure dilated residual U-Net
(PDRU-Net) has a decoder path for merging the extracted
global and local information and an encoder path for extracting
the information needed to produce dense predictions. Our
network's DC, which stands at 97.3%, is much higher than
those of the U-Net and FusionNet, which are, respectively,
91.8% and 94.4%. Anam et al. discussed that trabecular bone
holds the utmost importance for early bone loss. Diseases like
osteoporosis greatly affect the structure of the trabecular bone,
which results in different outcomes like a high risk of fracture
[58].
As an emerging biomedical image processing technology,
medical image segmentation has made great contributions to
sustainable medical care. Now it has become an important
research direction in the field of computer vision. With the
rapid development of deep learning, medical image processing
based on deep convolutional neural networks has become a
research hotspot [35]. Automatic segmentation of brain images
is a prerequisite for quantitative assessment of the brain in
patients of all ages. An important step in brain image
preprocessing involves removing nonbrain regions, such as the
skull [59]. There are outstanding segmentation networks, such
as U-Net, Mask R-CNN, Refine Net, and sDeconvNet, which
have a strong advantage in processing fine edges [35].
14 Current Medical Imaging, 2024, Volume 20
Fig. (15). U-net Architecture for biomedical image segmentation [36].
U-Net architecture (Fig. 15) for biomedical images was
widely used in medical image segmentation. Due to its
excellent performance, U-Net and its variants have been widely
used in various subfields of computer vision (CV) [36]. Jial et
al. stated multiorgan segmentation aims to segment more than
one organ simultaneously, which is widely used for abdominal
organ segmentation. The segmentation results of each pixel
were fused with the results of other FCNs to generate the final
segmentation output. The technique produced higher accuracy
for big organs, such as the liver (Dice value of 0.937) but
yielded lower accuracy while dealing with smaller organs, for
instance, the pancreas (Dice value of 0.553). FCN has also
been used for multiorgan segmentation from 3D images [60].
Convolutional Neural Network (CNN) learning with
VGGSegNet and VGG-Unet models was applied to a USCT
image dataset in order to achieve an automatic segmentation of
the region. Thus, we improved the Variable Structure Model of
neurons (VSMN) and applied it to medical images to get a
significant increase in data, given the problem of the
unavailability of USCT images [61].
Using AI for image augmentation helps to increase the
efficiency of anomaly detection. The segmentation procedure is
essential for making predictions. It currently stands as an
important subject that needs more research in the field of
computer vision. Prediction of osteoporosis in multiple bones,
including the rib, spine, knee, femur, and hip, was done using
inferred knowledge from a variety of existing models,
including CNN, FRAX, DNN, U-net, GoogleNet, AlexNet, and
Resnet. The ROI from bone X-Ray pictures can be determined
with the aid of ground truth and mask images, summarized in
Table 4.
6. DISCUSSION AND SCOPE OF POSSIBILITIES
Diagnosing various diseases through artificial intelligence
realizes the idea of sustainable medical treatment. It has
become a powerful tool for clinicians. But it is still an open
Inigo et al.
problem, so we can expect a series of innovations and research
results in the next few years. Improved deep learning method
has strong potential application in real clinical environments.
Data-driven feature representations, especially in an
unsupervised manner, have helped to enhance accuracy, and it
would be desirable to devise a new methodological architecture
involving domain-specific knowledge. The segmentation
accuracy is not high, the number of medical images in the data
set is small, and the resolution is low. The inaccurate
segmentation results are unable to meet the actual clinical
requirements. Among technological advancements that can
alleviate the high demands on high-quality, large-scale datasets
could be one of the future developments in this area. For
medical image segmentation, deep learning has performed very
well. Many new methods are used to improve the accuracy and
robustness of segmentation continuously. It is necessary to
develop an algorithmic technique to efficiently handle images
acquired with different scanning protocols so that it would not
be necessary to train modality-specific deep models. A plan
must be put forth that has the capacity to preprocess and resize
the images to effectively disseminate the normal and abnormal
bone in different modality images. Workload and time taken
for diagnosis can also be considered. After carefully analyzing
the review process (Fig. 16), it is observed that,
For performance analysis, a benchmark dataset and
evaluation criteria should be constructed. It is
challenging to compare the deep models focused on
image analysis based on the accuracy determination
perspective in many of the proposals.
Manual annotation of images is a tedious and costly
process that causes problems with labelled dataset
acquisition. Additionally, it offers a new line of
research into semi-supervised and unsupervised deep
learning models for medical image processing.
Semi-supervised deep models use co-training, self-
Artificial Intelligence Models for Osteoporosis Prediction Current Medical Imaging, 2024, Volume 20 15

labeling, ensemble approaches, consistency-based
methods, and generative methods to analyze medical
image data. These techniques may be employed to
analyze X-ray images and both labelled and unlabeled
datasets for training.
Using expert knowledge in deep decision-making
models is significant. This expert knowledge can be
encoded in such a way that it can be used to train a
deep model. For instance, in addition to CNN's general
features, customized features like color, texture, and
geometric features can be used for anomaly
identification.
Attention-guided learning and the incorporation of
expert knowledge into the deep model for the decision-
making process, so the deep learning models enhance
the explainability.

Fig. (16). Referred paper for analysis.

Table 4. Outline approaches of deep learning in the fields of image segmentation and classification.

Image Remarks
References Objective Model Used Data Sets Used
Modality
[6] Hip DEXA, X-ray CNN, Resnet, Custom Data set-1131 images • Adding clinical covariates improved the
Effi sensitivity and AUC score for osteoporosis.
cient Net b3
[2] General fracture X-ray CNN, SoftMax Around 100 images of normal and • Image quality can be increased.
bone Layer fractured images are compared • Train large datasets for accuracy.
[19] Arm bone X-ray Nearly 4000 arm fracture X-ray • MURA datasets are used, and images are in
fracture CNN, R-CNN, radiographs collected from MURA low quality.
FPN, Res-Net dataset • Trained using the ground-truth bounding-box
annotated images.
[46] Lumbar spine, DEXA Kuopio -2949 images • This model classifies lumbar scoliosis and
CNN
Hip, BMD BMD risk factor.
[9] Spine, Hip DEXA, Custom Dataset- 5164 and 18175 • BMD Evaluation is done based on these
CNN, Relu,
FRAX BMD Images parameters sensitivity, specificity, positive
VGG16, Resnet
predictive value, and negative predictive value.
[55] Thigh bone X-Ray Dataset including 3842 thigh • Dilated bottleneck blocks are used to predict
fracture X-ray radiographs fracture risk.
DCFPN, Res-net
collected from Linyi People’s
Hospital
[56] Rib CT A total of 1707 patients were • Time of radiologist assisted with this
U- net, Dense
included in this study from a single detection system was reduced by 65.3 s.
net, CNN
center
[57] Femur, Hip DEXA Custom Datast-1012 Images • External Validation is done for real-time
DNN, CNN, datasets.
VGG-16 • Confusion Matrix was also calculated for
better accuracy.
[63] Spine, Femur, DEXA Custom Datasets-600 Images • CAOD model increases the preciseness and
CAOD
Hip accuracy of BMD measurements.
16 Current Medical Imaging, 2024, Volume 20
CONCLUSION
This study was conducted to review the deep models and
image processing techniques used to assess the risk of fracture
in osteoporosis bone images. The importance of applying deep
learning for image analysis also examines the dataset used and
its benefits and challenges [67 - 71]. Existing deep models are
observed to be supervised learning models that only need a
limited amount of labeled training data. The quality of the
training data is found to be low due to the limitations of the
current medical imaging data sets and data enhancement, such
as geometric transformation, color, space enhancement, and
lack of labeled datasets affecting the classification accuracy
overall. In the future, deep models can incorporate domain
knowledge to enhance decision-making, and target-specific
learning can be acquired through an attention mechanism.
CONSENT FOR PUBLICATION
Not applicable.
FUNDING
None.
CONFLICT OF INTEREST
The authors declare no conflicts of interest, financial or
otherwise.
ACKNOWLEDGEMENTS
Declared none.
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