Bone quality of the femoral bone represents a major determinant in the choice of therapeutic options and durability of total hip replacement. Several x-ray classifications have been proposed to help in the assessment of trabecular and/or cortical bone quality. Recently, it was shown that bone quality is inadequately assessed by the two most common used roentgenographic indices, i.e. the Singh and Engh indices and it was postulated that iliac crest bone biopsies which provide information on the systemic (iliac) bone status, offer a more precise index of bone quality. In a previous study we examined both systemic abnormalities in patients undergoing total hip replacement. Even though there was good overall agreement between bone remodelling activities measured at the two sites, local changes seemed to predict, somewhat better, patients at risk of complications. Nonetheless, in all the above mentioned approaches aimed at assessing bone quality, the shape of the proximal femoral bone has not been taken into consideration. The purpose of the present study was (1) to investigate whether different roentgenographic patterns of proximal femoral bones can be identified and quantitatively validated taking into account shape and cortical thicknesses and if so, (2) to reconcile those patterns with demographic characteristics, biochemical data and histologic parameters of femoral bone structure and cellular activities.