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Screening for Osteoporosis -Making an Informed Choice of DXA or Calcaneal QUS

  • Dr Varsha's Health Solutions


Osteoporosis is characterized by a reduction in bone mass or bone mineral density and an increase in fracture risk. As it runs a silent course before presenting with a fracture, the importance of screening especially of risk groups for timely diagnosis and treatment, cannot be overemphasized. Often in developing countries, where access to labs and devices like DXA may be limited, onsite high-volume screening can contribute significantly in diagnosing Osteoporosis cases and contribute towards reduction in morbidity and economic burden due to development of fractures. Though DXA is the gold standard for Osteoporosis diagnosis, recently calcaneal quantitative ultrasound is emerging as a convenient, portable, low cost and radiation free device for in-clinic or onsite screening. Therefore, the differences in parameter interpretation and evaluation, along with relative advantages and disadvantages of using calcaneal QUS over DXA should be well understood before making an informed choice.
ARC Journal of Orthopedics
Volume 4, Issue 1, 2019, PP 9-13
ISSN 2456-0588
ARC Journal of Orthopedics Page | 9
Screening for Osteoporosis Making an Informed Choice of DXA
or Calcaneal QUS
Varsha Narayanan*
Health and Pharmaceutical Consultant, Dr Varsha’s Health Solutions, Andheri west, Mumbai India
Osteoporosis is a disease characterized by low
bone mass (bone mineral density- BMD),
decreased quality of bone tissue, and increased
risk of fracture. [1] The loss in bone density
usually continues silently over many years and a
fracture may often be the first clinical
manifestation usually of advanced disease by that
The common Osteoporotic fractures sites include
the hip, spine, wrist, and shoulder. [1, 2]
Osteopenia refers to decreased bone mineral
density (BMD) as compared to normal peak
density, but not low enough to significantly
increase fracture risk and be considered as
Osteoporosis, however it is a risk factor for
Osteoporosis. [1] A single cause of Osteoporosis
is not established therefore risk factor
identification often helps in selecting screening
groups to facilitate timely diagnosis. (Table 1).
Over 200 million people worldwide, and
approximately 30% of all postmenopausal
women have Osteoporosis in the United States
and in Europe. [13] In India more than 50 million
people are either osteoporotic (T-score lower
than-2.5) or have low bone mass (T-score
between-1.0 and-2.5), and studies indicate that
Osteoporosis and Osteopenia or low bone mass
may occur at a relatively younger age in Indian
population. [14] Screening has an important
place in early diagnosis, care and treatment of
However, for mass screening or camps, cost and
portability of equipment are realistic challenges
and limitations. Though Dual-energy X-ray
Absorptiometry (DXA or DEXA) remains the
gold standard of diagnosis of Osteoporosis, the
calcaneal Quantitative Ultrasound (QUS) has
been increasingly used in screening camps due to
it lower cost, easy transportation and
convenience. Therefore, it becomes pertinent to
understand how the calcaneal ultrasound
compares to the standard DEXA, and what
should be its rational and scientific place for
measuring bone mineral density (BMD) for the
screening and diagnosis of Osteopenia and
*Corresponding Author: Varsha Narayanan, Health and Pharmaceutical Consultant, Dr Varsha’s Health
Solutions, Andheri west, Mumbai India. Email:
Abstract: Osteoporosis is characterized by a reduction in bone mass or bone mineral density and an increase
in fracture risk. As it runs a silent course before presenting with a fracture, the importance of screening
especially of risk groups for timely diagnosis and treatment, cannot be overemphasized. Often in developing
countries, where access to labs and devices like DXA may be limited, onsite high-volume screening can
contribute significantly in diagnosing Osteoporosis cases and contribute towards reduction in morbidity and
economic burden due to development of fractures. Though DXA is the gold standard for Osteoporosis diagnosis,
recently calcaneal quantitative ultrasound is emerging as a convenient, portable, low cost and radiation free
device for in-clinic or onsite screening. Therefore, the differences in parameter interpretation and evaluation,
along with relative advantages and disadvantages of using calcaneal QUS over DXA should be well understood
before making an informed choice.
Keywords: DXA, DEXA, QUS, Osteoporosis, T score, BMD, Fracture
Screening for Osteoporosis Making an Informed Choice of DXA or Calcaneal QUS
ARC Journal of Orthopedics Page | 10
Table1. Risk factor identification for Osteoporosis screening
90% hip fractures occur in people aged ≥50 years. (independent risk factor)
Bone mineral density reduces with age.
Female gender[4]
Post-menopausal women are more susceptible to bone loss than men due to reduced
estrogen hormone which is important in bone formation.
Women are more likely to sustain an osteoporotic fracture than men with a 40-50%
lifetime risk in women, compared to 13-22% in men
Peak bone mass reduced by late menarche.
Premature menopause, especially before the age of 45, is a strong determinant of bone
loss and increased risk of fracture [1]
Hysterectomy, with removal of ovaries, increases the risk for Osteoporosis
Osteoporosis is more common in Caucasian and Asian populations
Lower incidence of Osteoporosis and hip fractures in black than in white people
Family history[6]
Parental history of fracture (especially hip fracture) is associated with increased risk
of fracture (independent of BMD)
Past fracture
A previous fracture increases the risk of any fracture by 86%,
Double risk (1.86 times) of a second fracture
comorbidities and
Some systemic conditions constitute secondary risk factors that directly or indirectly
affect bone remodeling, mobility and balance, and increased risk of falling and
sustaining a fracture
Like Asthma, Crohn’s or celiac disease, Rheumatoid arthritis, Hematological
disorders or Malignancies, Hypogonadal states, Endocrine disorders like Cushing’s
syndrome, Hyperparathyroidism, Diabetes and Chronic Renal Failure.
Some drugs directly weaken bone or increase fracture risk due to fall or trauma.
Like Corticosteroids, Immunosuppressant (calcineurin inhibitors), L-Thyroxine,
Progesterone treatment, Aromatase inhibitors, Certain Antipsychotics, Antiepileptics,
Lithium, Methotrexate, Heparin, Antacids and Proton Pump Inhibitors
Associated with lower BMD, reduced body weight, earlier menopause, increased
metabolic breakdown of exogenous estrogen in women.
BMD 2% lower in smokers than in non-smokers for each 10-year increase in age (6%
at age 80 years)
Cigarette smoking is independent risk factor for hip fracture
Physical loading and mechanical stress increase BMD
Certain forms of exercise may retard bone loss.
Epidemiological relationship exists between physical inactivity in elderly and the risk
of hip and vertebral fracture.
Dual-energy X-ray absorptiometry
(DXA, previously DEXA) measures bone
mineral density (BMD). Two X-ray beams, with
different energy levels, are aimed at the
patient's bones (hip and lumbar spine) and
the bone mineral density (BMD) is determined
from the absorption of each beam by bone after
soft tissue absorption is subtracted.[15] Dual-
energy X-ray absorptiometry is the most and
thoroughly studied bone density measurement
technology and is the gold standard for
measuring BMD and diagnosing Osteoporosis.
Bone densities are expressed as T score or Z
score. [16] T score expresses BMD in
comparison to a young adult of the same gender
with peak BMD. A normal T score is ≥ -1.0, low
bone density (Osteopenia) is between -1.0 and -
2.5, and Osteoporosis is -2.5. Z score expresses
BMD in comparison to the average BMD of a
male or female of their age and weight. Severe or
established Osteoporosis refers to a T-score more
than -2.5 standard deviations below the young
adult female reference mean in the presence of
one or more fragility fractures.
Quantitative ultrasound (QUS) has recently
emerged as a convenient and popular screening
tool for Osteoporosis, because it is portable,
easier to handle, lower in cost and does not emit
ionizing radiation, especially in developing
countries where dual-X-ray absorptiometry
devices are less accessible to the general
population.[17] QUS employs high frequency
sound waves with an emission and receiver
probe, to determine bone quality, bone
microarchitecture and mechanical parameters by
studying speed (Speed of Sound - SOS) and
Screening for Osteoporosis Making an Informed Choice of DXA or Calcaneal QUS
ARC Journal of Orthopedics Page | 11
attenuation (Broadband Ultrasonic Attenuation-
BUA) of ultrasonic waves. Sophisticated devices
use additional QUS indices like eBMD
(Estimated Bone Mineral Density) which can be
calculated from the SOS and BUA.18
Longitudinal transmission is more often used,
and the preferred, most researched and
recognized bone segment measured is the
calcaneus as it consists of 95% trabecular bone
and has two lateral surfaces to facilitate the
movement of ultrasound through it.
In the classification of low bone density using
DXA, T-score with cut-off points of ≤-1.0 SD for
Osteopenia and -2.5 SD for Osteoporosis are
used, however, simply applying the DXA cut-
offs in QUS measurement can significantly
underestimate the true prevalence of
Osteoporosis. This was seen in a Korean study
(Hologic Sahara QUS device - eBMD) where
applicable T-scores for women and men were -
2.25 and -1.85, respectively as compared to T-
score of -2.5, the WHO threshold for
Osteoporosis. [19] Another device (Osteometer
DTUone) has T score cut offs of -1.45 and -2.10
for BUA and SOS. [20] Reference ranges maybe
affected by ethnicity (Caucasian reference BMD
range is higher than Asian) and gender. In India
and Asia, the light weight Furano CM-200 QUS
using SOS parameter is commonly used in
Osteoporosis screening camps.
The optimal T-score threshold for Osteoporosis
diagnosis in QUS was calculated in eight studies
where the value varied between -1 and -2.6, with
a DXA T-score of -0.9 to -3.3 with one study
proposing a T-score threshold as low as -3.65.
[21] In most of the studies the QUS T score cut
off was either higher (average -2.2+/-0.8) or
equal to DXA cut off which correlates with other
studies above.
Therefore, the QUS and DXA measurements
should not be compared with each other using the
same T-score criteria, because of different bone
properties measured and different reference
populations. A good predictive relationship
between hip bone mineral density, as estimated
by calcaneal QUS, and direct DXA measurement
has been seen, however this correlation decreases
for lumbar spine. [22, 23] In patients with
Osteoporosis determined by calcaneal QUS or
DXA in a Brazilian study, complementing with
X-ray was suggested for predicting vertebral
fracture. [24]
Based on the population data, investigators have
found that 1.455 for the right QUS T score and
1.48 for the left QUS T score achieved adequate
screening parameters to identify Osteoporosis.
[25] Cutoff scores produced a sensitivity of 41%
and a specificity of 86.6% for the right QUS T
score and a sensitivity of 51.3% and a specificity
of 83.3% for the left QUS T score. With a higher
QUS T score cut-off of -1.25, sensitivity was
higher at 80.4% with a specificity of 59.7% as
seen in a study from China. [26] A meta-analysis
of 25 studies to assess the accuracy of
quantitative ultrasonography compared with
DXA in identifying patients with Osteoporosis,
various quantitative ultrasonography index
parameter cutoffs were used, and the results
varied widely in sensitivity and specificity for
identifying individuals with a T-score of -2.5 or
less on DXA. No quantitative ultrasonography
cutoff existed at which sensitivity and specificity
were both high. [27]
Using the WHO cutoff value for the definition of
osteoporosis based on the t-score of 2.5 the
sensitivity and specificity of DXA were seen to
be 88.2% 62.5%. [28]
Also, QUS cannot be used for diagnostic
classification or staging of Osteoporosis, and it is
not clinically useful for monitoring the effects of
therapy. [29] Physiologically, calcaneal bone
tissue undergoes remodeling much more slowly
than central bone (spine and hip). Since bone
mineral content changes at different rates in
different sites of the body, QUS which evaluates
a single site will not be as accurate as a more
composite evaluation by DXA therefore early
osteoporotic changes may not be captured as
effectively by QUS as they would be by DXA
scan. [30] Analysis has shown, women diagnosed
by QUS are four times more likely to have a
fracture in the following year than women
screened with DEXA. [31]
Table 2 summarizes the relative advantages and
disadvantages of Calcaneal QUS versus Gold
standard DXA. For developing countries,
Calcaneal QUS can serve as a useful tool for
screening but does not have the value of
monitoring changes over time. Moreover,
different QUS machines have different cut off
parameters therefore cannot be compared either
with DXA or with each other over time. However
Calcaneal QUS, has the advantage of
convenience, mass use, low cost, avoiding
radiation and easy transport and portability. Its
results corroborate with DXA for predicting hip
fractures. Traditional WHO DXA cut offs should
Screening for Osteoporosis Making an Informed Choice of DXA or Calcaneal QUS
ARC Journal of Orthopedics Page | 12
not be applied to Calcaneal QUS, and the same
should be based on individual device
recommendations. With these points in mind, a
QUS device maybe chosen for screening
Osteoporosis risk groups especially in
developing countries.
Table2. Comparative advantages and disadvantages of DXA and Calcaneal QUS
Most studied, gold standard and first line screening
method recommended by standard guidelines[30-32]
Done at multiple sites like hip, and spine
Standardized T score cut offs for low bone mass and
Can be used for diagnosis and monitoring response to
Can be used for diagnostic classification and disease
Can pick up early disease
Difficult to transport device, requires skill in usage.
Not conducive for camps and high-volume onsite
High cost
Exposure to ionizing radiation not advised during
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Citation: Varsha Narayanan, Screening for Osteoporosis Making an Informed Choice of DXA or Calcaneal
QUS. ARC Journal of Orthopedics. 2019; 4(1):9-13. 10.20431/2456-0588.0401003.
Copyright: © 2019 Authors. This is an open-access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original author and source are credited.
Introduction. There is a need to search for new publicly available methods for screening and diagnosing bone lesions in patients with liver cirrhosis (LC), one of which the detection of changes in individual parameters of the erythrogram and their combination in a routine general blood test could be. The aim of the study. To characterize the parameters of erythrogram and their constellation in patients with liver cirrhosis of various etiologies with osteopenia and osteoporosis, to find out their diagnostic value. Materials and methods. The study involved 79 patients with LC (women - 22; men - 57 aged 18 to 66 years) with bone mineral density (BMD) disorders (experimental group) (62 (78.48 %) , which is divided into 2 subgroups: patients with LC with osteopenia (38 (48.10 %) and osteoporosis (24 (30.38%)) and without it (comparison group (17 (21.52 %)). The control group consisted of 25 healthy individuals of the same gender and age. We studied the characteristics of changes in individual erythrogram parameters and their constellations: sensitivity (Se), specificity (Sp), accuracy (Ac), positive and negative predicted values (PPV and NPV), the likelihood ratios of positive and negative result (LR + and LR-), post-test probability of bone damage, the difference between the frequency of cases. The relationship between individual erythrogram parameter or constellation and bone damage was considered statistically confirmed at the modulus of G. U. Yule's coefficient of association (YCA) more than 0.5 or contingency coefficient (CC) more than 0.3. Results. We found the confirmed inverse stochastic relationship between the constellation «normal hemoglobin (HGB) + normal mean cell hemoglobin (MCH) + increase in red cell distribution width in percent (RDWC)», which may be combined with normal red blood cells (RBC) and/or normal mean corpuscular hemoglobin concentration (MCHC), and each of the bone lesions (with osteopenia: YCA = -0.69; CC = -0.33, with osteoporosis: YCA = -1.00, CC = -0.39), which most likely indicates BMD within normal limits. The individual erythrogram parameters and their constellations diagnostically valuable for osteopenia were not identified. We found such changes of the individual erythrogram parameters: revealed highly sensitive decrease in RBC, as the the most valuable (Se = 95.83 %; NPV = 83.33 %; LR- = 0.14; post-test probability of osteoporosis in its absence - 5.82%), decrease in HGB, decrease in hematocrit (HCT), moderately sensitive increase in red cell distribution width standard deviation in femtoliters (RDWS) (Se = 87.50-95.83%; NPV = 66.67-80.00 %; LR- = 0.17-0.35) and highly specific decrease in MCH (Sp = 94.12 %; PPV = 80.00 %; LR + = 2.83), between which and osteoporosis the direct stochastic relationship was confirmed (YCA = 0.52-0.81), being characteristic for the diagnosis of osteoporosis. Among the constellations, «normal RBC + normal mean corpuscular volume (MCV) + normal MCHC» and «normal RBC + normal MCH + normal MCHC + normal RDWS» were found indicating the absence of osteoporosis, as evidenced by the presence of an inverse stochastic relationship between constellations and osteoporosis (YCA = -1.00; CC = -0.33). Also the moderately sensitive constellation «decrease in RBC + increase in RDWS» (Se = 83.33 %; LR- = 0.35) and constellations - highly specific «decrease in MCV + increase in RDWS» and the most specific (most valuable) «decrease in RBC + decrease in MCV + increase in RDWS» were found which can be combined with a decrease in HGB, and/or a decrease in HCT, and/or an increase in RDWC, and/or normal MCHC (Sp = 94.12-100.00 %; PPV = 88.89-100,00 %; LR + = 5.67 - tends to infinity), between which there and osteoporosis there is a confirmed direct stochastic relationship (YCA = 0.63-1.00; SS = 0.33-0.38). Conclusions. The presence of the constellation «normal HGB + normal MCH + increase in RDWC», which may be combined with normal RBC and/or normal MCHC, indicates the absence of bone damage in a patient with liver cirrhosis. The individual erythrogram parameters or their constellations diagnostically valuable for osteopenia were not identified. The absence of such highly sensitive changes of erythrogram parameters as decrease in RBC being of the greatest diagnostic value, or decrease in HGB content, HCT, or moderately sensitive increase in RDWS, or constellation «decrease in RBC + increase in RDWS», or presence of constellations «normal RBC + normal MCV + normal MCHC» or «normal RBC + normal MCH + normal MCHC + normal RDWS» most likely indicates the absence of osteoporosis in patients with liver cirrhosis. The presence of highly specific decrease in MCH and/or constellations - highly specific «decrease in MCV + increase in RDWS», or the most specific and most valuable «decrease in RBC + decrease in MCV + increase in RDWS» which can be combined with decrease in HGB and/or decrease in HCT, and/or increase in RDWC, and/or normal MCHC, indicates that patients with liver cirrhosis have osteoporosis.
Full-text available
Objectives Calcaneal quantitative ultrasound (QUS) is a readily accessible and radiation‐free alternative to dual‐energy x‐ray absorptiometry (DXA) for assessing bone mineral density (BMD). Results obtained from QUS measurement cannot directly be compared to DXA, since these techniques capture different bone‐specific parameters. To identify individuals who are likely to have osteoporosis by DXA, device‐specific thresholds have to be defined for QUS. This cross‐sectional study evaluated the accuracy of QUS to identify postmenopausal women with osteoporosis, defined as a T score of –2.5 SDs or lower by DXA, and to calculate device‐specific cutoff values for the QUS device investigated. Methods We assessed BMD at the lumbar spine, bilateral femoral neck, and total hip sites with DXA and QUS parameters of the right and left calcanei in a cohort of 245 postmenopausal treatment‐naïve women between 40 and 82 years. Correlation coefficients for BMD and QUS parameters were calculated. Receiver operating characteristic curves were generated, and areas under the curves (AUCs) were evaluated. Cutoff values for QUS were defined. Results Calcaneal QUS had the ability to identify postmenopausal women with a T score of –2.5 or lower at the right hip (AUC, 0.887) and left femoral neck (AUC, 0.824). Cutoff values for the QUS T scores at the right (–1.455) and left (–1.480) calcanei were defined for screening purposes. Conclusions This study provides insights into the comparative performance of QUS with DXA. Considering the diagnostic accuracy of this modality in comparison to DXA, it can be recommended as a prescreening tool to reduce the number of DXA screenings.
Full-text available
Purpose The aim of study was to assess the prevalence of osteoporosis and changes in bone mass with increasing age and compare bone health status of apparently healthy men, premenopausal and postmenopausal women. Methods Data were collected on anthropometric and sociodemographic factors in 421 apparently healthy Indian adults (women = 228), 40–75 years of age, in a cross-sectional study in Pune city, India. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry at two sites-lumbar spine (LS) and left femur. Individuals were classified as having osteoporosis or osteopenia based on the World Health Organization criteria of T-scores. Results Mean age of study population was 53.3 ± 8.4 years. Of the total women, 44.3% were postmenopausal with 49.2 ± 3.5 years as mean age at menopause. Postmenopausal women showed a rapid decline in BMD with age till 50 years while men showed a gradual decline. Premenopausal women showed no significant decline in BMD with age (P > 0.1). Significantly lower T-scores were observed at LS in men compared to premenopausal (P < 0.05). At left femur, T-scores were lower in men compared to premenopausal women (P < 0.05) but not postmenopausal women (P > 0.1). The prevalence of osteoporosis in men at LS was lower than postmenopausal women but higher than premenopausal women. Conclusion In Indian men, a low T-score compared to women indicates higher susceptibility to osteoporosis. In women, menopause causes a rapid decline in BMD. Therefore, both Indian men and postmenopausal women require adequate measures to prevent osteoporosis during later years in life.
Full-text available
Introduction: Osteoporosis represents one of the most frequent comorbidity among HIV patients. The current standard method for osteoporosis diagnosis is dual-energy X-ray absorptiometry (DXA). Calcaneal quantitative ultrasound (QUS) can provide information about bone quality. The aims of this study are to compare these two methods and to evaluate their ability to screen for vertebral fracture (VF). Methods: This cross-sectional study was conducted in HIV patients attending the Clinic of Infectious and Tropical Diseases of Brescia during 2014 and who underwent lumbar/femoral DXA, VF assessment and QUS. The assessment of osteoporosis diagnostic accuracy was performed for QUS and for VF comparing them with DXA. Results: We enrolled 73 patients and almost 48% of them had osteoporosis with at least one of the method used. VF were present in 27.4%. Among patients with normal bone measurements, we found VF in proportion between 10% and 30%. If we used QUS method and/or X-ray as screening, the percentages of possible savable DXA ranged from 12% to 89% and misclassification rates ranged from 0 to 24.6%. A combined strategy, QUS and X-Ray, identified 67% of patients with low risk of osteoporosis, but 16.4% of patients were misclassified. Conclusions: We observed that patients with osteoporosis determined by QUS and/or DXA have higher probability to undergo VF, but neither of them can be used for predicting VF. Use of QUS for screening is a reasonable alternative of DXA since our study confirm that none strategy is clearly superior, but both screen tools must be always completed with X-ray.
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Drug-induced osteoporosis is a significant health problem and many physicians are unaware that many commonly prescribed medications contribute to significant bone loss and fractures. In addition to glucocorticoids, proton pump inhibitors, selective serotonin receptor inhibitors, thiazolidinediones, anticonvulsants, medroxyprogesterone acetate, aromatase inhibitors, androgen deprivation therapy, heparin, calcineurin inhibitors, and some chemotherapies have deleterious effects on bone health. Furthermore, many patients are treated with combinations of these medications, possibly compounding the harmful effects of these drugs. Increasing physician awareness of these side effects will allow for monitoring of bone health and therapeutic interventions to prevent or treat drug-induced osteoporosis.
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Quantitative ultrasound (QUS) has emerged as a convenient and popular screening tool for osteoporosis. This review aimed to provide basic information on the principle of QUS measurement and discuss the properties of bone reflected by QUS indices. QUS employed high frequency sound waves generated by the device to determine bone health status in humans. In vitro studies showed that QUS indices were significantly associated with bone mineral density (BMD), bone microarchitecture and mechanical parameters. In humans, QUS indices were found to be associated with BMD as well. In addition, QUS could discriminate subjects with and without fracture history and predict risk for future fracture. In conclusion, QUS is able to reflect bone quality and should be used in the screening of osteoporosis, especially in developing countries where dual-X-ray absorptiometry devices are less accessible to the general population.
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The aim of this study was to assess the feasibility of calcaneal quantitative ultrasonography (QUS) as a screening method for increased risk of osteoporosis in a unique population of people with chronic epilepsy, intellectual disability (ID), and chronic use of antiepileptic drugs. A total of 205 patients from a long-stay care facility for people with epilepsy underwent dual-energy X-ray absorptiometry (DXA) and QUS of the calcaneus. T-scores for both DXA and QUS were calculated and correlated. A total of 195 patients (95.1%) were successfully measured with DXA and 204 (99.5%) with QUS. High correlations were found between DXA and QUS T-scores: r = 0.666 (QUS versus T-score total femur), r = 0.631 (QUS versus T-score femur neck) and r = 0.485 (QUS versus T-score lumbar spine). All correlations were statistically significant (p = 0.01). QUS showed a strong correlation with DXA and proved to be a feasible measuring method in a population with ID and epilepsy. Including osteopenia in the screening process increases the sensitivity of QUS to identify those patients at risk for the development of bone diseases.
Osteoporosis -related to various factors including menopause and aging- is the most common chronic metabolic bone disease, which is characterized by increased bone fragility. Although it is seen in all age groups, gender, and races, it is more common in Caucasians (white race), older people, and women. With an aging population and longer life span, osteoporosis is increasingly becoming a global epidemic. Currently, it has been estimated that more than 200 million people are suffering from osteoporosis. According to recent statistics from the International Osteoporosis Foundation, worldwide, 1 in 3 women over the age of 50 years and 1 in 5 men will experience osteoporotic fractures in their lifetime. Every fracture is a sign of another impending one. Osteoporosis has no clinical manifestations until there is a fracture. Fractures cause important morbidity; in men, in particular, they can cause mortality. Moreover, osteoporosis results in a decreased quality of life, increased disability-adjusted life span, and big financial burden to health insurance systems of countries that are responsible for the care of such patients. With an early diagnosis of this disease before fractures occur and by assessing the bone mineral density and with early treatment, osteoporosis can be prevented. Therefore, increasing awareness among doctors, which, in turn, facilitates increase awareness of the normal populace, will be effective in preventing this epidemic.
This study aims to evaluate an osteoporosis self-assessment tool for Asians (OSTA) and quantitative bone ultrasound (QUS) and their combination in detecting populations at high risk for osteoporosis, and to determine the best cutoff value for the diagnosis of osteoporosis among elderly Chinese men. A group of Chinese men, aged ≥ 60 years, recruited from the health checkup population of Zhongshan Hospital, Fudan University, were included. The OSTA index was calculated from age and weight. Bone mineral density (BMD) at left hip (femoral neck, internal, and total hip) and lumbar spine (L1-L4, L-Total) was measured with dual-energy X-ray absorptiometry (DXA), and calcaneal BMD was measured with QUS. Receiver operating characteristic analysis was used to determine the best cutoff values, sensitivity, and specificity. The area under the curve (AUC) between the different screening tools was compared. Our study included 472 men with mean age of 78.0 years. The prevalence of osteoporosis was 27.7 %.The best cutoff for OSTA was -3.5 for predicting men with osteoporosis at any site; this yielded a sensitivity and specificity of 47.3 % and 76.8 %, respectively. The AUC for OSTA was 0.676. The optimal cutoff for QUS-T score was -1.25, with a sensitivity of 80.4 % and specificity of 59.7 %. The AUC for QUS-T score was 0.762. Combining QUS with OSTA improved the specificity to 92.9 % but reduced sensitivity to 36.1 %. A new variable derived from a combination of OSTA and the QUS-T score gave a better performance, with sensitivity of 70.1 % and specificity of 72.1 %; the AUC for this variable was 0.771, which was greater than OSTA but not different from QUS alone. In conclusion, OSTA and QUS, respectively, and their combination may help find populations at high risk for osteoporosis, which could be an alternative method for diagnosing osteoporosis, especially in areas where DXA measurement is not accessible.
Osteoporotic fractures are a major public health issue. The literature suggests there are variations in occurrence of fractures by ethnicity and race. My purpose is to review current literature related to the influence of ethnicity and race on the (1) epidemiology of fracture; (2) prevalence of osteoporosis by bone mineral density; (3) consequences of osteoporotic hip fracture; (4) differences in risk fracture for fracture; and (5) disparities in screening, diagnosis, and treatment of osteoporosis. Current literature was selectively reviewed related to osteoporosis, ethnicity, and race. Ethnicity and race, like sex, influence the epidemiology of fractures, with highest fracture rates in white women. Bone mineral density is higher in African Americans; however, these women are more likely to die after hip fracture, have longer hospital stays, and are less likely to be ambulatory at discharge. Consistent risk factors for fracture across ethnicity include older age, lower bone mineral density, previous history of fracture, and history of two or more falls. Ethnic and racial disparities exist in the screening, diagnosis, and treatment of osteoporosis. Across ethnic and racial groups, more women experience fractures than the combined number of women who experience breast cancer, myocardial infarction, and coronary death in 1 year. Prevention efforts should target all women, irrespective of their race/ethnicity, especially if they have multiple risk factors.
Osteoporosis remains underdiagnosed in orthopaedic trauma patients. Recently, protocols have emerged to identify and treat osteoporosis in this population. Our purpose was to compare the usefulness of quantitative ultrasound of calcaneus (QUS) with dual-energy x-ray absorptiometry (DXA) for identifying orthopaedic trauma patients at risk for osteoporotic fractures. A retrospective review of an osteoporosis screening protocol comparing QUS and DXA. Regional trauma center. Three hundred sixty consecutive hospitalized orthopaedic trauma patients treated by a single surgeon. QUS T-score and DXA bone mineral density T-scores (hip or radius) were obtained relative to U.S. normative data. QUS and DXA data were statistically compared to analyze their relationship. Potential thresholds for osteoporosis risk were subsequently defined. Testing was successfully performed with heel QUS in 350 patients and with DXA in 129 patients. One hundred twenty-six patients underwent testing with both modalities. According to World Health Organization criteria, 17% of patients tested with DXA had osteoporosis. A good predictive relationship between hip bone mineral density, as estimated by calcaneal QUS, and direct DXA measurement was seen (Pearson's r correlation coefficient of 0.53; area under the curve of 0.84 with 95% confidence interval=0.75-0.90; P=0.0001). QUS T-score cutoffs of greater than -0.9 resulted in 90% sensitivity (defining low osteoporosis risk) and a threshold of -1.6 or less resulted in a specificity of 80% (defining high osteoporosis risk). Substantial logistical difficulties are inherent in attempting to obtain DXA scans in orthopaedic trauma patients at our regional trauma center. For those patients who did undergo DXA, a strong predictive relationship was seen between hip bone mineral density and QUS parameters. QUS thresholds in defining low- and high-risk subjects for osteoporosis in this population using this device are proposed. QUS is a simple, reliable, and relatively inexpensive tool for evaluating osteoporosis risk in orthopaedic trauma patients.