Ultrasound measurements at the proximal phalanges in healthy women and patients with hip fractures

Quantitative Ultrasound Examination (QUS) of the Calcaneus in Long-Term Martial Arts Training on the Example of Long-Time Practitioners of Okinawa Kobudo/Karate Shorin-Ryu

Quantitative research of bone tissue related to physical activity (PA) and sport has a preventive dimension. Increasing the parameters of bone tissue strength, especially reaching the maximum value of peak bone strength in childhood, adolescence, and early adulthood due to practicing sports can contribute to maintaining bone health throughout life. Practicing martial arts (tai chi, traditional karate, judo, and boxing) can effectively improve the quality of bone and reduce the risk of falls and fractures. The study aimed to evaluate the calcaneus bones among Okinawa Kobudo/Karate Shorin-Ryu practitioners using the quantitative ultrasound method as an indicator for assessing bone fracture risk. Forty-four adult martial arts practitioners with a mean age of 36.4 participated in this study. Quantitative ultrasound (QUS) with a portable Bone Ultrasonometer was used in this study. Speed of sound (SOS), broadband ultrasound attenuation (BUA), and the stiffness index (SI) were measured. Subjects were assigned to two groups of black and color belts, according to the advancement in Kobudo/karate practice. The measurements of the SI, BUA, SOS, T-score, and Z-score were significantly higher in subjects from the advanced, long-term practice (black belts) (p < 0.05). The long-term martial arts training in traditional karate and Kobudo significantly impacts the parameters of the calcaneus quantitative ultrasound measurements. Significantly higher bone density was observed among the black belt holders. Long-term practice subjects achieved results far beyond the norm for their age groups. Further studies using non-invasive methods of bone quantification are needed to determine the specific conditions for preventing osteoporosis through physical activity, sports, and martial arts, particularly the duration of the activity, the magnitude of loads, and other related factors.

Quantitative Ultrasound (QUS) in the Management of Osteoporosis and Assessment of Fracture Risk: An Update

Quantitative ultrasound (QUS) presents a low cost and readily available alternative to DXA measurements of bone mineral density (BMD) for osteoporotic fracture risk assessment. It is performed in a variety of skeletal sites, among which the most widely investigated and clinically used are first the calcaneus and then the radius. Nevertheless, there is still uncertainty in the incorporation of QUS in the clinical management of osteoporosis as the level of clinical validation differs substantially upon the QUS models available. In fact, results from a given QUS device can unlikely be extrapolated to another one, given the technological differences between QUS devices. The use of QUS in clinical routine to identify individuals at low or high risk of fracture could be considered primarily when central DXA is not easily available. In this later case, it is recommended that QUS bone parameters are used in combination with established clinical risk factors for fracture. Currently, stand-alone QUS is not recommended for treatment initiation decision making or follow-up. As WHO classification of osteoporosis thresholds cannot apply to QUS, thresholds specific for given QUS devices and parameters need to be determined and cross-validated widely to have a well-defined and certain use of QUS in osteoporosis clinical workflow. Despite the acknowledged current clinical limitations for QUS to be used more widely in daily routine, substantial progresses have been made and new results are promising.

Quantitative Ultrasound (QUS) in the Management of Osteoporosis and Assessment of Fracture Risk

The use of quantitative ultrasound (QUS) for a variety of skeletal sites, associated with the absence of technology-specific guidelines, has created uncertainty with respect to the application of QUS results to the management of individual patients in clinical practice. However, when prospectively validated (this is not the case for all QUS devices and skeletal sites), QUS is a proven, low-cost, and readily accessible alternative to dual-energy X-ray absorptiometry (DXA) measurements of bone mineral density (BMD) for the assessment of fracture risk. Indeed, the clinical use of QUS to identify subjects at low or high risk of osteoporotic fracture should be considered when central DXA is unavailable. Furthermore, the use of QUS in conjunction with clinical risk factors (CRF),allows for the identification of subjects who have a low and high probability of osteoporotic fracture. Device- and parameter-specific thresholds should be developed and cross-validated to confirm the concurrent use of QUS and CRF for the institution of pharmacological therapy and monitoring therapy.

Noncontact ultrasound imaging applied to cortical bone phantoms

PURPOSE

The purpose of this paper was to take the first steps toward applying noncontact ultrasound (NCU) to the tasks of monitoring osteoporosis and quantitative ultrasound imaging (QUS) of cortical bone. The authors also focused on the advantages of NCU, such as its lack of reliance on a technologist to apply transducers and a layer of acoustical coupling gel, the ability of the transducers to operate autonomously as specified by preprogrammed software, and the likely reduction in statistical and systematic errors associated with the variability in the pressure applied by the clinician to the transmitting transducer that NCU might provide. The authors also undertook this study in order to find additional applications of NCU beyond its past limited usage in assessing the severity of third degree burns.

METHODS

A noncontact ultrasound imaging system using a pair of specially designed broadband, 1.5 MHz noncontact piezoelectric transducers and cortical bone phantoms, were used to determine bone mineral density (BMD), speed of sound (SOS), integrated response (IR), and ultrasonic transmittance. Air gaps of greater than 3 cm, two transmission and two reflection paths, and a digital signal processor were also used in the collection of data from phantoms of nominal mass densities that varied from 1.17 to 2.25 g/cm(3) and in bone mineral density from 0 to 1.7 g/cm(3).

RESULTS

Good correlations between known BMD and measured SOS, IR, and transmittance were obtained for all 17 phantoms, and methods for quantifying and minimizing sources of systematic errors were outlined. The BMD of the phantom sets extended through most of the in vivo range found in cortical bone. A total of 16-20 repeated measurements of the SOS, thickness, and IR for the phantom set that were conducted over a period of several months showed a small variation in the range of measurements of ±1%-2%. These NCU data were shown to be in agreement with similar results using contact ultrasound to be within 1%-2%. Transmittance images of cortical bone phantoms showed differences in the nominal overall BMD values of the phantoms that were large enough to be distinguished by a visual examination. A list of possible sources of errors in quantitative NCU was also included in this study.

CONCLUSIONS

The results of this paper suggest that NCU might find additional applications in medical imaging, beyond its original and only previous usage in assessing third degree burns. The fact that the authors' phantom measurements using conventional, gel coupled ultrasound are in agreement with those obtained with NCU demonstrates that in spite of large additional levels of attenuation of up to 150 dB and new error sources, NCU could have comparable levels of accuracy to those of conventional quantitative ultrasound, while providing the medical and patient comfort-related advantages of not involving direct contact.

Quantitative ultrasound in the management of osteoporosis: the 2007 ISCD Official Positions

Dual-energy X-ray absorptiometry (DXA) is commonly used in the care of patients for diagnostic classification of osteoporosis, low bone mass (osteopenia), or normal bone density; assessment of fracture risk; and monitoring changes in bone density over time. The development of other technologies for the evaluation of skeletal health has been associated with uncertainties regarding their applications in clinical practice. Quantitative ultrasound (QUS), a technology for measuring properties of bone at peripheral skeletal sites, is more portable and less expensive than DXA, without the use of ionizing radiation. The proliferation of QUS devices that are technologically diverse, measuring and reporting variable bone parameters in different ways, examining different skeletal sites, and having differing levels of validating data for association with DXA-measured bone density and fracture risk, has created many challenges in applying QUS for use in clinical practice. The International Society for Clinical Densitometry (ISCD) 2007 Position Development Conference (PDC) addressed clinical applications of QUS for fracture risk assessment, diagnosis of osteoporosis, treatment initiation, monitoring of treatment, and quality assurance/quality control. The ISCD Official Positions on QUS resulting from this PDC, the rationale for their establishment, and recommendations for further study are presented here.

An assessment of the use of quantitative ultrasound and the Osteoporosis Self-Assessment Tool for Asians in determining the risk of nonvertebral fracture in postmenopausal Chinese women

This cross-sectional study aims to assess the effectiveness of a simple, noninvasive scoring system, the Osteoporosis Self-Assessment Tool for Asians (OSTA), and quantitative bone ultrasound (QUS) in assessing nonvertebral fracture risk in Chinese postmenopausal women. A group of 513 community-dwelling women including 271 postmenopausal individuals participated in this study. Speed of sound (SOS m/s) at the radius, phalanx, and tibia were assessed by using the Omnisense prototype (Sunlight Ltd., Israel). Body height and weight were measured, and body mass index (BMI) and OSTA indices were calculated. Self-reported fractures were identified using a structured questionnaire. Phalanx SOS was significantly lower among postmenopausal women with a history of nonvertebral fracture occurred after menopause than those without (3755 m/s vs. 3841 m/s, P = 0.017, adjusted for age and weight), with an AUC of 0.66. The AUC of the OSTA for predicting nonvertebral fracture occurred after menopause was 0.64. SOS at the radius, phalanx, and tibia showed a positive correlation with OSTA index (r = 0.376-0.401, P < 0.001). The prevalence of nonvertebral fractures also increased significantly with the decreasing order of OSTA index (chi2 = 5.432, P = 0.02). The OSTA values of <or=-1 and phalanx QUS T-score of <or=-1.95 can differentiate postmenopausal nonvertebral fracture with sensitivity of 75% and 81%, respectively, and specificity of 48% and 40%, respectively. Combining OSTA and phalanx QUS yielded a sensitivity of 83% and a specificity of 84% to detect postmenopausal nonvertebral fracture, with an AUC of 0.64. We conclude that OSTA and phalanx QUS are simple and effective clinical tools for identifying postmenopausal women at increased risk of nonvertebral fractures and can thereby facilitate the appropriate and more cost-effective use of bone densitometry to prevent osteoporotic fractures in developing countries.

Prediction and discrimination of osteoporotic hip fracture in postmenopausal women

Osteoporotic hip fractures increase dramatically with age and are responsible for considerable morbidity and mortality. Several treatments to prevent the occurrence of hip fracture have been validated in large randomized trials and the current challenge is to improve the identification of individuals at high risk of fracture who would benefit from therapeutic or preventive intervention. We have performed an exhaustive literature review on hip fracture predictors, focusing primarily on clinical risk factors, dual X-ray absorptiometry (DXA), quantitative ultrasound, and bone markers. This review is based on original articles and meta-analyses. We have selected studies that aim both to predict the risk of hip fracture and to discriminate individuals with or without fracture. We have included only postmenopausal women in our review. For studies involving both men and women, only results concerning women have been considered. Regarding clinical factors, only prospective studies have been taken into account. Predictive factors have been used as stand-alone tools to predict hip fracture or sequentially through successive selection processes or by combination into risk scores. There is still much debate as to whether or not the combination of these various parameters, as risk scores or as sequential or concurrent combinations, could help to better predict hip fracture. There are conflicting results on whether or not such combinations provide improvement over each method alone. Sequential combination of bone mineral density and ultrasound parameters might be cost-effective compared with DXA alone, because of fewer bone mineral density measurements. However, use of multiple techniques may increase costs. One problem that precludes comparison of most published studies is that they use either relative risk, or absolute risk, or sensitivity and specificity. The absolute risk of individuals given their risk factors and bone assessment results would be a more appropriate model for decision-making than relative risk. Currently, a group appointed by the World Health Organization and lead by Professor John Kanis is working on such a model. It will therefore be possible to further assess the best choice of threshold to optimize the number of women needed to screen for each country and each treatment.

Comparison of phalangeal ultrasound and dual energy X-ray absorptiometry in healthy male and female adolescents

The aims of this study were to determine if there is a correlation between dual energy X-ray absorptiometry (DXA) and phalangeal quantitative ultrasound (QUS) in identifying children and adolescents with low bone density, and to assess if body size influences the results of the two techniques to the same degree. Measurements were performed in 67 girls and 83 boys aged 14 to 19 y using DBM Sonic 1200 (IGEA, Carpi, Italy) and the DXA equipment (LUNAR Radiation Corp., Madison, WI, USA). Twelve adolescents (eight males and four females) reported a past history of nonosteoporotic fractures. Lumbar spine bone mineral density (LS BMD), total body bone mineral density (TB BMD) and total body bone mineral content (TB BMC) correlated positively with age, height, BMI and weight, in both genders. Amplitude-dependent speed of sound (Ad-SOS) was positively correlated with age, height and Tanner stages in both genders and negatively correlated with BMI in females. TB BMD, TB BMC and LS BMD positively correlated with Ad-SOS only in males. In females, there were no significant correlations between Ad-SOS, TB BMD, TB BMC and LS BMD measurements. Twelve teenagers with previous fractures (high impact fractures) were found to have lower DXA and QUS values than age-matched teenagers without fractures but the statistical significance was found only in relation to TB BMD values (p = 0.02). In conclusion, we obtained results similar to those that have been reported by other authors using different QUS techniques. Furthermore, the Ad-SOS measurements taken at the distal metaphysis of the proximal phalanges correlate poorly with LS BMD and TB BMD measured by DXA in growing subjects.

Evaluation of skeletal status by quantitative ultrasonometry in postmenopausal women without known risk factors for osteoporosis

The objective of our study was to evaluate bone density in Italian postmenopausal women without clinical risk factors for osteoporosis resident in the Naples area using quantitative ultrasonometry of bone (QUS). Subjects were 1149 Italian postmenopausal women (age: 54.9 +/- 5.0 years (mean +/- standard deviation); range: 45-74 years) resident in the Naples area. Clinical risk factors for osteoporosis resulting in exclusion from the study were family history of osteoporosis, dietary, smoking and alcohol habits, personal history of fractures and/or metabolic diseases. The following QUS parameters were calculated: amplitude-dependent speed of sound (AD-SoS), T-score and Z-score. We found significant inverse correlations between AD-SoS and age (r = - 0.23), time since menopause (r = - 0.25) and body mass index (BMI) (r = - 0.16). The same was observed for T-score. In contrast, Z-score showed a significant positive correlation with age and time since menopause, and a negative correlation with BMI. A T-score suggestive of high risk for osteoporosis (less than -3.2) was found in 1.6% of subjects, while a T-score suggestive of moderate risk for osteoporosis (between -3.2 and -2) was found in 19.3% of patients. In this group of women without clinical risk factors for osteoporosis we found a very low prevalence of QUS results suggesting a high risk for osteoporosis. However, a condition of 'moderate' risk for osteoporosis was present in a remarkable percentage of these women.

Ten-year probabilities of clinical vertebral fractures according to phalangeal quantitative ultrasonography

The objectives of the present study were to estimate 10-year probabilities of clinical vertebral fractures in women, according to age and bone mineral assessment using phalangeal quantitative ultrasound (QUS). Risks were computed from UK derived data on the incidence of a first symptomatic vertebral fracture and mortality rates for each year of age using Poisson models. The 10-year probability of vertebral fracture was determined as the proportion of individuals fracture-free at that site from the age of 45 years. We assumed that the risk of fracture increased with decreasing QUS as assessed by an independent re-analysis of a previously published, multicenter cross-sectional study. For amplitude-dependent speed of sound (AD-SoS) information was available from 8,502 women, and vertebral fracture risk increased 1.7-fold for each SD decrease in measurement. For fast wave amplitude (FWA), available in 6,573 women, the risk gradient was 2.4/SD. In a subset of the population ( n =1,572) in whom bone mineral density was measured at the lumbar spine, the gradient of risk was 2.3/SD, with similar gradients of risk noted for AD-SoS (1.8/SD) and FWA (2.6/SD). Ten-year probabilities increased with age and decreasing Z -score. The use of absolute risk permits information from different types of bone mineral measurements to be applied for the assessment of patients, either alone or in combination with other independent risk factors.

Comparison of quantitative ultrasound of the phalanges with conventional bone densitometry in healthy postmenopausal women

The objective of this study was to evaluate the utility of the quantitative ultrasound (QUS) technique for the identification of subjects with spine fracture or low bone mineral density (BMD) previously determined by dual energy X-ray absorptiometry (DEXA). QUS of the phalanges in 1,350 postmenopausal women (60-83 years old) was compared with DEXA measurements of four skeletal sites (lumbar spine, total hip, femoral neck, and distal radius) of the same subjects. The contribution of body mass index (BMI) was also assessed. Amplitude dependent speed of sound (AD-SoS), ultrasound bone profile index (UBPI), and BMD of all anatomical regions, except for the spine, decreased significantly with increasing age quartiles. QUS parameters correlated weakly but significantly with BMD ( r =0.21-0.31, p <0.01). After adjustment for BMI, the association between QUS parameters and BMD remained unchanged. UBPI was found to be independent of BMI. All techniques and all sites were able to significantly discriminate fractured from non-fractured subjects by receiver operating characteristic (ROC) analysis (area under the curve [AUC]> or =0.60, p <0.0001). AD-SoS and UBPI showed similar fracture discrimination ability of spine, distal radius and total body BMD in terms of odds ratios, but BMD of the total hip and femoral neck showed the best performance in discriminating fractured from non-fractured subjects. In conclusion, QUS assessment of the phalanges correlates moderately with BMD of all skeletal sites and is able to effectively discriminate fractured from non-fractured subjects.

Quantitative ultrasound at the hand phalanges in 2850 females aged 7 to 77 yr: a cross-sectional study

In the study, skeletal status was evaluated in 2850 females aged 7 to 77 yr using quantitative ultrasound (QUS amplitude-dependent speed of sound [Ad-SoS]). Ad-SoS ranged from 1923 +/- 30 to 1876 +/- 81 m/s, and the peak value (2121 m/s) was achieved in 19-yr-old females. Ad-SoS increased significantly between subgroups aged 11 and 12 yr, 12 and 13 yr, 13 and 14 yr, 14 and 15 yr, and 15 and 16 yr. After the age of 19 yr the only significant drop was noted between age groups 47 and 48 yr. Ad-SoS was regressed on age, weight, and height for age ranges 7 to 11 yr.(before an increase in Ad-SoS), 12 to 19 yr (from the onset of the increase to the peak value), and older than 19 yr to menopause. In females after menopause, years since menopause (YSM) were taken into consideration. In the two youngest groups Ad-SoS was affected positively by age, and in the two next groups, age had a negative influence on Ad-SoS, whereas weight had a negative and height a positive influence in all groups. YSM did not influence the Ad-SoS value. It was concluded that QUS measurements at the hand phalanges are a useful tool in assessment of skeletal status in the female population.

Assessing bone status beyond BMD: evaluation of bone geometry and porosity by quantitative ultrasound of human finger phalanges

In an in vitro study, we found significant associations between QUS variables and properties and geometrical parameters of the compact bone of human finger phalanges. QUS variables were not only related to BMD but also to other skeletal properties, which explained 70% of the variability of speed of sound.

INTRODUCTION

Transverse transmission quantitative ultrasound (QUS) measurements at the finger phalanges are known to be correlated with BMD and to predict osteoporotic fractures. To determine which other skeletal properties are affected by ultrasound, we investigated the impact of density, geometry, and porosity on QUS variables in vitro.

MATERIALS AND METHODS

Ultrasound variables were correlated with density, porosity, and geometrical characteristics of cortical bone. Additionally, we tested which combinations of geometry and bone properties best predicted the ultrasound results observed. Forty-four proximal phalanges from the middle finger were investigated at their distal metaphysis, similar to the typical clinical measurement procedure. Donor age ranged from 52 to 98 years (15 males and 29 females; mean age, 80.9 +/- 9.4 years). QUS variables were measured on the metaphysis of the phalanges using the DBMSonic 1200. Quantitative CT was used for the measurement of BMD, and high-resolution MRI was used for the measurement of porosity and geometrical variables.

RESULTS

Speed of sound (SOS) and the clinically used variable AD-SOS correlated significantly with area, relative area, density, and porosity of the compact bone (R2 = 0.28-0.58, p < 0.0001). Signal amplitude correlated significantly only with relative area of the compact bone and area of the medullary canal (R2 = 0.18-0.20, p < 0.01). The combination of cortical area, density, and porosity improved the determination of SOS to R2 = 0.70, with a residual unexplained variability of 54 m/s (3.2%).

CONCLUSIONS

These results clarify the impact of skeletal properties on QUS variables. SOS is affected by cortical area, cortical bone density, and cortical porosity, whereas attenuation only depends on geometry of the medulla. AD-SOS, the variable routinely measured in clinical practice, is primarily affected by cortical area. QUS of the finger phalanges is not only related to BMD but also to other skeletal properties.

Quantitative ultrasound at the phalanxes discriminates osteoporotic women with vertebral but not with hip fracture

Caucasian postmenopausal women with vertebral fracture (38), hip fracture (38) and without fracture (124) were measured by spine and femoral neck bone mineral density (BMD) (Norland XR 36), and two quantitative ultrasound (US) or QUS parameters (Igea DBM sonic 1200): the amplitude-dependent speed of sound (Ad-Sos) and the US bone profile score (UBPS), at the proximal hand phalanxes to investigate the ability of QUS to detect previous fracture. Age, height and weight were not different among groups, but menopausal age was lower with vertebral fracture (p < 0.005). QUS parameters of hip (AdSos = 1806.2 +/- 104.6 m s(-1); UBPS = 0.22 +/- 0.13) or spine fracture (AdSos = 1774.4 +/- 90.0 m s(-1); UBPS = 0.19 +/- 0.10) were not significantly lower than controls (AdSos = 1819.1 +/- 111.9 m s(-1); UBPS = 0.25 +/- 0.17), and BMD of hip (spine: 756.0 +/- 138.9 mg cm(-2); femoral neck: 583.6 +/- 61.8 mg cm(-2)) and vertebral (spine: 727.4 +/- 120.4 mg cm(-2); femoral neck: 592.8 +/- 82.1 mg cm(-2);) fracture was lower than controls (spine: 829.2 +/- 167.6 mg cm(-2); femoral neck 665.0 +/- 108.9 mg cm(-2)) (p < 0.001). Spine and femoral neck BMD significantly separated both types of fractures from controls, but AdSos and UBPS significantly separated only vertebral fractures. Femoral neck BMD has the best receiver operating characteristic (ROC) area for both hip (0.715, SE 0.043) and vertebral (0.693, SE 0.047) fractures, being significantly better (p < 0.01) than that of AdSos (0.503, SE 0.056) and UBPS (0.501, SE 0.057) for hip fractures, but not for vertebral fractures (AdSos 0.604, SE 0.050; UBPS 0.563, SE 0.048). In conclusion, QUS at hand phalanxes predicts vertebral fracture as effectively as BMD, but does not predict hip fracture.

The usefulness of quantitative ultrasound at the hand phalanges in the detection of the different types of nontraumatic fractures

The aim of this retrospective study was to determine whether quantitative ultrasound (QUS) at the hand phalanges has the ability to discriminate between individuals without and with different types of nontraumatic fractures. All women (n = 2466) (age range 38-88 years) not affected by metabolic diseases or under treatment with drugs known to interfere with bone metabolism were divided into controls without fractures (n = 1883) and women with nontraumatic previous fractures (n = 583). Fractures were the result of minimal trauma involving a fall from a standing height or less during normal daily activity. Fractured group was divided into subgroups on the basis of the types of fractures: hip, spine, wrist or other fractures. Skeletal status was assessed using the DBM Sonic 1200 (IGEA, Carpi, Italy) which measures the amplitude-dependent speed of sound, Ad-SoS (m/s) in the distal metaphyses of the proximal phalanges of the second through fifth finger of the dominant hand. Women with hip, spine, wrist or other fractures had significantly lower Ad-SoS values than controls (1814 +/- 60 m/s, 1829 +/- 57 m/s, 1870 +/- 64 m/s, 1893 +/- 66 m/s, respectively, vs. 1943 +/- 73 m/s, p < 0.001). Ad-SoS revealed the following areas under the ROC curve: 0.91 +/- 0.027 for hip fracture, 0.89 +/- 0.019 for spine fracture, 0.77 +/- 0.012 for wrist fracture and 0.70 +/- 0.023 for other fractures. By multiple logistic regression analysis, the probability of having fracture, estimated as odds ratio for each 1 SD reduction in Ad-SoS, was: 3.49 (95% CI, 1.57-7.75) for hip, 3.25 (95% CI, 1.94-5.45) for spine, 2.24 (95% CI, 1.86-2.70) for wrist and 1.81 (95% CI, 1.36-2.40) for other fractures. The present study demonstrates the ability of phalangeal QUS to discriminate between subjects with and without different types of nontraumatic fractures. Phalangeal QUS revealed the best sensitivity and specificity in discriminating hip- and spine-fractured patients from controls.

Ultrasound velocity through the cortex of phalanges, radius, and tibia in normal and osteoporotic postmenopausal women using a new multisite quantitative ultrasound device

RATIONALE AND OBJECTIVES

To assess a new multisite quantitative ultrasound (QUS) device (Sunlight Omnisense 7000 S) suitable for the measurement of speed of sound (SOS) in the phalanges, radius, and tibia.

METHODS

The study group consisted of 270 healthy Caucasian postmenopausal patients (mean age: 60.0 +/- 7.6 years) and 53 Caucasian postmenopausal patients (mean age: 67.2 +/- 7.4 years) with osteoporotic fractures. Measurements of SOS and bone mineral density (BMD) were carried out in all subjects.

RESULTS

Intraobserver in vivo short-term precision was on average 0.76% for the radius, 0.47% for the tibia, and 1.54% for the phalanges. The interobserver precision ranged from 0.77% to 2.39%. Measurements of SOS at the 3 skeletal sites were significantly correlated (r = 0.28-0.44; P < 0.001). Significant correlations were found between SOS at all sites and BMD (r = 0.21-0.41; P < 0.001). The odds ratio for fracture prediction for SOS was 1.47 for tibia, 1.69 for radius, and 2.69 for phalanx. The corresponding odds ratios for BMD at the lumbar spine, femoral neck, and total hip ranged from 2.08 to 3.26. The area under the receiver operating characteristic curve ranged from 0.611 to 0.741 for SOS measurements and from 0.745 to 0.797 for BMD measurements.

CONCLUSIONS

The Omnisense multisite QUS device exhibits reproducible performance. Among the QUS variables, the phalangeal SOS provides the best discrimination of fracture patients.

Reference curve of bone ultrasound measurements in proximal phalanges in normal Spanish women

There are clear discrepancies in how the different measurements of phalangeal bone ultrasound, such as the amplitude-dependent speed of bone ultrasound (Ad-SoS), correlate with age, given their dependence on gonadal status and other anthropometric variables. In order to contribute to clarifying these discrepancies, we evaluated the phalangeal Ad-SoS in healthy women-295 postmenopausal, 59 perimenopausal, and 270 premenopausal. Phalanges (II-V) of the nondominant hand were measured and the mean Ad-SoS was computed. There were significant differences between groups (p < 0.0001 in all cases), with the perimenopausal group presenting the intermediate values. For the overall group of women, the Ad-SoS was significantly and negatively correlated with age, weight, and body mass index (BMI), and positively correlated with height (p < 0.0001 in all cases). By gonadal status group, the premenopausal women showed the three significant negative correlations of Ad-SoS with age, weight, and BMI (each, p < 0.0001), the perimenopausal group only with BMI (p < 0.007), and the postmenopausal group with age and BMI (p < 0.0061 to p < 0.0001) and also with years since menopause (p < 0.0001). The premenopausal decline in AD-SoS requires further longitudinal studies, although in our experience it may depend on dietary habits and/or a diminished quality, though not quantity, of bone in this period of a woman's fertile life.

Phalangeal ultrasonography in forearm fracture discrimination

Over the last decade, the use of ultrasounds has been developed into an effective tool for investigating bone tissue and predicting the risk of fracture in osteoporosis. Studies have focused on hip and vertebral fractures while no information is available on the use of phalangeal ultrasonography to identify patients with forearm fractures. Thus, the current authors decided to compare 50 postmenopausal women with low energy forearm fractures (Fractured Group) with a control age-matched group of 94 women (Control Group). Measurements were taken at the distal metaphysis of the proximal phalanxes of the hand of the non-fractured arm using the DBM Sonic Bone Profiler. The reproducibility of the method was assessed by amplitude-dependent speed of sound (AD-SoS) CV% = 0.64 and by Ultrasound Bone Profiler Index (UBPI) CV% = 2.38. In the Control Group, the AD-SoS and UBPI mean values and standard deviations were significantly higher compared to the group with fractures (P < 0.0005). The receiver operating characteristic (ROC) curves were calculated and the areas under the curve (AUC) were 0.78 +/- 0.04 for AD-SoS and 0.77 +/- 0.05 for UBPI, respectively. Logistic regression analysis adjusted to age revealed that both AD-SoS (78.2%, ORAD-SoS = 12.03, P < 0.0005) and UBPI (76.0%, ORAD-SoS = 7.39, P < 0.0005) parameters discriminated correctly between fractured and non-fractured control women whereas the association of both parameters could not allow better discrimination. The present results showed that ultrasound investigation at the phalanxes is reproducible and efficiently discriminates between subjects with forearm fractures and those in the control subjects.

Ultrasound of the phalanges is not related to a previous fracture. A comparison between ultrasound of the phalanges, calcaneus, and DXA of the spine and hip in 75-year-old women

Recently, an ultrasound (US) device for measurement of amplitude-dependent speed of sound in four proximal phalanges of the hand (DBM Sonic 1200, IGEA, Carpi, Mo, Italy) has been introduced but has not been thoroughly investigated in populations at most risk for fragility fractures (i.e., elderly women). As part of the Malmö Osteoporosis Prospective Risk Assessment study (OPRA), we investigated 1044 randomly selected women, all 75 yr of age, with US of the phalanges and, for comparison, also with two more established methods for bone mass measurement: US of the calcaneus and dual-energy X-ray absorptiometry (DXA) of the hip and spine, both methods having an ability to predict fracture. A self-assessment questionnaire was used to obtain information on previous fracture and age at fracture event. We found a low correlation between US of the phalanges and US of the calcaneus speed of sound (SoS) (r = 0.11, p < 0.01), US of the calcaneus (stiffness) (r = 0.09, p < 0.05), DXA of the femoral neck (r = 0.09, p < 0.05), and DXA of the spine (r = 0.10, p < 0.01) and no significant correlation between US of the phalanges and US of the calcaneus broadband ultrasound attenuation (BUA) and DXA trochanter. Also, no differences in US of the phalanges were found when comparing women without any fracture with women with at least one fracture, whereas US of the calcaneus (SoS, BUA, and stiffness) and DXA of the femoral neck, trochanter, and spine were all lower in the women with a fracture history (p < 0.0001). In addition, the precision of the US of the phalanges method was evaluated and found to be lower in these elderly women, compared to the precision reported by others and the manufacturer. In summary, the present data indicate that US of the phalanges is not a usable tool for estimating fracture risk in an elderly female population.

Dual X-ray absorptiometry of hip, heel ultrasound, and densitometry of fingers can discriminate male patients with hip fracture from control subjects: a comparison of four different methods

Few studies have examined different bone densitometry techniques to determine male hip fracture risk. We conducted a case-control study of 31 noninstitutionalized men, mean age 77 yr, with a first hip fracture and compared the results with 68 randomly selected age-matched control subjects. The methods used were dual X-ray absorptiometry (DXA) of the proximal femur, quantitative ultrasound (QUS) of the heel and fingers, and radiographic absorptiometry of the fingers. Case patients had significantly lower values (4-17%; p < 0.01) for all methods. The odds ratios for every SD reduction in bone values were 4.8 (95% confidence interval [CI]: 2.3-9.9) for DXA of the femoral neck, 2.2 (95% CI: 1.2-3.9) for QUS of the heel, 2.0 (95% CI: 1.2-3.3) for QUS of the phalanges, and 3.1 (95% CI: 1.5-6.6) for radiographic absorptiometry of the phalanges. The results indicate a strong capability of DXA of the femoral neck to distinguish between men with a first hip fracture and control subjects. Furthermore, ultrasound of the heel and fingers as well as radiographic absorptiometry proved capable of discriminating men with hip fractures from control subjects.

The CAG repeat polymorphism in the androgen receptor gene affects bone density and bone metabolism in healthy males

OBJECTIVE

Bone metabolism and bone density (BD) are influenced by sex hormones. Testosterone (T) action is exerted through the androgen receptor (AR). We investigated the potential impact of the CAG repeat (CAGR) polymorphism within the AR gene on BD and bone metabolism in healthy younger males.

PATIENTS AND MEASUREMENTS

The number of CAGRs in 110 healthy men aged 20-50 years was determined by sequence analysis. We assessed BD by the radiation-free method of quantitative ultrasound (QUS) of the phalanges. Serum levels of bone-specific alkaline phosphatase (BAP) and urine secretion of free deoxypyridinoline (DPD, corrected for creatinine), serum levels of sex hormones, body fat content and lifestyle factors were determined.

RESULTS

In stepwise multiple regression models controlling for age, body fat content and lifestyle factors, the number of CAGRs was an independent negative predictor of BD (partial r = - 0.286, P = 0.001), whereas it was positively associated with markers of bone turnover (for BAP: partial r = 0.32, P= 0.001; for DPD: partial r = 0-241, P = 0.013). Levels of free T and oestradiol showed an independent and positive association with BD; age contributed significantly to lower BD. Age and free T were negatively associated with markers of bone turnover, whereas oestradiol showed a positive correlation with BAP and DPD. ANOVA in groups according to age and the CAGR length suggested an increased age-dependent bone loss in subjects with a CAGR length of 22-31 compared with 14-21 CAGRs (overall P < 0.01).

CONCLUSIONS

A high number of CAG repeats within the androgen receptor gene attenuates testosterone effects on bone density and bone metabolism. This seems to be associated with accelerated age-dependent bone loss.

Quantitative ultrasound (QUS) at the calcaneus and hand phalanges in Polish healthy postmenopausal women

In a cross-sectional study, 109 postmenopausal, healthy women, mean age 58.8 years, were studied. The aim of the study was to compare quantitative ultrasound (QUS) performed at two measurement sites of the same persons (correlations between parameters studied, age, and years since menopause (YSM)-related changes, influence of body size). Bone status was established using measurements at the calcaneus by Achilles (Lunar, USA), which measures speed of sound (SOS [m/s], CV% = 0.22%), broadband ultrasound attenuation (BUA [dB/MHz], CV% = 1.8%), stiffness index (SI [%], CV% = 1.3%), and by DBM Sonic 1200 (Igea, Italy), which measures amplitude-dependent speed of sound (Ad-SoS [m/s], CV% = 0.64%) at the hand phalanges. Mean and SD values were: SOS = 1498 +/- 24.8 m/s, BUA = 104.6 +/- 9.4 dB/MHz, SI = 69.2 +/- 12.3%, Ad-SoS = 1879 +/- 90.1 m/s. Age- and YSM-related changes were as follows: age-SOS r = -0.37, p < 0.0001, age-BUA r = -0.33, p < 0.001, age-SI r = -0.36, p < 0.001, age-Ad-SoS r = -0.62, p < 0.00001, YSM-SOS r = -0.27, p < 0.01, YSM-BUA r = -0.32, p < 0.001, YSM-Ad-SoS r = -0.44, p < 0.00001, YSM-SI r = -0.29, p < 0.01. In stepwise, multiple regression analyses of ultrasound parameters on age, YSM, height, and weight, the following equations were obtained: SOS [m/s] = 1564.9 - 1.1 x age [y], r = -0.37, p < 0.0001; BUA [dB/MHz] = 88.7 + 0.28 x weight [kg] - 0.36 x YSM [y], r = -0.51, p < 0.00001; SI [%]) = 79.2 - 0.5 x age [y] + 0.28 x weight [kg], r = -0.47, p < 0.00001; Ad-SoS [m/s] = 2287 to 6.9 x age [y], r = -0.62, p < 0.00001. In conclusion, QUS at the calcaneus and hand phalanges express similar trends in skeletal changes due to aging and the postmenopausal period, although measurements at the phalanges seem to be more sensitive for detecting bone changes, due to faster decrease rate of the Ad-SoS value than calcaneal measurements.

Phalangeal osteosonogrammetry study: age-related changes, diagnostic sensitivity, and discrimination power. The Phalangeal Osteosonogrammetry Study Group

Phalangeal osteosonogrammetry was introduced as a method for bone tissue investigation in 1992. It is based on the measure of the velocity of ultrasound (amplitude-dependent speed of sound [AD-SoS]) and on the interpretation of the characteristics of the ultrasound signal. In this study we have collected a database of 10,115 subjects to evaluate the performance of AD-SoS and to develop a parameter that is able to quantify the signal characteristics: ultrasound bone profile index (UBPI). The database only includes females of which 4.5% had documented vertebral osteoporotic fractures, 16% lumbar spine dual X-ray absorptiometry (DXA), and 6% hip DXA. The analysis of the ultrasound signal has shown that with aging the UBPI, first wave amplitude (FWA), and signal dynamics (SDy) follow a trend that is different from the one observed for AD-SoS; that is, there is no increase during childhood. In the whole population, the risk of fracture per SD decrease for AD-SOS was odds ratio (OR) 1.71 (CI, 1.58-1.84). The AD-SoS in fractured subjects was significantly lower than in a group of age-matched nonfractured subjects (p < 0.0001). In a small cohort of hip-fractured patients UBPI proved to be lower than in a control age-matched group (p < 0.0001). When the World Health Organization (WHO) working group criteria were applied to this population to identify the T score value for osteoporosis, for AD-SoS we found a T score of -3.2 and for UBPI we found a T score of -3.14. Sixty-six percent of vertebral fractures were below the AD-SoS -3.2 T score and 62% were below UBPI -3.14. We observed the highest incidence of fractures (63.6%) among subjects with AD-SoS who had both DXA T score values below the threshold. We conclude from this study that ultrasound investigation at the hand phalanges is a valid methodology for osteoporosis assessment. It has been possible to quantify signal changes by means of UBPI, a parameter that will improve the possibility of investigating bone structure.

Quantitative ultrasound in postmenopausal osteoporosis

Ultrasound has been proposed as a low-cost, radiation-free method for osteoporosis assessment in postmenopausal women. Large prospective studies have shown that ultrasound parameters can be used for fracture risk estimate in this population, providing that adequate quality control is performed. The places of both ultrasound and the current gold standard method for bone assessment, dual energy x-ray absorptiometry, are still to be determined. Further studies are needed on the diagnosis of osteoporosis using ultrasound, because current diagnostic thresholds, designed by the World Health Organization, do not apply to this-new technology. Monitoring of skeletal changes and treatment effects by ultrasound cannot be recommended.

Factors influencing the speed of sound through the proximal phalanges

The amplitude-dependent speed of sound (AD-SOS) in the proximal phalanges is reported to be sensitive to osteoporotic changes. We investigated the influence of bone thickness and cortical thickness on AD-SOS. Phantoms made of Perspex were designed to simulate different bone width (11-16 mm) and cortical thickness (3-7.5 mm). The phantoms were designed with two opposing flat and cylindrical surfaces. The effect of cortical thickness was examined by drilling holes (simulating the medullary canal) of different diameters (1-7 mm) in the middle of the Perspex cylinders. The effect of sample thickness was investigated on solid Perspex phantoms of varied lengths. The standardized precision errors of AD-SOS measurement in vivo and in vitro on volunteers and phantoms were 2.8 and 0.9%, respectively. AD-SOS was influenced by the bone width, cortical thickness, and location along the phalanx. A decrease in either cortical width or cortical thickness resulted in a decrease in AD-SOS. The effect is dependent on whether the contact surface is curved or flat. It is possible that a curved surface has a focusing effect on the wave through the porous core, whereas for a flat surface, the path of the waves might not pass through the center. When cortical thickness and bone width were expressed as a ratio, there was a linear relationship between this ratio and AD-SOS through the phantoms. AD-SOS was independent of thickness for samples greater than 11 mm.