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Donlon CM, Chou SH, Yu CY, LeBoff MS. Accounting for Surgical Confounding Factors Affecting Dual-Energy X-ray Absorptiometry in a Large Clinical Trial. J Clin Densitom 2022; 25:127-132. [PMID: 34266768 PMCID: PMC8900483 DOI: 10.1016/j.jocd.2021.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/10/2021] [Accepted: 06/10/2021] [Indexed: 11/26/2022]
Abstract
Joint replacements are among the most common orthopedic procedures performed in the U.S. and will continue to increase with the aging population. It is therefore necessary to account for these and other confounding factors, such as breast implants, when performing dual-energy X-ray absorptiometry (DXA) measurements. Whole-body DXA scans were performed in 771 participants (men ≥50 yr and women ≥55 yr) to assess bone mineral density (BMD) and body composition (fat and lean mass). In the DXA scan analyses of participants with internal metal, these affected regions of interest were replaced with measures from the unaffected, contralateral side, consistent with recommendations of the International Society for Clinical Densitometry. T-scores and Z-scores were recalculated using default sex and ethnicity-matched databases. We also explored effects of breast implants on bone density and body composition analyses. Approximately 13.1% of participants had internal metal artifacts at baseline. Replacing metal artifacts with the unaffected, contralateral side decreased the whole-body BMD by an average of 8.1% (SEM 0.84%; n = 67). In participants with unilateral hip (n = 17) and knee replacements (n = 20), BMD was decreased by an average of 14.1% (SEM 1.7%) and 11.2% (SEM 1.1%), respectively. Fat and lean mass were not significantly affected by metal artifacts, as differences between values with and without metal were within 1%. Two participants had bilateral breast implants, and in a separate trial, one participant had a unilateral breast implant. Bone mineral content (BMC) in the region with the breast implant was 5.8 times higher than the contralateral side, and whole-body BMC was increased by 4.7%. Metal artifacts and breast implants can confound DXA whole-body bone but not fat and lean results. It is therefore important in clinical studies to account for these factors to detect physiologically relevant differences in bone measures.
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Affiliation(s)
- Catherine M Donlon
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital (BWH), Harvard Medical School, Boston MA, USA
| | - Sharon H Chou
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital (BWH), Harvard Medical School, Boston MA, USA
| | - Cindy Y Yu
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital (BWH), Harvard Medical School, Boston MA, USA
| | - Meryl S LeBoff
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital (BWH), Harvard Medical School, Boston MA, USA.
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Abstract
The phenotypic trait of high bone mass (HBM) is an excellent example of the nexus between common and rare disease genetics. HBM may arise from carriage of many 'high bone mineral density [BMD]'-associated alleles, and certainly the genetic architecture of individuals with HBM is enriched with high BMD variants identified through genome-wide association studies of BMD. HBM may also arise as a monogenic skeletal disorder, due to abnormalities in bone formation, bone resorption, and/or bone turnover. Individuals with monogenic disorders of HBM usually, though not invariably, have other skeletal abnormalities (such as mandible enlargement) and thus are best regarded as having a skeletal dysplasia rather than just isolated high BMD. A binary etiological division of HBM into polygenic vs. monogenic, however, would be excessively simplistic: the phenotype of individuals carrying rare variants of large effect can still be modified by their common variant polygenic background, and by the environment. HBM disorders-whether predominantly polygenic or monogenic in origin-are not only interesting clinically and genetically: they provide insights into bone processes that can be exploited therapeutically, with benefits both for individuals with these rare bone disorders and importantly for the many people affected by the commonest bone disease worldwide-i.e., osteoporosis. In this review we detail the genetic architecture of HBM; we provide a conceptual framework for considering HBM in the clinical context; and we discuss monogenic and polygenic causes of HBM with particular emphasis on anabolic causes of HBM.
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Affiliation(s)
- Celia L. Gregson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Emma L. Duncan
- Department of Twin Research & Genetic Epidemiology, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
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Fighera TM, da Silva ED, Borba GDS, Spritzer PM. Does (mis)use of industrial liquid silicone implants interfere with bone mineral density in transgender women? Arch Osteoporos 2020; 15:149. [PMID: 32964330 DOI: 10.1007/s11657-020-00824-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/15/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED The effects of gluteal implants on bone mass remain unclear. Transgender women with ILS presented higher BMD in the hip compared with transgender women without implants, while no difference was observed in other sites. These results may be artifactual and suggest using spine/forearm sites for DXA in individuals with ILS. PURPOSE The inappropriate use of industrial liquid silicone (ILS) injections for cosmetic purposes is practiced by some transgender women. The aim of this study was to evaluate the impact of gluteal ILS on femur BMD in transgender women. METHODS A total of 46 trans women with and without ILS injection in the gluteal region were selected. All patients underwent clinical and hormonal evaluation, and bone mass was assessed by DXA. RESULTS Bone mineral density (BMD) values were significantly higher in trans women with ILS (n = 23) in femoral neck and total femur when compared with trans women without implants (n = 23). Similar BMD was observed in other sites, such as lumbar spine and forearm. Good agreement was found in the evaluation of low BMD using spine/forearm or spine/femur in patients without implants (k = 0.744 and 1.000 for male and female reference database, respectively), but poor to fair index was found in patients with ILS implants (k = 0.330 and 0.646 for male and female reference database, respectively). CONCLUSIONS In transgender women with ILS implants, poor to moderate agreement was found on BMD when comparing lumbar spine/femur DXA with an alternative site to the femur, depending on using male or female database. These results may be artifactual and suggest using spine/forearm sites for more accurate DXA assessments in trans women with ILS gluteal implants.
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Affiliation(s)
- Tayane Muniz Fighera
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Porto Alegre, RS, 90035-003, Brazil.,Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Eliane Dias da Silva
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Porto Alegre, RS, 90035-003, Brazil.,Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Gustavo da Silva Borba
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Porto Alegre, RS, 90035-003, Brazil
| | - Poli Mara Spritzer
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Porto Alegre, RS, 90035-003, Brazil. .,Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. .,Department of Physiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
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Morgan SL, Prater GL. Quality in dual-energy X-ray absorptiometry scans. Bone 2017; 104:13-28. [PMID: 28159711 DOI: 10.1016/j.bone.2017.01.033] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 01/17/2017] [Accepted: 01/29/2017] [Indexed: 11/27/2022]
Abstract
Dual-energy X-ray absorptiometry (DXA) is the gold standard for measuring bone mineral density (BMD), making the diagnosis of osteoporosis, and for monitoring changes in BMD over time. DXA data are also used in the determination of fracture risk. Procedural steps in DXA scanning can be broken down into scan acquisition, analysis, interpretation, and reporting. Careful attention to quality control pertaining to these procedural steps should theoretically be beneficial in patient management. Inattention to procedural steps and errors that may occur at each step has the possibility of providing information that would inform inappropriate clinical decisions, generating unnecessary healthcare expenses and ultimately causing avoidable harm to patients. This article reviews errors in DXA scanning that affect trueness and precision related to the machine, the patient, and the technologist and reviews articles which document problems with DXA quality in clinical and research settings. An understanding of DXA errors is critical for DXA quality; programs such as certification of DXA technologists and interpreters help in assuring quality bone densitometry. As DXA errors are common, pay for performance requiring DXA technologists and interpreters to be certified and follow quality indicators is indicated.
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Affiliation(s)
- Sarah L Morgan
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham Osteoporosis Prevention and Treatment Clinic, Bone Densitometry Unit, USA.
| | - Ginnie L Prater
- Division of Gerontology, Geriatrics and Palliative Care, The Department of Medicine, School of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
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Abstract
Dual-energy x-ray absorptiometry (DXA) is the method of choice to measure bone mineral density in elderly patients and others at risk for osteoporosis. Early detection is important because fractures represent an enormous health burden. In this article, the authors discuss the application and interpretation of DXA scans as well as limitations and conditions that can affect results.
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Affiliation(s)
- Monica Agarwal
- University of Illinois at Chicago/Christ Medical Center, USA.
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Buehring B, Krueger D, Binkley N. Effect of including historical height and radius BMD measurement on sarco-osteoporosis prevalence. J Cachexia Sarcopenia Muscle 2013; 4:47-54. [PMID: 22872366 PMCID: PMC3581618 DOI: 10.1007/s13539-012-0080-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 07/09/2012] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND A clinical need exists to improve identification of those who will sustain fragility fractures. Individuals with both osteoporosis (OP) and sarcopenia (SP), so-called "sarco-osteoporosis" (SOP), might be at higher fracture risk than those with OP or SP alone. Approaches to facilitate SOP identification, e.g., use of tallest historical rather than current height and inclusion of radius bone mineral density (BMD) measurement, may be of benefit. This study examined the effect of advancing age on SOP prevalence with and without use of historical tallest height and radius BMD measurement. METHODS Adults age 60+ underwent dual-energy X-ray absorptiometry (DXA) BMD and total body composition measurement. OP and SP were defined using standard criteria: T-score ≤-2.5 at the lumbar spine or hip and appendicular lean mass (ALM)/current height(2) <5.45 kg/m(2) (female) and <7.26 kg/m(2) (male). Proposed "sensitive" SP criteria used historical tallest height instead of current height, while "sensitive" OP criteria added the 1/3(rd) radius T-score. The primary outcome was SOP prevalence by decade (60-69, 70-79, 80+). RESULTS A total of 304 individuals (146 M/158 F) participated. OP, SP and SOP prevalence were higher in older adults and increased (p < 0.05) with the "sensitive" criteria. SOP prevalence was lower than that of OP or SP and increased (standard/sensitive) criteria from 1.1 % / 4.5 % in the 60-69 years age group to 10.4 % / 21.9 % in the 80+ years age group. CONCLUSIONS SOP prevalence is higher in older adults. Use of historical tallest height and 1/3(rd) radius BMD increases SOP prevalence. Future studies need to assess whether having SOP increases fracture risk and whether use of tallest height and/or one-third radius BMD improves fracture risk prediction.
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Affiliation(s)
- Bjoern Buehring
- University of Wisconsin Osteoporosis Clinical Research Program, 2870 University Avenue, Suite 100, Madison, WI, 53705, USA,
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Gregson CL, Hardcastle SA, Cooper C, Tobias JH. Friend or foe: high bone mineral density on routine bone density scanning, a review of causes and management. Rheumatology (Oxford) 2013; 52:968-85. [PMID: 23445662 DOI: 10.1093/rheumatology/ket007] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
A finding of high BMD on routine DXA scanning is not infrequent and most commonly reflects degenerative disease. However, BMD increases may also arise secondary to a range of underlying disorders affecting the skeleton. Although low BMD increases fracture risk, the converse may not hold for high BMD, since elevated BMD may occur in conditions where fracture risk is increased, unaffected or reduced. Here we outline a classification for the causes of raised BMD, based on identification of focal or generalized BMD changes, and discuss an approach to guide appropriate investigation by clinicians after careful interpretation of DXA scan findings within the context of the clinical history. We will also review the mild skeletal dysplasia associated with the currently unexplained high bone mass phenotype and discuss recent advances in osteoporosis therapies arising from improved understanding of rare inherited high BMD disorders.
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Affiliation(s)
- Celia L Gregson
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK.
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Hassan A, Grady E, Ringelstein J, Halama JR, Mazhari A, Friedman NC. Effect of silicone gluteal implant on bone mineral density evaluation by DXA scan. J Clin Densitom 2012; 15:124-8. [PMID: 21852169 DOI: 10.1016/j.jocd.2011.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 06/07/2011] [Accepted: 07/05/2011] [Indexed: 10/17/2022]
Affiliation(s)
- Aamna Hassan
- Department of Nuclear Medicine, Hines VA Medical Center, Hines, IL, USA.
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Canadian Association of Radiologists technical standards for bone mineral densitometry reporting. Can Assoc Radiol J 2010; 62:166-175. [PMID: 20627445 DOI: 10.1016/j.carj.2010.04.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Revised: 04/09/2010] [Accepted: 04/09/2010] [Indexed: 11/23/2022] Open
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Krueger D, Checovich M, Gemar D, Wei X, Binkley N. Calcium supplement ingestion may alter lumbar spine bone mineral density measurement. J Clin Densitom 2006; 9:159-63. [PMID: 16785075 DOI: 10.1016/j.jocd.2006.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2005] [Revised: 12/26/2005] [Accepted: 01/16/2006] [Indexed: 10/24/2022]
Abstract
Densitometry centers commonly request patients abstain from ingesting calcium supplements prior to dual-energy X-ray absorptiometry (DXA) examination to avoid interference with bone mineral density (BMD) measurement. However, it is not clear that this practice is necessary. This study assessed the impact of recent calcium supplement intake on lumbar spine BMD measurement. The phase 1 experiment demonstrated BMD differences when placing a supplement over various areas of two encapsulated phantoms. To determine whether these results were clinically relevant, the phase 2 study enrolled 36 subjects who received spine scans before and after random assignment to ingest one Citracal, OsCal or People's Choice tablet providing 315, 500, and 600 mg of elemental calcium, respectively. The phase 3 study evaluated 15 subjects that had three spine scans with repositioning between to establish BMD precision, and then ingested a calcium carbonate tablet. Post-dosing scans were performed 15 and 30 minutes after tablet ingestion. The difference in L1-L4 BMD on subsequent scans was compared with the study derived least significant change (LSC) of 0.028 g/cm(2). In phase 2, L1-L4 BMD changes outside the LSC occurred in 36% of subjects with 47% having visualized tablets. Similarly, 33% of the phase 3 subjects demonstrated changes outside the LSC after calcium ingestion and 53% of the subjects in phase 3 had tablets visualized. Visualization of calcium tablets was not associated with BMD changes. In conclusion, calcium tablet intake may affect measured L1-L4 BMD within 30 minutes of ingestion. As such, it is appropriate to request patients abstain from calcium tablet ingestion prior to a spine DXA examination.
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Affiliation(s)
- Diane Krueger
- University of Wisconsin Osteoporosis Clinical Center & Research Program, Madison, 53705, USA.
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Yildiz M, Canatan D. Soft tissue density variations in thalassemia major: a possible pitfall in lumbar bone mineral density measurements by dual-energy X-ray absorptiometry. Pediatr Hematol Oncol 2005; 22:723-6. [PMID: 16251180 DOI: 10.1080/08880010500278707] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Osteoporosis is common in patients with thalassemia major. A 16-year-old patient with thalassemia major was referred for evaluation of osteoporosis. The results of dual-energy X-ray absorptiometry in a patient with thalassemia major are presented. The patient underwent measurements of the spine in both AP and lateral position. The DXA scan of the spine in AP projection showed diffusely increased density overlying the lower thoracic and upper lumbar vertebrae. The overall density of L(2)-L(4) was 0.6465 g/cm(2) (4.93 SD as compared with young adults). The DXA scan of the spine in lateral projection showed diffusely increased density in front part of the spine. The BMD of the L(3) vertebra was 0.3669 g/cm(2) (0.30 SD as compared with young adults). It is important to interpret the images visually in order to obtain true values of BMD, and preclude invalid BMD measurements.
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Affiliation(s)
- Mustafa Yildiz
- School of Medicine, Department of Nuclear Medicine, Süleyman Demirel University, 32100 Isparta, Turkey.
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Binkley N, Krueger D, Vallarta-Ast N. An overlying fat panniculus affects femur bone mass measurement. J Clin Densitom 2003; 6:199-204. [PMID: 14514987 DOI: 10.1385/jcd:6:3:199] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2002] [Accepted: 10/30/2002] [Indexed: 11/11/2022]
Abstract
Dual-energy X-ray absorptiometry (DXA) is currently the gold standard technique for osteoporosis diagnosis. However, DXA has limitations, including artifacts, such as degenerative disease or metallic foreign bodies, that may confound bone mineral density (BMD) results. Because fat folds overlying the proximal femur may alter soft-tissue density in a nonuniform manner, this may be a currently unappreciated confounder of proximal femur BMD measurement. This possibility was evaluated in 127 patients (52 women/75 men) referred for routine BMD measurement who were identified as having a fat panniculus overlying their proximal femur scan area. Presence of a fat panniculus within the scan field was confirmed by visual assessment of images obtained utilizing a GE Lunar Expert-XL. Subsequently, these individuals were rescanned while retracting their fat panniculus away from the femur scan area without other repositioning between scans. In 49% of the men, and 56% of the women, either the femoral neck, trochanter, or total femur BMD differed by more than the least significant change at our facility. No pattern was observed to predict whether BMD would increase or decrease upon fat retraction. Subsequently, 30 patients were scanned using the standard and retracted technique twice, with repositioning between scans to establish precision. Retracted and standard precision was similar. In conclusion, an overlying fat panniculus may alter proximal femur BMD measurement, which would be expected to impair the ability to accurately diagnose low bone mass and monitor osteoporosis therapy. When a fat panniculus overlays the proximal femur scan area, its retraction should be part of routine densitometric practice.
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Affiliation(s)
- Neil Binkley
- University of Wisconsin Institute on Aging, Madison 53706, USA.
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