Quantitative ultrasound and dual-energy X-ray absorptiometry in the prediction of fragility fracture in men

Abstract

Fragility fractures in men represent a major health problem, and this prompts a necessity for reliable tools for the identification of men at risk of fracture. In order to assess the ability of dual-energy X-ray absorptiometry (DXA) and quantitative ultrasound (QUS) in the prediction of fracture risk in men and whether their combination might be useful in a clinical setting, we studied 401 men (age range 45-82 years, mean 60.3+/-12.5), of whom 133 had osteoporotic fractures and 268 did not. In all subjects we measured bone mineral density at the lumbar spine (BMD-LS) and at the femur, calculating thereafter the standard femoral subregions: neck (BMD-FN), total hip (BMD-T), trochanter (BMD-TR), intertrochanter (BMD-ITR), and Ward's triangle (BMD-W), by DXA. We also performed ultrasound parameters at the calcaneus: speed of sound (SOS), broadband ultrasound attenuation (BUA) and Stiffness, by Achilles plus, and at the phalanxes: amplitude dependent speed of sound (AD-SoS) and the parameters of the graphic trace: bone transmission time (BTT), fast wave amplitude (FWA), signal dynamic (SDy) and ultrasound bone profile index (UBPI), by Bone Profiler. All DXA and QUS parameters, apart from FWA, were significantly (P<0.001) lower in patients with a history of fracture. BMD at the proximal femur showed the best ability in discriminating men with or without fractures. QUS at the heel showed discriminatory ability significantly better than QUS at the fingers. By logistic regression analysis, adjusted for age and BMI, BMD-T showed the best association with fragility fracture [odds ratio (OR)=3.43, 95% confidence interval (CI)=2.47-4.77]. Among QUS parameters, the highest value of the OR was shown by stiffness (OR=3.18, CI=2.27-4.48). FWA and SDy were not associated with fragility fractures in men. If DXA and QUS were combined, the prediction of the OR of fragility fracture events in men increases; in fact Stiffness was able to increase the OR when added to BMD-LS (OR=5.44, CI=3.16-10.13) and BMD-T (OR=6.08, CI=2.63-14.27). SOS and BUA showed a similar pattern. AD-SoS improved the prediction of fracture only when combined with BMD-LS (OR=4.36, CI=1.99-9.57). If BMD-LS and BMD-FN or BMD-T were combined, the value of the OR increases (OR=4.59, CI=2.27-9.25 and OR=4.68, CI=2.24-9.76), respectively. Our study supports the effectiveness of QUS in the identification of osteoporotic fractures in men. QUS seems to play an independent and complementary role, with respect to DXA, in order to enhance the power for predicting osteoporotic fractures in men.

Influence of bone remodelling rate on quantitative ultrasound parameters at the calcaneus and DXA BMDa of the hip and spine in middle-aged and elderly European men: the European Male Ageing Study (EMAS)

“…While the associations between bone turnover and QUS tended to be slightly weaker than with DXA, findings were consistent across different skeletal sites and across different assessment methods, supporting the concept that QUS measurements in calcaneal bone should be primarily regarded as an indicator of bone density (66). In line with this concept, QUS parameters and DXA-assessed BMD a have been shown to be equally predictive for incident fractures, in both sexes (67)(68)(69).…”

Physical activity is the strongest predictor of calcaneal peak bone mass in young Swedish men

“…Cummings et al [24] also found that high physical activity was an independent protective factor against hip fracture. In 45-82-year-old men, heel broadband ultrasound attenuation (BUA) assessed using quantitative ultrasound (QUS), has been associated with fragility fractures [36]. Furthermore, it was recently reported in a study in adolescent males that prevalent upper limb fractures were associated with reduced calcaneal BUA [37].…”

Positive Association Between Adipose Tissue and Bone Stiffness

“…While DXA measures bone mass, BMD, and BMC [31], QUS provides information on bone microarchitecture and strength [32]. The different aspects of bone health covered by DXA or QUS produce complementary information on a patients bone status and might be independently linked to osteoporosis and fracture risk [33]. Thus, a low DXA or QUS result corresponds to a high fracture risk [30].…”

“…Indeed, it is well accepted that low BMI is associated with high osteoporosis prevalence and high risk for self-reported and radiologically verified fractures [10,21]. Among the QUS parameters, stiffness index provides the best validity to estimate fracture risk [33]. Apart from stiffness index, other parameters including fall history and clinical risk factors contribute to the individual risk for fragility fracture [41].…”

“…Besides, DXA and QUS measurements are performed on different skeletal sites [34]. Due to differences in bone structure throughout the skeleton [33], our measurements at the heel are not directly comparable to measurements obtained at the femoral neck or spine. Thus, our findings at the calcaneus might not be directly applicable to the hip or spine, where fragility fractures most often occur.…”