Radial and Metacarpal Bone Mineral Density and Calcaneal Quantitative Ultrasound Bone Mass in Normal Japanese Women

The purpose of this study was to examine the effect of lifetime physical activity of farmers on skeletal status. Seventy-one healthy, postmenopausal women (mean age 52.3 ± 5.9 years, range 42–61 years) who worked professionally on farms were compared with 78 matched controls (mean age 51.8 ± 5.5 years, range 42–61 years). Broadband ultrasound attenuation (BUA) and speed of sound (SOS) at the os calcis were measured using an ultrasound transmission imaging system. Bone mineral density (BMD) of the lumbar spine and femoral neck were measured by dual-energy X-ray absorptiometry (DXA). Differences in BUA, SOS, and BMD between farmers and controls were expressed relative to standard deviation (SD) of the farmers. Farmers had significantly higher density values than controls (difference = 1.3 SD in the spine and 1.5 SD in the femoral neck, P < 0.0001 for both comparisons). Ultrasound values were significantly higher in the farmers compared with the controls in calcaneus (difference = 1.1 SD for BUA and 0.7 SD for SOS, P < 0.0001 for both comparisons). The difference of spine BMD, femoral neck BMD, BUA, and SOS between farmers and controls, as judged by comparison of the slopes of the regression lines, was unchanged with age and years since menopause. These results suggest that lifetime physical activity has a positive effect on bone status of postmenopausal farmers. Received: 19 March 1998 / Accepted: 7 August 1998     

Quantitative Ultrasound Measurements of the Tibia and Calcaneus in Comparison with DXA Measurements at Various Skeletal Sites

The performance of quantitative ultrasound (QUS) measurements of the tibia and calcaneus was studied in 109 elderly people (age range 65–87 years). Broadband ultrasound attenuation (BUA) and speed of sound (SOS) were measured at the calcaneus and SOS was assessed at the tibia. Short-term precision of tibial QUS was studied in 16 volunteers. The coefficient of variation (CV) was 0.4% and the standardized CV (sCV) was 4.4%. We compared the calcaneal and tibial QUS measurements with bone mineral density (BMD) measurements of the lumbar spine, femoral neck, trochanter and total body assessed by dual-energy X-ray absorptiometry (DXA). Calcaneal QUS correlated better with BMD at various skeletal sites than tibial QUS. Calcaneal BUA showed higher correlations with BMD values of the lumbar spine, femoral neck, trochanter and total body than calcaneal and tibial SOS (r= 0.48–0.64, r= 0.30–0.47, r= 0.35–0.47, respectively; p<0.001). Body weight modified the relationships between calcaneal and tibial QUS and BMD measurements of the hip. Higher body weight was associated with higher BMD values at the femoral neck and trochanter for the same calcaneal and tibial QUS values. After adjustments for body weight correlations of tibial and calcaneal QUS with BMD improved and were very similar. This suggests that correction for body weight is important and could add to the predictive value of QUS measurements. Received: 16 July 1997 / Accepted: 8 July 1998     

Influence of Physical Activity on Ultrasound and Dual-Energy X-ray Absorptiometry Bone Measurements in Peripubertal Girls: A Cross-Sectional Study

The aim of this cross-sectional study was to investigate whether two types of physical exercise affect the growing skeleton differently. We used calcaneal quantitative ultrasound measurements (QUS) and dual-energy X-ray absorptiometry (DXA) for measurement of bone mineral density (BMD), and to test how QUS values reflect the axial DXA values in these various study groups. A total of 184 peripubertal Caucasian girls aged 11–17 years (65 gymnasts, 63 runners, and 56 nonathletic controls) were studied. Weight, height, stage of puberty, years of training, and the amount of leisure-time physical activity were recorded. Broadband ultrasound attenuation (BUA) and sound of speed (SOS) through the calcaneus were measured. The BMD of the femoral neck and the lumbar spine were measured by DXA. The differences in mean values of bone measurements among each exercise group were more evident in pubertal than prepubertal girls. The mean BUA and SOS values of the pubertal gymnasts were 13.7% (77.8 dB/MHz versus 68.4 dB/MHz, P < 0.05) and 2.2% (1607.7 m/s versus 1572.4 m/s, P < 0.001) higher than of the controls, respectively. The mean BMD of the femoral neck in the pubertal gymnasts and runners was 20% (0.989 g/cm² versus 0.824 g/cm², P < 0.001) and 9.0% (0.901 g/cm² versus 0.824 g/cm², P < 0.05) higher than in the controls, respectively. The amount of physical activity correlated weakly but statistically significantly with all measured BMD and ultrasonographic values in the pubertal group (r = 0.19–0.35). The correlation between ultrasonographic parameters and BMD were weak, but significant among pubertal runners (r = 0.47–0.55) and controls (r = 0.39–0.42), whereas the DXA values of the femoral neck and the ultrasonographic parameters of the calcaneus did not correlate among highly physically active gymnasts. By stepwise regression analysis, physical activity accounted for much more of the variation in the DXA values than the ultrasonographic values. We conclude that the beneficial influence of exercise on bone status as measured by ultrasound and DXA was evident in these peripubertal girls. In highly active gymnasts the increase of the calcaneal ultrasonographic values did not reflect statistically significantly the BMD values of the femoral neck. Received: 28 June 1999 / Accepted: 2 November 1999     

Ultrasound and X-ray-Based Bone Densitometry in Patients with Anorexia Nervosa

In 20 patients (mean age 23 ± 5 years) with anorexia nervosa (AN), bone mass was evaluated by broadband ultrasound attenuation (BUA) of the calcaneus, peripheral quantitative computed tomography (pQCT) of the distal radius, and dual X-ray absorptiometry (DXA) of the lumbar spine and the hip. Compared with 20 age- and sex- matched healthy controls, patients with AN showed marked osteopenia at all measuring sites. Values of BUA (33.0 ± 9dB/MHz vs. 51.0 ± 5.7 dB/MHz; P < 0.0001) and of BMD of all regions of the hip (e.g., femoral neck: 0.71 ± 0.13 g/cm² versus 0.89 ± 0.07 g/cm²; P < 0.001), lumbar spine (0.82 ± 0.15 g/cm² versus 1.24 ± 0.06 g/cm²; P < 0.003) and total BMD of the peripheral radius (303.2 ± 75 g/cm³ versus 369.4 ± 53.2 g/cm³, P < 0.001) were significantly reduced. Calculating a Z-score we found the most prominent differences between AN and controls by BUA of the calcaneus (−3.2 ± 1.6), followed by DXA at the lumbar spine (−2.9 ± 2.2) and the hip (femoral neck −2.1 ± 1.7) and by pQCT at the distal radius (total BMD −1.2 ± 2.0). There were highly significant correlations between BUA of the calcaneus and BMD of the femoral neck (r = 0.78, P < 0.0001) and lumbar spine (r = 0.75, P < 0.0001) as well as between BMD values of the femoral neck and lumbar spine (r = 0.95; P < 0.0001). In addition, there were significant correlations (P < 0.001) between body mass index (BMI) and the three different measuring sites and between the duration of the disease and BUA (r = 0.5, P < 0.05). Our data suggest that BUA of the calcaneus is a valuable tool in the management of osteoporosis. Being a fast, radiation-free investigation method of good acceptance, it may be well suited for an assessment of the skeletal status in patients with AN. Received: 14 October 1998 / Accepted: 10 December 1999     

Effect of Region of Interest Location on Ultrasound Measurements of the Calcaneus

Ultrasound (US) measurements of the calcaneus are usually carried out in a region of interest (ROI) at a fixed site relative to a footplate. Recently, US transmission systems have been developed with imaging capability that enable selection of the position of ROI; the region of measurement is always the area of minimum attenuation in the posterior part of the calcaneus. This study compares measurements of broadband ultrasound attenuation (BUA) and speed of sound (SOS) at the variable ROI of minimum attenuation (ROI_v) and at fixed coordinates (ROI_f). Ultrasound variables were estimated at ROI_v and ROI_f in 212 female subjects, including 26 patients with osteoporotic fractures. Among the 186 women without fractures, 63 were classified as having osteoporosis on the basis of their vertebral bone density. Precision of BUA and SOS were better at ROI_v than at ROI_f. BUA was more highly correlated with bone mineral density (BMD) at the lumbar spine and femoral neck at ROI_v than ROI_f (r = 0.64 for lumbar spine and 0.68 for femoral neck at ROI_v versus 0.50 for lumbar spine and 0.54 for femoral neck at ROI_f, P < 0.05 for both comparisons). There were no significant differences between the correlations of SOS with axial BMD at ROI_v compared with ROI_f. Significant difference was found between the areas under the ROC curve for each ultrasound variable at ROI_v and ROI_f for both groups of patients, subjects with osteoporosis (area under curve = 0.87 for BUA at ROI_v versus 0.82 at ROI_f, P < 0.05; area under curve = 0.85 for SOS at ROI_v versus 0.81 at ROI_f, P < 0.05), and women with fractures (area under curve = 0.93 for BUA at ROI_v versus 0.86 at ROI_f, P < 0.05; area under curve = 0.91 for SOS at ROI_v versus 0.82 at ROI_f, P < 0.05). Ultrasound variables measured at ROI_v enable improved reproducibility and significantly better differentiation of diseased subjects from healthy individuals as compared with measurements at ROI_f. Received: 3 November 1997 / Accepted: 20 February 1998     

Correlation of ultrasound velocity in the tibial cortex,calcaneal ultrasonography,and bone mineral densitometry of the spine and femur

We compared the attributes of tibial cortex speed of sound (SOS) measurements with the SOS and broadband ultrasound attenuation (BUA) of the calcaneus, and bone mineral densities of the lumbar spine and femoral neck in a patient crossover study. The three instruments used in the crossover study were the LUNAR DPX and Achilles^TM, and a newly introduced device for measuring tibial cortical SOS, the SoundScan^TM 2000. Ultrasound precision determinations on the two instruments were performed with the same group of 10 volunteers, and the bone densitometry precision was derived from 22 patients who were assessed twice in a single visit, with repositioning between spine and hip scans. There were 220 female patients in the clinical study, 28 of whom had thoracic spine fractures, and all had measurements with the three instruments. Of the three instruments, the best precision, or lowest coefficient of variation and standardized coefficient of variation, was obtained with the SoundScan^TM 2000; 0.20% and 1.39%, respectively. The tibial SOS correlated more poorly with the lumbar spine and femoral neck bone mineral densities (BMDs) than the calcaneal parameters in 220 patients. Tibial SOS measurements could not distinguish the group with spinal fracture from an age-matched control group to aP<0.05 level, whereas the lumbar spine BMD and calcaneal BUA and stiffness showed a significant difference. We conclude that the SoundScan^TM 2000 system measures propagation of sound in the tibial cortex with great precision, but its role in clinical practice is moot. Yet to be established by a long-term prospective study is its efficacy in predicting fracture risk and how well it reflects bone change in response to treatment of osteoporosis.     

Imaging Ultrasonometry of the Calcaneus: Dependence on Calcaneal Area

The purpose of this study was (1) to investigate the dependence of broadband ultrasound attenuation (BUA) and speed of sound (SOS) measured in a circular region of interest (ROI) having a fixed size on calcaneal area and (2) to examine whether the normalization of ultrasonic variables for the area of the calcaneus provides better differentiation of diseased subjects from healthy individuals. Ultrasound variables were estimated in 169 healthy postmenopausal women (mean age 66.5 years, range 42–87 years) and 39 women with vertebral fractures (mean age 72.9 years, range 51–86 years). A minimum attenuation ROI, 15 mm in diameter, with a commercial imaging ultrasonometer was used. Significant relationships were found between both ultrasonic variables and calcaneal area (r²= 0.06, P < 0.001 for BUA, r²= 0.12, P < 0.0001 for SOS). Normalization of ultrasound variables (BUAn and SOSn) was based on the regression equations of the relationships among BUA, SOS, and calcaneal area. In a precision study, nine women were examined five times each to determine the errors arising from both the repositioning of the foot and selection of the calcaneal area. The reproducibility errors of BUA, SOS, BUAn, SOSn, and area were 0.87%, 0.20%, 1.07%, 0.27%, and 3.72%, respectively. Significant differences were found between the areas under the ROC curve for BUAn and BUA (area under the curve = 0.93 for BUAn versus 0.90 for BUA, P= 0.003) as well as for SOSn and SOS (area under the curve = 0.85 for SOSn versus 0.79 for SOS, P= 0.003). Normalization of ultrasound variables for calcaneal area improves the discrimination of clinical studies. Received: 7 June 1999 / Accepted: 18 January 2000     

Imaging Ultrasonometry of the Calcaneus: Optimum T-Score Thresholds for the Identification of Osteoporotic Subjects

The purpose of the present study was to (1) examine the age dependence of T-score results for calcaneal imaging ultrasonometry and dual X-ray absorptiometry of the axial skeleton and (2) determine the optimum T-score thresholds appropriate for broadband ultrasound attenuation (BUA) and speed of sound (SOS) measurements. A total of 453 healthy women aged 20-9 years were included in the study. All study participants underwent bone mineral density (BMD) measurements of the lumbar spine, femoral neck, total hip and calcaneal measurements of the BUA and SOS. An imaging ultrasound device (UBIS, DMS, France) was used for the ultrasound measurements. T-scores were calculated using a subgroup of 71 healthy women aged 20-35 years to estimate the mean value of young normals and SD for BUA, SOS, and BMD. The age-related decline in both BUA and SOS T-scores was slower than that in the equivalent figures obtained by BMD measurements. The optimum T-score thresholds estimated by receiver operating characteristic (ROC) analysis were 1.3 for BUA and 1.5 for SOS. Using the optimum threshold, the sensitivity and specificity for BUA was 68% and 83%, respectively. Corresponding values for SOS were 63% and 79%. Utilizing calculated optimum T score thresholds for BUA and SOS, the agreement among BUA, SOS, and BMD at the femoral neck was improved compared with that found using the T-score of < or = -2.5 criterion. In conclusion, the definition of osteoporosis by a T-score of , or = -2.5 was not applicable to imaging ultrasonometry of the calcaneus. Optimum T-score thresholds were determined for both BUA and SOS suitable to Ubis QUS device.     

Ultrasound Velocity Through the Phalanges in Normal and Osteoporotic Patients

Quantitative ultrasound (US) measurements have been shown to be a new technique assessing bone status. This study aimed to assess a new US instrument, the DBM Sonic 1200? (IGEA) which permits the measurement of the speed of sound in the proximal phalanges (SOSp) of the hand. The results obtained were compared with DXA (SOPHOS) and US measurements at the calcaneus (Achilles? LUNAR). The in vivo precision expressed by coefficient of variation was 0.91%. Ultrasound measurements of phalanges were significantly correlated with BMD in the entire group of 90 subjects: osteoporotic patients (n = 47) and controls (n = 43) (r = 0.44, femoral neck and 0.45, lumbar spine, P < 0.01). A significant correlation was also found in the control group (r = 0.33, lumbar spine and 0.38, femoral neck, P < 0.05) but not in the osteoporotic group (r = 0.3, lumbar spine and 0.17, femoral neck, P > 0.05). Mean values for 31 postmenopausal, osteoporotic women and age-matched controls showed a significant decrease in US measurements at the phalanges (P < 0.05) and the calcaneus (P < 0.01) as well as bone mineral density (BMD) at the spine and femoral neck (P < 0.01) in the osteoporotic group. A decision threshold for a sensitivity of 80% for osteoporotic fractures resulted in a specificity value of only 37% for SOSp, between 53 to 65% for calcaneus US measurements and 45 to 56% for BMD. The Z score, the odds ratio, the ROC curves, and areas under the curves plotted for the subgroup of 31 fractures and their healthy controls showed poorer values for SOSp than BMD and calcaneus US measurements. In conclusion, US measurements of phalanges seem to be less efficient than calcaneus US and BMD measurements to distinguish osteoporotic from healthy women. Other studies and also prospective studies are required to assess the interest in fracture risk assessment. Received: 23 September 1996 / Accepted: 25 November 1997     

In Vivo MRI Measurements of Bone Quality in the Calcaneus: A Comparison with DXA and Ultrasound

Magnetic resonance imaging (MRI) has shown promise in the assessment of bone architecture. The precision and feasibility of MRI measurements in osteoporosis in vivo have been assessed in this study. T2′ was calculated from measurements of T2 and T2* in the calcaneus of 32 postmenopausal women using a gradient-echo sequence PRIME (Partially Refocused Interleaved Multiple Echo). This sequence allows the measurement of T2 and T2* in one acquisition. In vivo measurements of bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA) were made in the calcaneus, spine and femoral neck. The ultrasound parameters broadband ultrasound attenuation (BUA) and speed of sound (SOS) were also measured in the calcaneus. These three techniques have not previously been compared in the same study population. The precision of the MRI technique was poor relative to the DXA and ultrasound techniques, with a CV of 6.9%± 4.4% for T2′ and 5.5%± 3.6% for T2*. Approximately 4% of this is due to system error as determined by phantom measurements. The postmenopausal women were classified as having low BMD if they had a lumbar spine (L2–4) BMD of less than 0.96 g/cm² (more than 2 standard deviations below normal peak bone mass). Calcaneal T2′ was significantly correlated with calcaneal BMD (r = –0.79, p <0.0001), BUA (r = –0.59, p = 0.0004) and SOS (r = –0.58, p = 0.0006). T2′ was significantly different in postmenopausal women with normal BMD and those with low BMD (p <0.01). However, the difference was of only borderline significance (p <0.06) after adjustment for age and years since menopause. Received: 8 July 1997 / Accepted: 29 April 1998     

Contact Quantitative Ultrasound: An Evaluation of Precision, Fracture Discrimination, Age-Related Bone Loss and Applicability of the WHO Criteria

The aim of this study was to assess a dry calcaneal quantitative ultrasound (QUS) device by examining: (i) short- and long-term precision; (ii) the ability of the ultrasound parameters to identify women with vertebral fractures; (iii) age- and menopause-related bone loss; (iv) applicability of the WHO criteria in scan interpretation. The study group consisted of 422 healthy women with no risk factors associated with osteoporosis (227 premenopausal and 195 postmenopausal) and 93 women with one or more vertebral fractures. All women had calcaneal QUS and bone mineral density (BMD) measurements of the lumbar spine and hip performed. Broadband ultrasound attenuation (BUA) and speed of sound (SOS) measurements in the heel were combined and expressed as estimated heel BMD. Short-term precision studies yielded coefficient of variations of 0.3% for SOS, 4% for BUA and 3.3% for estimated heel BMD. Standardized short-term precision values were approximately 0.2 SD. Long-term standardized precision errors ranged from 0.17 to 0.38 SD. All the QUS and BMD measurement parameters showed significant negative relationships with age in the postmenopausal group. Annual losses were 0.35 dB/MHz per year for BUA, 0.56 m/s per year for SOS and 0.002 g/cm² per year for estimated heel BMD. All the QUS and BMD parameters were able to discriminate between healthy postmenopausal women and women with vertebral fracture. Age-adjusted odds ratios for each SD decline in QUS measurements were 3.63, 5.25 and 4.79 for BUA, SOS and estimated heel BMD respectively. Corresponding odds ratios for BMD at the lumbar spine, femoral neck and total hip were 2.39, 2.51 and 2.95 respectively. When the QUS and BMD parameters were expressed as T-scores, estimated heel BMD showed the least age-related decline, while femoral neck BMD displayed the greatest decrease with age. The mean T-score and prevalence of osteoporosis (T<−2.5) for a Caucasian woman aged 60–65 years were −1.35 and 21% respectively for the lumbar spine compared with −0.59 and 2% for estimated heel BMD. In conclusion, this study revealed that contact ultrasound can detect age- and menopause-related influences on bone status and was able to discriminate between healthy individuals and women with vertebral fracture. However, the widely accepted threshold of a T-score of less than −2.5 for the definition of osteoporosis may need modifying for the interpretation of QUS scans. Received: 8 February 1999 / Accepted: 5 May 1999     

Quantitative ultrasound imaging of the calcaneus: precision and variations during a 120-Day bed rest

This study reports on the precision and variation of quantitative ultrasound (US) parameters [broadband ultrasonic attenuation (BUA) or slope of the frequency-dependent attenuation in dB/MHz and speed of sound (SOS m/second)] after 120 days of continuous bed rest in six normal male volunteers. Quantitative US was measured at the calcaneus using a new US bone imaging scanner. The measurements were carried out on both heels at approximately 2-week intervals. The short-term precision was 0.31% for SOS and 2.8% for BUA. The long-term precision was 0.58% for SOS, 4.7% for BUA. A significant decrease of SOS values of −26 m/second (P < 0.0001) for the right heel and −17 m/second (P < 0.05) for the left heel was found at the group level. In terms of percentage change this represents −1.7% for the right heel and −1.1% for the left heel. These percentage decrements were 3.5–5.5 times that of the short-term precision and 2–3 times that of the long-term precision of the technique. At the individual level, the decrease of SOS was statistically significant (P < 0.05) or marginally significant (P < 0.1) for four out of 6 subjects. For 2 other subjects, similar trends were observed, but without reaching statistical significance. BUA did not change significantly during follow-up. These results are consistent with previous findings on changes of ultrasonic properties from the calcaneus during aging, pregnancy, or therapy, showing that calcaneus SOS is a valuable index of bone loss. These preliminary data suggest that prolonged exposure to simulated weightlessness may lead to a lower SOS, which then could be used for the follow-up of bone demineralization occurring during long-term space flights. Received: 5 January 1999 / Accepted: 1 July 1999     

Site-Specific Bone Measurements in Patients with Ankle Fracture

Ankle fracture is one of the most common fractures in adults, particularly postmenopausal women. Few studies have examined the bone mineral density (BMD) and ultrasound properties of bone close to the site of fracture in patients with ankle fracture. The aim of this study was to evaluate these measurements in women with ankle fractures compared with controls. We studied 31 healthy post-menopausal women ages 50–79 years (mean age 63.2 ± 3.3 years) from a population-based group and 31 postmenopausal women ages 52–76 years (mean age 61.2 ± 2.2 years) with an ankle fracture. Distal tibia and fibula BMD were measured by dual-energy X-ray absorptiometry using the Hologic QDR 1000/W densitometer. In addition to total distal and tibia BMD, three subregions were automatically selected: ultradistal, middle and one-quarter regions. Speed of sound (SOS) and broadband ultrasound attenuation (BUA) of the calcaneus were measured using the Lunar Achilles+ (LA+) and CUBA Clinical (CC). In addition to SOS and BUA, LA+ Stiffness Index (SI) was also measured. The nondominant limb was measured in the population group and the contralateral limb in the ankle group. Differences between the groups were determined using t-tests. The ankle fracture group was heavier than the control group by an average of 10 kg. BMD measurements were therefore adjusted for weight. There were no significant differences between the ankle fracture and control groups in lumbar spine BMD, total or regional ankle BMD or calcaneal BUA. However, calcaneal SOS was decreased in the ankle fracture group when measured on the LA+ and CC by 50 m/s (–2.0 SD units, p<0.001) and 19 m/s (–0.5 SD units, p<0.01) respectively. LA+ SI was decreased in the ankle fracture group by 14 units (–1.1 SD units, p<0.001). In conclusion, ankle fracture is not a typical osteoporotic fracture. However, there may be structural changes in the bone (unrelated to bone density) which result in increased fragility and susceptibility to fracture. Received: 7 May 2001 / Accepted: 29 August 2001     

Usefulness of Ultrasound in Sudeck's Atrophy of the Foot

Quantitative ultrasound (QUS) of bone has been proposed as an inexpensive and radiation-free device method of assessing skeletal status. QUS has been widely used in the assessment of osteoporosis. Until now only few data are available on the usefulness of QUS in different disorders, such as Sudeck's atrophy. To evaluate the ability of QUS in the diagnosis and monitoring of regional osteoporosis, we investigated 19 patients (12 women and 7 men, age range 30–65 years) with osteoporosis of the foot (Sudeck's atrophy), as evidenced by X-ray study and Technetium-99 bone scan. In all patients we measured speed of sound (SOS), broadband ultrasound attenuation (BUA), and stiffness of the calcaneus using Lunar Achilles Ultrasound, both in the affected and unaffected foot. Bone mineral density at the lumbar spine, by DXA (Hologic QDR 1000), was also performed. QUS was repeated after 3 and 6 months of treatment with salmon calcitonin (100 IU I.M. every second day). At baseline, SOS, BUA, and stiffness, expressed as T-score, were −1.9, −2.4, and −2.4 in unaffected feet and −2.9, −5.1, and −4.3, respectively, in affected feet. The difference between the unaffected and affected foot was significant for SOS, BUA, and stiffness (P < 0.001). No significant difference was found in QUS parameters in the unaffected foot during the study period. After 3 and 6 months of treatment, SOS increased in the affected foot by 0.2% and 0.3%, BUA increased by 6.2% and 8.2%, and stiffness by 7.5% and 11.1%, respectively. In conclusion, BUA and stiffness seem to be influenced more than SOS by Sudeck's atrophy; QUS, namely, BUA and stiffness, significantly increase with calcitonin treatment. In conclusion, QUS is a sensitive tool in the diagnosis of Sudeck's atrophy of the foot and is adequate for measuring improvement in bone status following treatment. Received: 7 June 1997 / Accepted: 15 October 1997     

Clinical Performance of a Highly Portable, Scanning Calcaneal Ultrasonometer

The aim of this study was to establish a normative database, assess precision, and evaluate the ability to identify women with low bone mass and to discriminate women with fracture from those without for a highly portable, scanning calcaneal ultrasonometer: the QUS-2. Fourteen hundred and one Caucasian women were recruited for the study. Among them were 794 healthy women 25–84 years of age evenly distributed per 10-year period to establish a normative database. Of these, 171 aged 25–34 years were defined as the young normal group for the purpose of T-score determination. Precision was assessed within 1 day (short-term) and over a 16-week period (long-term) in 79 women aged 25–84 years. Five hundred twenty-eight women ranging from 50 to 84 years of age with or without prevalent fractures of the spine, hip or forearm were measured to compare the QUS-2 with bone mineral density (BMD) of the hip and spine. Mean calcaneal broadband ultrasound attenuation (BUA) was constant in healthy women from 25 to 54 years of age and decreased with increasing age thereafter. Short-term precision, with and without repositioning of the heel, and long-term precision yielded comparable results (BUA SDs of 2.1–2.4 dB/MHz, coefficients of variations (CVs) of 2.5–2.9%). Calcaneal BUA was significantly correlated with BMD of the total hip (TH), femoral neck (FN) and lumbar spine (LS) in 698 women (r= 0.6–0.7, all p<0.0001). A similar relationship was observed for LS BMD compared with either TH or FN BMD (r= 0.7, p<0.0001). Prevalence of osteoporosis in our population (WHO criteria) was 20%, 17%, 21%, and 24% for BUA, BMD of the TH, FN and LS, respectively. Age-adjusted values for a 1 SD reduction in calcaneal BUA and TH and FN BMD predicted prevalent fractures of the spine, forearm, and hip with significant (p<0.05) odds ratios of 2.3, 2.0 and 2.1, respectively. Areas under the receiver operating characteristic curves for age-adjusted bone mass values predicting prevalent fracture were 0.62 for BUA, 0.59 for TH BMD, 0.60 for FN BMD, and 0.57 for LS BMD; all statistically equivalent. We conclude that the QUS-2 calcaneal ultrasonometer exhibits reproducible clinical performance that is similar to BMD of the spine and hip in identifying women with low bone mass and discriminating women with fracture from those without. Received: 19 July 2000 / Accepted: 6 December 2000     

Genetic Variation in α2HS-Glycoprotein Is Related to Calcaneal Broadband Ultrasound Attenuation in Older Women

Calcaneal broadband ultrasound attenuation (BUA) is an independent predictor of hip and vertebral fractures. BUA is under genetic control, but the specific genes contributing to BUA are not well defined. We examined the relationship between genetic variation in α₂HS-glycoprotein (AHSG), an abundant noncollagenous protein of bone matrix, and calcaneal BUA. Genetic polymorphism in AHSG was determined in 222 Caucasian women (age 66–92) enrolled in the Pittsburgh Study of Osteoporotic Fractures clinical center by isoelectric focusing of serum samples. Calcaneal BUA and bone mineral density (BMD) were measured on the same foot with a Walker Sonix UBA 575⁺ and single X-ray absorptiometry. Hip and spine BMD were determined with a Hologic QDR-1000 densitometer using dual-energy X-ray absorptiometry. AHSG polymorphism was not significantly related to hip, lumbar spine, or calcaneal BMD. Compared with the homozygous AHSG*2 women, calcaneal BUA was 13% lower in heterozygous (P < 0.05) and 16% lower in homozygous AHSG*1 women (P < 0.05). This relationship persisted after controlling for age, weight, height, walks for exercise, and calcaneal BMD. Current and self-reported height were also lowest in homozygous AHSG*1 women, intermediate in heterozygous women, and highest among homozygous AHSG*2 subjects. These results suggest that the AHSG polymorphism may contribute to the genetic influence on calcaneal BUA and stature. Received: 28 August 1997 / Accepted: 8 January 1998     

Quantitative Ultrasound and Symptomatic Vertebral Fracture Risk in Chinese Women

Quantitative ultrasound (QUS) is emerging as a simple, inexpensive and noninvasive method for assessing bone quality and assessing fracture risk. We assessed the usefulness of a contact calcaneal ultrasonometer by studying normal premenopausal women (group I, n= 53), normal postmenopausal women (group II, n= 198), and osteoporotic women without (group III, n= 141) and with vertebral fractures (group IV, n= 53). The osteoporotic subjects had a T-score of the spine or hip neck bone mineral density (BMD) <−2.5 based on the local Chinese peak young mean values. When compared with postmenopausal controls, mean broadband ultrasound attenuation (BUA), speed of sound (SOS), and quantitative ultrasound index (QUI) were 26%, 2.1% and 25% lower in women with vertebral fractures (p all <0.005). The correlation coefficients between QUS parameters and BMD of the spine and hip ranged between 0.4 and 0.5. The ability of the QUS to discriminate between patients groups was determined based on the mean value of normal premenopausal women in group I. The mean T-score for women with fractures was −2.87 ± 1.02 for BUA, −2.54 ± 0.79 for SOS, −3.17 ± 0.70 for QUI, −2.65 ± 0.86 for L2–4 BMD and −2.53 ± 0.66 for hip neck BMD. After adjustment for age and body mass index, the odds ratio of vertebral fracture was 1.71 (95% CI 1.2–2.6) for each 1 SD reduction in BUA, 2.72 (1.3–5.3) for SOS, 2.58 (1.4–4.6) for QUI, 2.33 (1.6–3.3) for L2–4 BMD, 2.09 (1.37–3.20) for femoral neck BMD and 1.88 (1.34–2.92) for total hip BMD. The association between the QUS parameters and vertebral fracture risk persisted even adjustment for BMD. The area under the receiver operating characteristic curve for BUA for vertebral fracture was 0.92, for SOS, QUI, L2–4 BMD and femoral neck BMD was 0.95, and for total hip was 0.91. Received: 7 January 1999 / Accepted: 18 May 1999     

Quantitative Ultrasound and Bone Mineral Density in Patients with Primary Hyperparathyroidism Before and after Surgical Treatment

The aim of this study was to assess the pattern of ultrasound (QUS) parameters and bone mineral density at different skeletal sites in patients with primary hyperparathyroidism (PHPT) before and after surgical treatment. In 22 patients (age range 28–74 years) with PHPT we measured speed of sound (SOS), attenuation (BUA) and Stiffness at the calcaneus, amplitude-dependent speed of sound (AD-SoS) at proximal phalanges, and bone mineral density at lumbar spine (BMD-LS) and at the mid-radius (BMD-MR) and ultradistal radius (BMD-UDR) before, 1 and 2 years after surgical operation. Twenty-two age- and sex-matched healthy subjects provided control data. Before surgery, all parameters apart from SOS were significantly lower in PHPT patients than in controls. At the end of the study period, BMD-LS increased by 7.0%, BMD-UDR by 7.4% and BMD-MR by 11.0%. The changes in ultrasound parameters after surgery were lower (0.44% for SOS, 2.2% for BUA, 3.3% for Stiffness and 2.6% for AD-SoS); however, the increase was statistically significant (p<0.05 and p<0.01, respectively) only for Stiffness and AD-SoS. Our results indicate that parathyroidectomy increases both axial and appendicular BMD and influences QUS parameters differently at the calcaneus and at the phalanges. The combined use of BMD and QUS could improve the assessment of skeletal status in patients with PHPT before and after surgery. Received: 22 January 1999 / Accepted: 25 August 1999     

Correlates of Quantitative Ultrasound in the Women’s Healthy Lifestyle Project

Quantitative ultrasound (QUS) assessment of bone is a strong predictor of hip fractures and is currently an FDA-approved tool to identify women at risk of osteoporosis. However, few studies have investigated the lifestyle and genetic correlates of QUS in women. This study investigated the cross-sectional associates of several lifestyle, demographic and genetic factors with calcaneal QUS parameters (broadband ultrasound attenuation (BUA) and speed of sound (SOS)) in 393 women aged 45–53 years. Leisure-time and historical physical activity, dietary calcium and protein, body composition, vitamin D receptor genotypes, menopause status, other health behaviors, calcaneal QUS parameters and bone mineral density (BMD) were assessed at a single clinic visit. Lean mass, recent physical activity and African-American race were the strongest correlates of SOS whereas dietary protein, calcium and recent physical activity were the strongest correlates of BUA. These predictors explained 13% and 6% of the variance in SOS and BUA, respectively. Smoking, alcohol intake, education, hormone replacement therapy, calcium and vitamin D supplements, historical physical activity and vitamin D receptor genotypes were not significantly associated with BUA or SOS. Lean body mass and premenopausal status were the strongest correlates of lumbar BMD whereas lean body mass, physical activity, African-American race and body mass index were significantly related to femoral neck BMD. Physical activity remained predictive of SOS after controlling for lumbar BMD. The spectrum and magnitude of risk factors for SOS and BUA, including lean body mass, physical activity, race, protein and calcium intake, parallel previously observed predictors of BMD. Received: 25 November 1998 / Accepted: 1 April 1999     

Influence of Bone Quality on Precision of Calcaneal Ultrasonometry

This study was designed to determine the changes in precision of the ultrasound parameters speed of sound (SOS), broadband ultrasound attenuation (BUA), and stiffness index (SI) as a function of bone quality. The instrument used in this investigation was the LUNAR Achilles. Of the 608 female patients who had paired measurements with repositioning, 200 had t scores ≥−1 and 408 had t scores ≤−2.5, thus rendering a normal and a grossly abnormal group for comparison of precision results. It was found that the median precision error (CV%) for BUA was 1.99% for normal bone and 1.44% for abnormal bone (P= 0.02). No significant difference was obtained between median precision errors in normal and abnormal bone for the parameters SOS and SI, which were 0.23% and 0.19%, and 2.15% and 2.02%, respectively. In the interquartile range, the mean precision errors for SOS and BUA were significantly different in normal and abnormal bone: SOS was 0.25% and 0.21%, respectively, and BUA was 2.31% and 1.85%, respectively. No significant change was registered for SI. Precision error appears to decrease slightly at lower values for calcaneal variables. Received: 21 August 1996 / Accepted: 5 March 1997