Bone Densitometry and Osteoporosis

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H. K. Genant, G. Guglielmi, M. Jergas (Eds.)

Bone Densitometry and Osteoporosis With Contributions by S. Adami, J. Adams, L.V. Avioli, C. Berkovich, E. Bonucci, V. Braga, M. Cammisa, E. Canalis, R. Civitelli, M. T. DiMuzio, K. Engelke, L.K. Fattore, D. Felsenberg, J.L. Ferretti, T. Fuerst, H.K. Genant, C. Gennari, V. Gilsanz, G. Guglielmi, D. Hans, S.T. Harris, K. Houki, M. Jergas, O. Johnell, W. Kalender, M. Kleerekoper, C. van Kuijk, T.F. Lang, Y. Lu, S. Majumdar, G. Martini, A. Mathur, P.D. Miller, S. Mora, R. Nuti, S. Ortolani, R. Pacifici, C. Reiners, P.D. Ross, P. Schneider, C. Trevisan, M. Uffmann, C.B. Westlund, A. Zallone Zambonin, G. Zambonin, K. Ziambaras

With 132 Figures and 34 Tables

i Springer

Editors:

Professor Dr. Harry K. Genant Chief, Musculoskeletal Radiology Professor of Radiology, Medicine, Epidemiology & Orthopadic Surgery Executive Director, Osteoporosis & Arthritis Research Group University of California, San Francisco, CA 94143-0628, USA

Giuseppe Guglielmi, M.D. Scientific Institute Hospital "Casa Sollievo della Sofferenza", Department of Radiology Viale Cappuccini, 71013 San Giovanni Rotondo (FG), Italy

Michael Jergas, M.D. St. Josef-Hospital, Department of Radiology GudrunstraBe 56,44791 Bochum, Germany

Library of Congress Cataloging-in-Publication Data Bone densitometry and osteoporosis 1 H. K. Genant, G. Guglielmi, M. Jergas (eds.). Includes bibliographical references and index. ISBN-13:978-3-642-80442-7 e-ISBN-13:978-3-642-80440-3 DOl: 10.1007/978-3-642-80440-3

1. Osteoporosis. 2. Bone densitometry. I. Genant, Harry K. II. Guglielmi, G. (Giuseppe). III. Jergas, M. (Michael) [DNLM: 1. Osteoporosis-diagnosis. 2. Osteoporosis-therapy. 3. Densitometry-methods. 4. BoneDensity-physiology. WE 250 B7119 1998] RC931.073B6541998 616.7'16-dc21 DNLM/DLC.

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Preface

The diagnosis of osteoporosis and the determination of fracture risk has always been a challenge for radiologists, epidemiologists, and clinicians as well as oth­er researchers and health care professionals working in the field. It is bone min­eral density that is closely related to bone fragility, and the advent of techniques to quantitatively assess bone density has been welcomed. It has reduced the sub­jectivity inherent to conventional radiologic assessment of osteoporosis. The on­going technical process has made various techJ)iques to assess bone density wide­ly available. However, these measurement techniques have also incurred some crit­icism because bone densitometry has sometimes been applied without specific indications and without appropriate clinical ramifications.

The purpose of this text is to provide a perspective on the current status of bone densitometry and ist relevance to osteoporosis diagnosis and management. Therefore, this book will give the reader an introduction to the nature of osteo­porosis, its pathophysiology and epidemiology, and the clinical consequences of performing bone densitometry. Aside from standard bone densitometry, newer technologies such as quantitative ultrasound techniques, magnetic resonance imaging and bone structure analysis are discussed in the context of diagnosing osteoporosis.

The excellent cooperation with the publisher has made possible a short inter­val between the receipt of manuscripts and publication of this volume. There­fore, the chapters included are as close as possible to the current state ofknowl­edge in this field. In this regard, we would like to thank Ms. Adelheid Duhm, Ms. Doris Engelhardt and Dr. Ute Heilmann from Springer-Verlag and Ms. Regine Schadlich from ProduServ Verlagsservice. We would also like to thank all of the authors for their excellent contributions that will make this volume a worthy read for clinicans, radiologists, physicists, and all researchers in the field of osteoporo­sis.

Harry K. Genant, San Francisco Giuseppe Guglielmi, San Giovanni Rotondo Michael Jergas, Bochum

Contents

Contributors ..................................................... XIX

1 Osteoporosis: The Clinical Problem .............................. 1 L.V. AVIOLI AND M. KLEEREKOPER

Epidemiology ....................... , ......................... . Pathogenesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Classifications of Osteoporosis ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Clinical Manifestations of Osteoporosis ........................... 5 Diagnostic Studies in Osteoporosis ............................... 7 Calcitropic Hormones and Biochemical Markers of Bone Remodeling .............................................. 8 Medical Therapy ........ ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Selecting a Therapy and Monitoring the Response to Therapy. . . . . . . . 14 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

2 Epidemiology of Osteoporosis ................................... 21 P.D. Ross

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 21 Skeletal Development and Aging ................................. 22

Skeletal Development ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 22 Prevalence of Low Bone Density . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 23

Fracture Incidence and Prevalence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 25 Vertebral Fractures .......................................... 25 Hip Fractures ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 26 Other Fractures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 27 Secular Trends ........................................ '. . . . .. 28 Lifetime Risk ............................................... 28

Mortality and Morbidity ........................................ 29 Mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 29 Economic Costs and Morbidity. . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .. 30

Summary ..................................................... 33 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 33

X Contents

3 The Physiology of Bone Turnover ................................ 43 R.PACIFICI

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 43 Cytokines and Bone Remodeling ................................. 44 Role of the Bone Matrix in the Regulation of Bone Turnover ......... 46 Effect of Menopause and Estrogen Replacement on the Production of Bone Resorbing Cytokines ... . . . . . . . . . . . . . . . . . . . . . .. 47 Effect of Menopause on the Stromal Cell Responsiveness to Cytokin"es . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Conclusions ................................................... 52 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

4 Growth Factors and the Skeleton................................. 61 E.CANALIS

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 61 Platelet-Derived Growth Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 62 Fibroblast Growth Factors ....................................... 65 Transforming Growth Factors-b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 66 Insulin-Like Growth Factors I and II .............................. 69 Growth Factors and Clinical Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 References .................................................... .

5 Cellular Basis of Bone Resorption ................................ 83

A. ZAMBONIN ZALLONE AND G. ZAMBONIN

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Osteoclast Morphology and Functions ............................ 84 Coupling Between Osteoclast and Osteoblast Activity ............... 87 Systemic and Local Factors in Bone Remodeling . . . . . . . . . . . . . . . . . . .. 88 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 89

6 Biochemical Markers of Bone Turnover ........................... 95 K. ZIAMBARAS AND R. CIVITELLI

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 95 Parameters of Bone Formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 96

Serum Alkaline Phosphatase .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 96 Serum Osteocalcin (Bone Gla Protein) .................. ,. . . . . .. 98 Serum Type I Pro collagen Propeptide .......................... 100

Parameters of Bone Resorption .................................. 101 Urine Hydroxyproline ....................................... 101 Urine Hydroxylysine Glycosides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 103 Plasma Tartrate-Resistant Acid Phosphatase .................... 103 Urine Pyridinoline Cross-Links ............................... 104

Contents XI

Clinical Applications ............................................ 107 Diagnostic Value in Osteoporosis .............................. 107

Prediction of Bone Loss and Fracture Risk . . . . . . . . . . . . . . . . . .. 108 Selection of Treatment .................................... 11 0 Monitoring Treatment Compliance and Efficacy . . . . . . . . . . . . .. 110

Diagnostic Value in Other Metabolic Bone Diseases .............. 111 Future Directions .............................................. 113 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 114

7 Determinants of Bone Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 127 S. ADAMI AND V. BRAGA

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 127 Genetic Factors ................................................ 128 Age ........................................................... 128 Estrogen Deficiency ............................................ 129" Body Weight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 130 Smoking ...................................................... 131 Alcohol ............................ "~.......................... 132 Nutrition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 132

Calcium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 132 Vitamin D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 133 Protein and Phosphate ....................................... 134 Caffeine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 134 Sodium Intake .............................................. 134

Physical Exercise ............................................... 135 Conclusions ................................................... 135 References ..................................................... 135

8 Biomechanical Properties of Bone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 143 J. L. FERRETTI

What Are Bones Made For? ...................................... 143 Why Be Stiff? .................................................. 143 How To Achieve Stiffness? ....................................... 145 Why Not Just Be Massive? ....................................... 146 What Is Necessary To Be Strong? ................................. 148 Are Bone Strength and Bone "Quality" Equivalent Concepts? ......... 148 How Do Bones Acquire an Optimal Mechanical Quality? . . . . . . . . . . . .. 149 Are Bones No More Than "Mechanical Structures"? ........... " ..... 150 What Then Is a "Bone-Weakening" Disease? . . . . . . . . . . . . . . . . . . . . . . .. 152 How Should a Bone-Weakening Condition Be Diagnosed and Controlled? ................................................ 152 How Can Bone Absorptiometry Assess Bone Quality? ............... 153

Bone Mass Measurements .................................... 153 Bone Material Quality Determinations ......................... 154

XII Contents

Bone Macroarchitecture Assessment ........................... 154 Noninvasive Estimations of Whole-Bone Quality ................ 155

References ..................................................... 158

9 Risk Factors for Osteoporosis Fractures . . . . . . . . . . . . . . . . . . . . . . . . . .. 163 O.JOHNELL

Risk Factors for Osteoporosis Fractures ........................... 163 Anthropometric Measurements ............................... 164

Height .................................................. 164 Body Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 165 Body Mass Index ......................................... 166

Previous Fractures .......................................... 166 Falling Tendency ............................................ 167 Physical Activity ............................................ 168 Risk Factors in Men ......................................... 169 Combination of Risk Factors for Prediction of Hip Fractures ...... 170

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 170

10 Bone Biopsy in Metabolic Bone Disease . . . . . . . . . . . . . . . . . . . . . . . . . .. 173 E.BoNUCCI

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 173 The Bone Biopsy ............................................... 173 The Microscopic Structure of Bone ............................... 174 Bone Remodeling .............................................. 177 Bone Biopsy in Metabolic Bone Diseases. . . . . . . . . . . . . . . . . . . . . . . . . .. 178 Conclusions ................................................... 182 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 182

11 Radiology of Osteoporosis ...................................... 193 M.JERGAS

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 193 Principal Radiographic Findings in Osteopenia and Osteoporosis . . . .. 193 Diseases Characterized by Generalized Osteopenia ................. 197

Involutional Osteoporosis .................................... 197 Osteopenia and Osteoporosis of the Axial Skeleton ............ 198 Vertebral Fractures and Their Diagnosis . . . . . . . . . . . . . . . . . . . .. 199 Osteopenia and Osteoporosis at Other Skeletal Sites .... , ....... 199

Other Causes of Generalized Osteoporosis ... . . . . . . . . . . . . . . . . . .. 204 Endocrine Disorders Associated with Osteoporosis ........... 204 Medication-Induced Osteoporosis .......................... 206 Miscellaneous Causes of Generalized Osteoporosis. . . . . . . . . . .. 208

RegionalOsteoporosis ....................................... 211 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 213

Contents XIII

12 Assessment of Vertebral Fracture ................................ 227 M. JERGAS AND D. FELSENBERG

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 227 Standardized Visual Assessment of Vertebral Fractures .............. 228 Quantitative Morphometric Assessment of Vertebral Fractures ....... 235 Defining Vertebral Deformity Using Quantitative Morphometry ... . .. 246 Applying Standardized Visual and Quantitative Morphometric Diagnosis of Vertebral Fracture .................................. 255 Summary and Conclusion ....................................... 260 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 261

13 Basic Considerations and Definitions in Bone Densitometry. . . . . . . .. 269 M. JERGAS AND M. UFFMANN

Acronyms in Bone Densitometry ................................. 269 Bone Mineral Density Is Not Bone Mineral Density Is Not Bone Mineral Density. . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 270 Quantity Versus Quality: Diagnosing Osteoporosis with Quantitative Ultrasound Techniques .............................. 272 Being in Conformity to Fact: Accuracy ............................ 274 Being Within Specified Limits: Precision and Its Impact on Serial Bone Mass Measurements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 275 Which Site To Measure? ......................................... 276 Interpretation of Bone Densitometry for Diagnosing Osteoporosis and Predicting Future Fractures . . . . . . . . . . . . . . . . . . . . .. 278 Radiation Exposure in Bone Densitometry. . . . . . . . . . . . . . . . . . . . . . . .. 280 Quality Control in Bone Densitometry ............................ 280 Summary and Conclusion ....................................... 281 References ..................................................... 281

14 Radiogrammetry and Radiographic Absorptiometry ............... 291 C. VAN KUIJK AND H. K. GENANT

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 291 History ....................................................... 291

Radiogrammetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . .. 291 Radiographic Absorptiometry ................................ 292

Outline of Present Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 293 Radiogrammetry ...................................... ,. . . . .. 293 Radiographic Absorptiometry ................................ 294

Applications .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 297 Radiogrammetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 297 Radiographic Absorptiometry ................................ 298

Future Developments ........................................... 299 References ............................. '. . . . . . . . . . . . . . . . . . . . . . .. 300

XIV Contents

15 Single- and Dual-Energy: X-Ray Absorptiometry . . . . . . . . . . . . . . . . . .. 305 J.E.ADAMS

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 305 Past Radionuclide Methods ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 306

Single-Photon Absorptiometry .. . . . . . . .. .. .. . .. .. . . . .. .. . . .. .. 306 Dual-Photon Absorptiometry ................................. 309

Present Photon Absorptiometric Methods ......................... 309 Single-Energy X-Ray Absorptiometry ......................... , 309 Dual-Energy X-Ray Absorptiometry ........................... 311

Indications for DXA Bone Densitometry .......................... 320 Interpretation of DXA Bone Densitometry and Reference Ranges ..... 321 Conclusions ................................................... 322 References ..................................................... 323

16 Quantitative Computed Tomography at the Axial Skeleton ........... 335 G. GUGLIELMI, T. F. LANG, M. CAMMISA, AND H. K. GENANT

Introduction ...................... <_ ••••••••••••••••••••••••••• , 335 Spinal QCT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 335 Measurement of BMD Using Volumetric CT Images of the Spine and Hip .............................................. 338 High-Resolution Imaging of Trabecular Microarchitecture Using CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 341 Conclusion .................................................... 343 References .......................................... '. . . . . . . . . .. 343

17 Peripheral Quantitative Computed Tomography ................... 349 P. SCHNEIDER AND C. REINERS

Development of the pQCT Technology ............................ 349 Technical Aspects of pQCT ...................................... 350 Precision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 353 Clinical Evaluation of the pQCT Technology ....................... 354 Animal Models Assessed by pQCT .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 357 Noninvasive Estimation of Bone Stability . . . . . . . . . . . . . . . . . . . . . . . . .. 357 Future Prospects ............................................... 358 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 358

18 Comparison of Quantitative Computed Tomography and Dual X-Ray Absorptiometry at the Lumbar Spine in the Diagnosis of Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 365 T. FUERST, G. GUGLIELMI, M. CAMMISA, AND H. K. GENANT

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 365 Quantitative Computed Tomography. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 365 Dual X-Ray Absorptiometry ..................................... 366

Contents xv

Comparison of QCT and DXA ................................... 369 Age-Related Changes and Response to Treatment . . . . . . . . . . . . . . .. 369 Influence of Degenerative Joint Disease on BMD Assessed by DXA and QCT ................................... 370

Fracture Association. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 371 Estimates of Volumetric Bone Density from DXA ................... 372 Conclusions ................................................... 374

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 374

19 Quantitative Ultrasound for Assessing Bone Properties ............. 379 D. HANS, T. FUERST, G. GUGLIELMI, AND H. K. GENANT

Introduction ................................................... 379 Quantitative Ultrasound Parameters .............................. 380

Attenuation and Broadband Ultrasound Attenuation ............. 381 Velocity of Ultrasound ....................................... 382 Composite Parameter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 383

Quantitative Ultrasound Equipment .............................. 383 Calcaneus .................................................. 384 Tibia ...................................................... 386 Finger Phalanges .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 386 Other Skeletal Sites .......................................... 387 Quality Control of QUS Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 387

Investigation of Quantitative Ultrasound In Vitro .................. , 388 Investigation of Quantitative Ultrasound In Vivo ................... 390

Precision and Sensitivity ..................................... 391 QUS and Bone Mineral Density ............................... 391 Age-Related Change ......................................... 392 Quantitative Ultrasound and Osteoporotic Fracture Risk ......... 392 QUS and Type of Hip Fracture ................................ 394 Combining QUS and DXA to Improve Fracture Prediction ........ 395 QUS and Longitudinal Monitoring During Intervention .......... 397

Conclusions ................................................... 397 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 398

20 Applications of Magnetic Resonance Imaging in the Study of Osteoporosis .......................................... 407 S. MAJUMDAR AND H. K. GENANT

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 407 Effect of Trabecular Bone on MR Relaxation Time T2* .............. 407 High-Resolution Magnetic Resonance Imaging of Trabecular Bone Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 408

Specimen Studies ............................................ 410 In Vivo Studies .............................................. 412

XVI Contents

Conclusion .................................................... 414 References ..................................................... 414

21 Beyond Bone Densitometry: Assessment of Bone Architecture by X-Ray Computed Tomography at Various Levels of Resolution. . . .. 417 K. ENGELKE AND W. KALENDER

Introduction ................................................... 417 Assessment of Bone Macrostructure .............................. 419 In Vivo Assessment of Bone Microstructure . . . . . . . . . . . . . . . . . . . . . . .. 422 Ultrahigh-Resolution In Vitro Assessment of Bone Microstructure and In Vivo Examinations of Small Animals. . . . . . . . . . . . . . . . . . . . . . .. 431 A Digital Bone Model as a Standard to Investigate Segmentation and Analysis Techniques ........................................ 436 Conclusions and Outlook ........................................ 437 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 439

22 Which Site, Which Method? Dilemmas in Bone Densitometry. . . . . . .. 449 Y. Lu, A. MATHUR, AND H. K. GENANT

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 449 Dilemmas in Bone Densitometry .... . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 450

Correlations Between Techniques for Measuring BMD . . . . . . . . . . .. 450 Correlation Between the Techniques in Monitoring Age-and Menopause-Related BMD Loss ............................ 452 Discrimination of Osteoporotic Women ........................ 453

Considerations in Choosing Measurement Sites and Methods ........ 456 Conclusions ................................................... 457 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 458

23 Quality Assurance in Bone Densitometry ......................... 461 T. FUERST, Y. Lu, D. HANS AND H. K. GENANT

Introduction ................................................... 461 Review of Techniques for Bone Mass Measurement ................. 461 Monitoring Densitometer Performance ........................... 462

Standards for Quality Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 462 Lunar Spine Phantom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 463 Norland Spine Phantom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 463 Hologic Spine Phantom ............................ ,....... 463 European Spine Phantom. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 464

D,aily Quality Control Procedures of the DXA Manufacturers . . . . . . . .. 466 Analysis of Longitudinal Quality Control Data ..................... 466 Replacing Old Densitometers with New Equipment ................. 469 Quality Control of the DXA Examination . . . . . . . . . . . . . . . . . . . . . . . . .. 472 References ............................ ' ......................... 474

Contents XVII

24 Clinical Application of Bone Densitometry . . . . . . . . . . . . . . . . . . . . . . .. 477 P. D. MILLER AND S. T. HARRIS

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 483

25 Bone Densitometry in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 489 S. MORA AND V. GILSANZ

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 489 Dual-Energy X-Ray Absorptiometry .............................. 489 Quantitative Computed Tomography. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 493 Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 496 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 498

26 Bone Mass and Bone Loss in Secondary Osteoporosis . . . . . . . . . . . . . .. 503 R. NUTI, G. MARTINI, AND C. GENNARI

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 503 Glucocorticoids .......... :..................................... 504 Heparin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 506 Hyperthyroidism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 507 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 509 Gastrointestinal Disorders and Alcohol Abuse . . . . . . . . . . . . . . . . . . . . .. 510 Immobilization ................................................ 512 Anorexia Nervosa .............................................. 512 Pregnancy and Lactation ........................................ 513 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 514

27 Assessing the Response to Treatment for Osteoporosis . . . . . . . . . . . . .. 527 R. NUTI, G. MARTINI, AND C. GENNARI

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 534

28 Periprosthetic Bone Mineral Density and Other Orthopedic Applications ........................................ 541 C. TREVISAN AND S. ORTOLANI

Introduction ................................................... 541 Assessment of Bone Reaction to Metal Implants .................... 545

Total Hip Arthroplasty ....................................... 552 Total Knee Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . .. 562 Other Implants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 564

Assessment of Bone Healing and Bone Regeneration ................ 567 Bone Healing After Fracture and New Bone Formation During Limb Lengthening .................................... 567 Post-traumatic Osteopenia ........... ~ ....................... 569

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 572

XVIII Contents

29 Osteoporosis and Oral Bone Loss: Mandibular Bone Density and Its Relationship to Systemic Osteoporosis in Edentulous Women 583 M.T. DIMuZIO, K. HOUKI, C. B. WESTLUND, C. BERKOVICH, AND

1. K. FAT TORE

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 583 Materials and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 584

Subjects .................................................... 584 Bone Densitometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 585 Patient Positioning .......................................... 586

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 587 Discussion .................................................... 588 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 590

Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 593

Contributors

S.Adami e.O.C. di Valeggio, University of Verona, 37067 Valeggio slM, Verona, Italy

J.Adams Department of Diagnostic Radiology, The University of Manchester, Stopford Building, Oxford Road, Manchester M13 9PT, UK

1. V.Avioli Departments of Medicine and Orthopaedic Surgery, Washington University School of Medicine, 216 South Kingshighway Blvd., Ms, Mo 63110, St. Louis, Mis­souri, and Department of Internal Medicine, Wayne State University School of Medicine, Detroit Michigan, USA

e. Berkovich Department of Periodontics, Northwestern University Dental School, 240 E. Hurons, Chicago, IL 60611, USA

E. Bonucci Dipartimento di Medicina Sperimentale e Patologia, Sezione die Anatomia Pa­tologica, Policlinico Umberto I, Viale Regina Elena 324, 00161 Roma, Italy

V. Braga e.O.C. di Valeggio, University of Verona, 37067 Valeggio slM, Verona, Italy

M.Cammisa Department of Radiology, Scientific Institute Hostpital "CSS", 71013 San Giovan­ni Rotondo, Italy

E. Canalis Saint Francis Hospital and Medical Center, 114 Woodland Street, Hartford, CT 06105-1299, USA

R. Civitelli Division of Bone and Mineral Diseases, Washington University School of Medi­cine, and Barnes-Jewish Hospital, North Campus, 216 S. Kingshighway Blvd., St. Louis, MO 63110, USA

xx Contributors

M. T. DiMuzio Highland Park Hospital, 718 Glenview Avenue, Highland Park, IL 60035-2497, USA

K.Engelke University of Erlangen, Institute of Medical Physics (IMP), KrankenhausstraBe 12,91054 Erlangen, Germany

1. K. Fattore Department of Geriatric Dentistry, Northwestern University Dental School, Chi­cago, IL 60611, USA

D. Felsenberg Department of Radiology, Klinikum Benjamin Franklin of the Free University of Berlin, Hindenburgdamm 30,12200 Berlin, Germany

J. 1. Ferretti Center for P-Ca Metabolism Studies, National University of Rosario, Juan B. Jus­to 1427,2000 Rosario, and Metabolic Research Institute, Libertad 836, 1er.piso, 1012 Buenos Aires, Argentina

T.Fuerst Osteoporosis and Arthritis Research Group, Department of Radiology, Univer­sity of California San Francisco, 505 Parnassus Avenue M -392, San Francisco, CA 94143-0628, USA

H.K.Genant Osteoporosis and Arthritis Research Group, Department of Radiology, Univer­sity of California San Francisco, 505 Parnassus Avenue M -392, San Francisco, CA 94143-0628, USA

C.Gennari Istiuto di Patologia Speciale Medica, Universita di Siena, Policlinico Le Scotte, Viale Bracci,53100 Siena, Italy

V.Gilsanz Department of Radiology, Childrens Hospital Los Angeles, Radiology Depart­ment MS# 81,4650 Sunset Boulevard, Los Angeles, CA 90027, USA

G. Guglielmi Department of Radiology, Scientific Institute Hospital "CSS", 71013 San Gio­vanni Rotondo, Italy

Contributors XXI

D.Hans Osteoporosis and Arthritis Research Group, Department of Radiology, Univer­sity of California San Francisco, 505 Parnassus Avenue M -392, San Francisco, CA 94143-0628, USA

S. T. Harris University of California San Francisco, 350 Parnassus Ave., Suite # 706, USA, CA 94117-3608

K.Houki Department of Geriastric Dentistry, Northwestern University Dental School, Chicago, IL 60611, USA

M. Jergas Department of Radiology, St. Josef-Hospital, Ruhr-University Bochum, Gudrun­stra:Be 56,44791 Bochum, Germany

O. Johnell Department of Orthopaedics, Malmo University Hospital, S-20502 Malmo, Swe­den

W.Kalender University of Erlangen, Institute of Medical Physics (IMP), Krankenhausstra:Be 12,91054 Erlangen, Germany

M. Kleerekoper Departments of Medicine and Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, and Department of Internal Medicine, Wayne State University School of Medicine, Harper Hospital, 1 Webber South, 3990 John R, Detroit, Mi 48201 USA

C. van Kuijk Osteoporosis and Arthritis Research Group, Department of Radiology, Univer­sity of California San Francisco, 505 Parnassus Avenue M-392, San Francisco, CA 94143-0628, USA

T. F. Lang Department of Radiology, University of California San Francisco, 505'Parnassus Avenue M-392, San Francisco, CA 94143-0628 USA

Y.Lu Osteoporosis and Arthritis Research Group, Department of Radiology, Univer­sity of California San Francisco, 505 Parnassus Avenue M -392, San Francisco, CA 94143-0628, USA

XXII Contributors

S.Majumdar Osteoporosis and Arthritis Research Group, Department of Radiology, Univer­sity of California San Francisco, 505 Parnassus Avenue M -392, San Francisco, CA 94143-0628, USA

G.Martini Istituto di Patologia Speciale Medica, Universita di Siena, Policlinico Le Scotte, Viale Bracci, 53100 Siena, Italy

A.Mathur Osteoporosis and Arthritis Research Group, Department of Radiology, Univer­sity of California San Francisco, 505 Parnassus Avenue M-392, San Francisco, CA 94143-0628, USA

P. D. Miller University of Colorado Health Sciences Center, Colorado Center for Bone Re­search, 3190 S Wadsworth # 250, Lakewood, CO 80227, USA

S.Mora Division of Pediatrics, University of Milan Clinical Pediatrica 3, H. San Raffaele, Via Olgettina 60, Milan, 20132 Italy

R.Nuti Istituto di Patologia Speciale Medica, Universita di Siena, Policlinico Le Scotte, Viale Bracci, 53100 Siena, Italy

S.Ortolani Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico, Via 1. Ariosto, 13, 20145 Milano, Italy

R. Pacifici Division of bone and Mineral Diseases, Barnes-Jewish Hospital St. Louis MO, 216 S. Kinghighway, St. Louis, MO 63110, USA

C.Reiners Clinic for Nuclear Medicine, University ofWiirzburg, Josef-Schneider-StraBe 2, 97080 Wiirzburg, Germany

P. D. Ross Hawaii Osteoporosis Center, 401 Kamakee Street, Honolulu, HI 96814, USA

P. Schneider Clinic for Nuclear Medicine, University ofWiirzburg, Josef-Schneider-StraBe 2, 97080 Wiirzburg, Germany

Contributors XXIII

C. Trevisan Centro Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico, Via L. Ariosto, 13, 20145 Milano, Italy

M.Uffmann Department of Radiology, St. Josef-Hospital, Ruhr-University Bochum, Gudrun­straBe 56,44791 Bochum, Germany

C. B. Westlund Highland Park Hospital, 718 Glenview Avenue, Highland Park, IL 60035-2497, USA

A. Zallone Zambonin Istituto Anatomia Umana Normale, Policlinico, Piazza Giulio Cesare, 11, 70124 Bari,Italy

G.Zambonin Istituto Anatomia Umana Normale, Policlinico, Piazza Giulio Cesare, 11, 70124 Bari,Italy

K. Ziambaras Division of Bone and Mineral Diseases, Washington University School of Medi­cine, and Barnes-Jewish Hospital, North Campus, 216 S. Kingshighway Blvd., St. Louis, MO 63110, USA