Classification of Osteoporosis and Osteopenia in Postmenopausal Women Is Dependent on Site-Specific Analysis

doi:10.1385/JCD:2:3:275

Journal of Clinical Densitometry

Volume 2, Issue 3, Autumn 1999, Pages 275-283

https://doi.org/10.1385/JCD:2:3:275 Get rights and content

Abstract

Despite the availability of guidelines from the World Health Organization study group for the classification of osteoporosis in postmenopausal Caucasian women, confusion still exists about the number of sites used for diagnosis and the clinical utility of peripheral bone mass assessments. To examine the diagnosis of osteoporosis and osteopenia based on bone density measurements at single or multiple sites using central and peripheral measurements, we studied 115 ambulatory, community-dwelling, Caucasian postmenopausal women. Bone mineral density of the hip, PA spine, forearm, and finger were assessed by dual X-ray absorptiometry. Bone mass of the calcaneus was obtained using ultrasound. The diagnosis of osteoporosis based on a single measurement varied from 4% using the trochanteric region to 34% using Ward's triangle, 17% using the calcaneus, and 13% using the finger. Twenty-eight percent of the women had osteoporosis if the diagnosis was based on at least one osteoporotic value at three standard central sites (PA spine, total hip, femoral neck). Among these women, using T-scores provided by the manufacturers, 16% of osteoporotic patients would be misclassified as normal using the Sahara Clinical Bone Sonometer® (Hologic, Waltham, MA) (heel) and 34% misclassified using the accuDEXA® (Schick, New York, NY) (finger). We conclude that there is significant variability in the classification of osteoporosis based on site selection, with significant potential for misdiagnosis.

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Citation Excerpt :
When examining the number of postmenopausal women identified as osteoporotic, the percentage of women with a T-score of −2.5 or less were 8.7%, 22.8%, 14.5%, and 7.8% for AccuDEXA, spine, femoral neck, and total-hip BMD, respectively. Varney et al (21) carried out a similar analysis for 115 ambulatory, community-dwelling, Caucasian postmenopausal women. They reported similar results for the central sites, but a significantly higher number of patients were identified using AccuDEXA finger measurements, with figures of 13%, 20%, 17%, and 6% for AccuDEXA, spine, femoral neck, and total-hip BMD, respectively, for the percentage of women with a T-score less than or equal to −2.5.
Because osteoporosis is common and usually managed in primary care, there is a requirement for cheap and convenient methods of measuring bone mineral density (BMD). AccuDEXA (Lone Oak Medical Technologies, Doylestown, PA) is a tabletop dual-energy X-ray absorptiometry (DXA) device that performs BMD measurements of the hand in the middle phalanges of the third finger. The aims of this study were to (1) evaluate the use of AccuDEXA in UK women; (2) investigate the concordance between AccuDEXA T-scores and DXA T-scores for central (spine and hip) sites; (3) investigate the comparative response of AccuDEXA measurements to clinical risk factors for osteoporosis. Measurements of phalangeal and central BMD were performed in 620 women referred by their family doctors for bone densitometry (group 1) and 159 healthy female volunteers (group 2). For 65 women in group 2, aged 39 yr or younger, the mean Z-scores for AccuDEXA and the central sites calculated from US reference ranges were consistent with the expected value of 0, whereas for the 62 group 2 women, aged 50 yr or older, the mean Z-scores for AccuDEXA and the central sites were in the range 0.4–0.7 and were statistically significantly different from 0. In both group 1 and group 2, the AccuDEXA T-scores in older and younger women were systematically higher than those in the central sites by up to 1 unit. Of the 157 women aged 50 yr or older, with osteoporosis, based on their central DXA results, only 34 (22%) had an AccuDEXA T-score less than or equal to −2.5, whereas 76 (48%) had osteopenia and 47 (30%) were normal based on their AccuDEXA T-scores. When assessed by the effect of clinical risk factors on Z-scores, both AccuDEXA and central BMD were affected to a similar extent. We conclude that the conventional World Health Organisation T-score criteria for the diagnosis of osteoporosis should not be applied to AccuDEXA measurements in UK women. Clinical risk factors for low BMD were found to affect AccuDEXA measurements to a similar extent as central BMD measurements. AccuDEXA measurements could, therefore, provide an alternative method for identifying individuals with low bone mass, provided care is taken in interpreting T-scores, perhaps, through the use of device-specific thresholds.
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Although these WHO criteria were not designed for individual clinical diagnosis of osteoporosis or for use in making treatment decisions, they have been widely used for these purposes. As T-score values from different skeletal sites often disagree, individual patients may be classified as having osteoporosis, low bone mass, or normal BMD depending on which skeletal site or sites are measured (5–8). Clinicians may resolve this labeling dilemma by following International Society for Clinical Densitometry and American Society for Bone and Mineral Research recommendations to classify patients on the basis of the skeletal site (total hip, femoral neck, or lumbar spine) with the lowest T-score (9–11).
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Original ArticleClassification of Osteoporosis and Osteopenia in Postmenopausal Women Is Dependent on Site-Specific Analysis

Abstract

J Clin Densitom

J Clin Densitom

J Clin Densitom

J Clin Densitom

Lancet

Assessment of Fracture Risk and Its Application to Screening for Postmenopausal Osteoporosis

Who are candidates for prevention and treatment for osteoporosis?

Osteoporos Int

Measurement of bone density with dual-energy x-ray absorptiometry (DEXA)

JAMA

Diagnosis and management of osteoporosis: guidelines for the utilization of bone densitometry

Calcif Tissue Int

Noninvasive assessment of bone mineral and structure: state of the art

J Bone Miner Res

Original Article
Classification of Osteoporosis and Osteopenia in Postmenopausal Women Is Dependent on Site-Specific Analysis