Clinical Review

The Potential Value of Dual-Energy X-Ray Absorptiometry in Orthopedics

Publish date: May 16, 2018

References

1. Miller PD. The history of bone densitometry. Bone. 2017;104:4-6 [Epub ahead of print].

2. Blake GM, Fogelman I. Technical principles of dual energy X ray absorptiometry. Semin Nucl Med. 1997;27(3):210-228.

3. Faulkner KG. The tale of the T-score: review and perspective. Osteoporo Int. 2005;16(4):347-352. doi:10.1007/s00198-004-1779-y.

4. Solomou G, Damilakis J. Radiation exposure in bone densitometry. Semin Musculoskelet Radiol. 2016;20(4):392-398. doi:10.1055/s-0036-1592430.

5. Adams J. Bone densitometry in children. Semin Musculoskelet Radiol. 2016;20(3):254-268. doi:10.1055/s-0036-1592369.

6. Duan Y, Parfitt AM, Seeman E. Vertebral bone mass, size, and volumetric density in women with spinal fractures. J Bone Miner Res. 1999;14(10):1796-1802. doi:10.1359/jbmr.1999.14.10.1796.

7. Szaulc P, Munoz F, Duboeuf F, Delmas PD. Low width of tubular bones is associated with increased risk of fragility fracture in elderly men–the MINOS study. Bone 2006;38(4):595-602. doi:10.1016/j.bone.2005.09.004.

8. Mi J, Li K, Zhao X, Zhao CQ, Li H, Zhao J. Vertebral body compressive strength evaluated by dual-energy x-ray absorptiometry and Hounsfield units in vitro. J Clin Densitom. 2018;21(1):148-153. doi:10.1016/j.jocd.2016.08.011.

9. Ambrose CG, Kiebzak GM, Sabonghy EP, et al. Biomechanical testing of cadaveric specimens: importance of bone mineral density assessment. Foot Ankle Int. 2002;23(9):850-855. doi:10.1177/107110070202300913.

10. Kiebzak G, Sassard WR. Smaller radius width in women with distal radius fractures compared to women without fractures. Cureus. 2017;9(12):e1950. doi:10.775/cureus.1950.

11. Krappinger D, Bizzotto N, Riedmann S, Kammerlander C, Hengg C, Kralinger FS. Predicting failure after surgical fixation of proximal humerus fractures. Injury 2011;42(11):1283-1288. doi:10.1016/j.injury.2011.01.017.

12. Suhm N, Hengg C, Schwyn R, Windolf M, Quarz V, Hänni M. Mechanical torque measurement predicts load to implant cut-out: a biomechanical study investigating DHS anchorage in femoral heads. Arch Orthop Trauma Surg. 2007;127(6):469-474. doi:10.1007/s00402-006-0265-8.

13. Persiani P, Ranaldi FM, Graci J, et al. Isolated olecranon fractures in children affected by osteogenesis imperfecta type I treated with single screw or tension band wiring system: outcomes and pitfalls in relation to bone mineral density. Medicine (Baltimore). 2017;96(20):e6766. doi:10.1097/MD.0000000000006766.

14. Andersen MR, Winther NS, Lind T, Schrøder HM, Flivik G, Petersen MM. Low preoperative BMD is related to high migration of tibia components in uncemented TKA–92 patients in a combined DEXA and RSA study with 2-year follow-up. J Arthroplasty. 2017;32(7):2141-2146. doi:10.1016/j.arth.2017.02.032.

15. Yip BH, Yu FW, Wang Z, et al. Prognostic value of bone mineral density on curve progression: A longitudinal cohort study of 513 girls with adolescent idiopathic scoliosis. Sci Rep. 2016;6:39220. doi:10.1038/srep39220.

16. Pourabbas Tahvildari B, Erfani MA, Nouraei H, Sadeghian M. Evaluation of bone mineral status in adolescent idiopathic scoliosis. Clin Orthop Surg. 2014;6(2):180-184. doi:10.4055/cios.2014.6.2.180.

17. Li XF, Li H, Liu ZD, Dai LY. Low bone mineral status in adolescent idiopathic scoliosis. Eur Spine J. 2008;17(11):1431-1440. doi:10.1007/s00586-008-0757-z.

18. Venesmaa PK, Kröger HP, Miettinen HJ, Jurvelin JS, Suomalainen OT, Alhava EM. Monitoring of periprosthetic BMD after uncemented total hip arthroplasty with dual-energy X-ray absorptiometry--a 3-year follow-up study. J Bone Miner Res. 2001;16(6):1056-1061. doi:10.1359/jbmr.2001.16.6.1056.

19. Arabmotlagh M, Pilz M, Warzecha J, Rauschmann M. Changes of femoral periprosthetic bone mineral density 6 years after treatment with alendronate following total hip arthroplasty J Orthop Res. 2009;27(2):183-188. doi:10.1002/jor.20748.

20. Gruen TA, McNeice GM, Amstutz HC. Modes of failure of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res. 1979;(141):17-27.

21. Zeytinoglu M, Jain RK, Vokes TJ. Vertebral fracture assessment: Enhancing the diagnosis, prevention, and treatment of osteoporosis. Bone. 2017;104:54-65. doi:10.1016/j.bone.2017.03.004.

22. Kiebzak GM. Radiolucent casting tape allows for accurate measurement of forearm bone mineral density using dual-energy X-ray absorptiometry. J Clin Densitom. 1998;1(4):369-374.

23. Sung KH, Chung CY, Lee KM, et al. Correlation between central and peripheral bone mineral density around the elbow measured by dual-energy x-ray absorptiometry in healthy children and adolescents. J Clin Densitom. 2017;20(1):114-119. doi:10.1016/j.jocd.2016.04.007.

24. Hamdy R, Kiebzak GM, Seier E, Watts NB. The prevalence of significant left-right differences in hip bone mineral density. Osteoporos Int. 2006;17(12):1772-1780. doi:10.1007/s00198-006-0192-0.

25. Kelly TL, Berger N, Richardson TL. DXA body composition: Theory and practice. Appl Radiat Isot. 1998;49(5-6):511-513.

26. Kiebzak GM, Leamy LJ, Pierson LM, Nord RH, Zhang ZY. Measurement precision of body composition variables using the lunar DPX-L densitometer. J Clin Densitom. 2000;3(1):35-41.

27. Bilborough JC, Greenway k, Par D, Coutts AJ. The accuracy and precision of DXA for assessing body composition in team sport athletes. J Sports Sci. 2014;32(19):1821-1828. doi:10.1080/02640414.2014.926380.

28. Malkov S, Cawthon PM, Peters KW, et al. Health ABC Study. Hip fractures risk in older men and women associated with DXA-derived measures of thigh subcutaneous fat thickness, cross-sectional muscle area, and muscle density. J Bone Miner Res. 2015;30(8):1414-1421. doi:10.1002/jbmr.2469.

29. Arangio GA, Chen C, Klady M, Reed JF. Thigh muscle size and strength after anterior cruciate ligament reconstruction and rehabilitation. J Orthop Sports Phys Ther. 1997;26(5):238-245. doi:10.2519/jospt.1997.26.5.238.

30. Ledford CK, Millikan PD, Nickel BT, et al. Percent body fat Is more predictive of function after total joint arthroplasty than body mass index. J Bone Joint Surg. 2016;98(10):849-857. doi:10.2106/JBJS.15.00509.

31. Berlet G, Kiebzak GM, Dandar A, et al. Prospective analysis of body composition and SF36 profiles in professional dancers over a 7-month season: is there a correlation to injury? J Dance Med Sci. 2002;6(2):54-61.

32. Grant JA, Bedi A, Kurz J, Bancroft R, Gagnier JJ, Miller BS. Ability of preseason body composition and physical fitness to predict the risk of injury in male collegiate hockey players. Sports Health. 2015;7(1):45-51. doi:10.1177/1941738114540445.

33. Stewart AD, Hannan J. Subregional tissue morphometry in male athletes and controls using DXA. Int J Sport Nutr Exerc Metab. 2000;10(2):157-169. doi:10.1123/ijsnem.10.2.157.

34. Sannicandro I, Cofano G, Rosa RA, Piccinno A. Balance training exercises decrease lower-limb strength asymmetry in young tennis players. J Sports Sci Med. 2014;13(2):397-402.

35. Guglielmi G, Ponti F, Agostini M, Amadori M, Battista G, Bazzocchi A. The role of DXA in sarcopenia. Aging Clin Exp Res. 2016;28(6):1047-1060. doi:10.1007/s40520-016-0589-3.

36. Janssen I, Baumgartner RN, Ross R, Rosenberg IH, Roubenoff R. Skeletal muscle cutpoints associated with elevated physical disability risk in older men and women. Am J Epidemiol. 2004;159(4):413-421.

37. Landi F, Calvani R, Ortolani E, et al. The association between sarcopenia and functional outcomes among older patients with hip fracture undergoing in-hospital rehabilitation. Osteoporos Int. 2017;28(5):1569-1576. doi:10.1007/s00198-017-3929-z.

38. Roh YH, Noh JH, Gong HS, Baek GH. Effect of low appendicular lean mass, grip strength, and gait speed on the functional outcome after surgery for distal radius fractures. Arch Osteoporos. 2017;12(1):41. doi:10.1007/s11657-017-0335-2.

39. Miller MS, Callahan DM, Toth MJ. Skeletal muscle myofilament adaptations to aging, disease, and disuse and their effects on whole muscle performance in older adult humans. Front Physiol. 2014;5:369. doi:10.3389/fphys.2014.00369.

40. Waters DJ, Baumgartner RN. Sarcopenia and obesity. Clin Geriatr Med. 2011;27(3):401-421. doi:10.1016/j.cger.2011.03.007.

41. Bachrach LK, Gordon CM. Bone densitometry in children and adolescents. Pediatrics. 2016;138(4):e20162398. doi:10.1542/peds.2016-2398.

For older patients being followed after orthopedic care, there is a growing concern about age-related loss of muscle mass, or sarcopenia, which can lead to functional impairment (eg, balance, gait, etc.), and physical disability leading to falling and increased risk of fracture.^35-40 Even obese patients can be sarcopenic (a concept known as sarcopenic obesity), and their large body mass can mask the relative deficiency of lean mass.⁴⁰ DXA total body scans can be used to monitor patients at risk for sarcopenia.

Finally, DXA total body composition scans are underused in the pediatric population. Given the low radiation burden, DXA can be used safely in children of all ages. In addition to the same uses as in adults for presurgical assessment, monitoring bone and soft-tissue changes after treatment and rehabilitation, scans can be used to monitor growth and development.⁴¹

CASE STUDY: MONITORING DEVELOPMENT AND TREATMENT

A 12-year-old boy with polyostotic fibrous dysplasia (McCune Albright Syndrome) was started on treatment with cyclic pamidronate to mitigate bone pain and reduce fracture risk. Use of DXA was planned to provide evidence of treatment efficacy by documenting increasing BMD. However, the severe skeletal deformity prevented standard site-specific DXA scans, and consequently, total body scans were effectively used to acquire the BMD data needed to monitor treatment (Figure 4).

CASE STUDY: AGE-RELATED SARCOPENIA

Figure 5 shows images of a 64-year-old woman who was followed after a distal radius fracture. A total body scan and body composition assessment was performed in 2002. At follow-up in 2004, total body weight seemed stable with only a seemingly benign 5.1-lb loss of weight, and the patient’s overall physical appearance was unchanged (Table 2).

Table 2. Age-Related Changes Potentially Leading to Sarcopenia

	Baseline, 2002	Follow-up, 2004	Change, %
Body weight, kg	57.9 (127.6 lb)	55.6 (122.5 lb)	4
BMI	20.6	19.8
Total body fat, g	13,619	13,390	−1.7
Total body percent fat	23.5	24.1
Total body lean, g	42,038	39,949	−5.0

Dual-energy X-ray absorptiometry scans were performed using a GE Lunar Prodigy system.

However, body composition assessment revealed a disproportionate loss of lean mass, with a resultant total percent body fat increase. This imbalance between the change in fat and lean mass could lead to clinical sarcopenia unless appropriate dietary and exercise measures are taken. Such subtle developing imbalances in body composition could only be quantitated using DXA total body scans.

Continue to: It is not uncommon...