Skip to main content

Advertisement

SpringerLink
Log in

Calcaneal quantitative ultrasound has a role in out ruling low bone mineral density in axial spondyloarthropathy

  • Original Article
  • Published:
Clinical Rheumatology Aims and scope Submit manuscript

Abstract

Objective

The aim of this study was to investigate the role of quantitative ultrasound (QUS) of the calcaneus in screening for osteoporosis in adults with axial spondyloarthropathy (axSpA).

Method

Postmenopausal women and men over 50 years with axSpA were recruited for this observational cross-sectional study. Dual-energy x-ray absorptiometry (DXA) assessed bone mineral density (BMD) of the spine and hip. QUS of the calcaneus produced broadband ultrasound attenuation (BUA), speed of sound (SOS), stiffness index (SI), and T-scores. Receiver-operating characteristics (ROC) curve analysis determined the ability of QUS to discriminate between low and normal BMD. Thresholds were identified to (1) out rule low BMD, (2) identify osteoporosis, and (3) identify low BMD. The number of DXAs which could be avoided using this approach was calculated.

Results

56 participants were analyzed. BUA, SI, and T-score QUS parameters correlated with BMD by DXA; SOS did not. All QUS parameters had the ability to discriminate between low and normal BMD (area under the curve varied from 0.695 to 0.779). QUS identified individuals without low BMD with 90% confidence, with BUA performing best (sensitivity 93%, negative predictive value 86%). Using QUS as a triage tool, up to 27% of DXA assessments could have been avoided. QUS could not confidently identify individuals with osteoporosis.

Conclusions

QUS of the calcaneus confidently out ruled low BMD in individuals with axSpA, reducing the need for onward DXA referral by up to 27%. QUS is promising as a non-invasive triage tool in the assessment of osteoporosis in adults with axSpA.

Key Points

• Osteoporosis is common in axial spondyloarthropathy (SpA), but evaluation of bone health is suboptimal in this population.

• Quantitative ultrasound (QUS) of the calcaneus can out rule low bone mineral density in individuals with axial SpA, reducing the need for DXA assessment.

• QUS is a promising non-invasive triage tool in the assessment of bone health in axial SpA.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1.

Similar content being viewed by others

References

  1. Molto A, Etcheto A, van der Heijde D, Landewe R, van den Bosch F, Bautista Molano W, Burgos-Vargas R, Cheung PP, Collantes-Estevez E, Deodhar A, El-Zorkany B, Erdes S, Gu J, Hajjaj-Hassouni N, Kiltz U, Kim TH, Kishimoto M, Luo SF, Machado PM, Maksymowych WP, Maldonado-Cocco J, Marzo-Ortega H, Montecucco CM, Ozgocmen S, van Gaalen F, Dougados M (2016) Prevalence of comorbidities and evaluation of their screening in spondyloarthritis: results of the international cross-sectional ASAS-COMOSPA study. Ann Rheum Dis 75(6):1016–1023. https://doi.org/10.1136/annrheumdis-2015-208174

    Article  CAS  PubMed  Google Scholar 

  2. Pray C, Feroz NI, Nigil Haroon N (2017) Bone mineral density and fracture risk in ankylosing spondylitis: a meta-analysis. Calcif Tissue Int 101(2):182–192. https://doi.org/10.1007/s00223-017-0274-3

    Article  CAS  PubMed  Google Scholar 

  3. Westerveld LA, Verlaan JJ, Oner FC (2009) Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. Eur Spine J 18(2):145–156. https://doi.org/10.1007/s00586-008-0764-0

    Article  CAS  PubMed  Google Scholar 

  4. Bessant R, Harris C, Keat A (2003) Audit of the diagnosis, assessment, and treatment of osteoporosis in patients with ankylosing spondylitis. J Rheumatol 30(4):779–782

    PubMed  Google Scholar 

  5. Fitzgerald G, Gallagher P, O'Shea F (2019) Multimorbidity is common in axial spondyloarthropathy and is associated with worse disease outcomes: results from the ASRI cohort. J Rheumatol. https://doi.org/10.3899/jrheum.181415

    Article  PubMed  Google Scholar 

  6. Shepherd JA, Schousboe JT, Broy SB, Engelke K, Leslie WD (2015) Executive summary of the 2015 ISCD position development conference on advanced measures from DXA and QCT: fracture prediction beyond BMD. J Clin Densitom 18(3):274–286. https://doi.org/10.1016/j.jocd.2015.06.013

    Article  PubMed  Google Scholar 

  7. European Commission (2018) The 2018 ageing report: economic and budgetary projections for the 28 EU member states (2016-2070). Brussels. https://doi.org/10.2765/615631

  8. Chin KY, Ima-Nirwana S (2013) Calcaneal quantitative ultrasound as a determinant of bone health status: what properties of bone does it reflect? Int J Med Sci 10(12):1778–1783. https://doi.org/10.7150/ijms.6765

    Article  PubMed  PubMed Central  Google Scholar 

  9. Guglielmi G, de Terlizzi F (2009) Quantitative ultrasound in the assessment of osteoporosis. Eur J Radiol 71(3):425–431. https://doi.org/10.1016/j.ejrad.2008.04.060

    Article  PubMed  Google Scholar 

  10. Schousboe JT, Shepherd JA, Bilezikian JP, Baim S (2013) Executive summary of the 2013 international society for clinical densitometry position development conference on bone densitometry. J Clin Densitom 16(4):455–466. https://doi.org/10.1016/j.jocd.2013.08.004

    Article  PubMed  Google Scholar 

  11. Thomsen K, Jepsen DB, Matzen L, Hermann AP, Masud T, Ryg J (2015) Is calcaneal quantitative ultrasound useful as a prescreen stratification tool for osteoporosis? Osteoporos Int 26(5):1459–1475. https://doi.org/10.1007/s00198-014-3012-y

    Article  CAS  PubMed  Google Scholar 

  12. Meszaros S, Toth E, Ferencz V, Csupor E, Hosszu E, Horvath C (2007) Calcaneous quantitative ultrasound measurements predicts vertebral fractures in idiopathic male osteoporosis. Joint Bone Spine 74(1):79–84. https://doi.org/10.1016/j.jbspin.2006.04.008

    Article  PubMed  Google Scholar 

  13. Gonnelli S, Cepollaro C, Gennari L, Montagnani A, Caffarelli C, Merlotti D, Rossi S, Cadirni A, Nuti R (2005) Quantitative ultrasound and dual-energy X-ray absorptiometry in the prediction of fragility fracture in men. Osteoporos Int 16(8):963–968. https://doi.org/10.1007/s00198-004-1771-6

    Article  PubMed  Google Scholar 

  14. Speden DJ, Calin AI, Ring FJ, Bhalla AK (2002) Bone mineral density, calcaneal ultrasound, and bone turnover markers in women with ankylosing spondylitis. J Rheumatol 29(3):516–521

    PubMed  Google Scholar 

  15. Jansen TL, Aarts MH, Zanen S, Bruyn GA (2003) Risk assessment for osteoporosis by quantitative ultrasound of the heel in ankylosing spondylitis. Clin Exp Rheumatol 21(5):599–604

    CAS  PubMed  Google Scholar 

  16. Rudwaleit M, Landewe R, van der Heijde D, Listing J, Brandt J, Braun J, Burgos-Vargas R, Collantes-Estevez E, Davis J, Dijkmans B, Dougados M, Emery P, van der Horst-Bruinsma IE, Inman R, Khan MA, Leirisalo-Repo M, van der Linden S, Maksymowych WP, Mielants H, Olivieri I, Sturrock R, de Vlam K, Sieper J (2009) The development of assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part I): classification of paper patients by expert opinion including uncertainty appraisal. Ann Rheum Dis 68(6):770–776. https://doi.org/10.1136/ard.2009.108217

    Article  CAS  PubMed  Google Scholar 

  17. (1993) Consensus development conference: Diagnosis, prophylaxis, and treatment of osteoporosis. Am J Med 94(6):646–650

  18. Jenkinson TR, Mallorie PA, Whitelock HC, Kennedy LG, Garrett SL, Calin A (1994) Defining spinal mobility in ankylosing spondylitis (AS). The Bath AS metrology index. J Rheumatol 21(9):1694–1698

    CAS  PubMed  Google Scholar 

  19. GE Healthcare (2011) Achilles InSight product data sheet. http://www3.gehealthcare.com.au/~/media/documents/us-global/products/bone-health/abstracts/quantitative%20ultrasound/achilles/gehealthcare-achilles-insight-productspec.pdf. Accessed 23 Nov 2017

  20. Garrett S, Jenkinson T, Kennedy LG, Whitelock H, Gaisford P, Calin A (1994) A new approach to defining disease status in ankylosing spondylitis: the bath ankylosing spondylitis disease activity index. J Rheumatol 21(12):2286–2291

    CAS  PubMed  Google Scholar 

  21. Calin A, Garrett S, Whitelock H, Kennedy LG, O'Hea J, Mallorie P, Jenkinson T (1994) A new approach to defining functional ability in ankylosing spondylitis: the development of the bath ankylosing spondylitis functional index. J Rheumatol 21(12):2281–2285

    CAS  PubMed  Google Scholar 

  22. Doward LC, Spoorenberg A, Cook SA, Whalley D, Helliwell PS, Kay LJ, McKenna SP, Tennant A, van der Heijde D, Chamberlain MA (2003) Development of the ASQoL: a quality of life instrument specific to ankylosing spondylitis. Ann Rheum Dis 62(1):20–26

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Pincus T, Summey JA, Soraci SA Jr, Wallston KA, Hummon NP (1983) Assessment of patient satisfaction in activities of daily living using a modified Stanford health assessment questionnaire. Arthritis Rheum 26(11):1346–1353

    Article  CAS  PubMed  Google Scholar 

  24. Creemers MC, Franssen MJ, van't Hof MA, Gribnau FW, van de Putte LB, van Riel PL (2005) Assessment of outcome in ankylosing spondylitis: an extended radiographic scoring system. Ann Rheum Dis 64(1):127–129. https://doi.org/10.1136/ard.2004.020503

    Article  CAS  PubMed  Google Scholar 

  25. van der Linden S, Valkenburg HA, Cats A (1984) Evaluation of diagnostic criteria for ankylosing spondylitis. a proposal for modification of the New York criteria. Arthritis Rheum 27(4):361–368

    Article  PubMed  Google Scholar 

  26. Miller PD, Njeh CF, Jankowski LG, Lenchik L (2002) What are the standards by which bone mass measurement at peripheral skeletal sites should be used in the diagnosis of osteoporosis? J Clin Densitom 5(Suppl):S39–S45

    Article  PubMed  Google Scholar 

  27. Cryer JR, Otter SJ, Bowen CJ (2007) Use of quantitative ultrasound scans of the calcaneus to diagnose osteoporosis in patients with rheumatoid arthritis. J Am Podiatr Med Assoc 97(2):108–114

    Article  PubMed  Google Scholar 

  28. Clowes JA, Peel NF, Eastell R (2006) Device-specific thresholds to diagnose osteoporosis at the proximal femur: an approach to interpreting peripheral bone measurements in clinical practice. Osteoporos Int 17(9):1293–1302. https://doi.org/10.1007/s00198-006-0122-1

    Article  CAS  PubMed  Google Scholar 

  29. Zha XY, Hu Y, Pang XN, Chang GL, Li L (2015) Diagnostic value of osteoporosis self-assessment tool for Asians (OSTA) and quantitative bone ultrasound (QUS) in detecting high-risk populations for osteoporosis among elderly Chinese men. J Bone Miner Metab 33(2):230–238. https://doi.org/10.1007/s00774-014-0587-5

    Article  PubMed  Google Scholar 

  30. Compston JE, McClung MR, Leslie WD (2019) Osteoporosis. Lancet 393(10169):364–376. https://doi.org/10.1016/s0140-6736(18)32112-3

    Article  CAS  PubMed  Google Scholar 

  31. Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, Lindsay R (2014) Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int 25(10):2359–2381. https://doi.org/10.1007/s00198-014-2794-2

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgments

We would like to thank all the patients who willingly gave up their time to participate in the study. We would also like to also thank the staff of the Rheumatology Department in Tallaght University Hospital for their expertise and enthusiasm in assisting with patient recruitment. Additionally, we would like to express our deep gratitude to all the staff of the bone clinic in St. James’s Hospital.

Funding

We would like to acknowledge that the corresponding author (GF) was a recipient of the Bresnihan-Molloy Scholarship from the Royal College of Physicians of Ireland, funded by AbbVie pharmaceuticals. However, AbbVie pharmaceuticals had no role in the design of the study, collection of the data, analysis, and interpretation of the data or any part of manuscript preparation.

Author information

Authors and Affiliations

  1. School of Medicine, Trinity College Dublin, The University of Dublin, College Green, Dublin 2, Ireland

    Gillian E. Fitzgerald & Finbar O’Shea

  2. Department of Rheumatology, St. James’s Hospital, Dublin 8, Ireland

    Gillian E. Fitzgerald, Tochukwu Anachebe & Finbar O’Shea

  3. Department of Medicine for the Elderly, St. James’s Hospital, Dublin 8, Ireland

    Kevin G. McCarroll

Authors
  1. Gillian E. Fitzgerald
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Tochukwu Anachebe
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kevin G. McCarroll
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Finbar O’Shea
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Gillian E. Fitzgerald.

Ethics declarations

Disclosures

None.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Data from this manuscript has been published as an abstract in conference proceedings: Fitzgerald G, Anachebe T, Mullan R, Kane D, McCarroll K, O'Shea F. Quantitative Ultrasound of the Calcaneus Has a Role to Play in Detecting Low Bone Mineral Density in Axial Spondyloarthropathy Patients [abstract]. Arthritis Rheumatol. 2018; 70 (suppl 10). https://acrabstracts.org/abstract/quantitative-ultrasound-of-the-calcaneus-has-a-role-to-play-in-detecting-low-bone-mineral-density-in-axial-spondyloarthropathy-patients/. Accessed October 28, 2019.

Electronic supplementary material

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Fitzgerald, G.E., Anachebe, T., McCarroll, K.G. et al. Calcaneal quantitative ultrasound has a role in out ruling low bone mineral density in axial spondyloarthropathy. Clin Rheumatol 39, 1971–1979 (2020). https://doi.org/10.1007/s10067-019-04876-9

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10067-019-04876-9

Keywords

Search

Navigation