Osteoporosis International

, Volume 23, Issue 1, pp 143–153

Quantitative ultrasound of the heel and fracture risk assessment: an updated meta-analysis

  • A. Moayyeri
  • J. E. Adams
  • R. A. Adler
  • M.-A. Krieg
  • D. Hans
  • J. Compston
  • E. M. Lewiecki
Original Article



Meta-analysis of prospective studies shows that quantitative ultrasound of the heel using validated devices predicts risk of different types of fracture with similar performance across different devices and in elderly men and women. These predictions are independent of the risk estimates from hip DXA measures.


Clinical utilisation of heel quantitative ultrasound (QUS) depends on its power to predict clinical fractures. This is particularly important in settings that have no access to DXA-derived bone density measurements. We aimed to assess the predictive power of heel QUS for fractures using a meta-analysis approach.


We conducted an inverse variance random effects meta-analysis of prospective studies with heel QUS measures at baseline and fracture outcomes in their follow-up. Relative risks (RR) per standard deviation (SD) of different QUS parameters (broadband ultrasound attenuation [BUA], speed of sound [SOS], stiffness index [SI], and quantitative ultrasound index [QUI]) for various fracture outcomes (hip, vertebral, any clinical, any osteoporotic and major osteoporotic fractures) were reported based on study questions.


Twenty-one studies including 55,164 women and 13,742 men were included in the meta-analysis with a total follow-up of 279,124 person-years. All four QUS parameters were associated with risk of different fracture. For instance, RR of hip fracture for 1 SD decrease of BUA was 1.69 (95% CI 1.43–2.00), SOS was 1.96 (95% CI 1.64–2.34), SI was 2.26 (95%CI 1.71–2.99) and QUI was 1.99 (95% CI 1.49–2.67). There was marked heterogeneity among studies on hip and any clinical fractures but no evidence of publication bias amongst them. Validated devices from different manufacturers predicted fracture risks with similar performance (meta-regression p values > 0.05 for difference of devices). QUS measures predicted fracture with a similar performance in men and women. Meta-analysis of studies with QUS measures adjusted for hip BMD showed a significant and independent association with fracture risk (RR/SD for BUA = 1.34 [95%CI 1.22–1.49]).


This study confirms that heel QUS, using validated devices, predicts risk of different fracture outcomes in elderly men and women. Further research is needed for more widespread utilisation of the heel QUS in clinical settings across the world.


Dual-energy X-ray absorptiometry Meta-analysis Osteoporosis Quantitative ultrasound Risk assessment 

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2011

Authors and Affiliations

  • A. Moayyeri
    • 1
    • 2
  • J. E. Adams
    • 3
  • R. A. Adler
    • 4
  • M.-A. Krieg
    • 5
  • D. Hans
    • 6
  • J. Compston
    • 7
  • E. M. Lewiecki
    • 8
  1. 1.Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
  2. 2.Department of Twin Research and Genetic EpidemiologyKing’s College LondonLondonUK
  3. 3.Manchester Royal InfirmaryCentral Manchester Universities Hospitals NHS Foundation TrustManchesterUK
  4. 4.Department of Internal Medicine and Department of Epidemiology and Community HealthVirginia Commonwealth University School of MedicineRichmondUSA
  5. 5.Lausanne University HospitalLausanneSwitzerland
  6. 6.Department of Bone and JointLausanne University HospitalLausanneSwitzerland
  7. 7.Department of MedicineAddenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation TrustCambridgeUK
  8. 8.New Mexico Clinical Research & Osteoporosis CenterAlbuquerqueUSA

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