Osteoporosis International

, Volume 28, Issue 7, pp 2115–2128 | Cite as

The comparability of HR-pQCT bone measurements is improved by scanning anatomically standardized regions

  • S. Bonaretti
  • S. Majumdar
  • T. F. Lang
  • S. Khosla
  • A. J. BurghardtEmail author
Original Article



We investigated the sensitivity of distal bone density, structure, and strength measurements by high-resolution peripheral quantitative computed tomography (HR-pQCT) to variability in limb length. Our results demonstrate that HR-pQCT should be performed at a standard %-of-total-limb-length to avoid substantial measurement bias in population study comparisons and the evaluation of individual skeletal status in a clinical context.


High-resolution peripheral quantitative computed tomography (HR-pQCT) measures of bone do not account for anatomic variability in bone length: a 1-cm volume is acquired at a fixed offset from an anatomic landmark. Our goal was to evaluate HR-pQCT measurement variability introduced by imaging fixed vs. proportional volumes and to propose a standard protocol for relative anatomic positioning.


Double-length (2-cm) scans were acquired in 30 adults. We compared measurements from 1-cm sub-volumes located at the default fixed offset, and the average %-of-length offset. The average position corresponded to 4.0% ± 1.1 mm for radius, and 7.2% ± 2.2 mm for tibia. We calculated the RMS difference in bone parameters and T-scores to determine the measurement variability related to differences in limb length. We used anthropometric ratios to estimate the mean limb length for published HR-pQCT reference data, and then calculated mean %-of-length offsets.


Variability between fixed vs. relative scan positions was highest in the radius, and for cortical bone in general (RMS difference Ct.Th = 19.5%), while individuals had T-score differentials as high as +3.0 SD (radius Ct.BMD). We estimated that average scan position for published HR-pQCT reference data corresponded to 4.0% at the radius, and 7.3% at tibia.


Variability in limb length introduces significant bias to HR-pQCT measures, confounding cross-sectional analyses and limiting the clinical application for individual assessment of skeletal status. We propose to standardize scan positioning using 4.0 and 7.3% of total bone length for the distal radius and tibia, respectively.


Bone HR-pQCT Multicenter study Osteoporosis Precision Standardization 



The authors would like to thank Isra Said, MD of UCSF, and Margaret Holets, Louise McCready, and James Peterson of Mayo Clinic for their assistance with clinical coordination and data collection. This study was supported by NIH/NIAMS R01 AR060700.

Compliance with ethical standards

All subjects provided written informed consent to participate in this study. The Committees on Human Research of UCSF and Mayo Clinic approved all study procedures.

Conflicts of interest



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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2017

Authors and Affiliations

  • S. Bonaretti
    • 1
    • 2
  • S. Majumdar
    • 1
  • T. F. Lang
    • 1
  • S. Khosla
    • 3
  • A. J. Burghardt
    • 1
    Email author
  1. 1.Musculoskeletal Quantitative Imaging Research Group, Department of Radiology & Biomedical ImagingUniversity of CaliforniaSan FranciscoUSA
  2. 2.Department of RadiologyStanford UniversityStanfordUSA
  3. 3.Division of Endocrinology, Metabolism and Nutrition, Department of Internal MedicineCollege of Medicine, Mayo ClinicRochesterUSA

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