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The Singh Index does not correlate with bone mineral density (BMD) measured with dual energy X-ray absorptiometry (DXA) or peripheral quantitative computed tomography (pQCT)

  • Trauma Surgery
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Abstract

The Singh Index (SI), a classification system by which the severity of osteoporosis is assessed based on plain radiographs, is a renowned, simple and inexpensive form of evaluating osteoporosis. The aim of this study was to evaluate the correlation between the SI and bone mineral density (BMD) as measured by dual energy X-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT). The SI was evaluated in 128 cadaveric femora (64 patients, mean age 66.7 years, range 24–89 years) by three independent observers, all blinded to plain radiographs. BMD was also analysed by means of DXA and pQCT in the cadaveric femora. The mean interrater correlation was found to be 0.629. The correlation of the mean BMD measured by DXA (DXA-BMD) and SI was found to be poor, with r = 0.49. The corresponding sensitivity of 45.2 % and specificity of 92.3 % were even poor. The BMD measured by pQCT (pQCT-BMD) also revealed a poor correlation with SI, such that r = 0.337 and r = 0.428 for the trochanteric and neck regions, respectively. Due to the poor correlation of the SI with BMD and the poorer interrater correlation, the SI should be rejected as a tool for evaluating osteoporosis. The SI was found to be too imprecise and is therefore unsuitable for diagnosing osteoporosis and osteopenia.

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References

  1. Link TM, Majumdar S (2003) Osteoporosis imaging. Radiol Clin North Am 41(4):813–839

    Article  PubMed  Google Scholar 

  2. O’Gradaigh D, Debiram I, Love S, Richards HK, Compston JE (2003) A prospective study of discordance in diagnosis of osteoporosis using spine and proximal femur bone densitometry. Osteoporos Int 14(1):13–18

    Article  PubMed  Google Scholar 

  3. Salaffi F, Silveri F, Stancati A, Grassi W (2005) Development and validation of the osteoporosis prescreening risk assessment (OPERA) tool to facilitate identification of women likely to have low bone density. Clin Rheumatol 24(3):203–211

  4. Seeman E, Delmas PD (2006) Bone quality-the material and structural basis of bone strength and fragility. N Engl J Med 354(21):2250–2261

    Article  CAS  PubMed  Google Scholar 

  5. Chapurlat RD (2009) Bone microdamage. Osteoporos Int 20(6):1033–1035

    Article  CAS  PubMed  Google Scholar 

  6. Singh M, Nagrath AR, Maini PS (1970) Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone Joint Surg Am 52(3):457–467

    CAS  PubMed  Google Scholar 

  7. Wachter NJ, Augat P, Hoellen IP, Krischak GD, Sarkar MR, Mentzel M, Kinzl L, Claes L (2001) Predictive value of Singh index and bone mineral density measured by quantitative computed tomography in determining the local cancellous bone quality of the proximal femur. Clin Biomech 16(3):257–262

    Article  CAS  Google Scholar 

  8. Krischak GD, Augat P, Wachter NJ, Kinzl L, Claes LE (1999) Predictive value of bone mineral density and Singh index for the in vitro mechanical properties of cancellous bone in the femoral head. Clin Biomech 14:346–351

    Article  CAS  Google Scholar 

  9. Koot VC, Kesselaer SM, Clevers GJ, de Hooge P, Weits T, van der Werken C (1996) Evaluation of the Singh index for measuring osteoporosis. J Bone Joint Surg Br 78(5):831–834

    CAS  PubMed  Google Scholar 

  10. Heneghan JP, Kirke PN, Murphy BL, Darcy E, Daly L, Bourke GJ, Dinn E, Masterson J (1997) Evaluation of quantitative CT vertebral bone mineral density measurement and the Singh index in elderly females with hip fractures-a case control study. Br J Radiol 70(837):923–928

    Article  CAS  PubMed  Google Scholar 

  11. Gulati D, Kumar S, Arora A, Aggarwal AN, Bhargava SK (2010) Bone mineral density in young Indian adults with traumatic proximal femoral fractures. A case control study. Acta Orthop Belg 76(3):335–340

    PubMed  Google Scholar 

  12. Goldhahn J, Suhm N, Goldhahn S, Blauth M, Hanson B (2008) Influence of osteoporosis on fracture fixation- a systematic literature review. Osteoporos Int 19(6):761–772

    Article  CAS  PubMed  Google Scholar 

  13. Soontrapa S, Soontrapa S (2011) Modified Singh index in diagnosing femoral neck osteoporosis. J Med Assoc Thai 94(5):79–83

    Google Scholar 

  14. Bauer JS, Kohlmann S, Eckstein F, Mueller D, Lochmüller EM, Link TM (2006) Structural analysis of trabecular bone of the proximal femur using multislice computed tomography: a comparison with dual X-ray absorptiometry for predicting biomechanical strength in vitro. Calcif Tissue Int 78(2):78–89

    Article  CAS  PubMed  Google Scholar 

  15. Kastl S, Sommer T, Klein P, Hohenberger W, Engelke K (2002) Accuracy and precision of bone mineral density and bone mineral content in excised rat humeri using fan beam dual-energy X-ray absorptiometry. Bone 30(1):243–246

    Article  CAS  PubMed  Google Scholar 

  16. Bland JM, Altman DG (1995) Calculating correlation coefficients with repeated observations: part2—correlation between subjects. BMJ 312(7030):572

    Google Scholar 

  17. Shrout PE, Fleiss JL (1979) Intraclass correlations: uses in assessing rater reliability. Psychol Bull 86(2):420–428

    Article  CAS  PubMed  Google Scholar 

  18. Bes C, Güven M, Akman B, Atay EF, Ceviz E, Soy M (2012) Can bone quality be predicted accurately by Singh index in patients with rheumatoid arthritis? Clin Rheumatol 31(1):85–89

    Article  PubMed  Google Scholar 

  19. Khairi MR, Cronin JH, Robb JA, Smith DM, Johnston CC Jr (1976) Femoral trabecular-pattern index and bone mineral content measurement by photon absorption in senile osteoporosis. J Bone Joint Surg Am 58(2):221–226

    CAS  PubMed  Google Scholar 

  20. Lips P, Taconis WK, van Ginkel FC, Netelenbos JC (1984) Radiologic morphometry in patients with femoral neck fractures and elderly control subjects. Comparison with histomorphometric parameters. Clin Orthop Relat Res 183:64–70

    PubMed  Google Scholar 

  21. Hauschild O, Ghanem N, Oberst M, Baumann T, Kreuz PC, Langer M, Suedkamp NP, Niemeyer P (2009) Evaluation of Singh index for assessment of osteoporosis using digital radiography. Eur J Radiol 71(1):152–158

    Article  CAS  PubMed  Google Scholar 

  22. Cummings S, Melton L (2002) Epidemiology and outcomes of osteoporotic fractures. Lancet 359:1761–1767

    Article  PubMed  Google Scholar 

  23. Yu EW, Finkelstein JS (2012) Bone density screening intervals for osteoporosis: one size does not fit all. JAMA 307(24):2591–2592

    Article  CAS  PubMed  Google Scholar 

  24. Masud T, Jawed S, Doyle DV, Spector TD (1995) A population study of the screening potential of assessment of trabecular pattern of the femoral neck (Singh index): the Chingford Study. Br J Radiol 68:389–393

    Article  CAS  PubMed  Google Scholar 

  25. Zebaze RM, Jones A, Knackstedt M, Maalouf G, Seeman E (2007) Construction of the femoral neck during growth determines its strength in old age. J Bone Miner Res 22(7):1055–1061

    Article  PubMed  Google Scholar 

  26. Boutroy S, Bouxsein ML, Munoz F, Delmas PD (2005) In vivo assessment of trabecular bone microarchitecture by high-resolution peripheral quantitative computed tomography. J Clin Endocrinol Metab 90(12):6508–6515

    Article  CAS  PubMed  Google Scholar 

  27. Sawada K, Morishige K, Ohmichi M, Nishio Y, Yamamoto T, Hayakawa J, Mabuchi S, Isobe A, Sasaki H, Sakata M, Tasaka K, Murata Y (2007) Peripheral quantitative computed tomography (pQCT) is useful for monitoring bone mineral density of the patients who receive hormone replacement therapy. Maturitas 56(4):343–349

    Article  CAS  PubMed  Google Scholar 

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Acknowledgments

The authors thanks to Ms. Kimberley Day and Mr. Olaf Stark for excellent technical assistance in preparing the samples for qualitative and quantitative data acquisition and helping with the draft of the manuscript.

Conflict of interest

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. All authors have no conflicts of interest.

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Authors and Affiliations

  1. Center for Biomechanics and Skeletal Biology, University Medical Center Hamburg-Eppendorf, Lottestrasse 59, 22529, Hamburg, Germany

    M. Amling & M. Gebauer

  2. HELIOS ENDO-Klinik Hamburg, Holstenstraße 2, 22767, Hamburg, Germany

    M. Gebauer

  3. Department of Trauma-, Hand- and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany

    T. O. Klatte

  4. Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany

    E. Vettorazzi

  5. Department of Forensic Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany

    K. Pueschel

  6. Sportklinik Stuttgart GmbH, Taubenheimstr. 8, 70372, Stuttgart, Germany

    J. Beckmann

Authors
  1. T. O. Klatte
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  2. E. Vettorazzi
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  3. J. Beckmann
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  4. K. Pueschel
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  5. M. Amling
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  6. M. Gebauer
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Correspondence to M. Gebauer.

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Klatte, T.O., Vettorazzi, E., Beckmann, J. et al. The Singh Index does not correlate with bone mineral density (BMD) measured with dual energy X-ray absorptiometry (DXA) or peripheral quantitative computed tomography (pQCT). Arch Orthop Trauma Surg 135, 645–650 (2015). https://doi.org/10.1007/s00402-015-2187-9

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  • DOI: https://doi.org/10.1007/s00402-015-2187-9

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