DEXA overestimates bone mineral density in adults with knee replacements

Abstract

We examined bone mineral density (BMD) measurements made by dual-energy-xray-absorptiometry (DEXA) taken from 100 patients (♂46/♀54, 66±6yr) who previously underwent single total-knee arthroplasty (TKA) to determine if automated software-based artifact detection (ASAD) adequately removes implant artifact from the DXA image before analysis and if potential inaccuracies could be overcome through manual artifact correction (MAC). We also sought to determine if software-based inaccuracies would result in fracture risk misclassification (Low-BMD/Osteopenia = Young-Adult T-Score < −1). Select

Results:

When using ASAD, limbs with implants had higher BMD (+12.0 ​± ​1.7%, p ​< ​0.001) compared to control limbs resulting in a 2.5 ​± ​0.2% overestimation of total-body BMD (single implant). Consequently, the prevalence of osteopenia in 95% of patients who would have been observed to have low leg BMD (18/19 patients) and 80% of those found to have low total-body BMD (4/5 patients) would have gone un-diagnosed. This overestimation was eliminated when using MAC. These results reveal a potential issue with ASAD for total-body DEXA scans in TKA patients and highlight the importance of careful review and MAC in those with joint replacements before making diagnostic decisions.

Keywords

Dual-energy-xray-absorptiometry / DXA / DEXA / Bone density / Total joint replacement / Arthroplasty / Osteopenia / Osteoporosis

Authors’ contributions

Katharine D. Harper assisted in data analysis, primary literature review, and was the primary manuscript writer. Terry A. Clyburn and Stephen J. Incavo provided the primary source of patients within the database used for analysis. Both also contributed to manuscript development. Bradley S. Lambert was responsible for facility and equipment support, data collection, analysis, statistics, generation of figures and tables, assistance in manuscript writing.

Ethical approval

The procedures were approved by the institutional review board for research involving human subjects (IRB PRO00015628), and all volunteers signed a written informed consent prior to participating in the experimental procedures.

Conflict of interest

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

[1] N.C. Wright, A.C. Looker, K.G. Saag, et al.. The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res, 29 (11) ( 2014), pp. 2520-2526, DOI: 10.1002/jbmr.2269

[2] A. El Maghraoui, C. Roux. DXA scanning in clinical practice. QJM, 101 (8) ( 2008), pp. 605-617, DOI: 10.1093/qjmed/hcn022

[3] J.A. Kanis. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report. Osteoporos Int, 4 (6) ( 1994), pp. 368-381, DOI: 10.1007/BF01622200

[4] S. Yedavally-Yellayi, A.M. Ho, E.M. Patalinghug. Update on osteoporosis. Prim Care, 46 (1) ( 2019), pp. 175-190, DOI: 10.1016/j.pop.2018.10.014

[5] N. Denton, F. Karpe. Measuring body composition and regional fat mass accurately. Practical Diabetes, 33 (7) ( 2016), pp. 224-226

[6] M. Fang, N. Noiseux, E. Linson, P. Cram. The effect of advancing age on total joint replacement outcomes. Geriatr Orthop Surg Rehabil, 6 (3) ( 2015), pp. 173-179, DOI: 10.1177/2151458515583515

[7] M. Sloan, A. Premkumar, N.P. Sheth. Projected volume of primary total joint arthroplasty in the US, 2014 to 2030. J Bone Joint Surg, 100 (17) ( 2018), pp. 1455-1460, DOI: 10.2106/JBJS.17.01617

[8] L.G. Borrud, K.M. Flegal, A.C. Looker, J.E. Everhart, T.B. Harris, J.A. Shepherd.Body composition data for individuals 8 years of age and older: US population, 1999-2004. Vital and health statistics. Series 11. Data from the national health survey ( 250) ( 2010), p. 1

[9] A. Looker, L. Borrud, J. Hughes, B. Fan, J. Shepherd, M. Sherman. Total body bone area, bone mineral content, and bone mineral density for individuals aged 8 years and over: United States, 1999-2006. Vital and health statistics. Series 11. Data from the National Health Survey ( 253) ( 2013), pp. 1-78

[10] E.S. Leib, E.M. Lewiecki, N. Binkley, R.C. Hamdy. Official positions of the international society for clinical densitometry. J Clin Densitom, 7 (1) ( 2004), pp. 1-5, DOI: 10.1385/jcd:7:1:1

[11] C. Ialongo. Understanding the effect size and its measures. Biochem Med, 26 (2) ( 2016), pp. 150-163, DOI: 10.11613/BM.2016.015

[12] D. Eddy, J.J. Cc, S. Cummings, et al.. Osteoporosis: review of the evidence for prevention, diagnosis, and treatment and cost-effectiveness analysis. Status report. Osteoporos Int, 8 (suppl 4) ( 1998)

[13] M. Elvey, H. Pugh, G. Schaller, G. Dhotar, B. Patel, M. Oddy. Failure in the application of fragility fracture prevention guidelines. Ann R Coll Surg Engl, 96 (5) ( 2014), pp. 381-385, DOI: 10.1308/003588414X13946184901164

[14] S.W. Blume, J.R. Curtis. Medical costs of osteoporosis in the elderly Medicare population. Osteoporos Int, 22 (6) ( 2011), pp. 1835-1844, DOI: 10.1007/s00198-010-1419-7

[15] N. Prasad, D. Sunderamoorthy, J. Martin, J. Murray. Secondary prevention of fragility fractures: are we following the guidelines? Closing the audit loop. Ann R Coll Surg Engl, 88 (5) ( 2006), pp. 470-474, DOI: 10.1308/003588406X116891

[16] M. Garg, S. Kharb.Dual energy X-ray absorptiometry: pitfalls in measurement and interpretation of bone mineral density. Indian J Endocrinol Metab, 17 (2) ( 2013), p. 203, DOI: 10.4103/2230-8210.109659

[17] E.M. Lewiecki, N.E. Lane. Common mistakes in the clinical use of bone mineral density testing. Nat Clin Pract Rheumatol, 4 (12) ( 2008), pp. 667-674, DOI: 10.1038/ncprheum0928

[18] A.M. Abdelmohsen. Comparison of central and peripheral bone mineral density measurements in postmenopausal women. J Chiropr Med, 16 (3) ( 2017), pp. 199-203, DOI: 10.1016/j.jcm.2017.08.001

[19] G.M. Blake, I. Fogelman. Peripheral or central densitometry: does it matter which technique we use?. J Clin Densitom, 4 (2) ( 2001), pp. 83-96, DOI: 10.1385/jcd:4:2:083

[20] D.B. Hans, J.A. Shepherd, E.N. Schwartz, et al.. Peripheral dual-energy X-ray absorptiometry in the management of osteoporosis: the 2007 ISCD Official Positions. J Clin Densitom, 11 (1) ( 2008), pp. 188-206, DOI: 10.1016/j.jocd.2007.12.012

[21] V.M. Mattila, K. Tallroth, M. Marttinen, H. Pihlajamäki. Body composition by DEXA and its association with physical fitness in 140 conscripts. Med Sci Sports Exerc, 39 (12) ( 2007), pp. 2242-2247, DOI: 10.1249/mss.0b013e318155a813

[22] P. Zanzonico. Technical aspects of dual-energy X-ray absorptiometry and quantitative computed tomography for assessment of bone mineral density and body composition. Nuclear Medicine Textbook, Springer ( 2019), pp. 1085-1098

[23] B. Moreno, A.B. Crujeiras, D. Bellido, I. Sajoux, F.F. Casanueva. Obesity treatment by very low-calorie-ketogenic diet at two years: reduction in visceral fat and on the burden of disease. Endocrine, 54 (3) ( 2016), pp. 681-690, DOI: 10.1007/s12020-016-1050-2