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Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004 ABSTRACTS
Comparison to other techniques: 2000 Cortical and Trabecular BMD: 2003 Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004 Am J Med 1995 Feb 27; 98(2A):41S-47S
Radiographic absorptiometry in the diagnosis of osteoporosis.

Yates AJ, Ross PD, Lydick E, Epstein RS
Merck Research Laboratories, Rahway, New Jersey, USA.

Radiographic absorptiometry (RA) is a technique for bone mass
measurement from radiographs of peripheral sites, most commonly the hand
or heel. The principle was first described in 1939, and RA became relatively
widely used as a research technique in the 1960s, although interest in RA
subsequently dwindled as precise nonradiographic densitometry techniques
became available. Recently, however, computerized image processing has
been applied to radiography, with the result that current RA techniques
applicable to a routine clinical setting are as precise and accurate as dual-
energy or single-energy x-ray absorptiometry (DXA or SXA). In addition,
recent studies demonstrate that the strength of association between low
bone mass measured by RA and fracture risk is comparable to that for other
forms of bone mass measurement. The relatively low cost and lack of need
for specialized equipment make RA a highly attractive option for the
diagnosis of osteoporosis that is available to specialist and nonspecialist
physicians alike.
Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004 Arch Intern Med 1997 Feb; 24;157(4):433-8
Phalangeal bone density and hip fracture risk.

Mussolino ME, Looker AC, Madans JH, Edelstein D, Walker RE, Lydick E,
Epstein RS, Yates AJ
National Center for Health Statistics, Hyattsville, MD, USA.

OBJECTIVE: To assess the long-term predictive usefulness of radiographic
absorptiometry measurements of phalangeal bone density for hip fracture
risk. METHODS: Participants were members of the First National Health and
Nutrition Examination Survey Epidemiologic Follow Up Study cohort.
Subjects were followed up for a maximum of 16 years. The First National
Health and Nutrition Examination Survey data were obtained from a
nationally representative sample of non-institutionalized civilians. A cohort of
3481 white and black subjects (1559 white women) aged 45 through 74
years at baseline (1971-1975) were observed through 1987. Ninety-eight
percent of the original cohort completed the study. Hospital records and
death certificates were used to identify a total of 72 hip fracture cases.
Phalangeal bone density at baseline was measured using photodensitometry
(PD), and later reanalyzed by radiographic absorptiometry (RA), a newer,
more sophisticated technique. RESULTS: Results were evaluated to
determine the relative risk for hip fracture per 1-SD decrease in bone density,
after controlling for age at baseline, race, gender, weight, and previous
fractures. Both RA and PD measurements showed a significant inverse
relationship to hip fracture risk, with RA density measurements showing a
slightly higher adjusted relative risk per 1-SD density decrease than PD
measurements. For RA bone density, the relative risk for all subjects was
1.81 (95% confidence interval, 1.34-2.44) compared with 1.57 (95%
confidence interval, 1.19-2.07) for PD bone density after adjusting for age at
baseline, race, gender, weight, and previous fractures. Results for white
women were essentially the same as those for all subjects for RA bone
density and PD bone density. CONCLUSIONS: Phalangeal bone density
determined from standard hand x-ray films is a significant predictor of future
hip fracture risk. Availability of a valid method to assess fracture risk using
conventional radiographs will expand the ability to identify individuals with
Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004 Calcif Tissue Int 1998 Nov; 63(5):380-4
Prediction of fracture risk by radiographic absorptiometry and
quantitative ultrasound: a prospective study.

Huang C, Ross PD, Yates AJ, Walker RE, Imose K, Emi K, Wasnich RD
Hawaii Osteoporosis Foundation, 401 Kamakee Street, Honolulu, Hawaii
96814, USA.

Recent developments in computer-assisted radiographic absorptiometry (RA)
and quantitative ultrasound techniques (QUS) provide readily accessible and
relatively inexpensive methods for assessing bone mineral status. However,
few population-based studies have investigated the ability of RA and
ultrasound to predict fracture risk prospectively. We explored the ability of RA
and QUS to predict fracture risk among 560 postmenopausal women from
the Hawaii Osteoporosis Study; average follow-up was 2.7 years. An incident
vertebral fracture was defined as a decrease of more than 15% in vertebral
heights on subsequent films. Self-reported nonspine fractures were verified
by medical records. The prospective associations of vertebral fractures,
nonspine fractures, and any (spine or nonspine) fractures with bone
measurements were examined using logistic regression, adjusting for age.
Both phalangeal bone mineral density (BMD) and metacarpal BMD,
measured using RA, predicted future fracture risk. The age-adjusted odds
ratios (corresponding to 1 SD decrease in BMD) for vertebral fractures,
nonspine fractures, and any fractures were 3.41, 1.50, and 1.91,
respectively, for phalangeal BMD, and 1.71, 1.49, 1.55, respectively for
metacarpal BMD. Calcaneal broadband ultrasound attenuation (BUA) also
showed significant association with fracture risk, with age-adjusted odds
ratios of 1.50, 1.89, and 1.72 for vertebral fractures, nonspine fractures, and
any fractures, respectively. We conclude that hand RA and calcaneal BUA
are significant predictors of nonspine fracture, vertebral fracture, and overall
fracture risk. The attractive features of these techniques, such as portability,
relatively low cost, and ease of use, make them promising alternatives to
conventional bone measurement techniques used for the assessment of
fracture risk.
Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004
Radiographic absorptiometry for bone mineral measurement of the
phalanges: precision and accuracy study.

Yang SO, Hagiwara S, Engelke K, Dhillon MS, Guglielmi G, Bendavid EJ,
Soejima O, Nelson DL, Genant HK
Department of Radiology, University of California, San Francisco 94143-

PURPOSE: To evaluate the accuracy and precision of a radiographic
absorptiometry (RA) method for assessment of bone mineral of the middle
phalanges. MATERIALS AND METHODS: Nineteen cadaveric hands were
radiographed with an aluminum wedge, once at 50 kVp and 400 mA and
once at 60 kVp and 300 mA. Bone mineral content (BMC) and bone mineral
density (BMD) of the second to fourth middle phalanges, expressed in
arbitrary units (BMC-AU and BMD-AU), were analyzed and averaged in each
hand. RESULTS: The precision error of this method was 1.0% for BMC-AU
and 0.6% for BMD-AU. A 2.0%-2.4% reduction in BMD-AU seen on
radiographs obtained through ethanol thicknesses of 5 and 6 mm compared
with that seen on controls was statistically significant (P < .01). The
correlation between BMC-AU and forearm BMC determined with dual x-ray
absorptiometry was good (r = .887), and that between BMC-AU and ash
weight in the phalanges was excellent (r = .983). CONCLUSION: The RA
method is precise and accurate for bone mineral assessment of the
peripheral appendicular skeleton.
Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004 J Bone Miner Res 1994 Nov; 9(11):1745-9
Comparison of radiographic absorptiometry with dual-energy x-ray
absorptiometry and quantitative computed tomography in normal older
white and black women.

Kleerekoper M, Nelson DA, Flynn MJ, Pawluszka AS, Jacobsen G, Peterson
Department of Internal Medicine, Wayne State University School of Medicine,
Detroit, Michigan.

Bone mineral density (BMD) of the phalanges of the hand was measured by
the technique of radiographic absorptiometry (RA) in 199 older
postmenopausal women previously determined to have normal BMD by dual-
energy x-ray absorptiometry (DXA) and quantitative computed tomography
(QCT). The average age of the women was 66.8 +/- 4.9 years, and they were
19.9 +/- 6.7 years postmenopause. In the 54 black women, phalangeal BMD
was 11.7% greater than in the 145 white women, a difference comparable to
that found using DXA at the radial midshaft, the lumbar spine, and femoral
neck. A correlation matrix comparing BMD measured by RA to BMD
measured by DXA and QCT indicates that, in general, RA was related to the
various DXA and QCT measurement sites as well as these sites were related
to each other. When results for RA, DXA, and QCT obtained in our cohort of
older women were compared to available reference data for peak adult bone
mass, the average difference (SD units) from peak value was greatest for RA
(-1.77 radius, -1.24 spine, -2.13 femoral neck, -2.34 QCT spine, and -2.71
phalanges). We conclude that RA is an acceptable measure of phalangeal
BMD and that the data in our cohort can serve as reference data for older
white and black women aged 55-75 years. Once the ability of RA to predict
future fracture occurrence has been demonstrated, it could be rapidly
deployed as a low-cost, widely available bone mass measurement technique.
Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004 Pediatr Res 2001 Sep; 50(3):417-22
Bone mineral density assessed by phalangeal radiographic
absorptiometry before and during long-term growth hormone treatment
in girls with Turner's syndrome participating in a randomized dose-
response study.

Sas TC, de Muinck Keizer-Schrama SM, Stijnen T, van Teunenbroek A, van
Leeuwen WJ, Asarfi A, van Rijn RR, Drop SL; Dutch Advisory Group on
Growth Hormone.
Department of Pediatrics, Division of Endocrinology, Sophia Children's
Hospital, Rotterdam, The Netherlands.

To assess bone mineral density (BMD) in girls with Turner's syndrome before
and during long-term treatment with GH, longitudinal measurements using
phalangeal radiographic absorptiometry were performed in 68 girls with
Turner's syndrome. These previously untreated girls, age 2-11 y,
participating in a randomized, dose-response trial, were randomly assigned
to one of three GH dosage groups: group A, 4 IU/m(2)/d ( approximately
0.045 mg/kg/d); group B, first year 4 IU/m(2)/d, thereafter 6 IU/m(2)/d (
approximately 0.0675 mg/kg/d); or group C, first year 4 IU/m(2)/d, second
year 6 IU/m(2)/d, thereafter 8 IU/m(2)/d ( approximately 0.090 mg/kg/d). In
the first 4 y of GH treatment, no estrogens for pubertal induction were
prescribed to the girls. Thereafter, girls started with 17beta-estradiol (5
microg/kg body weight/d, orally) when they had reached the age of 12 y.
BMD results were adjusted for bone age and sex, and expressed as SD
scores using reference values of healthy Dutch girls. At baseline, almost
every individual BMD value of bone consisting predominantly of cortical
bone, as well as that of bone consisting predominantly of trabecular bone,
was within the normal range of healthy girls and the SD scores were not
significantly different from zero [mean (SE) 0.38 (0.22) and -0.04 (0.13)].
During 7 y of GH treatment, BMD SD scores showed a significant increase to
values significantly higher than zero [mean (SE) 0.87 (0.15) and 0.95 (0.14)].
The increment in BMD SD score of bone consisting predominantly of cortical
bone was significantly higher in group C compared with that of the other two
GH dosage groups. The pretreatment bone age was significantly negatively
related to the increment in BMD SD score. We found no significant influence
of spontaneous puberty or the use of low-dose estrogens in the last 3 y of the
study period on the increment in BMD SD score during 7 y of GH treatment.
In conclusion, most untreated young girls with Turner's syndrome have a
normal volumetric BMD. During 7 y of GH treatment with 4, 6, or 8 IU/m(2)/d,
the BMD SD score increased significantly.
Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004 J Clin Densitom 2002 Spring; 5(1):79-85
Dual X-ray absorptiometry of hip, heel ultrasound, and densitometry of
fingers can discriminate male patients with hip fracture from control
subjects: a comparison of four different methods.

Ekman A, Michaelsson K, Petren-Mallmin M, Ljunghall S, Mallmin H.
Department of Surgery, Orthopedic Unit, University Hospital, Uppsala,

Few studies have examined different bone densitometry techniques to
determine male hip fracture risk. We conducted a case-control study of 31
noninstitutionalized men, mean age 77 yr, with a first hip fracture and
compared the results with 68 randomly selected age-matched control
subjects. The methods used were dual X-ray absorptiometry (DXA) of the
proximal femur, quantitative ultrasound (QUS) of the heel and fingers, and
radiographic absorptiometry of the fingers. Case patients had significantly
lower values (4-17%; p < 0.01) for all methods. The odds ratios for every SD
reduction in bone values were 4.8 (95% confidence interval [CI]: 2.3-9.9) for
DXA of the femoral neck, 2.2 (95% CI: 1.2-3.9) for QUS of the heel, 2.0 (95%
CI: 1.2-3.3) for QUS of the phalanges, and 3.1 (95% CI: 1.5-6.6) for
radiographic absorptiometry of the phalanges. The results indicate a strong
capability of DXA of the femoral neck to distinguish between men with a first
hip fracture and control subjects. Furthermore, ultrasound of the heel and
fingers as well as radiographic absorptiometry proved capable of
discriminating men with hip fractures from control subjects.
Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004
Comparison of bone densitometry of the phalanges, distal forearm and
axial skeleton in early postmenopausal women participating in the EPIC

Ravn P, Overgaard K, Huang C, Ross PD, Green D, McClung M
Center for Clinical and Basic Research, Ballerup, Denmark.

We present baseline bone densitometry from the Early Postmenopausal
Interventional Cohort study (EPIC, sponsored by Merck, Sharp & Dohme) for
the first time, in which 1609 women from England, Oregon, Hawaii and
Denmark are participating to investigate the efficacy of daily oral alendronate
to prevent early postmenopausal bone loss. We compared radiographic
absorptiometry (RA) of the phalanges for bone mineral density (BMD)
measurement with single-energy X-ray absorptiometry (SXA) of the distal
forearm, and dual-energy X-ray absorptiometry (DXA) of the lumbar spine,
proximal femur and distal forearm. In a random subgroup of 308 women,
aged 45-60 years, on average 6 years since menopause (YSM), bone
densitometry was measured once at baseline by RA of the phalanges
besides the mandatory measurements by DXA. Bone densitometry was
furthermore measured by SXA at the Danish site (89 women). Sixty-eight of
the women had duplicate measurements performed within 1-3 weeks to
evaluate the short-term precision error (CV%). One hundred and one healthy
premenopausal women, aged 25-48 years, were recruited at the Danish and
Hawaiian sites to establish a reference group. The precision error was 1.5%
for RA of the phalanges and in the range 1.0-2.2% for SXA and DXA. BMD
by RA correlated with BMD measured by SXA and DXA in the range 0.45 < r
< 0.72 (p < 0.001). In conclusion, bone densitometry by RA of the phalanges
is highly correlated with bone densitometry by SXA and DXA. RA of the
phalanges has a short-term precision error comparable to that of SXA and
Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004
Predicting vertebral deformity using bone densitometry at various
skeletal sites and calcaneus ultrasound.

Ross P, Huang C, Davis J, Imose K, Yates J, Vogel J, Wasnich R
Hawaii Osteoporosis Center, Honolulu 96814, USA.

We investigated the usefulness of bone density measurements from multiple
skeletal sites and calcaneus ultrasound for evaluating the probability of
vertebral deformation. Bone mineral density (BMD) was measured at the
second metacarpal and middle phalanges using radiographic absorptiometry
of hand radiographs, and at the lumbar spine using dual-energy x-ray
absorptiometry. Distal radius and proximal radius were measured using
single-energy x-ray absorptiometry (SXA), expressed as bone mineral
content (BMC, grams per centimeter), and as BMD (grams per square
centimeter). The calcaneus was measured using both SXA (BMD) and
broadband ultrasound attenuation (BUA). Among the women in this study
(mean age 74, SD = 5), 84 women developed new vertebral deformations
(57 cases with one and 27 cases with two or more deformations), which were
identified on serial radiographs during an average of 9 years prior to the
measurements of bone density. Logistic regression analysis was used to
calculate odds ratios for risk of deformation corresponding to a 1-SD
difference in density or ultrasound, adjusted for age. All bone measurements
were significantly associated with vertebral deformation, with odds ratios
(95% confidence intervals) ranging from 1.40 (1.10, 1.78) for proximal radius
BMD to 1.88 (1.45, 2.44) for calcaneus BMD measurements. Measurements
of calcaneal BUA, calcaneal BMD, and hand BMD generally remained
significant when included simultaneously with another measurement in the
same model, suggesting that spine or radius BMD may not provide much
additional information about risk of deformation. It appears that all of the
measurements of bone density and ultrasound provide useful information
regarding the probability of deformation. These findings await confirmation in
a prospective study.
Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004 Bone Miner Res 1997 May; 12(5):697-711
Comparisons of noninvasive bone mineral measurements in assessing
age-related loss, fracture discrimination, and diagnostic classification.

Grampp S, Genant HK, Mathur A, Lang P, Jergas M, Takada M, Gluer CC,
Lu Y, Chavez M
Department of Radiology, University of California, San Francisco 94143,

The purpose of this study was to examine the commonly available methods
of noninvasively assessing bone mineral status across three defined female
populations to examine their interrelationships, compare their respective
abilities to reflect age- and menopause-related bone loss, discriminate
osteoporotic fractures, and classify patients diagnostically. A total of 47
healthy premenopausal (age 33 +/- 7 years), 41 healthy postmenopausal
(age 64 +/- 9 years), and 36 osteoporotic postmenopausal (age 70 +/- 6
years) women were examined with the following techniques: (1) quantitative
computed tomography of the L1-L4 lumbar spine for trabecular (QCT TRAB
BMD) and integral (QCT INTG BMD) bone mineral density (BMD); (2) dual X-
ray absorptiometry of the L1-L4 posterior-anterior (DXA PA BMD) and L2-L4
lateral (DXA LAT BMD) lumbar spine, of the femoral neck (DXA NECK BMD)
and trochanter (DXA TROC BMD), and of the ultradistal radius (DXA UD
BMD) for integral BMD; (3) peripheral QCT of the distal radius for trabecular
BMD (pQCT TRAB BMD) and cortical bone mineral content (BMC) (pQCT
CORT BMC); (4) two radiographic absorptiometric techniques of the
metacarpal (RA METC BMD) and phalanges (RA PHAL BMD) for integral
BMD; and (5) two quantitative ultrasound devices (QUS) of the calcaneus for
speed of sound (SOS CALC) and broadband ultrasound attenuation (BUA
CALC). In general, correlations ranged from (r = 0.10-0.93) among different
sites and techniques. We found that pQCT TRAB BMD correlated poorly (r <
or = 0.46) with all other measurements except DXA UD BMD (r = 0.62,p < or
= 0.0001) and RA PHAL BMD (r = 0.52, p < or = 0.0001). The strongest
correlation across techniques was between QCT INT BMD and DXA LAT
BMD (r = 0.87, p < or = 0.0001), and the weakest correlation within a
technique was between pQCT TRAB BMD and pQCT CORT BMC (r =
0.25,p < or = 0.05). Techniques showing the highest correlations with age in
the healthy groups also showed the greatest differences among groups.
They also showed the best discrimination (as measured by the odds ratios)
for the distinction between healthy postmenopausal and osteoporotic
postmenopausal groups based on age-adjusted logistic regression analysis.
For each anatomic site, the techniques providing the best results were: (1)
Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004 spine, QCT TRAB BMD (annual loss, -1.2% [healthy premenopausal and healthy postmenopausal]); Student's t-value [not the T score], 5.4 [healthy postmenopausal vs. osteoporotic postmenopausal]; odds ratio, 43 [age-adjusted logistic regression for healthy postmenopausal vs. osteoporotic postmenopausal]); (2) hip, DXA TROC BMD (-0.46; 3.5; 2.2); (3) radius, DXA UD BMD (-0.44; 3.3; 1.9) and pQCT, CORT BMC (-0.72; 2.9; 1.7); (4) hand, RA PHAL (-0.51; 3.6; 2.0); and (5) calcaneus, SOS (-0.09; 3.4; 2.1) and BUA (-0.52; 2.6; 1.7). Despite these performance trends, the differences among sites and techniques were statistically insignificant (p > 0.05) using age-adjusted receiver operating characteristic (ROC) curve analysis. Nevertheless, kappa score analysis (using -2.0 T score as the cut-off value for osteopenia and -2.5 T score for osteoporosis) showed that in general the diagnostic agreement among these measurements in classifying women as osteopenic or osteoporotic was poor, with kappa scores averaging about 0.4 (exceptions were QCT TRAB/INTG BMD, DXA LAT BMD, and RA PHAL BMD, with kappa scores ranging from 0.63 to 0.89). Often different patients were estimated at risk by using different measurement sites or techniques. Radiology 2000 Aug; 216(2):586-91
Bone mineral measurement of phalanges: comparison of radiographic
absorptiometry and area dual X-ray absorptiometry.

Gulam M, Thornton MM, Hodsman AB, Holdsworth DW
With a standard, image-intensifier-based, digital radiographic system, high-
spatial-resolution images of the hand were acquired for analysis of
phalangeal bone mineral density with dual x-ray absorptiometry (DXA).
Results with phalangeal DXA had precision of plus or minus 0.67% and
accuracy of 4.1% and correlated well with those with radiographic
absorptiometry. This phalangeal DXA technique is potentially useful for
clinical diagnosis of osteoporosis.
Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004 Radiology 1997 Mar; 202(3):759-63
Assessment of osteoporosis: comparison of radiographic
absorptiometry of the phalanges and dual X-ray absorptiometry of the
radius and lumbar spine.

Takada M, Engelke K, Hagiwara S, Grampp S, Jergas M, Gluer CC, Genant
Department of Radiology, University of California, San Francisco 94143-
0628, USA.

PURPOSE: To evaluate radiographic absorptiometry (RA) of the phalanges
in healthy women and in women with osteoporosis and to compare the
results of RA with those of dual x-ray absorptiometry (DXA) of the radius and
spine. MATERIALS AND METHODS: Thirty-two healthy premenopausal
women, 39 healthy postmenopausal women, and 35 postmenopausal
women with osteoporosis underwent RA of the phalanges and DXA of the
radius and lumbar spine. Pairwise comparisons, age-related bone losses,
and percentage decrements and Student t values for intergroup
discrimination were calculated. The ability to identify patients with
osteoporotic fractures was evaluated by using receiver operating
characteristic and age-adjusted logistic regression analyses. The diagnostic
agreement for osteoporosis was assessed with kappa statistics. RESULTS:
Findings from RA were correlated with those from spinal DXA (r = .56). The
annual bone losses in healthy women, as measured with RA, radial DXA,
and spinal DXA, were 0.47%, 0.47%, and 0.32%, respectively. Intergroup
percentage decrements and t values obtained with RA were comparable to
those obtained with radial and with spinal DXA. Receiver operating
characteristic analysis showed no statistically significant differences. The
odds ratios for RA, radial DXA, and spinal DXA were 2.1, 1.9, and 2.4,
respectively. The kappa scores were 0.44 for both RA versus radial DXA and
RA versus spinal DXA, and the score was 0.22 for radial DXA versus spinal
DXA. CONCLUSION: RA appears to be a useful technique for assessing
age- and menopause-related bone loss and for identifying women with
Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004 Osteoporos Int 1991 Oct; 2(1):34-8
Radiographic absorptiometry: a simple method for determination of
bone mass.

Cosman F, Herrington B, Himmelstein S, Lindsay R
Department of Medicine, Columbia University, New York, New York.

Bone mass measurements have been shown to be useful determinants of
the risk of development of osteoporotic fractures and may help identify
individuals who are most likely to benefit from both primary and secondary
prevention of osteoporosis. As standard bone density measurements are not
available to all physicians, there is a need for a fast, inexpensive, and widely
available technique to measure bone mass. Radiographic absorptiometry of
the phalanges requires only routine radiography with processing of the films
done at a special off-site laboratory. We performed a preliminary
investigation to see whether this simple technique could be used to predict a
low bone mass as defined by dual- and single-photon absorptiometry.
Correlations between radiographic absorptiometry. Correlations between
radiographic absorptiometry and the standard techniques were as good as
those among the standard techniques themselves (r = 0.58-0.9).
Radiographic absorptiometry measurements predicted low bone mass of the
lumbar spine and femoral neck with 90% and 82% sensitivity respectively. If
further evaluation supports these initial conclusions, radiographic
absorptiometry may be useful as a screening technique for primary care
physicians and in research settings where dual-photon or dual-energy X-ray
absorptiometry are impossible.
Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004 J Rheumatol 1996 Oct; 23(10):1734-8
Bone densitometry: comparison of dual energy x-ray absorptiometry to
radiographic absorptiometry.

Swezey RL, Draper D, Swezey AM
Arthritis and Back Pain Center, Santa Monica, California, USA.

OBJECTIVE: To assess the reliability and validity of radiographic
absorptiometry of middle phalanges when compared to dual energy x-ray
absorptiometry (DEXA) of the spine and hip as an indicator of osteoporosis.
METHODS: DEXA readings from the spine and femur were compared with
radiographic absorptiometry measurements obtained the same day in a
sample of 50 women (average age 63 yrs; range 23-86). RESULTS: Both
spine and femur DEXA scores were significantly correlated with radiographic
absorptiometry scores (R = 0.70 and 0.68, respectively; approximate
standard errors 0.08). DEXA scores were used as the standard, defining
moderate fracture risk by a standardized t score < -2 and marked risk by t < -
3. Using cutpoints of t < -2 for DEXA and t < -3 for standardized radiographic
absorptiometry values, the sensitivity to osteopenia was 0.62 for DEXA of the
spine and 0.63 for DEXA of the femur, with specificities of 0.90 and 0.96,
respectively, at these cutpoints; the corresponding false positive and false
negative rates for our cohort of women were 0.19 and 0.24 (spine) and 0.07
and 0.24 (femur). Receiver operating characteristic (ROC) curves were
plotted, varying DEXA measurement site from spine to femur and
standardized cutoff from -2 to -3; the areas under the resulting ROC curves
ranged from 0.82 to 0.91. CONCLUSIONS: Radiographic absorptiometry
holds promise as a practical method for screening for osteoporosis.
Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004 Aging (Milano) 1998 Jun; 10(3):240-8
Instrumental diagnosis of osteoporosis.

Rossini M, Viapiana O, Adami S
Chair of Rheumatology, Valeggio Hospital, University of Verona, Italy.

Considerable progress in the development of methods for assessing the
skeleton now makes it possible to detect osteoporosis non-invasively and
early. There is a variety of techniques available at present: single-photon
(SPA) and single X-ray absorptiometry (SXA), dual-photon (DPA) and dual
X-ray absorptiometry (DXA), quantitative computed tomography (QCT),
radiographic absorptiometry (RA), and quantitative ultrasound (QUS), and
their development has certainly been driven by the need to overcome the
inherent shortcomings of plain radiography for this purpose. Both SPA and
SXA methods make a quantitative assessment of the bone mineral content
(BMC) or density (BMD) at peripheral sites of the skeleton possible. Single
energy measurements are not possible at sites with variable soft tissue
thickness and composition, i.e., the axial skeleton. For these purposes, DPA
and DXA techniques were introduced. The main advantages of an X-ray
system over a radionuclide system are shortened examination time, greater
accuracy and precision limited to higher resolution, and removal of errors due
to source decay correction. Low radiation dose, availability, capacity to
evaluate multiple sites, and ease of use have made DXA the most widely
used technique for measuring bone mineral density. QCT can determine the
true volumetric density of trabecular or cortical bone in three dimensions at
any skeletal site. Recently developed new computer-assisted methods have
improved RA precision, thus providing a simple and inexpensive technique
for screening of bone mineral status of large populations. QUS was reported
to provide information regarding the structural characteristics of bone, which
may be relevant to the appearance of osteoporotic fractures; indeed, some
studies suggest a relationship between QUS and bone strength beyond that
which can be explained by BMD. Recent experimental studies suggested
that magnetic resonance might also constitute a promising tool for assessing
Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004 Calcif Tissue Int 2000 Jan; 66(1):1-4
The relationship between phalangeal bone density and vertebral

Versluis RG, Petri H, Vismans FJ, van de Ven CM, Springer MP, Papapoulos

Department of General Practice, Leiden University Medical Centre, PO-box
2088, 2301 CB Leiden, The Netherlands.

Radiographic absorptiometry (RA) of the phalanges is a convenient and
reliable technique for measuring bone mineral density (BMD). It needs only a
radiograph of the hand, which can be sent for evaluation to a central facility,
whereas other techniques require specialized equipment. We assessed the
relationship between RA measurements and the presence of vertebral
deformities in a population-based cohort of postmenopausal women, and to
compare the results with simultaneously obtained BMD of the hip by dual-
energy X-ray absorptiometry (DXA). A total of 389 women aged 55-84 (mean
age 67.2 years, SD 8.7) were randomly selected from a large general
practice. RA, DXA of the hip, and vertebral deformities in the lateral spine X-
rays by vertebral morphometry were assessed. Thirty-eight women (9.8%)
had severe (grade II) vertebral deformities, and their BMD at the phalanges
and femoral neck was significantly lower than that of women without severe
vertebral deformities. Odds ratios for the presence of severe vertebral
deformities of 1.5 (95% CI: 1.1-2.1) for RA and 1.3 (95% CI: 0.9-1. 9) for
DXA, together with similar receiver operating characteristics curves, were
found using age-adjusted logistic regression. Phalangeal BMD is related to
vertebral deformities at least as closely as BMD of the femoral neck BMD.
RA may therefore help to evaluate fracture risk, especially if no DXA
equipment is available.
Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004 J Clin Densitom. 1998 Jan; 1(3):259-68.
Perspective on Fracture Risk and Phalangeal Bone Mineral Density.

Wasnich RD
Clinical Professor of Medicine, Hawaii Osteoporosis Center, Honolulu, HI

Current bone mineral density (BMD) represents the composite, cumulative
effect of many past and present risk factors, including both genetic and
lifestyle influences. Reduced BMD, increasing age, and the presence of pre-
existing fractures independently increase the risk of osteoporotic fracture.
BMD is the most clinically useful of these indicators.
Assessment of phalangeal BMD by dual-energy X-ray absorptiometry (DXA)
or radiographic absorptiometry (RA) has been shown to provide long-term
value in predicting the risk of both hip and spine fracture. Data from
phalangeal BMD measurements may be most valuable to the patient if they
are used to compute the patient’s remaining lifetime fracture probability
J Bone Miner Res 2003 Sep; 18(S2):S116
A Pilot Study of the Use of Radiographic Absorptiometry in the
Measurement of Cortical and Trabecular Phalangeal Bone Mineral
Density in Chinese Men and Women.

Z. H. Liu1, X. Bi2, L. Aldayeh2, S. Silverman3
1. Osteoporosis Committee of China Gerontological Society, Beijing, China,
2. CompuMed, Inc., Los Angeles, CA, USA,
3. OMC Clin Res Ctr, Beverly Hills, CA, USA.

Radiographic Absorptiometry (RA) automatically measures volumetric BMD
in the 2nd, 3rd, and 4th middle phalanges. A study was conducted to
investigate the ability of RA to separate cortical and trabecular phalangeal
BMD, offering an inexpensive and safer alternative to QCT. The study was
Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004 conducted using X-rays from RA tests of 556 patients. These x-rays were analyzed to compare the rate of decline of cortical, trabecular and total phalangeal BMD. A normal Chinese population with no known osteoporosis or arthritis, of ages 10 to 89, with 277 male and 279 female were considered for the study. A two view standard AP x-ray was acquired for the non-dominant hand of each volunteer with an aluminum reference wedge placed near the hand. Based on the OsteoGram R technology (CompuMed Inc, Los Angeles, CA), which applies RA, a customized module has been developed to perform automated bone tissue segmentation isolating three distinct areas in each phalanx: 1. An axial cylinder, 2.2x2.2 m.m. in size, in the middle of the distal trabecular zone 2. An axial cylinder, 2.2x2.2 m.m. in size, in the middle of the proximal trabecular zone 3. A tube segment in middle of the phalanx that includes the cortical tissue and excludes the central non-cortical tissue. The module performed BMD assessments in the cortical and the two trabecular areas in addition to the standard total phalangeal BMD. Considering the two radiographic views for each volunteer's hand and the three bones in each view, the unsupervised automated algorithm properly segmented the trabecular and cortical areas with a success rate of 90% for male and 92% for female. Time courses of unadjusted BMD results showed peaks in the age range of 25-35. Using linear regression analysis the rate of BMD loss was calculated in BMD-AU (Arbitrary Units) per year for all subjects 35 years and older. For males, BMD decreased at the same rate in both trabecular and cortical tissues (~ -0.3), where as total BMD decreased at a higher rate (~ -0.5). For females, trabecular BMD decreased at a slightly higher rate than male (~ -0.4). However, cortical BMD decrease was much higher and close to total BMD decrease at the rate of -1.0. Further development of the module will investigate applying cortical thickness measurements. We believe that adding cortical and trabecular measurements to the RA BMD report could provide useful information to assist clinicians in providing better osteoporosis care. Abstracts of Selected Peer-Reviewed Scientific Papers & Conference Proceedings 1991-2004 J Bone Miner Res 2004 Oct; 19(S1):S125
Radiographic Absorptiometry (RA) Assessment of Bone Mineral
Density Using a CR-based System Compared to the Film-based System.

M. Greenwald1, L. Al-Dayeh2, X. Bi2, S. L. Silverman3
1. Desert Medical Advances, Palm Desert, CA, USA,
2. CompuMed, Los Angeles, CA, USA,
3. UCLA, Los Angeles, CA, USA.

Phalangeal BMD assessment using Radiographic Absorptiometry (RA) by
means of scanning standard hand radiographs has been in use for years. It
is a reliable and inexpensive method for assessing peripheral BMD with high
predictability of future fracture risk of the hip and spine. With the recent
development and availability of digital radiography platforms, i.e., Computed
Radiography (CR), Direct Radiography (DR) and Picture Archiving and
Communications Systems (PACS), there exists a need for a reliable Digital
Imaging and Communications in Medicine (DICOM) compliant BMD method,
such as a DICOM-based RA. This study reports the comparison of BMD
results between a DICOM-based RA system that utilizes a CR device
(ACLxy, Orex, Yokneam, Israel) and a standard film-based RA system.
The 45 Caucasian and Asian volunteers between the ages of 50 to 81
participated in this study. Two consecutive x-rays of the non-dominant hand
were acquired for each volunteer, one using a standard film and another
using a CR cassette. The standard films were scanned using a flatbed
scanner at the resolution of 254 dpi matching the CR resolution. The CR
cassette was read at its native resolution of 254 dpi. The images of both x-
ray platforms were analyzed for RA results using the OsteoGram®
(CompuMed, Inc., Los Angeles, CA) software which performs automated RA
Regression analysis of the results showed a significant (p<0.001) Pearson
correlation coefficient of 0.98, between a DICOM-based RA system and a
film-based RA system.
We conclude that BMD may be measured using RA on a digital x-ray
platform. The availability of DICOM-compliant RA may help improve access
to BMD testing in settings where central DXA is not available.


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