During the last twenty-five years, there has been increasing interest within the

orthopaedic community in the noninvasive measurement of the bone-mineral content of various

regions of the skeleton. This interest has been stimulated, in part, by the recognition and
understanding that conventional radiographs are neither sensitive nor accurate for the diagnosis
of early bone loss. It has been reported, for example, that a reduction in bone-calcium content
must exceed 30 percent to be observed with certainty on conventional radiographs1. In addition,
factors including radiographic technique and positioning of the patient lead to variability in
radiodensity and affect the accuracy of conventional radiographs.
Bone densitometry originally was developed to aid in the diagnosis and treatment of the
so-called boneloss syndromes, especially osteoporosis71. Current methods include radiographic
absorptiometry, single-energy x-ray absorptiometry, dual-energy x-ray absorptiometry,
quantitative computed tomography, and quantitative ultrasound. All of these modalities are
relatively safe and allow good accuracy and precision of measurement. Bone densitometry has
far-reaching implications for orthopaedic practice, in terms of both diagnosis and treatment.
Diagnostically, one of the major applications is in the evaluation and management of patients
who have osteoporosis, as this technology allows an assessment of the risk of fracture as well as
the quantity of bone before pharmacological treatment or operative intervention.
Bone densitometry also allows an evaluation of periprosthetic bone-remodeling after total
hip arthroplasty. This information has been shown to be useful in research protocols for
evaluation of the response of the proximal aspect of the femur to the altered strain environment
imposed by the implant21,23,48. Clinically, periprosthetic measurements may allow the
detection of bone-remodeling that is not otherwise apparent because of the limited sensitivity of
radiographs. In this article, the basic principles of bone densitometry are reviewed, the different
modalities available for the measurement of bone-mineral content are described, and the existing
data on how information obtained from these measurements can be used to manage patients who
have bone disease or who have had a total hip arthroplasty are summarized.
Basic Principles and Technical Considerations
The unit of measurement for bone densitometry is bone-mineral content, expressed in
grams. Although the instrumentation varies with different modalities, all record the attenuation of
a beam of energy as it passes through bone and soft tissue. The energy originates from gamma
rays from either isotope sources or x-ray tubes. Quantitative computed tomography is the only
odality that allows the direct measurement of volumetric density, expressed as grams per cubic
centimeter. When other techniques are used, the values for bone-mineral content may be
converted into areal bone-mineral measurements (that is, bone-mineral density, expressed as
grams per square centimeter) by dividing the bone-mineral content by the area that is scanned11.
As a result, comparisons of results are necessarily limited to bones of equal shape, which
assumes a constant relationship between the thickness of the bone and the area that is scanned.
Moreover, the measurements are strictly skeletal-sitespecific; thus, individuals can be compared
only when identical locations in the skeleton are studied.
Radiographic Absorptiometry
Radiographic absorptiometry is a technique for measuring radiographic density with use
of standardized radiographs of peripheral sites, most commonly the hand or the heel. This
method requires that the personnel in a standard radiology facility follow a simple protocol for

making two radiographs for example, of the fingers of the hand at different radiographic
energies and with use of an aluminum reference wedge. A single radiograph is made with use of
direct-exposure settings (Fig. 1). The radiograph then is mailed to a central reading facility,
where the image is captured electronically with use of a high-resolution video camera and is
analyzed to determine the mean density of the middle phalanges of the second, third, and fourth
fingers.
The results are given in aluminum-equivalent values. The advantages of radiographic
absorptiometry include a relatively low cost and a lack of a need for specialized equipment15.
Radiographic absorptiometry has been used mostly by primary-care physicians as a screening
technique for the diagnosis of osteoporosis. It is less expensive and more widely available than
other bone-densitometry techniques such as dual-energy xray absorptiometry and quantitative
computed tomography. n addition, it has been shown to be both precise and accurate for
obtaining bone-mineral-content measurements of the phalanges of the hand80. Yang et al., in a
study of cadavera, reported that the short-term precision error was small, with a coefficient of
variation of 1 percent for bone-mineral content, and the correlation between radiographic
bsorptiometry determinations of bone-mineral content in the hand and dual-energy x-ray
absorptiometry measurements of bone-mineral content in the forearm was good (r = 0.887)80. A
significant correlation between bone-mineral content as determined by radiographic
absorptiometry and the ash weight of the bones also was reported (r = 0.983)80. The major
disadvantage of radiographic absorptiometry is that, because the measurements are sensitive to
changes in the overlying soft tissues, the technique is limited to the appendicular skeleton.
Single-Energy X-Ray Absorptiometry
Single-energy x-ray absorptiometry is a technique for measuring the bone-mineral
content of the appendicular skeleton (usually the distal aspect of the radius or the calcaneus). A
collimated photon beam is directed from an x-ray source through the measurement site. The
photon attenuation of the beam by bone then is measured and converted to bone-mineral content
with use of a known standard.
Single-energy x-ray absorptiometry is commonly used because it is relatively simple to
perform and the total dose of radiation to the body is negligible. Single-energy x-ray
absorptiometry has largely replaced single-photon absorptiometry, an earlier version of this
technique that used a photon source and emitted much more radioactivity. The major
disadvantage of singleenergy x-ray absorptiometry is that it is restricted to the appendicular
skeleton. The measurements correspond well with the status of the peripheral long bones but
poorly with that of the axial skeleton68.
Dual-Energy X-Ray Absorptiometry
Dual-energy x-ray absorptiometry, which was introduced in 1987, is currently the most
widely used modality for the clinical measurement of bone-mineral content12. Together with
single-energy x-ray absorptiometry and single-photon absorptiometry, this technology has
replaced dual-energy photon absorptiometry. Specifically, the x-ray tube used in dual-energy xray absorptiometry has replaced the radionuclide source employed in dual-energy photon
absorptiometry. Compared with dual-energy photon absorptiometry, dual-energy x-ray
absorptiometry requires less time for the examination, is more reproducible, and involves less
exposure to radiation. With this technique, the x-ray tube emits an x-ray beam, the attenuation of

which is detected by an energy discriminating photon-counter. The x-rays are generated either by
an energy-switching system (Hologic, Waltham, Massachusetts) or by rare-earth-filtered x-ray
sources (Lunar, Madison, Wisconsin, or Norland, Fort Atkinson, Wisconsin). An energyswitching system is produced by rapidly switching the x-ray potential between two energies
synchronously with line frequency, resulting in rapid pulses of different frequencies and different
energy levels.
Filtered x-ray systems use different effective energies that are emitted simultaneously.
The output from constant potential x-ray generators is passed through a rare-earth filter with
specific absorption characteristics, resulting in energy output at different levels of voltage.
Perhaps the major advantage of an x-ray source compared with a radioisotope is the greater
intensity, which greatly improves precision and accuracy. The photon flux produced by an x-ray
source with a mean tube current of one milliampere is 500 to 1000 times greater than that
produced by a one-curie gadolinium-153 source used in standard dual-photon absorptiometry
systems66. Dual-energy x-ray absorptiometry provides bonemineral measurements both axially
and peripherally47,77 as well as total-body scans. Scans of the spine and the femur can be
performed in approximately one minute and two minutes, respectively, and total-body scans
require approximately four minutes. The dose of radiation is so low (0.5 to 5.0 microsieverts) as
to be essentially unimportant9; hence, there is no need to shield either the patient or the
personnel who operate the equipment2.
High-resolution images are produced54,66; consequently, the precision and the accuracy
are excellent (0.5 to 2 percent and 3 to 5 percent, respectively54,73). Thus, dualenergy x-ray
absorptiometry can be used to detect small changes in bone-mineral content at multiple
anatomical sites, with little exposure to radiation, short examination times, and excellent
precision, accuracy, and resolution5,67,76. A major disadvantage of the technique is that it does
not enable the examiner to differentiate between cortical and trabecular bone.
Recently, new software has made it possible to evaluate bone-mineral content in the
forearm and the calcaneus with use of standard dual-energy x-ray absorptiometry
equipment30,79. Yamada et al. reported that assessment of the bone-mineral density of the
calcaneus with dual-energy x-ray absorptiometry revealed substantially lower measurements in
women who had osteoporosis compared with those in a control population of women who did
not have osteoporosis79. Those authors concluded that assessment of the bone-mineral density of
the calcaneus with dual-energy x-ray absorptiometry can be useful for predicting the risk of
fracture of the femoral neck, intertrochanteric fracture, or fracture of the spine, particularly when
other methods are not available. Compared with quantitative computed tomography, dual-energy
x-ray absorptiometry has superior precision, is less expensive, and is associated with lower
absorbed doses of radiation.
Quantitative Computed Tomography
Quantitative computed tomography is another modality that can be used to measure bonemineral content. This technique involves the use of a mineral calibration phantom in conjunction
with a computed tomography scanner. The vertebral body is the usual site of measurement. The
phantom (a reference source used to calibrate measurements of bone density) usually consists of
hydroxyapatite in plastic that is scanned simultaneously with the vertebrae. A lateral computed
tomography scan localizes the mid-plane of two, three, or four lumbar vertebral bodies.
Quantitative readings are then obtained from a region of trabecular bone in the anterior portion
of the vertebra (Figs. 2-A and 2-B). The computed tomographic determinations of vertebral bone

density are compared with known density readings of solutions in the phantoms. The
measurements of the vertebrae are then averaged, and a commercially available software
package is used to convert Hounsfield units (provided by standard computed tomography
scanners) to bone-mineral equivalents. A Hounsfield unit is a measure of x-ray attenuation for
computed tomography scans in which each pixel is assigned a value on a scale, with air being
equivalent to 1000; water, to 0; and compact bone, to +1000.
Quantitative computed tomography has several theoretical and practical advantages
compared with other techniques for the evaluation of bone-mineral content. First, it is the only
method available that allows separate assessments of trabecular and cortical bone areas; in fact, it
may be used to measure cancellous bone, cortical bone, or an integrated sum of both7,28,36,65.
Furthermore, it is the only currently available modality that allows the direct
measurement of a volume of bone, which can be expressed directly as density (grams per cubic
centimeter). With other instruments, the density of the region of interest is calculated by dividing
the bone-mineral content (grams) by the area that is scanned (square centimeters) and then is
expressed as grams per square centimeter. Thus, quantitative computed tomography provides the
examiner with an accurate measure of the three-dimensional geometry of bone and, specifically,
its trabecular component. Finally, quantitative computed tomography can be performed with use
of standard computed tomography systems, which are available in most hospitals and radiology
offices7. Most manufacturers provide a quantitative computed tomography option with their
operating systems.
The principal disadvantage of quantitative computed tomography is that it exposes the
patient to a higher dose of radiation than do other bone-densitometry techniques. The dose of
radiation with modern quantitative computed tomography has been reported to be approximately
twenty-nine microsieverts37, whereas the dose with a typical dual-energy x-ray absorptiometry
scan of the hip ranges from 0.5 to 5.0 microsieverts and that with radiography of the chest is fifty
microsieverts9,37.
Quantitative computed tomography is available in both single-energy and dual-energy
modalities. The single-energy technique offers better reproducibility and is most commonly
recommended and widely indicated. However, standard single-energy computed tomographic
analysis of the lumbar spine fails to account for increases in bone-marrow fat concentration that
occur with increasing age45,53. As a result, measurements in elderly, osteoporotic individuals
may be falsely decreased by 20 to 25 percent. In part to address these concerns, dual-energy
quantitative computed tomography was developed. The accuracy error is reportedly decreased
with dual-energy computed tomography, but the dose of radiation is higher than that with the
singleenergy modality7.
In general, densitometry techniques can be performed in either the axial or the
appendicular skeleton. Peripheral measurements, performed in the appendicular skeleton, help to
predict the risk of fracture; however, they are less sensitive for the monitoring of therapy than are
measurements in the axial skeleton because changes due to age, therapeutic intervention, and
estrogen deficiency occur less rapidly in appendicular bone than they do in the axial skeleton.
Peripheral quantitative computed tomography systems originally used a nuclear energy source;
however, newer systems use an x-ray source.
The technique requires a special computed tomography unit with a small circular
gantry31,64. The principal advantage of this technique is the ability to investigate separately the
mineral contents of cortical and trabecular bone with use of a cross-sectional x-ray image that

localizes the site to be studied. Again, the measurements are expressed as apparent density in
grams per cubic centimeter.
The most commonly studied appendicular site is the distal aspect of the radius49. Perhaps
the major advantage of quantitative computed tomography scanning of the appendicular skeleton
is that it delivers a lower dose of radiation than does conventional computed tomography. To this
end, a low-radiation-dose gamma-ray computed tomography scanner was developed for the
measurement of the trabecular and cortical bone-mineral content of the distal aspect of the
radius33,72. The dose of radiation associated with this procedure is typically 0.4 microsievert to
the skin34. An additional, theoretical advantage is that bone strength at the tissue or organ level
can be determined, and this may ultimately prove to be of practical value.
Quantitative Ultrasound
The use of ultrasound for the measurement of bone density recently has received
widespread attention because it involves no radiation, is relatively simple to implement and
process, is portable, and is inexpensive. Some investigators have suggested that quantitative
ultrasound, in contrast to other bone-densitometry methods that measure only bone-mineral
content, can measure additional properties of bone such as mechanical integrity39,75. The most
accessible sites for ultrasound measurement are the calcaneus and the patella, and, to a lesser
extent, the radius, tibia, and phalanges.
Ultrasound assessment of bone is based on the velocity and attenuation of an ultrasound
wave, as determined by a pair of coaxially aligned transducers. An ultrasound signal, generated
by one transducer, is sent through the bone. A second (receiver) transducer detects the ultrasound
wave as it emerges from the bone. This technology assumes that bones with different
biomechanical properties have different ultrasounddetermined values for attenuation and
velocity39,75. Specifically, propagation of the ultrasound wave through bone is affected by bone
mass, bone architecture, and the directionality of loading.
Quantitative ultrasound measurements as a means for assessing the strength and stiffness
of bone are based on the processing of the received ultrasound signals. The speed of sound and
the ultrasound velocity both provide measurements on the basis of how rapidly the ultrasound
wave propagates through the bone and the soft tissue. Newer ultrasound-imaging devices create a
parametric image of broadband ultrasound attenuation at the calcaneus46,63. This is a measure
of the increase in attenuation of the ultrasound wave as a function of increasing frequency. Roux
et al. reported that broadband ultrasound attenuation at the calcaneus was highly associated with
local bone-mineral content and was also associated with bone-mineral content in the lumbar
spine and the femur63. The precision of this technique was 1.4 to 3.3 percent. Roux et al. noted
that parametric imaging enhanced the reproducibility of ultrasound measurements of the
calcaneus. However, the value of the technique with regard to the prediction of future fracture
requires additional investigation.
The values obtained with use of quantitative ultrasound have been shown to correlate
with those obtained with use of standard bone-densitometry techniques such as dual-energy x-ray
absorptiometry. At the calcaneus, quantitative ultrasound and dual-energy x-ray
absorptiometrymeasurements have been shown29 to have a correlation of approximately 0.80 to
0.85. This high correlation led the United States Food and Drug Administration to recommend
that quantitative ultrasound be used clinically.
Clinical Indications for the Use of Bone Densitometry

Many factors that can lead to a decrease in bone mass have been identified. As a result,
numerous potential indications for bone densitometry have been proposed. However, there are
insufficient data to justify routine screening with use of this technique. Recently, the Health Care
Financing Administration defined five diagnostic categories that it considers to be indications for
the use of bone densitometry32. These categories include estrogen deficiency in women at
clinical risk for osteoporosis, evidence of vertebral abnormalities, long-term glucocorticoid
therapy, a diagnosis of primary hyperparathyroidism, and the need for monitoring in order to
assess the response to or the efficacy of an approved drug therapy for the treatment of
osteoporosis.Congress passed legislation requiring Medicare to reimburse for the cost of both
performing and interpreting the examination for individuals in these diagnostic categories.
Use of Bone-Mineral Data for the Management of Patients Who Have Osteoporosis
Osteoporosis is a pathological condition of bone that is characterized by decreased bone
mass and increased risk of fracture13,38. It is well accepted that bone-mineral content and bonemineral density are associated with bone strength10,24,56,57. In addition, it has been shown that
most fractures in elderly individuals are related, at least in part, to low bone mass69. Thus,
measurements provided by bone densitometry are important for assessing bone strength and the
corresponding risk of fracture8,25,61,62. Fracture of the proximal aspect of the femur is perhaps
the most serious consequence of osteoporosis. Approximately 250,000 such fractures occur in the
United States each year, resulting in annual health-care costs of more than 8.7 billion dollars60.
The risk of fracture of the proximal aspect of the femur is associated with advancing age and is
more common in women. One of every six white women in the United States will sustain such a
fracture, and as many as 20 percent will die as a result16.
Because of the devastating medical and economic impact of these fractures, the hip is a
major site of interest for the information provided by bone densitometry. The ability to predict an
individuals risk of sustaining a fractureof the proximal aspect of the femur, and the subsequent
initiation of prophylactic measures to avoid this occurrence, is one of the most important
applications of this technology. Bone-densitometry measurements can be used to help to identify
individuals who are at risk for fracture and to stratify that risk62. The probabilities of fracture of
the proximal aspect of the femur, the vertebrae, the radius, and the calcaneus have all been
shown to be predictable on the basis of bone densitometry3,17,18,27,35,43,55,59.
Some studies have indicated that information regarding bone-mineral content at any
anatomical site is equally valuable for predicting the risk of fracture in general3,55; however,
other studies have suggested that measurements obtained at a particular site of interest may
provide the most important information for the prediction of fracture at that site18. Bone
densitometry also has been used to analyze subtle morphological differences in the anatomy of
the proximal aspect of the femur between individuals. Such analysis includes measurement of the
length of the hip axis (the length along the axis of the femoral neck from a point distal to the
lateral aspect of the greater trochanter, along the femoral neck, and to the inner pelvic brim),
measurement of the femoral neck-shaft angle, and measurement of the width of the femoral neck
at its mid-portion. Faulkner et al. performed dual-energy x-ray absorptiometry scans in white
women in an at- tempt to predict the risk of subsequent fracture of the femoral neck or
intertrochanteric fracture26. The precision error of measurement of the hip axis was less than 1
percent. Those investigators reported that the length of the hip axis predicted fracture
independently of bone-mineral density, age, weight, or height. A hip-axis length that was one
standard deviation greater than the mean was associated with a twofold increase in the risk of

subsequent fracture of the femoral neck or intertrochanteric fracture. Moreover, each decrease in
the standard deviation for the bone-mineral density increased the risk of fracture by a factor of
2.7. No association was found between the risk of fracture and the diameter of the femoral neck
or the neck-shaft angle26.
Although we consider these data to be important, we believe that the length of the hip
axis is only one of many independent risk factors for fracture of the proximal aspect of the femur.
Finally, bone densitometry may be useful in the preoperative evaluation of osteoporotic patients
when the success of an operation may depend on the quality and quantity of the bone. For
example, patients who have indications for internal fixation of a fracture or for procedures such
as spinal arthrodesis may be candidates for bone densitometry. In these instances, a preoperative
assessment of bone-mineral content may help to identify the necessity for enhancement of
existing bone mass, augmentation of a fusion mass, internal fixation, or, alternatively,
consideration of other procedures. However, such a use for bone densitometry has not yet been
studied extensively, and data to help the physician to determine directly which individuals would
or would not benefit from operative intervention are not available.
Interpretation of a Bone-Densitometry Report
A standard bone-mineral report consists of measurements expressed as bone-mineral
content (the amount of hydroxyapatite, in grams) and converted to areal density (grams per
square centimeter) within the region of interest. In addition, normal values are provided
according to gender and race and are plotted according to age. Demographic data, including the
clinical indications and the patients age, gender, race, weight, and height, also are listed (Figs. 3A and 3-B). In order to interpret a standard bone-mineral report, a region of interest must be
selected. In order to compare individuals, the sites of measurement should be constant because
the bone-mineral content may vary between different bones and between different regions of the
same bone.
In order to avoid error based on differences in patientsheights, it is important that the
region of interest be an anatomical region, such as a percentage of the total length of the bone,
and not a region of fixed length. The results are compared with normative values, and standard
curves of normative values are provided for individuals of both genders and several races.
Comparison of measured values with mean values for normal young or age-matched individuals
permits an assessment of the risk of fracture.
Both a Z score and a T score are determined for each record to help in analyzing the
results. The Z score is used to compare the patients bone-mineral density with the mean value
for individuals of the same age. A low Z score indicates an etiology other than age-related bone
loss. The Z score is calculated by subtracting the patients result from the mean value for agematched controls and dividing this value by the standard deviation of the mean. Therefore, by
definition, the Z score is zero at the mean value for the population. The Z score is expressed as a
standard deviation. The T score is used to compare the patients bone-mineral density with the
mean value for young adults of the same gender and race. Like the Z score, it is expressed as a
standard deviation. It is calculated by dividing the difference between the patients result and the
mean value for normal young adults by the standard deviation of the mean.
The T score is used for the diagnosis of low bone mass or osteoporosis. The World Health
Organization recently published a document in which it attempted to clarify definitions and to
assist clinicians in their interpretation of bone-densitometry results78. According to that report, a
normal value for bone-mineral content is within one standard deviation of the mean value for

young adults of the same age and gender (that is, the T score is more than 1). Osteopenia is
considered to be present when the value for bone-mineral content is more than one standard
deviation but not more than 2.5 standard deviations below the mean for young adults (that is, the
T score is less than 1 and more than 2.5). Osteoporosis is considered to be present when the
value is more than 2.5 standard deviations below the mean bonemineral content for young adults
(that is, the T score is less than 2.5). Severe osteoporosis is considered to be present when the
value for bone-mineral content is more than 2.5 standard deviations below the mean for young
adults and there is at least one so-called fragility fracture (a fracture assumed to be associated
with osteoporosis because it occurred as a result of slight trauma).
Physicians should initiate therapy to reduce the risk of fracture in patients on the basis of
the presence or absence of risk factors for osteoporosis19. For white women, those risk factors
include a maternal history of fracture of the proximal aspect of the femur, a previous fracture of
any type after the age of fifty years, a tall height at the age of twenty-five years, fair or poor
health (as rated by the woman), previous hyperthyroidism, treatment with long-acting
benzodiazepines or anticonvulsant drugs, excessive intake of caffeine, a duration of less than
four hours per day on the feet, an inability to rise from a chair without use of the upper
extremities, poor depth perception, poor contrast sensitivity, tachy cardia at rest, and low
calcaneal bone density19. Therapy should be initiated to reduce the risk of fracture in women
who have a bone-mineral-density T score of less than 2 in the absence of risk factors and in
those who have a T score of less than 1.5 if other risk factors are present. Pharmacological
treatment should be offered to all individuals especially women older than the age of seventy
years59 with risk factors who are seen with a fracture of the proximal aspect of the femur or a
vertebral fracture.
The therapeutic options for patients who have osteoporosis include hormone-replacement
therapy, bisphosphonates (currently, only alendronate has been approved for marketing by the
Food and Drug Administration for use in the treatment of osteoporosis), selective estrogenreceptor modulators (currently, only raloxifene has been approved for marketing by the Food
and Drug Administration for use in the treatment of osteoporosis), and calcitonin.
Bone Densitometry for the Evaluation of Periprosthetic Remodeling of Bone After Total Hip
Arthroplasty
Total hip arthroplasty alters the strain environment in the proximal aspect of the femur,
and the resultant effects on bone-remodeling lead to a redistribution of bone mass adjacent to the
prosthesis. This sometimes results in substantial and progressive bone loss that is characterized
by extensive resorption in the remodeled femur, with the greatest mean decrease in bone-mineral
content occurring adjacent to the proximal one-third of the femur22,23,44,48,52. Although
osteolysis associated with wear debris has been implicated as the dominant etiology of
periprosthetic bone loss, stress-shielding also has been suggested as a cause of the observed
changes44,52.
The evaluation and quantification of periprosthetic bone-remodeling is important
clinically, as mechanical loosening of the implant is the most frequently reported complication of
total hip arthroplasty51. Resorption of bone from the proximal aspect of the femur is an
important factor contributing to failure of total hip implants that have been inserted either with or
without cement. Prosthetic loosening or subsidence, and fracture of the femur or the prosthesis,
are associated with bone loss6,14,74. Consequently, an accurate assessment of progressive
quantifiable changes in periprosthetic bone-mineral content may help the treating surgeon to

determine when to intervene in order to preserve bone stock for revision arthroplasty. This
information is also useful to manufacturers in their efforts to redesign and improve implants, and
it gives physicians a means of determining when an unfavorable situation may be developing in a
prosthetic system. In the future, pharmacological agents may be used to inhibit progressive bone
loss70, and bone densitometry may be useful in determining when and how to use these drugs.
Dual-energy x-ray absorptiometry has been used to assess the bone-mineral content of the
proximal aspect of the femur in vivo4,22,40,44,48,50,52. The use of special software supplied by
the manufacturer of the device enables the magnitude of the loss (or gain) of periprosthetic bone
to be determined. Furthermore, dualenergy x-ray absorptiometry requires only a small volume of
bone and thus is appropriate for the evaluation of an osteoporotic femoral shaft adjacent to a
prosthesis that has been inserted with or without ce ment. Dual-energy x-ray absorptiometry
software also allows analysis of regional percentage variations in bone-mineral content over the
length of the proximal aspect of the femur. The entire femoral component, as well as surrounding
bone and soft tissue, may be included in an anteroposterior scan. Local soft-tissue density may
be subtracted from the scan with use of a standardized soft-tissue baseline value. Areas of the
scan in which the x-ray beams are attenuated by the implant also may be subtracted (Fig. 4).
Dual-energy x-ray absorptiometry provides both the accuracy and the precision that are
necessary to detect and to quantify changes in bone that occur after total hip arthroplasty4042,50,54. Error attributable to nonuniform distribution of soft tissue or to observer bias is
virtually eliminated. Kiratli et al. found that dual-energy x-ray absorptiometry was accurate, with
an error of less than 1 percent, for the determination of bone-mineral content in patients who had
had a total hip arthroplasty42.
The precision error in vivo was 2 to 4.5 percent and was attributed mainly to variable
positioning of the patient and to the nonhomogeneous distribution of soft tissue42. In the clinical
setting, positioning of the patient is probably the most important variable. It is well established
that the initial bone stock in the femur has an important influence on the extent of boneremodeling22. Accordingly, some authors have advocated the use of dual-energy x-ray
absorptiometry for the routine preoperative analysis of bone-mineral content in order to predict
the change in bone mass after total hip arthroplasty, especially for patients who have poor bone
stock and those who are at risk for osteoporosis22.
However, the efficacy of dual-energy x-ray absorptiometry as a means for determining
whether or not cement should be used in an arthroplasty has not yet been demonstrated. There is
concern about the adverse effects of remodeling and subsequent mechanical loosening of
extensively porous-coated implants. Several investigators have used dual-energy x-ray
absorptiometry to quantitate the remodeling changes characteristic of periprosthetic bone after
total hip arthroplasty without cement22,40,42,44,52. Engh et al. performed dual-energy x-ray
absorptiometry analyses of the femora obtained from five cadavera in which an anatomic
medullary locking prosthesis had been in situ for at least seventeen months before death22. The
contralateral, normal femur in each cadaver was used as a control. None of the contralateral
femora had sustained a previous fracture.
It is widely accepted that fractures cause permanent changes in bone-mineral content,
even remote from the fracture site. The largest decreases in bone-mineral content were noted at
the most proximal aspect of the remodeled femora. The percentage decrease in bonemineral
content also was inversely related to the corresponding bone-mineral content of the contralateral,
control femur. On the basis of these results, Engh et al. suggested that dual-energy x-ray
absorptiometry may be useful preoperatively for predicting the extent of bone-remodeling that

will occur after total hip arthroplasty. Several authors have noted that more extensively porouscoated femoral implants inserted without cement produce greater stress-shielding and more
marked bone resorption4,20,21,40. Kilgus et al. used dual-energy x-ray absorptiometry to
compare the bone-mineral content adjacent to a femoral implant that had been inserted without
cement with that of the normal, contralateral femur40. That study included forty-six patients who
had an extensively porous-coated implant and twenty-six who had a proximally coated implant.
The greatest decreases in bone-mineral content compared with the content in the controls
occurred in the most proximal one centimeter of the medial cortex around the extensively
porous-coated implants Bone-remodeling after total hip arthroplasty is most pronounced in the
first two postoperative years, after which time it continues at a much slower rate. Kiratli et al.,
using dual-energy x-ray absorptiometry, reported a rapid decrease in bone-mineral density in the
proximal aspect of the femur, compared with the immediate postoperative values, during the first
two years after total hip arthroplasty42. The density of both cortical and cancellous bone adjacent
to the proximal portion of extensively porous-coated implants was decreased. Engh et al. noted
that, although radiographic decreases in bone density continued for at least five years after
implantation, these changes were most marked during the first two years and subsequently
proceeded at a slower rate23.
In summary, dual-energy x-ray absorptiometry provides a precise and accurate means for
the evaluation of periprosthetic bone-remodeling after total hip arthroplasty. It can be performed
with use of a relatively small volume of bone. In addition, dual-energy x-ray absorptiometry
software allows the subtraction of surrounding soft tissue and metal implants. The literature
supports the use of this modality for evaluation of the magnitude and rate of changes in bonemineral content after total hip arthroplasty, particularly in patients in whom a femoral component
has been inserted without cement. This information may be useful to manufacturers, who must
evaluate the response of the bone to the implant in order to minimize any deleterious effects of
bone-remodeling. If current research on the use of antiosteoclastic drug regimens proves useful
in the management of patients who have an implant70, data on bone-mineral content may be
used to help guide treatment.
The efficacy of bone densitometry in the evaluation of the proximal aspect of the femur
before primary total hip arthroplasty has not been established.
Overview
Bone densitometry provides critical information about osseous integrity, the risk of fracture, and
periprosthetic bone-remodeling. Consequently, an understanding of this technology is important
in current orthopaedic practice. Proposed clinical indications for the measurement of bonemineral content have been based on both medical need and cost-effectiveness. Universal
screening for prophylaxis against osteoporosis and monitoring of bone-mineral content to assess
the efficacy of therapeutic intervention are not currently recommended uses for bone
densitometry. Perhaps the major value of bone densitometry in current orthopaedic practice is the
identification of patients with osteoporosis who are at increased risk for fracture. With the
numerous modalities that are available for measuring bone-mineral content, it is important for
the clinician to choose the proper technique and to interpret the information in a useful manner