Verfahren der quantitativen Knochenmessung in der Vorhersage des individuellen Frakturrisikos - Übersicht und neue Befunde

Zusammenfassung

Osteoporotische Frakturen stellen ein schwerwiegendes Gesundheitsproblem dar, von dem vor allem postmenopausale Frauen betroffen sind. Da wirksame Therapeutika verfügbar sind, mit welchen die Frakturrate effektiv gesenkt werden kann, stellt die nicht invasive Abschätzung des individuellen Frakturrisikos mit Methoden der quantitativen Knochenmessung eine wichtige Herausforderung in der Diagnostik dar, speziell auch in der Gynäkologie. Ziel der vorliegenden Übersichtsarbeit ist es, eine umfassende Darstellung osteodensitometrischer Methoden sowie ihrer Wertigkeit für die Vorhersage des individuellen Frakturrisikos zu geben.

Wir berichten über aktuelle epidemiologische Erkenntnisse zu den durch Osteoporose verursachten Frakturen. Es folgt eine technische Beschreibung der diagnostisch eingesetzten Röntgenprojektionsverfahren (DXA), Röntgenschnittbildverfahren (QCT und pQCT), quantitativer Ultraschallmethoden (QUS) und der Magnetresonanztomographie (MRT). Es werden retrospektive und prospektive klinische Studien zur Wertigkeit dieser Verfahren in Bezug auf die Vorhersage des Frakturrisikos referiert. Abschließend stellen wir die Ergebnisse aktueller, experimenteller Untersuchungen zur Abschätzung mechanischer Versagenslasten mit den unterschiedlichen Methoden der quantitativen Knochenmessung dar.

Wir schließen aus den vorliegenden Daten, dass die DXA (Zweienergie-Röntgenabsorptiometrie) nach wie vor als Referenzverfahren in der Diagnostik der Osteoporose zu betrachten ist. Eine Verbesserung durch Röntgenschnittbildverfahren konnte bislang nicht stichhaltig nachgewiesen werden. Der QUS stellt für den niedergelassenen Arzt ein attraktives diagnostisches Verfahren für die primäre Risikoeinschätzung dar. Die Messung ist auf das periphere Skelett beschränkt; in der klinischen Diagnostik sollte er umsichtig interpretiert und gegebenenfalls durch die DXA ergänzt werden. Weitere Fortschritte in der Einschätzung des Frakturrisikos erhofft man sich von Analysen der trabekulären Mikroarchitektur mit der hochauflösenden CT, pQCT und MRT sowie durch Computersimulationsverfahren. Diese Techniken sind Gegenstand aktueller Forschung.

Abstract

Osteoporotic fractures are a severe medical problem that dominantly affects postmenopausal women. Effective therapy for reducing fracture rates is available today and, therefore, non-invasive estimates of the individual fracture risk represent an important challenge for medical diagnostics. The objective of the current article is to comprehensively review methods for quantitative measurements of bone properties and their value in predicting individual fracture risk.

We report epidemiologic findings in the context of osteoporotic fractures and give a technical description of current diagnostic methods, including projectional X-ray techniques (DXA), tomographic X-ray techniques (QCT and pQCT), quantitative ultrasound (QUS), and magnetic resonance imaging (MRI). We summarize cross-sectional and prospective clinical trials and results of recent experimental findings in estimating mechanical failure loads, using different quantitative methods.

Based on the existing data we conclude that DXA continues to be a reference method for diagnosing osteporosis. No improvement has so far been demonstrated for tomographic X-ray techniques. QUS is an attractive diagnostic tool in private practice in primary risk evaluation. However, measurements are confined to the peripheral skeleton; they must therefore be interpreted with caution and may have to be supplemented by DXA. Further improvements in evaluating fracture risk may be achieved by analyzing trabecular microarchitecture with high resolution CT, pQCT and MRI, and by computer simulation techniques. These methods are the focus of current research.

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