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Rheumatology Advance Access originally published online on April 4, 2006
Rheumatology 2006 45(10):1273-1275; doi:10.1093/rheumatology/kel028
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© The Author 2006. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Quantitative ultrasonometry of the calcaneus in children with juvenile idiopathic arthritis

S. Kutilek, M. Bayer, P. Dolezalova and D. Nemcova

Department of Pediatrics, 1st Medical Faculty, Charles University, Prague, Czech Republic.

Correspondence to: S. Kutilek, Center for Clinical and Basic Research (CCBR), Kyjevská 40, 530 03 Pardubice, Czech Republic. E-mail: sk{at}ccbr.cz


   Abstract
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 Abstract
Introduction
 Patients and methods
 Results
 Discussion
 References
 
Objectives. To evaluate bone quality by means of quantitative ultrasonometry (QUS) in children with juvenile idiopathic arthritis (JIA).

Methods. Seventy children [37 with oligoarticular JIA, mean age (±S.D.) 10.54 ± 3.42 yr; and 33 with polyarticular rheumatoid factor negative JIA, mean age (± S.D.) 11.33 ± 2.88 yr] were enrolled. Quantitative ultrasonometry was measured on both heels with a Cuba Clinical portable device. Body height, weight and body mass index were recorded together with disease duration and cumulative dose of prednisone.

Results. The lowest QUS parameters were observed in children with polyarticular JIA (P< 0.001 and 0.01 when compared with reference data and oligoarticular JIA, respectively). In children with oligoarticular JIA, the QUS values were also significantly lower in comparison with the reference data (P< 0.002). The QUS parameters were strongly influenced by body height, and to a lesser degree by body weight. In children with polyarticular JIA, there were significant inverse correlations between QUS parameters and disease duration [r=–0.57, P< 0.01 for broadband ultrasound attenuation (BUA) and r = – 0.67, P< 0.01 for velocity of sound (VOS)]. Similarly, there were inverse correlations between QUS and cumulative dose of prednisone (r = – 0.48, P< 0.05 for BUA and r =– 0.50, P < 0.01 for VOS, respectively). Similar results were obtained when BUA and VOS were adjusted for height.

Conclusions. Disease duration and cumulative dose of prednisone in children with polyarticular JIA are risk factors of stunted growth and decreased QUS values of bone quality.

KEY WORDS: Quantitive ultrasound, Juvenile idiopathic arthritis, Bone quality


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Discussion
 References
 
Osteoporosis and growth delay are encountered in patients with juvenile idiopathic arthritis (JIA) as a result of disease activity and corticosteroid (CS) therapy [1, 2]. Previous reports have revealed low bone density in children with JIA, either evaluated by dual X-ray absorptiometry (DXA) or by quantitative ultrasound (QUS) of the calcaneus, radius, tibia or phalanges [3–8]. Our aim was to perform QUS of the calcaneus in children with JIA, and to relate its results to basic anthropometric parameters [height, weight, body mass index (BMI)] and to the disease duration and cumulative dose of CS.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Discussion
 References
 
Seventy children with JIA were enrolled: 37 children had oligoarticular JIA and 33 polyarticular rheumatoid factor-negative disease (Table 1) [9]. Informed consent, fully in accordance with the Declaration of Helsinki, was obtained from all study patients and/or their legal representatives prior to the study procedures. The design of the work fully conforms to standards currently applied in the Czech Republic. All children with ankle oedema or other low limb impairment that might interfere with the QUS measurement were excluded. The mobility status of the patients was not severely impaired, as all were community or neighbourhood walkers. Basic anthropometric parameters were collected in all subjects on the day of the QUS measurement. Body height was recorded to the nearest ±0.5 cm using a stadiometer; weight was measured on a calibrated scale to ±0.5 kg. The BMI was calculated using the equation BMI = weight (kg)/height2 (m).


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  		TABLE 1. Patient data

 
A Cuba Clinical (McCue Ultrasonics) dry ultrasound portable device was used to measure velocity of sound (VOS), expressed in m/s, and broadband ultrasound attenuation (BUA), expressed in dB/MHz. The VOS depends on the density and elasticity of the bone, while BUA is determined by bone density and by trabecular quality, spacing and orientation. The measurements were performed at both heels. For each individual, the mean values of BUA and VOS [(left heel + right heel)/2] were calculated to eliminate the possibility of significant intraindividual differences in QUS parameters on right and left foot as mentioned before [10]. Measurement precision, based on regular weekly phantom measurements, was expressed as coefficient of variation: 3.2% for BUA and 0.18% for VOS. To eliminate the influence of age, the body weight, body height, BMI, BUA and VOS were calculated as standard deviation scores (SDS) or Z-scores by the equation SDS = (actual individual value – mean value for age and sex) standard deviation for age and sex. Czech anthropometric parameters from a 1991 survey [11] and previously obtained QUS values of the healthy Czech paediatric population (206 boys and 203 girls, aged 5–18 yr) served as reference data. Furthermore, the BUA and VOS results were calculated as height-adjusted values with the use of height age-matched standards. Statistics were performed by t-test, ANOVA and linear regression analysis. For all results, a P value of <0.05 was required for statistical significance.


   Results
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 Abstract
 Introduction
 Patients and methods
 Results
Discussion
 References
 
The children with polyarticular JIA had significantly lower height and weight when compared with both the reference data and to the patients with oligoarticular JIA (Table 1). We found high and significant correlations between age- and height-matched BUA values (r = 0.83, P<0.05 for oligoarticular JIA and r = 0.85, P<0.05 for polyarticular JIA). Similar correlations were observed in VOS (r = 0.88, P<0.05 for both oligoarticular and polyarticular JIA). The lowest BUA and VOS values, either related to age- or height-matched standards, were observed in children with polyarticular JIA. In children with oligoarticular JIA, the BUA and VOS values were also significantly lower in comparison with the reference data (Table 1). There was a significant difference in QUS parameters between patients with polyarticular and oligoarticular JIA. This applied to height-adjusted values as well (Table 1). Furthermore, the values of BUA and VOS in children with polyarticular JIA treated with CS were significantly lower than BUA and VOS in children with either polyarticular JIA who were not treated with CS (P<0.003) or in children with oligoarticular JIA (P<0.002). There were no differences in the BUA and VOS between children with polyarticular JIA who were not treated with CS and those children with oligoarticular JIA also not treated with CS. Significant correlations were found between age-matched BUA and body weight or height in patients with either poly- or oligoarticular JIA and between age-matched VOS and height in polyarticular JIA (Table 2). There were no correlations between disease duration and BUA or VOS in children with oligoarticular JIA. In children with polyarticular JIA, there were significant inverse correlations between QUS parameters, disease duration and cumulative dose of CS (Table 2).


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  		TABLE 2. Correlations between QUS values, anthropometric parameters and clinical data

 

   Discussion
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 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
References
 
The obtained results suggest that QUS parameters, especially BUA, are strongly influenced by body height and to a lesser degree by body weight. Children with JIA have significantly lower BUA and VOS, which are especially dependent on body height. However, the BUA and VOS values remain low even when adjusted for height.

The fact, that patients with polyarticular JIA had significantly lower BUA and VOS values in comparison with children with oligoarticular JIA can be attributed to various different factors, such as inflammation, impaired mobility and, in particular, to corticotherapy and disease duration [1, 2]. Our data confirm the significant role of the latter two factors. Disease duration and cumulative dose of CS in children with polyarticular JIA should be considered as risk factors for stunted growth and decreased bone quality. Another issue is the role of QUS in the evaluation of bone quality/bone density. QUS is clearly not a surrogate for DXA [8, 12]; however, in post-menopausal women, QUS has been used to predict the fracture risk [13]. The role of QUS in the evaluation of bone status in paediatric patients needs to be further assessed.

In conclusion, disease duration and cumulative dose of prednisone in children with polyarticular JIA are risk factors for stunted growth and decreased QUS values of bone quality.

The authors have declared no conflicts of interest.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 

  1. McDonaugh JE. (2001) Osteoporosis in juvenile idiopathic arthritis. Curr Opin Rheumatol 13:399–404.[CrossRef][Web of Science][Medline]
  2. Prieur AM and Chedeville G. (2001) Prognostic factors in juvenile idiopathic arthritis. Curr Rheumatol Rep 3:371–8.[Medline]
  3. Njeh CF, Shaw N, Gardner-Medwin JM, Boivin CM, Southwood TR. (2000) Use of quantitative ultrasound to assess bone status in children with juvenile idiopathic arthritis. J Clin Densitom 3:251–60.[CrossRef][Web of Science][Medline]
  4. Falcini F, Bindi G, Ermini M, et al. (2000) Comparison of quantitative calcaneal ultrasound and dual-energy X-ray absorptiometry in the evaluation of osteoporotic risk in children with chronic rheumatic diseases. Calcif Tissue Int 67:19–23.[CrossRef][Web of Science][Medline]
  5. Falcini F, Bindi G, Simonini G, et al. (2003) Bone status evaluation with calcaneal ultrasound in children with chronic rheumatic diseases. A one year follow-up study. J Rheumatol 30:179–84.[Abstract/Free Full Text]
  6. Lernbass I, Wutzl A, Grisar J, et al. (2002) Quantitative ultrasound in the assessment of bone status of patients suffering from rheumatic diseases. Skeletal Radiol 31:270–6.[CrossRef][Web of Science][Medline]
  7. Baroncelli GI, Federico G, Bertelloni S, et al. (2003) Assessment of bone quality by quantitative ultrasound of proximal phalanges of the hand and fracture rate in children and adolescents with bone and mineral disorders. Pediatr Res 54:125–36.[CrossRef][Web of Science][Medline]
  8. Hartmanm C, Shamir R, Esbach-Adiv O, Iosilevsky G, Brik R. (2004) Assessment of osteoporosis by quantitative ultrasound versus dual-energy X-ray absorptiometry in children with chronic rheumatic diseases. J Rheumatol 31:981–5.[Abstract/Free Full Text]
  9. Cleary AG, Sills JA, Davidson JE. (2000) Revision of the proposed classification criteria for juvenile idiopathic arthritis: Durban 1997. J Rheumatol 27:1568.[Web of Science][Medline]
  10. Bayer M and Kutilek S. (1997) Ultrasound transmission through the os calcis in children: which side should we measure? Calcif Tissue Int. 61:441–2.
  11. Lhotská L, Bláha P, Vignerová J, Roth Z, Prokopec M. (1993) Vth nationwide anthropological survey of children and adolescents 1991 (Czech Republic)(National Institute of Public Health, Prague).
  12. Oliveri B, Di Gregorio S, Parisi MS, Solis F, Mautalen C. (2002) Is ultrasound of bone relevant for corticosteroid-treated patients? A comparative study with bone densitometry measured by DEXA. Joint Bone Spine 70:46–51.[CrossRef][Web of Science]
  13. Hans D, Dargent Molina P, Schott AM, et al. (1996) Ultrasonographic heel measurements to predict hip fracture in elderly women: the EPIDOS prospective study. Lancet 348:511–14.[CrossRef][Web of Science][Medline]
Submitted 19 August 2005; revised version accepted 6 January 2006.
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