Calcaneal ultrasound but not bone turnover predicts fractures in vitamin D deficient frail elderly at high risk of falls

Background: Biochemical markers of bone turnover have been reported to predict fracture risk independent of bone mass in postmenopausal women. We investigated their use in predicting fractures in the frail elderly. Methods: Cases were 151 low trauma fractures. For each case, a control was selected marched for sex, age, institution type and follow-up period. We measured two bone resorption markers (serum ICTP and serum CTX-I) and two bone formation markers (serum PINP and serum BAP). Quantitative Ultrasound (QUS) was measured in the calcaneus. Fractures were ascertained by x-ray reports. Results: The mean age of subjects was 86.8 years (± 5.8 SD) and 86% were female. 76% had hypovitaminosis D (a serum 25 hydroxy vitamin D (25OHD) level < 39 nmol/L) and 81% had BUA < 67.4 dB/MHz (corresponding to a BMD T-score < -2.5). No significant differences in bone turnover markers were detected between fracture cases and their matched controls. In contrast, there was a significant difference between cases and controls for both broadband ultrasound attenuation (BUA) and velocity of sound (VOS) (both P < 0.05). These results remained the same after adjusting for weight, lower leg length and walking aids as well as the higher falls incidence in cases than controls (average 2.7 vs 0.9 falls respectively; P < 0.001) during the follow-up period. Conclusion: In the frail elderly with vitamin D deficiency and high falls risk, calcaneal ultrasound but not markers of bone turnover were associated with fractures.