Utility of the trabecular bone score (TBS) in secondary osteoporosis

Automatic phantom-less calibration of routine CT scans for the evaluation of osteoporosis and hip fracture risk

BACKGROUND/PURPOSE

The diagnosis of osteoporosis remains a paramount concern for orthopedic surgeons worldwide. We aim to (1) evaluate the efficacy of automatic phantom-less quantitative computed tomography (PL-QCT) in diagnosing osteoporosis and (2) investigate its clinical value in predicting hip fracture risk.

METHODS

A cohort of 705 patients was included in the study. Hip CT scans from 310 patients and spinal CT scans from 315 patients were analyzed using automatic PL-QCT. The consistency of bone mineral density (BMD) measurement obtained by dual-energy X-ray absorptiometry (DXA), phantom-based QCT (PB-QCT), and automatic PL-QCT was examined through linear regression analysis and Bland-Altman plots. The ability of automatic PL-QCT to predict osteoporosis and hip fracture risk was assessed using ROC analysis.

RESULTS

Linear regression and Bland-Altman plots demonstrated a high level of agreement between BMD measurements from PL-QCT and those from hip DXA and lumbar PB-QCT. The AUC values for PL-QCT and PB-QCT in diagnosing osteoporosis were 0.903 (95 % CI 0.852-0.955) and 0.900 (95 % CI 0.847-0.953). The AUC values for predicting hip fracture risk, based on femoral neck BMD measured by PL-QCT and DXA, were 0.869 (95 % CI 0.823-0.915) and 0.831(95 % CI 0.778-0.885), respectively. When the femoral neck BMD was combined with the percentage of inter-muscular adipose tissue area, the AUC increased to 0.929 (95 % CI 0.897-0.961).

CONCLUSION

Automatic PL-QCT has shown superior performance in predicting hip fracture risk compared to DXA. Furthermore, the novel PL-QCT demonstrates comparable predictive efficacy to that of PB-QCT, suggesting its potential as a valuable tool in clinical practice.

The Diagnosis and Therapy of Osteoporosis in Gaucher Disease

Gaucher disease is a rare lysosomal storage disorder characterized by the accumulation of glucocerebroside lipids within multiple organs due to a deficiency of the lysosomal enzyme (acid β-glucosidase). It is an inherited autosomal recessive disease. The onset of symptoms can vary depending on disease type and severity, with milder forms presenting in adulthood. The main clinical manifestations include cytopenia, splenomegaly, hepatomegaly, and bone lesions. GD is characterized by several bone manifestations, such as osteopenia/osteoporosis, focal lytic or sclerotic lesions, osteonecrosis acute or chronic bone pain, Erlenmeyer flask deformity, and subchondral joint collapse with secondary degenerative arthritis. In 70-100% of patients affected by Gaucher disease type 1, clinical or radiographic evidence of bone disease occurs. Among bone complications, osteoporosis is very common, but its etiopathogenesis in GD is not completely clear. Results deriving from experimental studies support the hypothesis that there is an aberrant activity of both osteoclasts and osteoblasts due to several factors, resulting in impaired bone turnover. Bone complications represent the main cause of pain, disability, and reduced quality of life in these patients. Therefore, there is a need to enhance awareness among physicians on the skeletal manifestations throughout life of GD patients, in order to improve diagnosis and management of bone complications. In particular, this narrative review focuses on risk of bone fragility in GD, etiopathogenetic hypotheses, epidemiological data, diagnosis, monitoring, and treatment of osteoporosis in patients suffering from Gaucher disease, specifying the challenges not yet addressed.

Age-related trends in trabecular bone scores and bone mineral density in Chinese men with type 2 diabetes mellitus: a cross-sectional study

Patients with Type 2 diabetes mellitus(T2DM) typically have an average or higher bone mineral density (BMD) but are at a significantly higher risk of fracture than patients without diabetes. Trabecular bone score (TBS) is a textural index derived from pixel gray-level variations in lumbar spine DXA image, which has been introduced as an indirect measure of bone quality. This study aimed to discuss the trends and annual rates of change in BMD and TBS with age in Chinese men with T2DM and men without diabetes mellitus. Lumbar spine(LS) TBS was significantly lower in males with T2DM compared to men without diabetes(1.279 ± 0.117 vs. 1.299 ± 0.090, P = 0.005). However, TBS in men with T2DM peaked around age 60, which occurred later and was lower than the peak observed in men without diabetes, who reached their peak TBS around age 50 (1.294 ± 0.126 vs. 1.328 ± 0.088). Femoral neck, total hip, and lumbar spine BMD in men with T2DM were not significantly different from those in men without diabetes. The results showed that both men with or without T2DM exhibited the lowest annual rates of change in TBS at 66-75 years of age, with values of -1.05%(P < 0.001) and - 0.90%(P < 0.001), respectively. Patients with great glycemic control demonstrated higher TBS and BMD. Men with T2DM have later and lower peak TBS and faster bone loss, suggesting that diabetes may negatively impact bone microarchitecture and mineralization.

Decreased trabecular bone score in patients affected by Fabry disease

BACKGROUND

Fabry disease (FD) is an inherited X-linked lysosomal storage disease characterized by increased risk of osteoporosis and fractures. The impact of FD on clinical measures of bone quality is unknown. This considered, aim of our study was to evaluate whether trabecular bone microarchitecture, measured by trabecular bone score (TBS), is altered in patients with FD compared to control subjects.

METHODS

This retrospective monocentric study enrolled 14 patients (M/F 1/1, median age 46 [37-63] years, range 31-72 years) newly diagnosed with FD between January 2016 and July 2023 who underwent dual-energy X-ray absorptiometry (DXA) image at the time of diagnosis and 42 matched controls. In all subjects, data about bone mineral density (BMD) and lumbar spine TBS were collected and total calcium, parathyroid hormone (PTH), 25(OH) vitamin D, alkaline phosphatase (ALP), creatinine and estimated glomerular filtration rate (eGFR) were evaluated. In subjects with FD, globotriaosylsphingosine (lyso-Gb3), 24-hour proteinuria and albumin-creatinine ratio were also assessed.

RESULTS

Patients with FD presented significantly lower lumbar spine TBS (1.29 [1.22-1.38] vs. 1.42 [1.39-1.47], p < 0.001) and lower lumbar spine BMD (0.916 ± 0.166 vs. 1.031 ± 0.125 g/cm2, p = 0.008) compared to controls; moreover, FD was shown to be an independent risk factor for both low lumbar spine TBS (β = -0.118, p < 0.001) and BMD (β = -0.115, p = 0.009). No differences were found in serum calcium, ALP, 25(OH) vitamin D and eGFR in both groups, but FD patients had significantly higher PTH levels compared to controls (p = 0.016). Finally, 8 patients with FD presented either moderately or severely increased albuminuria and only 2 patients presented normal lyso-Gb3 levels.

CONCLUSION

Patients affected by FD present significantly lower lumbar spine TBS and BMD compared to controls. Our findings strongly support the importance of carrying out a thorough evaluation of bone status in all patients affected by FD at baseline.

Normative vertebral deformity measurements in a clinically relevant population using magnetic resonance imaging

BACKGROUND

Osteoporosis is the leading cause of vertebral fractures. Dual-energy X-ray absorptiometry (DXA) and radiographs are traditionally used to detect osteoporosis and vertebral fractures/deformities. Magnetic resonance imaging (MRI) can be utilized to detect the relative severity of vertebral deformities using three-dimensional information not available in traditional DXA and lateral two-dimensional radiography imaging techniques.

AIM

To generate normative vertebral parameters in women using MRI and DXA scans, determine the correlations between MRI-calculated vertebral deformities and age, DXA T-scores, and DXA Z-scores, and compare MRI vertebral deformity values with radiography values previously published in the literature.

METHODS

This study is a retrospective vertebral morphometric analysis conducted at our institution. The patient sample included MR images from 1638 female patients who underwent both MR and DXA imaging between 2005 and 2014. Biconcavity, wedge, crush, anterior height (Ha)/posterior height (Hp), and middle height (Hm)/posterior height values were calculated from the MR images of the patient's vertebrae. Associations between vertebral deformity values, patient age, and DXA T-scores were analyzed using Spearman correlation. The MRI-derived measurements were compared with radiograph-based calculations from population-based data compiled from multiple studies.

RESULTS

Age was positively correlated with lumbar Hm/Hp (P = 0.04) and thoracic wedge (P = 0.03) and biconcavity (P = 0.001) and negatively correlated with thoracic Ha/Hp (P = 0.002) and Hm/Hp (P = 0.001) values. DXA T-scores correlated positively with lumbar Hm/Hp (P < 0.0001) and negatively with lumbar wedge (P = 0.046), biconcavity (P < 0.0001), and Ha/Hp (P = 0.046) values. Qualitative analysis revealed that Ha/Hp differed between MRI and radiography population-based data by no more than 0.3 and Hm/Hp by a maximum of 1.2.

CONCLUSION

Compared with traditional imaging techniques, MRI detects vertebral deformities with high accuracy and reliability. It may be a sensitive, ionizing, radiation-free tool for use in clinical settings.

Association between sensitivity to thyroid hormones and trabecular bone score in euthyroid individuals: a population-based cross-sectional study

BACKGROUND

Thyroid hormone is a known pivotal factor that affects bone metabolism; however, whether bone microarchitecture is associated with thyroid hormone sensitivity is poorly understood. The trabecular bone score (TBS) serves as an essential indicator for assessing bone microarchitecture. This study aimed to investigate the relationship between sensitivity to thyroid hormones and TBS in euthyroid individuals.

METHODS

This cross-sectional study involved 3320 euthyroid participants from the National Health and Nutrition Examination Survey (NHANES) 2007-2008. Data, including thyroid function, TBS and other related parameters, were extracted and analyzed. The indices of thyroid hormone sensitivity, including the thyrotropin thyroxine resistance index (TT4RI), thyroid-stimulating hormone index (TSHI), thyroid feedback quantile-based index (TFQI) and parametric thyroid feedback quantile-based index (PTFQI), were calculated. Greater values of these indicators indicated a greater degree of impaired thyroid hormone sensitivity.

RESULTS

Impaired sensitivity to thyroid hormones was associated with degraded bone microarchitecture following adjustments for confounding variables (TT4RI: P = 0.005, TSHI: P = 0.008, TFQI: P = 0.003 and PTFQI: P = 0.006). The restricted cubic spline model demonstrated a positive relationship between TT4RI, TSHI, TFQI, PTFQI and degraded bone microarchitecture. Similar findings were observed in the analysis of subgroups stratified by age, sex, race, diabetes status, hypertension status and hyperuricemia status.

CONCLUSIONS

In euthyroid individuals, impaired sensitivity to thyroid hormones is associated with degraded bone microarchitecture. However, further studies are required to confirm this relationship.

Skeletal fragility in pituitary disease: how can we predict fracture risk?

Pituitary hormones play a crucial role in regulating skeletal physiology, and skeletal fragility is a frequent complication of pituitary diseases. The ability to predict the risk of fracture events is crucial for guiding therapeutic decisions; however, in patients with pituitary diseases, fracture risk estimation is particularly challenging. Compared to primary osteoporosis, the evaluation of bone mineral density by dual X-ray absorptiometry is much less informative about fracture risk. Moreover, the reliability of standard fracture risk calculators does not have strong validations in this setting. Morphometric vertebral assessment is currently the cornerstone in the assessment of skeletal fragility in patients with pituitary diseases, as prevalent fractures remain the strongest predictor of future fracture events. In recent years, new tools for evaluating bone quality have shown promising results in assessing bone impairment in patients with pituitary diseases, but most available data are cross-sectional, and evidence regarding the prediction of incident fractures is still scarce. Of note, apart from measures of bone density and bone quality, the estimation of fracture risk in the context of pituitary hyperfunction or hypofunction cannot ignore the evaluation of factors related to the underlying disease, such as its severity and duration, as well as the specific therapies implemented for its treatment. Aim of this review is to provide an up-to-date overview of all major evidence regarding fracture risk prediction in patients with pituitary disease, highlighting the need for a tailored approach that critically integrates all clinical, biochemical, and instrumental data according to the specificities of each disease.

Effect of bisphosphonate and denosumab treatment on TBS in Japanese breast cancer patients with AIBL

INTRODUCTION

Bisphosphonates and denosumab increase bone mineral density (BMD) for osteoporosis treatment in patients with aromatase inhibitor-associated bone loss (AIBL). This study aimed to directly compare bisphosphonates with denosumab in treating patients with AIBL and to determine the effect of denosumab on the trabecular bone score (TBS).

MATERIALS AND METHODS

Thirty-nine patients with AIBL receiving osteoporosis treatment (21 in the bisphosphonates group and 18 in the denosumab group) were retrospectively evaluated for changes in lumbar spine and femoral BMD, lumbar spine bone quality (assessed by TBS), and blood bone metabolic markers. The Mann-Whitney and Wilcoxon tests were used for statistical evaluation.

RESULTS

After 24 months of treatment, the lumbar spine BMD change rate was 5.82 ± 1.10% with bisphosphonates and 10.49 ± 1.20% with denosumab, with the change rate of denosumab significantly increasing over that of bisphosphonates. The change rate in femoral BMD was 2.69 ± 1.16% with bisphosphonates and 2.95 ± 1.26% with denosumab, with no significant difference between the two groups. The rate of decrease in tartrate-resistant acid phosphatase isoform 5b was significantly higher in the denosumab group. The change rate in TBS at 24 months of treatment was 0.53 ± 1.26% in the bisphosphonates group and 1.08 ± 1.33% in the denosumab group, with no significant difference between the two groups. After 24 months, TBS remained stable.

CONCLUSION

Both bisphosphonates and denosumab may increase BMD, improve bone metabolism, and inhibit bone quality loss in patients with AIBL.

Trabecular Bone Score as a Complementary Tool for the Assessment of Bone Mineral Density in Patients with Asymptomatic Monoclonal Gammopathies

Background/Objectives: Monoclonal gammopathies, such as Monoclonal Gammopathy of Undetermined Significance (MGUS) and Smoldering Multiple Myeloma (SMM), are conditions marked by the overproduction of specific monoclonal proteins. Patients with these conditions are known to have a higher risk of fractures compared to the general population, yet there are no established guidelines for assessing or managing their skeletal health. The Trabecular Bone Score (TBS), which can be calculated from DXA images of the lumbar spine, provides additional insights into bone microarchitecture. Methods: This study aimed to determine whether TBS can serve as a supplementary tool in assessing bone loss in MGUS and SMM patients. Conducted from 2020 to 2023, the study involved 148 participants-74 diagnosed with a myeloma precursor state and 74 healthy controls-who underwent simultaneous DXA and TBS measurements. Results: The results indicated a weak positive correlation (R = 0.405) between DXA and TBS T-scores, suggesting that other factors may influence the measurements. When analyzed separately, the correlations remained weak for both MGUS (R = 0.250) and SMM (R = 0.485). Interestingly, discrepancies were noted in T-score classifications; for instance, a patient classified as normal via DXA could be deemed osteopenic or osteoporotic with TBS. Conclusions: Overall, the findings suggest that incorporating TBS alongside DXA can enhance the accuracy of bone density assessments, facilitating earlier diagnosis and treatment initiation for osteoporosis in asymptomatic patients with monoclonal gammopathies.

Usefulness of DXA-based bone strain index in postmenopausal women with type 2 diabetes mellitus

Bone Strain Index (BSI) is a new dual-energy x-ray absorptiometry (DXA)-based index. We retrospectively evaluated data from 153 postmenopausal women with a history of type 2 diabetes mellitus (T2DM). Lumbar spine and femoral Bone Strain Index (BSI) were sensitive to skeletal impairment in postmenopausal women suffering from T2DM.

PURPOSE

Bone Strain Index (BSI) is a new dual-energy X-ray absorptiometry (DXA)-based measurement. We evaluated the performance of BSI in predicting the presence of fragility fractures in type 2 diabetes mellitus (T2DM) postmenopausal women.

METHODS

We retrospectively evaluated data from a case-control study of 153 postmenopausal women with a history of at least 5 years of T2DM (age from 40 to 90 years). For each subject, we assessed the personal or familiar history of previous fragility fractures and menopause age, and we collected data about bone mineral density (BMD), BSI, and Trabecular Bone Score (TBS) measurements. Statistical analysis was performed having as outcome the history of fragility fractures.

RESULTS

Out of a total of 153 subjects, n = 22 (14.4%) presented at least one major fragility fracture. A negative correlation was found between lumbar BSI and lumbar BMD (r =  - 0.49, p < 0.001) and between total femur BSI and total femur BMD (r =  - 0.49, p < 0.001). A negative correlation was found between femoral neck BSI and femoral neck BMD (r =  - 0.22, p < 0.001). Most DXA-based variables were individually able to discriminate between fractured and non-fractured subjects (p < 0.05), and lumbar BSI was the index with the most relative difference between the two populations, followed by femoral BSI.

CONCLUSION

Lumbar spine and femoral BSI are sensitive to skeletal impairment in postmenopausal women suffering from T2DM. The use of BSI in conjunction with BMD and TBS can improve fracture risk assessment.

Trabecular Bone Score as a Marker of Skeletal Fragility Across the Spectrum of Chronic Kidney Disease: A Systematic Review and Meta-analysis

CONTEXT

The impairment of bone microarchitecture is a key determinant of skeletal fragility in patients with chronic kidney disease (CKD). The trabecular bone score (TBS) has been developed as a reliable noninvasive index of bone quality. However, its utility in this setting is still debated.

OBJECTIVE

The aim of this systematic review and meta-analysis was to summarize the available evidence about TBS as a marker of skeletal fragility across the spectrum of CKD.

METHODS

PubMed/Medline, EMBASE, and Cochrane Library databases were systematically searched until July 2023 for studies reporting data about TBS in patients with CKD. Effect sizes were pooled through a random-effect model.

RESULTS

Compared to controls, lower TBS values were observed in CKD patients not on dialysis (-0.057, 95%CI:[-0.090, -0.024], P < .01), in dialysis patients (-0.106, 95%CI:[-0.141, -0.070], P < .01), and in kidney transplant recipients (KTRs) (-0.058, 95%CI:[-0.103, -0.012], P = .01). With respect to fracture risk, TBS was able to predict incident fractures in nondialysis patients at unadjusted analyses (hazard ratio [HR] per SD decrease: 1.45, 95%CI:[1.05, 2.00], P = .02), though only a nonsignificant trend was maintained when fully adjusting the model for FRAX® (HR = 1.26, 95%CI:[0.88, 1.80], P = .21). Dialysis patients with prevalent fractures had lower TBS values compared to unfractured ones (-0.070, 95% CI:[-0.111, -0.028], P < .01). Some studies supported a correlation between TBS and fracture risk in KTRs, but results could not be pooled due to the lack of sufficient data.

CONCLUSION

CKD patients are characterized by an impairment of bone microarchitecture, as demonstrated by lower TBS values, across the whole spectrum of kidney disease. TBS can also be helpful in the discrimination of fracture risk, with lower values being correlated with a higher risk of prevalent and incident fractures.

Diagnosis and therapeutic approach to bone health in patients with hypopituitarism

The results of many studies in recent years indicate a significant impact of pituitary function on bone health. The proper function of the pituitary gland has a significant impact on the growth of the skeleton and the appearance of sexual dimorphism. It is also responsible for achieving peak bone mass, which protects against the development of osteoporosis and fractures later in life. It is also liable for the proper remodeling of the skeleton, which is a physiological mechanism managing the proper mechanical resistance of bones and the possibility of its regeneration after injuries. Pituitary diseases causing hypofunction and deficiency of tropic hormones, and thus deficiency of key hormones of effector organs, have a negative impact on the skeleton, resulting in reduced bone mass and susceptibility to pathological fractures. The early appearance of pituitary dysfunction, i.e. in the pre-pubertal period, is responsible for failure to achieve peak bone mass, and thus the risk of developing osteoporosis in later years. This argues for the need for a thorough assessment of patients with hypopituitarism, not only in terms of metabolic disorders, but also in terms of bone disorders. Early and properly performed treatment may prevent patients from developing the bone complications that are so common in this pathology. The aim of this review is to discuss the physiological, pathophysiological, and clinical insights of bone involvement in pituitary disease.

Potential Metabolic Pathways Involved in Osteoporosis and Evaluation of Fracture Risk in Individuals with Diabetes

Diabetes has a significant global prevalence. Chronic hyperglycemia affects multiple organs and tissues, including bones. A large number of diabetic patients develop osteoporosis; however, the precise relationship between diabetes and osteoporosis remains incompletely elucidated. The activation of the AGE-RAGE signaling pathway hinders the differentiation of osteoblasts and weakens the process of bone formation due to the presence of advanced glycation end products. High glucose environment can induce ferroptosis of osteoblasts and then develop osteoporosis. Hyperglycemia also suppresses the secretion of sex hormones, and the reduction of testosterone is difficult to effectively maintain bone mineral density. As diabetes therapy, thiazolidinediones control blood glucose by activating PPAR-γ. Activated PPAR-γ can promote osteoclast differentiation and regulate osteoblast function, triggering osteoporosis. The effects of metformin and insulin on bone are currently controversial. Currently, there are no appropriate tools available for assessing the risk of fractures in diabetic patients, despite the fact that the occurrence of osteoporotic fractures is considerably greater in diabetic individuals compared to those without diabetes. Further improving the inclusion criteria of FRAX risk factors and clarifying the early occurrence of osteoporosis sites unique to diabetic patients may be an effective way to diagnose and treat diabetic osteoporosis and reduce the risk of fracture occurrence.

Guidelines for fracture risk assessment and management of osteoporosis in postmenopausal women and men above the age of 50 in Qatar

We present comprehensive guidelines for osteoporosis management in Qatar. Formulated by the Qatar Osteoporosis Association, the guidelines recommend the age-dependent Qatar fracture risk assessment tool for screening, emphasizing risk-based treatment strategies and discouraging routine dual-energy X-ray scans. They offer a vital resource for physicians managing osteoporosis and fragility fractures nationwide.

PURPOSE

Osteoporosis and related fragility fractures are a growing public health issue with an impact on individuals and the healthcare system. We aimed to present guidelines providing unified guidance to all healthcare professionals in Qatar regarding the management of osteoporosis.

METHODS

The Qatar Osteoporosis Association formulated guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men above the age of 50. A panel of six local rheumatologists who are experts in the field of osteoporosis met together and conducted an extensive review of published articles and local and international guidelines to formulate guidance for the screening and management of postmenopausal women and men older than 50 years in Qatar.

RESULTS

The guidelines emphasize the use of the age-dependent hybrid model of the Qatar fracture risk assessment tool for screening osteoporosis and risk categorization. The guidelines include screening, risk stratification, investigations, treatment, and monitoring of patients with osteoporosis. The use of a dual-energy X-ray absorptiometry scan without any risk factors is discouraged. Treatment options are recommended based on risk stratification.

CONCLUSION

Guidance is provided to all physicians across the country who are involved in the care of patients with osteoporosis and fragility fractures.

Update on the utility of trabecular bone score (TBS) in clinical practice for the management of osteoporosis: a systematic review by the Egyptian Academy of Bone and Muscle Health

Trabecular bone score (TBS) is a grayscale textural assessment resulting from a computed evaluation of pixel gray-level variations in previously obtained lumbar spine DXA images. It is an index of bone microarchitecture correlated with parameters of bone strength. Higher values of TBS indicate a better microarchitecture, whereas lower values indicate a degraded microarchitecture. TBS can be used alongside Fracture Risk Assessment tool “FRAX” and bone mineral density (BMD) to enhance the assessment of fracture risk and to inform treatment initiation and monitoring. A systematic review was carried out aiming to update the evidence on the clinical use of the TBS in the management of both primary and secondary osteoporosis. Results revealed that in both primary and secondary osteoporosis, TBS enhances the prediction of fracture risk, and when adjust with BMD and clinical risk factors, it is able to inform the decision-making process regarding initiating osteoporosis therapy and the choice of anti-osteoporosis medication. Evidence also implies that TBS provides valuable adjunctive information in monitoring osteoporosis therapy. In conclusion, this work provides an up-to-date evidence-based review and recommendations which informs the utility of trabecular bone score in standard clinical practice.

Fast field echo resembling a CT using restricted echo-spacing (FRACTURE) sequence for shoulder joint in normal dogs

Shoulder disease is a common cause of forelimb lameness in dogs. Determining the precise underlying cause of shoulder lameness can be challenging, especially in veterinary practice. Computerized tomography (CT) is often the preferred imaging modality for bone evaluation; however, it uses ionizing radiation and provides limited soft tissue contrast. Conversely, magnetic resonance imaging (MRI) offers excellent soft tissue contrast but has limitations in bone imaging. This study aimed to introduce a new technical innovation that enhances cortical and trabecular bone contrast on MRI, which we refer to as Fast Field Echo Resembling a CT Using Restricted Echo-Spacing (FRACTURE). In this prospective pilot study, we aimed to evaluate the use of FRACTURE, CT, and conventional MRI sequences in assessing the normal canine shoulder using a 3.0 Tesla MRI scanner. Five research beagle dogs were included, and the following pulse sequences were acquired for each dog (1): three-dimensional (3D) FRACTURE, (2) T2-weighted (T2W) images using 3D turbo spin echo (TSE), (3) T1-weighted (T1W) images using 3D TSE, (4) PD-weighted (PDW) images using 3D TSE, and (5) CT. Various parameters, including the delineation of cortical bone (intertubercular groove, greater tubercle, and lesser tubercle), conspicuity of the trabecular bone, shoulder joint visualization, and image quality, were measured for each dog and sequence. In all sequences, the shoulder joint was successfully visualized in all planes with mild motion artifacts. The intertubercular groove was best visualized on CT and FRACTURE. Both the greater and lesser tubercles were easily identified on the CT, FRACTURE, and PDW images. The trabecular pattern scored significantly higher in the CT and FRACTURE images compared to the T1W, T2W, and PDW images. Overall, the visualization of the shoulder joint was excellent in all sequences except for T1W. The use of FRACTURE in combination with conventional MRI sequences holds promise for facilitating not only soft tissue evaluation but also cortical and trabecular bone assessment. The findings from this study in normal dogs can serve as a foundation for further FRACTURE studies in dogs with shoulder diseases.

Obesity and Skeletal Fragility

Skeletal fracture has recently emerged as a complication of obesity. Given the normal or better than normal bone mineral density (BMD), the skeletal fragility of these patients appears to be a problem of bone quality rather than quantity. Type 2 diabetes mellitus (T2DM), the incidence of which increases with increasing body mass index, is also associated with an increased risk for fractures despite a normal or high BMD. With the additional bone pathology from diabetes itself, patients with both obesity and T2DM could have a worse skeletal profile. Clinically, however, there are no available methods for identifying those who are at higher risk for fractures or preventing fractures in this subgroup of patients. Weight loss, which is the cornerstone in the management of obesity (with or without T2DM), is also associated with an increased risk of bone loss. This review of the literature will focus on the skeletal manifestations associated with obesity, its interrelationship with the bone defects associated with T2DM, and the available approach to the bone health of patients suffering from obesity.

Using Texture Analysis of Neck Computed Tomography Images to Differentiate Primary Hyperparathyroidism From Normal Controls

OBJECTIVE

To investigate the utility of texture analysis in detecting osseous changes associated with hyperparathyroidism on neck CT examinations compared with control patients and to explore the best regions in the head and neck to evaluate changes in the trabecular architecture secondary to hyperparathyroidism.

METHODS

Patients with hyperparathyroidism who underwent a 4D CT of the neck with contrast were included in this study. Age-matched control patients with no history of hyperparathyroidism who underwent a contrast-enhanced neck CT were also included. Mandibular condyles, bilateral mandibular bodies, the body of the C4 vertebra, the manubrium of the sternum, and bilateral clavicular heads were selected for analysis, and oval-shaped regions of interest were manually placed. These segmented areas were imported into an in-house developed texture analysis program, and 41 texture analysis features were extracted. A mixed linear regression model was used to compare differences in the texture analysis features contoured at each of the osseous structures between patients with hyperparathyroidism and age-matched control patients.

RESULTS

A total of 30 patients with hyperparathyroidism and 30 age-matched control patients were included in this study. Statistically significant differences in texture features between patients with hyperparathyroidism and control patients in all 8 investigated osseous regions. The sternum showed the greatest number of texture features with statistically significant differences between these groups.

CONCLUSIONS

Some CT texture features demonstrated statistically significant differences between patients with hyperparathyroidism and control patients. The results suggest that texture features may discriminate changes in the osseous architecture of the head and neck in patients with hyperparathyroidism.

Trabecular bone score in type 1 diabetes: a meta-analysis of cross-sectional studies

BACKGROUND

Bone fragility is a recognized complication of type 1 diabetes (T1D). Thus, lower trabecular bone score (TBS) measurements in T1D patients can be predicted. However, the results of current studies on TBS in patients with T1D are inconsistent. In this context, the present study aimed to test the hypothesis that T1D is associated with lower TBS through a meta-analysis.

METHODS

An electronic search of the literature was conducted using PubMed, Embase and Web of science databases to identify studies related to TBS and T1D, supplemented by an additional manual check of the reference list of relevant original and review articles. All data was analyzed using a random effects model. Results were compared using standardized mean differences (SMD) and 95% confidence intervals (CI). P ≤ 0.05 was considered statistically significant. Review Manager 5.4 software and Stata 17.0 software were used for statistical analysis.

RESULTS

Seven cross-sectional studies involving 848 participants were included. TBS was lower in T1D patients than in healthy controls on random effects analysis, with no heterogeneity (SMD =  - 0.39, 95% CI [- 0.53, - 0.24], P < 0.001; I2 = 0%). In addition, by subgroup analysis, T1D patients were strongly associated with reduced TBS in different regions and age groups, and the results were independent of covariate adjustment.

CONCLUSION

This study showed that TBS was lower in patients with T1D than in healthy individuals with normal blood glucose levels, suggesting that TBS may be a useful measure to assess fracture risk in T1D.

Radiofrequency Echographic Multispectrometry (REMS): A New Option in the Assessment Bone Status in Adults with Osteogenesis Imperfecta

This study aimed to estimate the utility of the Radiofrequency Echographic Multispectrometry (REMS) approach in the assessment of bone mineral density (BMD) in subjects with osteogenesis imperfecta (OI). In 41 subjects (40.5 ± 18.7 years) with OI and in 36 healthy controls, we measured BMD at the lumbar spine (LS-BMD), femoral neck (FN-BMD) and total hip (TH-BMD), employing a dual-energy X-ray absorptiometry tool. Additionally, REMS scans were also performed at the lumbar and femoral sites. The presence and number of reported fractures were assessed in the study population. Patients characterized by a history of fragility fractures represented 84.5% of the study population. OI subjects showed significantly reduced BMD values both at the level of the lumbar spine and the femoral subregions (p < 0.01) compared to healthy controls when performed using both the DXA and the REMS method. Dividing OI patients on the basis of the Sillence classification, no differences were found between the LS-BMD values carried out using the DXA technique between the OI type I group and OI Type III and IV groups. On the contrary, the OI Type III and IV groups presented significantly lower values of both Trabecular Bone Score (TBS) and LS-BMD through REMS with respect to OI type I patients (p < 0.05). Based on the data of this study, it is possible to conclude that even the new REMS assessment, which does not use ionizing radiation, represents an excellent method for studying the bone status in subjects affected by OI.

Bone safety of dual-release hydrocortisone in patients with autoimmune primary adrenal insufficiency

Background

Conventional glucocorticoids (C-GC) replacement regimens have a detrimental effect on skeletal health in patients with adrenal insufficiency (AI), ultimately leading to an increased fracture risk. The novel dual-release hydrocortisone (DR-HC) formulations are characterized by a more favourable safety profile on various clinical endpoints. Data comparing the impact of C-GC and DR-HC on bone, however, are scarce.

Methods

Twenty-seven patients with autoimmune primary AI (PAI; 13 treated with C-GC and 14 treated with DR-HC) were evaluated to compare bone-related parameters between the two treatment groups.

Results

No significant differences between the two treatments groups were observed with respect to bone turnover markers. Patients treated with C-GC showed a lower bone mineral density (BMD) at lumbar spine (LS; 0.791 ± 0.195 vs. 0.942 ± 0.124 g/cm2, p=0.025) and at femoral neck (FN; 0.633 ± 0.114 vs. 0.716 ± 0.088 g/cm2, p=0.045). Moreover, they were characterized by a lower trabecular bone score (TBS; 1.236 ± 0.035 vs. 1.383 ± 0.030, p=0.004) and by a higher mean number of vertebral fractures per patient (0.75 vs. 0 fractures, p=0.002). TBS was the best predictor of fracture risk, with a pseudo-R2 of 0.593; moreover, at mediation analysis, it was able to fully explain the observed detrimental effect of C-GC, compared to DR-HC, on fracture risk.

Conclusions

These results suggest that DR-HC is associated with less bone-related complications compared to C-GC in patients with PAI. Moreover, TBS seems to play a pivotal role in the mediation of the relationship between glucocorticoid treatment regimens and fracture risk.

Management of Adrenal Cortical Adenomas: Assessment of Bone Status in Patients with (Non-Functioning) Adrenal Incidentalomas

Our aim is to analyse the bone profile in adults with (non-functioning) adrenal incidentalomas (AIs), specifically addressing the impact of autonomous cortisol secretion (ACS). This narrative review, based on a PubMed search from inception to February 2023 (case reports, non-ACS, and other secondary causes of osteoporosis were excluded), included 40 original studies, a total of 3046 patients with female prevalence (female:male ratio of 1921:1125), aged between 20.5 and 95.5 years old. This three decade-based analysis showed that 37 studies provided dual-energy X-ray absorptiometry (DXA) information; another five studies reports results on bone micro-architecture, including trabecular bone score (TBS), spinal deformity index, and high-resolution peripheral quantitative computed tomography; 20 cohorts included data on bone turnover markers (BTMs), while four longitudinal studies followed subjects between 1 and 10.5 years old (surgical versus non-adrenalectomy arms). Post-dexamethasone suppression test (DST) cortisol was inversely associated with bone mineral density (BMD). TBS predicted incidental vertebral fractures (VFx) regardless of BMD, being associated with post-DST cortisol independently of age and BMD. Low BTMs were identified in ACS, but not all studies agreed. An increased prevalence of ACS-related osteoporosis was confirmed in most studies (highest prevalence of 87.5%), as well as of VFx, including in pre-menopause (42.5%), post-menopause (78.6%), and male patients (72.7%) depending on the study, with a 10-fold increased incidental VFx risk up to a 12-fold increased risk after a 2-year follow-up. No specific medication against osteoporosis is indicated in ACS, but adrenalectomy (according to four studies) should be part of the long-term strategy. This bone profile case sample-based study (to our knowledge, one of the largest of its kind) showed that AIs, including the subgroup designated as having ACS, embraces a large panel of osseous complications. The level of evidence remains far from generous; there are still no homogenous results defining ACS and identifying skeletal involvement, which might be a consequence of different investigation clusters underling adrenal and bone assessments over time. However, bone status evaluations and associated therapy decisions remain an essential element of the management of adults with AIs-ACS.

Trabecular Bone Score Significantly Influences Treatment Decisions in Secondary Osteoporosis

The trabecular bone score (TBS) can be determined in addition to the Dual Energy X-ray Absorptiometry (DXA) for bone mineral density (BMD) measurement to diagnose, evaluate, and stratify bone loss and decide on appropriate treatment in patients at risk. Especially in patients with secondary osteoporosis, TBS detects restricted bone quality. To investigate the influence of an additional evaluation of TBS on patients' treatment strategy decisions, we enrolled 292 patients, with a high proportion of patients with secondary osteoporosis, from one outpatient unit over one year. Patients eligible for BMD measurement had the option to opt-in for TBS measurement. We analyzed demographic data, leading diagnoses, bone metabolism parameters, and results of BMD and TBS measurements. More than 90% of patients consented to TBS measurement. TBS measurement influenced the decision in approximately 40% of patients with a treatment indication for anti-osteoporotic drugs. We demonstrate that depending on the underlying disease/risk spectrum, 21-25.5% of patients had an unremarkable BMD measurement with poor bone quality shown in the TBS measurement. In patients with secondary osteoporosis, the use of TBS supplementary to DXA seems useful to better assess fracture risk and, thus, to initiate therapy for osteoporosis in these patients in time.

Trabecular bone score, bone marrow fat and vertebral fractures in cushing syndrome

OBJECTIVE

Prediction of fragility fractures in Cushing syndrome (CS) is a challenge since dual energy X-ray absorptiometry (DXA) measurement of bone mineral density (BMD) does not capture all the alterations in bone microstructure induced by glucocorticoid excess. In this study we investigated the relationship between trabecular bone score (TBS), bone marrow fat (BMF) and vertebral fractures (VFs) in endogenous CS.

DESIGN

Cross-sectional.

METHODS

Thirty subjects (7 M and 23 F, mean age 44.8 ± 13.4 yrs, range: 25-71) with active hypercortisolism were evaluated for VFs by quantitative morphometry, BMD and TBS by lumbar spine DXA and BMF by single-voxel magnetic resonance spectroscopy of vertebral body of L3.

RESULTS

Subjects with VFs (17 cases; 56.7%) had higher BMF (P = 0.014) and lower BMD T-score (P = 0.012) and TBS (P = 0.004) as compared to those without VFs. Prevalence of VFs resulted to be significantly higher in individuals with impaired TBS as compared to those with normal TBS (77.8% vs. 25.0%; P = 0.008). Among patients with VFs, only 6 (35.3%) had either osteoporosis or "low BMD for age". In logistic regression analysis, impaired TBS maintained the significant association with VFs [odds ratio (OR) 6.60, 95% C.I. 1.07-40.61; P = 0.042] independently of BMF (OR 1.03, 95% C.I. 0.99-1.08; P = 0.152).

CONCLUSIONS

TBS might be more accurate than BMF in identifying subjects with active CS and skeletal fragility at risk of VFs.

SIGNIFICANCE STATEMENT

Excess in glucocorticoids is associated with alterations in bone remodeling and metabolism, leading to fragility fractures regardless of bone mineral density, making more challenging for the clinician the identification of high-risk population and the definition of preventing strategies. In this context, instrumental parameters suggestive of bone quality alterations and predictive of increased fracture risk are needed. In this study, we found CS patients to have bone quality alterations as indicated by the decreased trabecular bone score and increased bone marrow fat, as measured by DEXA and MRI respectively. Both parameters were associated with high risk of VFs, and were inversely correlated, although TBS seems to be more accurate than BMF in fractures prediction in this clinical setting.

Update on trabecular bone score

Trabecular bone score (TBS) is an indirect and noninvasive measure of bone quality. A low TBS indicates degraded bone microarchitecture, predicts osteoporotic fracture, and is partially independent of clinical risk factors and bone mineral density (BMD). There is substantial evidence supporting the use of TBS to assess vertebral, hip, and major osteoporotic fracture risk in postmenopausal women, as well as to assess hip and major osteoporotic fracture risk in men aged > 50 years. TBS complements BMD information and can be used to adjust the FRAX (Fracture Risk Assessment) score to improve risk stratification. While TBS should not be used to monitor antiresorptive therapy, it may be potentially useful for monitoring anabolic therapy. There is also a growing body of evidence indicating that TBS is particularly useful as an adjunct to BMD for fracture risk assessment in conditions associated with increased fracture risk, such as type-2 diabetes, chronic corticosteroid excess, and other conditions wherein BMD readings are often misleading. The interference of abdominal soft tissue thickness (STT) on TBS should also be considered when interpreting these findings because image noise can impact TBS evaluation. A new TBS software version based on an algorithm that accounts for STT rather than BMI seems to correct this technical limitation and is under development. In this paper, we review the current state of TBS, its technical aspects, and its evolving role in the assessment and management of several clinical conditions.

Skeletal disorders associated with the growth hormone-insulin-like growth factor 1 axis

Growth hormone (GH) and insulin-like growth factor 1 (IGF1) are important regulators of bone remodelling and metabolism and have an essential role in the achievement and maintenance of bone mass throughout life. Evidence from animal models and human diseases shows that both GH deficiency (GHD) and excess are associated with changes in bone remodelling and cause profound alterations in bone microstructure. The consequence is an increased risk of fractures in individuals with GHD or acromegaly, a condition of GH excess. In addition, functional perturbations of the GH-IGF1 axis, encountered in individuals with anorexia nervosa and during ageing, result in skeletal fragility and osteoporosis. The effect of interventions used to treat GHD and acromegaly on the skeleton is variable and dependent on the duration of the disease, the pre-existing skeletal state, coexistent hormone alterations (such as those occurring in hypogonadism) and length of therapy. This variability could also reflect the irreversibility of the skeletal structural defect occurring during alterations of the GH-IGF1 axis. Moreover, the effects of the treatment of GHD and acromegaly on locally produced IGF1 and IGF binding proteins are uncertain and in need of further study. This Review highlights the pathophysiological, clinical and therapeutic aspects of skeletal fragility associated with perturbations in the GH-IGF1 axis.

An Overlooked Bone Metabolic Disorder: Cigarette Smoking-Induced Osteoporosis

Cigarette smoking (CS) leads to significant bone loss, which is recognized as an independent risk factor for osteoporosis. The number of smokers is continuously increasing due to the addictive nature of smoking. Therefore it is of great value to effectively prevent CS-induced osteoporosis. However, there are currently no effective interventions to specifically counteract CS-induced osteoporosis, owing to the fact that the specific mechanisms by which CS affects bone metabolism are still elusive. This review summarizes the latest research findings of important pathways between CS exposure and bone metabolism, with the aim of providing new targets and ideas for the prevention of CS-induced osteoporosis, as well as providing theoretical directions for further research in the future.

The Bone Strain Index: An Innovative Dual X-ray Absorptiometry Bone Strength Index and Its Helpfulness in Clinical Medicine

Bone strain Index (BSI) is an innovative index of bone strength that provides information about skeletal resistance to loads not considered by existing indexes (Bone Mineral Density, BMD. Trabecular Bone Score, TBS. Hip Structural Analysis, HSA. Hip Axis Length, HAL), and, thus, improves the predictability of fragility fractures in osteoporotic patients. This improved predictability of fracture facilitates the possibility of timely intervention with appropriate therapies to reduce the risk of fracture. The development of the index was the result of combining clinical, radiographical and construction-engineering skills. In fact, from a physical point of view, primary and secondary osteoporosis, leading to bone fracture, are determined by an impairment of the physical properties of bone strength: density, internal structure, deformation and fatigue. Dual X-ray absorptiometry (DXA) is the gold standard for assessing bone properties, and it allows measurement of the BMD, which is reduced mainly in primary osteoporosis, the structural texture TBS, which can be particularly degraded in secondary osteoporosis, and the bone geometry (HSA, HAL). The authors recently conceived and developed a new bone deformation index named Bone Strain Index (BSI) that assesses the resistance of bone to loads. If the skeletal structure is equated to engineering construction, these three indexes are all considered to determine the load resistance of the construct. In particular, BSI allows clinicians to detect critical information that BMD and TBS cannot explain, and this information is essential for an accurate definition of a patient’s fracture risk. The literature demonstrates that both lumbar and femoral BSI discriminate fractured osteoporotic people, that they predict the first fragility fracture, and further fragility fractures, monitor anabolic treatment efficacy and detect patients affected by secondary osteoporosis. BSI is a new diagnostic tool that offers a unique perspective to clinical medicine to identify patients affected by primary and, specially, secondary osteoporosis. This literature review illustrates BSI’s state of the art and its ratio in clinical medicine.

Osteosarcopenia in autoimmune cholestatic liver diseases: Causes, management, and challenges

Primary biliary cholangitis and primary sclerosing cholangitis (PSC) are the most common cholestatic liver diseases (CLD) in adults and are both characterized by an immune pathogenesis. While primary biliary cholangitis is a model autoimmune disease, with over 90% of patients presenting very specific autoantibodies against mitochondrial antigens, PSC is considered an immune mediated disease. Osteoporosis is the most common bone disease in CLD, resulting in frequent fractures and leading to significant morbidity. Further, sarcopenia is emerging as a frequent complication of chronic liver diseases with a significant prognostic impact and severe implications on the quality of life of patients. The mechanisms underlying osteoporosis and sarcopenia in CLD are still largely unknown and the association between these clinical conditions remains to be dissected. Although timely diagnosis, prevention, and management of osteosarcopenia are crucial to limit the consequences, there are no specific guidelines for management of osteoporosis and sarcopenia in patients with CLD. International guidelines recommend screening for bone disease at the time of diagnosis of CLD. However, the optimal monitoring strategies and treatments have not been defined yet and vary among centers. We herein aim to comprehensively outline the pathogenic mechanisms and clinical implications of osteosarcopenia in CLD, and to summarize expert recommendations for appropriate diagnostic and therapeutic approaches.

Usefulness of the Trabecular Bone Score in Assessing the Risk of Vertebral Fractures in Patients with Cirrhosis

The trabecular bone score (TBS), a surrogate measure of bone microarchitecture, provides complementary information to bone mineral density (BMD) in the assessment of osteoporotic fracture risk. This cross-sectional study aimed to determine whether TBS can identify patients with liver cirrhosis that are at risk of vertebral fractures. We enrolled 275 patients who completed evaluations for lumbar BMD, TBS, and vertebral fractures between November 2018 and April 2021. BMD was measured using dual-energy X-ray absorptiometry (DXA), TBS was calculated by analyzing DXA images using TBS iNsight software, and vertebral fractures were evaluated using Genant’s semi-quantitative method with lateral X-ray images. Factors associated with vertebral fractures and their correlation with the TBS were identified using regression models. Of the enrolled patients, 128 (47%) were female, the mean age was 72 years, and 62 (23%) were diagnosed with vertebral fractures. The prevalence of vertebral fractures was higher in women than in men (33% vs. 14%; p < 0.001). The unadjusted odds ratio (OR) of the vertebral fractures for one standard deviation decrease in TBS and BMD was 2.14 (95% confidence interval [CI], 1.69−2.73) and 1.55 (95% CI, 1.26−1.90), respectively. After adjusting for age, sex, and BMD, the adjusted OR of the vertebral fractures in TBS was 2.26 (95% CI, 1.52−3.35). Multivariate linear regression analysis showed that TBS was independently correlated with age (β = −0.211), body mass index (β = −0.251), and BMD (β = 0.583). TBS can help identify patients with cirrhosis at risk of vertebral fractures.

Usefulness of the trabecular bone score in maintenance dialysis patients : A single center observational study

Background

The number of dialysis patients is steadily increasing. Associated comorbidities include impaired bone and mineral metabolism, termed chronic kidney disease-mineral and bone disorder (CKD-MBD), leading to a high fracture risk, increased morbidity and mortality and impaired quality of life. While the bone density is assessed with dual-energy X‑ray absorptiometry (DXA), the trabecular bone score (TBS) captures the image texture as a potential index of skeletal microarchitecture. The aim of this study was to evaluate the clinical relevance of DXA and TBS in dialysis patients with and without prevalent fractures.

Methods

Bone disorders were evaluated in 82 dialysis patients (37% female) at the University Hospital of Graz, Austria, by DXA including the assessment of the TBS based on a patient interview and the local routine patient database software. The patient cohort was stratified by having sustained a fragility fracture in the past or not. Descriptive statistics, t‑tests for continuous variables and χ²-tests for nominal variables including results of DXA and TBS were performed to compare these groups considering the dialysis modality and duration as well as the number of kidney transplantations.

Results

Of the 82 patients, 32 (39%) had a positive history of fractures. There was a significant association between dialysis duration and fracture prevalence (p < 0.05) as well as musculoskeletal pain (p < 0.01). No significant correlation between DXA/TBS parameters and musculoskeletal pain could be established. The DXA scores did not correlate with fracture prevalence with the exception of DXA radius measurements; however, fracture prevalence significantly correlated inversely with TBS (p < 0.001).

Conclusion

The use of DXA has a limited role in fracture prediction in dialysis patients; however, the TBS seems to add information as an additional tool for fracture risk estimation in this patient population.

Trabecular Bone Score and Osteoprotegerin as Useful Tools in the Assessment of Bone Deterioration in Acromegaly

PURPOSE

This study aimed to assess bone mineral density (BMD) and trabecular bone score (TBS) in 61 patients from the acromegaly group (AG) with regard to the activity of the disease in comparison to 42 patients-control group (CG). We also analyzed selected bone markers and their association with BMD and TBS.

MATERIALS AND METHODS

Lumbar spine and femoral neck BMD measurements were performed. TBS values were obtained. Serum concentrations of selected bone markers, including osteoprotegerin (OPG), were measured.

RESULTS

We revealed a difference in TBS values between the AG and CG as well as between the TCA (treatment-controlled acromegaly) vs. CG and TCA+CA (cured acromegaly) vs. CG. We did not observe any statistically significant difference in BMD. OPG had a lower concentration in the CG compared to the AG. TBS correlated negatively with OPG in the AG (r = -0.31, p = 0.01) and in the TCA+ CA group (r = -0.3, p = 0.01).

CONCLUSIONS

The acromegalic patients have altered bone microstructure as indicated by the decreased TBS regardless of the activity of the disease and BMD. OPG could be a marker of the destruction of the bone microstructure, but further studies are needed.

Fracture risk assessment in diabetes mellitus

Growing evidence suggests that diabetes mellitus is associated with an increased risk of fracture. Bone intrinsic factors (such as accumulation of glycation end products, low bone turnover, and bone microstructural changes) and extrinsic factors (such as hypoglycemia caused by treatment, diabetes peripheral neuropathy, muscle weakness, visual impairment, and some hypoglycemic agents affecting bone metabolism) probably contribute to damage of bone strength and the increased risk of fragility fracture. Traditionally, bone mineral density (BMD) measured by dual x-ray absorptiometry (DXA) is considered to be the gold standard for assessing osteoporosis. However, it cannot fully capture the changes in bone strength and often underestimates the risk of fracture in diabetes. The fracture risk assessment tool is easy to operate, giving it a certain edge in assessing fracture risk in diabetes. However, some parameters need to be regulated or replaced to improve the sensitivity of the tool. Trabecular bone score, a noninvasive tool, indirectly evaluates bone microstructure by analyzing the texture sparsity of trabecular bone, which is based on the pixel gray level of DXA. Trabecular bone score combined with BMD can effectively improve the prediction ability of fracture risk. Quantitative computed tomography is another noninvasive examination of bone microstructure. High-resolution peripheral quantitative computed tomography can measure volume bone mineral density. Quantitative computed tomography combined with microstructure finite element analysis can evaluate the mechanical properties of bones. Considering the invasive nature, the use of microindentation and histomorphometry is limited in clinical settings. Some studies found that the changes in bone turnover markers in diabetes might be associated with fracture risk, but further studies are needed to confirm this. This review focused on summarizing the current development of these assessment tools in diabetes so as to provide references for clinical practice. Moreover, these tools can reduce the occurrence of fragility fractures in diabetes through early detection and intervention.

Trabecular Bone Score (TBS) in Patients with Early Ankylosing Spondylitis-Limited Utility

Purpose: Ankylosing spondylitis (AS) not only results in pathological ossification of the spine, but can also be associated with osteoporosis. Due to the presence of syndesmophytes and possible involvement of the hip joints, classical dual X-ray absorptiometry (DXA) is of limited use in patients with advanced stages of AS. Trabecular bone score (TBS) is a method complementary to DXA, providing additional information about bone microarchitecture. There is a growing body of evidence for the usefulness of TBS in AS patients. The aim of this study was to assess the clinical utility of TBS in patients with AS. Methods: Patients with AS underwent DXA with additional TBS assessment. A cross-sectional analysis of the frequency of osteoporosis and bone microarchitecture deterioration and their association with patients’ characteristics was done. Results: A total of 51 male patients, mean age 40.7 years, were enrolled. Osteoporosis was diagnosed in seven patients (13.7%). Lumbar bone mineral density (BMD) was higher (p < 0.001) than femoral BMD, indicating abnormal BMD readings in the spine caused by syndesmophytes. Patients with DXA-diagnosed osteoporosis had lower TBS (p = 0.03) and TBS T-score (p = 0.043) values compared to patients without osteoporosis. However, disturbed bone microarchitecture (TBS < 1.23) was present in only three patients (5.9%). None of the patients had a history of an osteoporotic fracture. A lower TBS T-score (p = 0.032) was demonstrated in patients with sacroiliitis grade 4 than in patients with sacroiliitis grade 2, with no significant differences in BMD and T-score values. Conclusion: Among patients with early AS, the clinical utility of TBS is limited—it does not add value to DXA.

DXA parameters, Trabecular Bone Score (TBS) and Bone Mineral Density (BMD), in fracture risk prediction in endocrine-mediated secondary osteoporosis

Osteoporosis, a disease characterized by low bone mass and alterations of bone microarchitecture, leading to an increased risk for fragility fractures and, eventually, to fracture; is associated with an excess of mortality, a decrease in quality of life, and co-morbidities. Bone mineral density (BMD), measured by dual X-ray absorptiometry (DXA), has been the gold standard for the diagnosis of osteoporosis. Trabecular bone score (TBS), a textural analysis of the lumbar spine DXA images, is an index of bone microarchitecture. TBS has been robustly shown to predict fractures independently of BMD. In this review, while reporting also results on BMD, we mainly focus on the TBS role in the assessment of bone health in endocrine disorders known to be reflected in bone.

Update on vertebral fractures in pituitary diseases: from research to clinical practice

Derangement of pituitary hormone axes can induce changes in bone remodeling and metabolism with possible alterations in bone microarchitectural structure and increased susceptibility to fractures. Vertebral fractures (VFs), which are a hallmark of skeletal fragility, have been described in a very large number of patients with pituitary diseases. These fractures are clinically relevant, since they predispose to further fractures and may negatively impact on patients' quality of life. However, the management of skeletal fragility and VFs in the specific setting of pituitary diseases is a challenge, since the awareness for this disease is still low, prediction of VFs is uncertain, the diagnosis of VFs cannot be solely based on a clinical approach and also needs a radiological and morphometric approach, the risk of fractures may not be decreased via treatment of pituitary hormone disorders, and the effectiveness of bone-active drugs in this setting is not always evidence-based. This review is an update on skeletal fragility in patients with pituitary diseases, with a focus on clinical and therapeutic aspects concerning the management of VFs.

Impact of bone-active drugs and underlying disease on bone health after lung transplantation: A longitudinal study

INTRODUCTION

the effect of bone-active drugs on the risk of fragility fractures (Fx), bone mineral density (BMD) and trabecular bone score (TBS) changes in patients receiving lung transplantation (LTx) is largely unknown. This study assessed the bone-active drugs effect in patients undergoing LTx both with (CF) and without (nCF) cystic-fibrosis.

METHODS

We evaluated incident Fx, both clinical and morphometric vertebral Fx by spinal X-ray, BMD and trabecular bone score (TBS) in 117 patients (CF=50, nCF n = 67) before and 24-months after LTx. A bone-active therapy was proposed to all LTx candidates.

RESULTS

83.8% of patients started a bone-active drug. Lumbar-spine (LS) T-score improved significantly only in treated patients (-1.4 ± 1.0 vs -2.0±1.0, p = 0.0001), whereas femur BMD and TBS remained stable in treated and not treated subjects. The rate of incident Fx was 15.3%, with no difference between treated and not treated patients. After LTx, LS T-score improved significantly only in nCF group (-1.3 ± 1.0 vs -1.8 ± 1.1, p = 0.0001), while femur remained stable in both nCF and CF groups. Patients with CF showed a significant Z-TBS increase (-3.6 ± 1.7 vs -3.0 ± 1.7, p = 0.019) and a lower Fx incidence as compared with nCF patients (4.1% vs 24.2%, p  =0.003). Incident Fx were associated with nCF diagnosis (OR 7.300, CI95% 1.385-38.461, p = 0.019) regardless of prevalent Fx, previous glucocorticoid therapy and bone-active therapy introduced at least 6 months before LTx.

CONCLUSIONS

A prompt medical intervention helps in preventing BMD loss after LTx. As compared with nCF patients, CF patients show a TBS increase and a lower Fx risk after LTx.

Clinical Utility of Trabecular Bone Score (TBS) in Fracture Risk Assessment of Patients with Rheumatic Diseases Treated with Glucocorticoids

Chronic glucocorticoid therapy is associated with osteoporosis and can cause fractures in up to 50% of patients. Increased risk of fractures in patients with glucocorticoid-induced osteoporosis does not result only from the decreased bone mineral density (BMD) but also bone microarchitecture deterioration. Trabecular bone score (TBS) is a method complementary to DXA, providing additional information about trabecular bone structure. The aim of this study was to assess the clinical utility of TBS in fracture risk assessment of patients treated with glucocorticoids. Patients with rheumatic diseases treated with glucocorticoids for at least 3 months were enrolled. All recruited patients underwent DXA with additional TBS assessment. We analyzed the frequency of osteoporosis and osteoporotic fractures and assessed factors that might be associated with the risk of osteoporotic fractures. A total of 64 patients were enrolled. TBS and TBS T-score values were significantly lower in patients with osteoporosis compared to patients without osteoporosis. Low energy fractures occurred in 19 patients. The disturbed bone microarchitecture was found in 30% of patients with fractures without osteoporosis diagnosis based on BMD. In the multivariate analysis, only TBS and age were significantly associated with the occurrence of osteoporotic fractures. TBS reflects the influence of glucocorticoid therapy on bone quality better than DXA measured BMD and provides an added value to DXA in identifying the group of patients particularly prone to fractures.

Fracture Risk Assessment: An Update

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Our ability to accurately identify high fracture risk in individuals has improved as the volume of clinical data has expanded and fracture risk assessment tools have been developed.

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Given its accessibility, affordability, and low radiation exposure, dual x-ray absorptiometry (DXA) remains the standard for osteoporosis screening and monitoring response to treatment.

➤

The trabecular bone score (TBS) is a DXA software add-on that uses lumbar spine DXA imaging to produce an output that correlates with bone microarchitecture. It has been identified as an independent fracture risk factor and may prove useful in further stratifying fracture risk among those with a bone mineral density (BMD) in the osteopenic range (-1.0 to -2.4 standard deviations), in those with low-energy fractures but normal or only mildly low BMD, or in those with conditions known to impair bone microarchitecture.

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Fracture risk assessment tools, including the Fracture Risk Assessment Tool (FRAX), Garvan fracture risk calculator, and QFracture, evaluate the impact of multiple clinical factors on fracture risk, even in the absence of BMD data. Each produces an absolute fracture risk output over a defined interval of time. When used appropriately, these enhance our ability to identify high-risk patients and allow us to differentiate fracture risk among patients who present with similar BMDs.

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For challenging clinical cases, a combined approach is likely to improve accuracy in the identification of high-risk patients who would benefit from the available osteoporosis therapies.

Personalized fracture risk assessment: where are we at?

Introduction: Osteoporotic fracture imposes a significant health care burden globally. Personalized assessment of fracture risk can potentially guide treatment decisions. Over the past decade, a number of risk prediction models, including the Garvan Fracture Risk Calculator (Garvan) and FRAX®, have been developed and implemented in clinical practice. Areas covered: This article reviews recent development and validation results concerning the prognostic performance of the two tools. The main areas of review are the need for personalized fracture risk prediction, purposes of risk prediction, predictive performance in terms of discrimination and calibration, concordance between the Garvan and FRAX tools, genetic profiling for improving predictive performance, and treatment thresholds. In some validation studies, FRAX tended to underestimate fracture by as high as 50%. Studies have shown that the predicted risk from the Garvan tool is highly concordant with clinical decision. Expert opinion: Although there are some discrepancy in fracture risk prediction between Garvan and FRAX, both tools are valid and can aid patients and doctors communicate about risk and make informed decision. The ideal of personalized risk assessment for osteoporosis patients will be realized through the incorporation of genetic profiling into existing fracture risk assessment tools.

Spine Bone Texture Assessed by Trabecular Bone Score in Active and Controlled Acromegaly: A Prospective Study

Context

Acromegalic patients have an increased vertebral fracture (VFx) risk due to bone quality reduction, independently of bone mineral density (BMD).

Objective

The aim of the study is to describe bone quality in acromegaly, measured by trabecular bone score (TBS), a noninvasive index for assessing bone microarchitecture.

Methods

We collected data from 18 patients (13 female, age 56.2 ± 15 years) newly diagnosed with acromegaly. Thirty-six age- and sex-matched healthy controls were also recruited. Pituitary function, bone and calcium-phosphorous metabolism, and BMD at spine and femur and TBS (by dual-energy x-ray absorptiometry) were assessed in acromegalic patients at diagnosis and 12 months after the achievement of insulin-like growth factor 1 (IGF-1) normalization.

Results

At diagnosis, BMD and the VFx prevalence were comparable between patients and controls (28.3 ± 5.9 vs 27.6 ± 3.7 and 11% vs 8.3%), whereas TBS was significantly lower in acromegalic patients (1.20 ± 0.13 vs 1.30 ± 0.06; P < .001) and carboxyterminal telopeptide (CTX) and osteocalcin were significantly higher compared to controls (707 ± 365.7 vs 371 ± 104.1 pg/mL; P = .001 and 31.6 ± 15.4 vs 17.0 ± 5.7 ng/mL; P = .001, respectively). One year after IGF-1 normalization, a significant reduction of bone turnover indexes was observed in the group of acromegalic patients surgically cured (osteocalcin decrease of 61.2%, CTX decrease of 60.3%) compared to the ones controlled by medical therapy (osteocalcin decrease of 39%, CTX decrease of 40.7%; P = .01 and P = .001, respectively). Despite these findings, no TBS or BMD variations were observed.

Conclusion

Acromegalic patients have impaired bone quality despite normal density. Achieving normal growth hormone secretion rapidly leads to the normalization of bone turnover.

Osteopathy in mild adrenal Cushing's syndrome and Cushing disease

Pathophysiology and effects of endogenous glucocorticoid (GC) excess on skeletal endpoints as well as awareness and management of bone fragility are reviewed. Cushing's syndrome (CS) increase the risk of fracture affecting prevalently bone quality. Bone antiresorptive agents (SERMs, bisphosphonates and denosumab) as well as teriparatide increase bone mineral density and in some instances reduce fracture risk. Awareness and management of bone health in CS can be improved.

Skeletal health in patients with differentiated thyroid carcinoma

Osteoporosis and fractures are important comorbidities in patients with differentiated thyroid cancer (DTC), with potential negative impact on quality of life and survival. The main determinant of skeletal fragility in DTC is the thyrotropin (TSH)-suppressive therapy, which is commonly recommended to prevent disease's recurrence, especially in patients with structural incomplete response after thyroid surgery and radio-iodine therapy. TSH-suppressive therapy can stimulate bone resorption with consequent bone loss, deterioration of bone microstructure and high risk of fragility fractures. The skeletal effects of TSH-suppressive therapy may be amplified when thyroid cancer cells localize to the skeleton inducing alterations in bone remodelling, impairment of bone structure and further increase in risk of fractures. The management of skeletal fragility in DTC may be challenging, since prediction of fractures is a matter of uncertainty and data on effectiveness and safety of bone-active agents in this clinical setting are still scanty. This review deals with pathophysiological, clinical and therapeutic aspects of skeletal fragility of patients with DTC.

Beyond Bone Mineral Density: A New Dual X-Ray Absorptiometry Index of Bone Strength to Predict Fragility Fractures, the Bone Strain Index

For a proper assessment of osteoporotic fragility fracture prediction, all aspects regarding bone mineral density, bone texture, geometry and information about strength are necessary, particularly in endocrinological and rheumatological diseases, where bone quality impairment is relevant. Data regarding bone quantity (density) and, partially, bone quality (structure and geometry) are obtained by the gold standard method of dual X-ray absorptiometry (DXA). Data about bone strength are not yet readily available. To evaluate bone resistance to strain, a new DXA-derived index based on the Finite Element Analysis (FEA) of a greyscale of density distribution measured on spine and femoral scan, namely Bone Strain Index (BSI), has recently been developed. Bone Strain Index includes local information on density distribution, bone geometry and loadings and it differs from bone mineral density (BMD) and other variables of bone quality like trabecular bone score (TBS), which are all based on the quantification of bone mass and distribution averaged over the scanned region. This state of the art review illustrates the methodology of BSI calculation, the findings of its in reproducibility and the preliminary data about its capability to predict fragility fracture and to monitor the follow up of the pharmacological treatment for osteoporosis.

Physical and lifestyle factors associated with trabecular bone score values

TBS is associated with age, weight, childhood physical activity, and BMD in men and age, height, BMD, and mobility in women.

INTRODUCTION

Trabecular bone score (TBS) indirectly assesses trabecular microarchitecture at the lumbar spine, providing complementary information to areal BMD. Many studies have investigated the relationships between BMD and lifestyle factors known to affect bone, but such research is limited for TBS. The aim of this study was to assess the relationship between TBS and lifestyle factors in Australian men and women.

METHODS

This cross-sectional study involved 894 men and 682 women (ages 24-98 years) enrolled in the Geelong Osteoporosis Study. TBS was assessed by analysis of lumbar spine DXA scans (Lunar Prodigy) using TBS iNsight software (Version 2.2). Bivariate and multivariable linear regression models were used to explore the associations between TBS and physical and lifestyle factors, including anthropometry, alcohol consumption, childhood physical activity, mobility, smoking status, prior low trauma fracture, medication use, and intakes of calcium and vitamin D.

RESULTS

In bivariate regression modelling, low mobility and the use of antiresorptive medication were associated with lower TBS in both men and women. Low childhood physical activity was also associated with lower TBS in men. Prior fracture, use of glucocorticosteroids, and total calcium intake were also associated with lower TBS in women. The final adjusted model for men included age, weight, childhood physical activity, and BMD, and for women, age, height, BMD, and mobility. No interaction terms were identified in the models.

CONCLUSIONS

Lower TBS is associated with older age, increased weight, low childhood physical activity, and lower BMD in men and older age, shorter stature, lower BMD, and low mobility in women.

Trabecular bone score improves fracture risk assessment in glucocorticoid-induced osteoporosis

OBJECTIVE

To analyse the clinical utility of trabecular bone score (TBS) evaluation for fracture risk assessment in glucocorticoid (GC)-treated patients compared with BMD assessment.

METHODS

One hundred and twenty-seven patients on GC treatment were included [mean age 62 (18) years, 63% women] in this cross-sectional study. The medical history, anthropometric data, lumbar and femoral BMD (DXA) [considering osteoporosis (OP): T-score ⩽-2.5], TBS (considering degraded microarchitecture: <1.230) and dorsolumbar X-ray [to assess vertebral fractures (VF)] were evaluated. BMD and TBS sensitivity, specificity, and positive and negative predictive values (PPV, NPV) were evaluated to determine the diagnostic accuracy of the two methods.

RESULTS

All patients were receiving GC treatment for autoimmune diseases during 47.7 (68.9) months at a mean daily dose of 14.5 mg; 17% had VF, 28% any type of fragility fracture (VF + non-VF), 29% OP and 52% degraded microarchitecture. Degraded microarchitecture was significantly more frequent than densitometric OP in patients with VF (76% vs 38%) and with any fragility fracture (69% vs 36%). For VF, TBS and BMD sensitivity, specificity, PPV, and NPV were 0.76, 0.53, 0.25 and 0.92, and 0.38, 0.72, 0.22 and 0.85, respectively. Specificity increased to 0.89 for VF and 0.9 for any fragility fracture on combining BMD+TBS. TBS had better ability than BMD to discriminate between patients with fracture, especially VF (area under the curve = 0.73).

CONCLUSION

TBS seems to have greater discriminative power than BMD for fracture risk assessment in GC-treated patients, confirming the utility of this method as a complementary tool in the diagnosis of GC-induced OP.

Glucocorticoids and Trabecular Bone Score

TBS (Trabecular Bone Score) is the latest tool for clinicians to evaluate bone micro-architecture based on a pixel greyscale, which is provided by lumbar dual-energy X-ray absorptiometry (DXA). Its use enhances fracture prediction in addition to DXA-BMD (Bone Mineral Density). This is independent of fracture risk assessment (FRAX) and DXA results. We present a narrative review regarding the connection between TBS and Glucocorticoids (GC), either as a drug used for different conditions or as a tumor-produced endogenous excess. TBS is a better discriminator for GC-induced vertebral fractures compared to DXA-BMD. This aspect is similarly available for patients with osteoporosis diagnosed by DXA. TBS is inversely correlated with the cumulative dose of GC (systemic or inhaled), with disease duration, and positively correlated with respiratory function in patients with asthma. Low TBS values are found in females with a T-score at the hip within the osteoporosis range, with diabetes mellitus, or who use GC. Lumbar TBS is a screening tool in menopausal women with type 2 diabetes mellitus. TBS is an independent parameter that provides information regarding skeleton deterioration in diabetic patients receiving GC therapy in a manner complementary to DXA-BMD. TBS might become an essential step regarding the adrenalectomy decision in patients with adrenal incidentaloma in whom autonomous cortisol secretion might damage bone micro-architecture. TBS currently represents a standard tool of fracture risk evaluation in patients receiving GC therapy or with endogenous Cushing's syndrome, a tool easy to be applied by different practitioners since GCs are largely used.

Trabecular bone score in patients with chronic kidney disease

Patients with chronic kidney disease have high risk of osteoporotic fractures. Lower trabecular bone score (TBS) was associated with poorer kidney function and higher fracture risk when kidney function was normal. Addition of TBS to The Fracture Risk Assessment Tool with bone mineral density did not improve fracture risk prediction.

INTRODUCTION

We sought to determine whether trabecular bone score (TBS) either independently or adjusted for The Fracture Risk Assessment Tool (FRAX) could predict risk of major osteoporotic fractures (MOFs) in a large population-based sample of patients with all stages of chronic kidney disease (CKD).

METHODS

We used population-based administrative databases to identify patients above age 20 years who had dual-energy X-ray absorptiometry (DXA) scan and serum creatinine measured within 1 year, during the years 2005 to 2010. Patients were excluded if they were on dialysis or had a functioning renal transplant. We stratified patients by estimated glomerular filtration rate (eGFR). We collected femoral neck bone mineral density (BMD), lumbar spine TBS, incident major osteoporotic fractures (MOF) and hip fractures, and other clinical characteristics.

RESULTS

Among 8289 patients, there were 6224 (75.1%) with eGFR ≥ 60 mL/min/1.73 m², 1624 (19.6%) with eGFR 30-60 mL/min/1.73 m², and 441 (5.3%) with eGFR < 30 mL/min/1.73 m². There were 593 patients (7.2%) with MOFs and 163 (2.0%) with hip fractures. Lower TBS score was associated with increased risk of MOF and hip fractures across all eGFR strata in unadjusted Cox proportional hazards models but after adjusting for FRAX with BMD, lower TBS was only statistically significant for MOF prediction for eGFR ≥ 60 mL/min/1.73 m².

CONCLUSION

Lower TBS scores were associated with lower eGFR and increased fracture risk in patients with eGFR ≥ 60 mL/min/1.73 m². However, the addition of TBS to the FRAX score with BMD did not significantly improve fracture risk prediction in patients with CKD.

Vertebral fracture risk in glucocorticoid-induced osteoporosis: the role of hypogonadism and corticosteroid boluses

OBJECTIVE

The aim of this study was to identify the risk factors associated with fragility fracture (FF) development in glucocorticoid (GC)-treated patients.

METHODS

127 patients (aged 62±18 years, 63% women) on GC-treatment (mean dose 14.5±14.1 mg/day and duration 47.7±69 months) were included. The clinical data collected included bone metabolism study (including gonadal axis), GC-treatment, disease activity, dual-energy X-ray absorptiometry analysis (evaluating densitometric osteoporosis (OP) and trabecular bone score (TBS) degraded microarchitecture values (DMA)), X-ray (assessing vertebral fractures (VF)), FRAX risk (GC-adjusted) and previous FF.

RESULTS

17% of the patients had VF, 28% FF (VF and/or non-VF), 29% OP and 52% DMA. Patients with VF received more GC boluses (57.1% vs 29.5%, p=0.03), were older (68±13 vs 60±19 years, p=0.02), postmenopausal (100% vs 67%, p=0.02), had low testosterone levels (57% vs 11%, p=0.02), lower TBS values (1.119±0.03 vs 1.237±0.013, p<0.001) and higher FRAX risk (17.2±16 vs 9.3±7.6, p=0.003). Patients with FF showed higher accumulated GC doses (16.6±18.4 vs 11.1±12.9 g, p=0.046). On multivariate analysis, hypogonadism (OR 12.38; 95% CI 1.85 to >100, p=0.01) and having received GC boluses (OR 3.45; 95% CI 1.04 to 12.15, p=0.01) were the main factors related to VF. Hypogonadism (OR 7.03; 95% CI 1.47 to 38.37, p=0.01) and FRAX >20 (OR 7.08; 95% CI 1.28 to 53.71, p=0.02) were factors related to FF.

CONCLUSION

Hypogonadism is the principal risk factor for developing fractures in GC-treated men and women, whereas receiving GC boluses is a major factor for VF. These results indicate the importance of evaluating the gonadal axis in these patients.