Use of Trabecular Bone Score (TBS) as a Complementary Approach to Dual-energy X-ray Absorptiometry (DXA) for Fracture Risk Assessment in Clinical Practice

Correlation between Trabecular Bone Score and Homocysteine Level in Rheumatoid Arthritis Patients on Anti-TNF Inhibitors

Rheumatoid arthritis (RA) is an independent osteoporosis risk factor. Biologic and immunosuppressive treatment, and levels of homocysteine and 25-OH vitamin D may influence the trabecular bone score (TBS) in RA patients. We aimed to compare the effects of biological (b) and conventional synthetic (cs) disease-modifying anti-rheumatic drugs (DMARDs) on TBS in patients with RA and hyperhomocysteinemia (HHcy) or 25-OH vitamin D deficiency. Patients who had tests conducted for trabecular bone score, bone mineral density (BMD), homocysteine (Hcy) and 25-OH vitamin D at an interval of one year and met the inclusion criteria were enrolled in this retrospective study. Sixty-four patients with RA were enrolled and were divided into the following two groups: the first group (34 patients) had received treatment with bDMARDs and the second group (30 patients) had received csDMARDs. BDMARDs and csDMARDs had a positive influence on TBS and BMD. The best results were observed in the Adalimumab group (p = 0.033). Hyperhomocysteinemia and 25-OH vitamin D deficiency led to lower TBS values. Both bDMARDs and csDMARDs positively affected TBS and BMD in RA patients. High homocysteine serum levels or 25-OH vitamin D deficiency had a negative impact on TBS and BMD after 12 months. Our study aims to show the potential benefits of anti-TNF α drugs on TBS. This impact appears to be strongly associated with serum 25-OH vitamin D and homocysteine levels. Anti-TNF drugs may increase bone mineral density and microstructure. As a result, they may minimize the incidence of fractures in RA patients.

Imaging in osteogenesis imperfecta: Where we are and where we are going

Osteogenesis imperfecta (OI) is a rare phenotypically and genetically heterogeneous group of inherited skeletal dysplasias. The hallmark features of OI include bone fragility and susceptibility to fractures, bone deformity, and diminished growth, along with a plethora of associated secondary features (both skeletal and extraskeletal). The diagnosis of OI is currently made on clinical grounds and may be confirmed by genetic testing. However, imaging remains pivotal in the evaluation of this disease. The aim of this article is to review the current role played by the various radiologic techniques in the diagnosis and monitoring of OI in the postnatal setting as well as to discuss recent advances and future perspectives in OI imaging. Conventional Radiography and Dual-energy X-ray Absorptiometry (DXA) are currently the two most used imaging modalities in OI. The cardinal radiographic features of OI include generalized osteopenia/osteoporosis, bone deformities, and fractures. DXA is currently the most available technique to assess Bone Mineral Density (BMD), specifically areal BMD (aBMD). However, DXA has important limitations and cannot fully characterize bone fragility in OI based on aBMD. Novel DXA-derived parameters, such as Trabecular Bone Score (TBS), may provide further insight into skeletal changes induced by OI, but evidence is still limited. Techniques like Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) can be useful as problem-solvers or in specific settings, including the evaluation of cranio-cervical abnormalities. Recent evidence supports the use of High-Resolution peripheral Quantitative Computed Tomography (HR-pQCT) as a promising tool to improve the characterization of bone fragility in OI. However, HR-pQCT remains a primarily research technique at present. Quantitative Computed Tomography (QCT) is an alternative to DXA for the determination of BMD at central sites, with distinct advantages but considerably higher radiation exposure. Quantitative Ultrasound (QUS) is a portable, inexpensive, and radiation-free modality that may complement DXA evaluation, providing information on bone quality. However, evidence of usefulness of QUS in OI is poor. Radiofrequency Echographic Multi Spectrometry (REMS) is an emerging non-ionizing imaging method that holds promise for the diagnosis of low BMD and for the prediction of fracture risk, but so far only one published study has investigated its role in OI. To conclude, several different radiologic techniques have proven to be effective in the diagnosis and monitoring of OI, each with their own specificities and peculiarities. Clinicians should be aware of the strategic role of the various modalities in the different phases of the patient care process. In this scenario, the development of international guidelines including recommendations on the role of imaging in the diagnosis and monitoring of OI, accompanied by continuous active research in the field, could significantly improve the standardization of patient care.

Bone involvement in the early stages of Parkinson's disease: a case-control study

OBJECTIVE

To evaluate the qualitative and quantitative alterations of bone tissue in patients with early-stage Parkinson's disease (PD) and to measure the associations between bone mineral density (BMD), trabecular bone score (TBS) and physical performance.

METHODS

This case-control study enrolled patients with early-stage PD and age-matched controls. BMDs for the left femoral neck (L-FN) and lumbar spine (LS) were measured. Bone microarchitecture for the LS was determined using TBS. Muscle performance was assessed using the short physical performance battery (SPPB). Patients and controls were stratified in two groups based on the SPPB score: a poor performance group (SPPB score ≤8) and high performance group (SPPB > 8).

RESULTS

This study included 26 patients: 13 in the PD group and 13 age-matched controls. The mean ± SD BMD results in the PD group were: L1-L4 BMD = 0.935 ± 0.183 g/cm2; L-FN BMD = 0.825 ± 0.037 g/cm2; with bone microarchitecture degraded in four patients and partially degraded in three patients. TBS was significantly different in the patients with PD stratified according to SPPB. Among the controls, there was a significant difference in body mass index between the two SPPB groups.

CONCLUSION

TBS might identify bone involvement earlier than BMD in the initial stages of PD.

Quality of life in postmenopausal women with osteoporosis and osteopenia: associations with bone microarchitecture and nutritional status

PURPOSE

Primary aim of the study was to investigate the status of different health-related quality of life (HRQoL) domains in postmenopausal women with osteoporosis and osteopenia, and to explore possible associations with bone microarchitecture and nutritional status.

METHODS

This was a single-center cross-sectional study that included 232 postmenopausal women, from which they were divided into three groups-osteoporosis (OP, N = 63), osteopenia (OPIA, N = 123), and control group (N = 46). Detailed medical history data and anthropometric measurements were taken from all women. Bone structure parameters were taken with DXA device, with additional analysis of bone microarchitecture status with Trabecular Bone Score (TBS). Nutritional status was assessed with Mini Nutritional Assessment (MNA) questionnaire, and HRQoL with Medical Outcomes Study Short Form-36 (SF-36) questionnaire.

RESULTS

Nutrition evaluation analysis have shown that patients in OP group had significantly lower values of MNA score compared to the OPIA group and control group (P = 0.005). Furthermore, a significant positive correlation was found between all of the SF-36 domains and MNA scores, while significant positive correlation was found between TBS values and Physical functioning (P < 0.001), Bodily pain (P = 0.027), Social functioning (P = 0.029), and Vitality domains (P = 0.041) in total investigated population. Further analyses were performed only in OP and OPIA groups, and TBS score showed significant positive correlation with Physical functioning (r = 0.248, P < 0.001) and Bodily pain domains as well (r = 0.180, P = 0.014), while MNA score positively correlated with each of the SF-36 domains. Multiple regression models have shown that MNA score retained significant association with each SF-36 domains, and TBS value with Physical functioning (P = 0.003), Social functioning (P = 0.012), and Vitality domains (P = 0.014).

CONCLUSION

This study highlights the associations that TBS has with some domains of HRQoL in postmenopausal women with osteoporosis and osteopenia. Moreover, nutritional status could play a role in the complex interplay between TBS and HRQoL.

Trabecular bone score in adults with type 1 diabetes: a meta-analysis

Type 1 diabetes mellitus (T1DM) is associated with a disproportionately high fracture rate despite a minimal decrease in bone mineral density. Though trabecular bone score (TBS), an indirect measure of bone architecture, is lower in adults with T1DM, the modest difference is unlikely to account for the large excess risk and calls for further exploration.

INTRODUCTION

Fracture rates in type 1 diabetes mellitus (T1DM) are disproportionately high compared to the modestly low bone mineral density (BMD). Distortion of bone microarchitecture compromises bone quality in T1DM and is indirectly measured by trabecular bone score (TBS). TBS could potentially be used as a screening tool for skeletal assessment; however, there are inconsistencies in the studies evaluating TBS in T1DM. We performed this meta-analysis to address this knowledge gap.

METHODS

An electronic literature search was conducted using PubMed, Scopus, and Web of Science resources (all-year time span) to identify studies relating to TBS in T1DM. Cross-sectional and retrospective studies in adults with T1DM were included. TBS and BMD data were extracted for pooled analysis. Fracture risk could not be analyzed as there were insufficient studies reporting it.

RESULT

Data from six studies were included (T1DM: n = 378 and controls: n = 286). Pooled analysis showed a significantly lower TBS [standardized mean difference (SMD) =  - 0.37, 95% CI - 0.52 to - 0.21; p < 0.00001] in T1DM compared to controls. There was no difference in the lumbar spine BMD (6 studies, SMD - 0.06, 95% CI - 0.22 to 0.09; p = 0.43) and total hip BMD (6 studies, SMD - 0.17, 95% CI - 0.35 to 0.01; p = 0.06) in the case and control groups.

CONCLUSIONS

Adults with T1DM have a lower TBS but similar total hip and lumbar spine BMD compared to controls. The risk attributable to the significant but limited difference in TBS falls short of explaining the large excess propensity to fragility fracture in adults with T1DM. Further studies on clarification of the mechanism and whether TBS is suited to screen for fracture risk in adults with T1DM are necessary.

Romosozumab is associated with greater trabecular bone score improvement compared to denosumab in postmenopausal osteoporosis

In this study, romosozumab demonstrated significantly greater improvement in trabecular bone score compared to denosumab therapy in postmenopausal women previously treated with antiresorptive agents. Notably, in patients previously treated with anti-resorptive agents, treatment with romosozumab resulted in similar increases in trabecular bone score compared to that of drug-naïve patients.

PURPOSE

Romosozumab significantly increases bone mineral density (BMD) and rapidly reduces fracture risk. Whether romosozumab can improve the spinal trabecular bone score (TBS) as a bone quality indicator merits further investigation.

METHODS

Data for postmenopausal women starting romosozumab or denosumab treatment at Severance Hospital, Korea, were analyzed. Romosozumab and denosumab groups were 1:1 matched using propensity scores, considering relevant covariates. Good responders were defined as those with TBS improvement of 5.8% or greater.

RESULTS

Overall, 174 patients (romosozumab, n = 87; denosumab, n = 87) were analyzed. Matched groups did not differ in age (64 years), weight, height, previous fracture (38%), lumbar spine or femoral neck BMD (T-score, -3.4 and -2.6, respectively), or prior bisphosphonate or selective estrogen receptor modulator (SERM) exposure (50%). The romosozumab group exhibited a greater increase in lumbar spine BMD (15.2% vs. 6.9%, p < 0.001) and TBS (3.7% vs. 1.7%, p = 0.013) than the denosumab group. In patients transitioning from bisphosphonate or SERM, romosozumab users showed greater improvement in TBS compared to denosumab users (3.9% versus 0.8%, P = 0.006); the drug-naive group showed no significant difference (3.6% versus 2.7%, P = 0.472). The romosozumab group had a higher proportion of good responders than the denosumab group (33.3% vs. 18.4%, p = 0.024). Romosozumab therapy for 12 months resulted in 3.8-fold higher odds of a good response in TBS than denosumab after covariate adjustment (adjusted odds ratio 3.85, p = 0.002).

CONCLUSION

Romosozumab could improve bone mass and bone quality, measured by TBS, in postmenopausal osteoporosis, particularly as a subsequent regimen in patients previously taking anti-resorptive agents.

Demystifying the Risk Factors and Preventive Measures for Osteoporosis

Background

Osteoporosis is a major health problem, globally. It is characterized by structural bone weakness leading to an increased risk of fragility fractures. These fractures commonly affect the spine, hip and wrist bones. Consequently, Osteoporosis related proximal femur and vertebral fractures represent a substantial, growing social and economic burden on healthcare systems worldwide. Indentification of the risk factors, clinical risk assessment, utilization of risk assessment tools and appropriate management that play a crucial role in reducing the burden of Osteoporosis by tackling modifiable risk factors.

Methods

This chapter explores various risk factors that are associated with Osteoporosis and provides an overview of various clinical and diagnostic risk assessment tools with a particular emphasis on evidence-based strategies for their prevention.

Conclusion

The role of emerging technologies such as Artificial Intelligence (AI) and perspectives such as newer diagnostic modalities, monitoring and surveillance approaches in prevention of risk factors in the pathogenesis of Osteoporosis is highlighted.

High prevalence of low bone mineral density but normal trabecular bone score in Norwegian elite Para athletes

Background

Low bone mineral density (BMD) increases the risk of bone stress injuries (BSI) and is one of several clinical concerns in Para athlete sports medicine. However, whether bone microarchitecture is altered in Para athletes is not known.

Objective

We aimed to investigate BMD, bone microarchitecture and incidence of bone stress injuries in Norwegian elite Para athletes.

Design

In this cross-sectional study in Para athletes, Dual energy x-ray absorptiometry (iDXA, Lunar, GE Health Care) derived areal BMD, trabecular bone score (TBS), a surrogate marker for bone microarchitecture, and body composition (body weight (BW), lean body mass (LBM), fat mass (FM), fat percentage) were investigated and compared between ambulant and non-ambulant athletes. Also, the association between BMD, TBS and body composition variables was investigated. Incidence of BSI was assessed with a questionnaire and confirmed by a sports physician in a clinical interview. BMD Z-score <-1 was defined as low and ≤-2 as osteoporotic. TBS ≥ 1.31 was normal, 1.23-1.31 intermediate and <1.23 low.

Results

Among 38 athletes (26 ± 6 yrs, 14 females), BMD Z-score was low in 19 athletes, and osteoporotic in 11 athletes' lumbar spine (LS) or femoral neck (FN). BMD was lower in non-ambulant vs. ambulant athletes both in LS (1.13 ± 0.19 vs. 1.25 ± 0.14 g/cm2, p = 0.030) and FN (0.90 ± 0.15 vs. 1.07 ± 0.16 g/cm2, p = 0.003). TBS was normal for all athletes. BMD Z-score in LS was positively associated with TBS (r = 0.408, p = 0.013), body weight (r = 0.326, p = 0.046) and lean body mass (r = 0.414, p = 0.010), but not with fat mass or fat percentage. None of the athletes reported any BSI.

Conclusions

Half of the Norwegian elite Para athletes had low BMD, and 29% had BMD Z-score <-2 suggesting osteoporosis. Non-ambulant athletes were more prone to low BMD than ambulant athletes. However, despite high prevalence of low BMD, TBS was normal in all athletes, and BSI was absent in this young population.

The association of vitamin D with bone microarchitecture, muscle strength, and mobility performance in older women in long-term care

BACKGROUND

Osteoporosis and sarcopenia are prevalent in older adults. Trabecular bone score (TBS) is a novel method to evaluate bone microarchitecture, whereas grip strength and gait speed are simple methods to assess muscle strength and function. Few studies have linked the relationship between vitamin D levels (25OHD) with TBS, grip strength, and gait speed in healthy community dwelling adults. We sought to investigate this relationship in older women with osteoporosis and multiple comorbid conditions residing in long-term care (LTC) facilities.

METHODS

We analyzed baseline 25OHD, spine TBS, grip strength, and gait speed in 246 women with osteoporosis who were residents of LTC and enrolled in a randomized controlled clinical trial.

RESULTS

On average, participants were 81.6 years old and had a BMI of 26.8 kg/m2. The correlation (r) of 25OHD with spine TBS, grip strength, and gait speed were (r = 0.15; p = 0.0208), (r = - 0.05; p = 0.4686), and (r = 0.19; p = 0.0041), respectively. Each 5 ng/dl increase in 25OHD was associated with an increase of 0.006 in spine TBS and 0.014 m/s in gait speed. After adjusting for covariates, each 5 ng/dl increase in 25OHD was associated with an increase of 0.004 in spine TBS (p = 0.0599) and 0.012 m/s in gait speed (p = 0.0144).

CONCLUSION

In older women residing in LTC facilities, 25OHD was associated with spine TBS and gait speed. The strengths of the associations suggest there may be other factors with a more prominent role in bone microarchitecture, muscle strength, and physical function in this population.

MINI ABSTRACT

Our study found in older women who are residents of long-term care facilities, vitamin D level is associated with bone microarchitecture and mobility performance.

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.

New Insights in the Pathophysiology, Epidemiology, and Response to Treatment of Osteoporotic Vertebral Fractures

CONTEXT

Vertebral fractures (VFs) make up an important but challenging group of fractures often caused by osteoporosis. Osteoporotic fractures pose unique diagnostic challenges in generally requiring imaging for diagnosis. The objective of this narrative mini-review is to provide an overview of these recent advances in our knowledge of VF pathophysiology and epidemiology with particular focus on endocrine diseases, prevention, and treatment.

EVIDENCE ACQUISITION

We searched PubMed on May 23, 2022, for studies of VFs in humans. Results were limited to papers available as full-text publications in English, published from 2020 and onward. This yielded 3457 citations. This was supplemented by earlier publications selected to add context to the recent findings.

EVIDENCE SYNTHESIS

Studies addressed VF risk in hyperthyreosis, hyperparathyroidism, acromegaly, Cushing syndrome, primary aldosteronism, and diabetes. For pharmaceutical treatment, new studies or analyses were identified for romosozumab and for weekly teriparatide. Several studies, including studies in the immediate pipeline, were intervention studies with vertebroplasty or kyphoplasty, including combination with stem cells or pharmaceuticals.

CONCLUSIONS

Endocrinologists should be aware of the high likelihood of osteoporotic VFs in patients with endocrine diseases. Though licensed treatments are able to substantially reduce the occurrence of VFs in patients with osteoporosis, the vast majority of recent or ongoing randomized controlled trials in the VF area focus on advanced invasive therapy of the fracture itself.

Evaluation of the trabecular bone score in 35 children and adults with X-linked hypophosphatemic rickets

INTRODUCTION

 The aim of this study is to evaluate and compare the trabecular bone scores (TBSs) of 11 children and 24 adults with X-linked hypophosphatemic rickets (XLH) and non-XLH subjects from a tertiary center.

MATERIALS AND METHODS

 The areal bone mineral density at the lumbar spine (LS-aBMD) and LS-aBMD Z score were analyzed by dual-energy X-ray absorptiometry. The bone mineral apparent density (BMAD) and LS-aBMD Z score adjusted for height Z score (LS-aBMD-HAZ) were calculated. The TBS was determined using TBS iNsight software based on DXA images from the Hologic QDR 4500 device.

RESULTS

The XLH patients exhibited a higher mean LS-aBMD Z score, BMAD, and TBS than the non-XLH subjects (p < 0.01). LS-aBMD-HAZ and BMAD were greater in the XLH children than those in their corresponding non-XLH subjects (p < 0.01 and p = 0.02), and the XLH children trended toward a greater TBS (p = 0.06). The XLH adults had a higher LS-aBMD Z score, BMAD, and TBS than the non-XLH subjects (p < 0.01). When stratified by metabolic status according to the serum values of bone formation markers, compensated adult patients had a higher LS-aBMD Z score, BMAD, and TBS than non-XLH subjects (p < 0.01). Noncompensated patients had higher LS-aBMD Z scores and BMAD results than non-XLH subjects. However, TBS values did not differ statistically significantly between those groups (p = 0.45).

CONCLUSION

The higher LS-aBMD Z score, BMAD, and TBS result in the XLH patients compared to non-XLH subjects indicates an increased amount of trabecular bone within the lumbar spine, regardless of extraskeletal calcifications.

Does locomotive syndrome severity predict future fragility fractures in community-dwelling women with osteoporosis?

OBJECTIVES

We investigated whether the locomotive syndrome (LS) severity affects future fragility fractures in osteoporosis patients.

METHODS

In this retrospective cohort study, 315 women with osteoporosis (mean follow-up period, 2.8 years) were reviewed, of whom 244 were included in the analysis. At baseline, we obtained medical information, bone mineral density of the lumbar spine and femoral neck, and sagittal vertical axis. Additionally, LS risk was assessed using the two-step test, stand-up test, and 25-question geriatric locomotive function scale scores. The LS risk test results were used to classify LS severity, which was rated on a 4-point scale from stage 0 (robust) to 3 (worsening). Cox proportional hazards regression analysis was used to determine the association of the severity with future fragility fracture.

RESULTS

Fragility fractures occurred in 37 of 315 participants (11.8%). This study showed that sagittal vertical axis (hazard ratio = 1.014; 95% confidence interval, 1.005-1.023; p value = 0.003) and LS severity (hazard ratio =1.748; 95% confidence interval, 1.133-2.699; p = 0.012) were independent risk factors for incidence of fragility fracture.

CONCLUSIONS

This study revealed the LS severity to predicted fragility fractures. We suggested that the progression of LS associated with osteoporosis increases the fracture risk.

Fracture risk gradient assessed by categories of bone mineral density and trabecular bone score: the Manitoba BMD Registry

Trabecular bonescore (TBS) helps to predict fracture risk in older adults. In this registry-based cohort study of patients aged 40 years and older, reduction in bone mineral density (BMD) and TBS are complementary for fracture risk prediction enhancement with lower BMD imparting greater risk than reduction in TBS.

PURPOSE

Trabecular bone score (TBS) enhances fracture risk prediction independent of bone mineral density (BMD) in older adults. The purpose of this study was to further evaluate the gradient of fracture risk based on TBS tertile categories and WHO BMD categories, adjusted for other risk factors.

METHODS

Using the Manitoba DXA registry, patients aged 40 years and older with spine/hip DXA and L1-L4 TBS were identified. Any incident fractures, major osteoporotic fractures (MOF), and hip fractures were identified. Cox regression models were used to estimate unadjusted and covariate-adjusted hazard ratios (HR, 95%CI) for incident fracture by BMD and TBS category and for each SD decrease in BMD and TBS.

RESULTS

The study population included 73,108 individuals, 90% female with mean age 64 years. Mean (SD) minimum T-score was - 1.8 (1.1), and mean L1-L4 TBS was 1.257 (0.123). Lower BMD and TBS, both per SD, by WHO BMD category and by TBS tertile category, were significantly associated with MOF, hip, and any fracture (all HRs p < 0.001). However, the quantum of risk was consistently greater for BMD than TBS, with HRs showing non-overlapping CIs.

CONCLUSION

TBS is complementary to BMD in prediction of incident major, hip, and any osteoporosis-related fracture, but reductions in BMD impart greater risk than reductions in TBS on both continuous and categorical scales.

The Significance of Dual-Energy X-ray Absorptiometry (DXA) Examination in Cushing's Syndrome-A Systematic Review

In recent years, the usefulness of dual-energy X-ray absorptiometry (DXA) as a valuable complementary method of assessing the content and distribution of adipose and lean tissue as well as bone mineral density and estimating the risk of fractures has been increasingly confirmed. The diagnosis and treatment of Cushing's syndrome remain challenging, and monitoring the effects of treatment is often necessary. DXA tests offer a potential solution to many problems related to the availability of a quick, detailed, and reliable analysis of changes in the content and distribution of individual body composition components. The article discusses total body DXA scans (FMI, VAT, ALMI), lumbar spine scans (VFA, TBS), and osteoporosis scans (BMD, T-score, Z-score)-all are of potential interest in Cushing's syndrome. The article discusses the use of the most important indicators obtained from a DXA test (FMI, VAT, ALMI, BMD, T-score, Z-score, VFA, TBS) and their clinical significance in Cushing's syndrome was verified. The literature from the last decade was used for the study, available in MEDLINE, Web of Science, and ScienceDirect.

Long-term effect of denosumab on bone microarchitecture as assessed by tissue thickness-adjusted trabecular bone score in postmenopausal women with osteoporosis: results from FREEDOM and its open-label extension

In postmenopausal women with osteoporosis, up to 10 years of denosumab treatment significantly and continuously improved bone microarchitecture assessed by tissue thickness-adjusted trabecular bone score, independently of bone mineral density. Long-term denosumab treatment decreased the number of high fracture-risk patients and shifted more patients to lower fracture-risk categories.

PURPOSE

To investigate the long-term effect of denosumab on bone microarchitecture assessed by tissue thickness-adjusted trabecular bone score (TBS_TT) in post-hoc subgroup analysis of FREEDOM and open-label extension (OLE).

METHODS

Postmenopausal women with lumbar spine (LS) or total hip BMD T-score <-2.5 and ≥-4.0 who completed the FREEDOM DXA substudy and continued in OLE were included. Patients received either denosumab 60 mg subcutaneously every 6 months for 3 years and same-dose open-label denosumab for 7 years (long-term denosumab; n=150) or placebo for 3 years and open-label denosumab for 7 years (crossover denosumab; n=129). BMD and TBS_TT were assessed on LS DXA scans at FREEDOM baseline, month 1, and years 1-6, 8, and 10.

RESULTS

In long-term denosumab group, continued increases from baseline to years 4, 5, 6, 8, and 10 in BMD (11.6%, 13.7%, 15.5%, 18.5%, and 22.4%) and TBS_TT (3.2%, 2.9%, 4.1%, 3.6%, and 4.7%) were observed (all P < 0.0001). Long-term denosumab treatment decreased the proportion of patients at high fracture-risk (according to TBS_TT and BMD T-score) from baseline up to year 10 (93.7 to 40.4%), resulting in increases in the proportions at medium-risk (6.3 to 53.9%) and low-risk (0 to 5.7%) (P < 0.0001). Similar responses were observed in crossover denosumab group. Changes in BMD and TBS_TT were poorly correlated during denosumab treatment.

CONCLUSION

In postmenopausal women with osteoporosis, up to 10 years of denosumab significantly and continuously improved bone microarchitecture assessed by TBS_TT, independently of BMD, and shifted more patients to lower fracture-risk categories.

High prevalence of vertebral deformity in tumor-induced osteomalacia associated with impaired bone microstructure

PURPOSE

Patients with tumor-induced osteomalacia (TIO) often suffer from irreversible height loss due to vertebral deformity. However, the prevalence of vertebral deformity in TIO patients varies among limited studies. In addition, the distribution and type of vertebral deformity, as well as its risk factors, remain unknown. This study aimed to identify the prevalence, distribution, type and risk factors for vertebral deformity in a large cohort of TIO patients.

METHODS

A total of 164 TIO patients were enrolled in this retrospective study. Deformity in vertebrae T4-L4 by lateral thoracolumbar spine radiographs was evaluated according to the semiquantitative method of Genant. Bone microstructure was evaluated by trabecular bone score (TBS) and high-resolution peripheral QCT (HR-pQCT).

RESULTS

Ninety-nine (99/164, 60.4%) patients had 517 deformed vertebrae with a bimodal pattern of distribution (T7-9 and T11-L1), and biconcave deformity was the most common type (267/517, 51.6%). Compared with patients without vertebral deformity, those with vertebral deformity had a higher male/female ratio, longer disease duration, more height loss, lower serum phosphate, higher bone turnover markers, lower TBS, lower areal bone mineral density (aBMD), lower peripheral volumetric BMD (vBMD) and worse microstructure. Lower trabecular vBMD and worse trabecular microstructure in the peripheral bone and lower spine TBS were associated with an increased risk of vertebral deformity independently of aBMD. After adjusting for the number of deformed vertebrae, we found little difference in clinical indexes among the patients with different types of vertebral deformity. However, we found significant correlations of clinical indexes with the number of deformed vertebrae and the spinal deformity index.

CONCLUSION

We reported a high prevalence of vertebral deformity in the largest cohort of TIO patients and described the vertebral deformity in detail for the first time. Risk factors for vertebral deformity included male sex, long disease duration, height loss, abnormal biochemical indexes and bone impairment. Clinical manifestation, biochemical indexes and bone impairment were correlated with the number of deformed vertebrae and degree of deformity, but not the type of deformity.

Association between mixed aldehydes and bone mineral density based on four statistical models

Aldehydes as an environmental pollutant may lead to oxidative stress, which is an important mechanism in the development of osteoporosis. This suggests a possible link between aldehyde exposure and osteoporosis. Considering the mixed nature of aldehyde exposure and the interactions between different aldehydes, we explored for the first time the associations between mixed six aldehydes (benzaldehyde, butyraldehyde, heptanal, hexanal, isovaleraldehyde, and propionaldehyde) and BMD in three populations (men, premenopausal women, and postmenopausal women) by applying four statistical models: quantile g-computation (qgcomp) model, Bayesian kernel machine regression (BKMR) model, generalized linear regression model (GLM), and generalized additive model (GAM), based on the National Health and Nutrition Examination Survey (NHANES) 2013-2014. We found that mixed aldehydes could significantly reduce BMD in men, with hexanaldehyde and propanaldehyde having the greatest negative qgcomp model and BKMR model weights, also confirmed by GLM. The associations between isopentanaldehyde and propanaldehyde and femoral BMD in men were non-linear and had threshold effects as derived from the BKMR model and GAM. The associations turned positive when the concentrations of isopentanaldehyde and propanaldehyde exceeded their respective inflection points. To conclude, our study might provide new ideas for the prevention and treatment of osteoporosis, and hexanaldehyde and propanaldehyde should be more regulated to prevent osteoporosis.

Associations between mixed urinary phenols and parabens metabolites and bone mineral density: Four statistical models

Phenols and parabens widely exist in personal care and consumer products and have been proved to be endocrine disrupting chemicals that could disturb bone metabolism. The current studies focusing on the associations between phenols and parabens with bone mineral density (BMD) drew contradictory conclusions. Considering the bias might be due to not considering the effects of mixed exposure, we conducted the first cross-sectional study to investigate the associations of both single and mixed metabolites of phenols and parabens with BMD in three populations by setting up four models: generalized linear regression model (GLM), weighted quantile sum (WQS) regression model, quantile g-computation (qgcomp) model and Bayesian kernel machine regression (BKMR) model, based on the US National Health and Nutrition Examination Survey (NHANES) database. We found that the association between the mixtures and total femur BMD in men was significantly negative. Bisphenol A (BPA) was shown to play the most important role in this negative association in the BKMR model, and this negative association was also confirmed in the GLM model with β coefficient (95% CI) being -0.02 (-0.04, -0.01). The relationships between the mixtures and femoral neck and trochanter BMD in postmenopausal women were significantly positive. Benzophenone-3 (BP-3) played the most significant role in the positive association with trochanter BMD, as confirmed by the WQS, qgcomp and BKMR models, and this positive association was also verified by the GLM model with β coefficient (95% CI) being 0.01 (0.00, 0.02). In conclusion, the association between the mixed phenols and parabens and BMD was negative in men while was positive in postmenopausal women, which was gender-specific. This study might provide new ideas for the prevention and treatment of osteoporosis and the control of personal care and consumer products containing phenols and parabens in the future.

Detrimental Association Between Blood Cadmium Concentration and Trabecular Bone Score

Osteoporosis has been recognized as a significant cause of disability in the elderly leading to heavy socioeconomic burden. Current measurements such as dual-energy X-ray absorptiometry (DEXA) and bone mineral density (BMD) have limitations. In contrast, trabecular bone score (TBS) is an emerging tool for bone quality assessment. The objective of our study was to investigate the relationship between TBS and trace elements (cadmium and lead). We analyzed all subjects from the 2005-2006 and 2007-2008 National Health and Nutrition Examination Survey (NHANES) dataset and included a total of 8,244 participants in our study; 49.4% of the enrolled subjects were male. We used blood cadmium (Cd) and lead (Pb) concentrations to define environmental exposure. The main variables were TBS and BMD. Other significant demographic features were included as covariates and later adjusted using linear regression models to determine the association between TBS and four quartiles based on the blood trace element concentrations with or without sex differences. The fully adjusted regression model revealed a negative relationship between TBS and blood cadmium (B-Cd) significant for both males and females (both p < 0.05). The β-coefficient for males was -0.009 (95% confidence intervals (CI): (-0.015 to -0.004)) and -0.019 for female (95% CI: (-0.024 to -0.013)). We also found a dose-dependent relationship between TBS and B-Cd for both sexes (both trend's p < 0.05). Our study concluded that TBS could measure Cd-related bone quality deterioration for both males and females.

Trabecular Bone Score as a Risk Factor of Major Osteoporotic Fracture in Postmenopausal Women: The First Study in Thailand

OBJECTIVES

To compare the trabecular bone score (TBS) between Thai postmenopausal women with and without major osteoporotic fracture, and to determine whether TBS is associated with fracture risk.

METHODS

All postmenopausal women sent for dual-energy X-ray absorptiometry (DXA) at the Police General Hospital were retrospectively recruited. The hospital's online database and radiographs were reviewed to collect information on underlying disease, medication, previous fractures, bone mineral density, and trabecular bone score. Patients with anti-osteoporotic medication use, skeletal malignancy, fracture from high-energy trauma, and uninterpretable DXA images were excluded.

RESULTS

A total of 407 Thai postmenopausal women were enrolled. They were divided into 292 women without fractures and 115 women with major osteoporotic fractures. The fracture group was older (73.36 ± 9.95 vs. 66.00 ± 8.58, P < 0.001) and had lower serum 25-hydroxyvitamin D levels (23.28 ± 9.09 vs. 26.44 ± 9.20, P = 0.023). The mean TBS was lower in the fracture group, compared to the non-fracture group (1.244 ± 0.101 vs. 1.272 ± 0.099, P = 0.011). The subgroup analysis resulted in noticeably lower TBS in spine fracture, but not other fracture sites. The odds ratio of fracture was 1.355 (P = 0.013) for a decrease in one standard deviation of TBS.

CONCLUSIONS

TBS was significantly lower in postmenopausal women having fractures with an odd ratio of 1.355 (P = 0.013) per SD decrease in TBS. Categorizing by fracture sites, TBS was only found to be noticeably lower in the lumbar spine despite similar lumbar spine bone mineral density.

Updated trabecular bone score accounting for the soft tissue thickness (TBSTT) demonstrated significantly improved bone microstructure with denosumab in the FREEDOM TBS post hoc analysis

TBS algorithm has been updated to account for regional soft tissue noise. In postmenopausal women with osteoporosis, denosumab improved tissue thickness-adjusted TBS vs placebo independently of bone mineral density over 3 years, with the magnitude of changes from baseline or placebo numerically greater than body mass index-adjusted TBS.

INTRODUCTION

To evaluate the effect of denosumab on bone microarchitecture assessed by trabecular bone score (TBS) in the FREEDOM study using the updated algorithm that accounts for regional soft tissue thickness (TBS_TT) in dual-energy X-ray absorptiometry (DXA) images and to compare percent changes from baseline and placebo with classical body mass index (BMI)-adjusted TBS (TBS_BMI).

METHODS

Postmenopausal women with lumbar spine or total hip bone mineral density (BMD) T score <  - 2.5 and ≥  - 4.0 received placebo or denosumab 60 mg subcutaneously every 6 months. TBS_BMI and TBS_TT were assessed on lumbar spine DXA scans at baseline and months 1, 12, 24, and 36 in a subset of 279 women (129 placebo, 150 denosumab) who completed the 3-year FREEDOM DXA substudy and rolled over to open-label extension study.

RESULTS

Baseline characteristics were similar between groups. TBS_TT in the denosumab group showed numerically greater changes from both baseline and placebo than TBS_BMI at months 12, 24, and 36. Denosumab led to progressive increases in BMD (1.2, 5.6, 8.1, and 10.5%) and TBS_TT (0.4, 2.3, 2.6, and 3.3%) from baseline to months 1, 12, 24, and 36, respectively. Both TBS changes were significant vs baseline and placebo from months 12 to 36 (p < 0.0001). As expected, BMD and TBS_TT were poorly correlated both at baseline and for changes during treatment.

CONCLUSION

In postmenopausal women with osteoporosis, denosumab significantly improved bone microstructure assessed by TBS_TT over 3 years. TBS_TT seemed more responsive to denosumab treatment than TBS_BMI and was independent of BMD.

Diabetes and bone

Globally, one in 11 adults has diabetes mellitus of which 90% have type 2 diabetes. The numbers for osteoporosis are no less staggering: 1 in 3 women has a fracture after menopause, and the same is true for 1 in 5 men after the age of 50 years. Aging is associated with several physiological changes that cause insulin resistance and impaired insulin secretion, which in turn lead to hyperglycemia. The negative balance between bone resorption and formation is a natural process that appears after the fourth decade of life and lasts for the following decades, eroding the bone structure and increasing the risk of fractures. Not incidentally, it has been acknowledged that diabetes mellitus, regardless of whether type 1 or 2, is associated with an increased risk of fracture. The nuances that differentiate bone damage in the two main forms of diabetes are part of the intrinsic heterogeneity of diabetes, which is enhanced when associated with a condition as complex as osteoporosis. This narrative review addresses the main parameters related to the increased risk of fractures in individuals with diabetes, and the mutual factors affecting the treatment of diabetes mellitus and osteoporosis.

Identifying vertebral fractures in the Japanese population using the trabecular bone score: a cross-sectional study

Background

The trabecular bone score (TBS) is reported to be an independent predictor of fracture risk in patients with primary or secondary osteoporosis. However, there have been few reports on its use in the Japanese population. This study aimed to investigate the risk factors for vertebral fracture in the Japanese population and to evaluate the usefulness of TBS.

Methods

This cross-sectional study involved 279 patients aged 60–90 years in whom bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry (DXA). TBS was calculated based on the DXA scans. The presence or absence of vertebral fractures was assessed from T11 to L5. The patients were divided into those with vertebral fractures (VF group, n = 104) and those without vertebral fractures (non-VF group, n = 175).

Results

Of the 104 patients in the VF group, 75 had 1 vertebral fracture and 29 had 2 or more fractures. The mean TBS was 1.28 in the VF group and 1.35 in the non-VF group (p < 0.001). The mean BMD values at the lumbar spine and femoral neck were lower in the VF group (p < 0.001). The areas under the receiver-operating characteristic curve for incidence of vertebral fractures were 0.700, 0.737, and 0.689 for TBS, lumbar spine BMD, and femoral neck BMD, respectively. Multiple logistic regression analysis identified lumbar spine BMD, TBS, and female sex as significant risk factors for vertebral fractures. The proportion of patients in the group with osteoporosis or osteopenia who had vertebral fractures was higher in those with a low TBS (≤ 1.23) than in those with a non-low TBS (> 1.23).

Conclusion

TBS was a significant indicator of vertebral fractures in the Japanese population and might contribute to identifying patients with vertebral fractures, particularly those with osteopenia who need pharmacologic therapy.

ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update

Osteoporosis constitutes a significant public health risk. An estimated 10.2 million adults in the United States >50 years of age have osteoporosis, a systemic condition that weakens the bones increasing the susceptibility for fractures. Approximately one-half of women and nearly one-third of men >50 years of age will sustain an osteoporotic fracture. These fractures are associated with a decrease in quality of life, diminished physical function, and reduced independence. Dual-energy X-ray absorptiometry (DXA) is the primary imaging modality used to screen for osteoporosis in women >65 years of age and men >70 years of age. DXA may be used in patients <65 years of age to evaluate bone mass density if there are additional risk factors. In certain situations, vertebral fracture assessment and trabecular bone score may further predict fracture risk, particularly in patients who are not yet osteoporotic but are in the range of osteopenia. Quantitative CT is useful in patients with advanced degenerative changes in the spine. Given the proven efficacy of pharmacologic therapy, the role of imaging to appropriately identify and monitor high-risk individuals is critical in substantially reducing osteoporosis-associated morbidity and mortality, and reducing the considerable cost to the health care system. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Spine trabecular bone scores and bone mineral density of postmenopausal Taiwanese women

OBJECTIVES

The aims of the study were to determine the mean trabecular bone score (TBS) of postmenopausal Taiwanese women and to analyze the value of TBS in predicting osteoporosis.

METHODS

A total of 1,915 postmenopausal women with lumbar spine and hip bone mineral density (BMD) and spine TBS were enrolled from a single medical center into this study. The women's BMD and TBS were measured using dual x-ray absorptiometry (Discovery Wi; Hologic, Bedford, Mass) and iNsight software (Med-Imaps SASU, Merignac, France), respectively. The women's demographic characteristics; lumbar spine, total hip, and femoral neck BMD; and lumbar spine TBS were recorded, and correlations among the parameters were identified using a 2-tailed Pearson test, in which a P value less than 0.05 was considered statistically significant. We developed simple linear regression models to represent changes related to TBS and performed an analysis of variance on the selected variables.

RESULTS

The average age of the women was 62.5 ± 9.1 years (range, 25.7-93.7 years). The mean TBS was 1.300 ± 0.086 (range, 1.015-1.596). The TBS was weakly and negatively correlated with body mass index ( r = -0.078) and moderately and positively correlated with the lumbar spine BMD ( r = 0.619). The patients' lowest BMD values among those measured at multiple sites revealed a higher rate of osteoporosis (32.5%) than those measured at individual sites. Degraded TBS were noted in 21.2% of the participants, and a combination of BMD and TBS results predicted more individuals (7.8%) at a high risk of fracture than did the BMD result only. The rates of both osteoporosis and degraded TBS increased with age.

CONCLUSIONS

Bone mineral density and TBS can be used in combination to predict osteoporosis in a greater number of postmenopausal Taiwanese women. Because the incidence of osteoporosis is the highest among older women, clinicians should pay careful attention to TBS degradation among older patients without low BMD.

Age Related Trends in Structural Indices of Proximal Femur in Women Aged 20-70 in Southern Sri Lanka

Age related trends of the indices of hip structure help understanding how bone strength changes with age and the increased bone fragility in old age. Community-dwelling women aged 20-70years (n = 419) were selected by stratified random method and divided into age categories; 20-29years (n-69), 30-39years (n = 60), 40-49years (n = 69), 50-59years (n = 107) and 60-70years (n = 114). All subjects underwent dual energy x-ray absorptiometry (DXA) and hip structure analysis using Hologic Discovery scanner (Hologic Inc, Bedford, USA). Measured indices included hip axis length (HAL) and neck shaft angle (NSA) of the proximal femur. Cross sectional area (CSA), cross sectional moment of inertia (CSMI), section modulus (SM), cortical thickness (CT), buckling ration (BR) of three regions of interest; narrow neck, intertrochanteric region and femoral shaft, were also measured. Age related trends of all indices were studied with Locally Weighted Scatterplot Smoothing lines (LOESS) and ANOVA. Mean HAL and NSA values were not different between age categories. CSA, CSMI, SM and CT in three different regions showed curvilinear relationships with age. These indices gradually increased with age between 20-50 years and the maximum values were seen in the 40-49years age category and they declined afterwards. The decline of these indices was more rapid in the narrow neck and intertrochanter regions when compared with femoral shaft and the lowest mean CSA, CSMI, SM and CT in these two regions were seen in the 60-70 age category. BR showed a gradual decrease with age between 20-50 years and the lowest mean value was seen in the 40-49 age category. BR increased afterwards and the maximum mean value was seen in the 60-70 age category. This study demonstrates the dynamics of structural properties of proximal femur in the three selected cross sections of community-dwelling women aged 20-70 years and the increased bone fragility in old age.

Disrupted Sleep Architecture Is Associated With Incident Bone Loss in Indian Postmenopausal Women: A Prospective Study

Inadequate sleep has been shown to be detrimental to several body systems, including the bone. We proposed to study the impact of insomnia on bone health in Indian postmenopausal women. In a 2-year prospective study, ambulant community-dwelling postmenopausal women aged >50 years were recruited through simple random sampling. Sleep duration was recorded based on self-reported sleep duration and sleep quality using the Women's Health Initiative Insomnia Rating Scale (WHIIRS). Anthropometry, bone biochemistry including bone turnover markers (C-terminal telopeptide of type 1 collagen [CTX], N-terminal telopeptide of type 1 pro-collagen [P1NP]), bone mineral density (BMD), and trabecular bone score (TBS) were assessed at baseline and at the end of 2 years. Among 190 postmenopausal women with mean (SD) age of 58.2 (6.9) years, 65/190 (34.2%) had insomnia (WHIIRS ≥ 9) and 20/190 (10.5%) developed osteoporosis at any site on follow-up. The percentage decline over 2 years in BMD in women with insomnia was significantly (p < 0.001) higher at femoral neck (2.9 [1.6] versus 1.2 [1.2]%) and lumbar spine (4.5 [2.0] versus 1.6 [1.1]%). The decrement in TBS was also significantly higher (p < 0.001) in women with suboptimal sleep (1.5 [2.1] versus 0.5 [1.0] %) when compared with those with adequate sleep. The increment in CTX (46.4 [32.2] versus 18.9 [26.4]) and decrement in P1NP (35.4 [9.1] versus 16.7 [18.9]), respectively, were also greater (p < 0.001) in women with insomnia compared with those without. On multivariate analysis, insomnia was the sole factor that was predictive (adjusted odds ratio [OR] = 9.3; 95% confidence interval [CI] 2.9-29.6; p < 0.001) of incident osteoporosis. In conclusion, poor sleep quality was associated with incident osteoporosis in Indian postmenopausal women. Optimal sleep may help to retard ongoing bone loss that results from sleep deprivation and requires further research. © 2022 American Society for Bone and Mineral Research (ASBMR).

Weight Loss Interventions and Skeletal Health in Persons with Diabetes

PURPOSE OF REVIEW

Weight loss is recommended for improving glycemic control and reducing cardiovascular risk factors in persons with diabetes. However, both diabetes and weight loss have been associated with detrimental skeletal health. This review aims to summarize recent study findings on the effects of lifestyle interventions for weight loss on skeletal health among persons with type 2 diabetes (T2D).

RECENT FINDINGS

A few large-scale observational studies have demonstrated an increased fragility fracture risk associated with weight loss among persons with T2D. Randomized control trials in persons with T2D also have shown that intentional lifestyle interventions for weight loss are associated with a greater decrease in bone mineral density (BMD) and an increase in the risk of fracture. The biological mechanisms underlying the compromised bone health during lifestyle interventions for weight loss are complex and not yet conclusive. However, there is evidence to suggest that bone loss and increased fracture risk during intentional weight loss may be mitigated by some intervention approaches, such as high protein intake, calcium supplementation, and resistance and balance training. There is still a lack of studies investigating the effects of different interventions for weight loss on skeletal health among persons with T2D. However, certain types of diet and physical activity intervention combined with bone monitoring and fracture risk prediction may help achieve weight loss goals and maintain skeletal health among persons with T2D during intentional weight loss.

The clinician's guide to prevention and treatment of osteoporosis

Osteoporosis is the most common metabolic bone disease in the USA and the world. It is a subclinical condition until complicated by fracture(s). These fractures place an enormous medical and personal burden on individuals who suffer from them and take a significant economic toll. Any new fracture in an adult aged 50 years or older signifies imminent elevated risk for subsequent fractures, particularly in the year following the initial fracture. What a patient perceives as an unfortunate accident may be seen as a sentinel event indicative of bone fragility and increased future fracture risk even when the result of considerable trauma. Clinical or subclinical vertebral fractures, the most common type of osteoporotic fractures, are associated with a 5-fold increased risk for additional vertebral fractures and a 2- to 3-fold increased risk for fractures at other sites. Untreated osteoporosis can lead to a vicious cycle of recurrent fracture(s), often resulting in disability and premature death. In appropriate patients, treatment with effective antifracture medication prevents fractures and improves outcomes. Primary care providers and medical specialists are critical gatekeepers who can identify fractures and initiate proven osteoporosis interventions. Osteoporosis detection, diagnosis, and treatment should be routine practice in all adult healthcare settings. The Bone Health and Osteoporosis Foundation (BHOF) - formerly the National Osteoporosis Foundation - first published the Clinician's Guide in 1999 to provide accurate information on osteoporosis prevention and treatment. Since that time, significant improvements have been made in diagnostic technologies and treatments for osteoporosis. Despite these advances, a disturbing gap persists in patient care. At-risk patients are often not screened to establish fracture probability and not educated about fracture prevention. Most concerning, the majority of highest risk women and men who have a fracture(s) are not diagnosed and do not receive effective, FDA-approved therapies. Even those prescribed appropriate therapy are unlikely to take the medication as prescribed. The Clinician's Guide offers concise recommendations regarding prevention, risk assessment, diagnosis, and treatment of osteoporosis in postmenopausal women and men aged 50 years and older. It includes indications for bone densitometry as well as fracture risk thresholds for pharmacologic intervention. Current medications build bone and/or decrease bone breakdown and dramatically reduce incident fractures. All antifracture therapeutics treat but do not cure the disease. Skeletal deterioration resumes sooner or later when a medication is discontinued-sooner for nonbisphosphonates and later for bisphosphonates. Even if normal BMD is achieved, osteoporosis and elevated risk for fracture are still present. The diagnosis of osteoporosis persists even if subsequent DXA T-scores are above - 2.5. Ongoing monitoring and strategic interventions will be necessary if fractures are to be avoided. In addition to pharmacotherapy, adequate intake of calcium and vitamin D, avoidance of smoking and excessive alcohol intake, weight-bearing and resistance-training exercise, and fall prevention are included in the fracture prevention armamentarium. Where possible, recommendations in this guide are based on evidence from RCTs; however, relevant published data and guidance from expert clinical experience provides the basis for recommendations in those areas where RCT evidence is currently deficient or not applicable to the many osteoporosis patients not considered for RCT participation due to age and morbidity.

Bone Texture Assessment on Lateral VFAs Using the Texture Research Investigational Platform (TRIP) and its Fracture Discrimination Ability

Texture Research Imaging Platform applies trabecular bone score (TBS) measurement principles to images acquired with multiple modalities to assess bone texture at various skeletal sites. This study aimed to assess the bone texture score in dual-energy X-ray absorptiometry-acquired lateral vertebral fracture assessment (VFA) images (BTS_VFA), evaluate its reproducibility, and vertebral fracture discrimination ability. Subjects included 178 VF cases and 178 non-VF controls, 136 women and 42 men in each group, age 55-92 years, from two research centers. Cases and controls were matched for age (±5 years), body mass index (±5 kg/m²) and TBS. All participants underwent dual-energy X-ray absorptiometry TBS assessment from standard posterior-anterior lumbar spine scans and BTS_VFA assessment. VF presence was determined using VFA images applying the Genant's method. BTS_VFA was lower among fractured women compared to non-fractured (0.626 ± 0.109 vs 0.675 ± 0.099, p < 0.01), but not among men. In a binary logistic regression adjusted for study center and sex, for each SD lower BTS_VFA, there was a 40% increase (OR 1.40, 95% CI (1.13-1.74)) in the risk of having a prevalent VF; area under the curve (95% CI) 0.616 (0.557-0.675). Inter-assessor and inter-centers ICCs for BTS_VFA measurements were very good; 0.96 (0.64-0.99) and 0.98 (0.95-0.99), respectively. The BTS_VFA precision (coefficient of variation) was 2.42%. This feasibility study demonstrates the potential to assess trabecular bone texture in lateral VFA images with good reproducibility. BTS_VFA can discriminate between fractured and non-fractured women independent of their age, body mass index and TBS. In conclusion, BTS_VFA, a potential trabecular texture assessment that excludes the posterior elements, may have value in fracture prediction or as a novel approach to be further investigated in spine surgery planning.

Trabecular bone score in the hip: a new method to examine hip bone microarchitecture-a feasibility study

Our study found, in older adults who are residents of long-term care facilities, assessing hip microarchitecture with DXA-derived bone texture score may serve as a supplement to bone mineral density to improve fracture prediction and to facilitate decision-making for pharmacological management.

PURPOSE

Many patients with high fragility fracture risk do not have a sufficiently low bone mineral density (BMD) to become eligible for osteoporosis treatment. They often have deteriorated bone microarchitecture despite a normal or only mildly abnormal BMD. We sought to examine the beta version of the trabecular bone score (TBS) algorithm for the hip: TBS Hip, an indirect index of bone microarchitecture, and assess if TBS Hip brings complementary information to other bone quality indices such as BMD and bone turnover markers (BTMs) to further improve identifying individuals who are at high risk for fractures.

METHODS

In this analysis, we considered baseline TBS Hip at total hip, femoral neck, and greater trochanter, TBS at lumbar spine, BMD at all of these skeletal sites, and BTMs in 132 postmenopausal women who were residents of long-term care (LTC) facilities enrolled in a randomized placebo-controlled osteoporosis clinical trial.

RESULTS

On average, participants were 85.2 years old and had a BMI of 26.9 kg/m². The correlation coefficient between BMD and TBS Hip at total hip, femoral neck, and greater trochanter was 0.50, 0.32, and 0.39 respectively (all p < 0.0001). The correlation coefficient between BMD and lumbar spine TBS was 0.52 (p < 0.0001). There was no statistically significant correlation between BTMs with TBS at lumbar spine or TBS Hip at total hip, femoral neck, and greater trochanter.

CONCLUSION

Among older women residing in LTC facilities, there was a moderate correlation between measures of BMD and TBS Hip at total hip, femoral neck, and greater trochanter, suggesting TBS Hip may provide complementary information to BMD .

OSTA as a screening tool to predict osteoporosis in Indian postmenopausal women - a nationwide study

This cross-sectional study done on 5356 postmenopausal women showed that OSTA may be used as a reliable screening tool for osteoporosis across different regions of India, a country known for its ethno-linguistic, cultural, and genetic diversity.

BACKGROUND

The gold standard for diagnosing osteoporosis is DXA (dual-energy X-ray absorptiometry) scan, and this is not widely available across India. OSTA (Osteoporosis Self-Assessment Tool for Asians) score predicts risk of osteoporosis and can be used as reference tool for DXA. At a cutoff of ≤  + 1, OSTA predicted femoral neck osteoporosis with a sensitivity of 88% in a previous study among south Indian postmenopausal women. This study was done to validate the OSTA score in postmenopausal women across India.

METHODOLOGY

A cross-sectional study in 5356 postmenopausal women from four regions of India namely south, east, north, and west. Bone mineral density (BMD) and trabecular bone score (TBS) were assessed by DXA. The performance of OSTA in predicting BMD and TBS was assessed using ROC curve.

RESULTS

The mean (SD) age was 61.6 (7.6) years. The performance of OSTA in predicting osteoporosis was fair (P < 0.001) with an AUC of 0.727 (95% CI 0.705-0.749) in the south, 0.693 (95% CI 0.664-0.723) in east India, 0.730 (95% CI 0.700-0.759) in the north, and 0.703 (95% CI 0.672-0.735) in the western region. At a cut-off below + 1.0, sensitivity was 76-84% and specificity was 45-53% in diagnosing osteoporosis at any site. In predicting degraded microarchitecture, the AUC was 0.500-0.600.

CONCLUSION

OSTA may be reliably used as a screening tool for women at high risk of osteoporosis across India and may circumvent the limited availability of DXA scanners across the country.

Trabecular bone score as an additional therapeutic decision tool in osteoporosis and osteopenia

Objectives

To evaluate the role of trabecular bone score (TBS), in addition to bone mineral density (BMD), and to aid decision making to initiate anti-osteoporotic treatment in postmenopausal women with osteopenia.

Methods

TBS was assessed in a cohort of Thai postmenopausal women with BMD of femoral neck (FN), total hip (TH), and lumbar spine (LS) performed at the Police General Hospital, Bangkok, Thailand from July 2019 to October 2020. We retrospectively reviewed hospital database for underlying diseases, medication, and fractures, including relevant imaging and vertebral fracture assessment (VFA). Patients with previous osteoporosis treatment, skeletal malignancy, high-energy trauma, and uninterpretable BMD were excluded.

Results

In total there were 407 postmenopausal women, including 115 with osteoporotic fractures. The mean TBS of the cohort was 1.264 ± 0.005. The proportion of osteoporotic subjects ranged from 9.1% by TH BMD to 27.0% by lowest BMD. In fractured patients, 21.7%–54.8% were found to have osteoporosis while osteopenia was found in 37.4%–43.5%. Among subjects with osteopenia and degraded TBS, fractures ranged from 21.7 to 50.9%. Addition of osteopenic subjects with degraded microarchitecture yielded a significantly higher number of subjects eligible for treatment with 3.25-fold increase in non-fractured participants, and 7 to 11 additional osteopenic patients should be treated to detect 1 fracture.

Conclusions

Addition of TBS helped capturing osteopenic women with high risk of fracture. Decision to treat osteopenic women with degraded TBS increased the number of patients receiving treatment. We recommend evaluating TBS in osteopenic women without fractures to aid therapeutic decision on treatment initiation.

Bone Density and Bone Geometry in University Athletes From Sports With Different Levels of Impact: Simultaneous Association With Multiple Factors

ABSTRACT

Moraes, MS, Fernandes, RA, Moreno, YMF, Pelegrini, A, and Silva, DAS. Bone density and bone geometry in university athletes from sports with different levels of impact: simultaneous association with multiple factors. J Strength Cond Res XX(X): 000-000, 2022-The aim of this study was to use the bone loading unit (BLU) classification to compare bone density and bone geometry of sports with different levels of impact, simultaneously controlling the multiple factors that interfere with bone metabolism in athletes. Overall, 167 university athletes (92 men) participated in the study. Bone mineral density (BMD), strength index, cross-sectional area (CSA) at the moment of inertia, section modulus (Z), CSA, neck-shaft angle (NSA), and hip axis length (HAL) were measured. Sports were categorized by level of impact, high BLU (higher impact) and moderate/low BLU (lower impact). Covariates were fat mass, lean tissue mass, training volume, time of practice, dietary supplementation, use of oral contraceptives and menstrual status. Multiple linear regression with 5% significance level (p < 0.05) was used. In men, HAL was higher in sports with high BLU compared with those with moderate/low BLU (β: -0.21; R2: 0.30; p = 0.03). In women, NSA was higher in sports with moderate/low BLU compared with those with high BLU (β: 0.31; R2: 0.11; p = 0.02). There was no difference between BLU groups for BMD. These results persisted when the simultaneous interference of covariates was controlled. Thus, this study recommends BLU to classify sports and reinforces the importance of monitoring HAL and NSA in athletes in addition to the control of multiple factors that interfere with bone metabolism, because they influence physical performance and bone health during and after athletic life.

Reproducibility and Accuracy of the Radiofrequency Echographic Multi-Spectrometry for Femoral Mineral Density Estimation and Discriminative Power of the Femoral Fragility Score in Patients with Primary and Disuse-Related Osteoporosis

We aimed to investigate the reproducibility and accuracy of Radiofrequency Echographic Multi-Spectrometry (REMS) for femoral BMD estimation and the reproducibility and discriminative power of the REMS-derived femoral fragility score. 175 patients with primary and disuse-related osteoporosis were recruited: one femoral Dual-energy X-ray Absorptiometry (DXA) scan and two femoral REMS scans were acquired. No significant test—retest differences were observed for all REMS-derived variables. The diagnostic concordance between DXA and REMS was 63% (Cohen’s kappa = 0.31) in patients with primary osteoporosis and 13% (Cohen’s kappa: −0.04) in patients with disuse-related osteoporosis. No significant difference was observed between REMS and DXA for either femoral neck BMD (mean difference between REMS and DXA: −0.015 g/cm²) or total femur BMD (mean difference: −0.004 g/cm²) in patients with primary osteoporosis. Significant differences between the two techniques were observed in patients with disuse-related osteoporosis (femoral neck BMD difference: 0.136 g/cm²; total femur BMD difference: 0.236 g/cm²). Statistically significant differences in the fragility score were obtained between the fractured and non-fractured patients for both populations. In conclusion, REMS showed excellent test-retest reproducibility, but the diagnostic concordance between DXA and REMS was between minimal and poor. Further studies are required to improve the REMS—derived estimation of femoral BMD.

Bone mass and microarchitecture in T2DM patients and corticosteroids therapy: the Bushehr Elderly Health program

Purpose

Our study examined whether T2DM and glucocorticoids treatment affect bone quality and quantity that are measured by Bone Mineral Density (BMD) and Trabecular Bone Score (TBS).

Materials & methods

Participants in this study were 2294 women and men aged over 60 years who participated in stage II of the Bushehr Elderly Health (BEH) program. Patients with T2DM and those who received glucocorticoids were included. BMD was detected using the DXA method and the TBS of L1-L4 was evaluated by TBS iNsight® software. To evaluate the correlation between TBS and BMD levels with diabetes and taking corticosteroids sex-specific multivariable linear regression models were appplied.

Results

TBS and BMD were not significantly different in those who had received glucocorticoids versus those who did not.T2DM revealed a significant association with both BMD and TBS in men (beta = 0.12, p < 0.001 and beta = 0.063, p = 0.03, respectively). BMD values were significantly higher in diabetic women (beta = 0.073, p < 0.01). BMI had a significant association with both TBS and BMD but in an opposite direction, in women and men (BMD: beta = -0.22, -0.24, and regarding TBS: beta = 0.37, 0.25, all p-values < 0.001).

Conclusion

Our findings showed that T2DM had major effects on BMD in both men and women. However, T2DM only affects TBS in men. Furthermore, neither BMD nor TBS were affected by GC intake in men or women.Based on the variable importance of covariates, BMI was the most influential factor on both BMD and TBS, although in opposite directions, in both sexes.

Association with sagittal alignment and osteoporosis-related fractures in outpatient women with osteoporosis

The baseline sagittal vertical axis (SVA) and pelvic tilt (PT) are independent risk factors of osteoporosis-related fractures in women with osteoporosis. We clarified the SVA and PT to predict the incidence of osteoporosis-related fractures.

PURPOSE

Sagittal alignment with osteoporosis women deteriorates with advancing age and sagittal alignment may indicate osteoporosis-related fractures in the future. However, whether the sagittal alignment predicts future osteoporosis-related fracture in patients with osteoporosis has not been clarified. We aimed to investigate the association between sagittal alignment and future osteoporosis-related fractures.

METHODS

This was a retrospective cohort study. Of the 313 participants (mean follow-up period, 2.9 years), 236 were included in the analysis. At baseline, we measured bone mineral density (BMD) of the lumbar spine and the femoral neck, sagittal vertical axis (SVA), thoracic kyphosis, pelvic incidence minus lumbar lordosis, sacral slope, pelvic tilt (PT), geriatric locomotive function scale (GLFS), two-step value, and stand-up test. The information on medications and the duration of treatment were reviewed from the medical records. Additionally, participants reported their history of falls at baseline. Multiple logistic regression analysis was used to determine the association of future osteoporosis-related fracture, and adjusted Odds ratios (OR) and 95% confidence interval (CI) were calculated with all predictors as covariates. All continuous variables were calculated using standardized OR (sOR).

RESULTS

Osteoporosis-related fractures occurred in 33 of 313 participants (10.5%). Multiple logistic regression analysis showed that a history of falls (OR =4.092, 95% CI: 1.029-16.265, p =0.045), SVA (sOR =4.228, 95% CI: 2.118-8.439, p <0.001), and PT (sOR =2.497, 95% CI: 1.087-5.733, p =0.031) were independent risk factors for future osteoporosis-related fractures.

CONCLUSIONS

This study revealed the SVA and PT to predict osteoporosis-related fractures.

TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION

UMIN000036516 (April 1, 2019).

Osteoporosis in Rheumatic Diseases

The risk of osteoporosis and fragility fracture is increased in patients with autoimmune rheumatic diseases. Although the use of glucocorticoids is the major contributing factor, inflammation mediated by cytokines and growth factors and other medications, including the biologic and targeted disease-modifying antirheumatic drugs, also play important roles in bone remodeling. Pro-inflammatory cytokines such as IL-1, IL-6, IL-17, and TNF[Formula: see text] increase RANK expression and promote osteoclast activity while inhibiting osteoblast-mediated bone formation through the Dickkopf-1 pathway. Certain autoantibodies stimulate differentiation of the osteoclasts, resulting in localized bone resorption. This article covers the prevalence and risk factors for osteoporosis in patients with common rheumatic diseases and the role of inflammatory cytokines and other clinical factors. Controlling disease-related inflammation and optimizing the diagnostic and therapeutic instrumentation is needed to reduce fragility fractures in patients with rheumatic diseases.

Impact of Sarcopenia and Bone Mineral Density on Implant Failure after Dorsal Instrumentation in Patients with Osteoporotic Vertebral Fractures

Background and Objectives: Age-related loss of bone and muscle mass are signs of frailty and are associated with an increased risk of falls and consecutive vertebral fractures. Management often necessitates fusion surgery. We determined the impacts of sarcopenia and bone density on implant failures (IFs) and complications in patients with spondylodesis due to osteoporotic vertebral fractures (OVFs). Materials and Methods: Patients diagnosed with an OVF according to the osteoporotic fracture classification (OF) undergoing spinal instrumentation surgery between 2011 and 2020 were included in our study. The skeletal muscle area (SMA) was measured at the third lumbar vertebra (L3) level using axial CT images. SMA z-scores were calculated for the optimal height and body mass index (BMI) adjustment (zSMA_HT). The loss of muscle function was assessed via measurement of myosteatosis (skeletal muscle radiodensity, SMD) using axial CT scans. The bone mineral density (BMD) was determined at L3 in Hounsfield units (HU). Results: A total of 68 patients with OVFs underwent instrumentation in 244 segments (mean age 73.7 ± 7.9 years, 60.3% female). The median time of follow-up was 14.1 ± 15.5 months. Sarcopenia was detected in 28 patients (47.1%), myosteatosis in 45 patients (66.2%), and osteoporosis in 49 patients (72%). The presence of sarcopenia was independent of chronological age (p = 0.77) but correlated with BMI (p = 0.005). The zSMA_HT was significantly lower in patients suffering from an IF (p = 0.0092). Sarcopenia (OR 4.511, 95% CI 1.459–13.04, p = 0.0092) and osteoporosis (OR 9.50, 95% CI 1.497 to 104.7, p = 0.014) increased the likelihood of an IF. Using multivariate analysis revealed that the zSMA_HT (p = 0.0057) and BMD (p = 0.0041) were significantly related to IF occurrence. Conclusion: Herein, we established sarcopenic obesity as the main determinant for the occurrence of an IF after instrumentation for OVF. To a lesser degree, osteoporosis was associated with impaired implant longevity. Therefore, measuring the SMA and BMD using an axial CT of the lumbar spine might help to prevent an IF in spinal fusion surgery via early detection and treatment of sarcopenia and osteoporosis.

Why Aboriginal and Torres Strait Islander Australians fall and fracture: the codesigned Study of Indigenous Muscle and Bone Ageing (SIMBA) protocol

OBJECTIVES

Aboriginal and Torres Strait Islander Australians have a substantially greater fracture risk, where men are 50% and women are 26% more likely to experience a hip fracture compared with non-Indigenous Australians. Fall-related injuries in this population have also increased by 10%/year compared with 4.3%/year in non-Indigenous Australians. This study aims to determine why falls and fracture risk are higher in Aboriginal and Torres Strait Islander Australians.

SETTING

All clinical assessments will be performed at one centre in Melbourne, Australia. At baseline, participants will have clinical assessments, including questionnaires, anthropometry, bone structure, body composition and physical performance tests. These assessments will be repeated at follow-up 1 and follow-up 2, with an interval of 12 months between each clinical visit.

PARTICIPANTS

This codesigned prospective observational study aims to recruit a total of 298 adults who identify as Aboriginal and Torres Strait Islander and reside within Victoria, Australia. Stratified sampling by age and sex will be used to ensure equitable distribution of men and women across four age-bands (35-44, 45-54, 55-64 and 65+ years).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome is within-individual yearly change in areal bone mineral density at the total hip, femoral neck and lumbar spine assessed by dual energy X-ray absorptiometry. Within-individual change in cortical and trabecular volumetric bone mineral density at the radius and tibia using high-resolution peripheral quantitative computed tomography will be determined. Secondary outcomes include yearly differences in physical performance and body composition.

ETHICAL APPROVAL

Ethics approval for this study has been granted by the Monash Health Human Research Ethics Committee (project number: RES-19-0000374A).

TRIAL REGISTRATION NUMBER

ACTRN12620000161921.

The Impact of Bariatric Surgery on Bone Health: State of the Art and New Recognized Links

Bariatric surgery (BS) is the most effective therapy for severe obesity, which improves several comorbidities (such as diabetes, hypertension, dyslipidemia, among others) and results in marked weight loss. Despite these consensual beneficial effects, sleeve gastrectomy and Roux-en-Y gastric bypass (the two main bariatric techniques) have also been associated with changes in bone metabolism and progressive bone loss. The objective of this literature review is to examine the impact of bariatric surgery on bone and its main metabolic links, and to analyze the latest findings regarding the risk of fracture among patients submitted to bariatric surgery.

Trabecular bone score and sclerostin concentrations in patients with primary adrenal insufficiency

BACKGROUND

Patients with primary adrenal insufficiency need lifelong replacement therapy with glucocorticoids and mineralocorticoids, which may influence their bone quality.

AIM

The aim of the study was to evaluate densitometry parameters, trabecular bone score and sclerostin concentrations in patients with primary adrenal insufficiency in comparison to control group.

MATERIALS AND METHODS

We included 29 patients (62% females) with diagnose of autoimmune primary adrenal insufficiency (mean age 49.7 ± 11.7 years, mean duration of the disease 13.2± 13.6 years) and 33 healthy subjects (adjusted with age, sex and body mass index). Bone mineral density at the femoral neck, lumbar spine, total body and trabecular bone score were evaluated. Serum sclerostin concentrations were measured.

RESULTS

There were no significant differences in densitometry parameters (T-score, Z-score, bone mineral density in all locations) as well as in trabecular bone score in patients with adrenal insufficiency in comparison to control group. Mean serum sclerostin concentration was significantly higher in patients with adrenal insufficiency than in control group (44.7 ± 23.5 vs 30.7 ± 10.4 pmol/l, p=0.006). There was a negative correlation between trabecular bone score and the duration of adrenal insufficiency and age, also a negative correlation between femoral neck and total densitometry parameters and 24-hour urine cortisol as a marker of hydrocortisone daily dose in patients with adrenal insufficiency.

CONCLUSIONS

The bone status in patients with primary adrenal insufficiency was not impaired in comparison to control group, while sclerostin concentration was higher. The duration of the disease and higher hydrocortisone doses may affect negatively bone status.

Proximal Hip Geometry, Trabecular Bone Score, Bone Mineral Density and Bone Mineral Parameters in Patients With Cryptogenic and Hepatitis B Related Cirrhosis- A Study From the Indian Subcontinent

The impact of cryptogenic cirrhosis on skeleton has not been studied in Indian context. So this study investigated bone health in male patients with early cryptogenic cirrhosis as defined by Child-Turcot-Pugh A (CTP-A) categorization and compared it with patients diagnosed to have hepatitis B related chronic liver disease (CLD) on treatment and age, sex-matched healthy controls. It was a cross-sectional study, in which thirty male subjects were recruited in each group. Bone mineral density (BMD), trabecular bone score (TBS), hip structural analysis (HSA) and bone mineral parameters were assessed. The mean ±SD age of the study subjects was 39.3 ± 9.2 years. The mean 25-hydroxy vitamin D was significantly lower in subjects with cryptogenic cirrhosis as compared to controls (p = 0.001). Subjects with cryptogenic cirrhosis had significantly lower (1.297 ± 0.099) TBS as compared to hepatitis-B related CLD (1.350 ± 0.094) control subjects (1.351 ± 0.088) (p = 0.04). BMD at the hip and lumbar spine was also significantly lower in subjects with cryptogenic cirrhosis as compared to hepatitis-B related CLD and healthy age matched controls (p < 0.05). Most components of HSA were significantly affected in subjects with cryptogenic cirrhosis as compared to control subjects (p < 0.05). Patients with cryptogenic cirrhosis had significantly low TBS and BMD lumbar spine and hip as well as poor proximal hip geometry which may be good predictor of future fragility fractures.

Postmenopausal osteoporosis: risk evaluation and treatment options

Postmenopausal osteoporosis is a chronic progressive condition characterized by reduced bone mass and impaired bone quality, leading to an increased risk of fragility fractures. Osteoporotic fractures reduce quality of life and are associated with high morbidity, mortality and economic burden. Primary and secondary prevention interventions are always recommended starting from the premenopausal age, in women after menopause, however, it is essential to develop a long-term intervention strategy that allows to identify patients at high risk of fracture and the choice of therapy based on the estimated risk. This narrative review described the tools for layering the management approach in relation to low, high and very high fracture risk. Several medications are now available for the treatment of osteoporosis and the prevention of fractures; the knowledge of the efficacy, safety and additional benefits profile of the individual preparations allows an appropriate choice between the different drugs available and the possibility of adapting the prescription to the lifetime fracture risk spectrum. From the literature it emerges that menopausal hormone therapy (MHT), TSEC combination and SERMs can be drugs of choice to counteract postmenopausal bone loss in younger women or at low risk of fracture, while bisphosphonates and denosumab are appropriate for women with high risk or at an older age. Therapy with denosumab and anabolic agents such as teriparatide and romosozumab is particularly indicated for subjects with very high risk of fracture.

Effect of testosterone treatment on the trabecular bone score in older men with low serum testosterone

The trabecular bone score (TBS) is an indirect measure of vertebral bone microarchitecture. Our objective was to examine the effect of testosterone treatment on TBS. One hundred and ninety-seven hypogonadal men were randomized to testosterone or placebo. After 12 months, there was no difference in the changes in TBS by randomized group.

INTRODUCTION

In the Bone Trial of the Testosterone Trials, testosterone treatment increased trabecular volumetric bone mineral density (vBMD) and increased estimated bone strength as determined by finite element analysis. The trabecular bone score (TBS) is an indirect measure of vertebral bone microarchitecture. TBS predicts fracture independent of lumbar spine areal (a) BMD. The objective of this study was to examine the effect of testosterone treatment on TBS compared to its effects on vBMD and aBMD.

METHODS

Two hundred and eleven men were enrolled in the Bone Trial of the Testosterone Trials. Of these, 197 men had 2 repeat TBS and vBMD measurements; 105 men were allocated to receive testosterone, and 92 men to placebo for 1 year. TBS, aBMD, and vBMD were assessed at baseline and month 12.

RESULTS

There was no difference in the percent change in TBS by randomized group: 1.6% (95% confidence intervals (CI) 0.2-3.9) in the testosterone group and 1.4% (95% CI -0.2, 3.1) in the placebo group. In contrast, vBMD increased by 6% (95% CI 4.5-7.5) in the testosterone group compared to 0.4% (95% CI -1.65-0.88) in the placebo groups.

CONCLUSIONS

TBS is not clinically useful in monitoring the 1-year effect of testosterone treatment on bone structure in older hypogonadal men.

The Polygenic and Monogenic Basis of Paediatric Fractures

PURPOSE OF REVIEW

Fractures are frequently encountered in paediatric practice. Although recurrent fractures in children usually unveil a monogenic syndrome, paediatric fracture risk could be shaped by the individual genetic background influencing the acquisition of bone mineral density, and therefore, the skeletal fragility as shown in adults. Here, we examine paediatric fractures from the perspective of monogenic and complex trait genetics.

RECENT FINDINGS

Large-scale genome-wide studies in children have identified ~44 genetic loci associated with fracture or bone traits whereas ~35 monogenic diseases characterized by paediatric fractures have been described. Genetic variation can predispose to paediatric fractures through monogenic risk variants with a large effect and polygenic risk involving many variants of small effects. Studying genetic factors influencing peak bone attainment might help in identifying individuals at higher risk of developing early-onset osteoporosis and discovering drug targets to be used as bone restorative pharmacotherapies to prevent, or even reverse, bone loss later in life.

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.

Multi-hole spherical CT scan method to characterize large quantities of bones in rats

BACKGROUND New therapeutic options are often explored in in vivo studies using animals like rats. Since rats are small, it is difficult to examine them in a computed tomography (CT) scan. This study aimed to introduce a multi-hole spherical model CT scan method as a new, fast, economical, and reliable method to characterize large quantities of rat bones at once in estimating the timing of osteoporosis in ovariectomized white rats. METHODS 50 female white rats (12 weeks old) were treated as the control group, and 40 rats of the same age were ovariectomized to establish the osteoporosis model. Sham rats were sacrificed at 13, 15, 17, 19, and 21 weeks old, while the ovariectomized rats were sacrificed at 15, 17, 19, and 21 weeks old. Afterward, tibia bones were removed, placed in the multi-hole spherical model, and characterized using a CT scan. Their characteristics were compared using a scanning electron microscope (SEM), transmission electron microscopy (TEM), and X-ray diffraction (XRD). RESULTS The Hounsfield unit scores resulted from the multi-hole spherical model CT scan method of tibia bones of rats were consistent with the percentage of the osteocyte cavities, canalicular diameters, and crystal size. The multi-hole spherical model CT scan method could produce 50 times more data than the SEM, TEM, or XRD. CONCLUSIONS Multi-hole spherical model CT scan was considered good and reliable in assessing bone quality parameters in rat samples simultaneously.

Osteoporosis in spine surgery patients: what is the best way to diagnose osteoporosis in this population?

OBJECTIVE

The goal of this study was to compare different recognized definitions of osteoporosis in patients with degenerative lumbar spine pathology undergoing elective spinal fusion surgery to determine which patient population should be considered for preoperative optimization.

METHODS

A retrospective review of patients in whom lumbar spine surgery was planned at 2 academic medical centers was performed, and the rate of osteoporosis was compared based on different recognized definitions. Assessments were made based on dual-energy x-ray absorptiometry (DXA), CT Hounsfield units (HU), trabecular bone score (TBS), and fracture risk assessment tool (FRAX). The rate of osteoporosis was compared based on different definitions: 1) the WHO definition (T-score ≤ -2.5) at total hip or spine; 2) CT HU of < 110; 3) National Bone Health Alliance (NBHA) guidelines; and 4) "expanded spine" criteria, which includes patients meeting NBHA criteria and/or HU < 110, and/or "degraded" TBS in the setting of an osteopenic T-score. Inclusion criteria were adult patients with a DXA scan of the total hip and/or spine performed within 1 year and a lumbar spine CT scan within 6 months of the physician visit.

RESULTS

Two hundred forty-four patients were included. The mean age was 68.3 years, with 70.5% female, 96.7% Caucasian, and the mean BMI was 28.8. Fracture history was reported in 53.8% of patients. The proportion of patients identified with osteoporosis on DXA, HUs, NBHA guidelines, and the authors' proposed "expanded spine" criteria was 25.4%, 36.5%, 75%, and 81.9%, respectively. Of the patients not identified with osteoporosis on DXA, 31.3% had osteoporosis based on HU, 55.1% had osteoporosis with NBHA, and 70.4% had osteoporosis with expanded spine criteria (p < 0.05), with poor correlations among the different assessment tools.

CONCLUSIONS

Limitations in the use of DXA T-scores alone to diagnose osteoporosis in patients with lumbar spondylosis has prompted interest in additional methods of evaluating bone health in the spine, such as CT HU, TBS, and FRAX, to inform guidelines that aim to reduce fracture risk. However, no current osteoporosis assessment was developed with a focus on improving outcomes in spinal surgery. Therefore, the authors propose an expanded spine definition for osteoporosis to identify a more comprehensive cohort of patients with potential poor bone health who could be considered for preoperative optimization, although further study is needed to validate these results in terms of clinical outcomes.