Therapeutic approaches to osteosarcopenia: insights for the clinician

MicroRNAs and their Modulatory Effect on the Hallmarks of Osteosarcopenia

PURPOSE OF THE REVIEW

Osteosarcopenia is a geriatric syndrome associated with disability and mortality. This review summarizes the key microRNAs that regulate the hallmarks of sarcopenia and osteoporosis. Our objective was to identify components similarly regulated in the pathology and have therapeutic potential by influencing crucial cellular processes in both bone and skeletal muscle.

RECENT FINDINGS

The simultaneous decline in bone and muscle in osteosarcopenia involves a complex crosstalk between these tissues. Recent studies have uncovered several key mechanisms underlying this condition, including the disruption of cellular signaling pathways that regulate bone remodeling and muscle function and regeneration. Accordingly, emerging evidence reveals that dysregulation of microRNAs plays a significant role in the development of each of these hallmarks of osteosarcopenia. Although the recent recognition of osteosarcopenia as a single diagnosis of bone and muscle deterioration has provided new insights into the mechanisms of these underlying age-related diseases, several knowledge gaps have emerged, and a deeper understanding of the role of common microRNAs is still required. In this study, we summarize current evidence on the roles of microRNAs in the pathogenesis of osteosarcopenia and identify potential microRNA targets for treating this condition. Among these, microRNAs-29b and -128 are upregulated in the disease and exert adverse effects by inhibiting IGF-1 and SIRT1, making them potential targets for developing inhibitors of their activity. MicroRNA-21 is closely associated with the occurrence of muscle and bone loss. Conversely, microRNA-199b is downregulated in the disease, and its reduced activity may be related to increased myostatin and GSK3β activity, presenting it as a target for developing analogues that restore its function. Finally, microRNA-672 stands out for its ability to protect skeletal muscle and bone when expressed in the disease, highlighting its potential as a possible therapy for osteosarcopenia.

Osteosarcopenia and Mortality in Older Adults Undergoing Transcatheter Aortic Valve Replacement

Importance

Osteosarcopenia is an emerging geriatric syndrome characterized by age-related deterioration in muscle and bone. Despite the established relevance of frailty and sarcopenia among older adults undergoing transcatheter aortic valve replacement (TAVR), osteosarcopenia has yet to be investigated in this setting.

Objective

To determine the association between osteosarcopenia and adverse outcomes following TAVR.

Design, Setting, and Participants

This is a post hoc analysis of the Frailty in Aortic Valve Replacement (FRAILTY-AVR) prospective multicenter cohort study and McGill extension that enrolled patients aged 70 years or older undergoing TAVR from 2012 through 2022. FRAILTY-AVR was conducted at 14 centers in Canada, the United States, and France between 2012 and 2016, and patients at the McGill University-affiliated center in Montreal, Québec, Canada, were enrolled on an ongoing basis up to 2022.

Exposure

Osteosarcopenia as measured on computed tomography (CT) scans prior to TAVR.

Main Outcomes and Measures

Clinically indicated CT scans acquired prior to TAVR were analyzed to quantify psoas muscle area (PMA) and vertebral bone density (VBD). Osteosarcopenia was defined as a combination of low PMA and low VBD according to published cutoffs. The primary outcome was 1-year all-cause mortality. Secondary outcomes were 30-day mortality, hospital length of stay, disposition, and worsening disability. Multivariable logistic regression was used to adjust for potential confounders.

Results

Of the 605 patients (271 [45%] female) in this study, 437 (72%) were octogenarian; the mean (SD) age was 82.6 (6.2) years. Mean (SD) PMA was 22.1 (4.5) cm2 in men and 15.4 (3.5) cm2 in women. Mean (SD) VBD was 104.8 (35.5) Hounsfield units (HU) in men and 98.8 (34.1) HU in women. Ninety-one patients (15%) met the criteria for osteosarcopenia and had higher rates of frailty, fractures, and malnutrition at baseline. One-year mortality was highest in patients with osteosarcopenia (29 patients [32%]) followed by those with low PMA alone (18 patients [14%]), low VBD alone (16 patients [11%]), and normal bone and muscle status (21 patients [9%]) (P < .001). Osteosarcopenia, but not low VBD or PMA alone, was independently associated with 1-year mortality (odds ratio [OR], 3.18; 95% CI, 1.54-6.57) and 1-year worsening disability (OR, 2.11; 95% CI, 1.19-3.74). The association persisted in sensitivity analyses adjusting for the Essential Frailty Toolset, Clinical Frailty Scale, and geriatric conditions such as malnutrition and disability.

Conclusions and Relevance

The findings suggest that osteosarcopenia detected using clinical CT scans could be used to identify frail patients with a 3-fold increase in 1-year mortality following TAVR. This opportunistic method for osteosarcopenia assessment could be used to improve risk prediction, support decision-making, and trigger rehabilitation interventions in older adults.

Three-Year Mortality of Older Hospitalized Patients with Osteosarcopenia: Data from the OsteoSys Study

Osteosarcopenia, the concurrent presence of sarcopenia and osteopenia/osteoporosis, poses a significant health risk to older adults, yet its impact on clinical outcomes is not fully understood. The aim of this prospective, longitudinal multicentre study was to examine the impact of osteosarcopenia on 3-year mortality and unplanned hospitalizations among 572 older hospitalized patients (mean age 75.1 ± 10.8 years, 78% female). Sarcopenia and low bone mineral density (BMD) were evaluated using Dual Energy X-ray Absorptiometry and the European Working Group on Sarcopenia in Older People (EWGSOP2) and WHO criteria, respectively. Among participants, 76% had low BMD, 9% were sarcopenic, and 8% had osteosarcopenia. Individuals with osteosarcopenia experienced a significantly higher rate of mortality (46%, p < 001) and unplanned hospitalization (86%, p < 001) compared to those without this condition. Moreover, "healthy" subjects-those without sarcopenia or low BMD-showed markedly lower 3-year mortality (9%, p < 001) and less unplanned hospitalization (53%, p < 001). The presence of osteosarcopenia (p = 0.009) increased the 3-year mortality risk by 30% over sarcopenia alone and by 8% over low BMD alone, underscoring the severe health implications of concurrent muscle and bone deterioration. This study highlights the substantial impact of osteosarcopenia on mortality among older adults, emphasizing the need for targeted diagnostic and therapeutic strategies.

Bone turnover profile and muscular status in major orthopaedic surgery: a case series

BACKGROUND Sarcopenia refers to a chronic loss of skeletal muscle mass, often associated with hypovitaminosis D and advanced age, which involves a greater risk of falls and fractures. The association of sarcopenia and osteoporosis defines osteo-sarcopenia. In this work, the authors analyzed the osteometabolic profile and the loco-regional muscular state of patients undergoing major orthopedic surgery, in order to define the incidence of district osteosarcopenic states, linked to a condition of disuse.   METHODS   19 patients (10M-9F), between 15 and 85 years old, underwent major orthopedic surgery (15 resection prosthesis and custom made, 2 resection and reconstruction with transplant) were evaluated, of which 9 on an oncological basis. In all patients, the phospho-calcium metabolism was assessed by blood tests and intraoperative muscle biopsy was performed at the intervention site and contralaterally; in 3 cases a densitometric comparative study of the affected/contralateral limb was performed.   RESULTS   Results shows 5 patients with hypovitaminosis D; 7 pcs with hypocalcemia; 5 with PTH rise; 4pcs with ALP increase. In 100% of cases, the biopsy revealed sarcopenic patterns exclusively on the affected limb. 2 out of 3 DEXAs (66%) showed loco-regional osteoporosis compared to the contralateral.   CONCLUSIONS   The fact that in our sample sarcopenia is unilateral affecting only the pathological limb, that it is frequently associated with osteoporosis which is also unilateral and that for the most part it is not associated with vitamin D deficiency, suggests that it is an independent condition, with etiopathogenetic mechanisms different from osteosarcopenia itself. In major orthopedic surgery, bone integration and muscle status are both essential for achieving and lasting positive results. Considering the high incidence of district osteosarcopenia, an integrated surgical, pharmacological, and rehabilitative approach is desirable for the optimization of results, as well as more studies for the definition of the etiopathogenesis of this pathological condition.

Sarcopenia and osteosarcopenia among patients undergoing hemodialysis

Background

Sarcopenia and osteoporosis are closely interconnected and associated with adverse health outcomes. Osteosarcopenia is the concurrent presence of the two conditions and has rarely been reported in hemodialysis patients. Whether hemodialysis patients with osteosarcopenia are at greater risk of mortality than those with either condition alone remains unknown. The aim of this study was to explore the prevalence of sarcopenia and its association with osteoporosis and to determine its impact on survival risk in hemodialysis patients.

Methods

A total of 209 adults undergoing hemodialysis were enrolled from the dialysis center in the West China Hospital of Sichuan University, and our study was registered at the Chinese Clinical Trial Register (number: ChiCTR2100043932). Muscle mass, handgrip strength, bone mineral density (BMD), and biochemical parameters were assessed. All deaths were recorded during a follow-up of 35.15 ± 15.37 months.

Results

Seventy-eight patients were diagnosed with sarcopenia, with a prevalence of 37.3%. After adjustment for potential confounders, age (OR=1.094, P <0.001), female sex (OR= 3.44, P =0.005), diabetes (OR=3.756, P =0.008), CRP (OR=1.09, P =0.015), serum magnesium (OR=0.755, p=0.042) and BMI (OR=0.701, P <0.001) were independently associated with sarcopenia. Among the 209 patients, 103 patients completed the BMD assessment. The prevalence of osteosarcopenia was 22.3%, while 20.4% of participants had sarcopenia alone and 12.6% had osteoporosis alone. The proportions of patients who died were 13.0% for nonsarcopenia&nonosteoporosis, 15.4% for osteoporosis alone, 47.6% for sarcopenia alone, and 52.2% for osteosarcopenia. Cox regression analysis showed that osteosarcopenia was independently associated with all-cause mortality (HR=3.74, 95% CI: 1.172-11.938), while osteoporosis alone and sarcopenia alone were not.

Conclusion

Patients undergoing hemodialysis had a high incidence of sarcopenia and osteosarcopenia, muscle mass and strength showed a significant association with BMD, and osteosarcopenia might have a powerful impact on mortality in those patients.

Clinical trial registration

http://www.chictr.org.cn/, identifier ChiCTR2100043932.

Denosumab's Therapeutic Effect for Future Osteosarcopenia Therapy : A Systematic Review and Meta-Analysis

BACKGROUND

Osteosarcopenia, a combination of osteopenia/osteoporosis and sarcopenia, is a common condition among older adults. While numerous studies and meta-analyses have been conducted on the treatment of osteoporosis, the pharmacological treatment of osteosarcopenia still lacks evidence. Denosumab, a human monoclonal antibody, has shown encouraging results for the treatment of osteosarcopenia. Our systematic review and meta-analysis aimed to investigate the potential dual role of denosumab as an anti-resorptive agent and for other beneficial muscle-related effects in patients with osteosarcopenia, and to evaluate whether denosumab can be a treatment of choice compared to bisphosphonate.

METHODS

Relevant literature was collated from the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and Google Scholar databases. The primary outcome was denosumab's effect on lumbar spine bone mineral density (LS BMD), handgrip strength, and gait speed change. The secondary outcome was the effect of denosumab on appendicular lean mass (ALM). The outcomes were presented as mean difference (MD). A random effects model was used in the analysis to represent the population. The risk of bias was assessed using funnel plots.

RESULTS

Out of the 3,074 studies found, four full-text studies met the inclusion criteria, including 264 and 244 participants in the intervention and control groups, respectively. Regarding a primary outcome, our meta-analysis showed that denosumab showed no significant differences in LS BMD and gait speed changes compared to other agents-MD=0.37, 95% confidence interval (CI), -0.35 to 0.79; p=0.09 and MD=0.11; 95% CI, -0.18 to 0.40; p=0.46, respectively. Denosumab had a significant effect on handgrip strength change compared to standard agents-MD=5.16; 95% CI, 1.38 to 18.94; p=0.007, based on the random effects model.

CONCLUSIONS

Denosumab was better than bisphosphonate and placebo in improving muscle strength (handgrip strength). Therefore, denosumab may be favored in individuals with osteosarcopenia to improve muscular performance and reduce fall risk.

Post-fracture care program in Egypt: merging subsequent fracture prevention and improving patients’ outcomes—an initiative by the Egyptian Academy of Bone Health

Background

Despite the associated high prevalence of morbidity and mortality, osteoporotic fragility fractures remain underdiagnosed and undertreated. Furthermore, those who sustain a fragility fracture are at imminent risk of sustaining subsequent fractures. Post-fracture care (PFC) programs are systematic, coordinated care programs that recognize, evaluate, and manage older adults who sustained a fragility fracture with the goal of managing all the risk factors and preventing succeeding fractures.

Main text

This work was carried out to outline the PFC program adopted in Egypt and its applicability in standard clinical practice. A review of literature was conducted to identify an evidence-informed PFC strategies and protocols, which outlines the optimal manner to manage older adults living with fragility fractures. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist was used to guide the reporting of this review. Based on this, a PFC integrated model of care based on a patient-centered approach has been developed aiming to optimize the outcomes.

Conclusion

This manuscript described the integrated model of care adopted in Egypt to provide care for older adults presenting with fragility fractures. This will pave the way to standardize patient identification and management. Additionally, to prevent occurrence of subsequent fractures and to enhance equity of care for patients with fragility fracture and osteoporosis, expansion of such service to rural and remote areas is highly recommended.

Sarcopenia and bone health: new acquisitions for a firm liaison

Osteosarcopenia (OS) is a newly defined condition represented by the simultaneous presence of osteopenia/osteoporosis and sarcopenia, the main age-related diseases. The simultaneous coexistence of the two phenotypes derives from the close connection of the main target tissues involved in their pathogenesis: bone and muscle. These two actors constitute the bone-muscle unit, which communicates through a biochemical and mechanical crosstalk which involves multiple factors. Altered pattern of molecular pathways leads to an impairment of both the functionality of the tissue itself and the communication with the complementary tissue, composing the OS pathogenesis. Recent advances in the genetics field have provided the opportunity to delve deeper into the complex biological and molecular mechanisms underlying OS. Unfortunately, there are still many gaps in our understanding of these pathways, but it has proven essential to apply strategies such as exercise and nutritional intervention to counteract OS. New therapeutic strategies that simultaneously target bone and muscle tissue are limited, but recently new targets for the development of dual-action drug therapies have been identified. This narrative review aims to provide an overview of the latest scientific evidence associated with OS, a complex disorder that will pave the way for future research aimed at understanding the bone-muscle-associated pathogenetic mechanisms.

Associations of the Alpha-Actinin Three Genotype with Bone and Muscle Mass Loss among Middle-Aged and Older Adults

Bone and muscle mass loss are known to occur simultaneously. The alpha-actinin three (ACTN3) genotype has been shown to potentially affect bone and muscle mass. In this study, we investigated the association between the ACTN3 genotype and bone and muscle mass loss in community-dwelling adults aged ≥ 60 years. This study was a cross-sectional analysis of data from 295 participants who participated in a community health checkup. The ACTN3 genotypes were classified as RR, RX, or XX types. Bone mass loss was defined as a calcaneal speed of sound T-score of <−1.32 and <−1.37, and muscle mass loss was defined as an appendicular skeletal muscle index of <7.0 kg/m2 and <5.7 kg/m2 in men and women, respectively. The percentages of XX, RX, and RR in the combined bone and muscle mass loss group were 33.8%, 30.8%, and 16.7%, respectively, with a significantly higher trend for XX. Multinomial logistic regression analysis showed that XX had an odds ratio of 3.00 (95% confidence interval 1.05−8.54) of being in the combined bone and muscle mass loss group compared to the RR group (covariates: age, sex, grip strength, and medications). The ACTN3 genotype of XX is associated with a higher rate of comorbid bone and muscle mass loss. Therefore, ACTN3 genotyping should be considered for preventing combined bone and muscle mass loss.

Osteosarcopenia: A Narrative Review on Clinical Studies

Osteosarcopenia (OS) is defined by the concurrent presence of osteopenia/osteoporosis and sarcopenia. The pathogenesis and etiology of OS involve genetic, biochemical, mechanical, and lifestyle factors. Moreover, an inadequate nutritional status, such as low intake of protein, vitamin D, and calcium, and a reduction in physical activity are key risk factors for OS. This review aims to increase knowledge about diagnosis, incidence, etiology, and treatment of OS through clinical studies that treat OS as a single disease. Clinical studies show the relationship between OS and the risk of frailty, falls, and fractures and some association with Non-communicable diseases (NCDs) pathologies such as diabetes, obesity, and cardiovascular disease. In some cases, the importance of deepening the related mechanisms is emphasized. Physical exercise with adequate nutrition and nutritional supplementations such as proteins, Vitamin D, or calcium, represent a significant strategy for breaking OS. In addition, pharmacological interventions may confer benefits on muscle and bone health. Both non-pharmacological and pharmacological interventions require additional randomized controlled trials (RCT) in humans to deepen the synergistic effect of exercise, nutritional interventions, and drug compounds in osteosarcopenia.

A pas de deux of osteoporosis and sarcopenia: osteosarcopenia

The musculoskeletal conditions osteoporosis and sarcopenia are highly prevalent in older adults. Osteoporosis is characterized by low bone mass and microarchitectural deterioration of bone, whereas sarcopenia is identified by the loss of muscle strength, function and mass. Osteoporosis represents a major health problem contributing to millions of fractures worldwide on an annual basis, whereas sarcopenia is associated with a range of adverse physical and metabolic outcomes. They both affect physical and social function, confidence and quality of life as well as contributing to high health-care costs worldwide. Osteosarcopenia is the term given when both conditions occur concomitantly and it has been suggested that interactions between these two conditions may accelerate individual disease progression as co-existence of osteoporosis and sarcopenia is associated with higher morbidity from falls, fracture, disability as well as mortality. In this review, we will outline the epidemiology, pathogenesis and clinical consequences of osteosarcopenia and discuss available management strategies.

Prevalence of Sarcopenia and Its Association with Quality of Life, Postural Stability, and Past Incidence of Falls in Postmenopausal Women with Osteoporosis: A Cross-Sectional Study

In this cross-sectional analysis of 61 postmenopausal osteoporosis patients who regularly visited an osteoporosis outpatient clinic, we aimed to clarify the prevalence of sarcopenia and its related clinical factors. Of 61 patients (mean age 77.6 ± 8.1 years), 24 (39.3%) had osteosarcopenia and 37 (60.7%) had osteoporosis alone. Age, nutritional status, and the number of prescribed drugs were associated with the presence of sarcopenia (p = 0.002, <0.001, and 0.001, respectively), while bone mineral density (BMD) and % young adult mean BMD were not (p = 0.119 and 0.119, respectively). Moreover, patients with osteosarcopenia had lower quality of life (QOL) scores, greater postural instability, and a higher incidence of falls in the past year than patients with osteoporosis alone. In contrast, BMD status showed no correlation with the nutritional status, QOL score, postural instability, or incidence of falls in the past year. In conclusion, the incidence of sarcopenia was relatively high among postmenopausal osteoporosis female patients in an osteoporosis outpatient clinic. Our results suggest that in addition to routine BMD evaluation, assessment and management of sarcopenia may be promoted at osteoporosis outpatient clinics to limit the risk of falls and prevent consequent fragility fractures in osteoporosis patients.

Exercise and Nutrition Impact on Osteoporosis and Sarcopenia-The Incidence of Osteosarcopenia: A Narrative Review

Osteoporosis and sarcopenia are diseases which affect the myoskeletal system and often occur in older adults. They are characterized by low bone density and loss of muscle mass and strength, factors which reduce the quality of life and mobility. Recently, apart from pharmaceutical interventions, many studies have focused on non-pharmaceutical approaches for the prevention of osteoporosis and sarcopenia with exercise and nutrition to being the most important and well studied of those. The purpose of the current narrative review is to describe the role of exercise and nutrition on prevention of osteoporosis and sarcopenia in older adults and to define the incidence of osteosarcopenia. Most of the publications which were included in this review show that resistance and endurance exercises prevent the development of osteoporosis and sarcopenia. Furthermore, protein and vitamin D intake, as well as a healthy diet, present a protective role against the development of the above bone diseases. However, current scientific data are not sufficient for reaching solid conclusions. Although the roles of exercise and nutrition on osteoporosis and sarcopenia seem to have been largely evaluated in literature over the recent years, most of the studies which have been conducted present high heterogeneity and small sample sizes. Therefore, they cannot reach final conclusions. In addition, osteosarcopenia seems to be caused by the effects of osteoporosis and sarcopenia on elderly. Larger meta-analyses and randomized controlled trials are needed designed based on strict inclusion criteria, in order to describe the exact role of exercise and nutrition on osteoporosis and sarcopenia.

Osteosarcopenia School

Osteosarcopenia has been proposed as a syndrome in a subset of frail individuals at higher risk of falls, fractures and institutionalization. In this paper, we will go over the translational aspects of sarcopenia and osteoporosis research and highlight outcomes from different interventions. In addition, preventative measures and therapeutic interventions that can benefit both muscle and bone simultaneously will be analysed also. A new holistic concept called Osteosarcopenia School will be presented. This new concept is based on counselling and education of patients as part of a rehabilitation program, aiming to reduce the risk of social isolation, falls and fractures, and subsequent disability through muscle strengthening and balance training. In this patient group, the combination of pharmaceutical treatments and specific exercise programmes are essential to counteract the consequences of osteosarcopenia. Finally, educational programmes targeting patient functionality through social reintegration may have a substantial impact on their daily living activities and overall quality of life.

Effects of hormonal changes on sarcopenia in chronic kidney disease: where are we now and what can we do?

Sarcopenia or muscle wasting is a progressive and generalized skeletal muscle disorder involving the accelerated loss of muscle mass and function, often associated with muscle weakness (dynapenia) and frailty. Whereas primary sarcopenia is related to ageing, secondary sarcopenia happens independent of age in the context of chronic disease states such as chronic kidney disease (CKD). Sarcopenia has become a major focus of research and public policy debate due to its impact on patient's health-related quality of life, health-care expenditure, morbidity, and mortality. The development of sarcopenia in patients with CKD is multifactorial and it may occur independently of weight loss or cachexia including under obese sarcopenia. Hormonal imbalances can facilitate the development of sarcopenia in the general population and is a common finding in CKD. Hormones that may influence the development of sarcopenia are testosterone, growth hormone, insulin, thyroid hormones, and vitamin D. Although the relationship between free testosterone level that is low in uraemic patients and sarcopenia in CKD is not well-defined, functional improvement may be seen. Unlike testosterone, it is known that vitamin D is associated with muscle strength, muscle size, and physical performance in patients with CKD. Outcomes after vitamin D replacement therapy are still controversial. The half-life of growth hormone (GH) is prolonged in patients with CKD. Besides, IGF-1 levels are normal in patients with Stage 4 CKD-a minimal reduction is seen in the end-stage renal disease. Unresponsiveness or resistance of IGF-1 and changes in the GH/IGF-1 axis are the main causes of sarcopenia in CKD. Low serum T3 level is frequent in CKD, but the net effect on sarcopenia is not well-studied. CKD patients develop insulin resistance (IR) from the earliest period even before GFR decline begins. IR reduces glucose utilization as an energy source by hepatic gluconeogenesis, decreasing muscle glucose uptake, impairing intracellular glucose metabolism. This cascade results in muscle protein breakdown. IR and sarcopenia might also be a new pathway for targeting. Ghrelin, oestrogen, cortisol, and dehydroepiandrosterone may be other players in the setting of sarcopenia. In this review, we mainly examine the effects of hormonal changes on the occurrence of sarcopenia in patients with CKD via the available data.

Clinical Usefulness of FRAX Score for Predicting Sarcopenia in Patients with Chronic Liver Disease

We investigated the usefulness of the Fracture Risk Assessment tool (FRAX) for predicting sarcopenia in chronic liver disease (CLD). In this cross-sectional study, we evaluated 321 patients with CLD. The FRAX with and without bone mineral density (BMD) was employed to calculate the 10-year risks of major osteoporotic and hip fractures. The FRAX score for high fracture risk was defined as a 10-year major osteoporotic fracture probability of ≥20% or a 10-year hip fracture probability of ≥3%. The diagnosis of sarcopenia was based on the Japan Society of Hepatology criteria. According to the FRAX, with and without BMD, 134 (41.7%) and 193 (60.1%) patients had a high fracture risk, respectively. The high fracture risk group had a significantly higher frequency of sarcopenia than the non-high fracture risk group. FRAX scores of major osteoporotic and hip fractures were negatively correlated with handgrip strength and muscle mass. Using the FRAX with BMD, the cutoff scores of major osteoporotic and hip fractures for predicting sarcopenia were 8.55% (sensitivity/specificity, 0.847/0.568) and 3.35% (0.729/0.746), respectively. Using the FRAX without BMD, they were 18.5% (0.635/0.725) and 7.65% (0.729/0.758), respectively. The FRAX is a simple and convenient screening tool for predicting sarcopenia in patients with CLD.

Prevalence of Musculoskeletal Disorders in Patients with Coronary Artery Disease

Aim. To study the prevalence of musculoskeletal disorders in patients with stable coronary artery disease (CAD).

Material and methods. Patients with stable CAD (n=387) were included in the study. The subjects were admitted to the hospital for planned myocardial revascularization (ages of 50-82). The median age was 65 [59;69] years. Most of the sample consisted of males - 283 (73.1%). 323 (83.5%) patients had arterial hypertension (AH), 57.1% - history of myocardial infarction, and a quarter of the patients had type 2 diabetes mellitus (DM). The study of musculoskeletal system included the identification of sarcopenia in accordance with The European Working Group on Sarcopenia in Older People (EWGSOP, 2019); verification of osteopenia/osteoporosis according to the WHO criteria (2008); diagnosing osteosarcopenia in case of sarcopenia and osteopenia/osteoporosis coexistence.

Results. At the initial screening of sarcopenia in accordance with EWGSOP, clinical signs (according to the Strength, assistance with walking, rising from a chair, climbing stairs, and falls (SARC-F) questionnaire) were detected in 41.3% of cases, but further examination (dynamometry, quantitative assessment of skeletal muscle) confirmed this diagnosis only in 19.9% of patients with CAD. Among the examined patients with CAD a low T-score according to DEXA was found in 53 (13.7%) of cases, and osteopenia was diagnosed 10 times more often than osteoporosis (90.6% vs. 9.4%). Furthermore, due to combination of low bone density (osteopenia/osteoporosis) and reduced muscle mass and strength (sarcopenia), osteosarcopenia was verified in one patient. Thus, the study revealed the prevalence of particular types of musculoskeletal disorders in 105 (27.1%) patients with stable CAD. The most common type of musculoskeletal disorder was sarcopenia - 52 cases (13.4%); osteopenia/osteoporosis was detected in 28 patients (7.2%), osteosarcopenia in 25 (6.5%). The most pronounced clinical manifestation of sarcopenia and osteopenia/osteoporosis, reflected by a higher score on the SARC-F questionnaire, low handgrip strength, small area of muscle tissue, low musculoskeletal index, as well as low values of bone mineral density, were observed in patients with osteosarcopenia. Patients with osteopenia/osteoporosis did not differ significantly from patients without musculoskeletal conditions in most parameters, with the exception of the T-score, the average SARC-F score, and muscle strength in men. The conducted correlation analysis revealed not only the relationship between the parameters of musculoskeletal function, but also their association with age, duration of AH, CAD, and type 2 DM.

Conclusion. Several types of musculoskeletal disorders were found in a third of patients with CAD. Sarcopenia was revealed to be the most frequent type of musculoskeletal disorder.

Effectiveness of exercise for osteosarcopenia in older adults: a systematic review protocol

INTRODUCTION

Osteosarcopenia is defined as the concomitant occurrence of sarcopenia and osteopenia or osteoporosis. Older adults with this syndrome have a greater fragility and mortality risk compared with those without these conditions. Based on separate interventions with individuals with sarcopenia and osteoporosis, exercise has been recommended as a treatment for osteosarcopenia. However, there is no evidence of its efficacy. Our objective is to identify whether physical exercise can improve osteosarcopenia in older adults and lead to good health outcomes.

METHODS AND ANALYSIS

We will perform a systematic review in the following databases: PubMed, Embase, Cochrane and Scopus. The criterion of inclusion will be clinical trials involving physical exercise interventions in older adults diagnosed with osteosarcopenia. To assess the risk of bias, the Grading of Recommendations, Assessment, Development and Evaluation and Downs and Black tools will be used. For each search result, the quality of the evidence will ultimately receive one of four grades: high, moderate, low or very low. The outcome of this study is to demonstrate the effectiveness of physical exercise in improving the parameters that lead to the diagnosis of osteosarcopenia (bone mineral density, quality of muscle mass, muscle strength and physical function) in older adults. The possibility of meta-analysis will be assessed according to the homogeneity of the studies, using the methods of fixed or random effects. Sensitivity analyses will be performed, and the funnel plot will be used to assess publication bias. The proposed statistical analyses will be performed using STATA software, V.14.0.

ETHICS AND DISSEMINATION

The results of the systematic review will be disseminated via publication in a peer-reviewed journal and presented at a relevant conference. As we will not use individual patient data, ethical approval is not required.

TRIAL REGISTRATION NUMBER

CRD42020215659.

Osteoporosis in Parkinson's Disease: Relevance of Distal Radius Dual-Energy X-Ray Absorptiometry (DXA) and Sarcopenia

Osteoporotic fractures are common in Parkinson's disease (PD). Standard dual-energy X-ray absorptiometry (DXA) measuring bone mineral density (BMD) at the femoral neck and lumbar spine (central sites) has suboptimal sensitivity in predicting fracture risk in the general population. An association between sarcopenia and osteoporosis in PD has not been studied. We compared BMD and osteoporosis prevalence in PD patients vs controls; determined the osteoporosis detection rates using central alone vs central plus distal radius DXA; and analyzed factors (in particular, sarcopenia) associated with osteoporosis. One hundred and fifty-six subjects (102 patients with PD, 54 spousal/sibling controls) underwent femoral neck-lumbar spine-distal radius DXA. Seventy-three patients and 46 controls were assessed for sarcopenia using whole-body DXA and handgrip strength. Patients underwent clinical and serum biochemical evaluations. PD patients had significantly lower body mass index compared to controls. After adjustment for possible confounders, distal radius BMD and T-scores were significantly lower in PD patients compared to controls, but not at the femoral neck/lumbar spine. With distal radius DXA, an additional 11.0% of patients were diagnosed with osteoporosis (32.0% to 43.0%), vs 3.7% in controls (33.3% to 37.0%) additionally diagnosed; this increase was largely driven by the markedly higher detection rate in female PD patients. Female gender (adjusted odds ratio [OR_adjusted] = 11.3, 95% confidence interval [CI]: 2.6-48.6) and sarcopenia (OR_adjusted = 8.4, 95% CI: 1.1-64.9) were independent predictors for osteoporosis in PD. Distal radius DXA increased osteoporosis detection, especially in female PD patients, suggesting that diagnostic protocols for osteoporosis in PD could be optimized. A close association between osteoporosis and sarcopenia was documented for the first time in PD, which has important implications for clinical management and future research.

Role of Physical Activity in Bone-Muscle Crosstalk: Biological Aspects and Clinical Implications

Bone and muscle tissues influence each other through the integration of mechanical and biochemical signals, giving rise to bone-muscle crosstalk. They are also known to secrete osteokines, myokines, and cytokines into the circulation, influencing the biological and pathological activities in local and distant organs and cells. In this regard, even osteoporosis and sarcopenia, which were initially thought to be two independent diseases, have recently been defined under the term "osteosarcopenia", to indicate a synergistic condition of low bone mass with muscle atrophy and hypofunction. Undoubtedly, osteosarcopenia is a major public health concern, being associated with high rates of morbidity and mortality. The best current defence against osteosarcopenia is prevention based on a healthy lifestyle and regular exercise. The most appropriate type, intensity, duration, and frequency of exercise to positively influence osteosarcopenia are not yet known. However, combined programmes of progressive resistance exercises, weight-bearing impact exercises, and challenging balance/mobility activities currently appear to be the most effective in optimising musculoskeletal health and function. Based on this evidence, the aim of our review was to summarize the current knowledge about the role of exercise in bone-muscle crosstalk, highlighting how it may represent an effective alternative strategy to prevent and/or counteract the onset of osteosarcopenia.

Osteosarcopenia in Very Old Age Adults After Hip Fracture: A Real-World Therapeutic Standpoint

Loss of bone and muscle mass and strength (i. e., osteosarcopenia) is a highly prevalent clinical condition in older adults, associated with an increased risk of fragility fractures and unfavorable clinical outcomes. Although sarcopenia is a potential risk factor for osteoporosis and subsequent fracture, and the management of this hazardous duet is the key to preventing osteoporotic fracture, evidence pertaining to the treatment of sarcopenia for the purpose of preventing fragile fractures remains insufficient. Given this scenario we aimed at prospectively compare the long-term effectiveness of bisphosphonates vs. denosumab, on bone and muscle, in a cohort of old age hip fractured patients by virtue of a timely osteo-metabolic and sarcopenic assessment. Ninety-eight patients consecutively enrolled at the IRCCS Hospital San martino, Genoa, Italy, received at baseline comprehensive geriatric assessment and Bone Densitometry (DXA) with the quantitative and quantitative bone analysis and evaluation of relative skeletal muscle index (RSMI) and longitudinally after 1 year form hip surgery. The results showed a slightly and non-significant osteo-metabolic improvement in the Alendronate group compared to the Denosumab group, and a positive trend of RSMI measurements in the Denosumab group. Although preliminary in nature, this is the first report to longitudinally analyze osteosarcopenia in a real-world cohort of very old age patients after hip fracture and moved a step forward in the understanding of the best osteo-metabolic therapy for long- term treatment, exploring as well the potential dual role of denousumab as antiresorptive and muscle strength specific drug for osteosarcopenia in this vulnerable population.

Effects of 16 months of high intensity resistance training on thigh muscle fat infiltration in elderly men with osteosarcopenia

Osteosarcopenia is characterized by a progressive decline in muscle function and bone strength and associated with muscle fat accumulation. This study aimed to determine the effect of long-term high intensity resistance training (HIRT) on thigh muscle fat infiltration in older men with osteosarcopenia. Forty-three community-dwelling men (72 years and older) were randomly assigned to either an exercise group (EG, n = 21) or an inactive control group (CG, n = 22). EG participants performed a supervised single-set exercise training with high effort two times per week. Participants of both groups were individually provided with dietary protein to reach a cumulative intake of 1.5-1.6 g/kg/day or 1.2-1.3 g/kg/day (EG/CG), respectively, and Up to 10,000 IE/week of Vitamin-D were supplemented in participants with 25 OH Vitamin-D 3 levels below 100 nmol/l. Magnetic resonance (MR) imaging was performed to determine muscle and adipose tissue volume and fat fraction of the thigh. At baseline, there were no significant differences between the two groups. After 16 month,, there were significant training effects of 15% (p = 0.004) on intermuscular adipose tissue (IMAT) volume, which increased in the CG (p = 0.012) and was stable in the EG. In parallel, fat fraction within the deep fascia of the thigh (Baseline, EG: 18.2 vs CG: 15.5, p = 0.16) significantly differed between the groups (Changes, EG: 0.77% vs. CG: 7.7%, p = 0.009). The study confirms the role of fat infiltration of the muscles as an advanced imaging marker in osteosarcopenia and the favorable effects of HIRT on adipose tissue volume of the thigh, in men with osteosarcopenia.

Nutritional Orthopedics and Space Nutrition as Two Sides of the Same Coin: A Scoping Review

Since the Moon landing, nutritional research has been charged with the task of guaranteeing human health in space. In addition, nutrition applied to Orthopedics has developed in recent years, driven by the need to improve the efficiency of the treatment path by enhancing the recovery after surgery. As a result, nutritional sciences have specialized into two distinct fields of research: Nutritional Orthopedics and Space Nutrition. The former primarily deals with the nutritional requirements of old patients in hospitals, whereas the latter focuses on the varied food challenges of space travelers heading to deep space. Although they may seem disconnected, they both investigate similar nutritional issues. This scoping review shows what these two disciplines have in common, highlighting the mutual features between (1) pre-operative vs. pre-launch nutritional programs, (2) hospital-based vs. space station nutritional issues, and (3) post-discharge vs. deep space nutritional resilience. PubMed and Google Scholar were used to collect documents published from 1950 to 2020, from which 44 references were selected on Nutritional Orthopedics and 44 on Space Nutrition. Both the orthopedic patient and the astronaut were found to suffer from food insecurity, malnutrition, musculoskeletal involution, flavor/pleasure issues, fluid shifts, metabolic stresses, and isolation/confinement. Both fields of research aid the planning of demand-driven food systems and advanced nutritional approaches, like tailored diets with nutrients of interest (e.g., vitamin D and calcium). The nutritional features of orthopedic patients on Earth and of astronauts in space are undeniably related. Consequently, it is important to initiate close collaborations between orthopedic nutritionists and space experts, with the musculoskeletal-related dedications playing as common fuel.

A Vicious Cycle of Osteosarcopeniain Inflammatory Bowel Diseases-Aetiology, Clinical Implications and Therapeutic Perspectives

Sarcopenia is a disorder characterized by a loss of muscle mass which leads to the reduction of muscle strength and a decrease in the quality and quantity of muscle. It was previously thought that sarcopenia was specific to ageing. However, sarcopenia may affect patients suffering from chronic diseases throughout their entire lives. A decreased mass of muscle and bone is common among patients with inflammatory bowel disease (IBD). Since sarcopenia and osteoporosis are closely linked, they should be diagnosed as mutual consequences of IBD. Additionally, multidirectional treatment of sarcopenia and osteoporosis including nutrition, physical activity, and pharmacotherapy should include both disorders, referred to as osteosarcopenia.

Distrectual osteosarcopenia in limb disuse: case report and mini literature review

Osteosarcopenia is a new concept and it is the association of osteoporosis and sarcopenia. Both of these pathologies are more frequent in elderly people and generally affects all the skeleton increasing risk of falls and fractures, loss of global function, fragility, and mortality, and also surgical failures. The coexistence of these conditions derives from a close relationship, not only anatomical, between bone and muscle tissues. Sometimes they can involve only a skeleton segment, due to a local disuse, causing a different form of sarcopenia. In this clinical case, Authors describes a case of isolated lower limb osteosarcopenia in a young non-osteoporotic patient, due to a prolonged limb disuse, complicated by surgical treatment failure for previous pathology, diagnosed by clinical, laboratory, instrumental and histopathological exams.

Bone-Muscle Mutual Interactions

PURPOSE OF REVIEW

The purpose of this review is to describe the current state of our thinking regarding bone-muscle interactions beyond the mechanical perspective.

RECENT FINDINGS

Recent and prior evidence has begun to dissect many of the molecular mechanisms that bone and muscle use to communicate with each other and to modify each other's function. Several signaling factors produced by muscle and bone have emerged as potential mediators of these biochemical/molecular interactions. These include muscle factors such as myostatin, Irisin, BAIBA, IL-6, and the IGF family and the bone factors FGF-23, Wnt1 and Wnt3a, PGE2, FGF9, RANKL, osteocalcin, and sclerostin. The identification of these signaling molecules and their underlying mechanisms offers the very real and exciting possibility that new pharmaceutical approaches can be developed that will permit the simultaneous treatments of diseases that often occur in combination, such as osteoporosis and sarcopenia.

Osteosarcopenia: epidemiology, diagnosis, and treatment-facts and numbers

BACKGROUND

Osteosarcopenia, the presence of osteopenia/osteoporosis and sarcopenia, is an emerging geriatric giant, which poses a serious global health burden.

METHODS AND RESULTS

The prevalence of osteosarcopenia ranges in community-dwelling older adults [5-37% (≥65 years)] with the highest rates observed in those with fractures (low-trauma fracture: ~46%; hip fracture: 17.1-96.3%). Among 2353 community-dwelling adults, risk factors associated with osteosarcopenia include older age [men: 14.3% (60-64 years) to 59.4% (≥75 years); women: 20.3% (60-64 years) to 48.3% (≥75 years), P < 0.05], physical inactivity [inverse relationship: 0.64, 95% confidence interval (CI) 0.46-0.88 (sexes combined)], low body mass index (inverse relationship: men: 0.84, 95% CI 0.81-0.88; women: 0.77, 95% CI 0.74-0.80), and higher fat mass (men: 1.46, 95% CI 1.11-1.92; women: 2.25, 95% CI 1.71-2.95). Among 148 geriatric inpatients, osteosarcopenic individuals demonstrate poorer nutritional status (mini-nutritional assessment scores: 8.50 ± 2.52 points, P < 0.001) vs. osteoporosis or sarcopenia alone, while among 253 older Australians, osteosarcopenia is associated with impaired balance and functional capacity [odds ratios (ORs): 2.56-7.19; P < 0.05] vs. non-osteosarcopenia. Osteosarcopenia also associates with falls (ORs: 2.83-3.63; P < 0.05), fractures (ORs: 3.86-4.38; P < 0.05), and earlier death [hazard ratio (1-year follow-up): 1.84, 95% CI; 0.69-4.92, P = 0.023] vs. non-osteosarcopenia.

CONCLUSIONS

This syndrome is expected to grow in age-related and disease-related states, a likely consequence of immunosenescence coinciding with increased sedentarism, obesity, and fat infiltration of muscle and bone. Evidence suggests the pathophysiology of osteosarcopenia includes genetic polymorphisms, reduced mechanical loading, and impaired endocrine functioning, as well as altered crosstalk between muscle, bone, and fat cells. Clinicians should screen for osteosarcopenia via imaging methods (i.e. dual-energy X-ray absorptiometry) to quantify muscle and bone mass, in addition to assessing muscle strength (i.e. grip strength) and functional capacity (i.e. gait speed). A comprehensive geriatric assessment, including medical history and risk factors, must also be undertaken. Treatment of this syndrome should include osteoporotic drugs [bone anabolics/antiresorptives (i.e. teriparatide, denosumab, bisphosphates)] where indicated, and progressive resistance and balance exercises (at least 2-3 times/week). To maximize musculoskeletal health, nutritional recommendations [protein (1.2-1.5 g/kg/day), vitamin D (800-1000 IU/day), calcium (1300 mg/day), and creatine (3-5 g/day)] must also be met. It is anticipated that diagnosis and treatment for osteosarcopenia will become part of routine healthcare in the future. However, further work is required to identify biomarkers, which, in turn, may increase diagnosis, risk stratification, and targeted treatments to improve health outcomes.

Osteosarcopenia: A case of geroscience

Many older persons lose their mobility and independence due to multiple diseases occurring simultaneously. Geroscience is aimed at developing innovative approaches to better identify relationships among the biological processes of aging. Osteoporosis and sarcopenia are two of the most prevalent chronic diseases in older people, with both conditions sharing overlapping risk factors and pathogenesis. When occurring together, these diseases form a geriatric syndrome termed "osteosarcopenia," which increases the risk of frailty, hospitalizations, and death. Findings from basic and clinical sciences aiming to understand osteosarcopenia have provided evidence of this syndrome as a case of geroscience. Genetic, endocrine, and mechanical stimuli, in addition to fat infiltration, sedentarism, and nutritional deficiencies, affect muscle and bone homeostasis to characterize this syndrome. However, research is in its infancy regarding accurate diagnostic markers and effective treatments with dual effects on muscle and bone. To date, resistance exercise remains the most promising strategy to increase muscle and bone mass, while sufficient quantities of protein, vitamin D, calcium, and creatine may preserve these tissues with aging. More recent findings, from rodent models, suggest treating ectopic fat in muscle and bone marrow as a possible avenue to curb osteosarcopenia, although this needs testing in human clinical trials.