Discordance in diagnosis of osteoporosis using spine and hip bone densitometry

Increased bone resorption that outpaces increased bone formation: An important pathology of rapidly destructive coxarthrosis

Rapid joint destruction caused by rapidly destructive coxarthrosis (RDC) can increase surgical complexity and intraoperative blood loss. This single-center retrospective study investigates osteoporosis-related biomarkers for early RDC diagnosis and explores new treatment targets. We included 398 hip joints from patients who underwent total hip arthroplasty, examining medical records for preoperative patient demographics, bone mineral density of the hip and lumbar spine from dual-energy X-ray absorptiometry scans, and osteoporosis-related biomarkers including TRACP-5b, total P1NP, intact parathyroid hormone, and homocysteine. We compared RDC and osteoarthritis (OA) patients, and univariate analysis showed that RDC patients were older (p < 0.001) and had lower serum levels of albumin (p < 0.001) and higher serum levels of TRACP-5b, total P1NP (p < 0.001), and homocysteine (p = 0.006). Multivariable analysis showed that the ratio of serum TRACP-5b to total P1NP had a more significant difference in RDC patients than in OA patients (p = 0.04). Serum TRACP-5b levels were negatively correlated with the time between RDC onset and blood collection, and Japanese Orthopedic Association pain score. Receiver operating characteristic curve analysis revealed that the ratio of serum TRACP-5b to total P1NP had the highest area under the curve value. This study is the first to demonstrate that the ratio of serum TRACP-5b to total P1NP-increased bone resorption that outpaces increased bone formation-is significantly elevated in patients with RDC and that TRACP-5b is higher in the early stages of RDC. Inhibiting serum levels of TRACP-5b, activated osteoclasts, during early RDC may suppress disease progression.

Clinical Significance of Discordance between Hip and Spine Bone Mineral Density in Korean Elderly Patients with Hip Fractures

The clinical significance of BMD discordance has not yet been elucidated. The objective of this study was to evaluate the clinical significance of BMD discordance between the hip and spine for hip fractures. The BMD was measured and related factors were investigated in 109 elderly patients hospitalized for a hip fracture (fracture group) and 109 patients hospitalized without a hip fracture (non-fracture group). BMD discordance of the hip and spine was classified as minor discordance (normal and osteopenia, and osteopenia and osteoporosis) and major discordance (normal and osteoporosis). The risk of hip fracture was calculated according to the type of discordance: no discordance, low hip, and lower spine. There was no significant difference between the general characteristics of the fracture group and the non-fracture group. The rate of BMD discordance and low hip discordance were significantly higher in the fracture group (53.2%, 43.1%) than in the non-fracture group (28.4%, 19.3%). The odds ratio of hip fracture was 2.86 times higher in patients with BMD discordance than in those without discordance and 3.42 times higher in the patients with low hip discordance than in those without no hip discordance. The presence of discordance, particularly when there is low hip discordance, might be related to the hip fractures.

Association Between Combat-Related Traumatic Injury and Skeletal Health: Bone Mineral Density Loss Is Localized and Correlates With Altered Loading in Amputees: the Armed Services Trauma Rehabilitation Outcome (ADVANCE) Study

The association between combat-related traumatic injury (CRTI) and bone health is uncertain. A disproportionate number of lower limb amputees from the Iraq and Afghanistan conflicts are diagnosed with osteopenia/osteoporosis, increasing lifetime risk of fragility fracture and challenging traditional osteoporosis treatment paradigms. The aim of this study is to test the hypotheses that CRTI results in a systemic reduction in bone mineral density (BMD) and that active traumatic lower limb amputees have localized BMD reduction, which is more prominent with higher level amputations. This is a cross-sectional analysis of the first phase of a cohort study comprising 575 male adult UK military personnel with CRTI (UK-Afghanistan War 2003 to 2014; including 153 lower limb amputees) who were frequency-matched to 562 uninjured men by age, service, rank, regiment, deployment period, and role-in-theatre. BMD was assessed using dual-energy X-ray absorptiometry (DXA) scanning of the hips and lumbar spine. Femoral neck BMD was lower in the CRTI than the uninjured group (T-score -0.08 versus -0.42 p = .000). Subgroup analysis revealed this reduction was significant only at the femoral neck of the amputated limb of amputees (p = 0.000), where the reduction was greater for above knee amputees than below knee amputees (p < 0.001). There were no differences in spine BMD or activity levels between amputees and controls. Changes in bone health in CRTI appear to be mechanically driven rather than systemic and are only evident in those with lower limb amputation. This may arise from altered joint and muscle loading creating a reduced mechanical stimulus to the femur resulting in localized unloading osteopenia. This suggests that interventions to stimulate bone may provide an effective management strategy. © 2023 Crown copyright and The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR). This article is published with the permission of the Controller of HMSO and the King's Printer for Scotland.

Identifying microbial signatures for patients with postmenopausal osteoporosis using gut microbiota analyses and feature selection approaches

Osteoporosis (OP) is a metabolic bone disorder characterized by low bone mass and deterioration of micro-architectural bone tissue. The most common type of OP is postmenopausal osteoporosis (PMOP), with fragility fractures becoming a global burden for women. Recently, the gut microbiota has been connected to bone metabolism. The aim of this study was to characterize the gut microbiota signatures in PMOP patients and controls. Fecal samples from 21 PMOP patients and 37 controls were collected and analyzed using amplicon sequencing of the V3-V4 regions of the 16S rRNA gene. The bone mineral density (BMD) measurement and laboratory biochemical test were performed on all participants. Two feature selection algorithms, maximal information coefficient (MIC) and XGBoost, were employed to identify the PMOP-related microbial features. Results showed that the composition of gut microbiota changed in PMOP patients, and microbial abundances were more correlated with total hip BMD/T-score than lumbar spine BMD/T-score. Using the MIC and XGBoost methods, we identified a set of PMOP-related microbes; a logistic regression model revealed that two microbial markers (Fusobacteria and Lactobacillaceae) had significant abilities in disease classification between the PMOP and control groups. Taken together, the findings of this study provide new insights into the etiology of OP/PMOP, as well as modulating gut microbiota as a therapeutic target in the diseases. We also highlight the application of feature selection approaches in biological data mining and data analysis, which may improve the research in medical and life sciences.

Bipolar Disorder and Bone Mineral Density Z-Scores in Relation to Clinical Characteristics and Lithium Medication

Bipolar disorder is associated with a long range of medical comorbidities, including migraine, diabetes, and cardiovascular disease. Bipolar disorder has also been associated with an increased risk of bone fractures. Osteoporosis is a reduction in bone mineral density, which leads to an increased risk for fragility fractures. Currently there is limited research on the association between bipolar disorder and osteoporosis. We aimed to study the association between high and low bone mineral density in relation to disease and treatment history in a sample of bipolar patients. We found that bipolar patients with high bone mineral density were more often on lithium medication, had a more active lifestyle and expressed lower current disease burden. Low mineral density was not associated with any of the addressed aspects of disease and treatment history. In conclusion our results support that patients on lithium treatment have higher bone mineral density; further studies are needed to address if lithium medication causes an increase in bone mineral density, and lowers the risk of bone fractures in bipolar disorder.

Global, regional prevalence, and risk factors of osteoporosis according to the World Health Organization diagnostic criteria: a systematic review and meta-analysis

This systematic review and meta-analysis estimated the global, regional prevalence, and risk factors of osteoporosis. Prevalence varied greatly according to countries (from 4.1% in Netherlands to 52.0% in Turkey) and continents (from 8.0% in Oceania to 26.9% in Africa). Osteoporosis is a common metabolic bone disorder in the elderly, usually resulting in bone pain and an increased risk of fragility fracture, but few summarized studies have guided global strategies for the disease. Therefore, we pooled the epidemiologic data to estimate the global, regional prevalence, and potential risk factors of osteoporosis. We conducted a comprehensive literature search through PubMed, EMBASE, Web of Science, and Scopus, to identify population-based studies that reported the prevalence of osteoporosis based on the World Health Organization (WHO) criteria. Meta-regression and subgroup analyses were used to explore the sources of heterogeneity. The study was registered in the PROSPERO database (CRD42021285555). Of the 57,933 citations evaluated, 108 individual studies containing 343,704 subjects were included. The global prevalence of osteoporosis and osteopenia was 19.7% (95%CI, 18.0%-21.4%) and 40.4% (95%CI, 36.9%-43.8%). Prevalence varied greatly according to countries (from 4.1% in Netherlands to 52.0% in Turkey) and continents (from Oceania 8.0% to 26.9% in Africa). The prevalence was higher in developing countries (22.1%, 95%CI, 20.1%-24.1%) than in developed countries (14.5%, 95%CI, 11.5%-17.7%). Our study indicates a considerable prevalence of osteoporosis among the general population based on WHO criteria, and the prevalence varies substantially between countries and regions. Future studies with robust evidence are required to explore risk factors to provide effective preventive strategies for the disease.

Low bone mineral density and its related factors in adults with congenital heart disease in Vietnam: A cross‐sectional study

Background and Aims

Recent studies have highlighted the increased risk of low bone mineral density (BMD) in adults with cardiovascular disease. However, little is known about BMD in adults with congenital heart disease (CHD), particularly in developing countries. We hypothesized that factors related to BMD would lead to a high prevalence of low BMD in adults with CHD. This study aimed to determine the prevalence of low BMD and its related factors in Vietnamese adults with CHD.

Methods

We conducted a cross‐sectional study of 73 adults diagnosed with CHD in Vietnam. Low BMD was classified based on their site‐specific Z‐scores and T‐scores at the posteroanterior lumbar spine and left proximal femur. Logistic regression analyses were performed to evaluate factors related to low BMD.

Results

Low BMD was confirmed in one‐third of the adults with CHD. There were trends of more bone loss in certain parts of the body than in others, with the prevalence of low BMD at the sites of the lumbar vertebrae (L1‒L4) and left proximal femur (femoral neck, trochanteric femur, and intertrochanteric area) of 43.9%, 31.8%, 28.8%, 33.3%, 8.8%, 1.5%, and 6.1%, respectively. The prevalence of low BMD in the lumbar spine was significantly higher than that in the left proximal femur (34.3% vs. 2.9%, p < 0.001). Moreover, the prevalence of low BMD was significantly higher in adults with CHD than in those without polycythemia and vitamin D deficiency (55.6% vs. 20.9%, p = 0.001 and 46.2% vs. 19.4%, p = 0.002, respectively). A stratified multivariate logistic regression analysis revealed that low BMD was associated with polycythemia (odds ratio: 4.72; 95% confidence interval: 1.64–13.58, p = 0.004).

Conclusions

Low BMD is common among adults with CHD in Vietnam and related to polycythemia.

Prevalence and Risk Factors of Discordance Between Hip and Spinal Bone Mineral Density Among Saudi Subjects

Background

Discordance between hip and spine on dual-energy x-ray absorptiometry is a well-known problem in diagnosing osteoporosis. The prevalence and risk factors of this problem have not been studied in the Saudi population. The objective of this study was to document this discordance in our population and its possible risk factors.

Materials and methods

We analyzed data obtained from subjects who had dual x-ray absorptiometry (DXA) between January 2021 and December 2021 at King Khalid University Hospital, Riyadh, Saudi Arabia. Subjects with the following conditions were excluded: secondary osteoporosis, patients taking anti-osteoporotic agents, patients on steroids or hormonal replacement therapy, hyperparathyroidism, hypoparathyroidism, and chronic renal disease. A total of 1388 patients satisfied our inclusion criteria. World Health Organization (WHO) criteria for diagnosis were implemented. Major discordance was defined as osteoporosis in one site and normal in the other. Minor discordance was defined as a difference of no more than one World Health Organization diagnostic class between two sites. Bivariate statistical analysis was achieved using appropriate statistical tests (chi-square, student’s t-test, one-way analysis of variance, and Pearson’s correlation), based on the type of study and outcome variables. A p-value of < 0.05 and 95% CI were used to report the statistical significance and precision of results.

Results

A total of 1388 subjects were analyzed, of which, 1196 (86%) were females with a mean age of 58.8 (13.8 SD) and 192 were males with a mean age of 58 (18.0 SD). Lumbar osteoporosis was found in 312 (22.5%) participants while hip osteoporosis was reported in 73 (5.3%) of the participants. Major discordance was documented in 85 (6.1%) of all participants (6.3% of the male and 6.1% of the female patients). All of these subjects had lumbar spine osteoporosis with normal hip bone mineral density (BMD). Minor discordance was found in 591 patients (42.6%). Obesity (BMI > 30) was found to be a risk factor for both major (2.10-11.6, 95% CI) and minor (2.5-11.4, 95% CI) discordance.

Conclusion

Discordance between hip and spine BMD is common among Saudi subjects. Lumbar spine osteoporosis with normal hip BMD caused this discordance in our subjects. Obesity could be responsible for the occurrence of this discordance. Mechanisms may include higher rate of turnover in spine, technical artifacts in the measurements of lumbar spine BMD, or due to the effects of weight loading. Caution should be exercised when interpreting DXA results, especially in obese subjects.

Evaluation of the bone mineral density in the Mexican female population using the Radiofrequency Echographic Multi Spectrometry (REMS) technology

The bone health status of a Mexican female population, including a cohort of 455 women aged over 40 years, was assessed by Radiofrequency Echographic Multi Spectrometry (REMS).

PURPOSE

Assessment of the bone health status in an average female Mexican population with REMS. The secondary objective investigated age- and body mass index (BMI)-related effects on the diagnostic classification and the influence of risk factors for osteoporosis.

METHODS

Women aged over 40 years underwent a REMS scan at the lumbar spine and both femoral necks. The degree of correlation of the bone mineral density (BMD) across axial sites was assessed by the Pearson correlation coefficient (r), along with the diagnostic discordance. The association between risk factors, age, and BMI and diagnostic classification was determined by the chi-squared test.

RESULTS

Four hundred seventy-one women were enrolled. Osteoporosis was diagnosed in 11.0%, 8.1%, and 8.3% of cases at the lumbar spine and right and left femoral neck, respectively. The diagnostic agreement between the lumbar spine and femoral necks was about 73% (85% considering a 0.3 T-score tolerance), whereas the agreement between the femoral necks was 97.4% (99.6% considering a 0.3 T-score tolerance). Most of discordant cases were minor discordances. The correlation between the lumbar spine and femoral neck was r = 0.82 and 0.85, respectively, whereas both femoral necks correlated with r = 0.97. As expected, the prevalence of osteoporosis increased with age and decreased as BMI increased.

CONCLUSION

The widespread applicability of the non-ionizing REMS technology has been demonstrated in a representative Mexican cohort, covering wide age and BMI ranges. Age and BMI variations correlate with the prevalence of osteoporosis, in line with the recent scientific literature.

Prevalence and Risk Factors of T-Score Spine-Hip Discordance in Patients with Osteoporotic Vertebral Compression Fracture

Background: T-score discordance between the spine and hip is commonly observed when dual energy X-ray absorptiometry (DXA) is used to diagnose osteoporosis. However, information is scarce regarding the prevalence and risk factors for this problem in Korea. This study evaluated the prevalence of major/minor discordance and associated risk factors in elderly Korean patients with osteoporotic vertebral compression fractures (OVCFs).Methods: This study included 200 patients (37 men, 163 women) treated for thoracic or lumbar compression fractures between January 2015 and August 2021. DXA was performed to examine T‐scores and determine the prevalence of discordance, defined as a difference between the T-score categories of the femur and spine in the same individual. The t-tests, χ2 tests, and regression analyses were used to assess the associated risk factors of T-score discordance among the subjects.Results: T-score concordance, minor discordance, and major discordance were observed in 137 (68.5%), 59 (29.5%), and 4 (2%) patients with OVCFs, respectively. The spinal T-score was lower than the femoral T-score in all major discordance and 81.3% (48/59) of minor discordant cases. Overall, the only factor related to T-score discordance was the age at fracture (odds ratio, -0.01; P=0.014).Conclusions: The results of this study showed that a significant number of subjects (31.5%) showed spine-hip discordance, even with a mean age in their 80s. More attention should be paid to the appropriate evaluation and management of elderly patients with OVCFs. Moreover, a longitudinal study is necessary to verify the clinical importance of T-score discordance in this population.

Discordance in Bone Mineral Density between the Lumbar Spine and Femoral Neck Is Associated with Renal Dysfunction

PURPOSE

Bone mineral density (BMD) determined by dual-energy X-ray absorptiometry is considered a gold standard for diagnosing osteoporosis. Some people show discordance in BMD values measured at the femur and that at the lumbar spine (LS). The aim of the present study was to investigate whether differences in BMD T-scores between the LS and femur neck (FN) are associated with renal dysfunction in the general population of Korea.

MATERIALS AND METHODS

We analyzed national data for 17306 adults from the Korean National Health and Nutrition Examination Survey conducted between 2008 and 2011. BMD T-score differences between LS and FN (termed BMD offset) were calculated by subtracting FN T-scores from LS T-scores. Diminished renal function was defined as estimated glomerular filtration rates (eGFR) less than 60 mL/min/1.73 m².

RESULTS

Among those aged ≥50 years, BMD offset was negatively associated with eGFR levels. Additionally, eGFR levels decreased linearly across increasing BMD offset quartiles. Men and women with an offset of >1.5 showed a 4.79-times and 2.51-times higher risk of renal dysfunction, respectively, compared to individuals with an offset of ≤0, after adjusting for age, body mass index, educational level, current smoking, and physical activity. In contrast, there was little evidence of an association between renal dysfunction and BMD offset in subjects aged <50 years.

CONCLUSION

Discordance between LS and FN BMDs was significantly associated with renal dysfunction in subjects aged ≥50 years. When assessing bone health in older chronic kidney disease patients, physicians should consider the possibility of BMD discordance between LS and FN.

Factors affecting spine–femur discordance in the percentage of young adult mean on dual-energy X-ray absorptiometry in the elderly population: a retrospective study

Background

Several retrospective studies have reported spine–femur discordance in bone mineral density (BMD) values. However, the average age of individuals in these studies was the mid-50s, which is younger than the typical age of individuals requiring treatment for primary osteoporosis. Therefore, we aimed to investigate factors associated with discordance in the percentage of young adult mean (YAM) between the lumbar spine and femoral neck in the elderly population.

Methods

We evaluated 4549 dual-energy X-ray absorptiometry (DXA) measurements obtained from 2161 patients (269 men and 1892 women) between January 2014 and December 2017 at our hospital. For individuals with more than one eligible set of measurements, the first record was used. We investigated each patient’s age, sex, body mass index, current smoking status, alcohol consumption, use of steroids, presence of diabetes mellitus, and presence of rheumatoid arthritis.

Results

The mean age of the patients was 76.4 ± 8.9 years. Older age (p <  0.001), male sex (p <  0.001), and diabetes mellitus (p = 0.007) were significantly associated with spine–femur discordance in the percentage of YAM.

Conclusion

The frequency and magnitude of spine–femur discordance in the percentage of YAM from DXA scans increased with age. Notably, more than 77.4% of patients in their 90s had spine–femur discordance > 10% of YAM. Furthermore, the frequency of spine–femur discordance was higher in men and in patients with diabetes mellitus, suggesting that the percentage of YAM at the lumbar spine may not be reliable for diagnosis of osteoporosis in patients with these factors.

Similarities and differences between bone quality parameters, trabecular bone score and femur geometry

Bone quality is a critical factor that, along with bone quantity, determines bone strength. Image-based parameters are used for assessing bone quality non-invasively. The trabecular bone score (TBS) is used to assess quality of trabecular bone and femur geometry for cortical bone. Little is known about the associations between these two bone quality parameters and whether they show differences in the relationships with age and body mass index (BMI). We investigated the associations between the trabecular bone score (TBS) and femur cortical geometry. Areal bone mineral density (BMD) was assessed using dual energy X-ray absorptiometry (DXA) and the TBS was assessed using iNsight software and, femur geometry using APEX (Hologic). A total of 452 men and 517 women aged 50 years and older with no medical history of a condition affecting bone metabolism were included. Z-scores for TBS and cortical thickness were calculated using the age-specific mean and SD for each parameter. A ‘discrepancy group’ was defined as patients whose absolute Z-score difference between TBS and cortical thickness was > 1 point. TBS and cortical thickness correlated negatively with age both in men and women, but the associations were stronger in women. Regarding the associations with BMI, TBS provided significant negative correlation with BMI in the range of BMI > 25 kg/m². By contrast, cortical thickness correlated positively with BMI for all BMI ranges. These bone quality-related parameters, TBS and cortical thickness, significantly correlated, but discordance between these two parameters was observed in about one-third of the men and women (32.7% and 33.4%, respectively). Conclusively, image-based bone quality parameters for trabecular and cortical bone exhibit both similarities and differences in terms of their associations with age and BMI. These different profiles in TBS and FN cortical thickness might results in different risk profiles for the vertebral fractures or hip fractures in a certain percentage of people.

Comparative Analysis of T-score Discordance between a Registry-Based Korean Population and Atypical Femoral Fracture Patients of a Single Institution

Background

The purpose of this study was to analyze the epidemiology of T-score discordance between the spine and femur in the South Korean population and compare the prevalence of T-score discordance between the Korean osteoporosis population and atypical femoral fracture (AFF) patients.

Methods

A total of 12,422 subjects from the Korea National Health and Nutrition Examination Survey were reviewed retrospectively. T-score discordance was defined as a difference of ≥ 1 standard deviation between the lumbar spine (LS) and femoral neck (FN) bone mineral density (BMD). The prevalence of T-score discordance (low LS [LS BMD < FN BMD], low FN [LS BMD > FN BMD], and total [low LS + low FN]) was investigated in the osteoporosis and non-osteoporosis groups and stratified by sex and age. T-score discordance of 63 patients with AFFs diagnosed at a single institution was compared with that of the Korean osteoporosis population using propensity score matching.

Results

T-score discordance was prevalent in the Korean osteoporosis population (44.8%), and low LS discordance (37.5%) was more frequently seen than low FN discordance (7.2%) (p < 0.001). The prevalence of total and low LS discordance was significantly higher in AFF patients than in the Korean osteoporosis population (total discordance: 69.8% and 42.5%, respectively; low LS discordance: 63.5% and 31.7%, respectively; p < 0.001).

Conclusions

T-score discordance was highly prevalent in the Korean osteoporosis population, and low LS discordance was more common than low FN discordance. Nevertheless, the prevalence of low LS discordance was significantly higher in AFF patients than in the Korean osteoporosis population.

Association between the appendicular lean mass index or handgrip strength and bone mineral density in patients undergoing peritoneal dialysis

Background: Few studies have investigated the association between muscle mass and bone mineral density (BMD) in patients undergoing peritoneal dialysis (PD). We aimed to investigate the association between muscle mass or strength and BMD in patients undergoing PD. Methods: The data of all prevalent PD cases at a tertiary medical center between September 2017 and November 2020 were collected. Among all patients, 199 patients undergoing PD were finally analyzed. Baseline measurements including handgrip strength (HGS), appendicular lean mass (ALM) index, and BMD were obtained during a peritoneal membrane equilibration test. Patients with a T-score of ≤ -2.5 were categorized into the low BMD group. Results: The number of male patients was 113 (56.8%). Significant differences were observed in various indices, such as BMD, body composition parameters, and laboratory findings, between male and female patients. There was a stronger association between BMD and ALM index than between BMD and HGS in male patients (r = 0.432 and P < 0.001). The association between BMD and HGS was more definitive in female patients than in male patients (r = 0.357 and P = 0.001). Univariate and mutivariate linear regression and AUROC analyses showed similar trends those obtained in correlation analyses. Conclusion: The present study demonstrated that BMD is associated with the ALM index in male patients and with HGS in female patients undergoing PD.

Determination of anisotropic elastic parameters from morphological parameters of cancellous bone for osteoporotic lumbar spine

In biomechanics, large finite element models with macroscopic representation of several bones or joints are necessary to analyze implant failure mechanisms. In order to handle large simulation models of human bone, it is crucial to homogenize the trabecular structure regarding the mechanical behavior without losing information about the realistic material properties. Accordingly, morphology and fabric measurements of 60 vertebral cancellous bone samples from three osteoporotic lumbar spines were performed on the basis of X-ray microtomography (μCT) images to determine anisotropic elastic parameters as a function of bone density in the area of pedicle screw anchorage. The fabric tensor was mapped in cubic bone volumes by a 3D mean-intercept-length method. Fabric measurements resulted in a high degree of anisotropy (DA = 0.554). For the Young’s and shear moduli as a function of bone volume fraction (BV/TV, bone volume/total volume), an individually fit function was determined and high correlations were found (97.3 ≤ R² ≤ 99.1,p < 0.005). The results suggest that the mathematical formulation for the relationship between anisotropic elastic constants and BV/TV is applicable to current μCT data of cancellous bone in the osteoporotic lumbar spine. In combination with the obtained results and findings, the developed routine allows determination of elastic constants of osteoporotic lumbar spine. Based on this, the elastic constants determined using homogenization theory can enable efficient investigation of human bone using finite element analysis (FEA).

Graphical Abstract

New technology REMS for bone evaluation compared to DXA in adult women for the osteoporosis diagnosis: a real-life experience

Osteoporosis is a prevalent skeletal disorder in postmenopausal women. REMS represents a potential technology for osteoporosis diagnosis in clinical practice.

OBJECTIVE

To assess the accuracy of Radiofrequency Echographic Multi Spectrometry (REMS) technology in diagnosing osteoporosis in comparison with dual X-ray absorptiometry (DXA) on a population of Brazilian women.

METHODS

A population of women age ranged between 30 and 80 was recruited at DXA Service of São Paulo School-Hospital, Brazil. They underwent REMS and DXA scans at the axial sites. The REMS accuracy for the osteoporosis diagnosis was evaluated in comparison with DXA on both sites. The intra-operator and inter-operator coefficient of variation (CV) was also calculated.

RESULTS

A total of 343 patients were enrolled in the study. Erroneous scans due to poor quality acquisitions with both methods or to other technical reasons were excluded; 227 lumbar spine exams and 238 hip exams were acceptable for comparison analysis. The comparison between REMS and DXA outcomes showed that the average difference in BMD (expressed as bias±1.96 SD) was -0.026±0.179g/cm² for the spine and -0.027±0.156g/cm² for the femoral neck. When accepted 0.3 tolerance on T-score, there were no cases diagnosed as osteoporosis by DXA that were defined as normal by REMS. The REMS intra-operator CV was 0.51% for the lumbar spine and 1.08% for the femoral neck. The REMS inter-operator CV was 1.43% for the lumbar spine and 1.93% for the femoral neck.

CONCLUSION

The REMS approach had high accuracy for the diagnosis of osteoporosis in comparison with DXA in adult women. According to our results, this new technology has shown to be a promising alternative for populations without access to DXA densitometry.

Spine-Hip Discordance and FRAX assessment Fracture Risk in Postmenopausal Women with Osteopenia from Concordant Diagnosis Between Lumbar Spine and Femoral Neck

The diagnostic criteria proposed by the World Health Organization did not consider the discrepancy in diagnosis between lumbar spine (LS) and femoral neck (FN) and the clinical implications is unclear. Therefore, this retrospective study evaluated the probability of fracture risk in postmenopausal women with lumbar spine (LS)-femoral neck (FN) bone mineral density (BMD) discordance or not Patients included 1066 healthy postmenopausal women (median age 55.5 years) who visited our hospital for a health check-up between May 2013 and April 2017. Discordance was defined as a difference of one or two degrees between LS BMD and FN BMD. TBS was calculated from dual energy absorptiometry (DXA) images. Fracture risk was assessed using the Fracture Risk Assessment Tool (FRAX), including TBS-adjusted FRAX Seven hundred and two patients (65.9%) showed concordant LS and FN results, whereas 364 patients (34.1%) exhibited discordance. Normal BMD was found in 519 concordant patients (73.9%). Concordant patients showed significantly higher FRAX scores, including TBS-adjusted FRAX results, than discordant patients with low LS or FN. Furthermore, FRAX results in concordant osteopenia patients were similar to that of osteoporosis patients with osteopenia or a normal result at one site. FRAX and TBS-adjusted FRAX results in concordant osteopenia patients were comparable to that of discordant osteoporosis patients We concluded that patients with colncordant osteopenia in both the FN and LS should be managed in a similar way to patients with discordant osteoporosis.

Effect of T12 Mislabeling as L1 on the Diagnosis of Low BMD at Lumbar Spine

Mislabeling of T12 vertebra as L1 has been shown to reduce L1-L4 bone mineral density (BMD). However, the effect of such mislabeling on the L1-L4 BMD and prevalence of osteoporosis and/or osteopenia in a clinical setting is not known. The study aimed to the effect of mislabelling of T12 as L1 on the L1-L4 BMD and diagnosis of osteoporosis and/or osteopenia. It is a retrospective study done at a tertiary health care center in South India. Database of dual X-ray absorptiometry machine at our center was reviewed and BMD data of men aged more than 50 years and postmenopausal women who underwent BMD during the last 3.5 years were included in the analysis. A total of 570 subjects had undergone BMD testing at the lumbar spine of whom images of the T12 and lower part of the T11 were available for 293 subjects. Six of these with ≤1 eligible vertebra for the calculation of L1-L4 BMD were further excluded from the analysis. The BMD data of the remaining 287 subjects were noted. Later T12 was labeled as L1 and a new set of BMD data was obtained. Using the WHO classification, BMD status was classified as normal BMD, osteopenia, and osteoporosis for both the analyses. L1-L4 BMD (0.916 ± 0.163 vs 0.937 ± 0.170, p < 0.0001) and T-scores of L1-L4 (-2.23 ± 1.37 vs -2.06 ± 1.43, p < 0.0001) with mislabeling were significantly lower than those measured with correct labeling. BMD status was misclassified by T12 mislabelling as L1 in a total of 30 (10.4%) individuals. Inter-rater agreement between the 2 scenarios for the diagnosis of osteoporosis, osteopenia, and normal BMD was substantial (weighted Kappa: 0.87 [95%CI: 0.83-0.91]). To conclude, mislabeling of T12 as L1 significantly reduces L1-L4 BMD. However, the diagnosis of BMD status by mislabeling has a substantial agreement with that obtained with correct labeling.

Low Grip Strength and Muscle Mass Increase the Prevalence of Osteopenia and Osteoporosis in Elderly Women

The risk of developing low muscle strength and muscle mass is affected by aging, osteopenia, and osteoporosis and increases with age. The purpose of this study was to investigate the prevalence and cutoff values for osteoporosis and osteopenia according to the level of grip strength and muscle mass associated with sarcopenia. A cross-sectional study was conducted, and data from 734 women aged from 60 to 79 years old who visited the healthcare center from 2016 to 2019 were analyzed. Bone mineral density was measured on the lumbar spine from 1-4 using dual X-ray absorptiometry. Osteopenia and osteoporosis were classified on the basis of a T-score ranging from -1.0 to -2.4 and under -2.5, respectively. The diagnostic criteria for sarcopenia were a grip strength of <18 kg and muscle mass of <5.7 kg/m² according to the Asian Working Group of Sarcopenia. Logistic regression analysis was used to determine the odds ratio, and the receiver operating characteristic curve was applied for the cutoff values. There were 351 (47.8%) patients with osteopenia and 152 (20.7%) patients with osteoporosis. The prevalence of osteopenia increased 1.593 times in the lowest grip strength group and 1.810 times in the lowest muscle mass group (p < 0.05). For osteoporosis, the lowest grip strength increased 2.512 times and the lowest muscle mass increased 2.875 times, compared to the highest grip strength group. In the sarcopenia group, osteopenia increased 2.451 times and osteoporosis increased 3.137 times, compared to the non-sarcopenia group (p < 0.05). In conclusion, the prevalence of osteoporosis and osteopenia was increased in elderly women with low grip strength and muscle mass.

Does Quantitative Ultrasound at the Calcaneus Predict an Osteoporosis Diagnosis in Postmenopausal Women from the Silesia Osteo Active Study?

The aims of the study were to assess the clinical conformity between quantitative ultrasound (QUS) and densitometry with use of the standard World Health Organization T-score thresholds to determine optimal diagnostic cutoff values for QUS T-scores in different age groups. Three hundred sixty-five postmenopausal Caucasian women were enrolled into the study and divided into two age groups (<65 y and ≥65 y). Skeletal status was assessed using QUS measurements at the calcaneus and bone densitometry at the spine and proximal femur (Hologic Explorer, Bedford, MA, USA). QUS measurement results expressed as the stiffness index (SI) correlated significantly with both femoral neck bone mineral density (r = 0.51, p < 0.0001) and lumbar spine bone mineral density (r = 0.52, p < 0.0001). On the basis of receiver operating characteristic curve analyses, the thresholds for correspondence between QUS T-score values and T-score -2.5SD in dual X-ray absorptiometry (DXA) were established. They ranged between -1.63SD and -1.70SD in relation to femoral neck DXA and between -1.22SD and -1.51SD in relation to lumbar spine DXA, depending on age category. In conclusion, the study described here confirmed that QUS measurements at the calcaneus may provide information comparable to DXA examinations at the femoral neck and lumbar spine in postmenopausal women.

Prevalence and Risk Factors of Osteoporosis in Chinese Postmenopausal Women Awaiting Total Knee Arthroplasty

Background

Total knee arthroplasty (TKA) complications associated with low bone quality are challenging for orthopaedic surgeons to treat, but little is known about bone quality in Chinese postmenopausal women awaiting TKA. This study investigated the incidence of osteoporosis (OP) and explored the preoperative risk factors for OP in this population.

Methods

We retrospectively reviewed the data of Chinese postmenopausal women who were indicated for TKA between May 2017 and June 2020. The bone mineral density (BMD) of the hip and lumbar spine and multiple preoperative parameters were collected and analyzed. Binary logistic regression analysis was performed to identify independent risk factors for OP in this population.

Results

A total of 204 postmenopausal women with advanced knee OA were included in the study (age: 69.7±8.5 years; body mass index [BMI]: 25.5±4.0 kg/m2). The OP prevalence among all participants was 59.8%, and the patients aged 60–80 years had a significantly lower BMD than did the age/ethnicity-adjusted population. An age ≥60 years, a BMI<25, and the presence of a varus knee deformity were independent risk factors for preoperative OP in the postmenopausal women awaiting TKA.

Conclusion

The prevalence of OP in Chinese postmenopausal women awaiting TKA is higher than that in the age/ethnicity-adjusted normal population. An age ≥60 years, a BMI<25, and the presence of a varus knee deformity are independent risk factors that can be used to predict preoperative OP in this population.

Metabolic activities affect femur and lumbar vertebrae remodeling, and anti-resorptive risedronate disturbs femoral cortical bone remodeling

Metabolic activities are closely correlated with bone remodeling and long-term anti-resorptive bisphosphonate treatment frequently causes atypical femoral fractures through unclear mechanisms. To explore whether metabolic alterations affect bone remodeling in femurs and lumbar vertebrae and whether anti-osteoporotic bisphosphonates perturb their reconstruction, we studied three mouse strains with different fat and lean body masses (BALB/c, C57BL6, and C3H mice). These mice displayed variable physical activity, food and drink intake, energy expenditure, and respiratory quotients. Following intraperitoneal calcein injection, double calcein labeling of the femoral diaphysis, as well as serum levels of the bone-formation marker procollagen type-I N-terminal propeptide and the bone-resorption marker C-terminal telopeptide of type-I collagen, revealed increased bone turnover in mice in the following order: C3H > BALB/c ≥ C57BL6 mice. In addition, bone reconstitution in femurs was distinct from that in lumbar vertebrae in both healthy control and estrogen-deficient osteoporotic mice with metabolic perturbation, particularly in terms of femoral trabecular and cortical bone remodeling in CH3 mice. Interestingly, subcutaneous administration of bisphosphonate risedronate to C3H mice with normal femoral bone density led to enlarged femoral cortical bones with a low bone mineral density, resulting in bone fragility; however, this phenomenon was not observed in mice with ovariectomy-induced femoral cortical bone loss. Together, these results suggest that diverse metabolic activities support various forms of bone remodeling and that femur remodeling differs from lumbar vertebra remodeling. Moreover, our findings imply that the adverse effect of bisphosphonate agents on femoral cortical bone remodeling should be considered when prescribing them to osteoporotic patients.

Prolonged Amenorrhea and Low Hip Bone Mineral Density in Women Living With HIV-A Controlled Cross-sectional Study

BACKGROUND

Women living with HIV (WLWH) have higher rates of prolonged secondary amenorrhea (no flow for ≥1 year) than HIV-negative women. Both having amenorrhea and being HIV positive are associated with lower areal bone mineral density (BMD). However, their combined BMD effects remain unclear. Therefore, we investigated prolonged amenorrhea and BMD in WLWH and controls.

METHODS

This cross-sectional study enrolled WLWH and HIV-negative control women aged 19-68 years of similar backgrounds. We assessed BMD (Hologic; as age- and ethnicity-matched Z-scores) in the Children and women: AntiRetrovirals and Markers of Aging cohort. Participants were stratified by amenorrhea history defined as past/present lack of menses for ≥1 year at age 45 and younger and not because of surgery, breastfeeding, pregnancy, or hormonal contraception. Hip and spine Z-scores by amenorrhea/no amenorrhea used linear models with multivariable analysis for relationships within WLWH.

RESULTS

WLWH (N = 129) were similar to controls (N = 129) in age, body mass index, ethnicity, and substance use. Among WLWH, 21% experienced prolonged amenorrhea vs. 9% in controls. WLWH had significantly lower total hip (mean ± SD: -0.4 ± 0.9 vs. 0.3 ± 1.1; P < 0.001) and spine (-0.5 ± 1.3 vs. 0.2 ± 1.3; P = 0.001) Z-scores than controls. Amenorrhea was independently associated with hip (P = 0.01) but not spine (P = 0.94) BMD by multivariable linear regression. WLWH with amenorrhea had lower hip Z-scores (-0.8 ± 0.9) than those without (-0.3 ± 0.8; P = 0.01). They also had higher rates of substance use, smoking, opioid therapy, hepatitis C coinfection, and lower CD4 nadir.

CONCLUSIONS

WLWH had higher rates of prolonged amenorrhea and lower BMD than controls. WLWH with amenorrhea experienced lower hip BMD Z-scores than those without. Prolonged amenorrhea is an added osteoporosis risk in WLWH.

Trabecular bone mineral density correlations using QCT: Central and peripheral human skeleton

Musculoskeletal injuries to the lower leg and foot-ankle joint are associated with external mechanical loads resulting from motor vehicle crashes, under body blasts, falls from height, or sports. As an intrinsic material property, the bone mineral density (BMD) is related to bone strength. The clinically recognized biological sites for BMD evaluation are the hip and spine. The focus of this study was to define the correlation between BMD from standard clinical sites (hip and lumbar spine) compared to BMD from non-standard sites (foot-ankle-distal tibia bones). Twenty-one post-mortem human subjects (PMHS) with mean age, height, and mass of 63 ± 11 years, 179 ± 7 cm, and 86 ± 13 kg, respectively were used for analysis. Clinical BMD software (Mindways Software, Inc.) was used for trabecular BMD quantification using quantitative computed tomography (QCT). In quantification of BMD of the foot-ankle-distal tibia (hind foot), the trabecular BMD of the talus (316 ± 86mg/cc) was highest followed by the distal tibia (238 ± 72 mg/cc) and then calcaneus (147 ± 51 mg/cc). To correlate BMD values from foot bone regions with the central skeleton BMD values within the same PMHS, there were 18 lumbar spine and 12 hip BMDs available. The BMD of the distal tibia correlated best with the hip intertrochanter BMD (R² of 0.72). Calcaneus BMD best correlated with the hip femoral neck BMD (R² = 0.64). In summary, the hind foot bone BMD values correlated better with the hip as compared to the lumbar spine BMD from the same PMHS. These findings indicate that, in the absence of a direct measure of foot-bone BMD, hip BMD might be a better predictor of injury risk to hind foot rather than lumbar spine BMD, or alternatively, calcaneal trabecular BMD can be used to predict the risk of injury to hip. Further, these relationships between central and peripheral regions can also be implemented in finite element models for improved failure predictions.

Prevalence of low bone mineral density in inflammatory bowel disease and factors associated with it

BACKGROUND

Patients with inflammatory bowel disease (IBD) have numerous risk factors for low bone mineral density (BMD). We aimed to study the prevalence of low BMD in IBD and the factors associated with it.

METHODS

BMD was measured by radial quantitative ultrasound, and clinical and biochemical characteristics were compared in prospectively enrolled patients and healthy age and gender-matched controls. Chi-square test, t test for independent samples, analysis of variance (ANOVA), Mann-Whitney U test and Kruskal-Wallis H tests were used as appropriate for univariate analysis to compare the characteristics between patients with and without abnormal BMD. Binary logistic regression analysis was done to determine the factors associated with low BMD in IBD patients.

RESULTS

One hundred and six patients (Crohn's disease [CD] = 35, ulcerative colitis [UC] = 71) and 55 controls were included. Low BMD was equally prevalent in CD, UC and controls (42.9%, 36.6%, 36.4% respectively, p = 0.791). Serum calcium and vitamin D were significantly lower in IBD patients compared to controls (p < 0.001 and p = 0.003, respectively) but not between patients with low and normal BMD. Older age (Odds ratio [OR] = 66.12 [9.299-470.243], p < 0.001), late onset of disease (OR = 4.795 [1.067-21.543], p = 0.041) and absence of steroid usage (OR = 0.272 [0.089-0.832], p = 0.022) were significantly associated with low BMD.

CONCLUSIONS

The prevalence of low BMD in patients with IBD was similar to controls and this was associated with increasing age, late onset of disease, and absence of steroid usage. Judicious use of steroids can help preserve bone health in IBD.

Major and Minor Discordance in Dual-Energy X-Ray Absorptiometry Diagnosis of Osteoporosis - A Cross-Sectional, Population-Based, Observational Study in Indian Women

Objective

The study objective was to evaluate the presence of major and minor discordance in the diagnosis of osteoporosis in a population-based screening program of Indian women using hip and spine dual-energy X-ray absorptiometry (DEXA).

Methods

In this institutional review board-approved study, a population-based screening program was offered to women aged > 40 using a mobile van model. A total of 5708 women underwent DEXA between May 2012 and May 2016 as a population-based, opt-in screening program offered to women as an outreach program. Bone mineral density (BMD) was measured at the hip and spine, which was used to derive T-scores and to determine the prevalence of discordance.

Results

The densitometry scores were concordant in 42.50% of the cases, with abnormal bone mineral density, whereas in 54.15% of cases, there was minor discordance and major discordance in 3.35% of cases. Body mass index, weight, age, and postmenopausal status of the patient were important predictors of the presence of discordance.

Conclusions

Clinicians and epidemiologists should be prepared for at least five out of every ten women screened to have discordance of the T scores at the two anatomical sites scanned. If there is discordance of BMD in underweight persons or in those with low body mass index, then causes other than physiological discordance should be considered, which may be further evaluated.

The role of using different reference population in the prevalence of low BMD in the thalassemia patients

Purpose

Prevalence of osteoporosis reported as high as 50% in thalassemia major patients. We compared bone density (BMD) of our patients with results of bone densitometry of participants of a national study, to find if BMD diagnosis is ethnicity sensitive or not.

Methods

In 177 adult beta thalassemia major patients and 490 normal subjects of 20-39 y/o range, dual-energy X-ray absorptiometry of the spine and femur performed. Normal subjects participated in Iranian Multi-center Osteoporosis Study (IMOS). Mean and standard deviation of normal ones achieved and Z-score of patients re-calculated based on normal Iranians. As BMD of normal participants and patients performed by devices of different brands, analyses done based on calculated standard BMD of all participants.

Results

BMD of patients was significantly lower than normal participants (P value <0.001). Frequency of Z-score ≤-2 found in 52% and 56% of patients in femur and spine regions, respectively. New Z-score of patients according to Iranian normal populations calculated. Frequency of this new Z-score ≤-2 found in 16% and 72% of patients in femur and spine regions, respectively.

Conclusions

We think in secondary osteoporosis, may be other cut-off points, especially according to BMD of normal population of that geographical region are needed.

Metabolic characteristics of subjects with spine-femur bone mineral density discordances: the Korean National Health and Nutrition Examination Survey (KNHANES 2008-2011)

The diagnosis of osteoporosis is determined based on the lowest bone mineral density (BMD) T-score at the lumbar spine (LS) and hip. However, there are occasional marked discordances between the T-score of LS and femur neck (FN). We aimed to examine the prevalence and characteristics of individuals with spine-femur BMD discordance using a nationwide survey. A total of 3233 men aged ≥ 50 years and 2915 postmenopausal women were included from the Korean National Health and Nutrition Examination Surveys (2008-2011). The spine-femur discordance was defined as a difference of ≥ 1.5 SD between LS and FN BMD. Subjects were divided into three groups: low LS (LS < FN), low FN (LS > FN), and no discordance. Four-hundred and seventeen men (12.9%) and two hundred and ninety women (10%) exhibited spine-femur BMD discordance. The prevalence of hypertension and diabetes was higher in men and women with low FN BMD than in any other group. Fasting plasma glucose and homeostasis model assessment of insulin resistance was the highest in subjects with low FN BMD among the three groups. Low FN BMD revealed higher serum parathyroid hormone and lower 25-hydroxyvitamin D3 levels compared to any other group in women, but this was not observed in men. Osteoporosis was prevalent in subjects with discordance in both genders, particularly, in those with low LS BMD (31.6% in men and 63.5% in women). Given the high prevalence of spine-femur BMD discordance, low FN BMD may be associated with vitamin D deficiency and insulin resistance, but low LS BMD may present severe osteoporosis.

Comparison of Bone Mineral Densitometry at 2 Sites Versus 3 Sites in Patients Suspicious for Osteoporosis

Objectives:

In this study, we aim to evaluate the bone mineral density (BMD) results of 2 standard sites with 3 sites including wrist in diagnosing osteoporosis.

Methods:

We evaluated the BMD results of 1272 individuals referred for suspected osteoporosis between 2012 and 2015. Those individuals were included with BMD at lumbar spine, femur neck, and wrist. Bone mineral density was measured using a dual-energy X-ray absorptiometry (DXA) device. Bone mineral density and T score were measured for all 3 sites.

Results:

There was significant correlation between wrist T score with hip T score (r = 0.606, P < .001) and lumbar T score (r = 0.527, P < .001). With BMD of 2 sites, patients had osteopenia in 46.3% and osteoporosis in 23.7%, while by adding wrist T-BMD, subjects had osteopenia in 46.6% and osteoporosis in 33%. Between BMD at 2 sites and 3 sites, there was concordance in 81.9%, minor discordance in 17.6%, and major discordance in 0.5%.

Conclusions:

We observed discordance between BMD measurements of 2 sites and 3 sites, with latter detecting more cases with osteoporosis. In fact, measurement of T scores of wrist along with lumbar and femur neck improves the diagnosis.

Discordance in diagnosis of osteoporosis by quantitative computed tomography and dual-energy X-ray absorptiometry in Chinese elderly men

Objective

The objective of this study was to investigate the diagnostic discordance of osteoporosis by quantitative computed tomography (QCT) and dual-energy X-ray absorptiometry (DXA) in Chinese elderly men.

Methods

A total of 313 males older than 60 years, who underwent both spinal QCT and lumbar spine and hip DXA in our department, were included. The diagnostic criteria established by the World Health Organisation in 1994 were used for DXA to diagnose osteoporosis, and the criteria recommended by the International Society of Clinical Densitometry were used for QCT. The osteoporosis detection rate by the two techniques was calculated, and the difference was compared. The minor discordance was considered present when the different diagnostic classes between the two techniques were adjacent. Major discordance was present when the diagnosis by one technique was osteoporosis and the other was normal. The computed tomography images were reviewed by radiologists to assess whether vertebral fracture, aorta calcification or degeneration was present.

Results

In the 313 participants (mean age, 79.6 ± 7.2 years), the osteoporosis detection rate was 10.9% for DXA (lumbar spine and hip) and 45.1% for QCT, a significant difference (p < 0.001). The major discordance, minor discordance and concordance of diagnosis between the two techniques were seen in 8.3%, 50.8% and 40.9%, respectively. QCT detected osteoporosis better than DXA. The causes of this discordance were degeneration of spine, abdominal aorta calcification and vertebral fractures.

Conclusion

Our study demonstrated that discordance was common when using QCT and DXA to diagnose osteoporosis and that spinal degeneration, aorta calcification and fracture obscure the bone mineral density measurement of spine by DXA. QCT is a more sensitive method of choice to identify osteoporosis in elderly Chinese men.

The translational potential of this article

This study investigated the diagnostic discordance of osteoporosis by quantitative computed tomography (QCT) and dual-energy X-ray absorptiometry (DXA) in Chinese elderly men. The results demonstrated that QCT is a more sensitive method of choice to identify osteoporosis in elderly Chinese men. This work may help clinicians make an appropriate choice of technique for the accurate diagnosis of osteoporosis and identify the patients at high risk of osteoporosis who should be treated early to prevent fractures. This may influence the therapeutic plan and the overall prognosis of patients.

Subchondral bone microarchitecture analysis in the proximal tibia at 7-T MRI

Background Bone remodels in response to mechanical loads and osteoporosis results from impaired ability of bone to remodel. Bone microarchitecture analysis provides information on bone quality beyond bone mineral density (BMD). Purpose To compare subchondral bone microarchitecture parameters in the medial and lateral tibia plateau in individuals with and without fragility fractures. Material and Methods Twelve female patients (mean age = 58 ± 15 years; six with and six without previous fragility fractures) were examined with dual-energy X-ray absorptiometry (DXA) and 7-T magnetic resonance imaging (MRI) of the proximal tibia. A transverse high-resolution three-dimensional fast low-angle shot sequence was acquired (0.234 × 0.234 × 1 mm). Digital topological analysis (DTA) was applied to the medial and lateral subchondral bone of the proximal tibia. The following DTA-based bone microarchitecture parameters were assessed: apparent bone volume; trabecular thickness; profile-edge-density (trabecular bone erosion parameter); profile-interior-density (intact trabecular rods parameter); plate-to-rod ratio; and erosion index. We compared femoral neck T-scores and bone microarchitecture parameters between patients with and without fragility fracture. Results There was no statistical significant difference in femoral neck T-scores between individuals with and without fracture (-2.4 ± 0.9 vs. -1.8 ± 0.7, P = 0.282). Apparent bone volume in the medial compartment was lower in patients with previous fragility fracture (0.295 ± 0.022 vs. 0.317 ± 0.009; P = 0.016). Profile-edge-density, a trabecular bone erosion parameter, was higher in patients with previous fragility fracture in the medial (0.008 ± 0.003 vs. 0.005 ± 0.001) and lateral compartment (0.008 ± 0.002 vs. 0.005 ± 0.001); both P = 0.025. Other DTA parameters did not differ between groups. Conclusion 7-T MRI and DTA permit detection of subtle changes in subchondral bone quality when differences in BMD are not evident.

T-Score Discordance of Bone Mineral Density in Patients with Atypical Femoral Fracture

BACKGROUND

Although atypical femoral fracture (AFF) occurs more frequently in patients taking bisphosphonates and longer treatment is associated with higher risk, the causal relationship between AFF and bisphosphonates has not been established. Most patients with AFF have osteoporosis that is being treated with bisphosphonates, but we are not aware of any reports regarding the areal bone mineral density (aBMD) and discordance between the T-scores of the femur and spine in such patients. We investigated the prevalence of aBMD discordance and the characteristics of patients with AFF.

METHODS

Medical records for 63 consecutive patients treated for AFF were retrospectively evaluated, and 48 patients, all female, were eligible for the study. The average age at the time of fracture was 73.0 years, the average duration of bisphosphonate use was 68.5 months, and the average presumed age at bisphosphonate initiation was 67.2 years. We evaluated the prevalence of discordance, defined as a difference between the T-score categories of the femur and spine in the same individual as well as demographic differences between the discordance and concordance groups. We also compared the prevalence of discordance in patients with AFF with that in 114 female patients with intertrochanteric femoral fracture (ITFF).

RESULTS

T-score concordance, minor discordance, and major discordance were seen in 14 (29%), 32 (67%), and 2 (4%) of the patients with AFF, respectively. The prevalence of discordance was significantly higher in those with AFF (71%) than in those with ITFF (23%) (p < 0.001). The average age at bisphosphonate initiation in the AFF group was lower in the discordance group (65.7 years) than in the concordance group (70.7 years) (p = 0.04).

CONCLUSIONS

The prevalence of T-score discordance between the hip and lumbar spine was relatively high in patients with AFF, and the presumed age at the initiation of bisphosphonate therapy was younger in patients with discordant T-scores in this study.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Dienogest 2 mg Daily in the Treatment of Adolescents with Clinically Suspected Endometriosis: The VISanne Study to Assess Safety in ADOlescents

STUDY OBJECTIVE

To study the safety and efficacy of dienogest 2 mg in adolescents with suspected endometriosis.

DESIGN

A 52-week, open-label, single-arm study.

SETTING

In 21 study centers, in 6 European countries.

PARTICIPANTS

Adolescents aged 12 to younger than 18 years with clinically suspected or laparoscopically confirmed endometriosis.

INTERVENTIONS

Dienogest 2 mg once daily.

MAIN OUTCOME MEASURES

The primary end point was relative change in lumbar spine (L2-L4) bone mineral density (BMD) measured using dual-energy x-ray absorptiometry. A key secondary end point was change in endometriosis-associated pain assessed using a visual analogue scale.

RESULTS

Of 120 patients screened, 111 comprised the full-analysis set (ie, patients who took ≥1 dose of study drug and had ≥1 post-treatment observation) and 97 (87.4%) completed the study. Mean lumbar BMD at baseline was 1.1046 (SD, 0.1550) g/cm². At the end of dienogest treatment (EOT; defined as at 52 weeks or premature study discontinuation), mean relative change in BMD from baseline was -1.2% (SD, 2.3%; n = 103). Follow-up measurement 6 months after EOT in the subgroup with decreased BMD at EOT (n = 60) showed partial recovery in lumbar BMD (mean change from baseline: -2.3% at EOT, -0.6% 6 months after EOT). Mean endometriosis-associated pain score was 64.3 (SD, 19.1) mm at baseline and decreased to 9.0 (SD, 13.9) mm by week 48.

CONCLUSION

In adolescents with suspected endometriosis, dienogest 2 mg for 52 weeks was associated with a decrease in lumbar BMD, followed by partial recovery after treatment discontinuation. Endometriosis-associated pain was substantially reduced during treatment. Because bone accretion is critical during adolescence, results of the VISanne study to assess safety in ADOlescents (VISADO) study highlights the need for tailored treatment in this population, taking into account the expected efficacy on endometriosis-associated pain and an individual's risk factors for osteoporosis.

Dietary Patterns and Fractures Risk in the Elderly

PURPOSE

Although the role of dietary factors in the prevention of bone loss and fractures has been investigated in many studies, few studies have examined the association between dietary patterns and total body bone density. Our aim was to determine the relations between dietary patterns and whole-body bone mineral density (WB-BMD) and the association between dietary patterns, fractures, and multiple fractures in the elderly.

METHODS

This cross-sectional study included 177 individuals aged ≥65 years. A dual X-ray absorptiometry scan was performed to measure BMD. Dietary patterns were ascertained by a combination of dietary intake assessment and principal components analysis.

RESULTS

Only three dietary patterns correlated with whole-body bone density. The multivariate-adjusted mean bone density across tertiles of these dietary patterns showed that the highest tertile of both the patterns 1 and 2 had a significantly higher bone density than the lowest tertile (pattern 1: 1.021 ± 0.01 and 1.070 ± 0.01 g/cm² for T1 and T3, respectively; p = 0.043; pattern 2: 1.023 ± 0.01, and 1.081 ± 0.01 g/cm² for T1 and T3, respectively; p = 0.003). We also find significant gender difference in these results. The highest adherence to the dietary pattern 5 was associated with decreased odds of having fractures (OR = 0.20, p = 0.009), and adherence to the pattern 1 was negatively associated with multiple fractures.

CONCLUSION

A high adherence to the dietary pattern 1 (high intake of grains, fish and olive oil) was associated with a high BMD and a low number of fractures. The highest adherence to the dietary pattern 5 (legumes and wine) was associated with decreased odds of having fractures. Our finding would suggest a potential bone-preserving properties of specific dietary patterns in the elderly.

Wrist bone mineral density utility in diagnosing hip osteoporosis in postmenopausal women

BACKGROUND

Osteoporosis is a common bone disease that increases with age. Wrist bone mineral density (BMD) has significant correlation with other skeletal sites and it could be used as a diagnostic method for osteoporosis. The purpose of this study was to evaluate the role of wrist BMD in diagnosing osteoporosis in postmenopausal women.

METHODS

In this cross-sectional study, 99 postmenopausal women with mean age of 57 ± 6.9 (range 50-76) years were evaluated. BMD of nondominant wrist, lumbar spine (L2-L4) and femur bone using a dual-energy X-ray absorptiometry (DXA) device as well as lateral lumbosacral X-ray for degenerative joint disease (DJD) evaluation were measured. Mean T-score of wrist was lower than hip and lumbar area.

RESULTS

Osteopenia and osteoporosis were observed in 40.4% and 59.6% in the wrist, 38.4% and 24.2% in the hip and 36.4% and 49.5% in lumbar-spine BMD measurements, respectively. There was positive correlation between wrist BMD with hip BMD (r = 0.468,p < 0.001) and lumbar BMD (r = 0.322, p = 0.001). DJD due to lumbosacral X-ray was reported in 84 cases (84.8%) including mild DJD in 45 (53.5%), moderate DJD in 33 (39.3%) and severe DJD in 6 (7.2%).

CONCLUSIONS

Our results showed that wrist BMD has better accuracy than lumbar BMD in diagnosing osteoporosis in postmenopausal women.

Z-score discordance and contributing factors in healthy premenopausal women with low bone mineral density: the Korean National Health and Nutrition Examination Survey 2008-9

The premenopausal period is important for bone health and prevention of future fractures, but measuring bone mineral density (BMD) at only one site may not be sufficient to determine therapeutic strategies for low BMD in premenopausal women due to the presence of Z-score discordance. In this study, we investigated Z-score discordance in addition to contributing factors of idiopathic low BMD in healthy premenopausal Korean women. We studied 3003 premenopausal women aged 18-50 years, without secondary causes for low BMD and history of fragility fracture, who had participated in the Fourth Korean National Health and Nutrition Examination Surveys (2008-2009). Low body mass index (BMI), low vitamin D level, and low body muscle mass were associated with low BMD even in premenopausal women. Risk factors differed depending on the anatomic site. Low BMI and low vitamin D level were risk factors for low femoral neck BMD (FN-BMD), but not for low lumbar spine BMD (LS-BMD). Only total muscle mass had a slight effect on low LS-BMD. Z-score discordance was much higher than expected, in 75 and 73.8 % of the low LS-BMD and low FN-BMD groups, respectively. Our findings suggest the need to consider BMD discordance in premenopausal women and also to provide information on correctable factors affecting low BMD in younger populations. Long-term follow-up is needed to evaluate the possible effect of Z-score discordance on the prognosis of osteoporosis and subsequent fracture risk.

Prevalence of Osteoporosis in Women in Buenos Aires Based on Bone Mineral Density at the Lumbar Spine and Femur

The aim of the study was to report values for osteoporosis (OP) prevalence in Buenos Aires. Bone mineral density (BMD) at different skeletal sites was measured from November 2012 to July 2014. Participants were recruited through a newspaper advertisement inviting women at least 50 yr of age to receive free BMD measurement. After signing an informed consent form, 5448 women living in Buenos Aires and surrounding districts were studied. Lumbar spine (L1-L4), femur neck, and total hip BMDs were measured (Lunar Prodigy, software version 12.3 GE, Madison, WI, USA). OP was defined as a T-score ≤-2.5 at the lumbar spine or the femoral neck. Results showed that 1021 out of 5448 studied subjects (18.7%) had OP at the lumbar spine or the femoral neck. Comparison of age of the population sample with reference data for the general population showed a moderate (+0.6%) increase in prevalence. Prevalence of OP was low, up to the age of 70 yr when based on femoral neck BMD only. Conversely, the prevalence of OP at the lumbar spine, which was reportedly high in women up to the age of 70 yr, tended to level off over that age. The results of the total femur only added a slight (+0.7%) nonsignificant increase to the OP prevalence. A total 346,500 out of 1,853,000 women aged 50+ yr in Buenos Aires had OP at the lumbar spine or femoral neck, whereas only 163,500 had OP at the upper femur, reducing the number by 53%. The present study assessed OP prevalence in the most densely populated urban area in Argentina. The results are similar to those reported for Caucasian populations in the United States and Canada. As measurement of only the BMD of femoral neck overlooks the diagnosis in half of the women, future studies should include measurement of the lumbar spine in combination with the femoral neck for a more accurate estimation of OP prevalence.

High Cardiorespiratory Fitness Is Associated with Reduced Risk of Low Bone Density in Postmenopausal Women

PURPOSE

The goal of this study was to determine the association between cardiorespiratory fitness (CRF) and bone mineral density (BMD) of the femoral neck (FN) in postmenopausal women using existing Cooper Center Longitudinal Study data.

MATERIALS AND METHODS

A cohort of 1,720 predominantly healthy Caucasian women (57.1 ± 6.9 years) underwent preventive medical examinations that included CRF assessment by maximal Balke treadmill testing and measurement of BMD by dual-energy X-ray absorptiometry. CRF was estimated from total treadmill time and categorized into five categories of CRF (further defined as fitness category 1 = low fitness, 2-3 = moderate fitness, and 4-5 = high fitness). Logistic regression was used to characterize the association between CRF and BMD, adjusting for age, weight, and resistance activity level.

RESULTS

Overall, the mean body-mass index (BMI) for all subjects was 25.0 ± 4.5 kg/m2, although BMI was in the obese range in the low fitness group. The prevalence of osteoporosis (T-score ≤ -2.5 at the FN) was greater in the low fit group than moderate or high fit (5.8% vs. 3.0% or 3.9%, respectively); with a similar pattern seen for prevalence of osteopenia (T-score > -2.5 and ≤ -1.0 at the FN) (47.5% vs. 46.4% or 44.8%, respectively). Higher age and lower weight were associated with low BMD. Fully adjusted logistic regression models showed an inverse association between CRF and low BMD of the FN. For T-score ≤ -1.0, the primary outcome, the odds ratio (OR) was 0.50 (95% confidence interval [CI] 0.32-0.79) for moderate fitness, and OR of 0.32 (95% CI 0.21-0.51) for high fitness was seen. For T-score ≤ -2.5 at the FN, OR was 0.30 (95% CI 0.11-0.80) for moderate fitness, and OR was 0.29 (95% CI 0.12-0.71) for high fitness.

CONCLUSION

Increased CRF levels are associated with reduced risk for low bone density in postmenopausal women.

Is It Possible to Increase the Clinical Effectiveness of the Fracture Risk Assessment Tool in Osteopenia Patients by Taking Into Account Bone Mineral Density Values?

The study aimed to investigate the effectiveness of the clinical use of the Fracture Risk Assessment Tool (FRAX(®)) developed by the World Health Organization identifying patients at risk of osteoporotic fracture and to evaluate changes in osteoporotic fracture risk prediction according to bone mineral density (BMD) values. We identified the occurrence of osteoporotic fracture among patients whose BMD was measured in our hospital between April 2003 and March 2013. We then analyzed FRAX(®) scores obtained with or without BMD on the day before the occurrence of an osteoporotic fracture in actual osteoporotic fracture patients. According to the National Osteoporosis Foundation high-risk criteria, we identified the percentage of high-risk patients before the actual fracture. Among 445 osteoporotic fracture patients, when FRAX(®)-BMD was used, 281 patients (63%) were identified as high-risk before an actual osteoporotic fracture, and when FRAX(®) without BMD was used, 258 patients (58%) were identified (p = 0.115). In the 84 osteopenia patients, 39 patients (46.4%) were identified as high-risk when FRAX(®) without BMD was used, and 19 patients (22.6%) were identified when FRAX(®)-BMD was used (p = 0.001). The use of BMD in FRAX(®) does not seem to increase the clinical effectiveness of predicting osteoporotic fracture in osteopenia patients.

The Relationship Between Cardiorespiratory Fitness and Bone Mineral Density in Men: A Cross-sectional Study

OBJECTIVE

To determine the relationship between estimated cardiorespiratory fitness (CRF) and femoral neck (FN) bone mineral density (BMD) in men.

PATIENTS AND METHODS

This cross-sectional study included 2569 men aged 50 to 90 years (mean, 63.5 years) who had at least 1 health examination at a preventive medicine clinic between January 27, 1998, and February 24, 2015. Maximal treadmill tests were conducted using the Balke protocol and were used to estimate CRF. We stratified patients into low, moderate, and high CRF categories. The FN BMD was measured by dual-energy x-ray absorptiometry. Odds ratios (ORs) for T-scores of -2.5 or less (osteoporosis) and -1.0 or less (low BMD) were calculated for categorical CRF and were adjusted for weight, age, and days per week of resistance activity.

RESULTS

The sample prevalence of osteoporosis in the FN was 4.1% and of low BMD was 49.4%. There was a significant inverse association between higher CRF category and osteoporosis measured at the FN (moderate vs low: OR=0.34; 95% CI, 0.16-0.74; high vs low: OR=0.19; 95% CI, 0.09-0.42) and low BMD (moderate vs low: OR=0.64; 95% CI, 0.43-0.96; high vs low: OR=0.43; 95% CI, 0.29-0.65).

CONCLUSION

In men, CRF is directly associated with BMD. These results suggest that moderate-to-high CRF levels attained through regular physical activity may attenuate age-related decline in BMD. Further studies are needed to determine whether this translates to a lower risk of osteoporotic fracture in more fit men.

Prevalence of Osteoporosis and Low Bone Mass in Older Chinese Population Based on Bone Mineral Density at Multiple Skeletal Sites

Diagnosis of osteoporosis is based on bone mineral density (BMD) measurement, which is site dependent and commonly discordant between measurement sites. We aimed to determine the prevalence of osteoporosis diagnosed based on BMD T-scores measured by dual-energy x-ray absorptiometry (DXA) at different sites: the lumbar spine (LS) alone, femoral neck (FN) alone, or both. A total of 1712 women and 2028 men with LS and FN BMD measurements were enrolled. Over 50% discordance was found between osteoporosis classifications based on T-scores measured at the LS and FN. Use of the lowest T-scores measured at both the LS and right and left FN (rather than one site) significantly increased the prevalence of osteoporosis from 4.03 to 10.75% in postmenopausal women and 1.82 to 4.29% in men aged ≧50 years (p < 0.001). The trends of overall and age-adjusted prevalence of osteoporosis were similar in women and men. Osteoporosis was diagnosed at a higher rate if the USA reference rather than the Asia reference was used to calculate the T-score (26.64% vs. 10.75%). In conclusion, diagnosis based on the lowest T-score from multiple site BMD measurement can increase the prevalence of osteoporosis, demonstrating the higher sensitivity of the multiple site measurement strategy.

Contribution of Lumbar Spine BMD to Fracture Risk in Individuals With T-Score Discordance

Fracture risk estimates are usually based on femoral neck (FN) BMD. It is unclear how to address T-score discordance, where lumbar spine (LS) T-score is lower than FN T-score. The objective of this work was to examine the impact of LS BMD on fracture risk, in individuals with lower LS T-score than FN T-score. Participants aged 60+ years from the Dubbo Osteoporosis Epidemiology Study with LS and FN BMD measured at first visit, and were followed from 1989 to 2014. Five-hundred and seventy-three (573) of 2270 women and 131 of 1373 men had lower LS than FN T-score by ≥ 0.6 standard deviation (SD) (low-LS group based on least significant change). In low-LS women, each 1 SD lower LS T-score than FN was associated with a 30% increase in fracture risk (hazard ratio [HR] 1.30; 95% CI, 1.11 to 1.45). For low-LS men there was a 20% nonsignificant increase in fracture risk for each 1 SD lower LS than FN T-score (HR 1.20; 95% CI, 0.10 to 1.67). Low-LS women had greater absolute fracture risks than the rest of the women. This increased risk was more apparent for lower levels of FN T-score and in older age groups. At an FN T-score of -2, low-LS women had a 3%, 10%, and 23% higher 5-year absolute fracture risk than non-low LS women in the 60 to 69 year, 70 to 79 year, and 80+ years age-groups, respectively. Furthermore, an osteoporotic LS T-score increased 5-year absolute fracture risk for women with normal or osteopenic FN T-score by 10% to 13%. Men in the low-LS group had very few fractures; therefore, a meaningful analyses of fracture risk could not be conducted. This study shows the significant contribution of lower LS BMD to fracture risk over and above FN BMD in women. A LS BMD lower than FN BMD should be incorporated into fracture risk calculators at least for women in older age-groups.

Correlating Whole-Body Bone Mineral Densitometry Measurements to Those From Local Anatomical Sites

Background:

Using the same cutoff points for whole-body measurements as for site-specific measurements will result in underestimation of osteoporosis.

Objectives:

We assessed the correlation between densitometry measurements for the whole body with those for the femur, lumbar spine, and forearm to evaluate the possibility of replacing site-specific values with whole-body measurements.

Patients and Methods:

In this cross-sectional study, we evaluated all patients referred to a single rheumatology clinic for bone mineral density measurements from 2009 to 2010. All patients who had bone mineral density measurements taken from the hip, lumbar spine, forearm, and whole body were enrolled in the study. Standard bone mineral density measurements were performed using a dual energy X-ray absorptiometry device (Hologic Delphi A; Hologic, Bedford, MA, USA). Bone mineral density, Z-score, and T-score were measured for all patients and all body regions.

Results:

The mean age of the 152 participating patients was 56.7 ± 12.6 years, and 97.4% were female. Pearson correlation coefficients of the whole-body bone mineral density values compared with site-specific values in patients over age 50 were 0.66 – 0.75. Using T-score cutoff points of -1 and -2.5 for osteopenia and osteoporosis, whole-body measurements underestimated the percentage of abnormal patients compared with the site-specific measurements (all P < 0.001). Using receiver operating characteristic (ROC) analysis, the whole-body bone mineral density showed respective areas under the curve of 0.96 and 0.84 for the diagnosis of abnormal hip bone mineral density and osteoporosis.

Conclusion:

Using the same cutoff points for whole-body measurements as for site-specific measurements will result in overestimation or especially underestimation of osteopenia and osteoporosis diagnosis. Choosing new and appropriate cutoff points for whole-body densitometric measurements when we want to substitutes this assessment instead of site specific measurements seems mandatory and will decrease the rate of false diagnoses of densitometric deficiencies in these anatomical sites.

Prevalence and associated factors of T-score discordance between different sites in Iranian patients with spinal cord injury

OBJECTIVES

The present study was conducted to determine the prevalence of T-score discordance and its risk factors in a group of patients with spinal cord injury in a university teaching hospital in the Iranian capital of Tehran.

METHODS

This cross-sectional study was conducted on paraplegic men undergoing bone density testing in an outpatient clinic at a hospital in the Iranian capital, Tehran, between March 2011 and 2012. A questionnaire on demographic and anthropometric characteristics, including age, height, weight, engagement in physical activity and personal smoking habits, was filled out for each subject. All the subjects underwent bone mineral density measurement and blood samples were sent for laboratory testing.

RESULTS

Major T-score discordance between two sites was noted in 54 (41.22%) patients. Multivariate logistic regression revealed that every unit increase in serum calcium levels, as the only factor influencing T-score discordance, was associated with a 2.49-fold increased risk in T-score discordance in the area. As for the spine and radius, BMI was the only influencing factor as every unit increase in BMI was associated with a 14% lower risk for T-score discordance in these regions. Body mass index was the only factor, based on the multivariate model, affecting the risk of developing T-score discordance between two sites.

CONCLUSION

Our study revealed the high prevalence of T-score discordance in patients with spinal cord injury. Physicians should therefore be encouraged to perform BMD at three sites when visiting patients with such injuries.

Lumbar spine bone mineral density in US adults: demographic patterns and relationship with femur neck skeletal status

This analysis examines lumbar spine bone mineral density (BMD) of US adults from NHANES 2005-2008 by age, sex, and race/ethnicity. Prevalence of low spine BMD and agreement between the prevalence of low BMD at the spine and femur neck in older adults are also assessed.

INTRODUCTION

Lumbar spine BMD data from a representative sample of the US population have not been previously available.

METHODS

We used data from the National Health and Nutrition Examination Survey 2005-2008 to examine demographic patterns in lumbar spine BMD among US adults age ≥20 years and the prevalence of low lumbar spine BMD in adults age ≥50 years. Agreement between the prevalence of low BMD at the femur neck and spine in older adults was also assessed. Dual-energy X-ray absorptiometry was used to measure lumbar spine and femur neck BMD. World Health Organization definitions were used to categorize skeletal status as normal, osteopenia, or osteoporosis.

RESULTS

Compared to non-Hispanic whites, non-Hispanic blacks had higher and Mexican Americans had lower lumbar spine BMD. Lumbar spine BMD declined with age in women, but not in men. Approximately 4.7 million (10%) older US women and 1 million (3%) older men had lumbar spine osteoporosis in 2005-2008. Roughly one third of them differed in skeletal status at the spine and hip but most were normal at one site and osteopenic at the other. Only 3-10%, depending on sex, had osteoporosis at one skeletal site but not at the other skeletal site. Between 76% and 87% with discordant skeletal status had lumbar spine T-scores within 1 unit of the category threshold.

CONCLUSIONS

These findings suggest that measuring either the femur neck or the lumbar spine will correctly classify the majority of individuals who present for care as osteoporotic or not.