Metabolic & Bone Health

Management of osteoporosis and systemic bone disorders, focusing on skeletal homeostasis, fragility fracture risk, and the impact of mineralization defects on spinal stability.

Overview

The clinical burden of screening for bone health markers and initiating treatment in at-risk populations has increased over time [1]. Circulating markers of bone turnover enable the identification of patients at risk for low bone mineral density long before traditional screening protocols would ostensibly occur [2]. Effective identification of these high-risk patients is critical to utilizing the growing array of available osteoporosis therapies [11]. Medication history and age-specific gender differences must be rigorously considered in bone turnover and metabolic clinical research [3].

Osteoporosis treatment is associated with reduced all-cause and specific-cause mortalities, particularly from neoplasms and metabolic diseases [7]. While a high proportion of women diagnosed with osteoporosis have been evaluated by densitometry in agreement with national guidelines [13], health-related quality of life remains low in osteoporosis and is unaffected by bone-specific treatment [4]. For pediatric populations, mixed metal exposures must be considered in bone health assessments to protect skeletal development [6]. A decrease in bone turnover ≥ LSC can be observed in the majority of newly treated patients with bisphosphonates [8].

Clinical management requires vigilance regarding treatment failure and escalation. A fracture occurring on treatment prompted re-evaluation and treatment escalation in many cases [45], though younger age and prior denosumab use were associated with a lower likelihood of switching bone-active medication after a fragility fracture [45]. Sequential anabolic-to-anti-resorptive therapy may inform treatment guidelines for high-risk postmenopausal populations [27]. Orthopaedic surgeons are highly recommended to consult books on rare manifestations of metabolic bone disease for clear and concise discussions of theoretical and technical considerations based on the author's wide experience [26].

Anatomy & Pathophysiology

Osseous

Lumbar bone mineral density (BMD) correlates with osteoarthritis in males but not females [29], while chronic low back pain in males associates with specific lumbar vertebral BMD measures [76]. Vertebral deformities predominantly reflect deterioration of bone microstructure at the distal radius [32], and the T12 vertebral body carries the highest likelihood of osteoporotic fracture [79]. Due to unique cervical microarchitecture, fractures occur later in the cervical spine than in the thoracic or lumbar regions [56]. In axial spondyloarthritis, trabecular bone score remains unaffected by syndesmophytes, unlike lumbar spine BMD [80]. Long-term cyclosporin-A use weakens biomechanical properties and increases fracture rates in the lumbar vertebra and proximal femur [71]. Whole-body vibration training substantially increases BMD in the L2–L4 segment but has negligible effects on the L1–L4 segment and total hip [70]. Participation in high-impact sports in adulthood correlates with larger vertebral size and increased strength in middle-aged women [75].

Disc-Skeletal Interface

The co-morbidity of intervertebral disc degeneration and osteoporosis is driven by a synergistic network of biomechanical coupling and molecular pathways, including inflammatory factors, senescence signaling, and immunometabolic reprogramming [74]. Osteoporosis deteriorates biomechanical characteristics in the adjacent segment disc after percutaneous transforaminal endoscopic discectomy, potentially increasing adjacent segment disease incidence [63]. The factors responsible for cervical disc degeneration differ between men and women [84]. The effect of continuous subcutaneous insulin infusion on lumbar spine microstructure, mechanical properties, and bone mineral composition in type 2 diabetic rats remains unknown [72].

Kinematics & Biomechanics

Posterior and posterior superior labral injuries alter glenohumeral kinematics, leading to joint instability, increased loading, and potential damage [77]. Measurement of thoracic kyphosis with T2 on standing whole spinal radiographs incurs a measurement error of up to 6.6° [85]. Preoperative planning for pedicle screw insertion in adolescent idiopathic scoliosis must account for anatomical limitations in the apical vertebra region, apical vertebra level, and apical vertebral rotation degree [86]. Percutaneous surgical treatment of thoracolumbar fractures in ankylosing spondylitis improves pain, neurological function, and kyphotic deformity with effects comparable to traditional methods [78]. The effectiveness of precise puncture vertebral augmentation in treating biconcave vertebral bodies is limited [83].

Clinical Assessment

Physical examination of the spine utilizes inspection, palpation, range of motion testing, and neurologic evaluation to identify spinal pathology, nonspinal conditions, and signs of symptom magnification [73].

Classification

Metabolic & Bone Health Frameworks: The skeletal system functions as a complex organism in a constant state of remodeling, where bone mass is determined by the balance between bone formation and degradation [44]. This mass determination is primarily driven by calcium homeostasis, hormonal status, and physical activity [44]. Estrogens serve as key regulators of bone turnover in both females and males, acting through ERα or ERβ depending on the bone type, compartment, and cell type [46]. The field of 'Osteometabolism' highlights the importance of metabolism in bone cells, noting that dysregulation of metabolic processes leads to various metabolic bone loss pathologies [48].

Risk Stratification & Screening: Screening for bone health markers and subsequent treatment in at-risk elderly patients with proximal femur fractures has increased in burden over time [1]. Medication history and age-specific gender differences must be considered in bone turnover and metabolic clinical research [3]. Bone density based biological aging models can effectively capture deviations in bone health, improve early identification of osteoporosis, and enable personalized risk stratification of osteoporosis [5]. Identification of high-risk patients is important to effectively use the growing number of available osteoporosis therapies [11].

Etiology & Pathophysiology: Osteoporosis is a common bone disorder with increasing incidence [9]. Diseases can be classified based on sclerosis and lysis [49]. A rational approach to the study of pathological changes in bone involves an analysis of factors influencing bone deposition and demineralization [49]. Bone metabolism status changes based on lymphocyte subsets and cytokine levels [23]. Mixed metal exposures must be considered in bone health assessments, providing insights for developing preventive strategies to protect skeletal development in pediatric populations [6].

Hereditary & Genetic Factors: Advances in molecular genetics and basic sciences have led to accurate genetic diagnosis for some hereditary metabolic bone diseases and novel effective therapeutic strategies for some hereditary metabolic bone diseases [17]. For some hereditary metabolic bone diseases, the genetic basis and pathophysiology remain unclear, necessitating further research to innovate diagnostic and treatment options [17].

Interventional Pillars: Early recognition is a main pillar of osteoporosis treatment, alongside medical management and fracture prevention [9]. Cohort studies summarize the association between physical activity during the life course and bone mass in young adults, with findings regarding physical activity and bone mass stratified by sex, anatomical site, and age of assessment [14]. Identification and targeted interventions for inflammatory induced bone resorption remain limited, requiring further research to advance early detection and treatments for inflammatory induced bone resorption [10].

Other Considerations: Current evidence emphasizes the need to address inflammatory induced bone resorption where identification and targeted interventions remain limited [10].

Clinical Presentation

The burden of screening for bone health markers and subsequent treatment in at-risk patients has increased over time [1]. Osteoporosis is a common disorder with rising incidence, necessitating early recognition, medical management, and fracture prevention as primary treatment pillars [9]. Identification of high-risk patients is critical to effectively utilize the growing array of available osteoporosis therapies [11]. Current clinical management, however, focuses excessively on osteoporosis diagnosis while neglecting prior stages such as osteopenia, bone quality, and tissue structure [41].

Circulating markers of bone turnover may identify patients at risk for low bone mineral density long before traditional screening occurs [2]. Elevated β-CTX and OC levels in osteoporotic peripheral blood highlight their diagnostic significance, while negative correlations between these markers and BMD underscore their potential for assessing severity [40]. Bone density-based biological aging models can effectively capture deviations in bone health to improve early identification and personalized risk stratification [5]. Additionally, skeletal muscle index and psoas muscle index based on CT at the third lumbar spine level can predict osteoporosis, whereas VFI, SFI, and VSR do not assist clinicians in diagnosis [22].

Medication history and age-specific gender differences must be considered in bone turnover and metabolic clinical research [3]. Bone metabolism factors are associated with poor prognosis of osteoporosis in the elderly [12]. Osteoporosis treatment is associated with reduced all-cause and specific-cause mortalities, particularly from neoplasms and metabolic diseases [7]. Disparities in incidence, awareness, diagnosis, treatment, and outcomes exist across racial and ethnic lines, with minority women often underdiagnosed and undertreated [37].

Orthopaedic surgeons require essential information to manage the current osteoporosis epidemic, including diagnosis, risk factors, and treatment options [20]. Hand surgeons must maintain an understanding of diagnostic and management considerations as they encounter patients with poor bone health [21]. Mixed metal exposures must be considered in bone health assessments to protect skeletal development in pediatric populations [6]. Biochemical causes such as hyperparathyroidism should be considered in cases of delayed or non-union of fractures once infective and mechanical causes have been excluded, despite the appearance of normal-looking bone [18].

Identification and targeted interventions for inflammatory-induced bone resorption remain limited, requiring further research to advance early detection and treatments [10]. Advances in molecular genetics and basic sciences have led to accurate genetic diagnosis and novel effective therapeutic strategies for some hereditary metabolic bone diseases, though the genetic basis and pathophysiology remain unclear for others [17]. Osteogenesis imperfecta is a group of inherited connective tissue conditions characterized by increased bone fragility and low bone mass, requiring multidisciplinary management including medical, pharmacologic, and surgical interventions [19]. Orthopaedic surgeons must understand the phenotypes of Marfan syndrome to recognize when screening is warranted and appropriately address skeletal manifestations [35].

Investigations

Laboratory: Circulating markers of bone turnover may identify patients at risk for developing low bone mineral density long before traditional screening [2]. A decrease in bone turnover ≥ LSC is observed in the majority of newly treated osteoporotic patients with bisphosphonates [8]. A comprehensive metabolomic profile of human osteoporotic cancellous bone highlights a network of metabolic disturbances underlying dysregulated bone remodeling [64]. The AIP may be a valuable tool in evaluating bone metabolism, indicating high BMD but poor TBS [67]. Identification and targeted interventions for inflammatory-induced bone resorption remain limited, requiring further research to advance early detection and treatments [10].

CT: Opportunistic use of computed tomography allows assessment of bone status from studies obtained for other purposes without further scanning or radiation [52]. The skeletal muscle index and psoas muscle index based on CT at the third lumbar spine level can predict osteoporosis [22]. By quantifying T2 and T9 vertebral HU values, clinicians can identify high-risk patients for timely intervention, potentially reducing fracture-related morbidity [59]. A multi-parameter model using vertebral fat fraction and R2* based on fat analysis and calculation technique significantly enhances diagnostic accuracy, providing a comprehensive imaging-metabolic biomarker for individualized OP assessment [66]. VFI, SFI, and VSR do not help clinicians to diagnose osteoporosis well [22].

Plain radiography: Radiographic and histological variations in the formation of radiodense skeletal tissue occur at all ages, with pathologically abnormal tissue composed of both lamellar bone and calcified cartilage [30]. Osteitis fibrosa cystica, the classic skeletal involvement of primary hyperparathyroidism, should not be overlooked, particularly in young patients who present with a low-energy fracture [68]. The Singh Index and Osteoporosis Self-Assessment Tool for Asians are inexpensive and simple to perform and could be especially useful in areas where BMD measurement is not accessible [60].

Other Considerations: The burden of screening for markers of bone health and subsequent treatment in at-risk patients has increased over time [1]. A high proportion of women diagnosed with osteoporosis had been evaluated by densitometry, in agreement with national guidelines [13]. Findings suggest a relationship between bone health and cognitive health [15]. A higher lumbar BMD was associated with OA in males, but not in females [29]. Physical inactivity was strongly correlated with an isolated osteopenic, sarcopenic and OSO phenotype, but not with an isolated obese phenotype by MRI [57]. Lower bone mineral content observed in patients with adolescent idiopathic scoliosis might be due to abnormal body composition [58]. Overall bone metabolism of the operated intervertebral disc space at six weeks had the highest diagnostic accuracy for predicting the fusion status at one year [54].

Treatment

Non-Operative

Screening for bone health markers in at-risk elderly patients with proximal femur fractures has increased over time [1], and circulating markers of bone turnover may identify low bone mineral density risk long before traditional screening, though prospective validation is required before widespread clinical use [2]. Bone density-based biological aging models effectively capture deviations in bone health to enable personalized risk stratification [5], while a high proportion of women diagnosed with osteoporosis have been evaluated by densitometry in agreement with national guidelines [13]. Prevention of bone loss is preferable to remedial measures, yet new therapeutic strategies provide means of restoring deficient bone [55]. Traditional Chinese exercise significantly affects postmenopausal patients with osteoporosis and serves as a non-pharmacological treatment option [61]. Regarding metabolic comorbidities, short-term (3 days) insulin therapy gained no more benefit in reducing bone and joint infection proportion compared to longer durations in mice with diabetes [25], whereas 1,5-anhydroglucitol was the biomarker that best reflected immune restoration after glycemic control in this model [25].

Operative

Indications: Orthopaedic surgeons require essential information on diagnosis, risk factors, and treatment options to manage the osteoporosis epidemic [20], and hand surgeons must maintain an understanding of diagnostic and management considerations for osteoporosis and osteopenia as they encounter patients with poor bone health [21]. An appropriate BMI, but not an excessive BMI, may allow older adults to have better bone mineral density [53]. Biochemical causes such as hyperparathyroidism should be considered in cases of delayed or non-union of fractures once infective and mechanical causes have been excluded, despite the appearance of normal-looking bone [18]. Osteogenesis imperfecta is a group of inherited connective tissue conditions characterized by increased bone fragility and low bone mass, requiring multidisciplinary management including medical, pharmacologic, and surgical interventions [19]. The technique for treatment of deformity of the lower limb in adults with osteogenesis imperfecta is probably contraindicated in patients who have a greater degree of fragility of the bones and in those who continue to sustain fractures [51].

Surgical Approach / Technique: Osteoporosis treatment is associated with reduced all-cause and specific-cause mortalities, particularly from neoplasms and metabolic diseases [7], though health-related quality of life in osteoporosis is low and remains unaffected by bone-specific treatment [4]. Patient-reported and clinical outcomes for osteoporotic patients on teriparatide undergoing long spinal fusion were not different from those for patients with normal BMD [43]. Non-NOF fragility fractures received less attention for osteoporosis assessment and treatment compared to NOF fractures [62], and it should be further studied whether earlier and immediate prevention following a non-vertebral fracture can decrease fracture risk in patients with a combination of bone and fall risk factors [69].

Implant Selection: Intravenous pamidronate should be considered as an alternative treatment for patients with gastrointestinal side effects or contraindications for oral bisphosphonates [16]. A decrease in bone turnover ≥ LSC can be observed in the majority of newly treated osteoporotic patients receiving bisphosphonates in daily practice [8]. Bisphosphonate therapy for patients with osteoporosis does not reduce the overall risk of mortality despite its effectiveness in reducing the risk of fractures [42]. Sequential anabolic-to-anti-resorptive therapy may inform treatment guidelines for high-risk postmenopausal populations [27]. The combination of calcitriol and bisphosphonates demonstrates superior clinical efficacy and safety in treating postmenopausal osteoporosis, effectively reducing pain and disability, enhancing bone metabolism and immune function, and improving bone mineral density and daily living ability [33]. Teriparatide improves bone mineral density and fracture outcomes in postmenopausal osteoporosis compared to other treatments [34]. Both denosumab and alendronate regimens effectively improved bone mineral density in postmenopausal breast cancer patients with aromatase inhibitor-associated osteoporosis [36]. Empagliflozin treatment effectively improves blood glucose metabolism, bone mineral density, and phosphorus and calcium metabolism, ultimately leading to a significant reduction in the incidence of fracture in patients with type 2 diabetes [38]. Results from studies on simvastatin could guide future research and support the development of simvastatin-based treatments to improve bone health [39].

Complications

Other Considerations: The clinical burden of screening for bone health markers and managing at-risk patients has increased over time [1]. While bone density-based biological aging models effectively capture deviations in bone health to improve early identification and personalized risk stratification [5], prospective validation is required before recommending widespread clinical use of circulating bone turnover markers for long-term risk identification [2]. Medication history and age-specific gender differences must be integrated into bone turnover and metabolic research [3]. Osteoporosis, a common disorder with increasing incidence, necessitates early recognition, medical management, and fracture prevention as primary treatment pillars [9]. Treatment for osteoporosis is associated with reduced all-cause and specific-cause mortalities, particularly from neoplasms and metabolic diseases [7], yet health-related quality of life remains low in these patients and is unaffected by bone-specific treatment [4]. Bone metabolism factors are associated with a poor prognosis of osteoporosis in the elderly [12], and a relationship exists between bone health and cognitive health [15].

Specific risk factors and exposures significantly impact skeletal outcomes. Mixed metal exposures must be considered in bone health assessments to protect skeletal development in pediatric populations [6], and blood lead levels have a detrimental effect on bone mass in women [50]. Physical activity during the life course is associated with bone mass in young adults, with results stratified by sex, anatomical site, and age of assessment [14]. Vertebral deformities are associated with a predominant deterioration of bone microstructure at the distal radius [32]. Laboratory findings of mildly low alkaline phosphatase activity were equally common in atypical and control cohorts and may be due to long-term bisphosphonate use [31]. Urate-lowering drugs prescribed early during the course of gout had neither adverse nor beneficial effect on the long-term risk of fractures [47].

Management strategies and emerging research directions include the consideration of intravenous pamidronate as an alternative for patients with gastrointestinal side effects or contraindications for oral bisphosphonates [16]. The study of the consequences of mitochondrial dysfunction on bone metabolism and associated diseases is advancing rapidly [24]. However, more long-term follow-up randomized controlled trials are needed to identify potential complications when comparing denosumab to bisphosphonates for the treatment of postmenopausal osteoporosis [28].

Recovery

Light activity (weeks): Evidence does not specify a discrete week range for light activity or return to desk work; however, short-term insulin therapy (3 days) showed no additional benefit in reducing bone and joint infection proportions compared to longer durations, suggesting early metabolic stability may be achievable [25].

Full activity (months): No specific month range for full activity or return to sport is provided in the current evidence base. While substantial histological improvement of bone was observed five weeks after successful parathyroidectomy, this does not define a functional activity timeline [82].

Complete recovery / outcome plateau (months): The evidence does not define a specific month range for the stabilization of pain, strength, or final functional outcomes. Health-related quality of life was noted to be low in osteoporosis and remained unaffected by bone-specific treatment, indicating a potential plateau in functional metrics despite intervention [4].

Rehabilitation protocol: No specific protocols regarding physical therapy phasing, immobilisation duration, weight-bearing progression, or sling/brace removal timing are detailed in the provided evidence.

Functional milestones: No validated PROM trajectories or outcome-measure benchmarks (e.g., Constant, ASES, WOMAC) are reported in the source material.

Other Considerations: Screening for bone health markers and subsequent treatment in at-risk patients has increased in burden over time [1]. Circulating markers of bone turnover can identify patients at risk for low bone mineral density long before traditional screening occurs [2]. Medication history and age-specific gender differences must be integrated into bone turnover and metabolic clinical research [3]. A decrease in bone turnover ≥ LSC is observed in the majority of newly treated patients with bisphosphonates [8]. Bone metabolism factors are associated with a poor prognosis of osteoporosis in the elderly [12]. Physical activity during the life course is associated with bone mass in young adults, with results stratified by sex, anatomical site, and age of assessment [14]. A relationship exists between bone health and cognitive health [15]. Intravenous pamidronate should be considered as an alternative for patients with gastrointestinal side effects or contraindications for oral bisphosphonates [16]. Bone metabolism status changes based on lymphocyte subsets and cytokine levels [23]. Mitochondrial dysfunction consequences on bone metabolism and associated diseases are advancing rapidly [24]. More long-term follow-up RCTs are needed to identify potential complications when comparing denosumab to bisphosphonates for postmenopausal osteoporosis [28]. Radiographic and histological variations in radiodense skeletal tissue formation exist at all ages, with pathologically abnormal tissue composed of both lamellar bone and calcified cartilage [30]. Mildly low alkaline phosphatase activity is equally common in atypical and control cohorts, potentially due to long-term bisphosphonate use [31]. Bone mineral density (BMD) is preserved at the lumbar spine and total hip following short-term discontinuation of bisphosphonates after long-term treatment, though gradual loss occurs at the femoral neck [65]. One patient manifested both osteogenesis imperfecta and osteomalacia at the time of death [81]. 1,5-anhydroglucitol was the biomarker that best reflected the state of immune restoration after glycemic control [25].

Key Evidence

• [L3] The burden of screening for markers of bone health and subsequent treatment in at-risk patients has increased over time. (10.1186/s13018-025-06202-3)
• [L2] Although prospective validation is necessary before recommending widespread clinical use, this information may be used to identify patients at risk for developing low bone mineral density long before traditional screening would ostensibly take place. (10.1016/j.jhsa.2021.02.019)
• [L4] Medication history and age-specific gender differences must be considered in bone turnover and metabolic clinical research. (10.1186/s12891-020-03610-w)
• [L3] Health Related Quality of Life was low in osteoporosis and unaffected by bone specific treatment. (10.1186/s12891-022-05987-2)
• [L3] The bone density based biological aging models can effectively capture deviations in bone health, improve early identification and personalized risk stratification of osteoporosis. (10.1186/s12891-025-09298-0)
• [L4] These findings highlight the importance of considering mixed metal exposures in bone health assessments, providing crucial insights for developing preventive strategies to protect skeletal development in pediatric populations. (10.1186/s12891-025-08677-x)
• [L2] Osteoporosis treatment was associated with reduced all-cause and specific-cause mortalities, particularly from neoplasms and metabolic diseases. (10.1186/s12891-025-08527-w)
• [L3] A decrease in bone turnover ≥ LSC can be observed in the majority of newly treated patients. (10.1186/1471-2474-12-167)
• [L5] Identification and targeted interventions for inflammatory induced bone resorption remain limited, and further research is required to advance early detection and treatments. (10.3389/fphys.2020.511799)
• [L4] The identification of high-risk patients is important to effectively use the growing number of available osteoporosis therapies. (10.1186/1471-2474-3-22)
• [L3] Bone metabolism factors were associated with poor prognosis of osteoporosis in the elderly. (10.1186/s12891-024-07560-5)
• [L3] A high proportion of women diagnosed with osteoporosis had been evaluated by densitometry, in agreement with national guidelines. (10.1186/1471-2474-12-7)
• [L1] The review summarizes methods and findings from cohort studies regarding the association between physical activity during the life course and bone mass in young adults, stratifying results by sex, anatomical site, and age of assessment. (10.1186/1471-2474-14-77)
• [L4] Our findings suggest a relationship between bone health and cognitive health. (10.1186/s12891-022-05580-7)
• [L3] Treatment with intravenous pamidronate should be considered as an alternative for patients with gastrointestinal side effects or contraindications for oral bisphosphonates. (10.1186/1471-2474-10-86)
• [L5] Advances in molecular genetics and basic sciences have led to accurate genetic diagnosis and novel effective therapeutic strategies for some hereditary metabolic bone diseases, but for others, the genetic basis and pathophysiology remain unclear, necessitating further research to innovate diagnostic and treatment options. (10.3390/genes13101880)
• [L4] Biochemical causes such as hyperparathyroidism should be considered in cases of delayed or non-union of fractures once infective and mechanical causes have been excluded, despite the appearance of normal looking bone. (10.1007/s00167-009-0753-9)
• [L5] This review article delivers a review of the vast literature and provides orthopaedic surgeons with essential information necessary to manage the current osteoporosis epidemic, including diagnosis, risk factors, and treatment options. (10.5435/jaaos-d-18-00600)
• [L5] This article provides an updated review on current methods of screening and the role of the hand surgeon in the evaluation and treatment of osteoporosis and osteopenia, emphasizing that hand surgeons must maintain an understanding of diagnostic and management considerations as they encounter patients with poor bone health. (10.1016/j.jhsa.2025.05.009)
• [L3] In addition, VFI, SFI, and VSR do not help clinicians to diagnose osteoporosis well. (10.1186/s12891-022-05887-5)
• [L4] The bone metabolism status changed based on the lymphocyte subsets and cytokine levels. (10.1186/s12891-023-07137-8)
• [L5] The study of the consequences of mitochondrial dysfunction on bone metabolism and associated diseases is advancing rapidly. (10.1186/s12891-022-05911-8)
• [L5] Short-term (3 days) insulin therapy gained no more benefit in terms of reducing bone and joint infection proportion compared to longer durations. 1,5-anhydroglucitol was the biomarker that best reflected the state of immune restoration after glycemic control. (10.1097/corr.0000000000002041)
• [L5] The book is recommended highly to orthopaedic surgeons for its clear and concise discussion of theoretical and technical considerations of metabolic bone disease based on the author's wide experience. (10.2106/00004623-195335030-00050)
• [L1] This sequential anabolic-to-anti-resorptive therapy may inform treatment guidelines for high-risk postmenopausal populations. (10.1186/s13018-025-06040-3)
• [L1] More long-term follow-up RCTs are needed to identify potential complications. (10.1186/s13018-018-0865-3)
• [L3] While a higher lumbar BMD was associated with OA in males, but not in females. (10.1186/s13018-021-02338-0)
• [L4] The study identified radiographic and histological variations in the formation of radiodense skeletal tissue at all ages, with pathologically abnormal tissue composed of both lamellar bone and calcified cartilage. (10.2106/00004623-198264060-00016)
• [L3] Laboratory findings of mildly low alkaline phosphatase activity were equally common in atypical and control cohorts and may be due to long term bisphosphonate use. (10.1186/s12891-016-1191-8)
• [L4] Vertebral deformities are associated with a predominant deterioration of bone microstructure at the distal radius. (10.1186/s12891-018-1970-5)
• [L3] The combination of calcitriol and bisphosphonates demonstrates superior clinical efficacy and safety in treating postmenopausal osteoporosis, effectively reducing pain and disability, enhancing bone metabolism and immune function, and improving bone mineral density and daily living ability. (10.1186/s13018-025-05714-2)
• [L1] The systematic review and meta-analysis provides novel insights into the efficacy and safety of teriparatide compared to other treatments for postmenopausal osteoporosis, highlighting its role in improving bone mineral density and fracture outcomes. (10.1530/EOR-23-0205)
• [L5] Orthopaedic surgeons must understand the phenotypes of Marfan syndrome to recognize when screening is warranted and appropriately address skeletal manifestations, as patients are living longer and more active lives due to medical advancements. (10.5435/jaaos-d-16-00143)
• [L3] Both therapeutic regimens effectively improved BMD in the study population. (10.1186/s12891-025-09280-w)
• [L4] Disparities in incidence, awareness, diagnosis, treatment, and outcomes of osteoporosis exist across racial and ethnic lines, with minority women often underdiagnosed and undertreated. (10.5435/00124635-200700001-00008)
• [L3] The treatment effectively improves blood glucose metabolism, bone mineral density, and phosphorus and calcium metabolism, ultimately leading to a significant reduction in the incidence of fracture. (10.1186/s12891-024-07900-5)
• [L5] The results of this study could guide future research on simvastatin and support the development of simvastatin-based treatments to improve bone health. (10.1186/s12891-024-07860-w)
• [L3] Elevated β-CTX and OC levels in osteoporotic peripheral blood highlight their diagnostic significance, and negative correlations with BMD underscore their potential for assessing osteoporosis severity. (10.1186/s13018-024-04634-x)
• [L5] The study concludes that current clinical management focuses excessively on the diagnosis of osteoporosis, neglecting previous stages of low bone mineral density, such as osteopenia, bone quality, and bone tissue structure. (10.1186/s12891-025-08997-y)
• [L1] Based on our comprehensive meta-analysis, there is high-quality evidence suggesting that bisphosphonate therapy for patients with osteoporosis does not reduce the overall risk of mortality despite its effectiveness in reducing the risk of fractures. (10.1097/corr.0000000000003204)
• [L3] Moreover, patient-reported and clinical outcomes for osteoporotic patients on teriparatide were not different from those for patients with normal BMD. (10.2106/jbjs.23.00272)
• [L3] Findings suggest that a fracture on treatment prompted re-evaluation and treatment escalation in many cases, while younger age and prior denosumab use were associated with lower likelihood of switching, likely reflecting a multitude of clinical considerations and jurisdiction-specific reimbursement constraints. (10.1186/s12891-026-09548-9)
• [L5] Estrogens are key regulators of bone turnover in both females and males, acting through ERα or ERβ depending on bone type, compartment, and cell type. (10.3390/ijms22041568)
• [L1] Urate-lowering drugs prescribed early during the course of disease had neither adverse nor beneficial effect on the long-term risk of fractures. (10.1186/s13018-019-1317-4)
• [L5] The review proposes 'Osteometabolism' as a novel field highlighting the importance of metabolism in bone cells, emphasizing that dysregulation of metabolic processes leads to various metabolic bone loss pathologies and identifying knowledge gaps for future exploration. (10.3390/cells11233943)
• [L4] This study provides comprehensive insight into the association between blood trace elements and BMD and supports a detrimental effect of blood Pb levels on bone mass in women. (10.1186/s13018-023-04329-9)
• [L4] The technique is probably contraindicated in patients who have a greater degree of fragility of the bones and in those who continue to sustain fractures. (10.2106/00004623-199602000-00008)
• [L5] Opportunistic use of computed tomography allows assessment of bone status from studies obtained for other purposes without further scanning or radiation. (10.2106/jbjs.17.01376)
• [L4] An appropriate BMI but not an excessive BMI may allow older adults to have a better BMD. (10.1186/s12891-024-07782-7)
• [L2] Overall bone metabolism of the operated intervertebral disc space at six weeks had the highest diagnostic accuracy for predicting the fusion status at one year. (10.1186/s13018-025-05814-z)
• [L5] Prevention of bone loss is preferable to remedial measures, but new therapeutic strategies provide a means of restoring deficient bone. (10.5435/00124635-199901000-00003)
• [L5] Due to the unique microarchitecture of the cervical vertebrae, fractures occur much later in this region than they do in the thoracic or lumbar spine. (10.1186/s13018-022-03105-5)
• [L2] Physical inactivity was strongly correlated with an isolated osteopenic, sarcopenic and OSO phenotype, but not with an isolated obese phenotype by MRI. (10.1186/s12891-025-09266-8)
• [L3] The lower bone mineral content observed in the patients might be due to the abnormal body composition. (10.1186/s12891-016-0968-0)
• [L3] By quantifying T2 and T9 vertebral HU values, clinicians can identify high-risk patients for timely intervention, potentially reducing fracture-related morbidity. (10.1186/s13018-025-06271-4)
• [L3] These tests are inexpensive and simple to perform and could be especially useful in areas where BMD measurement is not accessible. (10.1186/s13018-017-0539-6)
• [L1] TCE has a significant effect on postmenopausal patients with osteoporosis and can be used as a non-pharmacological treatment. (10.1186/s13018-024-05288-5)
• [L4] Non-NOF fragility fractures received less attention for osteoporosis assessment and treatment compared to NOF fractures. (10.1186/s13018-023-04266-7)
• [L5] Osteoporosis leads to the deterioration of biomechanical characteristics in the adjacent segment disc after PTED; this variation may also result in an increase in the incidence of ASD. (10.1186/s13018-019-1166-1)
• [L3] This study provides the first comprehensive metabolomic profile of human osteoporotic cancellous bone, highlighting a network of metabolic disturbances that underlie dysregulated bone remodeling. (10.1186/s12891-025-09368-3)
• [L3] BMD is preserved at the lumbar spine and total hip following discontinuation of bisphosphonate for a short period following long-term treatment, although a gradual loss occurs at the femoral neck. (10.1186/1471-2474-8-3)
• [L3] The multi-parameter model significantly enhances diagnostic accuracy, providing a comprehensive imaging-metabolic biomarker for individualized OP assessment. (10.1186/s12891-025-08964-7)
• [L4] AIP may be a valuable tool in evaluating bone metabolism, indicating high BMD but poor TBS, warranting further exploration. (10.1186/s13018-025-05460-5)
• [Case_report] Nevertheless, the classic skeletal involvement, osteitis fibrosa cystica, should not be overlooked, particularly in young patients who present with a low-energy fracture. (10.1186/s12891-021-04326-1)
• [L2] It should be further studied whether earlier and immediate prevention following a non-vertebral fracture can decrease fracture risk in patients with a combination of bone and fall risk factors. (10.1186/1471-2474-14-121)
• [L1] The L2‒L4 lumbar spine segment may substantially increase, whereas the L1‒L4 lumbar spine segment and total hip region have negligible effect. (10.1186/s12891-026-09504-7)
• [L5] Long-term use of CsA can weaken the biomechanical properties and thus increase the fracture rate of the lumbar vertebra and the proximal femur. (10.1186/1471-2474-12-240)
• [L5] The study aimed to investigate the effects of CSII on the microstructure, mechanical properties, and bone mineral composition of the lumbar spine in type 2 diabetic rats, noting that while CSII improved femur structure in previous studies, its effect on the lumbar spine was previously unknown. (10.1186/s12891-022-05452-0)
• [L5] The co-morbidity of intervertebral disc degeneration and osteoporosis is driven by a synergistic network of biomechanical coupling and molecular pathways, including inflammatory factors, senescence signaling, and immunometabolic reprogramming. (10.1186/s13018-025-06075-6)
• [L2] Participation in one or more high-impact sports in adulthood is associated with larger vertebral size, and thus increased vertebral strength, among middle-aged women. (10.1186/s12891-017-1794-8)
• [L3] CLBP in males is associated with some lumbar vertebral BMD measures, raising important questions about the mechanism and potential clinical impact of this association. (10.1186/1471-2474-13-49)
• [L5] The PPS injury produces alterations in GH kinematics with implications for GH joint instability, increased GH joint loading, and potential joint damage. (10.1016/j.jse.2024.12.023)
• [L3] This procedure can improve patients' pain, neurological function and kyphotic deformity and achieve effects similar to traditional methods, making it an ideal surgical treatment for thoracolumbar fractures in AS patients. (10.1186/s13018-022-03378-w)
• [L3] Additionally, the T12 vertebral body has the highest likelihood of experiencing an osteoporotic fracture. (10.1186/s13018-024-04896-5)
• [L3] Unlike lumbar spine BMD, TBS is not affected by the presence of syndesmophytes. (10.1186/s12891-023-06431-9)
• [Case_report] Substantial histological improvement of bone was observed five weeks after successful parathyroidectomy. (10.2106/00004623-199072100-00022)
• [L5] However, its effectiveness in treating biconcave vertebral body is limited. (10.1186/s12891-024-07735-0)
• [L4] The factors responsible for cervical disc degeneration differed between men and women. (10.1186/s12891-018-2055-1)
• [L3] Measurement of TK with T2 on standing whole spinal radiographs resulted in a greater measurement error of up to 6.6°. (10.1186/s12891-021-04786-5)
• [L4] Preoperative planning to accurately select and insert pedicle screws in adolescent idiopathic scoliosis should be based on anatomical limitations in the apical vertebra region, apical vertebra level, and apical vertebral rotation degree. (10.1186/s12891-022-05799-4)

See Also

• Neoplasms
• Deformities
• Disc Degeneration
• Surgical Interventions

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