We report the updated guidelines for the management of osteoporosis in Greece, which include guidance on fracture risk assessment, diagnosis-pharmacological treatment-follow-up of osteoporosis based on updated information, and national evidence from Greek clinical practice and the healthcare setting.The purpose of this report was to update the Guidelines for the Management of Osteoporosis in Greece that was published in 2011.In line with the GRADE system, the working group initially defined the main clinical questions that should be addressed when dealing with the diagnosis and management of osteoporosis in clinical practice in Greece. Following a literature review and discussion on the experience gained from the implementation of the 2011 Guidelines transmitted through the national electronic prescription network, the Hellenic Society for the Study of Bone Metabolism (HSSBM) uploaded an initial draft for an open dialogue with the relevant registered medical societies and associations on the electronic platform of the Greek Ministry of Health. After revisions, the Central Health Council approved the final document.The 2018 Guidelines provide comprehensive recommendations on the issues of the timing of fracture risk evaluation and dual-energy X-ray absorptiometry (DXA) measurement, interpretation of the DXA results, the diagnostic work-up for osteoporosis, the timing as well as the suggested medications for osteoporosis treatment, and the follow-up methodology employed during osteoporosis treatment.These updated guidelines were designed to offer valid guidance on fracture risk assessment, diagnosis-pharmacological treatment-follow-up of osteoporosis based on updated information and national evidence from clinical practice and the healthcare setting. Clinical judgment is essential in the management of every individual patient for the purpose of achieving the optimal outcome in the safest possible way.

目前我国中老年骨质疏松症发病率很高，但由于其发展缓慢、临床症状隐匿，常得不到足够重视。骨质疏松症及相关慢性疼痛的诊治也经常等到出现骨折等严重并发症时才会得到积极治疗，而此时的治疗成本和难度明显增加。本文介绍了我国骨质疏松症的一般流行病学特点及目前骨质疏松症防治现状，并阐述了对社区层面的医护人员进行相关培训的必要性及适合社区开展的相关慢性疼痛诊疗技术和方法，最终提出了从社区层面进行骨质疏松症以及其相关慢性疼痛的诊断和治疗会更加有效的观点。

Bone densitometry provides a measure of bone mass expressed as bone mineral content (BMC) or areal bone mineral density (aBMD). BMC is unadjusted for bone size while aBMD is adjusted for the projected area of the region scanned but not its depth. Because patients with fractures often have reduced bone size, the deficit in BMC or aBMD relative to controls may be partly the result of the comparison of a smaller bone in patients with fractures with a bigger bone in controls without fractures. We asked, what proportion of the deficit in BMC and aBMD found in women with spine fractures relative to controls is attributable to smaller vertebral size? We measured BMC (g), volume (cm3, derived from projected area3/2), aBMD (g/cm2), and volumetric BMD (vBMD, g/cm3) of the third lumbar vertebra by dual-energy X-ray absorptiometry in 270 premenopausal women aged 18-43 years, 163 postmenopausal women with spine fractures aged 54-83 years, and 209 women without fractures aged 54-87 years. The regression of BMC and aBMD on volume in the premenopausal women was used to calculate volume adjusted BMC and aBMD in postmenopausal women with and without fractures (adjusted BMC = observed BMC + [50 - observed volume] x 0.29; adjusted aBMD = observed aBMD + [50 - observed volume] x 0.0044). The data were expressed in the original units and as standard deviation scores (SD) above or below the young normal mean (T scores) or the age predicted mean (Z scores). All results were expressed as mean +/- SEM. Women with spine fractures had reduced BMC (T = -2.35 +/- 0.07 SD, Z = -1.18 +/- 0.06 SD), volume (T = -1.08 +/- 0.08 SD, Z = -0.82 +/- 0.08 SD), aBMD (T = -3. 06 +/- 0.09 SD, Z = -1.14 +/- 0.06 SD) and vBMD (T = -2.67 +/- 0.10 SD, Z = - 0.94 +/- 0.07 SD) (all p < 0.001). About 48% of the difference in BMC between postmenopausal women with and without spine fractures, and about 16% of the difference in aBMD was explained by the difference in vertebral volume between them. When women with and without spine fractures were intentionally matched by aBMD (and age, height, and weight), vertebral volume was reduced (Z = -0.66 +/- 0.13 SD, p < 0.001). When women with and without fractures were intentionally matched by vertebral volume (and age, height, and weight), vBMD was reduced (Z = -1.07 +/- 0.10 SD, p < 0. 001). Women with spine fractures have smaller vertebrae with less bone in the smaller bone. About half the deficit in BMC relative to controls is due to their smaller bone size. The remainder may be due to reduced bone accrual, increased bone loss, or both. Thus, the pathogenesis of bone fragility is heterogeneous. Factors responsible for a deficit in bone mass (due to reduced accrual or excess bone loss) are unlikely to be identified when reduced bone size exaggerates the deficit, and increased bone size obscures it. Understanding the pathogenesis of bone fragility requires acknowledgment of this heterogeneity and the description of its varied morphological basis. This can be achieved by the study of the periosteal and endosteal surfaces of bone because the absolute and relative changes in these surfaces during growth and aging determine skeletal size, its mass, and architecture.

A precise method of measuring vertebral mineral content by computed tomography has been developed. Calibration phantoms scanned with patients are used to provide corrections for machine drifts. Advanced software manipulation of the display images is used to reposition precisely to the midportion of each vertebral body. A long-term precision of 2.8% for mineral content has been obtained in excised vertebrae in a phantom simulating the human torso.

Although many studies have examined the association between low bone mineral density (BMD) and fracture risk in older men, none have simultaneously studied the relationship between multiple BMD sites and risk of different types of fractures. Using data from the Osteoporotic Fractures in Men study, we evaluated the association between areal BMD (aBMD) by dual-energy X-ray absorptiometry (DXA) and volumetric BMD (vBMD) by quantitative computed tomography (QCT) measurements, and different types of fractures during an average of 9.7years of follow-up. Men answered questionnaires about fractures every 4months (>97% completions). Fractures were confirmed by centralized review of radiographic reports; pathological fractures were excluded. Risk of fractures was assessed at the hip, spine, wrist, shoulder, rib/chest/sternum, ankle/foot/toe, arm, hand/finger, leg, pelvis/coccyx, skull/face and any non-spine fracture. Age and race adjusted Cox proportional-hazards modeling was used to assess the risk of fracture in 3301 older men with both aBMD (at the femoral neck (FN) and lumbar spine) and vBMD (at the trabecular spine and FN, and cortical FN) measurements, with hazard ratios (HRs) expressed per standard deviation (SD) decrease. Lower FN and spine aBMD were associated with an increased risk of fracture at the hip, spine, wrist, shoulder, rib/chest/sternum, arm, and any non-spine fracture (statistically significant HRs per SD decrease ranged from 1.24-3.57). Lower trabecular spine and FN vBMD were associated with increased risk of most fractures with statistically significant HRs ranging between 1.27 and 3.69. There was a statistically significant association between FN cortical vBMD and fracture risk at the hip (HR=1.55) and spine sites (HR=1.26), but no association at other fracture sites. In summary, both lower aBMD and vBMD were associated with increased fracture risk. The stronger associations observed for trabecular vBMD than cortical vBMD may reflect the greater metabolic activity of the trabecular compartment.Copyright © 2016 Elsevier Inc. All rights reserved.

Cohort study.The aim of this study is to propose and evaluate a new technique to assess bone mineral density of fractured vertebrae using quantitative computed tomography (QCT).There is no available technique to estimate bone mineral density (BMD) at the fractured vertebra because of the alterations in bony structures at the fracture site.Forty patients with isolated fracture from T10 to L2 were analyzed from the vertebrae above and below the fracture level. Apparent density (AD) was measured based on the relationship between QCT images attenuation coefficients and the density of calibration objects. AD of 8 independent regions of interest (ROI) within the vertebral body and 2 ROI within the pedicles of vertebrae above and below the fractured vertebra were measured. At the level of the fractured vertebra, AD was measured at the pedicles, which are typically intact. AD of the fractured vertebral body was linearly interpolated, based on the assumption that AD at the fractured vertebra is equivalent to the average AD measured in vertebrae adjacent to the fracture. Estimated and measured AD of the pedicles at the fractured level were compared to verify our assumption of linear interpolation from adjacent vertebrae.The difference between the measured and the interpolated density of the pedicles at the fractured vertebra was 0.006 and 0.003 g/cm for right and left pedicle respectively. The highest mean AD located at the pedicles and the lowest mean AD was found at the anterior ROI of the vertebral body. Significant negative correlation exist between age and AD of ROI in the vertebral body.This study suggests that the proposed technique is adequate to estimate the AD of a fractured vertebra from the density of adjacent vertebrae.

The distribution of bone tissue within the vertebra can modulate vertebral strength independently of average density and may change with age and disc degeneration. Our results show that the age-associated decrease in bone density is spatially non-uniform and associated with disc health, suggesting a mechanistic interplay between disc and vertebra.While the decline of bone mineral density (BMD) in the aging spine is well established, the extent to which age influences BMD distribution within the vertebra is less clear. Measures of regional BMD (rBMD) may improve predictions of vertebral strength and suggest how vertebrae might adapt with intervertebral disc degeneration. Thus, we aimed to assess how rBMD values were associated with age, sex, and disc height loss (DHL).We measured rBMD in the L3 vertebra of 377 participants from the Framingham Heart Study (41-83 years, 181 M/196 F). Integral (Int.BMD) and trabecular BMD (Tb.BMD) were measured from QCT images. rBMD ratios (anterior/posterior, superior/mid-transverse, inferior/mid-transverse, and central/outer) were calculated from the centrum. A radiologist assigned a DHL severity score to adjacent intervertebral discs (L2-L3 and L3-L4).Int.BMD and Tb.BMD were both associated with age, though the decrease across age was greater in women (Int.BMD, - 2.6 mg/cm per year; Tb.BMD, - 2.6 mg/cm per year) than men (Int.BMD, - 0.5 mg/cm per year; Tb.BMD, - 1.2 mg/cm per year). The central/outer (- 0.027/decade) and superior/mid-transverse (- 0.018/decade) rBMD ratios were negatively associated with age, with similar trends in men and women. Higher Int.BMD or Tb.BMD was associated with increased odds of DHL after adjusting for age and sex. Low central/outer ratio and high anterior/poster and superior/mid-transverse ratios were also associated with increased odds of DHL.Our results indicate that the distribution of bone within the L3 vertebra is different across age, but not between sexes, and is associated with disc degeneration.

Finite element (FE) models built from quantitative computed tomography (QCT) scans can provide patient-specific estimates of bone strength and fracture risk in the spine. While prior studies demonstrate accurate QCT-based FE predictions of vertebral stiffness and strength, the accuracy of the predicted failure patterns, i.e., the locations where failure occurs within the vertebra and the way in which the vertebra deforms as failure progresses, is less clear. This study used digital volume correlation (DVC) analyses of time-lapse micro-computed tomography (μCT) images acquired during mechanical testing (compression and anterior flexion) of thoracic spine segments (T7-T9, n=28) to measure displacements occurring throughout the T8 vertebral body at the ultimate point. These displacements were compared to those simulated by QCT-based FE analyses of T8. We hypothesized that the FE predictions would be more accurate when the boundary conditions are based on measurements of pressure distributions within intervertebral discs of similar level of disc degeneration vs. boundary conditions representing rigid platens. The FE simulations captured some of the general, qualitative features of the failure patterns; however, displacement errors ranged 12-279%. Contrary to our hypothesis, no differences in displacement errors were found when using boundary conditions representing measurements of disc pressure vs. rigid platens. The smallest displacement errors were obtained using boundary conditions that were measured directly by DVC at the T8 endplates. These findings indicate that further work is needed to develop methods of identifying physiological loading conditions for the vertebral body, for the purpose of achieving robust, patient-specific FE analyses of failure mechanisms.Copyright © 2016. Published by Elsevier Ltd.

To evaluate the relationship between cortical Bone Mineral Density (BMD) at pedicle entry points with trabecular BMD of the vertebral body in a spinal fracture.Quantitative computed tomography of the thoracolumbar spine was analyzed using dedicated software - QCT Pro (Mindways, Austin, TX).Forty-six patients were evaluated. Among them 36 females were diagnosed with osteoporosis; the remaining 10 randomly selected from the database both males and females served as a control group. Overall measurements for 138 vertebrae were assessed. Cortical BMD of entry points for transpedicular screws was higher than trabecular vertebral BMD in osteoporotic (p < 0.001) and non-osteoporotic patients (p = 0.003). The difference was 3.6 times higher in low BMD cases (osteoporosis), compared to 2.3 times in normal subjects. Spearman's rank correlation coefficient showed the strongest correlation between patient's age and trabecular bone mineral density of L1 vertebral body (r = -0.94, p < 0.05), while cortical entry points were less correlated (r = -0.8, p < 0.05 and r = -0.65, p < 0.05 for left and right entry points, respectively). The strength of the correlations between BMD and age decreased gradually from L1 to L4, from r = -0.94 to r = -0.58 for the trabecular vertebral body; from r = -0.8 to r = -0.37 for entry points. Significant correlations were not found for BMD and the height or weight of the patients.Cortical BMD at pedicle entry points decreases with osteoporosis. The relative contribution of cortical vs trabecular BMD increases with osteoporosis. Vertebral trabecular BMD is highly correlated with the cortical BMD of the entry points and allows predicting the bone support in fracture cases.Copyright © 2018 The International Society for Clinical Densitometry. Published by Elsevier Inc. All rights reserved.

Following internal fixations for intertrochanteric fractures in elderly patients, lag screws or screw blades frequently cut the femoral head, leading to surgical failure. The bone mineral density (BMD) at various parts of the proximal femur is significantly correlated with the holding force of the lag screw, which in turn is closely associated with the stability of the fixation. However, the appropriate placement of the lag screw has been controversial. As a novel detection method for BMD, quantitative computed tomography (QCT) may provide relatively accurate measurements of three-dimensional structures and may provide an easy way to determine the appropriate lag screw placement. A total of 50 elderly patients with intertrochanteric fractures were selected for the present study. The BMD of the proximal femur on the healthy side, including the femoral intertrochanter, neck and head, was measured using QCT. For testing, the femoral head was divided into medial, central and lateral sections. The BMD of the femoral head was determined to be the highest, while the BMD of the femoral neck was the lowest. In the femoral head, the central section had the highest BMD, while the lateral section had the lowest BMD. The present study used QCT to detect differences in the BMD at various regions of the proximal femur and provided a novel theoretical reference for the placement of lag screws. To obtain maximum holding power, the lag screw must be placed in the central section of the femoral head.Copyright © 2020, Spandidos Publications.

Discontinuation of denosumab during osteoporosis treatment leads to rapid loss of bone mineral density and induces a bone turnover rebound effect. Previous studies have reported analysis based on dual-energy X-ray absorptiometry scanning (DXA). Here, we report the first case involving analysis of three-dimensional bone mineral density and bone strength, measured by quantitative computed tomography (QCT) after discontinuation of denosumab. An 82-year-old woman who discontinued denosumab because of patient's wish was administered the fifth dose after a gap of 14 months. Her bone mineral density evaluated by DXA and QCT, bone strength, and bone turnover marker levels showed significant rebound phenomenon. The levels of the cortical parameters of the hip were also decreased indicating an increased risk of femoral fractures after denosumab interruption. Our case highlights the increased risk of fractures after discontinuation of denosumab. Therefore, denosumab must be used judiciously without interruption in the dosage schedule.