Male Osteoporosis and Fracture Outcomes
Richard Bockman, MD, PhD
Chief, Endocrine Service - Hospital for Special Surgery
Senior Scientist, Hospital for Special Surgery
Professor of Medicine, Weill Cornell Medicine
One in two women and one in four men over the age of 50 will suffer a fracture with minimal trauma from age-related deteriorated to bone structure, and for hip fracture the outcomes are severe, with high first-year mortality in women of 12.8% and 26.6% in men3-5.
Newer studies with high-resolution peripheral QCT (HrpQCT) provides mechanistic insight into predicting fracture outcomes by documenting microarchitectural skeletal changes over time. For example, while there was no difference in trabecular number in the diaphyseal bone at the wrist or distal femur on the imaging studies, the trabecular were 28% thicker in men versus women and trabecular bone volume to total bone volume was 26% greater in men versus women. Both men and women lose trabecular volume (thickness) in a similar fashion but men increase the trabecular number by 7% while women showed a twofold loss, -13%6.
A large collaborative study7(BoMIC) prospectively followed men and women (ages 40-96 years) by HrPQCT to the time of their first fracture. Patients were divided by certain combinations of bone properties that were identified by HrPQCT and the following specific phenotypes were identified:
- Low bone density
- Low bone volume
- Healthy bone
Most of the male subjects were associated with the "healthy bone" phenotype which represented better bone volume and bone density and had a significantly lower fracture risk compared to the “Low Density” and “Low Volume” groups.
The women who had a “Low Density” phenotype had the highest association with cumulative hazard of major osteoporotic fracture. All three phenotypes differed significantly from each other in their cumulative fracture risk. The data from microarchitectural features captured by HrPQCT documented that osteoporotic fracture risk was associated with specific features of bone degradation that cannot be captured by the typical areal bone density measurements.
So based strictly on anatomically different characteristics of bone microarchitecture, there is a valid stratification of fracture risk.
The take-home message for the “Low Bone Density” phenotype was that a decline in volumetric bone mineral density was strongly associated with the highest fracture risk.
For the “Low Bone Volume” phenotype, the decline in failure load determined by finite element analysis was associated with a middle fracture risk. The specificity for identifying fracture risk by HrPQCT was greater than that achieved by areal DXA.
Finally, both men and women were included in this study and the phenotypes were determined solely on the basis of the microarchitectural parameters, not gender. Therefore, the risk stratification was gender neutral.
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