UNLABELLED: This study examined the association between abdominal muscle quality and bone mineral density (BMD) in 2021 postmenopausal women. A better muscle quality was associated with higher BMD and lower osteoporosis...UNLABELLED: This study examined the association between abdominal muscle quality and bone mineral density (BMD) in 2021 postmenopausal women. A better muscle quality was associated with higher BMD and lower osteoporosis risk, independent of fat and muscle mass, highlighting the clinical relevance of muscle quality in bone health. PURPOSE: Loss of skeletal muscle and bone strength increases the risk of falls and fractures. The association between abdominal muscle quality-assessed by myosteatosis using computed tomography (CT)-and bone mineral density (BMD) remains unclear. We investigated this association in postmenopausal women who underwent abdominal CT during health check-ups. METHODS: The total abdominal muscle area (TAMA), visceral fat area (VFA), subcutaneous fat area (SFA), and skeletal muscle area (SMA) at the third lumbar vertebral level were measured. SMA was classified into normal attenuation muscle area (NAMA) and low attenuation muscle area (LAMA). The NAMA/TAMA index, which reflects the proportion of higher-quality muscle, was calculated. RESULTS: Among 2021 women, 259 (12.8%) had osteoporosis. TAMA, SMA, NAMA (p < 0.001), and the NAMA/TAMA index (p = 0.012) were lower in the osteoporosis group. The prevalence of osteoporosis tended to decrease with increasing tertiles of the NAMA/TAMA index (15.3%, 12.2%, and 11.0%; p = 0.051). The prevalence of vertebral fractures decreased with increasing tertiles of the NAMA/TAMA index (p = 0.005). Lumbar spine, femoral neck, and total hip BMD increased significantly with higher NAMA/TAMA index tertiles after adjusting for confounders (p < 0.001, p = 0.011, and p < 0.001, respectively). The adjusted odds ratio (OR) for osteoporosis in the highest tertile was lower than in the lowest (OR = 0.58, 95% confidence interval = 0.38-0.87), even after adjusting for both abdominal fat and muscle area. CONCLUSION: Postmenopausal women with higher-quality abdominal muscles exhibited higher BMD at all sites and a lower prevalence of osteoporosis, independent of abdominal adiposity and total muscle mass.
Ferrari S, Hars M, Biver E
… +5 more, Uebelhart B, Joly AC, Herrmann F, Meier C, Lippuner K
Osteoporos Int
· 2026 Jun · PMID 42366269
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UNLABELLED: This study investigated the timing and effects of zoledronate infusions in long-term denosumab users having reached T-score targets (BMD > -2.0 T-score). Findings support that early and multiple zoledronate i...UNLABELLED: This study investigated the timing and effects of zoledronate infusions in long-term denosumab users having reached T-score targets (BMD > -2.0 T-score). Findings support that early and multiple zoledronate injections are needed to preserve as much BMD as possible after stopping denosumab. PURPOSE: This study evaluated the effects of zoledronate (Zol) administration and the need for multiple infusions to prevent bone loss after stopping denosumab (Dmab) in long-term users, and the influence of previous bisphosphonates (BPs) exposure. METHODS: This was a multicentric, randomized, open-label study, including 44 post-menopausal women treated with Dmab > 2 years and reaching BMD T-scores > -2.0. Patients without pre-Dmab BPs were randomized into 3 groups receiving Zol at 6 months (6 M, n = 12) or 9 months (9 M, n = 11) after the last Dmab, or to a group receiving Zol if CTX > 644 ng/l or BMD decreased ≥ 5% (OBS, n = 11). A parallel observational group exposed to pre-Dmab BPs (OBS-BPs, n = 10) received Zol under the same criteria as the OBS group. Zol was re-administered during the 2‑year follow‑up according to CTX threshold or BMD loss criteria. Co-primary outcomes were lumbar spine BMD changes 1-year post-Zol and frequency of Zol treatments required. RESULTS: A majority of post-Dmab patients without previous BPs required multiple Zol infusions (median 2, range 1-5), while most patients in OBS group with previous BPs needed only one Zol. Median LS BMD changes 12 and 24 months post-Zol were similar between groups. However, LS BMD changes at 12 months after the end of the last Dmab dose effect were numerically larger in 9 M group (-8.25%) and OBS group (-8.13%) than in 6 M (-4.71%) and OBS-BPs (-4.62%) groups. CONCLUSION: Findings support that early and multiple Zol injections are needed better to preserve BMD after stopping Dmab in long-term users.
Chandran M, Wong CMJ, Helgason B
… +9 more, Leong YE, Chan A, Malhotra R, Gupta P, Jha D, Praveen AD, Tan DYZ, Choo HMC, Lamoureux EL
Osteoporos Int
· 2026 Jun · PMID 42360325
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UNLABELLED: The Osteoporosis Self-Assessment Tool (OST) is a useful discriminator of densitometric osteoporosis, but its long-used fixed threshold performs poorly, especially in younger postmenopausal women. In this mult...UNLABELLED: The Osteoporosis Self-Assessment Tool (OST) is a useful discriminator of densitometric osteoporosis, but its long-used fixed threshold performs poorly, especially in younger postmenopausal women. In this multi-ethnic cohort study, optimal screening thresholds varied strikingly by age, supporting a shift from a single cut-off to age-dependent thresholds. PURPOSE: The Osteoporosis Self-Assessment Tool (OST) is used worldwide to identify individuals likely to have osteoporosis on dual-energy X-ray absorptiometry (DXA) and fixed thresholds are widely used. We evaluated OST performance in a multi-ethnic population and examined whether age-dependent thresholds better reflect its role as a screening tool. METHODS: Women (n = 2787) and men (n = 1465), ≥ 50 and ≥ 60-years respectively, from three cohorts were studied. Osteoporosis was defined as a DXA T-score ≤ - 2.5 at the lumbar spine, total hip, or femoral neck. We evaluated the originally identified (≤ - 1), the historically propagated- (≤ - 4), Youden index-derived-, and screening-oriented-OST thresholds targeting 80% sensitivity. Stability was assessed using fivefold cross-validation supported by a real-world patient cohort. RESULTS: OST showed acceptable discrimination (AUC 0.79 in women; 0.72 in men). The - 1 threshold showed only moderate sensitivity in younger women (0.54, aged 50-59 years) and poor specificity in older women (0.21, aged 70-79 years; 0.03 at ≥ 80 years). The - 4 threshold showed poor sensitivity overall, particularly in younger women (0.02, aged 50-59 years; 0.14, aged 60-69 years). Youden thresholds demonstrated clear age-dependence shifting from - 0.15, (50-59 years) to - 6.20 (≥ 80 years), with stability on cross-validation ((mean - 2.18, SD 0.45)). Screening thresholds targeting 80% sensitivity also showed a steep age-dependent gradient (+ 0.25 to - 5.39). Similar age-dependent patterns were observed in men. CONCLUSION: OST thresholds show substantial variation in performance across age groups. Age-dependent thresholds provide a more appropriate framework for osteoporosis screening.
Meng Q, Wang Y, Yang L
… +6 more, Vuong AM, Leslie WD, Lix LM, Javaid S, Kan B, Yang S
Osteoporos Int
· 2026 Jun · PMID 42342916
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UNLABELLED: We examined the multimorbidity patterns among fragility fracture patients in China and the US. Except for female fracture patients in US, hyperlipidemia was the most prevalent comorbidity among fracture patie...UNLABELLED: We examined the multimorbidity patterns among fragility fracture patients in China and the US. Except for female fracture patients in US, hyperlipidemia was the most prevalent comorbidity among fracture patients in China and the US. US fracture patients demonstrated a similar complex comorbidity network to non-fracture individuals. PURPOSE: To examine the multimorbidity patterns among fragility fracture patients aged 50 + years in China and the US. METHODS: We extracted inpatient electronic medical records at the First Affiliated Hospital of Jinzhou Medical University, China between 2018 and 2023, and data from the National Health and Nutrition Examination Survey (NHANES) 1999-2020. Fragility fracture patients aged ≥ 50 years were identified. In the NHANES, we matched each fracture patient with a non-fracture individual by age (< 1 year), sex and survey cycle. We identified 28 and 19 chronic diseases in the Chinese and NHANES databases, respectively. Average degree was used to characterize the complexity of comorbidity network. RESULTS: A total of 2086 Chinese fracture patients, 1227 US fracture and 1227 non-fracture individuals were included (73% females). The most prevalent comorbidity among Chinese fracture patients was hyperlipidemia (male: 63.3%; female: 65.2%). In US fracture patients, the most prevalent comorbidity was hyperlipidemia (67.3%) in males and osteoporosis (78.3%) in females. The most prevalent disease pair was osteoporosis and hyperlipidemia among US fracture patients (male: 40.8%; female: 61.4%), and hypertension and hyperlipidemia among Chinese fracture patients (male: 26.6%; female: 29.4%). The multimorbidity pattern of US fracture patients was similar to that of non-fracture individuals (average degree: 7.82 vs. 7.59 in males; 7.94 vs. 7.44 in females). CONCLUSION: Except among female fracture patients in the US, hyperlipidemia was the most prevalent comorbidity among Chinese and US fragility fracture patients. US fracture patients demonstrated a similar complex comorbidity network to non-fracture individuals.
Park J, Kwon BT, Han K
… +3 more, Park SM, Suh DH, Hong JY
Osteoporos Int
· 2026 Jun · PMID 42321476
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UNLABELLED: Smoking cessation reduces hip fracture risk; however, subsequent weight loss may offset this benefit. In a nationwide cohort, weight loss after smoking cessation was associated with increased hip fracture ris...UNLABELLED: Smoking cessation reduces hip fracture risk; however, subsequent weight loss may offset this benefit. In a nationwide cohort, weight loss after smoking cessation was associated with increased hip fracture risk. Maintaining stable body weight after quitting smoking may be important for fracture prevention. PURPOSE: Smoking cessation reduces fracture risk but is often accompanied by changes in body weight that may influence bone health. However, it remains unclear whether weight change after smoking cessation is associated with hip fracture risk. We therefore examined the association between post-cessation weight change and the incidence of hip fractures. METHODS: This retrospective cohort study used data from the Korean National Health Insurance Service. Adults aged ≥ 40 years who underwent consecutive biennial health examinations in 2007 and 2009 were categorized as nonsmokers, quitters, or current smokers based on their smoking status. Quitters were further stratified by weight change between two examinations: loss (> 5% decrease), weight maintenance (± 5%), or weight gain (> 5% increase). Participants were followed from 2010 through 2018 for incident hip fractures. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using multivariable Cox proportional hazards models. RESULTS: Among 913,805 participants (672,858 nonsmokers; 34,143 quitters; 206,804 current smokers), 6,001 incident hip fractures occurred during a mean follow-up of 8.1 years. Compared with nonsmokers, current smokers had a higher risk of hip fracture (aHR = 1.700, 95% CI 1.557-1.856). Quitters also showed increased risks across all weight-change categories: weight loss (aHR = 1.878, 95% CI 1.164-3.031), weight maintenance (aHR = 1.461, 95% CI 1.188-1.797), and weight gain (aHR = 1.611, 95% CI 1.151-2.255). Quitters who maintained or gained weight had numerically lower risk estimates than current smokers, whereas those who lost weight had a higher point estimate; however, confidence intervals overlapped across groups. In analyses of the entire cohort, both weight loss (aHR = 1.425, 95% CI 1.336-1.519) and weight gain (aHR = 1.150, 95% CI 1.064-1.242) were associated with higher hip fracture risk compared with weight maintenance. CONCLUSIONS: Smoking cessation was associated with a lower risk of hip fracture than continued smoking, although the risk remained higher than in nonsmokers. Weight loss after smoking cessation was associated with higher fracture risk, while maintaining stable body weight appeared to be associated with more favorable outcomes. These findings suggest that maintaining a stable body weight after smoking cessation may be important for hip fracture prevention.
Chandran M, Anastasilakis AD, Blank RD
… +15 more, Binkley N, Chevalley T, Javaid MK, Lems WF, Lewiecki EM, Makras P, Paccou J, Silverman S, Thomas T, Brandi ML, McCloskey E, Cavalier E, Åkesson KE, Holzer G, Fracture Working Group of the Committee of Scientific Advisors (CSA) of the IOF
Osteoporos Int
· 2026 Jun · PMID 42313180
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UNLABELLED: This expert position statement reframes arthroplasty and spinal fusion complications under the unified endpoint of implant fixation failure, defined as loss of mechanical integrity of the bone-implant unit ov...UNLABELLED: This expert position statement reframes arthroplasty and spinal fusion complications under the unified endpoint of implant fixation failure, defined as loss of mechanical integrity of the bone-implant unit over time. It synthesizes mechanistic and clinical evidence and provides evidence-informed recommendations for peri-operative bone health optimization. BACKGROUND: Osteoporosis is traditionally conceptualized as causing fragility fractures. However, compromised bone quality also affects the integrity of bone-implant constructs, influencing whether implants maintain fixation, interfaces remain stable, and fusion constructs consolidate. OBJECTIVE: To synthesize mechanistic, translational, and clinical evidence on how osteoporosis and osteoporosis pharmacotherapies influence implant fixation failure across arthroplasty and spinal fusion, and to provide evidence-informed clinical recommendations for peri-operative bone health assessment and optimization within a unified construct-level framework. METHODS: A position statement was developed following a structured literature search. Evidence was synthesized narratively by defining implant fixation failure as a construct-level outcome encompassing periprosthetic fracture, loosening, subsidence, pseudarthrosis, and junctional failure. Recommendations were categorized by strength (strong or conditional) and certainty of evidence (high, moderate, or low). RESULTS: Low bone mineral density (BMD) is associated with implant fixation failure across arthroplasty and spinal fusion. In arthroplasty, randomized trials demonstrate preservation of periprosthetic BMD with bisphosphonates, while registry analyses suggest improved implant survival. In spinal fusion, antiresorptive and anabolic therapies influence fixation-related parameters, with anabolic agents showing the most consistent evidence for enhanced fusion mass and earlier union. Much of the literature relies on radiographic or biomechanical endpoints rather than definitive outcomes. CONCLUSIONS: Viewing arthroplasty and spinal fusion complications through a shared construct-level perspective provides a coherent link between osteoporosis and reconstructive durability. Systematic peri-operative bone health optimization may improve construct longevity, although more definitive outcome-driven trials are needed. Closer integration between orthopedic surgeons and osteoporosis specialists will be central to advancing peri-operative bone health care.
Tseng TH, Huang TT, Huang JE
… +11 more, Tzeng SC, Wang YC, Tsao PC, Hung CC, Lee CC, Hsu JY, Yen HK, Wu CH, Li CY, Wang CY, Fu SH
Osteoporos Int
· 2026 Jun · PMID 42313179
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UNLABELLED: AI-derived bone mineral density from routine radiographs showed strong agreement with DXA and comparable ability to predict incident fractures. This opportunistic approach may support osteoporosis screening a...UNLABELLED: AI-derived bone mineral density from routine radiographs showed strong agreement with DXA and comparable ability to predict incident fractures. This opportunistic approach may support osteoporosis screening and early identification of high-risk individuals without reliance on dedicated DXA examinations. INTRODUCTION: Osteoporosis is a major cause of fragility fractures, yet limited access to DXA leads to underdiagnosis and delayed treatment. Recent advances in artificial intelligence enable extraction of bone structural information from routine radiographs, providing a potential tool for opportunistic osteoporosis screening. Whether AI-derived BMD can approximate DXA and predict real-world fracture risk remains unclear. METHODS: Adults aged ≥ 20 years who underwent both lumbar DXA and radiographic examinations (lumbosacral or kidney-ureter-bladder) within six months between January 2014 and December 2024 were retrospectively analyzed. Lumbar BMD was estimated using DeepXray Spina and compared with DXA using Pearson correlation, intraclass correlation coefficient (ICC), and Bland-Altman analysis. Diagnostic performance for osteoporosis (T-score ≤ - 2.5) and fracture prediction was evaluated using receiver operating characteristic (ROC) analysis, Cohen's κ, and logistic regression. RESULTS: Among 540 participants (73.9% female; mean age 57.0 years; mean follow-up 6.4 years), AI- and DXA-derived BMD showed strong agreement (r = 0.943; ICC = 0.934). For osteoporosis diagnosis, AI-derived T-scores achieved an AUC of 0.959, κ = 0.74, and 90% accuracy. AI- and DXA-derived BMD showed comparable performance for predicting vertebral (AUC 0.704 vs. 0.678) and hip fractures (0.716 vs. 0.678). For all-site fractures, AI-derived BMD showed a modestly higher AUC than DXA-derived BMD (AUC, 0.699 vs 0.677; P = 0.042). Lower AI-derived BMD was independently associated with higher fracture risk. CONCLUSIONS: AI-derived BMD from routine radiographs closely correlates with DXA and demonstrates comparable fracture prediction. This approach may support opportunistic osteoporosis screening without reliance on DXA.
Diz-Lopes M, Rovetta CF, Pollastri F
… +13 more, Mastropaolo F, Somma R, Tugnolli M, Pasetto E, Benini C, Messina V, Fassio A, Gatti D, Viapiana O, Grendene E, Mozzo P, Rossini M, Adami G
Osteoporos Int
· 2026 Jun · PMID 42313178
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UNLABELLED: We evaluated how romosozumab affects bone structure, density, and strength at the wrist over 12 months. Volumetric bone mineral density did not increase, but high-resolution quantitative computed tomography i...UNLABELLED: We evaluated how romosozumab affects bone structure, density, and strength at the wrist over 12 months. Volumetric bone mineral density did not increase, but high-resolution quantitative computed tomography imaging showed modest improvements in bone strength. These findings suggest that romosozumab may improve bone quality even in areas where density changes are not seen with standard scans and highlight the importance of using more detailed imaging to fully understand how osteoporosis treatments work across different skeletal sites. PURPOSE: Romosozumab (ROMO) is a monoclonal antibody that inhibits sclerostin, promoting bone formation and suppressing resorption. While ROMO leads to substantial BMD gains at the lumbar spine and the hip, its effects on distal radius volumetric BMD (vBMD) remain unclear. High-resolution peripheral quantitative computed tomography (HR-pQCT) allows for detailed assessment of bone microarchitecture and strength at peripheral regions. We aimed to evaluate the effects of 12 months of ROMO on vBMD, microarchitecture and biomechanical properties of the distal radius using HR-pQCT. METHODS: We did a prospective study on 49 postmenopausal women with osteoporosis treated with ROMO for 12 months who underwent HR-pQCT with Cone Beam CT and microfinite element analysis (uFEA) assessments at baseline, 3, 6, and 12 months. We also performed DXA at lumbar spine, femoral neck, and total hip. HR-pQCT parameters trajectories were analyzed using mixed-effects modeling. RESULTS: No significant increases were observed in cortical or trabecular vBMD or microarchitectural parameters at the distal radius. On the other hand, uFEA showed early increases in cortical failure load and shear strength, suggesting potentially improved bone mechanical behavior. Lumbar spine, femoral neck, and total hip aBMD significantly increased by 11.6%, 8.3%, and 3.1%, respectively (all p < 0.001). CONCLUSION: ROMO treatment was associated with modest early changes in biomechanical parameters, without significant improvement in vBMD at the distal radius. ROMO treatment might improve skeletal health beyond BMD gains.
Osteoporos Int
· 2026 Jun · PMID 42303774
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Medication-related osteonecrosis of the jaw (MRONJ) is a rare but clinically important adverse event in antiresorptive osteoporosis care. The most recently approved osteoporosis medication, romosozumab, has a dual mechan...Medication-related osteonecrosis of the jaw (MRONJ) is a rare but clinically important adverse event in antiresorptive osteoporosis care. The most recently approved osteoporosis medication, romosozumab, has a dual mechanism, combining antiresorptive and osteoanabolic effects. Thus, concern exists regarding a possible risk for MRONJ with romosozumab, although current evidence is limited mainly to isolated case reports. We performed a retrospective new-user active comparator propensity score-matched cohort study in the TriNetX Global Collaborative Network comparing women treated with romosozumab vs. parathyroid hormone (PTH) analogs (teriparatide or abaloparatide). Women aged ≥ 18 years with no prior osteonecrosis, jaw inflammatory disease, oral/head-neck cancer, or radiation exposure and no recent exposure to chemotherapy were eligible. After 1:1 propensity score matching, 15,689 patients remained in each cohort. During 1 year of follow-up, MRONJ occurred in 11 romosozumab-treated patients and 12 PTH analog-treated patients (hazard ratio [HR] 0.89, 95% CI 0.39-2.01; log-rank p = 0.78). Absolute event rates were very low in both groups (0.070% vs. 0.076%). As expected, the positive control outcome of hypercalcemia occurred less often with romosozumab (HR 0.66, 95% CI 0.58-0.75). These real-world data do not indicate a detectable excess short-term MRONJ risk with romosozumab compared with PTH analogs over the approved treatment window, although modest differences cannot be excluded because events were rare.
Kawazoe M, Masuoka S, Kaneko K
… +12 more, Yamada Z, Furukawa K, Watanabe E, Koshiba K, Yamada S, Muraoka S, Sato H, Irita I, Kanaji M, Sugihara T, Nishio J, Nanki T
Osteoporos Int
· 2026 Jun · PMID 42301302
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UNLABELLED: The efficacy of romosozumab (ROMO) in treating glucocorticoid-induced osteoporosis remains unclear. This randomized clinical trial demonstrated that in patients initiating glucocorticoid therapy, a treatment...UNLABELLED: The efficacy of romosozumab (ROMO) in treating glucocorticoid-induced osteoporosis remains unclear. This randomized clinical trial demonstrated that in patients initiating glucocorticoid therapy, a treatment regimen of 12 months of ROMO followed by 24 months of denosumab (DMAb) was effective compared to either 36 months of DMAb or bisphosphonate monotherapy. PURPOSE: The efficacy of romosozumab (ROMO), an antibody against sclerostin-an inhibitor of Wnt signaling-in the treatment of glucocorticoid-induced osteoporosis remains uncertain, particularly regarding the sequential use of ROMO and denosumab (DMAb). This study aimed to compare the long-term efficacy of 12 months of ROMO followed by 24 months of DMAb (ROMO-DMAb) to 36 months of DMAb or bisphosphonates (BP) alone. METHODS: Patients with rheumatic diseases who had not previously received osteoporosis drugs and were newly treated with prednisolone ≥ 15 mg/day were randomly assigned to receive ROMO (ROMO-DMAb group), DMAb, or risedronate. Over a 36-month period, we measured bone mineral density (BMD) at the lumbar spine, femoral neck, and total hip every 6 months. RESULTS: Thirty-nine patients (median [interquartile ranges] age 72.0 [67.3 - 78.8] years; 69.2% women; prednisolone dose 20.0 [15.0 - 50.0] mg/day) were enrolled. The median percent change in lumbar spine BMD from baseline at 36 months was greatest in the ROMO-DMAb group (ROMO-DMAb; 11.3 [6.8 - 13.8] %, DMAb; 9.4 [4.7 - 13.5] %, BP; 2.1 [-1.3 - 6.8] %). The changes in the femoral neck and total hip were similar between the ROMO-DMAb and DMAb groups, and the increases were much smaller than that in the lumbar spine. Serum levels of total type I procollagen-N-propeptide and tartrate-resistant acid phosphatase-5b decreased in all groups from month 3. CONCLUSION: Sequential treatment with ROMO followed by DMAb increased lumbar spine BMD more than DMAb or BP alone up to 36 months, demonstrating the efficacy of this treatment strategy.
Chandran M, Mitchell P, Ebeling PR
… +4 more, Mithal A, Halbout P, Harvey NC, McCloskey EV
Osteoporos Int
· 2026 Jun · PMID 42283749
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The APCO-IOF Asia Pacific Regional Audit on the epidemiology, costs and burden of osteoporosis 2025 is not just a regional report; it is a systems stress test for global osteoporosis preparedness and ageing. Across 22 co...The APCO-IOF Asia Pacific Regional Audit on the epidemiology, costs and burden of osteoporosis 2025 is not just a regional report; it is a systems stress test for global osteoporosis preparedness and ageing. Across 22 countries, structural gaps recur: incomplete fracture surveillance, uneven diagnostic access, misaligned reimbursement, and limited secondary fracture prevention. These are not failures of knowledge but of system design. The lessons are universal: count fractures, define quality, fund post-fracture pathways, develop coherent guidelines, align financing with risk, and track outcomes. Osteoporosis is not a niche specialty concern but a defining test of how health systems respond to demographic ageing.
Jing LQ, Chen C, Fang YD
… +12 more, Wang JN, Zhou HJ, Xue RR, Yao RY, Zeng B, Wu W, Li H, Shu B, Shen QX, Xu JH, Ye J, Mo W
Osteoporos Int
· 2026 Jun · PMID 42260120
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Multiple clinical studies have demonstrated that vestibular dysfunctions, such as benign paroxysmal positional vertigo (BPPV) and Meniere's disease (MD), are associated with osteoporosis or osteopenia in adults. Animal s...Multiple clinical studies have demonstrated that vestibular dysfunctions, such as benign paroxysmal positional vertigo (BPPV) and Meniere's disease (MD), are associated with osteoporosis or osteopenia in adults. Animal studies have also indicated that selective ablation of peripheral vestibular organs leads to reduced bone mineral density in mice, potentially through effects on the sympathetic nervous system. This review systematically evaluates the association between vestibular dysfunction and osteoporosis in adults and reports the prevalence of this comorbidity. We systematically searched PubMed, MEDLINE, EMBASE, the Cochrane Library, Scopus, and Web of Science databases for studies published from January 2000 to December 2025. Two authors independently screened and extracted data. Meta-analyses were performed to compare vestibular function test results between adults with and without osteoporosis and to compare the morbidity of osteoporosis between individuals with and without vestibular dysfunction. A total of 33 studies were included. Among these, 21 case-control studies examined the risk of osteoporosis in adults with vestibular dysfunction, and the remaining cross-sectional/prospective studies reported its prevalence. Findings are presented in four sections. (1) Risk of vestibular dysfunction: osteoporosis vs non-osteoporosis controls: due to moderate heterogeneity persisting after sensitivity analysis (I = 58%, P = 0.03), 7 studies were analyzed descriptively. Three large-sample studies associated osteoporosis with increased BPPV risk (OR (odds ratio) = 1.77, 95% CI = 1.69-1.86; OR = 1.28, 95%CI = 1.15-1.42; OR = 2.03, 95%CI = 1.52-2.70). One large-sample study showed higher MD history risk in osteoporosis patients (OR = 1.88, 95%CI = 1.76-2.02). Three studies on VEMP abnormalities had very small samples, limiting conclusion reliability. (2) Risk of osteoporosis: vestibular dysfunction vs normal controls: most studies (13 of 16) focused on osteoporosis risk in BPPV patients, 11 of these 13 studies were included in the meta-analysis. Overall heterogeneity was high even after sensitivity analysis (I = 74%, P < 0.0001). Subgroup analysis of four Chinese studies showed very low heterogeneity (I = 0%, P = 0.43), with a significantly higher osteoporosis risk in BPPV patients (OR = 3.42, 95% CI = 2.12-5.50, P < 0.00001). Conversely, five Korean studies exhibited high heterogeneity (I = 94%, P < 0.00001), but each study also reported a significantly increased risk in BPPV patients (OR = 1.65, 95% CI = 1.57-1.73; OR = 8.63, 95% CI = 1.75-42.54; OR = 3.32, 95% CI = 1.78-6.19; OR = 1.26, 95% CI = 1.19-1.33; OR = 5.09, 95% CI = 1.86-13.91). (3) Prevalence of vestibular dysfunction in osteoporosis: due to substantial heterogeneity, a random-effects model was used to pool effect sizes. The prevalence of BPPV in the osteoporotic population was approximately 8.3% (95% CI = 3.8-14.5%; I = 97%, P < 0.00001); the prevalence of abnormal Romberg test results in the osteoporotic population was 10.7% (95% CI = 2.0-46.8%; I = 100%, P < 0.00001). (4) Prevalence of osteoporosis in BPPV: using a random-effects model, the pooled prevalence was 17.4% (95%C I = 9.1-31.5%; I = 96%, P < 0.00001). A close bidirectional association may exist between vestibular dysfunction, particularly BPPV, and osteoporosis in adults. Data from Chinese populations showed robust results with very low heterogeneity. However, due to substantial heterogeneity across most studies and limited sample sizes in some subgroup analyses, these findings should be interpreted with caution. Attention to bone health is recommended in the management of vestibular disorders, especially BPPV. Well-designed prospective studies are warranted to further elucidate causal relationships and underlying mechanisms.