Osteoporosis Diagnosis and Management: A Review from an Orthopedic Perspective.

INTRODUCTION

Affecting an estimated 200 million people worldwide, osteoporosis is a major global public health issue 1 ) . As populations age, the prevalence of osteoporosis continues to rise, especially in Asia, where demographic transitions are occurring rapidly. In Korea, population-based data indicate that the prevalence of osteoporosis in patients aged 50 years or older is approximately 38% among women and about 7% among men 2 ) . The clinical impact is substantial: fragility fractures lead not only to acute morbidity but also to long-term disability, institutionalization, and increased mortality. While vertebral fractures contribute to chronic pain, spinal deformity, impaired pulmonary function, and psychological distress, hip fractures are particularly devastating, with one-year mortality approaching 20% 3 , 4 ) . Collectively, these outcomes highlight osteoporosis as both a medical and socioeconomic burden.

In 1994, the World Health Organization (WHO) provided a landmark framework by defining diagnostic thresholds based on T-scores: normal (≥–1.0), osteopenia (–1.0 to –2.5), and osteoporosis (≤–2.5) 5 ) . These criteria, however, were primarily derived from Caucasian women in the National Health and Nutrition Examination Survey (NHANES) III dataset 6 ) . Since then, growing evidence has demonstrated that bone mineral density (BMD) and fracture risk differ substantially across racial and ethnic groups. Black populations tend to have higher hip BMD with lower fracture risk, whereas Asian populations often exhibit lower BMD but variable fracture rates. These differences underscore the importance of interpreting dual-energy X-ray absorptiometry (DEXA) results within the context of population-specific characteristics rather than applying uniform diagnostic thresholds indiscriminately 7 , 8 ) .

For orthopedic surgeons, osteoporosis is not merely a medical disease. It is also a critical surgical challenge. Poor bone quality compromises fixation stability, increases the risk of construct failure, and contributes to perioperative complications, particularly in hip joint arthroplasty 9 ) . Moreover, the growing burden of fragility fractures represents a major source of morbidity, mortality, and healthcare costs 3 , 4 ) . As Surgeons are positioned at the frontline of secondary prevention as they frequently encounter patients with previously undiagnosed osteoporosis at the time of fracture repair. In this context, accurate DEXA interpretation, recognition of potential artifacts or site discordance, and integration with laboratory evaluation for secondary causes are essential. Timely initiation of pharmacologic and non-pharmacologic interventions can reduce refracture risk, improve functional outcomes and, ultimately, lessen the socioeconomic impact of osteoporosis.

METHODS

This study conducted a narrative review emphasizing practice-oriented synthesis. Searches of PubMed, Web of Science, and Google Scholar (January 2009 to December 2024) used terms combining osteoporosis with DEXA/DXA, T-/Z-scores, artifacts/precision/least significant change (LSC), secondary causes/laboratory evaluation/bone turnover markers (BTMs), and fracture liaison service (FLS). Eligibility criteria included international guidelines and consensus statements (WHO, International Society for Clinical Densitometry [ISCD], American Association of Clinical Endocrinologists/American College of Endocrinology [AACE/ACE], American Society for Bone and Mineral Research [ASBMR], Endocrine Society), original studies such as randomized controlled trials, cohort studies, and large observational or registry-based research, as well as systematic reviews and meta-analyses on fracture outcomes, DEXA reproducibility, or longitudinal monitoring. Conversely, pediatric studies, animal or in-vitro experiments, case reports or small case series, and imaging articles not focused on DEXA were excluded ( Fig 1 ). Screening prioritized orthopedic applicability (practical DEXA use, LSC, tiered labs, FLS linkage). This review incorporated contemporary, high-quality evidence with a focus on methodological rigor and relevance. When multiple sources addressed the same topic, preference was given to recent clinical guidelines, expert consensus statements, and robust studies. Rather than applying a formal risk-of-bias tool, a quality-weighted strategy was employed in which guidelines, randomized controlled trials, and meta-analyses were prioritized. In cases where randomized evidence was insufficient, observational data were incorporated.

INTERPRETATION OF DEXA REPORTS

1. Principles of DEXA

DEXA remains the gold standard for quantifying BMD. It measures areal BMD (g/cm 2 ) based on the differential attenuation of two X-ray beams through bone and soft tissue. This technique is reproducible, safe, and minimally invasive, which accounts for its widespread adoption 10 , 11 ) . However, as DEXA measures areal rather than volumetric density, body size can influence results—smaller individuals may appear osteoporotic despite having normal volumetric density. Compared to earlier pencil-beam devices, modern fan-beam systems have improved resolution and scan times, further enhancing clinical usability.

2. T-scores and Z-scores

Used primarily for diagnosing osteoporosis in postmenopausal women and men ≥50 years, the T-score compares a patient’s BMD to the mean peak BMD of a healthy young adult reference population (usually women aged 20-29 years). According to WHO criteria for T-scores, osteoporosis is defined as ≤–2.5, osteopenia as between –1.0 and –2.5, and normal bone mass as ≥–1.0 5 ) . Each 1 standard deviation (SD) decrease in T-score roughly doubles fracture risk 12 ) .

Z-score compares a patient’s BMD to an age-, sex-, and ethnicity-matched population. A Z-score ≤–2.0 is defined by ISCD as “below the expected range for age” and should prompt evaluation for secondary causes 11 , 12 ) .

3. Graphical Bands and Visual Interpretation

The majority of modern DEXA reports now include a graphical component in addition to raw numbers ( Fig. 2 ). Results are often plotted on a color-coded chart.

• Green: normal bone density (T-score ≥–1.0)

• Yellow: osteopenia (–1.0> T-score >–2.5)

• Red: osteoporosis (T-score ≤–2.5)

• Blue band: the age-matched Z-score reference range, which contextualizes the patient’s bone density relative to peers of the same age and sex, and is a feature specific to Lunar (GE HealthCare) DEXA systems, and is not present in the output generated by Hologic DXA systems.

These graphical displays improve communication with patients and can highlight cases where bone density is abnormally low for age, prompting investigation for secondary causes.

4. Spine–Hip Discordance

One of the most frequent interpretive challenges is spine–hip discordance, where the lumbar spine and hip yield different diagnostic categories. This occurs in 35%-50% of patients and may result from degenerative changes, scoliosis, or regional differences in bone turnover 13 ) . According to ISCD, the lowest valid T-score across sites should be used to guide diagnosis and management 14 ) . This recommendation is particularly important for orthopedic surgeons, because hip fractures carry the highest morbidity and mortality, whereas lumbar spine BMD may be artifactually elevated, potentially masking underlying osteoporosis and delaying timely intervention.

5. Artifacts and Exclusions

Artifacts must be taken into account in DEXA interpretation. Lumbar BMD can be spuriously elevated by osteophytes, endplate sclerosis, or aortic calcifications, while metallic implants can distort hip and spine scans. ISCD recommends excluding vertebrae affected by artifacts, prior fractures, structural abnormalities, or if their T-score differs by >1.0 SD from adjacent vertebrae 12 , 15 ) . At least two contiguous vertebrae must remain valid. If fewer than two are usable, the lumbar spine should not be employed diagnostically. Similarly, when both femoral neck and total hip can be measured, the lower T-score should guide interpretation. Furthermore, Ward’s triangle is not recommended due to poor reproducibility. When neither the hip nor the spine is valid, the 33% (one-third) radius of the forearm is the recommended alternative site.

6. Precision Error and Least Significant Change

As DEXA is used for longitudinal monitoring, understanding precision error is crucial. Precision varies by device type, technologist expertise, and patient factors. To distinguish true biological change from variability, ISCD recommends calculating the LSC using the formula:

LSC=2.77×precision error (95% confidence interval).

For example, if the lumbar spine precision error is 1.5%, the LSC is 4.16%. Only changes greater than 4.16% should be considered clinically significant 16 ) . Applying site-specific LSC thresholds ensures that effects of treatment or disease progression are not misinterpreted due to measurement noise.

LABORATORY EVALUATION OF OSTEOPOROSIS

1. Screening Tests

Initial evaluation should include a panel of basic tests that are universally recommended for osteoporosis patients: serum calcium and phosphate (mineral homeostasis), alkaline phosphatase (ALP; high-turnover states), creatinine/estimated glomerular filtration rate (eGFR) (renal function and treatment selection), 25-hydroxyvitamin D [25(OH)D; common deficiency with secondary hyperparathyroidism], and complete blood count (CBC; anemia, hematologic disease). Common contributors such as vitamin D deficiency or renal insufficiency, both of which are frequent in fragility fracture patients, are identified by these screening tests 17 - 19 ) .

2. Targeted Tests

When screening results or clinical suspicion indicate, further targeted tests are warranted. These additional tests include thyroid-stimulating hormone (TSH), parathyroid hormone (PTH), sex hormones, cortisol, serum and urine protein electrophoresis (SPEP/UPEP), and 24-hour urinary calcium. By structuring evaluation as a two-tier algorithm—universal screening first, followed by conditional targeted testing—unnecessary investigations are minimized while ensuring important secondary causes are not overlooked ( Table 1 ).

3. Bone Turnover Markers

BTMs offer dynamic insight into skeletal metabolism. Among the most widely used are procollagen type 1 N-terminal propeptide (P1NP) (formation) and C-terminal telopeptide of type I collagen (CTX) (resorption). In response to therapy, these markers change more rapidly than BMD, often within 3-6 months, making them useful for monitoring adherence and treatment efficacy 20 ) . Although BTMs were once thought to have limited clinical utility, they are now used for specific purposes such as monitoring therapeutic response and patient adherence. However, variability and lack of assay standardization remain limitations. Ongoing international efforts (International Osteoporosis Foundation–International Federation of Clinical Chemistry and Laboratory Medicine [IOF–IFCC], National Bone Health Alliance [NBHA]) aim to harmonize pre-analytical procedures, assay calibration, and reporting formats so that BTM measurements can be interpreted consistently across laboratories 20 - 22 ) .

PERIOPERATIVE BONE HEALTH OPTIMIZATION & FLS PATHWAYS

1. Preoperative Optimization

For orthopedic surgeons, optimizing bone health is integral to ensuring stable fixation and successful union. Therefore, preoperative evaluation should include DEXA, correction of vitamin D and calcium deficiency and, in high-risk patients, initiation of pharmacologic therapy. Evidence indicates that anabolic agents such as teriparatide can accelerate spinal fusion and reduce hardware complications 23 ) , underscoring the surgeon’s ability to directly influence both surgical and skeletal outcomes.

2. Perioperative Considerations

Surgeons should continue to safeguard bone quality during the perioperative period by maintaining calcium/vitamin D adequacy, considering timely initiation of bisphosphonates or denosumab, and applying sequential therapy (anabolic followed by antiresorptive) in very-high-risk patients 24 , 25 ) . These strategies not only reduce refracture risk but also improve implant survival and recovery, thus linking surgical success with systemic osteoporosis management.

3. Fracture Liaison Services

FLS programs remain the most effective framework for secondary prevention, providing systematic patient identification, initiation of treatment, and follow-up 26 , 27 ) . However, orthopedic surgeons are the first and decisive actors as they recognize fragility fractures as sentinel events, initiate immediate bone health measures, and ensure referral to FLS. In some models, surgeons also collaborate directly within bone health clinics, bridging acute surgical care with long-term skeletal management.

ORTHOPEDIC CLINICAL IMPLICATIONS

Fragility fractures are sentinel events that expose underlying skeletal fragility, with hip, vertebral, and distal radius fractures being the most clinically relevant. Hip fractures often result in significant loss of function and independence, and a large proportion of patients require long-term support or institutional care 28 , 29 ) . Although frequently undiagnosed, vertebral fractures, contribute to chronic pain, progressive kyphosis, impaired pulmonary function, and reduced quality of life. They also strongly predict both vertebral and non-vertebral refractures 4 ) . Distal radius fractures, which usually occur about a decade earlier than hip or vertebral fractures, should also be regarded as early warning signs, as they increase the likelihood of subsequent major fractures 29 , 30 ) .

From an orthopedic perspective, fragility fractures should not be only considered surgical problems. They should be viewed as opportunities for secondary prevention. Incorporating FLS protocols into routine fracture care enables orthopedic surgeons to link surgical repair with long-term skeletal management, thereby reducing morbidity, risk of refracture, and healthcare costs.

TREATMENT AND MONITORING

1. Pharmacologic Therapy

Over the past three decades, pharmacologic management of osteoporosis has evolved significantly. Bisphosphonates remain the most widely prescribed first-line agents. Large randomized controlled trials have demonstrated that alendronate, risedronate, and zoledronic acid can reduce vertebral and hip fractures by up to 40%-50% 31 ) . These drugs act by binding to bone mineral and inhibiting osteoclast-mediated bone resorption. In low-to-moderate risk patients, continuous therapy for 3-5 years is generally sufficient. After this time period, a “drug holiday” may be considered to minimize rare adverse events such as atypical femoral fractures and osteonecrosis of the jaw. In high-risk patients, continued treatment is often necessary.

Denosumab, a monoclonal antibody targeting receptor activator of nuclear factor-κB ligand (RANKL), is a potent antiresorptive agent that has shown substantial reductions in vertebral, hip, and non-vertebral fractures 32 ) . Unlike bisphosphonates, its effects are rapidly reversible, and discontinuation can lead to rebound bone loss and multiple vertebral fractures. Therefore, transition therapy with an alternative antiresorptive, usually a bisphosphonate, is strongly recommended when discontinuing denosumab.

Teriparatide, recombinant human PTH (1-34), is the prototypical anabolic therapy. It stimulates osteoblastic activity, leading to rapid gains in both spine and hip BMD. Based on animal trial data, its use was formerly restricted to 24 months. However, teriparatide no longer carries this limitation following U.S. Food and Drug Administration label changes in 2020, allowing extended use in carefully selected patients 33 , 34 ) . Therefore, extended use may be considered in selected very-high-risk patients. Teriparatide remains particularly beneficial for individuals with severe osteoporosis or multiple fragility fractures.

Romosozumab is representative of a new therapeutic class which targets sclerostin to simultaneously stimulate bone formation and inhibit resorption 35 ) . Among high-risk women, clinical trials have demonstrated significant reductions in vertebral and clinical fractures. However, concerns about increased cardiovascular risk require careful patient selection, with particular avoidance of those individuals who have experienced recent myocardial infarction or stroke. Current approval limits its use to 12 months, after which sequential antiresorptive therapy is recommended to preserve the achieved gains in BMD and fracture risk reduction 35 , 36 ) .

Therapy selection in clinical practice should be individualized based on fracture risk, comorbidities, patient preference, and cost considerations. In high-risk populations, sequential strategies, such as initiating treatment with an anabolic agent followed by an antiresorptive to maintain gains, are increasingly recommended ( Table 2 ).

2. Non-pharmacologic Therapy

Non-pharmacologic interventions remain the cornerstone of comprehensive osteoporosis management. Adequate calcium intake (1,000-1,200 mg/day) and vitamin D supplementation (800-1,000 IU/day) are universally recommended to support bone mineralization 37 ) . Lifestyle modifications, including weight-bearing and resistance exercise, improve BMD as well as muscle strength, balance, and fall resistance. Fall prevention strategies, particularly in frail elderly populations, are equally critical. Interventions include home safety modifications (removing loose rugs, installing grab bars), vision correction, appropriate footwear, and, when necessary, walking aids 38 ) . Multidisciplinary fall-prevention programs have demonstrated reductions in fracture incidence and healthcare utilization.

3. Monitoring and Follow-up

Long-term monitoring is essential to confirm treatment efficacy and maintain adherence. DEXA scanning every 1-2 years is recommended, with interpretation based on the facility-specific LSC to separate true biological change from measurement variability 15 , 18 ) . BTMs such as P1NP and CTX provide earlier signals of therapeutic response, often within 3-6 months of treatment initiation 20 , 22 ) . Although their wider clinical use is limited by assay variability and lack of standardization, these markers can help assess adherence and early efficacy. The incorporation of structured monitoring alongside pharmacologic therapy, lifestyle optimization, and fall-prevention strategies ensures a comprehensive approach to osteoporosis management and improves long-term outcomes.

DISCUSSION

This review sought to integrate orthopedic perspectives into the diagnosis and management of osteoporosis, with particular attention to how DEXA interpretation and laboratory evaluation intersect in clinical practice. Several themes have emerged which highlight both the strengths and limitations of current approaches.

DEXA has become the global reference standard because it is widely available, reproducible, and supported by international guidelines 6 , 10 , 11 ) . However, DEXA interpretation extends beyond numerical thresholds. Body size, artifacts such as degenerative changes or vascular calcifications, and discrepancies between skeletal sites all introduce complexity 14 , 15 ) . As such, careful contextual reading of DEXA results is essential. Graphical bands enhance communication by visually illustrating whether a patient’s values fall within expected ranges. When values are below age-matched references, they often prompt investigation for secondary causes. In this manner, graphical outputs function as powerful tools for patient education and engagement as well as diagnostic aids 10 , 14 ) .

Longitudinal follow-up requires attention to precision. Without applying LSC thresholds, minor fluctuations in bone density may be overinterpreted, leading to inappropriate therapeutic adjustments. Determining center-specific precision errors and calculating LSC ensures that only meaningful biological changes are acted upon, thereby improving the reliability of monitoring 15 ) .

Laboratory evaluation provides another critical dimension of care. By starting with broad screening tests and moving toward targeted assessments when clinically indicated, a tiered algorithm improves diagnostic efficiency and helps differentiate primary from secondary osteoporosis 16 - 18 ) . BTMs further enrich this process by offering insight into treatment adherence and by signaling early therapeutic response, often months before changes appear on DEXA scans 19 , 20 ) . Despite these advantages, assay variability and lack of universal standardization continue to limit their routine adoption 20 ) .

From an orthopedic perspective, clinical implications are especially clear at the time of fracture. Rather than being treated as isolated injuries, fragility fractures are sentinel events that should trigger comprehensive evaluation. Hip, vertebral, and distal radius fractures each carry unique consequences. However, all point toward underlying skeletal fragility and future fracture risk 3 , 4 , 29 , 30 ) . FLS have emerged as an effective solution to bridge the gap between acute surgical repair and long-term bone health. FLS reduce refracture risk, improve survival, and increase adherence to therapy by systematically identifying fracture patients, ensuring bone health assessment, and initiating pharmacologic and non-pharmacologic interventions. Importantly, FLS also facilitate coordination between orthopedic surgeons and other specialists, allowing fracture care pathways to evolve into opportunities for secondary prevention 25 - 27 ) .

Looking ahead, the field is moving toward more goal-directed and sequential therapy, where treatment choices are aligned with fracture type, severity, and timing. Anabolic-first strategies in very-high-risk patients, followed by antiresorptive therapy to maintain gains, represent a paradigm shift that aligns with emerging consensus 34 ) . Systemically, scaling FLS models, refining population-specific reference data, and standardizing BTM use remain key priorities 20 - 22 ) . Personalized risk models that integrate clinical, biochemical, genetic, and imaging data may further advance precision care 34 , 39 ) .

CONCLUSION

Ultimately, osteoporosis management cannot be reduced to T-scores alone. Instead, a contextual and multidimensional approach is required in which imaging, laboratory testing, clinical risk assessment, and system-level coordination are integrated. For orthopedic surgeons, who are often first to encounter osteoporosis at the time of fracture, this approach provides a unique opportunity to link acute surgical management with long-term skeletal health, thereby reducing morbidity, preventing future fractures, and improving patient outcomes.

Footnotes

Funding

No funding to declare.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

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