Bone density, bone quality, and FRAX: changing concepts in osteoporosis management

Bone densitometry was originally developed to diagnose a high risk for fragility fractures in older postmenopausal women who may have primary osteoporosis. Its widespread availability, however, has led to its use in healthy peri- and premenopausal patients and the unexpected findings of low bone density in this group of patients. Their low bone density caused much uncertainty about the likelihood of fracture risk and what treatment might be needed. Conceptually, bone density reflected bone strength, and so a low density reflected increased fracture risk. Clinical experience and the results of pivotal studies of therapy for osteoporosis suggested that bone density was only partly responsible for skeletal strength. Many structural and material properties of bone, not measured by bone density, made it resist fracturing. Clinical risk factors helped determine these characteristics, albeit imperfectly, and aided clinicians decide whether and what treatment was needed. But now, new fracture risk assessment protocols (namely, FRAX, the WHO risk assessment tool) are available to help resolve this dilemma. This paper reviews some of the clinical observations that led to rethinking the concept bone density and bone strength and how it changes the clinical approach to therapy for the healthy young patient.