This study examined the relationship between trabecular bone score (TBS) and prevalent and incident vertebral fractures in elderly women. TBS was significantly associated with an increased risk of both prevalent and incident vertebral fractures, independent of bone mineral density measured by dual-energy X-ray absorptiometry. Combining TBS and BMD measurements slightly improved the prediction of fracture risk compared to BMD alone. The study suggests TBS provides additional information on bone quality and fracture risk beyond BMD.

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Prediction of vertebral fracture by Trabecular Bone
Score in elderly women of The Rotterdam Study
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Atanasovska Biljana
Department of Internal Medicine, Erasmus MC
Rotterdam, The Netherlands
Osteoporosedag der Hoge Landen
November 30th 2013

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Authors
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Biljana Atanasovska, MSc1,2, Ling Oei, MD, MSc, MA1,2,3, Carolina Medina-Gomez,
MSc1,2,3, Natalia Campos Obando, MD, MSc1,2,3, Karol Estrada, PhD1,2,3,4, Albert
Hofman, MD, PhD2,3, Berengere Aubry-rozier, MD5, M. Carola Zillikens, MD, PhD1,3,
André G. Uitterlinden, PhD1,2,3, Edwin H.G. Oei, MD, PhD6, Didier Hans, MBA, PhD5,
Fernando Rivadeneira, MD, PhD1,2,3,.
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1Department
of Internal Medicine Erasmus MC Rotterdam, the Netherlands.
2Department
of Epidemiology Erasmus MC Rotterdam, the Netherlands.
3Netherlands
Genomics Initiative (NGI)-sponsored Netherlands Consortium for Healthy Aging
(NCHA), the Netherlands.
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4Analytical
& Translational Genetics Unit, Massachusetts General Hospital, USA.
5Lausanne
University Hospital, Switzerland.
6Department
of Radiology Erasmus MC Rotterdam, the Netherlands.
Disclosures:
Didier Hans has a co-ownership of the TBS patent
The other co-authors have nothing to declare

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BMD measured by DXA is an imperfect predictor of fracture
risk, therefore, additional assessments are desirable
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Dual-energy X-ray absorptiometry (DXA) is commonly used to diagnose
osteoporosis, providing accurate estimates of bone mass through the
evaluation of bone mineral density (BMD)
BMD is not always an accurate predictor of fracture; it is an assessment of
the quantity of bone but does not provide information on bone quality
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Further, > 50% of fractures occur above the “osteoprosis” BMD threshold
Evaluating other bone parameters, such as bone microarchitecture, could
significantly enhance the assessment of bone strength and fracture risk

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§ The trabecular bone score (TBS) is a measure of bone texture;
correlates with 3D parameters of bone microarchitecture and a marker
for the risk of oteoporosis
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§ TBS strongly correlated with the number and connectivity of trabeculae,
while it is negatively correlated with the space between trabeculae
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TBS ≤1.2 defines degraded microarchitecture
TBS 1.20 - 1.35 is partially degraded microarchitecture
TBS ≥1.35 is considered normal
After calibration

6. § Trabecular bone score measurement
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- Identifying a method that differentiates these 2 types of structures will obtain a
way to describe a 3-dimensional (3D) structures
Hans at al., Journal of Clinical Densitometry 2011
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7. Aim of this study
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examine the relation of trabecular bone score (TBS) with vertebral
fracture in a population-based setting for:
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§ 1) prevalent vertebral fractures assessed on radiographs (X-rays)
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§ 2) incident clinical vertebral fractures (general practioner+hospital)

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Study population
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§ Rotterdam Study cohorts (RS-I, RS-II and RS-III)
§ N = 2760 women with DXA scans
§ DXA scans (GE-Lunar Prodigy; Madison, WI), LS-BMD and TBS measurement
(TBS iNsight software – not calibrated) available in:
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§ RS-I during the third follow-up
§ RS-II during the first follow-up
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§ RS-III during the baseline visit
§ Women with BMI>35g/cm2 excluded

9. Study population
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Clinical fracture follow-up
TBS
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X-ray
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10. § RS-I and RS-II (combined n=1484, 21 cases)
§ HR from Cox-regression*
§ Radiographic vertebral fractures were available for :
§ RS-I-3 (McCloskey-Kanis; n=845, 53 cases)
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§ RS-III-1 (Optasia quantitative morphometry; n=1272, 221 cases)
§ OR from Logistic- regression*
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§ Incident clinical vertebral fractures occurring during follow-up:
§ * Models corrected for age, height and weight

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Results
Population characteristics
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- Both TBS and BMD mean levels are significantly lower in fracture cases than noncases (P<0.05)
- Correlation between TBS and LS-BMD was low (Pearson rho 0.25-0.30) across
studies (P<0.001)

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§ Lower TBS scores were associated with increased risk
for prevalent and incident clinical vertebral fractures
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§ Radiographic prevalent vertebral fractures were associated with increased risk
per SD decrease in TBS score:
§ RS-I
OR 1.71 95%CI [1.29-2.27]; P=0.0002
§ RS-III
OR 1.27 95%CI [1.08-1.48]; P=0.004
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§ Combined analysis of incident clinical vertebral fractures was suggestive of
increased risk per SD decrease in TBS score:
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§ RS-I+RS-II
HR 1.48 95%CI [0.96-2.29]; P=0.08
§ Additional adjustment for lumbar spine BMD did NOT affect the risk estimates nor
the interaction TBS x BMD

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TBS and LS-BMD together predict slightly better than LS-BMD alone
Prevalent vertebral fractures
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AUC
LS-­‐BMD
0.685
TBS
LS-­‐BMD+TBS
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Incident vertebral fractures
__ Reference
__ Age, wgt, hgt
__ + BMD
__ + TBS
__ + BMD & TBS
CI
AUC
CI
0.655-­‐0.716
LS-­‐BMD
0.664
0.560-­‐0.767
0.686
0.655-­‐0.717
TBS
0.692
0.584-­‐0.800
0.701
0.670-­‐0.732
LS-­‐BMD+TBS
0.693
0.585-­‐0.801

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Conclusions
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§ Trabecular bone score (TBS) is strongly & significantly associated with 1.3
to 1.7 increased risk for prevalent vertebral fractures per SD decrease
§ Each SD decrease in TBS is also associated (borderline significant) with
1.5 increased risk for clinical incident vertebral fractures
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§ TBS associations with vertebral fractures are independent of DXA-based
lumbar spine BMD and their combination slightly improves risk prediction
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§ Subsequent studies with larger sample sizes are currently underway

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Acknowledgments
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Anis Abuseiris
Jolande Verkroost Frank van Rooij
Marijn Verkerk
Nano Suwarno
Edward Peters
Joost Verburg
Jan Heeringa
René Vermeeren
Mart Rentmeester Hans Bowier
Hannie van den Boogert
Mette Offerhaus
Florian Buisman
Bart Hazemeijer
Lisanne van de Koevering
Nuray Çakici
Nienke Bart
Rodinde Bloot
Hanna Ning
Maarten Meijer
Khadija Moumni
Sander Verkade
Sebastian Valk Bonila
Nadia Rbia
Maria Tihaya
Burak Kalin
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Eugene McCloskey, Sheffield University, UK
TBS inSIGHT:
Research and Development section, Nuclear Medicine Division,
University of Geneva.
Optasia:
SpineAnalyzer® software
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