Today’s current technology for diagnosing osteoporosis only measures bone density, which is only half of the World Health Organization's definition of osteoporosis. The full definition includes bone mineral density (BMD) and microarchitecture - trabecular bone score (TBS).

1. USE OF TRABECULAR
BONE SCORE (TBS), AN
INDEX OF BONE QUALITY,
IN DAILY CLINICAL
PRACTICE
Today & Tomorrow
Structure matters
Lynn Kohlmeier, MD
Spokane Osteoporosis and Endocrinology, Director
Strong Start DXA BMD and TBS Reports
West Coast Strides For Strong Bones, Spokane CME TeleECHO,
Medical Director
Nonprofit Strides For Strong Bones, Director
HypoPara Association Medical Advisory Board, Chief

2. DID YOU KNOW?
 Osteoporotic Fractures Are Very Common! 1 fracture occurs every
3s worldwide! ~1 in 2 US women over age of 50 will break a bone!
 Estimated cost/fracture is $14,000 or ~ $124B /year worldwide
 Osteoporosis is Underdiagnosed and Undertreated! 70% of
patients at risk for osteoporosis have not had a bone density test
and have not been referred to a bone expert
 40-50% of osteoporotic fractures occur in patients that do not
meet criteria for osteoporosis by T-score
 Osteoporosis medical treatment can reduce fracture risk by 40-
70%, improving Quality of Life and Independence!
 Mortality 1 year after a hip fracture is 20 to 40%, with higher rates
in men than in women
National Osteoporosis Foundation. https://www.nof.org/patients/what-is-osteoporosis. Accessed
January 5, 2021. https://josr-online.biomedcentral.com/articles/10.1186/s13018-019-1226-6

3. OSTEOPOROSIS
IS…
Systemic skeletal disease characterised by low
bone mass and a micro-architectural
deterioration of bone tissue…leading to fracture
normal osteoporotic
Historically, we have not had a clinical tool to speak to
bone architecture
Severe osteoporosis

4. BONE MINERAL
DENSITY (BMD): is
the Gold Standard
FRACTURE RISK
INCREASES with
Decreasing BMD
BUT…
there’s MORE to
Fracture Risk than just
BMD!
Fracture
rate
for
1000
people
per
year
Number
of
fractured
women
1.0 0.5 0.0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -3.5
Fracture rate
Number of fractured women
0
10
20
30
40
50
0
100
200
300
400
Normal / Osteopenic Zone
?
Bone Structure
BMD 1 BMD 2
=
Source: Siris et al. Arch Intern Med. 2004; 164:1108-1112 – The NORA cohort
BMD T-score (-2.5 or less is used to diagnose osteoporosis)

5. MEDIMAPS
GROUP IS..
….. Software as a Medical Device
(SaMD) company developing and selling
bone micro-architecture software
analytics solutions with artificial
intelligence (AI) capabilities.
Main technology framework is known as
“Trabecular Bone Score” (TBS).

6. Trabecular Bone Score
A higher TBS correlates with better bone architecture
A lower TBS with worse bone architecture

7. TBS IS PROCESSED
FROM DXA SCAN
2. BMD spine analysis 3. Software Processing 10s 4. TBS Analysis & Report fully
automatic
Seamlessly integrated into your workflow!

8. TBS: EXTENSIVE
CLINICAL VALIDATION
More than 1000 publications
and 25+ guidelines
 TBS is strongly correlated to 3D bone microarchitecture
independent of bone mineral density (BMD)
 TBS predicts fracture independent of BMD, clinical risk
factors, and FRAX®
 TBS helps fine tune assessment of fracture risk and
medical treatment decisions in men and women
 Secondary Osteoporosis such as Diabetes, Steroid or Glucocorticoid
Use, Primary Hyperparathyroidism...
 Osteopenia or Low Bone Density
 Osteoarthritis (BMD can be inaccurate due to arthritis/osteophytes)
 FRAX score close to intervention thresholds
ISCD /
BHOF
ESCEO /
IOF
FRAX®
SVGO,
DVO, GRIO
European Society for Clinical and Econiomic Aspects of Osteoorosis and Osteoarthritis (ESCEO), International
Osteoporosis Foundation (IOF), Fracture Risk Assessment Tool (FRAX®), Bone Health Osteoporosis Foundation (BHOF)
/ International Society for Clinical. Densitometry (ISCD), Swiss Association against Osteoporosis (SVGO), Head
Osteology Organization of Germany (DVO), Osteoporosis Research and Inforrmation Group (GRIO)

9. FRACTURE
PREDICTION
TBS Provides Fracture Risk Information
Independent of BMD & Clinical Risk
Factors
• 33,352 women, Manitoba
• 40-100 yrs, mean 63 yrs
• Mean FU 4.7 yrs
• Adjusted for FRAX clinical risk factors
Adapted from Hans et al., JBMR 2011; Leslie et al., OI 2014
TBS and BMD are Complementary!

10. TBS & FRAX
Adapted from WD. Leslie et al. Osteoporos Int. 2014 Jun 21 - McCloskey EV, et. al, Calcif Tissue Int, 2015: 96; 500-509
TBS and FRAX are Complementary
TBS Results Are Used to Adjust FRAX

11. SECONDARY
CAUSES OF
BONE LOSS AND
OSTEOPOROSIS
TBS
Bone Health Optimization
Pre-operative
Peri-operative
Post-operative
… Let’s Turn the Wheel!
*Rare Bone Disease: HPP, Hypophosphatasia; XLH, X-Linked Hypophosphatemia; OI, Osteogenesis Imperfecta

12. DIABETES AND
OSTEOPOROSIS:
TBS IS IMPORTANT
FOR THE ASSESSMENT
OF FRACTURE RISK IN
PATIENTS WITH
DIABETES!
Association Between TBS and Diabetes
Diabetes vs Non-diabetes
 Type II Diabetics in general
had a lower TBS than Non-
diabetics
 In fact, patients with
Prediabetes had a
significantly lower TBS
than normal subjects
 In addition, TBS appears
to be related to glycemic
control in diabetic patients
Ho-Pham & Nguyen, Osteoporosis Int. 2019 & IOF/ESCEO position paper on diabetes
TBS adjusted FRAX improves assessment of fracture risk
in patients with Diabetes, especially for women!

13. Fracture Risk Based on BMD and TBS
HOW DO WE
IMPLIMENT TBS
INTO CLINICAL
PRACTICE?
FRACTURE RISK
TBS SCORE RESULTS REFERENCE RANGE:
> 1.310 Good or Normal bone quality or microarchitecture
> 1.230 and < 1.310 Moderate or partially deteriorated bone quality or
microarchitecture
< 1.230 Poor or degraded bone quality or microarchitecture
Normal for age?
Secondary Cause for Bone Loss?
Undiagnosed Fracture?
Prevalent Fracture?

14. SHOULD WE TREAT?
If a patient has low bone density or
osteopenia AND a FRACTURE
(MOF) they should be treated,
irrespective of TBS & FRAX values
!
1. FRAX adjusted by TBS
2. BMD T-score adjusted for TBS

15. ALL IN ONE REPORT
Fully automated
conclusions for easy
reporting

Seamlessly integrated into workflow in 10 seconds!

16. TBS IS REIMBURSED
SINCE JANUARY 22
Independent CPT codes
(category I)

$ 86.88
$ 86,88
$ 40
$ 2,64
$ 27,77
$ 9,59
1,21
0,29
0,84
0,08
To COMPLETE SLIDE…

17. Patient Journey
throughout our
product lines
Prognostic rather than diagnostic
70%
of patients
not diagnosed
timely
50%
of DXA patients
incompletely
diagnosed
30%
of implant
revisions due
to loosening &
instability
Mrs. Jones
Mrs. Jones
TBS
AI
TBS AI X-ray TBS Osteo DXA (Today)
TBS Ortho
Mrs. Jones had an X-ray of her knee
because of pain and difficulty to
walk. She felt young (63) so don’t
feel concerned by osteoporosis yet.
Mrs. Jones has a DXA performed to
diagnose osteoporosis (today due to
age and risk factors…, in the future,
also when referred from Osteo X-ray)
Mrs. Jones elects to have
a knee replacement

18. BMD ALONE
OR
BMD + TBS?
To conclude…
Which DXA do you
want? The one with
only BMD or the
blue one with both
BMD & TBS

19. Even if you do not see it sometime…
…structure really matters…
Booth #3955 South Hall – Level 3
contact@medimapsgroup.com
Lynn Kohlmeier, MD