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Cascade fractures despite improvement of DXA results and trabecular bone score assessment

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The risk of osteoporotic fracture includes Bone Mineral Density (BMD) loss as well as micro-architecture damage as revealed by Trabecular Bone Score (TBS) and the risk of fall which does not have a specific medication but rather lifestyle interventions and adequate therapy of co-morbidities.
A 61-year woman (with menopause 13 years ago) had severe menopausal osteoporosis with cascade fractures despite specific anti-osteoporotic therapy between 2007 up to present (in association with vitamin D and calcium supplements). Although BMD improved during the years, she had the fracture on December 2014 so we performed a BMD and a TBS analysis for the last 2 years of therapy. In 2014 (before the latest fracture), she had the DXA results: L1-4 lumbar BMD of 0.841 g sqcm, T-score of -2.8 SD, Z-score of -1.9 SD; femoral neck BMD of 0.855 g sqcm, T-score of -1.3 SD, Z-score of -0.2 SD. In 2016, after 2 years of injectable bisphosphonate, DXA revealed: L1-4 BMD of 0.904 g sqcm, T-score of -2.3 SD, Z-score of -1.5 SD; total hip BMD of 0.836 g sqcm, T-score of -1.4 SD, Z-score of -0.6SD. TBS showed in 2014 a value of 1,093 with an improvement to 1,172 in 2016 after specific anti-osteoporotic therapy.
No additional causes of fragility fractures were found except for the risk of fall which seemed to matter in this particular situation. Further bone anabolic therapy with daily teriparatide in association with vitamin D and calcium was offered to the patient. The risk of fall is not prevented by the anti-osteoporotic specific medication while DXA – BMD and spine TBS are improved thus a new fragility fracture may be registered.

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