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Bone Health and Osteoporosis

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How bone strength affects fractures, fixation and recovery — bone density, fragility fractures, and what helps keep bones strong (lifestyle, supplements and medications).

Updated Sep 202622 citations
Cross-section of trabecular bone showing its honeycomb internal structure.
Bone is living tissue; its internal honeycomb thins with age and osteoporosis, raising fracture risk. Kieran Hirpara 4.0

What it is

Illustration of spongy bone changing from normal to thinned to osteoporotic.
Inside a bone: the spongy 'honeycomb' thins and loses struts as bone density falls — the change osteoporosis describes. Servier Medical Art, CC BY-SA 3.0

Osteoporosis means your bones have lost density, so they are thinner and weaker than they should be. Think of healthy bone as a honeycomb with thick walls. With osteoporosis, those walls get thin and full of gaps. The bone is still there, but it breaks more easily, sometimes from a small fall or even a simple bump. A break like this is called a fragility fracture.

This condition is common after menopause, and it becomes more likely as you age. Some people find out they have it only after a fracture, because there is often a gap between the break happening and the diagnosis and treatment being sorted out [1]. That gap matters. Trials have shown that treating osteoporosis after a fragility fracture can cut the risk of another fracture by up to 50%, and lower mortality rates by up to 30% [2].

How it is thought to work: your body is always remodelling bone, breaking down old bone and building new bone. Osteoporosis develops when breakdown outpaces building. Some treatments slow the breakdown. Others, called anabolic treatments, push the building side instead, and one approach uses an anabolic treatment first, then switches to a treatment that slows breakdown [3]. Your bone density can be measured, and models using routine blood test markers can help predict your fracture risk [4].

A few other things are worth knowing. Each 1-unit increase in body mass index was associated with a 9% reduction in osteoporosis risk across nine studies [5]. Exercise helps too: resistance and impact exercise to strengthen bone, balance work to prevent falls, and spinal extension exercise for posture [6]. If you have osteoporosis and need shoulder surgery, it is not a barrier. Overall complication rates after keyhole rotator cuff repair were low, and osteoporosis should not be considered a reason to avoid that surgery [7].

Does it work?

Yes, but it depends on what you mean by "work". There is no single cure for osteoporosis. The goal is to make your bones stronger and lower your chance of breaking one. Some treatments do this well. Others are still being tested.

The strongest evidence is for medicines that slow bone loss or build new bone. One large trial found that a bone-building hormone injection helped broken bones heal faster, at 7.8 weeks compared with 12.6 weeks without it [1]. Other medicines, called bisphosphonates, work better than older nasal sprays at protecting your bones [2]. Exercise matters too. Resistance and impact exercise builds bone strength, balance work helps prevent falls, and spinal extension exercise can improve your posture and may lower your risk of a spine fracture [3].

Some other treatments have weaker evidence behind them. A few small trials suggest acupuncture may help with symptoms [4]. A traditional herbal capsule has shown some benefit for pain and bone density [5]. Stem cell therapy looks promising in animal studies, but it is not ready for people yet [6]. Researchers are also testing whether the timing of a daily injection matters, and whether new tools like hand X-rays and online calculators can spot bone loss earlier [7, 8, 9].

There are some honest gaps. Many people who break a hip are not offered bone medicine afterwards, even though guidelines say they should be [10]. And there is no perfect way to study this condition in a lab, so some questions remain open [11].

What does this mean for you? If you have osteoporosis, proven treatments exist. They can cut your risk of another fracture. Your doctor will talk you through which options suit you, and will be straight with you about where the evidence is thin.

What are the risks?

The main risk of osteoporosis itself is a fracture. Bones in the hip, spine and wrist break most easily when they are thin. If you break a bone and are not treated for osteoporosis afterwards, you can break another one. Studies show many people who fracture a hip are still not offered bone medicine, even though guidelines recommend it [1]. In one study of women admitted to hospital with fractures, 76.9% had osteoporosis [2]. Prolonged menopause, spine fractures and recent fractures marked the women at highest risk in that study [2].

Treatment risks depend on the treatment. Bisphosphonate tablets work better than older nasal sprays at protecting bone, so the nasal spray is generally kept for people who cannot take the first-line medicines [3]. Some newer options are still being studied. A trial is under way to work out the best timing for a daily bone-building injection [4]. Acupuncture and herbal capsules have some supporting evidence, but it is thinner than the evidence for standard medicines [5, 6]. Stem cell therapy has only been tested in animals so far, so its effects in people are unknown [7].

If you need surgery, there are a few specific points. Bone density measurements taken before an operation do not predict whether a broken bone will fail to heal, so that test has no clinical value for that purpose [8]. For people with thin bones having joint replacement, complication rates at 2 and 5 years were low and similar whether or not they took acid-reducing tablets around the time of surgery [9]. For a spine procedure that injects cement into a crushed vertebra, continuous cement and standard osteoporosis treatment were linked to good outcomes [10].

One more risk worth naming: online information about osteoporosis often fails basic quality standards [11]. Check where your facts come from, and bring your questions to your doctor.

Is it right for you?

Treatment is worth considering if you have been told you have osteoporosis, especially after a fracture. Women after menopause are the group most often affected. In one study of women admitted to hospital with fractures, most had osteoporosis, and the strongest warning signs were long-lasting menopause, a spine fracture or a recent fracture [1]. If any of these apply to you, it makes sense to ask about your bones.

Treatment may also suit you if you want to stay active and lower your chance of a fall. Alongside medicine, the key recommendations are resistance and impact exercise to strengthen bone, balance work to reduce falls, and spinal extension exercise for posture [2]. These are things you can start talking about with your doctor today.

Treatment is probably not for you if your bones are healthy and you have no fracture history or major risk factors. And if you already take bone medicine, this page is about whether to keep going, not whether to start.

Compared with doing nothing, treatment is the clear choice after a fracture. Compared with each other, the options differ in how they work: some slow bone loss, some build new bone, and some do both in sequence [3]. Your doctor can explain which fits you.

This should be a shared decision. Bring your questions, your fracture history and your list of medicines. Ask what your bone density shows and what it means for you. The right answer depends on your bones, your health and your goals, not on a single test result.

The bottom line

If you have been told you have osteoporosis, or you have broken a bone from a small fall, it is worth acting on. Treating thin bones after a fracture lowers your chance of breaking another one, and it can also lower your risk of dying early [1]. The realistic expectation is stronger bones and fewer fractures, not a cure. The most important caveat: many people who break a hip are never offered bone medicine afterwards, so you may need to raise it yourself [2].

Reviewed by Kieran Hirpara · 13 June 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

References
  1. The osteoporosis care gap in Canada. *BMC Musculoskeletal Disorders*. 2004. 10.1186/1471-2474-5-11
  2. Medical management of osteoporosis and the doctor's' role. *Injury*. 2016. 10.1016/s0020-1383(16)30014-6
  3. Effectiveness of anabolic and anti-resorptive agents for preventing postmenopausal osteoporosis fractures: a systematic review and network meta-analysis. *Journal of Orthopaedic Surgery and Research*. 2025. 10.1186/s13018-025-06040-3
  4. SuperLearner approach for predicting imminent risk of fracture in older Chinese patients with newly diagnosed osteoporosis based on their routine blood test markers. *BMC Musculoskeletal Disorders*. 2026. 10.1186/s12891-026-09768-z
  5. The association between body mass index and osteoporosis, with consideration of sex differences: a systematic review and dose-response meta-analysis. *BMC Musculoskeletal Disorders*. 2026. 10.1186/s12891-026-09675-3
  6. Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis. *British Journal of Sports Medicine*. 2022. 10.1136/bjsports-2021-104634
  7. Osteoporosis is a risk factor for complications and reoperations at 1 and 3 years after arthroscopic rotator cuff repair. *JSES International*. 2026. 10.1016/j.jseint.2026.101678
  8. Use of teriparatide in osteoporotic fracture patients. *Injury*. 2016. 10.1016/s0020-1383(16)30009-2
  9. Revisiting Intranasal Salmon Calcitonin: Historical Osteoporosis Evidence and a Potential Role in Acute Orthopaedic Pain Management. *JBJS Reviews*. 2026. 10.2106/jbjs.rvw.26.00021
  10. Efficacy of acupuncture for primary osteoporosis: a systematic review and meta-analysis of randomized controlled trials. *Journal of Orthopaedic Surgery and Research*. 2025. 10.1186/s13018-025-05513-9
  11. The effect of Jintiange capsules on pain in patients with primary osteoporosis: a systematic review and meta-analysis. *BMC Musculoskeletal Disorders*. 2025. 10.1186/s12891-025-08694-w
  12. Genetically modified stem cells for osteoporosis: a systematic review and meta-analysis of preclinical studies. *BMC Musculoskeletal Disorders*. 2025. 10.1186/s12891-025-08507-0
  13. Application of Machine Learning to Osteoporosis and Osteopenia Screening Using Hand Radiographs. *The Journal of Hand Surgery*. 2025. 10.1016/j.jhsa.2024.09.008
  14. A nomogram with online dynamic calculator for predicting osteoporosis: development and validation based on NHANES. *BMC Musculoskeletal Disorders*. 2026. 10.1186/s12891-026-09920-9
  15. Timing optimization of teriparatide dosing for postmenopausal osteoporosis: a randomized controlled trial. *Journal of Orthopaedic Surgery and Research*. 2025. 10.1186/s13018-025-06083-6
  16. A Missed Opportunity? Osteoporosis Treatment Following Femoral Neck Fractures: Reducing the Risk of Secondary Hip Fracture. *The Journal of Arthroplasty*. 2026. 10.1016/j.arth.2025.07.028
  17. Can we induce osteoporosis in animals comparable to the human situation?. *Injury*. 2016. 10.1016/s0020-1383(16)30002-x
  18. How prevalent is osteoporosis in a high-risk subgroup? A multicenter study of postmenopausal women hospitalized for fractures in China. *BMC Musculoskeletal Disorders*. 2026. 10.1186/s12891-026-09517-2
  19. A89 Osteoporosis is not a risk factor for the development of nonunion: a cohort nested case-control study. *Injury*. 2011. 10.1016/s0020-1383(11)70106-1
  20. Effects of Perioperative Proton Pump Inhibitor Use on Outcomes of Total Joint Arthroplasty Patients Who Have Osteoporosis and Osteopenia. *The Journal of Arthroplasty*. 2026. 10.1016/j.arth.2025.07.067
  21. Continuity and volume of bone cement and anti osteoporosis treatment were guarantee of good clinical outcomes for percutaneous vertebroplasty: a multicenter study. *BMC Musculoskeletal Disorders*. 2025. 10.1186/s12891-024-08153-y
  22. Mapping the quality of information on osteoporosis: a cross-sectional analysis of online health information. *BMC Musculoskeletal Disorders*. 2026. 10.1186/s12891-026-09711-2
Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

  • A bone density-based aging model approach may facilitate and support the development of precision medicine strategies in osteoporosis prevention and management [1].
  • Investigators must select an osteoporotic fracture model that best reflects the clinical problem being studied and the underlying pathophysiology of the osteoporosis in the target patient group [2].
  • Current online health information on osteoporosis often fails to meet basic standards of evidence-based health information, highlighting the urgent need to improve quality to support informed decision-making [3].
  • Each 1-unit increase in body mass index was associated with a 9% reduction in osteoporosis risk based on a dose-response analysis of nine studies [4].
  • Sequential anabolic-to-anti-resorptive therapy may inform treatment guidelines for high-risk postmenopausal populations [5].
  • There is no perfect model for osteoporosis, but a variety of models are appropriate for answering specific questions [6].
  • There is evidence of a care gap between the occurrence of a fragility fracture and the diagnosis and treatment of osteoporosis in Canada [7].
  • A nomogram with an online dynamic calculator could facilitate the early prediction, diagnosis, and treatment of osteoporosis, contributing to the bone health of the elderly population and promoting the development of public health [10].
  • Patients with osteoporosis may experience a higher incidence of medical complications within the 90-day global period than nonosteoporotic patients following rotator cuff repair [12].
  • Overall rates of complication were low and osteoporosis should not be considered a contraindication to arthroscopic rotator cuff repair [18].

How It Works

  • A randomized controlled trial on the timing optimization of teriparatide dosing is expected to provide insights into optimizing administration timing, potentially guiding personalized dosing strategies to enhance bone formation and reduce fracture risk in osteoporosis [8].
  • The book "Radiology of Osteoporosis" summarises the thoroughly researched topic of osteoporosis in a scientific approach [9].
  • Data showed no relationship between decreased bone mineral density and 2-year clinical outcomes following arthroscopic rotator cuff repair, despite previous literature showing the negative effect of osteoporosis on rotator cuff healing [11].
  • Recent research progress on natural traditional Chinese medicine products provides a theoretical and experimental basis for the development of new drugs and the improvement of osteoporosis management [13].
  • Current evidence suggests that the efficacy of acupuncture in improving the symptoms of primary osteoporosis is encouraging for its use in clinical practice as a physical intervention [14].
  • Macrophage polarization-related genes with potential causal roles in osteoporosis identified via multi-omics Mendelian randomization are exploratory and hypothesis-generating findings that require validation in bone marrow-specific and functional studies [21].
  • The gut microbiota–metabolite–bone network may be involved in the skeletal effects of leptin, providing novel mechanistic insights and potential therapeutic strategies for osteoporosis management [22].
  • MiR-137 promotes TLR4/NF-κB pathway activity through targeting KDM4A, which inhibits osteogenic differentiation of human bone marrow mesenchymal stem cells and aggravates osteoporosis [23].
  • There is some promising experimental and clinical evidence for possible enhancement of the bone repair process via administration of systemic agents [24].
  • In humans, de novo use of bisphosphonate therapy after fracture does not appear to have a significant effect on fracture healing [25].
  • Although bone quality may be diminished in the elderly, this does not influence the occurrence of nonunion [26].

What the Evidence Shows

Risk Factors and Prediction

  • Each 1-unit increase in BMI was associated with a 9% reduction in osteoporosis risk based on a dose–response analysis of nine studies [4].
  • A nomogram with an online dynamic calculator developed based on NHANES data could facilitate the early prediction, diagnosis, and treatment of osteoporosis [10].
  • A SuperLearner approach was successfully developed and validated as a fracture risk prediction model for patients newly diagnosed with osteoporosis based on routine blood test markers [29].
  • Mendelian randomization results show varying associations between diabetes and BMD across different sites and methods, with significant associations found for T2D on femoral neck and total body BMD, and HbA1c on heel BMD [30].
  • Machine learning application to hand radiographs represents a possible step toward more accessible, cost-effective, automated diagnosis and earlier treatment of osteoporosis/osteopenia [17].

Diagnosis and Information Quality

Treatment and Management

  • Randomized controlled trials have demonstrated that treatment of osteoporosis in patients with fragility fractures can reduce the risk of subsequent fractures by up to 50% and mortality rates by up to 30% [16].
  • A randomized controlled trial on teriparatide dosing timing is expected to provide insights into optimizing administration to enhance bone formation and reduce fracture risk in osteoporosis [8].
  • Intranasal salmon calcitonin is less effective than bisphosphonates and modern anabolic agents for increasing BMD and reducing fracture risk, and its use is best reserved for patients who cannot take first-line therapies due to contraindications, intolerance, or personal preference [19].
  • The current evidence suggests that the efficacy of acupuncture in improving the symptoms of primary osteoporosis is encouraging for its use in clinical practice as a physical intervention [14].
  • Natural traditional Chinese medicine products provide a theoretical and experimental basis for the development of new drugs and the improvement of osteoporosis management [13].
  • Key recommendations for people with osteoporosis include undertaking resistance and impact exercise to maximise bone strength, activities to improve strength and balance to reduce falls, and spinal extension exercise to improve posture and potentially reduce risk of falls and vertebral fractures [20].
  • Findings from a retrospective cross-sectional study on long-term hospitalized patients with muscular dystrophy may help inform strategies for osteoporotic treatment and nutritional care in this patient population [15].

Surgical Outcomes and Complications

  • Continuous bone cement and standardized treatment for osteoporosis were guarantees of good clinical outcomes for percutaneous vertebroplasty, and injected bone cement >5.5 ml might be a guarantee [28].
  • Patients who received PTH (1–84) injections accelerated radiographic and clinical fracture healing (7.8 weeks) when compared to patients who received no treatment (12.6 weeks) [27].

Research Models

Practical Considerations

Risk Factors and Screening

  • A bone density-based aging model approach may facilitate the development of precision medicine strategies in osteoporosis prevention and management [1].
  • Each 1-unit increase in body mass index is associated with a 9% reduction in osteoporosis risk [4].
  • Machine learning application to hand radiographs represents a possible step toward more accessible, cost-effective, automated diagnosis and earlier treatment of osteoporosis and osteopenia [17].

Treatment and Management

  • Treatment of osteoporosis in patients with fragility fractures can reduce the risk of subsequent fractures by up to 50% and mortality rates by up to 30% [16].
  • Intranasal salmon calcitonin is less effective than bisphosphonates and modern anabolic agents for increasing bone mineral density and reducing fracture risk [19].
  • The use of intranasal salmon calcitonin is best reserved for patients who cannot take first-line therapies due to contraindications, intolerance, or personal preference [19].
  • Optimizing teriparatide administration timing may guide personalized dosing strategies to enhance bone formation and reduce fracture risk in osteoporosis [8].
  • People with osteoporosis should undertake resistance and impact exercise to maximise bone strength [20].
  • People with osteoporosis should undertake activities to improve strength and balance to reduce falls [20].
  • People with osteoporosis should undertake spinal extension exercise to improve posture and potentially reduce risk of falls and vertebral fractures [20].

Surgical Outcomes and Complications

  • There is no relationship between decreased bone mineral density and 2-year clinical outcomes following arthroscopic rotator cuff repair [11].
  • Patients with osteoporosis may experience a higher incidence of medical complications within the 90-day global period than nonosteoporotic patients [12].
  • Osteoporosis should not be considered a contraindication to arthroscopic rotator cuff repair [18].

Research and Information Quality

  • Current online health information on osteoporosis often fails to meet basic standards of evidence-based health information [3].

Key Evidence

  • [L3] This approach may facilitate and support the development of precision medicine strategies in osteoporosis prevention and management. [1] (10.1186/s12891-025-09298-0)
  • [L5] Investigators must select a model that best reflects the clinical problem being studied, and the underlying pathophysiology of the osteoporosis in the target patient group. [2] (10.1016/s0020-1383(16)30004-3)
  • [Paper] Current OHI on osteoporosis often fails to meet basic standards of EBHI, highlighting the urgent need to improve the quality to support informed decision-making. [3] (10.1186/s12891-026-09711-2)
  • [L1] Based on our dose–response analysis of nine studies, each 1-unit increase in BMI was associated with a 9% reduction in osteoporosis risk. [4] (10.1186/s12891-026-09675-3)
  • [L1] This sequential anabolic-to-anti-resorptive therapy may inform treatment guidelines for high-risk postmenopausal populations. [5] (10.1186/s13018-025-06040-3)
  • [Paper] However, there is no perfect model for osteoporosis, but a variety of models appropriate for answering specific questions. [6] (10.1016/s0020-1383(16)30002-x)
  • [L4] There is evidence of a care gap between the occurrence of a fragility fracture and the diagnosis and treatment of osteoporosis in Canada. [7] (10.1186/1471-2474-5-11)
  • [L2] This trial is expected to provide crucial insights into optimizing teriparatide administration timing, potentially guiding personalized dosing strategies to enhance bone formation and reduce fracture risk in osteoporosis. [8] (10.1186/s13018-025-06083-6)
  • [Paper] The book summarises the thoroughly researched topic of osteoporosis in a scientific approach. [9] (10.1016/s0020-1383(03)00201-8)
  • [L3] Ultimately, this tool could facilitate the early prediction, diagnosis, and treatment of osteoporosis, thus contributing to the bone health of the elderly population and promoting the development of public health. [10] (10.1186/s12891-026-09920-9)
  • [L3] Despite previous literature showing the negative effect of osteoporosis on rotator cuff healing, our data showed no relationship between decreased bone mineral density and 2-year clinical outcomes following RCR. [11] (10.1016/j.jse.2025.02.011)
  • [L3] In addition, patients with osteoporosis may experience a higher incidence of medical complications within the 90-day global period than nonosteoporotic patient. [12] (10.1016/j.xrrt.2026.100723)
  • [L4] This paper summarises recent research progress on natural TCM products in preventing and treating osteoporosis and provides a theoretical and experimental basis for the development of new drugs and the improvement of osteoporosis management. [13] (10.1186/s13018-025-05879-w)
  • [L1] The current evidence suggests that the efficacy of acupuncture in improving the symptoms of primary osteoporosis is encouraging for its use in clinical practice as a physical intervention. [14] (10.1186/s13018-025-05513-9)
  • [L4] These findings may help inform strategies for osteoporotic treatment and nutritional care in this patient population. [15] (10.1186/s12891-026-10045-2)
  • [Paper] Randomized controlled trials have demonstrated that treatment of osteoporosis in patients with fragility fractures can reduce the risk of subsequent fractures by up to 50% and mortality rates by up to 30%. [16] (10.1016/s0020-1383(16)30014-6)
  • [L2] The findings represent a possible step toward more accessible, cost-effective, automated diagnosis and therefore earlier treatment of osteoporosis/osteopenia. [17] (10.1016/j.jhsa.2024.09.008)
  • [L3] Overall rates of complication were low and osteoporosis should not be considered a contraindication to arthroscopic RCR. [18] (10.1016/j.jseint.2026.101678)
  • [Paper] IN-CAL is less effective than bisphosphonates and modern anabolic agents for increasing BMD and reducing fracture risk; accordingly, its use is best reserved for patients who cannot take first-line therapies due to contraindications, intolerance, or personal preference. [19] (10.2106/jbjs.rvw.26.00021)
  • [L5] Key recommendations are that people with osteoporosis should undertake (1) resistance and impact exercise to maximise bone strength; (2) activities to improve strength and balance to reduce falls; (3) spinal extension exercise to improve posture and potentially reduce risk of falls and vertebral fractures. [20] (10.1136/bjsports-2021-104634)
  • [Paper] These findings are exploratory and hypothesis-generating and require validation in bone marrow-specific and functional studies. [21] (10.1186/s13018-026-06905-1)
  • [Paper] These findings suggest that the gut microbiota–metabolite–bone network may be involved in the skeletal effects of leptin, providing novel mechanistic insights and potential therapeutic strategies for osteoporosis management. [22] (10.1186/s12891-026-09950-3)
  • [Paper] This mechanism inhibits osteogenic differentiation of human bone marrow mesenchymal stem cells and aggravates osteoporosis. [23] (10.1186/s13018-023-03918-y)
  • [Paper] There is some promising experimental and clinical evidence for possible enhancement of the bone repair process via administration of systemic agents. [24] (10.1016/s0020-1383(16)30003-1)
  • [L4] In humans, de novo use of bisphosphonate therapy after fracture does not appear to have a significant effect on fracture healing. [25] (10.1016/s0020-1383(16)30015-8)
  • [L3] Although bone quality may be diminished in the elderly, this does not influence the occurrence of nonunion. [26] (10.1016/s0020-1383(11)70106-1)
  • [Paper] Patients who received the PTH (1–84) injections accelerated radiographic and clinical fracture healing (7.8 weeks) when compared to patients who received no treatment (12.6 weeks). [27] (10.1016/s0020-1383(16)30009-2)
  • [L3] Continuous bone cement and standardized treatment for osteoporosis were guarantees of good clinical outcomes for PVP, and injected bone cement >5.5 ml might be a guarantee. [28] (10.1186/s12891-024-08153-y)
  • [L3] We successfully developed and validated a fracture risk prediction model for patients newly diagnosed with osteoporosis. [29] (10.1186/s12891-026-09768-z)
  • [Paper] The results show varying associations across different BMD sites (femoral neck, lumbar spine, heel, total body) and methods (IVW, MR-Egger, Weighted median), with some significant associations found for T2D on femoral neck and total body BMD, and HbA1c on heel BMD. [30] (10.1186/s12891-024-07430-0)

References

[1] Unveiling risk factors and predicting osteoporosis through bone density based aging model: a community-based cohort in Guangdong, China. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09298-0

[2] Main differences in osteoporotic fracture models: which should I use?. Injury. 2016. DOI: 10.1016/s0020-1383(16)30004-3

[3] Mapping the quality of information on osteoporosis: a cross-sectional analysis of online health information. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09711-2

[4] The association between body mass index and osteoporosis, with consideration of sex differences: a systematic review and dose-response meta-analysis. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09675-3

[5] Effectiveness of anabolic and anti-resorptive agents for preventing postmenopausal osteoporosis fractures: a systematic review and network meta-analysis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06040-3

[6] Can we induce osteoporosis in animals comparable to the human situation?. Injury. 2016. DOI: 10.1016/s0020-1383(16)30002-x

[7] The osteoporosis care gap in Canada. BMC Musculoskeletal Disorders. 2004. DOI: 10.1186/1471-2474-5-11

[8] Timing optimization of teriparatide dosing for postmenopausal osteoporosis: a randomized controlled trial. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06083-6

[9] Radiology of Osteoporosis. Injury. 2004. DOI: 10.1016/s0020-1383(03)00201-8

[10] A nomogram with online dynamic calculator for predicting osteoporosis: development and validation based on NHANES. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09920-9

[11] No difference in 2-year outcomes of arthroscopic rotator cuff repair in patients with osteoporosis. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2025.02.011

[12] Impact of osteoporosis on post-operative outcomes following rotator cuff repair. JSES Reviews, Reports, and Techniques. 2026. DOI: 10.1016/j.xrrt.2026.100723

[13] Natural traditional Chinese medicine products: emerging therapeutic targets for the treatment of osteoporosis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05879-w

[14] Efficacy of acupuncture for primary osteoporosis: a systematic review and meta-analysis of randomized controlled trials. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05513-9

[15] Osteoporosis in long-term hospitalized patients with muscular dystrophy: a retrospective cross-sectional study. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-10045-2

[16] Medical management of osteoporosis and the surgeons' role. Injury. 2016. DOI: 10.1016/s0020-1383(16)30014-6

[17] Application of Machine Learning to Osteoporosis and Osteopenia Screening Using Hand Radiographs. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2024.09.008

[18] Osteoporosis is a risk factor for complications and reoperations at 1 and 3 years after arthroscopic rotator cuff repair. JSES International. 2026. DOI: 10.1016/j.jseint.2026.101678

[19] Revisiting Intranasal Salmon Calcitonin: Historical Osteoporosis Evidence and a Potential Role in Acute Orthopaedic Pain Management. JBJS Reviews. 2026. DOI: 10.2106/jbjs.rvw.26.00021

[20] Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis. British Journal of Sports Medicine. 2022. DOI: 10.1136/bjsports-2021-104634

[21] Macrophage polarization-related genes with potential causal roles in osteoporosis: a multi-omics Mendelian randomization study. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-026-06905-1

[22] Role and mechanism of leptin in improving osteoporosis via the “gut–bone axis”. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09950-3

[23] MiR-137 promotes TLR4/NF-κB pathway activity through targeting KDM4A, inhibits osteogenic differentiation of human bone marrow mesenchymal stem cells and aggravates osteoporosis. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03918-y

[24] Fracture repair: general aspects and influence of osteoporosis and anti-osteoporosis treatment. Injury. 2016. DOI: 10.1016/s0020-1383(16)30003-1

[25] How do bisphosphonates affect fracture healing?. Injury. 2016. DOI: 10.1016/s0020-1383(16)30015-8

[26] A89 Osteoporosis is not a risk factor for the development of nonunion: a cohort nested case-control study. Injury. 2011. DOI: 10.1016/s0020-1383(11)70106-1

[27] Use of teriparatide in osteoporotic fracture patients. Injury. 2016. DOI: 10.1016/s0020-1383(16)30009-2

[28] Continuity and volume of bone cement and anti osteoporosis treatment were guarantee of good clinical outcomes for percutaneous vertebroplasty: a multicenter study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-024-08153-y

[29] SuperLearner approach for predicting imminent risk of fracture in older Chinese patients with newly diagnosed osteoporosis based on their routine blood test markers. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09768-z

[30] Diabetes and osteoporosis: a two-sample mendelian randomization study. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07430-0

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Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.