Skip to content

Clinicians › General-Health

Bone Health and Osteoporosis

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

38 citationsUpdated Sep 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Osteoporosis management is increasingly supported by precision medicine strategies, including bone density-based aging models [1] and machine learning applications to hand radiographs for accessible, automated diagnosis [12]. Clinical decision-making is further enhanced by validated fracture risk prediction models using routine blood markers [14] and nomograms with online dynamic calculators for early prediction and treatment [15]. While current online health information often fails to meet basic evidence-based standards [4], rigorous scientific resources such as "Radiology of Osteoporosis" provide thorough summaries of the condition [7].

The clinical imperative for treatment is underscored by randomized controlled trials demonstrating that osteoporosis therapy in patients with fragility fractures reduces subsequent fracture risk by up to 50% and mortality rates by up to 30% [11]. Despite these benefits, a significant care gap persists between fragility fracture occurrence and osteoporosis diagnosis and treatment in Canada [2], with low rates of pharmacotherapy observed in patients with femoral neck fractures despite established guidelines [19]. Sequential anabolic-to-anti-resorptive therapy may inform treatment guidelines for high-risk postmenopausal populations [6], while acupuncture shows encouraging efficacy as a physical intervention for primary osteoporosis symptoms [8].

Surgical outcomes in osteoporotic patients remain favorable, with decreased bone mineral density not contraindicating arthroscopic rotator cuff repair, where overall complication rates are low [22] and excellent 2-year outcomes are achievable [16]. However, osteoporotic patients may experience a higher incidence of medical complications within the 90-day global period compared to nonosteoporotic patients [21]. Each 1-unit increase in body mass index is associated with a 9% reduction in osteoporosis risk [5]. Research models must reflect the specific clinical problem and pathophysiology of the target patient group [3], as no perfect model exists, though various models are appropriate for specific questions [10]. Intranasal salmon calcitonin is less effective than bisphosphonates and modern anabolic agents for increasing bone mineral density and reducing fracture risk [13], and its use is best reserved for patients who cannot take first-line therapies due to contraindications, intolerance, or personal preference [13]. Findings from long-term hospitalized patients with muscular dystrophy may inform osteoporotic treatment and nutritional care strategies [9]. The standard Fragility Index (FI) for dichotomous data and the Continuous Fragility Index (CFI) for continuous outcomes should be used complementarily to provide distinct valuable insights [37].

How It Works

Risk Prediction and Screening

A dose–response analysis of nine studies demonstrates that each 1-unit increase in BMI is associated with a 9% reduction in osteoporosis risk [5]. For patients newly diagnosed with osteoporosis, a fracture risk prediction model developed and validated using routine blood test markers offers a practical screening tool [14]. Additionally, a nomogram with an online dynamic calculator facilitates the early prediction, diagnosis, and treatment of the condition [15]. Current machine learning-based prediction models for postmenopausal osteoporosis without fractures demonstrate good discriminative ability; however, these models are generally characterized by a high risk of bias, a notable lack of calibration performance evaluation, and insufficient validation of clinical utility [18].

Pathophysiology and Mechanisms

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 [23]. At the cellular level, 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 [31]. Obesity-associated dyslipidemia drives BMD loss partly through inflammation-mediated pathways, with key inflammatory cytokines significantly mediating lipid metabolism's impact on bone health [32]. Macrophage polarization-related genes with potential causal roles in osteoporosis represent exploratory and hypothesis-generating findings that require validation in bone marrow-specific and functional studies [30].

Treatment and Management

Pharmacologic Therapy: Intranasal salmon calcitonin is less effective than bisphosphonates and modern anabolic agents for increasing BMD and reducing fracture risk; its use is best reserved for patients who cannot take first-line therapies due to contraindications, intolerance, or personal preference [13]. A randomized controlled trial on timing optimization of teriparatide dosing is expected to provide crucial insights into optimizing teriparatide administration timing, potentially guiding personalized dosing strategies to enhance bone formation and reduce fracture risk [17].

Alternative and Complementary Interventions: The efficacy of acupuncture in improving the symptoms of primary osteoporosis is encouraging for its use in clinical practice as a physical intervention [8]. Natural traditional Chinese medicine products provide a theoretical and experimental basis for the development of new drugs and the improvement of osteoporosis management [24].

Exercise Recommendations: Key recommendations for people with osteoporosis are to undertake (1) resistance and impact exercise to maximise bone strength; (2) activities to improve strength and balance to reduce falls; and (3) spinal extension exercise to improve posture and potentially reduce risk of falls and vertebral fractures [20].

Fracture Healing and Surgical Outcomes

There is some promising experimental and clinical evidence for possible enhancement of the bone repair process via administration of systemic agents [25]. In humans, de novo use of bisphosphonate therapy after fracture does not appear to have a significant effect on fracture healing [27]. Conversely, 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) [28]. The use of BMD measurements preoperatively to identify osteoporosis as a possible risk factor of nonunion has no clinical value [26].

Care Gaps and Information Quality

Current online health information on osteoporosis often fails to meet basic standards of evidence-based health information, highlighting the urgent need to improve the quality to support informed decision-making [4].

What the Evidence Shows

Risk Factors and Prediction

A nomogram with an online dynamic calculator facilitates the early prediction, diagnosis, and treatment of osteoporosis [15]. Mendelian randomization results indicate varying associations between diabetes and osteoporosis across different BMD sites and methods. Significant associations were found for type 2 diabetes on femoral neck and total body BMD, and for HbA1c on heel BMD [38].

Diagnosis and Screening

Application of machine learning to hand radiographs represents a possible step toward more accessible, cost-effective, automated diagnosis and therefore earlier treatment of osteoporosis or osteopenia [12].

Treatment and Management

Intranasal salmon calcitonin is less effective than bisphosphonates and modern anabolic agents for increasing bone mineral density and reducing fracture risk; its use is best reserved for patients who cannot take first-line therapies due to contraindications, intolerance, or personal preference [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 [8]. Jintiange capsules are a good choice for patients with osteoporosis in terms of relieving pain, improving bone mineral density, improving activity function, improving gait, and preventing fracture [34]. Genetically modified stem cell therapy is a safe and effective method that can significantly improve bone mineral density and bone volume fraction in animal models of osteoporosis [36].

Key recommendations for people with osteoporosis include: * Resistance and impact exercise to maximise bone strength. * Activities to improve strength and balance to reduce falls. * Spinal extension exercise to improve posture and potentially reduce risk of falls and vertebral fractures [20].

A randomized controlled trial on the timing optimization of teriparatide dosing is expected to provide crucial insights into optimizing administration timing, potentially guiding personalized dosing strategies to enhance bone formation and reduce fracture risk in osteoporosis [17].

Surgical Outcomes and Complications

Overall rates of complication were low after arthroscopic rotator cuff repair, and osteoporosis should not be considered a contraindication to the procedure [22]. In osteopenic and osteoporotic patients undergoing total joint arthroplasty, rates of 2- and 5-year postoperative complications were low and similar among patients who used proton pump inhibitors perioperatively and those who did not [29]. Continuous bone cement and standardized treatment for osteoporosis were guarantees of good clinical outcomes for percutaneous vertebroplasty, and injected bone cement greater than 5.5 ml might be a guarantee [33].

Fracture Healing and Models

Patients who received parathyroid hormone (1–84) injections accelerated radiographic and clinical fracture healing at 7.8 weeks when compared to patients who received no treatment at 12.6 weeks [28]. There is no perfect model for osteoporosis, but a variety of models appropriate for answering specific questions exist [10].

Care Gaps and Special Populations

Despite established guidelines, low rates of osteoporotic pharmacotherapy were seen in patients who had femoral neck fractures [19]. Findings regarding osteoporosis in long-term hospitalized patients with muscular dystrophy may help inform strategies for osteoporotic treatment and nutritional care in this patient population [9].

Practical Considerations

Risk Prediction and Screening

A bone density-based aging model approach may facilitate the development of precision medicine strategies in osteoporosis prevention and management [1]. Current machine learning-based prediction models for postmenopausal osteoporosis without fractures demonstrate good discriminative ability but are characterized by a high risk of bias, a lack of calibration performance evaluation, and insufficient validation of clinical utility [18]. Machine learning application to hand radiographs represents a possible step toward more accessible, cost-effective, automated diagnosis and earlier treatment of osteoporosis or osteopenia [12].

Diagnosis and Care Gaps

Low rates of osteoporotic pharmacotherapy were observed in patients who had femoral neck fractures despite established guidelines [19]. In China, the prevalence of osteoporosis among postmenopausal women hospitalized for fractures was 76.9% [35]. Prolonged menopause, vertebral fractures, and recent fracture history were identified as key risk profiles in this population [35]. Current online health information on osteoporosis often fails to meet basic standards of evidence-based health information [4].

Pharmacological 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% [11]. Randomized controlled trials are expected to provide insights into optimizing teriparatide administration timing to enhance bone formation and reduce fracture risk [17].

Non-Pharmacological and Adjunctive Interventions

Key recommendations for people with osteoporosis include: * Resistance and impact exercise: To maximize bone strength [20]. * Strength and balance activities: To reduce falls [20]. * Spinal extension exercise: To improve posture and potentially reduce the risk of falls and vertebral fractures [20].

Surgical and Perioperative Considerations

The use of preoperative bone mineral density measurements to identify osteoporosis as a possible risk factor for nonunion has no clinical value [26].

Special Populations and Research Models

Investigators must select an animal model that best reflects the clinical problem being studied and the underlying pathophysiology of the osteoporosis in the target patient group [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)
  • [L4] There is evidence of a care gap between the occurrence of a fragility fracture and the diagnosis and treatment of osteoporosis in Canada. [2] (10.1186/1471-2474-5-11)
  • [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. [3] (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. [4] (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. [5] (10.1186/s12891-026-09675-3)
  • [L1] This sequential anabolic-to-anti-resorptive therapy may inform treatment guidelines for high-risk postmenopausal populations. [6] (10.1186/s13018-025-06040-3)
  • [Paper] The book summarises the thoroughly researched topic of osteoporosis in a scientific approach. [7] (10.1016/s0020-1383(03)00201-8)
  • [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. [8] (10.1186/s13018-025-05513-9)
  • [L4] These findings may help inform strategies for osteoporotic treatment and nutritional care in this patient population. [9] (10.1186/s12891-026-10045-2)
  • [Paper] However, there is no perfect model for osteoporosis, but a variety of models appropriate for answering specific questions. [10] (10.1016/s0020-1383(16)30002-x)
  • [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%. [11] (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. [12] (10.1016/j.jhsa.2024.09.008)
  • [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. [13] (10.2106/jbjs.rvw.26.00021)
  • [L3] We successfully developed and validated a fracture risk prediction model for patients newly diagnosed with osteoporosis. [14] (10.1186/s12891-026-09768-z)
  • [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. [15] (10.1186/s12891-026-09920-9)
  • [L3] Patients with decreased bone mineral density can still achieve excellent 2-year outcomes. [16] (10.1016/j.jse.2025.02.011)
  • [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. [17] (10.1186/s13018-025-06083-6)
  • [L1] Current machine learning-based prediction models for postmenopausal osteoporosis without fractures demonstrate good discriminative ability but are generally characterized by a high risk of bias, a notable lack of calibration performance evaluation, and insufficient validation of clinical utility. [18] (10.1186/s12891-025-09385-2)
  • [L3] Despite established guidelines, low rates of osteoporotic pharmacotherapy were seen in patients who had femoral neck fractures. [19] (10.1016/j.arth.2025.07.028)
  • [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)
  • [L3] In addition, patients with osteoporosis may experience a higher incidence of medical complications within the 90-day global period than nonosteoporotic patient. [21] (10.1016/j.xrrt.2026.100723)
  • [L3] Overall rates of complication were low and osteoporosis should not be considered a contraindication to arthroscopic RCR. [22] (10.1016/j.jseint.2026.101678)
  • [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. [23] (10.1186/s12891-026-09950-3)
  • [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. [24] (10.1186/s13018-025-05879-w)
  • [Paper] There is some promising experimental and clinical evidence for possible enhancement of the bone repair process via administration of systemic agents. [25] (10.1016/s0020-1383(16)30003-1)
  • [L3] These results indicate that the use of BMD measurements preoperatively to identify osteoporosis as a possible risk factor of nonunion has no clinical value. [26] (10.1016/s0020-1383(11)70106-1)
  • [L4] In humans, de novo use of bisphosphonate therapy after fracture does not appear to have a significant effect on fracture healing. [27] (10.1016/s0020-1383(16)30015-8)
  • [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). [28] (10.1016/s0020-1383(16)30009-2)
  • [L3] In osteopenic and osteoporotic patients undergoing TJA, rates of 2- and 5-year postoperative complications were low and similar among patients who used PPIs perioperatively and those who did not. [29] (10.1016/j.arth.2025.07.067)
  • [Paper] These findings are exploratory and hypothesis-generating and require validation in bone marrow-specific and functional studies. [30] (10.1186/s13018-026-06905-1)
  • [Paper] This mechanism inhibits osteogenic differentiation of human bone marrow mesenchymal stem cells and aggravates osteoporosis. [31] (10.1186/s13018-023-03918-y)
  • [L4] Obesity-associated dyslipidemia drives BMD loss partly through inflammation-mediated pathways, with key inflammatory cytokines significantly mediating lipid metabolism's impact on bone health. [32] (10.1186/s12891-026-09576-5)
  • [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. [33] (10.1186/s12891-024-08153-y)
  • [L1] In terms of relieving pain, improving BMD, improving activity function, and improving gait and preventing fracture, JTG is a good choice for patients with osteoporosis (OP). [34] (10.1186/s12891-025-08694-w)
  • [L4] This study reveals an alarmingly high prevalence (76.9%) of osteoporosis among postmenopausal women hospitalized for fractures in China, identifying prolonged menopause, vertebral fractures, and recent fracture history as key risk profiles. [35] (10.1186/s12891-026-09517-2)
  • [L1] Genetically modified stem cell therapy is a safe and effective method that can significantly improve the BMD and BV/TV in animal models of osteoporosis. [36] (10.1186/s12891-025-08507-0)
  • [Paper] We advocate for the complementary use of both the standard Fragility Index (FI) for dichotomous data and the Continuous Fragility Index (CFI) for continuous outcomes, recognizing the distinct valuable insights each metric offers. [37] (10.1177/23259671251409149)
  • [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. [38] (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] The osteoporosis care gap in Canada. BMC Musculoskeletal Disorders. 2004. DOI: 10.1186/1471-2474-5-11

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

[4] 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

[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. DOI: 10.1186/s12891-026-09675-3

[6] 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

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

[8] 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

[9] 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

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

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

[12] 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

[13] 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

[14] 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

[15] 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

[16] 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

[17] 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

[18] Risk prediction models for postmenopausal osteoporosis: a systematic review and meta-analysis study. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-025-09385-2

[19] A Missed Opportunity? Osteoporosis Treatment Following Femoral Neck Fractures: Reducing the Risk of Secondary Hip Fracture. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.07.028

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

[22] 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

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

[24] 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

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

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

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

[29] Effects of Perioperative Proton Pump Inhibitor Use on Outcomes of Total Joint Arthroplasty Patients Who Have Osteoporosis and Osteopenia. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.07.067

[30] 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

[31] 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

[32] Perioperative inflammatory cytokines nursing screening test indicate the link between dysregulated lipid metabolism and reduced bone mineral density in obese osteoporosis patients: a retrospective study. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09576-5

[33] 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

[34] The effect of Jintiange capsules on pain in patients with primary osteoporosis: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08694-w

[35] How prevalent is osteoporosis in a high-risk subgroup? A multicenter study of postmenopausal women hospitalized for fractures in China. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09517-2

[36] Genetically modified stem cells for osteoporosis: a systematic review and meta-analysis of preclinical studies. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08507-0

[37] Fragility of Assumptions: Response. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671251409149

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

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

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.