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Osteoporosis is associated with increased fragility of bone and a subsequent increased risk of fracture. The diagnosis of osteoporosis is intimately linked with the imaging and quantification of bone and BMD. Scanning modalities, such as dual-energy X-ray absorptiometry or quantitative CT, have been developed and honed over the past half century to provide measures of BMD and bone microarchitecture for the purposes of clinical practice and research. Combined with fracture prediction tools such as Fracture Risk Assessment Tool (FRAX) (which use a combination of clinical risk factors for fracture to provide a measure of risk), these elements have led to a paradigm shift in the ability to diagnose osteoporosis and predict individuals who are at risk of fragility fracture. Despite these developments, a treatment gap exists between individuals who are at risk of osteoporotic fracture and those who are receiving therapy. In this Review, we summarize the epidemiology of osteoporosis, the history of scanning modalities, fracture prediction tools and future directions, including the most recent developments in prediction of fractures.This Review highlights various medical imaging techniques and fracture prediction tools that are used to diagnosis osteoporosis and discusses the potential importance of screening in at-risk populations.

Rheumatoid arthritis (RA) and periodontitis are both chronic inflammatory diseases, which demonstrate similarities in terms of mechanism, histopathology, and demography. An association between these conditions has been demonstrated previously but has been called into question more recently. The published databases, such as MEDLINE, EMBASE, and PsycINFO, were searched using search terms related to RA and periodontitis. Articles were selected if they included data on the number of people with RA diagnosed with periodontitis (or periodontal disease parameters) compared to a control comparison group. Review articles, case reports, animal model studies, non-English language, and articles with unavailable abstracts were excluded. Data were extracted, critically appraised using the Downs and Black tool, and a random-effect Mantel-Haenszel meta-analysis was performed. Twenty-one papers met the eligibility criteria and provided data for the meta-analysis; 17 studies (including a total of 153,492 participants) comparing RA to healthy controls and 4 (including a total of 1378 participants) comparing RA to osteoarthritis (OA). There was a significantly increased risk of periodontitis in people with RA compared to healthy controls (relative risk: 1.13; 95% CI: 1.04, 1.23; p = 0.006; N = 153,277) with a significantly raised mean probing depth, risk of bleeding on probing (BOP), and absolute value of clinical attachment loss in those with RA. When comparing RA and OA, there was no significant difference in the prevalence of periodontitis; however, the risk of BOP was greater in OA than RA. A significant association between RA and periodontitis is supported by the results of our systematic review and meta-analysis of studies comparing RA to healthy controls. In our meta-analysis, however, this is not replicated when comparing RA to OA controls.

Background Ageing is commonly associated with sarcopenia (SP) and osteoporosis (OP), both of which are associated with disability, impaired quality of life, and mortality. The aims of this study were to explore the relationships between SP, OP, frailty, and multimorbidity in community‐dwelling older adults participating in the Hertfordshire Cohort Study (HCS) and to determine whether coexistence of OP and SP was associated with a significantly heavier health burden. Methods At baseline, 405 participants self‐reported their comorbidities. Cut‐offs for low grip strength and appendicular lean mass index were used according to the EWSGOP2 criteria to define SP. OP was diagnosed when T‐scores of < −2.5 were present at the femoral neck or the participant reported use of the anti‐OP medications including hormone replacement therapy (HRT), raloxifene, or bisphosphonates. Frailty was defined using the standard Fried definition. Results One hundred ninety‐nine men and 206 women were included in the study. Baseline median (interquartile range) age of participants was 75.5 (73.4–77.9) years. Twenty‐six (8%) and 66 (21.4%) of the participants had SP and OP, respectively. Eighty‐three (20.5%) reported three or more comorbidities. The prevalence of pre‐frailty and frailty in the study sample was 57.5% and 8.1%, respectively. Having SP only was strongly associated with frailty [odds ratio (OR) 8.28, 95% confidence interval (CI) 1.27, 54.03; P = 0.027] while the association between having OP alone and frailty was weaker (OR 2.57, 95% CI 0.61, 10.78; P = 0.196). The likelihood of being frail was substantially higher in the presence of coexisting SP and OP (OR 26.15, 95% CI 3.13, 218.76; P = 0.003). SP alone and OP alone were both associated with having three or more comorbidities (OR 4.71, 95% CI 1.50, 14.76; P = 0.008 and OR 2.86, 95% CI 1.32, 6.22; P = 0.008, respectively) although the coexistence of SP and OP was not significantly associated with multimorbidity (OR 3.45, 95% CI 0.59, 20.26; P = 0.171). Conclusions Individuals living with frailty were often osteosarcopenic. Multimorbidity was common in individuals with either SP or OP. Early identification of SP and OP not only allows implementation of treatment strategies but also presents an opportunity to mitigate frailty risk.

Musculoskeletal disorders are common among older people. Preventive strategies require understanding of age-related changes in strength, function and body composition, including how they interrelate. We have described, and examined associations between, 9-year changes in these parameters among 2917 Health, Aging and Body Composition Study participants (aged 70–79 years). Appendicular lean mass (ALM), whole body fat mass and total hip BMD were ascertained using DXA; muscle strength by grip dynamometry; and muscle function by gait speed. For each characteristic annualised percentage changes were calculated; measures of conditional change (independent of baseline) were derived and their interrelationships were examined using Pearson correlations; proportion of variance at 9-year follow-up explained by baseline level was estimated; and mean trajectories in relation to age were estimated using linear mixed models. Analyses were stratified by sex. Median [lower quartile, upper quartile] annual percentage declines were grip strength (1.5 [0.0, 2.9]), gait speed (2.0 [0.6, 3.7]), ALM (0.7 [0.1, 1.4]), fat mass (0.4 [− 1.1, 1.9]) and hip BMD (0.5 [0.0, 1.1]). Declines were linear for ALM and accelerated over time for other characteristics. Most conditional change measures were positively correlated, most strongly between ALM, fat mass and hip BMD ( r  > 0.28). Proportion of variation at follow-up explained by baseline was lower for grip strength and gait speed (39–52%) than other characteristics (69–86%). Strength and function declined more rapidly, and were less correlated between baseline and follow-up, than measures of body composition. Therefore, broader intervention strategies to prevent loss of strength and function in later life are required as those targeting body composition alone may be insufficient.

Background Osteoarthritis is the most prevalent type of arthritis. Many approaches exist for characterising radiographic knee OA, including machine learning (ML). Aims To examine Kellgren and Lawrence (K&L) scores from ML and expert observation, minimum joint space and osteophyte in relation to pain and function. Methods Participants from the Hertfordshire Cohort Study, comprising individuals born in Hertfordshire from 1931 to 1939, were analysed. Radiographs were assessed by clinicians and ML (convolutional neural networks) for K&L scoring. Medial minimum joint space and osteophyte area were ascertained using the knee OA computer-aided diagnosis (KOACAD) program. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was administered. Receiver operating characteristic analysis was implemented for minimum joint space, osteophyte, and observer- and ML-derived K&L scores in relation to pain (WOMAC pain score > 0) and impaired function (WOMAC function score > 0). Results 359 participants (aged 71–80) were analysed. Among both sexes, discriminative capacity regarding pain and function was fairly high for observer-derived K&L scores [area under curve (AUC): 0.65 (95% CI 0.57, 0.72) to 0.70 (0.63, 0.77)]; results were similar among women for ML-derived K&L scores. Discriminative capacity was moderate among men for minimum joint space in relation to pain [0.60 (0.51, 0.67)] and function [0.62 (0.54, 0.69)]. AUC < 0.60 for other sex-specific associations. Discussion Observer-derived K&L scores had higher discriminative capacity regarding pain and function compared to minimum joint space and osteophyte. Among women, discriminative capacity was similar for observer- and ML-derived K&L scores. Conclusion ML as an adjunct to expert observation for K&L scoring may be beneficial due to the efficiency and objectivity of ML.

Background Significant correlation has been previously demonstrated between radiographic and clinical diagnoses of knee osteoarthritis (OA); however, the specific findings on clinical examination that relate best to a radiographic diagnosis have not been fully elicited. Aims We aimed to explore the relationship between clinical symptoms and physical findings with radiographic diagnoses of tibiofemoral and patellofemoral OA. Methods This study was based on 409 individuals from the Hertfordshire Cohort Study, born between 1931 and 1939. Antero-posterior and lateral radiographs were taken of both knees. The presence of tibiofemoral and patellofemoral OA was defined according to the Kellgren and Lawrence score. Clinical symptoms, assessed using WOMAC, and physical findings were ascertained by examination. Relationships were assessed using multilevel univariate logistic regression. Results In the 775 knees studied, the prevalence of physical findings was crepitus (25%), tibiofemoral tenderness (15%), bony swelling (12%), and pain on flexion (10%). Thirty-one percent ( n  = 238) knees demonstrated tibiofemoral OA, 28% ( n  = 220) showed patellofemoral OA, and 16% demonstrated OA in both locations. A global clinical symptom score was associated with increased risk of tibiofemoral OA (OR 12.5, 95% CI 5.4–29.0) and patellofemoral OA (OR 5.1, 95% CI 2.3–13.1). On clinical examination, the presence of crepitus, tibiofemoral tenderness, bony swelling, and pain on flexion was associated with increased risk of tibiofemoral OA; however, only tenderness was found to be associated with patellofemoral OA. Conclusion Global clinical symptom score was associated with radiographic tibiofemoral and patellofemoral OA. However, individual clinical signs were more strongly associated with tibiofemoral than patellofemoral OA.

To investigate how social media has affected the use of pagers we compared pager activity with instant messaging patterns over a 6-month period in a large, UK, teaching hospital. Pagers are typically associated with substantial time inefficiency,2 a quarter of pager messages are unnecessary3 and 65% interrupt patient care.4 Understandably, therefore, pagers are not popular with doctors.2 In response to these shortcomings, the UK Health and Social Care Secretary has called for the health service to ‘#purgethepager’.5 Instant messaging on the wards either takes the form of informal, non-condoned usage via social media platforms such as WhatsApp (which are not designed for communication of patient information), or hospital-provided applications that are specifically tailored for clinical use. In 2018, a large university hospital introduced one such application, Medxnote, a mobile encrypted instant messaging application. Discussion This summary analysis suggests that, while popular and potentially of significant benefit to hospital communication, instant messaging will not naturally displace pager activity.

Historically, osteoporosis has been viewed as a disease of women, with research, trials of interventions and guidelines predominantly focused as such. It is apparent, however, that this condition causes a substantial health burden in men also, and that its assessment and management must ultimately be addressed across both sexes. In this article, an international multidisciplinary working group of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases presents GRADE-assessed recommendations for the diagnosis, monitoring and treatment of osteoporosis in men. The recommendations are based on a comprehensive review of the latest research related to diagnostic and screening approaches for osteoporosis and its associated high fracture risk in men, covering disease burden, appropriate interpretation of bone densitometry (including the use of a female reference database for densitometric diagnosis in men) and absolute fracture risk, thresholds for treatment, and interventions that can be used therapeutically and their health economic evaluation. Future work should specifically address the efficacy of anti-osteoporosis medications, including denosumab and bone-forming therapies.In this Evidence-Based Guideline article, an international multidisciplinary working group of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases presents recommendations for the diagnosis, monitoring and treatment of osteoporosis in men.

Radiofrequency Echographic Multi Spectrometry (REMS) is a radiation-free, portable technology, which can be used for the assessment and monitoring of osteoporosis at the lumbar spine and femoral neck and may facilitate wider access to axial BMD measurement compared with standard dual-energy x-ray absorptiometry (DXA). There is a growing literature demonstrating a strong correlation between DXA and REMS measures of BMD and further work supporting 5-year prediction of fracture using the REMS Fragility Score, which provides a measure of bone quality (in addition to the quantitative measure of BMD). The non-ionising radiation emitted by REMS allows it to be used in previously underserved populations including pregnant women and children and may facilitate more frequent measurement of BMD. The portability of the device means that it can be deployed to measure BMD for frail patients at the bedside (avoiding the complications in transfer and positioning which can occur with DXA), in primary care, the emergency department, low-resource settings and even at home. The current evidence base supports the technology as a useful tool in the management of osteoporosis as an alternative to DXA.

Knee osteoarthritis (OA) is one of the most common and disabling medical conditions. In the case of moderate to severe pain, a single intervention may not be sufficient to allay symptoms and improve quality of life. Examples include first-line, background therapy with symptomatic slow-acting drugs for OA (SYSADOAs) or non-steroidal anti-inflammatory drugs (NSAIDs). Therefore, the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) performed a review of a multimodal/multicomponent approach for knee OA therapy. This strategy is a particularly appropriate solution for the management of patients affected by knee OA, including those with pain and dysfunction reaching various thresholds at the different joints. The multimodal/multicomponent approach should be based, firstly, on different combinations of non-pharmacological and pharmacological interventions. Potential pharmacological combinations include SYSADOAs and NSAIDs, NSAIDs and weak opioids, and intra-articular treatments with SYSADOAs/NSAIDs. Based on the available evidence, most combined treatments provide benefit beyond single agents for the improvement of pain and other symptoms typical of knee OA, although further high-quality studies are required. In this work, we have therefore provided new, patient-centered perspectives for the management of knee OA, based on the concept that a multimodal, multicomponent, multidisciplinary approach, applied not only to non-pharmacological treatments but also to a combination of the currently available pharmacological options, will better meet the needs and expectations of patients with knee OA, who may present with various phenotypes and trajectories.