Bone Quality in Elderly Patients with Type 2 Diabetes Mellitus

Bone Quality in Elderly Patients with Type 2 Diabetes Mellitus | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Bone Quality in Elderly Patients with Type 2 Diabetes Mellitus Mercè Giner, Cristina Miranda, María Ángeles Vázquez-Gámez, Patricia Altea, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-100157/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background: Type 2 Diabetes Mellitus (T2DM) is one of the most common chronic diseases worldwide and it is associated with an increased risk of osteoporosis and fragility fractures. Our purpose was to analyse microstructural and bone mechanics from femoral heads, markers of bone turnover and bone mineral density in T2DM patients with or without recent fragility fractures. To identify the factors that influence this risk and elucidate diabetes-induced alterations in trabecular bone microarchitecture and bone turnover markers. Methods: The studied population consisted of 28 patients, divided in 4 groups: 6 subjects with hip fracture (OP) without T2DM, 8 patients with hip fracture and T2DM (OP-T2DM), 7 patients with osteoarthritis (OA) without T2DM and 7 patients OA and with T2DM (OA-T2DM). Bone markers, bone mineral density, FRAX score, microstructural and bone material strength from femoral heads and were assessed. Results: The group with hip fracture presented lower BMD values ​​than OA (p <0.05). The OP, OP-T2DM and OA-T2DM groups showed a decrease in bone volume fraction (BV/TV); trabecular number (Tb.N); trabecular thickness (Tb.Th) and increase of the structural model index (SMI) and trabecular bone pattern factor (Tb.Pf), as microstructure results and Young's modulus or elastic modulus; toughness; ultimate stress; ultimate load; extrinsic stiffness and work to failure, as biomechanical results, regarding OA patients (p <0.05). Conclusion: Our results show the negative effect of Type 2 Diabetes Mellitus on trabecular bone structure and mechanical properties. These results emphasize the importance of evaluating diabetic bones using not only bone markers and bone mass, but also bone quality parameters. Therefore, diabetes should be included as a risk factor for osteoporotic fracture in daily clinical practice and in the FRAX tool. Orthopedics Trauma Fracture Hip Diagnostic Imaging Osteoporosis Type 2 Diabetes Mellitus Figures Figure 1 Figure 1 Figure 2 Figure 2 Figure 3 Figure 3 Figure 4 Figure 4 Background Type 2 Diabetes Mellitus (T2DM) is one of the most common chronic diseases worldwide. T2DM patients exhibit an increased risk of suffering further complications of the disease, which are mainly due to complex and interconnected mechanisms, such as hyperglycaemia, insulin-resistance, low-grade inflammation and accelerated atherogenesis [ 1 ]. In addition, these chronic complications adversely affect multiple organ systems including bones, which have been widely associated with an increased risk of osteoporosis and fragility fractures [ 2 , 3 ]. Osteoporosis (OP) is a metabolic bone disease that is characterized by low bone mineral density (BMD) and microarchitectural deterioration in the bone structure, with a higher risk of fragility fractures [ 4 ]. Osteoarthritis (OA) is a metabolically active and dynamic process that involves all joint tissues. OA can lead to mechanical failure, pain and surgical joint replacement with a prosthesis [ 5 ]. Clinical and epidemiological studies suggest that OP and OA may coexist in the same patient. BMD values are usually normal or elevated in OA patients at any age, in contrast to OP [ 6 ]. T2DM is also very frequent in elderly people, and it exhibits high morbidity and mortality. Furthermore, various lifestyle factors contribute to the increased incidence of T2DM, OA and OP [ 7 , 8 ]. On the other hand, patients with T2DM are at significant risk for fragility fractures at skeletal sites, such as the hip, spine and forearm, although these patients often have normal or increased BMD [ 9 , 10 ]. A published meta-analysis showed that T2DM patients exhibit a relative risk of 1.7 (95% CI: 1.3 to 2.2) for hip fracture, and surprisingly, BMD was generally higher in patients with T2DM [ 11 ]. The low cortical bone strength and poor bone quality, due to the glycation of bone proteins, may also underlie increased fracture risk in diabetes [ 12 ]. The greater risk of an osteoporotic fracture despite normal or high BMD [ 13 ] makes necessary to identify the factors that influence this risk and elucidate diabetes-induced alterations in trabecular bone microarchitecture and bone turnover markers. The goal of this study is to analyze trabecular microstructural and mechanical properties from femoral heads using micro-CT, BMD and bone turnover markers (BTM) in patients with T2DM with or without recent fragility fractures in order to examine skeletal outcomes related to this disease and to establish a relative risk assessment method in the clinical setting. In this regard, we hypothesized that Diabetic patients have higher BMD values than expected, and T- score and FRAX can predict fracture but underestimate risk, therefore skeletal properties must be altered in these patients. Methods Study design and subjects The study was designed as a cross-sectional study. Subjects were included in a consecutive manner (October 2019 to July 2020). We calculated the sample size with the Granmo sample size and power calculator (v.7.12, IMIM,Spain) ( https://www.imim.es/ofertadeserveis/software-public/granmo/ ), in order to detect a significant standardized mean difference of 0.5 (one size average effect) in BV/TV with a type I error rate of 5% (alpha = .05) and a 90% power (1-beta = .90), we required 7 subjects in each group. The studied population consisted of 31 patients (aged 65–93), the cases group constituted the 14 patients with hip osteoporotic fracture (OP group) undergoing prosthetic hip replacement and the control group constituted the 14 patients with hip osteoarthritis (OA group) but not having any osteoporotic fracture along their life, undergoing total hip arthroplasty. Both groups were subdivided according to the criteria of whether the patient had T2DM. Then the case group was subdivided into OP without T2DM (6 patients) and OP-T2DM (8 patients). Like the control group that was divided into OA without T2DM (7 patients) and OA-T2DM (7 patients) (Fig. 1 ). 3 patients were excluded, 2 in OP group because not had a normal kidney function and 1 subject in OA group because not had osteoporosis criteria. The inclusion criterion for the OP patients was to have a current frailty hip fracture (a fall from less than the patient’s height without an acceleration mechanism). OA patients could not have been previously diagnosed with osteoporosis or have a history of frailty fracture since the age of 50 nor could they have congenital or acquired dysplasia or avascular necrosis. The medical history of all patients was checked and the diagnosis of T2DM for more than 5 years was confirmed for the diabetic patients and discarded for the rest of them. All of the T2DM patients have been treated with metformin. The exclusion criteria for all the groups included malignant diseases, hyperthyroidism, hyperparathyroidism, multiple myeloma, rheumatoid arthritis, osteomalacia, secondary OP due to corticosteroids or those who were treated with osteoporosis drugs. In addition, patients with congenital or acquired dysplasia or avascular necrosis were excluded from the OA and OA-T2DM groups. In both group of patients had a normal kidney function. Standardized interviews were used to obtain the following information: age (years), weight (kg), height (cm), body mass index or BMI (kg/m2), use of calcium and vitamin D supplements (none vs. any), use of medication and family history of hip fracture. We estimated the 10-year risk of major osteoporotic fracture (clinical spine, hip, forearm, or humerus fracture) and the 10-year risk of hip fracture for each patient by the FRAX® tool, calibrated for Spain ( www.shef.ac.uk/FRAX/index.htm ). The criteria of the Scientific Advisory Council of Osteoporosis in Canada was used to classify the FRAX® scores [ 14 ]. The study was approved by the Ethical Review Board of Seville (internal references 2147) and was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. Written informed consent were obtained from all participants. All patients included in the study agreed to donate their bone samples. Arthroplasty was performed in the Orthopaedics & Traumatology Department of the “Virgen Macarena” University Hospital (Seville, Spain). Because of the difficulty to obtain healthy hip bone donors, the osteoarthritic samples (OA) were considered the reference group since the BMD values classified them as non-osteoporotic. Biochemical measurements Fasting morning blood was drawn and stored at -80ºC. We assessed carboxy-terminal telopeptide of type I collagen (CTX), aminoterminal propeptide of type I procollagen (PINP), parathyroid hormone (PTH) and 25-hydroxyvitamin D (25(OH)D), insuline-like growth factor I (IGF-I) and glycated haemoglobin (HbA1c). PTH, CTX and P1NP were analyzed by immunoassay by an autoanalyzer COBAS 601 (Roche, Spain); inter-assay CV < 5.8%, < 7.6% and < 4.2% respectively. 25(OH)D were analyzed by direct competitive immunoassay by an autoanalyzer LIAISON (DiaSorin, Italy); inter-assay CV < 5.5%. IGF-I was determined using a chemiluminescence immunoassay (CLIA) by an autoanalyzer (IMMULITE 2000, Siemens); inter-assay CV was 6.9%. HbA1c was measured using an autoanalyzer (ADVIA 2400, Siemens; inter-assay CVs was 1%). In all cases, the intra-assay CV was < 5%. Bone mineral density BMD of the total hip and femoral neck was measured using a Dual-energy X-ray absorptiometry using the Hologic Discovery W densitometer (Hologic, Inc, Waltham, MA) using the APEX 3.1.1 software. In vivo CV was 2.4% (femoral neck) and 1.1% (total hip). Microstructural and bone material strength Femoral heads were stored frozen in phosphate-buffered saline (PBS, Lonza) at -20 °C until processing. A cylinder of trabecular bone was extracted from each femoral head and processed as previously optimized and described by our laboratory[ 15 ]. The bone cores were analyzed without further preparation by micro-CT (Skyscan 1172, Bruker micro-CT NV, Kontich, Belgium). The following histomorphometry parameters were measured: bone volume fraction (BV/TV; %), bone surface density (BS/TV; 1/mm), trabecular thickness (Tb.Th; mm), trabecular separation (Tb.Sp; mm), trabecular number (Tb.N; 1/mm), structural model index (SMI) and trabecular bone pattern factor (Tb.Pf; 1/mm). To visualize material failure on a microstructural level, compression tests of the bone cores were performed using a micro-mechanical testing device (Material Testing Stage, Bruker micro-CT NV, Kontich, Belgium). The following mechanical parameters were measured: ultimate load (Fult; N), extrinsic stiffness (S; N/mm); work to failure (U; mJ); and intrinsic or material mechanical properties: ultimate stress (σult; MPa); Young's modulus (E; MPa); and toughness (u; MPa). Statistical analysis Continuous variables are presented as the mean and standard deviation (SD). To compare continuous variables with a normal distribution, ANOVA was used with more than two samples, and Student's t-test with two samples; if the distribution was not normal, the Kruskal-Wallis test or the Mann-Whitney U test was used. Normality testing was performed using a combination of the Kolmogorov-Smirnov test. An adjustment for age, analysis of covariance (ANCOVA), was applied in OA group when needed (to compare microstructural and bone material strength parameters). Correlations between variables were examined using the Spearman correlation, which is appropriate for smaller sample sizes with more robust potential outliers. All hypotheses were two-tailed, and a p value < 0.05 was considered statistically significant. Statistical package SPSS 20.0 for Windows (IBM Corp., Armonk, NY, USA). Results In order to check whether type 2 diabetes mellitus has a related effect on bone fragility and risk of fracture we compared the microstructural and biomechanical parameters among osteoporotic patients (OP) with type 2 diabetes mellitus (OP-T2DM group) or without T2DM (OP group) with recent fragility fractures, and we also compared between the OA and OA-T2DM group patients. Because of the difficulty in using bone samples from heathy donors, osteoarthritis patients (OA group) were used as non-osteoporotic control as in other studies they have been used [ 15 ]. In Tables 1 and 2 we observe the anthropometric characteristics, BMD and biochemistry of all the groups. We did not find any significant difference between the values by gender, so we performed the statistical analysis with the total means of the group. Table 1 Patient characteristics (total and by gender) and analyzed parameters. OA OA-T2DM p Gender (Male/Female) 3/4 2/4 Age (years) Male Female 73.0 ± 5.3 73.7 ± 7.5 72.5 ± 4.4 76.7 ± 2.2 76.0 ± 2.8 77.0 ± 2.1 n.s BMI (kg/m2) Male Female 33.9 ± 3.9 34.2 ± 5.6 32.1 ± 2.7 30.1 ± 4.0 25.8 ± 3.2 31.2 ± 3.6 n.s 10-year risk of major fracture (FRAX® tool) Male Female 5.7 ± 4.6 2.7 ± 1.8 7.9 ± 5.0 8.2 ± 5.4 3.5 ± 1.8 10.4 ± 5.1 n.s. 10-year risk of hip fracture (FRAX® tool) Male Female 2.6 ± 3.6 1.4 ± 1.8 5.5 ± 5.5 7.3 ± 11.2 1.9 ± 1.2 7.9 ± 5.1 n.s Femoral neck BMD (gHA/cm2) Male Female 0.700 ± 0.09 0.760 ± .015 0.673 ± 0.06 0.688 ± 0.14 0.744 ± 0.25 0.64 ± 0.12 n.s. Hip BMD (gHA/cm2) Male Female 0.858 ± 0.15 0.99 ± 0.19 0.80 ± 0.10 0.930 ± 0.18 1.15 ± 0.12 0.86 ± 0.13 n.s. 25-hydroxyvitamin D (ng/mL) 14.2 ± 5.8 12.8 ± 6.8 n.s PTH (pg/mL) 48.0 ± 20.1 53.4 ± 40.1 n.s β-CrossLaps (µg/mL) 0.45 ± 0.20 0.32 ± 0.15 n.s P1NP (ng/mL) 50.7 ± 25.0 37.6 ± 11.5 n.s IGF-1 (ng/mL) 57.1 ± 16.5 77.0 ± 39.0 n.s HbA1c (%) 5.4 ± 0.3 7.0 ± 1.3 0.019 Values are shown as the means ± standard deviation (SD). n.s. not statistically significant p values Table 2 Patient characteristics (total and by gender) and analyzed parameters. OP OP-T2DM p Gender (Male/Female) 2/4 2/6 Age (years) Male Female 83.7 ± 6.2 83.0 ± 5.2 84.2 ± 7.6 79.4 ± 6.9 74.5 ± 2.2 81.0 ± 7.3 n.s BMI (kg/m2) Male Female 28.5 ± 5.2 24.8 ± 3.5 31.3 ± 4.7 28.47 ± 4.8 26.9 ± 5.0 29.0 ± 5.0 n.s 10-year risk of major fracture (FRAX® tool) Male Female 20.2 ± 9.6 13.7 ± 5.9 25.0 ± 9.4 20.3 ± 7.0 24.0 ± 4.5 19,7 ± 7.4 n.s. 10-year risk of hip fracture (FRAX® tool) Male Female 13.2 ± 8.8 9.5 ± 5.9 16.0 ± 10.1 13.0 ± 7.9 21.0 ± 3.8 19.7 ± 7.4 n.s Femoral neck BMD (gHA/cm2) Male Female 0.493 ± 0.06 0.538 ± 1.2 0.471 ± 0.1 0.437 ± 0.06 0.354 ± 0.03 0.453 ± 0.05 n.s. Hip BMD (gHA/cm2) Male Female 0.712 ± 0.10 0.813 ± 0.04 0.662 ± 0.09 0.608 ± 0.10 0.517 ± 0.04 0.625 ± 0.09 n.s. 25-hydroxyvitamin D (ng/mL) 13.5 ± 7.8 12.8 ± 9.9 n.s PTH (pg/mL) 49.0 ± 33.1 77.0 ± 34.8 n.s β-CrossLaps (µg/mL) 0.75 ± 0.34 0.58 ± 0.53 n.s P1NP (ng/mL) 63.6 ± 23.6 46.1 ± 31.9 n.s IGF-1 (ng/mL) 73.0 ± 45.4 63.8 ± 40.0 n.s HbA1c (%) 5.4 ± 0.3 6.4 ± 1.3 n.s Values are shown as the means ± typical deviation (SD). n.s. is not statistically significant p values (insert in the text Table 1 and 2 ) Due to OA patients were younger (73.0 ± 5.4 years) than the other groups, an adjustment for age was applied to the successive statistical analyses. No significant differences were found in weight, height, or BMI between the study groups (Table 1 y 2). Densitometric parameters were higher in the OA and OA-T2DM groups. We observed significant differences in BMD at the femoral neck and total hip between OA vs OP-T2DM (p = 0.000; p = 0.008) and between OA-T2DM vs OP-T2DM (p = 0.032; p = 0.007). While between OA and OP there are significant differences at femoral neck BMD (p = 0.001). This indicates that fracture patients have worse BMD values, both at total hip and femoral neck, and OA patients, regardless of whether they have T2DM, their BMD is in normal ranges. The FRAX® 10-year risk of major or hip fracture was higher in OP and OP-T2D patients than OA patients (p = 0.004; p = 0.001) and with T2DM (p = 0.005). The FRAX® 10-year risk of major and hip fracture between the OP and OP-T2DM groups and the OA and OA-T2DM patients were statistically not significant. The serum levels of the bone turnover markers were also analyzed in all groups. CTX and P1NP were lower in the OA-T2DM patients than the other groups and the highest levels were observed in OP group no significant difference. Vitamin D levels were below 20 ng/mL in all groups of patients, without significant differences between groups (Tables 1 and 2 ). Three-dimensional reconstruction and micro-CT images were shown in Fig. 2 . We can observe how the samples of the OA group show a higher BMD than the other groups and how the effect of the T2DM produces a significant deterioration at the macroscopic level in the trabecular bone structure. Microstructural indices showed differences in cancellous bone microarchitecture between groups. Most of the studied parameters in osteoporotic subjects, with and without T2DM, and OA-T2DM subjects showed significant differences compared to control group (OA group) (Fig. 3 ). The OP, OP-T2DM and OA-T2DM bone samples had smaller BV/TV compared to OA bone biopsies (-53%, p = 0.001; -36%, p = 0.01; -53%, p = 0.001). At the trabecular level, the OP group, OP-T2DM and OA-T2DM, show a lower number of trabeculae, TbN ( -33%, p = 0.0013; -32%, p = 0.233; -14% p = 0.016) and less width of the trabeculae Tb.Th (-37%, p = 0.001; -35%, p = 0.001; -27%, p = 0.000). There are no significant differences with the separation of the trabeculae, although the tendency is to be less in all of them compared to the OA group, Tb.Sp (-10%, -15% and − 5%). Furthermore, these three groups also had higher Tb.Pf (in all groups almost 6 times more p < 0.02). Among OP group vs OP-T2DM, we found significant differences in SMI parameter (OP: 1.7 ± 0.16; OP-T2DM 1.1 ± 0.16, p = 0.015), the other microstructural indices were no significant differences. These results show that the OA-T2DM patients had similar microstructural characteristics to patients OP and OP-T2DM in trabecular bone characteristics, which indicates that the diabetic disease maintains BMD but the microarchitecture is of poor quality and more fragile. In order to test whether the strength of the trabecular bone is lower in the T2DM patients (OA-T2DM and OP-T2DM) and OP compared with OA patients, different biomechanical parameters were studied (Fig. 4 ). The OA-T2DM, OP-T2DM and OP samples showed lower stiffness because of the structural features and material properties of bone: Young's modulus (-59%, -38% and – 51%, respectively; p < 0.022) and ultimate stress (-61%, -46% and − 68%; p < 0.001). Toughness (-34%, -51% and − 80%, respectively; p = 0.021), work to failure (-61%, -54% and − 80%, respectively; p = 0.005), extrinsic stiffness (–58%, -38% and-49%, respectively) and ultimate load (-65%, -49% and – 68%, respectively; p < 0.001) were lower in T2DM groups and the OP group compared with the OA group. The OA-T2DM patients exhibited similar biomechanical parameters to patients with osteoporotic hip fracture (OP) in the trabecular bone, while the OP-T2DM group showed the most impacted values in biomechanical parameters. The statistical power for significant differences (p < 0.05) for each of the variables studied was calculated, and we always found a higher statistical power of 88% (beta error < 12%). Finally, we found no statistically significant correlations between duration of T2DM or serum levels of HbA1c with microstructural values. Discussion It is widely accepted by the scientific community that T2DM impairs bone metabolism [ 8 , 16 ], and the risk of fragility fractures is increased in these patients [ 9 , 10 ]. The mechanisms by which the risk of fracture is increased, and this impairment occurs are not clear. In addition, BMD measurements or FRAX® tool cannot predict these risks. Therefore, there is a need to establish a relative risk assessment method in the clinical setting in patients with T2DM to predict possible impacts on bone fracture related to the disease. The purpose of our analysis was to study the impact in the microstructural and bone mechanics in T2DM patients with or without recent fragility fractures and the relationship of these fractures with type 2 diabetes mellitus. To verify the influence of T2DM on quantity and quality of trabecular bone tissue from 28 patients, we have assessed BMD, microarchitecture and biomechanical properties of femoral heads from 4 patient groups: OA, OP, OA-T2DM and OP-T2DM. The control group is made up of patients with osteoarthritis, these patients tend to have a localized increase of bone density and/or sclerosis in subchondral bone of the femoral head, but minimal differences in bone density of the femoral neck [ 17 ], where we obtained the samples by micro-CT. Moreover, both our diabetic and non-diabetic subjects were undergoing total hip replacement, and therefore the groups should be comparable. Thus, we do not believe presence of osteoarthritis negatively affected our ability to draw conclusions about diabetes vs. non-diabetes. As expected, osteoporotic patients with hip fractures had lower BMD values than osteoarthritic patients, but no differences between osteoporotic patients with and without T2DM were found and neither between the OA group and OA-T2DM. Previous data demonstrated that T2DM patients have normal or increased BMD values [ 18 – 20 ], even when this variable was normalized by the BMI [ 21 ]. Although it can be prevalent in juveniles, T2DM is very common in the elderly, and it frequently coexists with age-related bone loss [ 18 ]. Therefore, the establishment of risk factors for fragility fractures during ageing should be identified since these factors can contribute to fracture risk in older diabetic patients. In our case, OP-T2DM and OP patients showed BMD values lower than − 2.5T (T-score score < -2.5) at all hip sites, which is consistent with the stablished World Health Organization Definitions. We found no differences in BMD between osteoarthritic groups with and without T2DM, and the values of BMD were considered normal or healthy by T-score in these groups. As our BMD values shown, clinical and epidemiological studies suggested an inverse relationship between many parameters studied in OP and OA patients [ 6 , 22 – 25 ]. The increased BMD may minimize the expected negative effects on bone metabolism caused by diabetes. The more relevant data obtained in the present study is based on decrease of the values observed of the bone microarchitecture and biomechanical properties that we tested in the trabecular hip bone of patients with both osteoarthritis and T2DM compared with non-diabetic osteoarthritic patients. Both groups of osteoarthritic patients were similar in terms of age, weight, lifestyle and evolutionary stage of degenerative disease. However, bone strength in the T2DM group was importantly damaged, and it was in a similar range in patients with osteoporotic hip fracture. These results show the negative effect of T2DM on trabecular bone structure and mechanical properties. Our findings are also broadly consistent with reports of lower bone material strength index in patients with T2D compared to non-diabetic controls [ 19 , 26 ]. Conversely, improved properties of trabecular bone were noted in subjects with T2DM compared with controls; however, compromised cortical bone microarchitecture (e.g., increased cortical porosity) [ 26 , 27 ] was observed. Cortical bone characteristics were not evaluated in this study, but we demonstrated damage in bone microstructure and the mechanics, which are important elements in trabecular bone quality in these subjects with T2DM [ 28 , 29 ]. We also demonstrated a significant deterioration in these parameters in hip fracture patients. However, a lower quality of trabecular bone was not observed in OP-T2DM patients compared to non-diabetics. Patsch et al. showed similar results in younger people with diabetes using HR-pQCT of the ultradistal and distal radius and tibia [ 30 ]. These data note that diabetic disease is a key factor that is directly involved in the deterioration of bone quality, which is likely responsible for the increased risk of fragility fractures. We found no correlation between microstructure parameters and mechanical values with bone turnover markers. OP subjects exhibited more active bone remodeling, primarily because of bone resorption, as evidenced by the significantly higher levels of β-CrossLaps, which is consistent with a previous study [ 15 ]. However, a trend of a reduced bone remodeling activity was observed in T2DM patients, which was demonstrated by the lower levels of formation and resorption markers than the respective controls [ 19 , 20 , 31 , 32 ]. Some authors reported defects in bone formation that were produced by a decrease in osteoblast differentiation and an increase in apoptosis in these cells [ 33 ]. These changes may lead to an imbalance between bone resorption and bone formation [ 32 , 34 ]. Considerable evidence suggests that specific factors, such as poor glycemic control and T2DM duration (e.g., a glycated haemoglobin level ≥ 7.5%) [ 35 ] exacerbate risk factors in T2DM patients, although this relationship has not been established unequivocally [ 36 ]. In the present study, both groups of diabetic patients were fairly well controlled. The average glycated haemoglobin level was lower than the previously mentioned average [ 35 ], and it was not associated with mechanical or microstructural parameters. We did not find a correlation among these values and the duration of diabetic disease, remaining very similar in OP-T2DM and OA-T2DM groups, which is consistent with a previous study [ 19 ]. The FRAX tool revealed that the OP and OP-T2DM subjects showed moderate to high risk. However, OA-T2DM patients of similar age showed low risk probability for both types of fracture, but mechanical and microstructure indicated the opposite risk. These results suggest that effective intervention thresholds for fracture prevention in patients with T2DM might be different than those that are effective for non-diabetic patients, as discussed recently [ 30 , 37 ]. Despite the potential of the present entered data obtained from hip bone human samples, our study had several limitations. Our sample size was relatively small although with sufficient power to obtain significant differences between the differences found. Therefore, our results should be eventually confirmed. The lack of cortical bone microarchitecture and histomorphometry indices of the samples is an additional concern. Nevertheless, this study includes BMD, BTM, trabecular bone microarchitecture and mechanical strength measures in T2DM patients with and without recently suffered fragility hip fracture, thus allowing for establishment a relationship between osteoporotic fracture and diabetes. Conclusions Our findings are the first demonstration of compromised trabecular bone microarchitecture and material properties using measurements of human bone biopsies from hip with and without fragility fracture in T2DM subjects. In conclusion, our results show the potential detrimental effects of diabetic disease on bone quality. Furthermore, our results in OA-T2DM subjects confirm that diabetes does not affect BMD, so T2DM affects quality and not bone quantity. These findings emphasize the importance of evaluating diabetic patient using bone markers and bone quality parameters. Therefore, diabetes should be included as a risk factor for osteoporotic fracture in daily clinical practice. Abbreviations T2DM: Type 2 Diabetes Mellitus; OP: osteoporosis; OA: osteoarthritis; BMD: bone mineral density; BTM: bone turnover markers; BV/TV: bone volume fraction; Tb.N: trabecular number; Tb.Th; trabecular thickness; SMI: structural model index; Tb.Pf: trabecular bone pattern factor; BMI: body mass index; Fult: ultimate load; S: extrinsic stiffness; U: work to failure; σult: ultimate stress; E: Young's modulus; u: toughness; CTX: carboxy-terminal telopeptide of type I collagen; PINP: aminoterminal propeptide of type I procollagen (PINP); PTH: parathyroid hormone; 25(OH)D: 25-hydroxyvitamin D (25(OH)D; IGF-1: insuline-like growth factor I; Hba1C: glycated haemoglobin; CV: confident interval. Declarations Acknowledgments : We express our deepest gratitude to all the study participants and staff in the Orthopaedics & Traumatology Department of the Virgen Macarena Hospital (Seville, Spain). Author Contributions : Data curation: MJM and MJMG; Formal analysis, MG, CM and MJMG; Funding acquisition, RPC and MJMG; Investigation, MG, CM, MAMG,MJM; Methodology, CM and MAMG and PA; Project administration, RPC and CM; Visualization, PA and ACD; Writing – original draft, MG and PA; Writing – review & editing, PRC and MJMG. All authors have approved the final version of the manuscript. Funding: The study was financially supported by the Research Project of Excellence, Junta de Andalucía of Spain, grant number CTS-5360/09. Availability of data and material: The data that support the findings of this study are available from the corresponding author, upon reasonable request. Declarations Ethics approval and consent to participate: All patients gave informed and written consent to participate in the study. The study has been approved by the Ethical Review Board of Hospital Universitario Virgen Macarena (2147) and was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. Competing interests: The authors declare that they have no competing interests. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. Author details 1 Departamento de Citología e Histología Normal y Patológica, Universidad de Sevilla, Avda. Dr. Fedriani s/n, Sevilla 41009, Spain. References Khazai NB, Beck GR, Umpierrez GE. Diabetes and fractures: an overshadowed association. Curr Opin Endocrinol Diabetes Obes. 2009;16:435–45. doi: 10.1097/MED.0b013e328331c7eb . Hamann C, Kirschner S, Günther KP, Hofbauer LC. Bone, sweet bone—osteoporotic fractures in diabetes mellitus. Nat Rev Endocrinol. 2012;8:297–305. doi: 10.1038/nrendo.2011.233 . Jackuliak P, Payer J. Osteoporosis, Fractures, and Diabetes. Int J Endocrinol. 2014;2014:820615. doi: 10.1155/2014/820615 . Johnston CC, Slemenda CW. Pathogenesis of osteoporosis. Bone. 1995;17:19S–22S. Hinton R, Moody RL, Davis AW, Thomas SF. Osteoarthritis: diagnosis and therapeutic considerations. Am Fam Physician. 2002;65:841–8. Dequeker J, Aerssens J, Luyten FP. Osteoarthritis and osteoporosis: clinical and research evidence of inverse relationship. Aging Clin Exp Res. 2003;15:426–39. Adami S. Bone health in diabetes: considerations for clinical management. Curr Med Res Opin. 2009;25:1057–72. doi: 10.1185/03007990902801147 . Oei L, Rivadeneira F, Zillikens MC, Oei EHG. Diabetes, diabetic complications, and fracture risk. Curr Osteoporos Rep. 2015;13:106–15. doi: 10.1007/s11914-015-0260-5 . Bonds DE, Larson JC, Schwartz AV, Strotmeyer ES, Robbins J, Rodriguez BL, Johnson KC, Margolis KL. Risk of Fracture in Women with Type 2 Diabetes: the Women’s Health Initiative Observational Study. J Clin Endocrinol Metab. 2006;91:3404–10. doi: 10.1210/jc.2006-0614 . de Liefde II, van der Klift M, de Laet CEDH, van Daele PLA, Hofman A, Pols HA. Bone mineral density and fracture risk in type-2 diabetes mellitus: the Rotterdam Study. Osteoporos Int. 2005;16:1713–20. doi: 10.1007/s00198-005-1909-1 . Vestergaard P. Discrepancies in bone mineral density and fracture risk in patients with type 1 and type 2 diabetes–a meta-analysis. Osteoporos Int. 2007;18:427–44. doi: 10.1007/s00198-006-0253-4 . Yamamoto M, Yamaguchi T, Yamauchi M, Sugimoto T. Low Serum Level of the Endogenous Secretory Receptor for Advanced Glycation End Products (esRAGE) Is a Risk Factor for Prevalent Vertebral Fractures Independent of Bone Mineral Density in Patients With Type 2 Diabetes. Diabetes Care. 2009;32:2263–8. doi: 10.2337/dc09-0901 . Janghorbani M, Van Dam RM, Willett WC, Hu FB. Systematic Review of Type 1 and Type 2 Diabetes Mellitus and Risk of Fracture. Am J Epidemiol. 2007;166:495–505. doi: 10.1093/aje/kwm106 . Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010;182:1864–73. doi: 10.1503/cmaj.100771 . Montoya MJ, Giner M, Miranda C, Vázquez MA, Caeiro JR, Guede D, Pérez-Cano R. Microstructural trabecular bone from patients with osteoporotic hip fracture or osteoarthritis: Its relationship with bone mineral density and bone remodelling markers. Maturitas. 2014;79:299–305. doi: 10.1016/j.maturitas.2014.07.006 . Yan W, Li X. Impact of diabetes and its treatments on skeletal diseases. Front Med. 2013;7:81–90. doi: 10.1007/s11684-013-0243-9 . Arokoski JP, Arokoski MH, Jurvelin JS, Helminen HJ, Niemitukia LH, Kroger H. Increased bone mineral content and bone size in the femoral neck of men with hip osteoarthritis. Ann Rheum Dis. 2002;61:145–50. Sosa M, Saavedra P, Jódar E, Lozano-Tonkin C, Quesada JM. Torrijos A, et al. Bone mineral density and risk of fractures in aging, obese post-menopausal women with type 2 diabetes. The GIUMO Study. Aging Clin Exp Res. 2009;21:27–32. Farr JN, Drake MT, Amin S, Melton LJ, McCready LK, Khosla S. In vivo assessment of bone quality in postmenopausal women with type 2 diabetes. J Bone Miner Res. 2014;29:787–95. doi: 10.1002/jbmr.2106 . Hunt HB, Torres AM, Palomino PM, Marty E, Saiyed R, Cohn M, et al. Altered Tissue Composition, Microarchitecture, and Mechanical Performance in Cancellous Bone From Men With Type 2 Diabetes Mellitus. J Bone Miner Res. 2019 Jul;34(7):1191–1206. doi: 10.1002/jbmr.3711 . Giangregorio LM, Leslie WD, Lix LM, Johansson H, Oden A, McCloskey E, Kanis JA. FRAX underestimates fracture risk in patients with diabetes. J Bone Miner Res. 2012;27:301–8. doi: 10.1002/jbmr.556 . Hart DJ, Mootoosamy I, Doyle DV, Spector TD. The relationship between osteoarthritis and osteoporosis in the general population: the Chingford Study. Ann Rheum Dis. 1994;53:158–62. Sambrook P, Naganathan V. What is the relationship between osteoarthritis and osteoporosis? Baillieres. Clin Rheumatol. 1997;11:695–710. Sainz-Aja Guerra JA, Alonso MA, Ferreño Blanco D, Pérez-Núñez MI, Ruiz Martínez E, García-Ibarbia C, et al. Study of the microstructure of femoral patients with hip osteoarthritis and hip fracture by microCT. Rev Osteoporos Metab Miner. 2016;8:75–81. Stewart A, Black AJ. Bone mineral density in osteoarthritis. Curr Opin Rheumatol. 2000;12:464–7. Karim L, Moulton J, Van Vliet M, Velie K, Robbins A, Malekipour F, et al. Bone microarchitecture, biomechanical properties, and advanced glycation end-products in the proximal femur of adults with type 2 diabetes. Bone. 2018;114:32–9. doi: 10.1016/j.bone.2018.05.030 . Burghardt AJ, Issever AS, Schwartz AV, Davis KA, Masharani U, Majumdar S, Link TM. High-Resolution Peripheral Quantitative Computed Tomographic Imaging of Cortical and Trabecular Bone Microarchitecture in Patients with Type 2 Diabetes Mellitus. J Clin Endocrinol Metab. 2010;95:5045–55. doi: 10.1210/jc.2010-0226 . Seeman E, Delmas PD. Bone Quality — The Material and Structural Basis of Bone Strength and Fragility. N Engl J Med. 2006;354:2250–61. doi: 10.1056/NEJMra053077 . Chavassieux P, Seeman E, Delmas PD. Insights into material and structural basis of bone fragility from diseases associated with fractures: how determinants of the biomechanical properties of bone are compromised by disease. Endocr Rev. 2007;28:151–64. doi: 10.1210/er.2006-0029 . Patsch JM, Burghardt AJ, Yap SP, Baum T, Schwartz AV, Joseph GB, Link TM. Increased cortical porosity in type 2 diabetic postmenopausal women with fragility fractures. J Bone Miner Res. 2013;28:313–24. doi: 10.1002/jbmr.1763 . Montoya MJ, Vázquez MA, Miranda C, Miranda MJ, Pérez-Cano R, Giner M. Influence of vitamin D on biomechanical microstructure and properties of patients with hip fracture. Rev Osteoporos Metab Min. 2017;9:121–9. doi: 10.4321/S1889-836X2017000400004 . Starup-Linde J, Vestergaard P. Biochemical bone turnover markers in diabetes mellitus—A systematic review. Bone. 2016;82:69–78. doi: 10.1016/j.bone.2015.02.019 . Manolagas SC. From estrogen-centric to aging and oxidative stress: a revised perspective of the pathogenesis of osteoporosis. Endocr Rev. 2010;31:266–300. doi: 10.1210/er.2009-0024 . Manavalan JS, Cremers S, Dempster DW, Zhou H, Dworakowski E, Kode A, Kousteni S, Rubin MR. Circulating Osteogenic Precursor Cells in Type 2 Diabetes Mellitus. J Clin Endocrinol Metab. 2012;97:3240–50. doi: 10.1210/jc.2012-1546 . Oei L, Zillikens MC, Dehghan A, Buitendijk GHS, Castaño-Betancourt MC, Estrada K, et al. High bone mineral density and fracture risk in type 2 diabetes as skeletal complications of inadequate glucose control: the Rotterdam Study. Diabetes Care. 2013;36:1619–28. doi: 10.2337/dc12-1188 . Schwartz AV, Margolis KL, Sellmeyer DE, Vittinghoff E, Ambrosius WT, Bonds DE, et al. Intensive Glycemic Control Is Not Associated With Fractures or Falls in the ACCORD Randomized Trial. Diabetes Care. 2012;35:1525–31. doi: 10.2337/dc11-2184 . Moayeri A, Mohamadpour M, Mousavi SF, Shirzadpour E, Mohamadpour S, Amraei M. Fracture risk in patients with type 2 diabetes mellitus and possible risk factors: a systematic review and meta-analysis. Ther Clin Risk Manag. 2017;13:455–68. doi: 10.2147/TCRM.S131945 . Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 21 Jan, 2021 Review # 2 received at journal 12 Jan, 2021 Reviewer # 2 agreed at journal 22 Dec, 2020 Review # 1 received at journal 05 Dec, 2020 Reviewer # 1 agreed at journal 28 Nov, 2020 Reviewers invited by journal 26 Nov, 2020 Editor assigned by journal 18 Oct, 2020 Submission checks completed at journal 17 Oct, 2020 Editor invited by journal 17 Oct, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-100157","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":5024311,"identity":"ac99e6f6-8157-4dfd-8d9b-f28ea4b6f572","order_by":0,"name":"Mercè Giner","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAnElEQVRIiWNgGAWjYFACxgYgYUO6ljTSrTpMglrd/sVtDz7uOZ84v4H58AeitJjdeNhuOOPZ7cQNB9jSJIjUcrBNmucAUAsDjxlxDgNr+XPgHNBh/J+JdNj5xjZphgMHEhsO8DAQ6zDGNsmeA8nGGw6zmRGp5fzxZxI/DtjJzm9vfkycwxgkEqAMZuLUAwH/AaKVjoJRMApGwUgFAFdwNHAWxD8OAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-8285-0767","institution":"Universidad de Sevilla: Universidad de Sevilla","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Mercè","middleName":"","lastName":"Giner","suffix":""},{"id":5024312,"identity":"f53cc16b-9597-4579-90a0-eafd391ab2f0","order_by":1,"name":"Cristina Miranda","email":"","orcid":"","institution":"Hospital Universitario Virgen 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of Seville Faculty of Medicine: Universidad de Sevilla Facultad de Medicina","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"María-José","middleName":"","lastName":"Montoya-García","suffix":""}],"badges":[],"createdAt":"2020-10-29 16:52:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-100157/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-100157/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":3767160,"identity":"2d88c2cd-d743-4414-926e-5030dc9c1fc7","added_by":"auto","created_at":"2020-11-23 14:27:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":28395,"visible":true,"origin":"","legend":"Outline of patient selection and study groups ","description":"","filename":"1.PNG","url":"https://assets-eu.researchsquare.com/files/rs-100157/v1/788ac0d7de1e17b81cd05529.PNG"},{"id":3767154,"identity":"9e06576f-53e9-41df-a8da-1dd9fff88b38","added_by":"auto","created_at":"2020-11-23 14:27:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":28395,"visible":true,"origin":"","legend":"Outline of patient selection and study groups ","description":"","filename":"1.PNG","url":"https://assets-eu.researchsquare.com/files/rs-100157/v1/e3cde199e186937e81d4cbf5.PNG"},{"id":3767161,"identity":"97afc85a-3234-429a-aa39-180bdea246a1","added_by":"auto","created_at":"2020-11-23 14:27:34","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":233296,"visible":true,"origin":"","legend":"Three-dimensional reconstruction and micro-CT images of bone trabecular from femoral heads in the four groups. Two different samples from: (A) OA group; (B) OA-T2DM; (C) OP; (D) OP-T2DM.","description":"","filename":"2.PNG","url":"https://assets-eu.researchsquare.com/files/rs-100157/v1/c3da688c1f9720a8190830ab.PNG"},{"id":3767155,"identity":"ea3b272d-1bff-48ff-9270-221172662c07","added_by":"auto","created_at":"2020-11-23 14:27:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":233296,"visible":true,"origin":"","legend":"Three-dimensional reconstruction and micro-CT images of bone trabecular from femoral heads in the four groups. Two different samples from: (A) OA group; (B) OA-T2DM; (C) OP; (D) OP-T2DM.","description":"","filename":"2.PNG","url":"https://assets-eu.researchsquare.com/files/rs-100157/v1/7e26d7bef1a23e12af560573.PNG"},{"id":3767162,"identity":"8d7cdb3b-d77d-4201-a620-282fed20a043","added_by":"auto","created_at":"2020-11-23 14:27:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":82086,"visible":true,"origin":"","legend":"Comparisons of structural parameters between patients with OA and OP with or without T2DM. BV/TV, bone volume fraction; SMI, structural model index; Tb.Pf, trabecular bone pattern factor; Tb.N, trabecular number; Tb.Th, trabecular thickness; Tb.Sp, trabecular separation; Values are expressed as the means ± SEM. * p\u003c 0.05, ** p\u003c0.01 and *** p\u003c 0.001 statistically significant. ","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-100157/v1/e55024b1df85a313abeed4d6.png"},{"id":3767156,"identity":"04bb0009-c745-4334-9efb-a34f9e10d4cb","added_by":"auto","created_at":"2020-11-23 14:27:28","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":82086,"visible":true,"origin":"","legend":"Comparisons of structural parameters between patients with OA and OP with or without T2DM. BV/TV, bone volume fraction; SMI, structural model index; Tb.Pf, trabecular bone pattern factor; Tb.N, trabecular number; Tb.Th, trabecular thickness; Tb.Sp, trabecular separation; Values are expressed as the means ± SEM. * p\u003c 0.05, ** p\u003c0.01 and *** p\u003c 0.001 statistically significant. ","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-100157/v1/e1b6568d3df46870ba99fc35.png"},{"id":3767163,"identity":"0e397a40-8184-4ae1-8cb5-4a7915022367","added_by":"auto","created_at":"2020-11-23 14:27:34","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":160180,"visible":true,"origin":"","legend":"Comparisons of biomechanical parameters between patients with OA and OP. E, Young's modulus or elastic modulus; u, toughness; σult, ultimate stress; Fult, ultimate load; S, extrinsic stiffness; U, work to failure. Values are expressed as the means ± SEM. * p\u003c 0.05, ** p\u003c 0.01 and *** p\u003c 0.001 statistically significant. ","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-100157/v1/e8f90a6e030b8e4d729e59d2.png"},{"id":3767157,"identity":"ac8df683-cc58-4054-b904-bc136ed45f7d","added_by":"auto","created_at":"2020-11-23 14:27:28","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":160180,"visible":true,"origin":"","legend":"Comparisons of biomechanical parameters between patients with OA and OP. E, Young's modulus or elastic modulus; u, toughness; σult, ultimate stress; Fult, ultimate load; S, extrinsic stiffness; U, work to failure. Values are expressed as the means ± SEM. * p\u003c 0.05, ** p\u003c 0.01 and *** p\u003c 0.001 statistically significant. ","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-100157/v1/abd90f429e6fe595907a889a.png"},{"id":13617259,"identity":"dc46277d-283d-485d-8dcd-fbdf138998e0","added_by":"auto","created_at":"2021-09-17 06:53:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1393339,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-100157/v1/88d22376-9f7f-405e-a038-01d1345bee88.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eBone Quality in Elderly Patients with Type 2 Diabetes Mellitus\u003c/p\u003e","fulltext":[{"header":"Background","content":" \u003cp\u003eType 2 Diabetes Mellitus (T2DM) is one of the most common chronic diseases worldwide. T2DM patients exhibit an increased risk of suffering further complications of the disease, which are mainly due to complex and interconnected mechanisms, such as hyperglycaemia, insulin-resistance, low-grade inflammation and accelerated atherogenesis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In addition, these chronic complications adversely affect multiple organ systems including bones, which have been widely associated with an increased risk of osteoporosis and fragility fractures [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOsteoporosis (OP) is a metabolic bone disease that is characterized by low bone mineral density (BMD) and microarchitectural deterioration in the bone structure, with a higher risk of fragility fractures [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Osteoarthritis (OA) is a metabolically active and dynamic process that involves all joint tissues. OA can lead to mechanical failure, pain and surgical joint replacement with a prosthesis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Clinical and epidemiological studies suggest that OP and OA may coexist in the same patient. BMD values are usually normal or elevated in OA patients at any age, in contrast to OP [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eT2DM is also very frequent in elderly people, and it exhibits high morbidity and mortality. Furthermore, various lifestyle factors contribute to the increased incidence of T2DM, OA and OP [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. On the other hand, patients with T2DM are at significant risk for fragility fractures at skeletal sites, such as the hip, spine and forearm, although these patients often have normal or increased BMD [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A published meta-analysis showed that T2DM patients exhibit a relative risk of 1.7 (95% CI: 1.3 to 2.2) for hip fracture, and surprisingly, BMD was generally higher in patients with T2DM [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The low cortical bone strength and poor bone quality, due to the glycation of bone proteins, may also underlie increased fracture risk in diabetes [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe greater risk of an osteoporotic fracture despite normal or high BMD [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] makes necessary to identify the factors that influence this risk and elucidate diabetes-induced alterations in trabecular bone microarchitecture and bone turnover markers.\u003c/p\u003e \u003cp\u003eThe goal of this study is to analyze trabecular microstructural and mechanical properties from femoral heads using micro-CT, BMD and bone turnover markers (BTM) in patients with T2DM with or without recent fragility fractures in order to examine skeletal outcomes related to this disease and to establish a relative risk assessment method in the clinical setting. In this regard, we hypothesized that Diabetic patients have higher BMD values than expected, and T- score and FRAX can predict fracture but underestimate risk, therefore skeletal properties must be altered in these patients.\u003c/p\u003e "},{"header":"Methods","content":" \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and subjects\u003c/h2\u003e \u003cp\u003eThe study was designed as a cross-sectional study. Subjects were included in a consecutive manner (October 2019 to July 2020). We calculated the sample size with the Granmo sample size and power calculator (v.7.12, IMIM,Spain) (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.imim.es/ofertadeserveis/software-public/granmo/\u003c/span\u003e\u003c/span\u003e), in order to detect a significant standardized mean difference of 0.5 (one size average effect) in BV/TV with a type I error rate of 5% (alpha\u0026thinsp;=\u0026thinsp;.05) and a 90% power (1-beta\u0026thinsp;=\u0026thinsp;.90), we required 7 subjects in each group.\u003c/p\u003e \u003cp\u003eThe studied population consisted of 31 patients (aged 65\u0026ndash;93), the cases group constituted the 14 patients with hip osteoporotic fracture (OP group) undergoing prosthetic hip replacement and the control group constituted the 14 patients with hip osteoarthritis (OA group) but not having any osteoporotic fracture along their life, undergoing total hip arthroplasty. Both groups were subdivided according to the criteria of whether the patient had T2DM. Then the case group was subdivided into OP without T2DM (6 patients) and OP-T2DM (8 patients). Like the control group that was divided into OA without T2DM (7 patients) and OA-T2DM (7 patients) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). 3 patients were excluded, 2 in OP group because not had a normal kidney function and 1 subject in OA group because not had osteoporosis criteria.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe inclusion criterion for the OP patients was to have a current frailty hip fracture (a fall from less than the patient\u0026rsquo;s height without an acceleration mechanism). OA patients could not have been previously diagnosed with osteoporosis or have a history of frailty fracture since the age of 50 nor could they have congenital or acquired dysplasia or avascular necrosis.\u003c/p\u003e \u003cp\u003eThe medical history of all patients was checked and the diagnosis of T2DM for more than 5\u0026nbsp;years was confirmed for the diabetic patients and discarded for the rest of them. All of the T2DM patients have been treated with metformin.\u003c/p\u003e \u003cp\u003eThe exclusion criteria for all the groups included malignant diseases, hyperthyroidism, hyperparathyroidism, multiple myeloma, rheumatoid arthritis, osteomalacia, secondary OP due to corticosteroids or those who were treated with osteoporosis drugs. In addition, patients with congenital or acquired dysplasia or avascular necrosis were excluded from the OA and OA-T2DM groups. In both group of patients had a normal kidney function.\u003c/p\u003e \u003cp\u003eStandardized interviews were used to obtain the following information: age (years), weight (kg), height (cm), body mass index or BMI (kg/m2), use of calcium and vitamin D supplements (none vs. any), use of medication and family history of hip fracture.\u003c/p\u003e \u003cp\u003eWe estimated the 10-year risk of major osteoporotic fracture (clinical spine, hip, forearm, or humerus fracture) and the 10-year risk of hip fracture for each patient by the FRAX\u0026reg; tool, calibrated for Spain (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"https://www.imim.es/ofertadeserveis/software-public/granmo/\" target=\"_blank\"\u003ewww.shef.ac.uk/FRAX/index.htm\u003c/a\u003e\u003c/span\u003e\u003c/span\u003e). The criteria of the Scientific Advisory Council of Osteoporosis in Canada was used to classify the FRAX\u0026reg; scores [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study was approved by the Ethical Review Board of Seville (internal references 2147) and was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. Written informed consent were obtained from all participants. All patients included in the study agreed to donate their bone samples. Arthroplasty was performed in the Orthopaedics \u0026amp; Traumatology Department of the \u0026ldquo;Virgen Macarena\u0026rdquo; University Hospital (Seville, Spain). Because of the difficulty to obtain healthy hip bone donors, the osteoarthritic samples (OA) were considered the reference group since the BMD values classified them as non-osteoporotic.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eBiochemical measurements\u003c/h2\u003e \u003cp\u003eFasting morning blood was drawn and stored at -80\u0026ordm;C. We assessed carboxy-terminal telopeptide of type I collagen (CTX), aminoterminal propeptide of type I procollagen (PINP), parathyroid hormone (PTH) and 25-hydroxyvitamin D (25(OH)D), insuline-like growth factor I (IGF-I) and glycated haemoglobin (HbA1c).\u003c/p\u003e \u003cp\u003ePTH, CTX and P1NP were analyzed by immunoassay by an autoanalyzer COBAS 601 (Roche, Spain); inter-assay CV\u0026thinsp;\u0026lt;\u0026thinsp;5.8%, \u0026lt;\u0026thinsp;7.6% and \u0026lt;\u0026thinsp;4.2% respectively.\u003c/p\u003e \u003cp\u003e25(OH)D were analyzed by direct competitive immunoassay by an autoanalyzer LIAISON (DiaSorin, Italy); inter-assay CV\u0026thinsp;\u0026lt;\u0026thinsp;5.5%. IGF-I was determined using a chemiluminescence immunoassay (CLIA) by an autoanalyzer (IMMULITE 2000, Siemens); inter-assay CV was 6.9%. HbA1c was measured using an autoanalyzer (ADVIA 2400, Siemens; inter-assay CVs was 1%). In all cases, the intra-assay CV was \u0026lt;\u0026thinsp;5%.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eBone mineral density\u003c/h2\u003e \u003cp\u003eBMD of the total hip and femoral neck was measured using a Dual-energy X-ray absorptiometry using the Hologic Discovery W densitometer (Hologic, Inc, Waltham, MA) using the APEX 3.1.1 software. In vivo CV was 2.4% (femoral neck) and 1.1% (total hip).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eMicrostructural and bone material strength\u003c/h2\u003e \u003cp\u003eFemoral heads were stored frozen in phosphate-buffered saline (PBS, Lonza) at -20\u0026nbsp;\u0026deg;C until processing. A cylinder of trabecular bone was extracted from each femoral head and processed as previously optimized and described by our laboratory[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The bone cores were analyzed without further preparation by micro-CT (Skyscan 1172, Bruker micro-CT NV, Kontich, Belgium). The following histomorphometry parameters were measured: bone volume fraction (BV/TV; %), bone surface density (BS/TV; 1/mm), trabecular thickness (Tb.Th; mm), trabecular separation (Tb.Sp; mm), trabecular number (Tb.N; 1/mm), structural model index (SMI) and trabecular bone pattern factor (Tb.Pf; 1/mm).\u003c/p\u003e \u003cp\u003eTo visualize material failure on a microstructural level, compression tests of the bone cores were performed using a micro-mechanical testing device (Material Testing Stage, Bruker micro-CT NV, Kontich, Belgium). The following mechanical parameters were measured: ultimate load (Fult; N), extrinsic stiffness (S; N/mm); work to failure (U; mJ); and intrinsic or material mechanical properties: ultimate stress (σult; MPa); Young's modulus (E; MPa); and toughness (u; MPa).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous variables are presented as the mean and standard deviation (SD). To compare continuous variables with a normal distribution, ANOVA was used with more than two samples, and Student's t-test with two samples; if the distribution was not normal, the Kruskal-Wallis test or the Mann-Whitney U test was used. Normality testing was performed using a combination of the Kolmogorov-Smirnov test. An adjustment for age, analysis of covariance (ANCOVA), was applied in OA group when needed (to compare microstructural and bone material strength parameters). Correlations between variables were examined using the Spearman correlation, which is appropriate for smaller sample sizes with more robust potential outliers. All hypotheses were two-tailed, and a p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Statistical package SPSS 20.0 for Windows (IBM Corp., Armonk, NY, USA).\u003c/p\u003e \u003c/div\u003e "},{"header":"Results","content":"\u003cp\u003eIn order to check whether type 2 diabetes mellitus has a related effect on bone fragility and risk of fracture we compared the microstructural and biomechanical parameters among osteoporotic patients (OP) with type 2 diabetes mellitus (OP-T2DM group) or without T2DM (OP group) with recent fragility fractures, and we also compared between the OA and OA-T2DM group patients. Because of the difficulty in using bone samples from heathy donors, osteoarthritis patients (OA group) were used as non-osteoporotic control as in other studies they have been used [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]. In Tables \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e we observe the anthropometric characteristics, BMD and biochemistry of all the groups. We did not find any significant difference between the values by gender, so we performed the statistical analysis with the total means of the group.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePatient characteristics (total and by gender) and analyzed parameters.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOA\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOA-T2DM\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ep\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eGender (Male/Female)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3/4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2/4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e73.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e73.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e\n\u003cp\u003e72.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e76.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e76.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e\n\u003cp\u003e77.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eBMI (kg/m2)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e33.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e34.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e\n\u003cp\u003e32.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e30.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e25.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e\n\u003cp\u003e31.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e10-year risk of major fracture (FRAX\u0026reg; tool)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e5.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e\n\u003cp\u003e7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e8.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e\n\u003cp\u003e10.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e10-year risk of hip fracture (FRAX\u0026reg; tool)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e\n\u003cp\u003e5.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;11.2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e\n\u003cp\u003e7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eFemoral neck BMD (gHA/cm2)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e0.700\u0026thinsp;\u0026plusmn;\u0026thinsp;0.09\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e0.760\u0026thinsp;\u0026plusmn;\u0026thinsp;.015\u003c/p\u003e\n\u003cp\u003e0.673\u0026thinsp;\u0026plusmn;\u0026thinsp;0.06\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e0.688\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e0.744\u0026thinsp;\u0026plusmn;\u0026thinsp;0.25\u003c/p\u003e\n\u003cp\u003e0.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHip BMD (gHA/cm2)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e0.858\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e0.99\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19\u003c/p\u003e\n\u003cp\u003e0.80\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e0.930\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e\n\u003cp\u003e0.86\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e25-hydroxyvitamin D (ng/mL)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePTH (pg/mL)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e48.0\u0026thinsp;\u0026plusmn;\u0026thinsp;20.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e53.4\u0026thinsp;\u0026plusmn;\u0026thinsp;40.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026beta;-CrossLaps (\u0026micro;g/mL)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.32\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eP1NP (ng/mL)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50.7\u0026thinsp;\u0026plusmn;\u0026thinsp;25.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e37.6\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eIGF-1 (ng/mL)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e57.1\u0026thinsp;\u0026plusmn;\u0026thinsp;16.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e77.0\u0026thinsp;\u0026plusmn;\u0026thinsp;39.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en.s\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHbA1c (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.019\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\"\u003eValues are shown as the means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). n.s. not statistically significant p values\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" style=\"width: 558px;\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePatient characteristics (total and by gender) and analyzed parameters.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth style=\"width: 308px;\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth style=\"width: 87px;\" align=\"left\"\u003e\n\u003cp\u003eOP\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 88px;\" align=\"left\"\u003e\n\u003cp\u003eOP-T2DM\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 24px;\" align=\"left\"\u003e\n\u003cp\u003ep\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 308px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eGender (Male/Female)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 87px;\" align=\"left\"\u003e\n\u003cp\u003e2/4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 88px;\" align=\"left\"\u003e\n\u003cp\u003e2/6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 24px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 308px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 87px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e83.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e83.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e\n\u003cp\u003e84.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 88px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e79.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e74.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\n\u003cp\u003e81.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 24px;\" align=\"left\"\u003e\n\u003cp\u003en.s\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 308px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eBMI (kg/m2)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 87px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e28.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e24.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e\n\u003cp\u003e31.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 88px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e28.47\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e26.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/p\u003e\n\u003cp\u003e29.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 24px;\" align=\"left\"\u003e\n\u003cp\u003en.s\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 308px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e10-year risk of major fracture (FRAX\u0026reg; tool)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 87px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e20.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e13.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9\u003c/p\u003e\n\u003cp\u003e25.0\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 88px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e20.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e24.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e\n\u003cp\u003e19,7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 24px;\" align=\"left\"\u003e\n\u003cp\u003en.s.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 308px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e10-year risk of hip fracture (FRAX\u0026reg; tool)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 87px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e13.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e9.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9\u003c/p\u003e\n\u003cp\u003e16.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 88px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e13.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e21.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e\n\u003cp\u003e19.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 24px;\" align=\"left\"\u003e\n\u003cp\u003en.s\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 308px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eFemoral neck BMD (gHA/cm2)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 87px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e0.493\u0026thinsp;\u0026plusmn;\u0026thinsp;0.06\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e0.538\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e\n\u003cp\u003e0.471\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 88px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e0.437\u0026thinsp;\u0026plusmn;\u0026thinsp;0.06\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e0.354\u0026thinsp;\u0026plusmn;\u0026thinsp;0.03\u003c/p\u003e\n\u003cp\u003e0.453\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 24px;\" align=\"left\"\u003e\n\u003cp\u003en.s.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 308px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHip BMD (gHA/cm2)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 87px;\" align=\"left\"\u003e\n\u003cp\u003e0.712\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10\u003c/p\u003e\n\u003cp\u003e0.813\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04\u003c/p\u003e\n\u003cp\u003e0.662\u0026thinsp;\u0026plusmn;\u0026thinsp;0.09\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 88px;\" align=\"left\"\u003e\n\u003cp\u003e0.608\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10\u003c/p\u003e\n\u003cp\u003e0.517\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04\u003c/p\u003e\n\u003cp\u003e0.625\u0026thinsp;\u0026plusmn;\u0026thinsp;0.09\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 24px;\" align=\"left\"\u003e\n\u003cp\u003en.s.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 308px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e25-hydroxyvitamin D (ng/mL)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 87px;\" align=\"left\"\u003e\n\u003cp\u003e13.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 88px;\" align=\"left\"\u003e\n\u003cp\u003e12.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 24px;\" align=\"left\"\u003e\n\u003cp\u003en.s\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 308px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePTH (pg/mL)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 87px;\" align=\"left\"\u003e\n\u003cp\u003e49.0\u0026thinsp;\u0026plusmn;\u0026thinsp;33.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 88px;\" align=\"left\"\u003e\n\u003cp\u003e77.0\u0026thinsp;\u0026plusmn;\u0026thinsp;34.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 24px;\" align=\"left\"\u003e\n\u003cp\u003en.s\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 308px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026beta;-CrossLaps (\u0026micro;g/mL)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 87px;\" align=\"left\"\u003e\n\u003cp\u003e0.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 88px;\" align=\"left\"\u003e\n\u003cp\u003e0.58\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 24px;\" align=\"left\"\u003e\n\u003cp\u003en.s\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 308px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eP1NP (ng/mL)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 87px;\" align=\"left\"\u003e\n\u003cp\u003e63.6\u0026thinsp;\u0026plusmn;\u0026thinsp;23.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 88px;\" align=\"left\"\u003e\n\u003cp\u003e46.1\u0026thinsp;\u0026plusmn;\u0026thinsp;31.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 24px;\" align=\"left\"\u003e\n\u003cp\u003en.s\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 308px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eIGF-1 (ng/mL)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 87px;\" align=\"left\"\u003e\n\u003cp\u003e73.0\u0026thinsp;\u0026plusmn;\u0026thinsp;45.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 88px;\" align=\"left\"\u003e\n\u003cp\u003e63.8\u0026thinsp;\u0026plusmn;\u0026thinsp;40.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 24px;\" align=\"left\"\u003e\n\u003cp\u003en.s\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 308px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHbA1c (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 87px;\" align=\"left\"\u003e\n\u003cp\u003e5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 88px;\" align=\"left\"\u003e\n\u003cp\u003e6.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 24px;\" align=\"left\"\u003e\n\u003cp\u003en.s\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 523px;\" colspan=\"4\"\u003eValues are shown as the means\u0026thinsp;\u0026plusmn;\u0026thinsp;typical deviation (SD). n.s. is not statistically significant p values\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003e(insert in the text\u003c/em\u003e Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDue to OA patients were younger (73.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u0026nbsp;years) than the other groups, an adjustment for age was applied to the successive statistical analyses. No significant differences were found in weight, height, or BMI between the study groups (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003ey 2). Densitometric parameters were higher in the OA and OA-T2DM groups. We observed significant differences in BMD at the femoral neck and total hip between OA vs OP-T2DM (p\u0026thinsp;=\u0026thinsp;0.000; p\u0026thinsp;=\u0026thinsp;0.008) and between OA-T2DM vs OP-T2DM (p\u0026thinsp;=\u0026thinsp;0.032; p\u0026thinsp;=\u0026thinsp;0.007). While between OA and OP there are significant differences at femoral neck BMD (p\u0026thinsp;=\u0026thinsp;0.001). This indicates that fracture patients have worse BMD values, both at total hip and femoral neck, and OA patients, regardless of whether they have T2DM, their BMD is in normal ranges. The FRAX\u0026reg; 10-year risk of major or hip fracture was higher in OP and OP-T2D patients than OA patients (p\u0026thinsp;=\u0026thinsp;0.004; p\u0026thinsp;=\u0026thinsp;0.001) and with T2DM (p\u0026thinsp;=\u0026thinsp;0.005). The FRAX\u0026reg; 10-year risk of major and hip fracture between the OP and OP-T2DM groups and the OA and OA-T2DM patients were statistically not significant.\u003c/p\u003e\n\u003cp\u003eThe serum levels of the bone turnover markers were also analyzed in all groups. CTX and P1NP were lower in the OA-T2DM patients than the other groups and the highest levels were observed in OP group no significant difference. Vitamin D levels were below 20\u0026nbsp;ng/mL in all groups of patients, without significant differences between groups (Tables\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThree-dimensional reconstruction and micro-CT images were shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. We can observe how the samples of the OA group show a higher BMD than the other groups and how the effect of the T2DM produces a significant deterioration at the macroscopic level in the trabecular bone structure.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMicrostructural indices showed differences in cancellous bone microarchitecture between groups. Most of the studied parameters in osteoporotic subjects, with and without T2DM, and OA-T2DM subjects showed significant differences compared to control group (OA group) (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). The OP, OP-T2DM and OA-T2DM bone samples had smaller BV/TV compared to OA bone biopsies (-53%, p\u0026thinsp;=\u0026thinsp;0.001; -36%, p\u0026thinsp;=\u0026thinsp;0.01; -53%, p\u0026thinsp;=\u0026thinsp;0.001). At the trabecular level, the OP group, OP-T2DM and OA-T2DM, show a lower number of trabeculae, TbN ( -33%, p\u0026thinsp;=\u0026thinsp;0.0013; -32%, p\u0026thinsp;=\u0026thinsp;0.233; -14% p\u0026thinsp;=\u0026thinsp;0.016) and less width of the trabeculae Tb.Th (-37%, p\u0026thinsp;=\u0026thinsp;0.001; -35%, p\u0026thinsp;=\u0026thinsp;0.001; -27%, p\u0026thinsp;=\u0026thinsp;0.000). There are no significant differences with the separation of the trabeculae, although the tendency is to be less in all of them compared to the OA group, Tb.Sp (-10%, -15% and \u0026minus;\u0026thinsp;5%). Furthermore, these three groups also had higher Tb.Pf (in all groups almost 6 times more p\u0026thinsp;\u0026lt;\u0026thinsp;0.02). Among OP group vs OP-T2DM, we found significant differences in SMI parameter (OP: 1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16; OP-T2DM 1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16, p\u0026thinsp;=\u0026thinsp;0.015), the other microstructural indices were no significant differences. These results show that the OA-T2DM patients had similar microstructural characteristics to patients OP and OP-T2DM in trabecular bone characteristics, which indicates that the diabetic disease maintains BMD but the microarchitecture is of poor quality and more fragile.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn order to test whether the strength of the trabecular bone is lower in the T2DM patients (OA-T2DM and OP-T2DM) and OP compared with OA patients, different biomechanical parameters were studied (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). The OA-T2DM, OP-T2DM and OP samples showed lower stiffness because of the structural features and material properties of bone: Young's modulus (-59%, -38% and \u0026ndash; 51%, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.022) and ultimate stress (-61%, -46% and \u0026minus;\u0026thinsp;68%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Toughness (-34%, -51% and \u0026minus;\u0026thinsp;80%, respectively; p\u0026thinsp;=\u0026thinsp;0.021), work to failure (-61%, -54% and \u0026minus;\u0026thinsp;80%, respectively; p\u0026thinsp;=\u0026thinsp;0.005), extrinsic stiffness (\u0026ndash;58%, -38% and-49%, respectively) and ultimate load (-65%, -49% and \u0026ndash; 68%, respectively; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were lower in T2DM groups and the OP group compared with the OA group. The OA-T2DM patients exhibited similar biomechanical parameters to patients with osteoporotic hip fracture (OP) in the trabecular bone, while the OP-T2DM group showed the most impacted values in biomechanical parameters. The statistical power for significant differences (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) for each of the variables studied was calculated, and we always found a higher statistical power of 88% (beta error\u0026thinsp;\u0026lt;\u0026thinsp;12%).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, we found no statistically significant correlations between duration of T2DM or serum levels of HbA1c with microstructural values.\u003c/p\u003e"},{"header":"Discussion","content":" \u003cp\u003eIt is widely accepted by the scientific community that T2DM impairs bone metabolism [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], and the risk of fragility fractures is increased in these patients [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The mechanisms by which the risk of fracture is increased, and this impairment occurs are not clear. In addition, BMD measurements or FRAX\u0026reg; tool cannot predict these risks. Therefore, there is a need to establish a relative risk assessment method in the clinical setting in patients with T2DM to predict possible impacts on bone fracture related to the disease. The purpose of our analysis was to study the impact in the microstructural and bone mechanics in T2DM patients with or without recent fragility fractures and the relationship of these fractures with type 2 diabetes mellitus.\u003c/p\u003e \u003cp\u003eTo verify the influence of T2DM on quantity and quality of trabecular bone tissue from 28 patients, we have assessed BMD, microarchitecture and biomechanical properties of femoral heads from 4 patient groups: OA, OP, OA-T2DM and OP-T2DM. The control group is made up of patients with osteoarthritis, these patients tend to have a localized increase of bone density and/or sclerosis in subchondral bone of the femoral head, but minimal differences in bone density of the femoral neck [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], where we obtained the samples by micro-CT. Moreover, both our diabetic and non-diabetic subjects were undergoing total hip replacement, and therefore the groups should be comparable. Thus, we do not believe presence of osteoarthritis negatively affected our ability to draw conclusions about diabetes vs. non-diabetes. As expected, osteoporotic patients with hip fractures had lower BMD values than osteoarthritic patients, but no differences between osteoporotic patients with and without T2DM were found and neither between the OA group and OA-T2DM. Previous data demonstrated that T2DM patients have normal or increased BMD values [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], even when this variable was normalized by the BMI [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Although it can be prevalent in juveniles, T2DM is very common in the elderly, and it frequently coexists with age-related bone loss [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Therefore, the establishment of risk factors for fragility fractures during ageing should be identified since these factors can contribute to fracture risk in older diabetic patients. In our case, OP-T2DM and OP patients showed BMD values lower than \u0026minus;\u0026thinsp;2.5T (T-score score \u0026lt; -2.5) at all hip sites, which is consistent with the stablished World Health Organization Definitions. We found no differences in BMD between osteoarthritic groups with and without T2DM, and the values of BMD were considered normal or healthy by T-score in these groups. As our BMD values shown, clinical and epidemiological studies suggested an inverse relationship between many parameters studied in OP and OA patients [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The increased BMD may minimize the expected negative effects on bone metabolism caused by diabetes.\u003c/p\u003e \u003cp\u003eThe more relevant data obtained in the present study is based on decrease of the values observed of the bone microarchitecture and biomechanical properties that we tested in the trabecular hip bone of patients with both osteoarthritis and T2DM compared with non-diabetic osteoarthritic patients. Both groups of osteoarthritic patients were similar in terms of age, weight, lifestyle and evolutionary stage of degenerative disease. However, bone strength in the T2DM group was importantly damaged, and it was in a similar range in patients with osteoporotic hip fracture. These results show the negative effect of T2DM on trabecular bone structure and mechanical properties. Our findings are also broadly consistent with reports of lower bone material strength index in patients with T2D compared to non-diabetic controls [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Conversely, improved properties of trabecular bone were noted in subjects with T2DM compared with controls; however, compromised cortical bone microarchitecture (e.g., increased cortical porosity) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] was observed. Cortical bone characteristics were not evaluated in this study, but we demonstrated damage in bone microstructure and the mechanics, which are important elements in trabecular bone quality in these subjects with T2DM [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. We also demonstrated a significant deterioration in these parameters in hip fracture patients. However, a lower quality of trabecular bone was not observed in OP-T2DM patients compared to non-diabetics. Patsch et al. showed similar results in younger people with diabetes using HR-pQCT of the ultradistal and distal radius and tibia [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These data note that diabetic disease is a key factor that is directly involved in the deterioration of bone quality, which is likely responsible for the increased risk of fragility fractures.\u003c/p\u003e \u003cp\u003eWe found no correlation between microstructure parameters and mechanical values with bone turnover markers. OP subjects exhibited more active bone remodeling, primarily because of bone resorption, as evidenced by the significantly higher levels of β-CrossLaps, which is consistent with a previous study [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, a trend of a reduced bone remodeling activity was observed in T2DM patients, which was demonstrated by the lower levels of formation and resorption markers than the respective controls [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Some authors reported defects in bone formation that were produced by a decrease in osteoblast differentiation and an increase in apoptosis in these cells [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. These changes may lead to an imbalance between bone resorption and bone formation [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConsiderable evidence suggests that specific factors, such as poor glycemic control and T2DM duration (e.g., a glycated haemoglobin level\u0026thinsp;\u0026ge;\u0026thinsp;7.5%) [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] exacerbate risk factors in T2DM patients, although this relationship has not been established unequivocally [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In the present study, both groups of diabetic patients were fairly well controlled. The average glycated haemoglobin level was lower than the previously mentioned average [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], and it was not associated with mechanical or microstructural parameters. We did not find a correlation among these values and the duration of diabetic disease, remaining very similar in OP-T2DM and OA-T2DM groups, which is consistent with a previous study [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe FRAX tool revealed that the OP and OP-T2DM subjects showed moderate to high risk. However, OA-T2DM patients of similar age showed low risk probability for both types of fracture, but mechanical and microstructure indicated the opposite risk. These results suggest that effective intervention thresholds for fracture prevention in patients with T2DM might be different than those that are effective for non-diabetic patients, as discussed recently [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the potential of the present entered data obtained from hip bone human samples, our study had several limitations. Our sample size was relatively small although with sufficient power to obtain significant differences between the differences found. Therefore, our results should be eventually confirmed. The lack of cortical bone microarchitecture and histomorphometry indices of the samples is an additional concern. Nevertheless, this study includes BMD, BTM, trabecular bone microarchitecture and mechanical strength measures in T2DM patients with and without recently suffered fragility hip fracture, thus allowing for establishment a relationship between osteoporotic fracture and diabetes.\u003c/p\u003e "},{"header":"Conclusions","content":" \u003cp\u003eOur findings are the first demonstration of compromised trabecular bone microarchitecture and material properties using measurements of human bone biopsies from hip with and without fragility fracture in T2DM subjects. In conclusion, our results show the potential detrimental effects of diabetic disease on bone quality. Furthermore, our results in OA-T2DM subjects confirm that diabetes does not affect BMD, so T2DM affects quality and not bone quantity. These findings emphasize the importance of evaluating diabetic patient using bone markers and bone quality parameters. Therefore, diabetes should be included as a risk factor for osteoporotic fracture in daily clinical practice.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eT2DM: Type 2 Diabetes Mellitus; OP: osteoporosis; OA: osteoarthritis; BMD: bone mineral density; BTM: bone turnover markers; BV/TV: bone volume fraction; Tb.N: trabecular number; Tb.Th; trabecular thickness; SMI: structural model index; Tb.Pf: trabecular bone pattern factor; BMI: body mass index; Fult: ultimate load; S: extrinsic stiffness; U: work to failure; \u0026sigma;ult: ultimate stress; E: Young's modulus; u: toughness; CTX: carboxy-terminal telopeptide of type I collagen; PINP: aminoterminal propeptide of type I procollagen (PINP); PTH: parathyroid hormone; 25(OH)D: 25-hydroxyvitamin D (25(OH)D; IGF-1: insuline-like growth factor I; Hba1C: glycated haemoglobin; CV: confident interval.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003cstrong\u003e: \u003c/strong\u003eWe express our deepest gratitude to all the study participants and staff in the Orthopaedics \u0026amp; Traumatology Department of the Virgen Macarena Hospital (Seville, Spain).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Data curation: MJM and MJMG; Formal analysis, MG, CM and MJMG; Funding acquisition, RPC and MJMG; Investigation, MG, CM, MAMG,MJM; Methodology, CM and MAMG and PA; Project administration, RPC and CM; Visualization, PA and ACD; Writing \u0026ndash; original draft, MG and PA; Writing \u0026ndash; review \u0026amp; editing, PRC and MJMG. All authors have approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The study was financially supported by the Research Project of Excellence, Junta de Andaluc\u0026iacute;a of Spain, grant number CTS-5360/09.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u003c/strong\u003e The data that support the findings of this study are available from the corresponding author, upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e All patients gave informed and written consent to participate in the study. The study has been approved by the Ethical Review Board of Hospital Universitario Virgen Macarena (2147) and was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Departamento de Citolog\u0026iacute;a e Histolog\u0026iacute;a Normal y Patol\u0026oacute;gica, Universidad de Sevilla, Avda. Dr. Fedriani s/n, Sevilla 41009, Spain.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKhazai NB, Beck GR, Umpierrez GE. Diabetes and fractures: an overshadowed association. Curr Opin Endocrinol Diabetes Obes. 2009;16:435\u0026ndash;45. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/MED.0b013e328331c7eb\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamann C, Kirschner S, G\u0026uuml;nther KP, Hofbauer LC. Bone, sweet bone\u0026mdash;osteoporotic fractures in diabetes mellitus. Nat Rev Endocrinol. 2012;8:297\u0026ndash;305. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/nrendo.2011.233\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJackuliak P, Payer J. Osteoporosis, Fractures, and Diabetes. 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J Clin Endocrinol Metab. 2012;97:3240\u0026ndash;50. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1210/jc.2012-1546\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOei L, Zillikens MC, Dehghan A, Buitendijk GHS, Casta\u0026ntilde;o-Betancourt MC, Estrada K, et al. High bone mineral density and fracture risk in type 2 diabetes as skeletal complications of inadequate glucose control: the Rotterdam Study. Diabetes Care. 2013;36:1619\u0026ndash;28. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2337/dc12-1188\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchwartz AV, Margolis KL, Sellmeyer DE, Vittinghoff E, Ambrosius WT, Bonds DE, et al. Intensive Glycemic Control Is Not Associated With Fractures or Falls in the ACCORD Randomized Trial. Diabetes Care. 2012;35:1525\u0026ndash;31. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2337/dc11-2184\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoayeri A, Mohamadpour M, Mousavi SF, Shirzadpour E, Mohamadpour S, Amraei M. Fracture risk in patients with type 2 diabetes mellitus and possible risk factors: a systematic review and meta-analysis. Ther Clin Risk Manag. 2017;13:455\u0026ndash;68. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2147/TCRM.S131945\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Trauma, Fracture, Hip, Diagnostic, Imaging, Osteoporosis, Type 2 Diabetes Mellitus","lastPublishedDoi":"10.21203/rs.3.rs-100157/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-100157/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eType 2 Diabetes Mellitus (T2DM) is one of the most common chronic diseases worldwide and it is associated with an increased risk of osteoporosis and fragility fractures. Our purpose was to analyse microstructural and bone mechanics from femoral heads, markers of bone turnover and bone mineral density in T2DM patients with or without recent fragility fractures. To identify the factors that influence this risk and elucidate diabetes-induced alterations in trabecular bone microarchitecture and bone turnover markers.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The studied population consisted of 28 patients, divided in 4 groups: 6 subjects with hip fracture (OP) without T2DM, 8 patients with hip fracture and T2DM (OP-T2DM), 7 patients with osteoarthritis (OA) without T2DM and 7 patients OA and with T2DM (OA-T2DM). Bone markers, bone mineral density, FRAX score, microstructural and bone material strength from femoral heads and were assessed. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The group with hip fracture presented lower BMD values ​​than OA (p \u0026lt;0.05). The OP, OP-T2DM and OA-T2DM groups showed a decrease in bone volume fraction (BV/TV); trabecular number (Tb.N); trabecular thickness (Tb.Th) and increase of the structural model index (SMI) and trabecular bone pattern factor (Tb.Pf), as microstructure results and Young's modulus or elastic modulus; toughness; ultimate stress; ultimate load; extrinsic stiffness and work to failure, as biomechanical results, regarding OA patients (p \u0026lt;0.05).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eOur results show the negative effect of Type 2 Diabetes Mellitus on trabecular bone structure and mechanical properties. These results emphasize the importance of evaluating diabetic bones using not only bone markers and bone mass, but also bone quality parameters. Therefore, diabetes should be included as a risk factor for osteoporotic fracture in daily clinical practice and in the FRAX tool.\u003c/p\u003e","manuscriptTitle":"Bone Quality in Elderly Patients with Type 2 Diabetes Mellitus","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-11-23 14:27:26","doi":"10.21203/rs.3.rs-100157/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2021-01-22T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-01-13T00:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nSummary: This original investigation reports that type 2 diabetes mellitus adversely affects trabecular bone structure and mechanical properties. The authors recruited 28 patients with or without type 2 diabetes mellitus (T2DM) for duration of at least 5 years, with 6 having hip fracture without T2DM, 8 with hip fracture with T2DM, 7 with osteoarthritis (OA) without T2DM, and 7 with OA with T2DM. Bone parameters including bone markers, bone mineral density (BMD), FRAX scores, and microstructural and bone material strength derived from the femoral heads removed at hip surgery were recorded. The study reports that subjects with osteoporosis with hip fracture had lower BMD than those with OA without hip fracture. Bone histology showed that those with hip fracture with or without T2DM and those with OA with T2DM had lower bone volume fraction, trabecular number and trabecular thickness but not trabecular separation, as well as increased trabecular bone pattern factor and structural model index, with lower bone stiffness as assessed by Young's modulus, ultimate stress, toughness, work to failure, extrinsic stiffness, and ultimate load, compared to those with OA without T2DM. Duration of T2DM and serum hemoglobin A1c did not affect the microstructural values. The study concluded that T2DM adversely affects trabecular bone structure and mechanical properties. \n\nMajor points:\n1) Lines 87-88: How generalizable are these results? The sample size is quite small.\n2) Line 142: The bone cores used for histology were obtained from the femoral heads, rather than using transilial biopsies as is normally done to assess bone histology. Have normal ranges been derived for the femoral head core biopsies in healthy adults in the age range assessed? Were biopsies taken from patients matched for age and sex?\n3) Lines 170-171: Using OA patients without T2DM as controls makes sense, but if this cohort was younger than the other cohorts, would adjustment for age correct the presumably stronger bone histology values in this younger cohort to allow comparison to the other older cohorts?\n4) Lines 299-300: Was cortical bone not able to be assessed because of the effect of OA on the femoral head cortical bone where the biopsies were taken from? If OA affected cortical bone, was trabecular bone assessed in an area in the femoral head not affected by the OA changes?\n5) Table 2: Were patients with osteoporosis treated with vitamin D? Their levels of 25-hydroxyvitamin D are surprisingly low, given that vitamin D treatment has been standard of care for many years.\n6) Tables 1 and 2: The levels of hemoglobin A1c are quite well controlled. This might minimize the effect of T2DM on the skeleton.\n\nMinor points:\n1) Lines 183-185: Were the FRAX scores adjusted for diabetes?\n2) Lines 222-223: Was it surprising that microstructural values did not correlate with duration of T2DM or level of hemoglobin A1c? Some studies have shown effects only in those with less well-controlled diabetes.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. 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Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-12-23T00:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-12-06T00:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThe topic is of interest, methodology is correct and the paper is well-written. However, there are some problems that should be overcome.\nSpecific comments.\n1. although the aim of the study was to draw conclusions in diabetic patients, diabetes has been poorly characterized in the patients. In particular, there is no information about diabetes duration, markers of insulin-resistance and C-petide levels, which appear to play a role in the homeostasis of the bone (Pujia, Endocrine 2017; Maurotti, Calcif Tissue Int. 2020). This information may concur to clarify some of the points discussed by the authors. However, if the above data are not available, a precise discussion should be made.\n2. some references are quite old, especially for the studies regarding the relationship between diabetes and osteoporosis. I suggest to update them.\n3. introduction and discussion are too long, as both focus on the osteoporosis, while the main aim of the study is osteoporosis in diabetes.\n4. in the tables the authors report the abbreviation \"ns\" for variables not significant at the univariate analysis. Exact p-values should be reported.\n5. how diabetes was excluded in non diabetic patients should be indicated\n6. was a diabetes medication other than metformin considered as an exclusion criterium?\n7. clinical implications are lacking.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-11-29T00:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-11-27T00:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-10-18T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-10-17T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-10-17T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"339c92ce-d450-49d9-919c-73aecf600cab","owner":[],"postedDate":"November 23rd, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":1169409,"name":"Orthopedics"}],"tags":[],"updatedAt":"2020-11-23T14:27:26+00:00","versionOfRecord":[],"versionCreatedAt":"2020-11-23 14:27:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-100157","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-100157","identity":"rs-100157","version":["v1"]},"buildId":"rHA-KDH7Qsr4HCuvH75dn","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}