Introduction: Bone mineral density (BMD) is currently the gold standard in predicting osteoporotic fracture, but evidence suggests that over one third of such fractures occur in those with osteopenia or even normal BMD. The level of bone turnover may affect bone quality in these patients independently of BMD. Bone markers have evolved as tools in monitoring anti-resorptive treatment in osteoporosis.

Aims: The aim of this study was to investigate if levels of bone markers in postmenopausal women could be used as an adjunct to BMD measurements in the assessment of fragility fracture risk.

Patients and Methods: 60 postmenopausal women (30 osteoporotic, 30 with normal BDM) were studied. A single BMD measurement by dual energy x-ray absorptiometry (DEXA) enabled categorisation. Serum bone formation markers (bone specific alkaline phosphatase (BSAP) and osteocalcin (OC)), and resorption marker (C-telopetide of type 1 collagen (CTX)), were measured. History of low trauma fracture was documented for each woman.

Results: 36% of the osteoporotic group had experienced at least one fragility fracture. However, the femoral neck and combined spinal BMD in these women was not significantly different from the 64% of osteoporotic women who had no prior fracture. There was also no significant difference in the age of women in both subgroups. Serum bone markers were significantly increased in the osteoporotic fracture subgroup when compared to the non-fracture subgroup and also to the non-osteoporotic controls. The largest increases were seen in the levels of CTX. Smaller increases in all markers were seen when the non-fracture subgroup was compared to the non-osteoporotic control group but these increases did not reach statistical significance.

Conclusions: Bone turnover is significantly increased in postmenopausal osteoporotic women with previous fracture compared to both osteoporotic non-fracture counterparts and non-osteoporotic controls. This suggests higher bone turnover will increase fracture risk in osteoporotic women. It is possible that combining 2 or 3 markers to produce an “index of bone turnover” would be a useful tool when used in addition to BMD to identify those at greatest fracture risk.