New Tools for Assessing Fracture Risk
Phase: NA
Conditions: Osteoporosis, Fracture Risk Assessment
Sponsor: Vanderbilt University Medical Center

Protocol Version #: 9 
 
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Protocol Date: 3/8/2017 
 
 
 
 
 
 
 
 
New Tools for Assessing Fracture Risk 
 
 
 
Jeffry S. Nyman, PhD 
Vanderbilt Orthopaedic Institute 
Hand & Upper Extremity Center 
 Medical Center East, South Tower, Suite. 4200 
Nashville, TN 37232-8774 
 
 
 
 
 
 
 
 
Donald H. Lee, MD1 
Mark D. Does, PhD2 
 
1Vanderbilt Orthopaedic Institute 
Hand & Upper Extremity Center 
 Medical Center East, South Tower, Suite. 3200 
 
2Vanderbilt University Institute of Imaging Sciences 
1161 21st Avenue South, AA-1105 MCN 
 
 
 
 
 
 
 

Protocol Version #: 9 
 
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Protocol Date: 3/8/2017 
 
 
 
Table of Contents: 
 
Study Schema 
1.0 
Background 
2.0 
Rationale and Specific Aims 
3.0 
Animal Studies and Previous Human Studies 
4.0 
Inclusion/Exclusion Criteria 
5.0 
Enrollment/Randomization 
6.0 
Study Procedures 
7.0 
Risks of Investigational Agents/Devices (side effects) 
8.0 
Reporting of Adverse Events or Unanticipated Problems involving Risk to 
Participants or Others 
9.0 
Study Withdrawal/Discontinuation 
10.0 
Statistical Considerations 
11.0 
Privacy/Confidentiality Issues 
12.0 
Follow-up and Record Retention 
13.0 
References 
 
Appendices 
 
A. Screening Form 
B. Study Patient Information Form 
C. Clinical Measurements Form 
D. Advertisement Flyer 
E. Research Match and VICTR Research Notifications Distribution List Templates 
F. Data Variables List 
G. Subject Reimbursement Form 
H. Schedule of Events 
1. Operative Fracture Patients 
2. Healthy Volunteers 
3. Nonoperative Fracture Patients 
 
 
 
 
 
 

Protocol Version #: 9 
 
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Protocol Date: 3/8/2017 
1.0 
Background 
 
Bone fractures are a widespread and costly problem (1). A meta analysis of clinical studies 
concluded that people with type 2 diabetes mellitus (T2D) are at a higher-than-expected 
risk of a hip fracture than those who do not have the disease (2). Costs associated with 
treating osteoporotic fractures alone exceed $17.5 billion annually in the US (3), and the 
elderly who sustain a hip fracture are 4.6 (men) and 2.8 (women) times more likely to die 
within a year (4). Despite the economic burden to society and poor quality of life that 
fractures impose, the cause for the disproportionate increase in fracture risk with aging and 
T2D is unknown. 
 
 
Beyond bone strength and aBMD to assess fracture risk 
Traditionally, osteoporosis is viewed as a problem of low bone density causing reduced 
bone strength. However, there is a well-known disproportionate increase in fracture risk 
relative to the age-related decrease in bone density (5-8), which is commonly attributed to 
certain limitations in the clinical measurement of aBMD. Namely, DXA is a projection 
method that does not discern the relative contribution of macro-structure, micro-
architecture, collagen integrity, or porosity to fracture resistance. This is one reason why 
the NIH held a conference on bone quality defining it as “the sum total of characteristics of 
the bone that influence the bone’s resistance to fracture” (9) and the reason why the World 
Health Organization developed FRAX, an on-line fracture risk calculator using risk factors as 
input (10). To date, there is no definitive bone quality measurement that improves the 
assessment of fracture risk, and FRAX still underestimates risk for certain prevalent 
diseases like diabetes (11). Thus, what would be useful to improving clinical care is a 
diagnostic assessment that actually relates to the mechanism by which aging and 
diabetes lowers fracture 
resistance. 
 
Reference Point Indentation 
(RPI) measurements 
discriminate fracture patients 
from non-fracture patients 
In a hospital in Barcelona, RPI 
was performed using the BioDent 
instrument on the tibia mid-shaft 
of 27 women (79.1 ± 7.8 years) 
recovering from an osteoporotic 
fracture and 8 controls with a 
similar age range (83.2 ± 5.3 
years) (12). The indentation 
distance increase (IDI) for the 
fracture patients was 47% 
greater (i.e., more susceptible to 
damage formation) than for the 
non-fracture patients (p=0.008). 
In a follow-up study, the same 
research team performed similar 
RPI tests for 4 groups of patients: 
20 with no history of a fracture 
 
Fig. 1: The bone micro-anatomy gives rise 3 T2 components 
when analyzed by 1H NMR spectroscopy.   One of these 
components, bound water correlates with the fracture 
toughness (KIc) of bone. 

Protocol Version #: 9 
 
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Protocol Date: 3/8/2017 
or bisphosphonate (BP) use, 38 with typical hip fractures, 6 with atypical fractures (below 
lesser trochanter), and 6 on BP for 5 to 12 years (but no fracture). Total indentation 
distance (TID) and IDI were significantly higher (worse) for the fracture cases than for the 
non-fracture cases (no difference between typical and atypical). The proposed project aims 
to assess a new, hand-held RPI instrument (OsteoProbe) for its ability to discriminate 
osteoporotic bone from normal bone in comparison to the clinical gold standard DXA. 
Although the bone measurement from OsteoProbe at the tibia mid-shaft was found to be 
different between women with and without type 2 diabetes (13), there is currently no 
evidence that it is any better than DXA in predicting fracture risk. 
 
Other New Assessment Tools for Fracture Resistance Assessment 
 
Current efforts in the labs of the Co-PI Dr. Nyman and his collaborators to improve fracture 
prediction include Raman spectroscopy (RS) (14-15), (NMR) relaxometry (i.e., 
quantitative, sub-voxel MRI) (16-17), and reference point indentation (RPI). All these 
techniques can potentially be translated to the clinical assessment of bone, but NMR/MRI 
(18,19) and RPI (12,20) are closest to providing clinically useful information about bones. 
Moreover, the NMR technique can be combined with other MRI approaches that provide 
structural and architectural parameters of bone (21). 
 
After establishing the biophysical origins of proton signals within human cortical bone 
using NMR relaxometry (Fig. 1) (17), we reported that bound water can explain the age-
related decrease in the material strength of human cortical bone (r2=62%, p<0.001) (22) 
and that loosely bound water detected by NMR contributes to bone toughness (16). Perhaps 
more relevant to diabetes and aging effects on bone, we found that bound water also 
correlates with the ability of bone to resist crack propagation (Fig. 1). We hypothesize that 
increasing pore water (intra-cortical porosity) and decreasing bound water (surrogate of 
‘matrix quality’) makes bone susceptible to fracture. 
 
BioDent-RPI is a relatively new analytical technique that provides properties related to the 
ability of tissue to resist micro-indentation (a micron-size probe tip penetrates bone tissue 
over 10-20 cycles in force control). As such, the best way to quantify resistance to 
indentation is still an unresolved issue, and differences in RPI properties are likely context 
or disease dependent. Thus, we performed a series of experiments to show that RPI i) is 
sensitive to bone tissue organization (anisotropy), ii) provides significant correlations, 
albeit weak, with apparent bone fracture toughness (r2=24%, p<0.05), and iii) resistance to 
indentation decreases with age (manuscript under review). We hypothesize that low 
resistance to indentation is indicative of fragile bone. 
 
Innovation 
The proposed studies are based on i) novel view that water, collagen, and damage are 
important to fracture resistance, ii) state-of-the-art analysis tools that go beyond bone mass 
to quantify properties of the matrix, and iii) unique access to patients with clear differences 
in fracture resistance through an orthopaedic clinical at VUMC that fixes 100 distal radius 
fractures per year. These studies have the potential to i) shift the paradigm of bone health to 
one that includes characteristics of the bone matrix and its contribution to microdamage 
resistance, and ii) transform the manner in which clinical diagnostic methods for bone 
health are developed, from solely X-ray based to include MRI-based and mechanical 
characterization tools. 

Protocol Version #: 9 
 
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Protocol Date: 3/8/2017 
 
2.0 
Rationale and Specific Aims 
 
The goal of this study is to determine whether two new, non-X-ray techniques can 
discriminate between high-energy fractures of normal bone (trauma) and low-energy 
fractures (fragility) of osteoporotic bone. The current gold-standard for assessing fracture 
risk − areal bone mineral density (aBMD) by dual energy X-ray absorptiometry (DXA) − is 
not particularly effective at identifying individuals who are at risk of suffering a fracture (5, 
23-25). Yet, there is a growing population of diabetics and elderly individuals prone to 
fractures (6, 26-28). In effect, the age-related and diabetes-related increase in fracture risk 
is independent of a person’s aBMD (6, 7, 29, 30). These findings stress the urgency in 
developing diagnostic tools that can improve fracture risk prediction so that patients can be 
treated with the appropriate anti-fracture therapies. 
 
Shifting from the current paradigm of using X-ray based modalities to assess fracture risk, 
the reference point indentation (RPI) method acquires direct measurements of ‘material 
quality’ of the bone tissue (31), while magnetic resonance imaging (MRI) assesses bound 
water and pore water concentrations that relate to the material properties of cortical bone 
(18,22). Specifically, the OseteoProbe-RPI engages the patient’s bone, and upon applying an 
impact force, it measures the ability of the tissue to resist micro-indentation. Recently, this 
measurement − currently known as bone material strength (BMS) − was found to be lower 
in post-menopausal women with type 2 diabetes than age-matched women without 
diabetes (13). Our novel MRI methods utilize relaxation-selective preparations with ultra-
short echo-time (UTE) acquisition to separately measuring bound and pore water 
concentrations on bone (19), which we postulate to reflect matrix quality and porosity (16). 
Despite the encouraging results from studies applying RPI and UTE-MRI to bone, there is no 
evidence that a local measurement of bone material quality or bulk measurements of bound 
and pore water are predictive of fracture resistance at sites that are prone to fragility 
fractures.  
 
By affirming the ability of these tools to discriminate a fragility (osteoporotic) fracture from 
high-energy (trauma) fracture, the proposed study will provide justification for large 
prospective studies that i) evaluate the ability of these techniques to predict fracture, ii) 
assess whether these techniques are informative on how drug therapy is affecting bone, and 
iii) whether intra-operative RPI is useful to surgical guidance (e.g., placement of bone 
screws). 
 
AIM 1: DETERMINE WHETHER INDENTATION RESISTANCE IS DIFFERENT BETWEEN PATIENTS WITH 
FRAGILITY FRACTURES AND THOSE WITH HIGH ENERGY FRACTURES. 
Hypothesis: Local indentation resistance (BMS) of the distal one-third radius is lower for 
patients with a fragility wrist fracture than healthy patients with a traumatic wrist fracture. 
Approach: Men and women (>18 y.o.) undergoing surgery to fix a distal radius fracture 
involving the metaphysis will be recruited into the study. Exclusion criteria will include 
known risk factors of pathological fractures (e.g., bone metastasis) and long-term or recent 
treatment for osteoporosis (e.g., bisphosphonate). In addition to standard-of-care, the 
orthopaedic surgeon will indent the cortex between the one-third distal radius (10-15 sites 
separated by 2 mm) and the ultradistal (UD) site with the OsteoProbe prior to stabilizing 
the fracture with a volar plate. The patient’s arm will be secured to prevent rotation of the 
bone. Postoperatively, the patient’s hips, spine, and contra-lateral radius will be imaged by 
DXA to determine aBMD following standard protocols at the Vanderbilt Clinical Research 

Protocol Version #: 9 
 
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Protocol Date: 3/8/2017 
Center (CRC). Patients will be stratified into two groups: high-energy fracture (e.g., motor 
vehicle crash) of normal bone and low-energy fracture (e.g., fall from a chair or standing 
height) of osteoporotic bone. We expect BMS to be less for the fragility fractures than for 
non-osteoporotic fractures. In addition, the lower BMS for the fragility fracture group will 
be significant when including aBMD, age, and body mass index (BMI) as covariates. 
 
AIM 2: DETERMINE WHETHER BOUND WATER AND PORE WATER ARE DIFFERENT BETWEEN 
PATIENTS WITH FRAGILITY FRACTURES THAN THOSE WITH HIGH ENERGY FRACTURES. 
Hypothesis:  Bulk bound and pore water of the distal one-third radius will be lower and higher, 
respectively, for patients with fragility wrist fractures than healthy patients with a traumatic 
wrist fracture. 
Approach: Postoperatively, patients in Aim 1 may also have their contralateral arm (distal 
one-third) imaged by our unique UTE-MRI technique (Philips Achieva 3T scanner) using 
wrist coil at the VUIIS. By including reference markers in the scan, the average 
concentration of bound water and pore water (mol 1H per bone volume) will be quantified 
for a 14 mm axial segment (0.5 mm in-plane resolution). We will also image age-matched 
and gender-matched individuals without a history of fractures to the operative fracture 
patient group. We expect the fragility fracture patients to have significantly less bound 
water and more pore water than high-energy fracture patients and non-fracture patients, 
and this difference will be significant after adjusting for aBMD and BMI. In addition, bound 
water will be less and pore water more for the elderly fragility fracture group than for the 
elderly non-fracture group (also adjusting for aBMD).  A group of non-operative distal 
radius fracture patients will also be recruited to undergo a DXA scan at the CRC and some of 
those patients will be asked to undergo an MRI scan at VUIIS. 
 
3.0 
Animal Studies and Previous Human Studies 
 
PRELIMINARY STUDIES 
 
Since we were able to successfully apply the BioDent-RPI instrument to human cortical 
bone, we became intrigued about the possibility of using the newer RPI instrument from 
Active Life Scientific, Inc., known as the OsteoProbe®. Unlike the BioDent® that indents the 
bone over 10 to 20 cycles at a target force of 10 N, the OsteoProbe-RPI indents the bone 
with one impact load reaching a target force of 40-45 N (31) and recording the indentation 
depth. The probe tip geometry of the micro-indenter is the same between the BioDent and 
the OsteoProbe, but the higher force generated by the OsteoProbe causes greater wear of 
the tip. Therefore, indentation depth into bone is normalized by the indentation depth into a 
reference block of plastic, thereby accounting for any subtle changes in tip surface 
geometry. The inventors called this ratio bone material strength (BMS), although this 
normalized indentation depth or Index is not necessarily a measure of strength. The 
misnomer aside, the OsteoProbe has the advantage of being a hand-held instrument. As long 
as the OsteoProbe tip is normal to the bone surface (± 10°), there is enough internal spring 
force to properly trigger the impact force. In effect, an orthopaedic surgeon who has 
exposed a bone during surgery can use the OsteoProbe intra-operatively. 

Protocol Version #: 9 
 
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Protocol Date: 3/8/2017 
 
To examine the feasibility of indenting a 
patient’s bone with the OsteoProbe, we 
hypothesized that BMS differs between the 
thicker, less porous tibia mid-shaft and the 
thinner, more porous forearm bones (proximal 
humerus and distal radius), but that the 
measurements at the tibia correlate with those 
acquired from forearm bones. Distal radius, 
tibia mid-shaft, and proximal humerus (left and 
right side) were acquired from 10 cadavers 
(half males and half females; 78 yo to 98 yo). 
While keeping the bones moist with phosphate 
buffered saline, 8 indents were performed in a 
row (~3 mm spacing) using the OsteoProbe-
RPI (Fig. 2). BMS was the depth of the indent 
divided by the mean indentation depth into a 
PMMA standard (performed 8 times with each new tip 
and each donor). To determine whether BMS varied 
along the length of the bone, each BMS value per bone 
was normalized to the mean BMS among the 8 indents for 
each donor, and then these relative BMS values were 
plotted as a function of location of the indent (Fig. 2). In 
doing so, BMS increased moving from the thinner 
metaphysis (distal) to the thicker diaphysis portion 
(proximal) of the radius. We will indent the cortex 
between the one-third distal radius (10-15 sites separated 
by 2 mm) and the ultradistal (UD) site. Even though BMS 
varied among the anatomical locations but not between 
the left and right side (Fig. 3), tibia BMS directly 
correlated with proximal humerus BMS (avg of 8: r=0.69, 
p=0.027). Tibia BMS and distal radius BMS did not 
correlate (p=0.19). We will indent distal radius before 
fracture fixation to determine whether BMS differs 
between fragility fracture and high-energy fracture cases. 
Interestingly, BMS correlated with intra-cortical porosity 
as determined by high-resolution, micro-computed 
tomography (6 μm), especially for the distal radius (Fig. 
4). This raises the intriguing possibility that the 
OsteoProbe-RPI is sensitive to micro-structure and tissue 
quality, two determinants of 
fracture resistance. Even 
though some of the bones had 
a thin cortex, the indent did 
not punch through the cortex 
(Fig. 4). 
 
To translate and evaluate an 
in-vivo MRI protocol for 
Fig. 2. Location of indents for each cadaveric bone as performed 
by the hand-held OsteoProbe-RPI (Right). 
 
Fig. 3. Indentation resistance (bone material 
strength) increased from thinner metaphysis 
to thicker diaphysis of the distal radius. BMS 
varied among the different bones. 
 
Fig. 4. μCT images of the indent and pores for 
the thick cortex of the tibia med-shaft (above) 
and thin cortex of the radius (middle). BMS is 
negatively related to porosity. 

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Protocol Date: 3/8/2017 
quantitative mapping of bound and pore water concentrations in cortical bone, UTE imaging 
sequences (19) were implemented on a clinical 3T scanner. Images of the lower leg and 
wrist were acquired on three subjects (mean age 33, M/F 1/2) to generate bound and pore 
water concentration maps of the tibia and radius (Fig. 5). Inter-scan variability in bound 
water maps ranged from 3-13% (mean 7%) in the tibia and 1-23 % (mean 10%) in the 
radius. Pore water maps showed inter-scan variability ranging from 5-18% (mean 10%) in 
the tibia and 8-27% (mean 17%) in the radius. With the addition of a new wrist coil for the 
3T scanner, we anticipate a reduction in inter-scan variability by 2-4x. 
 
4.0 
Inclusion/Exclusion Criteria 
 
Inclusion/exclusion criteria for patients with a high-energy or fragility fracture requiring 
operative fixation (Arm 1) 
 
Number of patients in Arm#1= 60 patients 
Inclusion criteria: 
1. Patients who are 18 years of age or older. This age range accounts for 60% of all 
distal radius fractures seen at Vanderbilt University Medical Center. 
2. Patients who have sustained a low or high energy distal radius fracture that involves 
the metaphysis and requires open reduction internal fixation using volar plating.   
3. English speaking due to feasibility of employing study personnel to deliver and 
assess study intervention.   
 
Exclusion criteria: 
1. Patients who have known risk factors of pathologic fractures (e.g. bone metastasis) 
2. Patients who have received treatment for osteoporosis (e.g. bisphosphonate) within 
the last 5 years or whose treatment lasted longer than 5 years 
3. Patients who have Type 1 diabetes 
4. Patients who have other bone disease (e.g., osteogenesis imperfecta, Paget’s disease, 
thyroid disease, Vitamin D deficiency, hyperparathyroidism) 
5. Patients that have a history of cancer, abnormal serum calcium, or chronic steroid 
use 
6. Patients that would not be able to have a DXA scan (weight >350lbs, hardware in 
hips, patients that have lap band device) 
7. Patients who are pregnant or who think they may be pregnant 
8. Patients that have a medical contraindication to MRI (if patients are undergoing a 
study MRI) 
9. Patients who have concurrent, bilateral upper extremity fractures where hardware 
or casting may affect study scan measurements 
10. Patients who have distal radial shaft fractures 
 
Exclusion criteria 1-5 are included because the goal of the study is to demonstrate 
whether new bone measurements differentiate normal bone from fragile bone. These 
exclusion criteria eliminate confounding factors that affect fracture resistance of bone in 
ways that are independent of osteoporosis. Exclusion criteria 6-8 are practical since 
DXA/MRI scans cannot accommodate all people. 
 
Inclusion/exclusion criteria for patients with no fracture (Arm 2) 
 
Number of patients in Arm#2= 40 patients 

Protocol Version #: 9 
 
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Protocol Date: 3/8/2017 
Inclusion criteria: 
1. Patients who are 18 years of age or older.  
2. Patients who have no history of fracture or family history of pathologic fracture 
3. English speaking due to feasibility of employing study personnel to deliver and 
assess study intervention.   
 
Exclusion criteria: 
1. Patients who have received treatment for osteoporosis (e.g. bisphosphonate) within 
the last 5 years or whose treatment lasted longer than 5 years 
2. Patients who have Type 1 diabetes 
3. Patients who have other bone disease (e.g., osteogenesis imperfecta, Paget’s disease, 
thyroid disease, Vitamin D deficiency, hyperparathyroidism). 
4. Patients that have a history of cancer, abnormal serum calcium, or chronic steroid 
use. 
5. Patients that would not be able to have a DXA scan (weight >350lbs, hardware in 
hips, patients that have lap band device) 
6. Patients who are pregnant or who think they may be pregnant. 
7. Patients that have a medical contraindication to MRI. 
 
Exclusion criteria 1-5 are included because the goal of the study is to demonstrate 
whether new bone measurements differentiate normal bone from fragile bone. These 
exclusion criteria eliminate confounding factors that affect fracture resistance of bone in 
ways that are independent of osteoporosis. Exclusion criteria 6- 8 are practical since 
DXA/MRI scans cannot accommodate all people. 
 
Inclusion/exclusion criteria for patients with a high-energy or fragility fracture requiring 
nonoperative treatment (Arm 3) 
 
Number of patients in Arm#3= up to 10 patients 
Inclusion criteria: 
1. Patients who are 18 years of age or older. This age range accounts for 60% of all 
distal radius fractures seen at Vanderbilt University Medical Center. 
2. Patients who have sustained a low or high energy distal radius fracture that 
requires nonoperative treatment   
3. English speaking due to feasibility of employing study personnel to deliver and 
assess study intervention.   
 
Exclusion criteria: 
1. Patients who have known risk factors of pathologic fractures (e.g. bone metastasis) 
2. Patients who have received treatment for osteoporosis (e.g. bisphosphonate) within 
the last 5 years or whose treatment lasted longer than 5 years 
3. Patients who have Type 1 diabetes 
4. Patients who have other bone disease (e.g., osteogenesis imperfecta, Paget’s disease, 
thyroid disease, Vitamin D deficiency, hyperparathyroidism) 
5. Patients that have a history of cancer, abnormal serum calcium, or chronic steroid 
use 
6. Patients that would not be able to have a DXA scan (weight >350lbs, hardware in 
hips, patients that have lap band device) 
7. Patients who are pregnant or who think they may be pregnant 

Protocol Version #: 9 
 
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Protocol Date: 3/8/2017 
8. Patients that have a medical contraindication to MRI (if patients are undergoing a 
study MRI) 
9. Patients who have concurrent, bilateral upper extremity fractures where hardware 
or casting may affect study scan measurements 
 
Exclusion criteria 1-5 are included because the goal of the study is to demonstrate 
whether new bone measurements differentiate normal bone from fragile bone. These 
exclusion criteria eliminate confounding factors that affect fracture resistance of bone in 
ways that are independent of osteoporosis. Exclusion criteria 6-8 are practical since 
DXA/MRI scans cannot accommodate all people. 
 
This study will proceed until all eligible patients have been enrolled and have completed 
their follow-up.  
 
Randomization 
There is no randomization aspect to this study. 
 
5.0 
Enrollment/Randomization 
 
In this prospective, clinical trial we will enroll 60 patients set to undergo volar plate fixation 
for a distal radius fracture and up to 10 patients receiving nonoperative treatment for a 
distal radius fracture.  Operative patients will be stratified into two groups: 30 high-energy 
fractures of otherwise normal bone (e.g. motor vehicle crash) and 30 low-energy fractures 
of osteoporotic bone (e.g. fall from a chair or standing height). Patient study eligibility will 
be determined through a weekly assessment of the electronic clinic schedule, patient 
medical records, consultation visits, and by Vanderbilt Hand & Upper Extremity surgeons 
during preoperative/initial treatment clinical visits.  If the patient is determined to be 
eligible for the study the treating physician (attending, resident, or fellow) will explain the 
study to the patient and ask if they would like to participate.   
 
Physical Consent Form Process: 
If the patient agrees they will be asked to review/sign an informed consent document by 
the treating physician or other key study personnel. During this time the patient will be 
given the opportunity to ask any questions they may have about the study.  If the patient 
signs the consent form, the investigator or key study personnel will provide them with a 
copy of the signed form and a study contact number to call if they have any further 
questions. Consent will take place in the confines of a private area (e.g. clinic room). 
 
REDCap-based Electronic Consent Form: 
The patient consent process may be conducted using a Redcap-based electronic consent 
form.  The consent form has been developed in REDCap, a secure, web-based, HIPAA-
compliant, data collection platform with a user management system allowing project 
owners to grant and control varying levels of access to data collection instruments and data 
(e.g. read only, de-identified data views) for other users.  Potential participants may 
participate in the consent process by: being approached in-person at VUMC and accessing 
the REDCap survey via iPad or other portable electronic device.  During the in-person 
consent process, patients will be consented by a member of the key study personnel.  
Patient signatures will be obtained using a typed or written-signature (via stylus/cursor, 
etc.).   Upon completion of the consent, patients will be provided with a copy of their version 

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Protocol Date: 3/8/2017 
of the consent document by printing a pdf copy of the consent form in clinic/hospital or by 
providing a home address for mailing of a hard copy of the consent.   
 
In addition to the 60 operative and 10 non-operative distal radius fracture patients, we will 
enroll 40 healthy volunteers who have no history of a fracture. The age and gender of these 
individuals will be selected to match the demographics of the distal radius fracture patients 
requiring operative fixation.  These individuals will be recruited from the metropolitan 
Nashville community.  The means of advertising will include flyers placed in prominent 
campus and community locations, VICTR research notifications distribution list and 
ResearchMatch (Appendix E), and word-of-mouth.  A potential subject responding to one of 
these notifications would call key study personnel.  Initial screening will take place over the 
phone.  Key study personnel will explain the study to the volunteer and give them an 
opportunity to ask any questions they may have.  If the subject is still interested and eligible 
they will be scheduled for an enrollment visit, a DXA scan and an MRI.  At the enrollment 
visit, key study personnel will again explain the study to the study volunteer and ask if they 
would like to participate.  If the study volunteer agrees they will be asked to review/sign an 
informed consent document.  During this time the volunteer will be given another 
opportunity to ask any questions they may have about the study.  If the volunteer signs the 
consent form, key study personnel will provide them with a copy of the signed form.  
Consent will take place in the confines of a private area (e.g. meeting room). 
 
6.0 
Study Procedures 
 
Arm 1- Patients with a high-energy or fragility fracture requiring operative fixation 
 
Enrollment/Initial Visit- Study patient eligibility will be determined through a 
weekly assessment of the electronic clinic schedule, patient medical records, 
consultation visits, and by Vanderbilt Hand & Upper Extremity surgeons during 
preoperative clinical visits.  The aforementioned inclusion/exclusion criteria will be 
used to determine eligibility.  All patients who meet the general inclusion/exclusion 
criteria for Arm 1 and have elected to undergo routine volar plate fixation for their 
distal radius fracture will be asked to participate in the study by key study 
personnel.  If the patient agrees to participate they will be asked to review/sign an 
informed consent document.  Patients will also be asked to complete the following 
surveys: DASH (Disability of Arm, Shoulder, and Hand) and PRWE (Patient Rated 
Wrist Evaluation).  Patients enrolled electronically may have an opportunity to 
complete the DASH and PRWE surveys online using Redcap.   
 
Operative Visit- Patients will undergo a routine volar plate fixation for their distal 
radius fracture.  Once the patient has been anesthetized and prior to stabilizing the 
fracture with a volar plate, the patient’s arm will be secured and the orthopaedic 
surgeon will indent the area between the one-third distal radius and the ultradistal 
(UD)  at 10 to 15 locations (~2 mm apart) using the OsteoProbe-RPI.  The indent 
size is approximately ~300 μm in diameter and ~300 μm in depth.   
 
DXA/MRI Visit - Postoperatively, the patient will visit the Vanderbilt Clinical 
Research Center (CRC) to undergo a DXA scan of their hips, spine, and contralateral 
radius.   In addition, the patients will undergo an MRI of their contralateral radius at 
the VUIIS Human Imaging Core (which is near the CRC).  We will attempt to 
schedule this MRI on the same day that they have their DXA scan scheduled.  All 

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Protocol Date: 3/8/2017 
imaging will be performed within FDA safety guidelines. All female participants of 
child-bearing potential will be asked to undergo a serum pregnancy test at the CRC 
prior to the DXA scan.   
 
Postoperative Visit- Patients will be seen postoperatively in the clinic based on 
standard of care guidelines. This typically corresponds to visits at 8-10 days, 3 
weeks, 6 weeks, and 12 weeks, although these are not mandated dates. During these 
routine postoperative clinic visits the following will be recorded for research 
purposes: bilateral grip strength (12 week), pinch strength (12 week), and range of 
motion (6 & 12 weeks) measurements.  In addition, patients will also be asked to 
complete the following surveys: DASH and PWRE (3, 6, & 12 weeks).   
 
Osteoprobe Sterilization 
Each probe tip will be new and sterilized.  The PMMA block will be disinfected 
following standard sterilization procedures.  All patient bone indentations will be 
taken using the Osteoprobe and then the PMMA block will be indented.  The 
Osteoprobe will not be used on the patient following indentation of the PMMA block.  
The RPI instrument will be covered with a sterilized sleeve. 
 
Arm 2- Patients with no fracture (Healthy Volunteers) 
 
Enrollment Visit- The aforementioned inclusion/exclusion criteria will be used to 
determine eligibility for healthy volunteers.  All volunteers who report to Vanderbilt 
Hand Center to take part in this study will be asked to review/sign an informed 
consent document.  Healthy study participants will also be asked to complete a 
DASH questionnaire.   
 
DXA/MRI Visit- Healthy study participants will visit the Vanderbilt Clinical Research 
Center (CRC) to undergo a DXA scan of their hips, spine, and forearm (side chosen at 
random).  In addition, the participants will undergo an MRI of the same forearm 
scanned by DXA at the VUIIS Human Imaging Core (which is near the CRC).  All 
imaging will be performed within FDA safety guidelines. All female participants of 
child-bearing potential will be asked to undergo a serum pregnancy test at the CRC 
prior to the DXA scan.   
 
Arm 3- Patients with a high-energy or fragility fracture requiring non-operative 
treatment 
 
Enrollment/Initial Visit- Study patient eligibility will be determined through a 
weekly assessment of the electronic clinic schedule, patient medical records, 
consultation visits, and by Vanderbilt Hand & Upper Extremity surgeons during 
initial clinical visits.  The aforementioned inclusion/exclusion criteria will be used to 
determine eligibility.  All patients who meet the general inclusion/exclusion criteria 
for Arm 3 and have elected to undergo nonoperative treatment for their distal 
radius fracture will be asked to participate in the study by key study personnel.  If 
the patient agrees to participate they will be asked to review/sign an informed 
consent document.  Patients will also be asked to complete the following surveys: 
DASH (Disability of Arm, Shoulder, and Hand) and PRWE (Patient Rated Wrist 
Evaluation). 
 

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Protocol Date: 3/8/2017 
DXA/MRI Visit - Patients will visit the Vanderbilt Clinical Research Center (CRC) to 
undergo a DXA scan of their hips, spine, and contralateral radius.   In addition, the 
patients may undergo an MRI of their contralateral radius at the VUIIS Human 
Imaging Core (which is near the CRC).  We will attempt to schedule this MRI on the 
same day that they have their DXA scan scheduled.  All imaging will be performed 
within FDA safety guidelines. All female participants of child-bearing potential will 
be asked to undergo a serum pregnancy test at the CRC prior to the DXA scan.   
 
Follow-up Visits- Patients will be seen in the clinic based on standard of care 
guidelines. This typically corresponds to visits at 8-10 days, 1, 2, 3, 4, 6, 8, 12, and 16 
weeks post-treatment, although these are not mandated dates. During some of these 
routine follow-up clinic visits the following will be recorded for research purposes: 
bilateral grip strength (12 week), pinch strength (12 week), and range of motion (6 
& 12 weeks) measurements.  In addition, patients will also be asked to complete the 
following surveys: DASH and PWRE (3, 6, & 12 weeks).   
 
7.0 
Risks 
 
Potential Risks: 
 
Infection Risk (Arm 1 only): 
As with any surgical procedure there is a slight risk of infection. To minimize this 
risk, the OsteoProbe-RPI probe tip used to indent bone will be new and sterilized.  
The PMMA block will be disinfected prior to surgery.  All patient bone indentations 
will be taken using the Osteoprobe and then the PMMA block will be indented.  The 
Osteoprobe will not be used on the patient following indentation of the PMMA block.  
In addition, a sterilized sleeve will cover all other portions of the OsteoProbe 
machine that are located in the sterile, surgical field of the operating room.   During 
the routine surgical procedure, the patient will be anesthetized so the use of the 
OsteoProbe-RPI instrument should not cause any discomfort or pain to the patient. 
The indent is much smaller than the bone screws that will secure the fracture plate. 
 
Radiation Risks: 
All study participants will undergo a DXA scan to measure their areal bone mineral 
density (aBMD), which will slightly increase their radiation exposure.  The amount 
of radiation they receive from the DXA scan will be equivalent to exposure during a 
flight from Nashville to Denver or one day of exposure to natural background 
radiation.  Study participants who are pregnant will be excluded from participating 
in this study due to the DXA scan requirement. 
 
MRI Risks:  
Some study participants may be undergoing an MRI to measure pore and bound 
water.  MRIs do not use ionizing radiation so there are no known harmful side-
effects associated with temporary exposure to the strong magnetic field used by 
MRI scanners. However, risks of MRI include: 
• 
Ferromagnetic objects brought into the room will be pulled toward the 
magnet. 
• 
If a subject has implanted metal or medical devices they may experience 
abnormal torques or fail to function properly. 
• 
There is a risk of tissue heating if there is excessive power deposition of 

Protocol Version #: 9 
 
14 
Protocol Date: 3/8/2017 
radio-frequency electromagnetic waves. 
• 
There is a risk of peripheral nerve stimulation if gradients are switched too 
rapidly. 
• 
The subjects may experience a claustrophobic reaction when in the magnet. 
• 
There are loud banging noises with MR imaging that may be uncomfortable. 
 
Breach of Confidentiality Risk: 
Because patient data is being collected there is a slight risk of a breach of 
confidentiality.  To reduce this risk, most study data will be maintained in the 
Vanderbilt REDCap database.  Vanderbilt Redcap is a secure, web-based application 
for building and managing online databases.  The data obtained and stored in 
Redcap will only be accessible by research personnel.  All Redcap data will be de-
identified prior to statistical analysis. All Osteoprobe measurements taken will be 
relayed from the Osteoprobe to a laptop which is connected to the instrument 
during the surgical case.  The imported data will be displayed in an excel 
spreadsheet.  This excel spreadsheet will be saved on a key study personnel 
password-protected computer(s).  In addition, some data from the excel 
spreadsheet will be transferred to the Redcap study database. Any physical study 
forms (ex. consent documents, screening forms, surveys) will be kept in a locked 
cabinet in the Vanderbilt Hand & Upper Extremity Center Administrative Offices for 
6 years following completion of the study.  Following this 6 year period, all physical 
study forms will be disposed of in shred-it confidentiality bins provided by VUMC, 
and all Osteoprobe data kept in Excel spreadsheets will be permanently deleted 
from the key study personnel computer(s)  
 
Inconvenience: 
The time and inconvenience of participating in the DXA and MRI scans has been 
considered in this study.  We will make our best effort to schedule the DXA/MRI 
visits on the same day, and if applicable (fracture patients), on the same day as a 
routine care visit.   Patients will be reimbursed $50 following completion of their 
DXA scan, and if applicable, $50 following completion of their MRI scan.   
 
Potential Benefits: 
 
There is no direct patient benefit to participating in this study. Patients may receive 
a certain psychological reward knowing that they are contributing to increased 
medical knowledge about fracture risk testing and potential, new diagnostic tools 
that may improve anti-fracture therapies in future patient populations. 
  
Importance of the knowledge to be gained: 
This proposed study is intended to determine if two new, non-X-ray techniques can 
discriminate between high-energy fractures of normal bone (trauma-related 
fracture) and low-energy fragility fractures of osteoporotic bone.  By affirming the 
ability of these new techniques to discriminate differences in bone quality, it will 
provide justification for larger, prospective studies that can evaluate the ability of 
these new techniques to predict fracture risk, assess whether these techniques are 
informative on how drug therapy is affecting bone, and determine whether these 
techniques are useful in the surgical setting. Such knowledge is important because 
the current gold-standard for assessing fracture risk does not accurately identify 

Protocol Version #: 9 
 
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Protocol Date: 3/8/2017 
individuals at of an osteoporotic risk.  The potential importance of this knowledge 
outweighs the minimal risk of harm to study participants.   
 
8.0 
Reporting of Adverse Events or Unanticipated Problems involving Risk to 
Participants or Others 
 
A data and safety monitoring (DSM) team will be formed for this study, which will consist 
of: Drs. Donald Lee and Jeffry Nyman and other researchers involved in this study. The DSM 
team will meet every 6 months to review study procedures, recruitment, and adverse 
events that occur throughout the study. In the event of an adverse event or patient 
complication, both Drs. Lee and Nyman will be notified by key study personnel immediately 
so they can determine if any changes to the protocol need to be made.  The IRB will also be 
notified of any adverse events that may occur as a result of the patient’s participation in this 
study.  If an unexpected issue is identified with one of the study patients, the DSM team will 
be responsible for determining how to address, mitigate, and/or eliminate such risk from 
the study.  In such cases, the protocol will be terminated, until an appropriate course of 
action is determined by the research team, in conjunction with the IRB.   
 
9.0 
Study Withdrawal/Discontinuation 
 
Participation in this study is voluntary.  If at any time a study participant wishes to be 
withdrawn from the study, they may do so by contacting any of the key study personnel and 
letting them know they withdraw their consent.  The date in which the participant 
withdraws their consent will be noted in their study file.  Any information gathered up to 
the point of consent withdrawal will still be used for research and reporting. 
 
10.0 
Statistical Considerations 
 
Data will be analyzed using the statistical software package Stata (version 11.0, College 
Station, TX) with the assistance of Samuel K. Nwosu, Biostatistician III. Statistical 
comparisons will be performed using two-sided tests at the 5% significance level. Mann-
Whitney test will assess whether differences in properties between groups are statistically 
significant. Next, general linear models (GLMs) will be used to determine whether the case 
explains each property after adjusting for aBMD (or T-score), BMI, and age. Using a robust 
analysis with GLMs, the data will be bootstrap with 500 replicates. Based on the variance 
from our cadaver studies and expected mean BMS for ‘normal’ bone as measured by Farr et 
al. (32), a sample size of 15 per group will provide 87% power to detect a 11.2% difference 
between the 2 cases at an α of 0.05. With 60 participants (15 per variable) will allow us to 
determine whether fracture type significantly explains BMS after adjusting for 3 covariates 
(aBMD, BMI, age). Note that there will be overlap in the participants between Aim 1 and 
Aim 2. From our limited imaging studies, we can expect bound and pore water of normal 
bone to be 22 mol 1H/L and 10 mol 1H/L. A sample size of 10 per group will provide 81% 
power to detect a 22.8% and 51.8% difference in bound and pore water at an α of 0.05. Note 
that these changes are typically associated with a significant decrease in bone strength by 
destructive testing (18, 22). With 20 per group we can include a covariate in the regression 
models. 
 
11.0 
Privacy/Confidentiality Issues 
 

Protocol Version #: 9 
 
16 
Protocol Date: 3/8/2017 
During this study every attempt will be made to keep the patient’s protected health 
information (PHI) private.  To reduce this risk, most study data will be maintained in the 
Vanderbilt REDCap database.  Vanderbilt Redcap is a secure, web-based application for 
building and managing online databases.  The data obtained and stored in Redcap will only 
be accessible by research personnel.  All Redcap data will be de-identified prior to statistical 
analysis. All Osteoprobe measurements taken will be relayed from the Osteoprobe to a 
laptop (which his connected to the instrument during the surgical case).  The imported data 
will be displayed in an excel spreadsheet.  This excel spreadsheet will be saved on a key 
study personnel password-protected computer(s).  In addition, some data from the excel 
spreadsheet will be transferred to the Redcap study database. Any physical study forms (ex. 
consent documents, screening forms, surveys) will be kept in a locked cabinet in the 
Vanderbilt Hand & Upper Extremity Center Administrative Offices for 6 years following 
completion of the study.  Following this 6 year period, all physical study forms will be 
disposed of in shred-it confidentiality bins provided by VUMC, and all Osteoprobe data kept 
in Excel spreadsheets will be permanently deleted from the key study personnel 
computer(s).  
 
12.0 
Follow-up and Record Retention 
 
The duration of this study will last until we have enrolled and completed follow-up on all 
110 patients. All study records will be kept for six years following study closure, at which 
time the database/excel spreadsheets will be deleted and all forms will be disposed of 
properly. 
 
13.0 
References 
 
1. 
Lewiecki EM. Management of osteoporosis. Clin Mol Allergy. 2004 Jul 14;2(1):9. 
PMCID: PMC493281 
2. 
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 Sep 
1;166(5):495–505.  
3. 
Atik OS, Gunal I, Korkusuz F. Burden of osteoporosis. Clin Orthop Relat Res. 2006 
Feb;443:19–24.  
4. 
Omsland TK, Emaus N, Tell GS, Magnus JH, Ahmed LA, Holvik K, et al. Mortality 
following the first hip fracture in Norwegian women and men (1999-2008). A 
NOREPOS study. Bone. 2014 Mar 5.  
5. 
Siris ES, Brenneman SK, Barrett-Connor E, Miller PD, Sajjan S, Berger ML, et al. The 
effect of age and bone mineral density on the absolute, excess, and relative risk of 
fracture in postmenopausal women aged 50-99: results from the National 
Osteoporosis Risk Assessment (NORA). Osteoporos Int. 2006;17(4):565–74. 
6. 
Kanis JA, Johnell O, Oden A, Dawson A, De Laet C, Jonsson B. Ten year probabilities of 
osteoporotic fractures according to BMD and diagnostic thresholds. Osteoporos Int. 
2001 Dec;12(12):989–95. 
7. 
Hui SL, Slemenda CW, Johnston CC. Age and bone mass as predictors of fracture in a 
prospective study. J. Clin. Invest. 1988 Jun;81(6):1804–9. PMCID: PMC442628 
8. 
De Laet CE, Van Hout BA, Burger H, Weel AE, Hofman A, Pols HA. Hip fracture 
prediction in elderly men and women: validation in the Rotterdam study. J Bone 
Miner Res. 1998 Oct;13(10):1587–93. 
9. 
Fyhrie DP. Summary--Measuring "bone quality". J Musculoskelet Neuronal Interact. 
2005 Oct;5(4):318–20.  

Protocol Version #: 9 
 
17 
Protocol Date: 3/8/2017 
10. 
Kanis JA, McCloskey E, Johansson H, Oden A, Leslie WD. FRAX(®) with and without 
Bone Mineral Density. Calcif Tissue Int. 2012 Jan;90(1):1–13.  
11. 
Giangregorio LM, Leslie WD, Lix LM, Johansson H, Oden A, McCloskey E, et al. FRAX 
underestimates fracture risk in patients with diabetes. J Bone Miner Res. 2012 
Feb;27(2):301–8.  
12. 
Diez-Perez A, Güerri R, Nogues X, Cáceres E, Peña MJ, Mellibovsky L, et al. 
Microindentation for in vivo measurement of bone tissue mechanical properties in 
humans. J Bone Miner Res. 2010 Aug;25(8):1877–85. PMCID: PMC3153354 
13. 
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. 
2013 Oct 1. 
14. 
Nyman JS, Makowski AJ, Patil CA, Masui TP, O'quinn EC, Bi X, et al. Measuring 
differences in compositional properties of bone tissue by confocal Raman 
spectroscopy. Calcif Tissue Int. 2011 Aug;89(2):111–22.  
15. 
Makowski AJ, Patil CA, Mahadevan-Jansen A, Nyman JS. Polarization control of 
Raman spectroscopy optimizes the assessment of bone tissue. J Biomed Opt. 2013 
May 1;18(5):055005 
16. 
Nyman JS, Gorochow LE, Adam Horch R, Uppuganti S, Zein-Sabatto A, Manhard MK, 
et al. Partial removal of pore and loosely bound water by low-energy drying 
decreases cortical bone toughness in young and old donors. Journal of the 
Mechanical Behavior of Biomedical Materials. 2012 Oct 17. PMCID: PMC3655090 
17. 
Horch RA, Nyman JS, Gochberg DF, Dortch RD, Does MD. Characterization of 1H 
NMR signal in human cortical bone for magnetic resonance imaging. Magn Reson 
Med. 2010 Sep;64(3):680–7. PMCID: PMC2933073 
18. 
Horch RA, Gochberg DF, Nyman JS, Does MD. Clinically compatible MRI strategies for 
discriminating bound and pore water in cortical bone. Magn Reson Med. 2012 Jan 
31. PMCID: PMC3357454 
19. 
Manhard MK, Horch RA, Harkins KD, Gochberg DF, Nyman JS, Does MD. Validation of 
quantitative bound- and pore-water imaging in cortical bone. Magn Reson Med. 
2013 Jul 22. PMCID: PMC3899101 
20. 
Güerri-Fernández RC, Nogues X, Quesada Gómez JM, Torres Del Pliego E, Puig L, 
García-Giralt N, et al. Microindentation for in vivo measurement of bone tissue 
material properties in atypical femoral fracture patients and controls. J Bone Miner 
Res. 2013 Jan;28(1):162–8.  
21. 
Wehrli FW. Magnetic resonance of calcified tissues. J. Magn. Reson. 2013 
Apr;229:35–48.  
22. 
Horch RA, Gochberg DF, Nyman JS, Does MD. Non-invasive Predictors of Human 
Cortical Bone Mechanical Properties: T2-Discriminated 1H NMR Compared with 
High Resolution X-ray. PLoS ONE. Public Library of Science; 2011 Jan 
21;6(1):e16359. PMCID: PMC3025007 
23. 
Ott SM. When bone mass fails to predict bone failure. Calcif Tissue Int. 1993;53 
Suppl 1:S7–13.  
24. 
Stone KL, Seeley DG, Lui L-Y, Cauley JA, Ensrud K, Browner WS, et al. BMD at 
multiple sites and risk of fracture of multiple types: long-term results from the 
Study of Osteoporotic Fractures. J Bone Miner Res. 2003 Nov;18(11):1947–54.  
25. 
Sanders KM, Nicholson GC, Watts JJ, Pasco JA, Henry MJ, Kotowicz MA, et al. Half the 
burden of fragility fractures in the community occur in women without 
osteoporosis. When is fracture prevention cost-effective? Bone. 2006 
May;38(5):694–700.  

Protocol Version #: 9 
 
18 
Protocol Date: 3/8/2017 
26. 
Bonds DE, Larson JC, Schwartz AV, Strotmeyer ES, Robbins J, Rodriguez BL, et al. 
Risk of fracture in women with type 2 diabetes: the Women's Health Initiative 
Observational Study. Journal of Clinical Endocrinology & Metabolism. 2006 
Sep;91(9):3404–10.  
27. 
Vestergaard P, Rejnmark L, Mosekilde L. Diabetes and its complications and their 
relationship with risk of fractures in type 1 and 2 diabetes. Calcif Tissue Int. 2009 
Jan;84(1):45–55.  
28. 
Wade SW, Strader C, Fitzpatrick LA, Anthony MS. Sex- and age-specific incidence of 
non-traumatic fractures in selected industrialized countries. Arch Osteoporos. 2012 
Dec;7(1-2):219–27.  
29. 
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 
Apr;18(4):427–44.  
30. 
Schwartz AV, Ewing SK, Porzig AM, McCulloch CE, Resnick HE, Hillier TA, et al. 
Diabetes and change in bone mineral density at the hip, calcaneus, spine, and radius 
in older women. Front Endocrinol (Lausanne). 2013;4:62. PMCID: PMC3667237 
31. 
Bridges D, Randall C, Hansma PK. A new device for performing reference point 
indentation without a reference probe. Rev Sci Instrum. 2012 Apr;83(4):044301. 
PMCID: PMC3331866 
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 Apr;29(4):787–95. PMCID: PMC3961509