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Case contributed by Dr Gamaliel Tan Yu-Heng, Orthopaedic Spine Surgeon, Mount Elizabeth Hospital, Singapore.

Patient Information

Age: 84 years 

Sex: Female

Underlying diseases:

  • Dementia
  • History

    Presenting complaint

    • Right knee pain after a fall at home
      • Duration: 1 day
    • Patient uses walking frame at home, assisted by helper.
    • Patient fell in toilet and hit her right knee.

    Other relevant history

    • Patient underwent a left total hip replacement in 2011
  • Physical examination
    • Physical examination revealed right knee hemarthrosis
  • Investigation

    BMD on December 2023

    • Hip T-score: -3.7
    • Spine T-score: -0.5
    BMD on August 2024

    Right Hip BMD Before Romosozumab Initiation

    Region BMD
    (g/cm3)    		 T-score
    Right Neck 0.509 - 2.8
    Total 0.491 - 3.7
    BMD on August 2024

    Spine BMD Before Romosozumab Initiation

    Region BMD
    (g/cm3)    		 T-score
    L1 0.817 - 0.6
    L2 0.962 - 0.2
    L3 0.999 - 0.3
    L4 0.960 - 0.6
    Total 0.939 - 0.5
  • Treatment

    Non-pharmacological

    • Calcium
    • Vitamin D

    Pharmacological

    • Romosozumab was initiated for 12 months, until January 2025
      • Patient is at a high risk of falls given her dementia and frailty. Romosozumab was chosen as it provides the fastest way to improve her bone density.
    • Patient was maintained on denosumab.
  • Follow-up

    Disease progression

    • There is a sustained improvement of BMD scores after romosozumab initiation and denosumab initiation.
    • BMD on January 2025, 1 year after romosozumab initiation:
      • Hip T-score: -3.2
      • Spine T-score: +0.5
    Right Hip BMD After Romosozumab Initiation

    Right Hip BMD After Romosozumab Initiation

    Region BMD
    (g/cm3)    		 T-score
    Right Neck 0.557 - 2.4
    Total 0.541 - 3.2
    Spine BMD After Romosozumab Initiation

    Spine BMD After Romosozumab Initiation

    Region BMD
    (g/cm3)    		 T-score
    L1 0.944 0.4
    L2 1.087 0.8
    L3 1.126 0.7
    L4 1.056 0.1
    Total 1.059 0.5
    • BMD on January 2026, 1 year after denosumab initiation:
      • Hip T-score: -2.1
      • Spine T-score: +0.9
    Right Hip BMD After Denosumab Initiation

    Right Hip BMD After Denosumab Initiation

    Region BMD
    (g/cm3)    		 T-score
    Right Neck 0.589 - 2.1
    Spine BMD After Denosumab Initiation

    Spine BMD After Denosumab Initiation

    Region BMD
    (g/cm3)    		 T-score
    L1 0.956 0.5
    L2 1.082 0.8
    L3 1.132 0.8
    L4 1.185 1.1
    Total 1.097 0.9
  • Summary
    • Patient complained of right knee pain after a fall at home, and was found to have right knee haemarthrosis
    • The BMD values on presentation were:
      • Hip T-score: -3.7
      • Spine T-score: -0.5
    • Patient is at a high risk of falls given her dementia and frailty. Romosozumab was initiated for 1 year as it provides the fastest way to improve her bone density.
    • After 1 year on romosozumab, there was an improvement in her BMD scores.
      • Hip T-score: -3.2
      • Spine T-score: +0.5
    • After 1 year on denosumab, there was a sustained improvement in her BMD scores.
      • Hip T-score: -2.1
      • Spine T-score: +0.9
    • Patient was maintained on denosumab.
    • Changes in BMD after completing 1 year of Romosozumab
      • Total hip BMD changes: [(0.541 – 0.491)/0.491 X 100% = 10.2%
      • Lumbar spine BMD changes: [(1.059 – 0.939)/0.939 X 100% = 12.8%
    Summary
  • Estimated Fracture Risk Reduction Associated with BMD Improvement

    Estimated Fracture Risk Reduction1

    Estimated Fracture Risk Reduction
  • References

    1. Bouxsein ML, Eastell R, Lui LY, et al; FNIH Bone Quality Project. Change in Bone Density and Reduction in Fracture Risk: A Meta-Regression of Published Trials. J Bone Miner Res. 2019 Apr;34(4):632-642.

    Abbreviations

    BMD, bone mineral density

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