{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,3]],"date-time":"2026-10-03T22:04:01Z","timestamp":1791065041487,"version":"4.1.0"},"reference-count":40,"publisher":"Oxford University Press (OUP)","issue":"9","license":[{"start":{"date-parts":[[2023,5,17]],"date-time":"2023-05-17T00:00:00Z","timestamp":1684281600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100012345","name":"Forces in Mind Trust","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100012345","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100013529","name":"National Lottery Community Fund","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100013529","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["asbmr.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["J of Bone &amp; Mineral Res"],"published-print":{"date-parts":[[2023,9]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:p>\n                    The association between combat\u2010related traumatic injury (CRTI) and bone health is uncertain. A disproportionate number of lower limb amputees from the Iraq and Afghanistan conflicts are diagnosed with osteopenia\/osteoporosis, increasing lifetime risk of fragility fracture and challenging traditional osteoporosis treatment paradigms. The aim of this study is to test the hypotheses that CRTI results in a systemic reduction in bone mineral density (BMD) and that active traumatic lower limb amputees have localized BMD reduction, which is more prominent with higher level amputations. This is a cross\u2010sectional analysis of the first phase of a cohort study comprising 575 male adult UK military personnel with CRTI (UK\u2010Afghanistan War 2003 to 2014; including 153 lower limb amputees) who were frequency\u2010matched to 562 uninjured men by age, service, rank, regiment, deployment period, and role\u2010in\u2010theatre. BMD was assessed using dual\u2010energy X\u2010ray absorptiometry (DXA) scanning of the hips and lumbar spine. Femoral neck BMD was lower in the CRTI than the uninjured group (\n                    <jats:italic>T<\/jats:italic>\n                    \u2010score\u2009\u22120.08 versus \u22120.42\n                    <jats:italic>p<\/jats:italic>\n                    \u00a0=\u00a0.000). Subgroup analysis revealed this reduction was significant only at the femoral neck of the amputated limb of amputees (\n                    <jats:italic>p<\/jats:italic>\n                    \u00a0=\u00a00.000), where the reduction was greater for above knee amputees than below knee amputees (\n                    <jats:italic>p<\/jats:italic>\n                    \u2009&lt;\u20090.001). There were no differences in spine BMD or activity levels between amputees and controls. Changes in bone health in CRTI appear to be mechanically driven rather than systemic and are only evident in those with lower limb amputation. This may arise from altered joint and muscle loading creating a reduced mechanical stimulus to the femur resulting in localized unloading osteopenia. This suggests that interventions to stimulate bone may provide an effective management strategy. \u00a9 2023 Crown copyright and The Authors.\n                    <jats:italic>Journal of Bone and Mineral Research<\/jats:italic>\n                    published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR). This article is published with the permission of the Controller of HMSO and the King's Printer for Scotland.\n                  <\/jats:p>","DOI":"10.1002\/jbmr.4794","type":"journal-article","created":{"date-parts":[[2023,5,17]],"date-time":"2023-05-17T03:01:07Z","timestamp":1684292467000},"page":"1227-1233","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":23,"title":["Association Between Combat\u2010Related Traumatic Injury and Skeletal Health: Bone Mineral Density Loss Is Localized and Correlates With Altered Loading in Amputees: the Armed Services Trauma Rehabilitation Outcome (ADVANCE) Study"],"prefix":"10.1093","volume":"38","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7384-4202","authenticated-orcid":false,"given":"Louise","family":"McMenemy","sequence":"first","affiliation":[{"name":"Centre for Blast Injury Studies, Department of Bioengineering Imperial College London  London UK"},{"name":"Academic Department of Military Surgery and Trauma Royal Centre for Defence Medicine  Birmingham UK"},{"name":"Institute of Naval Medicine  Gosport UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9578-5725","authenticated-orcid":false,"given":"Fearghal P.","family":"Behan","sequence":"additional","affiliation":[{"name":"Centre for Blast Injury Studies, Department of Bioengineering Imperial College London  London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Josh","family":"Kaufmann","sequence":"additional","affiliation":[{"name":"Centre for Blast Injury Studies, Department of Bioengineering Imperial College London  London UK"},{"name":"Structural Biomechanics, Department of Civil and Environmental Engineering Imperial College London  London UK"},{"name":"Musculoskeletal Biodynamics Imperial College London  London 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Military Rehabilitation Defence Medical Rehabilitation Centre  Loughborough UK"},{"name":"Academic Department of Military Mental Health King's College London  London UK"},{"name":"Faculty of Health &amp; Social Sciences Bournemouth University  Bournemouth UK"},{"name":"Cardiology, University Hospitals Dorset NHS Foundation Trust, Poole Hospital  Poole UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5792-2925","authenticated-orcid":false,"given":"Nicola T.","family":"Fear","sequence":"additional","affiliation":[{"name":"Academic Department of Military Mental Health King's College London  London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9314-6468","authenticated-orcid":false,"given":"Paul","family":"Cullinan","sequence":"additional","affiliation":[{"name":"National Heart and Lung Institute, Faculty of Medicine Imperial College London  London 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