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Two hundred million women suffer from osteoporosis worldwide (a third of all women between 60 and 70 years of age and
two thirds of all women over 80 years of age), with a lifetime risk of fracture between 30 and 40 percent. In men, the
lifetime risk of osteoporotic fracture is currently about 13 percent, but the risk is expected to rise with increased
life expectancy. The annual incidence of hip fracture is also expected to rise, from 1.7 million in 1990 to 6.3 million
in 2050. It is because of these astonishing numbers that osteoporosis has become one of the hottest topics in medicine,
with thousands of articles and dozens of textbooks devoted to it every year. Just as I was becoming more and more
convinced that nobody needs another multiauthored textbook on osteoporosis (and enjoying the idea that I would not have
to write another review of such a book for a long time), there comes along a handsome book of about 600 pages on the
pathophysiology and clinical management of osteoporosis, with a twist: the perspectives of authors with basic-science
backgrounds are juxtaposed with those of authors with clinical interests, in pairs of chapters that address a single
aspect of osteoporosis. The credit for this innovative and ambitious concept goes to the editors, Eric S. Orwoll and
Michael Bliziotes, both clinical endocrinologists and well-respected authorities on the subject. Some examples of
successfully paired chapters are those on the genetics of osteoporosis in mice and humans, the technical aspects of the
assessment of peripheral bone mineral density and the use of this measurement in the clinical management of
osteoporosis, and mechanical influences on the mass and morphologic features of bone and the role of exercise in the
prevention of osteoporosis. Unfortunately, however, there are at least as many instances in which the pairing of basic
and clinical presentations of a topic falls apart. For example, after an extensive discussion in chapter 8 about the
development of new molecular markers, which, according to the authors, "has greatly enriched the spectrum of serum and
urine analytes used in the assessment" of pathologic processes involving the skeleton, we learn in chapter 9 that serum
and urine markers are of hardly any use in the diagnosis and management of osteoporosis or, for that matter, most other
metabolic bone diseases, with the exception of alkaline phosphatase in Paget's disease. Surprisingly, given the title of
the book, hardly any of its 28 chapters deal with the pathophysiology of osteoporosis in earnest. Current advances in
the molecular biology of bone in general and in the molecular, biochemical, and cellular changes responsible for the
development of osteoporosis in particular are largely ignored. In the few instances in which pathogenetic mechanisms are
considered (for example, in chapter 12), they are approached only superficially and without consideration of the
state-of-the-art understanding of molecular and cellular biology. The attempt in chapter 12 to review basic aspects of
the role of calcium in the development of osteoporosis yields little convincing, hard-core scientific evidence, and the
model the authors propose for the role of calcium transport in late postmenopausal bone loss is terribly outdated. In
contrast, chapter 13, entitled "Calcium, Bone, and Life," is beautifully written, insightful, and full of wisdom. Also
outdated and out of touch is chapter 15, on the basic biology of the action of estrogen on bone. All the major
breakthroughs that have taken place in this area during the past decade -- among them the elucidation of tight links
among estrogen, cytokines, and osteoclastogenesis and of the direct role of estrogen in the birth and death of
osteoblasts and osteoclasts -- are ignored, making the whole discussion of this subject irrelevant. Unfortunately,
because of the tardiness inevitable in the publication of a multichapter, multiauthored book, the discussion of the
clinical use of estrogens (in chapter 16) is also out of date; it was written before the recent publication of the
findings of the Women's Health Initiative study with respect to hormone-replacement therapy. In contrast, I found both
the basic and clinical chapters on the action of androgens on bone much more up to date and informative. Conspicuously
absent is a chapter on steroid-induced osteoporosis, the third most common form of the disease after postmenopausal and
age-related osteoporosis. To my disappointment, not a single chapter addresses the fundamental concepts of bone
remodeling or the fact that osteoporosis is caused not by some exotic, out-of-the-blue pathogenetic mechanism but rather
by disturbances in the normal process of periodic regeneration of the adult skeleton by teams of osteoblasts and
osteoclasts, which constitute the basic multicellular unit of bone. In sharp contrast to the lack of attention to
pathophysiology, more than 12 chapters deal in considerable detail with various treatments, from sex-steroid replacement
to the use of vitamin D and its metabolites, parathyroid hormone, calcitonin, and bisphosphonates. The two chapters on
the basic mechanism of action of bisphosphonates and their use in the treatment of osteoporosis, as well as the chapter
on the use of parathyroid hormone in the treatment of the disease, are particularly insightful and up to date. All in
all, this book represents an honest attempt at improving the didactic quality of textbooks on osteoporosis. As is
inevitable in a multiauthored book, the quality of the information is spotty and uncritical of "the good, the bad . . .
and the irreproducible" research in the field. However, I recommend it because of its innovations and because it is
packed with information.

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