Background: Low bone mass is common in adults with thalassemia (Thal) and sickle cell disease (SCD), though disease-specific artifacts may contribute to inaccuracies in bone mineral density (BMD) assessment. Trabecular bone score (TBS), an indicator of bone quality, is not susceptible to these challenges and may improve fracture risk prediction. Methods: A retrospective chart review was conducted in patients with Thal or SCD who had at least one spine BMD scan by DXA performed in the past 10 years. The most recent scan was reanalyzed for bone quality using TBS Insight (Medimaps v 3.0.2) with abnormal defined as TBS <1.20. Fracture prevalence was determined by patient report with medical record validation. Patients were compared to healthy controls who participated in previous research. Results: Data was abstracted from 126 patients with Thal (Mean: 31.7, SD: 11.9 yrs, 51% Male), 170 with SCD (Mean: 24.6, SD: 13.5 yrs, 43% Male), and 64 controls (Mean: 25.9, SD: 8.0 yrs, 17% Male). Low bone mass was observed in 63% of Thal compared with 36% of SCD and 3% of controls (p<0.001); while only 15% of patients had abnormal TBS. History of fracture was present in 35.6% of Thal and 22.9% of SCD; of which 15.7% were fragility fractures. After adjusting for age and hypogonadism, low bone mass was associated with an increased overall fracture prevalence (OR: 1.8, 95% CI: 1.03, 3.23; p=0.041), but not with fragility fracture. In contrast, abnormal bone quality was strongly associated with fragility fracture after adjustment for age, sex, and BMI (OR: 11.4, 95% CI: 2.2, 59.1, p=0.004). Conclusions: Bone quality by TBS may be a valuable tool in predicting the risk of fragility fractures in young adults with hemoglobinopathies and should be considered when making decisions for anti-resorptive therapy in those with low BMD naive to fracture or where disease-specific artifacts complicate accurate spine assessment by BMD alone.

The authors have declared no competing interest.

This project was funded in part by the following research training grants: Doris Duke Foundation (#2016-143, #2020-241)

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