Dual energy X-ray absorptiometry (DXA) is currently the reference technique to diagnose osteoporosis, estimate fracture risk and monitor antiosteoporotic therapy. However, there are other determinants of bone strength that cannot be evaluated by only measuring bone mineral density (BMD), which are those related to bone quality such as the bone microarchitecture and bone tissue characteristics, among others. In addition, it is important to know the effect of different antiosteoporotic treatments in determinants of bone strength other than BMD, especially after long-term therapy. In recent years several diagnostic tools addressed to evaluate different aspects of bone quality have been developed, allowing better evaluation of bone strength. In this sense, the trabecular bone score (TBS), a texture parameter computed from DXA images, seems to analyse bone microarchitecture, thereby enhancing the bone assessment made by BMD measurement by adding the dimension of bone quality. In addition, DXA-assisted vertebral fracture assessment (VFA) is a useful method to detect the presence of vertebral fractures, an important and frequently overlooked risk factor for further fractures, allowing evaluation of BMD in the same session. Other methods such as the bone microindentation testing provides direct in vivo estimation of bone material strength measured in the cortical bone of the tibia. Finally, although there are several discrepancies about the use of bone turnover markers in clinical practice, it should be noted that they can predict fracture risk and treatment-induced changes, accounting for a substantial proportion of fracture risk reduction. Nevertheless, controlling sources of variability and adopting international reference standards are necessary in this field. In summary, the integration of several new tools related to other aspects of bone quality may improve not only the identification of patients at high-risk of fracture but also the therapeutic approach and monitoring of these patients.