The definition of severe or established osteoporosis was identified as the reduced bone density, with a T-score value below the -2.5 SD determined by dual energy X-ray absorptiometry, and the presence of one or more fragility fractures. But this definition does not really reflect the spectrum of severity of the disease that determines a variable increase in fracture risk. Demographic and epidemiological changes in recent decades have brought osteoporosis and related fragility fractures to be an emerging clinical condition. Osteoporotic patients are old and affected by several comorbidities. The Korean Society of Osteoporosis propose the concept of advanced severe osteoporosis as a new classification of severe or established osteoporosis. The advanced severe osteoporosis is T-score value below the -2.5 SD and the presence of hip fracture and/or two of more fragility fractures. This paper review for severe osteoporosis and it's management about both pharmacological and surgical approaches.