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Assessment of Fracture Risk

  • Current Therapeutics (SL Silverman, Section Editor)
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Abstract

Osteoporosis-related fractures (low-trauma, fragility fractures) are associated with significant morbidity, mortality, and health care expenditure worldwide. In the absence of a defining fracture, the diagnosis of osteoporosis is based on the World Health Organization’s T-score criteria using central dual-energy x-ray absorptiometry (DXA). Paradoxically, the majority of those patients who will sustain a low-trauma fracture do not meet the T-score definition of osteoporosis. Conversely, younger individuals with bone density in the osteoporotic range but no other risk factors have relatively low fracture rates and yet are frequently considered candidates for osteoporosis therapies. The limited accuracy of bone density testing alone to predict fractures has led to the development of a variety of fracture assessment tools that utilize the combination of bone density and clinical risk factors to improve the prediction of low-trauma fractures. These fracture assessment tools quantitatively predict the 10-year fracture probability of hip and major osteoporosis-related fractures, and can be used to define cost-effective intervention strategies for primary and secondary fracture prevention.

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References

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  1. •• National Osteoporosis Foundation, Clinician’s Guide to prevention and treatment of osteoporosis. 2008; available at http//nof.org/professionals/NOF_clinicians_Guide pdf, accessed February 12, 2011. The NOF Clinician’s Guide to prevention and treatment of osteoporosis serves as a basic reference for the evaluation and treatment of osteoporosis in the United States.

  2. Kanis JA. 2007 WHO Technical Report, University of Sheffield, UK:66.

  3. Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. 2006;17:1726.

    Article  PubMed  CAS  Google Scholar 

  4. Gullber B, Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporos Int. 1997;7:407.

    Article  Google Scholar 

  5. Osteoporosis in the Workplace, 2002, www.IOF.org.

  6. Burge R, Dawson-Hughes B, Solomon DH, et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res. 2007;3:465–75.

    Google Scholar 

  7. World Health Organization. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Technical Report Series 843. Geneva: WHO; 1994.

  8. Kanis JA, Melton LJ, Christiansen C, Johnston CC, Khaltaev N. The diagnosis of osteoporosis. J Bone Miner Res. 1994;9:17-1141.

    Google Scholar 

  9. Kanis JA, Johnell O, Oden A, Jonsson B, et al. Risk of hip fracture according to the World Health Organization criteria for osteoporosis and osteopenia. Bone. 2000;27:585–90.

    Article  PubMed  CAS  Google Scholar 

  10. World Health Organization Guidelines for preclinical evaluation and clinical trials in osteoporosis. Geneva: WHO; 1998.

  11. Marshall D, Johnell O, Edel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ. 1996;312:1254–59.

    Article  PubMed  CAS  Google Scholar 

  12. Cooper C, Aihie A. Osteoporosis: recent advances in pathogenesis and treatment. Q J Med. 1994;87:203–9.

    PubMed  CAS  Google Scholar 

  13. Kanis JA, Borgstrom F, De laet C, et al. Assessment of fracture risk. Osteoporos Int. 2005;16:581–9.

    Article  PubMed  Google Scholar 

  14. Lewiecki EM, Compston JE, Miller PD, et al. 2010 Official Positions for FRAX® Bone Mineral Density and FRAX® Simplification from Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX®. J Clin Densitom. 2011;14:226–36.

    Article  PubMed  Google Scholar 

  15. Leslie WD, Tsang JF, Caetano PA, et al. Effectiveness of bone density measurement for predicting osteoporotic fractures in clinical practice. J Clin Endocrinol Metab. 2007;92(1):77–81.

    Article  PubMed  CAS  Google Scholar 

  16. Wainwright SA, Marshall LM, Ensrud KE, et al. Study of Osteoporotic Fractures Research Group. Hip fractures in women without osteoporosis. J Clin Endocrinol Metab. 2005;90(5):2787–93.

    Article  PubMed  CAS  Google Scholar 

  17. Pasco JA, Seeman E, Henry MJ, et al. The population burden of fractures originates in women with osteopenia, not osteoporosis. Osteoporos Int. 2006;17(9):1404–9.

    Article  PubMed  CAS  Google Scholar 

  18. Sornay-Rendu E, Muoz F, Garnero P, et al. Identification of osteopenic women at high risk of fracture. The OFELY study. J Bone Miner Res. 2005;20(10):1813–19.

    Article  PubMed  Google Scholar 

  19. Alonso-Coello P, García-Franco AL, Guyatt G, et al. Drugs for pre-osteoporosis: prevention or disease mongering? BMJ 2008;19;336(7636):126–9.

  20. Lewiecki M. Risk communication and shared decision making in the care of patients with osteoporosis. J Clin Densitom. 2010;13(4):335–45.

    Article  PubMed  Google Scholar 

  21. Woloshin S, Schwartz LM. Communicating data about the benefits and harms of treatment a randomized trial. Ann Intern Med. 2011;155:87–96.

    PubMed  Google Scholar 

  22. Leslie WD. Absolute fracture risk reporting in clinical practice: a physician-centered survey. Osteoporos Int. 2008;19:459–63.

    Article  PubMed  CAS  Google Scholar 

  23. Kanis JA, McCloskey EV, Johansson H, et al. Development and use of FRAX® in osteoporosis. Osteoporos Int. 2010;21(Suppl2):S407–13.

    Article  PubMed  Google Scholar 

  24. Papaionnou A, Morin S, Cheung AM, et al. 2010 Clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010;182(17):1864–73.

    Article  Google Scholar 

  25. Hamdy RC, Baim S, Broy SB. Algorithm for the management of osteoporosis. SMJ. 2010;103(10):1009–15.

    Article  Google Scholar 

  26. FRAX® available at http://www.sheffield.ac.uk/FRAX/index.jsp, accessed on February 24, 2011.

  27. World Health Organization. Assessment of osteoporosis at the primary health care level. WHO, Geneva, 2007; available at www.who.int/chp/topics/rheumatic/en/index.html, accessed February, 23; 2011.

  28. Nguyen ND, Frost SA, Center JR, et al. Development of prognostic nomograms for individualizing 5-year and 10-year fracture risks. Osteoporos Int 2008;19:1431–44, available at http://www.garvan.org.au/bone-fracture-risk, accessed February 24, 2011.

    Google Scholar 

  29. Hippisley-Cox J, Copuland C. Predicting risk of osteoporotic fracture in men and women in England and Wales: prospective derivation and validation of QFractureScores. BMJ 2009;339:b4229 available at http://www.qfracture.org/, accessed February 24, 2011.

  30. Kanis JA on behalf of the World Health Organization Scientific Group a, Assessment of osteoporosis at the primary health-care level. Technical Report. WHO Collaborating Centre, University of Sheffield, UK. 2008, available at http://www.shef.ac.uk/FRAX/index.htm, accessed February 24, 2011.

  31. Oden A, Johansson H, McCloskey EV. FRAX™ and the assessment of fracture probability in men and women from the UK. Osteoporos Int. 2008;19:385–97.

    Article  PubMed  Google Scholar 

  32. Kanis JA, Johnell O, Oden A, et al. FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int. 2008;19:385–97.

    Article  PubMed  CAS  Google Scholar 

  33. •• Hans D, Kanis J, Baim S, et al. Joint official positions of the International Society for Clinical Densitometry (ISCD) and International Osteoporosis Foundation (IOF) on FRAX®: Executive Summary of the 2010 Position Development Conference on Interpretation and Use of FRAX® in Clinical Practice. J Clin Densitom 2011;14(3):171–80. The joint Official Positions of the ISCD and IOF are the most updated and accepted guidelines for quantitatively or qualitatively adjusting FRAX CRFs and subsequent fracture probabilities for the individual patient.

    Article  PubMed  Google Scholar 

  34. •• Kanis J, Hans D, Cooper C, et al. Interpretation and use of FRAX® in clinical practice. Osteoporos Int 2011;22(9):2395–411. The joint Official Positions of the ISCD and IOF are the most updated and accepted guidelines for quantitatively or qualitatively adjusting FRAX CRFs and subsequent fracture probabilities for the individual patient.

    Article  PubMed  CAS  Google Scholar 

  35. FRAX available at http://www.shef.ac.uk//FRAX, accessed February 23, 2011.

  36. Kanis JA, Oden A, Johnell O, et al. The use of clinical risk factors enhances the performance of BMD in the prediction of hip and osteoporotic fractures in men and women. Osteoporos Int. 2007;18:1033–46.

    Article  PubMed  CAS  Google Scholar 

  37. Kanis JA, Johnell O, De Laet C, et al. International variations in hip fracture probabilities: implications for risk assessment. J Bone Miner Res. 2002;17:1237–44.

    Article  PubMed  Google Scholar 

  38. Cooper C, Cole ZA, Holroyd CR, et al. Secular trends in the incidence of hip and other osteoporotic fractures. Osteoporos Int. 2011;22(5):1277–88.

    Article  PubMed  CAS  Google Scholar 

  39. Leslie WD, Lix LM. Effects of FRAX® model calibration on intervention rates: a simulation study. J Clin Densitom. 2011;14(3):272–8.

    Article  PubMed  Google Scholar 

  40. Steyerberg EW. Clinical prediction models: a practical approach to development, validation, and updating. Springer (New York); 2008.

  41. • Leslie WD, Lix LM, Langsetmo L, et al. Construction of a FRAX® model for the assessment of fracture probability in Canada and implications for treatment. Osteoporos Int 2011;22:817–27. This describes the creation of a FRAX model for fracture assessment in Canadian men and women.

    Article  PubMed  CAS  Google Scholar 

  42. Leslie WD, Lix LM, Johansson H, et al. Independent clinical validation of a Canadian FRAX tool: fracture prediction and model calibration. J Bone Miner Res. 2010;25(11):2350–8.

    Article  PubMed  Google Scholar 

  43. Fraser L-A, Langsetmo L, Berger C, et al. Fracture prediction and calibration of a Canadian FRAX tool: a population-based report from CaMos. Osteoporos Int. 2011;22:829–37.

    Article  PubMed  Google Scholar 

  44. FRAX Implementation Guide available at http://www.nof.org/sites/default/files/pdfs/nof_FRAX_Implem_Guide.pdf, accessed February 24, 2011.

  45. FRAX Implementation Guide available at http://www.iscd.org/visitors/pdfs/FRAXimplementationGuide_000.pfd, accessed February 24, 2011.

  46. Watts NB, Siris ES, Cummings SR, Bauer DC. Perspective: Filtering FRAX®. Osteoporos Int. 2010;21:537–41.

    Article  PubMed  Google Scholar 

  47. McCloskey E, Compston J, Cooper C. The US FRAX® filter: avoiding confusion or hindering progress? Osteoporos Int. 2010;21:885.

    Article  PubMed  CAS  Google Scholar 

  48. •• National Osteoporosis Guideline Group (NOGG). Osteoporosis: clinical guidelines for prevention and treatment Executive Summary. 2010. The UK NOGG assessment and diagnosis of osteoporosis and therapeutic agents available for treatment provides different management strategies for the prevention and treatment of osteoporotic fractures in postmenopausal women and men over 50 years of age.

  49. Kanis JA, Johnell O, Oden A, Johansson H, McCloskey E. FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int. 2008;19(4):385–97.

    Article  PubMed  CAS  Google Scholar 

  50. •• Kanis JA, McCloskey EV, Johansson H, et al. Case finding for the management of osteoporosis with FRAX®-assessment and intervention thresholds for the UK. Osteoporos Int 2008;19:1395–408. The use of a case-finding strategy for the management of osteoporosis with FRAX reviews the use of FRAX as a screening tool with and without bone density testing for the treatment of osteoporosis in the United Kingdom.

    Article  PubMed  CAS  Google Scholar 

  51. Donaldson MG, Cawthon PM, Lui LY, et al. Estimates of the proportion of older white women who would be recommended for pharmacologic treatment by the new U.S. National Osteoporosis Foundation Guidelines. J Bone Miner Res. 2009;24:675–80.

    Article  PubMed  Google Scholar 

  52. Dawson-Hughes B, Looker AC, Tosteson AN, et al. The potential impact of new National Osteoporosis Foundation guidance on treatment patterns. Osteoporos Int. 2010;21(1):41–52.

    Article  PubMed  CAS  Google Scholar 

  53. •• Papaioannou A, Morin S, Cheung AM, et al. for the Scientific Advisory Council of Osteoporosis Canada. 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada. Can Med Assoc J 2010;182(17):1864–73. The Canadian Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada reviews the use of the FRAX model in Canada in contrast to US and UK Osteoporosis Guidelines.

    Article  Google Scholar 

  54. Leslie WD, Berger C, Langsetmo L, Adachi JD, et al. CaMos Research Group. Construction and validation of a simplified fracture risk assessment tool for Canadian women and men: results from the CaMos and Manitoba BMD cohorts. Osteoporos Int. 2011;22:1873–83.

    Article  PubMed  CAS  Google Scholar 

  55. Leslie WD, Morin S. Fracture burden in relation to low bone mineral density and FRAX® probability. J Clin Densitom. 2011;14(3):279–85.

    Article  PubMed  Google Scholar 

  56. Leslie WD, Morin S, Lix LM, et al. Fracture risk assessment without bone density measurement in routine clinical practice. Osteoporosis International 2011; August 18 [Epub ahead of print].

  57. Preventive Services US. Task Force. Screening for osteoporosis: U.S.Preventive services task force recommendation statement. Ann Intern Med. 2011;154(5):356–64.

    Google Scholar 

  58. Kanis JA, McCloskey E, Johansson H, et al. FRAX® with and without BMD. Calcified Tissue International 2011; [Epub ahead of print].

  59. Leslie WD, Morin S. Fracture burden in relation to low bone mineral density and FRAX® probability. J Clin Densitom. 2011;14(3):279–85.

    Article  PubMed  Google Scholar 

  60. Leslie WD, Lix LM, Johansson H, Oden A, McCloskey E, Kanis JA. A comparative study of using non hip bone density inputs with FRAX®. Osteoporos Int 2011;Oct 19. [Epub ahead of print].

  61. Gillespie LD, Robertson MC, Lamb SE, et al. 2010 Interventions for preventing falls in older people living in the community (Review); The Cochrane Collaboration; available at http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD007146/frame.html, accessed February 24, 2011.

  62. Cameron ID, Murray GR, Gillespie LD, et al. 2010 Interventions for preventing falls in older people in nursing care facilities and hospitals (Review); available at http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD005465/frame.html, accessed February 25, 2011.

  63. Howe TE, Rochester L, Jackson A. 2008 Exercise for improving balance in older people (Review); available at http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD004963/frame.html, accessed February 25, 2011.

  64. Kanis JA, Johansson H, Oden A, et al. Guidance for the adjustment of FRAX according to the dose of glucocorticoids. Osteoporos Int. 2011;22:809–16.

    Article  PubMed  CAS  Google Scholar 

  65. Grossman JM, Gordon R, Ranganath VK, et al. American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis Care Res. 2010;62(11):1515–26.

    Article  Google Scholar 

  66. Kanis article above, van Staa TP, Leufkens HG, Abenhaim L, et al. Oral corticosteroids and fracture risk: relationship to daily and cumulative doses. Rheumatology: (Oxford) 2000;39:1383–89.

    Google Scholar 

  67. Reid DM, Hughes RA, Laan RFJM, et al. Efficacy and safety of daily risedronate in the treatment of corticosteroid-induced osteoporosis in men and women: A randomized trial. J Bone Miner Res. 2000;15(6):1006–13.

    Article  PubMed  CAS  Google Scholar 

  68. Michel BA, Bloch DA, Wolfe F, et al. Fractures in rheumatoid arthritis: an evaluation of associated risk factors. The J of Rheum. 1993;20(10):1666–9.

    CAS  Google Scholar 

  69. Reid IR. Glucocorticoid osteoporosis-mechanisms and management. Eur J of Endocrin. 1997;137:209–17.

    Article  CAS  Google Scholar 

  70. Cooper C, Coupland C, Mitchell M. Rheumatoid arthritis, corticosteroid therapy and hip fracture. Annals of the Rheum Dis. 1995;54:49–52.

    Article  CAS  Google Scholar 

  71. De Vries F, Brache M, Leufkens HG, et al. Fracture risk with intermittent high-dose oral glucocorticoid therapy. Arthritis Rheum. 2007;56:208–14.

    Article  PubMed  Google Scholar 

  72. Johnell O, Kanis JA, Oden A, Johansson H, et al. Predictive value of BMD for hip and other fractures. J Bone Miner Res. 2005;20:1185–94.

    Article  PubMed  Google Scholar 

  73. Kanis JA, McCloskey EV, Johansson H, et al. A reference standard for the description of osteoporosis. Bone. 2008;42:467–75.

    Article  PubMed  CAS  Google Scholar 

  74. Looker AC, Wahner HW, Dunn WL, et al. Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int. 1998;8:468–89.

    Article  PubMed  CAS  Google Scholar 

  75. Jones G, Nguyen T, Sambrook PN, Kelly PJ, et al. A longitudinal study of the effect of spinal degenerative disease on bone density in the elderly. J Rheumatol. 1995;22:932–6.

    PubMed  CAS  Google Scholar 

  76. Phillipov G, Phillips PJ. Skeletal site bone mineral density heterogeneity in women and men. Osteoporos Int. 2001;12:362–5.

    Article  PubMed  CAS  Google Scholar 

  77. Schneider DL, Bettencourt R, Barrett-Connor E. Clinical utility of spine bone density in elderly women. J Clin Densitom. 2006;9:255–60.

    Article  PubMed  Google Scholar 

  78. Faulkner KG, von Stetten E, Miller P. Discordance in patient classification using T-scores. J Clin Densitom. 1999;2:343–50.

    Article  PubMed  CAS  Google Scholar 

  79. Leslie WD, Lix LM, Tsang JF, et al. Single-site vs multisite bone density measurement for fracture prediction. Arch Intern Med 2007;1641–47.

  80. Leslie WD, Lix LM. Absolute fracture risk assessment using lumbar spine and femoral neck bone density measurements: derivation and validation of a hybrid system. J Bone Miner Res. 2011;26:460–7.

    Article  PubMed  Google Scholar 

  81. Leslie WD, Lix LM, Johansson H, et al. Spine-hip discordance and fracture risk assessment: a physician-friendly FRAX enhancement. Osteoporos Int. 2011;22:839–47.

    Article  PubMed  CAS  Google Scholar 

  82. Leslie WD, Kovacs CS, Olszynski WP, et al. Spine-Hip T-score difference predicts major osteoporositic fracture risk independent of FRAX®: a population-based report from CAMOS. J Clin Densitom. 2011;14(3):286–93.

    Article  PubMed  Google Scholar 

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Disclosures

Conflicts of interest: S. Baim: none; W.D. Leslie: has received speaker fees and unrestricted research grants from Merck Frosst; has received unrestricted research grants from Sanofi-Aventis, Procter & Gamble, Novartis, Amgen, Genzyme; and is on advisory boards for Genzyme, Novartis, and Amgen.

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Baim, S., Leslie, W.D. Assessment of Fracture Risk. Curr Osteoporos Rep 10, 28–41 (2012). https://doi.org/10.1007/s11914-011-0093-9

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