Should age influence the choice of quantitative bone assessment technique in elderly women? The EPIDOS study

Is the occurrence of extra-articular calcaneal fractures of the joint depression type related to osteoporosis and aging?

PURPOSE

The authors experienced several cases of extra-articular calcaneal fracture accompanied by joint depression involving the entire posterior facet without joint involvement. This type of fracture and its characteristics and treatment outcomes have not been previously reported. The study was performed to analyze the characteristics of extra-articular calcaneal fractures of the joint depression type and their postoperative clinical and radiographic results and complications.

METHODS

Between February 2013 and March 2021, 23 extra-articular calcaneal fractures of the joint depression type were consecutively treated by a single surgeon. Relationships between fracture characteristics and patient demographics were assessed. Clinical results were quantified using visual analog scale, American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and Foot Function Index, radiographic results were evaluated using Böhler's angles, and calcaneal widths were determined using calcaneal axial and lateral radiographs obtained preoperatively and at last follow-up.

RESULTS

Twenty (87%) of the 23 cases occurred in women, and the mean age of all patients was 65.8 years (43-90). The three men were older than 65. Five (21.7%) patients had osteopenia, and 12 (52.2%) had osteoporosis. Bone mineral density testing could not be performed in the other six patients. Clinical and radiographic results were significantly improved after surgery.

CONCLUSION

Extra-articular calcaneal fractures of the joint depression type are much more common in women and occur at an older age than calcaneal fractures commonly occur. These fractures are also more common in patients with a low bone mineral density.

LEVEL OF EVIDENCE

Level IV.

CASE SERIES

Fracture risk based on high-resolution peripheral quantitative computed tomography measures does not vary with age in older adults-the bone microarchitecture international consortium prospective cohort study

Fracture risk increases with lower areal bone mineral density (aBMD); however, aBMD-related estimate of risk may decrease with age. This may depend on technical limitations of 2-dimensional (2D) dual energy X-ray absorptiometry (DXA) which are reduced with 3D high-resolution peripheral quantitative computed tomography (HR-pQCT). Our aim was to examine whether the predictive utility of HR-pQCT measures with fracture varies with age. We analyzed associations of HR-pQCT measures at the distal radius and distal tibia with two outcomes: incident fractures and major osteoporotic fractures. We censored follow-up time at first fracture, death, last contact or 8 years after baseline. We estimated hazard ratios (HR) and 95%CI for the association between bone traits and fracture incidence across age quintiles. Among 6835 men and women (ages 40-96) with at least one valid baseline HR-pQCT scan who were followed prospectively for a median of 48.3 months, 681 sustained fractures. After adjustment for confounders, bone parameters at both the radius and tibia were associated with higher fracture risk. The estimated HRs for fracture did not vary significantly across age quintiles for any HR-pQCT parameter measured at either the radius or tibia. In this large cohort, the homogeneity of the associations between the HR-pQCT measures and fracture risk across age groups persisted for all fractures and for major osteoporotic fractures. The patterns were similar regardless of the HR-pQCT measure, the type of fracture, or the statistical models. The stability of the associations between HR-pQCT measures and fracture over a broad age range shows that bone deficits or low volumetric density remain major determinants of fracture risk regardless of age group. The lower risk for fractures across measures of aBMD in older adults in other studies may be related to factors which interfere with DXA but not with HR-pQCT measures.

Tree-structured subgroup analysis of receiver operating characteristic curves for diagnostic tests

RATIONALE AND OBJECTIVES

Multiple diagnostic tests are often available for a disease. Their diagnostic accuracy may depend on the characteristics of testing subjects. The investigators propose a new tree-structured data-mining method that identifies subgroups and their corresponding diagnostic tests to achieve the maximum area under the receiver-operating characteristic curve.

MATERIALS AND METHODS

The Osteoporosis and Ultrasound Study is a prospectively designed, population-based European multicenter observational study to evaluate state-of-the-art diagnostic methods for assessing osteoporosis. A total 2837 women underwent dual x-ray absorptiometry (DXA) and quantitative ultrasound (QUS). Prevalent vertebral fractures were determined by a centralized radiology laboratory on the basis of radiographs. The data-mining algorithm includes three steps: defining the criteria for node splitting and selection of the best diagnostic test on the basis of the area under the curve, using a random forest to estimate the probability of DXA being the preferred diagnostic method for each participant, and building a single regression tree to describe subgroups for which either DXA or QUS is the more accurate test or for which the two tests are equivalent.

RESULTS

For participants with weights ≤54.5 kg, QUS had a higher area under the curve in identifying prevalent vertebral fracture. For participants whose weights were >58.5 kg and whose heights were ≤167.5 cm, DXA was better, and for the remaining participants, DXA and QUS had comparable accuracy and could be used interchangeably.

CONCLUSIONS

The proposed tree-structured subgroup analysis successfully defines subgroups and their best diagnostic tests. The method can be used to develop optimal diagnostic strategies in personalized medicine.

An epidemiological analysis of the incidence of osteoporosis and osteoporosis-related fractures among the Saudi Arabian population

BACKGROUND AND OBJECTIVES

Osteoporosis is common in Saudi Arabia and the burden of management in an aging population will increase in coming decades. There is still no national policy nor consensus on screening for this silent disease. The objective of this analysis was to determine from the published data the prevalence of osteopenia and osteoporosis in Saudi Arabians, the prevalence of secondary osteoporosis, and the prevalence of osteoporosis-related fractures (ORF). We also sought to determine the best age to begin and best modality for screening.

METHODS

Data Sources were MEDLINE (1966 to May 2011), EMBASE (1991 to May 2011), the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (1952 to May 2011), and the Science Citation Index (1966 to May 2011), published data from the Saudi Medical Journal (1985-2011) and Annals of Saudi Medicine (1985-2011). We selected English-language articles with at least 100 Saudi individuals. Two authors independently reviewed articles and abstracted data.

RESULTS

The authors identified 36 potentially relevant articles, of which 24 met the inclusion criteria. Of 5160 healthy women 50 to 79 years of age (mean, SD: 56.8 [2.7]), 36.6% (6.6%) were osteopenic and 34.0% (8.5%) were osteoporotic. In three studies on males (n=822), the prevalence of osteopenia was 46.3% and osteoporosis 30.7%. Males had a significantly higher frequency of osteopenia in comparison to females (P= < .001 95% CI < -0.0333), The mean age of the patients with secondary osteoporosis was 37.4 (13.5, 18-57) years, with the osteoporosis in 46.4% and osteopenia in 34.1%. In 5 studies of ORF, the incidence of vertebral fractures was between 20%-24%.

CONCLUSION

The currently available literature on Saudi Arabian population suggests that the ideal age for screening for low bone mass among the Saudi population should be earlier (55 years) than the >=65 years in Western countries. Both quatitative ultrasound and dual-energy x-ray absorptiometry could be used for screening. The relatively small number of studies on Saudi Arabians and the different machines used for diagnosis limited the authors ability make conclusions with surety.

A screening model for low bone mass in elderly Japanese men using quantitative ultrasound measurements: Fujiwara-Kyo Study

Screening for low bone mass is important to prevent fragility fractures in men as well as women, although men show a much lower prevalence of osteoporosis than women. The purpose of this study was to establish a screening model for low bone mineral density (BMD) using a quantitative ultrasound parameter and easily obtained objective indices for elderly Japanese men. We examined 1633 men (65-84 yr old) who were subjects of the Fujiwara-Kyo Study. Speed of sound (SOS) at the calcaneus was determined, and BMD was measured by dual-energy X-ray absorptiometry at the lumbar spine (LS), total hip (TH), and femoral neck (FN). Low BMD was defined as >1 standard deviation below the young adult mean, in accordance with World Health Organization criteria. We performed receiver operating characteristic (ROC) analysis to identify a better screening model incorporating SOS and determined the optimal cutoff value using Youden index. Prevalences of low BMD at the 3 skeletal sites were 27.8% (LS), 33.5% (TH), 48.6% (FN), and 43.3% at either LS or TH. The greatest area under the ROC curve (0.806, 95% confidence interval: 0.785-0.828) and smallest Akaike's information criterion were obtained in the multivariate model incorporating SOS, age, height, and weight for predicting low BMD at all skeletal sites. This model predicted low BMD at TH with the sensitivity of 0.726 and specificity of 0.739, whereas a similar model predicted low BMD at LS with much lower validity. We conclude that the multivariate model for TH could be used to screen for low BMD in elderly Japanese men.

Prediction of incident hip fracture by femoral neck bone mineral density and neck-shaft angle: a 5-year longitudinal study in post-menopausal females

OBJECTIVE

To compare hip fracture incidence in post-menopausal females who were differently stratified for the fracture risk according to bone mineral density and proximal femur geometry.

METHODS

In a 5 year follow-up study, the hip fracture incidence in 729 post-menopausal females (45 of whom suffered from incident hip fracture) was assessed and compared. Forward logistic regression was used to select independent predictors of hip fracture risk, including age, age at menopause, height, weight, femoral neck bone mineral density (FNBMD), neck-shaft angle (NSA), hip axis length, femoral neck diameter and femoral shaft diameter as covariates. Fracture incidence was then calculated for the categories of young/old age, high/low FNBMD and wide/narrow NSA, which were obtained by dichotomising each hip fracture independent predictor at the value best separating females with and without a hip fracture.

RESULTS

The hip fracture incidence of the whole cohort was significantly higher in females with a wide NSA (8.52%) than in those with a narrow NSA (3.51%). The combination of wide NSA and low FNBMD had the highest hip fracture incidence in the whole cohort (17.61%) and each age category. The combinations of narrow/wide NSA with low/high FNBMD, respectively, gave a significantly higher fracture incidence in older than in younger women, whereas women with a combined wide NSA and low FNBMD had no significantly different fracture incidence in young (14.60%) or old age (21.62%).

CONCLUSION

Our study showed that NSA is effective at predicting the hip fracture risk and that the detection in early post-menopause of a wide NSA together with a low FNBMD should identify females at high probability of incident hip fracture.

Quantitative ultrasound in the management of osteoporosis: the 2007 ISCD Official Positions

Dual-energy X-ray absorptiometry (DXA) is commonly used in the care of patients for diagnostic classification of osteoporosis, low bone mass (osteopenia), or normal bone density; assessment of fracture risk; and monitoring changes in bone density over time. The development of other technologies for the evaluation of skeletal health has been associated with uncertainties regarding their applications in clinical practice. Quantitative ultrasound (QUS), a technology for measuring properties of bone at peripheral skeletal sites, is more portable and less expensive than DXA, without the use of ionizing radiation. The proliferation of QUS devices that are technologically diverse, measuring and reporting variable bone parameters in different ways, examining different skeletal sites, and having differing levels of validating data for association with DXA-measured bone density and fracture risk, has created many challenges in applying QUS for use in clinical practice. The International Society for Clinical Densitometry (ISCD) 2007 Position Development Conference (PDC) addressed clinical applications of QUS for fracture risk assessment, diagnosis of osteoporosis, treatment initiation, monitoring of treatment, and quality assurance/quality control. The ISCD Official Positions on QUS resulting from this PDC, the rationale for their establishment, and recommendations for further study are presented here.

Which screening strategy using BMD measurements would be most cost effective for hip fracture prevention in elderly women? A decision analysis based on a Markov model

INTRODUCTION

Hip fractures are responsible for excessive mortality, decreasing the 5-year survival rate by about 20%. From an economic perspective, they represent a major source of expense, with direct costs in hospitalization, rehabilitation, and institutionalization. The incidence rate sharply increases after the age of 70, but it can be reduced in women aged 70-80 years by therapeutic interventions. Recent analyses suggest that the most efficient strategy is to implement such interventions in women at the age of 70 years. As several guidelines recommend bone mineral density (BMD) screening of postmenopausal women with clinical risk factors, our objective was to assess the cost-effectiveness of two screening strategies applied to elderly women aged 70 years and older.

METHODS

A cost-effectiveness analysis was performed using decision-tree analysis and a Markov model. Two alternative strategies, one measuring BMD of all women, and one measuring BMD only of those having at least one risk factor, were compared with the reference strategy "no screening". Cost-effectiveness ratios were measured as cost per year gained without hip fracture. Most probabilities were based on data observed in EPIDOS, SEMOF and OFELY cohorts.

RESULTS

In this model, which is mostly based on observed data, the strategy "screen all" was more cost effective than "screen women at risk." For one woman screened at the age of 70 and followed for 10 years, the incremental (additional) cost-effectiveness ratio of these two strategies compared with the reference was 4,235 euros and 8,290 euros, respectively.

CONCLUSION

The results of this model, under the assumptions described in the paper, suggest that in women aged 70-80 years, screening all women with dual-energy X-ray absorptiometry (DXA) would be more effective than no screening or screening only women with at least one risk factor. Cost-effectiveness studies based on decision-analysis trees maybe useful tools for helping decision makers, and further models based on different assumptions should be performed to improve the level of evidence on cost-effectiveness ratios of the usual screening strategies for osteoporosis.

Statistical fallacies in orthopedic research

BACKGROUND

A large number of statistical fallacies occur in medical research literature. These are mostly inadvertent and occur due to lack of understanding of the statistical concepts and terminologies. Many researchers do not fully appreciate the consequence of such fallacies on the credibility of their report.

MATERIALS AND METHODS

This article provides a general review of the issues that could give rise to statistical fallacies with focus on orthopedic research. Some of this is based on real-life literature and some is based on the actual experiences of the author in dealing with medical research over the past three decades. The text is in teaching mode rather than research mode.

RESULTS

Statistical fallacies occur due to inadequate sample that is used for generalized conclusion; incomparable groups presented as comparable; mixing of two or more distinct groups that in fact require separate consideration; misuse of percentages, means and graphs; incomplete reporting that suppresses facts; ignoring reality and depending instead on oversimplification; forgetting baseline values that affect the outcome; misuse of computer packages and use of black-box approach; misuse of P-values that compromises conclusions; confusing correlation with cause-effect; and interpreting statistical significance as medical significance.

CONCLUSION

Mere awareness of the situations where statistical fallacies can occur may be adequate for researchers to sit up and take note while trying to provide a credible report.

[The calcaneus as the site of manifestation for osteoporosis-associated fractures: age- and sex-specific changes in calcaneal morphology correlate with the incidence and severity of intra-articular calcaneal fractures]

BACKGROUND

While it is recognized that trauma energy at the time of injury is an important factor in the pathogenesis and severity of calcaneal fractures, the possible role of changes in calcaneal microarchitecture remains largely undefined. The purpose of this study was to determine whether the calcaneal bone structure changes with age and to address if local bone mass is of clinical relevance in respect to the occurrence and complexity of calcaneal fractures.

MATERIAL AND METHODS

The radiographic and clinical data of 182 patients with intra-articular calcaneal fractures were analyzed to provide correlative clinical evidence for a relation between local bone mass and fractures of the calcaneus. To measure bone mass, 60 calcanei were harvested from 30 age- and gender-matched patients at autopsy.

RESULTS

The average age at the time of fracture was higher in females (46.0+/-18.3 years) than in males (39.9+/-13.9 years). Furthermore, the relative frequency of fractures during aging shifted from males to females and the frequency of compound fractures was higher in females (65%) than in males (48%). The calcaneal bone mass was significantly reduced by 19% in older females (female symbol 20-40 years: 292 mg/cm(3); female symbol 61-80 years: 237 mg/cm(3); p<0.05).

CONCLUSION

The calcaneus displayed age- and gender-related changes in its microarchitecture that are known to reduce the biomechanical stability of trabecular bone. These results suggest that bone mass and structure are risk factors in respect to the occurrence and severity of calcaneal fractures.

Relationship between bone quantitative ultrasound and fractures: a meta-analysis

The relationship between bone QUS and fracture risk was estimated in a systematic review of data from 14 prospective studies of 47,300 individuals and 2350 incident fractures. In older women, low QUS values were associated with overall fracture risk, low-trauma fractures, and with hip, forearm, and humerus fractures separately.

INTRODUCTION

Bone quantitative ultrasound (QUS) has emerged as a promising technique to evaluate bone status. The aim of this study was to determine the association between measurements of QUS with the risk of fracture.

MATERIALS AND METHODS

A meta-analysis of prospective cohort studies published between 1985 and June 2005 with a baseline measurement of QUS and subsequent follow-up for fractures was carried out. Fourteen separate study populations, consisting of about 47,300 individuals (85.4% women), with about 124,000 person-years of observation and over 2350 fractures, including 653 hip, 529 forearm, and 386 humeral fractures, were analyzed. The main outcome measure was the estimated relative risk of fracture for a decrease in bone QUS parameters of 1 SD below sex- and age-adjusted mean in women.

RESULTS

Eleven studies evaluated QUS at the heel, with patella and phalanx (two studies each) and distal radius (one study) being scarcely used. There was not significant heterogeneity among the studies included in the review. Relative risk estimates (95% CI) for overall fractures were 1.55 (1.35-1.78) for each SD decrease in broadband ultrasound attenuation (BUA), 1.63 (1.37-1.93) for speed of sound (SOS), and 1.74 (1.39-2.17) for QUS index/stiffness index (QUI/SI). Risk estimates were similar or slightly higher for hip fractures and low-energy trauma fractures. Humeral and forearm/wrist fractures were also related with lower QUS values.

CONCLUSIONS

Measurements of bone QUS are significantly associated with nonspinal fracture risk in older women in a similar degree to DXA. QUS may be a valid alternative to evaluate fracture risk in situations where DXA is not accessible.

Bone microarchitecture of the calcaneus and its changes in aging: a histomorphometric analysis of 60 human specimens

Bone structure and quality are an important parameter in the propensity of bone to fracture. Although the calcaneus is used as diagnostic reference site for osteoporosis by ultrasound, its structure has never been analyzed in detail. The purpose of this study was therefore to histomorphometrically analyze the trabecular microarchitecture of the calcaneus, and to determine whether the calcaneal bone structure is changing with age. Sixty complete human calcanei were harvested from thirty age- and gender-matched patients at autopsy. Each of the three different age groups (group I: 20 to 40, group II: 41 to 60, group III: 61 to 80 years of age) was represented by 20 specimens. The specimens were subjected to radiographic, microCT, and histologic analysis. Bone structure and bone mass of the calcaneus were quantified for three different regions of interest: the anterior ROI, the superior ROI (the subtalar region under the posterior facet), and the posterior ROI. An iliac crest biopsy was obtained from all patients to exclude any metabolic bone disease. Histomorphometric analysis revealed significant differences in bone volume within the calcaneus with highest values in the superior ROI: age group I: 31.3% (27.8-34.8%); II: 25.5% (22.1-28.9%); III: 18.9% (16.6-21.2%) and lowest bone volumes in the anterior ROI; age group I: 6.2% (4.8-7.6%); II: 3.6% (2.1-5.1%); III: 3.9% (2.9-4.9%). There was a significant age-related decrease in bone volume (BV/TV) in aging. Interestingly, this bone loss was most prominent in the superior ROI, with a 39% decrease in BV/TV between age group I and III (p < 0.001). Qualitative and structural analysis of trabecular number, thickness, and spacing demonstrated that the bone loss in the thalamic portion of the calcaneus was due to the transition of plate-like trabecular elements into a rod-like structure. In conclusion, our study demonstrated that the calcaneus displayed age-related changes in its microarchitecture that are known to reduce the biomechanical stability of trabecular bone, and that the age-related bone loss was most prominent in the region adjacent to the posterior facet (superior ROI). These results suggest that bone mass and structure are risk factors in respect to the occurrence and severity of calcaneal fractures, and indicate that calcaneal fractures are at least in part osteoporotic fractures.

The effect of age and bone mineral density on the absolute, excess, and relative risk of fracture in postmenopausal women aged 50-99: results from the National Osteoporosis Risk Assessment (NORA)

INTRODUCTION

This study evaluates the effect of age and bone mineral density (BMD) on the absolute, excess, and relative risk for osteoporotic fractures at the hip, wrist, forearm, spine, and rib within 3 years of peripheral BMD testing in postmenopausal women over a wide range of postmenopausal ages.

METHODS

Data were obtained from 170,083 women, aged 50-99 years, enrolled in the National Osteoporosis Risk Assessment (NORA) following recruitment from their primary care physicians' offices across the United States. Risk factors for fracture and peripheral BMD T-scores at the heel, forearm, or finger were obtained at baseline. Self-reported new fractures at the hip, spine, rib, wrist, and forearm were obtained from questionnaires at 1- and 3-year follow-ups. Absolute, excess (attributable to low BMD), and unadjusted and adjusted relative risks of fracture were calculated.

RESULTS

At follow-up, 5312 women reported 5676 fractures (868 hip, 2420 wrist/forearm, 1531 rib, and 857 spine). Absolute risk of fracture increased with age for all fracture sites. This age-effect was most evident for hip fracture--both the incidence and the excess risk of hip fracture for women with low BMD increased at least twofold for each decade increase in age. The relative risk for any fracture per 1 SD decrease in BMD was similar across age groups (p>0.07). Women with low BMD (T-score <-1.0) had a similar relative risk for fracture regardless of age.

CONCLUSIONS

At any given BMD, not only the absolute fracture risk but also the excess fracture risk increased with advancing age. Relative risk of fracture for low bone mass was consistent across all age groups from 50 to 99 years.

Heel bone ultrasound predicts non-spine fracture in Japanese men and women

A number of prospective studies in the USA and Europe have demonstrated that quantitative ultrasound (QUS) measurements predict fracture risk. To our knowledge, there has been no such study in a Japanese population, and very few studies have measured the prognostic value of QUS measurements among men, even in the USA and Europe. We performed a three-center prospective study to investigate the relationship between baseline heel QUS measurements and non-spine fracture risk. There were 4,028 subjects (1,004 men and 3,024 women), 67.5+/-8.9 years [mean +/- standard deviation (SD)] of age), who underwent heel QUS (Achilles device) at three centers between 1993 and 2000. In 2002, the subjects were mailed a standardized questionnaire that asked about their history of fracture. The mean follow-up period was approximately 5 years. The Achilles measured speed of sound (SOS) and broadband ultrasound attenuation (BUA). We used Cox regression analysis to determine the hazard ratio (HR), using weighted coefficients. SOS, BUA, and stiffness index (SI) predicted self-reported hip, wrist, and total non-spine fractures. After we had adjusted for age, gender, and weight, the HRs of total non-spine fracture were 1.54 [95% confidence interval (CI) 1.39-1.69], 1.53 (1.37-1.70), and 1.80 (1.62-1.98) for 1 SD decrease in SOS, BUA, and SI, respectively. In men, SOS and SI also predicted total non-spine fractures with HRs similar to those in women. The HR of prediction for hip fracture by SOS and SI was better in the short term than in the long term, and the prediction for hip, wrist, and non-spine fracture remained significant between 5 to 10 years of follow-up. Measurements obtained from heel QUS predicted non-spine fracture in Japanese men and women, and the HRs of Japanese of both genders was similar to the risk ratio (RR) of Caucasian men and women. QUS parameters can predict hip, wrist, and non-spine fracture up to 10 years.

Does follow-up duration influence the ultrasound and DXA prediction of hip fracture? The EPIDOS prospective study

While the potential of quantitative ultrasound (QUS) in the management of osteoporosis has been accepted, its interaction with follow-up time has never been investigated. The aim of our study is to prospectively evaluate the influence of follow-up time on the prediction of hip fracture by ultrasound parameters in the elderly as compared to bone mineral density (BMD) and to establish a long-term fracture prediction model. In the multicenter prospective study EPIDOS, 5898 Caucasian healthy women, aged 75 and over, had femoral dual-energy X-ray absorptiometry (DXA) and heel ultrasound measurements at baseline. A survey of fracture occurrence was conducted every 4 months. Statistical analyses were performed for three different average lengths of follow-up, namely, 1.5, 2.5 and 3.5 years. Relative risks per standard deviation decrease (RR) and the area under the receiver operating characteristic (AUC) curves were given. Estimates of the long-term hip fracture prediction by DXA and QUS were extrapolated. During an average of 3.5 years follow-up, 227 women sustained their first non-traumatic hip fracture. For the three categories of follow-up, low values of both calcaneal ultrasound and hip BMD were associated with a significant increased risk of hip fracture [e.g. ultrasound Stiffness index RR = 2.8 (2.1-3.8), 2.1 (1.7-2.6) and 1.9 (1.7-2.3) for 1.5, 2.5 and 3.5 years of follow-up, respectively]. The combination of femoral neck BMD with the Stiffness showed an improvement of the hip fracture prediction model. Using extrapolation, the prediction of hip fracture by the Stiffness remained significant up to 7.5 years [RR = 1.2 (1.03-1.41)], whereas the limit of significance was reached at 10 years for the femoral neck BMD [RR = 1.25 (1.04-1.52)]. Our results indicate that the Stiffness tends to be the best short- and long-term predictor of hip fracture among ultrasound parameters. This paper provides additional information on the long-term prediction of hip fracture, which has always been an important issue in routine clinical practice as it influences the management of the disease. Our model should give a relatively good estimation of the fracture risk prediction at 5 years with the ultrasound and 10 years for the femoral neck BMD.