FRAX updates 2016

Skeletal muscle index based on CT at the 12th thoracic spine level can predict osteoporosis and fracture risk: a propensity score-matched cohort study

Background

Multiple studies have shown that skeletal muscle index (SMI) measured on abdominal computed tomography (CT) is strongly associated with bone mineral density (BMD) and fracture risk as estimated by the fracture risk assessment tool (FRAX). Although some studies have reported that SMI at the level of the 12th thoracic vertebra (T12) measured on chest CT images can be used to diagnose sarcopenia, it is regrettable that no studies have investigated the relationship between SMI at T12 level and BMD or fracture risk. Therefore, we further investigated the relationship between SMI at T12 level and FRAX-estimated BMD and fracture risk in this study.

Methods

A total of 349 subjects were included in this study. After 1∶1 propensity score matching (PSM) on height, weight, hypertension, diabetes, hyperlipidemia, hyperuricemia, body mass index (BMI), age, and gender, 162 subjects were finally included. The SMI, BMD, and FRAX score of the 162 participants were obtained. The correlation between SMI and BMD, as well as SMI and FRAX, was assessed using Spearman rank correlation. Additionally, the effectiveness of each index in predicting osteoporosis was evaluated through the receiver operating characteristic (ROC) curve analysis.

Results

The BMD of the lumbar spine (L1-4) demonstrated a strong correlation with SMI (r = 0.416, p < 0.001), while the BMD of the femoral neck (FN) also exhibited a correlation with SMI (r = 0.307, p < 0.001). SMI was significantly correlated with FRAX, both without and with BMD at the FN, for major osteoporotic fractures (r = -0.416, p < 0.001, and r = -0.431, p < 0.001, respectively) and hip fractures (r = -0.357, p < 0.001, and r = -0.311, p < 0.001, respectively). Moreover, the SMI of the non-osteoporosis group was significantly higher than that of the osteoporosis group (p < 0.001). SMI effectively predicts osteoporosis, with an area under the curve of 0.834 (95% confidence interval 0.771-0.897, p < 0.001).

Conclusion

SMI based on CT images of the 12th thoracic vertebrae can effectively diagnose osteoporosis and predict fracture risk. Therefore, SMI can make secondary use of chest CT to screen people who are prone to osteoporosis and fracture, and carry out timely medical intervention.

Bone damage and health-related quality of life in Hodgkin lymphoma survivors: closing the gaps

In the recent decades, remarkable successes have been recorded in the treatment of Hodgkin's lymphoma to the point that today it represents one of the neoplasms with the highest rates of cure and with the highest life expectancy. Nonetheless, this raises the concern for the health of long- term survivors. Late side effects of treatments in synergy with other risk factors expose survivors to increased morbidity and impaired quality of life. In the complexity of the topics concerning these last aspects, an area of growing interest is that of bone damage that follows Hodgkin Lymphoma and its treatments. In this narrative review, we conducted our work through assessment of available evidence focusing on several aspects linking bone damage and quality of life with Hodgkin lymphoma and its treatments. At present, the problem of osteopenia and osteoporosis in Hodgkin lymphoma survivors is a theme for which awareness and knowledge need to be implemented.

Osteoporosis and Fracture Risk among Older US Asian Adults

PURPOSE OF REVIEW

This review summarizes the current knowledge regarding osteoporosis and fracture among older US Asian adults.

RECENT FINDINGS

Asian adults have lower (areal) bone density than non-Hispanic White adults and thus are more likely to be diagnosed and treated for osteoporosis, despite their lower risk of hip fracture. The latter may relate to favorable characteristics in hip geometry, volumetric bone density, and bone microarchitecture; lower risk of falls; and other clinical factors. The fracture risk calculator FRAX accounts for the lower risk of hip fracture among US Asian adults. However, data on major osteoporotic fracture risk remain limited. Fracture rates also vary by Asian subgroup, which may have implications for fracture risk assessment. Furthermore, among women receiving bisphosphonate drugs, Asian race is a risk factor for atypical femur fracture, an uncommon complication associated with treatment duration. Recent clinical trial efficacy data pertaining to lower bisphosphonate doses and longer dosing intervals may be relevant for Asian adults. More research is needed to inform osteoporosis care of US Asian adults, including risk-benefit considerations and the optimal duration of bisphosphonate treatment. Greater evidence-based guidance for primary fracture prevention among US Asian adults will ensure health equity in the prevention of osteoporotic fractures.

Use of Clinical Practice Guidelines and Quality Metrics to Assess Primary Care Management of Osteoporosis

Background: Clinical practice guidelines and quality measures provide recommendations for physicians addressing osteoporosis management. This study explored the alignment of osteoporosis clinical practice in a primary care geriatric clinic with recommended guidelines. Methods: This retrospective chart review included 388 patients 65 or older from a primary care geriatric clinic diagnosed with osteopenia or osteoporosis, with or without a fragility fracture. Data included history of falls and use of DXA scans, FRAX® fracture risk assessment tool, osteoporosis medication, and fall risk mitigation plans. Results: For age-related primary fracture prevention, 68% of women and 87% of men had documented DXA scans, and 45% of patients diagnosed with osteoporosis and 42% determined at high risk were prescribed osteoporosis medication. For secondary fracture prevention, 72% of women aged 67 to 85 had DXA scans and 21% were prescribed osteoporosis medication. Only 10% of patients with a history of falls had documented fall risk management plans. Conclusion: Although showing higher rates of primary and secondary prevention outcomes than did research results from general primary care, gaps were identified for high fracture risk patients and fall risk management documentation. Medical record review may not provide sufficient data to capture factors influencing decision-making for fracture prevention.

Application of machine learning model to predict osteoporosis based on abdominal computed tomography images of the psoas muscle: a retrospective study

BACKGROUND

With rapid economic development, the world's average life expectancy is increasing, leading to the increasing prevalence of osteoporosis worldwide. However, due to the complexity and high cost of dual-energy x-ray absorptiometry (DXA) examination, DXA has not been widely used to diagnose osteoporosis. In addition, studies have shown that the psoas index measured at the third lumbar spine (L3) level is closely related to bone mineral density (BMD) and has an excellent predictive effect on osteoporosis. Therefore, this study developed a variety of machine learning (ML) models based on psoas muscle tissue at the L3 level of unenhanced abdominal computed tomography (CT) to predict osteoporosis.

METHODS

Medical professionals collected the CT images and the clinical characteristics data of patients over 40 years old who underwent DXA and abdominal CT examination in the Second Affiliated Hospital of Wenzhou Medical University database from January 2017 to January 2021. Using 3D Slicer software based on horizontal CT images of the L3, the specialist delineated three layers of the region of interest (ROI) along the bilateral psoas muscle edges. The PyRadiomics package in Python was used to extract the features of ROI. Then Mann-Whitney U test and the least absolute shrinkage and selection operator (LASSO) algorithm were used to reduce the dimension of the extracted features. Finally, six machine learning models, Gaussian naïve Bayes (GNB), random forest (RF), logistic regression (LR), support vector machines (SVM), Gradient boosting machine (GBM), and Extreme gradient boosting (XGBoost), were applied to train and validate these features to predict osteoporosis.

RESULTS

A total of 172 participants met the inclusion and exclusion criteria for the study. 82 participants were enrolled in the osteoporosis group, and 90 were in the non-osteoporosis group. Moreover, the two groups had no significant differences in age, BMI, sex, smoking, drinking, hypertension, and diabetes. Besides, 826 radiomic features were obtained from unenhanced abdominal CT images of osteoporotic and non-osteoporotic patients. Five hundred fifty radiomic features were screened out of 826 by the Mann-Whitney U test. Finally, 16 significant radiomic features were obtained by the LASSO algorithm. These 16 radiomic features were incorporated into six traditional machine learning models (GBM, GNB, LR, RF, SVM, and XGB). All six machine learning models could predict osteoporosis well in the validation set, with the area under the receiver operating characteristic (AUROC) values greater than or equal to 0.8. GBM is more effective in predicting osteoporosis, whose AUROC was 0.86, sensitivity 0.70, specificity 0.92, and accuracy 0.81 in validation sets.

CONCLUSION

We developed six machine learning models to predict osteoporosis based on psoas muscle images of abdominal CT, and the GBM model had the best predictive performance. GBM model can better help clinicians to diagnose osteoporosis and provide timely anti-osteoporosis treatment for patients. In the future, the research team will strive to include participants from multiple institutions to conduct external validation of the ML model of this study.

Osteoporosis Screening and Fracture Risk Assessment Tool: Its Scope and Role in General Clinical Practice

Osteoporosis is a widely prevalent condition among postmenopausal women characterized by low bone mass and skeletal fragility that increases the risk of fractures specifically in the hip, spine, wrist, humerus, and pelvis. It has become a major public health problem around the world. An osteoporotic fracture affects one in every three women and one in every five men aged 50 and above. Hip and spine fractures are linked to a higher death rate and can cause ambulation problems, depression, chronic pain, independence loss, and persistent discomfort. It not only puts a lot of strain on the individual but also causes a significant cost to society. Osteoporosis is a silent disease that goes unrecognized until a patient develops a pathological fracture. Diagnosis of osteoporosis is based on bone mineral density (BMD) estimation by dual-energy x-ray absorptiometry (DXA) as defined by WHO. However, in many resource-constrained and underdeveloped or low-middle income countries, it is not widely available. There are a number of questionnaire-based techniques available to identify such postmenopausal women and older men who may be at risk of having low BMD and osteoporosis. Our aim of the study is to search and compile such simple yet useful and validated screening and assessment tools for osteoporosis that can help to identify people at risk of having low BMD and the potential candidate who can benefit from BMD estimation in a resource-restricted geographical area or low/middle-income countries and benefit from treatment. Though these tools are not diagnostic can have broader applicability in general clinical practice and usefulness in identifying high-risk individuals and may prove cost-effective. Although it has limitations, FRAX is a widely used osteoporotic fracture risk assessment tool around the globe and when used with femoral neck BMD it has greater accuracy.

Estimation of fracture risk by the FRAX tool in patients with systemic lupus erythematosus: a 10-year longitudinal validation study

Background:

The fracture risk assessment tool has been widely used to stratify the 10-year fracture risk to guide therapy. Using the actual fracture data of a 10-year longitudinal cohort of older patients with systemic lupus erythematosus, we reported an underestimation of the tool in predicting major symptomatic osteoporotic fractures. Treatment of osteoporosis in systemic lupus erythematosus should not be based on fracture risk estimation alone. Relevant time-dependent risk factors should be taken into account for an individualized decision.

Objective:

To compare the observed fracture incidence in a 10-year longitudinal cohort of patients with systemic lupus erythematosus (SLE) with the fracture risk prediction from the fracture risk assessment (FRAX) tool.

Methods:

Adult patients (⩾40 years) with SLE who had a first DEXA scan performed in 2005–2009 were studied. The 10-year rates of major osteoporotic and hip fractures were estimated by FRAX using clinical data at DEXA with adjustment for prednisolone dosage. The actual incidence of clinical fractures at 10 years was compared with the estimated rates. Factors associated with new fractures were studied by logistic regression.

Results:

A total of 229 SLE patients were studied (age: 50.2 ± 6.6 years, 93% women). Glucocorticoid was used in 148 (65%) patients at baseline (mean dose: 7.3 ± 6.9 mg/day; 34% ⩾ 7.5 mg/day). Osteoporosis (bone mineral density T score ⩽ –2.5) at the hip, femoral neck, or spine was present in 61 (27%) patients. The estimated 10-year risk of major osteoporotic and hip fractures by FRAX was 3.4 ± 4.5% and 0.95 ± 2.3%, respectively. After 10 years, three patients developed hip fracture, 6 patients had limb fractures and 20 patients had symptomatic vertebral fractures (major osteoporotic fracture 12.7%, hip fracture 1.3%). The actual major osteoporotic fracture rate was significantly higher than the FRAX estimation (12.7% vs 3.4%; p < 0.001). Logistic regression revealed that osteoporosis (odds ratio (OR): 4.07 [1.51–10.9]), previous fragility fracture (OR: 3.18 [1.02–9.90]), and a parental history of fracture (OR: 4.44 [1.16–17.0]) were independently associated with new clinical fractures at 10 years.

Conclusion:

The FRAX tool underestimates the major clinical fracture risk at 10 years in patients with SLE.

Multidimensional prognostic index and the risk of fractures: an 8-year longitudinal cohort study in the Osteoarthritis Initiative

In this longitudinal study, with a follow-up of 8 years, multidimensional prognostic index (MPI), a product of the comprehensive geriatric assessment, significantly predicted the onset of fractures in older people affected by knee osteoarthritis.

PURPOSE

Frailty may be associated with higher fracture risk, but limited research has been carried out using a multidimensional approach to frailty assessment and diagnosis. The present research aimed to investigate whether the MPI, based on comprehensive geriatric assessment (CGA), is associated with the risk of fractures in the Osteoarthritis Initiative (OAI) study.

METHODS

Community-dwellers affected by knee OA or at high risk for this condition were followed-up for 8 years. A standardized CGA including information on functional, nutritional, mood, comorbidity, medication, quality of life, and co-habitation status was used to calculate the MPI. Fractures were diagnosed using self-reported information. Cox's regression analysis was carried out and results are reported as hazard ratios (HRs), with their 95% confidence intervals (CIs), adjusted for potential confounders.

RESULTS

The sample consisted of 4024 individuals (mean age 61.0 years, females = 59.0%). People with incident fractures had a significant higher MPI baseline value than those without (0.42 ± 0.18 vs. 0.40 ± 0.17). After adjusting for several potential confounders, people with an MPI over 0.66 (HR = 1.49; 95%CI: 1.11-2.00) experienced a higher risk of fractures. An increase in 0.10 point in MPI score corresponded to an increase in fracture risk of 4% (HR = 1.04; 95%CI: 1.008-1.07). Higher MPI values were also associated with a higher risk of non-vertebral clinical fractures.

CONCLUSION

Higher MPI values at baseline were associated with an increased risk of fractures, reinforcing the importance of CGA in predicting fractures in older people affected by knee OA.

Prevalence of Osteopenia in Drug-Naive Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: A Monocentric Study

OBJECTIVES

To examine the bone mineral density and prevalence of osteoporosis and osteopenia in glucocorticoid- and immunosuppressive drug-naive patients younger than 55 years with antineutrophil cytoplasmic antibody-associated vasculitis (AAV).

METHODS

This was a cross-sectional study. We reviewed the medical records of 35 AAV patients and 35 age-, sex-, and body mass index (BMI)-matched control subjects. We collected clinical data such as AAV-related variables and conventional risk factors for osteoporosis and assessed bone mineral density and the prevalence of osteoporosis and osteopenia in both groups. Categorical and continuous variables were compared between the 2 groups using the χ2 or Fisher exact test and Mann-Whitney U test, respectively. Multivariate logistic regression analysis was used to calculate the odds ratio (OR).

RESULTS

There were no statistically significant differences between the demographical data of AAV patients and control subjects. Patients with AAV showed significantly higher frequencies of conventional risk factors for osteoporosis than the control subjects, except for hyperthyroidism. Osteopenia was found more commonly in AAV patients than in control subjects (57.1% vs. 31.4%, p = 0.030). In the univariate logistic regression analysis, BMI (OR, 0.813) and AAV (OR, 2.620) were associated with osteopenia in all participants. In the multivariate analysis, both BMI and AAV were associated with osteopenia, but this was not statistically significant. In contrast, when analyzing AAV patients only, neither conventional risk factors nor AAV-related variables were associated with the prevalence of osteopenia.

CONCLUSIONS

Antineutrophil cytoplasmic antibody-associated vasculitis and BMI were both associated with osteopenia.

Assessment of the Relationship Between Bone Mineral Density and Fracture Risk Factors in the Family Doctor Practice

Osteoporosis is the fourth most common after cardiovascular, cancer and endocrine diseases. According to WHO experts, due to the aging population and the impact of negative environmental factors, the incidence of osteoporosis will increase further. The objective: determining the relationship between ultrasound densitometry data on the heel cyst and the risk of fractures in older women from different regions of the country. Materials and methods. The study was based on a survey of women in major cities of Ukraine – Kyiv, Kharkiv, Odessa. 116 women aged 40 to 79 years were included. The average age of the subjects was 56±9,62 years, the average body weight was 74,5±12,9 kg, height 163,1±5,62 cm, the average body mass index (BMI) was 28±4,90. Normal (BMI) 20–24,9 had 35 women (30,2%), rates of preobesity and clinical obesity were in 81 surveyed women (69,8%). All subjects were divided into 4 groups by age: 40–49 years, 50–59 years, 60–69 years, 70–79 years. Results. Decrease in bone mineral density was found in 59,5% of examined women, of which osteopenia was in 57%, osteoporosis in 2,5% of women, the norm in 40,5% of women. The number of women with low BMD increased with age. Analyzing the risk factors in women after 40 years revealed a high incidence of hypertension 40,5%, the frequency of previous fractures in the anamnesis was 22,% of respondents, fractures of the femur and other fractures in parents noted 33,6% of women, a decrease in growth by 3 cm during life occurred in 13,7%, early menopause (up to 45 years) in 16,3% of women. Physical activity less than 30 minutes a day was noted by 27,5%. The risk of FRAX and Q-fracture fractures is significantly correlated with densitometry. Conclusions. Early detection of osteoporosis risk factors in the practice of a family doctor will help prevent an epidemic of this disease in our country and will prevent negative medical and social consequences. All of the above should be considered for planning preventive measures for osteoporosis and its complications, as well as for subsequent diagnostic steps for early detection of the disease.

Osteoporotic fractures in second-generation immigrants and Swedish natives

In this national study of osteoporotic fractures in second-generation immigrants in Sweden, we found a similar risk of osteoporotic fractures in general compared to Swedish natives, which suggests that environmental factors are important for the high risk of osteoporotic fractures in Nordic countries.

INTRODUCTION

Second generation immigrants may have a similar environment as individuals with two native-born parents. These individuals may be of interest to study concerning whether environmental or hereditary factors could be mostly associated to the risk of osteoporotic fractures. The aim of this study was to analyse the risk of osteoporotic fractures in second-generation immigrants compared to Swedish natives.

METHODS

This was a nationwide study of individuals aged 50 years of age and older (N = 1,377,035; 691,750 men and 685,285 women). Osteoporotic fractures were defined as at least one registered diagnosis of fractures in the hip, humerus, forearm or vertebrae, in the National Patient Register between January 1, 1998, and December 31, 2012. Cox regression analysis was used to estimate the relative risk (hazard ratios (HR) with 95% confidence intervals (CI)) of incident osteoporotic fractures in second generation immigrants compared to Swedish natives. The Cox regression models were adjusted for age, comorbidities and for sociodemographic status.

RESULTS

A total of 114,505 osteoporotic fractures were registered, 109,622 (8.4%) were among individuals with Swedish-born parents and 4883 (7.5%) among those with foreign-born parents, with distal forearm fractures dominating in general (44.9%). Fully adjusted HRs (95% CI) were for all immigrants 0.95 (95% CI, 0.91-0.99), for men 0.96 (95% CI, 0.89-1.04) and for women 0.95 (95% CI, 0.90-1.00).

CONCLUSIONS

We observed a similar risk of osteoporotic fractures among second-generation immigrants as in Swedish natives, which suggests that environmental factors are important for osteoporotic fractures.

Glucocorticoid-Induced Osteoporosis: The Potential Role of Romosozumab

Glucocorticoid (GC)-induced osteoporosis (GIOP) is a major problem in patients with rheumatic diseases. The deleterious effect of GC on bone turnover is rapid and dose-dependent, with a predilection on the trabecular bone, resulting in vertebral fractures. Early recognition and prompt treatment of GIOP helps prevent bone loss and reduce fractures. There are pitfalls in current assessment tools for GIOP by dual-energy X-ray absorptiometry (DXA) and fracture risk assessment tool (FRAX) estimation formula. In this review, we evaluate different assessment methods for GIOP and summarize current therapies of GIOP, including the antiresorptive and anabolic agents. The potential role of newer anti-osteoporosis agent romosozumab, an anti-sclerostin monoclonal antibody, is also discussed.

Determinants of imminent fracture risk in postmenopausal women with osteoporosis

In elderly women with osteoporosis, prior fracture, low BMD, impaired physical functioning, poorer general health, and recent falls were all direct predictors of imminent (in next year) fracture risk. Prior fracture, older age, worse health, impaired cognitive functioning, and recent falls indirectly increased imminent risk by reducing physical functioning/general health.

INTRODUCTION

This study was designed to examine determinants of imminent risk of osteoporotic fracture (i.e., next 1-2 years) in postmenopausal women.

METHODS

This retrospective cohort study used data from Caucasian women age 65 or older with osteoporosis who participated in the observational Study of Osteoporotic Fractures (SOF). We examined potential direct and indirect predictors of hip and nonvertebral fractures in 1-year follow-up intervals including anthropometric measures, bone mineral density (T-score), fracture since age 50, physical function, cognition, medical conditions, recent (past year) falls, and lifestyle factors. Clinically related variables were grouped into constructs via factor analysis. These constructs and selected individual variables were incorporated into a theoretical structural equation model to evaluate factors that influence imminent risk.

RESULTS

Among 2261 patients, 19.4% had a nonvertebral fracture and 5.5% had a hip fracture within 1 year of a study visit between 1992 and 2008. Prior fracture, lower T-scores, lower physical functioning, and recent falls all directly increased 1-year risk of nonvertebral fracture. For both nonvertebral and hip fractures, prior fracture and recent falls influenced risk indirectly through general health, while cognition influenced risk via physical functioning. Age influenced both physical functioning and general health.

CONCLUSIONS

Several established risk factors for 10-year fracture risk also played a role in predicting imminent risk of fracture (e.g., T-scores, prior fracture), as did falls, cognition, physical functioning, and general health. Fracture risk assessments should also consider falls and fall risk factors as well as established bone-related risk factors in assessing imminent fracture risk.

Determinants of imminent fracture risk in postmenopausal women with osteoporosis

In elderly women with osteoporosis, prior fracture, low BMD, impaired physical functioning, poorer general health, and recent falls were all direct predictors of imminent (in next year) fracture risk. Prior fracture, older age, worse health, impaired cognitive functioning, and recent falls indirectly increased imminent risk by reducing physical functioning/general health.

INTRODUCTION

This study was designed to examine determinants of imminent risk of osteoporotic fracture (i.e., next 1-2 years) in postmenopausal women.

METHODS

This retrospective cohort study used data from Caucasian women age 65 or older with osteoporosis who participated in the observational Study of Osteoporotic Fractures (SOF). We examined potential direct and indirect predictors of hip and nonvertebral fractures in 1-year follow-up intervals including anthropometric measures, bone mineral density (T-score), fracture since age 50, physical function, cognition, medical conditions, recent (past year) falls, and lifestyle factors. Clinically related variables were grouped into constructs via factor analysis. These constructs and selected individual variables were incorporated into a theoretical structural equation model to evaluate factors that influence imminent risk.

RESULTS

Among 2261 patients, 19.4% had a nonvertebral fracture and 5.5% had a hip fracture within 1 year of a study visit between 1992 and 2008. Prior fracture, lower T-scores, lower physical functioning, and recent falls all directly increased 1-year risk of nonvertebral fracture. For both nonvertebral and hip fractures, prior fracture and recent falls influenced risk indirectly through general health, while cognition influenced risk via physical functioning. Age influenced both physical functioning and general health.

CONCLUSIONS

Several established risk factors for 10-year fracture risk also played a role in predicting imminent risk of fracture (e.g., T-scores, prior fracture), as did falls, cognition, physical functioning, and general health. Fracture risk assessments should also consider falls and fall risk factors as well as established bone-related risk factors in assessing imminent fracture risk.

Comparison of Fracture Prediction Tools in Individuals Without and With Early Chronic Kidney Disease: A Population-Based Analysis of CARTaGENE

Whether fracture prediction tools developed for the management of osteoporosis can be used in chronic kidney disease (CKD) is poorly known. We aimed to compare the performance of fracture prediction tools in non-CKD and CKD. We analyzed CARTaGENE, a population-based survey of 40-year-old to 69-year-old individuals recruited between 2009 and 2010. Renal function was assessed using baseline creatinine and categorized according to Kidney Disease Improving Global Outcomes (KDIGO) guidelines (non-CKD, stage 2, stage 3). Individuals without creatinine measurements or with advanced CKD (stage 4 or 5; prevalence <0.25%) were excluded. Predicted 5-year fracture probabilities (using Fracture Risk Assessment Tool [FRAX], QFracture, and Garvan) were computed at baseline. Fracture incidence (major fracture [MOF] or any fracture) was evaluated in administrative databases from recruitment to March 2016. Discrimination (hazard ratios [HRs] per standard deviation [SD] increase in Cox models; c-statistics) and calibration (standardized incidence ratios [SIRs] before and after recalibration) were assessed in each CKD strata. We included 19,393 individuals (9522 non-CKD; 9114 stage 2; 757 stage 3). A total of 830 patients had any fracture during follow-up, including 352 MOF. FRAX (HR = 1.89 [1.63-2.20] non-CKD; 1.64 [1.41-1.91] stage 2; 1.76 [1.10-2.82] stage 3) and QFracture (HR = 1.90 [1.62-2.22] non-CKD; 1.57 [1.35-1.82] stage 2; 1.86 [1.19-2.91] stage 3) discriminated MOF similarly in non-CKD and CKD. In contrast, the discrimination of Garvan for any fracture tended to be lower in CKD stage 3 compared to non-CKD and CKD stage 2 (HR = 1.36 [1.22-1.52] non-CKD; 1.34 [1.20-1.50] stage 2; 1.11 [0.79-1.55] stage 3). Before recalibration, FRAX globally overestimated fracture risk while QFracture and Garvan globally underestimated fracture risk. After recalibration, FRAX and QFracture were adequately calibrated for MOF in all CKD strata whereas Garvan tended to underestimate any fracture risk in CKD stage 3 (SIR = 1.31 [0.95-1.81]). In conclusion, the discrimination and calibration of FRAX and QFracture is similar in non-CKD and CKD. Garvan may have a lower discrimination in CKD stage 3 and underestimate fracture risk in these patients. © 2020 American Society for Bone and Mineral Research.

COPD as an independent risk factor for osteoporosis and fractures

Fractures are common in individuals with COPD and occur at higher bone mass values than expected. COPD appears to be an important risk factor for bone fragility.

INTRODUCTION

Patients with chronic obstructive pulmonary disease (COPD) have an increased risk of osteoporosis and fractures, but screening and prophylactic measures to prevent both disorders are often neglected in this population. This case-control study assessed the prevalence of osteopenia, osteoporosis, and fractures in patients with COPD, and identified potential risk factors for fractures in this population.

METHODS

Overall, 91 patients with COPD (COPD group; COPDG) and 81 age- and sex-matched controls (control group; CG) were assessed with bone mineral density (BMD), thoracic/lumbar spine radiographs, and serum PTH and 25-hydroxyvitamin D (25[OH]D) levels. The occurrence of prior fractures was retrieved from clinical history.

RESULTS

The prevalence of total fractures in the COPDG was 57.1% (odds of fracture 4.7 times greater compared with the CG), and the femoral neck T-score emerged as the best predictor of fractures. Compared with the CG, the COPDG had lower spine and femoral BMD (p ≤ 0.01) and 25(OH)D levels (p = 0.01) and 2.6 times greater odds of osteoporosis. Among men, vertebral fractures were more prevalent in the COPDG versus CG (25.9% vs. 6.5%, respectively, p = 0.01). The odds of fracture increased with femoral neck T-scores ≤ - 2.7 in the CG and ≤ - 0.6 in the COPDG.

CONCLUSION

These results add robust evidence to an increased odds of osteoporosis and fractures in COPD. Fractures in the COPDG occurred at higher BMD values than expected, suggesting that COPD may be an independent marker of fracture risk, reinforcing a need for regular osteoporosis screening with BMD measurement and prophylaxis of fractures in patients with this disorder.

Clinical Characteristics of Primary and Secondary Osteoporotic Fractures: Data from Single Referral Center Emergency Department

Background

To investigate the characteristics of patients with osteoporotic fractures (OF) who visited the emergency room, we analyzed the frequency and distribution of primary and secondary OF.

Methods

From March 2015 to April 2017, 406 patients with OF were assigned to wrist (W; n=132), spine (S; n=78), and hip (H; n=196) according to the site. All subjects were classified as having primary fracture or secondary fracture. Age, fracture site, the risk of future fracture using Fracture Risk Assessment Tool (FRAX) were compared.

Results

The mean age at fracture site was significantly different among the 3 groups, groups W (66.57±10.03), S (73.50±9.07), and H (78.50±7.72). The most common site of OF were in the order of wrist, spine, and hip with the increase of age. The FRAX scores significantly increased (P<0.001) in the order of W (8.35±5.67), S (10.74±6.99), and H (13.88±7.98) in total patient, and same in primary fracture group (W, 7.50±4.18; S, 9.76±5.91; H, 11.93±6.61; P<0.001). The main site of prior fractures in secondary fracture was same lesion, which means that the prior fracture of secondary wrist fracture was wrist fracture such as spine for spine, hip for hip.

Conclusions

We determined that as age increasing, the major sites of OF were different and FRAX scores increased. The most common site for secondary fracture was the same one. Hence, the risk of subsequent fracture in same site should be noted after patient suffered OF.

State of the art in osteoporosis risk assessment and treatment

BACKGROUND

Osteoporosis constitutes a major public health problem, through its association with age-related fractures, particularly of the hip, vertebrae, distal forearm, and humerus. Over recent decades, it has evolved from being viewed as an inevitable consequence of ageing, to being recognised as a serious and eminently treatable disease.

MATERIALS AND METHODS

In this article, we review the literature pertaining to the epidemiology of osteoporosis, associated health burden, approaches to risk assessment and treatment.

RESULTS

Although there is some evidence that fracture incidence has reached a plateau, or even started to decline, in the developed world, an ageing population and adoption of westernised lifestyles in transitioning populations is leading to an increasing burden of osteoporosis across the world. Whilst the clinical definition of osteoporosis has been based solely on bone mineral density, the prediction of fracture at the individual level has been improved by consideration of clinical risk factors in tools such as FRAX®, derived from a greater understanding of the epidemiology of osteoporosis. Such advances in approaches to primary and secondary prevention of fractures, coupled with elucidation of the underlying biology, and the development of a range of highly effective antiosteoporosis medications, have enabled a step change in our ability to prevent osteoporosis-related fractures. However, there remains a substantial disparity between the number of individuals at high fracture risk and number treated globally.

CONCLUSION

Urgent work is needed at the level of health care systems, national and international policy, and in communication with patients and public, to ensure that all patients who should receive treatment for osteoporosis actually do so.

Revised FRAX®-based intervention thresholds for the management of osteoporosis among postmenopausal women in Sri Lanka

This paper revised the fixed intervention thresholds (ITs) based on the Sri Lankan fracture risk assessment tool (FRAX) published in 2013 and introduced new ITs, hybrid and two-tier, aiming to help clinicians in the management of postmenopausal osteoporosis. The hybrid and two-tier ITs have a better discriminatory power than age-dependent and revised fixed ITs.

INTRODUCTION

This study revised the Sri Lankan FRAX®-based intervention thresholds (ITs) previously published in 2013.

METHOD

Age-dependent ITs were estimated, from 50-80 years with 5-year intervals, using a Sri Lankan FRAX® algorithm for a woman with a BMI of 24.8 kg/m² and history of prior fragility fracture without other clinical risk factors. Data of 653 postmenopausal women were used in estimating fixed, hybrid, and two-tier ITs. ITs were determined using the ROC curve and partial Youden index. New ITs were validated using data of 356 postmenopausal women who underwent DXA and 62 women who had a recent fragility fracture. Women in the two groups (n = 653 and n = 356) came from the Southern Province and had undergone DXA in our state-owned tertiary care hospital as a part of their routine clinical assessment.

RESULTS

The mean (SD) age and BMI of the subjects (n = 653) were 62 (8) years and 24.8 (1.2) kg/m², respectively. Age-dependent ITs of major osteoporotic fracture risk (MOFR) and hip fracture risk (HFR) ranged from 2.7 to 18% and from 0.4 to 7.1%. The best fixed ITs for women aged 50-80 years were 9% for MOFR and 3% for HFR. In the hybrid method, MOFR of 6% and HFR of 2% were found appropriate for women aged < 70 years. These were combined with age-dependent ITs for women aged 70 years and above. In the two-tier system, two sets of ITs were calculated (ITs of MOFR/HFR for women aged < 70 years and ≥ 70 years were 6%/2% and 12%/5%, respectively). When age-dependent ITs were considered the reference standard, sensitivities of the fixed, hybrid, and two-tier ITs were 0.63, 0.73, and 0.74, respectively. The specificities were 0.76, 0.86, and 0.80 in the same order. Sensitivities of the age-dependent, fixed, hybrid, and two-tier ITs in identifying a woman with an incident fracture were 26%, 48%, 61%, and 61%, respectively.

CONCLUSIONS

The new fixed MOFR is slightly lower than the previous value and hybrid and two-tier ITs perform better than age-dependent and fixed ITs.

Women with fracture, unidentified by FRAX, but identified by cortical porosity, have a set of characteristics that contribute to their increased fracture risk beyond high FRAX score and high cortical porosity

The Fracture Risk Assessment Tool (FRAX) is widely used to identify individuals at increased risk for fracture. However, cortical porosity is associated with risk for fracture independent of FRAX and is reported to improve the net reclassification of fracture cases. We wanted to test the hypothesis that women with fracture who are unidentified by high FRAX score, but identified by high cortical porosity, have a set of characteristics that contribute to their fracture risk beyond high FRAX score and high cortical porosity. We quantified FRAX score with femoral neck areal bone mineral density (FN aBMD), and femoral subtrochanteric architecture, in 211 postmenopausal women aged 54-94 years with non-vertebral fractures, and 232 fracture-free controls in Tromsø, Norway, using StrAx software. Of 211 fracture cases, FRAX score > 20% identified 53 women (sensitivity 25.1% and specificity 93.5%), while cortical porosity cut-off > 80th percentile identified 61 women (sensitivity 28.9% and specificity 87.9%). The 43 (20.4%) additional fracture cases identified by high cortical porosity alone, had lower FRAX score (12.3 vs. 26.2%) than those identified by FRAX alone, they were younger, had higher FN aBMD (806 vs. 738 mg/cm²), and fewer had a prior fracture (23.3 vs. 62.9%), all p < 0.05. They had higher cortical porosity (48.7 vs. 42.1%), thinner cortices (3.75 vs. 4.12 mm), lower cortical and total volumetric BMD (942 vs. 1053 and 586 vs. 699 mg HA/cm³), larger medullary and total cross-sectional areas (245 vs. 190 and 669 vs. 593 mm²), and higher cross-sectional moment of inertia (2619 vs. 2388 cm⁴) all p < 0.001. When the fracture cases and controls with high cortical porosity were compared, cases had higher cortical porosity, lower cortical vBMD, lower total vBMD, smaller cortical CSA/Total CSA, larger medullary CSA and larger total CSA than controls (all p ≤ 0.05). Thus, fracture cases, unidentified by FRAX, but identified by cortical porosity, had an architecture where the positive impact of larger bone size did not offset the negative effect of thinner cortices with increased porosity. A measurement of cortical porosity may be a marker of other characteristics that capture additional fracture risk components, not captured by FRAX.

Anti-osteoporosis drug use: too little, too much, or just right? The HUNT study, Norway

Use of anti-osteoporotic drugs (AODs) was examined in a Norwegian population 50-85 years. Among them with Fracture Risk Assessment Tool (FRAX) score for major osteoporotic fracture ≥ 20, 25% of the women and 17% of the men received AODs. The strongest predictors for AODs were high age in women and use of glucocorticoids among men.

INTRODUCTION

To examine the use of anti-osteoporotic drugs (AODs) and to identify predictors for prescriptions.

METHODS

Data were obtained from the Nord-Trøndelag Health Study (HUNT3) performed in 2006-2008 and the Norwegian Prescription Database, including 15,075 women and 13,386 men aged 50-85 years. Bone mineral density (BMD) in the femoral neck was measured in a subgroup of 4538 women and 2322 men. High fracture risk was defined as a FRAX score for major osteoporotic fracture (MOF) ≥ 20%; in the subgroup with BMD, high risk was in addition defined as FRAX_MOF ≥ 20% or T-score ≤ - 2.5. Hazard ratios (HRs) for predictors of incident use of AODs within 2 years after HUNT3 were estimated by Cox' proportional hazards model.

RESULTS

Among individuals with FRAX MOF ≥ 20%, 25% of the women and 17% of the men were treated with AODs. Among those with FRAX MOF < 20%, 3% and 1% were treated, respectively. In the subgroup with BMD measurement, 24% of the women and 16% of the men at high risk of fractures were treated, compared to 3 and 1% in women and men not fulfilling the criteria. In women, high age was the strongest predictor for treatment (HR 3.84: 95% confidence interval 2.81-5.24), followed by use of glucocorticoids (GCs) (2.68:1.84-3.89). In men, predictors were use of GCs (5.28: 2.70-10.35) followed by multimorbidity (3.16:1.31-7.63). In the subgroup with BMD, T-score ≤ - 2.5 was the strongest predictor (women 3.98:2.67-5.89; men 13.31:6.17-28.74).

CONCLUSIONS

This study suggests an undertreatment of AODs in individuals at high risk of fracture.

The Effectiveness of Osteoporosis Screening and Treatment in the Midwest

Introduction:

With osteoporosis on the rise across the United States, the goal of this prospective study is to determine the effectiveness of our Midwest level-1 trauma center in diagnosing, treating, and educating osteoporosis patients after fracture with the use of questionnaires. Secondarily, we aimed to identify barriers that prevent our patients from complying with bone health recommendations.

Methods:

One hundred participants (≥55 years) were given 2 questionnaires (Fracture Risk Assessment Tool and a study-specific questionnaire) that were administered during the patient’s visit to the orthopedic trauma clinic. A group of patients diagnosed with osteoporosis was compared to a group of patients not diagnosed with osteoporosis. Statistical analyses were performed using SPSS 24 (IBM Corp, Chicago, Illinois).

Results:

Patients who had been diagnosed with osteoporosis were significantly older (72.7 vs 66.5, P = .009) and more were women (86.2% vs 66.2%, P = .043). Significantly, fewer patients without the diagnosis of osteoporosis had a history of fragility fracture (56.3%) compared to 92.9% of those diagnosed with osteoporosis (P < .001). Of those with dual-energy X-ray absorptiometry (DXA) recommended by a healthcare provider, 20 (55.6%) of those without the diagnosis of osteoporosis and 13 (52%) of those with the diagnosis of osteoporosis had DXA screening before their fragility fracture (P = .499). More patients diagnosed with osteoporosis (93.1%) were taking calcium and vitamin D supplementation compared to 66.2% of those without the diagnosis of osteoporosis (P = .005). Only 37.9% of patients with the diagnosis of osteoporosis were receiving US Food and Drug Administration–approved medications for the management of their disease.

Discussion:

In patients without previous osteoporosis diagnosis, 59 (83.1%) of the 71 claimed that they did not receive any preventative education about osteoporosis, while 21 (72.4%) of the 29 patients with the diagnosis of osteoporosis claimed that they did not receive a preventative education (P = .165). Both groups lacked optimum diagnosis, treatment, and education of osteoporosis.

Conclusion:

Our study highlights the need for a deliberate effort of a multidisciplinary team to focus efforts in all stages of osteoporosis management.

FRAX Tool in Brazil: an integrative literature review following validation

Abstract The present article is an integrative review the objective of which was to assess research carried out with the FRAX tool in Brazil following its validation, and describe the conclusions drawn. Two databases were used to select the articles (the Capes Portal and the Virtual Health Library), and the sample of this review was the only four articles published in Brazil relating to the FRAX tool following its validation in May 2013. After analyzing the articles, the results demonstrated that despite some limitations the FRAX Tool can be used to reduce the prevalence of fractures due to its simplicity of use, with an emphasis on prediction and orientation, allowing early and safe therapeutic decision-making.

The impact of fragility fracture and approaches to osteoporosis risk assessment worldwide

Osteoporosis constitutes a major public health problem, through its association with age-related fractures, particularly of the hip, vertebrae, distal forearm and humerus. Substantial geographic variation has been noted in the incidence of osteoporotic fractures worldwide, with Western populations (North America, Europe and Oceania), reporting increases in hip fracture throughout the second half of the 20th century, with a stabilisation or decline in the last two decades. In developing populations however, particularly in Asia, the rates of osteoporotic fracture appears to be increasing. The massive global burden consequent to osteoporosis means that fracture risk assessment should be a high priority among health measures considered by policy makers. The WHO operational definition of osteoporosis, based on a measurement of bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA), has been used globally since the mid-1990s. However, although this definition identifies those at greatest individual risk of fracture, in the population overall a greater total number of fractures occur in individuals with BMD values above the threshold for osteoporosis diagnosis. A number of web-based tools to enable the inclusion of clinical risk factors, with or without BMD, in fracture prediction algorithms have been developed to improve the identification of individuals at high fracture risk, the most commonly used globally being FRAX®. Access to DXA, osteoporosis risk assessment, case finding and treatment varies worldwide, but despite such advances studies indicate that a minority of men and women at high fracture risk receive treatment. Importantly, research is ongoing to demonstrate the clinical efficacy and cost-effectiveness of osteoporosis case finding and risk assessment strategies worldwide. The huge burden caused by osteoporosis related fractures to individuals, healthcare systems and societies should provide a clear impetus for the progression of such approaches.

Validation of FRAX and the impact of self-reported falls among elderly in a general population: the HUNT study, Norway

Fracture Risk Assessment Tool (FRAX) without bone mineral density (BMD) for hip fracture prediction was validated in a Norwegian population 50-90 years. Fracture risk increased with higher FRAX score, and the observed number of hip fractures agreed well with the predicted number, except for the youngest and oldest men. Self-reported fall was an independent risk factor for fracture in women.

INTRODUCTION

The primary aim was to validate FRAX without BMD for hip fracture prediction in a Norwegian population of men and women 50-90 years. Secondary, to study whether information of falls could improve prediction of fractures in the subgroup aged 70-90 years.

METHODS

Data were obtained from the third survey of the Nord-Trøndelag Health Study (HUNT3), the fracture registry in Nord-Trøndelag, and the Norwegian Prescription Database (NorPD), including 15,432 women and 13,585 men. FRAX hip without BMD was calculated, and hip fractures were registered for a median follow-up of 5.2 years. The number of estimated and observed fractures was assessed, ROC curves with area under the curve (AUC), and Cox regression analyses. For the group aged 70-90 years, self-reported falls the last year before HUNT3 were included in the Cox regression model.

RESULTS

The risk of fracture increased with higher FRAX score. When FRAX groups were categorized in a 10-year percentage risk for hip fracture as follows, <4, 4-7.9, 8-11.9, and ≥12%, the hazard ratio (HR) for hip fracture between the lowest and the highest group was 17.80 (95% CI: 12.86-24.65) among women and 23.40 (13.93-39.30) in men. Observed number of hip fractures agreed quite well with the predicted number, except for the youngest and oldest men. AUC was 0.81 (0.78-0.83) for women and 0.79 (0.76-0.83) for men. Self-reported fall was an independent risk factor for fracture in women (HR 1.64, 1.20-2.24), and among men, this was not significant (1.09, 0.65-1.83).

CONCLUSIONS

FRAX without BMD predicted hip fracture reasonably well. In the age group 70-90 years, falls seemed to imply an additional risk among women.

Do we need bone mineral density to estimate osteoporotic fracture risk? A 10-year prospective multicentre validation study

Objective

Evaluate the performance of FRAX®, with and without bone mineral densitometry (BMD), in predicting the occurrence of fragility fractures over 10 years.

Methods

Participants aged ≥40 years at baseline, with a complete set of data and a minimum of 8.5 years of follow-up were identified from three cohorts (n=2626). Ten-year fracture risk at baseline were estimated with FRAX® and assessed by comparison with observed fractures and receiver operating characteristic analysis.

Results

During a mean (SD) follow-up of 9.12 (1.5) years, 178 participants suffered a major osteoporotic (MOP) fracture and 28 sustained a hip fracture. The predictive performance of FRAX® was superior to that of BMD alone for both MOP and hip fractures. The area under the curve (AUC) of FRAX® without BMD was 0.76 (95% CI 0.72 to 0.79) for MOP fractures and 0.78 (95% CI 0.69 to 0.86) for hip fractures. No significant improvements were found when BMD was added to clinical variables to predict either MOP (0.78, 95% CI 0.74 to 0.82, p=0.25) or hip fractures (0.79, 95% CI 0.69 to 0.89, p=0.72).

AUCs for FRAX® (with and without BMD) were greater for men than for women. FRAX®, with and without BMD, tended to underestimate the number of MOP fractures and to overestimate the number of hip fractures in females. In men, the number of observed fractures were within the 95% CI of the number predicted, both with and without BMD.

Conclusion

FRAX® without BMD provided good fracture prediction. Adding BMD to FRAX® did not improve the performance of the tool in the general population.

Increased cortical porosity and reduced cortical thickness of the proximal femur are associated with nonvertebral fracture independent of Fracture Risk Assessment Tool and Garvan estimates in postmenopausal women

The Fracture Risk Assessment Tool (FRAX) and Garvan Calculator have improved the individual prediction of fracture risk. However, additional bone measurements that might enhance the predictive ability of these tools are the subject of research. There is increasing interest in cortical parameters, especially cortical porosity. Neither FRAX nor Garvan include measurements of cortical architecture, important for bone strength, and providing independent information beyond the conventional approaches. We tested the hypothesis that cortical parameters are associated with fracture risk, independent of FRAX and Garvan estimates. This nested case-control study included 211 postmenopausal women aged 54–94 years with nonvertebral fractures, and 232 controls from the Tromsø Study in Norway. We assessed FRAX and Garvan 10-year risk estimates for fragility fracture, and quantified femoral subtrochanteric cortical porosity, thickness, and area from computed tomography images using StrAx1.0 software. Per standard deviation higher cortical porosity, thinner cortices, and smaller cortical area, the odds ratio (95% confidence interval) for fracture was 1.71 (1.38–2.11), 1.79 (1.44–2.23), and 1.52 (1.19–1.95), respectively. Cortical porosity and thickness, but not area, remained associated with fracture when adjusted for FRAX and Garvan estimates. Adding cortical porosity and thickness to FRAX or Garvan resulted in greater area under the receiver operating characteristic curves. When using cortical porosity (>80^th percentile) or cortical thickness (<20^th percentile) combined with FRAX (threshold >20%), 45.5% and 42.7% of fracture cases were identified, respectively. Using the same cutoffs for cortical porosity or thickness combined with Garvan (threshold >25%), 51.2% and 48.3% were identified, respectively. Specificity for all combinations ranged from 81.0–83.6%. Measurement of cortical porosity or thickness identified 20.4% and 17.5% additional fracture cases that, were unidentified using FRAX alone, and 16.6% and 13.7% fracture cases unidentified using Garvan alone. In conclusion, cortical parameters may help to improve identification of women at risk for fracture.

Reprint of: The impact of fragility fracture and approaches to osteoporosis risk assessment worldwide

Osteoporosis constitutes a major public health problem, through its association with age-related fractures, particularly of the hip, vertebrae, distal forearm and humerus. Substantial geographic variation has been noted in the incidence of osteoporotic fractures worldwide, with Western populations (North America, Europe and Oceania), reporting increases in hip fracture throughout the second half of the 20th century, with a stabilisation or decline in the last two decades. In developing populations however, particularly in Asia, the rates of osteoporotic fracture appears to be increasing. The massive global burden consequent to osteoporosis means that fracture risk assessment should be a high priority amongst health measures considered by policy makers. The WHO operational definition of osteoporosis, based on a measurement of bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA), has been used globally since the mid-1990s. However, although this definition identifies those at greatest individual risk of fracture, in the population overall a greater total number of fractures occur in individuals with BMD values above threshold for osteoporosis diagnosis. A number of web-based tools to enable the inclusion of clinical risk factors, with or without BMD, in fracture prediction algorithms have been developed to improve the identification of individuals at high fracture risk, the most commonly used globally being FRAX®. Access to DXA, osteoporosis risk assessment, case finding and treatment varies worldwide, but despite such advances studies indicate that a minority of men and women at high fracture risk receive treatment. Importantly, research is ongoing to demonstrate the clinical efficacy and cost-effectiveness of osteoporosis case finding and risk assessment strategies worldwide. The huge burden caused by osteoporosis related fractures to individuals, healthcare systems and societies should provide a clear impetus for the progression of such approaches.

Bisphosphonates and atypical femoral fractures

PURPOSE OF REVIEW

Bisphosphonates are used widely for the treatment of osteoporosis and prevention of fractures. Although generally well tolerated and effective, bisphosphonates (and denosumab, a newer antiresorptive agent) have been associated with unusual fractures of the femoral shaft.

RECENT FINDINGS

New information about the incidence, pathophysiology, and management of atypical femoral fractures (AFFs) are reviewed. Histomorphometric studies have shown variable amounts of bone turnover suppression, but new studies suggest that healing near bone cracks may not occur in patients with AFF. Some studies suggest that hip and femur geometry make certain people more at risk for AFF. In some but not all studies, the risk of AFF appears to be related to duration of treatment. Thus, the benefit/risk ratio needs to be reassessed as bisphosphonate therapy is prolonged.

SUMMARY

If we can better understand the pathogenesis of AFF, it may be possible to identify those patients at highest risk. In the meantime, clinicians must periodically assess risk for osteoporotic fracture versus risk for AFF in managing patients with osteoporosis.