1. Fracture risk assessment
Norwich, John A Kanis
SCOOP Launch, November 07

2. Consensus Development Conference, 1993 Common sites of fracture
03ca011
03 Osteoporosis
Definition
a systemic skeletal disease
characterised by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture
Consensus Development Conference, 1993
Common sites of fracture
Spine
Hip
Wrist

3. Diagnostic thresholds for women
99ca160 ex94ca117 from 91ca129
Diagnostic thresholds for women
Percent of population
0.6 15 50 85
>99
Osteoporosis
Low bone
Normal
mass -4 -3 -2 -1 1 2 3 4
Bone mineral density (SD units or T-score)

4. Indications for the diagnostic use of BMD
- Presence of strong risk factors
oestrogen deficiency
corticosteroid therapy (>7.5 mg >1 year)
maternal history of hip fracture
low BMI (<19 kg/m )
- Radiographic osteopenia
- Previous fragility fracture
- Height loss/ thoracic kyphosis (after radiography)

5. Case finding strategies
IOF NOF

6. Osteoporotic fracture and BMD
05ca085
Osteoporotic fracture and BMD
Fractures/1,000 person-years
Number of fractures 50
Fracture rate
Women with fractures
400 40
300 30
200 20
100 10
1.0
0.5
0.0
-0.5
-1.0
-1.5
-2.0
-2.5
-3.0
-3.5
Siris. Surgeon General’s Workshop on Osteoporosis and Bone Health, December 2002

7. Ten year probability of hip fracture in Sweden
00ca104
Ten year probability of hip fracture in Sweden -3 -2 -1 1 10 20
Fracture probability (%) 50 60 70 80
Age (years)
Women
T-score (SD)

8. Assessment of osteoporosis at primary health care level
04ca148rev
Assessment of osteoporosis at primary health care level
Objectives - to optimise sensitivity for fracture risk prediction - case finding or screening strategy
- men and women
- cost-effective setting
- international validity
- suitable for primary care

9. Risk factors Validated in multiple populations
03ca175
Risk factors
Validated in multiple populations
Data for age, sex and type of fracture
Readily assessable by primary care practitioners
Be intuitive rather than counterintuitive to medical care.
Contribute to a risk that is amenable to the therapeutic manipulation intended

10. Cohorts studied EVOS / EPOS Hiroshima CaMoS Rochester Sheffield
Rotterdam
Kuopio
Gothenburg I
Gothenberg II
EPIDOS
Dubbo
OFELY
n = 59, person-years = 249, % female = 74
Any fracture = 5, osteoporotic fractures = 3,495 hip fractures = 957

11. Femoral neck BMD and hip fracture prediction
04ca138
Femoral neck BMD and hip fracture prediction
RR/SD 5
Men and women 4 3 2 1 50 55 60 65 70 75 80 85
Age (years)

12. Prior fracture and hip fracture risk
05ca186
Prior fracture and hip fracture risk 2 4 6 50 55 60 65 70 75 80 85
Age (years) RR

13. Osteoporotic fracture
07ca080
BMI and fracture risk
RR (20 v 25 kg/m2)
3.0
Without BMD
With BMD
2.0
1.0
0.0
Osteoporotic fracture
Hip fracture

14. Risk factors for hip fracture in men and women
04ca248
Risk factors for hip fracture in men and women RR
Prior
fracture FH
(hip)
Smoking
current
Alcohol
>2u
Steroids
ever RA
3.0
2.0
1.0
0.0
Without BMD With BMD

15. 10-year probability of hip fracture in Malmo
99ca094
10-year probability of hip fracture in Malmo
Probability (%) 20
women 15 10 5
men 50 60 70 80 90
Age (years)

16. Ten year probability of hip fracture - Swedish women
01ca048
Ten year probability of hip fracture - Swedish women
10 year risk (%) 70 60 50 40 30
6.0
5.0 20
4.0
3.0 RR 10
2.0
1.0 50 55 60 65 70 75 80 85
Age (years)

17. FRAX
06ca106
Patient 65
-2.5 65
165 24
23.9
8.0

18. Clinical risk factors and fracture probability
10 year hip fracture probability (%)
Mrs X
Age = 65 y
Height =161cm
Weight = 61kg
BMI = 23.5 kg/m2 6 4 2 FH
None
Smoking
Alcohol
Steroids
Prior Fx
2o osteoporosis

19. Probability of osteoporotic fracture* at age 65
05ca106
Probability of osteoporotic fracture* at age 65
Men Women
10-year probability (%)
None
Prior fracture
+Glucocorticoids
+Family history 70 60 50 40 30 20 10 -1 -2 -3 -1 -2 -3
T-score
US Caucasian, no CRF, BMI=24
*Hip, spine, humerus, forearm

20. Case finding strategies

21. Stratification of hip fracture risk
Woman aged 65, BMI=24 No
Yes
Rheumatoid arthritis No
Yes No
Yes
Glucocorticoids No
Yes No
Yes No
Yes No
Yes
Prior fracture
10-year hip fracture
probability (%)
1.5
3.7
3.1
7.5
2.6
6.4
5.4
12.9

22. Gradient of risk for hip fracture prediction
07ca027
Gradient of risk for hip fracture prediction
RR/SD 6
CRFs BMD CRFs+BMD 5 4 3 2 1 50 60 70 80 90 50 60 70 80 90 50 60 70 80 90
Age (years)

23. Gradient of risk and fracture prediction
07ca030
Gradient of risk and fracture prediction 2 4 6 8 10 -4 -3 -2 -1 1 3
Risk ratio (vs. general population)
GR=2.6
GR=1.6
Z-score %
50.0
100.0
97.7
99.9
84.1
15.9
2.3
0.1
0.0
4.9
3.5
Mean RR
5.0
0.5
% Population
1.63
2.57
2.6
1.6 GR

24. Ten year probability of hip fracture compared with Sweden
01ca025
Ten year probability of hip fracture compared with Sweden
Relative probability
Very high
High
Moderate
Low risk
1.2
Sweden
1.0
Denmark
China (TW)
0.8
Switzerland
Australia
Netherlands
Finland
Greece
0.6
Argentina
Hungary
Japan
France
0.4
China
0.2
Korea
Norway
Iceland
USA
Canada UK
Italy
Spain
Chile
Singapore
Germany
Kuwait
Portugal
China (HK)
Venezuela
Turkey

25. 00ca008
End

26. Identification of reversible risk
Risk amenable to intervention Low BMD Previous fracture Use of glucocorticoids
Presence of risk factor does adversely affect therapeutic response Age Body mass index Family history of fracture Smoking and alcohol Markers of bone turnover
Uncertain effects Neuromuscular incompetence Liability to falling