MOST PATIENTS WITH A RECENT FRACTURE AFTER THE AGE OF 50 YEARS ARE NOT PREDICTED TO BE AT HIGH RISK: THE FRACTURE PREVENTION PARADOX

Abstract

Background: For the purpose of improving fracture risk assessment over bone mineral density (BMD), the FRAX® fracture risk prediction algorithm has been developed.

Objectives: To evaluate BMD and FRAX® in patients at the time they presented with a clinical fracture after the age of 50 years.

Methods: In 479 consecutive patients (75% women) who were able and willing to participate, we measured BMD in spine and hip and calculated the 10-year fracture riskusing FRAX®(calibrated for the Netherlands and calculated without and with BMD) for major fractures (FRAXMajor), for hip fracture (FRAXHip). Also the percentages of patients were estimated who, before the current fracture, had a FRAXMajor score ≥20% and FRAXHip ≥3% according to US guidelines (1), and FRAXMajor score above age-dependent variable thresholds for assessment (FRAXMajor≥As), and intervention (FRAXMajor≥Int) according to the European guidance (2).

Results: In 214 patients with a low-trauma major fracture, osteoporosis (BMD T-score ≤ -2.5) was present in 40% of patients, FRAXMajor≥20% in 12%, FRAXHip≥3% in 49%, FRAXMajor≥As in 47% and FRAXMajor≥Int in 7%. Adding BMD lowered the percentage of patients with FRAXMajor≥20% to 9% (p<0.05) and FRAXHip≥3% to 37% (p<0.001), and increased the percentage of patients with FRAXMajor>Int to 21% (p<0.05). FRAXMajor>Int was found in 43% of patients with a low-trauma hip fracture and in 21% of patients with a first low-trauma major fracture. Lower percentages were found in the 265 patients with other fractures than low-trauma major fractures.

Conclusions: More than half of all evaluated patients presenting with a clinical fracture are not estimated by FRAX®to be at high fracture risk before the current fracture, even when they have a low-trauma major or hip fracture. These results draw attention to the fracture prevention paradox, by which only limited patients with a fracture are estimated to be at high risk, whether using FRAX®, without or with BMD, or using BMD alone.