10-year Fracture Probability Research Articles

General Comorbidity Indicators Contribute to Fracture Risk Independent of FRAX: Registry-Based Cohort Study.

FRAX® estimates 10-year fracture probability from osteoporosis-specific risk factors. Medical comorbidity indicators are associated with fracture risk but whether these are independent from those in FRAX is uncertain. We hypothesized Johns Hopkins Aggregated Diagnosis Groups (ADG®) score or recent hospitalization number may be independently associated with increased risk for fractures. This retrospective cohort study included women and men age ≥ 40 in the Manitoba BMD Registry (1996-2016) with at least 3 years prior health care data and used linked administrative databases to construct ADG scores along with number of hospitalizations for each individual. Incident Major Osteoporotic Fracture and Hip Fracture was ascertained during average follow-up of 9 years; Cox regression analysis determined the association between increasing ADG score or number of hospitalizations and fractures. Separately, hospitalizations and ADG score independently increased the hazard ratio for fracture at all levels of comorbidity (hazard range 1.2-1.8, all P < 0.05), irrespective of adjustment for FRAX, BMD, and competing mortality. Taken together, there was still a higher than predicted rate of fracture at all levels of increased comorbidity, independent of FRAX and BMD but attenuated by competing mortality. Using an intervention threshold of major fracture risk >20%, application of the comorbidity hazard ratio multiplier to the patient population FRAX scores would increase the number of treatment candidates from 8.6% to 14.4%. Both complex and simple measures of medical comorbidity may be used to modify FRAX-based risk estimates to capture the increased fracture risk associated with multiple comorbid conditions in older patients.

Adjusting conventional FRAX estimates of fracture probability according to the number of prior fractures.

Prior fractures increase subsequent fracture risk. The aim of this study was to quantify the effect of the number of prior fractures on the 10-year probability of fracture determined with FRAX®. The study used data from the Reykjavik Study fracture register that documented prospectively all fractures at all skeletal sites in a large sample of the population of Iceland. Ten-year probabilities of hip fracture and major osteoporotic fracture (MOF) were determined according to the number of prior osteoporotic fractures over a 20-year interval from the hazards of death and fracture. Fracture probabilities were also computed for a prior osteoporotic fracture irrespective of the number of previous fractures. The probability ratios provided adjustments to conventional FRAX estimates of fracture probability according to the number of prior fractures. Probability ratios to adjust 10-year FRAX probabilities of a hip fracture and MOF increased with the number of prior fractures but decreased with age in both men and women. Probability ratios were similar in men and women and for hip fracture and MOF. Mean probability ratios according to the number of prior fractures for all scenarios were 0.95, 1.08, 1.21 and 1.35, for 1,2, 3 and 4 or more prior fractures, respectively. Thus, a simple rule of thumb is to downward adjust FRAX-based fracture probabilities by 5% in the presence of a single prior fracture and to uplift probabilities by 10, 20 and 30% with a history of 2, 3 and 4 or more prior fractures, respectively. The probability ratios provide adjustments to conventional FRAX estimates of fracture probability according to the number of prior fractures.

Trabecular bone score and phalangeal quantitative ultrasound are associated with muscle strength and fracture risk in hemodialysis patients.

There is growing interest in the relationship between chronic kidney disease (CKD) and fragility fracture risk. Bone mineral density (BMD) is a major determinant of bone strength, although its role as a predictor of fracture in advanced CKD and hemodialysis is still under debate. We aimed to further investigate surrogates of bone quality and their associations with muscle strength and fracture risk in hemodialysis. Multiple clinical risk factors for fracture and an estimated 10-year probability of fracture, BMD at lumbar spine and femur, trabecular bone score (TBS), X-ray vertebral morphometry, phalangeal bone quantitative ultrasonography (QUS), tibial pulse-echo ultrasonography (PEUS), and handgrip strength were evaluated in a setting of hemodialysis patients in treatment with acetate-free biofiltration (AFB) or bicarbonate hemodialysis. The bone ultrasound measurements, both at phalangeal and tibial sites, were significantly associated with lumbar and femoral DXA values. Handgrip strength was significantly associated with the 10-year probability of fracture (r = −0.57, p < 0.001 for major fractures and r = −0.53, p < 0.001 for hip fracture, respectively), with femur neck, total femur, and L1–L4 BMD values (r = 0.47, p = 0.04; r = 0.48, p = 0.02; r = 0.58, p = 0.007, respectively), with TBS at the lumbar spine (r = 0.71, p < 0.001) and with the phalangeal QUS measure of AD-SoS (r = 0.369, p = 0.023). In the hemodialysis group, 10 participants (24.3%) reported at least one morphometric vertebral fracture (Vfx); conversely, only six participants (15%) showed Vfx in the control group. In the hemodialysis group, participants with Vfx compared with participants without Vfx reported significantly different TBS, bone transmission time (BTT), cortical thickness, and handgrip strength (p < 0.05). At multiple regression analysis, by identifying as dependent variable the 10-year fracture risk for major fracture, after correcting for age, BMI, time since dialysis, AD-SoS, cortical bone thickness, and handgrip strength, only BTT (β = −15.21, SE = 5.91, p = 0.02) and TBS (β = −54.69, SE = 21.88, p = 0.02) turned out as independently associated with fracture risk. In conclusion, hemodialysis patients showed a higher fracture risk and lower surrogate indices of bone strength as TBS and QUS parameters. In this cohort of patients, handgrip strength measurements appeared to be a useful instrument to identify high-fracture-risk subjects.

Comparative analysis of risk factors for hip fracture in patients of different nationalities living in Kazakhstan

BACKGROUND: Osteoporosis is a multifactorial systemic skeletal disease characterized by a decrease in bone strength leading to an increased risk of fractures. Hip fracture is a serious complication of osteoporosis. It is expected in Kazakhstan by 2050 the annual number of hip fracture will increase by 140% compared to 2015 data and will amount to 28,048 cases. There are differences in the incidence of fractures and low bone mineral density in different ethnic groups. However, low bone mineral density is only one of many risk factors for osteoporotic fractures.&#x0D; AIM: To study the risk factors of osteoporosis and related osteoporotic fractures in patients with hip fracture living in Kazakhstan.&#x0D; MATERIALS AND METHODS: The case-control study included 98 patients with hip fracture of Kazakh (main group, n = 49) and other nationalities (control group, n = 49). In the registration card, risk factors for osteoporosis and osteoporotic fractures from the Fracture Risk Assessment (FRAX) model were distinguished, and the Find cases Assess Confirm Severity algorithm (2019) was used to diagnose sarcopenia. Statistical analysis was carried out using the Statistics 26 (IBM SPSS, США).&#x0D; RESULTS: The groups were comparable in terms of gender, disability, fracture location and functional activity, surgical treatment. An increase in cases of hip fracture at an older age was found in the main group than in the control group (р = 0.035).&#x0D; There were no differences in the groups for clinical risk factors for osteoporotic fractures (body weight, height, history of fractures, family history of fractures, medication, comorbidity), except for smoking (lower in Kazakhs than in the other group) (р = 0.033). Differences in 10-year probability of major osteoporotic fracture and hip fracture between groups (р = 0.34 and р = 0.74) were not found. The proportion of patients who entered the intervention threshold and at low risk did not differ in the groups (р = 0.623).&#x0D; The average SARC-F (Strength, Assistance with walking, Rise from a chair, Climb stairs and Falls) score was lower among Kazakhs (р = 0.011), there is a difference between the groups when walking (р = 0.044), climbing stairs (р = 0.003). A decrease of grip strength was noted in the main group (р = 0.008), especially in men (р = 0.011), but low grip strength (р 0.001) and signs of sarcopenia (р 0.001) were determined only by age, not nationality.&#x0D; CONCLUSIONS: The Fracture Risk Assessment (FRAX) model and intervention threshold can be applied to all residents of Kazakhstan.

Serum Insulin-Like Growth Factor 1 Levels, Facture Risk Assessment Tool Scores and Bone Disorders in Patients with Primary Biliary Cholangitis.

Insulin-like growth factor 1 (IGF-1) plays an important role in bone growth and maintenance, and its decreased levels are associated with bone disorders. This study aimed to evaluate the association of serum IGF-1 levels with osteoporosis, prevalent fractures and fracture risk based on the Fracture Risk Assessment Tool (FRAX) in patients with primary biliary cholangitis (PBC). This study included 127 consecutive patients with PBC. Based on the baseline serum IGF-1 levels, the participants were classified into the low (L)-, intermediate (I)- and high (H)-IGF-1 groups. According to the FRAX score, high fracture risk was defined as a 10-year major osteoporotic fracture probability (FRAX-MOF) ≥ 20% or a 10-year hip fracture probability (FRAX-HF) ≥ 3%. The serum IGF-1 levels were positively correlated with bone mineral density, and were negatively correlated with the FRAX-MOF/FRAX-HF. The L-IGF-1 group had the highest prevalence of osteoporosis (58.1%), prevalent fracture (48.4%) and high fracture risk (71.0%). Meanwhile, the H-IGF-1 group had the lowest prevalence of osteoporosis (9.7%), prevalent fracture (12.9%) and high fracture risk (9.7%). The prevalence of these events increased stepwise with decreasing serum IGF-1 levels. The cutoff values of IGF-1 for predicting osteoporosis, prevalent fracture and high fracture risk were 61.5 ng/mL (sensitivity/specificity, 0.545/0.894), 69.5 ng/mL (0.633/0.784) and 61.5 ng/mL (0.512/0.929), respectively. Serum IGF-1 levels were associated with bone disorders and the FRAX-derived fracture risk, and may be a useful indicator for initiating therapeutic intervention to prevent the incidence of fracture in patients with PBC.

The effectiveness of screening to identify patients with osteoporosis/high risk of fractures in primary health care

Background. The organization of screening for osteoporosis is an actual problem due to the need for early detection of patients with high risk of fractures and initiation of their treatment.Aim. The aim of our study was to study the effectiveness of screening for osteoporosis (high risk of fractures) in postmenopausal men and women 40 years and older.Materials and methods. Screening was performed by outpatient doctors for all people aged 40 years and older who applied for various reasons. The doctor asked standard questions included in the FRAX questionnaire.Results. In 2017– 2020, 11,013 people were screened by outpatient doctors — 31.7% of the total attached population aged 40 years and older. According to the screening results, 21.9% people were identified with a high risk of fractures. The average 10-year probability of major osteoporotic fractures in these patients (19.0±7.9%) was statistically significantly higher compared to the rest of the screened (7.6±3.3%), p=0.0001. 60% (1,450 people) of the group of individuals with an identified high risk of fractures were patients with FRAX in the area of therapeutic intervention. Among them were patients with indications of a fracture and without a history of fractures. In the remaining 40%, the high risk was determined only on the basis of the fact of a previously suffered fracture (their FRAX index was below the intervention threshold). In general, using only the FRAX calculator, 40 men and 1410 women were identified as having a high risk of fractures, which accounted for 1.3% of the male and 17.7% of the female screened population, respectively. With the simultaneous use of FRAX and anamnestic data on a previous fracture, 13.3% of men and 25.3% of women in the screening population had a high risk of fractures.Conclusion. Screening in primary health care has allowed us to identify 21.9% of the screened population of men and women aged 40 years and older (postmenopausal women) as having a high risk of fractures. Screening with simultaneous calculation of the 10-year risk of fractures according to FRAX and clarification of the presence of a history of fractures was the most effective.

Nutritional status and osteoporotic phenotype of body composition in patients with rheumatoid arthritis

Aim. To evaluate the nutritional status and its relationship with osteoporotic phenotype of body composition in women with rheumatoid arthritis (RA).Material and methods. The study included 91 women aged 40 to 75 years with RA according to ACR/EULAR criteria (2010). A questionnaire, laboratory examination and dual X-ray absorptiometry of whole body, lumbar spine and proximal femur were conducted. Nutritional status was assessed using a MNA (Mini Nutricial Assessment) questionnaire.Results. Risk of malnutrition and malnutrition according to the MNA were detected in 42.9 % and 1.1 % of patients with RA, respectively. These patients differed from those with normal nutritional status with a higher risk of osteoporotic hip fracture according to FRAX (p = 0.035), lower appendicular muscle mass (AMM) (p = 0.048) and lower QOL according to VAS (p = 0.012). A positive correlation was established between the nutritional status by MNA and BMI (r = 0.280; p = 0.007), as well as total muscle mass (r = 0.280; p = 0.008), AMM (r = 0.320; p = 0.002) and AMM index (r = 0.280; p = 0.009). In multivariate logistic regression analysis, age above 55 years (OR = 7.76; 95 % CI: 2.17–27.69), nutritional status by MNA (OR = 0.68; 95 % CI: 0.51–0.92) and AMM index less than 6 kg/m2 (OR = 3.43; 95 % CI: 1.16–10.21) were independent factors associated with osteoporotic phenotype in RA patients.Conclusion. Malnutrition occurred in 44.0 % of RA patients. Women at risk of malnutrition had a higher 10-year probability of hip fracture according to FRAX. Age and AMM index were positively associated, while nutrition status according to MNA was negatively associated with osteoporotic phenotype of body composition.

Menopausal hormone therapy reduces the risk of fracture regardless of falls risk or baseline FRAX probability—results from the Women’s Health Initiative hormone therapy trials

SummaryIn a combined analysis of 25,389 postmenopausal women aged 50–79 years, enrolled in the two Women’s Health Initiative hormone therapy trials, menopausal hormone therapy vs. placebo reduced the risk of fracture regardless of baseline FRAX fracture probability and falls history.IntroductionThe aim of this study was to determine if the anti-fracture efficacy of menopausal hormone therapy (MHT) differed by baseline falls history or fracture risk probability as estimated by FRAX, in a combined analysis of the two Women’s Health Initiative (WHI) hormone therapy trials.MethodsA total of 25,389 postmenopausal women aged 50–79 years were randomized to receive MHT (n = 12,739) or matching placebo (n = 12,650). At baseline, questionnaires were used to collect information on falls history, within the last 12 months, and clinical risk factors. FRAX 10-year probability of major osteoporotic fracture (MOF) was calculated without BMD. Incident clinical fractures were verified using medical records. An extension of Poisson regression was used to investigate the relationship between treatment and fractures in (1) the whole cohort; (2) those with prior falls; and (3) those without prior falls. The effect of baseline FRAX probability on efficacy was investigated in the whole cohort.ResultsOver 4.3 ± 2.1 years (mean ± SD), MHT (vs. placebo) significantly reduced the risk of any clinical fracture (hazard ratio [HR] 0.72 [95% CI, 0.65–0.78]), MOF (HR 0.60 [95% CI, 0.53–0.69]), and hip fracture (0.66 [95% CI, 0.45–0.96]). Treatment was effective in reducing the risk of any clinical fracture, MOF, and hip fracture in women regardless of baseline FRAX MOF probability, with no evidence of an interaction between MHT and FRAX (p > 0.30). Similarly, there was no interaction (p > 0.30) between MHT and prior falls.ConclusionIn the combined WHI trials, compared to placebo, MHT reduces fracture risk regardless of FRAX probability and falls history in postmenopausal women.

Reverse engineering the FRAX algorithm: Clinical insights and systematic analysis of fracture risk.

The Fracture Risk Assessment Tool (FRAX) is a computational tool developed to predict the 10-year probability of hip fracture and major osteoporotic fracture based on inputs of patient characteristics, bone mineral density (BMD), and a set of seven clinical risk factors. While the FRAX tool is widely available and clinically validated, its underlying algorithm is not public. The relative contribution and necessity of each input parameter to the final FRAX score is unknown. We systematically collected hip fracture risk scores from the online FRAX calculator for osteopenic Caucasian women across 473,088 unique inputs. This dataset was used to dissect the FRAX algorithm and construct a reverse-engineered fracture risk model to assess the relative contribution of each input variable. Within the reverse-engineered model, age and T-Score were the strongest contributors to hip fracture risk, while BMI had marginal contribution. Of the clinical risk factors, parent history of fracture and ongoing glucocorticoid treatment had the largest additive effect on risk score. A generalized linear model largely recapitulated the FRAX tool with an R2 of 0.91. Observed effect sizes were then compared to a true patient population by creating a logistic regression model of the Study of Osteoporotic Fractures (SOF) cohort, which closely paralleled the effect sizes seen in the reverse-engineered fracture risk model. Analysis identified several clinically relevant observations of interest to FRAX users. The role of major osteoporotic fracture risk prediction in contributing to an indication of treatment need is very narrow, as the hip fracture risk prediction accounted for 98% of treatment indications for the SOF cohort. Removing any risk factor from the model substantially decreased its accuracy and confirmed that more parsimonious models are not ideal for fracture prediction. For women 65years and older with a previous fracture, 98% of FRAX combinations exceeded the treatment threshold, regardless of T-score or other factors. For women age 70+ with a parent history of fracture, 99% of FRAX combinations exceed the treatment threshold. Based on these analyses, we re-affirm the efficacy of the FRAX as the best tool for fracture risk assessment and provide deep insight into the interplay between risk factors.

Update of the fracture risk prediction tool FRAX: a systematic review of potential cohorts and analysis plan.

The availability of the fracture risk assessment tool FRAX® has substantially enhanced the targeting of treatment to those at high risk of fracture with FRAX now incorporated into more than 100 clinical osteoporosis guidelines worldwide. The aim of this study is to determine whether the current algorithms can be further optimised with respect to current and novel risk factors. A computerised literature search was performed in PubMed from inception until May 17, 2019, to identify eligible cohorts for updating the FRAX coefficients. Additionally, we searched the abstracts of conference proceedings of the American Society for Bone and Mineral Research, European Calcified Tissue Society and World Congress of Osteoporosis. Prospective cohort studies with data on baseline clinical risk factors and incident fractures were eligible. Of the 836 records retrieved, 53 were selected for full-text assessment after screening on title and abstract. Twelve cohorts were deemed eligible and of these, 4 novel cohorts were identified. These cohorts, together with 60 previously identified cohorts, will provide the resource for constructing an updated version of FRAX comprising 2,138,428 participants with a follow-up of approximately 20 million person-years and 116,117 documented incident major osteoporotic fractures. For each known and candidate risk factor, multivariate hazard functions for hip fracture, major osteoporotic fracture and death will be tested using extended Poisson regression. Sex- and/or ethnicity-specific differences in the weights of the risk factors will be investigated. After meta-analyses of the cohort-specific beta coefficients for each risk factor, models comprising 10-year probability of hip and major osteoporotic fracture, with or without femoral neck bone mineral density, will be computed. These assembled cohorts and described models will provide the framework for an updated FRAX tool enabling enhanced assessment of fracture risk (PROSPERO (CRD42021227266)).

FC094: Frax is Useful Tool for Predicting All-Cause Mortality in Addition to the Risk of Fragile Fracture in Hemodialysis Patients

Abstract BACKGROUND AND AIMS The fracture risk assessment tool (FRAX®) was developed to predict the probability of fragile fractures during the next 10 years for the general population, and it is calculated by inputting risk factors of fractures such as age, gender, height, weight, fracture history, presence or absence of rheumatoid arthritis and steroid therapy. Although contents of FRAX do not include CKD as a risk factor, previous studies have shown that FRAX was useful in predicting fracture risk in maintenance dialysis patients. However, many reports are short-term observational studies targeting fracture risk. In the present study, we examined whether FRAX can be useful to predict the risk of fragile fractures and all-cause mortality in hemodialysis patients through the long-term observation. METHOD A retrospective cohort study was conducted in 273 patients aged 40 to under 90 who started hemodialysis at our hospital between March 2004 and the present and who could be followed for at least 3 years or had a fracture within 3 years. In order to assess the association between FRAX score and fragile fracture or all-cause mortality, a multivariate analysis was performed using the Cox proportional hazard model with factors related to fractures and mortality as covariates. The 10-year probability (%) of major osteoporotic fracture without bone mineral density was adopted as the FRAX score. RESULTS The average follow-up period was 6.7 years, and the average age of patients was 66 years, with women accounting for 29%. Of all 273 patients, 55 developed fragile fractures and 97 died. FRAX scores were divided into two groups (lower FRAX score and higher FRAX score) in accordance with a cut-off value of 8.2%, determined by ROC curve for fracture. Univariate analysis of factors associated with fractures revealed that higher FRAX score (8.2 or more) was a significant factor [hazard ratio (HR): 4.49 (2.59–7.85)]. Multivariate analysis conducted with significant factors in univariate analysis (mean serum albumin level, serum phosphorus level, magnesium level, C-reactive protein level and use or non-use of phosphate binder during the 3 years) as the covariates revealed that higher FRAX score was significantly associated with fractures [HR: 2.40 (1.27–4.5)]. Regarding the association between FRAX score and all-cause mortality, in univariate analysis, higher FRAX score was a significant predictive factor [HR: 4.34 (2.84–6. 64)]. In multivariate analysis adjusted with mean serum albumin level, creatinine level, magnesium level, C-reactive protein level, hemoglobin level, use or non-use of phosphate binder and calcimimetics as the covariates, higher FRAX score was found to be a significant factor of all-cause mortality [HR: 3.22 (1.97–5.22)]. CONCLUSION FRAX score was also a useful tool for predicting fractures and all-cause mortality in hemodialysis patients even in long-term analysis.

MO546: Association Between T Scores, FRAX, Frailty, Falls and Fractures in Patients Undergoing Maintenance Hemodialysis

Abstract BACKGROUND AND AIMS Despite the negative impact of fracture in hemodialysis (HD) patients, optimal risk assessment tools in this population are not well explored. Frailty (a syndrome of diminished capacity to respond to health stressors) and falls—known risk factors for fracture—are common in HD patients. While the relationship between T scores in relation to fractures in these patients is recognized, there is a paucity of data to the additional contributions of fracture risk assessment tool (FRAX), frailty and falls in relation to fractures. The clinical, societal and economic impact of fractures necessitates an active response from the HD programs. Therefore, we intended to evaluate the clinical utility of adding these factors to T scores at the femoral neck to determine whether it enhances fracture discrimination in HD patients. METHOD We conducted a cross-sectional study on 131 adult patients receiving HD at two dialysis units in Regina, Saskatchewan, Canada (January 2017–December 2018). After undergoing frailty assessments, patients were referred for dual-energy X-ray absorptiometry (DXA) scans and FRAX questionnaires. They were additionally sent for lumbar X-rays and contacted for a history of falls. The presence of fracture (hips, femur, pelvis, knee, foot, leg, toe, shoulder, elbow, ankle, arm, wrist, spine and lumbar) was documented based on the review of medical charts, self-recall and additionally vertebral fractures were identified by an X-ray. Bone mineral density (BMD) was measured by DXA. FRAX score (the 10-year probability of hip and major osteoporotic fracture) was calculated using an online algorithm based on 11 clinical risk factors with and without the inclusion of BMD. Frailty was assessed using the FRIED criteria (Figure 1). Patients were enquired about the history and frequency of falls. Association between the BMD-T score, FRAX score, frailty status, falls, with fracture were examined with sequential multivariable logistic regression models. The area under the receiver operating characteristic curve analysis was conducted for each model to assess its discrimination ability for fracture outcome (α = 0.05). RESULTS A total of 109 HD patients were included in the data analysis. The composite of fracture occurred in 38% of patients. About 60% were identified as frail, and 29% had at least one fall in the last year. Low T score and FRAX were both independent risk factors in patients on HD therapy. On multivariate analysis, each lower standard deviation in T score was associated with 48% higher odds of fracture [odds ratio (OR) = 1.48; 95% confidence interval (95% CI) 1.20–1.68, P = 0.005]. With the inclusion of FRAX score for hip fracture, the OR for fracture remained significant at 1.38 (OR = 1.38, 95% CI 1.04–1.63, P = 0.04). The addition of frailty status and history of falls did not further improve the model. Model 2 showed better discrimination ability and goodness-of-fit for fracture compared to Model 1 (P = 0.004) (Table). CONCLUSION This is the first study to our knowledge that looked at the independent contribution of frailty and falls in addition to T scores and FRAX in assessing for fractures in patients on HD. Our study showed both BMD measurements by DXA scans and FRAX are useful tools to assess fracture in patients receiving HD. The addition of frailty status and history of falls is not associated with fractures in this population. Results of this study should lead to prospective studies with larger sample sizes prior to DXA scans, FRAX and falls assessment being recommended as standards of care.

Management of Osteoporosis and Spinal Fractures: Contemporary Guidelines and Evolving Paradigms.

Physicians involved in treating spine fractures secondary to osteopenia and osteoporosis should know the pathogenesis and current guidelines on managing the underlying diminished bone mineral density, as worldwide fracture prevention campaigns are trailing behind in meeting their goals. This is a narrative review exploring the various imaging and laboratory tests used to diagnose osteoporotic fractures and a comprehensive compilation of contemporary medical and surgical management. We have incorporated salient recommendations from the Endocrine Society, the American Association of Clinical Endocrinology (AACE), and the American Society for Bone and Mineral Research (ASBMR). The use of modern scoring systems such as Fracture Risk Assessment Tool (FRAX®) for evaluating fracture risk in osteoporosis with a 10-year probability of hip fracture and major fractures in the spine, forearm, hip, or shoulder is highlighted. This osteoporosis risk assessment tool can be easily incorporated into the preoperative bone health optimization strategies, especially before elective spine surgery in osteoporotic patients. The role of primary surgical intervention for vertebral compression fracture and secondary fracture prevention with pharmacological therapy is described, with randomized clinical trial-based wisdom on its timing and dosage, drug holiday, adverse effects, and relevant evidence-based literature. We also aim to present an evidence-based clinical management algorithm for treating osteoporotic vertebral body compression fractures, tumor-induced osteoporosis, or hardware stabilization in elderly trauma patients in the setting of their impaired bone health. The recent guidelines and recommendations on surgical intervention by various medical societies are covered, along with outcome studies that reveal the efficacy of cement augmentation of vertebral compression fractures via vertebroplasty and balloon kyphoplasty versus conservative medical management in the elderly population.

P142 Fracture risk in diabetes: to FRAX or not to FRAX?

Abstract Background/Aims Diabetes mellitus is associated with decreased bone strength as well as increased fracture risk. The risk of fragility fracture increases with an increase in the duration of diabetes and worsening of glycemic control. However, this increased fracture risk often goes unidentified. Identifying patients at risk of fracture is fundamental in helping to prevent fractures. WHO FRAX (fracture risk assessment) tool computing the 10-year probability of hip fracture or a major osteoporotic fracture helps ascertain fracture risk. In Type 2 Diabetes Mellitus (T2DM), the diagnosis of osteoporosis by dual-energy X-ray absorptiometry (DXA) and the FRAX are only partially useful in assessing fracture risk. Our aims were: 1. To identify the fracture risk in patients with diabetes and 2. To assess the impact of adding diabetes as a risk factor in the calculation of FRAX score. Methods One hundred patients above the age of 50 years with duration of diabetes above a year who attended the diabetes clinic from December 2020 to June 2021 were included. Data was collected on demographics (age, sex, ethnicity), diabetes-related factors (the type, duration, complications and medications) and clinical risk factors for osteoporotic fracture (parental fracture, previous fracture, smoking, alcohol intake) from patient interviews and the FRAX score was calculated. FRAX tool was modified for diabetes by adding either 10 years of age or Rheumatoid arthritis as risk factor. Results Mean age of our cohort of patients was 67 years and their mean BMI was 33 kg/sq m. Duration of diabetes was over 5 years in 95% of the patients. T2DM was seen in 82% and Type 1 Diabetes mellitus (T1DM) in 18%. The mean HbA1c was 8.4%. Unadjusted mean FRAX score for a major osteoporotic fracture was 8.9% and hip fracture 2.3%. High risk of future fracture was seen in 4% of the patients and intermediate risk in 23% and low risk in 73%. Four patients had Rheumatoid arthritis and 21 had previous fragility fractures. Modifying the FRAX tool by adding 10 years to age moved 15% more patients to the intermediate-risk category needing DXA and 5% more to the high-risk category needing osteoporosis treatment. However, adding Rheumatoid arthritis changed 20% more patients to the intermediate-risk category needing DXA and 7% more to the high-risk category needing osteoporosis treatment. Conclusion Modifying FRAX tool in patients with diabetes mellitus will enable more patients to have a DXA scan and to receive osteoporosis treatment and the strategy using rheumatoid arthritis as a risk factor identified more patients than adding 10 years of age. Disclosure M. Mathew: None. S. Dwivedi: None. H. Buch: None. S. Venkatachalam: None.

Improved fracture risk prediction by adding VFA-identified vertebral fracture data to BMD by DXA and clinical risk factors used in FRAX

SummaryVertebral fracture (VF) is a strong predictor of subsequent fracture. In this study of older women, VF, identified by dual-energy X-ray absorptiometry (DXA) vertebral fracture assessment (VFA), were associated with an increased risk of incident fractures and had a substantial impact on fracture probability, supporting the utility of VFA in clinical practice.PurposeClinical and occult VF can be identified using VFA with dual-energy X-ray absorptiometry (DXA). The aim of this study was to investigate to what extent VFA-identified VF improve fracture risk prediction, independently of bone mineral density (BMD) and clinical risk factors used in FRAX.MethodsA total of 2852 women, 75–80 years old, from the prospective population-based study SUPERB cohort, were included in this study. At baseline, BMD was measured by DXA, VF diagnosed by VFA, and questionnaires used to collect data on risk factors for fractures. Incident fractures were captured by X-ray records or by diagnosis codes. An extension of Poisson regression was used to estimate the association between VFA-identified VF and the risk of fracture and the 5- and 10-year probability of major osteoporotic fracture (MOF) was calculated from the hazard functions for fracture and death.ResultsDuring a median follow-up of 5.15 years (IQR 4.3–5.9 years), the number of women who died or suffered a MOF, clinical VF, or hip fracture was 229, 422, 160, and 124, respectively. A VFA-identified VF was associated with an increased risk of incident MOF (hazard ratio [HR] = 1.78; 95% confidence interval [CI] 1.46–2.18), clinical VF (HR = 2.88; 95% [CI] 2.11–3.93), and hip fracture (HR = 1.67; 95% [CI] 1.15–2.42), adjusted for age, height, and weight. For women at age 75 years, a VFA-identified VF was associated with 1.2–1.4-fold greater 10-year MOF probability compared with not taking VFA into account, depending on BMD.ConclusionIdentifying an occult VF using VFA has a substantial impact on fracture probability, indicating that VFA is an efficient method to improve fracture prediction in older women.

Epidemiology of risk factors and estimating 10-year probability of osteoporotic fractures in the Russian Federation.

To investigate the prevalence of osteoporotic fractures (OPF) RFs and estimate absolute risk (AR) of OPF among urban vs rural residents of the Russian Federation. In total, 13,391 Russian women and men 40-69years old from 12 regions participated in the study. Groups of urban (n = 12,237) and rural (n = 1154) subjects were comparable in terms of their age. Participants were interviewed using a standard modular questionnaire. AR of OPF was calculated using the Russian FRAX model. Age-dependent diagnostic and therapeutic intervention thresholds (DIT, TIT) were employed to stratify AR of OPF. Among the OPF RFs, the most common were as follows: previous OPF (16.3%), causes of secondary osteoporosis (20.8%), and current smoking (17.9%). The frequencies of previous OPF and alcohol abuse in rural men were higher than in urban male residents. Urban women, compared with rural females, were characterized by such more frequent RFs as smoking and glucocorticoids' intake. AR increased with age and prevailed in women, compared with men, regardless of their age, region of residence, and settlement type. According to TIT, the frequency of high AR of major OPF in the sample was 7.0%. According to DIT, high, medium, and low AR of major OPF was detected in 3.1%, 42.2%, and 54.7% of participants, respectively. Among urban women compared with rural females, high AR of major OPF was more often detected (p < 0.05), using TIT, whereas there was no such pattern for men. We discovered the territorial variability of RFs and OPF AR. Prevalence of OPF RFs varied in Russia depending on age, gender, constituent entities, and the settlement type. Our data have demonstrated the typical age-gender causation pattern of OPF AR. Over 40% of participants required densitometry and fracture risk reclassification.

Role of Fracture Risk Assessment Tool and Bone Turnover Markers in Predicting All-Cause and Cardiovascular Mortality in Hemodialysis Patients.

BackgroundFracture Risk Assessment Tool (FRAX) and bone turnover markers (BTMs) predict fractures in the general population. However, the role of FRAX and BTMs in predicting mortality remains uncertain in hemodialysis (HD) patients.MethodsOne hundred and sixty-four HD patients stratified by low or high risk of 10-year fracture probability using FRAX. High risk of fracture was defined as 10-year probability of hip fracture ≥3% or major osteoporotic fracture ≥20%. The association of high risk of fracture and BTMs with all-cause mortality and cardiovascular (CV) mortality were evaluated using multivariate-adjusted Cox regression analysis.ResultsEighty-five (51.8%) patients were classified as high risk of fracture based on FRAX among 164 HD patients. During a mean follow-up period of 3.5 ± 1.0 years, there were 39 all-cause deaths and 23 CV deaths. In multivariate-adjusted Cox regression, high risk of fracture based on FRAX was independently associated with all-cause mortality [hazard ratio (HR): 2.493, 95% confidence interval (CI): 1.026–6.056, p = 0.044) but not with CV mortality (HR: 2.129, 95% CI: 0.677–6.700, p = 0.196). There were no associations between BTMs and mortality risk. Furthermore, lower geriatric nutritional risk index (GNRI) was significantly associated with increased CV mortality (HR: 0.888, 95% CI: 0.802–0.983, p = 0.022) after adjusting by confounding variables.ConclusionHigh risk of fracture using FRAX was an independent predictor of all-cause mortality in patients undergoing HD. FRAX, rather than BTMs, has an important role of prognostic significance in HD patients.

Mathematical model of the bone biological age based on the bone mineral density and quality indicex and Ukrainian FRAX model

Background. It is well-known that with aging there is a loss of bone mass and its strength, which leads to the development of osteoporosis and its complications. The aim of the study was to create a modern mathematical model for determining the biological age of the bone system, taking into account indices of bone mineral density (BMD) and quality and the FRAX® questionnaire. Materials and methods. 77 women and 44 men aged 30 to 90 years without any significant somatic pathology were included in the study. Patients were divided into 4 age groups: 30–44 years old — young, 45–59 years — mature, 60–74 years — old age and 75–90 years— senile age. We measured the parameters of BMD in the different areas of the skeleton by means of the dual-photon X-ray absorptiometry (DXA, “Prodigy”). The 10-year probability of major osteoporotic and hip fractures was measured using the Ukrainian version of the FRAX®. Statistical analysis was performed in the Statistica 7.0 program (StatSoft Inc., USA). Results. The dependence of the indices of BMD and bone quality, risk of osteoporotic fractures on age and the need for their early determination in young people to predict the risk of osteoporosis and its complications have been proven. The coefficient of determination of the R2 model was 0.62, which indicates that 62% of the variance of the “Age” can be explained by the predictors included in the model (DXA and FRAX indices); adjusted R2 index was 0.59 (p&lt;0.001), which indicates high significance of the model. Conclusions. The developed model for estimating the bone biological age has high accuracy and can be used to assess the risk of osteoporosis and its complications in young people for the purpose of predicting the disease.

Future Fracture Risk in Upper Extremity Fracture and Non-Fracture Patients.

Upper extremity (UE) fragility fractures are common and strong predictors of subsequent fractures. To investigate the relative importance of an UE fragility fracture in determining future fracture risk, we conducted a cross-sectional study to compare future fracture risk between patients presenting for osteoporosis evaluation after an UE fragility fracture and a similarly aged cohort of patients without an UE fracture. In all, 129 UE fracture patients seen in our bone health clinic (BHC) and 114 non-fracture UE fracture patients seen in an UE clinic completed clinic intake surveys assessing for fracture risk factors. Prefracture fracture risk (PFFR) and fracture risk assessment tool (FRAX) scores estimated the future fracture risks at the timepoint before and after the UE fragility fracture event, respectively. The primary study outcome was the 10-year risk of future fracture. The 10-year probability of major osteoporotic and hip fractures were significantly higher among the BHC group when estimated with FRAX. When estimated with PFFR score, there was no difference in the 10-year probability of hip fracture between the groups. Prevalence of secondary osteoporosis and glucocorticoid use was higher in the BHC group, and prevalence of rheumatoid arthritis was higher in the UE clinic group. This study underscores the importance of an UE fragility fracture in determining the risk of future fracture. A fragility fracture of the UE should be considered a sentinel event and physicians who evaluate these patients should recognize them as a high-risk group for future hip fracture.

FREM predicts 10-year incident fracture risk independent of FRAX® probability: a registry-based cohort study.

FREM was developed from Danish public health registers without DXA information to identify high imminent risk of major osteoporotic fracture (MOF) and hip fracture (HF), while FRAX® estimates 10-year fracture probability from clinical risk factors and femoral neck bone mineral density (BMD) from DXA. The FREM algorithm showed significant 1- and 2-year fracture risk stratification when applied to a clinical population from Manitoba, Canada. We examined whether FREM predicts 10-year fracture risk independent of 10-year FRAX probability computed with BMD. Using the Manitoba BMD Program registry, we identified women and men aged ≥ 45years undergoing baseline BMD assessment. We calculated FREM and FRAX scores, and identified incident fractures over 10years. Hazard ratios (HRs) for incident fracture were estimated according to FREM quintile, adjusted for FRAX probability. We compared predicted with observed 10-year cumulative fracture probability estimated with competing mortality. The study population comprised 74,446 women, mean age 65.2years; 7945 men, mean age 67.5years. There were 7957 and 646 incident MOF and 2554 and 294 incident HF in women and men, respectively. Higher FREM scores were associated with increased risk for MOF (highest vs middle quintile HRs 1.49 women, 2.06 men) and HF (highest vs middle quintile HRs 2.15 women, 2.20 men) even when adjusted for FRAX. Greater mortality with higher FREM scores attenuated its effect on 10-year fracture probability. In the highest FREM quintile, observed slightly exceeded predicted 10-year probability for MOF (ratios 1.05 in women, 1.49 in men) and HF (ratios 1.29 in women, 1.34 in men). Higher FREM scores identified women and men at increased fracture risk even when adjusted for FRAX probability that included BMD; hence, FREM provides additional predictive information to FRAX. FRAX slightly underestimated 10-year fracture probability in those falling within the highest FREM quintile.