John A. Kanis

An estimate of the worldwide prevalence and disability associated with osteoporotic fractures

ObjectiveThe aim of this study was to quantify the global burden of osteoporotic fracture worldwide.MethodsThe incidence of hip fractures was identified by systematic review and the incidence of osteoporotic fractures was imputed from the incidence of hip fractures in different regions of the world. Excess mortality and disability weights used age- and sex-specific data from Sweden to calculate the Disability Adjusted Life Years (DALYs) lost due to osteoporotic fracture.ResultsIn the year 2000 there were an estimated 9.0 million osteoporotic fractures of which 1.6 million were at the hip, 1.7 million at the forearm and 1.4 million were clinical vertebral fractures. The greatest number of osteoporotic fractures occurred in Europe (34.8%). The total DALYs lost was 5.8 million of which 51% were accounted for by fractures that occurred in Europe and the Americas. World-wide, osteoporotic fractures accounted for 0.83% of the global burden of non-communicable disease and was 1.75% of the global burden in Europe. In Europe, osteoporotic fractures accounted for more DALYs lost than common cancers with the exception of lung cancer. For chronic musculo-skeletal disorders the DALYs lost in Europe due to osteoporosis (2.0 million) were less than for osteoarthrosis (3.1 million) but greater than for rheumatoid arthritis (1.0 million).ConclusionWe conclude that osteoporotic fractures are a significant cause of morbidity and mortality, particularly in the developed countries.

Diagnosis of osteoporosis and assessment of fracture risk

The diagnosis of osteoporosis centres on the assessment of bone mineral density (BMD). Osteoporosis is defined as a BMD 2.5 SD or more below the average value for premenopausal women (T score < -2.5 SD). Severe osteoporosis denotes osteoporosis in the presence of one or more fragility fractures. The same absolute value for BMD used in women can be used in men. The recommended site for diagnosis is the proximal femur with dual energy X-ray absorptiometry (DXA). Other sites and validated techniques, however, can be used for fracture prediction. Although hip fracture prediction with BMD alone is at least as good as blood pressure readings to predict stroke, the predictive value of BMD can be enhanced by use of other factors, such as biochemical indices of bone resorption and clinical risk factors. Clinical risk factors that contribute to fracture risk independently of BMD include age, previous fragility fracture, premature menopause, a family history of hip fracture, and the use of oral corticosteroids. In the absence of validated population screening strategies, a case finding strategy is recommended based on the finding of risk factors. Treatment should be considered in individuals subsequently shown to have a high fracture risk. Because of the many techniques available for fracture risk assessment, the 10-year probability of fracture is the desirable measurement to determine intervention thresholds. Many treatments can be provided cost-effectively to men and women if hip fracture probability over 10 years ranges from 2% to 10% dependent on age.

European guidance for the diagnosis and management of osteoporosis in postmenopausal women

Summary Guidance is provided in a European setting on the assessment and treatment of postmenopausal women at risk of fractures due to osteoporosis. Introduction The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2008. This manuscript updates these in a European setting. Methods Systematic literature reviews. Results The following areas are reviewed: the role of bone mineral density measurement for the diagnosis of osteoporosis and assessment of fracture risk, general and pharmacological management of osteoporosis, monitoring of treatment, assessment of fracture risk, case finding strategies, investigation of patients and health economics of treatment. Conclusions A platform is provided on which specific guidelines can be developed for national use.

World-wide Projections for Hip Fracture

Abstract: The aims of this study were to estimate the present and future incidence of hip fracture world-wide. From a survey of available data on current incidence, population trends and the secular changes in hip fracture risk, the numbers of hip fractures expected in 2025 and 2050 were computed. The total number of hip fractures in men and women in 1990 was estimated to be 338000 and 917000 respectively, a total of 1.26 million. Assuming no change in the age- and sex-specific incidence, the number of hip fractures is estimated to approximately double to 2.6 million by the year 2025, and 4.5 million by the year 2050. The percentage increase will be greater in men (310%) than in women (240%). With modest assumptions concerning secular trends, the number of hip fractures could range between 7.3 and 21.3 million by 2050. The major demographic changes will occur in Asia. In 1990, 26% of all hip fractures occurred in Asia, whereas this figure could rise to 37% in 2025 and to 45% in 2050. We conclude that the socioeconomic impact of hip fractures will increase markedly throughout the world, particularly in Asia, and that there is an urgent need to develop preventive strategies, particularly in the developing countries.

Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report. WHO Study Group.

The criteria required for an effective screening strategy for osteoporosis are largely met in Caucasian women. The disease is common and readily diagnosed by the measurement of bone mineral with single- or dual-energy absorptiometry. Such measurements have high specificity but lower sensitivity, so that the value of the technique is greater for those identified as being at higher risk. Against this background there is little evidence that osteoporosis can usefully be tackled by a public health policy to influence risk factors such as smoking, exercise and nutrition. This suggests that it is appropriate to consider targetting of treatment with agents affecting bone metabolism to susceptible individuals. Since the main benefits of the use of hormone replacement therapy (HRT) are probably on cardiovascular morbidity, the major role for selective screening is to direct non-HRT interventions. An appropriate time to consider screening and intervention is at the menopause, but screening at later ages is also worthy of consideration. Since the cost of screening is low and that of bone-active drugs is high, the selective use of screening techniques will improve the cost-benefit ratio of intervention.

Predictive Value of BMD for Hip and Other Fractures.

The relationship between BMD and fracture risk was estimated in a meta‐analysis of data from 12 cohort studies of ∼39,000 men and women. Low hip BMD was an important predictor of fracture risk. The prediction of hip fracture with hip BMD also depended on age and z score.

Standardized nomenclature, symbols, and units for bone histomorphometry: A 2012 update of the report of the ASBMR Histomorphometry Nomenclature Committee

Before publication of the original version of this report in 1987, practitioners of bone histomorphometry communicated with each other in a variety of arcane languages, which in general were unintelligible to those outside the field. The need for standardization of nomenclature had been recognized for many years,(1) during which there had been much talk but no action. To satisfy this need, B Lawrence Riggs (ASBMR President, 1985 to 1986) asked A Michael Parfitt to convene an ASBMR committee to develop a new and unified system of terminology, suitable for adoption by the Journal of Bone and Mineral Research (JBMR) as part of its Instructions to Authors. The resulting recommendations were published in 1987(2) and were quickly adopted not only by JBMR but also by all respected journals in the bone field. The recommendations improved markedly the ability of histomorphometrists to communicate with each other and with nonhistomorphometrists, leading to a broader understanding and appreciation of histomorphometric data. In 2012, 25 years after the development of the standardized nomenclature system, Thomas L Clemens (Editor in Chief of JBMR) felt that it was time to revise and update the recommendations. The original committee was reconvened by David W Dempster, who appointed one new member, Juliet E Compston. The original document was circulated to the committee members and was extensively revised according to their current recommendations. The key revisions include omission of terminology used before 1987, recommendations regarding the parameters and technical information that should be included in all histomorphometry articles, recommendations on how to handle dynamic parameters of bone formation in settings of low bone turnover, and updating of references.

An Update on the Diagnosis and Assessment of Osteoporosis with Densitometry

Abstract: In 1994 the WHO proposed guidelines for the diagnosis of osteoporosis based on measurement of bone mineral density. They have been widely used for epidemiological studies, clinical research and for treatment strategies. Despite the widespread acceptance of the diagnostic criteria, several problems remain with their use. Uncertainties concern the optimal site for assessment, thresholds for men and diagnostic inaccuracies at different sites. In addition, the development of many new technologies to assess the amount or quality of bone poses problems in placing these new tools within a diagnostic and assessment setting. This review considers the recent literature that has highlighted the strengths and weaknesses of diagnostic thresholds and their use in the assessment of fracture risk, and makes recommendations for actions to resolve these difficulties.

Guidelines for diagnosis and management of osteoporosis

PreambleSignificant developments have occurred in the field of osteoporosis over the past several years. There is now considerable information concerning its impact on general health and an international consensus concerning the definition of osteoporosis. Conceptually, this recognizes the multifactorial nature of the events which give rise to the fractures, but operational definitions have now been agreed and have gained a wide measure of acceptance. Accurate and precise diagnostic tools are also available. Finally, there is substantial evidence that the natural history of osteoporosis can be modulated by agents which in turn decrease the risk of fracture. Despite an increasing professional and public awareness of osteoporosis, the management of osteoporosis has been confined mainly to specialists. With the large number of affected individuals and the wider availability of diagnostic aids and safe treatments, there is a need for osteoporosis to be managed predominantly by the primary care physician. Against this background the European Foundation for Osteoporosis and Bone Disease through their Scientific Advisory Board has recognized a need to develop practice guidelines for primary care physicians which are summarized in this paper.

Ten Year Probabilities of Osteoporotic Fractures According to BMD and Diagnostic Thresholds

Abstract: The objectives of the present study were to estimate 10 year probabilities of osteoporotic fractures in men and women according to age and bone mineral density (BMD) at the femoral neck. Risks were computed from the incidence of a first hip, distal forearm, proximal humerus and symptomatic vertebral fracture from patient records in Malmo¨, Sweden and future mortality rates for each year of age from Poisson models using the Swedish patient register and statistical year book. Fracture probability was computed using the Swedish population and cut-off values for T-scores based on the NHANES III female population. We assumed that the risk of fracture increased with decreasing BMD as assessed by meta-analysis in independent studies. The 10-year probability of any fracture was determined from the proportion of individuals fracture-free from the age of 45 years. With the exception of forearm fractures in men, 10 year probabilities increased with age and T-score. In the case of hip and spine fractures, fracture probabilities for any age with low BMD were similar between men and women. The effect of age on risk independently of BMD suggests that intervention thresholds should not be at a fixed T-score but vary according to absolute probabilities. Intervention thresholds based on hip BMD T-scores are similar between sexes.