Epidemiology of hip fracture in Tucuman, Argentina

A new FRAX model for Brazil

Fracture probabilities derived from the original FRAX model for Brazil were compared to those from an updated model based on more recent regional estimates of the incidence of hip fracture. Fracture probabilities were consistently lower in the updated FRAX model. Despite large differences between models, differences in the rank order of fracture probabilities were minimal.

OBJECTIVE

Recent epidemiological data indicate that the risk of hip fracture in Brazil is lower than that used to create the original FRAX model. This paper describes the epidemiology of hip fracture in Brazil and the synthesis of an updated FRAX model with the aim of comparing this new model with the original model.

METHODS

Hip fracture rates from three cities in three regions were combined, weighted by the population of each region. For other major fractures, incidence rates for Brazil were estimated using Swedish ratios for hip to other major osteoporotic fracture (humerus, forearm or clinical vertebral fractures). Mortality estimates were taken from the UN.

RESULTS

Compared to the original FRAX model, the updated model gave lower 10-year fracture probabilities in men and women at all ages. Notwithstanding, there was a very close correlation in fracture probabilities between the original and updated models (r > 0.99) so that the revisions had little impact on the rank order of risk.

CONCLUSION

The disparities between the original and updated FRAX models indicate the importance of updating country-specific FRAX models with the advent of significant changes in fracture epidemiology.

Fragility fracture systems, Latin America perspective

Osteoporosis is a worldwide epidemic, affecting an average of 30% to 50% of those over 50 years of age in Latin America. Resulting from it is another epidemic, that of fragility fractures, which adversely affects morbidity and mortality of this population. Increasing in their incidence, fragility fractures are expected to occur in 1 in 3 women and 1 in 5 men over 50years of age during their lifetimes. Currently, there are diagnostic and management guidelines for fragility fractures in Latin American countries, especially those for hip and spine fractures. In general, in Latin America, the quality indicators and standards for the care of these fractures vary greatly according to the health system, being suboptimal in many situations. The organization of health services is different in the different countries throughout Latin America. Common underlying characteristics, however, include the distinctions that exist in care between public and private medicine and the lack of economic resources directed to public healthcare systems from the national levels. Several important changes have been implemented in recent years, with the collaboration between national organizations and international associations such as the Fragility Fracture Network and the International Osteoporosis Foundation, aimed at improving quality standards in care and rates of morbidity and mortality in patients treated thorough fragility fracture programs. The underregistration in these programs and absence of formal national registries also contribute to a lack of recognition of the size, scope, and severity of the problem.

Osteoporotic fractures in rheumatoid arthritis patients in Argentina: a matched retrospective cohort study

BACKGROUND

To compare the incidence of osteoporotic fractures in patients with rheumatoid arthritis (RA) with matched controls from a university hospital.

METHODS

Consecutive RA patients (n = 100) were matched (age and sex) with controls (1:2). The follow-up period began at the index date, defined as the date of diagnosis for RA patients and the date of the first medical claim at the Health Management Organization (HMO) for non-RA patients. Fracture incidence rates per 1000 persons-years (PY) for distinct types of fractures were calculated. Multivariate cox regression analysis was performed to identify factors associated with fractures.

RESULTS

One hundred RA patients were followed for a total of 975.1 patients-years and 200 controls for 1485.7 patients-years. No difference was found in the overall fracture incidence rate per 1000 PY between RA and controls (19.5, 95% CI 12.7-28.6 vs 12.1, 95% CI 7.7-18.7, p = 0.07). In the Cox regression analysis, only age (HR 1.06, 95% CI 1.02-1.11, p = 0.006) and history of a prior fracture (HR 9.85, 95% CI 2.97-32.64, p <  0.001) were associated with fractures after the index date. The stratified analysis of the fractures by location showed that only the vertebral fractures were more frequent in RA patients compared with controls (12.9 per 1000 PY, 95% CI 8.9-25.8, vs. 3.4, 95% CI 1.4-8.1, respectively, p = 0.01).

CONCLUSION

Patients with RA didn't show an overall increased risk of osteoporotic fractures compared with matched controls, but vertebral fractures were more frequently observed in patients with RA.

Challenges and opportunities for quality densitometry in Latin America

Latin America and the Caribbean region account for 8% of the world's total population. Experts from 18 countries were invited to contribute to this article to provide the best available data on the number, types, and quality of densitometry, DXA experts, the local/national incidence and prevalence of osteoporosis and fragility fractures, and other uses and information on the challenges and opportunities for quality densitometry with examples of local initiatives. Osteoporosis is the primary reason for densitometry in our region, which is not a priority for public health in most countries. Access and quality are major challenges, and there is a clear trend to concentrate on densitometry services in the largest cities. Urgent action is needed to face the rapidly increasing burden of osteoporosis in our region, including robust and up to date epidemiology, access to health professionals, and quality densitometry. Health professionals require better access to training, courses, and other activities at a more local or regional level.

Fragility fractures in psoriatic arthritis patients: a matched retrospective cohort study

OBJECTIVE

To compare incidental fragility fractures in psoriatic arthritis (PsA) patients with matched controls from a university hospital.

METHODS

Consecutive PsA patients were matched (age and sex) with controls (1:2). Follow-up began at index date, defined as the date of PsA diagnosis for cases and their respective controls, until the last hospital visit, death or the end of the study (31 December 2017). Electronic medical records were reviewed for osteoporotic fractures. Incidence rates per 100,000 persons-years (PY) of distinct types of fractures after index dates were calculated and compared between groups. A multivariate Cox regression analysis was performed to investigate determinants of fractures.

RESULTS

Ninety-two PsA patients and 184 controls were included. No difference was found in the overall fracture incidence rate per 100,000 PY between PsA and controls (1020 95% CI 510-1930, vs 870 95% CI 520-1390, p = 0.36). Vertebral fractures were numerically more frequent in PsA patients with an incidence rate of 1020 (95% CI 510-1930) per 100,000 PY versus 460 (95% CI 240-920), per 100,000 PY in the control group but it did not reach statistical significance (p = 0.06). In the Cox regression analysis, after adjusting for bisphosphonate use, only age (HR 1.10, 1.05-1.16, p < 0.001) and female sex (HR 3.94, 1.11-13.91, p = 0.03) were associated with fractures while PsA diagnosis and use of glucocorticoids were not.

CONCLUSION

In this cohort of PsA patients, no overall increased risk of fractures was found in comparison with matched controls. Key Points • PsA could have different effects on bone, leading to confusing results in bone densitometry readings contributing to the difficulty in establishing the real prevalence of OP in PsA. • Vertebral fractures were more frequent in PsA patients compared to controls, but it did not reach statistical significance. No difference was found in the overall fracture incidence rate.

Epidemiology of low-energy fracture in Chinese postmenopausal women: changing trend of incidence since menopause and associated risk factors, a national population-based survey

OBJECTIVE

The aim of the study was to report the incidence of low-energy fracture since menopause in postmenopausal women ≤70 years and to explore associated risk factors METHODS:: This was a part of the Chinese National Fracture Survey (CNFS), which was carried out in eight provinces of China mainland between January and May 2015. Data on 68,783 postmenopausal women ≤70 years were extracted from the CNFS database for calculations and analyses.

RESULTS

A total of 309 women were confirmed to have low-energy fractures in 2014, indicating the incidence of 449.2 (95% CI, 399.3-499.2) per 100,000 women. There were two obvious peaks of fracture incidence at the 4th year and the 9th year since menopause. From the 10th year on, the fracture incidence rate presented the relatively steady trends over years, only with slight interannual fluctuation. After adjustment for confounding variables, advanced age, higher latitude, milk intake ≥1/d, residence ≥2nd floor without elevator, alcohol consumption, sleep duration <7 h/d, history of past fracture, and more births were identified as significant risk factors. Supplementation of calcium or vitamin D or both was associated with 44% of fracture reduction (OR, 0.56; 95% CI, 0.37-0.84).

CONCLUSIONS

These data on low-energy fractures in postmenopausal women provided an updated clinical evidence base for better national healthcare planning and preventive efforts in China.

Epidemiology of low-energy wrist, hip, and spine fractures in Chinese populations 50 years or older: A national population-based survey

The aim of the study was to investigate the incidence of low-energy fracture of wrist, hip, and spine and the related risk factors in Chinese populations 50 years or older.This study was a part of the Chinese National Fracture Survey (CNFS) carried out in 8 Chinese provinces in 2015. Data on 154,099 Chinese men and women 50 years or older were extracted from the CNFS database for calculations and analyses. Low-energy fracture was defined as fracture caused by slip, trip, or falls from standing height.A total of 247 patients sustained low-energy fractures in 2014, indicating the incidence rate was 160.3/100,000 person-years, with 120.0 [95% confidence interval (CI), 95.5-144.5] and 213.1(95% CI, 180.7-245.6)/100,000 person-years in men and women, respectively. In men, advanced age, alcohol consumption, residence at second floor or above without elevator, sleep duration <7 h/day, and history of past fracture were identified to be significant risk factors for low-energy fractures. In women, advanced age, living in east region, higher latitude zone (40°N -49.9°N), alcohol consumption, more births, sleep duration <7 h/day, and history of past fracture were identified as significant risk factors. Supplementation of calcium or vitamin D or both was identified to be associated with reduced risk of fracture in women (odds ratio, 0.38; 95% CI, 0.20-0.75), but not in men.These epidemiologic data on low-energy fractures provided updated clinical evidence base for national healthcare planning and preventive efforts in China. Corresponding interventions such as decreasing alcohol consumption and sleep improvement should clearly be implemented. For women, especially those with more births and past history of fracture, routine screening of osteoporosis, and intensive nourishment since menopause should be advocated.

A scorecard for osteoporosis in four Latin American countries: Brazil, Mexico, Colombia, and Argentina

The state of osteoporosis care in Latin America is not well known. The results of our scorecard indicate an urgent need to improve policy frameworks, service provision, and service uptake for osteoporosis in Brazil, Mexico, Colombia, and Argentina. The scorecard serves as an important marker to measure future progress.

PURPOSE

We developed a scorecard to summarize key indicators of the burden of osteoporosis and its management in Brazil, Mexico, Colombia, and Argentina. The goal of the scorecard is to reduce the risk of osteoporotic fractures by promoting healthcare policies that will improve patient access to timely diagnosis and treatment.

METHODS

We conducted a systematic review of osteoporosis. We also interviewed several key opinion leaders to gather information on government policy, access to fracture risk assessments, and access to medications. We then leveraged a peer-reviewed template, initially applied to 27 European countries, to synthesize the information into a scorecard for Latin America. We presented information according to four main categories: burden of disease, policy framework, service provision, and service uptake and used a traffic light color coding system to indicate high, intermediate, and low risk.

RESULTS

The systematic review included 108 references, of which 49 were specific to Brazil. The number of osteoporotic fractures in Brazil, Mexico, Colombia, and Argentina was forecasted to increase substantially (34% to 76% in each country) from 2015 to 2030. In general, policy frameworks, service provision, and service uptake were not structured to support current patients with osteoporosis and did not account for the future increases in fracture burden. Across all four countries, there was inadequate access to programs for secondary fracture prevention and only a small minority of patients received treatment for osteoporosis.

CONCLUSIONS

Osteoporosis management, including the rate of post-fracture care, is very poor in Brazil, Mexico, Colombia, and Argentina and needs to be strengthened. Improvements in the rates of care are necessary to curb the debilitating impact of osteoporotic fractures on patients and health systems.

Worldwide Fracture Prediction

The substantial increase in the burden of non-communicable diseases in general and osteoporosis in particular, necessitates the establishment of efficient and targeted diagnosis and treatment strategies. This chapter reviews and compares different tools for osteoporosis screening and diagnosis; it also provides an overview of different treatment guidelines adopted by countries worldwide. While access to dual-energy X-ray absorptiometry to measure bone mineral density (BMD) is limited in most areas in the world, the introduction of risk calculators that combine risk factors, with or without BMD, have resulted in a paradigm shift in osteoporosis screening and management. To-date, forty eight risk assessment tools that allow risk stratification of patients are available, however only few are externally validated and tested in a population-based setting. These include Osteoporosis Self-Assessment Tool; Osteoporosis Risk Assessment Instrument; Simple Calculated Osteoporosis Risk Estimation; Canadian Association of Radiologists and Osteoporosis Canada calculator; Fracture Risk Assessment Calculator (FRAX); Garvan; and QFracture. These tools vary in the number of risk factors incorporated. We present a detailed analysis of the development, characteristics, validation, performance, advantages and limitations of these tools. The World Health Organization proposes a dual-energy X-ray absorptiometry-BMD T-score ≤ -2.5 as an operational diagnostic threshold for osteoporosis, and many countries have also adopted this cut-off as an intervention threshold in their treatment guidelines. With the introduction of the new fracture assessment calculators, many countries chose to include fracture risk as one of the major criteria to initiate osteoporosis treatment. Of the 52 national guidelines identified in 36 countries, 30 included FRAX derived risk in their intervention threshold and 22 were non-FRAX based.  No universal tool or guideline approach will address the needs of all countries worldwide.  Osteoporosis screening and management guidelines are best tailored according to the needs and resources of individual counties. While few countries have succeeded in generating valuable epidemiological data on osteoporotic fractures, to validate their risk calculators and base their guidelines, many have yet to find the resources to assess variations and secular trends in fractures, the performance of various calculators, and ultimately adopt the most convenient care pathway algorithms.

Prevalence of Osteoporosis in Women in Buenos Aires Based on Bone Mineral Density at the Lumbar Spine and Femur

The aim of the study was to report values for osteoporosis (OP) prevalence in Buenos Aires. Bone mineral density (BMD) at different skeletal sites was measured from November 2012 to July 2014. Participants were recruited through a newspaper advertisement inviting women at least 50 yr of age to receive free BMD measurement. After signing an informed consent form, 5448 women living in Buenos Aires and surrounding districts were studied. Lumbar spine (L1-L4), femur neck, and total hip BMDs were measured (Lunar Prodigy, software version 12.3 GE, Madison, WI, USA). OP was defined as a T-score ≤-2.5 at the lumbar spine or the femoral neck. Results showed that 1021 out of 5448 studied subjects (18.7%) had OP at the lumbar spine or the femoral neck. Comparison of age of the population sample with reference data for the general population showed a moderate (+0.6%) increase in prevalence. Prevalence of OP was low, up to the age of 70 yr when based on femoral neck BMD only. Conversely, the prevalence of OP at the lumbar spine, which was reportedly high in women up to the age of 70 yr, tended to level off over that age. The results of the total femur only added a slight (+0.7%) nonsignificant increase to the OP prevalence. A total 346,500 out of 1,853,000 women aged 50+ yr in Buenos Aires had OP at the lumbar spine or femoral neck, whereas only 163,500 had OP at the upper femur, reducing the number by 53%. The present study assessed OP prevalence in the most densely populated urban area in Argentina. The results are similar to those reported for Caucasian populations in the United States and Canada. As measurement of only the BMD of femoral neck overlooks the diagnosis in half of the women, future studies should include measurement of the lumbar spine in combination with the femoral neck for a more accurate estimation of OP prevalence.

EPIDEMIOLOGY OF OSTEOPOROTIC FRACTURES IN THE RUSSIAN FEDERATION AND THE RUSSIAN MODEL OF FRAX

Introduction. The incidence of fractures of the proximal femur (FPF), fractures of the forearm and humerus was studied in two cities of the Russian Federation. This index was used to create the Russian model FRAX and to assess the present and future burden of fractures. Objective. So far, little is known about the epidemiology of fractures in Russia. The aim of the study was to determine the incidence of major fractures to create a Russian model of FRAX and evaluate the present and future burden of fractures. Materials and methods. In well-defined populations of two Russian cities, we had determined a number FPF and forearm fractures of the humerus for 2-2-year period. Data were combined and the resulting incidence used to calculate FRAX model for the Russian Federation and to calculate the projected number of fractures in the Russian Federation in 2010 and 2025. Results. A total of 6012 fractures were identified. Among all FPF, 27% of Pervouralsk and 1.8% in Yaroslavl were not registered on the official data of medical institutions. The incidence of fractures increased with age and was higher in women than in men. The probability of experiencing a FPF in later life at the age of 50 years was 4% of men and 7% of women. Total number FPF in 2010 was 112 thousand cases and it is expected to rise by 2025 to 159 thousand a year. The estimated number of major osteoporotic fractures will increase from 590 thousand to 730 thousand cases for the same period. Conclusions. Osteoporotic fractures are a serious health problem for Russia. It is necessary to take urgent measures to improve emergency care at FPF and long-term care for this and other osteoporotic fractures.

The effect of latitude on the risk and seasonal variation in hip fracture in Sweden

Although the optimal requirement of vitamin D for skeletal health in the general community is controversial, vitamin D deficiency impairs bone mineralization and increases bone turnover via secondary hyperparathyroidism, thus accelerating bone loss and increasing fracture risk. Support for a role of vitamin D deficiency in the epidemiology of hip fracture is found in the seasonal variation of hip fracture incidence that is reported in several studies. If the association were causal, then the incidence and amplitude of the seasonal variation in hip fracture risk should vary by latitude. We addressed this hypothesis by examining the incidence of hip fracture in men and women aged 50 years or more from Sweden (latitudes 55 to 69°) between 1987 and 2009. In order to reduce double counting, only one fracture in a period of a year was counted per individual. Men contributed 104,888 fractures in 33,313,065 person years and women 264,362 fractures in 38,387,660 person years. The effects of season and latitude were examined by Poisson regression. As expected, hip fracture rates were higher in women than in men. After adjustment for age, season and population density, hip fracture incidence increased by 3.0% (95% CI: 2.7-3.2%) per degree increase in latitude for men and by 1.9% (95% CI: 1.8-2.1%) for women. There was a marked seasonal variation of hip fracture with the highest risk in February and lower by 37.5% in men and by 23.5% women during the summer. There were significant interactions of amplitude of the seasonal variation with latitude (p < 0.001 for both men and women), indicating that seasonal variation during the year was more pronounced in the north of Sweden than in the south. The associations found with latitude and season is consistent with a role of vitamin D in hip fracture causation.

Secular trends in hip fractures worldwide: opposing trends East versus West

Despite wide variations in hip rates fractures worldwide, reasons for such differences are not clear. Furthermore, secular trends in the age-specific hip fracture rates are changing the world map of this devastating disease, with the highest rise projected to occur in developing countries. The aim of our investigation is to systematically characterize secular trends in hip fractures worldwide, examine new data for various ethnic groups in the United States, evidence for divergent temporal patterns, and investigate potential contributing factors for the observed change in their epidemiology. All studies retrieved through a complex Medline Ovid search between 1966 and 2013 were examined. For each selected study, we calculated the percent annual change in age-standardized hip fracture rates de-novo. Although occurring at different time points, trend breaks in hip fracture incidence occurred in most Western countries and Oceania. After a steep rise in age-adjusted rates in these regions, a decrease became evident sometimes between the mid-seventies and nineties, depending on the country. Conversely, the data is scarce in Asia and South America, with evidence for a continuous rise in hip fracture rates, with the exception of Hong-Kong and Taiwan that seem to follow Western trends. The etiologies of these secular patterns in both the developed and the developing countries have not been fully elucidated, but the impact of urbanization is at least one plausible explanation. Data presented here show close parallels between rising rates of urbanization and hip fractures across disparate geographic locations and cultures. Once the proportion of the urban population stabilized, hip fracture rates also stabilize or begin to decrease perhaps due to the influence of other factors such as birth cohort effects, changes in bone mineral density and BMI, osteoporosis medication use and/or lifestyle interventions such as smoking cessation, improvement in nutritional status and fall prevention.

Hip fractures in Hefei, China: the Hefei osteoporosis project

Hip fracture incidence rates in Hefei, China, over a period of 1 year (2010) were assessed. The aim of this study was to investigate the incidence and epidemiology of hip fracture in Hefei and compare it with other populations. All the hip fracture records were obtained from the Hefei Hospital Discharge Register for the entire population ≥50 years of age and restricted to cervical or trochanteric types. The incidence of hip fracture was standardized to the 2010 World population. A total of 1518 (aged ≥50) hip fractures (628 in men, 890 in women) were recorded during the study period. The age-adjusted incidence rate for 1 year was 144/100,000 (95 % CI = 135-153/100,000) for women and 97/100,000 (95 % CI = 85-109/100,000) for men. The standardized incidence rate against the 2010 World population was 151.7/100,000 for women and 98.2/100,000 for men. The mean age of patients with a hip fracture was 74.5 ± 10.1 years for women and 71.9 ± 11.9 years for men. The overall female to male ratio of hip fracture was 1.48:1 for hip fracture incidence and 1.54:1 for standardized incidence. Simple fall accounted for 85 % hip fractures in total cases. Hefei has a lower incidence of hip fracture compared with Beijing and other countries from the five continents in recent studies, but a higher incidence than those cities in north-east China in the early 1990s. The inequality incidence in different geographic areas could be due to the urbanization or life expectancy of the population, but further investigation needs to be done to confirm this hypothesis. We also found a higher incidence in women than in men. Simple fall may be the main mechanism of injury for hip fracture.

Cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures: an updated meta-analysis

OBJECTIVES

To compare the outcomes of cemented and uncemented hemiarthroplasty for treating displaced femoral neck fractures.

METHOD

We searched the PubMed, Medline, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar databases from 1966 to Mar 2012. No language restriction was applied. Reference lists of all the selected articles were hand-searched for any additional trials. Trial quality was assessed using the modified Jadad Scale. Two authors independently extracted data from all eligible studies, including study design, participants, interventions, and outcomes (mortality, hospital stay, blood loss, operation time, residual pain, and complications). The data were using fixed-effects and random-effects models with mean differences and risk ratios for continuous and dichotomous variables, respectively.

RESULTS

A total of 12 studies involving 1805 patients were identified in this analysis. Meta-analysis showed longer operation time (SMD, -0.43, 95 % CI -0.56, -0.30) in cemented versus uncemented hemiarthroplasty. There was no significant difference between the two treatment groups regarding mortality (OR, 1.08, 95 % CI 0.88, 1.34), hospital stay (SMD, -1.21, 95 % CI -2.24, -0.18), blood loss (SMD, -0.12, 95 % CI -0.33, 0.10), operation time (SMD, -0.43, 95 % CI -0.56, -0.30), residual pain (OR, 1.42, 95 % CI 0.99, 2.03), and complications (OR, 0.82, 95 % CI 0.63, 1.08).

CONCLUSIONS

The available evidence suggested there was no significant difference between uncemented and cemented hemiarthroplasty in treating displaced femoral neck fractures.

Geographic differences in fractures among women

Osteoporotic fracture is associated with considerable morbidity and mortality in women throughout the world. However, significant variation in hip fracture rates among women from different nations has been observed and is likely to represent a combination of real and apparent differences due to ascertainment bias. Higher rates are observed in Caucasian women, with lowest rates observed in black women and intermediate rates among Asian women. These differences are likely to represent a combination of genetic and environmental differences; for example, among European women, the highest fracture rates are observed in Scandinavian women where vitamin D insufficiency is common. In all groups, an increase in absolute fracture numbers is anticipated due to demographic changes.

A systematic review of hip fracture incidence and probability of fracture worldwide

The country-specific risk of hip fracture and the 10-year probability of a major osteoporotic fracture were determined on a worldwide basis from a systematic review of literature. There was a greater than 10-fold variation in hip fracture risk and fracture probability between countries.

INTRODUCTION

The present study aimed to update the available information base available on the heterogeneity in the risk of hip fracture on a worldwide basis. An additional aim was to document variations in major fracture probability as determined from the available FRAX models.

METHODS

Studies on hip fracture risk were identified from 1950 to November 2011 by a Medline OVID search. Evaluable studies in each country were reviewed for quality and representativeness and a study (studies) chosen to represent that country. Age-specific incidence rates were age-standardised to the world population in 2010 in men, women and both sexes combined. The 10-year probability of a major osteoporotic fracture for a specific clinical scenario was computed in those countries for which a FRAX model was available.

RESULTS

Following quality evaluation, age-standardised rates of hip fracture were available for 63 countries and 45 FRAX models available in 40 countries to determine fracture probability. There was a greater than 10-fold variation in hip fracture risk and fracture probability between countries.

CONCLUSIONS

Worldwide, there are marked variations in hip fracture rates and in the 10-year probability of major osteoporotic fractures. The variation is sufficiently large that these cannot be explained by the often multiple sources of error in the ascertainment of cases or the catchment population. Understanding the reasons for this heterogeneity may lead to global strategies for the prevention of fractures.

Epidemiology of fracture in the Russian Federation and the development of a FRAX model

The incidence of hip, forearm and humeral fractures was studied in two cities from the Russian Federation. Fracture rates were used to create a FRAX model for Russia and to estimate the current and future burden of fracture.

PURPOSE

There is scant information on the epidemiology of fracture in Russia. The aim of the study was to determine the incidence of major fractures in order to populate a new FRAX model and to characterise the burden and future burden of fractures.

METHODS

The number of hip, forearm and humeral fractures was determined in two Russian cities with a well-defined catchment population over a 2-3-year period. Incidence rates for the two cities were merged and used to populate a FRAX model for Russia. Incidence rates were also applied to the general population in 2010 and 25 years later in 2035.

RESULTS

A total of 6,012 fractures were documented. For hip fracture, 27 % of cases in Pervouralsk and 1.8 % in Yaroslavl were not registered in the hospital data base. The incidence of index fractures increased with age and was higher in women than in men. The lifetime probability of hip fracture at the age of 50 years was 4 % in men and 7 % in women. The total number of hip fractures estimated in 2010 (112,000) is expected to rise to 159,000 in 2035. The estimated number of major fractures will rise from 590,000 to 730,000 over the same time interval.

CONCLUSIONS

Fragility fractures pose a serious health care problem in Russia. Urgent steps are needed to improve the acute management of hip fracture and long-term care of other osteoporotic fractures.

Pitfalls in the external validation of FRAX

SUMMARY

Recent studies have evaluated the performance of FRAX® in independent cohorts. The interpretation of most is problematic for reasons summarised in this perspective.

INTRODUCTION

FRAX is an extensively validated assessment tool for the prediction of fracture in men and women. The aim of this study was to review the methods used since the launch of FRAX to further evaluate this instrument.

METHODS

This covers a critical review of studies investigating the calibration of FRAX or assessing its performance characteristics in external cohorts.

RESULTS

Most studies used inappropriate methodologies to compare the performance characteristics of FRAX with other models. These included discordant parameters of risk (comparing incidence with probabilities), comparison with internally derived predictors and inappropriate use and interpretation of receiver operating characteristic curves. These deficits markedly impair interpretation of these studies.

CONCLUSION

Cohort studies that have evaluated the performance of FRAX need to be interpreted with caution and preferably re-evaluated.

Rapidly increasing rates of hip fracture in Beijing, China

The age-specific rates of hip fractures have been declining in most countries in the West but a few studies suggest that the rates might be increasing in areas of Asia that are undergoing urbanization. We previously conducted a population-based study of hip fracture rates in Beijing, China, in 1990 to 1992 that included validation of hip fracture cases. Using a similar approach to validate cases, we estimated the age-specific hip fracture rates in Beijing, China, for 2002 to 2006. Specifically, we obtained hospital discharge data for hip fractures that were reported to the Beijing Bureau of Public Health. To confirm the diagnoses, Beijing residence, and find cases missed by the public records we checked individual cases in the public health records against medical records in a random sample of Beijing hospitals. The rates from public health data were adjusted for these under- and overestimations. We found that between 1990 and 1992 and 2002 and 2006, the adjusted age-specific rates of hip fracture over age 50 years increased 2.76-fold (95% confidence interval [CI], 2.68-2.84) in women and 1.61-fold (95% CI, 1.56-1.66) in men. Over age 70 years, the age-specific rates increased 3.37-fold (95% CI, 3.28-3.47) in women and 2.01-fold (95% CI, 1.95-2.07) in men. From 2002 to 2006, the rates over age 50 years increased 58% in women and 49% in men. We conclude that the rate of hip fracture has been rising very rapidly in Beijing, China. Therefore, the burden of hip fractures may be shifting rapidly from the West to urbanizing areas of the East.

Interpretation and use of FRAX in clinical practice

The introduction of the WHO FRAX® algorithms has facilitated the assessment of fracture risk on the basis of fracture probability. Its use in fracture risk prediction has strengths, but also limitations of which the clinician should be aware and are the focus of this review

INTRODUCTION

The International Osteoporosis Foundation (IOF) and the International Society for Clinical Densitometry (ISCD) appointed a joint Task Force to develop resource documents in order to make recommendations on how to improve FRAX and better inform clinicians who use FRAX. The Task Force met in November 2010 for 3 days to discuss these topics which form the focus of this review.

METHODS

This study reviews the resource documents and joint position statements of ISCD and IOF.

RESULTS

Details on the clinical risk factors currently used in FRAX are provided, and the reasons for the exclusion of others are provided. Recommendations are made for the development of surrogate models where country-specific FRAX models are not available.

CONCLUSIONS

The wish list of clinicians for the modulation of FRAX is large, but in many instances, these wishes cannot presently be fulfilled; however, an explanation and understanding of the reasons may be helpful in translating the information provided by FRAX into clinical practice.

Official Positions for FRAX® clinical regarding international differences from Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX®

Osteoporosis is a serious worldwide epidemic. Increased risk of fractures is the hallmark of the disease and is associated with increased morbidity, mortality and economic burden. FRAX® is a web-based tool developed by the Sheffield WHO Collaborating Center team, that integrates clinical risk factors, femoral neck BMD, country specific mortality and fracture data and calculates the 10 year fracture probability in order to help health care professionals identify patients who need treatment. However, only 31 countries have a FRAX® calculator at the time paper was accepted for publication. In the absence of a FRAX® model for a particular country, it has been suggested to use a surrogate country for which the epidemiology of osteoporosis most closely approximates the index country. More specific recommendations for clinicians in these countries are not available. In North America, concerns have also been raised regarding the assumptions used to construct the US ethnic specific FRAX® calculators with respect to the correction factors applied to derive fracture probabilities in Blacks, Asians and Hispanics in comparison to Whites. In addition, questions were raised about calculating fracture risk in other ethnic groups e.g., Native Americans and First Canadians. In order to provide additional guidance to clinicians, a FRAX® International Task Force was formed to address specific questions raised by physicians in countries without FRAX® calculators and seeking to integrate FRAX® into their clinical practice. The main questions that the task force tried to answer were the following: The Task Force members conducted appropriate literature reviews and developed preliminary statements that were discussed and graded by a panel of experts at the ISCD-IOF joint conference. The statements approved by the panel of experts are discussed in the current paper.