Osteoporosis International

, Volume 23, Issue 2, pp 423–431

Pitfalls in the external validation of FRAX

Opinion Paper

DOI: 10.1007/s00198-011-1846-0

Cite this article as:
Kanis, J.A., Oden, A., Johansson, H. et al. Osteoporos Int (2012) 23: 423. doi:10.1007/s00198-011-1846-0



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


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.


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


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.


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


Clinical risk factorsFracture probabilityFRAXOsteoporotic fractureReceiver operating characteristics

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2011

Authors and Affiliations

  • J. A. Kanis
    • 1
  • A. Oden
    • 1
  • H. Johansson
    • 1
  • E. McCloskey
    • 1
  1. 1.WHO Collaborating Centre for Metabolic Bone DiseasesUniversity of Sheffield Medical SchoolSheffieldUK