Osteoporosis International

, Volume 18, Issue 8, pp 1033–1046

The use of clinical risk factors enhances the performance of BMD in the prediction of hip and osteoporotic fractures in men and women


    • WHO Collaborating Centre for Metabolic Bone DiseasesUniversity of Sheffield Medical School
  • A. Oden
    • Consulting Statistician
  • O. Johnell
    • Department of OrthopaedicsMalmö General Hospital
  • H. Johansson
    • Consulting Statistician
  • C. De Laet
    • Scientific Institute of Public Health
  • J. Brown
    • Department of RheumatologySans Ospedale University de Quebec
  • P. Burckhardt
    • Department of MedicineCHUV University Hospital
  • C. Cooper
    • MRC Epidemiology UnitSouthampton General Hospital
  • C. Christiansen
    • CCBR
  • S. Cummings
    • SF Coordinating Center
  • J. A. Eisman
    • Bone and Mineral Research Program, Garvan Institute of Medical ResearchSt Vincent’s, Hospital and University of New South Wales
  • S. Fujiwara
    • Department of Clinical StudiesRadiation Effects Research Foundation
  • C. Glüer
    • Medizinische PhysikUniversitas Klinikum Schleswig-Hostein
  • D. Goltzman
    • Department of MedicineMcGill University
  • D. Hans
    • Nuclear Medicine DivisionGeneva University Hospital
  • M.-A. Krieg
    • CHUV University Hospital
  • A. La Croix
    • Fred Hutchinson Cancer Research Center
  • E. McCloskey
    • WHO Collaborating Centre for Metabolic Bone DiseasesUniversity of Sheffield Medical School
  • D. Mellstrom
    • Department of Geriatric MedicineGoteborg University
  • L. J. MeltonIII
    • Division of EpidemiologyMayo Clinic
  • H. Pols
    • Department of Internal MedicineErasmus Medical Centre Rotterdam
  • J. Reeve
    • Strangeway’s Research LaboratoryWort’s Causeway
  • K. Sanders
    • Department of Clinical and Biomedical SciencesUniversity of Melbourne
  • A-M. Schott
    • INSERM U831Hospices Civils de Lyon
  • A. Silman
    • ARC Epidemiology UnitUniversity of Manchester
  • D. Torgerson
    • Department of Health SciencesUniversity of York
  • T. van Staa
    • Department of Pharmaco-epidemiology and PharmacotherapyUniversity of Utrecht
  • N. B. Watts
    • University of Cincinnati College of Medicine
  • N. Yoshimura
    • Joint Disease Research, Graduate School of MedicineUniversity of Tokyo
Original Article

DOI: 10.1007/s00198-007-0343-y

Cite this article as:
Kanis, J.A., Oden, A., Johnell, O. et al. Osteoporos Int (2007) 18: 1033. doi:10.1007/s00198-007-0343-y



BMD and clinical risk factors predict hip and other osteoporotic fractures. The combination of clinical risk factors and BMD provide higher specificity and sensitivity than either alone.

Introduction and hypotheses

To develop a risk assessment tool based on clinical risk factors (CRFs) with and without BMD.


Nine population-based studies were studied in which BMD and CRFs were documented at baseline. Poisson regression models were developed for hip fracture and other osteoporotic fractures, with and without hip BMD. Fracture risk was expressed as gradient of risk (GR, risk ratio/SD change in risk score).


CRFs alone predicted hip fracture with a GR of 2.1/SD at the age of 50 years and decreased with age. The use of BMD alone provided a higher GR (3.7/SD), and was improved further with the combined use of CRFs and BMD (4.2/SD). For other osteoporotic fractures, the GRs were lower than for hip fracture. The GR with CRFs alone was 1.4/SD at the age of 50 years, similar to that provided by BMD (GR = 1.4/SD) and was not markedly increased by the combination (GR = 1.4/SD). The performance characteristics of clinical risk factors with and without BMD were validated in eleven independent population-based cohorts.


The models developed provide the basis for the integrated use of validated clinical risk factors in men and women to aid in fracture risk prediction.


Bone mineral densityHip fractureMeta-analysisOsteoporotic fractureRisk assessment

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2007