Original Article

Osteoporosis International

, Volume 18, Issue 8, pp 1033-1046

First online:

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

  • J. A. KanisAffiliated withWHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School Email author 
  • , A. OdenAffiliated withConsulting Statistician
  • , O. JohnellAffiliated withDepartment of Orthopaedics, Malmö General Hospital
  • , H. JohanssonAffiliated withConsulting Statistician
  • , C. De LaetAffiliated withScientific Institute of Public Health
  • , J. BrownAffiliated withDepartment of Rheumatology, Sans Ospedale University de Quebec
  • , P. BurckhardtAffiliated withDepartment of Medicine, CHUV University Hospital
  • , C. CooperAffiliated withMRC Epidemiology Unit, Southampton General Hospital
  • , C. ChristiansenAffiliated withCCBR
    • , S. CummingsAffiliated withSF Coordinating Center
    • , J. A. EismanAffiliated withBone and Mineral Research Program, Garvan Institute of Medical Research, St Vincent’s, Hospital and University of New South Wales
    • , S. FujiwaraAffiliated withDepartment of Clinical Studies, Radiation Effects Research Foundation
    • , C. GlüerAffiliated withMedizinische Physik, Universitas Klinikum Schleswig-Hostein
    • , D. GoltzmanAffiliated withDepartment of Medicine, McGill University
    • , D. HansAffiliated withNuclear Medicine Division, Geneva University Hospital
    • , M.-A. KriegAffiliated withCHUV University Hospital
    • , A. La CroixAffiliated withFred Hutchinson Cancer Research Center
    • , E. McCloskeyAffiliated withWHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School
    • , D. MellstromAffiliated withDepartment of Geriatric Medicine, Goteborg University
    • , L. J. MeltonIIIAffiliated withDivision of Epidemiology, Mayo Clinic
    • , H. PolsAffiliated withDepartment of Internal Medicine, Erasmus Medical Centre Rotterdam
    • , J. ReeveAffiliated withStrangeway’s Research Laboratory, Wort’s Causeway
    • , K. SandersAffiliated withDepartment of Clinical and Biomedical Sciences, University of Melbourne
    • , A-M. SchottAffiliated withINSERM U831, Hospices Civils de Lyon
    • , A. SilmanAffiliated withARC Epidemiology Unit, University of Manchester
    • , D. TorgersonAffiliated withDepartment of Health Sciences, University of York
    • , T. van StaaAffiliated withDepartment of Pharmaco-epidemiology and Pharmacotherapy, University of Utrecht
    • , N. B. WattsAffiliated withUniversity of Cincinnati College of Medicine
    • , N. YoshimuraAffiliated withJoint Disease Research, Graduate School of Medicine, University of Tokyo

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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 density Hip fracture Meta-analysis Osteoporotic fracture Risk assessment