Summary
The usefulness of various bone mineral measurement techniques is a subject of current controversy. In order to explore whether disparate conclusions may have arisen from differences in analytic methodology, data from published reports of bone mass and nonviolent fractures have been reanalyzed in terms of fracture risk. In the large majority of studies, reduced bone mass was associated with an increased risk of fractures. However, the magnitude of the relationship varied much more among cross-sectional studies than among prospective studies, suggesting that bias related to subject selection and/or postfracture bone loss may have strongly influenced the cross-sectional findings. We conclude that more emphasis should be given to the results of prospective studies, and that more attention should be paid to subject selection in all investigations. Analyzing and presenting results in terms of fracture risk would probably reduce the level of confusion in the field and provide more clinically relevant information. These issues are also applicable to studies of potential fracture risk factors other than bone mass, such as bone structure and bone quality.
Similar content being viewed by others
References
Cummings SR (1985) Are patients with hip fractures more osteoporotic? Am J Med 78:487–494
Hall FM, Davis MA, Baran DT (1987) Bone mineral screening for osteoporosis. New Engl J Med 316:212–214
Davis MR (1987) Screening for postmenopausal osteoporosis. Am J Obstet Gynecol 156:1–5
Canadian Task Force on the Periodic Health Examination (1988) The periodic health examination 2: 1987 update. Can Med Assoc J 138:618–626
National Center for Health Services Research and Health Care Technology Assessment (1986) Single photon absorptiometry for measuring bone mineral density. Health Technology Assessment Reports, no. 7. US Department of Health and Human Services, Public Health Service, Washington, DC
Wahner HW, Dunn WL, Riggs BL (1984) Assessment of bone mineral. Part 2. J Nucl Med 25:1241–1253
Avioli LV, Brandenburger G, Chesnut C, Gallagher JC, Heaney RP, Lappe J, Recker RR (1988) Ultrasound transmission velocity in screening for bone fragility. J Bone Miner Res 3:S215
Ross PD, Heilbrun LK, Wasnich RD, Davis JW, Vogel JM (1989) Methodologic issues in evaluating risk factors for osteoporotic fractures. J Bone Miner Res 4:649–656
Greenland S (1987) Quantitative methods in the review of epidemiologic literature. Epidemiol Rev 9:1–29
Rothman KJ (1986) Modern epidemiology. Little, Brown and Co. Boston
Schlesselman JJ (1982) Case-control studies: design, conduct, analysis. Oxford University Press, New York, pp 265–267
Melton LJ III, Kan SH, Frye MA, Wahner HA, O'Fallon WM, Riggs BL (1989) Epidemiology of vertebral fractures in women. Am J Epidemiol 129:1000–1011
Hui SL, Slemenda CW, Johnston CC (1988) Age and bone mass as predictors of fracture in a prospective study. J Clin Invest 81:1804–1809
Ross PD, Wasnich RD, MacLean CJ, Hagino R, Vogel JM (1988) A model for estimating the potential costs and savings of osteoporosis prevention strategies. Bone 9:337–347
Walker SH, Duncan DB (1967) Estimation of the probability of an event as a function of several independent variables. Biometrika 54:167–179
Yano K, Wasnich RD, Vogel JM, Heilbrun LK (1984) Bone mineral measurements among middle-aged and elderly Japanese residents in Hawaii. Am J Epidemiol 119(5):751–764
Khairi MRA, Cronin JH, Robb JA, Smith DM, Yu PL, Johnston CC (1976) Femoral trabecular-pattern index and bone mineral content measurement by photon absorption in senile osteoporosis. J Bone Joint Surg 58-A(2):221–226
Mazess RB, Barden HS, Ettinger M, Johnston C, Dawson-Hughes B, Baran D, Powell M, Notelovitz M (1987) Spine and femur density using dual-photon absorptiometry in US white women. Bone Miner 2:211–219
Cann CE, Genant HK, Kolb FO, Ettinger B (1985) Quantitative computed tomography for prediction of vertebral fracture risk. Bone 6:1–7
Bohr H, Schaadt O (1983) Bone mineral content of femoral bone and the lumbar spine measure in women with fracture of the femoral neck by dual photon absorptiometry. Clin Orthop Rel Res 179:240–245
Bohr H, Schaadt O (1984) Bone mineral content in women with fracture of the femoral neck. In: Christiansen C, Arnaud CD, Nordin BEC, Parfitt AM, Peck WA, Riggs BL (eds) Proc of the Copenhagen Intl Symp on Osteoporosis. Aalborg Stiftsbogtrykkeri, Denmark, pp 349–351
Cohn SH, Aloia JF, Vaswani AN, Yuen K, Yasumura S, Ellis KJ (1986) Women at risk for developing osteoporosis: determination by total body neutron activation analysis and photon absorptiometry. Calcif Tissue Int 38:9–15
Fujita T, Fukase M, Yoshimoto Y, Tsutsumi M, Fukami T, Imai Y, Sakaguchi K, Abe T, Sawai M, Seo I, Yaguchi T, Enomoto S, Droke D, Avioli LV (1983) Basic and clinical evaluation of the measurement of bone resonant frequency. Calcif Tissue Int 35:153–158
Härmä M, Karjalainen P, Hoikka V, Alhava E (1985) Bone density in women with spinal and hip fractures. Acta Orthop Scand 56:380–385
Hui SL, Slemenda CW, Johnston CC, Appledorn CR (1987) Effects of age and menopause on vertebral bone density. Bone Miner 2:141–146
Inoue T, Kusida K, Miyamoto S, Sumi Y (1983) Quantitative assessment of bone density on x-ray picture. J Jpn Orthop Ass 57:1923–1936
Jensen GF, Christiansen C, Boesen J, Hegedüs V, Transbol I (1983) Relationship between bone mineral content and frequency of postmenopausal fractures. Acta Med Scand 213(1):61–63
Krolner B, Pors Nielsen S, Lund B, Lund BJ, Sorenson OH, Uhrenholdt A (1980) Measurement of bone mineral content (BMC) of the lumbar spine. II. Correlation between forearm BMC and lumbar spine BMC. Scan J Clin Lab Invest 40:665–670
Krolner B, Pors Nielsen S (1982) Bone mineral content of the lumbar spine in normal and osteoporotic women: cross-sectional and longitudinal studies. Clin Sci 62:329–336
Krolner B (1982) Osteoporosis and normality: how to express the bone mineral content of lumbar vertebrae. Clin Physiol 2:139–146
Krolner B, Tondevold E, Toft B, Berthelsen B, Pors Nielsen S (1982) Bone mass of the axial and the appendicular skeleton in women with Colle's fracture: its relation to physical activity. Clin Physiol 2:147–157
LaFianza A, Dore R, Spinillo A, Franchi M, Danesino V (1987) Prediction of fracture risk in patients with postmenopausal osteoporosis (PMO) by quantitative computed tomography (QCT). In: Christiansen C, Johansen JS, Riis BJ (eds) Osteoporosis 1987. Osteopress, Copenhagen, Denmark, pp 382–383
Lee ST, Yeang M, Balasubramaniam P, Bose K (1987) Bone mineral content of a normal Asian population in Singapore—a cross-sectional study. In: Christiansen C, Johansen JS, Riis BJ (eds) Osteoporosis 1987. Osteopress ApS, Copenhagen, Denmark, pp 180–185
Mazess RB, Peppler WW, Chesney RW, Lange TA, Lindgren U, Smith E Jr (1984) Total body and regional bone mineral by dual-photon absorptiometry in metabolic bone disease. Calcif Tissue Int 36:8–13
Meema HE, Meema S (1987) Postmenopausal osteoporosis: simple screening method for diagnosis before structural failure. Radiology 164:405–410
Melton LJ III, Wahner HW, Richelson LS, O'Fallon WM, Riggs BL (1986) Osteoporosis and the risk of hip fracture. Am J Epidemiol 124:1–20
Nordin BEC, Robertson A, Seamark RF, Bridges A, Philcox JC, Need AG, Horowitz M, Morris HA, Deam S (1985) The relation between calcium absorption, serum dehydroepi-androsterone, and vertebral mineral density in postmenopausal women. J Clin Endocrinol Metab 60(4):651–657
Ott SM, Kilcoyne RF, Chesnut CH (1987) Ability of four different techniques of measuring bone mass to diagnose vertebral fractures in postmenopausal women. J Bone Miner Res 2:201–210
Pacifici R, Susman N, Carr PL, Birge SJ, Avioli LV (1987) Single and dual energy tomographic analysis of spinal trabecular bone: a comparative study in normal and osteoporotic women. J Clin Endocrinol Metab 64:209–214
Riggs BL, Wahner HW, Dunn WL, Mazess RB, Offord KP, Melton LJ III (1981) Differential changes in bone mineral density of the appendicular and axial skeleton with aging. J Clin Invest 67:328–335
Riggs BL, Wahner HW, Seeman E, Offord KP, Dunn WL, Mazess RB, Johnson KA, Melton LJ III (1982) Changes in bone mineral density of the proximal femur and spine with aging. J Clin Invest 70:716–723
Robinson B, Wagstaffe C, Roche J, Clifton-Bligh P, Posen S (1987) Is there a place for forearm osteodensitometry in clinical screening studies? Med J Aust 146:297–299
Ruegsegger P, Dambacher MA, Ruegsegger E, Fischer JA, Anliker M (1984) Bone loss in premenopausal and postmenopausal women. J Bone Joint Surg 66-A(7):1015–1023
Smith DM, Khairi MRA, Johnston CC Jr (1975) The loss of bone mineral with aging and its relationship to risk of fracture. J Clin Invest 56:311–318
Wasnich RD, Ross PD, Heilbrun LK, Vogel JM (1985) Prediction of postmenopausal fracture risk with use of bone mineral measurements. Am J Obstet Gynecol 153(7):745–751
Miller CG, Porter RW (1987) The prediction of fracture of the proximal femur by broadband ultrasonic attenuation. In: Christiansen C, Johansen JS, Riis BJ (eds) Osteoporosis 1987. Osteopress ApS, Copenhagen, Denmark, p 414
Wasnich RD, Ross PD, MacLean CJ, Davis JW, Vogel JM (1987) A prospective study of bone mass measurements and spine fracture incidence. In: Christiansen C, Johansen JS, Riis BJ (eds) Osteoporosis 1987. Osteopress ApS, Copenhagen, Denmark, pp 377–378
Farmer ME, White LR, Brody JA, Bailey KR (1984) Race and sex differences in hip fracture incidence. Am J Public Health 74:1374–1380
Bell GH, Dunbar O, Beck JS (1967) Variations in strength of vertebrae with age and their relation to osteoporosis. Calcif Tissue Res 1:75–86
Carter DR, Hayes WC (1976) Bone compressive strength: the influence of density and strain rate. Science 194:1174–1176
Carter DR, Schwab GH, Spengler DM (1980) Tensile fracture of cancellous bone. Acta Orthop Scand 51:733–741
Smith DM, Khairi MRA, Johnston CC Jr (1975) The loss of bone mineral with aging and its relationship to risk of fracture. J Clin Invest 56:311–318
Weaver JK, Chalmers J (1966) Cancellous bone: its strength and changes with aging and an evaluation of some methods for measuring its mineral content. I. Age changes in cancellous bone. J Bone Joint Surg 48A(2):289–298
Wilson CR (1972) The use of in vivo bone mineral determination to predict the strength of bone. PhD Thesis, University of Wisconsin
Mosekilde Li, Mosekilde Le, Danielsen CC (1987) Biomechanical competence of vertebral trabecular bone in relation to ash density and age in normal individuals. Bone 8:79–85
Ross PD, Wasnich RD, Vogel JM (1988) Detection of pre-fracture osteoporosis using bone mineral absorptiometry. J Bone Miner Res 3(1):1–11
Finsen V (1988) Osteopenia after osteotomy of the tibia. Calcif Tissue Int 42:1–4
Buckwalter JA, Cooper RR (1987) Bone structure and function. Instr Course Lect 36:27–48
Mazess RB, Barden H, Ettinger M, Schultz E (1988) Bone density of the radius, spine, and proximal femur in osteoporosis. J Bone Miner Res 3:13–18
Cole P (1980) Introduction. In: Breslow NE, Day NE, Davis W (eds) Statistical methods in cancer research, vol 1. The analysis of case-control studies. International Agency for Research on Cancer, Publication No. 32, Lyon, France, p 30
Hui SL, Slemenda CW, Johnston CC Jr (1989) Baseline measurement of bone mass predicts fracture in white women. Ann Intern Med 111:355–361
Gardsell P, Johnell O, Nilsson BE (1989) Predicting fractures in women by using forearm bone densitometry. Calcif Tissue Int 44:235–242
Cummings SR, Black D, Arnaud C, Browner WS, Cauley JA, Genant HK, Nevitt MC, Scott J, Seeley D, Sherwin R, Steiger P, Vogt T (1989) Appendicular densitometry predicts hip fractures: a prospective study (Abstract) J Bone Miner Res 4(Suppl 1):S327
Browner WS, Cummings SR, Genant HK, Mascioli S, Seeley D, Steiger P, Vollmer W (1989) Bone mineral density and fracture of the wrist and humerus in elderly women: a prospective study. (Abstract) J Bone Miner Res 4(Suppl 1):S171
Cleghorn DB, Nordin BEC, Need AG (1989) The relation between peripheral fracture and forearm mineral density in 358 normal postmenopausal women: a 5-year prospective study (Abstract) J Bone Miner Res 4(Suppl 1):S327
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Ross, P.D., Davis, J.W., Vogel, J.M. et al. A critical review of bone mass and the risk of fractures in osteoporosis. Calcif Tissue Int 46, 149–161 (1990). https://doi.org/10.1007/BF02555036
Received:
Revised:
Issue Date:
DOI: https://doi.org/10.1007/BF02555036