Balasubramanian, Osteoporos Int 2019 - Risk of Subsequent Fracture after Prior Fracture among Older Women - Article Summary

Risk of Subsequent Fracture after Prior Fracture among Older Women.

Balasubramanian, Curtis, et al.·Osteoporos Int·2019·336 citations·Trauma

This retrospective cohort study quantified the cumulative risk of subsequent fracture in over 377,000 female Medicare beneficiaries who sustained an incident clinical fracture. It asked how quickly and how often older women refracture, and whether the type of initial fracture matters for guiding early treatment decisions.

Key Findings

One in three older women refractured within 5 years of an index fracture. Overall cumulative risk was 10% at 1 year, 18% at 2 years, and 31% at 5 years. These figures held across a wide range of initial fracture types, making every fracture a potential treatment trigger.
Subsequent fracture risk is front-loaded: 35% of all refractures in the 5-year cohort occurred within the first year after the index event. This is why the window for initiating osteoporosis pharmacotherapy is measured in months, not years.
Vertebral fracture carries the highest refracture burden of any site studied. Risk of a subsequent fracture was 14% at 1 year, 26% at 2 years, and 40% at 5 years following a clinical vertebral fracture. In women 75–84, the 5-year risk reached 42%. This directly supports guideline recommendations for pharmacotherapy after vertebral fracture regardless of bone mineral density.
Nearly every subgroup of older women exceeded the 3% hip fracture risk threshold used to trigger pharmacotherapy consideration in US guidelines. The only exceptions were women aged 65–74 with an initial tibia/fibula fracture (2.9%) or ankle fracture (2.4%). Every other fracture site, in every age group studied, crossed this threshold within 5 years.
Hip fracture mortality is as clinically important as refracture risk. One-year mortality after hip fracture was 19%, rising to 64% at 5 years. Vertebral fracture mortality was nearly as high: 14% at 1 year and 54% at 5 years. Death is a competing risk that reduces the observed refracture rate — meaning true skeletal fragility is likely even greater.
Age and fracture site alone predicted refracture risk almost as well as complex multivariable models. The AUC ranged only from 0.61 to 0.64 across all models, from a simple two-variable model to the full model with 30+ covariates. For population-level risk stratification, you do not need elaborate scoring — you need the patient's age and where they broke.

Board PearlOne in three older women who sustain a clinical fracture will fracture again within 5 years — risk is highest in the first year, making early pharmacotherapy evaluation essential.

Supplemental

Risk of Subsequent Fracture after Prior Fracture among Older Women.

Balasubramanian, Curtis, et al.Osteoporos Int2019336 citations

Landmark

Bacterial Biofilms: A Common Cause of Persistent Infections.

Costerton, Greenberg, et al.Science199912,259 citations

Landmark

Radiological Assessment of Osteo-Arthrosis.

Kellgren, LawrenceAnn Rheum Dis195712,248 citations

Landmark

Mesenchymal Stem Cells.

CaplanJ Orthop Res19916,470 citations

Landmark

A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population.

Haynes, Safe Surgery Saves Lives Study Group, et al.N Engl J Med20095,579 citations

Landmark

Bone: Formation by Autoinduction.

UristScience19655,546 citations

Landmark

Treatment of Deep Cartilage Defects in the Knee with Autologous Chondrocyte Transplantation.

Brittberg, Peterson, et al.N Engl J Med19945,478 citations

Landmark

The Distribution of Secondary Growths in Cancer of the Breast. 1889.

PagetCancer Metastasis Rev19895,205 citations

Landmark

Osteoprotegerin: A Novel Secreted Protein Involved in the Regulation of Bone Density.

Simonet, Boyle, et al.Cell19975,166 citations

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Effect of Parathyroid Hormone (1-34) on Fractures and Bone Mineral Density in Postmenopausal Women with Osteoporosis.

Neer, Mitlak, et al.N Engl J Med20014,618 citations

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Osteoclast Differentiation Factor Is a Ligand for Osteoprotegerin/Osteoclastogenesis-Inhibitory Factor and Is Identical to TRANCE/RANKL.

Yasuda, Suda, et al.Proc Natl Acad Sci U S A19984,239 citations

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Evidence-Based Medicine. A New Approach to Teaching the Practice of Medicine.

Evidence-Based Medicine Working GroupJAMA19924,232 citations

Landmark

Magnetic Resonance Classification of Lumbar Intervertebral Disc Degeneration.

Pfirrmann, Boos, et al.Spine (Phila Pa 1976)20013,960 citations

Landmark

Novel Regulators of Bone Formation: Molecular Clones and Activities.

Wozney, Wang, et al.Science19883,906 citations

Landmark

Randomised Trial of Effect of Alendronate on Risk of Fracture in Women with Existing Vertebral Fractures. Fracture Intervention Trial Research Group.

Black, Ensrud, et al.Lancet19963,862 citations

Landmark

The Diagnosis of Osteoporosis.

Kanis, Khaltaev, et al.J Bone Miner Res19943,840 citations

Core

Measuring Inconsistency in Meta-Analyses.

Higgins, Altman, et al.BMJ200364,290 citations

Core

Multilineage Potential of Adult Human Mesenchymal Stem Cells.

Pittenger, Marshak, et al.Science199921,242 citations

Core

Evidence Based Medicine: What IT Is and What IT Isn't.

Sackett, Richardson, et al.BMJ199615,917 citations

Core

Vitamin D Deficiency.

HolickN Engl J Med200713,767 citations

Core

2010 Rheumatoid Arthritis Classification Criteria: An American College of Rheumatology/European League Against Rheumatism Collaborative Initiative.

Aletaha, Hawker, et al.Arthritis Rheum20109,748 citations

Core

Projections of Primary and Revision Hip and Knee Arthroplasty in the United States from 2005 to 2030.

Kurtz, Halpern, et al.J Bone Joint Surg Am20077,476 citations

Core

Traumatic Arthritis of the Hip after Dislocation and Acetabular Fractures: Treatment by Mold Arthroplasty. An End-Result Study Using a New Method of Result Evaluation.

HarrisJ Bone Joint Surg Am19695,899 citations

Core

Evaluation of Diagnostic Criteria for Ankylosing Spondylitis. A Proposal for Modification of the New York Criteria.

van der Linden, Cats, et al.Arthritis Rheum19845,772 citations

Core

Dystrophin: The Protein Product of the Duchenne Muscular Dystrophy Locus.

Hoffman, Kunkel, et al.Cell19874,747 citations

Core

Targeted Disruption of Cbfa1 Results in a Complete Lack of Bone Formation Owing to Maturational Arrest of Osteoblasts.

Komori, Kishimoto, et al.Cell19974,271 citations

Core

Meta-Analysis of How Well Measures of Bone Mineral Density Predict Occurrence of Osteoporotic Fractures.

Marshall, Wedel, et al.BMJ19963,734 citations

Core

Vertebral Fracture Assessment Using a Semiquantitative Technique.

Genant, Nevitt, et al.J Bone Miner Res19933,715 citations

Supplemental

Detection of Specific Sequences among DNA Fragments Separated by Gel Electrophoresis.

SouthernJ Mol Biol197532,829 citations

Supplemental

Induction of Pluripotent Stem Cells from Mouse Embryonic and Adult Fibroblast Cultures by Defined Factors.

Takahashi, YamanakaCell200627,066 citations

Supplemental

The Meaning and Use of the Area under a Receiver Operating Characteristic (ROC) Curve.

Hanley, McNeilRadiology198222,201 citations

Supplemental

Induction of Pluripotent Stem Cells from Adult Human Fibroblasts by Defined Factors.

Takahashi, Yamanaka, et al.Cell200720,127 citations

Supplemental

The American Rheumatism Association 1987 Revised Criteria for the Classification of Rheumatoid Arthritis.

Arnett, Luthra, et al.Arthritis Rheum198819,988 citations

Supplemental

Primer-Directed Enzymatic Amplification of DNA with a Thermostable DNA Polymerase.

Saiki, Erlich, et al.Science198817,141 citations

Supplemental

Comorbidity Measures for Use with Administrative Data.

Elixhauser, Coffey, et al.Med Care199810,057 citations

Supplemental

Osteoclast Differentiation and Activation.

Boyle, Lacey, et al.Nature20036,737 citations

Supplemental

Human Adipose Tissue Is a Source of Multipotent Stem Cells.

Zuk, Hedrick, et al.Mol Biol Cell20026,716 citations

Supplemental

Origin and Physiological Roles of Inflammation.

MedzhitovNature20086,634 citations

Supplemental

Porosity of 3D Biomaterial Scaffolds and Osteogenesis.

Karageorgiou, KaplanBiomaterials20056,476 citations

Supplemental

Cutaneous Wound Healing.

Singer, ClarkN Engl J Med19996,160 citations

Supplemental

Factors Affecting Wound Healing.

Guo, DipietroJ Dent Res20105,794 citations

Supplemental

The Pathogenesis of Rheumatoid Arthritis.

McInnes, SchettN Engl J Med20115,601 citations

Supplemental

Empirical Evidence of Bias. Dimensions of Methodological Quality Associated with Estimates of Treatment Effects in Controlled Trials.

Schulz, Altman, et al.JAMA19955,575 citations

Supplemental

Gout-Associated Uric Acid Crystals Activate the NALP3 Inflammasome.

Martinon, Tschopp, et al.Nature20065,356 citations

Supplemental

Clarifying Confusion: The Confusion Assessment Method. A New Method for Detection of Delirium.

Inouye, Horwitz, et al.Ann Intern Med19905,338 citations

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A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group.

Hébert, Yetisir, et al.N Engl J Med19995,244 citations

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Hospital Volume and Surgical Mortality in the United States.

Birkmeyer, Wennberg, et al.N Engl J Med20025,021 citations

Supplemental

Scaffolds in Tissue Engineering Bone and Cartilage.

HutmacherBiomaterials20005,002 citations

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Fear-Avoidance and Its Consequences in Chronic Musculoskeletal Pain: A State of the Art.

Vlaeyen, LintonPain20004,942 citations

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What Low Back Pain Is and Why We Need to Pay Attention.