This meta-analysis of 11 international prospective cohorts (60,161 participants; 254,582 person-years) quantifies how prior fracture history affects subsequent fracture risk. It examines whether that risk varies by age, sex, or BMD — and what fraction of the risk BMD alone can explain.
FRAX exists in part because of this paper. Before Kanis 2004, guidelines treated BMD as the primary gatekeeper for fracture risk — prior fracture was recognized as a risk factor, but its independent contribution beyond densitometry had not been rigorously quantified across international populations.
The key clinical decision rule: when a patient has a prior fragility fracture, do not wait for a T-score of -2.5 before initiating treatment. This paper shows prior fracture independently confers an ~85% increase in future fracture risk regardless of BMD. A T-score of -1.5 SD in that patient achieves the same cost-effectiveness as -2.5 SD in a fracture-naive patient.
In a younger patient (age 50-60) with a prior fracture, be especially alert: hip fracture risk is more than 4× that of a peer without fracture history, far exceeding what BMD would predict. This age-dependent effect is why younger patients with fragility fractures deserve aggressive secondary prevention even when BMD appears only mildly reduced.
This is the foundational paper behind prior fracture as a FRAX input. Understanding its data means you understand why the tool is structured the way it is, which is exactly what gets tested.
This meta-analysis of 11 international prospective cohorts (60,161 participants; 254,582 person-years) quantifies how prior fracture history affects subsequent fracture risk. It examines whether that risk varies by age, sex, or BMD — and what fraction of the risk BMD alone can explain.
FRAX exists in part because of this paper. Before Kanis 2004, guidelines treated BMD as the primary gatekeeper for fracture risk — prior fracture was recognized as a risk factor, but its independent contribution beyond densitometry had not been rigorously quantified across international populations.
The key clinical decision rule: when a patient has a prior fragility fracture, do not wait for a T-score of -2.5 before initiating treatment. This paper shows prior fracture independently confers an ~85% increase in future fracture risk regardless of BMD. A T-score of -1.5 SD in that patient achieves the same cost-effectiveness as -2.5 SD in a fracture-naive patient.
In a younger patient (age 50-60) with a prior fracture, be especially alert: hip fracture risk is more than 4× that of a peer without fracture history, far exceeding what BMD would predict. This age-dependent effect is why younger patients with fragility fractures deserve aggressive secondary prevention even when BMD appears only mildly reduced.
This is the foundational paper behind prior fracture as a FRAX input. Understanding its data means you understand why the tool is structured the way it is, which is exactly what gets tested.