Durosier Claire, Hans Didier, Krieg Marc-Antoine, Schott Anne-Marie
Nuclear Medicine Division, Geneva University Hospital, Geneva, Switzerland; Medical Information Department, Lyon University Hospital, Lyon, France.
J Clin Densitom. 2006 Oct-Dec;9(4):475-95. doi: 10.1016/j.jocd.2006.06.002. Epub 2006 Aug 9.
Osteoporotic hip fractures increase dramatically with age and are responsible for considerable morbidity and mortality. Several treatments to prevent the occurrence of hip fracture have been validated in large randomized trials and the current challenge is to improve the identification of individuals at high risk of fracture who would benefit from therapeutic or preventive intervention. We have performed an exhaustive literature review on hip fracture predictors, focusing primarily on clinical risk factors, dual X-ray absorptiometry (DXA), quantitative ultrasound, and bone markers. This review is based on original articles and meta-analyses. We have selected studies that aim both to predict the risk of hip fracture and to discriminate individuals with or without fracture. We have included only postmenopausal women in our review. For studies involving both men and women, only results concerning women have been considered. Regarding clinical factors, only prospective studies have been taken into account. Predictive factors have been used as stand-alone tools to predict hip fracture or sequentially through successive selection processes or by combination into risk scores. There is still much debate as to whether or not the combination of these various parameters, as risk scores or as sequential or concurrent combinations, could help to better predict hip fracture. There are conflicting results on whether or not such combinations provide improvement over each method alone. Sequential combination of bone mineral density and ultrasound parameters might be cost-effective compared with DXA alone, because of fewer bone mineral density measurements. However, use of multiple techniques may increase costs. One problem that precludes comparison of most published studies is that they use either relative risk, or absolute risk, or sensitivity and specificity. The absolute risk of individuals given their risk factors and bone assessment results would be a more appropriate model for decision-making than relative risk. Currently, a group appointed by the World Health Organization and lead by Professor John Kanis is working on such a model. It will therefore be possible to further assess the best choice of threshold to optimize the number of women needed to screen for each country and each treatment.
骨质疏松性髋部骨折的发生率随年龄急剧上升，会导致相当高的发病率和死亡率。在大型随机试验中，已有多种预防髋部骨折发生的治疗方法得到验证，当前面临的挑战是更好地识别那些能从治疗或预防干预中获益的高骨折风险个体。我们对髋部骨折预测因素进行了详尽的文献综述，主要聚焦于临床风险因素、双能X线吸收法（DXA）、定量超声和骨标志物。本综述基于原始文章和荟萃分析。我们选取了旨在预测髋部骨折风险以及区分有无骨折个体的研究。我们的综述仅纳入了绝经后女性。对于涉及男性和女性的研究，仅考虑有关女性的结果。关于临床因素，仅纳入了前瞻性研究。预测因素已被用作独立工具来预测髋部骨折，或通过连续选择过程依次使用，或组合成风险评分。对于这些不同参数组合作为风险评分、或依次或同时组合是否有助于更好地预测髋部骨折，仍存在诸多争议。对于这种组合是否比单独使用每种方法有所改进，存在相互矛盾的结果。与单独使用DXA相比，骨密度和超声参数的顺序组合可能具有成本效益，因为骨密度测量次数较少。然而，使用多种技术可能会增加成本。妨碍大多数已发表研究进行比较的一个问题是，它们要么使用相对风险，要么使用绝对风险，要么使用敏感性和特异性。根据个体的风险因素和骨评估结果得出的绝对风险，将是比相对风险更适合决策的模型。目前，由世界卫生组织任命、约翰·卡尼斯教授牵头的一个小组正在研究这样一个模型。因此，将有可能进一步评估最佳阈值选择，以优化每个国家和每种治疗所需筛查的女性人数。
