title: High prevalence of secondary factors for bone fragility in patients with a recent fracture independently of BMD.
abstract: In this study, we demonstrate a high prevalence of secondary factors in patients with a recent fracture independently of bone mineral density (BMD). Our results suggest that patients with a recent fracture should be screened for secondary factors for bone fragility regardless of BMD values.
  
  
  BACKGROUND
  Secondary factors for bone fragility are common in patients with osteoporosis who have sustained a fracture. The majority of fragility fractures occurs, however, in patients with osteopenia, and it is not known whether secondary factors may contribute to fracture risk in these patients or in those with normal BMD.
  
  
  METHODS
  Prospective cohort study evaluating the prevalence of secondary factors for bone fragility in consecutive patients referred to our fracture liaison service from June 2012 to June 2014 after a recent fracture.
  
  
  RESULTS
  Seven hundred nine patients were included, 201 (28 %) with osteoporosis, 391 (55 %) with osteopenia and 117 (17 %) with normal BMD. Mean age was 66.0 ± 9.8 years, 504 (73 %) were women and 390 (57 %) had one or more underlying secondary factor. Evaluation of clinical risk factors using fracture risk assessment tool (FRAX) identified 38 % of patients with ≥1 secondary factor including smoking (18 %), excessive alcohol use (12 %), glucocorticoid use (12 %) and rheumatoid arthritis (3 %). Laboratory investigations revealed chronic kidney disease in 13 %, monoclonal gammopathy also in 13 % and primary or secondary hyperparathyroidism in 1 and 6 %, respectively. Secondary factors for bone fragility were equally prevalent in patients with osteoporosis, osteopenia or normal BMD.
  
  
  CONCLUSIONS
  Our findings demonstrate a high prevalence of secondary factors for bone fragility in patients who have sustained a recent fracture, independently of BMD. The significant number of documented factors, which were treatable, suggest that patients who sustained a fracture should be screened for secondary factors for bone fragility regardless of BMD values to optimise secondary fracture prevention.
authors.affiliation: Center for Bone Quality and Department of Medicine, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands. f.malgo@lumc.nl.
authors.forename: F
authors.initials: F
authors.lastname: Malgo
authors.affiliation: Center for Bone Quality and Department of Medicine, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.
authors.forename: N M
authors.initials: NM
authors.lastname: Appelman-Dijkstra
authors.affiliation: Center for Bone Quality and Department of Traumatology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: M F
authors.initials: MF
authors.lastname: Termaat
authors.affiliation: Center for Bone Quality and Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: H J L
authors.initials: HJ
authors.lastname: van der Heide
authors.affiliation: Center for Bone Quality and Department of Traumatology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: I B
authors.initials: IB
authors.lastname: Schipper
authors.affiliation: Center for Bone Quality and Department of Medicine, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.
authors.forename: T J
authors.initials: TJ
authors.lastname: Rabelink
authors.affiliation: Center for Bone Quality and Department of Medicine, Leiden University Medical Center, P.O. Box 9600, 2300, RC, Leiden, The Netherlands.
authors.forename: N A T
authors.initials: NA
authors.lastname: Hamdy
mesh_terms: D000328:Adult; D000368:Aged; D001172:Arthritis, Rheumatoid / Q000150:complications; D015519:Bone Density; D001851:Bone Diseases, Metabolic / Q000150:complications; D005260:Female; D050723:Fractures, Bone / Q000453:epidemiology* / Q000209:etiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010024:Osteoporosis / Q000150:complications; D015995:Prevalence; D011446:Prospective Studies; D018570:Risk Assessment / Q000379:methods; D012307:Risk Factors; D012907:Smoking / Q000009:adverse effects
keywords: Fracture liaison service; Fragility fracture; Osteopenia; Osteoporosis; Secondary factors