Fracture Risk Assessment Tool May Guide Parathyroidectomy Decisions in Primary Hyperparathyroidism: JAMA
USA: A recent cohort study suggests that the Fracture Risk Assessment Tool can help identify patients with primary hyperparathyroidism (PHPT) who may benefit from parathyroidectomy (PTX), even without bone mineral density (BMD) data. Its use may expand patient selection beyond current guidelines, though further prospective validation is needed.
A recent study published in JAMA Network Open by Vivek R. Sant and colleagues evaluated the utility of the Fracture Risk Assessment Tool (FRAX) in guiding surgical decisions among patients with PHPT. The research aimed to determine whether FRAX could reliably estimate fracture risk and identify individuals who may derive benefit from parathyroidectomy compared to nonsurgical management.
The retrospective cohort study analyzed data from 59,194 adults aged 40 to 90 years diagnosed with PHPT using the TriNetX electronic health records database between 2000 and 2024. Among these patients, 25% underwent parathyroidectomy, while the remainder received conservative management. The investigators calculated 10-year fracture risk using FRAX without incorporating BMD values, reflecting real-world scenarios where such data may not always be available.
The key findings were as follows:
- Observed rates of major osteoporotic fractures (MOF) and hip fractures were slightly higher than FRAX-predicted estimates across all risk groups.
- FRAX showed acceptable performance in estimating fracture risk despite this underestimation.
- Parathyroidectomy was associated with reduced fracture risk compared to nonsurgical management.
- Surgery led to a 12% reduction in major osteoporotic fracture risk.
- Surgery was also associated with a 13% reduction in hip fracture risk.
- Patients with FRAX-estimated MOF risk above 1.2% showed consistent fracture risk reduction after surgery.
- Patients with hip fracture risk above 2.7% also experienced consistent benefit from parathyroidectomy.
- Many patients not meeting current guideline criteria still exceeded these FRAX thresholds.
- This suggests existing guidelines may miss patients who could benefit from surgical intervention.
These findings highlight the potential of FRAX as a practical tool for risk-based decision-making in PHPT. By incorporating easily obtainable clinical variables, FRAX may help clinicians identify high-risk patients and tailor treatment strategies, even in settings where BMD data is unavailable. The study supports a more individualized approach to care, moving beyond rigid guideline criteria.
However, several limitations should be acknowledged. The retrospective design introduces the possibility of selection bias and residual confounding, despite statistical adjustments. Certain FRAX inputs, such as parental history of hip fracture, were unavailable, and reliance on electronic health records may involve coding inaccuracies or incomplete data capture. Additionally, the timing of surgery could introduce minor bias, although its impact is likely limited.
Overall, the study suggests that FRAX can be a valuable adjunct in managing PHPT, helping to expand identification of patients who may benefit from parathyroidectomy. Further prospective studies are needed to validate these findings and refine their application in clinical practice.
Reference:
Sant VR, ElNakieb Y, Rousseau JF, Liu Y, Rubin CD, Maalouf NM. Use and Implications of the Fracture Risk Assessment Tool in Primary Hyperparathyroidism. JAMA Netw Open. 2026;9(3):e261549. doi:10.1001/jamanetworkopen.2026.1549
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