Osteoporosis

Prevention and Management

1. INTRODUCTION
2. EPIDEMIOLOGY
3. CLASSIFICATION
4. PATHOPHYSIOLOGY
5. S/S
6. INVESTIGATIONS
7. BMD
8. BTM
9. DIAGNOSIS
10. DD

10.MANAGEMENT
11.RECENT ADVANCES
12. ORTHOPAEDICIAN)
13.COMPLICATIONS

14.CASE
PRESENTATION
15.CONCLUSION

Osteoporosis: Nightmare
Of Post-menopause/ Old
Age

Normal vs Osteoporotic Bone

1. It is a disease of aging2. Silent disease3. fragility fracture/low trauma

fracture
4. spontaneous fracture
5. Hip fractures-Morbidity
6. QOL

What is Osteoporosis?
Osteoporosis is a systemic skeletal disease
characterized
1. low bone density and
2. a micro- architecture
deterioration of bone tissue
3. that enhances bone
fragility and

2.Epidemiolo

gy

Osteoporosis affects entire skeleton

Osteoporosis is responsible for >36.8 million

vertebral and non-vertebral fractures per year in

USA
Spine, hip, and wrist fractures are most common

Common Sites of fracture

Vertebral
column

Wris
t
Hip

women
In women it isThree times more
common than men

1.low peak bone mass (PBM)

2.hormonal changes at
menopause
3.live longer than men

vertebral #s and wrist #s more common in

that
Vertebral Fractures are UnderDiagnosed
140

132

934 hospitalised women

with a lateral chest x-ray

Patients (n)

120
100
80

65

60
40

23

20

25

Fracture
identified
by study
radiologists
Gehlbach et al.,Osteoporos Int 2000, 11:577

Fracture
noted in
radiology
report

Fracture
noted in
medical
record

Received
osteoporosis
treatment

Hip fractures
Hip fractures accounts for most of the

morbidity,
mortality and
cost of the disease

2.Classificati

on

Osteoporosis:
Classification
Primary Osteoporosis
Type 1- Post menopausal osteoporosis
Type 2- Senile/Age related osteoporosis

Secondary Osteoporosis
Secondary to various causes

13

Post-Menopausal
Osteoporosis
Caused by a lack of

estrogens, which helps

to regulate, the incorporation of calcium into

bone in women
Lack of estrogen increased bone resorption

14

Age Related/Senile
Osteoporosis
Usually affects people over 70 y.
Results from age-related calcium deficiency
There is decreased bone formation
Patients usually present with fractures of the hip

and the vertebrae

15

Secondary Osteoporosis
Congenit
l
Conditio
n
Diet

Homocystinuria;
hemolytic
anemia;
hypophosphatasia;
osteogenesis imperfecta

Drugs

Alcohol;
anticonvulsants;
cancer
chemotherapy;
excess
thyroid hormone; glucocorticoids;
heparin; methotrexate

Calcium deficiency; malabsorption

syndromes; scurvy; starvation

16

Endocrine Disorders
Cushing's syndrome; growth hormone
deficiency; hypercortisolism;
hyperparathyroidism; hyperthyroidism;
hypogonadism
Other Systemic Disorders
Diabetes mellitus; leukemia; multiple myeloma;
renal tubular acidosis
Rheumatologic disorders
Ankylosing spondylitis, rheumatoid arthritis
G.I. diseases

A.CHILDHOOD-chronic
diseases
During growth

30 -50y

>50 y.
Bed rest due to chronic illness
Undernutrition or malnutrition
Chronic Paediatric disorders
Glucocorticoid/growth hormone
Anorexianervosa
Exercise-associated amenorrhoea
Severe chronic paediatric diseases requiring
immunosuppressive agents

B.During late adulthoodendocrine diseases

Hypogonadism is a major cause
1.Women-menopause-estrgen deficiency-bone

marrow of cytokines such as tumour necrosis

factors
and
interleukins
that
stimulate
osteoclastic bone resorption
2.Men declining levels of gonadal hormones-

low rates of bone formation

Primary

and

hyperparathyroidsm,,hyperthyroidsm

C.Elderly-diet(calcium)
Low

calcium

intake

associated

with a
reduced endogenous production

of vit.D accelerate bone loss

By increasing the secretion of PTH.

3.Risk

Non-modifiable/Fixed Risk
Factors
Older age
Female gender
Ethnic background
Small bone structure
Family history of osteoporosis or osteoporosis-related

fracture in a parent or siblings

Previous fracture
Menopause/hysterectomy
Some medicines like steroids, anti-epileptics
Rheumatoid arthritis
Reduced levels of gonadal hormones in men

Modifiable Risk Factors

Alcohol
Smoking
Poor nutrition
Vitamin D deficiency/Lack of

sunlight exposure
Insufficient exercise
Low calcium intake in food

4.Pathophysiology
1.Peak bone mass
2.remodling

Determinants Of Peak
Bone Mass
Genetic factors

Nutritional status

Peak Bone Mass

Physical activity

Gonadal status

1.Peak bone mass &

Osteoporosis
Peak bone mass is the maximum mass of bone

achieved by an individual at skeletal maturity,

typically between ages 25 and 35
After peak bone mass is attained, both men

and women lose bone mass over the remainder

of their lifetimes
Because of the subsequent bone loss, peak

bone mass is an important factor in the

development of osteoporosis
26

Peak Bone Mass in Women

Women achieve lesser peak bone mass than
men

10
60

20

30

40

50
27

Stages of Peak Bone Mass in Women

28

2.Bone formation takes

place throughout liferemodeling
Bone is a living tissue and is

constantly
resorbed
and
formed by the process known
as remodeling

Remodelling

Imbalance
1.In Osteoporosis imbalance occurs between

bone resorption and bone formation

This imbalance might occur as a result of one or

a combination of the following factors:

Increased bone resorption
Decreased bone formation

A negative balance occurs and results in a net

loss of bone

31

5.Signs

Symptoms

&

Signs & Symptoms

In early stages usually no symptoms

therefore also known as silent disease

There may be back pain due to spinal
compression
First sign may be fractures due to slight
trauma or even due to bending or lifting or
rising-spontaneous or low trauma fracture
If several vertebrae break, an abnormal
curvature of spine (a dowager's hump) may
develop, causing muscle- strain and soreness
A loss of height by 4 to 8 inches may occur
33

Osteoporosis related bone

loss
Vertebrae, which have a large proportion of
trabecular bone, are commonly the first sites to
show bone loss in
Osteoporosis leading

spine collapse
(upto-4-8 inches)
to

34

Backbone Deformity in
Osteoporosis
Three generations
of women are
shown.
The elderly women
have hunched
back which is a
sign of vertebral
fractures caused by
osteoporosis

6.Differential

Diagnoses

Differential Diagnoses
Other Problems to Be Considered
1. Bony metastases
2. Multiple myeloma
3. Primary hyperparathyroidism
4. Secondary hyperparathyroidism
5. Osteomalacia
6. Renal osteodystrophy
7. Paget disease of bone

Osteomalacia/osteoporos
is
osteomalacia

osteoporosis

.h/o persistant skeletal pain of

long duration and muscle

weakness
h/o gastric surgery
Skeletal tenderness
A shuffling penguin gait
Biochemistry low ca,ph and
increased s.Alka.ph.
Reduced 24h urinary ca

1.transient episodes of pain

usually associated with #s

osteomalacia
X-ray-diminished bone

density- marked in the

peripheral bone than in the
axial
Skeletal deformity without #
Loosers zone
Histology presence of
excess osteoid tissue in
undercalcified
Treatment is rapidly and
consitently successful

osteoporosi

7.Diagnosis

BMD
Dual

energy
x-ray
absorptiometry (DEXA) is the
best current test to measure
bone density

The

ability of the BMD to

predict hip # is better than the

BMD 2.5 standard deviation or more below

the average for the young healthy female

population-osteoporosis
T score for BMD measured at the

hip using

DEXA is best one

For each standard deviation decrease in BMD,

fracture risk increases by approximately 50%.

How is osteoporos is
diagnosed
Diagnosis is made on the basis of
1. Detailed medical history
2. Physical examination
3. Investigations-1.BMD by DEXA or by single
energy x-ray absorptiometry
2.BTM

BMD Tests Other than

DEXA
Quantitative CT vertebral scanning
Single photon and dual photon absorptiometry
Peripheral DEXA

Bone Mineral Density

(BMD)
It is a simple test that

measures bone
thickness/ density at
different parts of the
body, like spine, hip etc
It employs two x-ray
beams of different
energy levels
Dual energy x-ray
absorptiometry (DEXA)
is the best current test
to measure bone

Dual-energy x-ray
absorptiometry
(DEXA)

Indications for Bone

Density test
1.All postmenopausal women <65 yr who have one or
more additional risk factors for osteoporosis,
besides menopause
2.All women >65 yr regardless of additional risk
factors
3.Documenting reduced bone density in a patient with a
vertebral abnormality or osteopenia on a radiograph
4.Estrogen-deficient women at risk for low bone
density, considering use of estrogen or an alternative
therapy, if bone density would facilitate the decision

5.Women who have been on estrogen

replacement therapy for prolonged periods

or to monitor the efficacy of a therapeutic
intervention or interventions for osteoporosis
6.Diagnosing low bone mass in
glucocorticoid-treated
individuals(Prednisolone at 7.5mg daily for
6m.)
7. patients with asymptomatic primary or
secondary hyperparathyroidism

8.Previous low trauma fragility #

9.Premature menopause <45y.
10.Prolonged secondary amenorrhoea

(>1.y.)
11.Primary
or
hypogonadism
12.Chronic
disorders
osteoporosis
13.A meternal h/o hip #

secondary
asso.

With

BMD Report

WHO Classification: T
score
1Normal
BMD or bone mineral content (BMC) not more than

1 SD below the young adult mean (T-score above -1)

2.Osteopenia
BMD or BMC between 1 SD and 2.5 SD below the

young adult mean (T-score between -1 to-2.5)

3.Osteoporosis
BMD or BMC 2.5 SD or more below the young adult

mean (T-score at or below -2.5)

4.Severe osteoporosis (or established

osteoporosis)
BMD or BMC 2.5 SD or more below the young51adult

Bone Turnover
Markers(BTM)
Biochemical markers of bone turnover are

substances in blood and urine that reflect

rates of bone resorption or bone formation

they measure the relative activity of

osteoclasts and osteoblasts

Bone resorption markers

Currently available markers of bone resorption

include
Pyridinoline (PYR)
Deoxy pyridinoline (DPD)
N-telopeptides of type 1 collagen (NTX)
C-telopeptides of type 1 collagen (CTX)

1.Pyridinolines are measured in urine

2. telopeptides can be measured in both serum
and urine

Markers of bone formation

The most common markers of bone formation

are:
Osteocalcin (OC)
Bone specific alkaline phosphatase (bone

ALP)
Procollagen type 1 N-terminal

propeptide

(P1NP)
Procollagen type 1 C-terminal propeptide

Management of
Osteoporosis
Prevention & Treatment

9.Pharmacological

management

1.Pharmacological
Management Osteoporosis
Calcium
Vitamin D
Estrogens/HRT
Selective Estrogen Receptor Modulator

(SERM)Raloxifene
Bisphosphonates
Strontium ranelate
Calcitonin
PTH
Teriparatide

Normal calcium
requirement
Age
Birth-6 months
6 months-1 year
1-3
4-8
9-18
19-50
51-70

Calcium/day (mg)
210
270
500
800
1300
1000
1200
58

Calcium
Calcium citrate may be advantageous for

older seniors
Divided 2 to 3 times daily

Vitamin D
Doses:
1).400IU per day until 60
2)600-800 IU per day after 60
3.)50,000 IU-D2Every 2-4 weeks
4.)To treat deficiency-50,000 D2IU every week for 2
to 4 m.

25 hydroxy Vit.D status

1. .30ng-sufficient
2. 20-29ng/ml-insufficiency
3. <20ng/ml-deficiency

Osteoporosis Therapy
Algorithm
Postmenopausal Women
During Hot
Flushes

Post Vasomotor Symptoms

Pre fracture

Post Fracture

PTH

Risk
of Fracture

Bisphosphonates Or

Raloxifene

Strontium Ranelate

HRT
Calcitonin

HRT

50

STAGE

55

60

At Risk/Osteopenia
Higher

65

70

75

AGE
Osteoporosis
Lower

80

85

90

Severe Osteoporosis

Pharmacologic therapy for

osteoporosis
AntiresoptiveHRT
SERM and
bisphonates

Anaboliclong PTH
Teriparatide

Both strontium ranelate

1.HRT&Raloxifene
1.HRT should not be used solely for prevention of
osteoporosisHot flushes
2.Raloxifene Approved in US to reduce the risk

for invasive breast cancer(increased risk for VTE

and fatal stoke)

Bisphosphonates
1.Oral
Alendronate
Residronate
Ibandronate

2.IV
Ibandronate
Zoledronic acid

calcitonin
3rd line therapy option
-benign

side
administration

effect

profile

and

ease

of

Spinal#s-short term Analgesic effect-4weeks

Should not replace the use of more effiective

therapies,such as bisphosphonates

PTH
PTH was introduced in Europe as a treatment for

postmenopausal osteoporosis in 2006

Anabolic with intermittent low dose and
catabolic with continuous high dose

Two different forms of PTH

PTH(1-84),OR full length PTH and

-PTH (1-34),.OR teriparatide

UK-PTH
USA-teriparatide

Teriparatide has also been licensed for GIOP and

male osteoporosis
Much more useful in Vertebral #s

PTHcomplications/Contraindica
tions
1 first dose dizziness
2Hypercalcemia

3Hyperuricemia
1.h/oRadiation
2.Renal failure

1o.Surgical

management

2.Role of
Orthopaedicians&surgical
management
The goals of surgical treatment of osteoporotic

fractures include
rapid mobilization
function and activities

and

return

Avoid too much manipulations

Progressive physio therapy

to

normal

A)Vertebral #s
Vertebroplasty to reduce vertebral fracture

associated pain
Kyphoplasty to restore height or to treat the

deformity associated with osteoporotic vertebral

fractures

Progressive vertebral collapse or

deformity-pedicle scrwe fixation

Kyphoplasty

Lateral radiograph demonstrates multiple osteoporotic vertebral

compression fractures. Kyphoplasty has been performed at one level

B) troch.#
1.Role for augmentation

2.IM hip#implants
3.coating of implants with hydroxyapatite
4.primary arthroplasty

1.Role for augmentation

Various biometerials have been used

1. to reinforce and increase the load

capacity of IF devices
2.Enhances # stability and
3.fill the residual defect commonly
associated with unstable IT # without
adverse affect or #healing

11.Complicati

ons

Complications
1.chronic back pain from vertebral compression
fractures
2. Increased morbidity and mortality secondary to
vertebral compression fractures and hip fractures
3.Loss of hight
3. QOL can be impaired by the presence of these
fractures and their consequences, such as
immobility

12.PREVENTIO

Glucocorticoid-induced
osteoporosis(GIOP)
1.RESPIRATORY(ASTHMA)
2.MUSCULOSKELETAL(Rh .A)
3.CUTANEOUS DISEASE
The American Society for Bone and Mineral

Research 2004
1.Prednisone -5mg/day- >3month.
2.BMD-T-score
below
-2.5SD-oral-IV
bisphosphonates
,calcium,Vit.D

prevention
1. prevention of falls
2.prevention and treatment of
bone fragility
3.use of external hip
protectors.

1. prevention of falls
1.Impaired balance
2.gait and mobility
3.Poor vision
4.reduced muscle strength
5.impaired cognition

Other causes for fallsMedication&co-morbid

disease
Psychoactive medicationbenzodiazepines.
antidepressant
Certain co-morbid diseasestroke,
Alzheimers dementia
and parkinsons diseases

Insufficient Vit.D increases

the Falls
Essential

to maintain muscle
function and strength
Reduced handgrip strength
heaviness in the legs
Reduced walking distance
-Less outdoor activity

Home environment
modifications
1

removing loose rugs

extension cords
2.repairing rickety stairs
3.Bathroom

or

ergonomicsadding grab bars

4.increasing lighting

Regular physical activity plays

a therapeutic role in severe

osteoporosis

Hip protectors
Specialized undergarments
Poor compliance
Latest data-ineffective and should

not be recommended alone

13.RECENT
ADVANCES

Latest in Osteoporosis
Treatment
1.Carotenoids, Lycopene Reduce Fracture Risk

(Antioxidants)
reactive oxygen intermediates may be involved in
the bone-resorptive process and that fruit and
vegetable-specific antioxidants, such as carotenoids,
are capable of decreasing this oxidative stress.
Therefore carotenoids may help in preventing
osteoporosis.
In particular, an inverse relation of carotenoids and
lycopene with biochemical markers of bone
turnover has recently been demonstrated.

2.Omega-3 Fatty Acids Reduce hs-CRP 1

This study provides evidence that in healthy
individuals, plasma n-3 fatty acid concentration is
inversely related to hs-CRP
High sensitivity C-reactive protein (hs-CRP) is a
marker of low grade sustained inflammation.
Increased hs-CRP by just 1SD increases fracture risk
by an amazing 23 percent2.
Consider supplementing the diet with omega-3 fatty
acids (fish oil). Theyre a great way to help reduce
inflammation, hs-CRP, cardiovascular disease, and
fractures related to osteoporosis.
1. Micallef M A et al., European Journal of Clinical Nutrition, 2009; April 8 [Epub ahead of print].
2. Pasco et al. JAMA. 2006;296(11):1353-1355

3.Vitamin K Improves Bone Strength and

Reduces Fractures
Review of RCTs showed that vitamin K(1) and

vitamin K(2) supplementation reduced serum

undercarboxylated osteocalcin levels
regardless of dose but that it had inconsistent
effects on serum total osteocalcin levels and no
effect on bone resorption.

Iwamoto J et al., Nutrition Research, 2009; 29(4): 221-228.

4.Atypical femoral
fractures due to
bisphosphonates
Atypical femoral fractures with bisphosphonate

treatment
Experience

in two
teaching hospitals

large

United

Kingdom

14. Case
study

Case 1. Sitaratnam 85y.

Severe

osteoporoti, Known
,HTN and hemiplegic pt

diabetic

.
presented with 1.y.post operative non

union troch.# with PFN

Cemented bipolar

Excised the femoral head from fracture site

reconstucted the femoral neck taking bone graft

from femoral head and cement

Replaced with bipolar porstesis

And put her on bisphosponates,calcium and vit.D

Pt.was

followed up for 2years-pt.is walking

without any support and refractures

Operative

procedure
more
difficult
than
conventional arthroplasty
Reduced length of hospital stay
Indications for primary prosthetic replacement
are remain ill defined
Prospective randomized trails are needed
to determine the role for acute prosthetic
replacement for treatment of IT #s

Case no 2.Secondary
osteoporosis

Pallavi,31/f,on Antiepileptic
drugs since 6m. age
Ref. from Apolo hospital
Secunderabad
9053725362,9700178806
D0A-27-4-12,4-5-12
She presented with fracture shaft femur due to

slip &fall in bath room on 9-4-12

First -.treated with pop cast for 3 weeks by an
orthopaedic surgeon
subsequantly they went to APOLO hospital from
there she was referred to GANDHI hospital

3rd x-ray on 18 -5- 12

Investigations
Low s.calcium and phosphorus
25 hydroxy vit.D- Insufficient -20Ng/ml
PTH,,Alk.phosphatase-normal
DEXA-severe osteoporosis

Calcium-7.5 (8.5-11mg%)
insufficiency

25 hydroxy Vit.D-20Ng/ml
insufficiency(6-20ng/ml)

BMD tasted by DEXA

DEXA-OSTEOPOROSISsevere osteoporosis
LT.FEMUR3.8
RT.FEMUR3.2
SPINE4.1

Now pt. is on
1.)Calcium-1g/d
2.)Vit.D 6o ooo/w
3)high protien diet

4.)Teriparatide-25microgram/day

BONISTA/FORTEO
1)BONISTA-ORTHOLANDS RANBAXY
2)FORTEO-Eli LILLY

Iatrogenic fracture
Epilepsy

has been diagnosed at

the age of 6m.in NIMS
Since then she is on antiepileptic
drugs for 30y.
Though she was suffured from
multiple fractures, attended big
hospitals,and treated by qualified
doctors. No one has suspected this

Had it diagnosed at early stage and

treated with simple calcium and vit.D it

would have been prevented both
fracture, as well as this costly
treatment (teriparatide)
This amounts to a iatrogenic fracture

15.CONCLUS

ION

Education
-Ignorance about osteoporosis is still
common among
Health professionals
Patients and
Public,
- So that the education of all of these
groups is necessary.

So ,Our aim should be

1. increase knowledge of bone physiology and

osteoporosis
2.raise the awareness of major risk factors

and

3.provide information on possibilities of primary

and secondary prevention and management

of the disease

Thank you