Osteoporosis

Osteoporosis is a disease characterized by low bone

mass and microarchitectural deterioration of bone tissue,
leading to
Enhanced bone fragility
Increase in fracture risk

1 in 2 white and Asian postmenopausal and at least 1 in 8

older and of other racial are likely to have an
osteoporotic fracture at some time during their lifetime.
World Health Organization issued diagnostic criteria for
postmenopausal women based on measurements of bone
mineral density (BMD) or bone mineral content.

Osteoporosis
Clinical manifestations are vertebral and
hip fractures, although fractures can
occur at any skeletal site no pain
Osteoporosis is defined as a BMD T
score of 2.5 standard deviations below
the young adult mean value

Epidemiology
Osteoporosis

health
problem
especially postmenopausal women
Osteoporosis
affects
>10
million
individuals in the US, but only a small
proportion are diagnosed and treated
Increased hip fractur in Asia global
issue health care, social and economic
problems.
Claus Christiansen, Am J Med 1993 dan WHO 1998

Osteoporosis
Primary Osteoporosis
Osteoporosis tipe 1
Osteoporosis tipe 2
Osteoporosis Juvenile
Osteoporosis Adulthood
Secondary Osteoporosis

Fracture of Osteoprosis

Vertebrae
Distal Radius
Collum femoris

Risk Factor
Non-Modifiable :

Modifiable :

History OP in 1st degree

relative
History of fracture in adult
Sex
Advanced age
Race

Smoking
Low Body Weight
Early menopause
Alcoholism
Low Ca intake
Inadequate physical
activity
Disease n drugs

PATHOGENESIS OF OSTEOPOROSIS FRACTURES

Aging

Heredity
Inadequate
Peak bone
mass

Menopause

Low bone
density
Fractures

Local
Factors
Sporadic
factors

Increased
Bone loss
Trauma

Diagnostic
X-ray exam > 40% bone loss
Bone mineral density DEXA - Dual
Energy X-ray Absorptiometry (gold stardard)
Biochemical exam.
blood : calsium, PTH, osteocalcin
urine : urine calcium, NTx (N-telopeptide)

Bone loss typically seen in X ray exam if bone density less then
40% or more

USG as diagnostic tool for OP

Dual Energy X-ray Absorptiometry (DEXA)

10

CLASSIFICATION OF
BONE MINERAL DENSITY LEVELS
DESCRIPTION
S
Normal BMD

MEANING

Low BMD or
osteopenia

BMD between - 1 SD and

2.5 SD

Osteoporosis

BMD is reduced < 2.5

SD

BMD above 1 SD from

the young normal mean

Severe or established BMD is reduced < 2.5

SD in the presence of
osteoporosis
WHO Technical Report Series. Geneva: WHO, 1994
fractures

WHO SHOULD HAVE BMD MEASSURE?

The National Osteoporosis Foundation recommend BMD
measurements:
for postmenopausal women > 65 yrs,
those < 65 yrs should have one or more risk factors
of osteoporosis besides menopause
The International Society for Clinical Densitometry (ISCD)
recommed BMD measurement:
for postmenopausal women > 65 yrs, and men > 70 yr
those younger than postmenopausal women and men
< 50 y.o. with one or more risk factors

Osteoporosis therapy
Increase bone density
Sodium fluorida
Paratiroid hormone
Steroid anabolic
Calcium

Inhibit bone resorption

Estrogen ( Primarin, Livial)
Calcitonin ( Miacalcic)
Bisphosphonate ( Risendronate, alendronate)
SERMs Selective Estrogen Receptor Modulators (Raloxifen)

Calcium
A G E (year)

CALCIUM (mg)

< 0.5

400

0.5 1

600

1 10

800

11 24

1200 1500

25 49

1000

Menopause (with estrogen R/) < 65

1000

Menopause (without estrogen R/) < 65

1500

Pregnant or breast feeding

Women > 65

1200 1500
1500

How to prevent Osteoporosis

Calcium supplement
Stop smoking
Stop alcohol
Exercise ( osteoporosis
exercise)

Hyperparathyrodism
Hypoparathyrodism

Calcium Regulation
99% of body calcium in skeleton
Miscible Pool: 40% bound to protein,
13% complexed w/ anions, 47% free
ionized
PTH: Increased Ca, Decreased PO4,
Increased Vitamin D
Vitamin D: Increased Ca, Increased
PO4, Decreased PTH (slow)
Kidney, Bones, GI Tract

Calcium Regulation

Localization
4 glands in 87 % of
patients ; range 2 - 6
glands

Internal
carotid
artery
to AP window
Superior parathyroid
glands within 1 cm of
RLN piercing
cricothyroid
membrane

Biologic Effects of PTH

To regulate ionized [Ca2+] levels by concerted
effects on three principal target organs: bone,
intestinal mucosa, and kidney
Other hormones related to Calcium : Vitamin D,
Calcitonin
Inhibits the reabsorption of phosphate in the
renal proximal tubule

Hyperparathyrodism
Usually asymptomatic
Fatigue and weakness
Bone and joint pain (fracture of long bone),
stones and hematuria(reflect decreased bone
density & nephrolithiasis)
Osteitis fibrosa cystica (Brown tumor) and
nephrocalcinosis rare

Etiology of hyperparathyrodism
Primary hyperPTH (most common)
Parathyroid adenoma (85%),
Parathyroid hyperplasia (15%)
Parathyroid carcinoma (< 1%)
Secondary HyperPTH
Usually renal failure
Tertiary HyperPTH
Chronic Renal Failure; low or normal Ca

Frank
hypercalcemia

HYPERCALCEMIA
Hypercalcemia
total serum calcium >
10.5 mg/dl ( >2.5 m
mol/L)) or ionized serum
calcium > 5.6 mg/dl ( >1.4
m mol/L )

Normal serum calcium levels are 8 to

10 mg/dl

GRADING OF
HYPERCALCEMIA

Clinical manifestation of
hypercalcemia
Hyperpolarization of cell membranes
Ca 10.5 11.9 mg /dl can be asymptomatic
Ca > 12 mg/dl multisystem manifestations :
Renal : polyuria , nephrolithiasis
GI : anorexia , nausea , vomiting , constipation , pancreatitis
Neuro - psychiatric : weakness , fatigue , confussion, psychosis,
stupor , coma
Cardiovascular : Shortened QT interval on ECG, bradyarrhythmias
and heart block and cardiac arrest
Cornea : band keratopathy

PATHOPHYSIOLOGY

Diagnosis of Hyper-PTH
Elevated serum Ca X 3
Elevated PTH
Other :

Albumin
Alkaline Phosphatase
Phosphorous
BUN/Cr
24-hour urine Ca
Bone Mineral Density

Medical Management
Severe Hypercalcemia

Saline-furosemide diuresis
Bisphosphonates (onset of action 2448h)
Calcitonin (immediate onset)
Hemodialysis

Surgical Management
NIH Guidelines (2002)
Serum calcium is greater than 1 mg/dL above the upper
limits of normal
Previous episode of life-threatening hypercalcemia
Creatinine clearance is reduced below 70% of normal;
Kidney stone is present
Urinary calcium is markedly elevated (> 400 mg/24 h);
BMD at the lumbar spine, hip, or distal radius is
substantially reduced (> 2.5 SD below peak bone mass;
T score < 2.5)
< 50 years of age
Long-term medical surveillance is not desired or
possible

Surgical Management
Adenoma
Unilateral vs. Bilateral Exploration
rPTH vs. Frozen Section
Hyperplasia/Multiple adenomata
Subtotal less hypocalcemia
Subtotal w/ autotransplantation MEN,
Renal Failure
Total w/ Cryopreservation up to 1 year

Hypoparathyrodism
Etiology

Iatrogenic
Neck irradiation
Surgically induced
Infiltrative Diseases
Hemachromatosis
Sarcoidosis
Thalassemia
Wilson's disease
Amyloidosis
Metastatic carcinoma

Neonatal

2
to
maternal
hyperparathyroidism
Autoimmune Genetic or
developmental disorders
DiGeorge Syndrome
Calcium sensor mutation

Sign and Symptoms of

Hypocalcemia
Neuro: Paresthesias, fasciculations,
muscle spasm, tetany, irritability,
movement
disorder,
SEIZURE,
psychosis
Visual:
Cataracts,
optic
neuritis,
papilledema
Pulmonary: Bronchospasm
CV: Prolonged QT, CHF, Hypotension
GI: Dysphagia, abdominal pain, biliary
colic

Signs of hypocalcaemia
Chvosteks sign:
Tap facial nerve twitching of
facial muscles

Trousseaus sign:
Inflate arm cuff > diastolic BP 3
minutes
carpopedal spasm
Flexion at Wrist
Flexion at MCP joints
Flexion of thumb against palm
Extension of PIP joints and DIP
joints
Adduction of fingers (forms a
cone)

Treatment of hypocalcemia
due to HypoPTH
Calcium gluconate in saline
Vitamin D
Calcium
Calcitriol
Thiazide