OSTEOPOROSIS

Ditha Marissya Daud

Pembimbing:
dr. Sugeng Yuwono, Sp.OT(K)

Stase Ilmu Bedah FK UGM-RSUP Dr. Sardjito

INTRODUCTION
 Osteoporosis

• a diseases characterized by low bone mass and micro

architectural deterioration of bone tissue, as a result of sub
normal osteoid production, excessive rate of
deossification and subnormal osteoid mineralisation 
enhanced bone fragility and consequent increase in
fracture risk.
 Osteoporosis

• The World Health Organization

(WHO) defines osteoporosis as
a lumbar (L2-4) density level
at least 2.5 standard
deviations (SDs) below the
peak bone mass of a 25-year-
old individual
• Osteopenia is defined as a
bone density level 1.0 to 2.5
SDs below the peak bone
mass of a 25-year-old
individual
BONE METABOLISM
 Bone Metabolism Regulators:

Calcium

Phosphate

Parathyroid hormone

Vitamin D

Calcitonin

Estrogen

Corticosteroid
 Normal bone metabolism: Calcium
• Important in muscle and nerve function, clotting, >99% of the
body’s calcium in bones.
• Plasma calcium: equally free and bound (usually to albumin)
• Approximately 400mg of calcium is released from bone daily
• Absorbed in the duodenum by active transport & jejunum by
passive diffusion
• Regulated by 1,25(OH)2-vitamin D3
• The kidney reabsorbs 98% of calcium (60% in the proximal
tubule)
• Primary homeostatic regulators of serum calcium are PTH &
1,25(OH)2-vitamin D3
• Dietary requirement of elemental calcium: approximately
750mg/day for adults
 Normal bone metabolism: Phosphate
• A key component of bone mineral
• Approximately 85% of the body’s phosphate stores are in bone
• Plasma phosphate is mostly unbound
• Also important in enzyme systems and molecular interactions
• Dietary intake of phosphate is usually adequate
• Daily requirement is 1000 to 1500mg
• Reabsorbed by the kidney (proximal tubule)
• Phosphate may be excreted in urine
 Normal bone metabolism: Parathyroid hormone

• PTH is an 84–AA peptide, synthesized in and secreted from the (four)

parathyroid glands
• PTH helps regulate plasma calcium
• Decreased Ca levels  stimulate receptors to release PTH at intestines,
kidneys, bones
• PTH directly activates osteoblasts
• PTH modulates renal phosphate filtration
• PTH-related protein and its receptor have been implicated in metaphyseal
dysplasia
 Normal bone metabolism: Vitamin D

• Naturally occurring steroid

• Activated by ultraviolet radiation from sunlight or utilized from dietary
intake
• Hydroxylated to 25(OH)-vitamin D3 (liver) and hydroxylated a second
time (kidney) to:
- 1,25(OH)2-vitamin D3, the active hormone
- 4,25(OH)2-vitamin D3, the inactive form
• 1,25(OH)2-vitamin D3 works at the intestines, kidneys, and bones
• Phenytoin impair metabolism of vitamin D
 Normal bone metabolism: Calcitonin

• A 32–amino acid peptide hormone

• Produced by clear cells in the parafollicles of the thyroid gland
• Limited role in calcium regulation
• Increased extracellular calcium levels cause secretion of calcitonin
• Inhibits osteoclastic bone resorption
• Osteoclasts have calcitonin receptors.
• Calcitonin decreases osteoclast number and activity.
• Decreases serum calcium level
• May have a role: - fracture healing
- reduces vertebral compression fractures in high-
turnover osteoporosis
 Normal bone metabolism: Estrogens

• Estrogen prevents bone loss by inhibiting bone resorption.

• Decrease in urinary pyridinoline cross-links
• Since bone formation and resorption are coupled, estrogen also decreases
bone formation.
• Supplementation: in pm women only if started within 5/10 years after
menopause.
• Risk of endometrial cancer: reduced when estrogens is combined with
cyclic progestin
• Hormone replacement therapy may increase risk of heart disease and
breast cancer.
• Other pharmacologic interventions (alendronate, raloxifene) should be
considered.
 Normal bone metabolism: Corticosteroids

• Increase bone loss

• Decrease gut absorption of calcium by decreasing binding proteins
• Decrease bone formation (more cancellous/cortical) by inhibiting
collagen synthesis and osteoblast productivity
• Do not affect mineralization
• Alternate-day therapy may reduce the effects
 Normal bone metabolism: Thyroid hormones

• Affect bone resorption more than bone formation

• Large doses of thyroxine can lead to osteoporosis
• Regulates skeletal growth at the physis
• Stimulates: - chondrocyte growth
- type X collagen synthesis
- alkaline phosphatase activity
 Bone Remodeling Process
Osteoclasts
Resorption
Cavities
Lining Cells

Bone

Lining Cells Osteoblasts

Mineralized Osteoid
Bone
 Bone Remodelling/Bone Turn Over
High Bone Turnover Leads to Development of Stress Risers and Perforations
Osteoclasts

Lining
Cells

Bone

Perforations

Stress Risers
 Shifting the Osteoporosis Paradigm
Bone Strength

Bone Bone Bone

Strength = Quality and Quantity

o Architecture o Bone size

o Turnover rate o Bone density
o Damage accumulation
o Degree of Mineralization
o Properties of the
collagen/mineral matrix

Adapted from NIH Consensus Development Panel on Osteoporosis. JAMA 285:785-95; 2001
Osteoporosis is a quantitative, not qualitative, defect in
bone; mineralization of bone remains normal
Men vs Women Bone Mass
 The Osteoporosis Continuum

Healthy Kyphotic
spine spine

50 Menopausal 55+ Postmenopausal 75+ Kyphotic

Experiencing At greater risk for vertebral At risk for
vasomotor fracture than any other hip fracture
symptoms type of fracture
 Risk Factors
Uncontrolled Risk Controlled Risk

• Age • Alkoholism
• Sex • Low calcium and
vit.D3 intake
• Hormonal Status
• Immobilization
• Race
• Lack of exercise
• Family History

• Postmenopause • Smoking
 Age
50 1 of 3 women are at risk
for Ostoporosis

1 of 5 men are at risk for

Age Osteoporosis
WHO ARE AT 60-70
RISK IN
DEVELOPING 30% women have
OSTEOPOROSIS? Ostoporosis
Age
>80
70% women have
Ostoporosis

 Men have 30% stronger bone mass than women.

 While in pregnancy and lactation period, women’s
Why are women bone mass are reduced to build baby’s bone.
have higher risk?  Women have more rapid bone mass loss during
early menopausal period.
OSTEOPOROSIS
MANAGEMENT
 Osteoporosis Management
• Osteoporosis not reversible
• Primary prevention most important
Osteoporosis Management
 Osteoporosis Management
High risk population Minimally traumatic
fracture or osteopenia
 Change the life style
 Diet, exercise,
 avoid smoking

Bone Densitometri

More than +1 SD +1 SD to –1 SD -1 SD to –2.5 SD Less than –2.5 SD

Repeat every 5 years Repeat every 1 year Estrogen/SERM

Estrogen/SERM Biphosphonate Calcitriol Calcitonin

OSTEOPOROTIC
FRACTURE
 Fracture in Osteoporosis
• Fragility fracture  low energy trauma

• Osteoporosis is a SILENT DISEASE until fracture

• Vertebral body > hip fracture > wrist

• Problems:
 Weaken bone
 Prolong rehabilitation
 Comorbidity factors
 Compliance problems
 Vertebral Body Fracture

• associated with 15% increase in 5-year

mortality
• associated with increased morbidity
• back pain, loss of height, poor balance,
respiratory compromise, restrictive lung
disease, pneumonia
• history of 1 vertebral fracture results in 5
fold increased risk of 2nd vertebral
fracture and 5 fold increased risk of hip
fracture
 Vertebral Body Fracture

• Treatment
 Non operative
• Most cases: get better within 6 to 8 weeks without specific
treatment
• short period of rest + limited use of pain medications
 Operative
• Kyphoplasty/vertebroplasty
 Hip Fracture
• associated with 20% increase
in mortality
• men have higher mortality rates
following hip fractures than
women
• associated with increased
morbidity
• reduced quality of life  only one
third of patients with hip fractures
return to their previous level of
function
• history of 1 hip fracture results
in up to 10 fold increased risk of
2nd hip fracture
 Hip Fracture

• Treatment
 Consideration
o patient's overall health and medical
condition
o prior ambulation
 Non Surgery
o Limited to non operable patients
o Instable fracture pattern
o Complications from prolonged
immobilization. These include infections,
bed sores, pneumonia, the formation of
blood clots, and nutritional wasting.
 Hip Fracture
 Operative
o Target : early weight bearing
o Minimal soft tissue damage
Plate fixation (DHS)
Intramedullary nailing
Arthroplasty
 Hip Fracture
• Related to high complication incidence due to prolong
immobilization
o Decubitus ulcer
o Deep vein thrombosis
o Muscle atrophy (disuse)
o Disuse Osteoporosis
 Wrist Fracture
• high incidence of distal radius
fractures in women >50
• distal radius fractures are
a predictor of subsequent fractures
 Wrist Fracture

• Treatment
o Nonoperative closed reduction and cast immobilization
o Operative surgical fixation (CRPP, External Fixation, ORIF)
Surgical Fixation
 Fall Prevention
• prevention of fall is better than treating fracture
• require holistic assessment of health status and also environmental
assessment
• Intrinsic factors vs extrinsic factors
Fall Prevention
• Intrinsic factors
Fall Prevention
• Extrinsic factors
 Summary

• Osteoporosis is a silent disease

• Fracture in osteoporosis is a complex management
• Fracture in osteoporosis may require different management
compared to normal bone
• Prevention is better than cure
TERIMA KASIH
Mohon Asupan 