OSTEOPOROSIS

DR. Md Akbar Khan MS(ORTHO) Asst. Prof of Orthopaedics ACSR Govt Medical College, Nellore

Jean Lobstein – coined the term & described its pathoanatomy.

Osteoporosis is a major public health problem, which results in substantial morbidity, mortality and high costs.

Silent disease – patients unaware of ongoing bone loss which is asymptomatic.

Fracture may be the first symptom

INTRODUCTION

Skeletal disorder characterized by low bone mass & micro-architectural deterioration of bone tissue which results in increased bone fragility and fracture susceptibility.

WHO definition – Bone density that falls 2.5 SD below the mean for young healthy adults of same race & gender

DEFINITION

Reduced bone mass Reduced mineralization Micro architectural deterioration of

bone tissue

There is Subnormal osteoid production Excessive rate of de-ossification Subnormal osteoid mineralization

CHARACTERISTIC FEATURES

CHARACTERISTIC FEATURES

Normal – BMD not more than 1 SD Osteopenia - 1 to 2.5 below SD Osteoporosis - 2.5 below SD Severe Osteoporosis – With fragility

fractures

WHO GRADING

PRIMARY OSTEOPOROSIS Type I - Postmenopausal

osteoporosis Type II - Senile osteoporosis Idiopathic - Premenopausal and

Younger

CLASSIFICATION

SECONDARY OSTEOPOROSIS Metabolic - Calcium & Vit. D deficiency Endocrine - Cushing syndrome,

Hyperparathyroidism Renal disease Gastrointestinal - IBD, Malabsorption Hereditary connective tissue diseases -

Marfan syndrome, Homocystinuria. Bone marrow infiltration - Multiple Myeloma,

lymphoma, leukemia. Drugs - Phenytoin, Corticosteroid, heparin,

lithium. Life style - Alcohol, smoking, inactivity,

immobilization, Miscellaneous - Rh. arthritis

CLASSIFICATION

Non-modifiable Peak bone mass Female sex Caucasian race Advanced age Family historyPotentially modifiable Cigarette smoking & Alcoholism Estrogen deficiency Low body weight Low calcium intake Lack of physical activity

CONTRIBUTING FACTORS

Bone formation & bone resorption - (2 Process) Osteoclast (bone resorbing cells) & Osteoblast

(bone forming cells) - (2 Type of Cells) Parathormone & Vitamin D - (2 Biomolecules) Cortical & Trabecular bones - (2 Types of

Bones) Investigations – Markers of bone formation &

resorption (2 Marker Investigations) Treatment – Drugs which enhance bone

formation & decrease resorption (2 Types of Drugs)

BALANCING ACT BETWEEN

Fragility fractures / Insufficiency fractures Outcome depends on

Bone density Severity of fall

In three most common fractures Distal radius – Fall > Density Vertebral body – Density > Fall Hip fractures – Fall & Density play equal

role

OSTEOPOROTIC FRACTURES

Risk Factors : Increased age Female gender Estrogen deficiency Inadequate calcium intake Low bone density (osteopenia) Low body weight History of fractures in adult life History of fractures in first-degree

relative Smoking and alcohol use Lack of physical activity

OSTEOPOROTIC FRACTURES

Osteoporosis is usually asymptomatic until fracture occurs.

May present as backache of varying degrees of severity

Spontaneous fracture Collapse of vertebrae Loss of height is common Thoracic kyphosis

CLINICAL MANIFESTATIONS

Osteoporosis is usually asymptomatic until fracture occurs.

May present as backache of varying degrees of severity

Spontaneous fracture Collapse of vertebrae Loss of height is common Thoracic kyphoses

CLINICAL MANIFESTATIONS

Hyperparathyroidism Paget’s disease Osteomalacia Osteogenesis imperfecta Multiple myeloma Renal Osteodystrophy Secondary tumors

DIFFERENTIAL DIAGNOSIS

Serum calcium Hyperparathyroidism / Malignancy Malnutrition / Osteomalacia

PTH Hyperparathyroidism Malignancy

PTHrP Malignancy TSH To r/o Hyperthyroidism Urinary free Cortisol Cushings disease

INVESTIGATIONS

Urine Calcium Low (<50mg/24 hrs)

Osteomalacia, Malnutrition, Malabsorption

High (300mg/24 hrs)

renal calcium leak -Males with osteoporosis

Absorptive hypercalciuria - Idiopathic

Granulomatous disease

Malignancy and diseases with bone turnover

INVESTIGATIONS

Serum & Urine immuno-electrophoresis

Multiple myeloma Urinary N – Telopeptide (NTX)

Marker of bone resorption

>40 n mol high turnover 25- hydroxy vitamin D & 1,25 hydroxy vitamin

Dlevels

Liver Disease, Renal Osteodystrophy

Monitor response to anti-osteoporotic treatments

INVESTIGATIONS

Ca PO4 ALP

Osteoporosis N N/ N

Hyperparathyroidism

Paget’s disease N or N /

Osteomalacia N/

Osteogenesis Imperfecta

N N N/

Multiple Myeloma

N/ N/ N

INVESTIGATIONS

Post menopausal osteoporosisTrabecular resorption & cortical resorption

Senile osteoporosisEndosteal resorption

HyperparathyroidismSubperiosteal resorption

RADIOLOGY

Principal tensile & compressive trabeculae on hip X Ray

Grade VI to Grade I Grade VI: Normal trabecular groups are visible  Upper end of femur is occupied by cancellous bone Grade V: Both Trabeculae is accentuated Ward's triangle appears prominent Grade IV: principal tensile trabeculae are markedly reduced can be traced from lateral cortex to upper part of

femoral neck

SINGH’S INDEX

Grade III: There is break in continuity of principal

tensile trabeculae opposite greater trochanter Grade II:

Only principal compressive trabeculae stand out prominently

Remaining trabeculae have been essentially absorbed

Grade I: Principal compressive trabeculae are markedly

reduced in number and are no longer prominent Grade 6 normal Grade 3 definite osteoporosis Grade 1 is severe osteoporosis

SINGH’S INDEX

SINGH’S INDEX

Cod fish vertebra Kyphosis Collapse of

vertebra Compression

Fractures Schmorl's

nodules Kleer Koper

Score

VERTEBRAL X RAY

Assessed from lateral view of spine – T4 – L5

Normal – Grade 0Biconcave deformity – Grade 1Wedge deformity – Grade 2Compression deformity – Grade 3

Kleer Koper Score

Reconstructive CT pictures show L 1, 2, and L3 fractures with biconcave deformities

COMPUTER TOMOGRAPHY

Chronic benign compression fractures

Sagittal MRI scan shows multiple collapsed vertebrae

MRI SCAN

Amount of bone matter per cubic centimeter of bone

Reported in Three terms – Gm/ mm3 , T score & Z score

Measured byDual Energy X Ray AbsortiometryQualitative UltrasoundQualitative Computer Tomography

BONE MINERAL DENSITY

Recommendation for bone density measurements:

Estrogen-deficient women at clinical risk. Individual with vertebral abnormalities - plain

film More than 3 months of steroid treatment Primary hyperparathyroidism Monitoring of drug therapy Women who have multiple risk factors Postmenopausal women who is not on

estrogen replacement. Pt. with strong Family History of osteoporosis.

All women age>65.

BONE MINERAL DENSITY

X ray photons of different energy

Sites recommended by WHO

Total proximal femurFemoral neckLumbar spineRadius with evidence

of OA / surgery at other 3 sites

DUAL ENERGY X RAY ABSORTIOMETRY

Results expressed in T & Z scores

DUAL ENERGY X RAY ABSORTIOMETRY

Emits ultrasonic waves Attenuation of waves which

predict strength of bone Measured in calcaneum At present outdated due to errors

QUALITATIVE ULTRASOUND

Mainly for spine Specifically analysis

trabecular bone Less precise than DEXA More radiation Costlier than DEXA

QUALITATIVE COMPUTER TOMOGRAPHY

Key to management is prevention. Prevention of osteoporosis is a misnomer It is actually prevention of fractures by

the time the patient already have osteoporosis

Increasing public awareness about importance and risks involved helps

Altering personal and dietary habits Regular physical activity(3-4 hrs/week) Peri-menopause & postmenopause:

calcium+ oestrogen – weight bearing exercises.

PRIMARY PREVENTION

Use handrails on stairs, Bathroom

Keep rooms free of clutter Keep floors clean but not

slippery Wear supportive, low-heeled

shoes. Don’t walk in socks; floppy

slippers Install ceiling lighting in

bedrooms Use rubber matt in

shower/tub Check posture in mirror

often

Conservative Surgical

MANAGEMENT

Calcium – 1 to 1.5 gm/day Vitamin D – 400 to 800 IU/day Weight bearing and gravity resistant

exercises Avoid alcohol, cigarette Moderate phosphate intake Prophylactic agents

Alendronate – 35mg Raloxifine – 60mg

PROPHYLAXIS

Anti resoptive class of DrugsCalcium/Vitamin D Bisphosphonates Calcitonin Selective Estrogen Receptor Modulators

(SERMS) Anabolic Drugs

Parathyroid Hormone Sodium fluoride & Strontium Renelate

Other AgentsVitamin K2-7 fortified calcitriol &

Denosumab

MEDICALTREATMENT

Mechanism of action Binds to the surface of

hydroxyapatite crystals and inhibits its resorption

First line of treatment in postmenopausal osteoporosis

Side effects Gastrointestinal intolerance Esophagitis Bone pain

BISPHOSPHONATES

Once a week (oral) Alendronate –35mg (prevention) & 70 mg treatment

Risedronate - 35mg (prevention) & 50 mg treatment

Once a month (oral) Ibandronate - 150 mg

Once In 3 months (Intravenous) Ibandronate - 3 mg / 3 ml over 15 – 30 sec

Once in a year(Intravenous)Zolendronate -5 mg / 100 ml infusion over 15–20 min

BISPHOSPHONATES

Salmon Calcitonin Nasal Spray

For postmenopausal osteoporosis

200 IU once a day intranasal, alternating nostrils

Side effects – nasal mucosal irritation SERM’S (Raloxifene)

For postmenopausal osteoporosis - 150 mg Recombinant Human PTH ( Teriparatide)

Produced genetically engineered E. Coli

Injection - 750 micrograms

Calcium & Vitamin D supplements to correct imbalance

Other Agents

Sodium Fluoride & Strontium Renelate

Increase bone mass by inhibiting osteoclasts

Stimulate osteoblasts Vitamin K2-7 fortified calcitriol &

calcium combinations Denosumab

monoclonal antibody binds with RANK Ligand

Inhibits bone resorption

Other Agents

GOALSImprove quality of lifeGive a stable fixationEarly mobilization & weight bearing

SURGICAL TREATMENT

BASIC PRINCIPLESBiological fixationLoad sharing implantsImpaction & compressionWide buttress platesLong splintageAugmentation of implantsReplacement arthroplasty

SURGICAL TREATMENT

Without opening fracture site & without disturbing biomechanics

Use of longer plate with less no of screws – greater stability

BIOLOGICAL FIXATION

Interlocking nails , tension band constructs

Moved from conventional plating, DCP & LC-DCP to Interlocking nails & LCP

These bones have poor holding power of screws

Bones are like tough spring Interlocking nails & LCP locking the

screws to plates creating angular stable devices, diminishing screw holding power of bone

LOAD SHARING IMPLANTS

TERMS:

Fixed Position

Fixed Angle

Locking Screw

Locking Plate

LOCKING PLATES

LOCKING SCREW-PLATE CONSTRUCTS

Locking head screw

Threaded plate hole

PULLOUT OF LOCKING SCREWS

Creates Fixed Angle Generates Friction/Compression

4.4mm Core Dia. 3.5mm Core Dia.

5.0 mm Locking Screw 4.5 mm Cortical Screw

Enhances stability In comminuted fractures – controlled

impaction &compression is advisable-DHS with wt. bearing

LCP plates are used in metaphyseal fractures, upper tibial fractures, & supracondylar fractures & proximal humerus with specialized plates

IMPACTION & COMPRESSION

Bone cement Bone graft Bone subsitutes

HydroxyapatiteTricalcium phosphate HydroxyapatiteTricalcium phosphate

Biodegradable bone cementCalcium phosphate – Norian skeletal repair system

Glass isometric cement

AUGMENTATION OF IMPLANTS

If no other option

REPLACEMENT ARTHROPLASTY

Contoured plates Proximal humeral platesDistal femoral platesProximal tibial platesDistal tibial plates

LISS platesProximal tibia distal femur with zig & minimally invasive techniques

SPECIAL PLATES