Prevention and Management
1. INTRODUCTION
2. EPIDEMIOLOGY
3. CLASSIFICATION
4. PATHOPHYSIOLOGY
5. S/S
6. INVESTIGATIONS
7. BMD
8. BTM
9. DIAGNOSIS
1...
Osteoporosis: Nightmare Of Post-
menopause/ Old Age
Normal vs Osteoporotic Bone
1. It is a disease of aging-
2. Silent disease-
3. fragility fracture/low trauma fracture
4. spontaneous fracture
5. Hip f...
What is Osteoporosis?
Osteoporosis is a systemic skeletal disease characterized
1. low bone density and
2. a micro- archit...
2.Epidemiology
Osteoporosis affects entire skeleton
 Osteoporosis is responsible for >36.8 million vertebral
and non-vertebral fractures...
Common Sites of fracture
Hip
Vertebral column
Wrist
women
In women it isThree times more common
than men
1.low peak bone mass (PBM)
2.hormonal changes at menopause
3.live lo...
A Retrospective Study Suggests that
Vertebral Fractures are Under-Diagnosed
934 hospitalised women
with a lateral chest x-...
Hip fractures
 Hip fractures accounts for most of the
morbidity,
mortality and
cost of the disease
2.Classification
Osteoporosis: Classification
 Primary Osteoporosis
 Type 1- Post menopausal osteoporosis
 Type 2- Senile/Age related os...
Post-Menopausal Osteoporosis
 Caused by a lack of estrogens, which helps to
regulate, the incorporation of calcium into b...
Age Related/Senile Osteoporosis
 Usually affects people over 70 y.
 Results from age-related calcium deficiency
 There ...
Secondary Osteoporosis
Congenitl
Condition
Homocystinuria; hemolytic anemia;
hypophosphatasia; osteogenesis
imperfecta
Die...
Endocrine Disorders
 Cushing's syndrome; growth hormone deficiency;
hypercortisolism; hyperparathyroidism; hyperthyroidis...
A.CHILDHOOD-chronic diseases
 During growth 30 -50y >50 y.
 Bed rest due to chronic illness
 Undernutrition or malnutri...
B.During late adulthood-
endocrine diseases
 Hypogonadism is a major cause
 1.Women-menopause-estrgen deficiency-bone ma...
C.Elderly-diet(calcium)
Low calcium intake associated with a
 reduced endogenous production of vit.D
accelerate bone los...
3.Risk factors
Non-modifiable/Fixed Risk Factors
 Older age
 Female gender
 Ethnic background
 Small bone structure
 Family history ...
Modifiable Risk Factors
Alcohol
Smoking
Poor nutrition
Vitamin D deficiency/Lack of sunlight
exposure
Insufficient ex...
4.Pathophysiology
1.Peak bone mass
2.remodling
Determinants Of Peak Bone Mass
Peak Bone Mass
Physical activity Gonadal status
Nutritional statusGenetic factors
1.Peak bone mass &
Osteoporosis
 Peak bone mass is the maximum mass of bone achieved
by an individual at skeletal maturit...
Peak Bone Mass in Women
10 20 30 40 50 60
•Women achieve lesser peak bone mass than men
27
Stages of Peak Bone Mass in Women
28
2.Bone formation takes place
throughout life-remodeling
Bone is a living tissue and is
constantly resorbed and formed by
...
Remodelling
Imbalance
 1.In Osteoporosis imbalance occurs between bone
resorption and bone formation
 This imbalance might occur as ...
5.Signs & Symptoms
Signs & Symptoms
 In early stages usually no symptoms
therefore also known as silent disease
 There may be back pain due...
Osteoporosis related bone loss
Vertebrae, which have a large proportion of trabecular
bone, are commonly the first sites t...
Backbone Deformity in Osteoporosis
Three generations of
women are shown.
The elderly women
have “hunched back”
which is a ...
6.Differential Diagnoses
Differential Diagnoses
 Other Problems to Be Considered
1. Bony metastases
2. Multiple myeloma
3. Primary hyperparathyroi...
Osteomalacia/osteoporosis
osteomalacia osteoporosis
 .h/o persistant skeletal pain
of long duration and muscle
weakness
...
osteomalacia osteoporosi
 X-ray-diminished bone
density- marked in the
peripheral bone than in the
axial
 Skeletal defor...
7.Diagnosis
BMD
Dual energy x-ray absorptiometry
(DEXA) is the best current test to
measure bone density
The ability of the BMD to p...
 BMD 2.5 standard deviation or more below the average
for the young healthy female population-
osteoporosis
 T –score fo...
How is osteoporos is diagnosed
Diagnosis is made on the basis of
1. Detailed medical history
2. Physical examination
3. In...
BMD Tests Other than DEXA
 Quantitative CT vertebral scanning
 Single photon and dual photon absorptiometry
 Peripheral...
Bone Mineral Density (BMD)
 It is a simple test that
measures bone thickness/
density at different parts of
the body, lik...
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 osteo...
 5.Women who have been on estrogen replacement
therapy for prolonged periods or to monitor the
efficacy of a therapeutic ...
 8.Previous low trauma fragility #
 9.Premature menopause <45y.
 10.Prolonged secondary amenorrhoea (>1.y.)
 11.Primar...
BMD Report
WHO Classification: T score
1Normal
BMD or bone mineral content (BMC) not more than 1 SD
below the young adult mean (T-sc...
Bone Turnover Markers(BTM)
 Biochemical markers of bone turnover are
substances in blood and urine that reflect rates of
...
Bone resorption markers
 Currently available markers of bone resorption include
 Pyridinoline (PYR)
 Deoxy pyridinoline...
Markers of bone formation
 The most common markers of bone formation are:
 Osteocalcin (OC)
 Bone specific alkaline pho...
Prevention & Treatment
9.Pharmacological
management
1.Pharmacological Management
Osteoporosis
 Calcium
 Vitamin D
 Estrogens/HRT
 Selective Estrogen Receptor Modulator (S...
Normal calcium requirement
Age Calcium/day (mg)
Birth-6 months 210
6 months-1 year 270
1-3 500
4-8 800
9-18 1300
19-50 100...
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 defici...
25 hydroxy Vit.D status
1. .30ng-sufficient
2. 20-29ng/ml-insufficiency
3. <20ng/ml-deficiency
Osteoporosis Therapy Algorithm
Postmenopausal Women
At Risk/Osteopenia Osteoporosis Severe OsteoporosisSTAGE
LowerHigher
-...
Pharmacologic therapy for
osteoporosis
Antiresoptive-
HRT
SERM and
bisphonates
Anabolic-
long PTH
Teriparatide
1.HRT&Raloxifene
1.HRT should not be used solely for prevention of
osteoporosis-
 Hot flushes
 2.Raloxifene –Approved in...
Bisphosphonates
 1.Oral
 Alendronate
 Residronate
 Ibandronate
 2.IV
 Ibandronate
 Zoledronic acid
calcitonin
 3rd line therapy option
 -benign side effect profile and ease of administration
 Spinal#s-short term Analge...
PTH
 PTH was introduced in Europe as a treatment for
postmenopausal osteoporosis in 2006
 Anabolic with intermittent low...
 UK-PTH
 USA-teriparatide
 Teriparatide has also been licensed for GIOP and male
osteoporosis
 Much more useful in Ver...
PTH-
complications/Contraindications
 1 first dose dizziness
 2Hypercalcemia
3Hyperuricemia
 1.h/oRadiation
 2.Renal f...
1o.Surgical
management
2.Role of
Orthopaedicians&surgical
management
 The goals of surgical treatment of osteoporotic fractures
include
 rapid ...
A)Vertebral #s
 Vertebroplasty to reduce vertebral fracture–associated pain
 Kyphoplasty to restore height or to treat t...
Kyphoplasty
Lateral radiograph demonstrates multiple osteoporotic vertebral
compression fractures. Kyphoplasty has been pe...
B) troch.#
 1.Role for augmentation
 2.IM hip#implants
 3.coating of implants with hydroxyapatite
 4.primary arthropla...
1.Role for augmentation
 Various biometerials have been used
1. to reinforce and increase the load capacity
of IF devices...
11.Complications
Complications
1.chronic back pain from vertebral compression fractures
2. Increased morbidity and mortality secondary to v...
12.PREVENTION
Glucocorticoid-induced
osteoporosis(GIOP)
 1.RESPIRATORY(ASTHMA)
 2.MUSCULOSKELETAL(Rh .A)
 3.CUTANEOUS DISEASE
 The A...
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 falls-
Medication&co-morbid disease
 Psychoactive medication-
 benzodiazepines.
 antidepressant
 Cert...
Insufficient Vit.D increases the
Falls
Essential to maintain muscle function
and strength
Reduced handgrip strength
 he...
Home environment modifications
1 removing loose rugs or extension
cords
2.repairing rickety stairs
3.Bathroom ergonomic...
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 intermedi...
 2.Omega-3 Fatty Acids Reduce hs-CRP1
 “This study provides evidence that in healthy
individuals, plasma n-3 fatty acid ...
 3.Vitamin K Improves Bone Strength and Reduces
Fractures
 Review of RCTs showed that vitamin K(1) and vitamin K(2)
supp...
4.Atypical femoral fractures due
to bisphosphonates
 Atypical femoral fractures with bisphosphonate
treatment
 Experienc...
 14. Case study
Case 1. Sitaratnam 85y.
 Severe osteoporoti, Known diabetic ,HTN and
hemiplegic pt
.
 presented with 1.y.post operative ...
Cemented bipolar
 Excised the femoral head from fracture site
 reconstucted the femoral neck taking bone graft from
femoral head and ceme...
 Operative procedure more difficult than conventional
arthroplasty
 Reduced length of hospital stay
 Indications for pr...
Case no 2.Secondary
osteoporosis
Pallavi,31/f,on Antiepileptic drugs
since 6m. age
 Ref. from Apolo hospital
 Secunderabad
 9053725362,9700178806
 D0A-...
3rd x-ray on 18 -5- 12
Investigations
 Low s.calcium and phosphorus
 25 hydroxy vit.D- Insufficient -20Ng/ml
 PTH,,Alk.phosphatase-normal
 DE...
Calcium-7.5 (8.5-11mg%)
insufficiency
25 hydroxy Vit.D-20Ng/ml
insufficiency(6-20ng/ml)
BMD tasted by DEXA
DEXA-OSTEOPOROSIS-severe
osteoporosis
 LT.FEMUR—3.8
 RT.FEMUR—3.2
 SPINE—4.1
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 30...
 Had it diagnosed at early stage and treated
with simple calcium and vit.D it would have
been prevented both fracture, as...
15.CONCLUSION
Education
-Ignorance about osteoporosis is still common
among
Health professionals
Patients and
Public,
- So that the educ...
 So ,Our aim should be
 1. increase knowledge of bone physiology and
osteoporosis
 2.raise the awareness of major risk ...
osteoporosis prevention management
osteoporosis prevention management
osteoporosis prevention management
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  • Women
  • Lycopene is the most common carotenoid found in blood and its levels have correlated with reduced risk of cancer and heart attacks in prior studies. The beneficial effects of lycopene are contributed to its antioxidant activity. In this study the authors concluded that data compiled from the Framingham Study indicated long-term carotenoid (lycopene) intake had beneficial effects on bone density in elderly men and women. In addition, the authors cited several studies that found high serum lycopene to be inversely associated with bone resorption markers such as N-telopeptide (NTX). Tomatoes are a great source of lycopene.Sahni S et al. Protective effect of total carotenoid and lycopene intake on the risk of hip fracture: a 17-year follow-up from the Framingham Osteoporosis Study. J Bone Miner Res. 2009 Jun;24(6):1086-94.In vitro and in vivo studies suggest that carotenoids may inhibit bone resorption, yet no previous study has examined individual carotenoid intake (other than beta-carotene) and the risk of fracture. We evaluated associations of total and individual carotenoid intake (alpha-carotene, beta-carotene, beta-cryptoxanthin, lycopene, lutein + zeaxanthin) with incident hip fracture and nonvertebral osteoporotic fracture. Three hundred seventy men and 576 women (mean age, 75 +/- 5 yr) from the Framingham Osteoporosis Study completed a food frequency questionnaire (FFQ) in 1988-1989 and were followed for hip fracture until 2005 and nonvertebral fracture until 2003. Tertiles of carotenoid intake were created from estimates obtained using the Willett FFQ adjusting for total energy (residual method). HRs were estimated using Cox-proportional hazards regression, adjusting for sex, age, body mass index, height, total energy, calcium and vitamin D intake, physical activity, alcohol, smoking, multivitamin use, and current estrogen use. A total of 100 hip fractures occurred over 17 yr of follow-up. Subjects in the highest tertile of total carotenoid intake had lower risk of hip fracture (p = 0.02). Subjects with higher lycopene intake had lower risk of hip fracture (p =0.01) and nonvertebral fracture (p = 0.02). A weak protective trend was observed for total beta-carotene for hip fracture alone, but associations did not reach statistical significance (p = 0.10). No significant associations were observed with alpha-carotene, beta-cryptoxanthin, or lutein + zeaxanthin. These results suggest a protective role of several carotenoids for bone health in older adults.
  • Omega-3 fatty acids have anti-inflammatory properties and the purpose of this study was to investigate whether their concentration in the blood is related to levels of the inflammatory marker, hs-CRP. Abnormally elevated hs-CRP is correlated to excess production of interleukin-6 (Il-6), a molecule produced in the body during times of chronic inflammation. High levels of hs-CRP are correlated to cardiovascular disease as well as low bone mineral density (BMD) and increased fracture risk.Reducing hs-CRP by just one point will reduce fracture risk by an amazing 23 percent An age-stratified sample of 1494 women (99% white), representing 77.1% of eligible participants, was randomly recruited from electoral rolls for the Geelong Osteoporosis Study. The inclusion criterion of age 65 years or older was met by 522 women. Of these, 33 were excluded because serum was unavailable for analysis and 45 were excluded for baseline use of hormone therapy or oral glucocorticoids for at least 6 months, leaving a study populationof 444 women. Baseline assessments were performed from 1994 to 1997, and participants were followed up until fracture, death, migration from the study region, or the end of 2002.The unadjusted HR for fracture increased by 23% for each SD increase in ln-hsCRP (HR, 1.23; 95% confidence interval, 1.01-1.51). The age-standardized absolute risk of fracture during the study period increased from 16.3% (95% CI, 6.8%-25.8%) for ln-hsCRP less than −1 SD (0.96 mg/L) to 28.9% (95% confidence interval, 17.7%-40.1%) for lnhsCRP greater than +1 SD (6.35 mg/L). Multivariate models consistently included significant contributions from lnhsCRP, prevalent fracture, and BMD. For each SD increase in ln-hsCRP, there was an independent 24% to 32% increase in fracture risk, depending on site-specific BMD used in the model. Fracture risk was independently increased 52% to 79% for each SD decrease in BMD and 52% to 73% by previous fracture.So supplementing the diet with omega-3 fatty acids (fish oil) should be considered. They’re a great way to help reduce inflammation,  hs-CRP, cardiovascular disease, and fractures related to osteoporosis.
  • Despite the lack of a significant change or the occurrence of.“Despite the lack of significant change or the occurrence of only a modest increase in bone mineral density, high-dose vitamin K1 and vitamin K2 supplementation improved indices of bone strength in the femoral neck and reduced the incidence ofIn a review of the literature to assess the effects of vitamin K supplementation on bone in postmenopausal women, the authors of this study found that high-dose vitamin K improves bone strength in the hip and reduces fracture. This reduction in fracture appears to be more from changes to the quality of bone rather than quantity, as only 7 randomized controlled trials found (modest) increases in bone mineral density.There was only a modest increase in bone mineral density, but high-dose vitamin K(1) and vitamin K(2) supplementation improved indices of bone strength in the femoral neck and reduced the incidence of clinical fractures
  • osteoporosis prevention management

    1. 1. Prevention and Management
    2. 2. 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
    3. 3. Osteoporosis: Nightmare Of Post- menopause/ Old Age Normal vs Osteoporotic Bone
    4. 4. 1. It is a disease of aging- 2. Silent disease- 3. fragility fracture/low trauma fracture 4. spontaneous fracture 5. Hip fractures-Morbidity 6. QOL
    5. 5. 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
    6. 6. 2.Epidemiology
    7. 7. 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
    8. 8. Common Sites of fracture Hip Vertebral column Wrist
    9. 9. 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 women
    10. 10. A Retrospective Study Suggests that Vertebral Fractures are Under-Diagnosed 934 hospitalised women with a lateral chest x-ray 0 20 40 60 80 100 120 140 Patients(n) 132 65 23 25 Fracture identified by study radiologists Fracture noted in radiology report Fracture noted in medical record Received osteoporosis treatment Gehlbach et al.,Osteoporos Int 2000, 11:577
    11. 11. Hip fractures  Hip fractures accounts for most of the morbidity, mortality and cost of the disease
    12. 12. 2.Classification
    13. 13. Osteoporosis: Classification  Primary Osteoporosis  Type 1- Post menopausal osteoporosis  Type 2- Senile/Age related osteoporosis  Secondary Osteoporosis  Secondary to various causes 13
    14. 14. 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
    15. 15. 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
    16. 16. Secondary Osteoporosis Congenitl Condition Homocystinuria; hemolytic anemia; hypophosphatasia; osteogenesis imperfecta Diet Calcium deficiency; malabsorption syndromes; scurvy; starvation Drugs Alcohol; anticonvulsants; cancer chemotherapy; excess thyroid hormone; glucocorticoids; heparin; methotrexate 16
    17. 17. 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  Gastrectomy, primary biliary cirrhosis, celiac disease
    18. 18. 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
    19. 19. B.During late adulthood- endocrine 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 hyperparathyroidsm,,hyperthyroidsm and  hypercortisolism
    20. 20. 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.
    21. 21. 3.Risk factors
    22. 22. 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
    23. 23. Modifiable Risk Factors Alcohol Smoking Poor nutrition Vitamin D deficiency/Lack of sunlight exposure Insufficient exercise Low calcium intake in food
    24. 24. 4.Pathophysiology 1.Peak bone mass 2.remodling
    25. 25. Determinants Of Peak Bone Mass Peak Bone Mass Physical activity Gonadal status Nutritional statusGenetic factors
    26. 26. 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
    27. 27. Peak Bone Mass in Women 10 20 30 40 50 60 •Women achieve lesser peak bone mass than men 27
    28. 28. Stages of Peak Bone Mass in Women 28
    29. 29. 2.Bone formation takes place throughout life-remodeling Bone is a living tissue and is constantly resorbed and formed by the process known as remodeling
    30. 30. Remodelling
    31. 31. 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
    32. 32. 5.Signs & Symptoms
    33. 33. 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
    34. 34. 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 to spine collapse (upto-4-8 inches) 34
    35. 35. 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
    36. 36. 6.Differential Diagnoses
    37. 37. 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
    38. 38. Osteomalacia/osteoporosis 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
    39. 39. osteomalacia osteoporosi  X-ray-diminished bone density- marked in the peripheral bone than in the axial  Skeletal deformity without #  Looser’s zone  Histology –presence of excess osteoid tissue in undercalcified  Treatment is rapidly and consitently successful
    40. 40. 7.Diagnosis
    41. 41. 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 measurement of BP to predict stroke
    42. 42.  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%.
    43. 43. 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
    44. 44. BMD Tests Other than DEXA  Quantitative CT vertebral scanning  Single photon and dual photon absorptiometry  Peripheral DEXA
    45. 45. 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 density
    46. 46. Dual-energy x-ray absorptiometry (DEXA)
    47. 47. 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
    48. 48.  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
    49. 49.  8.Previous low trauma fragility #  9.Premature menopause <45y.  10.Prolonged secondary amenorrhoea (>1.y.)  11.Primary or secondary hypogonadism  12.Chronic disorders asso. With osteoporosis  13.A meternal h/o hip #  14.Alow BMI
    50. 50. BMD Report
    51. 51. 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 young adult mean in the presence of one or more fragility fractures 51
    52. 52. 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
    53. 53. 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
    54. 54. 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 (P1CP)
    55. 55. Prevention & Treatment
    56. 56. 9.Pharmacological management
    57. 57. 1.Pharmacological Management Osteoporosis  Calcium  Vitamin D  Estrogens/HRT  Selective Estrogen Receptor Modulator (SERM)Raloxifene  Bisphosphonates  Strontium ranelate  Calcitonin  PTH  Teriparatide
    58. 58. Normal calcium requirement Age Calcium/day (mg) Birth-6 months 210 6 months-1 year 270 1-3 500 4-8 800 9-18 1300 19-50 1000 51-70 1200 58
    59. 59. Calcium  Calcium citrate may be advantageous for older seniors  Divided 2 to 3 times daily
    60. 60. 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.
    61. 61. 25 hydroxy Vit.D status 1. .30ng-sufficient 2. 20-29ng/ml-insufficiency 3. <20ng/ml-deficiency
    62. 62. Osteoporosis Therapy Algorithm Postmenopausal Women At Risk/Osteopenia Osteoporosis Severe OsteoporosisSTAGE LowerHigher -2.5BMD (T-score) Raloxifene PTH CalcitoninHRT HRT During Hot Flushes Post Vasomotor Symptoms Pre fracture Post Fracture Risk of Fracture AGE Bisphosphonates Or Strontium Ranelate 50 55 60 65 70 75 80 85 90
    63. 63. Pharmacologic therapy for osteoporosis Antiresoptive- HRT SERM and bisphonates Anabolic- long PTH Teriparatide
    64. 64. 1.HRT&Raloxifene 1.HRT should not be used solely for prevention of osteoporosis-  Hot flushes  2.Raloxifene –Approved in US to reduce the risk for invasive breast cancer(increased risk for VTE and fatal stoke)
    65. 65. Bisphosphonates  1.Oral  Alendronate  Residronate  Ibandronate  2.IV  Ibandronate  Zoledronic acid
    66. 66. calcitonin  3rd line therapy option  -benign side effect profile and ease of administration  Spinal#s-short term Analgesic effect-4weeks  Should not replace the use of more effiective therapies,such as bisphosphonates
    67. 67. 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
    68. 68.  UK-PTH  USA-teriparatide  Teriparatide has also been licensed for GIOP and male osteoporosis  Much more useful in Vertebral #s
    69. 69. PTH- complications/Contraindications  1 first dose dizziness  2Hypercalcemia 3Hyperuricemia  1.h/oRadiation  2.Renal failure
    70. 70. 1o.Surgical management
    71. 71. 2.Role of Orthopaedicians&surgical management  The goals of surgical treatment of osteoporotic fractures include  rapid mobilization and return to normal function and activities  Avoid too much manipulations  Progressive physio therapy
    72. 72. 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
    73. 73. Kyphoplasty Lateral radiograph demonstrates multiple osteoporotic vertebral compression fractures. Kyphoplasty has been performed at one level
    74. 74. B) troch.#  1.Role for augmentation  2.IM hip#implants  3.coating of implants with hydroxyapatite  4.primary arthroplasty
    75. 75. 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
    76. 76. 11.Complications
    77. 77. 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
    78. 78. 12.PREVENTION
    79. 79. 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
    80. 80. prevention 1. prevention of falls 2.prevention and treatment of bone fragility 3.use of external hip protectors.
    81. 81. 1. prevention of falls 1.Impaired balance 2.gait and mobility 3.Poor vision 4.reduced muscle strength 5.impaired cognition
    82. 82. Other causes for falls- Medication&co-morbid disease  Psychoactive medication-  benzodiazepines.  antidepressant  Certain co-morbid disease- stroke, Alzheimers dementia and parkinsons diseases
    83. 83. 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
    84. 84. Home environment modifications 1 removing loose rugs or extension cords 2.repairing rickety stairs 3.Bathroom ergonomics-adding grab bars 4.increasing lighting
    85. 85. Regular physical activity plays a therapeutic role in severe osteoporosis
    86. 86. Hip protectors Specialized undergarments Poor compliance Latest data-ineffective and should not be recommended alone
    87. 87.  13.RECENT ADVANCES
    88. 88. 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.”
    89. 89.  2.Omega-3 Fatty Acids Reduce hs-CRP1  “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). They’re 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
    90. 90.  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.
    91. 91. 4.Atypical femoral fractures due to bisphosphonates  Atypical femoral fractures with bisphosphonate treatment  Experience in two large United Kingdom teaching hospitals
    92. 92.  14. Case study
    93. 93. Case 1. Sitaratnam 85y.  Severe osteoporoti, Known diabetic ,HTN and hemiplegic pt .  presented with 1.y.post operative non union troch.# with PFN
    94. 94. Cemented bipolar
    95. 95.  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
    96. 96.  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
    97. 97. Case no 2.Secondary osteoporosis
    98. 98. 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
    99. 99. 3rd x-ray on 18 -5- 12
    100. 100. Investigations  Low s.calcium and phosphorus  25 hydroxy vit.D- Insufficient -20Ng/ml  PTH,,Alk.phosphatase-normal  DEXA-severe osteoporosis
    101. 101. Calcium-7.5 (8.5-11mg%) insufficiency
    102. 102. 25 hydroxy Vit.D-20Ng/ml insufficiency(6-20ng/ml)
    103. 103. BMD tasted by DEXA
    104. 104. DEXA-OSTEOPOROSIS-severe osteoporosis  LT.FEMUR—3.8  RT.FEMUR—3.2  SPINE—4.1
    105. 105. Now pt. is on  1.)Calcium-1g/d  2.)Vit.D 6o ooo/w  3)high protien diet 4.)Teriparatide-25microgram/day
    106. 106. BONISTA/FORTEO 1)BONISTA-ORTHOLANDS RANBAXY 2)FORTEO-Eli LILLY
    107. 107. 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 problem and adviced her
    108. 108.  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
    109. 109. 15.CONCLUSION
    110. 110. Education -Ignorance about osteoporosis is still common among Health professionals Patients and Public, - So that the education of all of these groups is necessary.
    111. 111.  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

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