MEDICAL MANAGEMENT OF OSTEOPOROSIS AND SURGICAL SIGNIFICANCE

1. OSTEOPOROSIS TREATMENT
DR. K.VINOTHKUMAR
FINAL YEAR POSTGRADUATE
OSMANIA GENERAL HOSPITAL,HYD

2. OSTEOPOROSIS TREATMENT
RISK FACTOR
ASSESSMENT
PREVENTION TREATMENT
• MEDICAL
• SURGICAL

3. PREVENTION
• DIET
• DAILY CALCIUM INTAKE 700 – 1200 MG
• DAILY VIT D INTAKE 800 IU
• IF INTAKE IS NOT ADEQUATE – SUPPLIMENT
• EXPOSE TO SUNLIGHT 20 MINS DAILY. BETWEEN 10am – 3pm. MIN 20-30 % BODY
SURFACE AREA SHOULD BE EXPOSED
• EXERCISE
• AIM – ATTAIN PEAK BONE MASS IN THIRD DECADE.
• NUTRITION AND WEIGHT BEARING EXERCISE.
• FALL REDUCTION : IMPROVING VISUAL ACUITY

4. RISK FACTOR ASSESSMENT
FEMALES AGE > 65 YEARS
MALES AGE > 75 YEARS
FEMALES AGE < 65 YRS
MALES AGE < 75 YRS
+
HISTORY OF FRAGILITY
FRACTURE
AGE < 50 YEARS
+
• H/O FRAGILITY FRACTURE
• H/O STEROID INTAKE
• PREMATURE MENOPAUSE
AGE < 40 YEARS
+
• MULTIPLE FRAGILITY #
• HIGH DOSE STEROID MORE
THAN 3 MONTHS
WHO NEED…?

5. FRAX TOOL

6. CLINICAL /
RADIOLOGICAL HIP
OR VERTEBRAL #
• T SCORE < -2.5
• T SCORE B/W -1 TO -2.5 WITH
HIP FRAGILITY # RISK >3%

7. MEDICAL MANAGEMENT
ANTI RESORPTIVES
• BISPHOSPHONATES
• DENOSUMAB
• HORMONE REPLACEMENT
THERAPY
• SELECTIVE ESTROGEN
RECEPTOR MODIFIER
ANABOLIC ANGENTS
• TERIPARATIDE
• CALCITRIOL

8. BISPHOSPHONATES
• DECREASE OSTEOCLASTIC ACTIVITY
• FIRST LINE TREATMENT
• TYPES:
• NON NITROGEN CONTAINING INCORPORATION OF NON HYDROLYSABLE
ATP APOPTOSIS OF OSTEOCLAST
• NITROGEN CONAINING  TOXIC ACCUMULATION IN OSTEOCLAST
• RENAL CLEARANCE 30-35 ML/MIN NEEDED

9. ALENDRONIC ACID
• MOST COMMONLY USED BISPHOSPHONATE
• 10MG DAILY 30 MINS BEFORE FOOD / 70 MG WEEKLY.
• REDUCE VERTEBRAL AND NON VERTEBRAL FRACTURES
• USED IN POST MENOPAUSAL WOMEN, GIOP, MEN WITH OSTEOPOROSIS
• SIDE EFFECTS: UPPER GI UPSET,ESOPHAGITIS,ESOPHAGIAL ULCERS,
OSTEONECROSIS OF JAW, ATYPICAL SUBTROCHANTRIC FRACTURE OF FEMUR
• ALL BISPHOSPHOANTES SHOULD BE TAKEN WITH FULL GLASS OF WATER TO
PREVENT ENLODGEMENT OF DRUG IN OESOPHAGUS

10. RISEDRONATE
• SIMILAR ANTIFRACTURE EFFICACY TO ALENDRONIC ACID
• 5 MG DAILY / 35MG WEEKLY
• REDUCE VERTEBRAL FRACTURES IN GIOP
• SLIGHTLY BETTER UPPER GI TOLERABLITY THAN
ALENDRONIC ACID

11. ZOLENDRONIC ACID
• DOSE – 5MG ONCE A YEAR IV WITH CALCIUM AND VITD SUPPLIMENT.
• REDUCE THE RISK OF VERTEBRAL ,NON VERTEBRAL AND HIP
FRACTURES IN POST MENOPAUSAL WOMEN.
• INCREASE BMD IN GIOP
• PREREQUISITES: RENAL FUNCTION 35ML/MIN, Sr. CALCIUM
• SIDE EFFECTS: INFLUENZA LIKE ILLNESS, HYPOCALCEMIA, ATRIAL
FIBRILLATION, OSTEONECROSIS OF JAW

12. IBADRONATE
• 2.5 MG DAILY ORAL OR 150 MG MONTHLY
• INTRAVENOUS 3MG/3 MONTHLY
• REDUCE THE RISK OF NON VERTEBRAL FRACTURES
• SIDE EFFECTS: INFLUENZA LIKE SYMPTOMS.
• EFFICACY: ZOLENDRONATE > RISENDRONATE > IBADRONATE > ALENDRONATE.
• OTHER USES: PAGETS DISEASE, OSTEOGENESIS IMPERFECTA , OSTEOLYTIC
MALIGNANCIES.

13. BISPHOSPHONATE USAGE
SIDE EFFECTS:
DYSPEPSIA
THIGH, GROIN PAIN  ATYPICAL
FEMUR #
EVALUATE
ASSESS BY 3-5 YEARS
(FRAX, BMD)
CONTINUE IN
• AGE > 75 YEARS
• H/O HIP OR VERTEBRAL #
• ANY FRACTURE DURING
TREATMENT
• PATIENT ON STEROID
• PATIENT CHOICE TO
CONTINUE
• RISK OF #
• LIFE EXPECTANCY
IF STILL CONTINUING
ASSESS BMD AT 5 YEARS
BMD – ADEQUATE STOP BMD IS
LESSCONTINUE
ALENDRONATE -10 YRS
RISENDRONATE- 7 YRS

14. COMPLICATIONS AND MANAGEMENT
ATYPICAL FRACTURES:
• REDUCTION IN MOPPING UP OF SUBCLINICAL MICROFRACTURES BY
OSTEOCLAST LEADS TO ACCUMULATION OF MICRODAMAGE.
• CLINICAL FEATURES:
• LOW ENERGY FALL/ NO TRAUMA (SIMILAR TO PATHOLOGICAL FRACTURE)
• PRODROMAL SYMPTOMS : THIGH PAIN

15. MAJOR FEATURES:
• BETWEEN JUST DISTAL TO LT
AND PROXIMAL TO
SUPRACONDYLAR FLARE
• ASSO. WITH NO OR MINIMAL
TRAUMA
• TRANSVERSE OR SHORT
OBLIQUE
• NON COMMUNITED
• COMPLETE FRACTURE ( IF
INCOMLETE IT INVOLVE ONLY
LATERAL CORTEX )
MINOR FEATURES:
• LOCALISED PERIOSTEAL
REACTION IN LATERAL CORTEX
• GENERALISED INCREASE IN
CORTICAL THICKNESS
• PRODROMAL THIGH PAIN
• BILATERAL # ,SYMPTOMS
• DELAYED HEALING
• USE OF MEDICATIONS
(BISPHOSPHONTES,
PPI,GLUCOCORTICOIDS )

16. INVESTIGATIONS
• XRAY
• ALWAYS TAKE BILATERAL XRAY
• CT : # LINE
• MRI : # LINE , EDEMA / HYPEREMIA

17. TREATMENT :
• COMPLETE FRACTURES
• PROXIMAL FEMORAL NAILING
• IMPENDING FRACTURES
• DREADED BLACK LINE IN XRAY .ENDOSTEAL THICKNESS IN LATERAL CORTEX
• CONFIRM WITH CT OR MRI
• INCOMPLETE FRACTURE
• LATERAL CORTEX THICKENING
• NO PAIN
• NO CORTICAL LUCENCEY
LIMITED WEIGHT BEARIING TILL
BONE EDEMA SUBSIDES IN MRI
(2-3 MONTHS )
• PAIN
• RADIOLOGICAL FEATURES OF #
PROPHYLACTIC NAILING

19. OSTEONECROSIS OF JAW
• SEEN IN BISPHOSPHONATES AND DENOSUMAB
• ESPECIALLY HIGH DOSE IV BP FOR METASTATIC CARCINOMA
• CAUSE – UNCLEAR
• PREVENTION- MAINTAIN ORAL HYGIENE, AVOID DENTAL
PROCEDURES IN PATIENTS ON HIGH DOSE BISPHOSPHONATES.

20. DENOSUMAB
• HUMANISED ANTIBODY WHICH TARGET RANK-L
• DOSE: 60 MG SC ONCE IN 6 MONTHS.
• 120MG IN GCT, HYPERCALCEMIA OF MALIGNANCY
• NO RENAL DOSE ADJUSTMENT NEEDED
• EFFECT IS REVERSIBLE ONCE TREATMENT IS STOPPED
• SIDE EFFECTS: HYPO CALCEMIA, ATYPICAL FEMUR FRACTURE, ONJ,
REBOUND EFFECT.

21. HORMONE REPLACEMENT THERAPY
• PREVENT POST MENOPAUSAL BONE LOSS, VERTEBRAL ,NON VERTEBRAL AND HIP FRACTURES.
• MOSTLY USED IN WOMEN WITH EARLY MENOPAUSE
• RALOXIFEN:
• SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM)
• ESTROGEN RECEPTOR AGONIST IN BONE AND ANTAGONIST IN BREAST AND OTHER TISSUES.
• DOSE : 60 MG DAILY
• PREVENT ONLY VERTEBRAL FRACTURES
• SIDE EFFECTS: PERIPHERAL EDEMA, HOT FLUSHES, ANXIETY, RISK OF VENOUS THROMBOSIS.

22. • TIBOLONE
• PARTIAL AGONIST AT ESTROGEN,PROGESTERON AND ANDROGEN RECEPTOR
• REDUCE BOTH VERTEBRAL AND NON VERTEBRAL FRACTURES
• REDUCE BREAST CANCER BUT INCREASED RISK OF STROKE
• TESTOSTERONE
• USED IN MALES WITH OSTEOPOROSIS AND HYPOGONADISM
• INJECTION ONCE IN EVERY 4-6 WEEKS

23. ANABOLIC AGENTS
• STIMULATES BONE REMODELING AND PRODUCE NEW BONE
• USED AS SECOND LINE THERAPY
• INDICATIONS:
• SEVERE OSTEOPOROSIS
• FAILED FIRST LINE OF TREATMENT
• USED FOR SHORT COURSE AND FOLLOWED BY ANTI RESORPTIVE
AGENTS

24. PARATHYROID HORMONE
• CAUSES BONE RESORPTION AND FORMATION. BUT IN CYCLICAL
APPLICATION BONE FORMATION EXCEEDS RESORPTION AND CAUSES
NET BONE GAIN.
• TERIPARATIDE:
• SYNTHETIC ANALOGUE OF PARATHORMONE
• DOSE : 20 MCG DAILY SUBCUTANEOUS.
• REDUCE VERTEBRAL AND NON VERTEBRAL FRACTURES
• DON’T USE MORE THAN 2 YEARS IN LIFETIME

25. • ABALOPARATIDE:
• SYNTHETIC ANALOGUE OF PTHrP
• DOSE : 80 MCG DAILY
• INCREASE BOTH CORTICAL AND TRABECULAR BONE
• SIDE EFFECTS:
• HEAD ACHE ,MUSCLE CRAMPS
• CONTRAINDICATIONS:
• PATIENTS WITH RENAL STONES
• HYPERCALCEMIC DISEASE: HYPERPARATHYROIDISM
• RISK OF OSTEOSARCOMA: PAGETS, RADIATION,BONE METS.

26. CALCITONIN
• SECRETED BY PARAFOLLICULAR CELLS (ALSO KNOWN AS C CELLS) OF
THE THYROID GLAND
• INHIBIT OSTEOCLAST ACTION AND INDIRECTLY INCREASE OSTEOBLASTIC ACTIVITY
• DOSE: 200 UNITS/ DAY INTRANASAL
• REDUCE THE RISK OF VERTEBRAL FRACTURES.
• SIDE EFFECTS:CRUSTING, PATCHES, OR SORES INSIDE THE NOSE,
NAUSEA, FLUSHING.

27. CALCIUM AND VITAMIN D
• USED AS ADJUNCT TO OTHER OSTEOPOROSIS TREATMENTS
STRONTIUM RANELATE:
• WEAK INHIBITION ON ABSORPTION AND WEAK STIMULATION ON BONE FORMATION
( DUAL EFFECT )
• STRONTIUM ION ATTACHES TO HYDROXYAPATITE IN PLACE OF CALCIUM  HUGE
RAISE IN BMD IN DEXA
• DOSE 2 GRAM DAILY ORAL 2 HOURS AFTER FOOD
• SIDE EFFECTS : GI UPSET , DIARRHOEA , RASH, MI
MONITERING THE RESPONSE
• DEXA, BONE TURNOVER MARKERS
• POORLY ASSOCIATED WITH FRACTURE REDUCTION

28. FIXATION OF OSTEOPOROTIC BONE
• WHY OSTEOPOROTIC BONE IS PROBLEM…?

29. TYPES OF FAILURES
CUT OUT CUT THROUGH VARUS COLLAPSE PLATE PULLOFF NON UNION

30. PRINCIPLES OF FIXATION
• ACCURATE FRACTURE REDUCTION
• STABLE FIXATION
• LOCKED SPLINTING WITH LONG PLATES
• LOAD DISTRIBUTION,NO PEAK STRESSES
• PRESERVE BLOOD SUPPLY

31. ALIGNMENT & ACCURATE REDUCTION
• LOAD TRANSFER THROUGH FRACTURE ONLY IF FRACTURE ALIGNED
PROPERLY
• ANATOMICAL REDUCTION NEEDED IN JOINTS.

32. PRIMARY STABILITY
• HELPS IN EARLY MOVEMENT , PARTIAL OR FULL WEIGHT BEARING.
• MINIMIZE THE STRESS IN BONE IMPLANT INTERFACE.
• LOAD SHARING WITH HOST BONE – ACCURATE REDUCTION.
• LARGE CONTACT AREA B/W BONE AND IMPLANT
LONG , LOCKING PLATES.
MORE THINNER SCEWS  DISTRIBUTE THE LOAD

33. NON LOCKING VS LOCKING PLATE
NON LOCKING PLATE:
• WORKS BASED ON FRICTION
BETWEEN PLATE AND BONE &
HOLDING STRENGTH OF
SCREW IN BONE
• 50% REDUCED HOLD IN
OSTEOPOROTIC BONE
• STRESS CONCENTRARED ON
ONE SCREW
LOCKING PLATE:
• SCREWS LOCKED TO PLATE.
• AGNGULAR STABLE
• DISTRIBUTE THE STRESS
• PRESERVE BLOOD SUPPLY.

34. • STRICT NO TO UNICORTICAL SCREWS.

35. PRESERVE BLOOD SUPPLY
• NO PERIOSTEAL STRIPPING
• DON’T USE ELEVATOR
• INDIRECT REDUTION IS PREFERED
• MIPO IF # CAN BE REDUCED

36. INTRA MEDULLARY NAILS
• CORRECT ENTRY POINT.
• PFN- VARUS COLLAPSE
• EXCESSIVE ANTERIOR BOWING – ANTERIOR ENTRY POINT.
• ADEQUATE NAIL SIZE.
• RESIST SHEAR STRAIN
• CORRECT LENGTH
• NAIL TILL SUBCHONDRAL BONE- REDUCE STRESS ON LOCKING
SCREWS
• DYNAMIC LOCKING.
• ALLOW AXIAL MICROMOTION

37. METAPHYSEAL BONE
• MEMBRANOUS HEALING IN TRABECULAR BONE
• PROCESS INVOLVE ONLY FEW MILLIMETRES FROM FRACTURE SITE.
• HEALING OF GAP MAY BE SLOW OR INCOMPLETE.
• NEEDS ACCURATE REDUCTION OR FILLING OF VOID – AUTOLOGUS BONE GRAFT/
ALLOGRAFT/ SYNTHETIC BONE GRAFTS/ CALCIUM PHOSPHATE BONE CEMENT

38. AUGMENTATION OF FIXATION
• WHAT? TECHNIQUE TO ENHANCE THE FIXATION STRENGTH OF AN IMPLANT
• WHY? QUICK POSSIBLE MOBILIZATION
AVOID FAILURE DUE TO OSTEOPOROTIC BONE
• WHEN? HU < 100, SD <-2.5, LOCAL BONE CONSIDERATIONS
• WHERE? METAPHYSEAL BONE
PROXIMAL HUMERUS
FEMUR HEAD
DISTAL FEMUR, PROXIAMAL TIBIA
SPINE

39. • HOW?

42. COMPLICATIONS:
• LEAK INTO JOINT / VESSEL
• THERMAL NECROSIS ?
• TISSUE DISTURBANCE ?
• IMPLANT REMOVAL

43. • PMMA AUGMENTATION IN PEDICLE SCREW
• VERTEBROPLASTY , KYPHOPLASTY

44. HOW TO IMPROVE HEALING
SYSTEMIC THERAPIES
( Ca, Vit D,
ANTIRESORPTIVE/
ANABOLIC AGENTS)
LOCAL CELL
THERAPY:
• MESENCHYMAL
CELLS FROM
BONE MARROW
OR FAT CELLS
• RIA
LOCAL HUMORAL FACTORS:
• PARATHYROID HORMONE
• 30-60 MIC/KG IN TRICALCIUM
PHOSPHATE + COLLAGEN
• MICRO RNA
• BMP2
• VIA MESSENGER RNA

45. ARTHROPLASTY - HIP
• PROBLEMS:
• ACTIVE BONE IMPLANT INTERFACE ( HIGH BONE TURNOVER)
• AGE RELATED MEDULLARY EXPANSION (FEMLAES RECEIVED THR BEFORE 60 YRS)
• ASEPTIC LOOSENING
• OSSEOINTEGRATION???
• SOLUTION…
• CEMENTED IMPLANTS
• BISPHOSPHONATES – IMPROVE BONE STOCK, REDUCE REVISION.
• NON TRAUMATIC PATIENTS – IMPROVE BONE HEALTH COLLERED CEMENTLESS HIP
ARTHROPLASTY.

46. TAKE HOME MESSAGE
• PREVENTION IS BETTER THAN CURE
• ASSESS PATIENTS WHO NEED TREATMENT
• TREAT THE CAUSE
• SUPPLIMENT WITH CALCIUM AND VITAMIN D
• IN SURGERY – DISTRIBUTE THE STRESS