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Osteoporosis Dr Akbar
1. OSTEOPOROSIS
DR. Md Akbar Khan MS(ORTHO)
Asst. Prof of Orthopaedics
ACSR Govt Medical College, Nellore
2. 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
3. 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
4. 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
6. 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
7. PRIMARY OSTEOPOROSIS
Type I - Postmenopausal osteoporosis
Type II - Senile osteoporosis
Idiopathic - Premenopausal and Younger
CLASSIFICATION
9. Non-modifiable
Peak bone mass
Female sex
Caucasian race
Advanced age
Family history
Potentially modifiable
Cigarette smoking & Alcoholism
Estrogen deficiency
Low body weight
Low calcium intake
Lack of physical activity
CONTRIBUTING FACTORS
10. 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
11. 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
12. 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
13. 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
14. 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
17. 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
18. 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
19. 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
21. 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
22. 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
28. Amount of bone matter per cubic centimeter of
bone
Reported in Three terms – Gm/ mm3
,T score &
Z score
Measured by
Dual Energy X Ray Absortiometry
Qualitative Ultrasound
Qualitative Computer Tomography
BONE MINERAL DENSITY
29. 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
30. X ray photons of different energy
Sites recommended by WHO
Total proximal femur
Femoral neck
Lumbar spine
Radius with evidence of
OA / surgery at
other 3 sites
DUAL ENERGY X RAY ABSORTIOMETRY
32. Emits ultrasonic waves
Attenuation of waves which predict strength
of bone
Measured in calcaneum
At present outdated due to errors
QUALITATIVE ULTRASOUND
33. Mainly for spine
Specifically analysis trabecular bone
Less precise than DEXA
More radiation
Costlier than DEXA
QUALITATIVE COMPUTER TOMOGRAPHY
34. 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
35. 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
38. Anti resoptive class of Drugs
Calcium/Vitamin D
Bisphosphonates
Calcitonin
Selective Estrogen Receptor Modulators (SERMS)
Anabolic Drugs
Parathyroid Hormone
Sodium fluoride & Strontium Renelate
Other Agents
Vitamin K2-7 fortified calcitriol & Denosumab
MEDICALTREATMENT
39. 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
40. 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
41. 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
42. 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
43.
44. GOALS
Improve quality of life
Give a stable fixation
Early mobilization & weight bearing
SURGICAL TREATMENT
46. Without opening fracture site & without
disturbing biomechanics
Use of longer plate with less no of screws –
greater stability
BIOLOGICAL FIXATION
47. 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
Maintaining a home environment that reduces the risk of falling is important. The next two slides list helpful considerations that patients should be made aware of.
Use handrails on stairs, in bathroom
Keep rooms free of clutter
Keep floor surfaces clean but not slippery
Wear supportive, low-heeled shoes. Do not walk in socks or floppy slippers
Use 100 watt bulbs in all rooms
Install ceiling lighting in bedrooms
Use rubber matt in shower/tub
Keep a flashlight at bedside
Check posture in mirror often
The quickest and easiest way to comprehend internal locking constructs is by using the external fixator as an analogy.
A internal locking construct is very similar to a “low profile” internal ex-fix. The main difference between the two is that the internal locking construct is positioned closer to the bone surface to increase position holding strength, and to also offset the bending moments and stress an ex-fix is typically exposed to when in use.
In addition to this analogy, we should bring to your attention terms such as ‘fixed position constructs,’ “fixed angle devices”, “locking screw and locking plate constructs”, all of these are frequently used to describe internal fixators. Incidentally fixed angle devices are not a new concept. Can anyone name a few?
Blade plates,
Dynamic hip screws
Dynamic condylar screws
With all this in mind, often the question arises…. Is an internal fixator any better than conventional plating? What are the benefits?
Liegt die herkömmliche Platte im Bereich der Schrauben nicht gut am Knochen an, kann es zum belastungsbedingten Abkippen kommen
To achieve fixed angles, a locking screw for an internal fixator incorporates one critical design feature, threads on the head of the screw. This is the main difference between standard cortex screws and locking screws. These threads screw into a matching thread on a plate when inserted.
However, other enhancements are also evident in specific locking screw designs, namely a larger core diameter (for resisting bending loads), a tighter thread pitch and a radial preload similar to that of the AO self drilling and tapping Schanz screw used in external fixators. Locking screws can be both bicortical and unicortical. however screws which are used in a unicortical manner, can feature self-drilling and self tapping tips.