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METABOLIC BONE DISEASE.pptx
- 1. METABOLIC BONE DISEASES PRESENTER DR. MANASIL MALLA, JR1 DEPARTMENT OF ORTHOPAEDICS KATHMANDU MEDICAL COLLEGE TEACHING HOSPITAL SINAMANGAL
- 2. APPROACH TO METABOLIC BONE DISEASE HISTORY PHYSICAL EXAMINATION INVESTIGATIONS RADIOLOGICAL LABS TREATMENT
- 3. HISTORY • PATIENT PARTICULARS – Age – Gender • Presenting Complaints • Past History • Personal History
- 4. Examination • Head to Toe Examination
- 5. Radiographs
- 9. DEXA Dual Energy Xray Absorptiometry • Sites to be examined in DEXA : Femoral Neck Lumbar Spine
- 10. DEXA • Patient positioning : Supine with hip Flexed
- 11. DEXA Advantages High Accuracy Radiation dose to patient low Radiation to Technician low Takes only about 20 min Limitations Cant differentiate Cortical or Trabecular Bone Bone spurs (OA) falsely increase bone density
- 12. OSTEOPOROSIS
- 13. OSTEOPOROSIS • Osteo means “bone” and porosis means “porous” Normal Bone Osteoporotic Bone
- 14. • Abnormally low bone mass with defects in bone structure leading to • Fragile • greater than normal risk of fracture
- 15. WHO definition Bone Mineral Density (BMD) 2.5 SD or more below the average value for young healthy adult (T score <-2.5 ) CLASSIFICATION T- SCORE NORMAL -1 AND ABOVE OSTEOPENIA -2.5 TO -1 OSTEOPOROSIS LESS THAN -2.5
- 16. T- Score Z - Score No. of SD the BMD is above or below the mean for young normal individual No. of SD the BMD is above or below the mean for a age and sex matched reference population
- 17. EPIDEMIOLOGY • 200 million people worldwide have osteoporosis • In Nepal, prevalence of osteoporosis 22.4%
- 18. DEMOGRAPHICS • Male : Female ratio is 1:4 Low Peak Bone Mass Hormonal changes after menopause • Men have a higher prevalence of secondary osteoporosis
- 19. Vertebral fractures > Hip Fractures > Colles Fractures
- 20. TYPES OF OSTEOPOROSIS PRIMARY SECONDARY Type I : (POST MENOPAUSAL ) • Estrogen Withdrawal Effect • Almost exclusively trabecular Type II : (SENILE ) • Age Related >70 years • Trabecular > Cortical bone SYSTEMIC DISEASES : Hyperthyroidism Skeletal Metastases Multiple Myeloma DRUGS : Corticosteroids Anticonvulsants LIFESTYLE : Alcohol Smoking
- 21. Systemic Diseases Causing Osteoporosis Endocrinal Disorders : Cushing’s Syndrome Hyperparathyroidism Rheumatological Disorders : Rheumatoid Arthritis Ankylosing Spondylitis Inherited Disorders Osteogenesis Imperfecta Marfans Syndrome Nutritional/ GI disorders Malabsorption Syndromes
- 22. Systemic Diseases Causing Osteoporosis Hypogonadal States Turners Syndrome Kleinfelters Syndrome Hematological Disorders Multiple Myeloma Leukemia Lymphoma
- 23. DRUGS THAT CAUSE OSTEOPOROSIS Glucocorticoids Cyclospoprine Anticonvulsant Drugs Aromatase Inhibitors SSRIs Proton Pump Inhibitors Lithium OHA (Thiazolidinediones) Excessive Thyroxine
- 24. Risk Factors Modifiable Risk Factors Inadequate nutritional absorption Lack of physical activity Underweight (BMI < 18.5 kg/m2 ) Cigarette Smoking Alcohol Consumption >14U/wk in women >21U/wk in men Vitamin D Deficiency
- 25. Risk Factors Non-modifiable Risk Factors Advancing age Sex White race Previous hip fractures Family history of osteoporosis Rheumatoid arthritis
- 26. PATHOPHYSIOLOGY Bone Formation Bone Resorption Imbalance between Bone Formation and Bone Resorption
- 27. • In young adults: – Resorbed bone replaced by equal amount of new bone tissue • After age 30–45: – resorption slowly exceeds formation (exaggerated in postmenopausal women)
- 28. • Loss of estrogen – increases production of Receptor Activator of Nuclear Factor-ќβ Ligand (RANKL) – Decreased production of osteoprotegerin increases osteoclast activation and resorption
- 29. CLINICAL FEATURES SYMPTOMS Mostly asymptomatic Back pain Back deformity
- 30. Signs Dowagers/ Widows hump Loss of height Point tenderness without neurological symptoms Thoracic kyphosis and Loss of height
- 31. XRAYS • 1st Investigation • Not Diagnostic • Radiological osteopenia : Bone which appears to be less ‘dense’ than normal on X-ray
- 32. • Signs of radiological osteopenia
- 33. SINGH’S INDEX Developed by Dr. Manmohan Singh (1970, JBJS) As osteoporosis progresses trabeculae get thinner and disappear
- 34. Five trabecular types can be present in the proximal part of the femur: 1. principal compression 2. secondary compression 3. primary tensile 4. secondary tensile 5. intertrochanteric
- 35. GRADE 6 All normal trabeculae groups visible
- 36. GRADE 5 Loss of trochanteric and secondary trabeculae
- 37. GRADE 4 • Reduced but continuous primary tensile group
- 38. GRADE 3 • Discontinuous primary tensile group
- 39. GRADE 2 Loss of primary tensile group
- 40. GRADE 1 • Reduction in primary compressive group
- 41. LAB INVESTIGATIONS DIAGNOSIS Investigate Secondary Causes Dual Energy Xray Absorptiometry (DEXA) Scan (Gold Standard ) Others: (FDA Approved) Quantitative CT Quantitative Ultrasound Liver Function Tests Renal Function Tests Thyroid Function Tests Serum Vitamin D Serum / 24 Hr Urine Calcium Urine Bence jones protein /Bone Biopsy
- 42. Indications for BMD measurement (The International Society for Clinical Densitometry) • Women ≥ 65 years and Men ≥ 70 years • Adults > 50 years with Risk Factors • Adults with fragility fracture • Anyone being considered for pharmacological therapy for osteoporosis
- 43. DEXA Dual Energy Xray Absorptiometry • GOLD Standard for measuring BMD • High Accuracy • Sites to be examined in DEXA : Femoral Neck Lumbar Spine
- 44. DEXA • 2 photons with different attenuation profiles produced • Patient positioning : Supine with hip Flexed
- 45. DEXA Advantages High Accuracy Low Radiation Dose to patient Very little Scatter Radiation to Technician Takes only about 20 min Limitations Cant differentiate Cortical or Trabecular Bone Bone spurs (OA) falsely increase bone density
- 46. Quantitative CT • Sensitivity of upto 85% and a specificity of 89% • The detection rate for osteoporosis : 10.9% for DEXA and 45.1% for QCT
- 47. Quantitative CT Advantages Geometry of bone ( spatial distribution of bone mass ) Bone Density + Bone mass Existing previous CT can be used Limitations High Radiation dose Expensive
- 48. Fracture Risk Assessment Tool FRAX®
- 49. Treatment
- 50. Non Pharmacological Treatments : • Exercise – Prevents bone loss but no gain of bone mass in osteoporosis
- 51. Non Pharmacological Treatments : Diet Rich in Calcium and Vitamins Dairy products Ground Nut Soyabeans Sardines
- 52. Dietary Supplements • Calcium and Vitamin D Calcium combined with vitamin D leads to ∼20– 30% fracture risk reduction With adequate Calcium intake greater BMD response to antiresorptive therapy
- 53. Pharmacological Therapy : Prevention Treatment ESTROGEN CALCITONIN TERIPARATIDE DENOSUMAB BISPHOSPHONATES Alendronate Zolendronic Acid Ibandronate Risedronate
- 54. DOC for osteoporosis treatment Reduce the incidence of new vertebral fractures by up to 50% hip fractures by 40% BISPHOSPHONATES
- 55. DRUG DOSE ROUTE FREQUENCY Alendronate 10 mg daily or 70 mg once weekly ORAL ONCE DAILY / WEEKLY Risedronate 5 mg daily or 35 mg weekly ORAL ONCE DAILY OR WEEKLY Ibandronate 150 mg monthly ORAL / I.V ONCE A MONTH ORALLY/ ONCE EVERY 3 MONTHS I.V Zoledronic acid 5 mg (pre and post Hydration ) I.V INFUSION ONCE A YEAR
- 56. Precautions (Oral Bisphosphonates) 1. Empty Stomach (reflux with food ) 2. Full glass of Water (Dilute) 3. Donot lie down till 30 min (gastric emptying )
- 57. Side Effects • Osteonecrosis of the jaw • Atypical femoral fracture (Subtrochanteric Fracture )
- 58. Denosumab Monoclonal Antibody Approved by the FDA in 2010 Given Subcutaneously (60 mg ) Every 6 months
- 59. Side effects Hypersensitivity reactions Hypocalcemia Skin reactions including dermatitis Rash and eczema rebound increase in bone turnover and acceleration of bone loss on discontinuation
- 60. TERIPARATIDE PTH ANALOGUE PTH 1-34 Full Molecule of PTH is 84 AA Osteoclastic Pth 1-34 Osteoblastic 20 mcg S/C daily
- 61. SURGICAL TREATMENT GOALS We are not just treating the fracture Elderly patient with several comorbidities Hollistic treatment
- 62. Osteoporosis and Orthopaedic Surgery In Cancellous Bone : • Trabeculae are thinned and reduced in number
- 63. • In Cortical Bone : • cortical thinning • loosening of screws Normal Cortical Thickness Reduced Cortical Thickness
- 64. 20 years/F 80 years/F
- 65. Use of Load Sharing Devices than Load bearing device Use of Wide Buttress Plates Longer Nails and Plates Use of Locking Screws Augmentation by Bone cement or Bone grafts
- 66. Pagets Disease
- 67. Etiology • Environmental factors • Genetic Factor :
- 68. Pathophysiology • Starts At Metaphysis • Marked Increase In Osteoblastic And Osteoclastic Activity • Accelerated Bone Turnover
- 69. • Osteolytic Or Vascular Stage • Osteoblastic Stage
- 70. Clinical Features Symptoms • Sites : Pelvis and Tibia – Femur, skull, clavicle and spine • Mostly asymptomatic • If symptomatic dull aching pain
- 71. Signs
- 72. Xray • Flame Shaped Osteolytic Areas • Osteoporosis Circumscripta • Stress fracture
- 73. LAB PARAMETERS • Serum Calcium And Phosphate Normal • Raised ALP (Reflects Osteoblastic Activity)
- 74. Complications • Fracture • Osteoarthritis • Nerve compression and Spinal stenosis • High Output Cardiac failure • Hypercalcemia • Intraop bleeding • Bone sarcoma
- 75. Treatment • Non-Surgical : – IV Zoledronate • Surgical
- 76. Reference • Apley & Solomon's System of Orthopaedics and Trauma – 10e • Harrison Principle of Internal medicine 21e • Review article : Diagnosis and Treatment of Osteoporosis: What Orthopaedic Surgeons Need to Know – Journal of the American Academy of Orthopaedic Surgeons 2019 • Review article : Diagnosis and Treatment of Osteoporosis – Institute for Clinical Systems Improvement / European Journal of Rheumatology 2017
Editor's Notes
- Osteoporosis – Elderly/ Post menopausal Rickets : Children (before fusion of physes ) Osteomalacia : Adults (After fusion of Physes) Primary hyperparathyroidism : Middle aged men and women Pagets Disease : >55 years Osteoporosis - M: F ratio 1:4 Primary Hyperparathyroidism – M:F ratio 1:2 Pagets Disease : Equal incidence
- Larger Head size : Pagets Kyphotic Deformity / Dowagers Hump Spine Tenderness /chvostek Trousseau sign
- Loosers zone : indentation of the acetabula producing the trefoil or champagne glass pelvis; Widening of physis , Flaring of Metaphyses
- subperiosteal cortical resorption of the middle phalanges. Hyperparathyroidism
- GOLD Standard for measuring BMD High Accuracy
- 2 photons with different attenuation profiles produced Photo from Metabolic Bone disease Springer k. DXA utilizes ionizing radiation with photon beams of two different energy levels, resulting in a 2- D projection of the bone and soft tissue that is visualized on a computer monitor. The difference in attenuation of the photon beams passing through body tissues with variable composition provides a quantitative measurement of areal BMD in grams per square centimeter (g/cm2). The more dense the bones (from greater mineral content), the more energy is absorbed, and the less energy detected
- Is made up two words osteo and porosis
- A clinical disorder characterized by abnormally low bone mass and defects in bone structure, a combination which renders the bone unusually fragile and at greater than normal risk of fracture in a person of that age, sex and race
- harrison
- Compares a persons BMD with young healthy adult age 30 Compares a person’s BMD with a person of same gender and sex
- 2019 Nepjol S Bagudai
- By the end of bone growth, mean bone mass is about 5–10% greater in young men than in young women, due mainly to increased appositional bone formation when androgen levels rise after puberty Osteoporotic fractures in men under 60 years of age should arouse the suspicion of some underlying disorder – notably hypogonadism, metastatic bone disease, multiple myeloma, liver disease, renal hypercalciuria, alcohol abuse, malabsorption disorder, malnutrition, glucocorticoid medication or anti-gonadal hormone treatment for prostate cancer.
- most fractures, especially those of the hip and vertebrae, show exponential increases with advancing age : harrison
- riggs
- Thyrotoxicosis Diabetes Adrenal Insufficiency Chronic Liver Disease Pernicious anemia
- (delayed puberty low bone mass that persists into adulthood)
- ppi
- Asian race
- (postmenopausal women)
- Remodelling Bone remodelling serves several crucial purposes: ‘old bone’ is continually replaced by ‘new bone’ and in this way the skeleton is protected from the excess accumulation of fatigue damage and the risk of stress failure;
- Pain kasto Stress fracture
- Codfish vertebra Compression fractures of the vertebral bodies Loss of trabecular definition Thinning of the cortices wedging or compression of the vertebral end plates Codfish vertebra
- Classified Xrays of Hip Based on the visibility of the trabecular types seen in the femoral neck
- Photo from Metabolic Bone disease Springer k. DXA utilizes ionizing radiation with photon beams of two different energy levels, resulting in a 2- D projection of the bone and soft tissue that is visualized on a computer monitor. The difference in attenuation of the photon beams passing through body tissues with variable composition provides a quantitative measurement of areal BMD in grams per square centimeter (g/cm2). The more dense the bones (from greater mineral content), the more energy is absorbed, and the less energy detected
- Measures precise Volumetric bone mineral density Separate BMD measurement for Trabecular and cortical bone
- Developed by WHO Predicts 10 year probability of major osteoporotic fractures Hip, vertebrae, humerus, wrist
- Both resistance and balance training
- HARRISON
- Patrick AR, Brookhart MA, Losina E, et al. The complex relation between bisphosphonate adherence and fracture reduction. J Clin Endocrinol Metab. 2010;95(7):3251–59. doi: 10.1210/jc.2009-2778.
- A, R I, Z for post menopausal ARZ for glucocorticoid induced Inhibit Osteoclast Alendronate : Inhibiting ATP in osteoclasts Apoptosis of Osteoclasts Risedronate/ Zolendronate : Inhibit Mevalonate pathway (cholesterol synthesis ) enzyme farnesyl pyrophosphate synthase no maturation of Osteoclasts Apoptosis of Osteoclasts
- (usually follows a dental procedure in whichh bone is exposed ) (overall risk low compared to the number of hip fractures saved by these therapies)
- Fully human monoclonal antibody to RANKL Binds to RANKL, inhibiting its ability to initiate formation of mature osteoclasts from osteoclast
- Only drug that improves Bone Architecture (Both Trabecular and Cortical ) Hypercalcemia Gout
- Thereby bone holding capacity of implant is reduced
- Excess bone destruction and unorganized bone formation Localized sites of increased bone turnover Enlargement and thickening of the bone Internal architecture is abnormal Unusually brittle bone
- Viral infections Pollutions SQTM1
- Large Resorption Filled With Vascular Fibrous Tissues Adjacent Area Osteoblastic Activity Involves Both Periosteum And Endosteum Increased Bone Thickness Thickened Bone Becomes Increasingly Sclerotic And Brittle
- Age Group : >50yrs of age Sex : M=F
- Deformity Anterior Tibial Bow Anterolateral Femoral Bow Head enlarged Osteitis Deformans (The limb looks bent and feels thick, and the skin is unduly warm - hence the term ‘osteitis deformans’. ) Bent Limb, Thick Bone, Warm Skin Skull Base Flattenig Short Neck Cranial Nerve Compression Steal Syndrome Spinal Claudication
- circumscribed patch of osteoporosis in the skull (osteoporosis circumscripta) Stress fractures in tibia and fibula
- Fracture Fixation Nerve decompression Arthroplasty For Severe And Painful Osteoarthritis