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Silent Bone Disease Osteoporosis -Hidden facts,Red flags,Prevention & Treatment dr.sandeep c agrawal agrasen hospital gondia india

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Bone Loss Trabeculae,Wedging,BMD,T score,Z Score,Vitamin D3,Calcium Deficiency,Osteomalacia,Hip Fracture Osteoporotic compression fracture and percutaneous vertrebroplasty, Ballon Kyphoplasty,Osteopotic Compression Fracture,Lumabar Spine,Thoracic Spine,Cement Leak,Spine Screw Fixation,CALCIUM,VITAMIN D,OSTEOPOROSIS,DIET FOR OSTEOPOROSIS,METABOLIC BONE DISEASE,HYPERPARATHYROIDISM,RENAL OSTEODYSTROPHY,RICKETS,BONE METABOLISM,OSTEOPOROSIS MYTHS,INTERNAL FIXATION IN OSTEOPOROTIC FRACTURES,Fracture Neck Femur,Intertrochanter Femur Fracture

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Silent Bone Disease Osteoporosis -Hidden facts,Red flags,Prevention & Treatment dr.sandeep c agrawal agrasen hospital gondia india

  1. 1. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 1 1 OSTEOPOROSIS :! PREVENTION,DIET & TREATMENT Dr.Sandeep C Agrawal Consultant Orthopedic Surgeon MS,DNB Agrasen Hospital Gondia Maharashtra India www.agrasenortho.com drsandeep123@gmail.com 09960122234 OSTEOPOROSIS: Red Flags & Preventive Cares
  2. 2. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 2 www.uc-osteoporosis.com
  3. 3. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 3
  4. 4. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 4 Selected Risk Factors “Red flags” 
 that can mean you could be at high risk for weak bones.
  5. 5. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 5 ❑ I’m older than 65 
 ❑ I’ve broken a bone after age 50 
 ❑ My close relative has osteoporosis or .has broken a bone 
 ❑ My health is “fair” or “poor” 
 ❑ I smoke 
 ❑ I am underweight for my height 
 5 1 Selected Risk factors
  6. 6. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 6 ❑ I started menopause before age 45 
 ❑ I've never gotten enough calcium
 ❑ I have more than two drinks of alcohol .several times a week 
 ❑ I have poor vision, even with glasses 
 ❑ I am prone to fall 
 ❑ I'm not active 6 2
  7. 7. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 7 I have one of these medical conditions: ❑ Hyperthyroidism ❑ Chronic lung disease ❑ Cancer ❑ Inflammatory bowel disease ❑ Chronic liver or kidney disease ❑ Hyperparathyroidism ❑ Vitamin D deficiency ❑ Cushing's disease ❑ Multiple sclerosis ❑ Rheumatoid arthritis 7 3
  8. 8. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 8 I take one of these medicines: ❑ Oral glucocorticoids (steroids) ❑ Cancer treatments (radiation, chemotherapy) ❑ Thyroid medicine ❑ Antiepileptic medications ❑ Gonadal hormone suppression ❑ Immunosuppressive agents 8 4
  9. 9. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 9 Strategies for prevention of osteoporosis: 1. High risk strategy: To identify women at risk & offer intervention 2. Global strategy: Population based, where the aim is to modify the risk factors in the general community  
  10. 10. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 10 ABOUBAKR ELNASHAR  
  11. 11. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 11 • Types of prevention of osteoporosis. 1. Primary: Aims at reaching at adolescent age a peak bone mass as high as possible. Should begin in childhood& continue throughout the life span to maximize bone mass. E.g. sufficient calcium intake, omit risk factors 2. Secondary: Aims at reducing bone loss peri & postmenopausal E.g. estrogens/gestagens, bisphosphonates &SERMs. 3. Tertiary: With manifest osteoporosis aims at preventing fractures.  
  12. 12. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 12 Bone mass •35% of cortical & 50% of cancellous bone mass are lost over a lifetime •The peak bone mass attained is a major determinant of subsequent bone mass& fracture risk in later life (Bonjour et al,1997). ABOUBAKR ELNASHAR  
  13. 13. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 13 5 steps for maximizing peak bone mass (National osteoporosis foundation) Most important for women who haven't reached their maximum peak bone mass, which usually occurs around the age of 30. Step 1: Daily recommended amounts of ca & vitamin D Step 2: Regular wt-bearing exercises Step 3: Avoid smoking& excessive alcohol intake Step 4: Risk factor assessment of developing osteoporosis. To institute strategies to maximize peak bone mass and minimize loss before it is too late to prevent the disease. Step 5: When indicated, BMD test to see if medication is needed ABOUBAKR ELNASHAR  
  14. 14. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 14 5 steps to minimizing bone loss especially after menopause (National osteoporosis foundation) Step 1: Balanced diet   Regular exercise program   Adequate intake of calcium in diet,   Regular sunlight exposure   Step 2: Stop smoking and reduce alcohol consumption   Step 3: Risk factor assessment & screening test Step 4: If required, medication for osteoporosis prevention Step 5: Avoid certain medications ABOUBAKR ELNASHAR  
  15. 15. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 15 Prevention Steps Are Simple National Osteoporosis Foundation (NOF) : ! FIVE simple steps to improve bone health and prevent osteoporosis.
  16. 16. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 16 www.uc-osteoporosis.com Pyramid for Osteoporosis Prevention and Treatment Pharmacotherapy (antiresorptives and anabolics) Address Secondary Factors (drugs and diseases) Lifestyle Changes (nutrition, physical activity, and fall prevention) What does this mean for your patients? Leading the Effort to Help Prevent and Treat Osteoporosis
  17. 17. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 17 OSTEOPOROSIS CARE:ABCDE Alcohol…No ! BMD Check up ! Calcium supplements: Cigarette(Smoking)..No ! Drug therapy,Diet & Doctor consultation ! Exercise
  18. 18. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 18 Steps 1 + 2 1.Daily recommended calcium and vitamin D. 
 2. Regular weight-bearing exercise
  19. 19. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 19 • FDA uses “Percent Daily Value” (% DV) to describe amount of calcium needed daily
 • 100% DV for calcium 
 = 1,000 mg
 • Look for this label: – “Nutrition Facts” on foods – “Supplement Facts” on vitamin/mineral supplements 19 Get enough calcium and vitamin D :
  20. 20. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 20 Example of “Daily Value” 
 If a food or supplement has 200 mg of calcium per serving, the “Nutrition Facts” or “Supplement Facts” panel shows:
 
 20 20% DV for calcium
 (200 mg ÷ 1,000 mg = 20%)
  21. 21. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 21 2. Vitamin D Essential for intestinal absorption of calcium. The recommended intake for women is 400 IU/d for ages 51 to 70, 600 IU/d over age 70, and 800 IU/day for all high-risk women (homebound, institutionalized, on chronic glucocorticoids, or who live in northern latitudes and therefore have limited exposure to sunlight) Sources of vitamin D include sunlight, vitamin D–fortified foods, fish oils, and supplements. Multivitamins typically contain 400 IU of vitamin D. Adequate calcium and vitamin D supplementation is key to ensure prevention of progressive bone loss. Calcium and vitamin D alone are insufficient to prevent fracture in those with osteoporosis.
  22. 22. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 22 Step 3 Avoid smoking and excessive alcohol.
  23. 23. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 23 Cessation of smoking • accelerates bone loss • smoking one pack per day throughout adult life was associated with a 5 to 10 percent reduction in bone density • negate the beneficial effect of estrogen therapy in postmenopausal women by acceleration of the metabolism of estrogen
  24. 24. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 24 Steps 4 & 5 4.Doctor Consultation ! 5. Bone density test and medication when appropriate.
  25. 25. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 25 TESTS AND DIAGNOSIS ▪ Osteopenia refers to mild bone loss that isn't severe enough to be called osteoporosis, but that increases the risk of osteoporosis. ! ▪ The best screening test is dual energy X-ray absorptiometry (DEXA) – measures the density of bones in the spine, hip and wrist and it's used to accurately follow changes in these bones over time. ▪ Ultrasound ▪ Quantitative CT scanning Dual energy X-ray absorptiometry
  26. 26. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 26 •T  score  ≥  -1 •T score -1 to -2.5 •T score < -2.5 Normal Osteopenia   Osteoporosis   WHO Classification of BMD using DEXA •T score < -2.5 + H. of fractureSevere Osteoporosis   T score represents the number of SD a patient is above or below
  27. 27. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 27 DEXA 1   ABOUBAKR ELNASHAR   DEXA Scan
  28. 28. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 28 Interpreting DEXA Results T scores (comparison with the young adult mean): relates to absolute fracture risk Z scores (comparison with reference values of the same  age):  related  to  the  individual’s  relative  risk   for their age.
  29. 29. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 29 www.uc-osteoporosis.com Low Z-score: Evaluate for secondary causes of osteoporosis Hypogonadism – Estrogen deficiency: menstrual history – Testosterone deficiency: serum testosterone Vit. D deficiency/ intestinal malabsorption – 24-h urine calcium – serum 25-hydroxy vitamin D – serum PTH Primary hyperparathyroidism: serum calcium and PTH Hyperthyroidism: serum TSH Idiopathic hypercalciuria: 24-h urine calcium Myeloma: SPEP
  30. 30. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 30 DEXA– Flaws? • DEXA overestimate bone mineral density of taller subjects and underestimate bone mineral density of smaller subjects. • In DEXA: bone mineral content is divided by the area of the site being scanned. • DEXA calculates BMD using area (aBMD: areal Bone Mineral Density), it is not an accurate measurement of true bone mineral density, which is mass divided by a volume.
  31. 31. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 31 • A repeat BMD measurements should be done on the same machine each time, or at least a machine from the same manufacturer. • Error between machines, or trying to convert measurements from one manufacturer's standard to another can introduce errors large enough to wipe out the sensitivity of the measurements. • DEXA results need to be adjusted if the patient is taking strontium, and calcium supplements. • Metallic artifacts in cloths or pockets cause errors. • Osteomalacia, Osteoarthritis of spine, old Fractures of spine and hip, aortic calcification affect BMD readings.
  32. 32. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 32 FRAX- 10 year risk of fragility fracture • Age, Sex, Height, Weight, • Previous fracture, • Family history of fracture, • Smoking, Alcohol, • Rheumatoid, Corticosteroid, • Secondary Osteoporosis • BMD
  33. 33. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 33   The FRAX® tool has been developed by WHO to evaluate fracture risk of patients. It is based on individual patient models that integrate the risks associated with clinical risk factors as well as bone mineral density (BMD) at the femoral neck.   The FRAX® models have been developed from studying population-based cohorts from Europe, North America, Asia and Australia. In their most sophisticated form, the FRAX® tool is computer-driven and is available on this site. Several simplified paper versions, based on the number of risk factors are also available, and can be downloaded for office use.   The FRAX® algorithms give the 10-year probability of fracture. The output is a 10-year probability of hip fracture and the 10-year probability of a major osteoporotic fracture (clinical spine, forearm, hip or shoulder fracture).    
  34. 34. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 34
  35. 35. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 35 II. Tests other than DEXA (peripheral bone densitometry devices (ACOG guideline, 2004) 1. Quantitative US (QUS) . 2. Single-energy x-ray absorptiometry. 3. Peripheral DEXA 4. Peripheral quantitative computed tomography less expensive low radiation exposure low precision& accuracy. Measure peripheral bone only. Cannot replace DEXA scans . ABOUBAKR ELNASHAR  
  36. 36. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 36
  37. 37. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 37
  38. 38. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 38
  39. 39. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 39 BMD Role?? • Osteoporosis is an arbitrary point on a scale, • Process of micro-architectural deterioration • Accelerated bone resorption exists throughout postmenopausal life, whereas osteoporosis does not. • Bone densitometry measures bone density, not bone turnover or bone stability. • 85% of the rise in risk of fracture in ageing women is attributable to something other than the loss of BMD. • Age is a better predictor of hip fracture than radial bone density.
  40. 40. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 40 BMD Monitoring Role?? Osteoporosis   Microarchitectural deterioration   Low bone density   ABOUBAKR ELNASHAR  
  41. 41. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 41 DRUG THERAPY www.uc-osteoporosis.com FDA-APPROVED MEDICATIONS INDICATIONS Postmenopausal Osteoporosis Glucocorticoid-induced Osteoporosis Men Drug Prevention Treatment Prevention Treatment Estrogen Calcitonin (Miacalcin®, Fortical®) Raloxifene (Evista®) Ibandronate (Boniva®) Alendronate (Fosamax®) Risedronate (Actonel®) Zoledronic acid (Reclast®) Teriparatide (Forteo®)
  42. 42. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 42 www.uc-osteoporosis.com
  43. 43. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 43 Pharmacologic Treatment
 Targets Osteoclast Inhibition of resorption Osteoblast Stimulation of formation
  44. 44. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 44 Bone marrow precursors Osteoblasts Osteoclast Lining cells Stimulators of Bone Formation Fluoride PTH analogs Sr Ranelate (?) Inhibitors of Bone Resorption Estrogen, SERMs Bisphosphonates Calcitonin Inhibitors of RANKL Cathepsin K Therapeutic strategies
  45. 45. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 45 www.uc-osteoporosis.com
  46. 46. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 46 Whom to treat ? Prior Hip/Vertebral Fracture or T Score < -2.5 or T Score -1 to -2.5 & 10 yr risk (FRAX) : HIP Fracture > 3 % or major osteoporotic Fracture> 20 % Postmenopausal women /men > 50 yrs with
  47. 47. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 47 Australian Family Physician, 2004   ABOUBAKR ELNASHAR  
  48. 48. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 48 Exercise • Any weight-bearing exercise regimen, including walking • Women with osteoporosis should exercise for at least 30 minutes three times per week • Improvements in bone density • reduced risk of hip fracture in older women
  49. 49. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 49 What keeps bones healthy
  50. 50. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 50 II. Regular exercise •In children& adolescents: Wt-bearing physical activity e.g.walking or running contributes to higher peak bone mass. •In postmenopausal: weight-bearing exercise produces small increases in bone density at the hip and improvement in balance& strength. Exercise in postmenopausal: resistance training {improve muscle mass, strength and balance} balance training which should be performed three times/w •Women with established osteoporosis: Activities that place an anterior load on the vertebral bodies e.g. forward flexion exercises: increased incidence of new vertebral deformities, and patients should be advised to avoid them.
  51. 51. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 51
  52. 52. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 52 VI. Fall reduction •Falls are the direct cause of more than 90% of osteoporotic hip fractures,and the tendency to fall increases with age. •Some studies have shown that, for women over age 70, the most important predictors of hip fractures are fall-related factors such as poor cognitive function, slow gait and otherwise impaired mobility, poor vision, drugs that impair alertness or balance, and history of falls. In women over 75, age and slow gait are equal to low BMD of the femoral neck as predictors of hip fracture.Unfortunately, labeling women as osteopenic or osteoporotic can cause fear of falling and lack of activity, leading to further acceleration of bone loss.
  53. 53. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 53 TOP CALCIUM SOURCES 1
  54. 54. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 54
  55. 55. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 55
  56. 56. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 56
  57. 57. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 57
  58. 58. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 59 Be happy when alone. Let happiness be your quality. And when you move from aloneness into involvement, into communication, relationship, carry that quality of happiness which was in loneliness — carry that.
  59. 59. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 60 References . IOF web site .“Osteoporosis and Bone Physiology” web site, 1999 - 2006 http:// courses.washington.edu/bonephys of Dr. Susan Marie Ott, MD. .Some slides are from teaching slides of British Medical Journal. • JAMA 2004;291(16):1999 • J Clin Densitom 2004;7(1):1-6 • J Am Acad Orthop Surg 2006;14:347 • National Osteoporosis Foundation (http://www.nof.org) • NEJM 2003;348:1187 • NEJM 2004;350(12):1189-99 • Osteoporosis Int 1998;8:1
  60. 60. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India www.agrasenortho.com! 61 .! Information contained and transmitted by this presentation is based on review of literature from internet and form Institute of Medicine summary on DRI for Vitamin D & Calcium,BJD AAOS,National Osteoporosis Foundation websites.! . Graphics,Images and jpeg files are taken from Google and yahoo  Image  to heighten the specific points in this presentation. ! ! • If there is any objection/or copyright violation, please inform drsandeep123@gmail.com for prompt deletion. ! ! • It is intended for use only by the doctors and orthopaedicians.! ! . Views expressed in this presentation are personal. • .For any confusion please contact the sole author for clarification. ! ! • Every body is allowed to copy or download and use the material best suited to him. ! ! There is no financial involvement.! !  • For any correction or suggestion please contact drsandeep123@gmail.com or www.agrasenorth.com.

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