This document provides information on osteoporosis, including its definition, classification, epidemiology, clinical features, investigations used for diagnosis, and management. Osteoporosis is defined as a reduction in bone density leading to an increased risk of fractures. It is classified based on whether it is primary/secondary and type. Diagnosis involves tests like DEXA scans, biomarkers, and imaging. Management includes lifestyle modifications, calcium/vitamin D supplementation, and medications like bisphosphonates, teriparatide, and denosumab that reduce resorption or stimulate bone formation.

1. OSTEOPOROSIS
Dr Rohil Singh Kakkar
PG Resident
Department of Orthopaedics
RHC, India

2. DEFINITION
 Osteoporosis is a diffuse reduction in
bone density that results when the rate of
bone resorption exceeds the rate of bone
absorption.
 Histologically , this is apparent by either
diminished osteoblastic activity or
excessive osteoclastic activity.

3. Osteoporosis byWHO
BMD(Bone Mineral Density ) 2.5 SD or more below the mean
for young healthy adult of same gender(T-score is equal to or
less than-2.5).

5. WHO CRITERIA FOR OSTEOPOROSIS
BMD compared with
young adult
T score
Normal < 1 SD below >/= -1
Low bone mass ( Osteopenia ) 1-2.5 SD below < -1
> -2.5
Osteoporosis >/= 2.5 SD below </= -2.5
Severe osteoporosis >/= 2.5 SD below
PLUS Fracture

6. CLASSIFICATION
RIGGS AND MELTON CLASSIFICATION :
a.Primary osteoporosis –
Type 1 : Postmenopausal
Type 2 : AgeRelatedOsteoporosis
b.Secondary osteoporosis

7. .  POST MENOPAUSAL OSTEOPOROSIS (TYPE 1)
 Caused by lack of estrogen
 Causes PTH to overstimulate osteoclast
 AGE RELATED OSTEOPOROSIS (TYPE 2 )
 Bone loss due to increased bone turnover
 Malabsorption
 Mineral and vitamin deficiency
 Patients usuallypresentwith fracturesof the hip ,
spine and forearm.
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8. SECONDARY OSTEOPOROSIS
ENDOCRINE : Cushing’s syndrome , Hypogonadism ,
Thyrotoxicosis , Hyperparathyroidism
DRUGS : Glucocorticoids , Heparin , Phenytoin ,
Immunosuppressants
CHRONIC DISEASES : Renal impairment , Liver
cirrhosis , Malabsorption , Rheumatoid Arthritis
OTHERS :Nutritional , Multiple Myeloma ,
Malignancy

9. Epidemiology
 In women it is 3 times morecommon than men due to
1.Low peak bone mass (PBM)
2.Hormonal changes at menopause
 1 in 3 women over 50 years suffer from osteoporosis.
 1 in 5 men over 50 years suffer from osteoporosis.
 15% - 30% men and 30%- 50% women suffer fractures related
to osteoporosis in their life time.
 Peak incidence :
 western countries – 70 -80
years
 india – 50 – 60years

10. Hormones & Growth factors regulating bone formation
Factor Target cells & tissue Effect
Interleukins
(IL-l, IL-3, lL-6, IL-ll)
Bone marrow,osteoclasts Stimulate osteoclast
formation & resorption
Tumor necrosisfactor
(TNF-a) ;
Granulocyte macrophage
stimulating factor
(GM-CSF)
Osteoclasts Stimulates bone resorption
Leukemic inhibitory Factor
(LIF)
Osteoblasts, osteoclasts Stimulates osteoblastand
Osteoclast formation in
marrow

11. Factor Target cells Effect
Parathyroid Hormone
(PTH)
Kidney & Bone Stimulate production of Vit-D &
helps resorption of calcium
Calcitonin Bone osteoclasts Inhibits resorptive action of
osteoclasts: lowerscirculating
Calcium.
Calcitriol
(1.25-dihydroxy vit-D3)
Bone Osteoblasts
Bone Osteoclasts,
Kidney,
Intestine
-Stimulates collagen,osteopontin,
osteocalcin synthesis;
-stimulates cell differentiation;
-Stimulates Calcium retention
-Stimulates calcium absorption
Estrogen Bone Stimulates formation of calcitonin
receptors, inhibiting resorption,;
Stimulate bone formation
Testosterone Muscle, Bone Muscle growth, placing stress on
bone to stimulate boneformation
Prostaglandins Osteoclasts Stimulate resorption and bone
formation
Bone Morphogenic
protein
Mesenchyme Stimulate cartilage protein &bone
matrix formation; replication

12. CLINICAL FEATURES
 Aka SILENT DISEASE.
 Low back ache- usuallymild.
 Loss of height
 KYPHOSIS
 Fractures- m/c at the level of
Dorso-Lumbar junction ,Hip
and Wrist Joint

13. MANAGEMENT
INCLUDES :
A.DIAGNOSIS
B. PREVENTION
C. TREATMENT

14. A. DIAGNOSIS
INVESTIGATIONS :
1.ROUTINE INVESTIGATIONS TO RULE OUT SECONDARY OSTEOPOROSIS
2. Plain Radiography
3. PHYSICAL EXAMINATION
4. DEXA (GOLD STANDARD FOR MEASURING BMD )
5.QUANTITATIVE ULTRASOUND
6. BONE TURN OVER MARKERS (BTM)

15. ROUTINE INVESTIGATIONS :
THE PRIMARY AIM IS TO EXCLUDE SECONDARY CAUSES OF OSTEOPOROSIS WHICH
INCLUDES :
COMPLETE BLOOD COUNT
ERYTHROCYTE SEDIMENTATION RATE (ESR)
SR. CALCIUM , PHOSPHATASE , ALBUMIN
ALKALINE PHOSPHATASE
PARATHYROID HORMONE (PTH) IF SERUM CALCIUM LEVEL IS HIGH THAN 10.5 mg %

16. X-ray
 Post menopausal osteoporosis : Trabecular
resorption and cortical resorption
 Senile osteoporosis: Endostealresorption
 Hyperparathyroidism: Sub periostealresorption
 Osteoporosis produces increased radiolucency of
vertebral bone. Approximately 30 to 80 percentof
bone tissue must be lost before a recognizable
abnormalitycan bedetected on spinal radiographs.
The main radiographic features of generalized osteoporosis
are cortical thinning and increased radiolucency.

17. CONVENTIONAL RADIOGRAPHY
 LS SPINE-
 Generalized osteopenia
 Thining and accentuation ofcortex
 Accentuationof primary trabeculaeand thinning of
secondary trabaculae.
 Vertically striated appearance vertebralbody.

18. KLEER KOPER score
Osteoporosis produces increased radiolucency of vertebral
bone. Approximately 30 to 80 per cent of bone tissue must
be lost before a recognizable abnormality can be detected on
spinal radiographs.

19. PHYSICAL EXAMINATION
For Osteoporosis
A.Height loss
B.Kyphosis
C.Humped back
For Vertebral fracture
A.Wall- occiput
distance Test
B.Rib-pelvis distance Test

21. Dual Energy X-ray Absorptiometry (DEXA)
 Commercially introduced in 1987.
 Principle – 2 x ray of 70Kvand 140kv are fired on site of
measurement with lag time of4ms.
 Detector detects accentuation of 2beams.
 CalculatesBMD.
 SITES-
 Central dexa- lumbar spine, hip, wholebody.
 Peripheral dexa- forearm , calcaneum.

22. Dual Energy X-ray Absorptiometry (DEXA)-
2-dimensional study
BMD = Amount of mineral
Area
Accuracy at hip > 90%
Low radiation exposure
Error in
Osteomalacia
Osteoarthritis
Previous fracture

23. BMD Interpretation
 T score: standard deviation of the BMD from
the average sex matched 35-year-old
 Z score: standard deviation score compared to
age matched control
 For every 1 decrease in T score, double risk of
fracture
 Regardless of BMD, patients with prior
osteoporotic fracture have up to 5 times risk of
future fracture.

24. INDICATIONS FOR BMD TESTING
 In females 60 yrs + and in men 65 yrs +
 In postmenopausal women above age 55 based on risk
factorprofile and symptoms.
 In postmenopausal women and men age 50 and older
who have had an adult age fracture, to diagnose and
determine degree ofosteoporosis
 At dual-energy X-ray absorptiometry (DXA)facilities
using accepted quality assurancemeasures

25. Sites of measurement are the spine, the hip, calcaneum
and the wrists.

26.  CONTRAINDICATIONS-
 PREGNANCY.
 RECENT ADMINISTRATION OF CONTRAST.
AGENT,NUCLEAR MEDICINE SCAN.
 RADIOPAQUE IMPLANT IN MEASUREMENTAREA.
 MARKED OBESITY.

27. Ultrasonic measurement
Broad-band ultrasound
attenuation
No radiation exposure
Preferred use in assessment
of fracture risk

28. Calcaneum is the most common skeletal site for
quantitative ultrasound assessment because
A.It has a high percentage of trabecular bone that
is replaced more often than cortical bone,
providing early evidence of metabolic change.
B. The calcaneus is fairly flat and parallel,
reducing repositioning errors.

29. The McCue CUBA Ultrasonometry
Technology That Can Assess Osteoporosis

30. CT scan
True volumetric study
Quantitative Computed
Tomography (QCT) utilizes CT
technology to detect low bone
mass and monitors the effects of
therapy in patients undergoing
treatment.
It is a fast, non-invasive exam
that detects low bone mass
earlier and more accurately than
other bone density exams

31.  The trabecular BMD is indicated as the
most important parameter, and
interpreted using the
Felsenberg classification based on the
following cut-off values:
Normal BMD > 120 mg/cc
Osteopenia < 120 mg/cc
Osteoporosis < 80 mg/cc
Very high fracture risk < 50 mg/cc

32. Advantages of CT scan over DEXA:
 Ability to separate cortical and trabecular bone
 Provides true volumetric density in units of mg/cc
 No errors due to spinal degenerative changes or aortic calcification
Clinicians and researchers favor DXA because
-Scanners are readily available and relatively
inexpensive.
-The radiation dose is negligible
-The T-score scale, defined by the WHO specifically for DXA, provides a
standardized classification.

33. BIOCHEMICAL MARKERS OF BONE
TURNOVER
1.PREDICT THE RISK OF FRACTURE INDEPENDENTLY
OF BONE DENSITYIN UNTREATED PATIENTS
2.PREDICT RAPIDITY OF BONE LOSS INUNTREATED PATIENTS
3.PREDICT EXTENT OF FRACTURE RISKREDUCTION WHEN
REPEATED AFTER 3-6 MONTHS OF TREATMENT
4. PREDICT MAGNITUDE OF INCREASE IN BMD
5.HELP DETERMINE DURATION OF DRUG HOLIDAY AND WHEN
AND IF MEDICATION SHOULD BE RESTARTED

34. BONE TURN OVER MARKERS

35. Risk Factors for Fracture
(Major) with relative risk>2 (Minor) with relative risk1-2
Age >70 Estrogen deficiency
Menopause Calcium intake <500mg/day
Hypogonadism Primary hyperparathyroidism
Rheumatoid arthritis
Hip fracture h/o inparents Hypercalciuria
Glucocorticoids Anticonvulsants
High bone turnover Diabetes mellitus
Anorexia nervosa Smoking
BMI < 18 Alcohol
Immobilisation/sedentary life
Chr. Renal failure
Transplantation
Chronic Inflammatory diseases

36. DIFFERENTIAL DIAGNOSIS
 HYPERPARATHYROIDISM
 PAGETS DISEASE
 OSTEOMALACIA
 OSTEOGENESIS IMPERFECTA
 MULTIPLE MYELOMA
 SECONDARYTUMOURS

37. 1.NON
PHARMACOLOGICAL–
PREVENTION OF
OSTEOPOROSIS AND
OSTEOPOROTIC
FARCTURE.
A.NUTRITION
B.LIFE STYLE
MODIFICATIONS
C.PREVENTION OF
FALL
D.HIP PROTECTORS
2. BASICTHERAUPETIC
MEASURES
A. VIT D AND
CALCIUM
SUPPLEMENTATIO
N
B. ESTEROGEN AND
HRT
3.ANTI RESORBTIVE
AGENTS
A.CALCITONIN
B. BISPHOSHPHANTES
C.SERM (SELECTIVE
ESTROGEN RECEPTOR
MODULATOR )
D.DONESUMAB
4. DRUGS STIMULATE
BONE FORMATION
1.TERIPARATIDE
2.STRONTIUM
RANELATE
TREATMENT

38. LIFESTYLE MODIFICATIONS-
a.Physical activity-weight bearing andmuscle
strengthing exercises.
Exercise improves bone strength by 30%to50%.
Exercise should be lifelong.
b.Cessation of smoking,alcohol,high caffeineintake.
c.Adequate sunexposure

39. HIP PROTECTORS
PREVENTS DIRECT IMPACTON PELVIS.
TYPES :
1.Energy absorptiontype
2.Energy shunting types
3.Crash helmet type
4.Airbag type

40. ca
 Men age 50–70 should consume 1000 mg/dayof
calcium.
 Womenage 51 and olderand men age 71 and older
consume 1200 mg/day of calcium.
 Intakes in excess of 1200 to 1500 mg/day mayincrease
the risk of developing kidney stones, cardiovascular
disease, and stroke.
PHARMACOLOGICAL PREVENTION OF
OSTEOPOROSIS
CALCIUM

41. VIT D3
 800 to 1000 international units (IU) of vitamin D perday
for adults age 50 andolder.
 Treatment of vitamin Ddeficiency-
Adults should be treated with 60,000 IU once aweek) for
4-6 weeks to achieve a level of approximately 30 ng/ml.
This regimen should be followed by
maintenance therapy of 1500–2000 IU/day.

42. Pharmacologic therapy
 All patients being considered for treatment of
osteoporosisshould also be counseled on risk factor
reduction including the importance of calcium,
vitamin D, and exercise as part of any treatment
program forosteoporosis.
 Prior to initiating treatment, patients should be
evaluated forsecondarycausesof osteoporosisand
have BMD measurements by central DXA, when
available, and vertebral imaging studies when
appropriate.
 Biochemical marker levels should be obtainedif
monitoring of treatment effects isplanned.

43. Who should be considered for
treatment?
Postmenopausal women and men age 50 and older
presenting with the following should beconsidered-
 A hip or vertebral fracture (clinically apparent or found on
vertebralimaging).
 T-score ≤−2.5 at the femoral neck, hip joint , or lumbar
spine.
 Low bone mass (T-score between −1.0 and −2.5 at the
femoral neck or lumbarspine)
 a 10-year probability of a hip fracture ≥3 % or a 10-year
probability of a major osteoporosis-relatedfracture
≥20 %.

44. Bisphosphonates
 Are analogues of pyrophosphates.
 Causeapoptosisof osteoclasts bydisrupting
cytoskeleton.

45. 1.Alendronate-
 prevention -5 mg daily and 35 mg weeklytablets.
 treatment -10 mg daily tablet, 70 mg weeklytablet.
 Alendronate is also used in treatmentof osteoporosis in
men and women takingglucocorticoids.
2.Ibandronate-
 2.5 mg daily for 3 years
3.Risedronate-
 prevention and treatment -5 mg daily tablet; 35mg
weekly tabletfor 6 months.

46. 4.Zoledronic acid
 prevention and treatment -5 mg by intravenous
infusionoverat least 15 min onceyearly for
treatment and onceevery 2 years for prevention.

47. Drug safety
 Side effects for all oral bisphosphonates gastrointestinal
problems such as difficulty swallowing and oesophagitis
andgastritis.
 All bisphosphonates are contraindicated inpatients
with estimated GFR below 30–35ml/min.
 osteonecrosis of the jaw (ONJ) can occurwith long-
term use of bisphosphonates(>5year).
 Although rare, low-trauma atypical femurfractures
may be associated with the long-term use of
bisphosphonates (e.g., >5 years ofuse).

48. Teriparatide
 Teriparatide is approved for the treatment of
osteoporosis in postmenopausal women and menat
high risk forfracture.
 It is also approved for treatment in men and women at
high risk of fracture with osteoporosis associated with
sustained systemic glucocorticoidtherapy.
 DOSE-20 μg daily subcutaneousinjection for 18 months.
 Regular monitoring of sr. calcium and uric acid at 1,6 and
12 months.

49. Calcitonin
 Treatment of osteoporosis in women who are at least
5 years postmenopausal when alternative treatments
are notsuitable.
 200 IU delivered as a singledaily intranasal spray.
 Intranasal calcitonin can cause rhinitis, epistaxis, and
allergicreactions.
 Verysmall increase in the risk of certain cancers.

50. SERM (SELECTIVE ESTROGEN RECEPTOR MODULATOR)
Used for both prevention and treatment of osteoporosis.
RALOXIFENE-60mg/day.

51. DONESUMAB[RANKL INHIBITOR]
Dose- 60mg every 6months S.C
Used in postmenopausalwomen.

52. HORMONE REPLACEMENTTHERAPHY
Esterogenwith orwithoutprogestin is used.
Also relieves symptoms of postmenopausalsymptoms,
vulvovaginal atrophy.
Dose-0.625mg daily.
Routes –oral,transdermal

53. PREVENTATION TREATMENT
Calcium 500mg to 1500 mg 1000 to 1500
Vit – D 400IU 400IU – 800IU
Bi phosphonates
1. Alendronate 5mg/day 10mg/day
2. Ibandronate - 150mg/month
3. Rsidronate - 5mg/day
4. Zolendronic acid 5mg once in 2 year 5mg once /1 year
SERMS
Rolaxifen 5mg/day 10mg/day
Calcitonin 200 IU 200IU
Teriparatide 20ug/d 20-40ug/d
Donesumab - 60mg/6 months

54. SURGERY IN VERTEBRAL FRACTURES
 Vertebroplasty
To reduce vertebralfracture–associated pain
 Kyphoplasty
To restore height or to treat the deformity
associated with osteoporotic vertebralfractures
 Pedicle screw fixation
In progressive vertebral collapse or deformity

56. Role of Orthopaedic Surgeons
 The goals of surgical treatment ofosteoporotic
fractures include
 Rapid mobilization and return to normalfunction and
activities.
 Back / Bowel / Bladder care.
 Avoid too much manipulations.
 Progressive physiotherapy.

57. Thank You