Definition, Diagnosis, Protocol, Pharmacotherapy, Surgery guidelines, Implant of Choice

1. OSTEOPOROSIS
DR SABYASACHI BARDHAN

2. WHAT IS……
Osteoporosis is a condition in which low bone mass and
micro-structural deterioration of bone tissue lead to increased
bone fragility
Often clinically silent

4. • Primary osteoporosis
a) Juvenile osteoporosis (8-14 yrs)
b) Post Menopausal osteoporosis
c) Senile Osteoporosis
• Secondary Osteoporosis

5. RISK FACTORS
LOw calcium intake
Seizure meds (anticonvulsants)
Thin build
Ethanol intake
HypOgonadism
Previous fracture
ThyrOid excess
Race (White, Asian)
Other relatives with osteoporosis
Steroids
Inactivity
Smoking

6. PRESENTATION
• Can be asymptomatic
• Loss of height
• Development of kyphosis
• Back pain
• Body ache
• Fragility fractures

7. APPROACH
• History and physical examination
• FBC
• ESR (if raised measure serum paraproteins and urine Bence Jones protein)
• Bone and liver function tests (Ca, P, Alk phos, albumin, ALT/GGT)
• Serum creatinine
Additional tests if indicated from the history
• TFT
• Serum 25OH Vit D and PTH
• Serum testosterone, LH, FSH and SHBG, PSA (men)
• 24 hour urinary cortisol/dexamethasone suppression test
• Endomysial and/or tissue transglutaminase antibodies (coeliac disease)
• Lateral radiographs of lumbar and thoracic spine/DXA-based vertebral imaging
• Isotope bone scan
• Bone densitometry ( DXA)

8. BONE DENSITOMETRY
BMD should be measured at both the posteroanterior (PA) spine and hip in
all patients undergoing DXA.
Forearm BMD should be measured under the following circumstances:
•Hip and/or spine cannot be measured or interpreted
•Hyperparathyroidism
•Very obese patients (over the weight limit for DXA table)
Conventional radiography is used for the qualitative and semiquantitative
evaluation
Assesses the presence of fractures.
Quantitative imaging methods commonly used are Dual-energy x-ray
absorptiometry (DXA) , Quantitative computed tomography (QCT)
scanning

9. DXA scan
DXA is currently the criterion standard for the evaluation of BMD.
BMD has been shown to be the best indicator of fracture risk according to
the National Osteoporosis Foundation (NOF)
WHO T-score and Z-score criteria
World Health Organization criteria define a normal T-score value as within 1
standard deviation (SD) of the mean BMD value in a healthy young adult. Values
lying farther from the mean are stratified as follows :
•T-score : –1 to –2.5 SD indicates osteopenia (low bone mass)
•T-score : less than –2.5 SD indicates osteoporosis
•T-score of less than –2.5 SD with fragility fracture(s) indicates severe
osteoporosis

10. ELLIGIBILITY FOR DXA
AACE recommends BMD testing in the following patients :
•Women age 65 or older
•Postmenopausal women with a history of fracture(s) without major trauma, with
osteopenia identified radiographically, or starting long-term systemic glucocorticoid
therapy (≥3 months)
•Perimenopausal or postmenopausal women with risk factors for osteoporosis if
willing to consider pharmacologic interventions, with low body weight (< 127 lb or
body mass index < 20 kg/m 2), taking long-term systemic glucocorticoid therapy
(≥3 months), or with a family history of osteoporotic fracture
Other indications :
•Early menopause
•Current smoking history
•Excessive consumption of alcohol
•Secondary osteoporosis

11. Serum markers of bone formation (osteoblast products) include the following:
•Bone-specific alkaline phosphatase (BSAP)
•Osteocalcin (OC)
•Carboxyterminal propeptide of type 1 collagen (P1CP)
•Aminoterminal propeptide of type 1 collagen (P1NP)
Urinary markers of bone resorption (osteoclast products) include the following:
•Hydroxyproline
•Free and total pyridinolines (Pyd)
•Free and total deoxypyridinolines (Dpd)
•N-telopeptide of type 1 collagen cross-links (NTX-1) (also available as a serum marker)
•C-telopeptide of type 1 collagen cross-links (CTX-1) (also available as a serum marker)
Serum markers of bone resorption include the following:
•Cross-linked C-telopeptide of type 1 collagen (ICTP)
•Tartrate-resistant acid phosphatase 5b (TRAP-5b)
•N-telopeptide of type 1 collagen cross-links (NTX-1) (also available as a urinary marker)
•C-telopeptide of type 1 collagen cross-links (CTX-1) (also available as a urinary marker)
BLOOD & URINE PARAMETERS

12. The 2020 update of the American Association of Clinical Endocrinologists (AACE) guidelines provides
the following criteria for the diagnosis of osteoporosis in postmenopausal women :
•T-score −2.5 or below in the lumbar spine, femoral neck, total proximal femur, or 1/3 radius
•Low-trauma spine or hip fracture (regardless of BMD)
•T-score between −1.0 and −2.5 and a fragility fracture of proximal humerus, pelvis, or distal forearm
•T-score between −1.0 and −2.5 and high FRAX® fracture probability based on country-specific
thresholds
DIAGNOSIS

14. ELLIGIBILITY FOR PHARMACOTHERAPY
The National Osteoporosis Foundation (NOF)
recommends that pharmacologic therapy should be
reserved for postmenopausal women and men aged 50
years or older who present with the following :
•A hip or vertebral fracture (vertebral fractures may be
clinical or morphometric [ie, identified on a radiograph
alone])
•T-score of –2.5 or less at the femoral neck or spine
after appropriate evaluation to exclude secondary
causes
•Low bone mass (T-score between –1.0 and –2.5 at the
femoral neck or spine) and a 10-year probability of a hip
fracture of 3% or greater or a 10-year probability of a
major osteoporosis-related fracture of 20% or greater
based on the US-adapted WHO algorithm
The 2020 updated guidelines from the American
Association of Clinical Endocrinologists (AACE)
strongly recommends pharmacologic treatment of
osteoporosis for postmenopausal women with any of
the following :
•T-score between −1.0 and −2.5 in the spine, femoral
neck, total hip, or 1/3 radius and a history of fragility
fracture of the hip or spine
•T-score of −2.5 or lower in the spine, femoral neck,
total hip, or 1/3 radius
•T-score between −1.0 and −2.5 in the spine, femoral
neck, total hip, or 1/3 radius, if the FRAX® 10-year
probability for major osteoporotic fracture is ≥20% or
the 10-year probability of hip fracture is ≥3% (in the
U.S.) or above the country-specific threshold in other
countries or regions

15. Bisphosphonates
Most commonly used medication
1. Alendronate: 70mg weekly (with or without Vit D), 50% reduction in fractures
2. Residronate: Daily, weekly or monthly; 50% reduction
3. Ibandronate: Oral monthly, IV every 3 months
4. Zolendronic Acid :IV, Most potent 40%-70%
In 2016, the American Society for Bone and Mineral Research published guidelines on long-term
bisphosphonate treatment that included the following recommendations] :
• After 5 years of oral bisphosphonates or 3 years of intravenous bisphosphonates, reassessment
of risk should be considered.
• In women at high risk (eg, older women, those with a low hip T-score or high fracture risk score,
those with previous major osteoporotic fracture, or those who fracture on therapy), continuation
of treatment for up to 10 years (oral) or 6 years (intravenous), with periodic evaluation, should be
considered.
• The risk of Atypical femoral fracture, but not ONJ, clearly increases with the duration of
bisphosphonate therapy, but such rare events are outweighed by vertebral fracture risk reduction
in high-risk patients.
• For women not at high fracture risk, a drug holiday of 2 to 3 years can be considered after 3 to 5
years of bisphosphonate treatment.

16. SELECTIVE ESTROGEN RECEPTOR
MODULATORS
• Raloxifene: 60mg/day with Ca & Vit D,
Inferior to bisphosphonates,
Reduces chances of Invasive breast CA,
Increase chance of DVT
• Bazedoxifene/Conjugated estrogens

17. PTH Analogue: Teriparatide
• Recombinant human parathyroid hormone (1-34) (PTH [1-34]) that acts as an anabolic
agent ; 20mcg/day subcutaneous.
• Indication: HighRisk of Fracture, Intolerant, Unresponsive
• Contraindications :
1. Pre-existing hypercalcemia
2. Severe renal impairment
3. Pregnancy
4. Breast-feeding mothers
5. History of bone metastases or skeletal malignancies
6. Increased baseline risk for osteosarcoma, including but not limited to Paget disease,
unexplained elevated alkaline phosphatase level, or prior external beam or implant
radiation therapy
7. Children and young adults with open epiphyses or prior radiotherapy of the skeleton
8. Monoclonal gammopathies of undetermined significance (MGUS)
Bone mass increasing up to
13% over 2 years in the
spine and to a lesser
degree in the hip.

18. MONOCLONAL ANTIBODIES: DENUSUMAB
• Decreases bone resorption by inhibiting osteoclast activity.
.
• 60 mg given subcutaneously every 6 months.
• Postmenopausal osteoporosis, and men with low BMD
• Indications: Renal Insufficiency, Cancer Patients

19. CALCITONIN
• Not a first line drug
• Reduces Osteoclast activity
• Reserved for patients who refuse or intolerant to bisphosphonates
• Risk of malignancies in calcitonin-treated patients
• Studies do show an increase in BMD with the use of calcitonin but no
reduction in fracture risk

20. • Strontium ranelate is approved for the treatment of osteoporosis in
some countries in Europe. It reduces the risk of both spine and
nonvertebral fractures.
• Strontium is not approved for the treatment of osteoporosis in the
United States.

21. HRT
• No longer recommended
• The American College of Physicians concluded that moderate-quality
evidence showed that estrogen treatment did not reduce fracture
rates in postmenopausal women with established osteoporosis

22. PRINCIPLES OF FIXATION OF OSTEOPOROTIC
FRACTURES
• Minimally Invasive Surgery
• Relative stability
• Splinting the whole bone
• Fixed angle devices
• Near Anatomical reduction
• Bone impaction
• Augmentation