osteoporosis and fracture management

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

5. 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

8. SECONDARY OSTEOPOROSIS
 Metabolic - Calcium & Vit. D deficiency
 Endocrine - Cushing syndrome, Hyperparathyroidism
 Renal disease
 Gastrointestinal - IBD, Malabsorption
 Hereditary connective tissue diseases - Marfan
syndrome, Homocystinuria.
 Bone marrow infiltration - Multiple Myeloma,
lymphoma, leukemia.
 Drugs - Phenytoin, Corticosteroid, heparin, lithium.
 Life style - Alcohol, smoking, inactivity,
immobilization,
 Miscellaneous - Rh. arthritis
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

15.  Hyperparathyroidism
 Paget’s disease
 Osteomalacia
 Osteogenesis imperfecta
 Multiple myeloma
 Renal Osteodystrophy
 Secondary tumors
DIFFERENTIAL DIAGNOSIS

16.  Serum calcium
↑  Hyperparathyroidism / Malignancy
↓  Malnutrition / Osteomalacia
 PTH
 ↑  Hyperparathyroidism
 ↓  Malignancy
 ↑ PTHrP  Malignancy
 TSH  To r/o Hyperthyroidism
 Urinary free Cortisol  Cushings disease
INVESTIGATIONS

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

20.  Post menopausal osteoporosis
Trabecular resorption & cortical resorption
 Senile osteoporosis
Endosteal resorption
 Hyperparathyroidism
Subperiosteal resorption
RADIOLOGY

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

23. SINGH’S INDEX

24.  Cod fish vertebra
 Kyphosis
 Collapse of vertebra
 Compression
Fractures
 Schmorl's nodules
 Kleer Koper Score
VERTEBRAL X RAY

25.  Assessed from lateral view of spine – T4 – L5
Normal – Grade 0
Biconcave deformity – Grade 1
Wedge deformity – Grade 2
Compression deformity – Grade 3
Kleer Koper Score

26.  Reconstructive CT
pictures show L 1,2,
and L3 fractures
with biconcave
deformities
COMPUTER TOMOGRAPHY

27.  Chronic benign
compression fractures
 Sagittal MRI scan
shows multiple
collapsed vertebrae
MRI SCAN

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

31.  Results expressed in T & Z scores
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

36.  Conservative
 Surgical
MANAGEMENT

37.  Calcium – 1 to 1.5 gm/day
 Vitamin D – 400 to 800 IU/day
 Weight bearing and gravity resistant exercises
 Avoid alcohol, cigarette
 Moderate phosphate intake
 Prophylactic agents
 Alendronate – 35mg
 Raloxifine – 60mg
PROPHYLAXIS

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

44.  GOALS
Improve quality of life
Give a stable fixation
Early mobilization & weight bearing
SURGICAL TREATMENT

45.  BASIC PRINCIPLES
Biological fixation
Load sharing implants
Impaction & compression
Wide buttress plates
Long splintage
Augmentation of implants
Replacement arthroplasty
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

48. TERMS:
Fixed Position
Fixed Angle
Locking Screw
Locking Plate
LOCKING PLATES

49. LOCKING SCREW-PLATE CONSTRUCTS
Locking head screw
Threaded plate hole

50. PULLOUT OF LOCKING SCREWS

51. Creates Fixed Angle Generates
Friction/Compression
4.4mm Core Dia. 3.5mm Core Dia.
5.0 mm Locking Screw 4.5 mm Cortical Screw

53.  Enhances stability
 In comminuted fractures – controlled impaction
&compression is advisable-DHS with wt. bearing
 LCP plates are used in metaphyseal fractures,
upper tibial fractures, & supracondylar fractures
& proximal humerus with specialized plates
IMPACTION & COMPRESSION

54.  Bone cement
 Bone graft
 Bone subsitutes
Hydroxyapatite
Tricalcium phosphate Hydroxyapatite
Tricalcium phosphate
 Biodegradable bone cement
Calcium phosphate – Norian skeletal repair system
Glass isometric cement
AUGMENTATION OF IMPLANTS

56.  If no other option
REPLACEMENT ARTHROPLASTY

57.  Contoured plates
Proximal humeral plates
Distal femoral plates
Proximal tibial plates
Distal tibial plates
 LISS plates
Proximal tibia distal femur with zig & minimally
invasive techniques
SPECIAL PLATES