This document provides information about osteoporosis. It begins by defining osteoporosis as a disease where bone density and quality are reduced, making bones more porous and fragile and greatly increasing the risk of fractures. It notes that bone loss occurs silently and progressively, with no symptoms until the first fracture. The document then discusses bone structure, the cells involved in bone formation and resorption, risk factors for osteoporosis, its prevalence in India, and common fracture sites. It outlines the assessment and diagnosis of osteoporosis as well as lifestyle and medical treatments to prevent fractures.

1. OSTEOPOROSIS
Prof. Dr. M. M. Prabhakar
Medical Superintendent,
Director Government Spine Institute,
Prof. & Head Department of Orthopaedics,
B. J. Medical College,
Ahmedabad.

2. 
Osteoporosis, which literally means “porous bone”, is a
disease in which the density and quality of bone are
reduced.

Bones become more porous and fragile

The risk of fractures is greatly increased

The loss of bone occurs “silently” and progressively

Often there are no symptoms until the first fracture
occurs.

3. 
Compact bone consists of
closely packed cylindrical
units called osteons.

The osteon consists of a
central canal called the
Haversian canal, which is
surrounded by concentric
rings (lamellae) of matrix.

Between the rings of matrix,
the bone cells (osteocytes)
are located in spaces
called lacunae.

4. • Spongy bone consists of
lattice of fine bone plates
(trabeculae) that has small,
irregular cavities containing
red bone marrow.
• The canaliculi connect to
the adjacent cavities,
instead of a central
Haversian canal, to receive
their blood supply.

5. 
The bone tissue is composed of a hard matrix of minerals (mostly
calcium and phosphorus) that is deposited around protein fibers
(collagen).
› Osteogenic cells – are precursor cells for all forms of
connective tissue.
› Osteoblasts – are responsible for bone formation that
secret the organic substances and mineral salts used in
ossification process.
› Osteocytes – are osteoblasts that have stopped laying
down new bone, but play a role in the maintaining the
cellular activities of the bone tissue.
› Osteoclasts – are cells found on the surface of the bone
that are responsible for bone resorption.

6. 


Bone resorping cells
Use acids or enzymes to
dissolve calcium and
collagen of old bone
Dissolved calcium reenters
blood stream and is carried
to various parts of the body

7. 



Osteoblasts are cells that
build bones.
Produce collagen
Then coat the collagen with
a protein "glue" that holds
the calcium in place.
Calcium from the
bloodstream then
automatically adheres to
the collagen, forming new
bone material.

8. 

Bone cells
These maintain bones by
maintaining the
concentration of calcium

9. 
The terms osteogenesis and ossification are
often used synonymously to indicate the process
of bone formation.

Osteoblasts, osteocytes and osteoclasts are the
three cell types involved in the development,
growth and remodeling of bones.

Bone formation occurs by three co-ordinated
processes: initially osteoblasts deposit collagen
rapidly, without mineralization, producing a
thickening osteoid layer.

10. 
The ossification process can occur by two
ways:
› Intramembranous ossification - involves the
replacement of sheet-like connective tissue
membranes with bony tissue.
› Endochondral ossification involves the
replacement of hyaline cartilage models with
bony tissue.

11. 
During childhood and the early years of
adulthood, while the epiphyses are still open,
the skeleton grows in length (growth), and the
bones expand in diameter and achieve their
external shape (modeling).

During bone modeling, osteoblasts and
osteoclasts work independently of each other
and on different bone surfaces - often over
large surface areas.

The net balance is positive (i.e. there is
increased bone mass) and bones reach their
final external form and high bone density
during this period.

12. 
Both the growth and the modeling processes are
controlled by hormones and by mechanical forces mechanical usage.

Around the age 20-25 years, peak bone mass is
achieved as a result of these processes.
Subsequently, there is continuous revision of bone
through resorption and formation, a process known
as remodeling.

Remodeling allows for the degradation of worn out
bone from damaged and/or unused regions and
for the deposition of minerals in regions of greater
stress.

13. 
Activation : Activation: via recruitment of
osteoclasts by cytokines like IL-1, IL-6

Resorption: via proteo-lytic enzymes & acids
secreted by osteoclasts

Coupling: recruitment of osteoblasts &
secretion of matrix

Mineralization: deposition of Ca &
phosphorous

14. The Bone Remodeling Cycle
Osteoclast
Osteoblast
Osteoblast
Recruitment
Resorption
Mineralization
Osteoid
Deposition

15. ►
High Remodeling


Hyperparathyroidism

Hyperthyroidism

►
Hypogonadal (including post-menopausal)
Others
Low Remodeling

Involutional (Aging)

Glucocorticoids (high dose)
HIV


16. Normal Remodeling
Osteoclast Overactivity
Hypogonadal States
Parathyroid and Thyroid
Osteoblast Dysfunction
Involutional (Aging)
Glucocorticoids
HIV

17. 


To supply Calcium
throughout our body
To replace old bones
Regeneration ensures
bone remains strong
and flexible

18. 
Calcium Regulating Hormones

Glucocorticoids

Growth Factors

Tumor Necrosis Factors

19. 
1, 25 (OH)2 Vit D (Calcitriol)

Calcitonin

Parathyroid Hormone (PTH)

20. Calcitriol
Absorbs Ca
from intestine
Calcitonin
Calcitonin α serum Ca
PTH
PTH α 1 / Serum Ca
Bone formation
Bone resorption
Ca absorption
from intestine
Ca absorption
from intestine
Ca reabsorption
from urine
Ca reabsorption
from urine

21. Aging
 From 40s onwards bone mass
starts declining gradually
 Bone formation <Bone
resorption
 Bones become weak and
danger for osteoporosis sets in

22. Normal
Osteoporosis
Osteopenia
Osteoporosis
Severe

23. 

Osteoporosis is responsible for >1.5 million vertebral
and non-vertebral fractures annually
Spine, hip, and wrist fractures are most common
15 %
19 %
19 %
Other
Vertebral
Hip
Wrist
46 %
NIH/ORBD (www.osteo.org), 2000

24. • Osteoporosis : Almost 50 % of post menopausal
women over 50 years. Affects 200 million women
worldwide
Osteoporotic fractures
• Approximately 30% of women over the age of 50
have one or more vertebral fractures
• Approximately one in five men over the age of 50
will have an osteoporosis-related fracture in their
remaining lifetime

25. 
Osteoporosis is highly prevalent in India.

An estimated 61 million people in India are
reported to be affected.

Life span of an average Indian has also
increased and this also contributes to the
increased incidence of osteoporosis.

Recent data indicate that Indians have
lower bone density than their North
American and European counterparts

Reported that osteoporotic fractures occur
10-20 years earlier in Indians as compared to
Caucasians

26. 0523
Projected to
reach 3250
million in
Asia by 2050
926
1950 2050
1950 2050
1950 2050
001
Total number of
hip fractures:
1950 = 1.66 million
2050 = 6.26 million
006
873
004
247
866
Projected number of osteoporotic
hip fractures worldwide
1950 2050
Estimated no of hip fractures: (1000s)
Adapted from Cooper C et al, Osteoporosis Int, 1992;2:285-289

27. 
Spine fractures (vertebral compression fractures)
can cause intense back pain, and may
eventually result in a gradual loss of movement
and the inability to carry out daily chores.
Arrr……hh
..Ouch

28. 
They can lead to loss of height, and in severe cases
the spine may curve to form what is termed a
“hump”.

29. 
Most common fractures (46%)

Insidious

Progressive

Often unrecognized

Associated with
› Deformity, height loss, back
pain
› Morbidity and mortality

Predict future vertebral and nonvertebral fractures

30. 
Entire skeleton can be involved
›
›
›
›
›
›

Wrist
Ankle
Pelvis
Humerus
Rib
Others
Associated with significant disability

31. Hip Fracture


Most serious clinical event
Morbidity is high
› 50% do not regain independence
› 50% do not regain previous mobility

Mortality is high
› 1 in 5 patients die within 1 year

Patients not treated for osteoporosis

32. 
Hip fractures almost
always require
surgery and in about
a third of patients,
result in loss of
independent living.

33. Risk of Fracture
All postmenopausal women with the following:








Low BMD
Fracture after 50 years
Age ≥65 years
Maternal history of fracture after 50 years
Low body weight (≤125 lb)
Smoking
Corticosteroid use
Other secondary causes

34. Patients (%)
Unable to carry out at
least one independent
activity of daily living
r an
afte :
ear ture
ne y frac
O
Unable to walk
hip
independently
Death within
one year
20%
Permanent
disability
30%
40%
80%

35. Annual incidence x 1000
2000 annual incidence
all ages
1500
1000
1 500 000
250 000
hip
250 000
forearm
250 000
other sites
500
0
annual estimate
women 29+
513 000 annual estimate
women 30+
750 000
vertebral
Osteoporotic
Fractures
228 000
Heart
Attack
Stroke
1996 new cases,
184 300 all ages
Breast
Cancer
The incidence of osteoporotic fractures is highest in women and
more than heart attack, stroke and breast cancer put together

36. Non-modifiable
If you are beyond 50 years of

age
Caucasian /Asian race
And feel you have more than

Advanced age
onerisk factors

Female sex

Premature menopause (<45 years)
Or
Modifiable

Cigarette smoking

Excessive alcohol intake

Inactivity

Low body weight

Poor general health

Prolonged immobilization
had a broken a bone after a
minor bump or fall
Need to consult immediately

37. 



Initial physical
examination
X-ray.
Laboratory
blood tests.
Bone
densitometry
(Bone Mineral
Density-BMD).

38. 
As osteoporosis has no obvious symptoms
other than a fracture when the bone is
already significantly weakened, it is
important to go to the doctor if any of the
risk factors apply to you.

39. 

A number of different types of BMD tests are available,
but the most accurate is DXA (dual energy X-ray
absorptiometry).
DXA is a low radiation X-ray capable of detecting quite
low percentages of bone loss. It is used to measure
spine and hip bone density.

40. 


The World Health Organization has defined a number
of threshold values for osteoporosis.
The reference measurement is defined as healthy
bone density in a young female of around 25 years.
‘ T- score’ is number that indicates whether or not
bone loss has occurred
-1
T score > -2.5
Normal
bone mass
Osteopenia
Low bone mass
- 2.5
Osteoporosis

41. 
If the results of your BMD test show osteopenia or
osteoporosis it does not automatically mean that you
will have a fracture.

There are a number of therapies available that your
doctor might prescribe that slow down the rate at
which bone loss occurs and help prevent fractures.

In addition, there are important nutritional and
lifestyle changes that you can make to help reduce
your risk
of fracture.

42. 
Encourage good general nutrition

Promote a diet with adequate calcium
content

Promote adequate vitamin D intake

Regular weight-bearing exercise

Avoid smoking and alcohol

Prevention of falls

43. 1.
Exercise is not just important to generalhealth, it helps
build bone mass in youth and slows down bone loss in
adults
Weight-bearing exercise in particular
is good for bone health. This type of
exercise includes walking, jogging,
tennis and similar sports, aerobics and
dancing.

44. 
Both calcium and vitamin D are essential to maintain healthy bones. As
we grow older we absorb calcium from food less efficiently. This means
that over time we need higher amounts of calcium
Milk and other dairy products like cheese and
yogurt are the most readily available dietary
sources of calcium.
Other good food sources include Tofu,
soya bean, Apricots, Almonds, fishes and
fruits like Orange
Good dietary sources of vitamin D include oily fishes,
fortified dairy foods and egg yolks
Avoid : caffeine , high salt diet, alcohol –
which increase calcium loss

45. Take an additional measure to reduce the risk of
fractures by fall-proofing your home.






Reduce clutter at floor level
Wear well-fitting shoes or slippers
Make sure surfaces are slip-proof: rugs should have a skid-proof
backing
Have grab rails installed in the bathroom and toilet
Make sure that lighting is bright enough.
Have regular eye checkups –vision is crucial in judging distances
and detail.

46. 
Calcium and Vitamin D supplementation is
basic requirement before any other
treatment is begun.
Recommended daily dietary allowance (RDA)
› Vitamin D (RDA : 400 – 800 IU)
› Calcium (RDA : 1200 – 1500 mg/day)

47. Treatment Options
Prevent Resorption
 Hormone Replacement
Therapy (HRT)
Build New Bone
 Parathyroid hormone
(PTH) - Teriparatide
 Raloxifene
 Bisphosphonates
• There is no cure, but several medications have been approved
• Each stops or slows bone loss, increases bone density, and
reduces fracture risk.

48. 

Oral : Alendronate – daily or weekly dose
Risedronate – daily or weekly dose
Ibandronate – monthly dose
IV
› Intravenous Ibandronate – inj. once in 3 month
› IV Zolendronate – inj. once a year
All biphsphonates have been shown to act quickly (within one year), to
maintain bone density and to reduce the risk of having fractures
They differ in their degree of reduction of risk

49. 



Health professionals
Osteoporosis patient support groups
Practical tips
Get the information regarding treatments
available
lessening the feelings of isolation and depression
experienced
by many patients with severe osteoporosis