A dangerous vicious circleA dangerous vicious circle

New fracture

First fracture

Inactivity

Socialisolation

Depression Pain

Loss of autonomy

Low bone mass

Mortality after Mortality after Major Types ofMajor Types ofOsteoporotic Osteoporotic FractureFracture

in in Men and WomenMen and Women: an : an Observational StudyObservational StudyCenter Center et al, et al, Lancet Lancet 19991999

5 - 5 - Year Year Prospective Prospective Cohort StudyCohort StudyAge-Age-Standardized Mortality Standardized Mortality RatioRatio

FractureFracture WomenWomen MenMen

Proximal Proximal FemurFemur 2.22.2 3.23.2VertebralVertebral 1.71.7 2.42.4Other Other MajorMajor 1.91.9 2.22.2Other MinorOther Minor 0.80.8 1.51.5

Time after hip fracture (years)Time after hip fracture (years)22 44 66 88 1010

0.000.00

0.250.25

0.500.50

0.750.75

1.001.00

Hip fractured WomenHip fractured Women

Hip fractured MenHip fractured Men

WomenWomen

MenMen

Surv

ival

pro

babi

lity

Surv

ival

pro

babi

lity

Expected survival in the the general populationExpected survival in the the general population

Survival after Survival after Hip FractureHip FractureTrombetti Trombetti et et alal, , Osteoporos Osteoporos Int 2002Int 2002

0 1000 2000 3000 40000 1000 2000 3000 4000

OsteoporosisOsteoporosisIschemic Heart DiseasesIschemic Heart Diseases

Chronic Chronic Obstructive Obstructive Pulmonary DiseasesPulmonary DiseasesOsteoarthritisOsteoarthritis

AlzheimerAlzheimer’’ssCirrhosisCirrhosis

AsthmaAsthmaMigraineMigraine

Hypertensive Hypertensive Heart DiseaseHeart DiseaseRheumatoid ArthritisRheumatoid Arthritis

Peptic UlcerPeptic UlcerParkinsonParkinson’’ss

Multiple Multiple SclerosisSclerosisBenign Prostatic Benign Prostatic HyperplasiaHyperplasia

JohnellJohnell & & KanisKanis, , OsteoporosOsteoporos Int 2006 Int 2006 Disability-Adjusted Life-Years Disability-Adjusted Life-Years ((DALYsDALYs) ) LostLost

Disability-Adjusted Life-Years Lost Disability-Adjusted Life-Years Lost because of because of Non-communicable Diseases Non-communicable Diseases in Europein Europe

Osteoporosis Results in More Cost thanOsteoporosis Results in More Cost thanMany Other DiseasesMany Other Diseases

Number of bed days Number of bed days (men and women)(men and women)•• 701,000 for osteoporosis701,000 for osteoporosis•• 891,000 for COPD891,000 for COPD•• 533,000 for stroke533,000 for stroke•• 328,000 for myocardial infarction328,000 for myocardial infarction•• 201,000 for breast cancer201,000 for breast cancer

Lippuner Lippuner et al. et al. Osteoporosis Osteoporosis IntInt 1997; 7: 414-251997; 7: 414-25

Osteoporosis# 1 whenlooking at

women only

DiagnosisDiagnosis

X-ray techniques

DXA

pQCT

pDXA

IIoo

II

DXA: PrincipleDXA: Principle

•• Two attenuation profiles:Two attenuation profiles:Low energy X-ray attenuationLow energy X-ray attenuation

High energy X-ray attenuation High energy X-ray attenuation

•• Multiply high energy profile by Multiply high energy profile by ‘‘kk’’factor (ratio of soft tissuefactor (ratio of soft tissueattenuation at low- & high-energy)attenuation at low- & high-energy)

•• BMD along scan = Low-energyBMD along scan = Low-energyprofile - profile - k-corrected k-corrected high energyhigh energyprofileprofile

00

22

44

66

88

1010

1212

II IIII IIIIII IVIV

BMD & HipBMD & Hip fracturefracture

BP & BP & strokestroke

CholesterolCholesterol & MI & MI

Gradients of Gradients of riskriskRelative Relative riskrisk

QuartileQuartile

Noninvasive Measurementof Bone Mineral Mass

Technique Site Precision Cost Responseto Therapy

SXA Forearm ++ ± ± Heel

DXA Spine ++ + ++Hip + + +Tot. Body ++ + ±

QCT Spine ± ++ +Forearm ++ +(+) ±

US Heel ± - -+ Fingers

Medicare Coverage Medicare Coverage for BMD Testsfor BMD Tests

ProcedureProcedure SiteSite Fee Fee ScheduleSchedule Medicare Medicare **

DXADXA AxialAxial $ 128$ 128pDXApDXA AppendicularAppendicular $ 40$ 40RXRX AbsorptiometryAbsorptiometry AppendicularAppendicular $ 38$ 38QUSQUS AppendicularAppendicular $ 53$ 53SXASXA AppendicularAppendicular $ 40$ 40QCTQCT AxialAxial $ 185$ 185pQCTpQCT AppendicularAppendicular $ 40$ 40

* * Medicare Allowable Medicare Allowable Charge = 80% of Charge = 80% of the Coststhe Costs

JAMA 288:1889-1897,2002 JAMA 288:1889-1897,2002

Example for Example for T-score = - 2.0T-score = - 2.0, 60 year old, 60 year oldand and Z-Score = - 0.5Z-Score = - 0.5

2020 4040 6060 8080 100100

1.201.20

0.960.96

0.840.84

0.720.72

1.081.08

1.321.32

BM

D g

/cm

BM

D g

/cm

22

Spine: L1-L4Spine: L1-L4

AgeAge

ZZ

T-ScoreT-Score

00

-1-1

-2-2

-3-3

+1+1

-4-4

TT

T-score

Normal ! -1

Osteopenia < -1 and > -2.5

Osteoporosis " -2.5

SevereOsteoporosis

" -2.5 with Fracture

Diagnosis of Osteoporosis Using Central DXADiagnosis of Osteoporosis Using Central DXA WHO-DefinitionWHO-Definition

Mainly Mainly for for Spine and Spine and Hip in Hip in WomenWomen

PathophysiologyPathophysiology

Osteoporosis Pathogenesis and Osteoporosis Pathogenesis and ManagementManagement

FractureFracture

Fracture Fracture TreatmentTreatment

RehabilitationRehabilitation-> To Restore -> To Restore IndependenceIndependence-> To-> To Reduce Disabilities Reduce Disabilities

Prevention Subsequent Prevention Subsequent FractureFracture