- 1.FRAGILITY FRACTURES & OSTEOPOROSIS:A HEALTH CARE CRISIS
KENNETH J EDWARDS,M.D,F.A.C.S
2. OSTEOPOROSIS MAJOR HEALTH CRISIS DECREASED BONE MASS
MICROARCHITECTURAL DETERIORATION ALTERED QUALITY 3. OSTEOPOROSIS
AFFECTS 50% OF WOMEN OVER 50 LIFETIME RISK OF FRACTURE OF
HIP,WRIST, AND SPINE IS 40% 4. Osteoporosis - Types Postmenopausal
osteoporosis (type I) Caused by lack of estrogen Causes PTH to
overstimulate osteoclasts Excessive loss of trabecular bone
Age-associated osteoporosis (type II) Bone loss due to increased
bone turnover Malabsorption Mineral and vitamin deficiency 5.
FRAGILITY FRACTURE FRACTURE OCCURING IN FALL FROM STANDING HEIGHT
OR LESS LOW TRAUMA RESULTING IN BIG FRACTURES 6. Fragility
fractures are common 1 in 2 women and 1 in 5 men over age 50 will
suffer a fracture in their remaining life time1 55% of persons over
age 50 are at increased risk of fracture due to low bone mass At
age 50, a womans lifetime risk of fracture exceeds combined risk of
breast, ovarian & uterine cancer At age 50, a mans lifetime
risk of fracture exceeds risk of prostate cancer 1. Johnell et al.
Osteoporos Int. 2005; 16: S3-7 7. Fractures will be more common
Fracture incidence projected to increase 2- to 4-fold in the next
decades due to aging of the population In Europe 12% to 17% of
population >65 in 2002 20% to 25% of population >65 in 2025
Aged 70+ Men Women 1990 2030 Men Wome n 8. Bone mass Bone structure
Bone quality Fall Risk Impact of fall Skeletal strength Fracture
risk Type of fall Energy reduction External protection
Neuromuscular function Environmental risks Age Pathogenesis of
fragility fractures 9. NORMAL VS OSTEOPOROTIC BONE 10. Costs of
Osteoporosis Affects 1 in 2 women and 1 in 8 men > 50 years old
Causes 1.5 million fractures/year - 700,000 spine, 300,000 hip and
300,000 wrist, 25,000 deaths from complications Menopause is the
biggest risk factor for disease Disease often not diagnosed until
after 1 or more fractures have occurred Prevalence could rise to 41
million by 2015 from 28 million today Cost to health care estimated
at $14 billion ($38M/day) Psychological and social effects of
disease are immense 11. Projected to reach 3.250 million in Asia by
2050 Adapted from Cooper et al, Osteoporos Int. 1992; 2:285-9
Estimated number of hip fractures: (1000s) 1950 2050 600 3250 1950
2050 668 400 1950 2050 742 378 1950 2050 100 629 Total number of
hip fractures: 1950 = 1.66 million 2050 = 6.26 million Projected
number of osteoporotic hip fractures worldwide 12. All fractures
are associated with morbidity Cooper. Am J Med. 1997;
103(2A):12s-19s 40% Unable to walk independentl y 30% Permanent
disability 20% Death within one year 80% Unable to carry out at
least one independent activity of daily living 13. Vertebral
fractures restrict daily activities 2.8 7.8 21.7 2.1 4.2 8.6 3.6
12.6 44.7 2.2 4.6 9.9 0 5 10 15 20 25 30 35 40 45 Oddsratio Back
pain Difficulty with >3 daily activities >3 activities
affected due to back pain Medical consultation 1 # 2 # 3 # Adapted
from Ross PD et al. No vertebral fractures over the last four years
People with vertebral fractures have greater pain, disability and
healthcare utilisation, on average, than those without fracture 14.
1.91.81.92.0Minor fracture 2.43.31.71.9Forearm 1.81.44.42.3Spine
1.91.42.52.3Hip Minor fractureForear m SpineHipSite of prior
fracture Risk of subsequent fracture Prior fracture increases the
risk of subsequent fracture Klotzbuecher et al. J Bone Miner Res
2000; 15:721-727 A prior fracture increases the risk of new
fracture 2- to 5-fold 15. Cost of osteoporosis in the United States
Ray et al. J Bone Miner Res 1997; 12:24-35 Total annual cost $13.8
Billion $3.9 (28%) $1.3 (10%) $8.6 (62%) Hospitalization Outpatient
Nursing Home 16. Economic impact of osteoporosis Annual direct cost
Disease Prevalence including hospitalization (millions) (US$
billion) Cardiovascular 4.6 20.3 disease Asthma 15 7.5 Osteoporosis
10 13.8 Information supplied by National Heart, Lung & Blood
Institute, National Osteoporosis Foundation, American Heart
Association Annual economic cost of treating fractures in the USA
is similar to that of treating cardiovascular disease and asthma
17. Osteoporotic fractures: comparison with other diseases 1996 new
cases, all ages 184 300 750 000 vertebra l 250 000 other sites 250
000 forear m 250 000 hip 0 500 1000 1500 2000 Osteoporotic
fractures Heart attack Stroke Breast cancer Annualincidencex1000 1
500 000 annual incidence all ages 513 000 annual estimate women 29+
228 000 annual estimate women 30+ American Heart Association, 1996
American Cancer Society, 1996 Riggs & Melton Bone, 1995;
17:505S-511S 18. ETHNIC DIFFERENCES 19. OSTEOPOROTIC FRACTURES POSE
A LIFETIME RISK OF DEATH COMPARABLE TO BREAST CANCER 20. BIOLOGY OF
BONE 21. Two Components of the Bone Cortical Bone Dense and compact
Runs the length of the long bones, forming a hollow cylinder
Trabecular bone Has a light, honeycomb structure Trabeculae are
arranged in the directions of tension and compression Occurs in the
heads of the long bones Also makes up most of the bone in the
vertebrae 22. Cancellous or Trabecular Bone 23. Bone Cells
Osteocytes - derived from osteoprogenitor cells Osteoblasts
Osteoclasts 24. Osteocytes Trapped osteoblasts In lacunae Keep bone
matrix in good condition and can release calcium ions from bone
matrix when calcium demands increase Osteocytic osteolysis 25.
Osteoclasts Resorb bone matrix from sites where it is deteriorating
or not needed Digest bone matrix components Focal decalcification
and extracellular digestion by acid hydrolases and uptake of
digested material Disappear after resorption Assist with mineral
homeostasis 26. Osteoblasts Make collagen Activate nucleation of
hydroxyapatite crystallization onto the collagen matrix, forming
new bone As they become enveloped by the collagenous matrix they
produce, they transform into osteocytes Stimulate osteoclast
resorptive activity 27. Bone Remodeling Process 28. Bone Remodeling
Process Proceeds in cycles first resorption than bone formation The
calcium content of bone turns over with a half-life of 1-5 years
29. Why Remodel Bone ???? Allows bone to respond to loads
(stresses) Maintain materials properties Allows repair of
microdamage Participates in serum Ca2+ regulation 30. Hormonal
Influence Vitamin D Parathyroid Hormone Calcitonin Estrogen
Androgen 31. Vitamin D Osteoblast have receptors for (1,25-(OH)2-D)
Increases activity of both osteoblasts and osteoclasts Increases
osteocytic osteolysis (remodeling) Increases mineralization through
increased intestinal calcium absorption Possibly linked to
CLL,Heart Disease 32. VITAMIN D 35-50% AMERICANS DEFICIENT
INSTITUTE OF MEDICINE: 600 IU/DAY < 70 800 IU/DAY >70 5-10
MIN/SUN 3000 IU VIT D NEED 3-4 DAYS/WEEK 33. PARATHYROID HORMONE
Accelerates removal of calcium from bone to increase Ca levels in
blood PTH receptors present on both osteoblasts and osteoclasts
Osteoblasts respond to PTH by Change of shape and cytoskeletal
arrangement Inhibition of collagen synthesis Stimulation of IL-6,
macrophage colony-stimulating factor secretion Chronic stimulation
of the PTH causes hypocalcemia and leads to resorptive effects of
PTH on bone 34. Calcitonin C cells of thyroid gland secrete
calcitonin Straight chain peptide - 32 aa Synthesized from a large
preprohormone Rise in plasma calcium is major stimulus of
calcitonin secretion Plasma concentration is 10-20 pg/ml and half
life is 5 min 35. Actions of Calcitonin Osteoclasts are target
cells for calcitonin Major effect of clacitonin is rapid fall of
plasma calcium concentration caused by inhibition of bone
resorption Magnitude of decrease is proportional to the baseline
rate of bone turnover 36. Other Systemic Hormones Estrogens
Increase bone remodeling Androgens Increase bone formation 37.
BIOLOGY OF OSTEOPOROSIS 38. ESTROGEN LOSS Estrogen loss triggers
increases in IL-1, IL-6, and TNF due to: Reduced suppression of
gene transcription of IL-6 and TNF Increased number of monocytes
Increased cytokines lead to increased osteoclast development and
lifespan 39. BONE DENSITY & FRACTURE RISK 40. Whole bone
strength declines dramatically with age 0 2000 4000 6000 8000 10000
Femoral neck (sideways fall) young old Courtney et al. J Bone Joint
Surg Am. 1995; 77:387-95 Mosekilde. Technology and Health Care
1998; 6:287-97 Lumbar vertebrae (compression) Wholebonestrength
(Newtons) 0 2000 4000 6000 8000 10000 young old 41. Cortical
porosity increases with age (41 iliac biopsies, age 19-90) Age
(years) 0 3 6 9 12 15 0 20 40 60 80 r = 0.78 P < 0.001 (%)
Brockstedt et al. Bone 1993; 14:681-91 4-fold increase in cortical
porosity from age 20 to 80 Increased heterogeneity with age 42.
20-year-old80-year-old Age-related changes in femoral neck cortex
and association with hip fracture Those with hip fractures have:
Preferential thinning of the inferior anterior cortex Increased
cortical porosity Bell et al. Osteoporos Int 1999; 10:248-57 Jordan
et al. Bone, 2000; 6:305-13 Mayhew et al, Lancet 2005 43. High Bone
Turnover Resorption > Formation Decreased Bone Strength Disrupts
Trabecular Architecture Decreases Bone Mass Increases Cortical
Porosity Decreases Cortical Thickness Alters Bone Matrix
Composition L. Mosekilde Tech and Health Care, 1998 Bouxsein. Best
Practice in Clin Rheum. 2005; 19:897-911 Seeman & Delmas, New
England J Med, 2006; 354:2250-61 44. Common Osteoporotic Fractures
Hip Shoulder Knee Elbow 45. POST- OP 2 MONTHS 6 MONTHS F 83yrs
Standard Screw: Complications 46. Vertebroplasty and kyphoplasty
Filling void in crushed vertebral body with PMMA Patient prone
transpedicular injection of cement Vertebroplasty high pressure
injection good pain relief Kyphoplasty pre-insertion of balloon to
create a void for low pressure injection aiming for height
restoration 47. Balloon kyphoplasty : Can you uncrush a bone? 48.
APPROACH TO OSTEOPOROTIC PATIENT PHYSICAL EXAM LABS/STUDIES
TREATMENT 49. Fragility fracture patient assessment * In addition
to routine pre-op or fracture evaluation Family history of OP
Menarche / Menopause Nutrition Medications (past and present) Level
of activity Fracture history Fall history & risk factors for
falls Smoking, alcohol intake Risk factors for secondary OP Prior
level of function History should include: 50. DRUGS THAT DECREASE
CALCIUM RETENTION CORTICOSTEROIDS HEPARIN LASIX NICOTINE CAFFEINE
ANTACIDS 51. SR / CRP Blood count Calcium Phosphate Alkaline
Phosphatase (AP) Renal function studies Basal TSH Intact PTH
Protein-immunoelectrophoresis Vit D (25 and 1.25) Laboratory tests*
NOTES: - * These are in addition to routine pre-op labs such as
coagulation studies - These are screening labs, more may be
indicated based on these results 52. Assessment of bone mineral
density by DXA Current gold standard for diagnosis of osteoporosis
BMD (g/cm2) = Bone mineral content (g) / area (cm2) Diagnosis based
on comparing patients BMD to that of young, healthy individuals of
same sex 53. WHO GUIDELINES FOR OSTEOPOROSIS Normal: Not less than
1 SD below the avg. for young adults Osteopenia: -1 to -2.5 SD
below the mean Osteoporosis: More than 2.5 SD below the young adult
average 70% of women over 80 with no estrogen replacement therapy
qualify Severe osteoporosis More than 2.5 SD below with fractures
54. When to Measure BMD in Postmenopausal Women All women 65 years
and older Postmenopausal women
