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OSTEOPOROSISDr Ramin RafieiAlzahra HospitalRheumatology Department
DEFINITION
Osteoporosis is defined by
systematic skeletal disorder
low bone density
deterioration of microarchitecture
bone strength reduction
increase fragility fracture risk
What are fragility fractures?
occur spontaneously or following minimal trauma
falling from a standing height or less
EPIDEMIOLOGY
most common metabolic bone disease
recognized as a global concern
Osteoporotic fractures
are common may have devastating consequences may be associated with increased mortality (hip and vertebral fractures)
Osteoporosis or osteopenia occurs in 55 percent of the population age 50 and over
prevalence
European Union in 2010
27.6 million
Americans older than 50 years
10 million (estimated to be 14 million in 2020)
34 million are at risk for the disease
OSTEOPOROSIS PREVALENCE IN IRAN
Osteoporosis 17%
Men 12%
postmenopausal women 19%
Osteopenia 35%
men 33%
postmenopausal women 40%
OSTEOPOROSIS PREVALENCE IN ISFAHAN
Bonakdar et al 2008
Salamat et al 2009
Sex Menoupause
Mean age(year)
Prevalence of Osteoporosis
Prevalance of Osteopenia
spinal Femur Spinal Femur
Female
Mix 44 9% 3% 25% 27%
Sex Menoupause Mean Age (yaer)
Prevalence of Osteoporosis
Prevalance of Osteopenia
spinal Femur spinal Femur
Female post 51.8 5% 40% 50% 45%
HEALTH IMPACT Mortality
increases the number of vertebral fractures leads to increased risk for death
CVD and pulmonary disease
9% In-hospital mortality
25% mortality within first year after a hip fracture
elevated mortality persists for up 10 years for hip fracture
excess mortality for 5 years after a vertebral fracture
relative risk of dying after a vertebral fracture is as high as 8.6
main predictors of higher mortality after fragility fractures
male sex
increasing age
coexisting illness
poor prefracture functional status
Smoking
low BMD
HEALTH IMPACT (MORBIDITY)
Hip fracture
leads to reduced function and loss of independence
Disability is 6 times that accounted for by hip fracture alone
physical performance had decreased by 51%
decreased Social function by 26%
40% are still unable to walk independently for 1 year
HEALTH IMPACT (MORBIDITY)
60% requiring assistance in at least one essential activity of daily living
80% are unable to perform at least one instrumental activity (driving or shopping)
patients are susceptible to the development of acute complications
pressure sores
bronchopneumonia
urinary tract infections
HEALTH IMPACT (MORBIDITY)
vertebral fracture
most are precipitated by routine daily activities
bending
lifting light objects
Leads to
loss of height
kyphosis
reduced pulmonary function (each fracture decreases FVC by 9%)
increased risk for back pain
disability
estimates of the prevalence of vertebral fractures
19% of women aged 75 to 79 years
22% of women aged 80 to 84 years
41% of those 85 years and older
osteoporotic fracture
increases as BMD declines
3-fold increase in fracture for each standard deviation fall in BMD
inverse correlation between BMD and the severity of fracture
3.5 million fragility fractures occur every year in the European Union
combined direct and indirect annual costs for hip fracture
$21,000 per patient
cost of osteoporosis in the European Union
€37 billion in yaer
RED:>300 FX/100000ORANGE:200-300 FX/100000GREEN:<200 FX/100000
BONE REMODELING
Bone is continually undergoing renewal called remodeling
bone laid down by osteoblasts
bone resorption is done by osteoclast
bone formation and bone resorption are closely coupled
BONE REMODELING
Bone remodeling follows an ordered sequence bone remodeling unit (BMU)
This cycle of coupling of bone formation and resorption is vital for skeletal integrity
Key regulators of osteoclastic bone resorption
RANK ligand (a member of the tumor necrosis factor
ligand family)
its two known receptors
RANK (Receptor activator of nuclear factor kappa-B)
osteoprotegerin (OPG)
DETERMINANTS OF BONE MASS
Genetic factors
Nutrition
calcium
phosphorus
vitamin D
other dietary factors
magnesium
vitamin C and K
Alcohol and smoking
Physical activity
Chronic diseases and medications
CLINICAL MANIFESTATIONS
Osteoporosis has no clinical manifestations
Vertebral fracture most common clinical manifestation of osteoporosis two-thirds are asymptomatic diagnosed as an incidental finding on chest or abdominal x-ray pain, usually subside gradually within 2 to 6 weeks loss of height greater than 3 cm in men and 4 cm in women Non–spine-related fractures level of trauma needed is relatively low Hip fractures relatively common in osteoporosis distal radius fractures (Colles fractures)
DOWAGER’S HUMP CORRESPONDINGNRADIOGRAPH
CLINICAL EXAMINATION
variable degrees of kyphosis of the thoracic spine
flattened (reduced) lumbar lordosis
loss of trunk height
Tenderness
Mobility of the spine is restricted
Painful spinal movements
CLASSIFICATION
primary
95% of cases in women
70% to 80% in men
Secondary
SECONDARY CAUSES
DIFFERENT PARAMETER IN BONE DENSITOMETRY REPORT T-score
number of SD the patient is below or above mean value for young (30 year old) normal subjects
Z-score
number of SD the patient is below or above the mean value for age-matched normal subjects
Absolute BMD
actual BMD expressed in g/cm2
the value that should be used to calculate changes in BMD during longitudinal follow-up
change of 1 standard deviation in either the T or Z score correlates
approximately 0.06 g/cm2
approximately 10% of BMD
SKELETAL SITE SELECTION World Health Organization (WHO) recommendation using T-score measured by DXA at the femoral neck
National Osteoporosis Foundation (NOF) the International Society for Clinical Densitometry (ISCD) using the lowest T-score of the lumbar spine (L1-L4) total proximal femur femoral neck following areas In the hip should not be used for diagnosis Ward's area trochanter other regions
WHAT ESTIMATES OF BONE LOSS AND FRACTURE RISK
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