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Osteoporosis is a major public health problem, and postmenopausal osteoporosis constitutes as a major part of the problem.
Claus Christiansen, Am J Med 1993
Hip fractures will increase sharply in the next half century, especially in Asia, making osteoporosis a truly global issue.
WHO 1998
EPIDEMIOLOGY
IntroductionIntroduction
Osteoporosis is a disease characterized Osteoporosis is a disease characterized by low bone mass and microarchitecturalby low bone mass and microarchitecturaldeterioration of bone tissue, leading to deterioration of bone tissue, leading to enhance bone fragility and a consequentenhance bone fragility and a consequentincrease in fracture riskincrease in fracture risk
(WHO)(WHO)
Osteoporosis is a skeletal disordersOsteoporosis is a skeletal disorders
compromised bone strength, compromised bone strength,
predisposing in an increase riskpredisposing in an increase risk
of fractureof fracture
Rigg and Nelson divided into :Rigg and Nelson divided into :
A/. Primary osteoporosisA/. Primary osteoporosis 1. Post menopause osteoporosis1. Post menopause osteoporosis 2. Senile osteoporosis2. Senile osteoporosis
B/. Secondary osteoporosisB/. Secondary osteoporosis Osteoporosis due to other conditionOsteoporosis due to other condition of disease such as metabolic,of disease such as metabolic, endocrine or malignancy endocrine or malignancy
Post menopausal osteoporosis
• Most common in woman 15 – 20 year after menopause
• Mostly affects trabecular bone, increasing patient
susceptibility to vertebral compression fractures,
distal radial fractures and intertrochanteric fractures.
• Esterogen deficiency plays a primary role
Senile OsteoporosisSenile Osteoporosis•Occurs in men and women over the age of 70 years
with female to male ratio of 2:1• It affects : cortical and trabecular bone equally,
predisposing patient to multiple wedges vertebral and femoral neck fractures •Aging and long-term calcium deficiency is more
important.
Primary osteoporosis mostly are old and
elderly people complaining of mild
backache but may also a sudden pain
with only a mild injury due to a
compression fractures of the vertebrae.
Before it reaches the threshold of fractures,
usually the height of patient reduces beside
deformity (kyphotic deformity)
It is a silent disease, meaning there isIt is a silent disease, meaning there is
no significant signs and symptoms no significant signs and symptoms
caused by osteoporosiscaused by osteoporosis
Etiology :Etiology :
General factor predictive of osteoporosis :General factor predictive of osteoporosis :
1. Peak bone mass at maturity :1. Peak bone mass at maturity : General / familialGeneral / familial Nutritional Nutritional Physical (activity status, exercise, etc)Physical (activity status, exercise, etc) Life style (alcohol, cigarettes, caffeine)Life style (alcohol, cigarettes, caffeine) Medical (chronic disease, hypogonadal states, etc)Medical (chronic disease, hypogonadal states, etc) Iatrogenic (corticosteroid, anticonvulsant, etc)Iatrogenic (corticosteroid, anticonvulsant, etc)
Orthopaedics Study Guide, Metabolic Bone Disease, 1999, p.885-889Orthopaedics Study Guide, Metabolic Bone Disease, 1999, p.885-889
20 40 8060
Bon
e M
ass
Peak Bone Mass
male
female
Menopause
Bone Loss
Bone Mass Development
ageAge (year)
2. Post menopausal bone loss2. Post menopausal bone loss
Accelerated trabecular bone loss for 3Accelerated trabecular bone loss for 3 to 10 years post menopausalto 10 years post menopausal Due to increased bone resorptionDue to increased bone resorption secondary to estrogen losssecondary to estrogen loss Loss of normally 1 to 2% per year to Loss of normally 1 to 2% per year to a maximum of 10%a maximum of 10%
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
3. Age-related (involutionall) bone loss3. Age-related (involutionall) bone loss
Starts at age 35 – 40 years in both sexes,Starts at age 35 – 40 years in both sexes, continues for 30 to 40 yearscontinues for 30 to 40 years Subtle uncoupling of rates of bone formationSubtle uncoupling of rates of bone formation and resorptionand resorption Both cortical and trabecular bone affectedBoth cortical and trabecular bone affected Loss normally less than 0.5% per year to aLoss normally less than 0.5% per year to a maximum of 20 %maximum of 20 %
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
4. Risk factors4. Risk factors
Genetic, life style, Medical, IatrogenicGenetic, life style, Medical, Iatrogenic
Risk factors for bone Risk factors for bone loss :loss :
1. Genetic : 1. Genetic :
- Female sex- Female sex- Caucasian / Asian ethnicity- Caucasian / Asian ethnicity- Family history of osteoporosis- Family history of osteoporosis
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
2. Life Style : 2. Life Style :
- Low calcium intake- Low calcium intake- Excessive alcohol use- Excessive alcohol use- Cigarette smoking- Cigarette smoking- Excessive caffeine use- Excessive caffeine use- Extreme or insufficient athlecity - Extreme or insufficient athlecity
- Excessive acid ash diet (high protein /- Excessive acid ash diet (high protein / soft drink intakes)soft drink intakes)
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
3. Medical : 3. Medical :
- Early menopause- Early menopause- Gonadal hormone deficiency - Gonadal hormone deficiency
statesstates- Eating disorders- Eating disorders- Chronic liver / kidney - Chronic liver / kidney
diseasedisease- Malabsorption syndrome- Malabsorption syndrome
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
4. Iatrogenic :4. Iatrogenic :
- Corticosteroids- Corticosteroids- Excessive thyroid hormone- Excessive thyroid hormone- Chronic heparin therapy- Chronic heparin therapy- Radiotherapy to skeleton- Radiotherapy to skeleton- Long-term anticonvulsants- Long-term anticonvulsants- Loop diuretics- Loop diuretics
Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
Bone is the most dynamic tissue.Bone is the most dynamic tissue.
Metabolism of catabolism and anabolismMetabolism of catabolism and anabolism
as the activity of osteoclast and osteoblastas the activity of osteoclast and osteoblast
as a process of bone remodeling or as a process of bone remodeling or
bone turn overbone turn over
Degeneration occurs as an aging processDegeneration occurs as an aging process
where the activity of osteoclast is not ablewhere the activity of osteoclast is not able
to compensate by the activity of osteoblast.to compensate by the activity of osteoblast.
As a result bone mineral density decreaseAs a result bone mineral density decrease
The main problem of osteoporosisThe main problem of osteoporosis
lies in the effectiveness of intervention-lies in the effectiveness of intervention-
prevention and treatmentprevention and treatment
Osteoporosis is preventable if preventionOsteoporosis is preventable if prevention
starts during the childhood and adolescencestarts during the childhood and adolescence
when bone reaches maturity at the end when bone reaches maturity at the end
of 3of 3rdrd decade to achieve maximum decade to achieve maximum
Peak Bone MassPeak Bone Mass
After the 3After the 3rdrd decade all organ include decade all organ include skeletal / bone will degenerate, the speed skeletal / bone will degenerate, the speed of degeneration, differs for different of degeneration, differs for different organ. organ.
In general organ will loose function In general organ will loose function
1% every year (the rule of 1% of Andreas 1% every year (the rule of 1% of Andreas and Tobin) and Tobin)
Diagnosis should include differential diagnosis of
primary and secondary osteoporosis by :
o Taking a good history
o Physical examination
o Laboratory examination
o Imaging examination
DIAGNOSIS
History :
o ras, sex and age
o health status
o life style (alcohol, smoking)
o physical activity (sports)
o history of previous disease including administration of
drugs, previous fracture.
Physical Examination :
Body weight and height (BMI)
Extremities and spine including :
deformity, MMT and ROM
LABORATORY FINDINGS :
Routine:
- Serum :
- Complete blood counts
- Electrolytes, creatinine, blood urea, nitrogen calcium
- Phosphorus, protein, albumin, alkaline phosphatase,
liver enzyme
- Protein electrophoresis
- Thyroid function tests
- Testoterone (men only)
- 24 hours urine :
- calcium
- Pyridinium cross-links
LABORATORY FINDINGS :
Spesial :
- Serum:
- 25 hydroxyvitamin D3
- 1,25 hydroxyvitamin D3
- intact parathyroid hormone
- osteocalcium (bone Gla protein)
- Urine :
- Immunoelectrophoresis
- Bence-Jones protein
IMAGING :
Radiology : plain X-ray
(especially the spine, hip and wirst)
The spine : - the ballooning disc
- deformity of vertebral body
(wedge, fish tail)
The Hip : - Singh Index
The Wirst : - Porotic / thinning cortex
The general diagnostic categoriesThe general diagnostic categoriesestablished in woven : (WHO working group)established in woven : (WHO working group)
Normal :Normal : Bone Mass Density (BMD)or Bone Mass Density (BMD)or Bone Mineral Content (BMC)Bone Mineral Content (BMC) -1 SD from T Score of the young-1 SD from T Score of the young adult reference meanadult reference meanOsteopenia :Osteopenia : BMD or BMC –1 SD to –2.5 SD BMD or BMC –1 SD to –2.5 SD Osteoporosis :Osteoporosis : BMD or BMC –2.5 SD BMD or BMC –2.5 SD
(severe osteoporosis when there is followed a fracture)(severe osteoporosis when there is followed a fracture)
Prevention and TreatmentT-score Fracture risk Teatment
> +1 very low • no treatment• densitometry with indication
-1 s/d 0 low • no treatment• densitometry after 5 years
- 1 s/d +1 low • no treatment• densitometry after 2 years
-1s/d -2,5 midle • prevention• densitometry after 1 years
< - 2,5 high • osteoporosis treatmentno fracture • continue prevention
• densitometry after 1 years
< - 2,5 very high • osteoporosis treatment With fracture • continue prevention
• surgery with indication • densitometry after within 6 month –1 years
T-score Fracture risk Teatment
> +1 very low • no treatment• densitometry with indication
-1 s/d 0 low • no treatment• densitometry after 5 years
- 1 s/d +1 low • no treatment• densitometry after 2 years
-1s/d -2,5 midle • prevention• densitometry after 1 years
< - 2,5 high • osteoporosis treatmentno fracture • continue prevention
• densitometry after 1 years
< - 2,5 very high • osteoporosis treatment With fracture • continue prevention
• surgery with indication • densitometry after within 6 month –1 years
PreventionPrevention
Aging process is a natural process of a personAging process is a natural process of a person getting oldgetting old
3 steps of osteoporosis prevention :3 steps of osteoporosis prevention : I. Up to the end of 3I. Up to the end of 3rdrd decade decade where Peak Bone Mass should be where Peak Bone Mass should be achievedachieved II. After the 3II. After the 3rdrd decade up to menopause / decade up to menopause / AndropauseAndropause III. Senile, prevent from minor injury / III. Senile, prevent from minor injury / accidentaccident
Goal of Osteoporosis PreventionGoal of Osteoporosis Prevention
Optimising skeletal development Nutrition Physical activity Life style changes Minimize medical / iatrogenic factors
Minimize postmenopausal bone loss Early identification of patients at risk Reduced risk factors Hormone replacement therapy (HRT) Other agents pre-emptively if HRT contraindicated raloxifene, alendronate
Minimize age-related bone loss Identification of patients at risk Reduce risk factors Full prevention and exercise program (physical therapy)Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889Orthopaedics A Study Guide, Metabolic Bone Disease, 1999, p.885-889
11stst Prevention : Prevention :
Good nutrition Good nutrition
Life style and physical exerciseLife style and physical exercise
To achieve maximum Peak Bone MassTo achieve maximum Peak Bone Mass
22ndnd Prevention Prevention
Early diagnose of osteoporosisEarly diagnose of osteoporosis The same prevention as 1The same prevention as 1stst prevention prevention In female patient after menopause with HRTIn female patient after menopause with HRT Prevention of the use of medicationPrevention of the use of medication consist steroid etcconsist steroid etc
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