Dr. Faisal Younis ShahPG2YBones and Joints Surgery Hospital GMC Srinagar.

OSTEOPOROSIS

Osteoporosis is a systemic disease of the old age. It means increased age related demineralisation of the skeleton leading to decreased bone strength.Osteoporosis literally means “porous bones”.

Osteoporosis may be Primary/Idiopathic:

Type 1: (post-menopausal)Type 2: (senile osteoporosis)

Secondary (Type 3) to endocrine, haematological, genetic, environmental or other factors.

osteoporosis is the DIABETES of Orthopedics

Osteoporosis is often described as the silent epidemic just like diabetes, as it is a pain-free and symptomless disease in which bone becomes progressively porous, fragile and loses strength. As bone strength decreases the outcome is often broken bones, even occurring after a minor trauma like sitting, bending over, lifting a vacuum cleaner or coughing.Unlike the underlying disease, fractures are certainly not silent – they are a major cause of suffering, disability, poor quality of life and premature death.

The most common and significant fractures occur in the spine (45%), hip (20%) or wrist (20%).

A 10% loss of bone mass in the vertebrae can double the risk of vertebral fractures, and similarly, a 10% loss of bone mass in the hip can result in a 2.5 times greater risk of hip fracture.

SYMPTOMSESSENTIALLY ASYMPTOMATIC…

till u get a fracture

Undiagnosed Fractures.. (2/3 of vertebral #)

Subtle: Back pain, other non specific pains Loss of height Stooped posture

.

How Serious is OsteoPorosis !

The lifetime risk of suffering an osteoporotic fragility fracture for adult women is 1 in 3. For males, the risk is less, but remains substantial at 1 in 5.

Following a fragility fracture, the risk of sustaining a subsequent fracture at least doubles, with a 30-80% increase during the three years following the fracture.

The combined lifetime risk for hip, forearm and vertebral fractures coming to clinical attention is around 40%, equivalent to the risk for cardiovascular diseases.

In women over 45 years of age, osteoporosis accounts for more days spent in hospital than many other diseases, including diabetes, myocardial infarction and breast cancer

About 25 % patients with a Hip fractures die within a year.

Those who survive often face serious disability.1 out of 4 osteoporotic hip fractures will need long-term nursing care

One half of these are unable to walk without assistance

In USA osteoporosis costs $20 Billion Annually

DIABETES MELITUS OSTEOPOROSISDiabetes is genetic as well as a lifestyle disease

Os.poros is genetic as well as a lifestyle disease

Diabetes is a silent disease.Without symptoms till it’s too late

Osteoporosis is a silent disease.Without symptoms till it’s too late

Disease of the Old25% of people above 65 years have DM

10% of people above 60 years have OSTEOPOROSIS

MORE THAN HALF of all diabetes cases go undiagnosed

ALMOST ALL are undiagnosed… although most kashmiris know “sugar bemayr”, no one has heard of OP

Most patient with DM are not serious about their disease

No-one in Kashmir knows that such a disease exists.

An additional 50% population over 65 have pre-Diabetes

Additional 40% population above 60 have osteopenia

ALMOST ALL are undiagnosed ALL are undiagnosed.

70,000 + 230,000 (300,000) deaths in USA (0.1%)

100,000 deaths in USA

4 clinical MI per 1000 persons per year 4 fractures per 1000 persons per year

EPIDEMIOOGY.

Post menopausal women are more commonly affected than men. This is because of the small bones in women, malnourishment in women that is common in developing countries as well as the deficiency of bone protective Estrogen in Post-menopausal women.

– Hormonal imbalances following MP result in rapid bone loss

– Women can lose up to 20% of their bone mass in 5-7 years of menopause (1-6% per yr)

The frequency of postmenopausal osteoporosis accounts for the overall female-male ratio of 2:1 to 3:1.

It is a common notion that OP occurs in women only and that all post-menopausal women have osteoporosis, but this is not true. Not all women have osteoporosis and Men too contribute to the share of this disease.

Causes:Bone mass loss is a natural phenomenon, that occurs with age in everyone.Why this happens, WE DONOT KNOW!…but when this loss becomes too much, that’s our clinical problem.

However there are certain RISK FACTOTS that increase this loss.Non-modifiable: Modifiable: Your sex. Low calcium/Vit D intake. Eating Menopause. Disorders, GI Problems Lifetime exposure to estrogen. Steroids, PPI, anti-convulsants Age. Heparin, Race. Alcohol, tobacco Family history. Sedentary life style, Your bone size when you were young.

Secondary Causes: Hormonal: Increase in Thyroid, Parathyroid, Adrenal activity; Early Menopause Decreased sex hormones: Oophorectomy, hysterectomy, orchidectomy, cancer treatment, RA/CKD/CLD

SCREENING

U.S. Preventive Services Task Force (USPSTF) in 2011 recommended screening of OP in…women aged 65 years and older and in younger women with risk factors. 

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men. 

After going through this data I would recommend that we should screen.

Females > 60, Postmenopausal females < 60 with risk factors for osteoporosis.Men should be individually assessed for risk factors, their severity and fall risk to be advised DEXA.

All patients with non pathological Fragility fractures can be treated as Osteoporosis even without DEXA.

RISK FACTORS:Delayed Puberty, Early menopause, Oophorectomy, hysterectomyOrchidectomy, cancer treatment,

Eating Disorders, GI Diseases, Deppression, MalnutritionSteroids, PPI, anti-convulsants, heparin use, Alcohol, tobacco, Sedentary LifestyleFamily history. Small frame/Underweight at 30 (ME)Increase in Thyroid, Parathyroid, Adrenal activity, RA/CKD/CLD

Dual-energy X-ray absorptiometry (DEXA) is the most common method used to study Bone Mineral Density (BMD) or bone mass. It is used to identify people with osteopenia or osteoporosis. Since 1994, WHO has established the standard of diagnosis of diagnosing osteoporosis as a bone mass density of 2.5 standard deviations below that of a young adult, while it defines osteopenia is defined as a bone density of 1standard deviations below that of a young adult of same gender.

BMD although a very useful tool, has its flaws…

Although percentage wise the highest percentage of fractures occur in Osteoporotic group…

…But because prevalence of osteopenia is much higher than osteoporosis, the major burden of fragility fractures comes from osteopenic group.

So, we have another tool to guide our treatment… FRAX (WHO Fracture Risk Assessment Tool)FRAX not only uses BMD but also 11 other factors to assess 10 year probability of a Major fracture and of Hip fracture.Age SmokingSex AlcoholWeight Steroid UseHeight RAPrevious fracture Secondary OPFamily historyAnother advantage of FRAX is that it will give you a 10 year fracture risk even without DEXA.

COMING TO REALITY…We all know that DEXA isn’t going to work in kashmir. Mainly because of the economic factors.

But we can always advise it to those few who can afford it. And those we donot advise it to, we can always start them on good diet, lifestyle and exercise.

PREVENTION:

Prevention begins at an early age• Regular exercise (Wt. Bearing/Stress)• Adequate amounts of calcium (1200 mg/day)

and vitamin D (800 U / day).• Stop Smoking/drinking• Fall prevention

• DRUGS: Bisphosphonates.

Foods rich in calcium:• Milk and milk products like Yogurt, Cheese• Green leafy vegetables.

Foods rich in Vitamin D:• Fatty fish• Cheese• Egg yolk• Liver

Preventing falls.If you have children in your house, you have to take some precautions, similarly if you have elderly, you have to make the home elder proof.

• Low-heeled shoes with nonslip soles • No electrical cords, loose rugs and slippery

surfaces in the house. • Rooms should be brightly lit.

• American bathroom: no wet areas, Install grab bars

ROAD AHEAD….

Osteoporosis will become a leading cause of morbidity and mortality unless we apply appropriate programs of prevention, screening, diagnosis and treatment of osteoporosis.

Although various authors have recommended screening in women older than 65 years, in people with risk factors for osteoporosis or patients with secondary causes that may lead to osteoporosis but the topic is still being debated and the risk to benefit ratio of screening for osteoporosis is still being evaluated.

THE CHALLENGES….

1. In Kashmir, the population of elderly is increasing. This population especially women are often neglected, malnourished and particularly have deficient intake of Calcium and Vitamin D (from an early age), this population has no concept of exercise, is prone to falls and the awareness about osteoporosis is poor.

2. Unfortunately both in developed as well as developing countries Orthopedicians and doctors in general as well as patients aren’t aware of and aren’t approaching osteoporosis with the seriousness that it deserves.

Various studies like NICE have highlighted the inadequate bone health services even in the developed countries and have advocated secondary prevention of osteoporotic fractures and have promoted the pharmacological management of osteoporosis.

3. There is no screening protocol for vitamin D levels and osteoporosis in general population, high risk population or even those with fractures suggestive of osteoporosis.

4. Orthopedicians and family physicians are more interested in fixing the fractures with very little attention paid to treating the underlying cause.

5. Patients with osteoporotic fractures are rarely advised DEXA,

6. vitamin D and Calcium supplements are prescribed for very brief durations;

7. Bisphosphonates are used in occasional patients,

8. there is no concept of lifestyle modification for treatment of osteoporosis

9. and the follow-up of osteoporosis is much less than adequate.

THANK YOU….