OSTEOPOROSIS
Dr Ramin Rafiei
Alzahra Hospital
Rheumatology
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

Men

postmenopausal women



Osteopenia
men
postmenopausal women
17%
12%
19%
35%
33%
40%
OSTEOPOROSIS PREVALENCE IN IRAN
OSTEOPOROSIS PREVALENCE IN ISFAHAN
Sex

Menoupau
se
Prevalence of Osteoporosis
Bonakdar et al 2008
Femal
e
Sex

Mean age
(year)
Salamat et al
Female
Mix
44
Menoupause
2009
post
Mean Age
(yaer)
51.8
Prevalance of Osteopenia
spinal
Femur
Spinal
Femur
9%
3%
25%
27%
Prevalence of
Osteoporosis
Prevalance of
Osteopenia
spinal
Femur
spinal
Femur
5%
40%
50%
45%




Mortality
HEALTH IMPACT
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/100000
ORANGE:200-300 FX/100000
GREEN:<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