Osteoporosis

Disediakan oleh :
Aini Izzati Abd Gaffar
112015443
What is osteoporosis?
Osteoporosis : porous bone
Definition
Abnormally low bone mass
Defects in bone structure
Unusually fragile
Greater than normal risk of fracture in a person of that
age, sex and race
 WHO

The WHO definition applies to postmenopausal women and men

aged 50 years or older. Not be applied to premenopausal women,
men younger than 50 years, or children.
 ETIOLOGY
Primary osteoporosis when a secondary cause of
osteoporosis cannot be identified.
Secondary osteoporosis occurs when an underlying
disease, deficiency, or drug causes osteoporosis
Primary osteoporosis
Secondary osteoporosis occurs when an underlying
disease, deficiency, or drug causes osteoporosis
PREVALENCE
PATHOPHYSIOLOGY
 Bone depletion

HOW??
Predominant bone resorption
Decreased bone formation
Or a combination of the two
Alterations in bone formation and remodelling imbalance
between bone resorption and bone formation
Estrogen deficiency In the absence of estrogen, T cells promote
osteoclast recruitment, differentiation, and prolonged survival via
IL-1, IL-6, and tumor necrosis factor (TNF)alpha.
Ageing progressive decline in the supply of osteoblasts in
proportion to the demand.
Calcium deficiency Insufficient dietary calcium or impaired
intestinal absorption of calcium due to aging or disease can lead
to secondary hyperparathyroidism
Vitamin D deficiency result in secondary hyperparathyroidism
via decreased intestinal calcium absorption
WHERE??
Particularly, diaphyseo-metaphyseal junctions (in tubular
bones) and mainly cancellous vertebral bodies
Eventually reaches state in which a comparatively
modest stress or strain causes a fracture
 Clinical features and diagnosis
Early stages without symptoms until fracture occurs
Loss of height over time (as much as 6 inches)
Stooped posture/kyphosis/ Dowagers hump may develop
Pain

Back pain
Increased thoracic kyphosis
Diminished height
 X-ray
may be indicated if a
fracture is already
suspected or if patients
have lost more than 1.5
inches of height
Wedging or
compressions of one or
more vertebral bodies
Lateral view : * Sometimes, the first clinical event is a low energy
calcification of aorta fracture of distal radius ( Colles fracture), hip or ankle
(often)
 Characteristics signs of severe postmenopausal
osteoporosis :
o compression fractures of vertebral bodies
o wedging at multiple levels
o biconcave distortion of vertebral end-plates
- due to bulging of intact intervertebral discs
 Clinical and radiographic diagnosis should be backed up
by assessment of BMD
- As measured by DXA of spine and hips
- Indicative osteoporosis :
Normal women over 50 years, -2.5sd
 DIAGNOSTIC APPROACH
Bone mass density (BMD) measurement
Indications:
Concerned perimenopausal woman willing to start drug therapy
Radiographic evidence of bone loss
Patient on long-term glucocorticoid therapy (more than one month of
therapy at a dosage of 7.5 mg [or higher] of prednisone per day)
Asymptomatic hyperparathyroidism where osteoporosis would suggest
parathyroidectomy
Monitoring therapeutic response in women undergoing treatment for
osteoporosis if the result of the test would affect the clinical decision
DXA
(Dual energy x ray Absorptiometry)
Show significantly reduced bone density
in vertebral bodies or femoral neck
 Postmenopausal osteoporosis
symptomatic postmenopausal osteoporosis : exaggerated
form of physiologic bone depletion
- Normally accompanies ageing and loss of gonadal
activity
 2 overlapping phases :
1. High turnover osteoporosis
- Early postmenopausal syndrome : rapid bone loss
( predominantly increased osteoclastic resorption)
2. Low turnover osteoporosis
- Emerges in elderly
- Due to gradual slow-down in osteoblastic activity
- Increasing effects of dietary insufficiencies
- Chronic ill-health
- Reduced mobility
 Bone loss accelerates to about 3% per year around
menopause and the next 10 years
Compared to 0.3% during preceding two decades
Mainly due to :
- Increased bone resorption
- Withdrawal oestrogen (restraints on osteoclastic activity)
- Genetic influences
- Risk factors
 Prevention and treatment
Prophylactic treatment :
- Women at more than usual risk of suffering fracture at
menopause (bone densitometry)
- DXA screening :
o usually reserved for women with multiple risk factors
o Particularly those with suspected oestrogen deficiency
(premature or surgically induced menopause)
o Bone losing disorder
o One who already suffered previous low-energy fractures
at menopause
 Maintain adequate levels of dietary calcium and vitamin D
Keep up high level of physical activity
Avoid smoking
Avoid excessive consumption alcohol
If necessary, calcium and vit D supplements (to met
recommended daily requirements)
 Hormone replacement therapy (HRT)
Was the most widely used medication for
postmenopausal osteoporosis
Oestrogen / combination oestrogen and progesterone (
for 5-10years)
Convincingly reduce risk of osteoporotic fractures
BUT
After stopping HRT, BMD gradually falls to usual low level
Apparent increase risks of thromboembolism, stroke,
breast cancer, uterine cancer
 Biphosphonates
Now regarded as preferred medications
Mechanism of action:
- Reducing osteoclastic bone resorption , general rate of
bone turnover
Prevent bone loss + reduce risk of vertebral and hip
fractures
Alendronate : peroral, once-weekly doses for both
prevention and treatment ( GI side effects)
Pamidronate : IV, 3 months intervals
 Parathyroid hormones

Patients with severe osteoporosis + not respond to

bisphosphonates alone
Trials of parathyroid hormone alone or by combination
with alendronate rise in BMD (postmenopausal
osteoporosis)
 VERTEBROPLASTY & KYPHOPLASTY
The goals rapid mobilization and return to normal function
and activities.
Operative interventions anterior and posterior
decompression and stabilization with placement of such
internal fixation devices as screws, plates, cages, or rods.
Vertebroplasty and balloon kyphoplasty indicated in
patients with incapacitating and persistent severe focal back
pain related to vertebral collapse
 KYPHOPLASTY

In kyphoplasty, a KyphX inflatable bone tamp is percutaneously advanced

into the collapsed vertebral body (A). It is then inflated, (B) elevating the
depressed endplate, creating a central cavity, and compacting the
remaining trabeculae to the periphery. Once the balloon tamp is deflated
and withdrawn, the cavity (C) is filled under low pressure with a viscous
preparation of methylmethacrylate (D)
PHYSICAL & OCCUPATIONAL THERAPY
Physical therapy focuses on improving a patient's
strength, flexibility, posture, and balance to prevent
falls and maximize physical function
Occupational Therapy -> improve performance of
activities of daily living (installing handrails and grab
bars in hallways, stairs, and bathrooms, shower
chair, tub bench)
 PREVENTION
Behavior modification
Patient education:
Exercise
cessation of smoking
moderation of alcohol consumption.
Adequate calcium and vitamin D supplements
 COMPLICATIONS
Vertebral compression fractures With minimal stress
Hips fractures most devastating, occur most commonly at
the femoral neck and intertrochanteric regions
Fractures complications:
chronic pain from vertebral compression fractures
functional decline
a poor quality of life
immobility,
including deep vein thrombosis (DVT)
pressure ulcers
 PROGNOSIS
The prognosis for osteoporosis is good if bone loss is detected
in the early phases and proper intervention is undertaken.
Patients can increase BMD and decrease fracture risk with the
appropriate anti-osteoporotic medication.
In addition, patients can decrease their risk of falls by
participating in a multifaceted approach that includes
rehabilitation and environmental modifications.
Worsening of medical status can be prevented by providing
appropriate pain management and, if indicated, orthotic
devices.