The Indian Practitioner

Open Access Open Access  Restricted Access Subscription Access
Open Access Open Access Open Access  Restricted Access Restricted Access Subscription Access

Osteoporosis in Orthopaedics:Review of Literature and Clinical Approach


Affiliations
1 Consulting Orthopaedic and Joint Reconstruction Surgeon, Lilavati Hospital and Research Centre, India
2 Registrar, Dept of Orthopaedic Surgery, Lilavati Hospital and Research Centre, India
     

   Subscribe/Renew Journal


Osteoporosis affects 8 to 62 percent of women in India, with osteoporotic fractures leading to preventable morbidity and often mortality. Osteoporosis does not have any clinical symptoms and may often present with fracture as the first symptom. Our aim to review the literature and describe a clinical approach in osteoporosis was to help the practitioner and orthopaedic surgeon suspect, diagnose, treat, prevent, monitor, and lead a patient through uneventful surgery. Early diagnosis and effective treatment of osteoporosis can lead to decreased morbidity, mortality, and financial burden on the elderly and also improve their quality of life.

Keywords

Osteoporosis, Osteopenia, Teriparatide, Bisphosphonates, Denosumab, Osteoporotic Fractures, T Score, Monitoring of Treatment, Bone Turnover Markers, Bone Density, DXA, BMD, FRAX Score.
Subscription Login to verify subscription
User
Notifications
Font Size


  • Consensus Development Conference: Diagnosis, Prophylaxis and Treatment of Osteoporosis. Am J Med. 1991; 90[1]; 107-10.

  • NIH Consensus Development Conference: Osteoporosis prevention, diagnosis and therapy. JAMA. 2001 Feb 14; 285[6]: 785-95.

  • Kanis JA on behalf of the World Health Organization Scientific Group. Technical Report. World Health Organization Collaborating Centre for Metabolic Bone Diseases, University of Sheffield; UK: 2007. Assessment of osteoporosis at the primary health-care level.

  • Sozen T, Ozisic L et al. An overview and management of osteoporosis : Eur J Rheumatol. 2017; 4[1]: 46-56.

  • Gullberg B, Johnell O et al. Worldwide projections for hip fracture. Osteoporos Int. 1997; 7[5]:407- 413.

  • Malhotra N, Mithal A et al. Osteoporosis in Indians. Indian J Med Res. 2008 Mar; 127[3]:263-8.

  • Khadilkar VA, Mandlik RM et al. Epidemiology and treatment of osteoporosis in women: an Indian perspective : Int J Women’s Health. 2015; 7: 841-850.

  • Gandhi AB, Shukla AK et al. Evaluation of BMD of women above 40 years of age: J Obstet Gynaecol India. 2005 May; 55[3]: 265-267.

  • Unni J, Garg R, Pawar R. Bone mineral density in women above 40 years. J Midlife Health. 2010:1:19-22.

  • Chhibber G, Roy R et al. Prevalence of osteoporosis among elderly women living in Delhi and rural Haryana. Indian J Endocr Metab. 2007; 11:11-14.

  • Shatrughna V, Kulkarni B et al. Bone status of Indian women from a low-income group and its relationship to nutritional status. Osteoporos Int. 2005; 16[12]:1827-1835.

  • Klotzbuecher CM, Ross PD et al. Patients with prior fractures have an increased risk of future fractures: A summary of the literature and statistical synthesis. J Bone Miner Res. 2000; 15[4]: 721-739.

  • Harrison RA, Siminoski K et al. Osteoporosis related kyphosis and impairments in pulmonary function: a systematic review. J Bone Miner Res. 2007; 22[3]: 447-457.

  • Cooper C, Atkinson EJ et al. Population based study of survival after osteoporotic fractures. Am J Epidemiol. 1993; 137[9]:1001-1005.

  • Ray NF, Chan JK et al. Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: Report from the National Osteoporosis Foundation. J Bone Miner Res. 1997; 12[1]:24- 35.

  • Adapted from Melton LJ and Regis BL. Osteoporosis: Etiology, Diagnosis and Management. Raven Press. 1988, 155-179.

  • Lin YC, Lyle RM et al. Peak spine and femoral neck bone mass in young women. Bone. 2003; 32[5]:546-553.

  • Rizzoli R, Bonjour JP et al. Osteoporosis, genetics and hormones. J Mol Endocrinol. 2001; 26[2]:79-94.

  • Eismann JA. Genetics of osteoporosis. Endocr Rev. 1999; 20[6]:788-804.

  • Riggs BL, Melton LJ. Involutional Osteoporosis. N Engl J Med. 1986; 314:1676-1686.

  • Ribot C, Pouilles JM et al. Assessment of the risk of postmenopausal osteoporosis using clinical factors.

  • Tannirandorn P, Epstein S. Drug-induced bone loss. Osteoporos Int. 2000; 11[8]:637-659.

  • Marshall D, Johnell O et al. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ. 1996;312[7041]:1254-1259.

  • Hui SL, Slemenda CW et al. Age and bone mass as predictors of fractures in a prospective study. J Clin Invest. 1998; 81[6]:1804-1809.

  • World Health Organization. Technical report series 843, WHO, Geneva. 1994.

  • Baim S, Binkley N et al. Official positions of the International Society for Clinical Densitometry and executive summary of the 2007 ISCD position development conference. J Clin Densitom. 2008; 11[1]:75-91.

  • Rauch F, Plotkin H et al. Fracture prediction and the definition of osteoporosis in children and adolescents: The ICSD 2007 Paediatric Official Positions. J Clin Densitom. 2008; 11[1]:22-28.

  • Gordon CM, Bachrach LK et al. Dual energy x-ray absorptiometry interpretation and reporting in children and adolescents: the 2007 paediatric official positions. J Clin Densitom. 2008; 11:43-58.

  • Unnanuntana A, Gladnick BP et al. The assessment of fracture risk. J Bone Joint Surg Am. 2010; 92[3]:743-753.

  • Dufresne TE, Chmielewski PA et al. Risedronate preserves bone architecture in early postmenopausal women in 1 year as measured by three-dimensional microcomputed tomography. Calcif Tissue Int. 2003;73: 423-32.

  • Cummings SR, Karpf DB et al. Improvement in spine bone density and reduction in risk of vertebral fractures during treatment with antiresorptive drugs. Am J Med. 2002;112: 281-9.

  • Lochmuller EM, Zeller JB, et al. Correlation of femoral and lumbar DXA and calcaneal ultrasound, measured in situ with intact soft tissues, with the in vitro failure loads of the proximal femur. Osteoporos Int. 1998; 8:591-8.

  • Melton LJ, Chrischilles EA et al. How many women have osteoporosis? J Bone Miner Res. 1992; 7:1005-10.

  • Siris ES, Chen YT, et al. Bone mineral density thresholds for pharmacological intervention to prevent fractures. Arch Intern Med. 2004; 164:1108-12.

  • Schuit SC, Vanderklift M et al. Fracture incidence and association with bone mineral density in elderly men and women: the Rotterdam study. Bone. 2004; 34:195-202. Erratum in: Bone. 2006; 38:603.

  • Sornay-Rendu E, Munoz F, et al. Identification of osteopenic women at high risk of fracture : the OFELY study. J Bone Miner Res. 2005; 20:1813-9.

  • Greenspan SL, Myers ER et al. Fall severity and bone mineral density as risk factors for hip fracture in ambulatory elderly. JAMA. 1994; 271:128-33.

  • Garnero P, Hausherr E et al. Markers of bone resorption predict hip fracture in elderly women: the EPIDOS prospective study. J Bone Miner Res. 1996;11: 1531-8.National Osteoporosis Foundation. Physician’s guide to prevention and treatment of osteoporosis. Belle Mead, NJ: Excerpta Medica; 2003.

  • Kanis JA, McCloskey EV et al; National Osteoporosis Guideline Group. Case finding for the management of osteoporosis with FRAX—assessment and intervention thresholds for the UK. Osteoporos Int. 2008; 19:1395-408.

  • Kanis JA, Oden A et al. FRAX and its applications to clinical practice. Bone. 2009; 44:734-43.

  • Kanis JA. Diagnosis of osteoporosis and assessment of fracture risk. Lancet. 2002; 359:1929-36.

  • Kanis JA, Johnell O et al. FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int. 2008;19:385-97.

  • Kanis JA, Johnell O et al. A meta-analysis of previous fracture and subsequent fracture risk. Bone. 2004; 35:375-82.

  • Kanis JA, Oden A, et al. The use of clinical risk factors enhances the performance of BMD in the prediction of hip and osteoporotic fractures in men and women. Osteoporos Int. 2007; 18:1033-46.

  • Zethraeus N, Borgstrom F et al. Cost-effectiveness of the treatment and prevention of osteoporosis — a review of the literature and a reference model. Osteoporos Int. 2007; 18:923.

  • Tang BM, Eslick GD et al. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: A meta-analysis. Lancet. 2007; 370[9588]:657-666.

  • Bonaiuti D, Shea B et al. Exercise for preventing and treating osteoporosis in postmenopausal women. The Cochrane database of systematic reviews. 2002; [2]:CD000333.

  • Feskanich D, Willett W et al. Walking and leisure time activity and risk of hip fracture in post- menopausal women. JAMA. 2002; 288[18]:2300-2306.

  • Masud T, Binkley N et al. Position development conference members. Official positions for FRAX clinical regarding falls and frailty : can falls and frailty be used in FRAX?

  • From joint official positions development conference of the ISCD and international osteoporosis foundation on FRAX. J Clin Densitom. 2011; 14[3]:194-204.

  • National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis. 2008. http://www.nof.org/professionals/cliniciansguide_ form.asp. Accessed 2009 Oct 22.

  • Dawson-Hughes B, Tosteson AN et al. National Osteoporosis Foundation Guide Committee. Implications of absolute fracture risk assessment for osteoporosis practice guidelines in the USA. Osteoporos Int. 2008; 19:449-58.

  • Riggs BL, Parfit AM. Drugs used to treat osteoporosis : the critical need for a uniform nomenclature based on their action on bone remodelling. J Bone Miner Res. 2005;20[2]:17784.

  • Hewitt RE, Lissina A, et al. The bisphosphonate acute phase response : rapid and copious production of pro inflammatory cytokines by peripheral blood and T cells in response to amino bisphosphonates is inhibited by statins. Clin Exp Immunol. 2005; 139[1]:101-111.

  • Perazella MA, Markowitz GS. Bisphosphonate nephrotoxicity. Kidney Int. 2008; 74[11]: 1385-1393.

  • Rizzoli R, Burlet et al. Osteonecrosis of the jaw and bisphosphonate treatment for osteoporosis. Bone. 2008; 42[5]:841-847

  • Allison MB, Markman L et al. Atypical incomplete femoral fractures in asymptomatic patients on long term bisphosphonate therapy. Bone. 2013; 55[1]:113-118.

  • McKenna MJ, van der Kamp S et al. Incomplete atypical femoral fractures: assessing the diagnostic utility of DXA by extending femur length. J Clin Densitom. 2013; 16[4]: 579583.

  • Diab DL, Watts NB, et al. Bisphosphonate drug holiday : Who when and how long. Ther Adv Musculoskelet Dis. 2013; 5[3]:107-111.

  • Boyle WJ, Simonet WS et al. Osteoclast differentiation and activation. Nature. 2003; 423[6937]: 337-342.

  • Black DM, Schwartz AV, et al. Effects of continuing or stopping alendronate after 5 years of treatment: The Fracture Intervention Trial Long - Term Extension [FLEX] : A randomised trial. JAMA. 2006; 296[24]:2927-2938.

  • Black DM, Greenspan SL, et al. The effects of parathyroid hormone and alendronate alone or in combination in postmenopausal osteoporosis. N Engl J Med. 2003; 349: 1207-1215.

  • Deal C, Omizo M, et al. Combination teriparatide and raloxifene therapy for postmenopausal osteoporosis : results from 6 - month —blind placebo - controlled trial. J Bone Miner Res. 2005; 20:1905-1911.

  • Cosman F, Eriksen EF et al. Effects of intravenous Zoledronic acid plus subcutaneous teriparatide [rhPTH[1-34]] in postmenopausal osteoporosis. J Bone Miner Res. 2011;26[3]:503511

  • Leder BZ, Tsai JN, et al. Two years of denosumab and teriparatide administration in postmenopausal women with osteoporosis [the DATA extension study]: A randomised control trial. J CLin Endocrine Metab; 2014; 99[5]:1694-1700.

  • van Staa TP, Leufkens HG et al. Does a fracture at one site predict later fractures at other sites? A British cohort study. Osteoporos Int. 2002; 13:624-629.

  • Johnell O, Oden A et al. Acute and long term increase in fracture risk after hospitalization for vertebral fracture. Osteoporos Int. 2001:12:207-214

  • Johnell O, Kanis JA et al. Fracture risk following an osteoporotic fracture. Osteoporos Int. 2004; 15:175-179

  • Kanis JA. Treatment of osteoporotic fracture. Lancet. 1984; 17[1]:27-33.

  • Seeley DG, Browner WS et al. Which fractures are associated with low appendicular bone mass in elderly women? The Study of Osteoporotic Fractures Research Group. Ann Intern Med. 1981; 115:837-842.

  • Kanis JA, Oden A et al. The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporos Int. 2001; 12:417-427.

  • Mackey DC, Black DM et al. Effects of anti- resorptive treatment on nonvertebral fracture outcomes. J Bone Miner Res. 2011; 26:2411-2418.

  • Cummings SR, Karpf DB et al. Improvement in spine bone density and reduction in risk of vertebral fractures during treatment with antiresorptive drugs. Am J Med. 2002; 112:281-289.

  • Sarkar S, Mitlak BH et al. Relationships between bone mineral density and incident vertebral fracture risk with raloxifene therapy. J Bone Miner Res. 2002; 17:1-10.

  • Delmas PD, Li Z et al. Relationship between changes in bone mineral density and fracture risk reduction with antiresorptive drugs: some issues with meta-analyses. J Bone Miner Res. 2004; 19:33-37.

  • Delmas PD, Seeman E. Changes in bone mineral density explain little of the reduction in vertebral or non-vertebral fracture risk with anti-resorptive therapy. Bone. 2004; 34:599-604.

  • Eastell R, Barton I et al. Relationship of early changes in bone resorption to the reduction in fracture risk with risedronate. J Bone Miner Res. 2003; 18:1051-1056.

  • Eastell R, Hannon RA et al. Relationship of early changes in bone resorption to the reduction in fracture risk with risedronate: review of statistical analysis. J Bone Miner Res. 2007; 22:1656-1660.

  • Reginster J-Y, Sarkar S, Zegels B et al. Reduction in PINP, a marker of bone metabolism, with raloxifene treatment and its relationship with vertebral fracture risk. Bone. 2004; 34:344-351.

  • Sarkar S, Reginster J-Y et al. Relationship between changes in biochemical markers of bone turnover and BMD to predict vertebral fracture risk. J Bone Miner Res. 2004; 19:394-401.

  • Bauer DC, Black DM, Garnero P et al. Change in bone turnover and hip, non-spine, and vertebral fracture in alendronatetreated women: the fracture intervention trial. J Bone Miner Res. 2004; 19:1250-1258.

  • Delmas PD, Munoz F et al. Effects of yearly zoledronic acid 5 mg on bone turnover markers and relation of PINP with fracture reduction in postmenopausal women with osteoporosis. J Bone Miner Res. 2009; 24:1544-1551.

  • Glover SJ, Gall M et al. Establishing a reference interval for bone turnover markers in 637 healthy, young, premenopausal women from the United Kingdom, France, Belgium, and the United States. J Bone Miner Res. 2009;24:389-397.

  • Vasikaran S, Eastell R, Bruyere O, for the IOF-IFCC Bone Marker Standards Working Group et al. Markers of bone turnover for the prediction of fracture risk and monitoring of osteoporosis treatment: a need for international reference standards. Osteoporos Int. 2011; 22:391-420.

  • Jobke B, Muche B et al. Teriparatide in bisphosphonate-resistant osteoporosis: microarchitectural changes and clinical results after 6 and 18 months. Calcif Tissue Int. 2011; 89:130-139.

  • Keaveny TM, McClung MR et al. Femoral strength in osteoporotic women treated with teriparatide or alendronate. Bone. 2012; 50:165-170.

  • Hadji P, Gamerdinger D et al. Rapid Onset and Sustained Efficacy [ROSE] study: results of a randomised, multi- centre trial comparing the effect of zoledronic acid or alendronate on bone metabolism in postmenopausal women with low bone mass. Osteoporos Int. 2012; 23:625-633.

  • Saag K, Lindsay R et al. A single zoledronic acid infusion reduces bone resorption markers more rapidly than weekly oral alendronate in postmenopausal women with low bone mineral density. Bone. 2007; 40:1238-1243.

  • Freemantle N, Satram-Hoang S et al. Final results of the DAPS [Denosumab Adherence Preference Satisfaction] study: a 24-month, randomized, crossover comparison with alendr- onate in postmenopausal women. Osteoporos Int. 2012; 23:317-326.

  • Nguyen TV, Eisman JA et al. Femoral neck bone loss predicts fracture risk independent of baseline BMD. J Bone Miner Res. 2009; 20[7]:1195-1201.

  • Lewiecki EM. Non-responders to osteoporosis therapy. J Clin Densitom. 2003; 6[4]:307-314.

  • Adami S, Isaia G et al. Fracture incidence and characterization in patients on osteoporosis treatment: the ICARO study. J Bone Miner Res. 2006; 21:1565-1570.

  • Diez-Perez A, Olmos JM et al. Risk factors for prediction of inadequate response to antiresorptives. J Bone Miner Res. 2012; 27:817-824.

  • Ip TP, Leung J et al. Management of osteoporosis in patients hospitalised for hip fractures, Osteoporos Int. 2010; 21[4]:605-614.

  • Joong BS, Yun JSn et al. Influence of Early Bisphosphonate Administration for Fracture Healing in Patients with Osteoporotic Proximal Humerus Fractures. Clin Orthop Surg. 2016; 8[4]:437-443.

  • Kim TY, Ha YC et al. Does early administration of bisphosphonate affect fracture healing in patients with intertrochanteric fractures? J Bone Joint Surg Br. 2012; 94[7]:956-960.

  • Gong HS, Song CH et al. Early initiation of bisphosphonate does not affect healing and outcomes of volar plate fixation of osteoporotic distal radial fractures. J Bone Joint Surg Am. 2012; 94[19]:1729- 1736.

  • Eriksen EF, Lyles KW et al. Antifracture efficacy and reduction of mortality in relation to timing of first dose of zoledronic acid after hip fracture. J Bone Miner Res. 2009; 24[7]:1308-1313.

  • Dirschl DR, Henderson RC et al. Accelerated bone mineral loss following a hip fracture: a longitudinal study. Bone. 1997; 21[1]:79-82.

  • Li YT, Cai HF et al. Timing of the initiation of bisphosphonates after surgery for fracture healing : a systematic review and meta-analysis of randomised controlled trials. Osteoporos Int. 2015; 26[2]:431-441.

  • Giannoudis P1, Tzioupis C et al. Fracture healing in osteoporotic fractures: is it really different? A basic science perspective. Injury. 2007; 38[1]:590-599.

  • Cortet B. Bone repair in osteoporotic bone: postmenopausal and cortisone induced osteoporosis. Osteoporosis Int. 2011; 22:2007-2010.

  • Cornell CN. Internal fracture fixation in patients with osteoporosis. J Am Acad Orthop Surg. 2003; 11:109-119.

  • Bogunovic L, Cherney SM et al. Biomechanical considerations for surgical stabilization of osteoporotic fractures. Orthop Clin North Am. 2013; 44:183-200.

  • Johanson NA, Litrenta J et al. Surgical treatment options in patients with impaired bone quality. Clin Orthop Relat Res. 2011; 469:2237-2240.


Abstract Views: 305

PDF Views: 1




  • Osteoporosis in Orthopaedics:Review of Literature and Clinical Approach

Abstract Views: 305  |  PDF Views: 1

Authors

Pranav Agrawal
Consulting Orthopaedic and Joint Reconstruction Surgeon, Lilavati Hospital and Research Centre, India
Gaurav Agrawal
Registrar, Dept of Orthopaedic Surgery, Lilavati Hospital and Research Centre, India

Abstract


Osteoporosis affects 8 to 62 percent of women in India, with osteoporotic fractures leading to preventable morbidity and often mortality. Osteoporosis does not have any clinical symptoms and may often present with fracture as the first symptom. Our aim to review the literature and describe a clinical approach in osteoporosis was to help the practitioner and orthopaedic surgeon suspect, diagnose, treat, prevent, monitor, and lead a patient through uneventful surgery. Early diagnosis and effective treatment of osteoporosis can lead to decreased morbidity, mortality, and financial burden on the elderly and also improve their quality of life.

Keywords


Osteoporosis, Osteopenia, Teriparatide, Bisphosphonates, Denosumab, Osteoporotic Fractures, T Score, Monitoring of Treatment, Bone Turnover Markers, Bone Density, DXA, BMD, FRAX Score.

References