Osteoporosis is a progressive metabolic bone disease that decreases bone density (bone mass per unit volume) with deterioration of the bone structure. This article will discuss: The article was written by Dr. Islam Elnagar. M.D, FRCSC, Orthopedic Surgery.
What Is Osteoporosis? It is often called the “ silent disease “. It is a decrease in bone mass due to uncoupling ( disconnection ) between osteoblast and osteoclast activity ( these are the cells responsible for bone formation and bone turnover in your body, respectively ). The National Osteoporosis Foundation ( NOF ) defined Osteoporosis as a condition when the body loses too much bone and/ or makes little bone. In general, bone mass increases during the first 30 years of life, then it gradually declines. This decline is faster in women after menopause due to the decreased estrogen level. The World Health Organization ( WHO ) defined osteoporosis as having Bone Mineral Density ( BMD ) less than what you should have at your age… This has been calculated in two ways ( scores ) :
If your score is less than the ‑2.5 standard deviation of the control group, therefore, you have Osteoporosis. However, if your score falls between ‑1 and ‑2.5, you have Osteopenia ( less severe than Osteoporosis ). This test can be ordered by your doctor if there is suspicion for have Osteoporosis. Osteoporosis can be age-related ( most commonly ) or secondary to a pathologic condition. Secondary osteoporosis can be more common in men ( can be due to hypogonadism, excess glucocorticoid and alcoholism ). It is more common in women than men in a ratio of approximately 4:1. Unfortunately ( and surprisingly ), women above 45 spend more time in the hospital due to osteoporosis than patients who have a heart attack, diabetes or some cancers.
- The T‑Score, which compares your score to that of a mature young healthy 30 years old woman.
- The Z‑Score, which compares your score to a similar-aged group.
When Should I Worry About Osteoporosis? Primary osteoporosis usually presents in women aged 50–70 years ( postmenopausal Osteoporosis ) and in men above 70 in the absence of risk factors. However, secondary osteoporosis can occur at any age due to an underlying medical condition ( less common ). Therefore, if you are a woman less than 45 or a man less than 60–70 with no risk factors and no underlying medical condition that would cause osteoporosis, you do not have to worry.
What Are The Chances Getting Osteoporosis ? Ageing is the most common cause of osteoporosis. However, there are other factors that can cause predispose you to osteoporosis. These risk factors can be classified into two categories : 1- Unmodifiable risk factors ( you have no control over them ), as : Ageing, females, white race and genetic factors. Genetic risk factors can be extensive as polymorphism in the genes for calcitonin receptors, estrogen receptor‑1, vitamin D receptor, etc Late menarche and early menopause can be risk factors in females as well. 2- Modifiable risk factors ( you can control to prevent or minimize your risk of having osteoporosis ) : Sedentary lifestyle, low protein intake, low body weight, smoking, heavy drinkers and breastfeeding with low vitamin D and calcium supplements. Some diseases can cause secondary Osteoporosis as Malabsorption syndrome, hyperthyroidism, liver diseases, type 1 diabetes mellitus, cancer, chronic renal failure, Chronic Obstructive Pulmonary Disease ( COPD ), multiple myeloma, inflammatory bowel disease, rheumatoid arthritis and sarcoidosis. Some medications can also cause secondary osteoporosis as phenytoin, selective serotonin uptake inhibitors, cyclosporin, furosemide, high dose methotrexate, antineoplastic medications, omeprazole, glucocorticoids, an overdose of levothyroxine, heparin and vitamin A, etc… These are just examples of a bigger list of medications; please discuss with your physician your medications list, especially if you have other risk factors in developing osteoporosis.
Diagnosis Of Osteoporosis How is osteoporosis diagnosed? The first step is getting a good history from your physician. Your doctor would assess your risk for osteoporosis based on the risk factors mentioned earlier. Then a full physical exam to assess your weight, height and any spine deformity ( kyphosis ). Neurologic examination to assess your balance and mobility is important as well. Any physical sign of other diseases causing secondary osteoporosis will be assessed by your physician as well, and the appropriate investigations will be arranged. Secondly, some laboratory tests can aid in diagnosing as the blood level of calcium and 25, hydroxyvitamin D. Tests to diagnose secondary osteoporosis would be directed according to your history of any of the pre-mentioned diseases that could cause osteoporosis. Finally, the main test to diagnose osteoporosis is the Dual-Energy X‑ray Absorptiometry DEXA ( or DXA ). It measures the bone mineral density ( BMD ) at the proximal femur (hip) and lumbar spine. This will be compared to a mature young healthy 30 years old woman to get your T‑Score and to a healthy matched group of the same age to get your Z‑Score.
When Should I Get Tested? The indications for having a BMD test are :
- Women: 65 years of age and older, any postmenopausal woman with low energy fracture, incidental finding of radiographic fracture, glucocorticoid treatment for 3 months and more, peri and postmenopausal women, menopause before 40 years old, family history of osteoporotic fracture and those with risk factors previously mentioned.
- Men: aged 70 and above, 50 – 70 years old with risk factors ( mentioned above )
What Happens If I Have Osteoporosis? It can be called the silent disease as it is most commonly asymptomatic till the first fracture occurs, which is the most common presentation. Therefore you might have osteoporosis ( maybe for years ) without notice. The most common fractures are in order: Vertebral body fractures, hip fractures and wrist fractures. However, other fractures can occur as well like: Pubic rami fractures, distal femur fractures proximal humerus fractures and elbow fractures. An estimate of 9 million fractures due to osteoporosis occur every year worldwide. Almost one-third of women and one-fifth of men above 50 are at risk of osteoporotic fractures. It can also present with kyphotic deformity due to vertebral body fractures and height loss. Vertebral body fractures can present as back pain, loss of height, poor balance and respiratory compromise( as pneumonia ). If you have any of these symptoms, you should be assessed by your doctor. Vertebral body fracture can be associated with a 15 % increase in mortality rate within 5 years. One vertebral body fracture can increase the risk of having a second one by 5 times and increases the risk of having a hip fracture by 5 folds. Hip fractures can be more severe than vertebral ones. In general, hip fractures have a 20% mortality rate within the first year. Once a hip fracture occurs, it should be surgically treated as soon as possible ( as far as the general condition permits surgical fixation and having spinal or general anaesthesia ). Data shows increased mortality with delayed surgical treatment for hip fractures. Therefore the best way to treat hip fractures is to prevent them! Only one-third of patients with hip fractures return to their baseline function after surgery. One hip fracture increases the risk of having a second hip fracture by up to 10 fold. Therefore, we cannot stress enough to prevent falling and fractures ( prevention is way better than treatment ). Luckily wrist fractures are not as severe as hip and vertebral body fractures. However, having a wrist fracture means you are at risk for other more serious fractures.
If I have Osteoporosis, How Can I Avoid or Minimize The Risk Of Having a Fracture? If you have poor balance and low baseline mobility, the best way to avoid falling is to use a walking aid like a walker or at least a cane. Age is just a number at the end, so if you know you have troubles with your walking (while having osteoporosis ) regardless of your numeric age, there is no harm in using aids to have a safe walk. Using an aid is way better than being in the hospital having surgery for fracture fixation!. A safe house environment is important as well, with a good setup for your bedroom/bathroom and easy access to your house.
Would Osteoporosis Affect My Elective Orthopaedic Surgery? Yes, even if you have no history of fractures. Osteoporosis has a bad impact on your elective joint replacement surgery. Some data showed that if you are having a shoulder arthroplasty, the chances of having a fracture around the implant ( peri-prosthetic fracture ) after surgery within the first 2 years is higher than those who do not have osteoporosis. Similar data supports the same for your lower extremity arthroplasty ( total hip and total knee replacements ).
Treatment Of Osteoporosis So what are the prevention/ treatment methods for osteoporosis? First of all, is lifestyle modifications as being active in your daily routine, exercises ( resistance as weight lifting or rubber bands and weight-bearing exercises as walking, jogging, running, etc.), healthy food, smoking cessation and limiting alcohol are keys to preventing osteoporosis and lots of other diseases. The Centres for Disease Control reported that from 120–300 minutes of moderate to severe exercise per week was associated with fewer hip fractures in older adults. Vitamin D and Calcium supplements: Vitamin D of 800 IU daily is recommended for prevention, and a Calcium dose of 1000–1200 mg daily is the recommended dose.
Pharmacologic Treatment Indications : The National Osteoporosis Foundation Guidelines for Osteoporosis treatment suggests pharmacological agents be considered for certain categories, as : Postmenopausal women and men who are above 50 years of age plus having one of the following :
( Discuss this with your physician as the explanation of these indications and scores is beyond the scope of this article ) ( Also, please remember this article is not intended to diagnose nor to treat your condition).
- Previous or current hip and/or vertebral fracture
- T score between ‑1.0 and ‑2.5 at the hip ( femoral neck )or spine and one of the following 2 risks :
- ≥ 3% hip fracture risk in the following 10 years or
- ≥ 20% related fracture risk in the following 10 years as per FRAX calculation or
- T score ‑2.5 or less at the hip ( femoral neck )or spine.
What Medications Can Be Used For Treatment ? Several pharmacologic agents can be prescribed as :
Like any other medications, these agents are associated with various side effects/complications depending on which drug you are taking as osteonecrosis of the jaw with intravenous bisphosphonate and atypical femur fractures with long-term bisphosphonates. Please review what medication you are on and be aware of its potential side effects, which is beyond this article’s scope.
- Calcium and Vitamin D
- Estrogen-only replacement (ERT)
- Conjugated Estrogen-progestin hormone replacement (HRT)
- Salmon calcitonin
In conclusion Osteoporosis is a prevalent condition worldwide. It can be asymptomatic till the first fracture occurs. The key is to identify in which category you are and modify your risk factors to minimize or prevent it from happening. The best treatment for osteoporosis is its prevention. And the earlier the diagnosis and treatment, the better the outcomes would be.