dr. Muh. Ardi Munir, M.Kes, Sp.OT, M.H, FICS GERIATRIC DISORDER OF BONE AND JOINT dr. Muh. Ardi Munir, M.Kes, Sp.OT, M.H, FICS

OSTEOPOROSIS Osteoporosis is defined as a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture. Bone strength primarily reflects the integration of bone quantity and bone quality. The textbook definition of osteoporosis is of a disease which decreases bone strength and therefore increases the risk of fracture. As you look at these visuals, you can see that the healthy (normal) bone is comprised of thick, inter-linking trabeculae, while the osteoporotic bone is thin and some of the connectors are broken. Importantly, the disease is no longer considered as just a low bone mineral density problem. There are multiple factors affecting the strength of bone and therefore fracture risk – including BMD and bone architecture. You can relate this to a steel bridge. A high quality bridge is not one with just a lot of steel. Both the steel and the way in which it is structured combine to make a bridge strong. The same could be said about bone mineral density and bone architecture. One of the first thing you have to consider in osteoporosis is its consequences, mainly due to the fractures that can occur quickly with the time. The typical physical image of osteoporosis spiral is the cascade of fractures from the first, very early peripheral fracture to the first vertebral fracture and then, to the hip fracture. The progression of the disease from the first vertebral fracture to many subsequent vertebral fractures can be a fast one. References: 1. Consensus Development Conference: Osteoporosis prevention, diagnosis, and therapy, JAMA 2001; 285: 785-95. 2. Dempster DW et al., A simple method for correlative light and scanning electron microscopy of human iliac crest bone biopsies: qualitative observations in normal and osteoporotic subjects, JBMR 1986; 1: 15-21. Normal Osteoporosis NIH Consensus Development Panel on Osteoporosis. JAMA 285 (2001): 785-95

Shifting the Osteoporosis Paradigm Bone Strength NIH Consensus Statement Quality Bone Quantity = Bone Strength and Architecture Turnover rate Damage Accumulation Degree of Mineralization Properties of the collagen/ mineral matrix Bone size Bone density Adapted from NIH Consensus Development Panel on Osteoporosis. JAMA 285:785-95; 2001

The Osteoporosis Continuum Healthy spine Kyphotic spine The Osteoporosis Continuum This slide illustrates both the anatomy of a normal spine versus a spine with multiple fractured vertebra, as well as its clinical impact on a woman as she ages from 50 to 75 years.  The clinical impact of vertebral fractures occurs with the collapse of one or more vertebra as a result of minimal trauma. Multiple vertebral fractures can cause spinal deformity (thoracic kyphosis or dowager’s hump), shortened stature, and chronic disability and pain. Vertebral fractures can ultimately have financial, physical, and psychosocial consequences affecting both the woman and her family. 50 Menopausal Experiencing vasomotor symptoms 55+ Postmenopausal At greater risk for vertebral fracture than any other type of fracture 75+ Kyphotic At risk for hip fracture

Peak Bone Mass

Bone Remodeling Process Osteoclasts Lining Cells Resorption Cavities The bone remodeling process begins when the cells lining the bone surface are activated to form osteoclasts. Osteoclasts secrete acid, which dissolves the bone mineral, to form resorption cavities (pits). Osteoblasts are recruited to the resorbed bone and secrete osteoid matrix, which is comprised mainly of collagen. Over time, the osteoid matrix becomes mineralized to form bone. Osteoblasts Osteoid Lining Cells Mineralized Bone

BONE REMODELLING/BONE TURN OVER High Bone Turnover Leads to Development of Stress Risers and Perforations Lining Cells Bone Osteoclasts Note that stress risers are NOT microfractures or microcracks. Stress risers are only points of critical mechanical compromise in the bone structure, at which the application of a significant mechanical stress (strain, torsion, etc) makes this area as very susceptible to sustaining a fracture. Perforations Stress Risers

Osteoporosis Osteoblast Osteoclast

MANAGEMENT OF OSTEOPOROSIS High risk population Minimally traumatic fraktur or osteopenia Change the life style Diet, exercise, avoid the cygarettes Bone Densitometri More than +1 SD +1 SD to –1 SD -1 SD to –2.5 SD Less than –2.5 SD Repeat every 5 years Repeat every 1 year Estrogen/SERM Estrogen/ SERM Bifosfonat Calcitriol Calcitonin