1. Osteoporosis
Dr Ramin Rafiei
Alzahra Hospital
Rheumatology Department

2. Definition Osteoporosis is defined by systematic skeletal disorder
low bone density
deterioration of microarchitecture
bone strength reduction
increase fragility fracture risk

3. What are fragility fractures?
occur spontaneously or following minimal trauma
falling from a standing height or less

4. 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

5. 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

6. Osteoporosis prevalence in Iran
Men %
postmenopausal women %
Osteopenia %
men %
postmenopausal women %
Osteoporosis prevalence in Iran

7. Osteoporosis prevalence in Isfahan
Bonakdar et al 2008
Salamat et al
Sex
Menoupause
Mean age
(year)
Prevalence of Osteoporosis
Prevalance of Osteopenia
spinal
Femur
Spinal
Female
Mix 44 9% 3%
25%
27%
Sex
Menoupause
Mean Age (yaer)
Prevalence of Osteoporosis
Prevalance of Osteopenia
spinal
Femur
Female
post
51.8 5%
40%
50%
45%

8. Health impact Mortality
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

9. main predictors of higher mortality after fragility fractures
male sex
increasing age
coexisting illness
poor prefracture functional status
Smoking
low BMD

10. 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

11. 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

12. 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

13. 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

14. 3-fold increase in fracture for each standard deviation fall in BMD
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

15. 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

16. Red:>300 Fx/100000 Orange:200-300 Fx/100000 Green:<200 Fx/100000

17. 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

18. 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

20. 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)

22. 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

23. 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)

24. Dowager’s hump Correspondingnradiograph

25. 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

26. Classification primary 95% of cases in women 70% to 80% in men
Secondary

27. Secondary causes

29. 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

30. 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

32. What estimates of bone loss and fracture risk