Medical Treatment of Osteoporosis Current concepts

1. Updates in OsteoporosisUpdates in Osteoporosis
Fadi Zein El Abidine, MD, MBA, MHS
Orthopaedic Spine Surgeon,
Najjar Hospital – Beirut

2. No Bones About ItNo Bones About It

3. “I’ve lost 10 cm in height and none of my clothes fit
me anymore.”
Typical comments from
people with osteoporosis

4. CommentsComments
“It’s hard to get clothes that look
nice when my back is so
hunched over.”

5. “What will I do if I have to give up driving?”
Comments

6. “Medications are
expensive. But I
can’t afford to let
my condition get
worse and this
medicine will help
stop or slow down
the bone loss.”
Comments

7. “If somebody had
told me sooner what
I know now about
osteoporosis, none
of this might be
happening to me!”
Comments

8. OverviewOverview
Bone with
Osteoporosis
Normal
Bone
Osteoporosis
causes weak bones.
In this common
disease, bones lose
minerals like
calcium. They
become fragile and
break easily.
Source: The 2004 Surgeon General’s Report on Bone Health and Osteoporosis:
What It Means to You at http://www.surgeongeneral.gov/library/bonehealth

9. OsteoporosisOsteoporosis
The Most Common Bone DiseaseThe Most Common Bone Disease
• Characterized by low bone
mass and deterioration of
bone structure
• Not a natural part of aging
• Increased risk for women,
post-menopausal, over age
65
• All races, sexes, and ages
are susceptible
• Preventable and treatable!

10. TheThe “silent disease”“silent disease”
• Often called the
“silent disease”
• Bone loss occurs without symptoms
– First sign may be a fracture due to weakened
bones
– A sudden strain or bump can break a bone

11. OsteoporosisOsteoporosis expansionexpansion
• 1 in 2 women and 1 in 5 men over age 50 will
suffer a fracture in their remaining lifetime
• 55% of persons over age 50 are at increased risk
of fracture due to low bone mass
• At age 50, a woman’s lifetime risk of fracture
exceeds combined risk of breast, ovarian &
uterine cancer
• At age 50, a man’s lifetime risk of fracture
exceeds risk of prostate cancer
1111

12. Other factorsOther factors
• Middle East being one of the sunniest regions
worldwide, but the prevalence of hypovitaminosis D
there was among the highest in the world, reaching >
80% in adolescent girls in Saudi Arabia.
• Role of veil in our region & heat
• Lack of funds for treatment and education about the
disease
• low socio-economic status in some countries
• multiparity
1212

13. Middle EastMiddle East
• Osteoporosis is set to rise alarmingly in the
Middle East and Africa, with rates of fragility
fracture incidences expected to quadruple in
several countries as the population ages- IOF
• By 2020, 25% of the population will be over
the age of 50 – reaching 40% by 2050. This
population is particularly at risk of
osteoporosis.
1313
The Middle East and Africa Regional Audit report

14. DEMOGRAPHIC DATADEMOGRAPHIC DATA
• It is projected that by 2050, Egypt will have the
largest population in the region with close to 130
million inhabitants, which represents a 40%
increase compared to its current population and
more than 30% of its population will be aged 50
years and over.
• In Lebanon, Iran and Tunisia, nearly 40% of the
population will be 50 years old and over,
compared to 20% today in Tunisia and Lebanon
and 15% in Iran. 1414

15. Total Population by Country inTotal Population by Country in
20502050
1515

16. Percent Population over 50 years byPercent Population over 50 years by
Country in 2050Country in 2050
1616

17. • After mid-30’s, you begin
to slowly lose bone mass.
• Women lose bone mass
faster after menopause.
• Men lose bone mass too.
Source: The 2004 Surgeon General’s Report on Bone Health and Osteoporosis:
What It Means to You at http://www.surgeongeneral.gov/library/bonehealth

18. Risk factorsRisk factors
If you have any of
these “red flags,”
you could be at high
risk for weak bones.
Talk to your health
care professional.
Source: The 2004 Surgeon General’s Report on Bone Health and Osteoporosis:
What It Means to You at http://www.surgeongeneral.gov/library/bonehealth

19. I’m older than 65
 I’ve broken a bone after age 50
 My close relative has osteoporosis or has
.broken a bone
 My health is “fair” or “poor”
 I smoke
 I am underweight for my height
1

20.  I started menopause before age 45
 I've never gotten enough calcium
 I have more than two drinks of
alcohol .several times a week
 I have poor vision, even with glasses
 I sometimes fall
 I'm not active
2

21. I have one of these medical conditions:
 Hyperthyroidism
 Chronic lung disease
 Cancer
 Inflammatory bowel disease
 Chronic liver or kidney disease
 Hyperparathyroidism
 Vitamin D deficiency
 Cushing's disease
 Multiple sclerosis
 Rheumatoid arthritis
3

22. I take one of these medicines:
 Oral glucocorticoids (steroids)
 Cancer treatments (radiation,
chemotherapy)
 Thyroid medicine
 Antiepileptic medications
 Gonadal hormone suppression
 Immunosuppressive agents
4

23. Bone Health & Oral HealthBone Health & Oral Health
• Oral health care is important.
• Bone loss in the jaw and osteoporosis
have been linked
• The loss of bone supporting the jaw
and anchoring our teeth can lead to
loose teeth, tooth loss and ill fitting
dentures.
• Your dentist may be the first health
professional to suspect osteoporosis.
• Women with osteoporosis have been
reported to have 3 x more tooth loss
than women without the disease.

24. OUTCOME OFOUTCOME OF OSTEOPOROSISOSTEOPOROSIS
2424

25. Hip FracturesHip Fractures
• Outcomes
– Fracture related outcomes
• Healing
• Quality of reduction
– Functional outcomes
• Ambulatory ability
• Mortality (25% at one year for age > 50)
• Return to pre-fracture activities of daily living

26. 26
DISEASE
BURDEN
MECHANISM
OF DISEASE
UNMET NEEDS
LIMITATIONS
OF THERAPIES
IDENTIFYING
FRACTURE RISK
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REFERENCES
Cortex Thinning in Patients with Hip Fractures
1. Poole KE, et al. PLoS One. 2012;7:e38766
In patients with acute hip fracture, the cortex was generally thinner
in the femoral neck vs age- and sex-matched controls.
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DISEASE
BURDEN
MECHANISM
OF DISEASE
UNMET NEEDS
LIMITATIONS
OF THERAPIES
IDENTIFYING
FRACTURE RISK
HOME DENOSUMAB
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REFERENCES
Kaplan–Meier survival curves for the general population
and fracture populations according to fracture type and
age (data from the Dubbo Osteoporosis Epidemiology
Study)
Fragility Fractures Are Associated With Increased Mortality
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Years
1.0
0.8
0.6
0.4
0.2
0
0 5 10 15 20
General population
Vertebral fracture
Hip fracture
Age >75 years
Log-rank P > 0.001
Men Women
Years
1.0
0.8
0.6
0.4
0.2
0
0 5 10 15 20

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DISEASE
BURDEN
MECHANISM
OF DISEASE
UNMET NEEDS
LIMITATIONS
OF THERAPIES
IDENTIFYING
FRACTURE RISK
HOME DENOSUMAB
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REFERENCES
Fragility Fractures Significantly Reduce Quality of Life
Bianchi ML et al. Health Qual Life Outcomes. 2005;3:78.
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*†
*†
*†
*†
*†
**
90
80
70
60
50
40
30
20
10
0
100
QP with fractures
QP without fractures
Controls
Pain Physical
Function
Social
Function
Health
Perception
Mental
Function
Global
Score
*P < 0.005; OP with fractures vs OP without fractures
**P < 0.05; OP without fractures vs OP controls
*†
P < 0.005; OP with fractures vs OP controls
Qualeffo-41 domain
**
**

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DISEASE
BURDEN
MECHANISM
OF DISEASE
UNMET NEEDS
LIMITATIONS
OF THERAPIES
IDENTIFYING
FRACTURE RISK
HOME DENOSUMAB
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REFERENCES
40%
Incapable of walking
independently
30%
Permanent
Discapacity*
20%
Die within
the first
year
80%
One Year After a Hip Fracture
Patients(%)
Not able to independently do at
least one daily life activity done
before the fracture
Hip fractures are associated with morbidity, permanent discapacity, lack of
ability to walk independently and complete daily life activities
1. Cooper C. Am J Med. 1997;103:12s17s.
2. *Refers to patients that are care dependent or have to move into a nursing home for the first time
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DISEASE
BURDEN
MECHANISM
OF DISEASE
UNMET NEEDS
LIMITATIONS
OF THERAPIES
IDENTIFYING
FRACTURE RISK
HOME DENOSUMAB
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REFERENCES
Premenopausal Osteoporotic
Trabecular Bone
•Sponge-like network of
delicate plates of bone
•20% of skeletal mass
Cortical Bone
•Dense outer shell of
compact bone; defines
bone shape
• 80% of skeletal mass
Cortical Bone Thinning
and Cortical Porositya
Trabecular Bone Loss
a
Cortical porosity is defined as the pore volume of cortical bone
1. Riggs BL, et al. N Engl J Med. 1986;314:1676-1686. 2. Dempster DW. In: Favus MJ, ed. Primer on the Metabolic Bone Diseases and
Disorders of Mineral Metabolism. 6th ed. Washington, DC: American Society for Bone and Mineral Research; 2006:7-11. 3. Burghardt AJ,
et al. J Bone Miner Res. 2010;25:983-993. 4. Davison SK, et al. Semin Arthritis Rheum. 2006;36:22-31.
Osteoporosis Can Occur in Both Cortical and Trabecular Bone
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Special considerations in fixation
of fragility fractures
•Arthroplasty / Hemiarthroplasty
» Also allows early mobilization
•Implants designed for osteoporotic bones
» Fixed angles locking plate
» HA coated screws
•Use of IM nails instead of plates & screws for diaphyseal
fractures
•Void filling with cement or bone graft 31

32. 32
Safe options
32

33. 33
Distal Radius
– Very common fracture in
the elderly
– Result from low energy
injuries
– Incidence increases with
age, particularly in
women
– Associated with
dementia, poor eyesight
and a decrease in
coordination

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Distal Radius- Epidemiology
– Increasing in incidence
oEspecially in women
– 125/100,000
– Peak incidence in females 60-70
– Lifetime risk is 15%
– Most frequent cause: fall on outstretched arm
– Decreased bone mineral density is a factor

35. 35
Distal Radius - Treatment
– Results are variable and depend on fracture type and
reduction achieved
– Minimally displaced and fractures in which a stable
reduction has been achieved result in good functional
outcomes

36. 36
Vertebral Compression Fractures
–Usually occur between T8 and L2
–Kyphosis and scoliosis may develop
oMarkers for osteoporosis

37. 37
Vertebral Compression Fractures
Epidemiology
– Estimated that only 1/3 of
vertebral fractures come to clinical
attention – highly underreported
– Prevalence similar for men and
women age 60-70
– 117/100,000
– A 50 year old white woman has a
16% lifetime risk of experiencing a
vertebral fracture
Image courtesy of International Osteoporosis Foundation

38. 38
Vertebral compression fracture
lebanon
•In a population-based sample, of subjects aged 65-84
years, the prevalence of vertebral fractures was estimated
at 19.9% in women and 12.0% in men.
•the annual incidence of vertebral fractures in women was
estimated at 1.5%
• 2,490 women aged 65 and above sustaining a vertebral
fracture per year.
38
ME_Audit- Lebanon

39. 39
Vcf – lebanon
39

40. 40
Vertebral Compression Fractures
–Present with acute back pain
–Tender to palpation
–Neurologic deficit is rare
•Patterns
–Biconcave (upper lumbar)
–Anterior wedge (thoracic)
–Symmetric compression (T-L
junction)

41. 41
Vertebral Compression Fractures
-Treatment
–Simple osteoporotic vertebral compression fractures
are treated non-operatively and symptomatically
–Prolonged bed rest should be avoided
–Progressive ambulation should be started early
–Back exercises should be started after a few weeks

42. 42
Vertebral Compression Fractures -
Treatment
– A corset may be helpful
– Most fractures heal uneventfully
– Kyphoplasty an option

43. 43
43

44. 44
Excess morbidity patterns by fracture type
44
Kanis JA, Johnell O. J Endocrinol Invest. 1999;22(8):583-588.
Figure reproduced with permission.
50 60 70 80 90
Age (years)
Colles’
fracture
Vertebral
fracture
Hip
fracture
IncreasingMorbidity
Age-related morbidity
Age- and
fracture-related
morbidity

45. ART OF TREATING
OSTEOPOROSIS
45

46. FDA-approved MedicationsFDA-approved Medications
Osteoporosis
Post-
menopausal
Glucocorticoid-
induced Male
Drug Prevent Treat Prevent Treat
Estrogen 
Calcitonin* (Miacalcin®, Fortical®) 
Raloxifene (Evista®)  
Ibandronate (Boniva®)  
Alendronate (Fosamax®)    
Risedronate (Actonel®)     
Risedronate (Atelvia®) 
Zoledronate (Reclast®)     
Denosumab (Prolia™)  
Teriparatide (Forteo®)   
iab DL, Watts NB. Endocrinol Metab Clin North Am. 2013;42(2):305-317.

47. Prevention Treatment
FDA-Approved TherapeuticFDA-Approved Therapeutic
OptionsOptions
Estrogen
Alendronate
Risedronate
Ibandronate
Zoledronic acid
Raloxifene
Calcitonin
PTH (teriparatide)
Denosumab

48. • Antiresorptive
• Decrease bone resorption
• Most treatment agents
• Examples: Bisphosphonates, SERMs, calcitonin,
estrogen, denosumab
• Anabolic
• Stimulate bone formation
• Example: teriparatide
Antiresorptive and Anabolic
Therapies

49. 49
MECHANISM
OF ACTION
EFFICACY
CLINICAL
BENEFITS
TRANSITIONING
PATIENTS
DRUG
HOLIDAYS
OSTEOPOROSISHOME
LONG TERM
SAFETY
DOWNLOAD
REFERENCES
Approved Drugs
Other Potential Bone Formation Drugs
• Oral PTH (CaPTHymone)
• PTHrP (1-36) inyectable
• Abaloparatide SC & Dermal Patch
• LRP5/ Wnt Inhibitors
− Anti-DKK1
− Anti-Sclerostin
Osteoblastos
• Teriparatide (Forteo®
)
• PTH (1-84) (Preotact®
)
• Strontium Ranelate (Protos®
)
Pre-osteoblast
Pharmacologic Modulation of Osteoblast Differentiation and its
Activity on Bone Formation
Adapted from de Boyle WJ, et al. Nature. 2003;423:337-342.

50. 50
MECHANISM
OF ACTION
EFFICACY
CLINICAL
BENEFITS
TRANSITIONING
PATIENTS
DRUG
HOLIDAYS
OSTEOPOROSISHOME
LONG TERM
SAFETY
DOWNLOAD
REFERENCES
Approved Antiresorptives
• Denosumab
• Bisphosphonates
• Estrogens/Tibolone
• SERMs
• Calcitonin IM, nasal
• Strontium Ranelate
Osteoclasts
Pre-osteoclast
Pharmacologic Modulation of Osteoclast Differentiation and its
Activity on Bone Resorption

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MECHANISM
OF ACTION
EFFICACY
CLINICAL
BENEFITS
TRANSITIONING
PATIENTS
DRUG
HOLIDAYS
OSTEOPOROSISHOME
LONG TERM
SAFETY
DOWNLOAD
REFERENCES
Osteoblast
Activated
Osteoclast
TNF-α
PTH
IL-1
PTHrP
Glucocorticoids
Vitamin D
PGE2
IL-11
RANK Ligand
RANK
Adapted from Boyle WJ, y cols. Nature. 2003;423:337-342.
Hofbauer LC, Schoppet Ml. JAMA. 2004;292:490-495.
Several Factors Stimulate RANKL Expression in the Osteoblast
IL-6
Pre-Osteoclast
M-CFU
Multinucleated
Osteoclast
M-CFU = Macrophage Colonies Forming Unit
Animation Courtesy of Dr. Fidencio Cons

52. 52
MECHANISM
OF ACTION
EFFICACY
CLINICAL
BENEFITS
TRANSITIONING
PATIENTS
DRUG
HOLIDAYS
OSTEOPOROSISHOME
LONG TERM
SAFETY
DOWNLOAD
REFERENCES
Osteoprotegerin (OPG) is a Decoy Receptor that Prevents RANKL
From Binding RANK
Hormones
Growth Factors
Cytokines
RANKL
RANK
OPG
Bone Formation Inhibition of Bone
Resorption
M-CFU Pre-Osteoclasts
Osteoblasts
In the Presence of M-CSF
M-CFU = Macrophage Colonies Forming Unit
M-CSF= Macrophage Colonies Stimulator Factor
Inhibition of Osteoclast
Formation, Function
& Survival
Adapted from de Boyle WJ, et al. Nature. 2003;423:337-342.

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MECHANISM
OF ACTION
EFFICACY
CLINICAL
BENEFITS
TRANSITIONING
PATIENTS
DRUG
HOLIDAYS
OSTEOPOROSISHOME
LONG TERM
SAFETY
DOWNLOAD
REFERENCES
When the RANK Ligand Exceeds the OPG, Bone Resorption can
Become Excessive Leading to Osteoporosis
Osteoblasts
CFU-M Pre-Osteoclasts
Multinucleated
Osteoclasts
RANKL
RANK
OPG
Bone Formation
Bone Resorption
.
In the Presence of M-CSF
CFU-M= Unidad formadora de colonias de macrófagos
M-CSF= Macrophage Colonies Stimulator Factor
Increased RANKL
Stimulates
Differentiation,
Function, and
Survival of OCs
Adapted from de Boyle WJ, et al. Nature. 2003;423:337-342.

54. 54
MECHANISM
OF ACTION
EFFICACY
CLINICAL
BENEFITS
TRANSITIONING
PATIENTS
DRUG
HOLIDAYS
OSTEOPOROSISHOME
LONG TERM
SAFETY
DOWNLOAD
REFERENCES
Denosumab is an Anti RANKL MAb That Mimics the Action of OPG
Inhibiting Formation, Function and Survival of OCs
Hormones
Growth Factors
Cytokines
RANKL
RANK
OPG
DENOSUMAB
Bone Formation Inhibited Bone
Resorption
M-CFU Pre-Osteoclasts
Osteoblasts
In the Presence of M-CSF
CFU-M= Unidad formadora de colonias de macrófagos
M-CSF= Macrophage Colonies Stimulator Factor
Denosumab has the same effect of OPG
blocking RANKL
and inhibiting bone resorption
Adapted from de Boyle WJ, et al. Nature. 2003;423:337-342.

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MECHANISM
OF ACTION
EFFICACY
CLINICAL
BENEFITS
TRANSITIONING
PATIENTS
DRUG
HOLIDAYS
OSTEOPOROSISHOME
LONG TERM
SAFETY
DOWNLOAD
REFERENCES
Study population
• 7808 postmenopausal women
• T-score < –2.5 at the lumbar
spine or total hip and
not < –4.0 at either site
Primary endpoint
• New vertebral fracture at
36 months
Secondary endpoints
• Time to first
non-vertebral fracture
• Time to first hip fracture
Placebo
n = 3906
Denosumab
60 mg SC Q6M
n = 3902
S
C
R
E
E
N
I
N
G
E
N
D
O
F
S
T
U
D
Y
Calcium and Vitamin D
R
A
N
D
O
M
I
Z
A
T
I
O
N
Day 1
Visit
36 Months
Q6M = once every 6 months.
Cummings SR, et al. N Engl J Med. 2009;361:756-765.
•International, randomized, double-blind, placebo-controlled study
Pivotal Phase 3 Trial
Study Design
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MECHANISM
OF ACTION
EFFICACY
CLINICAL
BENEFITS
TRANSITIONING
PATIENTS
DRUG
HOLIDAYS
OSTEOPOROSISHOME
LONG TERM
SAFETY
DOWNLOAD
REFERENCES
The Effect of Prolia®
(denosumab) on Fracture Risk at 36 Months
Pivotal Phase 3 Trial
*Composite measurement excluding pathological fractures and those associated with severe trauma, fractures of the vertebrae, skull, face,
mandible, metacarpals, fingers and toes.
RRR = relative risk reduction. ARR = absolute risk reduction.
Cummings SR, et al. N Engl J Med. 2009;361:756-765.
RRR = 40%
p = 0.04
RRR = 20%
p = 0.01RRR = 68%
p < 0.0001
8.0%
6.5%
1.2%0.7%
7.2%
2.3%
0
1
2
3
4
5
6
7
8
9
Non-vertebral*
ARR = 1.5%
Hip
ARR = 0.3%
IncidenceatMonth36(%)
Denosumab
Placebo
New Vertebral
ARR = 4.8%
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MECHANISM
OF ACTION
EFFICACY
CLINICAL
BENEFITS
TRANSITIONING
PATIENTS
DRUG
HOLIDAYS
OSTEOPOROSISHOME
LONG TERM
SAFETY
DOWNLOAD
REFERENCES
Exposure-adjusted Subject Incidence of Adverse Events
(Rates Per 100 Subject-years)
N = number of subjects who received ≥ 1 dose of investigational product. Treatment groups are based on the original randomized treatments
received in FREEDOM. AEs coded using MedDRA v13.0. Cumulative osteonecrosis of the jaw cases: 6 cross-over, 7 long-term. Cumulative
atypical femoral fracture cases: 1 cross-over, 1 long-term.
FREEDOM Years 1–3 Extension Years 1–7
Placebo
(N = 3883)
Cross-over Denosumab
(N = 2206)
Long-term Denosumab
(N = 2343)
All AEs 156.1 96.8 97.0
Infections 30.7 20.7 19.9
Malignancies 1.6 2.0 2.0
Eczema 0.6 0.9 0.9
Hypocalcemia < 0.1 < 0.1 < 0.1
Pancreatitis < 0.1 < 0.1 < 0.1
Serious AEs 10.4 10.1 10.3
Infections 1.3 1.4 1.5
Cellulitis or erysipelas < 0.1 < 0.1 < 0.1
Fatal AEs 0.8 0.8 0.8
Osteonecrosis of the jaw 0 < 0.1 < 0.1
Atypical femoral fracture 0 < 0.1 < 0.1
Extension Years 1–7
Cross-over Denosumab (N = 2206) Long-term Denosumab (N = 2343)
Year 1 2 3 4 5 6 7 1 2 3 4 5 6 7
Serious
infections
1.6 1.5 1.1 1.6 1.3 2.2 2.1 1.3 1.2 1.7 2.4 1.2 1.5 2.6
Malignancies 1.9 1.7 2.1 2.8 2.2 2.6 2.7 1.9 2.5 1.9 2.8 1.7 2.6 1.6
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MECHANISM
OF ACTION
EFFICACY
CLINICAL
BENEFITS
TRANSITIONING
PATIENTS
DRUG
HOLIDAYS
OSTEOPOROSISHOME
LONG TERM
SAFETY
DOWNLOAD
REFERENCES
Summary
•Denosumab treatment for up to 10 years was associated
with:
– persistent reduction of bone turnover
– continued increases in BMD without therapeutic plateau
– low incidence of new vertebral and non-vertebral
(including hip) fracture
•The benefit/risk profile for denosumab in an aging population
of postmenopausal women remains favorable
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59. Adherence to Treatment inAdherence to Treatment in
Osteoporosis PatientsOsteoporosis Patients

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MECHANISM
OF ACTION
EFFICACY
CLINICAL
BENEFITS
TRANSITIONING
PATIENTS
DRUG
HOLIDAYS
OSTEOPOROSISHOME
LONG TERM
SAFETY
DOWNLOAD
REFERENCES
Patients With Poor Treatment Compliance Have More Fractures Than
Those With Good Compliance
*Compliance = Medication possession rate ≥ 80%
Caro JJ, et al. Osteoporos Int. 2004;15:1003-1008
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16% reduction in
fracture rate
0.6
0.7
0.8
0.9
1.0
1.1
Patients with
poor compliance
Patients with
good compliance*
Rateoffractures
†
p<0.005

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MECHANISM
OF ACTION
EFFICACY
CLINICAL
BENEFITS
TRANSITIONING
PATIENTS
DRUG
HOLIDAYS
OSTEOPOROSISHOME
LONG TERM
SAFETY
DOWNLOAD
REFERENCES
Good Adherence Leads to a Reduction in Fracture Rates
In order to get significant fracture risk reduction MPR above 75% are needed.
Compliance rates below 50-60% do not lead to fracture risk reduction
0.07
0.08
0.09
0.10
0.11
0 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00
0.12
Fracture probability in bisphosphonate treated patients after 24 months
(35537 patients)
No Fracture
Reduction
Medication Possession Ratio (MPR)*
FractureProbability
Fracture
Reduction
*MPR is a way to assess treatment compliance using percentage of time the medication was available to the patient
Siris ES et al. Mayo Clin Proc. 2006;81:1013-1022.
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62. Technical challenges ofTechnical challenges of
fracture fixation in osteoporoticfracture fixation in osteoporotic
bonebone
• Impaired ability of osteoporotic bone to hold screws or
support implants
• Crushing of cancellous bone with subsequent voids after
fracture reduction
6262
These factors can lead to a higher risk of failure at
the implant-bone interface before healing achieved

63. The good news: Osteoporosis isThe good news: Osteoporosis is
preventable for most people!preventable for most people!
• Healthy diet and
lifestyle are
important for BOTH
men and women.
• If you have
osteoporosis, your
doctor can detect
and treat it

64. KEY isKEY is ………… PREVENTIONPREVENTION
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65. Step 1Step 1
Get your daily
recommended
amounts of calcium
and vitamin D.
Use MyPyramid.gov
to help plan an
overall healthy diet

66. Step 2Step 2
Be physically
active everyday
Improve strength
and balance
Even simple activities such as
walking, stair climbing and
dancing can strengthen bones.

67. Step 3Step 3
Avoid smoking
and excessive
alcohol. 12 oz. 5 oz.
1.5 oz.
MyPyramid.gov recommends
no more than 1 drink per day
for women and 2 for men.

68. Step 4Step 4
Talk to your doctor
about bone health.

69. Step 5Step 5
Have a bone density
test
and take medication
when appropriate.
Sourceofphoto:USDAARSPhotoUnitPhotobyPeggyGreb
Testing is a simple,
painless procedure.

70. Calcium Requirements for 50+ YearsCalcium Requirements for 50+ Years
Source: The 2004 Surgeon General’s Report on Bone Health and Osteoporosis:
What It Means to You at http://www.surgeongeneral.gov/library/bonehealth
Over 50 years 1,200 mg Goal

71. Nutrition labels & calciumNutrition labels & calcium
• FDA uses “Percent Daily Value”
(% DV) to describe amount of
calcium needed by general U.S.
population daily
• 100% DV for calcium
= 1,200 mg
• Look for this label:
– “Nutrition Facts” on foods
– “Supplement Facts” on
vitamin/mineral supplements

72. Calcium & vitamin D recommendationsCalcium & vitamin D recommendations
• 51 - 70 years
1,200 mg calcium (120% DV)
400 IU vitamin D (100% DV)
• 70 and older
1,200 mg calcium (120% DV)
600 IU vitamin D (150% DV)

73. Percent Daily Value (DV) ofPercent Daily Value (DV) of
calcium in common foodscalcium in common foods
Approximate % DV for foods based in part on The 2004 Surgeon General’s Report on Bone Health and
Osteoporosis: What It Means to You at http://www.surgeongeneral.gov/library/bonehealth

74. % DV calcium:% DV calcium: Milk groupMilk group
• Yogurt
1 cup (8 oz.) = 30% DV
• Milk
1 cup = 30% DV
• Cheese
1 ½ oz. natural/2 oz. processed = 30% DV
• Milk pudding
1/2 cup = 15% DV
• Frozen yogurt, vanilla, soft serve
½ cup = 10% DV
• Ice cream, vanilla
½ cup = 8% DV
• Soy or rice milk, calcium-fortified
1 cup = varies—check label
Choose fat-free
or low fat
most often

75. What about Vitamin D?What about Vitamin D?
Main dietary sources of vitamin D are:
• Fortified milk
(400 IU per quart)
• Some fortified cereals
• Cold saltwater fish
(Example: salmon, halibut, herring,
tuna, oysters and shrimp)
• Some calcium and vitamin/mineral
supplements

76. Vitamin D from sunlight exposureVitamin D from sunlight exposure
• Vitamin D is manufactured in your skin
following direct exposure to sun.
• Amount varies with time of day, season,
latitude and skin pigmentation.
• 10–15 minutes exposure of hands, arms
and face 2–3 times/week may be
sufficient (depending on skin sensitivity).
• Clothing, sunscreen, window glass and
pollution reduce amount produced.
Source: National Osteoporosis Foundation Web site; retrieved July 2005 at http://www.nof.org

77. Help for the lactose-intolerantHelp for the lactose-intolerant
Some people lack the
enzyme lactase
needed to digest
lactose
(milk sugar).

78. When you donWhen you don’t like to “drink”’t like to “drink”
milkmilk

79. Calcium supplementCalcium supplement
considerationsconsiderations

80. Vitamin D necessary forVitamin D necessary for
calcium absorptioncalcium absorption
• Choose a supplement with vitamin
D unless obtaining vitamin D from
other sources.
• Follow age group
recommendation. Avoid going
over a daily combined total of
2,000 IU or 50 mcg from food
and supplements.
• It’s not necessary to consume
calcium and vitamin D at the same
time to get the benefit of enhanced
calcium absorption.
Vitamin D is like a key
that unlocks the door
and lets calcium
into the body.

81. Limit calcium to 500 mg at a timeLimit calcium to 500 mg at a time
Our bodies can best
handle about 500
mg calcium at one
time from food
and/or supplements.
Spread your calcium
sources throughout
the day.

82. Increase amount slowlyIncrease amount slowly
• Start supplements with 500 mg calcium daily
for about a week, gradually adding more.
• Gas and constipation can be side effects:
– Increase fluids and high fiber foods if diet is low in
whole grains and fruits and vegetables.
– Try a different type of supplement if side effects
continue.

83. Bone Health Building BlocksBone Health Building Blocks

84. PreventionPrevention
• Strategies focus on controlling factors
that predispose to recurrent fracture
– Consider bone mineral density test
– Rule out secondary causes of
osteoporosis
– Initiate and monitor therapy, or refer
• Fall prevention

85. Hip Fracture Prevention: FallingHip Fracture Prevention: Falling
How do Younger Adults Fall?How do Younger Adults Fall?

86. Hip Fracture Prevention: FallingHip Fracture Prevention: Falling
How do Older Adults Fall?How do Older Adults Fall?

87. Protect YourProtect Your
BonesBones
Ways to MakeWays to Make
Your Home SaferYour Home Safer

88. Hip Fracture Prevention:Hip Fracture Prevention:
Hip ProtectorsHip Protectors

89. Prevention – advancedPrevention – advanced
rehabilitation plansrehabilitation plans
• Multidisciplinary programs
– Medical adjustment
– Behavior modification
– Exercise classes

90. More advanced preventiveMore advanced preventive
measuresmeasures
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91. Scc – forever young programScc – forever young program
• Hi- tech rehabilitation program for 50 +
• Use the most advanced & computerized machines to
stimulate muscles, increase activities & Coordination
• Prevents falls and walking instabilities
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92. Virtual RehabilitationVirtual Rehabilitation

94. ConclusionsConclusions
• Prevention is multifaceted: a fragility fracture is the
strongest predictor of a future fracture
• Cost containment is a joint effort between orthopaedists,
primary care physicians, PT and social work
• Functional outcome is maximized by early fixation and
mobilization in operative cases
• With the increasing population of elderly, orthopaedic
surgeons must be proactive in secondary prevention of
fragility fractures

95.  THANK YOUTHANK YOU 
QUESTIONS?QUESTIONS?
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