Osteoporosis:

Factors that Affecting

Progression
Agus H. Rahim, MD
Dept. Of Orthopaedic & Traumatology
Hasan Sadikin Hospital
 Definition
Osteoporosis is a:
• Bone disease
• The amount of bone ↓
• The structural integrity of trabecular bone
is impaired
• Cortical bone: > porous & thinner
• The bone: weaker & more likely to fracture
 NORMAL OSTEOPENIA OSTEOPOROSIS SEVERE OSTEOPOROSIS

Cortical
bone
                                                                                                                                       

Trabecular
bone
                                                                                                                                       
Normal2 Osteoporosis2

5
Loss of trabecular architecture of vertebrae
in 3-D Micro CT
Normal Woman Osteoporotic Woman
(with vertebral fracture)

Loss of bone mass and horizontal trabeculae

Borah, et al. Anat. Rec. 2001
Normal Bone Resorption
Osteoporotic Bone Resorption
 Bone Quality
Determined by:
• Bone mass (bone
density)
• Micro-architecture of
bone
• Crystal size & shape
• Brittleness
 Bone Quality
Determined by:
• Connectivity of the trabecular network
• Vitality of the bone cells
• Ability to repair micro-cracks
• The structure of the bone proteins
 How Fracture Occur?
• Result of: both trauma & ↓ bone strength
• Trauma:
– falling
– the force of the impact
• Bone strength: depends on density
(quantity) & the quality of the bone
 Clinical Features of Osteoporosis
• Hip Fractures
• Vertebral fractures
• Others fractures
• Changes in body shape
Vertebral Fractures
 What is a vertebral fracture?
Morphometric analysis
Even with radiographs, vertebral fractures are not always easy to
detect

Hp Ha Hp Ha

Genant et al. JBMR 1993; 8(9): 1137-48.

Changes in Body Shape
 How Bone Density
Predicts Fracture Risk?
• Many studies:
– Bone density to predict fractures
– Fragility fractures - by minor trauma
• The relative risk: between 1.3 & 2.6
BMD & Age
 BMD & Fracture

• Measurements of the TOTAL HIP using DEXA

• The overlying numbers represent the hip fracture incidence per
1000/year
 Bone Density

• DEXA (Dual Energy Xray Absorptiometry)

• Ultrasound
• QCT (Quantitative computed tomography)
T Score and The WHO Definitions
• Normal : > -1
• Osteopenia: between
-1 & -2.5
• Osteoporosis: < -2.5
• Established
osteoporosis: the
presence of a non-
traumatic fracture
Bone Density Loss with Aging
 Risk Factors or Conditions
that Cause Osteoporosis
• Postmenopausal woman (with family history of
hip fractures or kyphosis)
• Medications:
– Corticosteroids
– Dilantin
– Gonadotropin releasing hormone agonists
– Loop diuretics
– Methotrexate
– Thyroid
– Heparin
– Cyclosporin
– Depot-medroxyprogesterone acetate
 Risk Factors or Conditions
that Cause Osteoporosis
• Weight below healthy range
• Cigarette smoking
• Hepatic disease
• Depression
• Spinal cord injury
• Renal insufficiency
• Hypercalciuria
Epidemiologic Factors in Older
Caucasian Ambulatory Women
 Factors Associated with Bone Mass
in Older Women
• Age
• Body weight
• Muscle strength
• Maternal history of osteoporotic fractures
• Use of estrogens
 Factors Associated with Bone Mass
in Older Women
• Weight: stronger determinant of bone
mass than obesity
• Weight loss after age 50: substantial &
adverse effect on bone mass
• Duration of time after menopause: effect
on bone mass
 Factors Associated with Bone Mass
in Older Women
• Pregnancy: ↑ bone mass (by causing
weight gain)
• Beneficial effect of estrogen replacement
is proportional to the duration of treatment
• Alcohol use, associated with ↓ bone mass:
no evidence
 Factors Associated with Bone Mass
in Older Women
• Non-insulin-dependent diabetics: ↑ bone
mass (even after adjusting for weight)
• Lactation or regular antacid use: do not ↓
bone mass
 Anthropometric Variables
• Age & weight: the strongest predictors of bone
mass
– The association between weight & bone mass:
stronger than between bone mass & body mass index
– Suggesting that mechanical factors may be more
important than adiposity
• Other investigators: found adiposity to be
associated with bone mass
• Height: independently associated with bone
mass
 Anthropometric Variables
• Greater strength: associated with
increased bone mass
• A number of previous studies:
– Associations between bone mass & strength
in postmenopausal women
– Suggesting that mechanical loading of bone
preserves bone mass
 Reproductive and Family History
• Reproductive history: not related to bone mass
• Surgical menopause:
– Associated with rapid loss of bone mass
– Had no effect on bone mass after estrogen use
• Association between pregnancy and increased
bone mass (attributable to increased weight)
• The effect of breast-feeding on bone mass:
– Controversial
– No evidence to support an association
 Reproductive and Family History
• Twin studies:
– Strong familial similarity for bone mass
– Particularly among monozygotic twins
• Maternal history of fractures: more useful
than the fracture history of other first-
degree relatives
 Calcium Intake
• No association: calcium intake & bone
mass
• The relation: remains controversial
• Calcium intake < 400 mg/d: may result in
osteopenia
• The suggested association between
calcium intake as a teenager or young
adult & postmenopausal bone mass: not
confirmed
 Calcium Intake
• Calcium supplements: not associated with
bone mass
• The benefits of vitamin D supplements:
– Also remain controversial
– No association between bone mass & vitamin
D use or duration of use
 Habits
• Beneficial effects of weight-bearing
exercise:
– Remain unproven
– Modest beneficial effect of physical activity
• No beneficial effects of current or previous
weight-bearing exercise on bone mass
 Habits
• No association between bone mass &
current or previous use, intensity of use, or
total lifetime alcohol intake
• Chronic alcohol abuse: has been
associated with reduced bone mass
• Modest alcohol use: is not a risk factor for
decreased bone mass
 Habits
• Current smokers: had less bone mass
than nonsmokers
• No evidence existed that heavy smokers
had lower bone mass than moderate
smokers
• Smoking: to be associated with a
decreased bone mass or more rapid bone
loss
 Habits
• Statistically significant inverse association
between caffeine consumption & bone
mass
• Caffeine:
– May ↑ calcium excretion by the kidney
– May account for the slight decrease in bone
mass
• The clinical significance of this
association: is unclear
 Medical Conditions
• The association between diabetes & bone
mass: is controversial
• Even after adjusting for weight: bone mass
is increased in non-insulin-dependent
diabetics
• Relation between osteoarthritis &
increased bone mass
• Decreased bone mass: has been been
reported in rheumatoid arthritis
 Medical Conditions
• Hyperthyroidism: associated with
decreased bone mass
• The bone mass of women who took
thyroid hormone did not differ when
compared with women who did not take
thyroid hormone
 Medications
• Estrogen replacement therapy & duration of use:
strongly associated with increased bone mass
• Progestins:
– No or slightly beneficial effects on bone mass
– Progestins do not add to the protective effects of
estrogen on bone
• Thiazide diuretic:
– Increased bone mass
– The beneficial effects: approximately one half as great
as those for estrogen
 Conclussion
Factors Associated with Bone Mass
in Older Women:
• Age
• Body weight
• Muscle strength
• Maternal history of osteoporotic fractures
• Use of estrogens
• Reproductive & Family History
• Habits
• Medical condition & medication