60. Orthopaedic aspects of osteoporosis

Osteoporosis

Osteoporosis refers to the decreased bone density, which increases the risk for fractures. It’s defined according to the results of a DEXA (dual-energy x-ray absorptiometry) scan or by the presence of a pathological fracture. The DEXA scan calculates the bone mineral density and gives a T-score. Osteoporosis is defined as a T-score of less than -2,5 standard deviations. This means that a person with osteoporosis has 2,5 standard deviations lower bone density than an average young adult female.

T-score between -1 and -2,5 is less severe and is called osteopaenia.

Etiology

• Female gender
• Old age
• Smoking
• Low calcium intake
• Low vitamin D intake
• Low levels of physical exercise
• Alcohol consumption

Osteoporosis can also be secondary to:

• Glucocorticoids
• PPIs
• Hyperthyroidism
• Chronic kidney disease

Clinical features

Most patients with osteoporosis are asymptomatic, but the condition predisposes to so-called pathological fractures. These are fractures which are caused by normal activities which would otherwise not cause fracture in healthy people. Fractures can occur during bending over, sneezing, or falling from small height. These fractures most commonly affect the vertebrae.

Vertebral fracture

Orthopaedic surgeons are involved in the treatment of osteoporotic vertebral fractures.

• Vertebral fracture is usually a pathological fracture due to osteoporosis.
• Diagnosis
  • X-ray
• Clinical features
  • Loss of height
  • Local pain on percussion
  • Progressive kyphosis
• Stable fractures
  • Most osteoporotic vertebral fractures are stable
  • Most develop slowly over time and are therefore asymptomatic
  • The structural stability of the spine remains intact
  • No neurological problems
  • Treated conservatively
    • Anti-osteoporotic medication
    • NSAIDs or calcitonin nasal spray
    • Physical therapy
    • External bracing or orthotics
  • If pain remains despite conservative treatment -> vertebral augmentation
• Unstable fractures
  • Osteoporotic vertebral fractures are rarely unstable
    • Unstable fractures are most commonly traumatic in origin
  • The structural stability of the spine is compromised
    • This may cause spinal cord injury and neurological problems
  • Unstable fractures must be treated urgently to prevent permanent neurological injury
  • Treated surgically
    • Mostly with vertebral augmentation (vertebroplasty or kyphoplasty)
    • Alternative: spinal fusion surgery