With the gradual aging of our society, the number of elderly patients attending orthopedic outpatient emergency clinics for osteoporotic fractures has increased. This type of fracture often occurs in the spine or hip, causing great pain to patients and seriously affecting their quality of life. While almost everyone is aware of and able to prevent and treat geriatric diseases such as cardiovascular disease and diabetes, most elderly patients have no idea about osteoporosis and usually think that osteoporosis is an inevitable phenomenon as people get older. Many patients have this idea: “Osteoporosis is just a lack of calcium!” This statement cannot be said to be wrong, but it is only partially correct. In order to let the majority of elderly people understand osteoporosis and effectively prevent osteoporotic fractures, so as to make the “sunset red” more gorgeous, orthopedic surgeons should not only be perfect in fracture diagnosis and treatment and surgical skills, but also strengthen the patient’s osteoporosis education and related popularization work. Elderly patients themselves should also pay attention to the prevention and treatment of osteoporosis.
I. What is osteoporosis?
What is osteoporosis? The World Health Organization (WHO) gives this definition: “Osteoporosis is a systemic bone metabolic disease characterized by low bone mass and damage to bone microstructure, leading to increased bone fragility and susceptibility to fracture.” It encompasses not only the loss of inorganic substances such as calcium and phosphorus, but also the lack of organic substances in the bones, the essence of which is the deficiency of bone matrix and thus the decrease of both bone mass and bone density, making elderly patients prone to fragility fractures. This tells us that calcium supplementation alone cannot prevent and treat osteoporosis.
II. Epidemiology of osteoporosis
In 2010, there were about 1.37 billion people in China’s population census, of which 13.26%, or 181.7 million, were over 60 years old, while 8.87%, or 121.5 million, were over 65 years old. As the aging trend of our society becomes more and more obvious, this group will also increase further, and looking ahead to 2020, the total number of elderly people in China will be more than the entire population of the United States. Currently, there are about 84 million predicted osteoporosis patients in China, and the total number of people suffering from this disease worldwide is over 200 million, and there are 1.3-1.6 million fractures caused by osteoporosis every year. According to statistics, osteoporosis has become the seventh most common and prevalent disease in the world, with hip fracture patients ranked second only to breast cancer in terms of mortality. The medical community now places equal importance on the three diseases of hyperlipidemia, hypertension and osteoporosis.
China has the largest elderly population in the world
Bone of osteoporosis
Third, the clinical manifestations and results of osteoporosis
The early signs of osteoporosis are not obvious and people often fail to realize its existence. With further development of osteoporosis, systemic bone pain, shortening of height, hunchback and breathing disorders can occur, and the most serious result is that the patient has a fragility fracture (fragility fracture: i.e. a fracture that occurs with slight external force, often involving the hip, spine and wrist joints). Many elderly patients are aware that they have more serious osteoporosis when they visit orthopedic clinics because of various fractures, and only then do they think of receiving osteoporosis treatment.
Fourth, who are prone to osteoporosis?
1) Women with premature menopause.
2) Having genetic factors.
3) Thin body size (body mass index ≤ 19).
4) insufficient calcium or vitamin D.
5) lack of exercise.
6) smoking and alcohol abuse.
7) excessive consumption of coffee or strong tea.
8) long-term use of certain drugs, such as hormones.
(9) rheumatoid and other diseases.
V. Risk assessment of osteoporosis
How can you predict your risk of osteoporosis now or even in the near future? The International Osteoporosis Foundation (IOF) offers a one-minute self-assessment question.
1) Have you ever injured your bones from a minor collision or fall?
2) Have your parents ever had a hip fracture from a minor bump or fall?
(3) Do you often take hormonal drugs such as cortisone and prednisone for more than 3 months in a row?
4) Has your height decreased by more than 75px from your youth?
5) Do you regularly drink a lot of alcohol?
6) Do you smoke more than 20 cigarettes a day?
7) Do you often have diarrhea? (caused by gastrointestinal diseases or enteritis)
8) Answer for women: Did you go through menopause before the age of 45?
9) Answer: Have you ever had no menstruation for more than 12 months in a row? (except during pregnancy)
(10) Men: Have you ever experienced impotence or lack of sexual desire?
A “yes” answer to one of the ten questions above is considered positive for the risk of osteoporosis. Of course, there are other screening tools available, such as the Fracture Risk Assessment Simple Instrument (FRAX), which can be used to calculate the probability of hip fracture and any significant osteoporotic fracture over a 10-year period.
VI. Detection and diagnostic criteria of osteoporosis
Orthopedic surgeons usually diagnose osteoporosis qualitatively by plain X-rays of the patient’s lumbar spine or hip. Elderly patients often learn that they actually have severe osteoporosis only when they visit an orthopedic clinic for a fracture. In such cases, the patient will be advised to have a bone density test. Currently, dual-energy X-ray absorptive bone densitometry (DXA) is the internationally recognized gold standard for the diagnosis of osteoporosis in academic circles. This assay involves selecting several weight-bearing areas of the patient’s skeleton for measurement, including the lumbar spine and hip. By measuring and analyzing several weight-bearing areas, the patient’s degree of osteoporosis is determined in a comprehensive manner. Based on the diagnostic criteria recommended by the World Health Organization (WHO), BMD is expressed as a T value based on DXA, i.e. T value = (measured value – peak bone) / standard deviation of normal adult BMD, so the T value should be a negative value less than zero. If the T value is between 0 and -1, the bone density is normal; if the T value is between -1 and -2.5, the bone mass is reduced; if the T value is <-2.5, it belongs to osteoporosis; and if the T value is <-2.5 and accompanied by fragility fracture, it belongs to severe osteoporosis. (Note: T-values are only used for postmenopausal women and male patients over 50 years of age)
Although recognized as the gold standard by the international academic community, DXA has its limitations. Dual-energy X-ray DXA measurements are often influenced by the patient’s measured position, height and weight, and are positively correlated with height and weight. This means that the higher the patient’s height and weight, the closer the BMD measurement may be to normal, which is often referred to as “false negative” results, and some European and American people with osteoporosis use DXA to measure BMD, and sometimes the BMD appears normal. In addition, DXA bone densitometry only assesses the patient’s bone density, but does not accurately reflect bone quality. We already know that osteoporosis is essentially a systemic bone metabolic disease characterized by low bone mass, including both low bone density and low bone mass, and that measuring bone density alone is inaccurate. In view of this, the academic community is studying and exploring another more accurate and effective measurement method: quantitative CT testing (QCT). This method is still in its infancy, and there is no international standard for diagnosis yet. The Department of Orthopedics and the Department of Imaging will work together to move forward into this new field!
VII. Prevention of osteoporosis
What can be done to prevent osteoporosis? It is recommended to do more weight-bearing exercises, avoid excessive dieting, do not consume too salty food, eat less caffeine and protein-rich food, do not smoke, do not abuse alcohol, and for elderly patients should also strengthen calcium and vitamin D supplements. Calcium and vitamin D are the basis for the prevention and treatment of osteoporosis, just like the ingredients for cooking. The Osteoporosis Association recommends that we consume 1200mg to 1500mg of calcium per day, and the vast majority of Chinese people are still far from reaching this goal. With calcium supplements, it is best to supplement with organic calcium, which will have a better absorption rate than inorganic calcium. The common organic calcium in our daily life includes milk, yogurt, sesame seeds, etc. Regular consumption of these can better enhance the calcium supplement. Of course there are some patients in orthopedic clinics who ask the question, “Can I take calcium supplements if I have stones?” The answer is yes, but calcium citrate should be taken instead of calcium carbonate. Supplementation with active vitamin D is also essential as it effectively promotes calcium absorption in the small intestine and kidneys, but patients should be instructed to have their blood calcium tested regularly to prevent the development of hypercalcemia. It is still a controversial topic whether patients with combined kidney stones or gallstones can take vitamin D supplementation.
VIII. Treatment of osteoporosis
If an elderly patient is diagnosed with osteoporosis by bone density testing, he or she should take calcium and vitamin D supplements in addition to osteoporosis treatment drugs. Drugs for osteoporosis can be broadly divided into two categories: drugs that inhibit osteoclasts and drugs that promote osteoblasts, such as bisphosphonates, calcitonin, and parathyroid hormone (PTH). Of course, there are also osteoporotic drugs such as estrogens, selective estrogen receptor modulators (SERMs), strontium salts, and tetraene-methylnaphthoquinone. Each drug has its own advantages and disadvantages, for example, bisphosphonates, the first-line drug now commonly used to treat osteoporosis, are clinically satisfactory, but certain patients with reflux esophagitis can experience severe esophageal burning due to the drug’s irritation of the squamous epithelium of the lower esophagus; 70% to 80% of patients with intravenous infusions of bisphosphonates experience transient flu-like symptoms after the drug, which is contraindicated in patients with renal insufficiency. Calcitonin is effective for lumbar fractures and has significant pain relief, but in 2011 the European Osteoporosis Society found an increased incidence of tumors in patients with long-term use (>6 months) of salmon calcitonin. And tetraenolone is a vitamin K2 drug that is not to be used in combination with drugs such as warfarin. The newest osteoporosis treatment drug is Prolia, which is a monoclonal antibody, not belonging to the above two categories, and is injected subcutaneously once every six months (60 mg).
IX. Treatment of osteoporotic fractures
Osteoporotic fractures usually involve the spine, hip or wrist joints, which greatly reduces the quality of life of elderly patients and imposes a heavy burden on their families. These patients are often in poor physical condition and also have combined hypertension, coronary heart disease, diabetes and cerebrovascular disease. Some have also had heart bypass surgery, valve replacement surgery, poor heart function and are on long-term anticoagulants. Such conditions make certain hospitals in Beijing famous for orthopedics feel quite tricky. Relying on the help and support of cardiology and anesthesiology, the orthopedic department of our hospital has carried out osteoporotic fracture surgeries of a certain scale, such as vertebroplasty for spinal fractures and hip replacement for hip fractures, which have reached the advanced level in China with satisfactory clinical results and improved the quality of life of patients.