Fractures in Osteoporosis : How to treat ?

Most fractures associated with osteoporosis have occurred due to progressive weakening of the bone. This is also associated with generalized weakening of the bones elsewhere in the body, particularly the spine and the wrist.
So, any patient of osteoporosis presenting with fracture must be carefully assessed for fragility fractures elsewhere.
The second point of concern is, osteoporosis worsens with inactivity. So these patients must be made ambulatory at the earliest possible.
The third issue is regarding the stability of fixation, in such fractures. Osteoporotic bones are typically too soft to provide strong anchorage to screws and plates. This may be addressed either by using the newer locking plates or by cement augmentation of the standard screws and plates.

In patients with osteoporotic fractures, the treatment of osteoporosis must continue along with the care of fracture. This includes drugs like bisphosphonates, teri-paratide (forteo), calcitonin, calcium and vitamin D supplements. Adequate bracing should be done to the areas at risk of fragility fractures.

Medical Treatment: Avascular Necrosis (AVN) of Hip

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Dr Anurag Awasthi  Orthopaedic Specialist, Sohna Road, Gurgaon 9718112112

AVN Hip is defined as the irreversible changes in the femoral head, as a result of the interuption to the blood supply. It commonly follows fracture of femoral neck/ prolonged steroid intake/ alcoholism/ muco-polysaccharidoses/ sicle cell anemia etc.
The femoral head gradually undergoes changes in the density and architecture, ultimately leading to degenerative arthritis of hip joint.
In late stages, when arthritis has already set in, the only effective treatment is a total joint arthroplasty.
However, in the early pre-collapse stages, there is some role for a group of drugs known as Bisphosphonates.
Alendronate is a commonly used drug of this group. these drugs are available in both tablet and injection form; and dosing schedule varies from once daily to once a year.
Numerous studies have advocated that bisphosphonates, when used in early AVN hip (Ficat & Arlet stage I/II), results in improvement of symptoms and prevents radiological worsening in atleast 60-70 percent of patients. However, this drug needs to be taken for a period of 18-24 months to show appreciable improvement.
The prominent side effect associated with this drug is reflux oesophagitis.

Osteoporosis - Are We a Victim?

Osteoporosis is defined by WHO as a reduction in bone mineral density, more than two standard deviations below the corresponding age and sex matched control. It is usually defined as a disease involving elderly women who are post-menopausal. This is clearly one of the biggest subset of the patient spectrum. But, in addition, it may affect elderly men as well. And is some pathological conditions, it may affect much younger population. So, by far, nobody is immune to this disorder.

Among the many contributing factors that precipitate osteoporosis, the most important is prolonged immobility. Post-menopausal women (due to lack of estrogen), prolonged steroid therapy, anti-convulsive therapy, hypo- or hyperthyroidism, and alcoholism are among the common causes of osteoporosis.

A backache is the commonest complaint. In some patients, the diagnosis is first made when they present with a fracture of the vertebral body (most common), lower end radius (forearm) or fracture neck femur (hip). Such patients need treatment for the fracture and continued long-term prophylaxis to prevent subsequent similar events.

The golden rule to prevent osteoporosis is exercise.

This helps in adequate channelization of the Calcium and Vitamin D reserves of the body. Along with Calcium and Vitamin D supplementation in diet, and medication that block bone eating cell activity help restore the balance. Women in post-menopausal age group may need Hormone Replacement Therapy.

The medical treatment for osteoporosis includes the following categories:
1. Calcium and Vitamin D supplementation- Up to 1500 mg of Calcium in divided doses with 400 I.U. of vitamin D per day.
2. Estrogen supplementation- In post-menopausal women suffering with osteoporosis
3. Bisphosphonates- Osteophos in daily or weekly or even monthly depot injection may be administered.
4. Calcitonin- Nasal spray in the dose of 200 I.U. per day
5. Parathyroid Hormone- A novel drug with good result is low dose para-thyroid hormone (Forteo); drawback is cost.

The usual duration of therapy is 18-24 months, and Dual Energy X-ray Absorption (DEXA) scan is a good guide to both diagnosis and following treatment efficacy. Osteoporosis of men is a well known entity now. Usually considered as a disorder of women, it may affect men as well in all age groups. In elderly, it is often labeled as senile osteoporosis.

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