Osteoporosis is a silent disease that affects all bone in the skeletal system, but it often leads to broken bones in the hip, wrist, spine, and pelvis. The disease is common in women past menopause, and in men over 70 years of age, but it can also affect children who spend too much of their time indoors and breast-fed babies. Until a fracture occurs, osteoporosis often remains hidden and undetected by the physician and patient because it occurs slowly over many years.

Risk Factors
Osteoporosis is considered a disease of women, and it does, in fact, affect women past menopause. However, all females are at risk if they have an estrogen deficiency due to hysterectomy; amenorrhea (absence of menstrual periods) for any reason, including athletics; or oligomenorrhea (decreased frequency of menstrual periods). A sedentary lifestyle (secretaries, draftsmen, children who spend to much time playing video games, etc.) are also at an increased risk of osteoporosis. Breast-fed babies are at risk if the mother has low levels of Vitamin D. Elderly and institutionalized patients are at increased risk, as are men over 70 years of age. Smoking and alcoholism are risk factors for osteoporosis as well. Certain other diseases are associated with an increased risk of osteoporosis, including rheumatoid arthritis, kidney disease that requires dialysis, seizure disorders, cancer, and thyroid disease, to name a few.

Prevention
The most important treatment for osteoporosis is prevention. Osteoporosis may be partially prevented by building and then maintaining strong bones. The necessary building blocks for strong bones are calcium and Vitamin D. Growing children need 1200 mg (milligrams) of calcium per day. Adults need 1000 mg of calcium per day; postmenopausal women and elderly men need 1200 to1500 mg per day. Everyone needs 400 to 800 IU (International Units) of Vitamin D.

There are many forms of calcium and all are equally effective. Calcium citrate is the most easily absorbed, but calcium carbonate is the least expensive. If you hate pills, drink 4 glasses of milk per day and get 30 minutes of sunshine three times a week. It is also important to maintain a healthy weight and get at least 30 minutes of weight-bearing exercise, such as walking, running, dancing, or aerobics, each day. Decreasing the risk of falls for elderly patients by removing area rugs, adding nightlights, and hiding extension cords are also good preventive measures.

Diagnosis
Osteoporosis can be detected by a simple and painless test for bone mineral density (BMD) called a bone densitometry, or DXA, scan. This test is performed in the x-ray department, is completely painless, and can be completed in about 15 minutes. Every woman past menopause, every man over 70 years of age, anyone with a fragility fracture (broken bone due to minimal or no trauma), and children with risk factors should receive this simple test, before they have a broken bone. If the test is normal, it should be repeated every 3 to 5 years, or more often, if there is an increase in the risk factors.

Treatment
Treatment for osteoporosis is started when the bone mineral density identified on the DXA scan drops below normal. There are many medications that are used to treat osteoporosis. Two commonly used medications, alendronate (Fosamax) and risendronate (Actonel) both prevent the reabsorption of bone, thereby increasing the bone mineral density and decreasing the fracture risk. Raloxifone (Evista) helps increase bone density, but only decreases risks of fractures in the spine. Parathyroid hormone (Forteo), a daily injection, stimulates the formation of new bone and has been shown to dramatically decrease fracture risks. Once a fracture occurs, treatment becomes even more important to prevent more fractures in the future.

The pain of multiple spinal fractures can be treated by newer surgical techniques of vertebroplasty and kyphoplasty (injection of bone cement into fractured vertebrae). New medications are currently under development. However, the best treatment occurs before the first fracture.

For more information about osteoporosis go to www.aaos.org or www.osteoporosis.org.

Bobbi A. Farber, MD
Columbus, Georgia

References:
Roundtable insights on treating the fragility fracture patient, Part III. Orthopedics Today. 2004;24(7):18-27.