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OSTEOPOROSIS
A Silent Epidemic!

WHAT IS OSTEOPOROSIS?
Bone is a living tissue. There are cells that build bone (osteoblasts) and there are cells that destroy bone (osteoclasts). The process of bone formation and resorption should be balanced. If bone resorption is more than formation, there is a negative balance in which we lose bone more than forming bone.

Age related bone loss occurs both in men and women. Therefore, osteoporosis affects man as well as woman. However, during menopause, woman loses bone faster because of estrogen loss. This menopause related bone loss further compounding the age related bone loss.

Osteoporosis, a disease characterized by decrease bone mass and changes in the micro-architecture of bone, causes your bone to become brittle and easily fractured. Multiple fractures of the vertebrae lead to collapse of bone and subsequent hunch back deformity.

More than half of the post-menopausal women above fifty years of age will develop osteoporosis. Studies also show that more than two third of women above seventy years old will develop osteoporosis and related fractures.

ARE YOU AT RISK?
Following are the risk factors that might increase your risk of developing osteoporosis and sustaining a fracture:
1. Advancing age
2. Ethnic group (Oriental and Caucasian)
3. Female gender
4. Early menopause <45 years old (natural or surgical)
5. Maternal history of osteoporosis related hip fracture
6. Small frame with Body Mass Index (BMI) of less than 19kg/m2
7. Long term ingestion of medicines such as steroids
8. Excessive smoking and alcohol consumption
9. Sedentary life style and low calcium intake

Osteoporosis is a silent disease. You might lose your bone mass without knowing the damage that has occurred. In most cases, you only realize that you are suffering from osteoporosis after you have broken your bone!

Prevention of osteoporosis is important in the management of the disease. However, early detection and diagnosis is even far more important. This allows early intervention and treatment.

Individuals with risk factors should present themselves for examination. They should have their diagnosis made early before even the first fracture occurs.

DXA Scan (Bone Mineral Density –BMD Scan)
DXA (Dual Energy X ray Apsorptiometry) scan is currently the most accurate method to confirm the diagnosis of osteoporosis in clinical practice. The diagnosis is based on the WHO criteria of T score as listed below.

Normal                               T score of -1 and above the Standard Deviation (SD)
Osteopenia                       T score between -1 and -2.5 SD
Osteoporosis                   T score below -2.5 SD
Severe osteoporosis      Presence of fragility fracture

DXA scan is an X-ray scanning using extremely low dose x ray in the scanning process. Therefore it is a very safe procedure. The scanning is normally done on the lumbar spine and hip to determine the bone mineral density at these places. It is fast (within 5 minutes), accurate and simple. There is no injection required and you do not need to fast before the procedure. After the scan is completed, you will be given result sheets. Your doctor will explain to you the bone mineral density result. Recommendation will then be given.

DXA scan is recommended for diagnosis of osteoporosis. It is also the tool used for monitoring the effectiveness of your treatment. It is recommended to repeat the scan one to two years after treatment is initiated.

Please do not wait for fracture to happen. Diagnosis should be made even before the first fracture occurs!

WHAT WILL HAPPEN TO YOU IF YOU HAVE OSTEOPOROSIS?
Osteoporosis predisposes you to fractures, especially in elderly individuals. They sustain fracture even after trivial injury. The fractures commonly encountered are the wrist fractures involving younger individuals in their fifties. Treatments such as manipulation of fracture and immobilization in a cast for six weeks are often required. Besides the inconvenience while treated in a cast, patients require rehabilitation to mobilize the wrist to minimize stiffness. Strengthening exercise and functional training are also required to bring them back to normal function.

Vertebral (spine) fractures often happen in those in their sixties. These fractures will lead to chronic back pain, severe hunch back deformity, disfigurement, loss of self confidence and even long term immobilization in bed. Immobilization will further lead on to muscle wasting and further bone loss.

Hip fracture carries the highest morbidity and mortality. Twenty percents of elderly individuals with hip fracture will succumb to secondary complications such as pressure sore, pneumonia and sepsis within first year. There are only about twenty five percents of individuals might regain their normal function. The rest of the individuals will be bed bound, depending on wheelchair, walking frame and walking sticks for the rest of their life.

Therefore, early diagnosis and treatment is important. Do not wait for the first fracture to happen! There are treatments available to improve bone mass and subsequent reduction of fracture risk. Medical treatments for osteoporosis include various pharmacological agents. There are divided into two main groups, anti-resorptive agents and bone forming agents. Anti-resorptive agents include hormone replacement therapy (HRT), bisphosphonates, such as alendronate and risedronate; Selective Estrogen Receptor Modulators (SERMs) such raloxifene and calcitonin. Bone forming agents include parathyroid hormone (PTH) strontium.

The principle in the treatment of osteoporosis is to increase the bone mineral density (BMD), to maintain the micro-architecture of the trabeculae, to prevent occurrence of breakage and loss of connectivity of the trabeculae. All these effects are meant to prevent fracture and to reduce the chance of osteoporotic fracture by about fifty to seventy percents.

Early diagnosis is important in order to allow treatment to be initiated early. This will minimize your risk of getting a fracture and fracture related complications.

Dr. J.K. Lee
Consultant Orthopedic Surgeon
President
Malaysian Osteoporosis Society