Osteoporosis and the Orthopaedic Surgeon: How to Prevent and Treat

John D. Kaufman, MD

Disclosures

Medscape Orthopaedics & Sports Medicine eJourn. 2001;5(2) 

In This Article

Treatment of Osteoporosis

Michael McClung, MD, discussed new information on bisphosphonates. Currently, bisphosphonates are the only pharmacologic agents shown to reduce both spine and nonspine fractures.

The concept of once-weekly dosing with bisphosphonates was examined in several different presentations and poster exhibits. Dr. Henry Bone, from the Michigan Bone and Mineral Clinic, and Dr. Rene Rizzoli, of the University Hospital Cantonal in Geneva, Switzerland, reported on data which showed that a 70-mg tablet of alendronate taken once a week increased bone mineral density after 1 year in the hip and spine similar to increases in bone density resulting from taking a dose of 10 mg daily.[9] Because alendronate is highly specific for bone and remains present on the bone surface for long periods of time, the once-weekly dosing schedule provides the same continuous suppression of bone resorption seen with the once-a-day regimen. An FDA application is currently pending for a once-weekly 70-mg Fosamax tablet.

Dr. McClung also presented data from a risedronate study on a group of patients younger than 80 years old who had at least one clinical risk factor for hip fracture and a femoral neck T-score below -3.0. Risedronate significantly reduced hip fracture risk in this study group by 39% and reduced hip fracture risk by 58% if a prevalent vertebral fracture existed.[10]

Both Drs. McClung and Lindsey discussed the role of combination therapy in osteoporosis, reporting that the combination of alendronate and HRT has an additive effect that produces greater increases in bone density than those associated with either agent alone.[11] Dr. McClung cautioned, however, that no fracture data are currently available on combination therapy and therefore it should not be used routinely. He recommended adding a bisphosphonate to the regimen of only a select group of women taking HRT. Good candidates to receive combination therapy include women who (1) are on HRT with high indices of bone remodeling; (2) lose bone density on HRT, in whom secondary causes of osteoporosis have been ruled out; (3) are on HRT and who have had an osteoporotic fracture; and (4) are receiving high-dose glucocorticoid therapy.

Dr. McClung concluded that bisphosphonates should be the treatment of choice in patients with established osteoporosis because there is such a large amount of data documenting reduction of both spine and nonspine fractures.[11,12]

Felicia Cosman, MD, discussed the use of anabolic agents in osteoporosis. Currently, the pharmacologic agents approved by the FDA to treat osteoporosis all work by suppressing osteoclast activity and by primarily reducing the resorptive phase of the bone-remodeling cycle. Various agents that increase bone formation have been examined or are currently undergoing clinical trials.

For example, fluoride has been shown to increase bone density. However, there are no data demonstrating that fluoride reduces fracture incidence. Parathyroid hormone (PTH), however, is a more promising agent. Continuous administration of PTH produces a catabolic effect, but intermittent administration is anabolic. It can produce an increase in bone density and a decrease in vertebral fractures through increasing osteoblast activity, recruitment, and lifespan. Dr. Cosman presented data showing an additive effect of HRT with PTH and of alendronate with PTH that resulted in very large increases in bone density.[13] Clinical trials to study this agent are currently underway.

Joseph Lane, MD, presented data on a specific surgical treatment for vertebral compression fractures, known as kyphoplasty. This involves placing a catheter with a balloon into a compressed vertebral body, slowly expanding the balloon to reduce the fracture, and then injecting methylmethacrylate cement into the void created by the balloon.

Lane reported on the first 311 patients, with an average age of 70, treated with this technique at the Hospital for Special Surgery in New York. Diagnoses included primary osteoporosis (69%), secondary osteoporosis (21%), multiple myeloma (5%), and other conditions (6%). All patients had failed conservative medical management. Vertebral fractures ranging from levels of T5 to L5 were treated.[14]

There was a 1% complication rate and the average procedure time was 45-60 minutes. Lane reported outcomes of 96% good-to-excellent pain relief usually within the first 24 hours after the procedure. There was 1 incomplete spinal cord injury, 1 epidural bleed with a full recovery, and 1 case of transient acute respiratory distress syndrome. There were no reports of infections, pulmonary emboli, or myocardial diseases. He concluded that kyphoplasty offers a mechanism to provide relief from pain and deformity while awaiting later benefits of medical intervention.

Dr. K. Hindso and colleagues, from the Department of Orthopaedics, University of Copenhagen, Denmark, discussed another treatment modality. The researchers gave hip protector pads to 303 elderly orthopaedic patients admitted with primary hip fractures. The patients were instructed to wear the hip pads after discharge; 244 patients served as controls and did not use the pads. Patients were followed for 1-1.5 years. Of the patients offered hip protectors, 65% accepted and wore them. Patients who used the protectors everyday on a regular basis had no new hip fractures. The annual rate of second hip fractures in the control group was 4.6% (P = .03). They concluded that regular use of hip protectors significantly protected against second hip fractures among hip fracture patients.[15]

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