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Osteoporosis

Osteoporosis

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OSTEOPOROSIS

DEFINITION: A systemic skeletal disease characterized by low bone mass and micro-architectural deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to fracture (Consensus Development Conference for Osteoporosis – 1991).

NEWER THOUGHT: Osteoporosis is a skeletal disorder characterized by compromised bone strength (means bone density & bone quality) predisposing to an increased risk of fracture (NIH Consensus Conference).

Osteoporosis is most of the time a SILENT DISEASE. Symptomatic (painful) Osteoporosis is usually secondary to a primary cause (Eg.: Osteomalacia). Any fracture cannot be “Osteoporotic fracture” because, for it to be so, it has to be a “fragility fracture” with low BMD Scores (Fragility fracture is one which occurs with a fall from standing height or less – i.e. with trivial trauma).

Bone is a live, metabolically active tissue having cells, proteins & minerals. A cycle of bone resorption (Osteoclast – Mediated) & bone formation (Osteoblast – Mediated) is always on. From birth to 3rd decade is a positive balance with more & more formed. Then from age of 30 to death is a downgrade cycle. Peak bone mass (maximum calcium & protein in the bones) is achieved at 25-30 years of age in each individual’s life (peak bone mass achieved in trochanter is mid-teens, femoral neck is late-teens and spine is early-20s). Up to 10% of the skeleton is being remodeled at any one time. Cancellous bone has less mass (20%) but larger surface area (80%) and higher turnover each year (25%), whereas cortical bone has 80% mass and lesser surface area (20%) & only 3% turnover per year.

Types of Osteoporosis:

  1. Post-Menopausal (Occurring in females after menopause due to estrogen protection being taken away from bones)
  2. Senile Osteoporosis (Occurring in both sexes after 65 years of age)
  3. GIOP (Glucocortoid induced Osteoporosis)
  4. Others (Secondary to other factors): Eg. Hormonal, Drug induced, Osteomalacia, Hyper-Parathyroidism, GI Tract disorders, Marrow based disorders, etc.

WHO Classification for Post-Menopausal Osteoporosis through T-Score (It is standard deviation of BMD compared to young healthy normal individuals).

Normal is -1.0 or higher

Osteopenia is -1.0 to -2.5

Osteoporosis is -2.5 or lower

Severe Osteoporosis is -2.5 or lower with fracture

At present for measuring BMD (Bone Mineral Density), the gold standard is DXA (Dual Energy X-Ray Absorptiometry). Others available are Quantitative Computed Tomography (QCT), peripheral devices of X-Rays, ultrasound-based devices, etc.

 

FRAX is a WHO Fracture Risk Assessment Tool. FRAX Scores are calculated by a web-based tool filled by answering questions. They are important and significant for 10 years risk probability of fractures. (Hip fractures – 3% or more, all other fractures – 2% or more; become significant). The advantage of FRAX is fewer younger patients at low 10 Year Risk will be treated and more older patients at higher 10 Year Risk will be treated.

 

Blood tests for Osteoporosis treatment and finding early secondary factors are – S.Calcium, S.Phosphorus, S.Alkaline Phosphatase, Vit. D3, PTH, S.Creatinine & Urine Routine. Best bone markers in blood are P1NP (Procollagen Type 1 – N – Terminal Propeptide) for formation and CTX1 (Beta Cross – Telopeptide) for resorption.

For males below 50 years, pre-menopausal women and children DO NOT use T-Score for diagnosis of Osteoporosis. Always use Z-Score and when Z-Score is -2.0 or lesser then it is called “Lower than expected” hence better NOT to advise BMD DXA as a routine test for all age groups or for aches and pains. Only for post-menopausal females and males older than 50 years should T-Score be considered in diagnosing Osteoporosis. In children and adolescents, diagnosis of Osteoporosis is NOT on densitometric criteria alone. It is clinically significant history of fractures (long bone fractures of lower extremities &/or vertebral compression fractures &/or two or more long bone fractures of upper-extremities) with a BMD Z-Score of -2.0 or lower.

Low densitometry is not the ONLY cause of Osteoporotic fractures. Other associated problems of neurologic status, balance/gait abnormalities, poor proprioception play a negative influence and increase the risk of fracture. However, the most commonly missed associated problem is SARCOPENIA. Sarcopenia is less muscles (girth & strength). It can be seen in DXA studies as less than 20% of lean mass; & also, as the grip strength of less than 20Kg in females and less than 30Kg in males; &/or speed of walk in 10mins is less than 0.8m/s.

 

Treatment of Osteoporosis:

  1. Irrespective of the drugs chosen (Anti-Resorptive &/or Anabolic Pro-Osteoblastic drugs), the common components of treatment are –
    1. Calcium & Vit.D replete system (Supplementation &/or dietary)
    2. Walking, Sun bath & Weight bearing exercises
    3. Improving muscle strength, proprioception & balance
    4. Prevention of Falls: Remove clutter from the floor, apply grab handles in bathroom/toilets/stairs, keep non-slip floor mats, improve ergonomics of furniture, etc.
  2. 2. Bisphosphonates (Anti-Resorptive drugs – Anti Osteoclastic) –

The recommendation is NOT to start in pre-menopausal women, males younger than 50 & children.

They have to be started when BMD DXA T-Scores are lesser than -2.0 with fragility fractures or clinical states of higher risk of fractures or T-Scores of -2.5 and below without previous fracture.

Alendronate (70mg) oral – one per week OR Zoledronate (5mg) intravenous infusion – one per year are similar in effectiveness and are preferred over Ibandronate (150mg) – one per month or Resindronate (35mg) – One per week.

Bisphosphonates are contra-indicated if there is preexisting renal impairment (raised creatinine), hyperparathyroidism (primary or secondary).

CORRECT calcium and Vit.D depleted states BEFORE starting Bisphosphonates.

 

DRUG HOLIDAY from Bisphosphonates is very essential to prevent frozen bone phenomenon & subsequent atypical Bisphosphonates induced fractures. It is to be taken after 4-5 years in mild risk & stable patients and upto 10 years in high risk patients (Eg. GIOP).

 

REINSTATING Bisphosphonate therapy is to be done only if there is definite declining BMD scores and rising resorption markers (Eg. CTX1) over a period of 2 years of more.

  1. CALCITONIN Nasal Spray is anti-resorptive. It is now limited in use for “Analgesic” effect in acute Osteoporotic vertebral wedge-compression fractures. Not to be used more than 15 days (present guidelines).
  2. TERAPERATIDE (injectable Parathormone synthetic analogue). It is a pro-osteoblastic, hence anabolic agent for bone formation. 20µg to 40µg daily subcutaneous injection (patient self administered) for 18 months to max 24 months daily.

It is CONTRAINDICATED in Hyperparathyroidism & Hypovitaminosis D until they are treated and corrected. (So do a BMD DXA, S.Calcium, Vit.D, PTH before starting Teraperatide).

It is recommended to start Teraperatide in T-Scores lesser than -3.5 and/or multiple fragility fractures.

 

Combination therapy: Teraperatide followed by Bisphosphonate is preferred.

  1. DENOSUMAB (is a RANK-Ligand fully human monoclonal antibody): It is antiresorptive in nature and used as 60mg subcutaneous injection every 6 months. Till now no limit is set in the number of years it can be used (max use reported is upto 10 years). This is a drug to be used after the use of Bisphosphonate & Teraperatide. It is not to be used as a primary drug yet. Its effect wears off very fast after stopping.
  2. Other drugs are:

Raloxifene (SERM), Strontium Ranelate, HRT (Estrogen), Bazedoxifene, etc.

 

FOLLOW-UP studies of BMD are not just to compare T-Score but to measure BMD (Eg. Lumbar spine score of 0.756g/cm2 in 2017 is now gone to 0.781g/cm2 in 2019). So, the difference in the real value is important. Change is considered SIGNIFICANT if there is atleast 0.028g/cm2 in lumbar spine, 0.033g/cm2 in total hip & 0.060g/cm2 in neck femur. The LSC (Least Significant Change) is specific to each center and machine & for LS Spine is 1-2% and for hip 2-3%. The follow-up should be done from the same DXA machine and center. It should be atleast 1 year apart for it to be of value to see the real effectiveness of therapy.

Other things to Remember:

  • Low calcium intake and Vit.D deficiency should be corrected in all patients
  • Z-Score more negative than T-Score – Start thinking of Osteomalacia
  • Low BMD but NOT Osteoporosis is seen in Osteomalacia, Osteogenesis Imperfecta, Renal bone disease, Multiple Myeloma & Bone marrow proliferative disorders.
  • Bone formation reduces with very high protein intake, very high cola-drink consumption & very high salt intake

Vit.D & Calcium:

Vit.D daily requirement for maintenance in Vit.D replete system is 1000 IU to upper limit 2000 IU but clinical judgement is necessary (AACE Response to IOM).

Calcium intake in mg (dietary or supplementation) (Institute of Medicine 2011 Dietary reference)

 

-Dr. Pradumna S. Mamtora

MS Orth., D. Orth.

Consulting Orthopaedic Surgeon

Sunflower Diagnostics  |  KLS Memorial Hospital  |  Bhartiya Arogya Nidhi Hospital

AI Integration in Healthcare

AI Integration in Healthcare

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THOUGHTS ON HEALTHCARE |  INTEGRATION |  AI

 

Science has its basic tenets: Observation, objectivity, seeing the entirety & honesty. Medicine being a science MUST have these on top of that, it also must incorporate “the art”.

As we are moving at a rapid pace towards AI (Artificial Intelligence) in health care, our era of doctors have to be careful in what direction we take the AI. We doctors(any pathy, any speciality) are essentially clinicians and healers. Though we have to be OBJECTIVE & UNPREJUDICED in our evaluation and understanding the diseased state of our patient, we have to be SUBJECTIVE in the approach to each individual’s treatment. Since we deal with individual humans who react differently, we have to keep our HUMANE, INDIVIDUALISTIC, SUBJECTIVE touch in health care delivery. This is essential for the long term and overall betterment of the treatment of human diseased states.

We have the evidenced based medicine (EBM) helping us get better & better – BUT we should not forget that:

  1. New evidence is not the only evidence:

Eg. – Fractures of radius ulna treated by square nails or fractures of tibia fibula treated by conservative Sarmiento’s method are now “out of fashion”, but what about their old evidence of thousands of fractures that healed well for decades across different centers?

  1. The basics of anatomy, physiology, pathology and healing processes have not changed in humans overall and that honesty towards what is working on a day to day basis over a long period of time cannot be disregarded.

Eg. – Lot of acute inflammatory episodes in musculoskeletal disorders are given “Neuromodulators” because they are “safe” – whereas NSAIDs which are actually needed for the pathology are not given because they are “unsafe” (though it is very easy to monitor their use & side effects).

As I said before, we humans needed a subjective human touch for getting treated. These days we tend to disregard anything that is NOT new/modern or NOT from our branch/speciality or NOT from our pathy. Lot of evidence from basic sciences, paramedical sciences, other pathies’ scientific offerings are not known or not given any importance because it is not in the mainstream literature. We are becoming speciality fanatics more like the religious fanatics. The need of the hour is the INTEGRATION & ASSIMILATION of ALL these human body related knowledges, data, research from different specialities and pathies – along with individual experiences of clinicians. These accumulated data should be put into a COLLECTIVE CYBORG KIND OF AI; which will drive human healthcare to a truly higher level.

The WISDOM of humans (especially in medical management) cannot be murdered because of mere collection of information touted as EBM.

Eg. – Recent “Evidence” says DO NOT give calcium and Vit.D because it blocks heart arteries & does not help bones. But how about going to the basics which tells us that bone physiology cannot work without calcium and Vit.D metabolism being intact? In Osteoporosis, if all drugs are to work well, they have to have a system replete in Vit.D and calcium. If you do not treat Osteoporosis well – where calcium & Vit.D supplementation is integral – you end up with high health care cost of bedridden morbidity/mortality from fractures. So, it is like the old saying: Information is that tomato is a fruit & wisdom is not putting that tomato in the fruit salad.

 

Availability of information as sole evidence is detrimental to healthcare delivery – as all of us have experienced from the “google doctor” patients we treat. YouTube videos of exercises CANNOT ever replace the expertise, individual tailoring, supervision and guidance of a trained discerning physiotherapist. The individualistic, humane healthcare delivery here is important, if the patient has to get really better from proper physiotherapy.

 

When the AI will replace a pathologist &/or a radiologist, then who will write the newer advances and imaging algorithms, who will be able to give a clinico-pathological/clinic-radiological correlation?

Eg. – An Otrhopaedist talks to a MRI consultant on correlation in a case where minor information & clinical hunches are settled on discussion (that will be missed in the AI).

Not allowing the stupidity of following AI algorithms blindly is important to prevent disasters in healthcare delivery – Disasters like the ones created by AI in Boeing plane crashes & Tesla’s (car) autopilot feature. Remember, the AI is only as good as the person who programed it.

 

So the COLLECTIVE CYBORG should be the center of future AI – if it were to be of real human help. And if the healthcare delivery starts becoming like an “app” (Eg. – Tours/Travels app), then it will need a human interface to upload patient information & download/deliver healthcare in the correct, individualized format. That AI end point deliverer of healthcare will be the GP. The original FAMILY DOCTOR, who is now on the wane – WILL HAVE TO BE REBORN & REVIVED in a fresh avatar. This GP of AI will coordinate, give the humane touch, individualize the treatment & deliver it to the patient.

 

We are presently at the edge of the cliff of AI in healthcare. The next 25-50 years will show whether we fly off to way beyond our human potential by using COLLECTIVE CYBORG MODEL of Star Trek or hurtle down crashing into the abyss of healthcare by following the STUPIDITY of non-human computer algorithms as in the movie Idiocracy.

 

I am an eternal optimist & a huge fan of Star Trek.

 

-Dr. P. S. Mamtora

Orthopaedic Surgeon

Ortho Humour

Ortho Humour

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ORTHO HUMOUR – 1 

  1. THE CLASSIC
    Q: What do you call two orthopaedic surgeons looking at an ECG?
    A: A double blind study.
  1. The definition of shifting dullness – an orthopaedic ward round.
  2. Q: Why do anaesthetists take an instant dislike to orthopaedic surgeons?
    A: Because it saves time
  1. Q: How do you get an Orthopaedic Surgeon to refer you to someone else?
    A: Ask him the time
  1. Q: Why do orthopaedic surgeons make great lovers?
    A: Because when they tell the theatre nurse something will take half an hour in reality it will take three hours.
  1. An orthopaedic surgeon giving evidence told the court he was the best surgeon in the world, the judge objected to such arrogance. The orthopaedic surgeon pointed out he was under oath and had to tell the truth, the whole truth and nothing but the truth.
  2. Q: What is the difference between God and an Orthopaedic surgeon?
    A: God does not think he is an Orthopaedic surgeon.

 

ORTHO HUMOUR – 2

 

Things Orthopaedic Surgeons Sometimes Say:

  • One way to make sure a humerus doesn’t heal is to operate on it
  • If you’ve half a mind to do orthopaedics, you’re over-qualified.
  • The modern holistic approach to orthopaedics…..you don’t JUST treat the fracture, you treat the whole bone!
  • It’s only a five-minute operation sister
  • It’s much more urgent than any possible general surgical case!

 

 

ORTHO HUMOUR – 3

Q: Where do you learn about bones?

A: Osteoclasst.

 

Q: What do you call it when a skeleton is having a great time?

A: An osteoblast.

Q: Why does a skeleton always tell the truth?

A: He wants tibia honest.

Q: Why did the skeleton start a fight?

A: He had a bone to pick.

Q: What’s the coolest part of a skeleton?

A: The hip.

Q: What do you call a funny bone?

A: A humerus.

 

Q: Why couldn’t the skeleton get out of bed?

A: He was bone tired.

 

Q: What is a skeleton’s favourite plant?

A: A bone-zai tree.

Q: Why are skeletons such bad liars?

A: Everyone can see right through them.

 

Never break someone’s heart, they only have one. Break their bones instead, they have 206 of them.

 

ORTHO HUMOUR – 4

 

Munnabhai MS ORTH

Q: What does he call fracture patella?

A: FATELLA PATELLA

 

Q: What does he call dislocation of patella?

A: HATELLA PATELLA