WSOA Osteoporosis Initiative

Osteoporosis IMP: Act

(Identify – Manage – Prevent: Act)

What is IMP:Act?

A WSOA initiative to raise awareness of the need for more effective management of the growing public health care problem of osteoporosis through collaboration of likeminded medical specialties to improve the health of the public and save precious health care resources.  by application of simplified expanded screening efforts and more timely interventions as suggested by the AOA ‘Own the Bone’ program.

Some Osteoporosis Facts:

Definition:

Osteoporosis is the loss of bone mineral density decreased bone quality that results in reduced strength and increased risk of fracture.   This can be caused when the body loses too much bone, makes too little bone or both (BHOF).

Traditionally Osteoporosis was determined based on bone mineral density from DEXA scanning using world health organization WHO criteria. These are reported as T scores which are the standard deviations from a reference standard in the United States being young Caucasian adult females.

WHO Classification based on lowest t-score of femoral neck, total hip and lumbar spine
T-score Classification
>-1.0 Normal bone
-1.0 to -2.4 Osteopenia
< -2.5 Osteoporosis

Recently osteoporosis is diagnosed to include bone mineral density fracture history and fracture risk. (AACE, BHOF). Patient meeting any of these criteria are considered candidates for pharmacologic and physical therapy.

Clincal Diagnosis of osteoporosis
T-score < -2.5
Fragility fracture of hip or spine since age 50
Osteopenia and a high fracture risk using Fracture Risk Assessment Tool FRAX.
A 10-year hip fracture risk of > 3% or major osteoporotic fracture risk of 20%

How often does it happen? (1,2,3,4)

  • 1/3 women and 1/5 men after age 50 will have at least one osteoporotic fracture
  • 9 million facture s/ year worldwide (51% in Europe and US)
  • Hip, forearm with wrist, vertebrae most common
  • By 2050 compared to 1990 hip fractures will increase 240% in women and 310% in men

How bad is it? (2)

  • Women lose 2% of bone mass per year after menopause.
  • Women older than 45 years spend more days in hospital from osteoporosis than breast cancer, diabetes, myocardial infarctions together.
  • 86% of women have a second osteoporotic fracture if not treated for osteoporosis
  • 25% of hip fracturs happen in men, they suffer from a 20% higher mortality than women
  • Lifetime risk of osteoporotic fractures is 27 % for men (more than twice the risk of prostate cancer (11%)
  • There is loss of independence after osteoporotic related fractures which is of greatest concern to patients

Risk factors

Genetic problems:

  • Female
  • White and Asian race
  • Personal or family fracture history
  • Older patients

Intake problems:

  • Low calcium intake
  • Low Vit D diet
  • Alcoholism
  • Nicotine use
  • Limited exercise
  • Bone toxic medication e.g., anticonvulsant and daily corticosteroids

Medical conditions:

  • Diabetes
  • Low estrogen
  • Low testosterone
  • Intestinal malabsorption syndromes
  • Multiple myeloma/ monoclonal gammopathy of unknown significance (MGUS)
  • Renal failure
  • Rheumatoid arthritis
  • Inflammatory bowel disease
  • History of falling

Countermeasures (2)

  • Increase awareness / education
  • Minimize modifiable risk factors
  • Sufficient exercise (aerobic, strength, posture, balance)
  • Improve nutrition
  • Calcium intake
  • Daily Vitamin D
  • Rehabilitation efforts – Physical Medicine, Occupational Therapy, education, practitioner surveillance

Diagnostics (3,4)

  • Regular radiographs (XRays) – recognize typical fragility fractures and report
  • DXA: (Dual photon absorptiometry)
  • Derivatives of DXA can increase sensitivity including trabecular bone score and vertebral fracture assessment
  • Opportunistic CT scan screening: Calculate CT attenuation using Hounsfield (HU) units (Spine, Hips, wrists)
  • Dedicated other CT techniques (Synchronous, asynchronous quantitative CT, phantomless qCT).

Medications: (2,5,6)

Antiresorptive agents – inhibits osteoclasts

  • Bisphophonates
    • Alendronate (Fosamax, Binosto)
    • Risedronate (Actonel)
    • Ibandronate (Boniva)
    • Zoledronic acid (Reclast) (IV typically given yearly)
  • Denosumab (Prolia) – Antibody that binds RANK ligand thus inhibiting osteoclastic differentiation. Given as twice-yearly injections
  • Raloxifene (Evista) selective estrogen inhibitor
  • Calcitonin (Miacalcin) – Hormonal agent that inhibits osteoclastic function

Anabolic agents (bone forming agents)

  • Teriparatide (Forteo) PTH analog given by daily injection
  • Abaloparatide (Tymlos) PTH analog given by daily injection
  • Romosozumab antisclerostin antibody that has both anabolic and antiresorptive properties

Transition of medication 6

All patients being treated for osteoporosis should have a transition plan for how long the medication is continued and what if any medication’s will be needed.

For the spots and eats a trial of 3 to 5 years with a reassessment of risk and consideration of drug holiday at that time.

Denosumab should never be discontinued without transition to bisphosphonate or anabolic agent secondary to rapid long bone loss and potential for multiple spinal fractures.

The anabolic medications should be transition to bisphosphonates or denosumab to lock in any gains in bone mineral density and reduced fracture risk.

Rehabilitation efforts5

All patients with osteoporosis should receive rehabilitation efforts aimed at reducing falls and spontaneous fractures by improving body posture, balance and receiving formal training in fall prevention.

Continuity of Care5,6

Long term joint efforts by Primary Care Physicians, Radiologists, Emergency Room practitioners, interested Surgeons and the Interventionalist community as well as public health care minded politicians are needed to bend the rising curve of osteoporosis and its deleterious effects on patient and health care costs.

References:

1.       Ballane G, Cauley JA, Luckey MM, El-Hajj Fuleihan G (2017) Worldwide prevalence and incidence of osteoporotic vertebral fractures. Osteoporos Int 28:1531–1542

2.       Matskin EG, De Maio M, Charles JF, Franklin CC: Diagnosis and treatment of osteoporosis: What orthopaedic surgeons need to know.  J Am Acad Orthop Surg. 2019. Vol 27, No 20 e902-e912

  1. Anderson PA, Polly D, Binkley NC, Pickhardt PJ: Clinical use of opportunistic computed tomography screening for osteoporosis. J Bone Joint Surg Am 2018; 100:2073-81

 

4.       Blecher R, Ylmaz E, Ishak B, vGlinski A, Moisi M, Oskouian RJ, Detorri J, Kramer M, Drexler M, Chapman JR: Uptrend of cervical and sacral fractures underlie increase in spinal fractures in the elderly, 2003–2017: analysis of a state-wide population database. Europ Spine J (2020); 29:2543-2549

5.       LeBoff MS, Greenspan SL, Insogna KL, Lewiecki EM, Saag KG, Singer AJ, Siris ES. The clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int. 2022 Apr 28. doi: 10.1007/s00198-021-05900-y. Epub ahead of print. PMID: 35478046.

  1. Camacho PM, Petak SM, Binkley N, Diab DL, Eldeiry LS, Farooki A, Harris ST, Hurley DL, Kelly J, Lewiecki EM, Pessah-Pollack R, McClung M, Wimalawansa SJ, Watts NB. American Association of Clinical Endocrinologists/American College of Endocrinology. Clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis- 2020 update <i>EXECUTIVE SUMMARY</i>. Endocr Pract. 2020 May;26(5):564-570. doi: 10.4158/GL-2020-0524. PMID: 32427525.
Facebooktwittermail

Remembering Dr. Preston J. Phillips

The Washington State Orthopaedic Society mourns the loss of our former President and Board member Preston Phillips, M.D., FAAOS, FAOA, FSRS and JRGOS, who was senselessly killed last week in a mass shooting in his office at St. Francis Hospital, in Tulsa, Oklahoma, along with three other victims while tending to his clinical duties.  The shooter has been identified as a patient of Dr. Phillips who was unhappy with his pain management after back surgery.

Those who were lucky enough to know him during his time in the Pacific Northwest remember Dr. Phillips as an eminently well-regarded Orthopaedic Surgeon. Dr. Phillips practiced in Seattle from 1998 through 2003 at Swedish Medical Center as member of the Seattle Orthopaedic and Fracture Clinic. He was elected as President of the Washington State Orthopaedic Association in 2002, and served his term with distinction until his departure to Tulsa for a new practice opportunity.

Dr. Phillips is fondly remembered literally and figuratively as a gentle giant in our specialty. His story is an all-American story of accomplishment attained through talent, hard work and outstanding character. His all-too sudden loss due to deranged violence sadly ended his shining career and life prematurely.

Born in 1963 in Saginaw, Michigan as one of 9 children, his educational foundations were unique.  Dr. Phillips attained three bachelor’s degrees at Emory from Chemistry, Theology and Organic Chemistry. He completed Medical School at Harvard, followed by his Orthopaedic Internship and Residency at Yale, and fellowship specialty training in Spine surgery at Beth Israel Deaconess Medical Center and Boston Children’s Hospital. He also completed advanced  AO Fracture and Trauma skills, training alongside recognized leaders in their fields. As an Orthopaedic Surgeon he applied his bandwidth serving his patients as a dedicated spine, total joint and fracture surgeon. His focus on unconditional service to his patients was always delivered with wisdom, kindness, and a friendly demeanor. Beyond his practice in Seattle and later Tulsa, Dr. Phillips also applied his knowledge to those in need overseas by regularly serving in the Republic of Togo, West Africa as a volunteer Orthopaedic Surgeon. This volunteer service further reflects the selfless dedication Dr. Phillips routinely applied to his patients- regardless of their problems and station in life. With this knowledge, it is with particular sadness that we try to comprehend the loss of this cherished colleague.

Please consider joining the WSOA in remembrance of Dr. Preston Phillips by donating to the St. Francis Hospital Emergency Fund:

Donate to St. Francis Emergency Fund

With gratitude and condolences,

WSOA Board of Directors

Facebooktwittermail

Registration is OPEN for the WSOA Annual Meeting on Saturday, October 2

Register NOW for the Washington State Orthopaedic Association’s 2021 Annual Meeting
Jointly Sponsored by Seattle Science Foundation and the Washington State Orthopaedic Association

Saturday, October 2, 2021
8:30am – 2:00pm
Via Zoom Webinar

Register Here

There is no fee for WSOA members to attend. After registering, you will receive a confirmation email containing information about joining the webinar.

You won’t want to miss this year’s annual meeting, which includes these fantastic sessions:

  • ‘Own the Bone’ Revisited: The Other Epidemic & What We As Orthopaedic Surgeons Should Do About It, Paul Anderson, MD
  • ASCs: An Answer to Corporate Hospital Medicine Under Pressure, Neal Shonnard, MD
  • Training the Next Generation of Orthopaedic Surgeons in a Rapidly Changing World, Steven Theiss, MD
  • As well as the ever popular Resident Abstract Competition
  • And more!

View the Agenda here.

Accreditation
Seattle Science Foundation is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

AMA PRA Category 1 Credits
Seattle Science Foundation designates this live activity for a maximum of 4.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Non-Physician Attendance
A certificate of participation will be provided to other health care professionals requesting credits. Participants should ensure in advance that their credentialing or licensing organization accepts AMA PRA Category 1 Credits™.

Acknowledgements
This symposium is supported in part by educational grants in accordance with ACCME Standards. At this time a complete listing of financial supporters was not available. Appropriate acknowledgement will be given to all supporters at the time of the symposium.

Facebooktwittermail