Diagnosis and Treatment of Osteoporosis: What Orthopaedic... : JAAOS - Journal of the American Academy of Orthopaedic Surgeons

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• Osteoporosis, often called a silent disease, is a systemic condition of bone as a result of loss of bone mass and deterioration of its microarchitecture. The result is weakened bone, leading to an increased risk of fragility fractures. An estimated 9 million osteoporotic fractures occur every year worldwide

• Multiple risk factors exist for osteoporosis and/or fractures as a result of low BMD. Nonmodifiable risk factors include female sex, white race, increasing age, and genetic/familial history.

• Important points in the history include previous fractures, diseases associated with bone loss, chronic diseases, exercise, medications, alcohol and tobacco use, falls and fall risk, diet, and family history. For females, the number of pregnancies, lactation, menstrual history, and onset of menopause should be recorded.

• The orthopaedic surgeon may initiate general treatment strategies along with an evaluation and appropriate referral to osteoporosis consultants, as recommended by the American Orthopaedic Association Own the Bone Program (Figure 1). Many institutions have an osteoporosis multidisciplinary team, such as a fracture liaison service, for management and tracking, especially after hip and other major fractures. The treatment approach is best divided into prevention and treatment of low bone mass. Patients with low bone mass may be further classified using risk stratification predicting low-energy fracture and development of osteoporosis or using the presence of confirmed osteoporosis, as discussed later. Risk of future osteoporotic fracture is graded as low, moderate, or high. In general, patients with confirmed osteoporosis with moderate or high fractures meet indications for pharmacologic treatment as do those who present with an osteoporotic fracture.

• Treatment should always include advice to maximize modifiable factors. These include increased activity (resistance and weight bearing exercise), adequate dietary calcium intake, ensuring vitamin D sufficiency, smoking cessation, and limiting alcohol. Pharmacologic treatments of osteoporosis include antiresorptive drugs and anabolic (bone strengthening) drugs, and those that do both. The specific prescription depends on the extent of low bone mass (osteopenia or osteoporosis), previous low-energy fracture, risk of osteoporotic fracture, and comorbidities.

• Higher-risk patients are considered for pharmacologic osteoporotic agents to improve bone mass and to prevent fractures. In general, the guidelines are different for men and women. For patients diagnosed with osteoporosis, treatment is most often based on the BMD, a fracture risk assessment such as the Fracture Risk Assessment Tool (FRAX), and the presence of fragility fracture.

• Because osteoporosis is unlikely to be symptomatic before the first fracture, accurate risk assessment is essential (Table 3).11-13 As in most cases, the first step in diagnosis and assessment of osteoporosis is a detailed history and physical examination to elicit whether the patient has any relevant risk factors

• The Centers for Disease Control and Prevention reported that 120 to 300 minutes of moderate or higher intensity activity per week was associated with less hip fractures in older adults. Combining this with balance and muscle strengthening was associated with less falls.