Osteoporosis is a disease of the skeleton with a change in the structure of bones: weight reduction, strength reduction and increased fragility. The disease is asymptomatic and is often detected only after a fracture of the radius, femoral neck or vertebral bodies. It is important not only to identify osteoporosis, but also to determine its cause. For this purpose, a comprehensive examination of the patient is carried out, including radiography, densitometry, CT, bone metabolism and hormonal background. Treatment is carried out in a complex with calcium preparations, calcitonin, vitamin D, biophosphonates and hormonal preparations.
Osteoporosis is a disease of the skeleton with a change in the structure of bones. The mass of bones gradually decreases, they become less durable, more fragile. The disease is asymptomatic, often detected only after a fracture of the radius, femoral neck or vertebral bodies. According to WHO, osteoporosis is the fourth most common non-communicable disease after pathologies of the heart and blood vessels, oncological processes, diabetes mellitus. The disease mainly affects the elderly, postmenopausal women.
Pathology belongs to the category of polyethological. The most common cause of primary osteoporosis is age-related (involution) bone restructuring. Less often, the primary form of the disease is hereditary or occurs for unknown reasons. Predisposing factors of involutional osteoporosis are:
- family history (indications of fractures that occurred in elderly family members as a result of a minor injury);
- elderly and senile age;
- asthenic physique, weight loss;
- small growth;
- late onset of menstruation (at the age of 15 and older);
- early onset of menopause (up to 50 years);
- menstrual cycle disorders;
- a large number of pregnancies and births;
- prolonged breastfeeding.
Since the state of bone tissue depends on the production of estrogens, the frequency of osteoporosis increases dramatically in the postmenopausal period. Women aged 50-55 suffer from fractures due to osteoporosis 4-7 times more often than men. By the age of 70, fractures occur in every second woman.
Secondary systemic osteoporosis is caused by endocrine disorders, somatic pathologies, and the patient’s lifestyle. Risk factors for the development of a secondary form of the disease are considered to be:
- disorders of the activity of internal organs, including eating disorders and the activity of the endocrine glands, kidney diseases, some autoimmune pathologies;
- taking certain medications, abuse of nicotine, alcohol and coffee;
- lack of mobility, insufficient physical activity, prolonged bed rest (for injuries, operations, chronic pathologies).
Secondary local osteoporosis is formed against the background of diseases and pathological conditions accompanied by disorders of the bone structure. Possible reasons are:
- traumatic injuries in the presence of prolonged immobilization, neurotrophic disorders;
- inflammatory processes, for example, osteomyelitis;
- primary malignant bone tumors, bone metastases of neoplasms of other localizations.
There is no single mechanism for the development of osteoporosis, since the dynamics of changes in the structure and composition of bone tissue is determined by the provoking disease (in secondary osteoporosis) and the presence of various risk factors (in the primary process). At the same time, a number of successive stages are distinguished, which are observed in all types of pathology.
The formation of bone tissue is disrupted during growth or in the process of renewal. Bone destruction begins to prevail over its restoration. The density and mass of the bone are decreasing. The thickness of the cortical layer decreases, the number of trabeculae decreases. As a result, bone strength characteristics suffer in osteoporosis, deformities occur in children, fractures occur in adults.
The risk of fractures increases in proportion to the decrease in bone density. With a decrease in bone density by 10%, the frequency of fractures increases 2-3 times. Osteoporosis primarily affects bones with a predominance of spongy matter (vertebrae, forearm bones in the area of the wrist joint), so typical complications of the disease are fractures of the vertebral bodies, distal epiphysis of the radius.
Often, systemic pathology remains unnoticed for a long time. The only signs of the development of osteoporosis are sometimes pain in the spine (thoracic and lumbar). There may also be pain in the ribs, hip and ankle joints, pelvic bones. Pain syndrome is usually not intense, it increases after exercise, when weather conditions change.
Patients with postmenopausal and senile osteoporosis often do not attach importance to pain, explaining their natural aging process, so they do not turn to doctors. Osteoporosis has been progressing for several years. Back pain gradually increases, the patient’s height decreases, his posture changes, the spine becomes less mobile.
The most significant manifestation of osteoporosis is fractures, often accompanied by erased clinical symptoms. Beam fractures in a typical location are usually diagnosed in a timely manner due to a more pronounced pain syndrome, the presence of edema and external deformation. Vertebral fractures may remain unrecognized, with severe osteoporosis in elderly patients, a hump sometimes forms due to a significant decrease in the height of the bodies of several vertebrae against the background of compression fractures.
Hip fractures are particularly dangerous, which are more often detected in patients with senile osteoporosis, which is associated with simultaneous damage to the cortical and trabecular bones in this form of the disease. Due to forced immobility, many patients develop congestive pneumonia, the risk of developing thrombotic complications increases, which can cause death.
The clinical picture in genetically determined forms of osteoporosis is determined by the type of disease. With Marfan syndrome and homocystinuria, there is a moderate or slight decrease in the strength characteristics of the bone. Along with osteoporosis, characteristic skeletal changes (elongated limbs, arachnodactyly), typical ophthalmological and neurological disorders are revealed. The course of osteoporosis is relatively favorable.
There are four forms of osteogenesis imperfecta that are transmitted by autosomal dominant or autosomal recessive type. The most favorable is type IV, in which bone fragility is not accompanied by changes from other organs and systems. The severity of osteoporosis varies, pathology can be determined at birth, in childhood or adolescence, manifested by curvature of the limbs, single or multiple fractures.
Type II osteogenesis imperfecta is a lethal syndrome. In half of the cases, stillbirth is observed, the rest of the children die in infancy from respiratory failure. Type I disease is manifested by fractures and curvature of the limbs, sometimes – kyphoscoliosis in adults, proceeds more favorably compared to type III, in which, along with the listed symptoms, early pronounced kyphoscoliosis, severe cardiopulmonary complications are noted.
Pathological fractures are manifestations of osteoporosis and at the same time are its complications. With fractures of the radius in the outcome, there is often a restriction of mobility in the wrist joint, a decrease in the strength of the hand. Repeated fractures of the spine cause persistent pain, negatively affect the mobility of patients, limit the ability to perform household duties.
With fractures of the femoral neck, there is no independent bone fusion, therefore, if surgical treatment is refused or there are contraindications to surgery, the supporting function of the limb is not restored. In 20-25% of cases, such injuries cause the death of patients with osteoporosis during the first half of the year after the injury, and in 40-45% lead to the onset of severe disability.
The diagnosis of osteoporosis is made during the consultation of an orthopedic traumatologist, includes objective methods and procedures during which bone mineral density is measured. The following techniques are used:
- Survey, inspection. During the survey, the doctor finds out the duration of the existence and dynamics of the development of symptoms, pays attention to the characteristic anamnestic signs (prolonged pain, frequent fractures). With an objective examination, a specialist identifies posture disorders, and if genetically determined osteoporosis is suspected, he determines the signs of a particular disease.
- Densitometry. Allows you to estimate bone mineral density (BMD). The measurement accuracy during double X-ray absorptiometry is 2%. To determine bone density, single-photon (not always informative) and two-photon densitometry, quantitative CT of the spine are also used. For screening studies, less accurate ultrasound densitometry is used.
- Radiological methods. They are not informative in the diagnosis of the disease, they can reliably identify signs of osteoporosis only with a significant loss of bone mass (more than 30%). They are prescribed for the detection of fresh fractures, as well as bone calluses and post-traumatic deformities, indicating a violation of the integrity of bones in the anamnesis.
- Laboratory tests. Tests are carried out to assess the level of phosphorus, calcium, vitamin D and parathyroid hormone in the blood, the daily loss of phosphorus and calcium in the urine. With possible secondary osteoporosis, studies of thyroid hormones, testosterone, and liver markers can be performed.
According to WHO criteria, the diagnosis of osteoporosis is made with a decrease in BMD by 2.5 or more standard indicators compared to the average BMD of people 30 years of the same sex. Differential diagnosis is made between different forms of osteoporosis. When identifying hereditary syndromes accompanied by disorders on the part of other organs, it may be necessary to consult an ophthalmologist, neurologist, and other specialists.
The treatment is long-term, includes correction of the provoking pathology (if any), lifestyle changes, drug therapy, conservative and operative ways to eliminate the complications that have arisen. The main goal of the treatment of osteoporosis is to reduce the loss of bone tissue while simultaneously activating the process of its recovery, prevent the development of negative consequences or minimize their impact on the quality of life of the patient.
Correction of certain behavioral patterns can significantly slow down the development of osteoporosis. The standard program includes the following items:
- Diet. Calcium-rich foods are shown. With osteoporosis, dairy products, fish, green vegetables, legumes, hazelnuts, mineral water with a high calcium content should be regularly consumed. The absorption of calcium depends on the content of other trace elements and vitamins, so the diet should be balanced.
- Physical activity. Physical activity should be moderate, but regular. Women of pre-menopausal age are prophylactically recommended swimming, yoga, exercise equipment, cycling and long walks. In the presence of signs of osteoporosis, special exercise therapy complexes are prescribed.
- Giving up bad habits. It is necessary to give up smoking and alcohol consumption, limit the amount of coffee in the diet. This helps to avoid excessive calcium excretion by the kidneys, to improve the process of bone tissue restoration.
Complex medical treatment of osteoporosis involves taking medications in long courses, includes hormone therapy, vitamin D, biphosphonates, calcitonin and other means. The treatment plan for osteoporosis is made taking into account gender, age and risk factors:
- Anabolic medications. Preparations of parathyroid hormone (teriparatide, recombinant human PTH) increase the strength of bone tissue, lengthen the phase of bone formation, promote the healing of micro-fractures.
- Anti-catabolic drugs. Biphosphonates (alendronate, risedronate, ibandronate and their analogues), calcitonins (for example, salmon calcitonin) reduce the activity of bone resorption, prevent disruption of the architecture of bone tissue.
- Hormonal medications. They are a kind of anti-catabolic agents. Estrogens, androgens, and progestogens may be prescribed. When choosing medications for women, the menopause phase, the presence of the uterus, the desire of a woman to have menstrual-like reactions in the postmenstrual period are taken into account.
- Calcium and vitamin D preparations are used to normalize metabolic processes as part of the complex therapy of osteoporosis. The best option is to take triphosphate, citrate or calcium carbonate, the use of calcium gluconate is considered inappropriate. Vitamin D3 is more effective than vitamin D2.
Hormone therapy is contraindicated in concomitant severe liver and kidney diseases, thromboembolism, acute thrombophlebitis, uterine bleeding, tumors of the female genital organs and severe forms of diabetes mellitus. In the process of hormonal treatment of osteoporosis, it is necessary to monitor blood pressure and perform oncocytological studies. Mammography and pelvic ultrasound are performed once a year.
The program of drug treatment of osteoporosis is supplemented with physiotherapeutic methods that can reduce the severity of pain syndrome, reduce destruction and stimulate bone restoration, accelerate the fusion of pathological fractures. Used:
- medicinal electrophoresis – can be general or local, with preparations of calcium, phosphorus, fluoride, etc.;
- magnetotherapy – provides anti-inflammatory, analgesic and vasodilating effect, is prescribed in a general and local version;
- UV radiation – stimulates the production of vitamin D in the skin, unlike dosage forms does not cause hypervitaminosis.
- laser therapy – activates metabolic processes, has analgesic, vasodilating and anti-inflammatory effects, can be administered externally or in the form of VLOK.
The main indication for surgery for osteoporosis is a pathological fracture of the femoral neck. Interventions allow not only to improve the quality of life, but also to ensure early activation of the patient, therefore – to reduce the number of dangerous complications associated with prolonged bed rest, therefore, they are carried out even for patients of senile age. Used:
- Osteosynthesis of the femoral neck. It is performed using special nails, curved plates, spokes. Provides reliable fixation of fragments, strong connective tissue fusion while maintaining the function of walking.
- Hip replacement. It can be total or unipolar. It is usually used in physically active middle-aged and elderly patients. In the long-term period, the limb functions are fully restored, the service life of the endoprosthesis is 15-20 years.
In the postoperative period, analgesics, antibiotics are prescribed, restorative measures are carried out (massage, physical therapy, physiotherapy).
The prognosis for osteoporosis is determined by the cause of development and the severity of the process. With mild forms, slow progression, timely initiation of treatment, the outcome is favorable, patients retain their ability to work and motor activity. With late detection, a pronounced decrease in the strength of bone tissue, the presence of complications, a deterioration in the quality of life is possible.
Prevention of osteoporosis should begin at a young age and last a lifetime. Special attention should be paid to preventive measures during puberty and the postmenopausal period. Proper nutrition (balanced composition of food, sufficient intake of calcium into the body), regular physical activity contributes to increasing the strength of bone tissue and reducing its resorption.
It is necessary to limit the consumption of alcohol, coffee and nicotine. In old age, risk factors for the development of osteoporosis should be identified in a timely manner, if necessary, take vitamin D, calcium supplements. Prophylactic administration of hormonal drugs is possible. Peri- and postmenopausal women are advised to increase their intake of calcium-rich dairy products.
In case of allergies, food intolerance to milk, the need for calcium can be filled with tablet preparations in combination with vitamin D. Upon reaching 50 years of age, preventive examinations should be regularly carried out to identify the risks of osteoporosis and determine the need for hormone replacement treatment.
- Kanis J.A. Assessment of osteoporosis at the primary health-care level // WHO Collaboraiting Centre. — 2007. link
- Raman-Wilms L. Guidelines for preclinical evaluation and clinical trials in osteoporosis // Ann Pharmacother. — 1999; 33 (12): 1377-78. link
- Bethel M., Carbone L.D., Lohr K.M. Osteoporosis // Medscape Rheumatology. — 2018.
- Bono C.M., Einhorn T.A. Overview of osteoporosis: pathophysiology and determinants of bone strength // Eur Spine J. — 2003; 2: 90-6. link
- Raisz L.G. Pathogenesis of osteoporosis: concepts, conflicts, and prospects // J Clin Invest. — 2005; 115 (12): 3318-25. link
- Camacho P.M., Petak S.M., Binkley N., et al. American association of clinical endocrinologists and American College of Endocrinology Clinical Practice Guidelines for the diagnosis and treatment of postmenopausal osteoporosis // Endocr Pract. — 2016; 22: 1-42.