Overview of CORS/COA Symposium Osteoporosis in Orthopaedics
2003 Annual General Meeting, Winnipeg, MB

Beth Snowden, R.N.
OOA Osteoporosis Coordinator

On Saturday October 4th, 2003 at the COA AGM, a plenary symposium was held on the topic of Osteoporosis in Orthopaedics. Chaired by Dr. Earl R. Bogoch, of Toronto, Ontario, the topics presented at this symposium included presentations on: Bone Quality by Dr. Thomas Einhorn, Boston; Ian Macnab Lecture on the Economic Impact of Fractures by Dr. Laura Tosi, Washington, DC; Vertebroplasty and Kyphoplasty by Dr. Christopher Bono, Boston; Massachusetts, and a status report on Canadian Orthopaedic Osteoporosis initiatives by Dr. Bogoch. After the presentations, a session of interactive real-time polling captured the current opinions and practice patterns of the attendees. The following represents an overview of the symposium.

Getting Specific About Bone Quality
Dr Thomas Einhorn,
Professor and Chairman,
Department of Orthopaedic Surgery, Boston University School of Medicine, Chief, Orthopaedic Surgery, Boston Medical Center,
Boston, Massachusetts

Dr. Einhorn presented an elegant overview of the determinants of bone strength and the biomechanical properties of bone through the life stages from childhood periosteal bone formation to senile bone quality. Dr. Einhorn highlighted increased age and individual bone metabolism as increased risks for fracture independent of bone mass. Like other structures that efficiently support mechanical loads, the human skeleton uses a minimum of material organized in the most effective way. The two compartments, trabecular and cortical bone, are vastly different structures found in different parts of the skeleton. While the density of the skeleton is related to its mechanical properties, bone quality is often a more important determinant of skeletal integrity, and is an area where there is current academic interest as a determinant of bone strength.

The pathomechanics of fracture were presented in the context of susceptibility for fracture. Trabecular bone, for example, is typically found at the ends of long bones as well as in the spine and is organized as interconnecting plates oriented at right angles. In osteoporosis, the horizontal interconnections are lost, resulting in an exponential decline in load-carrying capacity independent of BMD. Cortical bone is found in the diaphyses of long bones, and, while the thickness of the cortex affects bone density, it is the distribution of bone from the center of the mechanical axis of bending which is a more important determinant of bone integrity. Therefore, a wider bone (greater diameter with a thinner cortex) is a better load-carrying structure than a solid bone with the same mass but a smaller diameter. Bone mass does not tell the whole story.

Therapeutically, it is more important that a pharmacological intervention increase the outer diameter of a bone than cortical thickness. With respect to trabecular bone, adding substance to vertical columns will do little to enhance skeletal integrity; enhancing interconnections is a much better therapeutic strategy. In osteoporosis, when osteoclastic activity exceeds osteoblastic bone formation in a high bone remodeling state, osteoclastic attack can create stress risers in the bone, which weaken it substantially. Therefore, without affecting bone mineral density significantly, simply reducing osteoclastic activity can improve skeletal integrity. Pharmacological interventions in osteoporosis should target cellular activities by decreasing bone resorption and increasing bone formation in ways that reduce mechanical stress concentration, increase trabecular connectivity and optimize bone geometry in support of local load-carrying capacity.

Economic Impact of Osteoporosis: an Orthopaedic Perspective
Dr. Lara Tosi,
Macnab Lecturer,
Board Member, American Association of Orthopaedic Surgeons and Secretary Pediatric Orthopaedic Society of North America

Dr. Tosis presentation supported by data from both Canadian and USA literature related to the exploding health care costs triggered by a fracture. She demonstrated the opportunity for orthopaedic surgeons in the continuum of care. The lag time between the first or sentinel fracture at the wrist or spine to hip fracture allows a unique opportunity, not present in most disease states, to alter the course of osteoporosis complications (future fractures). Data presented demonstrated the increased risk for future fracture after the sentinel event even when BMD was normal or osteopenic, rather than frankly osteoporotic. Reinforcing this point was a slide from Singer et al (1998) that demonstrated the majority of fracture patients do NOT have osteoporosis at the time of first fracture. The evidence presented demonstrated the patient population that has fractures have unique bone quality issues that are not always captured with current imaging techniques (BMD) and yet are the same population who achieve the most benefit with treatment.

The connection between osteoporosis and fractures in men has been overlooked until recently. Men present a unique opportunity for an effective intervention. It is clear from the literature that a high proportion of osteoporotic men have correctable causes for bone loss. Since fractures lead to future fractures in the patient population over 50, orthopaedic surgeons are in a unique position to change the long-term outcome by referring the patient or initiating treatment after fracture. Dr. Tosi offered congratulations to Canadian colleagues for their interest in osteoporosis and commended the COA for offering educational opportunities for their membership with the symposium.

Vertebroplasty and Kyphoplasty
Dr. Christopher Bono,
Assistant Professor Department of Orthopaedic Surgery,
Boston University School of Medicine,
Orthopaedic Staff Boston Medical Center,
Boston Massachusetts;
Attending Spine Surgeon, Department of Surgery, Quincy Medical Center

Dr. Bono presented an overview of the indications and surgical technique of two procedures, vertebroplasty and kyphoplasty, for the treatment of osteoporotic vertebral compression fractures. He presented a review of the literature as well as his clinical experience with the procedures. The specific material presented included: detailed descriptions of the procedural techniques; identification of the patient population(s) that would benefit most from each procedure; the potential complications and benefits of the procedures; and a brief comparison of minimally invasive surgical versus conservative management.

Key messages were:

  • pain control of acute vertebral fractures is achieved in a high percentage of patients treated with each procedure;
  • pain relief is less reliably achieved in sub-acute and chronic fractures;
  • benefits of the procedures are usually immediate with no need for postoperative orthosis or activity limitation; though various complications have been reported, they are uncommon;
  • vertebral body height can be partially restored with kyphoplasty;
  • use of pain medications can be reduced postoperatively, leading to better overall quality of life.


While the relative safety and benefits of kyphoplasty and vertebroplasty are encouraging, the exact indications and optimal surgical timing for both of these less invasive spinal procedures remains unclear. The relative merits of kyphoplasty and vertebroplasty have not been clearly defined in a randomized prospective study, but clinical trials are underway.

Current Orthopaedic Osteoporosis Initiatives Across Canada
Dr. Earl R. Bogoch,
St Michaels Hospital;
Professor, Director of Orthopaedic Surgery, University of Toronto

Dr. Bogoch referred to ongoing osteoporosis research projects in Vancouver, British Columbia and Kingston, Ontario. Active participation by orthopaedic surgeons in the area of osteoporosis and fragility fracture research is now a reality. On the patient management side, Dr. Bogoch presented data from the focused Exemplary Care Osteoporosis Program at St Michaels Hospital in Toronto that demonstrated a significant improvement in intervention and treatment of osteoporosis that can be achieved with dedicated personnel capturing cases in the fracture clinic and inpatient ward. The materials designed to create awareness and provide education from the province-wide Ontario Orthopaedic Association/Osteoporosis Society of Canada partnership program for Ontario Fracture Clinics were shared with the audience. However, osteoporosis funding promised by the previous government to continue and build on the above had not yet been released.

A session of real-time interactive polling was conducted to assess current views among members of the audience about the issue of osteoporosis care related to orthopaedic practice.

Results: Orthopaedic Surgeons and Others (Residents, Scientists, AHP)

  • A total of 70 orthopaedic surgeons were identified by polling responses among total respondents (104).
  • 16 of 104 respondents identified themselves as orthopaedic residents/ trainees.
  • 50% of respondents (overall) were from academic environments except 33% in the atlantic region.
  • Orthopaedic surgeons are aging. 43.5% >age 55; 27.5% aged 54-54 in the audience, similar to RCPSC national data
  • Forty-six of 54 respondents (85.2%) either refer or treat osteoporosis in fragility fracture patients.
  • The majority (90.4%) agree the emphasis on osteoporosis in orthopaedics is appropriate and that patients should be referred and treated.
  • 69.3% are comfortable prescribing calcium, Vitamin D +/- Bisphosphonates for their fragility fracture patients; 22.7% do not feel comfortable treating osteoporosis.


Conclusions
Orthopaedic surgeons in Canada are now participating in the care of osteoporosis in the fragility fracture patient population despite limited remuneration for medical management, lack of clinical resources and overworked clinic staff. The polling also highlighted the need curriculum development for orthopaedic teaching programs to support the front-line efforts of orthopaedic surgeons who are managing osteoporosis in their fragility facture patient populations.

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