Osteoporosis: the increasing role of the orthopaedist

Osteoporosis is an ever-increasing problem as our population ages. However, it is also to a large extent a preventable problem. The orthopaedist now has the ability to determine bone mass, the rate of turnover, and the fracture risk. Skeletal bone mass can be evaluated with DXA; the rate of bone resorption can be determined by assessment of collagen-degradation urinary products; and the weight status, fracture history, and history of smoking can be used to predict the fracture risk in individual patients. The orthopaedic physician also needs to take an active role in advising their younger patients about achieving peak bone mass. All individuals should follow a program that includes adequate calcium replacement, 400 to 800 units of vitamin D, appropriate exercise, avoidance of significant weight loss, and cessation of smoking. At menopause, women should evaluate their risk factors and consider the use of estrogen not only for its skeletal benefits but also for its nonosseous effects. In patients with contraindications or an aversion to hormone therapy, bone densitometry should be performed to determine risks before expensive nonhormonal treatment is initiated. Additional studies such as measurement of collagen degradation products will help establish whether the patient's resorptive rate is high or stable. If the bone mass is 2.5 SDs below normal peak or if there is an increase in resorption, use of either estrogen, bisphosphontes, or calcitonin may be appropriate. If there is evidence of low-turnover osteoporosis with decreased osteoblast formation, sodium fluoride should be considered. Two thirds of the cost of osteoporosis in the United States is due to hip fractures. The orthopaedist is the primary physician who comes in contact with these fracture patients. It is therefore his or her responsibility to become knowledgeable about the treatment and prevention of osteoporosis. The bisphosphonates, hormones, and calcitonin provide predictable restoration of bone mass and significantly decrease the rate of osteoporotic fractures.