Heri Suroto MD.

PhD
Dept. Of Orthopaedic & Traumatology, Dr. Soetomo General Hospital /
School of Medicine - Airlangga University, Surabaya
Nonsurgical approach: Surgical approach:

 Rehabilitation Medicine  Anasthetist

 Internist  Orthopaedic Surgeon
 Neurologist
 Cardiologist
 General exercise

 Gradual mobilization, start

from sitting, standing and
walking with walker.

 Prevent for further on going

bone loss

 Improve quality of life

 11-20 yo [CATEGORY NAME]
>100 yo 1
1 [PERCENTAGE]
91-100 yo 31-40 yo
2% 3% 51-60 yo
5%

81-90 yo 61-70 yo
29% 19%

71-80 yo
40%

13 years experiences (2005 – 2018) of managing Femoral Neck # with Hemiarthroplasty

 Male
22%

Female
78%

13 years experiences (2005 – 2018) of managing Femoral Neck # with Hemiarthroplasty

 81-90 yo 0-10 yo 11-20 yo
10% 1% 4% 21-30 yo
6%
31-40 yo
7%
71-80 yo
19%

41-50 yo
23%

61-70 yo
18%

51-60 yo
12%
13 years experiences (2005 – 2018) of managing Humeral Neck # with ORIF
 Female
50%

Male
50%

13 years experiences (2005 – 2018) of managing Humeral Neck # with ORIF

 81-90 yo 0-10 yo
71-80 yo 4% 5% 11-20 yo
9%
11%
21-30 yo
61-70 yo 7%
17%

31-40 yo
13%

51-60 yo 41-50 yo
21% 13%

13 years experiences (2005 – 2018) of managing Distal Radius # with ORIF

 Female
44%

Male
56%

13 years experiences (2005 – 2018) of managing Distal Radius # with ORIF

1. Characterization of bony tissue
2. The problem of bone loss & fracture in Osteoporosis
3. Earl detection of Osteoporosis & Osteoporotic Fracture
4. Protection of bone strength
1. Characterization of bony tissue
2. The problem of bone loss & fracture in Osteoporosis
3. Earl detection of Osteoporosis & Osteoporotic Fracture
4. Protection of bone strength
 It is a rigid connective tissue
 Organic (1/3) and Inorganic (2/3)
Adult bone: dynamic, active and plastic
1. Characterization of bony tissue
2. The problem of bone loss & fracture in Osteoporosis
3. Earl detection of Osteoporosis & Osteoporotic Fracture
4. Protection of bone strength
 Postmenopausal (Type I) and
 Age-related (Type II)

 Type 1: mostly in women; estrogen deficiency, rapid

with menopause, spine, wrist
 Type 2: men also, slow, many sites esp. hip
• Senescence of osteoblasts (impaired function)
 Also increase in PTH levels (due to decrease renal and Ca re-
absorption and intestinal Ca absorption that occurs in elderly
- as less Vit D exposure, less synthesis of calcitrol, or vitD
resistance?)
 Number of factors that play a role in peak bone mass
and loss:

 Genetics and ethnicity

 Lifestyle: alcohol, smoking, drugs
 diet/nutrition
 mechanical usage (physical activity)
 reproductive factors (pregnancy, parity and lactation)

• Since multifactorial interest to look at its evolution and

variation in different populations
 Risk of future fractures increases 1.5-9.5
fold following initial fracture
 History of fragility fracture is more
predictive of future fracture than bone
density
Vertebral Fractures Hip Fractures
 Most common fracture  200.000 women and 100.000 men

 Often unrecognized clinically each year (US)

 Associated with  Average age, 84 years

 Acute and chronic pain  Associated with

 Kyphosis and height loss  Acute & chronic pain
 Impaired function  Loss of ambulatory status in 30% of px
 Increased morbidity and mortality  Increase morbidity & mortality
 Increased fracture risk  Increase fracture risk

National Osteoporosis Foundation, 2005, http ://www.nof.org/osteoporosis/stats.htm

All normal adult human bone undergoes renewal and repair through a
process called bone remodeling.

Teams of bone resorbing and bone forming cells form basic multicellular
units (BMU) that function at discrete sites throughout the skeleton in a
highly coordinated sequence of cellular activity.
At any given remodeling site, bone resorption always precedes bone
formation, resulting in the removal and subsequent replacement of a
quantum of bone at each site.

Under normal steady state conditions, the amount of bone removed is

precisely replaced and there is no net change in bone mass. Only bone
architecture is changed.
The sequential events of the bone remodeling cycle are driven by an
evolution of cellular events that occurs over a time period of three to six
months:

 Activation – a quiescent bone surface becomes populated with cells that

have been recruited from osteoclast precursors and are destined to
become bone resorbing osteoclasts
 Resorption – osteoclasts mature and remove a finite quantum of
mineralized bone
 Reversal – osteoclast activity and numbers decline and are replaced by
pre-osteoblasts (bone forming cell precursors)
 Formation – preosteoblasts become mature osteoblasts and secrete
bone matrix, which subsequently undergoes mineralization
Lining cells produce collagenase,
which exposes the mineralized bone
surface for bone resorption
 (Mineralized bone)

Osteoclast Sealed
micro-environment Ruffled membrane

(Marrow)

The basal surface of the osteoclast is rich in HCl and cathepsin transfer
organelles and is called the ruffled membrane.
 Bone Remodeling
Resorption

Resorption (Howship’s) lacunae

Mature osteoclasts move over the surface, removing mineral and organic
components of mature bone simultaneously, leaving serrated footprints, or
Howship’s lacunae, on the surface
Osteoclastic resorption of mineralized bone releases minerals in support of mineral
homeostasis, and products of collagenous protein degradation, including the inter- and
intramolecular collagen cross links, into the circulation. The relative concentrations of
cross links in blood or urine reflect the degree of bone resorbing activity and are
considered to be “markers” of bone resorption.
 Preosteoblasts

As the resorptive phase wanes and is replaced by the reversal phase, resorption lacunae
become populated by mononuclear pre-osteoblasts (cells that may be derived from
recruited monocytes and circulating bone-forming cell precursors). Preosteoblasts are
destined to become bone-forming osteoblasts. Osteoclasts ultimately undergo cell
death, or apoptosis.
 Preosteoblasts Osteoblasts

Preosteoblasts (left) can be visually identified by their proximity to the resorption

surface, clear cytoplasm, single nuclei, and (+)stain for alkaline phosphatase. They
mature into osteoblasts (right), which appear as mononuclear cells with prominent
nucleoli and deeply stained cytoplasm. Osteoblasts form a cellular monolayer on the
resorption surface previously abandoned by osteoclasts.
 Unmineralized osteoid

Osteoblasts secrete type I collagen, called osteoid, from their basal surfaces onto
the previously resorbed surface. Osteoid forms the organic matrix of bone.
1. Characterization of bony tissue
2. The problem of bone loss & fracture in Osteoporosis
3. Earl detection of Osteoporosis & Osteoporotic Fracture
4. Protection of bone strength
 HISTORY FOR
NO
OSTEOPOROSIS RISK
FACTORS FINDING
YES
ALGORITHM DIAGNOSTIC
AND TREATMENT OF SCREENING BY USING:
§ SKIN FOLD
OSTEOPOROSIS MEASUREMENT
§ PLAIN X-RAY
as proposed by Prof. Djoko § OR Q US
Roeshadi
OSTEOPOROSIS NO NO SPECIAL FOR OSTEOPENIA CASE
TREATMENT
YES TRIAS:
-EXERCISE
-NUTRITION
LAB SCREENING -ELIMINATION OF BAD HABIT
REPEAT Q US NEXT 1Y

PRIMARY SECONDARY
EXPLORE
B.T.O. DEFINE THE B.T.O. DEFINE THE THE
PATERN BONE MASS PATERN BONE MASS UNDERLYING
USING DEXA USING DEXA DISEASE

TREATMENT TREATMENT

FOR
UNDERLYING
FAST LOOSER SLOW LOOSER DISEASE

TRIAS: TRIAS:
-EXERCISE -EXERCISE
-NUTRITION -NUTRITION
-ELIMINATION OF BAD HABIT -ELIMINATION OF BAD HABIT

ANTI OSTEOPOROTIC DRUG

-HRT
-ANTI RESORPTION AGENT
-BONE FORMATION STIMULATING AGENT

q REPEAT BIOCH BONE MARKERS EXAM NEXT 3 MONTHS

OR
10/27/2018 q REPEAT BONE MASS MEASUREMENT NEXT 1Y
REPEAT BONE MASS MEASUREMENT NEXT 1Y
55
Damayanti Tinduh, Djoko Roeshadi
sCTx, sNMid and sCTx/sNMid ratio (2004, Riset
Thesis)
Mean of
sCTx sNMid sCTx/sNMid ratio
pg/dl ng/dl pg/ng
This study 440.5 28.91 15.3
90 Post menopausal +256.1 +12.79 +5.6
women in Surabaya
Mehta’s study 570 32.1 17.7
134 American Post
menopausal women
Chailurkit’s study 420 17.21 24.35
214 Thai Post +30 +1.35 +.15
menopausal women
 Formation Resorption
(reflect osteoblast activity) (reflect osteoclast activity)

 Serum osteocalcin  Urinary pyridinolines and deoxypyridinoline

 Serum total and bone  Urinary and serum CTX*

alkaline phosphatase
 Urinary and serum N-telopeptide of the
 Serum type I collagen alpha chain of type I collagen (NTX)*
propeptide

*CrossLapsTM

10/27/2018 58
 REPEATATION BMD MEASUREMENT
(1-2 YEAR PERIODE) DEPEND UPON
THE C.V OF THE TOOLS. Fast
looser
 BIOCHEMICAL BONE MARKER
EXAM., to identify the OB and OC
activities. Slow
looser

10/27/2018 59
 HISTORY FOR
NO
OSTEOPOROSIS RISK
FACTORS FINDING
YES
ALGORITHM
DIAGNOSTIC AND SCREENING BY USING:
§ SKIN FOLD
TREATMENT OF MEASUREMENT
§ PLAIN X-RAY
OSTEOPOROSIS § OR Q US

OSTEOPOROSIS NO NO SPECIAL FOR OSTEOPENIA CASE

TREATMENT
YES TRIAS:
-EXERCISE
-NUTRITION
LAB SCREENING -ELIMINATION OF BAD HABIT
REPEAT Q US NEXT 1Y

PRIMARY SECONDARY
EXPLORE
B.T.O. DEFINE THE B.T.O. DEFINE THE THE
PATERN BONE MASS PATERN BONE MASS UNDERLYING
USING DEXA USING DEXA DISEASE

TREATMENT TREATMENT

FOR
UNDERLYING
FAST LOOSER SLOW LOOSER DISEASE

TRIAS: TRIAS:
-EXERCISE -EXERCISE
-NUTRITION -NUTRITION
-ELIMINATION OF BAD HABIT -ELIMINATION OF BAD HABIT

ANTI OSTEOPOROTIC DRUG

-HRT
-ANTI RESORPTION AGENT
-BONE FORMATION STIMULATING AGENT

q REPEAT BIOCH BONE MARKERS EXAM NEXT 3 MONTHS

OR
10/27/2018 q REPEAT BONE MASS MEASUREMENT NEXT 1Y
REPEAT BONE MASS MEASUREMENT NEXT 1Y
60
1. Characterization of bony tissue
2. The problem of bone loss & fracture in Osteoporosis
3. Earl detection of Osteoporosis & Osteoporotic Fracture
4. Protection of bone strength
 Exercise
Calcium & Active Vit-D
Elimination of bad habit

Anti resorptive drug Stimulate bone formation

HRT Sodium fluoride

SERM Bisphosphonates (?)
Bisphosphonates PTH and its fragment (low dose)
Calcitonin STRONTIUM
ANTI OXIDAN (?)

10/27/2018 62
  It’s not to reduce bone resorption
 It’s not to increase bone density
but
It’s a fracture reduction

10/27/2018 63
 Treatment

Goals
 Prevent future fractures

 Treat osteoporosis

 Decrease the risk of mortality

after fractures
 Treatment
3. Fall Prevention
Each year, more than 1.6 million older U.S. adults go to emergency
departments for fall-related injuries. Among older adults, falls are the
number one cause of:
Fall
• Fractures
• Hospital admissions for trauma
• Loss of independence
• Injury deaths 3
factors
that contribute
to fractures

Force Fragility

Source: National Institute of Health/National Institute on Aging