Prevention of Osteoporotic Hip Fracture

Transcription

1 Prevention of Osteoporotic Hip Fracture Dr Law Sheung Wai 8th July 2007 Associate Consultant Spine team / Orthopedic Rehabilitation Department of Orthopedics and Traumatology NTE Cluster 1

2 Objectives Problems of Geriatric Hip Fracture Importance of prevention Level of prevention Mechanism of injuries and Fractures Strategy of prevention Secondary prevention

3 Incidence of 3 Fractures Vertebrae Annual Fracture Incidence, per 100, Youngest BB Oldest baby boomers Hip Wrist Next 5 to 25 years Age

4 Projected number of osteoporotic hip fractures worldwide 3250 Projected to reach million in Asia by Total number of hip fractures: 1950 = 1.66 million 2050 = 6.26 million Estimated number of hip fractures: (1000s) Adapted from Cooper et al, Osteoporos Int. 1992; 2:285-9

5 Consequences of hip fracture One year after hip fracture Patients (%) Death within one year 20% Permanent disability 30% Unable to walk independently 40% Unable to carry out at least one independent activity of daily living 80% Cooper. Am J Med 1997; 103(2A):12s-19s.

6 End result 2004

7 Prevention Primary Prevention Prevention of first fracture Secondary Prevention Prevention of subsequent fracture 7

8 Intrinsic -General degeneration -Balance -Medical problems Extrinsic -Environmental hazard Interaction with environment (e.g. risky behavioral Fall 8

9 Extrinsic Environment Intrinsic Age Muscle weakness Previous falls Gait / balance Visual Arthritis Cognitive impairment Depression Poly-pharmacy Risk taking behavior NEJM 2002

10

11 Elderly with osteoporosis.. Progressive kyphosis Compensatory mechanism

12 12

13 13

14 14

15 Extrinsic factors 15

16 16

17 Fall 1. Orientation of fall 2.protective responses 3.Local shock absorbers Insufficient 4.Bone strength Insufficient Hip Fracture Journal of Geronotology 1989 Vol 44,M

18 Orientation of fall Hip fracture is different from colles fracture 18

19

20 Fall Orientation of fall protective responses Local shock absorbers Insufficient Bone strength Insufficient Hip Fracture Drugs 20

21 Bone strength is more than BMD young elderly Images from L. Mosekilde, Technology and Health Care Image courtesy of David Dempster

22 22

23 Screening for osteoporosis 23

24 24

25 Pharmacological agents for treatment of osteoporosis Effective therapies are widely available and can reduce vertebral, hip and other fractures by 30% to 65%, even in patients who have already suffered a fracture

26 Pharmacological agents shown to reduce fracture risk Bisphosphonates Alendronate (FOSAMAX ) Risedronate (ACTONEL ) Ibandronate Hormone (BONVIVA therapy ) Zolendronate Estrogen / progestin (ACLASTA ) SERMs Raloxifene (EVISTA ) Stimulators of bone formation rh-pth (FORTEO ) Mixed mode of action Strontium ranelate (PROTELOS )

27 Effect on vertebral fracture risk Osteoporosis With prior fractures Osteoporosis Effect on non-vertebral fracture risk With prior fractures Alendronate + + NA + (incl. hip) Risedronate + + NA + (incl. hip) Ibandronate NA + NA + HRT Raloxifene + + NA NA Teriparatide and PTH Strontium ranelate NA + NA (incl. hip) + (incl. hip) NA, No evidence available; +, effective drug ; a women with a prior vertebral fracture Adapted from Boonen S. et al. 2005; Osteoporos Int; 16:239-54

28 Hip protectors ======

29 Hip Protectors protective devices against hip fractures Protective Garments comprise of: Pressurized pants Protective pads on lateral sides

30 Different options in market AHIP protectors, Safe hip et Same principle external and direct protection to the hip region

31 Same Problem Compliance rate: about 40% annually dropping from 70% in autumn to 20% in summer

32 Secondary prevention End result 2004

33 Klotzbuecher et al. J Bone Miner Res 2000; 15: Prior fracture increases the risk of subsequent fracture Site of prior fracture Hip Spine Forearm Minor fracture Hip Risk of subsequent fracture Spine Forearm Minor fracture A prior fracture increases the risk of new fracture 2- to 5-fold

34 Risk of second hip fracture Incidence of second hip fracture. A population based study Osteoporosis International 2007 April 18 Cumulative risk one year ; 5.08 % second year ; 8.11 % At the time of second fracture -Osteoporosis diagnosed : 23% -Bisphonspahte : 16% -Calcium : 20% -Vit D : 16 %

35 Optimal care of the fragility fracture patient Diagnosis of fragility fracture Identify fragility fracture & underlying disease, incorporate into existing workup Influences treatment plan from the onset Fracture management Stabilize patient, pain relief, fracture care Rehabilitation Minimize dependence, maximize mobility Secondary prevention Treat and monitor underlying disease, prevent future fractures

36 Secondary Prevention of fracture

37 Intrinsic Extrinsic Strategy Accidental ( trip slip etc..) 14% Un-anticipated Physiological 8% Anticipated Physiological 78% ++++ Preventive Education +++ Protective Medical risk reduction Case findings Risk reduction Protective Preventive Rehabilitation

38 Thanks