Osteoporosis and Fractures The Size of the Problem

1
Osteoporosis and Fractures The Size of the
Problem

• Kristina Åkesson
• Department of Orthopaedics
• Malmö University Hospital
• Lund University
• Malmö, Sweden

2
A million fragility fractures a year
But can we do more ?
3
Lecture content

• Definition of Osteoporosis
• Epidemiology of Osteoporosis
• Ageing populations
• prevalence and incidence of osteoporotic
  fractures
• prevalence of low bone mass
• Quality of Life
• morbidity and mortality
• pain and limitations
• Economic burden

4
Definition of osteoporosis
a systemic skeletal disease characterized by
low bone mass and micro-architectural
deterioration of bone tissue, leading to enhanced
bone fragility and a consequent increase in
fracture risk.
World Health Organization (WHO), 1994
5
Trabecular bone
normal
osteoporotic
Bone quality is not the only factor
6
Pathogenesis of fragility fractures
7
Lecture content

• Definition of Osteoporosis
• Epidemiology of Osteoporosis
• Ageing populations
• prevalence and incidence of osteoporotic
  fractures
• prevalence of low bone mass
• Quality of Life
• morbidity and mortality
• pain and limitations
• Economic burden

8
The ageing population
In western countries

• In Europe, population over 65
• 12-17 in 2002
• 20-25 by 2025

United Nations Statistics Division, Demographic
Yearbook 2004
9
Life expectancy in men and women
Age (in years) Life expectancy (in years) in
1999 Male Female
At birth (0) 75.4 80.2 5 71.0 75.7
20 56.2 60.8 30 46.7 51.0 50
27.9 32.0 60 19.4 23.0 70 12.2
15.1 80 7.0 8.7
and life expectancy is increasing
Data from the UK
10
The ageing population

• In developing countries
• 0 - 15 years 30
• Over 65 years 5.5
• But changes are expected

11
Biological age a factor beyond chronological
age
All other women
Highest tertile
Higher mortality in women with high biological age
Higher fracture rate in women with high
biological age
N1044 women 75 years old
Gerdhem et al Gerontology 2004 50309-14
12
Epidemiology of fractures

• Incidence and prevalence depend on
• definition of fracture
• diagnostic method
• clinical vs. radiological
• quantitative vs. qualitative
• morphometric method
• study population

13
Age- and sex-specific incidence of all limb
fractures
Incidence per 100,000 person-years
Age group
Garraway et al. Mayo Clin Proc 1979 54701-7
14
Fracture and quality of life over the life span
Morbidity
Hip fracture
Vertebral fracture
Colles' fracture
Age
50
60
70
80
90
15
Osteoporotic fracture incidence
Women
4,000
3,000
Hip
Incidence per 100,000 person-years
2,000
Vertebrae
1,000
Forearm
55
75
35
Age (years)
Cooper et al. Trends Endocrinol Metab 1992 3224
16
Number of osteoporotic fractures worldwide
17
Remaining lifetime fracture risk () in Caucasian
population at the age of 50
Type of Fracture Men Women Forearm
4.6 20.8 Hip 10.7 22.9 Spine
8.3 15.1 Proximal Humerus 4.1 12.9 Other 22.4
46.4
Johnell et al. Osteoporos Int 2005 16 Suppl
2S3-7
18
Prior fracture increase risk for subsequent
fracture
Klotzbuecher et al. J Bone Miner Res 2000
15721-727
19
Mortality after major types of osteoporotic
fracture in men and women
5-year prospective cohort study
Age-standardized mortality ratio Fracture Women
Men Proximal femur 2.2 3.2 Vertebral 1.7 2
.4 Other major 1.9 2.2 Other minor 0.8 1.5
Center et al. Lancet 1999 353878-882
20
Vertebral fractures grading of severity
Adapted from Genant HK et al. J Bone Miner Res
1993 81137-1148
21
Incidence of vertebral fractures in women and men
50
men
women
40
30
n per 1000 person-years Vertebral fractures
20
10
0
50-54
55-59
60-64
65-69
70-74
75-79
The EPOS Study
Age group
EPOS Group, J Bone Miner Res 2002 17716-24
22
Proportion with vertebral deformity
Percentage
Age group
Hasserius et al. Acta Orthop Scand. 2001 72273-8
23
Vertebral fracture prevalence
30
Men
Women
25
25
20
18
17
15
13
13
12
12
11
10
10
10
8
5
5
0
50-54
55-60
60-64
65-69
70-75
75-79
Age (years)
McCloskey Method
ONeill, J Bone Miner Res 1996 111010
24
Incidence of fractures
Only 30 of morphometric vertebral fractures are
clinically apparent
700,000
750,000
500,000
Annual incidence
300,000
300,000
200,000
250,000
Clinically apparent
0
Hip
Vertebral (Morphometric)
Wrist
Other
Fracture type
US data
25
Risk for new vertebral fracture following first
vertebral fracture
15
RR7.3
RR5.1
10
Incidence of new vertebral fractures ()
RR2.6
5
0
0
1
?1
?2
Number of vertebral fractures at start of study
2725 post-menopausal women, randomized
placebo-controlled
Lindsay et al. JAMA 2001 285320-23
26
Vertebral deformity and the risk of future
fracture
Cumulative proportion without fracture
1.0
Without Vfx
With Vfx
0.5
Risk increase HR 2.0
Years
10
5
Hasserius et al. Osteoporos Int. 2003 1461-8
27
Vertebral fractures and mortality
Hasserius et al. Osteoporos Int. 2003 1461-8
28
Hip fracture incidence
1400
1400
Men
Women
Femoral Neck
1000
1000
Incidence per 100,000 person-years
Femoral Neck
500
500
Intertrochanteric
Intertrochanteric
40
50
60
70
80
40
50
60
70
80
Age (years)
Age (years)
Melton et al. Calcif Tissue Int 1987 4157
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Hip fracture incidenceGeographic variation
Turkey
Turkey
Men
Women
China
China
Hungary
Hungary
China (HK)
China (HK)
Portugal
Portugal
Greece
Greece
Spain
Spain
Finland
Finland
France
France
Japan
Japan
Canada
Canada
UK
UK
Germany
Germany
Netherlands
Netherlands
USA
USA
Denmark
Denmark
Australia
Australia
Italy
Italy
Iceland
Iceland
Switzerland
Switzerland
Norway
Norway
Sweden
Sweden
0
5
10
15
20
25
30
0
2
4
6
8
10
12
14
Lifetime risk ()
Lifetime risk ()
Kanis et al, J Bone Miner Res. 2002 171237
30
Incidence of hip fractures in women and men
The Medos Study
Elffors et al, Osteoporos Int. 1994 4253
31
Projected number of osteoporotic hip fractures
worldwide
742
Total number ofhip fractures1950 1.66
million 2050 6.26 million
378
Estimated number of hip fractures (1000s)
Adapted from Cooper et al, Osteoporos Int. 1992
2285-9
32
Distal radius fractures

• The most common fracture in women at middle age
• Incidence increase begins just after menopause in
  women
• The most common fracture in men below age 70 years

Holmberg et al, Osteoporos Int. 2006 71065-77
33
Distal radius fractures

• It is estimated that 16.6 of women and 2.9 of
  men will suffer a distal radius fracture from the
  age of 50 years in the UK
• Only 50 report good functional outcome at 6
  months and up to 30 of individuals may suffer
  some long-term complications

O'Neill et al. Osteoporos Int 2001 12555-558
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Proximal humerus fracture

• Estimated that fractures of the proximal part of
  the humerus account for 4-8 of all fractures
• In persons over 40, fractures of the proximal
  humerus account for 76 of all fractures of the
  humerus
• Data suggest that fracture of the proximal
  humerus is the third most common fracture over
  age 65
• Fractures of the proximal humerus have shown a
  pattern of increase similar to other common
  fragility fractures

35
Epidemiology of low bone mass

• Prevalence depends on
• definition of low bone mass (WHO)
• densitometry technique (DXA)
• skeletal site
• study population

36
WHO criteria for osteoporosis
T-score Difference expressed as standard
deviation compared to young reference population
Kanis et al. J Bone Miner Res 1994 91137-41
37
Prevalence of osteoporosis in men and women by
gender-specific scores
Normal BMD
Osteopaenia
Osteoporosis
100
80
60
Prevalence ()
40
20
0
85
85
55-59
60-64
65-69
70-74
75-79
80-84
55-59
60-64
65-69
70-74
75-79
80-84
Men
Women
Schuit et al. Bone 2004 34195
38
Prevalence of osteoporosis in women at different
skeletal sites
60
T-score -2.5
50
40
Prevalence ()
30
20
10
0
50-59
60-69
70-79
80
age 50
Age (years)
Spine
Hip
Mid-radius
Any site
Melton et al. J Bone Miner Res 1995 10175
39
Prevalence of osteoporosis at the femoral neck in
Caucasian women
50
40
Prevalence
30
20
10
0
50-54
55-59
60-64
65-69
70-74
75-79
80-84
Age (years)
(Sweden)
Kanis et al, Calcif Tissue Int 2001 69218
40
Prevalence of low bone mass in male Caucasians
aged 50 years and older
Femoral Neck
Osteopaenia T-score -1 to -2.5
Osteoporosis T-score -2.5
50
47
40
Prevalence
30
33
20
10
6
4
0
Female cut off points
Male cut off points
Looker et al. J Bone Miner Res 1997
121761 Melton et al. J Bone Miner Res 1998
131915
41
Bone density is not the only factor of fracture
risk
Bone mass Bone structure Bone quality
Type of fall Energy reduction External protection
Neuromuscular function Environmental risks Age
Fall Risk
Impact of fall
Skeletal strength
Fracture risk
42
Osteoporotic fracture and BMD
Fractures per 1,000 person-years
Number of fractures
50
Fracture rate Women with fractures
400
40
300
30
200
20
100
10
0
0
1.0
0.5
0.0
-0.5
-1.0
-1.5
-2.0
-2.5
-3.0
-3.5
Siris et al. Arch Intern Med. 2004 1641108-1112
43
Ten-year probability of hip fracture in Sweden
T-score (SD)
44
Ten-year probability of hip fracture in women at
Tscore 2.5
Age
45
Fracture risk multifactorial
46
Fracture risk multifactorial
The relative importance of risk factors
47
Fracture risk multifactorial
The relative importance of risk factors
BMD independent factors
Non- vertebral fractures
BMD dependent factors
Age
48
Fracture risk is

• highest in the oldest population
• highest in women
• highest in those with previous fracture
• high in those with low bone density
• high in very thin people
• high in those with comorbidity
• high in those on steroid treatment
• high in those who smoke

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Lecture content

• Definition of Osteoporosis
• Epidemiology of Osteoporosis
• ageing populations
• prevalence and incidence of osteoporotic
  fractures
• prevalence of low bone mass
• Quality of Life
• morbidity and mortality
• pain and limitations
• Economic burden

50
Active women have fewer fragility fractures and
better quality of life
City-living women
Ringsberg et al. Gerontology 2001 4715-20
51
All fractures are associated with morbidity
Unable to carry out at least one independent
activity of daily living
80
One year after a hip fracture
Unable to walk independently
Patients ()
Permanent disability
40
Death within one year
30
20
Cooper. Am J Med. 1997 103(2A)12s-19s
52
Morbidity after vertebral fractures

• Back pain
• Loss of height
• Deformity (kyphosis, protuberant abdomen)
• Reduced pulmonary function
• Diminished quality of life
• loss of self-esteem, distorted body image
• dependence on sleeping tablets, sleep disorders
• depression
• loss of independence

53
Vertebral fractures restrict daily activities
No vertebral fractures over the last four years
People with vertebral fractures have greater
pain, disability and healthcare utilisation, on
average, than those without fracture
Adapted from Ross PD et al.
54
All vertebral fractures are clinically important
Moderate Back Pain
Severe Back Pain
Limited Activity
Bed Rest
100
400
350
75
300
250
Percentage () of patients
50
Mean number of days
200
150
25
100
50
0
0
No incident fracture
Clinical fracture
Radiographic fracture
No incident fracture
Radiographic fracture
Clinical fracture
Nevitt et al. Arch Intern Med 2000 16077-85
55
Outcome after hip fracture The situation one
year after fracture
Sernbo et al. Osteoporos Int. 1993 3148-53
Sernbo 1993
56
Improvement in quality of life after surgery for
hip fracture
SF-36 at baseline and 3, 6, and 9 months after
surgery
Cranney et al. J Rheumatol. 2005 322393-9
57
Optimal fracture treatment a prerequisite for
maintaining quality of life
58
Lecture content

• Definition of Osteoporosis
• Epidemiology of Osteoporosis
• aging populations
• prevalence and incidence of osteoporotic
  fractures
• prevalence of low bone mass
• Quality of Life
• morbidity and mortality
• pain and limitations
• Economic burden

59
Cost of osteoporosis in the United States
Total annual cost
Nursing Home
Hospitalization
3.9(28)
13.8Billion
8.6(62)
1.3(10)
Outpatient
Ray et al. J Bone Miner Res 1997 1224-35
60
Economic impact of osteoporosis
Annual economic cost of treating fractures in the
USA is similar to that of treating cardiovascular
disease and asthma
Annual direct cost Disease Prevalence
including hospitalization (millions) (US
billion) Cardiovascular 4.6 20.3disease Ast
hma 15 7.5
Osteoporosis 10 13.8
Information supplied by National Heart, Lung
Blood Institute,National Osteoporosis
Foundation, American Heart Association
61
Osteoporotic fracturescomparison with other
diseases
annual incidence all ages
2000
1 500 000
1500
250 000hip
250 000forearm
Annual incidence x 1000
1000
annual estimate women 29
250 000 other sites
513 000
annual estimate women 30
500
1996 new cases, all ages
750 000 vertebral
228 000
184 300
0
Osteoporotic fractures
Heart attack
Stroke
Breast cancer
American Heart Association, 1996 American Cancer
Society, 1996 Riggs Melton Bone, 1995
17505S-511S
62
The burden of osteoporosisLecture summary

• Epidemiology of osteoporosis
• Prevalence and incidence of osteoporotic
  fractures is high and increases exponentially
  with age
• Quality of Life
• Morbidity and mortality are significantly
  increased after fractures
• Osteoporotic fractures result in pain and reduced
  quality of life
• Economic costs are huge
• In comparison with other diseases, osteoporosis
  is very common
• Osteoporosis important public health problem
• 30-50 of women and 15-30 of men will suffer an
  osteoporotic fracture