Various recent items of interest
A Medscape article. For an interesting and comprehensive review of new treatments for osteoporosis, see this Medscape article by Jean-Yves Reginster, MD, PhD. Although the Raloxifene segment applies only to women, most of the other information also applies to men. You must sign up at www.medscape.com to view the article, but sign up is free.
Kyphoplasty and percutaneous vertebroplasty. There is a segment on the Men's Osteoporosis Support Group Website dedicated to a discussion of this topic. But there are two recent articles with additional information that could be helpful to those who have a spinal compression fracture. The first article is by Theodorou D and others and is in Clin Imaging 2002 Jan-Feb;26(1):1-5. This study was done at the Department of Radiology, School of Medicine, University of California-San Diego and Thornton Hospital, San Diego, CA. The authors are reporting on the their experience with kyphoplasty that was performed on 15 patients having a total of 24 osteoporotic vertebral compression fractures from 2-24 weeks old. They report successful procedures on all patients and all fractures with the ability to regain vertebral height and to stop pain, "Often within hours." They note that three of the patients returned enthusiastically to have additional compression fractures treated which developed later (see next article). They also note that kyphoplasty has advantages over percutaneous vertebroplasty (PV) because they can insert an inflatable bone tamp to re-expand the collapsed vertebra and correct the wedging deformity, not just stabilize the fracture. Another plus with their system is that they can allow the bone cement to set up slightly for easy application of the more cohesive and doughy bone cement making it more unlikely that it could leak out into the adjacent tissues and cause problems. These excellent results are not a guarantee that every group performing kyphoplasty will have equal outcomes. Be sure your care provider has considerable experience in this technique and can document his or her excellent results. And remember, you can only expect to regain the height of the fractured vertebra if the procedure is done in a timely manner, so seek help as soon as you can after the fracture occurs. The second study is reported in Radiology 2003 Jan;226(1):119-24, by Uppin AA and others. This study used only PV on 177 patients. They note that 22 (12.4%) develop a total of 36 new vertebral body fractures after treatment, and these were often next to the previously treated vertebrae. Sixty-seven percent of fractures occurred within 30 days of treatment of the first fracture. Thus, when people need PV for a compression fracture, they must realize they are at considerable risk for another fracture in the near future. These people should certainly be on an approved osteoporosis medication and should be extremely careful to avoid traumatic injury to themselves until they've had a chance to respond to therapy. It occurs to me that a person with severe osteoporosis and a spinal compression fracture that requires kyphoplasty or PV would be a candidate for human parathyroid therapy--at least for the first few months. Such individuals might want to discuss this option with their care providers. Note the comparison of alendronate vs. human parathyroid showed very extensive improvement in BMD at three months on the 40 mg/day injection. This wasn't approved by the FDA, but might be possible as an off-label medication. At least it would be worth a try.
The effect of exercise during growth on BMD. See the article by Modlesky CM and Lewis RD in Exerc Sport Sci Rev 2002 Oct;30(4):171-6. The authors note that, "Considering that approximately 90% of total bone mineral content (BMC) is accumulated by the end of adolescence, coupled with the continual change in the size and shape of the immature skeleton, the growth period may be an optimal time for altering the mass, geometry, and microarchitecture of bone." This paper is a review of the evidence that indicates this may be possible. The reason it would be important to know if exercise during growth creates increased BMD and BMC, would be that this bone would be stronger, less fracture resistant, and that this improvement might last throughout life to decrease long-term fracture risk. But, does that happen? There is no study to show this, only fragments of studies from which we must estimate the overall result. An important finding is that in the studies of the dominant vs. nondominant arm areal BMD (aBMD) of racquet sports athletes. In female players who started racquet sports before menarche, the dominant arm aBMD is more than double that of players who started the sport after menarche. Obviously, this indicates the window of opportunity to increase BMD to the greatest extent starts and ends at a very young age. Similar large improvements in BMD occurred in nonathletes who did the most exercise in the two years surrounding peak BMC accrual. The best activities to increase BMD being those that load the hip and spine, such as jumping. An interesting finding for racquet players is that their increase in BMC is due to an increase in cortical bone width rather than an increase in material density. The overall findings suggest that the skeleton's response to exercise is specific to the site and type of load applied. But, are these gains in BMC and strength permanent? Studying former athletes provides most of the information on this topic. It has been shown that female gymnasts maintain a 9-22% improvement in BMD compared to nonathletic weight-matched controls ten years after they stop the sport. In retired soccer players, aBMD of the leg is 11.6% higher than controls, but 35 years after retirement this difference no longer existed. From studies on tennis players, it appears that continued exercise can help maintain the improvements that occurred during adolescence, even if the exercise is at a reduced level compared to earlier years. Whereas studies in rats show that if they are run-trained on a treadmill for 10.5 months, they have improved BMD which is maintained at a higher level than controls during later life. So the bottom line is that, "Exercise early in life and often throughout life" seems to be a good philosophy for those wanting to develop and maintain good BMD. The large increases in BMD that can occur during adolescence simply won't happen if you start exercising later in life. But, you will help retain the BMD that you have.
Hip fracture and osteoporosis treatment. A recent update discussed the problems with under diagnosis of osteoporosis after low-impact trauma. Yet another paper has shown the extent of the problem--and it is truly a serious one. See the study by Harrington JT and others in Arthritis Rheum 2002 Dec 15;47(6):651-4. Obviously from the findings in this study, there is a tremendous need to educate the physicians who treat patients who have fractures about the need for diagnosis and treatment of osteoporosis. This means both the orthopedic surgeons and primary care physicians who provide follow-up care. There is a huge backlash by physicians in this country against the high cost of malpractice insurance. Yet when you see clinical study results like this, it makes you wonder why that insurance doesn't cost even more. There simply is no excuse for this failure to diagnose and treat osteoporosis after low impact trauma. In essence the diagnosis has already been made, there is really no need for the DXA other than to get a baseline BMD so results of therapy can be evaluated. The fault isn't only with the physicians, but the residency training programs they go through and the medical schools where they receive early training. All of those responsible for these diagnosis and treatment failures must receive education and training to remedy the problem.