Metabolic Bone Disease

AB Govindaraj, FRCS

Consultant Orthopedic Surgeon, Fortis Malar Hospital

Aims & Objectives

• Aim:

• Create Awareness about Common Metabolic disorders

• Objective:

• Demonstrate understanding of Epidemiology, Aetiology, Clinical features and Management of Osteoporosis, Osteomalacia & Gout.

Case 1

• 72 year old lady

• Acute onset severe thoracic pain

• Keeping her awake at night

• Radiates around ribs

• No history of trauma

• PMH – COPD

• DH - Inhalers

Case 1

• On examination:

• Frail lady

• Afebrile

• Thoracic kyphosis

• Tender over spinous processes T10 area

• No neurological deficit

Diff. Diag. of Back Pain

• Simple strain

• Degenerative disease

• Metabolic – Osteoporosis, Osteomalacia, Pagets

• Inflammatory – Ankylosing spondylitis

• Infective – TB

• Neoplastic

• Others, Fracture

• Visceral

Case 1- Investigations

• HB 12.9

• WCC 9.0

• Plts 245

• Na 139, K 4.4

• Urea 7.3, Cr 0.96

• SAP 297

• Ca 6.5 mg%

• CRP 1

Imaging

Osteoporosis

Reduction in bone mass leading to increase risk of fracture Ratio of mineralised bone: matrix is normal

Imbalance of bone remodelling

DEXA

Osteoprotic fractures

Osteoporosis - Treatment

• Lifestyle factors: Falls prevention

• Ca and Vit D

• Bisphosphonates

• Salmon Calcitonin - SC/Nasal

• Teriparatide- PTH

• SERMs

• Monoclonal antibodies (MAbs) (Denosumab)

• Strontium

steroid induced osteoporosis

Case 2

• 33 year old lady

• Generalised bony pain 3 months

• PMH – Depression

• DH – Sertraline

• O/E – Generalised bony tenderness

• Joints – Normal ROM, No inflammation

Investigations

• Hb- 12.9 Calcium- 2.18 (2.2-2.6)

• WCC-4.7 Phosphate- 0.79 (0.85-1.45)

• Plt- 253 Albumin- 39 (35-50)

• ESR- 12 Alk Phos- 172 (25-96)

• Urea- 15 LFTs normal

• Creat- 0.8 1,25, Dihydroxy Levels - <5

Osteomalacia

• Deficiency or Resistance to Vit D or Phosphate handling problem

• Defective Mineralization of bone

• Proximal Myopathy, Bony pain, Malaise

• SAP raised, Ca and Vit D low or normal

• PO4 low or normal

osteomalacia - Causes

• Reduced availability of Vitamin D

• Diet: Oily fish, Eggs, Breakfast cereals

• Minimal sun exposure

• Dark skin, skin covering when outside

• Kidney failure

• Malabsorption

• Epilepsy: Phenytoin, Phenobarbitones

• Genetic disease

• Defective metabolism of Vitamin D

• Chronic renal failure, Vit D dependent rickets,

• Liver failure, anticonvulsants

• Receptor Defects

• Altered phosphate homeostasis

• Malabsorption, RTA, hypophosphatasia

Loosers zones

Treatment

• Diet rich in Sea foods/ Fortified Milk

• Exposure to Sunlight

• Vitamin D Supplements- IM/Oral

• Calcium supplements

Causes of Hypercalcaemia

Case 3

Gout - Management

• Acute attack-

• NSAID’s: Indomethacin/Diclofenac/Ketorolac

• Steroids: Prednisolone

• Colchicine:

• Prevention-

• Allopurinol: Zyloric

• Febuxostat: Febutaz, Uricostat

• Probenecid: Benemid

• Diet: Low Purine Diet. No Alcohol

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Thank You