Orthopaedic Surgery (2009), Volume 1, No.

4, 251–257

GUIDELINE

Diagnosis and treatment of osteoporotic fractures os4_47 251..257

Chinese Orthopaedic Association

42 Dongsi Xidajie, Beijing 100710, China

1. Overview comitant systemic diseases aside from degenerating

pathophysiological conditions are often present, manage-
Osteoporosis is a systemic, metabolic skeletal disease,
ment of osteoporotic fractures is inherently complex and
characterized by reduced bone quality and decreased bone
difficult and inevitably accompanied by an increase in
mass with destruction and deterioration of bone micro-
complication rates; and (vii) osteoporotic fragility frac-
structure. This in turn induces a predisposition to bone
tures, with their relatively high disability and fatality rate,
fragility and overall decrease in bone strength, conse-
endanger patients’ mental and physical health, interfere
quently leading to increased risk of fracture. Often referred
with their quality of life and reduce overall life expectancy
to as a silent disease, osteoporosis is categorized into two
in the elderly. Thus osteoporotic fracture treatment and
main categories: primary and secondary osteoporosis.
management is clearly different from that of general trau-
The term osteoporotic fracture (fragility fracture) used
matic fractures, requiring both a complete consideration
in this guideline indicates fracture induced by further
of orthopaedic fracture treatment and active anti-
reduction in bone density and bone strength in primary
osteoporosis therapy.
osteoporosis, as a result of a small or non-traumatic force.
Osteoporotic fragility fractures are severity endpoints of
osteoporosis related complications, bones commonly 2. Diagnosis and differential
affected by these fractures include the spine, hip, distal diagnosis
radius and proximal humerus. Osteoporotic fractures are particularly prevalent in
Osteoporotic fragility fractures pose extreme treatment elderly females, often resulting from low-energy micro-
difficulties with specific characteristics: (i) due to pro- trauma (meaning that these injuries are induced by minor
longed bed rest and immobilization, following falls on ordinary surfaces or simply by the force of
osteoporotic fracture accelerated bone loss occurs, further gravity), or occur with no apparent trauma history, but
aggravating the severity of the underlying disease; (ii) merely through the impact of normal daily activities.
because of the pre-existing low bone mass and poor bone
quality, osteoporotic fractures are usually comminuted Clinical manifestations
fractures, posing difficulty in reduction of the fracture, 1. General manifestations include localized pain, tender-
which leads to unsatisfactory results; (iii) when surgically ness, swelling, functional impairment and dysfunction
treated, poor bone quality contributes to decreased stabil- of the fractured limb. However, patients with
ity of internal fixation, often resulting in the complica- osteoporotic fractures may be asymptomatic, present-
tions of loosening, a need to extract of internal fixation ing either no pain or only non-specific mild discom-
implants, and failure of bone grafts to fuse due to graft fort, possibly with aggravation of some pre-existing
absorption; (iv) deferred fracture healing eventuating in tenderness. Limb function may be relatively normal,
delayed union or nonunion lengthens recovery time, pre- and any dysfunction can be so slight as to be unappar-
disposing patient to further complications; (v) there is a ent to an observer.
significantly increased risk of secondary fracture within 2. Specific manifestations particular to fractures include
the same or other, mostly adjacent, sites; (vi) because visible deformity and bony crepitus, along with abnor-
osteoporosis is a disease of the elderly, meaning that con- mal function and movement. However, such fracture
specific presentations may also be lacking in
Address for correspondence Gui-xing Qiu, MD, Department of osteoporotic fracture patients.
Orthopaedic Surgery, Peking Union Medical College Hospital, No 1
3. Clinical manifestations of osteoporosis include an
Shuaifuyuan Hutong, Beijing, China 100730 Tel and Fax: 0086-10-
65296081; Email: [email protected] obvious decrease in body height, scoliosis, kyphosis,
Received 31 July 2009; accepted 09 August 2009 and complications related to spinal deformity, such as
DOI: 10.1111/j.1757-7861.2009.00047.x neuropathy.

© 2009 Tianjin Hospital and Blackwell Publishing Asia Pty Ltd 251
252 Chinese Orthopaedic Association, Diagnosis & treatment of osteoporotic fractures

Radiological imaging healthy adult is considered to confirm osteopenia, which

X-ray examination provides visualization of the frac- is defined as a low or reduced bone mass (-2.5 SD < T
ture site and type, allowing assessment of the fracture score < -1.0 SD). Results greater than or equal to 2.5 SD
direction and extent of displacement, all of which is valu- (T score ⱕ -2.5 SD) are diagnostic of osteoporosis. When
able information with respect to diagnosis and treatment. the BMD is even less, as is often the case in patients with
Aside from providing radiological evidence of the pres- one or more simultaneous fractures, severe osteoporosis is
ence of fracture, X-ray films also offer clues towards definite. Common clinical BMD testing sites include
osteoporosis diagnosis, including reduced bone density, L1–L4 and the femoral neck (hip).
thinning of trabecular and cortical bone, and expansion of
the bone marrow cavity. Radiographic films should also Laboratory examinations
be taken of the joints immediately superior and inferior to 1. Routine blood and urine tests may be ordered accord-
the fracture site, or, in the case of hip fractures, the entire ing to the requirements of individual cases: these may
pelvis including both hip joints. In order to avoid misdi- include an array of tests of hepatic and renal function,
agnosis, possible spinal fractures should be assessed by serum alkaline phosphatase (ALP), blood glucose
thorough, detailed physical examination to determine (BG), serum electrolytes such as calcium and phospho-
which segments should be X-rayed. Computed tomogra- rus and so on. Other endocrine and biochemical
phy (CT) and magnetic resonance (MR) examinations parameters such as sex hormones, thyroid and/or par-
should be ordered where there are positive indications. CT athyroid hormone, calcitonin and 25-hydroxy-vitamin
imaging of the spine accurately depicts and locates the D may be assessed when required.
extent of fracture comminution and spinal cord compres- 2. Measurement in serum and urine of biochemical
sion. Three-dimensional CT allows for clear anatomical markers of bone remodeling, (both bone resorption
identification of intra-articular or peri-articular fractures. and formation), is a useful quantitative means of
MRI provides valuable assistance in the detection of monitoring the condition of the osteoporotic patient.
occult fractures, as well as in identifying both recent and Bone remodeling is an ongoing cyclic metabolic phe-
old fractures. nomenon in the life cycle of bone, and includes repair
and replacement of old, fatigued, damaged, and even
Bone mineral density fractured bone. Biochemical markers are useful in
There is uniform consensus that the diagnosis of initial assessment of patients with respect to predicting
osteoporosis should be established by bone mineral fracture risk, as well as in determining and affecting
density (BMD) measurements. A clinical diagnosis of selection of drug therapies. They allow determination
osteoporosis is often presumed in at-risk patients with of metabolic status, monitoring of drug efficacy, and
low-energy or low-trauma fractures. Various methods of establishment of differential diagnoses, as well as the
examination have been developed to measure and analyze prediction of fractures and assessment of any reduc-
BMD, including dual-energy X-ray absorptiometry tion in fracture risk. Biochemical indicators of bone
(DXA), peripheral dual-energy X-ray absorptiometry formation include serum ALP, osteocalcin, bone-
(pDXA), quantitative computed tomography (QCT), derived ALP, and type I pre-collagen C-terminal and
peripheral quantitative computed tomography (pQCT), N-terminal peptides. Bone resorption markers include
and quantitative ultrasound (QUS). However DXA is now plasma tartrate-resistant acid phosphatase and type I
internationally recognized as the gold standard for con- collagen C-terminal peptide, fasting urine calcium-
firming the diagnosis of osteoporosis and predicting frac- creatinine ratio, and urine pyridinoline and deoxypy-
ture risks. Areas of BMD are assessed in terms of grams of ridinoline, type I collagen C-terminal and N-terminal
mineral per square centimeter scanned (g/cm2). Using the peptides. A low BMD paired with a high bone turnover
figure thus obtained, which is referred to as the Z-score, rate denotes a marked increase in fracture risk.
the patient’s BMD is compared to values of BMD for 3. A combination diagnostic approach using radiogra-
normal, healthy adults of the patient’s race, age and phy, DXA and biochemical marker assessment is
gender, and this is termed the T-score. The difference superior to using single options of either BMD or
between the patient’s BMD score and the normal to which biochemical measurements.
it is compared is expressed as the number of standard
deviations (SD) greater or smaller than the mean. A Differential diagnosis
normal BMD is within one SD of that of a healthy adult of Identification of osteoporotic fractures secondary to
the same gender, age and race (T score ⱖ -1.0 SD). A concomitant conditions is crucial in selecting appropriate
BMD result ranging between 1 and 2.5 SD below that of a therapy. Secondary osteoporosis and osteoporotic frac-

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Orthopaedic Surgery (2009), Volume 1, No. 4, 251–257 253

tures may be caused by bone tumors, including metastatic 1. Thoughtful selection of special internal fixation instru-
tumors and multiple myeloma, as well as other metabolic mentation using locking compression plates, coarse
diseases such as hyperparathyroidism, calcium- spiral-thread screws, and special coated material.
phosphorus imbalance, renal osteodystrophy and other 2. Consideration of internal fixation instrumentation
related diseases which affect bone metabolism and with reduced stress-shields to decrease further bone
mineralization. loss.
3. An emphasis on delicate surgical manipulation during
Principles of diagnosis internal fixation, such as using gentle controlled force
Osteoporotic fracture diagnosis is based on consider- when implanting the fixation screw through bilateral
ations of the patient’s age, gender, menopausal state, cortical bone.
history of fragility fractures, and individual clinical mani- 4. Use of surgical techniques to strengthen and increase
festations, as well as a comprehensive analysis of radio- the stability of internal fixation, such as using bone
graphic imaging and/or BMD results. cement around screws, expandable screws and biologi-
cal materials.
5. With severe bone defects, autologous or allogenic bone
3. Treatment
graft and biological fillings (e.g. bone cement, calcium
Therapeutic principles of osteoporotic fracture include sulfate) should be considered.
fracture reduction, surgical or non-surgical immobiliza- 6. External fixation devices are selected according to frac-
tion, rehabilitative exercise, and anti-osteoporosis ture severity and location, and the overall general
therapy; ideally treatment involves an organic combina- condition of the patient. Integrity of external fixation
tion of all four principles. Reduction of the fracture must should guarantee an adequate healing period, and
include taking precautions to prevent any further trauma provide solid stability by sufficiently immobilizing the
or compromise of the local blood supply, and to imple- joints adjacent to the fracture.
ment early mobilization and rehabilitation once solid, Osteoporotic fracture rehabilitation and recovery man-
stable immobilization of the fracture has been achieved. agement share the same basic principles as general frac-
Such precautionary measures facilitate early healing of the ture rehabilitation, but in addition take into account the
fracture and reduce risks of complications to a minimum, characteristics specific to fragility fractures, for example
allowing for satisfactory results. Consideration of treat- poor bone quality, instability of internal fixation and
ment with anti-osteoporosis agents is important as this retarded fracture healing. Emphasis should be on active
can help to prevent worsening of the osteoporosis which muscle and joint rehabilitation, with immediate active
preceded the fragility fracture and to prevent fracture exercising of all joints not affected by surgery in order to
related complications. minimize the duration of bed rest, and thus minimize
Design of osteoporosis fracture treatment, whether complications associated with prolonged bed rest and
surgical or non-surgical, is based on the characteristics inactivity.
of individual patients. Specific treatment is determined Apart from prevention of local fracture related compli-
according to the fracture site and type, degree of cations in osteoporotic patients, measures should be taken
osteoporosis, and overall patient condition, judiciously to improve the patient’s general condition and prevent
balancing the advantages and disadvantages of surgery or systemic complications, especially those peri-surgical
medical treatment. complications such as deep vein thrombosis, hypostatic
The majority of osteoporotic fractures occur in elderly pneumonia, urinary tract infections and bed sores which
patients, and therefore require simple, safe and effective can cumulatively increase the rates of disability and
reconstructive fixation techniques to expedite restoration fatality.
of the patient’s quality of life to ‘pre-fracture’ levels. The
primary consideration is to select procedures involving
4. Common sites, features and
minimal trauma and impact upon joint function, focus-
surgical treatment of
ing on tissue repair and functional rehabilitation rather
osteoporotic fracture
than simple anatomical reduction. For patients requiring
surgery, orthopedic surgeons should fully understand the Spinal fractures
difference between osteoporotic and common traumatic Most osteoporotic fractures occur in the spinal column,
fractures; osteoporotic fractures have initial poor bone 85% of these patients experience various degrees of pain,
quality which adversely affects their healing. The follow- with the remaining 15% being asymptomatic. The thora-
ing measures may prevent unnecessary complications: columbar spine accounts for approximately 90% of

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254 Chinese Orthopaedic Association, Diagnosis & treatment of osteoporotic fractures

osteoporotic spinal fractures; these typically present as Hip fracture

vertebral compression fractures and/or vertebral burst Hip osteoporotic fractures occur mainly in the femoral
fractures. The latter may be caused by an incident of neck and intertrochanteric region and are characterized
minor trauma, but mostly there is no obvious trauma by high deformity and disability rates, deferred recovery
history, making these fractures susceptible to being com- and increased fatality.
pletely missed or misdiagnosed. With regard to femoral neck fractures, non-surgical or
Diagnosis involves combining an evaluation of the surgical treatment is chosen according to specific patient
patients’ age and medical history with radiological exami- characteristics. A non-surgical approach is considered a
nation. Post-traumatic back pain, reduction in height, priority in cases of inconspicuous displacement, or with
scoliosis or kyphosis, diffusely sparse bone trabeculae, impact fractures in patients whose poor general health
cortical bone thinning, and wedge-shaped or bi-concave would make them intolerant of surgery. Non-surgical
deformation of the vertebral body on the X-ray films are approaches include absolute bed rest with weighted trac-
all basic diagnostic parameters. DXA measurement is tion (either skeletal or skin traction), brace immobiliza-
useful for determining the extent of osteoporosis and tion and nutritional support. Femoral neck fractures often
evaluating bone density to allow for prediction of future require surgical treatment using either external or internal
fractures. CT scans can define the type of fracture, and fixation, prosthetic femoral head replacement or total hip
extent of vertebral destruction and spinal compression. replacement (total hip arthroplasty, THA).
MRI allows an assessment of spinal cord and nerve root THA or prosthetic femoral head replacement are
compression, as well as aids in the identification of both chosen according to the patient’s age, overall general
new and old fractures. health, life expectancy and condition of the acetabulum.
Non-surgical treatment is recommended in cases with In elderly patients in poor overall condition and with
mild pain and vertebral compression (vertebral height concomitant diseases, a short life expectancy is assumed
loss less than 1/3), while minimal invasive surgery is with a degenerative or pathogenic acetabulum; therefore
preferred for cases with obvious vertebral compression femoral head replacement is selected considering its
(vertebral height loss greater than 1/3), damage to the overall decreased surgical time, as complete removal
posterior wall of the vertebral body and significant pain simplifies manipulation and replacement, as well as better
responding poorly to conservative treatment. Percutane- control and reduction of intra-operative bleeding. Elderly
ous vertebroplasty and kyphoplasty are recommended for patients are prone to sedentary lifestyles especially when
effective analgesia, stabilization of the vertebral column, affected by disabling pain; surgical treatment therefore
restoration of the physical curvature of the spine and, allows an improvement in overall quality of life. For some
most importantly, early mobilization. This surgery should patients, THA may also be considered to be a positive
be conducted with intra-operative radiological assistance treatment choice.
(such as X-ray, CT, and navigation), and it is recom- For intertrochanteric fractures complicated by fracture
mended that surgeons gain accreditation through formal displacement, open reduction and internal fixation are
training programs, with resultant standardization of sur- considered, with optional intramedullary or extramedul-
gical techniques. Such measures reduce the risk of com- lary nail implantation. The intramedullary nail implanta-
plications such as bone cement leakage and nerve root or tion system includes the Gamma nail, proximal femoral
vascular injury. Vertebral burst fractures are often caused nail, and reconstruction nail. Extramedullary nail systems
by vertical compression or a vertical flexing compression include the dynamic hip screw, locking compression plate,
force, and are characterized by bursting of the anterior and hip anatomic plate. The best internal fixation tech-
and interior columns, causing fracture of the posterior nique to choose depends on specific patient characteris-
aspect of the vertebral body. Within recent years, there has tics, as well as on the individual surgeon’s experience in
been a positive trend in the surgical treatment of vertebral regards to these related procedures.
burst fractures towards active reconstruction and mainte-
nance of the mechanical stability of the vertebral column, Fracture of the distal radius
and as much restoration and maintenance of neural func- Because osteoporotic fractures of the distal radius are
tion as possible. often comminuted, these fractures can extend into, and
Because spinal osteoporotic fracture is associated with involve, the articular surface. Fracture healing can then be
a marked increase in new fracture risk (spinal or non- complicated by deformity, resulting in chronic residual
spinal), positive identification and diagnosis is a crucial pain and crippling dysfunction of the wrist and hand.
step in active enhancement of osteoporotic treatment and Treatment considerations should therefore focus ini-
prevention of falls. tially on closed manual reduction, with application of

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Orthopaedic Surgery (2009), Volume 1, No. 4, 251–257 255

external gypsum-splint fixation. With manual reduction, Judicious and sufficient calcium supplements can slow
careful restoration and alignment of a smooth articular bone loss, and have been reported to result in improve-
surface, normal volar tilting angle and ulnar inclination is ment in bone mineralization. Calcium supplements
crucial. For comminuted fractures of the distal radius should always be administered as an adjunct and in
involving articular surfaces, unstable distal radius frac- combination with other anti-osteoporosis agents in
ture, and unsatisfactory manual reductions, surgical treat- osteoporosis treatment. Vitamin D deficiency progresses
ment is recommended. Either external fixation, or open into secondary hyperparathyroidism, with increased bone
reduction and internal fixation implantation, may be resorption, and consequent worsening of osteoporosis.
selected according to the specific characteristics of the Managed Vitamin D supplements may promote bone
fracture. mineralization, through improving gastrointestinal
absorption of calcium, reducing overall calcium excretion,
Proximal humeral fracture enhancing muscle strength and hence improving neuro-
Non-surgical treatment is the principle option to be muscular coordination and balance.
considered for nondisplaced fractures of the proximal
humerus. Fracture reduction manipulation includes using Drug therapy
a simple suspending neck-wrist sling, chest bandage Because osteoporotic fracture is a complication of
immobilization and shoulder brace fixation. Surgery is osteoporosis; administration of effective anti-
considered without hesitation for displaced fractures of osteoporosis drugs lays the foundation for its treatment.
the proximal humerus, choosing between closed or open Drug therapy slows bone loss, improves bone quality and
reduction and internal fixation, or prosthetic femoral strength, alleviates pain, treats established osteoporosis
head replacement. without compromising fracture healing, and finally
For the open reduction and internal fixation of reduces the incidence of secondary fractures.
osteoporotic fractures, a proximal humerus plate, or Currently approved anti-osteoporosis agents include
locking compression plate is used, as these result in less the following (listed in alphabetical order):
loosening and disturbance of surrounding soft tissue than Bisphosphonates are anti-resorption drugs which
other techniques. Another commonly used, minimally inhibit osteoclast-mediated bone resorption, reducing
invasive procedure involving the use of a Kirschner wire, bone turnover. Strong inhibition of osteoclast absorption
screw and tensile wires facilitates surgical manipulation, results in an increase in bone mass. Evidence-based
fixes the greater tubercle firmly onto the humeral neck, medical studies indicate an increase in BMD of the
and also reduces peripheral tissue damage. However it is lumbar spine and hip, with decreased fracture risks.
less efficient for severe comminuted fractures. Prosthetic Calcitonin causes moderate inhibition of osteoclast
femoral head replacement is recommended for elderly biological activity, indirectly reducing the active osteoclast
patients with multiple fractures (more than three frac- population. Evidence-based medicine confirms that calci-
tures) or comminuted fractures of the distal humerus. tonin can inhibit bone resorption, improve the BMD of
the lumbar spine and hip, and provide a rapid, centrally
5. Anti-osteoporosis treatment mediated analgesic effect in acute osteoporotic bone pain.
Aside from surgery, active treatment of osteoporosis is The mechanism of estrogen in osteoporosis treatment
advocated in patients with fragility fractures. includes its effects on the hormone calmodulin and skel-
etal bone tissue, as well as inhibition of osteoclast activa-
Basic preventive measures tion. It is indicated only in postmenopausal patients.
The basic principles of general prevention depend Parathyroid hormone (PTH1–34) provides a new
upon maintenance of a healthy lifestyle, including a approach, as it promotes bone formation by increasing
balanced nutritious diet enriched with Vitamin D and collagen secretion by osteoblasts and promoting the
calcium, reduced salt consumption and adequate protein formation and mineralization of bone matrix, a mode of
intake. For patients with certain addictive tendencies, action rather different to the anti-resorption effects of
quitting smoking and reducing consumption of alcohol previously utilized drugs.
provides a general foundation for a healthy lifestyle. Selective estrogen receptor modulators (SERM) have
Various concomitant drug therapies can negatively influ- estrogen-like actions in regards to the skeletal and cardio-
ence bone metabolism, hence should be monitored closely vascular system. However in female specific organs such as
by a physician. Regular physical exercise and rehabilitation the breasts and uterus, SERM act as estrogen inhibitors,
to increase muscular strength and overall coordination are blocking necessary hormone function with resulting car-
also recommended. cinogenic complications. SERM act on skeletal estrogen

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256 Chinese Orthopaedic Association, Diagnosis & treatment of osteoporotic fractures

receptors which in turn inhibit osteoclast activity. quality. It is effective in reducing the incidence of
However, the use of SERM is confined strictly to post- osteoporotic vertebral fractures. Early calcitonin treat-
menopausal osteoporosis. ment offers an outstanding analgesic effect for acute
The newest anti-osteoporosis agent that has been intro- osteoporotic vertebral fracture, with simultaneous
duced clinically is strontium ranelate. Its mode of action is control and decrease of bone loss. Studies of calcitonin
of a new category and it has been uniformly accepted by have shown safety and tolerance with no adverse reac-
clinicians. In contrast to the original anti-resorption and tions or disturbance of the healing of osteoporotic
bone formation promoting drugs, strontium ranelate is fractures. Recommended treatment is salmon calcito-
an uncoupling agent which promotes ossification with nin 50 IU/day by subcutaneous or intramuscular injec-
simultaneous inhibition of bone resorption. It has been tion, or 200 IU/day as a nasal spray. Common transient
reported to restore dynamic bone turnover balance and adverse reactions following initial administration
reduce the risk of vertebral and hip fractures. However include flushing, nausea and mild dizziness, with spon-
current indications are limited to postmenopausal taneous relief within a few hours. However calcitonin
osteoporosis. treatment is contraindicated in patients with an
Various clinical studies have reported possible efficacy obvious history of drug allergy or calcitonin allergy.
of traditional Chinese herbal remedies, with symptom 4. Mineral bisphosphonates can increase the BMD of the
relief, and reduction in bone loss and incidence of lumbar spine and hips, with consequent reduction of
osteoporotic fractures. However further investigations are fracture or re-fracture risks. Recommended bisphos-
required to fully understand the mechanism and pharma- phonates include alendronate, risedronate sodium, and
cological dynamics of herbal treatments. zoledronic acid. Today, two therapeutic regimes are
in use for alendronate: 70 mg orally/week and 10 mg
Recommendations for post fracture orally/day. We recommend once daily administration,
anti-osteoporosis medication 30 min before breakfast, followed by at least 250 ml of
1. Moderate calcium supplements are the basis for all water. In order to reduce gastrointestinal complica-
anti-osteoporosis therapy. Calcium is absorbed mainly tions, the patient should remain standing and avoid
in the intestines, hence oral administration of calcium bed rest for at least 30 min after taking alendronate
agents ensures maximum efficacy. The recommended orally. Drug compliance should be closely monitored,
daily calcium dose for an adult ranges from 800 to especially in patients who are bed-ridden. The major
1200 mg. Insufficient daily calcium intake should be adverse reactions to bisphosphonates are gastrointesti-
countered with oral calcium supplements, in accor- nal, such as nausea, vomiting, abdominal pain and
dance with recommended dosage and frequency. Con- diarrhea.
sidering the rapid bone loss in cases of osteoporotic 5. SERM are effective ein improving the BMD and
fracture, an increase in calcium dosage is suggested. reducing postmenopausal osteoporotic fractures. The
However in order to minimize unwanted side effects, dosage generally recommended is raloxifene 60 mg/
when increasing dosage judicious attention should be day; its absorption is not affected by food. Some
paid to the prevention and avoidance of complications patients experience recurrent fever and spasms of the
of calcium overdose, such as renal lithiasis or cardio- lower extremities while taking this medication. For
vascular diseases induced by calcification and stenosis peri-menopausal patients with severe recurrent fever
of vessels. and flushing, the medication should be terminated
2. Active supplementation with Vitamin D3 not only and reconsidered. SERM treatment is contraindicated
enhances intestinal calcium absorption and promotes in patients with a positive history of venous throm-
bone formation and mineralization, but also strength- bosis and thrombotic risk factors, such as being bed
ens muscle, improves neuromuscular coordination, ridden, sedentary, or having concomitant cardiovas-
and reduces the risk of falling. Active vitamin D3 is cular disease.
recommended for elderly patients with osteoporotic 6. Strontium ranelate has a double mechanism of action.
fracture; the recommended adult dosage is 0.25– It can increase bone strength and decrease the risk of
0.5 mg/day., Serum or urinary calcium should be regu- vertebral fracture due to its effect on both bone resorp-
larly monitored during active vitamin D3 treatment, tion and formation. The recommended dosage is
and careful attention paid to individual patient differ- strontium ranelate 2 g/day, 2 h after dinner or at
ences and clinical safety. bedtime. Common adverse reactions include head-
3. Calcitonin enhances the overall biomechanical proper- ache, nausea, diarrhea, loose stools, dermatitis, and
ties of bone through an increase in BMD and bone eczema. Strontium ranelate should be used only after

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Orthopaedic Surgery (2009), Volume 1, No. 4, 251–257 257

careful consideration and with appropriate precau- Prophylactic treatment

tions when treating patients with a positive history of 1. Quit smoking, limit alcohol consumption, ensure a
thrombosis or embolism. balanced diet and adequate nutrition.
7. Chinese herbs may be effective in pain relief and in 2. Maintain a stable healthy body weight, refraining from
reducing swelling with some improvement in the sudden or massive weight fluctuation or loss.
BMD. However further studies are required to update 3. Adopt a moderate, individually designed exercise
and provide information regarding their true clinical regimen to increase muscle strength and improve sense
efficacy. of balance and coordination.
8. Osteoporosis is a chronic systemic metabolic bone 4. Ensure adequate sun exposure through selected appro-
disease. Osteoporotic fracture patients should adhere priate outdoor activities.
to long-term anti-osteoporosis therapy under the close 5. Adopt precautionary measures to prevent falls and
guidance of responsible physicians to prevent the trauma.
occurrence of further fractures. Patients with second- 6. Judicious preventive drug therapy.
ary osteoporosis should receive treatment for predis- This guideline serves only as an academic reference for
posing diseases and conditions. clinical practice. With future developments and improved
discoveries in the field of medicine, this information is
clearly subject to change. This guideline should be read
6. Prevention of osteoporotic
and applied in accordance with a thorough understanding
fractures
of individual patient characteristics and specific medical
Risk factors needs. The summarized product information provided is
1. Major risk factors: Falling, low BMD, positive history not to be regarded as definitive administration guidelines.
of osteoporotic fractures, age >65 years, and positive It is recommended that clinicians refer to and read
family history of fracture. product specific literature or product information before
2. Secondary risk factors: excessive smoking and alcohol prescribing anti-osteoporosis preventive and/ or thera-
consumption, low body mass index (kg/m2), hypogo- peutic measures.
nadism, premature menopause (<45 years old),
malnutrition, history of concomitant diseases, drug
Disclosure
therapy with substances which affect bone metabolism
(e.g. glucocorticoids, heparin), rheumatoid arthritis, A Chinese version of this paper was published in the
hyperthyroidism, and hyperparathyroidism. Chinese Journal of Orthopaedics, 2008, 28: 875–878.

© 2009 Tianjin Hospital and Blackwell Publishing Asia Pty Ltd