News Secondary osteoporosis: More than what meets the eye!
A Singapore General Hospital (SGH) study has revealed that considering all osteoporotic patients as having simple osteoporosis and treating all of them alike by putting them on potent long term medication without finding out the cause of their osteoporosis may be inef- fective and in most cases downright harmful. Secondary osteoporosis is a rather com- mon but lesser known type of osteoporosis that affects men and women of any age. It is caused by certain medical conditions that re- sult in bone loss or interfere with development of peak bone mass. Contributors of secondary osteoporosis include conditions such as hyper- calciuria, hyperthyroidism, hyperparathyroid- ism, vitamin D deficiency and hypogonadism. The study is the first of its kind in South East Asia. To find out how common these secondary osteoporosis contributors are in our popula- tion, a team led by Dr Manju Chandran, Pro- gramme Director, Osteoporosis and Bone Me- tabolism Unit at SGH, evaluated 400 patients
over two years. The study found that almost half of the patients with osteoporosis had one or more secondary contributors. Secondary osteoporosis, if not identified and treated, can lead to devastating consequences both in terms of fractures as well as from the disease that caused the osteoporosis in the first place. Conditions that contribute to secondary osteoporosis may not be obvious without de- tailed history taking and laboratory testing. The study revealed that 22 per cent of the pa- tients with a secondary cause had increased calcium excretion in the urine, which in most cases could be attributed to a high salt diet. An- other 18.5 per cent had vitamin D deficiency, 10.1 per cent had hyperthyroidism and nearly 10 per cent of the men had hypogonadism or low sex hormone levels. “In our study, the prevalence of secondary osteoporosis in men was found to be high, al- most 63 per cent. Our recommendation is for all men with osteoporosis to have some basic laboratory testing to look at their levels of male
hormone, urine calcium, vitamin D, thyroid function, etc.,” said Dr Chandran, who is also Consultant, Department of Endocrinology, SGH and President, Endocrine and Metabolic Society of Singapore. “For post-menopausal women, laboratory
testing may not be feasible or cost effective as post-menopausal osteoporosis is very com- mon. However, directed testing based on their bone mineral density loss can be done to de- termine the appropriate treatment for these pa- tients. The appropriate treatment for secondary osteoporosis is treating the condition, which caused it in the first place and not antiosteopo- rosis medicines,” Dr Chandran added. It is estimated that about 55,000 to 60,000
female Singaporeans above the age of 50 suffer from osteoporosis and that excludes men who are also hit by the disease. While secondary os- teoporosis may not be completely reversible, the right treatment can halt the progress of bone loss and prevent excessive fracturing and in some cases even save the life of the patient.
High blood sugar, obesity increase risk for surgical site infection
Two recent studies in the July issues of the Journal of Bone and Joint Surgery (JBJS) looked at surgical site infections and hyper- glycemia. According to the first study “Rela- tionship of Hyperglycemia and Surgical-Site Infection in Orthopaedic Surgery,” high blood sugar is a concern during the post-traumatic and post-operative period and it may help to preoperatively identify a population of pa- tients with musculoskeletal injuries who are at significant risk for infectious complications. Study authors reviewed data on patients 18 years or older who had isolated orthopaedic injuries requiring acute operative intervention. Patients diagnosed with diabetes or who were in the ICU were not included in the study. Of 790 patients, there were 268 open frac- tures (if the bone breaks in such a way that bone fragments stick out through the skin, or a wound penetrates down to the broken bone), and 21 surgical-site infections (SSIs) at 30- day follow-up. Age, race, comorbidities, in- jury severity, and blood transfusion were not associated with SSI at 30 days.
Specific study details: SSIs developed in 13 of 294 patients (4.4 percent) who had more than one glucose value greater than or equal to 200 mg/dL and 8 of 496 patients (1.6 percent) without more than one glucose value greater than or equal to 200 mg/dL. The au- thors concluded that hyperglycemia was an independent risk factor for thirty-day SSI in orthopaedic trauma patients without a history of diabetes.
This study suggests that recognition of the relationship between hyperglycemia and infectious complications may substantially influence post-operative care of orthopaedic patients. Large, prospective, randomised stud- ies are necessary to further delineate this re- lationship. A second study featured JBJS, found that
diabetes and morbid obesity increased the risk of infection following hip and knee replace- ment. Authors of “Obesity, Diabetes, and Preoperative Hyperglycemia as Predictors of Periprosthetic Joint Infection” analysed 7,181 hip and knee replacements and found that
52 post-operative joint infections occurred within the first year, and that the infection rate increased from a .37 percent in patients with a normal body index to 4.66 percent in the morbidly obese group. Normal BMI was defined as a body mass index (BMI) of less than 25, while morbid obesity was defined as more than 40. (BMI is a calculation that is de- termined using height and weight). The authors suggest that identifying and/ or treating hyperglycemic patients preopera- tively, especially if they are obese, would help patients achieve a better outcome by avoiding complications caused by infection. In addi- tion, identifying patients with undiagnosed diabetes would be important for their overall long-term prognosis. Authors further conclude that the benefits of joint replacement should be carefully weighed against the incidence of postoperative infection, especially among the morbidly obese patients.
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