Hip Care: Expert Diagnosis and Treatment

[MUSIC PLAYING] Hello, and welcome to "At the Forefront Live." Fragility fractures, broken bones related to osteoporosis, affect more than 2 million people over the age of 50 in the US each year. Yet less than 20% of these patients receive the right care for their underlying disease. The Bone Health Clinic at UChicago Medicine identifies, evaluates, and treats patients who have osteoporosis or have had fractures related to low bone density.

Orthopedic surgeon and fragility fracture expert Dr. Doug Dirschl and advanced practice nurse and bone health specialist Lauren Creighton join us today to discuss this issue. And as always, we'll take your questions during our 30-minute program. That's coming up right now on "At the Forefront Live."

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And we want to remind our viewers that today's program is not designed to take the place of a visit with your physician. Let's start off by having with each of you introduce yourselves and tell us what you do here at UChicago Medicine. Dr. Dirschl, let's start with you.

Thanks. It's a pleasure to be here. I'm Doug Dirschl. I serve as chairman of the Department of Orthopedic Surgery and Rehabilitation Medicine here at the University of Chicago. I am a fracture surgeon and have been instrumental in promoting national osteoporosis and fragility fracture programs over the last decade.

Lauren?

Hi, I'm Lauren Creighton. I'm a board-certified nurse practitioner. I work here in the orthopedic department seeing patients with general non-operative orthopedic issues. I also see patients in our Bone Health Clinic. These types of patients are normally over the age of 50 who have suffered a low-impact or fragility fracture.

All right. Let's just start off with kind of a general question, Dr. Dirschl, and let's talk about fragility fractures. And can you define what that means?

Yeah. Well, there are two ways to define fragility fracture, either of the following-- either a fracture that occurs through no more energy than a simple fall from a standing height. The second definition is any fracture in a patient over 50 years old. Given that osteopenia and osteoporosis are so prevalent in the population over 50, this is the most commonly used definition of a fragility fracture.

And we want to remind our viewers that we will take your questions from our experts, so just type them in the comments section, and we'll try to get to as many as possible over the course of the program. So can you tell us what causes bones to be fragile or break easily?

There are numerous causes. Many, many, many things cause bones to get weak-- diet, lifestyle are two things that can cause bones to be weak, medications. Believe it or not, the treatment for many common medical problems is bad for bones, causes bone to weaken. By far and away, though, osteoporosis, just general, overall loss of bone mass over years and years is the most common cause of weak bones that lead to fragility fracture.

And Lauren, I think the natural question that comes out of this is people will want to know what to do to prevent fragile bones or bone loss. And as Dr. Dirschl said, a lot of this just happens over time but aren't there steps you can take to help protect yourself?

Yes, there's a lot that we can do to help prevent bone loss and keep our bones healthy and strong, the first being making sure that we're getting enough calcium and vitamin D. A lot of calcium comes from the foods that we eat, things like dairy products, even spinach, leafy greens, and oranges. Vitamin D is a little bit tougher to get through dietary sources, so a lot of times, we'll encourage patients to take a supplement. Calcium helps to keep the bones strong, and vitamin D helps to absorb the calcium in our body. So they work hand in hand.

Making sure that you're maintaining an active, healthy lifestyle is also very important. The more active you are, the more good stress that you're putting on your body and your bones, keeping them healthy. So we encourage weight-- we call them weight-bearing exercises. These are exercises that force your body to work against gravity. So things like jogging, hiking walking, running are important physical activities that you can do.

Another huge factor is smoking. If you smoke, please stop. This severely impacts your bone health. We know that nicotine prevents how we absorb calcium and different minerals into our body. So it's important to try to quit smoking. Not only can it help your overall health, but it is an important factor in your bone health.

Two really interesting points you just made right there. And smoking is something we hear about in almost every one of these programs. We'll have our experts and our physicians that will come on and say you should stop it because of this reason. It impacts everything. It's just amazing to me. I didn't know that it even had an impact here, but here we are.

The other point that I'm kind of curious, and I wonder if you can expound on it a little bit, is muscle mass. And you mentioned exercise and how important that is. Having muscle mass, does that help take some of the stress off? Is that what you're looking at there?

Yes. It goes it goes hand in hand. Performing gentle kind of weight-resistant exercises that will help build up your bone mass is also an important activity. As we age, our muscle thins and atrophies. So making sure that we're doing weight training, whether it be light weight or working with a resistance band, can help increase our muscle strength and muscle mass.

So Dr. Dirschl, I've kind of got a two-parter for you here. How do you know that you have a fragility fracture? I imagine that's a little different than just a regular break of a bone, but maybe not. Can you answer that for us? And then how long does it take one of these fractures actually to heal?

As a general rule, fragility fractures are not unique as fractures go. They are common, everyday fractures. And just by looking at the X-ray or just by experiencing the fall, if you're the patient, you probably might not recognize this as a fragility fracture rather than any other sort of fracture. But it's really important that that is pointed out. What we've learned over the years is that most patients are in denial about whether or not their fracture might have been a fragility fracture, about whether or not they might have osteopenia or osteoporosis.

And that leads to the statistic you quoted at the beginning. That leads in a great way to the only one in five patients getting the proper treatment for their underlying bone condition. Also, it's really important that the providers, that the physician, that the nurse practitioner, that anyone who sees the patient after fracture points out to them there's a chance that this is a fragility fracture. And just like they check their blood pressure or their cholesterol or anything else, they ought to consider checking their bone health and managing that, because it's a very, very common contributor to any fracture in a patient over 50.

Fragility fractures are no different than other fractures in how they heal or in their rate of healing. Certainly, the rate of healing depends on a lot of factors. One's age, whether it's an upper- or lower-extremity fracture, your medical condition, your metabolic health, the medications you're on. We know, of course, that children's fractures heal faster than young-adult fractures, and young-adult fractures heal faster than older-adult fractures. But it's really important to recognize that osteoporosis doesn't cause fractures to heal more slowly. It just makes fractures far more likely.

An additional point there-- and this is a common misconception-- is that medications and treatments for osteoporosis actually don't delay or retard fracture healing. It is perfectly OK, it's safe, for a patient to be on an anti-osteoporosis medication while they are healing a fracture. Or it's not necessary to stop those medications because one has had a fracture, because they do not impair the fracture.

Interesting. So you've talked about osteoporosis a couple of times. Can you just tell us exactly what osteoporosis is and how that's diagnosed, Dr. Dirschl?

Yeah. There are two-- really two definitions. The most common definition, the most precise definition, is dependent on one's bone mineral density. There's a scan called a DEXA, Dual-Energy X-ray Absorptiometry. You can see why we call it DEXA. That is a simple, easy test to measure your bone density.

And if your bone density is more than 2.5 standard deviations lower than that expected for a young adult person of your gender, that is defined as osteoporosis. We call that a T-score. And so a T-score of minus 2.5 or lower is the diagnostic criteria for osteoporosis.

The other definition-- less precise, but equally as accurate-- is that anyone who has sustained a fracture of the hip or of the spine, a fragility fracture of the hip or spine, almost by definition has osteoporosis, even without the need for a bone density study.

Interesting. So we do have some questions coming in from viewers. And I want to get to as many of those as we possibly can. The first one is from Ally. If someone has already been diagnosed with low bone density or early osteoporosis, what are some of the best ways for them to prevent further bone loss or fractures? And Lauren, I don't know if that's one that you want to take?

Sure. So it's important that you-- even if you're on medication for osteoporosis, that you're still making sure that you're getting adequate daily calcium and vitamin D. Just because you have low bone density doesn't mean that you can't do some of the techniques that we talked about earlier to maintain the current bone that you have. So exercising, making sure that you have a healthy diet, that you're maintaining a healthy weight, these are all things that can help maintain the current bone that you have.

So our next question from a viewer is from Elizabeth. At what age should we start having bone density tests? And are there specific reasons why you should be having these bone density tests? I would imagine you don't just ask your physician for that, but maybe you do. And Dr. Dirschl, I don't know if you want to weigh in on that one.

I certainly can. The current recommendation is that if you're otherwise healthy and have never had a fragility fracture, you begin getting bone density studies sometime in your 60s or so. If, however, you've sustained a fragility fracture, or you are at high risk for fragility fractures due to medical conditions, due to treatments for medical conditions that can be bad for bones or other things, then you should get a bone density scan earlier.

One other point I want to be sure to make is, if someone has sustained a fragility fracture, they become far more likely to sustain future fragility fractures in the upcoming years. It's estimated that the incidence of fragility fractures goes up as high as 12-fold after one has sustained the first fragility fracture. There are numerous reasons for this, and we published some research here that indicated some of the causes of this.

But one of the key ones is that sustaining a fracture causes an inflammatory response, or a heightened metabolic response, in the patient, which accelerates the rate up to five times as great as how fast the bone mass is lost. So if you've sustained a fragility fracture, it's very, very important not to ignore that and to seek a bone health consultation and perhaps treatment if it's indicated.

So a fracture can actually cause you to have greater bone loss or faster bone loss? That's interesting.

Yeah. Our research indicated that in a large cohort of patients who had hip fractures, in the first year following their hip fracture, they lost bone throughout their body at a rate five times that expected in an otherwise normal postmenopausal female population.

That's kind of a frightening statistic. So definitely something you want to be aware of. Another question from a viewer, this is from Bonnie. I hear that some foods can leach calcium from the bones. What can you tell us about the latest thoughts on that? And I don't know, Lauren, do you want to take that one? Either one of you can take that one.

I'll take it. There are certainly foods that are less beneficial to your bones than others. I don't believe there are foods, when eaten as part of a normal diet in moderation, that are going to really, really leach calcium from your bones. So the best advice there is to have a good, balanced diet. Leafy green vegetables are one of the best sources of calcium.

At our latitude in the world, it's impossible to get enough vitamin D from sun exposure alone. So vitamin D supplementation should be a part of every adult's diet in Chicago or anywhere in North America. So I wouldn't be too concerned about foods that leach calcium, but I would strongly recommend a balanced diet with lots of vegetables.

You know, it's interesting, Dr. Dirschl. You brought up vitamin D, and Lauren did a few moments ago. And in this part of the world, particularly when we start hitting those January, February, March months, I think it can be more of an issue for people, even than perhaps the rest of the year. Would you advise people to have their vitamin D tested by their physician?

So now, vitamin D levels are checked normally as a part of a yearly or annual health screen done by your primary care provider. Vitamin D is also checked after you sustain a fracture or have been diagnosed with osteoporosis, since we know the two are so closely linked.

And you're right. Unfortunately, living in the Midwest, vitamin D is a little bit harder for us to get naturally. So making sure that you have an adequate vitamin D level makes you feel better. It protects your bones and helps your body to absorb calcium.

Yeah, it can help in just a myriad of different ways. So that's probably a really valuable thing for people to do. So another question from a viewer. This one's from Michael, can bone loss be reversed once it has set in? And Dr. Dirschl, I don't know if you have any thoughts on that one.

Bone loss can be reversed. There are numerous treatments that can actually not only prevent the loss of bone mineral, which, by the way, occurs naturally throughout our lives. We reach peak bone mass sometime in our late 20s or early 30s and then slowly lose bone mass for the rest of our lives.

And so many of the things Lauren has talked about and that we think are really important will help slow that rate of loss. But this is a natural loss of bone. But there are numerous treatments that can actually reverse it completely, that can help you build back more bone mass. These treatments come in two major categories. They're called anti-resorptive medications, and then there are anabolic medications, so those that actually build bone directly.

But both types of treatment are perfectly good. They're approved, and they're well-accepted and tried and true. And they can both reverse bone. At best, one will gain about 1% of bone mass per year. You probably can't expect anything faster than that. Bone is a wonderful thing, but it metabolizes very slowly. And so while bone mass loss tends to be slow, bone mass gain is also.

Interesting. So our vitamin D talk apparently is hitting a bit of a nerve with several people. We're getting more questions. This is a good question, very interesting. This is from Ben. Would I be able to take a low vitamin D supplement without seeing my provider, or do I really need to go and see someone? Also, does a vitamin D lamp suffice?

So most people can take a daily low-dose vitamin D without having to be monitored or see their healthcare provider. The thing to stress here, though, is a lot of times, we have no idea what our vitamin D level is, since we don't get a lot of vitamin D through food sources. So I do encourage people to have their vitamin D level checked.

The normal kind of daily recommended dosage of vitamin D is 800 to 1,000 international units per day. But we do see patients who are severely deficient, and they occasionally will need a prescription-strength vitamin D supplement.

Now, the other side of that question is, can you have too much vitamin D? We've had a couple people ask that.

It's very difficult to get too much vitamin D. Well, anything is possible. In clinical studies conducted where patients were administered 50,000 international units of vitamin D every day for six weeks, and none of them reached toxic levels. So while I don't recommend that dose routinely for everyone-- I recommend about 1,000 to 2,000 units a day for most adults-- vitamin D has a very wide safety range, and it's difficult to take too much.

Great. So Judy asks, what's the best osteoporosis treatment with the least amount of side effects? That's kind of a general question, but it's a good question.

So when we're talking about treatment options for osteoporosis, it's very patient-specific. And there's not a general overall treatment that's the best for everybody. So the goal of these medications is to help slow down bone loss and prevent fractures in the future.

A lot of factors go into deciding which medication is selected for which patient. so things such as, do you have other medical conditions-- for instance, kidney disease or cancer-- these types of things can play a role in what we choose to treat patients with osteoporosis. We also look at the severity of the bone loss and also patient preference in the type of medication that they're taking. Usually, we start with bisphosphonates. These are medications that are normally a first-line treatment for osteoporosis. All medications come with risks and side effects. And I encourage people to talk to their provider to go over these and really understand the risks versus benefits of a lot of these medications.

So Tiffany has a question, and that is, should menopausal women be concerned about their bone health? I've heard that when your estrogen levels decrease, it can affect your bones. Dr. Dirschl?

They absolutely should, as should every adult in this country, male or female. And osteoporosis in men is a very unrecognized disease, but it does occur. I talked earlier about that natural loss of bone mass from the peak in our-- around age 30. So that does occur around the time of menopause. For about five years, that rate of loss doubles. And then at some point after menopause, it then, in most people, returns back to that standard rate of loss of about 1% per year.

But yes, everyone, particularly around the time of menopause and for the rest of one's life, should be concerned about this. But it's not just a disease of women. I want to be very clear about that. Men should be conserved as well.

So that brings me to the next logical question, is there an age that maybe, for example, a man should go in to see his care provider and say, hey, maybe I need to have this checked out? What do you think?

So as we talked about the recommended testing for men for bone density screens, generally, the age is 70. Again, different risk factors can play a part in getting the bone density scans early. But most people should be getting annual physicals and talking about these things and looking at different levels of blood work, vitamin D, calcium, and these kinds of things. So as we are over 50 years old, I think it's very important to discuss these things at any visit that you have with your healthcare provider.

So are there specific risk factors for fragile bones that people need to be aware of, other than just age?

Yeah, there are a variety of factors.

I--

Sorry, Lauren. But one of the key issues with low bone mass, osteoporosis, and fragility fracture is that there aren't very many predispose-- well, there are a lot of predisposing factors. But it's a very silent disease. You don't get a warning shortly before or six months before you're likely to have a fracture.

And so it's really important that surveillance and awareness are really very, very critical. But yes, we talked about smoking earlier. Heavy alcohol use leads-- can help predispose to osteoporosis. Many medications, including some seizure medications, some cancer medications, and corticosteroids-type medications, can lead to rapid osteoporosis. If you have severe renal disease, that leads to a type of osteoporosis, but one with very weak bones. So there are a number of factors, in addition to just your age, that you need to think about as predisposing to poor bone mass or osteoporosis.

So Lauren, is osteoporosis hereditary?

Research has shown that there is a genetic component to osteoporosis. So if a parent had osteoporosis or had a hip fracture in their life, it does make you more prone to have osteoporosis in the future. We know that you can't pick your family, so a lot of times, these issues are genetic. But there's also a lot, as we discussed, that you can do to reduce your risk.

So we've talked a little bit about the Bone Health Clinic. It's been mentioned a couple of times in the program. Lauren, I wondered if-- we've only got a few minutes left-- if you could kind of take us out and tell us a little bit about the Bone Health Clinic and what happens there, what services are available there.

So we developed the Bone Health Clinic a few years ago. Our primary goal was to identify and evaluate patients that are high-risk from our current pool or current orthopedic population, as well as patients from other medical services. As Dr. Dirschl discussed, we know that having a fracture is one of the most powerful risk fractures-- sorry, risk factors to have a future risk, future fracture.

So when we see patients in the clinic, we are discussing certain risk factors that they might have. We're ordering bone density testing and lab work. We're also providing education around things that people can do to decrease their risk, as well as developing patient-specific treatment plans that will work for each individualized patient.

And Dr. Dirschl, you have a fantastic team. And I know this is certainly a team effort when you work with these patients. And there's a lot of folks that are involved in this work. And that's kind of critical, I think, to this, because it really-- it shows the care that patients do get here at UChicago Medicine.

One last thing I do, if you can comment on, is just the safety of obtaining care during COVID. We're a very safe place. And Dr. Dirschl, I don't know if you want to comment on that. But I think that's important. People do need to seek care if they need care. They shouldn't avoid it.

Yeah, I couldn't agree more. If you need care, you should seek care. And we do our very best to make that care safe in every way and in every location at the University of Chicago Medicine. Additionally, though, we have the availability of virtual visits, visits that occur much as we were recording this and broadcasting this today. We're not all in the same room, and we'd be more than happy to consult with you in a virtual manner.

Clearly, at some point, we may need a bone density study, a DEXA scan, or some laboratory studies. But many of the things that the Bone Health Clinic offers can be offered in a virtual manner. So that's always an option. But please, I assure you, it is safe to come to the University of Chicago Medicine outpatient locations. We have your safety at the forefront of our minds, and we'll provide you both safe care as well as high-quality care.

That is perfect, very well put. We are out of time. You were both fantastic, and you shared a lot of, I think, very valuable information with our audience. So thank you for doing that. And thank you to our viewers for your great questions. Remember to check out our Facebook page for our schedule of programs coming up in the future.

And if you want more information about UChicago Medicine, take a look at our website at UChicagoMedicine.org. If you need an appointment, give us a call at 888-824-0200. And remember, you can schedule those video visits that Dr. Dirschl just referenced a moment ago by going to the website. Thanks again for being with us today, and I hope you have a great week.

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