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Osteoporose –
Wissenschaftliche Basis
current concepts Christian Muschitz
II. Med. Abteilung – KH Barmherzige Schwestern Wien
Medizinische Universität Wien
Agenda 2016
Osteoporose – Klinische Einteilung
Knochen – ein endokrines Organ
Frakturen und Re-Frakturen in Österreich
BMD Messungen vs Struktur
Klinische Risikofaktoren (CRF) - Osteo Check, DVO Leitlinie
C. Muschitz Zicksee 2016
Osteoporose –
Klinische Einteilung
C. Muschitz Zicksee 2016
The clinical diagnosis of osteoporosis
Siris ES et al. Osteoporos Int. 2014
Position statement National Bone Health Alliance Working Group:
Low-trauma fracture („low-energy“ – fall from standing height):
• Hip
• Clinical or morphometric vertebral
• Proximal humerus
• Pelvis
• Distal radius
FRAX/clinical risk factors – 10 year fracture probability:
• Major osteoporotic fracture ≥ 20%
• Hip fracture ≥ 3% (USA) – ≥ 5.0% (Austria)
BMD testing: A T-score ≤ -2.5 at spine or hip contributes to the
diagnosis „osteoporosis“.
Treatment interventions should not solely based upon BMD
measurements.
Der Knochen –
ein endokrines Organ
C. Muschitz Zicksee 2016
Bone specific cells
Riggs A et al. J Bone Miner Res. 2015
Adaptiert nach Sims NA, et al. Bonekey Rep.
2014;3:481.
Osteoclast precursors
MSC
HSC
Pericyte
Canopy
Macrophage
T-cell
Osteoblasts
OC precursor
Osteocytes
Osteoblast precursors
Anatomy & Physiology, Stax College 2013
Peak Bone Mass – Gender Differences
Modeling vs Remodeling
Ominsky M et al. J Bone Miner Res. 2015
Bone modeling:
Child and adolescent – growth of
bone; formation and resorption
occur on seperate surfaces
Bone remodeling:
Formation and
resorption occur on
same surfaces
Frakturen in Österreich
C. Muschitz Zicksee 2016
Osteoporotische Frakturen
Die Größe
des Problems
Die AUVA - Frakturstudie
UKH Meidling
UKH Linz
UKH Salzburg
UKH Lorenz Böhler
UKH Graz
UKH Klagenfurt
UKH Kalwang
Muschitz C et al. Manuscript in preparation
AUVA is highly representative for the Austrian population
Dimai HP et al. Osteoporos Int. 2014
Retrospektive
Beobachtungsstudie
anonymisierter
Patienteninformationen
AUVA (alle 7 Spitäler in Österreich)
Jänner 2000 bis Dezember 2012
433.499 Patientinnen und Patienten
575.772 hoch- und niedrig-traumatische Frakturen
Ausschließlich de novo Frakturen
Die AUVA - Frakturstudie
Muschitz C et al. Manuscript in preparation
0
2000
4000
6000
8000
10000
12000
14000
16000
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 66 69 72 75 78 81 84 87 90 93 96 99
LOW TRAUMATIC HIGH TRAUMATIC
An
zah
l der
Pat
ien
ten
Alter
N = 433.499 Patienten
N = 575.722 de novo Frakturen
Die AUVA - Frakturstudie
Muschitz C et al. Manuscript in preparation
Alter
N = 433.499 Patienten
N = 575.722 de novo Frakturen
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
Low Traumatic
bis 15 Jahre bis 30 Jahre bis 53 Jahre bis 70 Jahre über 70 Jahre
An
zah
l der
Pat
ien
ten
Die AUVA - Frakturstudie
Muschitz C et al. Manuscript in preparation
COX Proportional
Hazard Models
Unterarm
Becken
Hand
Oberarm
Oberschenkel
Schenkelhals
N = 46.079, number of events = 7.250 high traumatic/any
N = 37.189, number of events = 4.079 high traumatic/low-traumatic
Die AUVA - Frakturstudie
Muschitz C et al. Manuscript in preparation
COX Proportional
Hazard Models
Unterarm
Becken
Hand
Oberarm
Oberschenkel
Schenkelhals
N = 46.079, number of events = 7.250 high traumatic/any
N = 37.189, number of events = 4.079 high traumatic/low-traumatic
BMD Messungen
vs Struktur
C. Muschitz Zicksee 2016
Transiliac Bone Biopsy - µCT/Nano-CT
1.
3. Bone volume fraction (BV/TV, %)
Trabecular thickness (Tb.Th, mm)
Trabecular number (Tb.N, mm_1)
Trabecular separation (Tb.Sp, mm)
Structural model index (SMI)*
Cortical porosity (Ct.Po, %)
*reflecting the rod-versus plate-like nature of the structure (0=plate-like; 3=rod-like)
KH BHS Wien
2.
HR-pQCT
(vBMD,
microstructure)
DXA
(aBMD, TBS)
DXL
(aBMD)
Non-invasive Assessment of BMD and Microstructure
BMD – Fraktur & T-Score
Patsch JM, Burghardt AJ et al. J Bone Miner Res. 2013
Muschitz C et al. Wien Klin Wochenschr. 2009
Microstructure: A main component of bone strength
Tim Arnett – University College London
Regular trabecular bone microstructure Osteoporotic trabecular bone microstructure
T – Score: –1,8
KH BHS Wien
Bassersdorf, CH – Juli 2006
Age related cortical changes
Zebaze RM et al. J Bone Miner Res. 2015
Verbesserung T – Score & Frakturinzidenz
Ferrari S et al. J Bone Miner Res. 2015 (Suppl 1)
FREEDOM population – 8 year data
The incidence of nonvertebral fracture was lower with higher total hip BMD T-
score throughout a wide and clinically relevant T-score interval.
Total hip BMD T-scores of -2.5 and -1.5
were associated with 1 year nonvertebral
fracture incidences of 3% and 2%,
respectively.
Flattening of curve between -2.0 and -1.0 is
similar to what is known to occur in
untreated subjects.
N=number of subjects randomized to DMAb in FREEDOM who had an
observed total hip BMD T-score at FREEDOM baseline and ≥ 1 observed
total hip BMD T-score during FREEDOM or the extension
Klinische Risikofaktoren (CRF) -
Osteo Check, DVO Leitlinie
C. Muschitz Zicksee 2016
BMD & Frakturvorhersage
CRF – FRAX™ Clinical Risk Factors
aBMD
CRF
CRF + aBMD
Muschitz C et al. Osteoporos Int. 2013
Der Osteo-Check
Kooperation ÖGKM – ÖGR 2014 www.oegkm.at
DVO Leitlinie 2014
DVO Leitlinie 2014
„Schwer wiegender“ Risikofaktor (z.B. Diabetes mellitus) verringert
den T-Score um 1,0
jeder weitere Risikofaktore (z.B. Femurfraktur beim Vater und
Herzinsuffizienz) verringern den T-Score um 0,5 je CRF
Beispiel einer 65 jährigen Frau mit einem T-Score von -2,1
FRAX
TBS – Trabecular Bone Score
TBS L1-L4: 1.457
TBS L1-L4: 1.132
Same BMD
Illustration of
Well-structured
trabecular bone
Illustration of
Altered
trabecular bone
BMD images TBS images
Experimental
variogram
Pothuaud et al. Bone. 2008;42:775-87. Hans et al. JCD. 2011;14:302-12. Winzenrieth et al. JCD. 2012;
Muschitz C et al. BONE. 2015
TBS – Trabecular Bone Score
Herbert Czitober Preis 2015 – Bestes klinisch-osteologische
Publikation in Österreich
Starke Strukturalteration: < 1.100
Verminderte Struktur: < 1.200
Normal: > 1.350
FRAX mit TBS
FRAX/clinical risk factors – 10 year fracture probability:
• Major osteoporotic fracture ≥ 20%
• Hip fracture ≥ 3% (USA) – ≥ 5.0% (Austria)
