1. .. 29 Aug 09

3. 2001 ( NIH of USA) 2001 ( NIH of USA) 1. 2. Consensus Development Conference, JAMA 2001; 285: 785- 95

4. Osteoporotic Fractures in US Women, Compared With Other Diseases 1,200,000 1 513,000 2 228,000 2 184,300 3 0 500,000 1,000,000 1,500,000 2,000,000 Osteoporotic Fractures Heart Attack StrokeBreast Cancer Annual Incidence 1 US National Osteoporosis Foundation, 2002. Available at: http://www.nof.org. 2 American Heart Association. Heart & Stroke Facts: 1999 Statistical Supplement. 3 American Cancer Society. Breast Cancer Facts & Figures 1999-2000.

8. INCIDENCE OF HIP FRACTURE /100,000 POPULATION T 1997US 1986 HK 1997 SINGAPORE 1997 M 1997

9. 269 114 487 203 * Lau EMC, Lee JK, Suriwongpaisal P, et al. (2001) The incidence of hip fracture in four Asian countries: The Asian Osteoporosis Study (AOS). Osteoporos Int 12, 239–43. ** in press * ** 118 50 * **

10. INCIDENCE OF HIP FRACTURE /100,000 POPULATION T 1997 T 2006 US 1986 HK 1997 SINGAPORE 1997 M 1997 10 yrs

11. 35 60

12. 1. 2.

16. 1. 2. 3.

17. 2552

18. Osteoporotic Fractures in US Women, Compared With Other Diseases 1,200,000 1 513,000 2 228,000 2 184,300 3 0 500,000 1,000,000 1,500,000 2,000,000 Osteoporotic Fractures Heart Attack StrokeBreast Cancer Annual Incidence 1 US National Osteoporosis Foundation, 2002. Available at: http://www.nof.org. 2 American Heart Association. Heart & Stroke Facts: 1999 Statistical Supplement. 3 American Cancer Society. Breast Cancer Facts & Figures 1999-2000.

19. 1. 1. 2. 2. 3. 3.

21. 26.. 2547

22. unstable intertroch anteric fracture status post internal fixation with DHS and side plate

23. *Ray NF et al. J Bone Miner Res. 1997;12:24-1235. Riggs BL, Melton LJ III. Bone. 1995;17(5 suppl):505S-511S. Kannus P et al. Bone. 1996;18(1 suppl):57S-63S. § Torgerson D, Dolan P. Ann Rheum Dis. 1998;57:378 - 379. Hip Fracture Outcomes 24% mortality rate within first year * 50% of patients are unable to walk without assistance ~ 33% are totally dependent In 1995, (2538) hip fractures accounted for $5.08 billion Up to 95% of women with recent hip or wrist fracture were not being treated with anti- osteoporotic regimens §

24. Long term mortality after osteoporotic hip fracture in Chiang Mai, THAILAND Tanawat Vaseenon, MD* Sirichai Luevitoonvechkij, MD* Sattaya Rojanasthien, MD* * Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand 50200 IOF abstract 2009

25. Aim: to investigate 10 years mortality and associated factors on the mortality. Long term mortality after osteoporotic hip fracture in Chiang Mai, THAILAND

26. Materials and Methods prospective cohort study Criteria of patient enrollment aged >50 hip fractures caused by simple fall Singh index of 3 or less 632 hip fracture patients and were admitted in Chiang Mai University hospital from 1998 to 2003. 367 patients (mean age 74 years) who met eligible criteria FU 4 to 10 years. Long term mortality after osteoporotic hip fracture in Chiang Mai, THAILAND

27. Total 18 % Male 30 %Female 16 % Mortality in First year 12

28. Median survival time = 6 years 72 68% mortality 120

29. J Med Assoc Thai 2005; 88 (Suppl 5): S65-71

30. Materials & Methods A retrospective study of all low energy trauma hip fracture patients, between 1998 and 2003 at the age of 50 years old or more.

31. The percentage of patients who received calcium, vitamin D, bisphosphonate, or calcitonin during admission

32. The percentage of the patients who received calcium, vitamin D, Bisphosphonate, or calcitonin after discharge

33. ? ?

36. WHO WHO WHO Study Group 1994

37. Diagnostic criteria of skeletal osteoporosis WHO 2537 Using DEXA (Dual Energy X-ray Abosrptiometry) to measure BMD and to diagnose osteoporosis Prodigy, Lunar Corp, USA ~ 3

38. 1. 1. 2. 2. 3. 3. 4. 4. WHO 1994

39. Peak bone mass (young adult reference mean)

40. Osteoporosis : BMD < -2.5 SD (T- score<-2.5) 14.4% OSTEOPENIA NORMAL 0.6% OSTEOPOROSIS

41. Severe osteoporosis : BMD< -2.5 SD with bony fracture

42. Bone mineral density is a good indicator for increased fracture risk T – score – 1SD 2 x Watts, ASBMR 2001

43. Advantage & Disadvantage of DEXA AdvantageDisadvantage Precise (1%-2%) and accuracy (5%) Lack of portability Gold standard for WHO criteria Exposure to radiation (albeit small amount) Expensive Lack of equipment esp. in rural area

44. DXA

45. Osteoporosis Self Assessment Tool for Asians (OSTA)

46. Integer of (0.2 X (weight – age)) OSTA index (Osteoporosis Self Assessment Tool for Asians) Wt=42, age = 75 =0.2X(42-75) = -6.6 OSTA index = -6 L.K.H. Koh et al. Osteoporos Int (2544) 12:699-705

47. Compared OSTA index with BMD of femoral neck By using OSTA index with cutoff value of -1 vs. Femoral neck BMD T-score < -2.5 –Sensitivity 91% –Specificity 45% –PPV 20.88% –NPV 96.85%

48. Quantitative Ultrasound (QUS) Heel QUS using a gel-coupled bone sonometer Achillis Express (GE-Lunar, Madison, USA)

49. Quantitative Ultrasound (QUS) Advantages –Low cost –Portability –No radiation –Easy to use

50. QUS ~ 5 ~ 15.

51. Many studies showed QUS had low sensitivity and high specificity –Suthee Panichkul, et al., (Phramongkutklao hospital) Obstet. Gynaecol. 2004 + QUS of the calcaneus (SI*) vs. femoral neck BMD (using WHO criteria: T-score < -2.5) Sensitivity = 39.25% Specificity = 91.71% PPV = 72.41% NPV = 73.14% Quantitative Ultrasound (QUS) + Achillis express (Lunar, Madison, USA)*SI = stiffness index SI (stiffness index)=([0.67xBUA]+[0.28xSOS]-420)

52. Many studies showed QUS had low sensitivity and high specificity –Vasi Naganathan, et al., (Royal North Shore hospital, Sydney) MJA 1999 QUS of the calcaneus (BUA, VOS) vs. lumbar spine & femoral neck BMD (using WHO criteria: T-score < - 2.5) Sensitivity = 9%- 47% depending on the QUS parameters Specificity = 88% - 100% depending on the QUS parameters Quantitative Ultrasound (QUS) CUBA Mark II (McCue Ultrasonics, London, UK) BUA = Board band ultrasound attenuation VOS =velocity of sound

53. Differences between OSTA index and QUS OSTA indexQUS High sensitivity (91%)Low sensitivity (9%-47%) Low specificity (45%)High specificity (~90%)

54. The combination of OSTA index and quantitative ultrasound to increase the efficacy and decrease the cost in diagnosis of osteoporosis Dr.Suppasin Soontrapa, et al. Srinagarind Hospital Khon Kaen University Khon Kaen Thailand

55. Research question Could sequential method of investigation (OSTA+QUS) has diagnostic power on osteoporosis vs. gold standard DXA

56. Objective To evaluate the efficacy of the combination of OSTA index and QUS in diagnosing osteoporosis in Thai elderly

57. Methods First step –Screening the participants by using OSTA index cutoff value of < -1 (sen 91%) Second step –Measuring all participants who had OSTA index < -1 by QUS (Achillis express®) (spec ~ 90%) and DXA –Comparing the T-score of QUS with T- score of DXA

60. Results Total one hundred elderly women with OSTA index < -1 were enrolled Average age = 69.97 yrs (age range 60-89 yrs) Average weight = 49.24 kg (weight range 30- 81 kg) Average BMI = 22.51 Kg/m 2 (range 15.75- 35.06) –BMI<19 = 19 cases –BMI > 19 = 81 cases

61. Reliability and reproducibility of measurement

62. r=0.973 p<0.001 Correlation between 1 st and 2 nd measurement of 1 st observer

63. Correlation between 1 st and 2 nd measurement of 2 nd observer r=0.976 p<0.001

64. Correlation of the measurement between 1 st and 2 nd observers r=0.925 p<0.001

65. Reliability or agreement of measurement Continuous value Limits of agreement of measurement –X axis = mean of measurement –Y axis = difference of measurement Test for significant difference –One sample t-test with zero value –Significant difference when p-value<0.05

66. Mean = SI 1+ SI 2 2 Diff_SI = SI1 – SI2

67. Limit agreement of SI between 1 st and 2 nd measurement of 1 st observer Mean diff. = 0.12 SD = 4 One sample t-test test value =0 P-value =0.765 SI = stiffness index

68. Limit agreement of SI between 1 st and 2 nd observer Mean diff. = 0.00 SD = 3.79 One sample t-test test value =0 P-value =1 Limit agreement of SI between 1 st and 2 nd measurement of 2 nd observer

69. Limit agreement of SI between 1 st and 2 nd observer Mean diff. = -0.08 SD = 6.63 One sample t-test test value =0 P-value =0.904

70. conclusion Correlation coefficient (r) of both intra and interobserver showed strong correlation (>0.9) Limits of agreement of both intra and interobserver showed no any significant difference from zero QUS has good reliability, reproducibility and easy to use

71. Diagnostic characteristic of OSTA + QUS vs. BMD of spine L1-4 (T-score < -2.5) 1-specsenspecppvnpvLR +accuracy T< -2.564.1574.4735.8550.7261.291.1654 T < -356.6068.0943.4051.6160.531.2055 T< -3.537.7463.8362.2660.0066.001.6963 T<-4T<-422.6438.3077.3660.0058.571.6959 T<-4.59.4325.5390.5770.5957.832.7160 T<-5T<-55.668.5194.3457.1453.761.5054

72. 1-specsenspecppvnpvLH + accuracy T< -2.5 63.2990.4836.7127.5493.551.43 48 T < -3 54.4390.4845.5730.6594.741.66 55 T< -3.5 41.7780.9558.2334.0092.001.94 63 T<-4T<-4 24.0552.3875.9536.6785.712.18 71 T<-4.5 10.1342.8689.8752.9485.544.23 80 T<-5T<-5 3.8019.0596.2057.1481.725.02 80 Diagnostic characteristic of OSTA + QUS vs. BMD of femoral neck (T-score < -2.5)

73. 1-specsenspecppvnpvLH + accuracy T< -2.5 64.77100.0035.2317.39100.001.54 43 T < -3 56.82100.0043.1819.35100.001.76 50 T< -3.5 44.3291.6755.6822.0098.002.07 60 T<-4T<-4 23.8675.0076.1430.0095.713.14 76 T<-4.5 9.0975.0090.9152.9496.398.25 89 T<-5T<-5 3.4133.3396.5957.1491.409.78 89 Diagnostic characteristic of OSTA + QUS vs. BMD of total femur (T-score < -2.5)

74. Diagnostic characteristic of QUS T-score < -4.5 VS BMD of spine and hip Site Spec.PPVNPVLH+ accuracy L1-4 (T< -4.5) 90.5770.5957.832.7160 Femoral neck (T< -4.5) 89.8752.9485.544.2380 Total femur (T< -4.5) 96.2052.9481.725.0289

75. Site Of Measurement of DXA for osteoporosis diagnosis WHO criteria (1994) No specific site WHO task force for Osteoporosis (1999) Femoral neck IOF (International Osteoporosis Foundation) year 2000 Total hip WHO criteria (1994) No specific site WHO task force for Osteoporosis (1999) Femoral neck IOF (International Osteoporosis Foundation) year 2000 Total hip

76. Diagnostic value of QUS T-score -4.5 for spine and hip Site Spec.PPVNPVLH+ accuracy L1-4 (T< -4.5) 90.5770.5957.832.7160 Femoral neck (T< -4.5) 89.8752.9485.544.23 80 Total femur (T< -4.5) 96.2052.9481.725.02 89

77. Conclusion OSTA index <-1 and QUS T-score <-4.5 performed well in diagnosis of osteoporosis (accuracy 80%-89% for hip BMD) Convenience to use Portability Cost effective

79. Calcium + vitamin D Vitamin K Raloxifene Calcitonin Alendronate Risedronate Ibandronate PTH Strontium ranelate Calcium + vitamin D

80. 1000 Women

81. . 2537. 2537 20- 80 400 20- 80 400 361. 361. 65 400./ 65 400./ 2 800./ 2 800./

82. 400 mg/day 400 mg/day RDA 800-1200 mg/day RDA 800-1200 mg/day 400-600 mg/day 400-600 mg/day

83. 77.98% 60% 65.4% 15.4% Pre-men. women Early post-menUrbanized elderly Rural elderly

84. 84 Results Site Odds ratio (95%CI) Chi-square (p-value) Lumbar spine (l2-4) Femoral neck Wards triangle Trochanter Total femur Radius UD Distal 1/3 of radius 1.38(0.6-3.19) 2.87(1.15-7.15)1.15(0.46-2.86) 2.03 (0.64-6.4) 0.75(0.28-2.01)0.42(0.12-1.51)1.32(0.54-3.24) 0.58 (p=0.44) 5.10 (p<0.03) 0.09 (p=0.76) 1.37 (p=0.24) 0.31 (p=0.58) 1.69 (p=0.19) 0.36 (p=0.55) Vitamin D insufficiency group had higher risk of femoral neck osteoporosis than the normal one (Odds ratio =2.87, p<0.03)

85. The percentage of the patients who received calcium, vitamin D, Bisphosphonate, or calcitonin after discharge

91. ...

92. T.P. 81 26.. 2547

95. J.S. 93 Vertebral fracture Pain and tenderness

96. J.S. 93 Vertebral fracture

102. Calcium + vitamin D Vitamin K Raloxifene Calcitonin Alendronate Risedronate Ibandronate PTH Strontium ranelate Calcium + vitamin D

103. 84% (.) –. 51 – 12,945 –84% 749,771 41,139 -- 6 2009 06:32:35.

105. www.osteokku.com