Osteoporosis

- Cortical bone becomes more porous

- Mineralization is normal but density declines
o Osteoblast build and osteoclast breaks down
o Remodeling bone takes place every few months replace head of femur
o Break down and build at an equal rate normally
o Estrogen blocks osteoclast activity
o Estrogen declines > osteoclast activity picks up
o Testosterone makes bone much thicker, so it is harder to weaken bones in men
- Bone density peaks at 30 years old
o Exercise will effect bone density
o Lifting weights -muscle pulling on bones also stimulates bone growth
o People in their 70s can start going to the gym and can build them back to their
muscle mass to what they had in their 50’s
- Osteopenia bone – 833 to 648 mg/cm2
- Osteoporosis below 600
CAUSES:
- Decreased level of estrogen and testosterone
- Decreased activity level
- Smoking
- Athletes
o No body fat and less estrogen can trip osteoclast activity
o Low peak bone pass or BMD > reduced bone density > osteoporosis > Fractures
o Not sure if it amenorrhea induced osteoporosis is reversible
 Stopping the sport might not bring back cycle
- Cushing disease
o Excess cortisol > bone breakdown
o Inhibits collagen deposition
- Hyperparathyroidism
o PTH removes calcium from the bone
- Early menopause
- Small stature
- Inadequate levels of Vitamin C, D or Mg
- Medications like PPI’s, glucocorticoids, anti-seizure drugs, SSRI’s (selective serotonin re;
antidepressants)
- Diabetics
- Alcohol
- Too much caffeine
TREATMENTS: injections like Fosamax and Boniva can improve bone density
- Denosumab – monoclonal AB treatment; not cleared by the kidneys so good for people
w. kidney problems
- Raloxifene – good for vertebral fx but not femur fracture
Iatrogenic osteoporosis – due to heparin which interferes w. collagen formation
- Increase in risks for fractures greatest in the wrist, spine, and head of femur, vertebrae >
compression fractures (weight of the body smashes bone down)
- Post-menopausal osteoporosis – affects osteoclasts
- Age related bone loss – 55% of people over age 50 have osteoporosis
- Dowager Hump – multiple compression fractures

Rheumatoid arthritis
- Systemic inflammatory disease – may present with fever, malaise, and leukocytes
- Mechanism is unknown
- Affects women three times more than men
- Exacerbations and remission
o Like all autoimmune diseases
- Symmetrical enlargement that is polyarticular
o Bilateral; usually effects more than one joint at a time
- Inflammatory joint disease of CT in joints
o We don’t know that it is happening
- Systemic damage to connective tissue, primarily effects joints
- Synovial membrane is the first to be affected
o Freely movable joints
- Spreads to articular cartilage and joint capsule, ligaments, and tendons
- Affects lungs, heart, kidney, and skin
- Similar symptoms to OA
- Antibodies against Ag = Rheumatoid factors > immune complexes
o Test for antibodies in CT; markers that confirm RA
- Inflammatory chemicals released such as metalloproteases,
- Usually feet, fingers, wrists, etc
- Pannus – synovium converts into a thick abnormal layer of granulose tissue > contain
macrophages > stim release of inflammatory compounds and fibronectin > B cells >
produce RF > synovial inflammation > involves blood vessels > occlusion > hypoxia
- Elevated ESR
- RA nodules = swelling in areas of pressure ; inflammatory cells w. core of cell debris
found in sub q in elbows and fingers, may be found in valves, splee, and lungs
- RA and AA Ab (anti citrulline protein Ab or ACPA) can be present years before disease
manifests
- ANA titers can also be elevated 20 years before you show any signs of disease
o But 20% of the population has high levels but show no signs of disease
- ACPA is more specific for diagnosing disease
DIAGNOSIS:
- Not always old people
- There is a juvenile form
- Presents with larger joints at first
TREATMENT
 - Corticosteroids
- Surgical repair
o Will come back though
- Joint replacement
- Humira and other immunosuppressants
o Biologics that are anti-inflammatory
o Don’t know what happens after 40-50 years of treatment
- Improves response to methotrexate
o Chemo drug
- Other drugs inhibit T cell activation or deplete B cells

Osteoarthritis
- Wear and tear arthritis
- Destruction of articular cartilage
o Starts in the hyaline cartilage
- Weight bearing joints are predisposed
- Joints that have been traumatized and also predisposed
- Obesity
o Hard on the joints
o Weight causes joint problems

- Primary OA – affects young people between ages of 18-24

- Common age-related disease of synovial joints
- More common in knees, hands, hips, neck and spine which are load bearing joints
- Cartilage loss > narrowing of joint spaces
- Bone spurs or osteophytes
o Bone on bone
o Need cushion of hyaline and bone on bone causes remodeling
- Possible changes in subchondral bone
o Cysts
- Primary problem is loss of articular cartilage stat starts w. destruction of proteoglycans
and collagen in the matrix
o Pull fluid out of joint and find chunks of proteoglycans and collagen and helps
with diagnosis of OA
- Term for bone w.o cartilage = denuted
- Enzymatic breakdown of articular car > denuded areas of bone > sclerosis of bone which
may develop cysts > rupture
- Joint mice irritate synovial membrane > inflammatory process > joint effusion >
thickening

OA changes in the pumping action of proteoglycan pump causes excess fluid to build up in
cartilage > drop in ability to withstand pressure
- Evidence of collagen breakdown
OA MANIFIESTATIONS
- Pain, stiffness, swelling, tenderness, limited motion, and deformity
- Joint effusion can develop with increase in synovial or inflammatory fluid in capsule

o Run fingers under hot water feels better, less viscous

- Thickening of fibrous capsule
- Heberdens nodes and Bouchards nodes due to sub endochondral ossification under
cartilage or by osteoporosis

TREATMENT
- Exercise and weight loss – good for knee oa
- NSAID’s
o Celebrex – reduce pain without gastric complications and so far, no increase in
cardiovascular events
- Cortisone injections
- Plasma rich plasma injections – may reduce joint pain
o Inject your own plasma into capsule