OSTEOARTHRITIS AND MALE

OSTEOPOROSIS: ARE THEY

INVERSELY RELATED?

By
Samia Zaki, Mamdouh Mahfouz, Ahmed
Mortagy, Hanan K Abdallah and Hala El
Badawy
 Osteoporosis and osteoarthritis are two
common age-related skeletal disorders
responsible for major health expenses in the
elderly.

Lane and Nevett , Arthritis Rheum; 2002

 Osteoarthritis
Degeneration of articular
cartilage

Osteophytes
Subchondral plate sclerosis
Bone widening
Osteoporosis
Low bone mass
Microarchitectural
deterioration of bony tissue

Bone fragility

Susceptibility to fractures
 There is a growing awareness that osteoporosis
in men is not a rare problem. Men loose bone
mineral density at a rate of about 1% per year
with advance in age.

 Their morbidity and mortality rates from this

disease are higher than in other patients.

Hannan et al., J Bone Miner Res, 2000

 The current lifetime risk for a fragility fracture is
approximately 27% in men aged 50 years or more,
and will increase further over the next 20 years.

 A twofold to threefold increased risk for death was

demonstrated in men with a history of a major
osteoporotic fracture versus men without a history
of fractures

Ebeling; Treat Endocrinol, 2004

Ebeling; N Engl J Med, 2008
 Osteoporosis is undetectable until the
onset of fractures,
Therefore detection just as hypertension
of the disease is
may remain
paramount undetected
before until a serious
the manifestations
consequence of
manifest clinically.untreated hypertension
occurs.
 Both hypertension and osteoporosis are
asymptomatic, but, if left untreated and
undetected may lead to their
perspective clinical consequences.
Rochira et al., Eur J Endocrinol, 2006
 Secondary causes for osteoporosis are more
common in men than women, and require
rigorous exclusion and treatment.

 Undiagnosed clinical hypogonadism is a

common cause of osteoporosis in men, and is
readily treatable.

Ebeling; Treat Endocrinol, 2004

 Osteoarthritis and osteoporosis are both
common conditions in the elderly.

 It would be anticipated that the conditions

frequently coexist due to their high prevalence,
but some studies have suggested that there is an
inverse association between the occurrence of
OA and osteoporosis.

Lane and Nevett; Arthritis Rheum, 2002

 Several epidemiological studies have shown a
lower prevalence of osteoporotic hip fractures
in patients with osteoarthritis.
 Other studies have demonstrated elevated bone
mineral density in patients with osteoarthritis.

The prevailing view is that there may be an

inverse relationship between osteoarthritis and
osteoporosis
 Objective
 The purpose of the present study was to examine
the hypothesis that OA and osteoporosis are
inversely related in male patients and to assess the
testosterone level in all subjects and its relation to
osteoporosis in males.
 Patients and Methods
 The study included 40 knee OA male patients and
40 age matched healthy male controls.

 Patients with risk factors for secondary

osteoporosis were excluded.

Hyperparathyroidism, thyroid
 All patients and controls had disease, intestinal
a full history taking
disorders, malignancies,
and physical glucocorticoids therapy,
examination.
immobilization, chronic diseases, drug therapy, or
adverse lifestyle practices that increase bone loss
 Patients and Methods
 Bilateral knee examination of all subjects for
tenderness, swelling, hard bony tissue enlargement
and deformity using the ACR clinical criteria for
classification of OA of the knee.

Altman et al., Arthritis Rheum, 1986

 Patients and Methods
 AP weight bearing knee radiographs, that were
scored for:
 global severity of OA (K&L, range 0-4)
 presence of osteophytes (range 0-3)
 joint space narrowing (range 0-3).

Spector and Hart; Ann Rheum Dis, 1992

 Patients and Methods
 Bone Mineral Density (g/cm2) was measured at the
hip, anteroposterior and lateral lumbar spine (L1-
L4 spinal region) using DXA.
 Osteoporosis was defined by BMD levels,
according to the WHO criteria, as 2.5 standard
deviations below young adult mean; according to
the T-score, and severe osteoporosis when
osteoporotic fractures were present.
 Patients and Methods
 Serum testosterone measurement was done for
all patients using an Enzyme Immunoassay,
which used a sensitive and specific rabbit anti-
human testosterone antibody.
 Results
 In this case-control study the mean age of OA
patients was 49.5 ± 13.6 (range: 39-60 yrs) and of
the 40 healthy male controls 48.3 ± 9.8 (range: 40-
60), they were age matched p>0.05.
 OA was bilateral in 16 cases (40%) and unilateral
in 24 cases (60%).
 Distribution of OA cases and Controls
by Body Mass Index
OA Cases, n=40 Controls, n=40
BMI No % No %
Normal 16 43.2 24 66.7
Overweight 16 43.2 8 22.2
Obese 5 13.5 4 11.1
Total 37 100.0 36 100.0
The BMI was not significantly different between the
osteoarthritis cases and the control group; p>0.05.
 Results
 There was no significant difference between OA
cases and controls as regards smoking (p>0.05)
and life style level of activity (p>0.05).

 There was no significant difference between the

osteoarthritis cases and the control group as
regards incidence of hypertension (p>0.05), or
diabetes (p>0.05).
 Distribution of Hypertension, diabetes and Thyroid
disease among OA cases and Controls
OA Cases Controls Total p
Hypertension No % No % No %
Present 10 25.6 8 20.0 18 22.8
>0.05
Absent 29 74.4 32 80.0 61 77.2
Total 39 100.0 40 100.0 79 100 NS

Diabetes
Present 8 20.0 9 22.5 17 78.8
>0.05
Absent 32 80.0 31 77.5 63 21.3
Total 40 100.0 40 100.0 80 100 NS

Thyroid disease
Present 4 10.0 4 10.0 8 10
>0.05
Absent 36 90.0 36 90.0 72 90
Total 40 100.0 40 100.0 80 100 NS
Spine T Score among OA cases and Controls

The difference was non significant; p=<0.05

Hip T Score among OA cases and Controls

The difference was non significant; p=<0.05

 Results
Bone Mineral Density among OA Cases and Controls

Mean BMD ± SD
OA Cases; Controls; P
n=40 n=40
Spine 0.926 ± 0.164 0.968 ± 0.160 0.251
Hip 1.002 ± 0.117 1.00 ± 0.136 0.292
The mean bone mineral density in the spine
and the femur was not significantly different
between the osteoarthritis group and the
controls
 To ensure that none of the men had
undiagnosed clinical hypogonadism, serum
testosterone was assessed for all patients and
control group.
 Results
Mean level of testosterone in OA Cases and
Controls
Type Mean ± SD (Mean ± SD) t-test P
OA
cases 14.35 ± 10.4 1.07 ± 0.23
n=40 2.68 0.007
Controls
19.65 ± 10.4 1.23 ± 0.25
n=40

The mean testosterone level in the

osteoarthritis patients was statistically lower
than among the control cases (p=0.007)
 Results
Mean level of testosterone in Cases with
Osteoporosis and Without
Type Mean ± SD P
Osteoporosis Spine (n=30) 17.11 ± 10.04
Hip (n=6) 15.76 ± 7.81
>0.05
No Spine (n=50) 16.95 ± 10.99 NS
Osteoporosi
Hip (n=74) 17.09 ± 10.89

The mean testosterone level was not

statistically different between cases with
osteoporosis and those without osteoporosis
Results
 There was no significant difference between OA
cases and controls in the frequency of osteoporosis
of the spine or hip.
 The mean BMD was not statistically different
among both groups.
 We did not find an association between BMD as
measured by DXA and clinical or radiographic
features of OA in the knee.
 There was no correlation between level of
testosterone and osteoporosis.
 Results
 With multiple logistic regression analysis, knee
osteoarthritis was a risk factor for spine
osteoporosis; patients with radiological findings
diagnostic of osteoarthritis could be 3.5 times at
risk of developing spinal osteoporosis.

 Smoking and presence of knee OA were risk

factors for occurrence of hip osteoporosis.
  Almost 40 years have passed since
Foss and Byers published their report
confirming observations made by
orthopedic surgeons on the relative
absence of osteoarthritic changes in
excised femoral heads from patients
who had had hip fracture.
 Association between these conditions
is still controversial
Foss MVL, Byers PD. Bone density, osteoarthrosis of the hip and fracture of
the upper end of the femur. Ann Rheum Dis 1972;31:259-64.
 Many studies have been conducted
examining the effect of OA on bone
density at different sites and with
different techniques.
 Most of them showed a significant
increase in bone mass or bone
mineral density in OA cases compared
to age-sex matched controls .

Lane and Nevett, Arthritis Rheum, 2002

 The Framingham Study (1993)
 Examined the BMD of the proximal femur
and radius in 932 men and women over
63 yrs of age in relation to knee OA.
 The mean femoral BMD, was 5-9% higher
in grade 1 and 2 knee OA compared with
no knee OA.
 The higher BMD was associated with
osteophytes, but not joint space
narrowing
Hannan MT, Anderson JJ, Zhang Y, Levy D, Felson DT: BMD and knee OA in
elderly men and women. The Framingham Study. Arthritis Rheum; 1993
 Speculation has been that weight-
bearing activities, which are beneficial
to the attainment and preservation of
peak bone mass, also increase the
risk of damage to articular cartilage
leading to OA in lower extremity
joints.
 Another explanation has been that
high BMI, which is associated with
higher BMD, confers a detrimental
biomechanical load to weight-bearing
joints, thus leading to OA
  The subchondral bone may play an
important role in the pathogenesis of
OA.
 The sclerotic subchondral bone is
considered to weaken the articular
cartilage by impairing its ability to
absorb mechanical shock, thereby
influencing the progression of OA.

Li B, Aspden RM: Composition and mechanical properties of cancellous bone from the
femoral head of patients with osteoporosis or osteoarthritis. J Bone Mine Res 1997
 The Rancho Bernardo Study in
2002
 Examined the relation between hand
OA and BMD levels (as measured by
DXA) among 1779 community-
dwelling, ambulatory white adults aged
50-96 years.
 OA was not associated with increased
BMD levels in men or women. The only
significant difference was that women
with hand OA had lower hip BMD
Schneider et al. BMD and clinical hand osteoarthritis in elderly men and
women: The Rancho Bernardo study. J Rheumatol;, 2002.
 In some others, however, no increase
was found and in others, bone mass
was reduced.
 Much of this controversy can be
attributed to differences in subject
selection, different anatomical sites
measured and different methods used
in evaluation and expression of the
results.
 Conclusion
 We could not find a relation between osteoarthritis
and osteoporosis, but owing to the small number of
patients we cautiously conclude that osteoarthritis
and osteoporosis are not inversely related.
 Conclusion
 Even though many have shown an inverse relation
between OA and osteoporosis, it does not mean
that the 2 conditions are mutually exclusive.

 The presence of OA in a joint should not exclude

the diagnosis of osteoporosis in a patient.
 Thank You

Thank You