0:03

Comprehensive, relevant, and insightful conversations

0:06

about health and medicine happen here when

0:09

MedStar health doc talk.

0:13

Consider your own skeletal frame, formed by

0:16

living, growing tissue we know as bones. healthy

0:19

bones are essential to mobility, to protecting your

0:21

organs and anchoring our muscle system.

0:25

But the more we age, the more our bones

0:28

weaken, increasing the risk of

0:31

fracturing. With 10 million

0:33

americans suffering osteoporosis, it's

0:36

important to understand the risks and symptoms

0:39

of these pathological bone fractures.

0:42

I'm happy to introduce Dr. Avi Giladi

0:45

and Dr. Malek Cheikh from the Bone Health and Fracture

0:48

prevention program at MedStar Health to

0:50

discuss those risks, the options for treatment

0:53

and prevention. I'm your host, Deborah Schindler. Thank you for bringing

0:57

your expertise to us here on MedStar Health doc talk.

1:00

Thanks, deb. Great to be here.

1:01

Dr. Avi Giladi, is a hand surgeon at the Curtis

1:04

National Hand Center at MedStar Union Memorial Hospital

1:07

and the surgical lead for the bone Fracture program.

1:10

Dr. Cheikh is the program's medical lead and

1:13

an endocrinologist at MedStar Good Samaritan Hospital here

1:16

in Baltimore. It would seem almost an unusual

1:19

pairing, an endocrine expert and a hand

1:22

surgeon who would like to start by explaining why it's

1:25

actually perfect for a bone fracture program.

1:27

So our, fracture prevention program has

1:31

been built out of a model

1:33

that really is led by both of our professional

1:36

societies, both across the United States and globally,

1:39

where there is an important focus

1:42

on the orthopedics or

1:45

bony side of the treatment team lining

1:48

up with the endocrine or other bone health expert

1:51

side of a treatment team for a patient and give them a full,

1:54

comprehensive care piece. Patients present to us, at

1:57

the hand center with distal radius fractures or wrist

1:59

fractures, often from a fall from standing

2:02

height. And we see those quite commonly. It's

2:05

actually the second most fracture that occurs, essentially, across all

2:08

people. it's something we deal with throughout the year.

2:11

Yet what those fractures often can tell us about the patient

2:14

is that there may be bigger underlying bone

2:17

health problems that are outside our area of expertise. So where

2:20

we are experts in dealing with the fracture, we don't have much

2:23

experience or longitudinal care over time

2:26

to make the bone health piece better. So the partnering

2:28

with experts like Dr. Cheikh and his partners in

2:31

our endocrinology group here make it so that we can provide

2:34

comprehensive care, not just about dealing with the fracture, but

2:37

doing our best to make sure additional fractures don't happen

2:40

and that the bone healing can go on as we would like it

2:43

to.

2:43

very well said, avi, in the community

2:45

oftentimes, what we have been seeing over the last

2:48

couple decades, that many patients

2:52

have bad bones enough that they would keep on

2:54

fracturing, and when they see the

2:57

surgeons and they get the fracture

3:00

repaired, they go about their

3:02

life not focusing on the

3:05

underlying cause that caused the fracture to happen. So

3:08

this collaboration was very natural, and we thought

3:11

that it would try to bridge the gap between the

3:14

common fragility fractures that we see in the

3:17

community and try to help to address the underlying issues

3:20

so they will not go back and recur again in the

3:23

future.

3:23

Are you referring to the same fracture or new

3:26

ones? Patients who have repeat visits for

3:29

the same.

3:30

So, interestingly enough, that's a very good point,

3:33

that once you have a fragility

3:36

fracture at a certain site in your body, that

3:39

increases the risk of the next fracture

3:41

dramatically. like these distal radial fractures

3:44

that Avi was just talking about can be the tip of the

3:47

iceberg that would reveal an underlying

3:50

bone issue that needs to be addressed,

3:53

because many of the patients that he has been sending me throughout

3:56

the years are, after a dyserradial

3:58

fracture turned out to have severe

4:01

osteoporosis that would benefit from,

4:04

and did benefit from treatments that we offered them in

4:06

the program.

4:07

It may seem od, most of all, to have

4:10

a surgeon focusing on

4:13

what is clearly a medicine problem, a medical

4:16

problem. No one's going to operate on the bone health and fix it. It's

4:19

treatments that are provided by Malek and his team or other bone

4:22

health experts. The reason this

4:25

team makes sense, though, is what

4:28

was sort of just being described. It's that tip of the iceberg

4:31

phenomenon where someone was otherwise healthy, going

4:34

about their day, had a trip and fall, that

4:37

when they were 25 or 30 years old, would have never caused a

4:40

problem, would have got right back up. But here they are in maybe

4:43

their early fifty s, and now they have a fracture or they've broken their

4:46

bone. That is an indication of an

4:48

underlying problem that if we don't address that,

4:51

next fall, could be a hip fracture, could be a spine

4:54

fracture. Things that go from two or three

4:57

months of wrist rehabilitation to

5:00

six months to a year of much bigger, life

5:03

altering rehabilitation. And we know that spine and

5:06

hip fractures have such a bigger impact on the overall

5:09

life of a patient that for me, as a hand surgeon and

5:12

for all of my partners as hand surgeons, we care so much

5:15

about not missing that opportunity. So it made sense

5:18

for me to be part of this program as a liaison,

5:21

really bridging that gap and getting our

5:23

patients, whether in our clinic or our hip fracture

5:26

clinic or our, upper arm and shoulder fracture

5:29

clinic. All of these are ways that we can capture

5:32

patients who really need this attention outside of

5:34

their orthopedic care. And that's why this program makes as much

5:37

sense as it does.

5:38

And oftentimes, it is the first fracture that

5:41

would reveal the underlying medical condition rather

5:44

than our three screening methods, because,

5:47

as Avi, was saying, patient may be very healthy, and

5:50

the first fracture should be the indicator to trigger

5:53

a consultation, or at least a Dexa scan, for

5:56

evaluation of the systemic bone health as

5:58

a general concept. So we can sort

6:02

between the patients who have good bone marrow density

6:04

versus the patients who need this, cascade

6:07

of an approach to help improve their bone

6:10

quality and density.

6:11

So you referred to them as fragility fractures. That

6:14

distinguishes a patient from someone who may

6:17

have fallen off their bike or fallen off a

6:20

skateboard.

6:21

Correct. That is a very

6:23

important concept to, clear. which

6:26

is that any fall from standing

6:29

height or what we call a

6:32

low trauma fracture, low velocity

6:34

fracture, that happens to any

6:37

patient that may have some

6:40

significance to try to

6:42

figure out what the bone density represents. In other words,

6:45

what I usually tell my patients is, if

6:48

you have a fall that

6:51

was not that significant or you're

6:54

fractured for a fall that did not make sense.

6:57

Or I rephrase by saying, if

7:00

you think that you would have not fractured the

7:02

bone 20 years ago and now you did,

7:05

there's something wrong with your bones that we need to talk

7:08

about, right?

7:09

I mean, ultimately, someone getting in a car accident,

7:12

falling off a bike, falling off an escooter,

7:14

breaking a bone that way, the energy at least

7:17

makes more sense to have sustained an injury. I mean, at some point,

7:20

bones don't hold up to everything we know. Know.

7:23

The bigger issue is, as Malek was

7:26

saying, breaks that just happen. When you kind of think back and

7:29

say, I can't believe I broke that. I can't believe that little trip and fall.

7:32

I can't believe tripping over my carpet, getting out of bed in the morning,

7:34

or I was just walking outside, took a little slip on

7:37

ice, went down, and all of a sudden felt that

7:40

pain. Those really surprise patients, and that surprise is

7:43

understandable, because they've probably fallen like that

7:46

ten times before in their life, and it never happened. And the fact that it happened

7:48

this time doesn't mean they have a problem.

7:51

But all of us, as providers that

7:54

care about the whole patient and not just our specific issue, want

7:57

to make sure we don't miss that problem if it's there.

7:59

So they would be referred to, you from the emergency room?

8:02

Yeah. I mean, I think from a fracture management

8:05

standpoint, we often get those patients either through the emergency department or

8:08

they are seen at an urgent care, told they have a break, and then they

8:11

call our know. We see patients here at Union Memorial, but

8:14

we also have multiple satellites across the

8:16

MedStar network and in a few other locations where

8:19

patients come through with these injuries. all of

8:22

those sites are great for outpatient

8:25

fracture management, but from there, we then want to

8:28

filter these patients into our program, where they can get the Dexa

8:31

scan or the lab workup, or everything else to figure out the bone

8:34

health piece. That can happen at the time that we're

8:37

managing the fracture. That can also happen a few months later once

8:40

we've dealt with the immediate problem, and then

8:43

we want to deal with the whole person beyond that. I think both of those

8:45

timelines are acceptable, but we really want to get them

8:48

within the first three, or at most, six months.

8:51

Is a, bone fracture the same as a break?

8:54

Absolutely. So, a fracture is very

8:57

similar to break. However, most people would

8:59

attribute the bone break as

9:02

a very clinically significant,

9:05

event. However, it's very important to

9:08

highlight that people can break their bones or

9:10

fracture their bones without even knowing. So, in our

9:13

literature, around 30% of people who would break

9:16

a part of their spine or vertebral body, that's what we call it,

9:19

can be subclinical or silent.

9:22

They don't know until we review, their

9:25

old records and we find on, like, a chest

9:28

CT or any other, image that they

9:31

may have had for some other reason, that we find

9:34

that there is a fracture that they never really

9:36

knew that they had it. And the significance of knowing

9:39

or highlighting those subclinical fractures or silent

9:42

fractures that may happen is that once we see them, we

9:45

don't wait. We treat, because oftentimes that

9:48

tells you that there's trouble that's going to happen in the

9:51

horizon, and we need to deal with it right now rather

9:53

than wait, which may exacerbate the problem

9:56

that we're dealing with.

9:57

Are you referring to seeing old

10:00

fractures that are healed, or are they still

10:03

showing to be a fracture?

10:04

Both. Well, I mean, the nice thing. Well, it's not so nice,

10:07

but the nice thing about reviewing old

10:10

images, looking at spine, is once you

10:13

see a fracture, that may decrease the height of

10:16

a vertebral body. And, we all remember when we

10:19

look at our grandmothers and how

10:22

sometimes they can lose weight or they shrink with age.

10:25

That happens because the height of the

10:28

vertebral bodies usually go down

10:30

because either they had severe,

10:33

osteoporosis or a fracture to their vertebral body that would

10:36

decrease that height and that, would

10:39

seem clinically, as somebody who's bent over.

10:41

Despite that, they may heal, but they would

10:44

still show loss of height when we

10:47

evaluate them with x rays.

10:48

So, to your original question, bone break,

10:51

fracture, compound fracture, or

10:53

all these terms get thrown around. Ultimately, it's a bone that

10:56

is not structurally

10:59

stable anymore. It means all the same thing, essentially, to us

11:01

as providers. The bone has been broken. What is

11:04

hard, I think, for a lot of people to conceptualize

11:07

is sometimes it's as simple as I

11:10

fell, I landed on my arm or my hip, and it

11:13

broke. Sometimes it's. I don't even know what I did, but

11:16

my spine has a break in it or my spine

11:18

bones are collapsing. Some. Sometimes

11:21

it's the dog leash pulled on my

11:24

arm and something happened. The more

11:27

weird for people or the more

11:29

unusual the event, the more the

11:32

sort of spidey sense about bone health should start going

11:35

off, because the bones are designed to be

11:38

strong and stable. And as we age, that changes.

11:41

So there's the obvious ones. I fell. It

11:43

broke. We know what happened here. Let's get your bone health check. But

11:46

there's also all sorts of things. Stress

11:49

fractures for runners. Sometimes these are people who are

11:52

healthy and they're active, and yet they're dealing with things

11:55

like that. Sometimes it's an overuse problem. Sometimes

11:57

it's an overuse plus bone health problem. And

12:01

what we've learned as a medical community, especially over the past

12:04

1015 years, number one, we have better and better ways

12:07

to treat it. But number two, there are a lot of situations that

12:10

we've kind of not focused on as indicators that

12:12

we're learning more and more, probably are. And so, again, getting

12:16

a unified program around those is much better than doing kind

12:18

of one off, trying to remember to refer a patient and

12:22

letting people go uncared for.

12:23

And also, if you don't mind me interrupting, it's very important that

12:26

we proactively seek out these

12:28

diagnoses after the event or the outcome

12:31

happens, because those are the patients that we can

12:34

definitely make a good

12:37

impact on their bone health. Because

12:40

once, we reach the threshold

12:43

of events happening with this low velocity or

12:46

low trauma, events that led to a

12:48

fracture, then, that will exponentially

12:51

continues to happen at a higher frequency. And

12:54

those are the patients who we call the highest risk of

12:57

fracture portion of the patients that we want to intervene on

13:00

by the medications that Avi was mentioning,

13:02

that have been shown over the last couple of decades

13:05

that not only they are effective, but they also

13:08

may raise the bone marrow density

13:11

to a point where it would be safe for the patient

13:14

to utilize, use, and

13:16

hopefully abuse their bones without, leading to

13:19

a break.

13:20

Okay, before we get to those treatments and medications,

13:23

I want to get back to what you were talking about, Dr.

13:26

Giladi, when you said, some overuse

13:28

activity could cause a fracture. That's kind of

13:30

understandable. Running fractures we've heard about.

13:33

But I also see that underuse

13:36

or undermobility could also lead

13:39

to a, higher risk of a bone fracture. Do you want to go

13:42

through the list of some of the factors that do play

13:45

into a, higher risk of bone fracture?

13:47

Yeah, I think to some degree, that's a very important concept.

13:51

Some of the patients that come through to the program,

13:53

or you might be a patient who has a doctor

13:56

who picked up on a bone health problem even before you've had a break. And the

13:59

first thing that they'll say is, consider certain supplements

14:02

and consider increasing your exercise or working in physical

14:05

therapy.

14:06

How would they pick up on that without a break?

14:08

So, there are screening guidelines,

14:11

across our, national societies that say if you are of a

14:14

certain age, whether you're male or female, those ages are a little bit

14:16

different. There should be just baseline screening,

14:19

or there are some people who've had,

14:21

With a Dexa scan.

14:23

With a Dexa scan, right. And there's also people who've had these

14:26

injuries. Maybe they didn't come to our clinic. Maybe they were seen elsewhere, and they

14:29

get this screening, and they get started on supplements.

14:31

Usually calcium and vitamin D are discussed as the easiest thing to get started

14:34

on. and I'm a little bit trailing into Malik's territory here, so I'm going to

14:38

hand off to the treatments pretty soon here. But the other thing that I

14:40

really want to stress is the exercise piece. Exercise

14:44

and physical therapy are a huge part of what we

14:46

address, especially in the early phases of bone health

14:49

treatment, because, to your point, deb, not, using your

14:52

bones, I want to say, you don't use it, you lose it. But it's

14:55

essentially, they do get a little bit weaker. They like being

14:58

loaded. Muscle is really helpful for bone health.

15:01

Use of the bones will sort of

15:04

stimulate your body to build them and make them stronger.

15:07

So one of the things we do with our patients through the

15:09

fracture prevention program is work with our

15:12

physical therapy colleagues. We have a great partnership with physical

15:15

therapy, and all of these patients have an opportunity to get

15:17

plugged in with additional physical therapy. Whether it's for

15:20

the event that led to their problem, a

15:23

fall, getting out of a hip fracture and recovering.

15:26

Recovering from their upper extremity fracture, their arm

15:29

or wrist fracture, or it's just that they have balance

15:31

challenges or strength, getting out of a chair

15:34

challenges. All those things could be improved with physical therapy

15:37

and work together with the bone health

15:40

effort to ultimately prevent, ah, additional breaks in the

15:43

future.

15:43

Okay, so just to provide a laundry list, sort of, of what

15:46

some of those risks are, I'm going to go through them and you guys

15:49

can comment if you'd like. Low dietary

15:52

intake, malabsorption, probably not enough

15:55

protein, vitamin D or calcium. Underweight

15:57

or overweight, abnormal body mass index, which you've touched

16:00

on bone or back pain, level of

16:03

physical activity and mobility, low sun

16:06

exposure.

16:07

That's a vitamin D overlap issue.

16:09

Fracture history in patient or family members.

16:12

Is it hereditary to have.

16:14

Absolutely. So there are

16:16

plenty of things that can run in the family that would lead

16:19

into low bone marrow density. Genetically,

16:22

one of the biggest things that we always ask our

16:25

patients that may highlight or increase our

16:27

suspicion to having low bone marrow density and

16:30

osteoporosis. That would be a family

16:33

member who had a hip fracture that

16:36

would increase the risk of low bone marrow

16:38

density in the individual themselves, if they have any family

16:41

members who had a fracture. And on top

16:44

of the nice list that you mentioned,

16:47

there's plenty of medical conditions that may

16:50

increase the risk of having low bone marrow density.

16:53

And we're talking about whether it's top one, top two, diabetes.

16:56

Any liver problem, smoking in itself can

16:59

cause it. Rheumatoid arthritis. COPD just to

17:01

say, if you have a celiac disease, any

17:04

inflammatory, arthritic issue in the body,

17:07

all these can increase the risk of fracture

17:09

and decrease the bone density in somebody.

17:12

And I just want to go back to when you

17:15

asked Avi about the usage.

17:17

The loading concept that he was talking about is

17:20

huge in what we do. That's why we always tell patients

17:23

to do weight bearing exercises for

17:26

maintenance of the bone density. There has

17:29

been a couple of studies looking at bone density

17:32

in astronauts before they flew to space

17:35

and after they came back. And not having

17:37

gravity is a huge factor that can

17:40

cause decline in bone marrow density. So think about

17:43

it. if you're not standing and using gravity or

17:46

walking, upright, for a long period of

17:49

time, that can decrease the loading of

17:52

your bones. Because despite the

17:55

myth of bones are just, inactive organs

17:58

in our body, they are very active. And the more we know

18:01

about the bone cells, we understand that

18:04

they can send signals to the

18:06

rest of the body to improve the bone density. And

18:09

that signal happens when you walk and when you use your

18:12

weight bearing exercises. That's why we tend

18:15

to, highlight and emphasize the importance of all

18:18

these exercises and also our, collaboration

18:21

that Dr. Giladi was talking about that is very

18:24

crucial for our patients after they had a

18:26

fracture, to, improve their balance and

18:29

improve their rehab back to their life.

18:32

It's so interesting about the astronauts. They actually came back

18:35

and their bone density was weaker.

18:38

I don't know if it's the aliens cast a spell on

18:41

these astronauts or.

18:42

What, but how does that Dexa

18:45

scan actually work? It's sort of like an x ray. I've never had

18:48

one.

18:50

It's mostly an x ray. I mean, it's a

18:53

table that you walk into a small room, you sit on the

18:56

table. We bring this not so big of a

18:58

device on top of your spine and then on

19:01

top of your hip, and sometimes on top of the distal

19:04

wrist radius. And we take

19:07

pictures. And those machines are capable

19:10

of looking at the penetration of the x ray

19:12

to the bone structure. And

19:15

according to how much penetration there was, it would

19:18

label it with a number, and we call that number the bone

19:21

density. And this bone density is

19:23

important to understand, because the lower it

19:26

is, the more fragile the bone is. And if it is

19:29

fragile, then that leads to higher risk of

19:32

fracture under any particular trauma that the

19:35

person may have.

19:36

What's a healthy number?

19:37

So, to make it a little bit more complicated, the bone marrow

19:40

density number is not what we look at. We look

19:43

at a statistical number

19:45

that we try

19:48

to come up with every time we look at

19:50

bone marrow density. In essence, all what it is

19:53

is how does it compare to a

19:56

30 year old person bone

19:59

density? So we're just comparing every person on the

20:02

Dexa scan with a 30 year old

20:04

person's bones and look at

20:07

this statistical model that we call standard

20:09

deviation. And the further you

20:12

are, or the lower you are from that number,

20:15

then the higher risk of fracture you have.

20:18

And the who, a long time ago told

20:21

us any two and a half standard deviations under the

20:23

mean equals what we call

20:26

osteoporosis, which, in essence, all what it is, it's just the

20:29

bones are weaker, and then that

20:32

needs to be intervened upon, and some

20:35

type of therapy needs to be implemented.

20:37

Okay, you mentioned, osteosorosis. You can't talk about bone

20:40

health without bringing up osteoporosis. Differentiate

20:43

for me what osteoporosis versus

20:46

osteopenia versus osteomalasia are.

20:49

Sure. So using the Dexa scan machine

20:52

and coming up with the numbers that we just talked about,

20:55

we call them bone marrow densities and the standard

20:58

deviations from the mean. we can look

21:00

at everybody who has a Dexa scan. We can

21:04

also break them down to three

21:06

categories. There would be normal bones, and that's when

21:09

the bones are not really that far off from the

21:12

mean, the healthy mean, which is the 30 year old people's

21:15

bones, the slightly worse

21:17

bones, we would call them osteopenia. And then when we reach

21:22

a much worse bone level, that's when we call

21:25

it osteoporosis. So it's just a

21:28

stage? A stage, in the progression of the

21:30

disease. Osteopenia is less

21:33

advanced stage than

21:35

osteoporosis is. That does not mean that if you're,

21:38

osteopenia, you don't fracture. In fact, there are other

21:41

factors other than this stage of the disease

21:44

that may predict the risk of fracture in the future.

21:46

What about osteomalasia?

21:48

So osteomalasia is something somewhat different

21:51

where the bones do not have

21:54

the right amount of minerals

21:57

to strengthen the structures.

21:59

Versus osteoporosis

22:02

means that the bones are thinning.

22:05

So think about it as not enough

22:08

scaffolding when you're building a

22:10

building versus that you are

22:13

using cheap material to build the building. And that's where

22:16

osteomy Malaysia is.

22:18

Is that age related, and is it treatable?

22:21

Or any of those three, are they treatable? Can it be

22:24

reversed?

22:25

Absolutely. Nowadays, we're so lucky to have

22:27

multiple options to improve the bone marrow

22:30

density and decrease the risk of fracture. Because the end of the day,

22:33

the risk of fracture, what we try to,

22:35

decrease, and fractures are what we try to

22:38

prevent from happening. So I'm going to start with osteomylation,

22:42

which is, again, a maritalization problem. It usually happens if

22:45

somebody does not have enough vitamin D or not taking

22:48

enough calcium in their diet. So it's very important to

22:51

figure out why people have osteomylation. It's not very common. It

22:54

usually happens with malnutrition. population,

22:57

we tend to improve the diet, improve the

23:00

calcium intake, improve the vitamin D, and that can fix

23:03

it somewhat in a

23:06

more rapid pace than what you would see with osteoporosis.

23:09

So maybe that is not age related.

23:10

Then it can be age related,

23:13

but it does not have to be age related versus the

23:16

osteoporosis. It's definitely age related.

23:19

Now we think about osteoporosis in our first

23:22

few decades of life. We build a healthy

23:24

bone in most cases, unless there's interruption of some

23:27

hormonal issue or malnutrition of some sort.

23:30

But at, usually, an age of 40,

23:33

that's when we start to have the best bone

23:36

in our lifetime. And then afterwards, slowly,

23:39

there is a continuous decline in the bone density

23:42

that would affect the strength of the bones.

23:44

And it usually depends on

23:47

how long we're going to live until we hit osteoporosis

23:50

ranges, because that decline is going to continue to

23:53

happen. It depends on when we

23:55

discover somebody to have osteoporosis.

23:58

And there are multiple options, as we just

24:01

mentioned, they kind of vary, between

24:03

pills that you can take once a day or once a week,

24:06

infusions that you can get once a year, injections

24:09

that you can get every six months. There are some pills you

24:12

take once a month. So there's plenty of options.

24:15

And they usually differ according to how

24:18

efficacious these medications are. And

24:20

oftentimes, I tell most of my patients, if

24:23

we treat you, for

24:26

a long enough period of time, we can

24:28

restore the bone strength

24:31

back to where it was before you developed

24:34

osteoporosis.

24:35

Oh, good to know.

24:36

Yep.

24:36

I thought maybe the medications would just stop the

24:39

progression.

24:39

It's definitely now, Dr. Diladi just

24:42

mentioned something very important. Initially, when we're talking

24:45

about, we can definitely restore the bone integrity,

24:48

we can help improve the bone density,

24:51

but there are some other factors that's very important to talk

24:54

about. these are the other elements that may

24:57

increase the risk of somebody having fractures, such as lack of

24:59

balance, frailty, not having good muscle

25:02

mass, maybe having bad joints that are going

25:05

to lead to multiple falls, that would lead to

25:08

fractures. So all these things needs to

25:10

be addressed, and that's where

25:13

the medication itself is not going to be the one thing that's going

25:16

to fix everything. So it's important

25:19

to pay attention to all these other components. That's

25:22

why I need, it's not going to be seeing an endocrinologist or

25:25

just a medical doctor and figuring it out. It takes, really, a village

25:27

reduce the risk of somebody's fracture. And that's when we talked

25:30

about having a surgical team involved, having

25:33

a physical therapy team also involved, and

25:36

nutritionists sometimes, and all sorts of

25:38

interventions that may be also needed.

25:41

How does menopause play into

25:44

bone health?

25:45

So, after those first four

25:48

or five decades in life, the female

25:50

body stops producing

25:53

estrogen and the reproductive hormones and

25:55

that may cause a rapid decline in bone

25:58

marrow density because the bone

26:01

maturation and improvement of the quality,

26:04

is somewhat dependent on

26:06

this surge or flow of the

26:09

female hormones. And because of that, in

26:12

the first two or three years after

26:15

menopause, there is a rapid decline in the

26:18

bone marrow density that takes place, and

26:21

that is associated with increased risk of fracture. And

26:24

that continues to happen because, of the next couple

26:27

decades and females, life,

26:30

typically there's no exposure to estrogen. That

26:33

deterioration continues to a point where the

26:36

bone density leads to all sorts of fragility

26:39

fractures that we started this.

26:40

Conversation, you had mentioned that some patients don't even

26:43

know they've had a fracture. What happens if some of these

26:46

fractures aren't treated? Is there a risk? Is there, another health

26:49

risk?

26:49

So the biggest health risk is that a

26:52

fragility fracture or fracture that has not been

26:55

clinically identified may

26:57

represent a poor bone state that

27:00

needs to be addressed. And if we don't, or if we didn't

27:03

know about it, or if we had a fragility fracture that we did not

27:06

address, that may lead to another,

27:09

maybe more significant fracture that would lead

27:12

to limitation in abilities of patients

27:15

activities. It also, when it

27:17

is bad enough, it can lead to increased

27:20

mortality. And we see that in males who had hip

27:23

fractures at an old age. So,

27:25

because of how serious these fractures

27:28

can be, cannot ignore the initial fracture. That can

27:31

sometimes be subclinical and sometimes can be, fragility in

27:34

nature, at.

27:35

Least, this is what I read, that there's a blood clot risk, there's

27:38

infection risk, there's damage to the skin tissues or muscles

27:41

around the fracture, and swelling of a nearby joint. Are those

27:44

realistic?

27:45

From a fracture?

27:46

Yeah. For an untreated fracture, yeah.

27:49

I think the impact lines are blurry.

27:52

It's a numbers game, right? So some fractures will come with

27:55

swelling and pain, and that's it. Certainly, you have increased

27:57

risk of much less common things

28:00

like skin, issues from the underlying

28:03

swelling or blood clot issues or other

28:06

really rare phenomena. And, so

28:09

you certainly would want to do anything you can to prevent additional fractures,

28:12

not only because the fracture itself is a problem, but because there are risks,

28:15

and over time, those risks mount.

28:18

Why is it so risky for seniors, though? And is

28:21

it an emergency if a senior falls

28:24

and a fracture is suspected?

28:26

I think anytime you have a fall and there's

28:29

concern for a fracture, you should be evaluated relatively

28:32

soon, because stabilizing the fracture will

28:35

likely reduce the symptoms associated with it. Pain in of

28:38

itself can have an impact beyond the fact that just

28:41

your arm or your leg or your shoulder hurts.

28:42

Right.

28:43

It can cause chronic stress. It can cause. I

28:46

mean, I'm not here to scare people, but certainly there are

28:48

associations of lack, of sleep or pain

28:51

or the combination resulting in cardiac events. I mean, if you get

28:54

really into the weeds on the literature, sure, those

28:57

things can happen. I also don't want anyone who has a fall

29:00

to think they're going to have a heart attack from it. I mean, that's not what we're here for.

29:03

We're not here to scare people. We're here for people to understand

29:06

that whether the break is big or small,

29:09

get the brake managed and stabilized.

29:11

But seniors are known to decondition very quickly.

29:14

Right.

29:15

And you're definitely on the money when you

29:18

mentioned that word, because it is all

29:21

about the loss of function that

29:23

may exacerbate further loss of

29:26

function, loss of activity, and change in the quality

29:29

of life. That scares people. Besides all

29:32

these very valid points about how it

29:35

may affect the body overall to systemic

29:37

inflammation or the

29:40

infection that may come with a surgical

29:43

intervention. But also, don't

29:45

underestimate that putting somebody,

29:48

on a bed for a month when they

29:51

are above a certain age may cause

29:54

them to lose some

29:56

functionalities that they may never

29:59

recover unless they were paired with

30:02

the right rehab program to

30:05

push them back to where they

30:08

were before the fracture took place. And it

30:11

is very important.

30:12

Ultimately, the lines around

30:15

our fracture prevention program are super blurry

30:17

because all of us care for people outside of these

30:20

specific events. So the bone health

30:23

program doesn't do any fracture management

30:26

specifically. But certainly, I am a person who takes

30:29

care of wrist fractures and things like that. And so

30:32

part of my care plan is to funnel patients

30:35

into the program. Similarly, patients come to

30:38

Malek and his partners for other bone health

30:41

concern reasons, whether it's metabolic concerns,

30:43

deconditioning concerns outside of the specific

30:46

program. But now that we have this program,

30:49

whether you got there because you had a fragility fracture, or

30:52

whether you got there because your, spine surgeon or

30:55

your total joint surgeon said, I want to make sure your bone health is great

30:58

before you have surgery, or because you're a runner and you

31:01

have shin splints. And those turned out to be stress

31:03

fractures that have persisted any number of reasons.

31:06

Deconditioned in, especially the more senior members of our

31:09

community. Those are all great reasons to see

31:12

someone with Malak's expertise. But now that we

31:15

have the program, it's one phone call and easy to get

31:18

them into a physical, therapist. It's easy for

31:21

us to work with our imaging providers and

31:24

our lab technicians and everybody else, because

31:27

it's now unified under one flow.

31:29

It's stuff where we take friction out of the system. For

31:32

patients, it's reducing the number of visits so that you're not

31:35

paying for parking and dealing with six different visits. You're

31:38

going once. And at that one or maybe two visits, everything

31:41

gets done. So it's taking

31:44

a problem, as you've probably heard throughout this

31:46

entire discussion, that is so

31:49

multifaceted, has so many aspects to it. It's

31:52

super complicated. And part of what makes managing

31:55

a problem like that better is when you take the friction out of the

31:57

system. And that's why, with the

32:00

support of our leadership here and the department

32:03

chairs here, we were able to put this program together so

32:05

quickly because everyone said, let's get the friction out of the

32:08

system. And without question, that's going to make care

32:11

for our patients better, and we'll probably be able to help

32:14

more people that way.

32:15

It's a very heterogeneous,

32:18

approach because of how

32:20

diverse the clinical problems that we're dealing

32:23

with. Think, about the youngster

32:26

who is a runner who abused their body, that led to a

32:29

stress fracture. We evaluate that, but we also evaluate somebody

32:32

who's 95 years of age who had a hip fracture,

32:35

and each one's needs are going to be very different. That's

32:37

where we were blessed to have

32:40

the multiple resources to tailor according

32:43

to everybody's needs. And usually it

32:46

saves time, and it saves a lot of effort from

32:49

our patients because we also can offer

32:52

them telehealth, appointments, rather than

32:55

them coming in to park in the parking lot and coming to see

32:57

especially. That can be very difficult just after

33:00

a fracture.

33:01

Let's talk about the treatment options.

33:03

Absolutely. So, we have two types of bone cells

33:06

that helps the bone to grow and to rebuild and to

33:09

remodel one. of them, we call them the

33:12

osteoclasts. What they do is mostly

33:15

they eat away the bones

33:18

and the other line of

33:20

cells called the osteoblasts, which builds the bones

33:23

and makes the connections inside of the bone to any given

33:26

time in person's life. There is quite a balance

33:29

between these two cells. So the eating away helps to

33:32

clean up the faulty bone structures,

33:35

and the osteoblast would build back

33:38

the bones into a stronger structure.

33:40

So this kind of dance keeps on

33:43

happening throughout their life. when the

33:46

medications started to get, designed,

33:49

either we prevent the eating away

33:52

from the bone eating cells. Those are

33:55

the osteoclasts, or we promote more

33:57

building from the osteoblast. So

34:00

the two options for therapy would be

34:03

either antirosuptive therapy to suppress

34:05

the eating away of the bones, or anabolic

34:08

therapy, or bone promoting therapies

34:11

to encourage the building up of the

34:14

bones. And recently we have therapies that

34:17

would do both mechanisms together

34:20

at the same time, and that we call them the dual therapies.

34:23

So the antirosopeptive therapies are the ones that we have been

34:25

dealing with for the longest. And most of our

34:28

listeners, would remember the bisphosphonates. It's the

34:31

cornerstone of treatment that most people would

34:34

be started on. These are treatments,

34:37

brand name phosphax may, ring some bells for some

34:40

of our listeners. Other brand names would

34:43

be reclassed or boneva.

34:46

they come in either pills you take once a week

34:49

or once a month. They can be infusions that you can get once

34:52

a year. Around 2010, we had

34:55

another antisopeptive treatment that is very

34:58

commonly used. This goes under the name of denosimab. The

35:00

brand name is Prolia, and it's injection every six months.

35:03

Also, it's very effective to help the

35:06

bones get stronger. And then we have the bone

35:09

promoting agents, the anabolic therapies,

35:12

they resemble a native

35:14

hormone and they help with building

35:17

bones, and they go under the brand names of

35:20

forteo or timlos. And the most

35:22

recently FDA approved medical therapy

35:25

is the dual mechanism of action

35:27

medication. It's called dromosozumab,

35:30

and it is maybe the most potent. It goes under the brand

35:33

name of vanity. That does both things at the same

35:36

time. It's injection once a month that lasts for a

35:39

year, and then afterwards we stop it and switch to something

35:42

else. Treatment for osteoporosis is a

35:44

long journey, and usually it starts with

35:47

identifying how severe the bone loss

35:49

is. And the initial step would be to

35:53

decide whether we're going to use the potent therapies

35:55

that I just mentioned. They're called the anabolic therapies

35:58

or utilize something that is more like a maintenance

36:01

therapy of antiresoptive nature.

36:03

And treatment can be switched

36:06

between the two, groups of therapies.

36:09

Typically, we like to start with anabolic therapy for a year or

36:12

two and then switch over to antiresoptive

36:15

treatment that can extend the treatment for two or three or four

36:18

years. We tend to stay away

36:21

from treatment for a longer duration of time,

36:24

and we like to, give what we

36:26

call medication holiday for the

36:29

bisphosphinate treatment. The

36:32

rationale being that long term

36:34

utilization of these medications may

36:37

increase the risk of having what we call long term side

36:40

effects. We discovered that long term treatment

36:43

with bisphosphonates may cause

36:46

increased risk of osteo necrosis to the jaw, which

36:48

is non healing of the jawbone, or atypical femur

36:51

fracture, which is a fracture of the mid femur that

36:54

is so atypical in nature, that is only

36:57

very rarely happens in any cases other

37:00

than long term treatment with bisphosphonates. And that

37:03

really focused a lot of media attention about

37:06

these long term side effects that are very

37:08

rare, these treatments. So nowadays, we

37:11

shy away from using them for more than five years and

37:14

maybe rarely ten years because of this

37:17

small uptick in the

37:20

incidence of these, fractures.

37:22

Yeah, necrosis of the jawbone sounds very specific,

37:24

very out of left field.

37:26

Honestly, my ten years of practice, I

37:29

had only one patient who developed that, and it

37:32

was mild, degree, and very

37:35

treatable. However, it's scary, and I totally understand

37:37

when people hear the stories or read about it, and that's

37:40

the first headliner that they may end up coming

37:43

across. However, in real life, it doesn't really happen. In fact,

37:46

there was a study that compared the frequency of these

37:49

things, and it was found that it's

37:52

really higher likely to be hit by

37:54

lightning than getting osteocorosis, necrosis of

37:57

the jaw, in many of these studies. So it does not really happen very

38:00

fast.

38:00

Okay, that's good to know. So, once the patient is

38:03

in the bone fracture and

38:06

prevention program, how long do you usually follow the

38:09

patient? Are they in it for life?

38:11

Now? Osteoporosis itself is a chronic medical

38:13

condition. Treatment for osteoporosis

38:16

is a long standing therapy plan

38:19

that needs to be initiated and sometimes

38:22

interrupted by side effects or maybe transitioned

38:24

to some other treatments. That being

38:27

said, it is a long

38:30

conversation. It is quite a few

38:32

years therapy, plan that we undergo with most

38:35

of our patients.

38:37

Okay. So we know prevention is key. What advice do

38:39

you have for listeners to prevent osteo and bone fractures?

38:42

The concept of prevention is a helpful term because ultimately

38:45

what we're doing is identifying a group that really has a

38:48

higher risk based on a number of factors.

38:51

One is that they already had a fragility fracture, which doesn't

38:54

necessarily mean that they're higher risk of falling. But certainly this does help

38:57

us find patients who might be and might not even be aware of some

39:00

areas where physical therapy or balance training could be

39:03

incredibly helpful for them. So in that way, it's preventative.

39:06

It also allows us to get them plugged in with physical therapy and build

39:09

strength, maybe even unrelated, to the fracture.

39:12

People who have leg strength or hip strength challenges, core

39:14

strength, challenges that make their balance a bigger

39:17

issue that gets picked up when they fall and have a wrist fracture.

39:20

So that connection, that synergy between

39:23

therapy and the bone health program is so important in that way of

39:26

prevention. It's not that we do anything to structurally protect

39:29

the bones from the outside, but that's what

39:31

Malek and his team do, is protect the bones from the inside, make them

39:34

stronger. And in that way, there's also a preventive

39:37

component as well.

39:38

There are good scientific evidence to support the notion

39:41

that smoking and consumption of more

39:44

than three servings of alcohol on daily basis

39:47

may increase the risk of fracture. So we always talk

39:50

about our patients, about avoiding these two

39:53

things. Protein and calcium is the two elements

39:56

of the diet that may help patients who have

39:58

deficiency in either these two things to

40:01

promote for healthier bones. Typically, protein

40:04

should be equally distributed on two or three

40:07

servings a day, depending on the patient's level of

40:09

exercise. The calcium intake should be

40:12

distributed over three separate meals a

40:15

day. We are shying away from giving patients calcium

40:18

supplementation, and we are encouraging more calcium

40:20

rich items through diet distributed through three

40:23

meals. And these usually

40:26

can come from either dairy product, milk, yogurt, cheese,

40:29

and ice cream. And. Yes, I said ice cream.

40:32

or it can be from fresh vegetables. The

40:35

other option would be taking nondairy items,

40:38

such as soy milk or almond

40:41

milk, which can be very rich with calcium.

40:44

The idea is to achieve around 1200 milligrams of calcium

40:47

on daily basis.

40:48

All right, any final thoughts?

40:50

I think, ultimately, if any of this conversation

40:53

resonates, or you have family who you think may be

40:56

appropriate, the easiest thing to do is to find out. We have a great

40:58

coordinator who really runs the show for our program, and she

41:01

can always help with, essentially triage decisions. Who belongs

41:04

seeing who is it appropriate, is it not? Or certainly can get in

41:07

touch with any of the providers about that. So the last thing we want is for

41:10

people to worry and think it might be an issue and not reach

41:13

out and not get the help that they need, because I think the biggest

41:16

message is that this is a sneaky, problem that has

41:19

kind of gone under addressed for quite some time. And

41:22

so a lot of people aren't aware of it, or even if they're aware,

41:25

don't understand how much we've done to make it easy

41:28

to treat or at least easy to address and evaluate. And

41:31

so, if your provider mentions it or if your

41:34

family thinks about it or if you're thinking about it for yourself,

41:37

reach out. We are always available to help. And

41:39

the best thing is for us to say, you, know what? No, you look

41:42

great. We don't need to do anything for this. But the worst thing would be

41:45

to think about it, not get it dealt with, and then have one of these big injuries that we're also

41:48

worried about.

41:49

Thank you, gentlemen.

41:50

Sweet.

41:51

We've been talking with Dr. Avi Giladi and Dr.

41:54

Malek Cheikh at MedStar Health in baltimore. Thank

41:57

you for sharing your expertise with us today on

42:00

MedStar Health doc talk. For more information

42:03

on bone fractures, go to medstarhealth.org

42:06

or to schedule an appointment at the MedStar

42:08

Health, bone health and fracture prevention program in

42:11

baltimore, call 410-554-7485

42:20

close.