Hand surgeon, Dr. Avi Giladi and endocrinologist Dr. Malik Cheikh discuss why their specialties lend to a fracture prevention program; why bone fractures are risky, particularly for seniors, as well as treatment and prevention tips.
For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.
Hand surgeon, Dr. Avi Giladi and endocrinologist Dr. Malik Cheikh discuss why their specialties lend to a fracture prevention program; why bone fractures are risky, particularly for seniors, as well as treatment and prevention tips.
For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.
Comprehensive, relevant, and insightful conversations about health and medicine happen here when MedStar health doc talk. Consider your own skeletal frame, formed by living, growing tissue we know as bones. healthy bones are essential to mobility, to protecting your organs and anchoring our muscle system. But the more we age, the more our bones weaken, increasing the risk of fracturing. With 10 million americans suffering osteoporosis, it's important to understand the risks and symptoms of these pathological bone fractures. I'm happy to introduce Dr. Avi Giladi and Dr. Malek Cheikh from the Bone Health and Fracture prevention program at MedStar Health to discuss those risks, the options for treatment and prevention. I'm your host, Deborah Schindler. Thank you for bringing your expertise to us here on MedStar Health doc talk.
>> Speaker B:Thanks, deb. Great to be here.
>> Speaker A:Dr. Avi Giladi, is a hand surgeon at the Curtis National Hand Center at MedStar Union Memorial Hospital and the surgical lead for the bone Fracture program. Dr. Cheikh is the program's medical lead and an endocrinologist at MedStar Good Samaritan Hospital here in Baltimore. It would seem almost an unusual pairing, an endocrine expert and a hand surgeon who would like to start by explaining why it's actually perfect for a bone fracture program.
>> Speaker B:So our, fracture prevention program has been built out of a model that really is led by both of our professional societies, both across the United States and globally, where there is an important focus on the orthopedics or bony side of the treatment team lining up with the endocrine or other bone health expert side of a treatment team for a patient and give them a full, comprehensive care piece. Patients present to us, at the hand center with distal radius fractures or wrist fractures, often from a fall from standing height. And we see those quite commonly. It's actually the second most fracture that occurs, essentially, across all people. it's something we deal with throughout the year. Yet what those fractures often can tell us about the patient is that there may be bigger underlying bone health problems that are outside our area of expertise. So where we are experts in dealing with the fracture, we don't have much experience or longitudinal care over time to make the bone health piece better. So the partnering with experts like Dr. Cheikh and his partners in our endocrinology group here make it so that we can provide comprehensive care, not just about dealing with the fracture, but doing our best to make sure additional fractures don't happen and that the bone healing can go on as we would like it to.
>> Speaker C:very well said, avi, in the community oftentimes, what we have been seeing over the last couple decades, that many patients have bad bones enough that they would keep on fracturing, and when they see the surgeons and they get the fracture repaired, they go about their life not focusing on the underlying cause that caused the fracture to happen. So this collaboration was very natural, and we thought that it would try to bridge the gap between the common fragility fractures that we see in the community and try to help to address the underlying issues so they will not go back and recur again in the future.
>> Speaker A:Are you referring to the same fracture or new ones? Patients who have repeat visits for the same.
>> Speaker C:So, interestingly enough, that's a very good point, that once you have a fragility fracture at a certain site in your body, that increases the risk of the next fracture dramatically. like these distal radial fractures that Avi was just talking about can be the tip of the iceberg that would reveal an underlying bone issue that needs to be addressed, because many of the patients that he has been sending me throughout the years are, after a dyserradial fracture turned out to have severe osteoporosis that would benefit from, and did benefit from treatments that we offered them in the program.
>> Speaker B:It may seem od, most of all, to have a surgeon focusing on what is clearly a medicine problem, a medical problem. No one's going to operate on the bone health and fix it. It's treatments that are provided by Malek and his team or other bone health experts. The reason this team makes sense, though, is what was sort of just being described. It's that tip of the iceberg phenomenon where someone was otherwise healthy, going about their day, had a trip and fall, that when they were 25 or 30 years old, would have never caused a problem, would have got right back up. But here they are in maybe their early fifty s, and now they have a fracture or they've broken their bone. That is an indication of an underlying problem that if we don't address that, next fall, could be a hip fracture, could be a spine fracture. Things that go from two or three months of wrist rehabilitation to six months to a year of much bigger, life altering rehabilitation. And we know that spine and hip fractures have such a bigger impact on the overall life of a patient that for me, as a hand surgeon and for all of my partners as hand surgeons, we care so much about not missing that opportunity. So it made sense for me to be part of this program as a liaison, really bridging that gap and getting our patients, whether in our clinic or our hip fracture clinic or our, upper arm and shoulder fracture clinic. All of these are ways that we can capture patients who really need this attention outside of their orthopedic care. And that's why this program makes as much sense as it does.
>> Speaker C:And oftentimes, it is the first fracture that would reveal the underlying medical condition rather than our three screening methods, because, as Avi, was saying, patient may be very healthy, and the first fracture should be the indicator to trigger a consultation, or at least a Dexa scan, for evaluation of the systemic bone health as a general concept. So we can sort between the patients who have good bone marrow density versus the patients who need this, cascade of an approach to help improve their bone quality and density.
>> Speaker A:So you referred to them as fragility fractures. That distinguishes a patient from someone who may have fallen off their bike or fallen off a skateboard.
>> Speaker C:Correct. That is a very important concept to, clear. which is that any fall from standing height or what we call a low trauma fracture, low velocity fracture, that happens to any patient that may have some significance to try to figure out what the bone density represents. In other words, what I usually tell my patients is, if you have a fall that was not that significant or you're fractured for a fall that did not make sense. Or I rephrase by saying, if you think that you would have not fractured the bone 20 years ago and now you did, there's something wrong with your bones that we need to talk about, right?
>> Speaker B:I mean, ultimately, someone getting in a car accident, falling off a bike, falling off an escooter, breaking a bone that way, the energy at least makes more sense to have sustained an injury. I mean, at some point, bones don't hold up to everything we know. Know. The bigger issue is, as Malek was saying, breaks that just happen. When you kind of think back and say, I can't believe I broke that. I can't believe that little trip and fall. I can't believe tripping over my carpet, getting out of bed in the morning, or I was just walking outside, took a little slip on ice, went down, and all of a sudden felt that pain. Those really surprise patients, and that surprise is understandable, because they've probably fallen like that ten times before in their life, and it never happened. And the fact that it happened this time doesn't mean they have a problem. But all of us, as providers that care about the whole patient and not just our specific issue, want to make sure we don't miss that problem if it's there.
>> Speaker A:So they would be referred to, you from the emergency room?
>> Speaker B:Yeah. I mean, I think from a fracture management standpoint, we often get those patients either through the emergency department or they are seen at an urgent care, told they have a break, and then they call our know. We see patients here at Union Memorial, but we also have multiple satellites across the MedStar network and in a few other locations where patients come through with these injuries. all of those sites are great for outpatient fracture management, but from there, we then want to filter these patients into our program, where they can get the Dexa scan or the lab workup, or everything else to figure out the bone health piece. That can happen at the time that we're managing the fracture. That can also happen a few months later once we've dealt with the immediate problem, and then we want to deal with the whole person beyond that. I think both of those timelines are acceptable, but we really want to get them within the first three, or at most, six months.
>> Speaker A:Is a, bone fracture the same as a break?
>> Speaker C:Absolutely. So, a fracture is very similar to break. However, most people would attribute the bone break as a very clinically significant, event. However, it's very important to highlight that people can break their bones or fracture their bones without even knowing. So, in our literature, around 30% of people who would break a part of their spine or vertebral body, that's what we call it, can be subclinical or silent. They don't know until we review, their old records and we find on, like, a chest CT or any other, image that they may have had for some other reason, that we find that there is a fracture that they never really knew that they had it. And the significance of knowing or highlighting those subclinical fractures or silent fractures that may happen is that once we see them, we don't wait. We treat, because oftentimes that tells you that there's trouble that's going to happen in the horizon, and we need to deal with it right now rather than wait, which may exacerbate the problem that we're dealing with.
>> Speaker A:Are you referring to seeing old fractures that are healed, or are they still showing to be a fracture?
>> Speaker C:Both. Well, I mean, the nice thing. Well, it's not so nice, but the nice thing about reviewing old images, looking at spine, is once you see a fracture, that may decrease the height of a vertebral body. And, we all remember when we look at our grandmothers and how sometimes they can lose weight or they shrink with age. That happens because the height of the vertebral bodies usually go down because either they had severe, osteoporosis or a fracture to their vertebral body that would decrease that height and that, would seem clinically, as somebody who's bent over. Despite that, they may heal, but they would still show loss of height when we evaluate them with x rays.
>> Speaker B:So, to your original question, bone break, fracture, compound fracture, or all these terms get thrown around. Ultimately, it's a bone that is not structurally stable anymore. It means all the same thing, essentially, to us as providers. The bone has been broken. What is hard, I think, for a lot of people to conceptualize is sometimes it's as simple as I fell, I landed on my arm or my hip, and it broke. Sometimes it's. I don't even know what I did, but my spine has a break in it or my spine bones are collapsing. Some. Sometimes it's the dog leash pulled on my arm and something happened. The more weird for people or the more unusual the event, the more the sort of spidey sense about bone health should start going off, because the bones are designed to be strong and stable. And as we age, that changes. So there's the obvious ones. I fell. It broke. We know what happened here. Let's get your bone health check. But there's also all sorts of things. Stress fractures for runners. Sometimes these are people who are healthy and they're active, and yet they're dealing with things like that. Sometimes it's an overuse problem. Sometimes it's an overuse plus bone health problem. And what we've learned as a medical community, especially over the past 1015 years, number one, we have better and better ways to treat it. But number two, there are a lot of situations that we've kind of not focused on as indicators that we're learning more and more, probably are. And so, again, getting a unified program around those is much better than doing kind of one off, trying to remember to refer a patient and letting people go uncared for.
>> Speaker C:And also, if you don't mind me interrupting, it's very important that we proactively seek out these diagnoses after the event or the outcome happens, because those are the patients that we can definitely make a good impact on their bone health. Because once, we reach the threshold of events happening with this low velocity or low trauma, events that led to a fracture, then, that will exponentially continues to happen at a higher frequency. And those are the patients who we call the highest risk of fracture portion of the patients that we want to intervene on by the medications that Avi was mentioning, that have been shown over the last couple of decades that not only they are effective, but they also may raise the bone marrow density to a point where it would be safe for the patient to utilize, use, and hopefully abuse their bones without, leading to a break.
>> Speaker A:Okay, before we get to those treatments and medications, I want to get back to what you were talking about, Dr. Giladi, when you said, some overuse activity could cause a fracture. That's kind of understandable. Running fractures we've heard about. But I also see that underuse or undermobility could also lead to a, higher risk of a bone fracture. Do you want to go through the list of some of the factors that do play into a, higher risk of bone fracture?
>> Speaker B:Yeah, I think to some degree, that's a very important concept. Some of the patients that come through to the program, or you might be a patient who has a doctor who picked up on a bone health problem even before you've had a break. And the first thing that they'll say is, consider certain supplements and consider increasing your exercise or working in physical therapy.
>> Speaker A:How would they pick up on that without a break?
>> Speaker B:So, there are screening guidelines, across our, national societies that say if you are of a certain age, whether you're male or female, those ages are a little bit different. There should be just baseline screening, or there are some people who've had,
>> Speaker A:With a Dexa scan.
>> Speaker B:With a Dexa scan, right. And there's also people who've had these injuries. Maybe they didn't come to our clinic. Maybe they were seen elsewhere, and they get this screening, and they get started on supplements. Usually calcium and vitamin D are discussed as the easiest thing to get started on. and I'm a little bit trailing into Malik's territory here, so I'm going to hand off to the treatments pretty soon here. But the other thing that I really want to stress is the exercise piece. Exercise and physical therapy are a huge part of what we address, especially in the early phases of bone health treatment, because, to your point, deb, not, using your bones, I want to say, you don't use it, you lose it. But it's essentially, they do get a little bit weaker. They like being loaded. Muscle is really helpful for bone health. Use of the bones will sort of stimulate your body to build them and make them stronger. So one of the things we do with our patients through the fracture prevention program is work with our physical therapy colleagues. We have a great partnership with physical therapy, and all of these patients have an opportunity to get plugged in with additional physical therapy. Whether it's for the event that led to their problem, a fall, getting out of a hip fracture and recovering. Recovering from their upper extremity fracture, their arm or wrist fracture, or it's just that they have balance challenges or strength, getting out of a chair challenges. All those things could be improved with physical therapy and work together with the bone health effort to ultimately prevent, ah, additional breaks in the future.
>> Speaker A:Okay, so just to provide a laundry list, sort of, of what some of those risks are, I'm going to go through them and you guys can comment if you'd like. Low dietary intake, malabsorption, probably not enough protein, vitamin D or calcium. Underweight or overweight, abnormal body mass index, which you've touched on bone or back pain, level of physical activity and mobility, low sun exposure.
>> Speaker B:That's a vitamin D overlap issue.
>> Speaker A:Fracture history in patient or family members. Is it hereditary to have.
>> Speaker C:Absolutely. So there are plenty of things that can run in the family that would lead into low bone marrow density. Genetically, one of the biggest things that we always ask our patients that may highlight or increase our suspicion to having low bone marrow density and osteoporosis. That would be a family member who had a hip fracture that would increase the risk of low bone marrow density in the individual themselves, if they have any family members who had a fracture. And on top of the nice list that you mentioned, there's plenty of medical conditions that may increase the risk of having low bone marrow density. And we're talking about whether it's top one, top two, diabetes. Any liver problem, smoking in itself can cause it. Rheumatoid arthritis. COPD just to say, if you have a celiac disease, any inflammatory, arthritic issue in the body, all these can increase the risk of fracture and decrease the bone density in somebody. And I just want to go back to when you asked Avi about the usage. The loading concept that he was talking about is huge in what we do. That's why we always tell patients to do weight bearing exercises for maintenance of the bone density. There has been a couple of studies looking at bone density in astronauts before they flew to space and after they came back. And not having gravity is a huge factor that can cause decline in bone marrow density. So think about it. if you're not standing and using gravity or walking, upright, for a long period of time, that can decrease the loading of your bones. Because despite the myth of bones are just, inactive organs in our body, they are very active. And the more we know about the bone cells, we understand that they can send signals to the rest of the body to improve the bone density. And that signal happens when you walk and when you use your weight bearing exercises. That's why we tend to, highlight and emphasize the importance of all these exercises and also our, collaboration that Dr. Giladi was talking about that is very crucial for our patients after they had a fracture, to, improve their balance and improve their rehab back to their life.
>> Speaker A:It's so interesting about the astronauts. They actually came back and their bone density was weaker.
>> Speaker C:I don't know if it's the aliens cast a spell on these astronauts or.
>> Speaker A:What, but how does that Dexa scan actually work? It's sort of like an x ray. I've never had one.
>> Speaker C:It's mostly an x ray. I mean, it's a table that you walk into a small room, you sit on the table. We bring this not so big of a device on top of your spine and then on top of your hip, and sometimes on top of the distal wrist radius. And we take pictures. And those machines are capable of looking at the penetration of the x ray to the bone structure. And according to how much penetration there was, it would label it with a number, and we call that number the bone density. And this bone density is important to understand, because the lower it is, the more fragile the bone is. And if it is fragile, then that leads to higher risk of fracture under any particular trauma that the person may have.
>> Speaker A:What's a healthy number?
>> Speaker C:So, to make it a little bit more complicated, the bone marrow density number is not what we look at. We look at a statistical number that we try to come up with every time we look at bone marrow density. In essence, all what it is is how does it compare to a 30 year old person bone density? So we're just comparing every person on the Dexa scan with a 30 year old person's bones and look at this statistical model that we call standard deviation. And the further you are, or the lower you are from that number, then the higher risk of fracture you have. And the who, a long time ago told us any two and a half standard deviations under the mean equals what we call osteoporosis, which, in essence, all what it is, it's just the bones are weaker, and then that needs to be intervened upon, and some type of therapy needs to be implemented.
>> Speaker A:Okay, you mentioned, osteosorosis. You can't talk about bone health without bringing up osteoporosis. Differentiate for me what osteoporosis versus osteopenia versus osteomalasia are.
>> Speaker C:Sure. So using the Dexa scan machine and coming up with the numbers that we just talked about, we call them bone marrow densities and the standard deviations from the mean. we can look at everybody who has a Dexa scan. We can also break them down to three categories. There would be normal bones, and that's when the bones are not really that far off from the mean, the healthy mean, which is the 30 year old people's bones, the slightly worse bones, we would call them osteopenia. And then when we reach a much worse bone level, that's when we call it osteoporosis. So it's just a stage? A stage, in the progression of the disease. Osteopenia is less advanced stage than osteoporosis is. That does not mean that if you're, osteopenia, you don't fracture. In fact, there are other factors other than this stage of the disease that may predict the risk of fracture in the future.
>> Speaker A:What about osteomalasia?
>> Speaker C:So osteomalasia is something somewhat different where the bones do not have the right amount of minerals to strengthen the structures. Versus osteoporosis means that the bones are thinning. So think about it as not enough scaffolding when you're building a building versus that you are using cheap material to build the building. And that's where osteomy Malaysia is.
>> Speaker A:Is that age related, and is it treatable? Or any of those three, are they treatable? Can it be reversed?
>> Speaker C:Absolutely. Nowadays, we're so lucky to have multiple options to improve the bone marrow density and decrease the risk of fracture. Because the end of the day, the risk of fracture, what we try to, decrease, and fractures are what we try to prevent from happening. So I'm going to start with osteomylation, which is, again, a maritalization problem. It usually happens if somebody does not have enough vitamin D or not taking enough calcium in their diet. So it's very important to figure out why people have osteomylation. It's not very common. It usually happens with malnutrition. population, we tend to improve the diet, improve the calcium intake, improve the vitamin D, and that can fix it somewhat in a more rapid pace than what you would see with osteoporosis.
>> Speaker A:So maybe that is not age related.
>> Speaker C:Then it can be age related, but it does not have to be age related versus the osteoporosis. It's definitely age related. Now we think about osteoporosis in our first few decades of life. We build a healthy bone in most cases, unless there's interruption of some hormonal issue or malnutrition of some sort. But at, usually, an age of 40, that's when we start to have the best bone in our lifetime. And then afterwards, slowly, there is a continuous decline in the bone density that would affect the strength of the bones. And it usually depends on how long we're going to live until we hit osteoporosis ranges, because that decline is going to continue to happen. It depends on when we discover somebody to have osteoporosis. And there are multiple options, as we just mentioned, they kind of vary, between pills that you can take once a day or once a week, infusions that you can get once a year, injections that you can get every six months. There are some pills you take once a month. So there's plenty of options. And they usually differ according to how efficacious these medications are. And oftentimes, I tell most of my patients, if we treat you, for a long enough period of time, we can restore the bone strength back to where it was before you developed osteoporosis.
>> Speaker A:Oh, good to know.
>> Speaker C:Yep.
>> Speaker A:I thought maybe the medications would just stop the progression.
>> Speaker C:It's definitely now, Dr. Diladi just mentioned something very important. Initially, when we're talking about, we can definitely restore the bone integrity, we can help improve the bone density, but there are some other factors that's very important to talk about. these are the other elements that may increase the risk of somebody having fractures, such as lack of balance, frailty, not having good muscle mass, maybe having bad joints that are going to lead to multiple falls, that would lead to fractures. So all these things needs to be addressed, and that's where the medication itself is not going to be the one thing that's going to fix everything. So it's important to pay attention to all these other components. That's why I need, it's not going to be seeing an endocrinologist or just a medical doctor and figuring it out. It takes, really, a village reduce the risk of somebody's fracture. And that's when we talked about having a surgical team involved, having a physical therapy team also involved, and nutritionists sometimes, and all sorts of interventions that may be also needed.
>> Speaker A:How does menopause play into bone health?
>> Speaker C:So, after those first four or five decades in life, the female body stops producing estrogen and the reproductive hormones and that may cause a rapid decline in bone marrow density because the bone maturation and improvement of the quality, is somewhat dependent on this surge or flow of the female hormones. And because of that, in the first two or three years after menopause, there is a rapid decline in the bone marrow density that takes place, and that is associated with increased risk of fracture. And that continues to happen because, of the next couple decades and females, life, typically there's no exposure to estrogen. That deterioration continues to a point where the bone density leads to all sorts of fragility fractures that we started this.
>> Speaker A:Conversation, you had mentioned that some patients don't even know they've had a fracture. What happens if some of these fractures aren't treated? Is there a risk? Is there, another health risk?
>> Speaker C:So the biggest health risk is that a fragility fracture or fracture that has not been clinically identified may represent a poor bone state that needs to be addressed. And if we don't, or if we didn't know about it, or if we had a fragility fracture that we did not address, that may lead to another, maybe more significant fracture that would lead to limitation in abilities of patients activities. It also, when it is bad enough, it can lead to increased mortality. And we see that in males who had hip fractures at an old age. So, because of how serious these fractures can be, cannot ignore the initial fracture. That can sometimes be subclinical and sometimes can be, fragility in nature, at.
>> Speaker A:Least, this is what I read, that there's a blood clot risk, there's infection risk, there's damage to the skin tissues or muscles around the fracture, and swelling of a nearby joint. Are those realistic?
>> Speaker B:From a fracture?
>> Speaker A:Yeah. For an untreated fracture, yeah.
>> Speaker B:I think the impact lines are blurry. It's a numbers game, right? So some fractures will come with swelling and pain, and that's it. Certainly, you have increased risk of much less common things like skin, issues from the underlying swelling or blood clot issues or other really rare phenomena. And, so you certainly would want to do anything you can to prevent additional fractures, not only because the fracture itself is a problem, but because there are risks, and over time, those risks mount.
>> Speaker A:Why is it so risky for seniors, though? And is it an emergency if a senior falls and a fracture is suspected?
>> Speaker B:I think anytime you have a fall and there's concern for a fracture, you should be evaluated relatively soon, because stabilizing the fracture will likely reduce the symptoms associated with it. Pain in of itself can have an impact beyond the fact that just your arm or your leg or your shoulder hurts.
>> Speaker C:Right.
>> Speaker B:It can cause chronic stress. It can cause. I mean, I'm not here to scare people, but certainly there are associations of lack, of sleep or pain or the combination resulting in cardiac events. I mean, if you get really into the weeds on the literature, sure, those things can happen. I also don't want anyone who has a fall to think they're going to have a heart attack from it. I mean, that's not what we're here for. We're not here to scare people. We're here for people to understand that whether the break is big or small, get the brake managed and stabilized.
>> Speaker A:But seniors are known to decondition very quickly. Right.
>> Speaker C:And you're definitely on the money when you mentioned that word, because it is all about the loss of function that may exacerbate further loss of function, loss of activity, and change in the quality of life. That scares people. Besides all these very valid points about how it may affect the body overall to systemic inflammation or the infection that may come with a surgical intervention. But also, don't underestimate that putting somebody, on a bed for a month when they are above a certain age may cause them to lose some functionalities that they may never recover unless they were paired with the right rehab program to push them back to where they were before the fracture took place. And it is very important.
>> Speaker B:Ultimately, the lines around our fracture prevention program are super blurry because all of us care for people outside of these specific events. So the bone health program doesn't do any fracture management specifically. But certainly, I am a person who takes care of wrist fractures and things like that. And so part of my care plan is to funnel patients into the program. Similarly, patients come to Malek and his partners for other bone health concern reasons, whether it's metabolic concerns, deconditioning concerns outside of the specific program. But now that we have this program, whether you got there because you had a fragility fracture, or whether you got there because your, spine surgeon or your total joint surgeon said, I want to make sure your bone health is great before you have surgery, or because you're a runner and you have shin splints. And those turned out to be stress fractures that have persisted any number of reasons. Deconditioned in, especially the more senior members of our community. Those are all great reasons to see someone with Malak's expertise. But now that we have the program, it's one phone call and easy to get them into a physical, therapist. It's easy for us to work with our imaging providers and our lab technicians and everybody else, because it's now unified under one flow. It's stuff where we take friction out of the system. For patients, it's reducing the number of visits so that you're not paying for parking and dealing with six different visits. You're going once. And at that one or maybe two visits, everything gets done. So it's taking a problem, as you've probably heard throughout this entire discussion, that is so multifaceted, has so many aspects to it. It's super complicated. And part of what makes managing a problem like that better is when you take the friction out of the system. And that's why, with the support of our leadership here and the department chairs here, we were able to put this program together so quickly because everyone said, let's get the friction out of the system. And without question, that's going to make care for our patients better, and we'll probably be able to help more people that way.
>> Speaker C:It's a very heterogeneous, approach because of how diverse the clinical problems that we're dealing with. Think, about the youngster who is a runner who abused their body, that led to a stress fracture. We evaluate that, but we also evaluate somebody who's 95 years of age who had a hip fracture, and each one's needs are going to be very different. That's where we were blessed to have the multiple resources to tailor according to everybody's needs. And usually it saves time, and it saves a lot of effort from our patients because we also can offer them telehealth, appointments, rather than them coming in to park in the parking lot and coming to see especially. That can be very difficult just after a fracture.
>> Speaker A:Let's talk about the treatment options.
>> Speaker C:Absolutely. So, we have two types of bone cells that helps the bone to grow and to rebuild and to remodel one. of them, we call them the osteoclasts. What they do is mostly they eat away the bones and the other line of cells called the osteoblasts, which builds the bones and makes the connections inside of the bone to any given time in person's life. There is quite a balance between these two cells. So the eating away helps to clean up the faulty bone structures, and the osteoblast would build back the bones into a stronger structure. So this kind of dance keeps on happening throughout their life. when the medications started to get, designed, either we prevent the eating away from the bone eating cells. Those are the osteoclasts, or we promote more building from the osteoblast. So the two options for therapy would be either antirosuptive therapy to suppress the eating away of the bones, or anabolic therapy, or bone promoting therapies to encourage the building up of the bones. And recently we have therapies that would do both mechanisms together at the same time, and that we call them the dual therapies. So the antirosopeptive therapies are the ones that we have been dealing with for the longest. And most of our listeners, would remember the bisphosphonates. It's the cornerstone of treatment that most people would be started on. These are treatments, brand name phosphax may, ring some bells for some of our listeners. Other brand names would be reclassed or boneva. they come in either pills you take once a week or once a month. They can be infusions that you can get once a year. Around 2010, we had another antisopeptive treatment that is very commonly used. This goes under the name of denosimab. The brand name is Prolia, and it's injection every six months. Also, it's very effective to help the bones get stronger. And then we have the bone promoting agents, the anabolic therapies, they resemble a native hormone and they help with building bones, and they go under the brand names of forteo or timlos. And the most recently FDA approved medical therapy is the dual mechanism of action medication. It's called dromosozumab, and it is maybe the most potent. It goes under the brand name of vanity. That does both things at the same time. It's injection once a month that lasts for a year, and then afterwards we stop it and switch to something else. Treatment for osteoporosis is a long journey, and usually it starts with identifying how severe the bone loss is. And the initial step would be to decide whether we're going to use the potent therapies that I just mentioned. They're called the anabolic therapies or utilize something that is more like a maintenance therapy of antiresoptive nature. And treatment can be switched between the two, groups of therapies. Typically, we like to start with anabolic therapy for a year or two and then switch over to antiresoptive treatment that can extend the treatment for two or three or four years. We tend to stay away from treatment for a longer duration of time, and we like to, give what we call medication holiday for the bisphosphinate treatment. The rationale being that long term utilization of these medications may increase the risk of having what we call long term side effects. We discovered that long term treatment with bisphosphonates may cause increased risk of osteo necrosis to the jaw, which is non healing of the jawbone, or atypical femur fracture, which is a fracture of the mid femur that is so atypical in nature, that is only very rarely happens in any cases other than long term treatment with bisphosphonates. And that really focused a lot of media attention about these long term side effects that are very rare, these treatments. So nowadays, we shy away from using them for more than five years and maybe rarely ten years because of this small uptick in the incidence of these, fractures.
>> Speaker A:Yeah, necrosis of the jawbone sounds very specific, very out of left field.
>> Speaker C:Honestly, my ten years of practice, I had only one patient who developed that, and it was mild, degree, and very treatable. However, it's scary, and I totally understand when people hear the stories or read about it, and that's the first headliner that they may end up coming across. However, in real life, it doesn't really happen. In fact, there was a study that compared the frequency of these things, and it was found that it's really higher likely to be hit by lightning than getting osteocorosis, necrosis of the jaw, in many of these studies. So it does not really happen very fast.
>> Speaker A:Okay, that's good to know. So, once the patient is in the bone fracture and prevention program, how long do you usually follow the patient? Are they in it for life?
>> Speaker C:Now? Osteoporosis itself is a chronic medical condition. Treatment for osteoporosis is a long standing therapy plan that needs to be initiated and sometimes interrupted by side effects or maybe transitioned to some other treatments. That being said, it is a long conversation. It is quite a few years therapy, plan that we undergo with most of our patients.
>> Speaker A:Okay. So we know prevention is key. What advice do you have for listeners to prevent osteo and bone fractures?
>> Speaker B:The concept of prevention is a helpful term because ultimately what we're doing is identifying a group that really has a higher risk based on a number of factors. One is that they already had a fragility fracture, which doesn't necessarily mean that they're higher risk of falling. But certainly this does help us find patients who might be and might not even be aware of some areas where physical therapy or balance training could be incredibly helpful for them. So in that way, it's preventative. It also allows us to get them plugged in with physical therapy and build strength, maybe even unrelated, to the fracture. People who have leg strength or hip strength challenges, core strength, challenges that make their balance a bigger issue that gets picked up when they fall and have a wrist fracture. So that connection, that synergy between therapy and the bone health program is so important in that way of prevention. It's not that we do anything to structurally protect the bones from the outside, but that's what Malek and his team do, is protect the bones from the inside, make them stronger. And in that way, there's also a preventive component as well.
>> Speaker C:There are good scientific evidence to support the notion that smoking and consumption of more than three servings of alcohol on daily basis may increase the risk of fracture. So we always talk about our patients, about avoiding these two things. Protein and calcium is the two elements of the diet that may help patients who have deficiency in either these two things to promote for healthier bones. Typically, protein should be equally distributed on two or three servings a day, depending on the patient's level of exercise. The calcium intake should be distributed over three separate meals a day. We are shying away from giving patients calcium supplementation, and we are encouraging more calcium rich items through diet distributed through three meals. And these usually can come from either dairy product, milk, yogurt, cheese, and ice cream. And. Yes, I said ice cream. or it can be from fresh vegetables. The other option would be taking nondairy items, such as soy milk or almond milk, which can be very rich with calcium. The idea is to achieve around 1200 milligrams of calcium on daily basis.
>> Speaker A:All right, any final thoughts?
>> Speaker B:I think, ultimately, if any of this conversation resonates, or you have family who you think may be appropriate, the easiest thing to do is to find out. We have a great coordinator who really runs the show for our program, and she can always help with, essentially triage decisions. Who belongs seeing who is it appropriate, is it not? Or certainly can get in touch with any of the providers about that. So the last thing we want is for people to worry and think it might be an issue and not reach out and not get the help that they need, because I think the biggest message is that this is a sneaky, problem that has kind of gone under addressed for quite some time. And so a lot of people aren't aware of it, or even if they're aware, don't understand how much we've done to make it easy to treat or at least easy to address and evaluate. And so, if your provider mentions it or if your family thinks about it or if you're thinking about it for yourself, reach out. We are always available to help. And the best thing is for us to say, you, know what? No, you look great. We don't need to do anything for this. But the worst thing would be to think about it, not get it dealt with, and then have one of these big injuries that we're also worried about.
>> Speaker A:Thank you, gentlemen.
>> Speaker B:Sweet.
>> Speaker A:We've been talking with Dr. Avi Giladi and Dr. Malek Cheikh at MedStar Health in baltimore. Thank you for sharing your expertise with us today on MedStar Health doc talk. For more information on bone fractures, go to medstarhealth.org or to schedule an appointment at the MedStar Health, bone health and fracture prevention program in baltimore, call 410-554-7485 close.