I want to thank the whole committee for giving us the privilege of speaking about bone health here, this case-based presentation. I think I can speak for Dr. Ciappella and Madsken that we're excited to talk about this huge topic in an efficient and practical way. So forgive me if I talk really fast about it in the limited time we have. So I think most of you are probably familiar with these statistics on osteoporosis, which is a worldwide epidemic affecting hundreds of millions of people. It has a great cost to financially, societally, and personally. And in orthopedics, since we're treating the fragility fractures associated with this, we see personally and up front and close the pain, the disability, the decrease in quality of life associated with these injuries. And for us, it's, come back here a little bit, up close and personal anyways. So we know the highest risk patients are those patients who've already had a fragility fracture. So if you've had one, there's a very high risk you'd have a second, particularly in the first year or so afterwards. So that's why it's imperative to address bone health expediently, especially after a fragility fracture at the very least. We also know that there's increased risk with aging. So two patients with the exact same bone marrow density of different ages, the older patient will have a much higher risk than the younger patient. So if you're asking yourself why a sports medicine physician who tries to focus on young, healthy athletes, should you be interested in this topic, it's important to remember that even though in children and adolescents, osteoporosis is not common, it is the time in life where the framework for their skeletal health is made. So it's very important to pay attention to bone health in this group in particular. In addition, because sports medicine physicians treat athletes across the lifespan, we have the opportunity to promote awareness about bone health in our older athletes and to educate and treat younger athletes to optimize their bone health and maximize bone acquisition as they progress through their young life. So we would argue that it's the role of the orthopedic surgeon to recognize and mitigate osteoporosis and be a champion of bone health. And there may be multiple avenues for you to do this. For example, referring a patient to a fracture liaison service or a bone health optimization program, or just to have awareness about bone health and the care of individual patients in the office. So our goal for today will be to demonstrate these points via case examples and make it more personal for you. So we'll just go with the first case here. This is a 19-year-old freshman male Division I athlete in cross-country and track with a BMI of 19.1. His legs were feeling tired from training in the transition from cross-country to indoor track, and he noticed thigh pain after an indoor track workout. His MRI revealed a grade three stress fracture. And you might notice, more commonly, where we see a femoral neck stress fracture, this was in the subtrochanteric region. So for that reason, it's good that the window was wide enough to pick up this injury. So Dr. Matzkin, what would you worry about in a case like this? So in a case like this, this is a 19-year-old, and I think I worry about the transition, often, of a high school athlete to a college athlete. I wanna know about whether this came on suddenly or it was slowly coming on. I wanna know about their training, whether they drastically increased their mileage or the intensity of their running and their workouts, what kind of shoes they were wearing, and more importantly, I really wanna know about their energy balance. And so relative energy deficiency in these athletes, both males and females, is probably the most common culprit for these stress fractures that we see. We wanna ask about what he's eating, sleeping, does he even monitor his nutritional intake, and then just whether his training was adequate enough to let him train for this Division I indoor track workouts. This patient had a limited laboratory evaluation. His vitamin D 250H level was 44 nanograms per milliliter, which was an excellent level. His basic metabolic panel and chemistries were normal. His CBC showed he had a mild anemia and was a little bit run down. He was educated on calcium, vitamin D, adequate calorie intake, sleep hygiene, which, at least in the military, has been shown to be one of the best predictors of stress fracture. He was educated on exercise dose as far as quantity and appropriate rest, and running surface. And when he did recover, he did have a running gait analysis. He had his running shoes checked out, and he had a basic return to run over three months, starting with limited weight bearing, emphasizing his core strength and gradual return. So what do you think the take-home points are in this case? So I think take-home points in this case are that we all need to know what the female athlete tried is that has now been termed relative energy deficiency in sport. And this is because this term now includes both males and females, and it also gets to the core of the problem, which is the relative energy deficit or deficiency, which really leads to, whether it's amenorrhea in our female athletes, or these stress fractures or decreased bone health in both our male and female athletes. So we all need to know about RED-S. Any absent menstruation in a young female athlete needs to be addressed immediately. This is going to affect their bone health, which may not affect them right then and there when they're in your clinic, but it's gonna affect them later in life. We see this more commonly in our endurance athletes and in our athletes that participate in judging sports. And what the athlete looks like in your clinic has no bearing on whether or not they can have this RED-S. We used to think it was the very kind of anorexic, skinny athlete. It has nothing to do with their weight or anything like that. It really has to do with whether or not they're fueling their body with the amount of nutrition they need for the amount of activity they're participating in. Okay, great. I didn't give you your slide there. Great job. So I think things to think about are caloric requirements. You can find charts, there are apps, you can plug in the amount of activity you do and it'll tell you about how many calories you need. And for a lot of our athletes, we're not trying to get them to eat an extra meal. Sometimes it's just an extra apple a day to maintain that energy balance. Making sure they're getting their calcium and their vitamin D. Vitamin D deficiency is very common in our athletes. It also can be seasonal depending on where you live and also can be race disparities with regards to vitamin D. So something to look into and ask about. Awesome. Okay, we have another case here. This is a 12-year-old female sixth grader. She was involved in travel soccer with her family and she also loved to run. So she did that on her own after practice and ran 10 to 15 miles a week. She did fall skateboarding in February on the year of presentation onto her tailbone, but she recovered completely and returned to all activities. About six weeks later, she came back from one of her runs with low back pain and she was evaluated shortly after. Her MRI revealed a sacral stress fracture that looked something like this. Her medical history was negative and benign. Her surgical history negative except for a tonsillectomy. She had just started her periods the year before, but she had missed a couple right during the time of the injury. She was on really very little medication just for allergies. Her height, 6'1", weight, 100 pounds, BMI 18.89. No previous fractures on her physicals and was pretty unremarkable. She had resolving tenderness in the sacrum. So what would you worry about in this case, Dr. Schappella? So this is a somewhat atypical injury by location. It's more likely to represent a training error than it is a nutritional issue. Nonetheless, I'd be concerned about red S and probably other cases or causes of disordered bone. So low vitamin D, low calcium, like Dr. Matzkin mentioned in case one. But we also have to think about other reasons to have low energy or low nutrition, and that would include malabsorption, other nutritional deficiencies like celiac disease, or a chronic disease that diminishes bone health, thyroid, liver, kidney disease. Okay, so this patient also had a limited lab evaluation. So her vitamin D 250H level was 30 nanograms per milliliters which is sufficient, but maybe not optimal. We usually aim for about 40 to 50. Her CBC was normal, so no evidence of leukemia or anything crazy like that. Her metabolic workup was normal with no evidence of renal or liver disease. Her celiac panel was positive. And in retrospect, mom says that there is a family history of celiac disease in the family, but mom had never thought about that for her daughter. So she was treated with activity modification and referral to her pediatrician and subsequently to a GI specialist. An upper GI confirmed celiac disease and she was recommended dietary changes to preserve her skeletal health through development. We also recommended vitamin D supplementation, adequate calcium intake at about 1300 milligrams a day at her age, adequate calorie intake, and then to monitor her menses and use that as a sign of whether or not her energy intake was adequate for the amount of energy that she does. What do you think the take-home points are for this case, Dr. Schapella? So this case reminds us of the importance of bone health in children and teens. And as Dr. Morganti mentioned at the beginning, not only for their current function, but for their lifelong bone health. And most of us have seen the image that I'm showing here or something like it. This figure shows bone gain and then loss across the lifespan. And age is on the X-axis, Y-axis is bone mass. You can see the women in red and the men in blue. And you see that both men and women gain bone rapidly during adolescence and then men achieve a higher peak bone mass than do women. And then women lose mass at a more rapid rate than men. So that women end up with lower bone mass in adulthood based on both a lower attainment of peak mass and then a more rapid loss. So they have a higher risk of osteoporosis. However, I'll point out that this figure includes outdated, inaccurate depiction of when bone mass is actually achieved. And if we switch to the next slide, you'll see a more accurate one. So this is actually a conglomeration of points that are taken from my longitudinal bone growth study. Each line represents an individual girl and they were dexascanned over a long period of years. Menarche is represented by the zero line. And then you can see the black line is the amalgamation of all those curves. They've gained a ton of bone during those perimenarcheal years and then flatten out really just three or four years after menarche. So by late adolescence, women have gained the vast majority of the bone that they're going to gain. And it just makes it more clear how important this timeframe is. So what determines peak bone mass? And if you recognize these factors here, it goes a long way toward thinking about how you wanna handle your patient. So genetic factors are paramount and we can't really do anything at all about that, making us want to pay more attention, obviously, to the other things that we can intervene or change. Hormonal factors are very important and need to be addressed when found to be abnormal. But nutritional factors and physical activity factors are really the changes or the factors that we can intervene and change for our young patients. And you have to think about those when you see a patient with potentially insufficient bone. We've talked a little bit about that already. So I'll dwell on activity on the next slide. I've spent my kind of lifetime of research looking at what activity matters, what makes bone grow best. And I can tell you that they're not all created equal. So I've represented some here. But what I really want the take-home point to be is that odd impact activity like a gymnast does or a weight trainer does, so different than the standard repetitive cyclical activity of life, is what really generates bone force, osteogenic force. So the gymnast and the weight trainers grow great bone. The cyclic long-distance runners, the swimmers, the cyclers, they're much less effective at bone growth. And it's important to know that when you're treating your young athletes. Awesome. And then the next few minutes here, we'll just go over a final case. This is an older patient, a 67-year-old massage therapist who's a master's competitive triathlete. This picture isn't her, but I can assure you that she looked much younger than our chronological age. It was very impressive. She underwent a meniscus repair and had a full recovery and got back to racing. And that's how I got to know her. Her medical history's negative except for an elevated iron level, which was worked up by her primary doctor. And her only surgery was a meniscus repair. She was on no medications, had no fractures as far as her medical history, but came back a year and a half after her meniscus repair quite concerned about her DEXA scan, which her primary care doctor had ordered as a screening test. Her DEXA scan was abnormal. She had hip and lumbar spine scores. Her T-scores were minus 4.0 in the lumbar spine, minus 2.2 in the total hip, minus 3.1 in the femoral neck, and minus 3.6 in the one-third radius. Otherwise, she had unremarkable workup. And because of the severity, how low her T-scores were, she was felt to have severe osteoporosis and was treated with an anabolic medication. Osteoporosis can be defined by low bone mass and the DEXA scores are reported as several things, bone mineral density and also T-scores and Z-scores. And what those numbers define are how many standard deviations your patient's numbers are often with standard normal, a reference population. So if you are within one standard deviation or one T-score or Z-score from the reference population, you're considered normal. If you're more than two and a half standard deviations below, that's considered osteoporosis. If you're somewhere in between, you're not normal, you don't have osteoporosis. So a T-score or Z-score of minus 1.0 or minus 2.5, they call it osteopenia or sometimes they call it low bone mineral density. There are a couple caveats with the DEXA scan. First of all, it evaluates bone mass, the quantity of bone. It doesn't clearly define what the bone quality is. There are some things that don't exactly explain why bone fractures based on the DEXA scan itself. Remember, the T-score is compared to the reference population of healthy adults, 20 to 29-year-old women, and a Z-score is comparing your patient's scores to an age-matched population. And most DEXA reports show both, a T-score and a Z-score. You can see on the bottom right there, this report does show both scores. Just remember, a DEXA scan is a 2D dimension of a three-dimensional structure, so it's just aerial bone density. So that can become problematic, particularly in small people and children because of the volumetric differences. And for that reason, you need specific pediatric databases for children. And also, for adults, spine and hip are the two scores typically used, whereas in children, the hip score isn't as accurate. So a spine score and a total body minus the head is used. And for that reason, it is important to have the children go to a center that has that available. You can define osteoporosis in several ways. So one is the DEXA scan with a T-score of minus 2.5 or lower in post-menopausal women and men over 50. In pre-menopausal women and men less than 50, the Z-score is used, and that's defined as a T-score, a Z-score of minus 2.0 or lower. In children and adolescents, osteoporosis is not diagnosed by DEXA scan alone. So by definition, you'd have to have a low-energy fracture in addition to the Z-score of minus 2.0 or worse to have the diagnosis of osteoporosis. And again, the referral center is excellent for getting the data that you need. In adults, a low fracture of the hip or spine itself, even without a DEXA scan, can confer the diagnosis of osteoporosis. And those in-between people with osteopenia that don't have normal, don't have osteoporosis, any other fracture, approximate humerus or wrist, in addition to this osteopenia score can give you the diagnosis of osteoporosis. For those people, those in-between people with osteopenia, this FRAC score was developed. So for people between 40 and 90 who have not been treated and have this diagnosis of osteopenia, so not normal, not osteoporosis, you can get a FRAC score. It's not developed for children. And a FRAC score looks like this. Anyone can get it. You just Google FRACs, and you get this tool that comes up. You need the DEXA score to put in there. So the person would have had to have a DEXA scan and would have been in the osteopenia range. And several other easy variables to put in there. And it does a statistical analysis and pops up this 10-year risk of hip fracture or other major fracture. And so typically, if your 10-year risk of hip fracture is greater than 3% or your 10-year risk of other major fracture is greater than 20%, it's recommended that you have pharmaceutical treatment for most practitioners. So Dr. Liz, who should get a DEXA scan? So I think for a lot of us, we may not be the ones ordering the DEXA scan, but we can be the ones recommending it. So according to preventative task force guidelines for adults, women over 65, men over 70, any patient that's had a fragility fracture, men and post-menopausal women over 50 with at least one risk factor, and young women and men with an elevated risk. And that can be alcohol use, tobacco use, a family history, immobility, they're on prednisone. So there's a lot of different risk factors, but they're definitely things to think about. For children, we use the ISCD guidelines. So any child that's had more than three long bone fractures by 10 years old, that's a big risk factor, more than two fractures by 19, a compression fracture. And then you gotta worry about your children with chronic diseases, either a primary bone disease or disease that secondarily can affect their bone, and it can be a malabsorption type kind of thing. And then we also worry about the kids that are on chronic medication. So I think take-home points from these kind of case-based discussions are what does osteoporosis look like? It is a silent disease until we see you with a fracture. And any time you see a patient with a fracture in your office, especially sports medicine surgeons, you need to start thinking about asking the other questions. We can manage the fracture, but what else is going on? It may be a pediatric disease with adult manifestations, and there can be increased prevalence with age. There's a role for screening, and I think it's our responsibility to think about that as we see athletes in our office, particularly a couple of groups. One is that master's level athlete, like case three. We must remember that even though they're active and physiologically look younger than they are, they're at risk for bone disease, just like any other person of their age group. So they're a good candidate for screening. And then the second question is, what is the role of the medical team as a good candidate for screening? And then the second group to think about are our young, developing athletes who are growing their skeleton for life. We want their bone health to be optimized, and we want to remember to give them the tools, the information they need to do that. So our bottom line is to please remember bone health in treating athletes of all ages, and to remember that your role as an orthopedic surgeon is a champion of bone health. Thank you very much for the opportunity to talk about this today. Thank you.

bone health

osteoporosis

fragility fractures

orthopedics

athletes

fracture risk assessment