PURPOSE: Osteoporosis and osteopenia are highly prevalent among older patients scheduled for elective arthroplasties and spinal surgeries. This position paper aims to establish, promote, and standardise effective Bone Health Optimization (BHO) strategies for such patients within orthopaedic practices in Malaysia. It emphasises the need for bone health assessments to be undertaken at the pre-operative, intra-operative, and post-operative stages, with tailored management strategies to meet individual patient needs.
METHODOLOGY: A comprehensive literature review was conducted, focusing on articles published from 2019 to 2024. Twelve broad themes were defined including definitions and importance of BHO, epidemiological data, assessment techniques, risk stratification, management strategies, and outcome metrics.
RESULTS: Elective surgeries on patients with poor bone health are associated with adverse outcomes, such as periprosthetic fractures, aseptic loosening of implants, and complications after spinal surgeries. This position paper advocates for routine bone health assessments and monitoring during the pre-operative, intra-operative, and post-operative phases. It provides summaries of imaging modalities, risk assessment tools, and techniques for each phase. By adapting the successful "5IQ" approach from secondary fracture prevention, we propose 5IQ-based Clinical Standards for BHO, including 18 Key Performance Indicators. A Malaysian BHO Registry is proposed to benchmark care in real-time and support a national quality improvement programme. Practical resources, such as a BHO algorithm and key practice points, are included.
CONCLUSION: This position paper proposes a paradigm shift in the management of bone health for patients undergoing elective orthopaedic surgery in Malaysia, aiming to improve surgical outcomes and patient care through standardised BHO strategies.
RESEARCH DESIGN AND METHOD: Data were obtained from the published biomedical literature as well as abstracts and posters presented at scientific meetings. Using MEDLINE, EMBASE and BIOSIS databases (to July 2007), epidemiological studies were identified using the search terms: 'human', 'vitamin D', 'vitamin D deficiency', 'vitamin D inadequacy', 'vitamin D insufficiency' and 'hypovitaminosis D', 'osteomalacia' and 'osteoporosis'. Additional references were also identified from the bibliographies of published articles.
RESULTS: The prevalence of vitamin D inadequacy in studies of postmenopausal women (ambulatory or with osteoporosis or related musculoskeletal disorders) in Eastern Asia ranged from 0 to 92%, depending on the cut-off level of serum 25-hydroxycholecalciferol [25(OH)D] that was applied (range < or =6-35 ng/mL [< or = 15-87 nmol/L]). One large international study found that 71% of postmenopausal women with osteoporosis in Eastern Asia had vitamin D inadequacy, defined as serum levels of 25(OH)D < 30 ng/mL (75 nmol/L). Prevalence rates using this cut-off level were 47% in Thailand, 49% in Malaysia, 90% in Japan and 92% in South Korea. High prevalences of vitamin D inadequacy were evident in two studies using a lower 25(OH)D level cut-off value of < 12 ng/mL (30 nmol/L) - 21% in China and 57% in South Korea. Dietary deficiency and inadequate exposure or reactivity to sunlight (due to lifestyle choices, cultural customs and/or aging) were identified as important risk factors for vitamin D inadequacy.
CONCLUSIONS: Non-uniform, epidemiological studies indicate a high prevalence of vitamin D inadequacy in postmenopausal women in Eastern Asia. Recommended remedial approaches are education campaigns and broad-based provision of vitamin D supplementation.
INTRODUCTION AND OBJECTIVE: T-score discordance between hip and spine is a common problem in bone mineral density assessment. A difference ≥ 1 standard deviation (SD) (regardless of diagnostic class) is considered minor, and a difference more than one diagnostic class is considered major discordance. This study aimed to determine the prevalence and factors of hip and spine T-score discordance in a population aged ≥ 40 years in Klang Valley, Malaysia.
SUBJECTS AND METHODS: In this cross-sectional study, subjects answered a demographic questionnaire and underwent body composition and bone health assessment using dual-energy X-ray absorptiometry. Chi-square and binary logistic regression analysis were used to assess the prevalence of T-score discordance among the subjects.
RESULTS: A total of 786 Malaysians (382 men, 404 women) subjects were recruited. The prevalence of minor and major discordance was 30.3% and 2.3%, respectively. Overall, factors related to T-score discordance were advanced age, decreased height, and being physically active. Sub-analysis showed that decreased height and being physically active predicted T-score discordance in men, being menopausal and Indian (vs Chinese) were predictors in women.
CONCLUSIONS: T-score discordance between hip and spine is common among Malaysian middle-aged and elderly population. Diagnosis of osteopenia/osteoporosis should be based on the T-score of more than one skeletal site as per the current recommendations.