Old Bones

Abstract

Bone is a dynamic organ in which osteoblasts, under inhibitory control of sclerostin, creates new bone osteoblasts by releasing RANK-L to activate osteoclasts to remove bone. This dynamic network is under local control of miRNAs and long noncoding RNAs to balance the effect of bone stressors on bone formation (1). With aging there is an increase in fragility fractures. Fractures are a more common reason for older persons requiring interaction with medical professionals than any other disease and are one of the higher components of annual hospital costs (2). Over 20% of older persons with hip fractures die within a year and they are a major cause of disability (3). Vertebral fractures are a major cause of back pain, loss of height, reduced pulmonary function, dysphagia, deformity and a decline in quality of life. The need for collaboration between orthopedic surgeons and geriatricians to improve outcomes of older persons with fractures led to the forming of the first geriatric orthopaedic unit by Bobby Irvine and Michael Devas in 1963 (4). The motto of this unit was "Bedrest is rehabilitation for the grave." Richard Lefroy published the first positive effects of a geriatric orthopedic unit in Perth, Australia (5). A meta-analysis found that these combined programs resulted in a decrease in both in-hospital and long-term mortality (6). Two recent approaches improving hip fracture care are: (i) providing regional nerve blocks on arrival at hospital to reduce pain and improve function outcomes (7) and (ii) injection of a triphasic calcium based implant (AGN-1) into the contralateral proximal femur to reduce subsequent hip fracture in the other hip (8). There are three major bone diseases in older persons-Paget's disease of bone, osteomalacia, and osteoporosis.