Selected Instructional Course Lecture   |    
Osteoporosis: Management and Treatment Strategies for Orthopaedic Surgeons
Laura Gehrig, MD1; Joseph Lane, MD2; Mary I. O'Connor, MD3
1 242 Patton Avenue, Shreveport, LA 71105. E-mail address: laura.gehrig@gmail.com
2 The Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021
3 Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224
View Disclosures and Other Information
Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy's Annual Meeting, will be available in February 2009 in Instructional Course Lectures, Volume 58. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 a.m.-5 p.m., Central time).
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from commercial entities (Glaxo, Roche, P&G, Lilly, Aventis, and Novartis). Also, commercial entities (Glaxo, Roche, P&G, Lilly, Aventis, and Novartis) paid or directed in any one year, or agreed to pay or direct, benefits of less than $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Jun 01;90(6):1362-1374
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The purpose of this lecture is to provide orthopaedic surgeons with a guide for osteoporosis management and treatment that may be used in the practice setting. Fracture prevention is the key efficacy end point in the medical management of osteoporosis for any patient. Enhancement of bone mass and improvement of bone quality are achieved by a combination of lifestyle modification, dietary supplementation with calcium and vitamin D, and pharmacologic treatment. This strategy has proved effective for the prevention and treatment of osteoporosis.
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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Laura MB Gehrig MD
    Posted on July 21, 2008
    Dr Gehrig et al. respond to Dr, Heaney
    Shreveport, Louisiana

    We thank Dr.Heaney for his thoughtful comments related to our article(1). While we tried to provide a thorough review on the treatment of osteoporosis, we recognize that there are many areas of controversy that still exist. What is agreed upon, however, is the importance of patients having adequate calcium intake. We greatly appreciate his highlighting the topic of calcium absorption from calcium salts.

    In response to the issue of whether calcium carbonate or calcium citrate is the preferred preparation, calcium carbonate has the highest concentration of calcium by weight (40%) among available oral calcium preparations and this property does reduces the number of pills needed per day. Calcium carbonate preparations are also cheaper than the ones containing calcium citrate. However, the literature on oral calcium preparations including a meta-analysis(2) supports the superiority of calcium citrate over calcium carbonate preparations. Higher values for absorption of calcium from calcium citrate over calcium carbonate have been consistently reported (even if the numerical differences in the absorption values are small).

    Several patients presenting with osteoporosis may have or may subsequently develop asymptomatic gastric hypochlorhydria and achlorhydria. The use of calcium carbonate by individuals with a physiologic or pharmacologically reduced gastric acid can result in suboptimal calcium absorption because calcium carbonate requires a low pH for dissociation, whereas calcium citrate dissociates adequately even when gastric pH is not in a low range. While co-ingestion with food enhances the bioavailability of both salts, calcium citrate is better absorbed than calcium carbonate when taken on an empty stomach or with meals(2). As a dietary supplement, calcium carbonate may not be ideal in older persons.(3.)

    The incidence of kidney stones is indeed reduced with intake of all forms of calcium. However, it is important to note that citrate is an important inhibitor of calcium salts crystallization in the urine. While the mechanism of action for prevention of urolithiasis and exact series of events that transform super saturation to crystal formation and renal stones are complex(4,5), supplementation with calcium citrate does not increase the risk of stone formation(6). The incidence of calcium kidney stones is generally not increased because ionic calcium, (introduced into the gut) binds with intraluminal oxalate (from food) producing a relatively insoluble calcium-oxalate complex which is less readily absorbed. Indeed, since oxalate is much more lithogenic than an equivalent molar amount of calcium, in the treatment of intestinal hyperoxalosis a standard therapeutic approach is to co-ingest large amounts of calcium (from calcium carbonate, or calcium citrate), thus radically decreasing the percentage gut absorption of oxalate. However, in a recurrent calcium stone former, we prefer to administer calcium as calcium citrate rather than calcium oxalate(7,8). Although both forms of calcium can elevate urine calcium, urine citrate is elevated by calcium citrate, and citrate is strongly antilithogenic. The facts about urinary citrate elevation from calcium carbonate are not as well investigated. In a patient who has had recurrent calcium kidney stones, but requires significant calcium loading (e.g., a normal serum calcium, but a PTH elevation signifying secondary hyperparathyroidism triggered by negative calcium balance), thiazides can be co-administered along with calcium citrate, as well as restrict sodium intake. Such manipulations rapidly lower urinary calcium and have a strong, protective antilithogenic effect.

    Numerous factors including patient characteristics such as age, period of lactation, growth, type of diet (fiber, oxalate), type of calcium supplementation, mental/physical stress, medications that impede calcium absorption, medical conditions (lactose intolerance, impaired gastric secretion) affect the absorption of calcium(9). A patient may present with a combination of adversities. It is crucial that the reader ensure that the calcium intake is optimized at the earliest without getting lost in the maze of conditions affecting absorption. A serum calcium level at the onset will help to identify patients with hypercalcaemia (primary hyperparathyroidism, sarcoidosis) for referral to a metabolic bone specialist for further evaluation. After consideration of the cost benefits, calcium citrate has a marginal superior absorption and protection profile.


    1. Gehrig, L.; Lane, J.; and O'Connor, M. I.: Osteoporosis: management and treatment strategies for orthopaedic surgeons. J Bone Joint Surg Am, 90(6): 1362-74, 2008.

    2. Sakhaee, K.; Bhuket, T.; Adams-Huet, B.; and Rao, D. S.: Meta- analysis of calcium bioavailability: a comparison of calcium citrate with calcium carbonate. Am J Ther, 6(6): 313-21, 1999.

    3. Holt Peter R.; Russell Robert M: Chronic Gastritis and Hypochlohydria in the Elderly 1993 Effects of Gastritis Acidity and Atrophic Gastritis on Calcium page 195

    4. Kumar, V., and Lieske, J. C.: Protein regulation of intrarenal crystallization. Curr Opin Nephrol Hypertens, 15(4): 374-80, 2006.

    5. Rodgers, A.; Allie-Hamdulay, S.; and Jackson, G.: Therapeutic action of citrate in urolithiasis explained by chemical speciation: increase in pH is the determinant factor. Nephrol Dial Transplant, 21(2): 361-9, 2006.

    6. Sakhaee, K.; Poindexter, J. R.; Griffith, C. S.; and Pak, C. Y.: Stone forming risk of calcium citrate supplementation in healthy postmenopausal women. J Urol, 172(3): 958-61, 2004.

    7. Coe, F. L.; Parks, J. H.; and Webb, D. R.: Stone-forming potential of milk or calcium-fortified orange juice in idiopathic hypercalciuric adults. Kidney Int, 41(1): 139-42, 1992.

    8. Levine, B. S.; Rodman, J. S.; Wienerman, S.; Bockman, R. S.; Lane,

    9. Levenson, D. I., and Bockman, R. S.: A review of calcium preparations. Nutr Rev, 52(7): 221-32, 1994. J. M.; and Chapman, D. S.: Effect of calcium citrate supplementation on urinary calcium oxalate saturation in female stone formers: implications for prevention of osteoporosis. Am J Clin Nutr, 60(4): 592-6, 1994.

    Robert P. Heaney, M.D.
    Posted on June 11, 2008
    Calcium supplementation
    Creighton University, Omaha, NE

    To The Editor:

    I wish to comment on some aspects of the section on calcium supplementation that appeared in the recently published Instructional Course Lecture on the management and treatment of osteoporosis(1). After correctly pointing out the importance of calcium intake and the likely need for use of supplements, the paragraph proceeds to make some misstatements with respect to calcium absorption from the carbonate salt.

    Several different investigators have shown that acid production is not necessary for calcium absorption from salts such as calcium carbonate or calcium phosphate, so long as the salt is co-ingested with food (which is how calcium supplements should normally be taken)(2,3). This has been demonstrated by such diverse methods as testing in patients with pentagastrin-resistant achlorhydria(2), and testing in normal volunteers with a gastric pH stat, clamping the stomach pH at 7.4(3).

    Second, the incidence of kidney stones is reduced with all forms of calcium, the citrate as well as the carbonate salts. The reason is not, as the paragraph states, because the citrate ion binds to oxalate in the gut;it does not. Rather, it is the calcium ion that binds with oxalate; and so far as is known, the citrate and carbonate salts of calcium function equivalently in this respect. Large doses of calcium carbonate have long been part of the standard treatment for the syndrome of intestinal hyperoxalosis, in which the salt is used to reduce kidney calcification.

    Both the carbonate and citrate salts are good products, so long as they come from reputable manufacturers. The Creighton Osteoporosis Center prescribes both salts for their patients. It is good, in fact, to have options. But it is not correct to assert that one salt is intrinsically better than the other, as the authors contend. If anything, the edge might tip toward calcium carbonate, because it requires the taking of only half as many pills per day, a factor which leads to improved patient compliance.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.


    1. Gehrig L, Lane J, O’Connor MI. Osteoporosis: management and treatment strategies for orthopaedic surgeons. J Bone Joint Surg Am. 2008;90-A:1362-64.

    2. Recker RR. Calcium absorption and achlorhydria. N Engl J Med. 1985;313:70-73.

    3. Bo-Linn GW, David GR, Buddrus DJ, Morawski SG, Santa Anna C, Fordtran JS. An evaluation of the importance of gastric acid secretion in the absorption of dietary calcium. J Clin Invest. 1984;73:640-7.

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