RENAL OSTEODYSTROPHY

• comprises a continuum of diseases ranging from low turn over bone disease like osteomalacia – to high turn over disease like 2⁰hyperparathyroidism

Pathology

• renal disease – PTH -Vit D axis is deranged – hydroxylation to form 1,25 dihydroxy VitD decreased – impairs calcium absorption in gut – increased calcium excretion – hypocalcemia – effect of PTH on kidney decreased
• impaired renal clearance – hyperphosphatemia

High turnover form

• hyperphosphatemia – secondary hyperparathyroidism – increase bone resorption
• osteitis fibrosa – fibrous tissue accumulates in bone
• osteoblast activity increases – osteoid is woven – increased turnover
• bone pain, brown tumors, ulcers
• classic salt and pepper skull, soft tissue calcification, osteopenia next to osteosclerosis, erosions of phalangeal tuft, distal clavicle
• children – metaphyseal and epiphyseal changes – rickets like
• unlike rickets – premature genu valgum, SCFE common
• epiphyseal slippage also in distal femoral or proximal tibial

Low turnover form

• due to Al toxicity in aluminum contaminated water in dialysis
• also Al in phosphate binders to prevent hyperphosphatemia and 2⁰hyperparathyroidism
• Al deposited along mineralization front – impair calcification of osteoid – decrease in number of osteoblasts
• histologically – excessive osteoid (unmineralized collagen)
• prevented by use of CaCO₃ - to buffer high phosphate in blood

Symptoms

• patients rarely have one extreme form of disease – mixed pattern is common
• bone pain, muscle weakness, skeletal deformities, ectopic calcification, growth retardation
• ectopic calcification – more in adults - periarticular
• skeletal deformities – children both axial and appendicular – adult mostly axial esp. in Al toxicity
• children up to 4yrs – resembles Vit D deff rickets
• 4- 10yrs – bowing of tibia and femur, genu valgum, SCFE

Amyloidosis

• complication of long term renal disease
• CTS most common presenting syndrome
• pathologic fracture
• scapulohumeral periarthritis
• arthritis of MCP, IP, shoulder, hand, wrist, knee
• bone cysts – femoral head, acetabulam, humerus, radius, carpal bone, tibial plateau, pubis – resembles brown tumor
• no adequate treatment options

Treatment

• primary treatment of renal osteodystrophy – restriction of phosphorous intake in diet to 400-800 mg/day
• PO₄ binding antacids
• Calcium supplements as CaCO₃ – increases available Ca for absorption and also act as PO₄ binders
• Ca supplements given only when PO serum level fall to 6.5mg/dl – to minimize risk of extra skeletal calcification
• Vit D derivatives – Oral calcitriol (0.25 to 1.5microgm/day) – improve muscle strength, decrease bone pain, growth increase in ureamic children – risk of hypercalcemia
• 2⁰ hyperparathyroidism – surgery – in case of persistent hypercalcemia, intractable pruritus, progressive ectopic calcification, severe skeletal pain/ fractures
• Al toxicity – chelator deferoxamine – only in symptomatic Al toxicity cases
• Pinning for SCFE
• bracing or osteotomy in bowing of long bones
• pseudofractures causing bone pain – weight restriction and analgesics
• rule out fractures – treat fractures accordingly
• surgery for CTS
• Arthroplasty only cemented – high incidence of prosthesis loosening
• surgery planning – r/o clotting abnormalities, anemia, arteriovenous fistula, infections

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7. Davangere Orthopaedic notes pdf
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14. MRCS Package
15. Orthopaedic Surgery Technique teaching videos - Trauma
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20. Anatomical Approach technique and exposure teaching videos
21. Orthopaedic PG Course Videos