Advanced imaging assessment of bone fragility in glucocorticoid-induced osteoporosis

Advanced bone imaging techniques provide structural information, beyond bone mineral density (BMD), and growing evidence indicates that BMD only partially explains bone strength and fracture resistance. Assessing glucocorticoid-induced osteoporosis (GIO) is important, especially the documentation of glucocorticoid (GC) impact on trabecular and cortical bone and on macro and microstructural features. Advanced methods for assessing macrostructure of bone include volumetric quantitative computed tomography (vQCT), high-resolution computed tomography (hrCT), and high-resolution magnetic resonance imaging (hrMRI). The methods for assessing bone microstructure include micro computed tomography (μCT) and micro magnetic resonance imaging (μMRI). Many advanced imaging techniques have been used in vitro and in vivo to examine structural effects of GIO in animals and in humans, and these applications are explored in this review. In human in vitro studies, investigators have used standard bone histomorphometry and μCT to compare trabecular microarchitecture and bone remodeling in postmenopausal women and in males with GIO, and have found that high-dose GC produces dramatic bone loss, accompanied by major reduction in trabecular connectivity and increases in trabecular perforations. In animal studies, investigators have used standard histomorphometry along with pQCT, vQCT, hrMRI or μCT to examine GIO in a variety of animal models including rats, minipigs and sheep. They generally have found excellent relationships between treatment-induced structural changes assessed by these advanced imaging techniques and changes in BMD and biomechanical properties. They also have examined various therapeutic interventions in animals and monitored their efficacy using quantitative imaging methods. In human in vivo studies, investigators have serially examined postmenopausal women and males with GIO in order to assess the extent of skeletal deterioration and to determine the best advanced measures of BMD and structure, with which to monitor disease activity and therapeutic response, and to predict fracture risk. They generally have found that bone density and structural measures obtained by pQCT, vQCT and hrMRI contributed substantially to understanding the skeletal effects of glucocorticoids and to predicting the risk of fracture in human GIO. These animal and human applications, illustrating advanced imaging in GIO, are still in early stages of development. However, as discussed in this review, the novelty and power of the imaging approaches are compelling, and their utility is promising.     

Bone and bone marrow pro-osteoclastogenic cytokines are up-regulated in osteoporosis fragility fractures

Summary

This study evaluates cytokines production in bone and bone marrow of patients with an osteoporotic fracture or with osteoarthritis by real time PCR, Western blot and immunohistochemistry. We demonstrate that the cytokine pattern is shifted towards osteoclast activation and osteoblast inhibition in patients with osteoporotic fractures.

Introduction

Fragility fractures are the resultant of low bone mass and poor bone architecture typical of osteoporosis. Cytokines involved in the control of bone cell maturation and function are produced by both bone itself and bone marrow cells, but the roles of these two sources in its control and the amounts they produce are not clear. This study compares their production in patients with an osteoporotic fracture and those with osteoarthritis.

Methods

We evaluated 52 femoral heads from women subjected to hip-joint replacement surgery for femoral neck fractures due to low-energy trauma (37), or for osteoarthritis (15). Total RNA was extracted from both bone and bone marrow, and quantitative PCR was used to identify the receptor activator of nuclear factor kB Ligand (RANKL), osteoprotegerin (OPG), macrophage colony stimulating factor (M-CSF), transforming growth factor ?? (TGF??), Dickoppf-1 (DKK-1) and sclerostin (SOST) expression. Immunohistochemistry and Western blot were performed in order to quantify and localize in bone and bone marrow the cytokines.

Results

We found an increase of RANKL/OPG ratio, M-CSF, SOST and DKK-1 in fractured patients, whereas TGF?? was increased in osteoarthritic bone. Bone marrow produced greater amounts of RANKL, M-CSF and TGF?? compared to bone, whereas the production of DKK-1 and SOST was higher in bone.

Conclusions

We show that bone marrow cells produced the greater amount of pro-osteoclastogenic cytokines, whereas bone cells produced higher amount of osteoblast inhibitors in patients with fragility fracture, thus the cytokine pattern is shifted towards osteoclast activation and osteoblast inhibition in these patients.     

Altered organization of non-collagenous bone matrix in osteoporosis

In osteoporosis it is postulated that while the amount of bone is diminished, the quality of the bone is unaltered. Recently relatively novel methods of analysis have shown that, at the fracture site of osteoporotic subcapital fractures, there is a marked change in the molecular orientation of components of the non-collagenous bone matrix. These procedures, now applied to iliac crest biopsies, confirm earlier findings of altered orientation of the proteoglycans at the subcapital fracture site but show that very similar changes occur even in the iliac crests from patients with both types of osteoporotic proximal femoral fracture. Thus, whereas the amount of these acidic moieties of the non-collagenous bone matrix was unchanged, the molecular orientation was markedly altered, albeit not to the same extent as that found at the fracture site. These results imply that the quality of the bone, as well as the quantity, may be generally affected in osteoporosis.     

Toward a cure for osteoporosis: Reversal of excessive bone fragility

While estrogen replacement therapy and calcium supplementation appear to be effective at preventing postmenopausal osteoporosis, therapy for established osteoporosis is far less effective. The reduction of bone fragility should be a goal of a treatment for established osteoporosis. To this end, increases in cortical bone mass by subperiosteal new bone formation may produce the greatest mechanical advantage. Antiresorptive drugs, such as etidronate, have shown potential for reducing the incidence of osteoporotic fracture in the short term, but their ability to produce a long-term benefit may be limited. An alternative approach might be to develop drug therapies that substantially increase cortical bone strength, namely by stimulating periosteal bone formation. Although sodium fluoride has proved to be problematic, there are several other potential osteoporosis therapies. They include treatment with anabolic hormones (e.g. growth hormone and anabolic steroids) and targeted delivery of growth factors. Also, antiresorptive and formation-stimulating drugs might be combined in a new form of ADFR (coherence) therapy where the new acronym means: Activate-Depress-Formation stimulation-Repeat.     

Mechanical strength of bone in canine osteoporosis model: Relationship between bone mineral content and bone fragility

The purpose of this study was to clarify the relationship between bone mineral content (BMC) and mechanical strength in beagle dog models, and to find whether the mechanical strength changed with changes in BMC. We used 17 beagle dogs to create an experimental osteoporotic model, dividing them into six groups, based on age and experimental period. Presence and absence of ovariectomy (OVX); and calcium content of the diet. BMC was determined by dual-energy quantitative computed tomography in the lumbar vertebrae, and the mechanical strength of cancellous bone harvested from the lumbar vertebral body and femoral neck was measured. OVX alone did not affect either BMC or mechanical strength. However, when the dogs were ovariectomized, and then given a reduced calcium diet, the mechanical strength of the femoral neck decreased in parallel with the cortical BMC of the lumbar vertebrae. The mechanical strength of the vertebral cancellous bone was not decreased when the BMC was reduced by 20%, but was decreased when BMC was reduced by 30%.     

Collagen cross-links as a determinant of bone quality: a possible explanation for bone fragility in aging, osteoporosis, and diabetes mellitus

Collagen cross-linking, a major post-translational modification of collagen, plays important roles in the biological and biomechanical features of bone. Collagen cross-links can be divided into lysyl hydroxylase and lysyl oxidase-mediated enzymatic immature divalent cross-links, mature trivalent pyridinoline and pyrrole cross-links, and glycation- or oxidation-induced non-enzymatic cross-links (advanced glycation end products) such as glucosepane and pentosidine. These types of cross-links differ in the mechanism of formation and in function. Material properties of newly synthesized collagen matrix may differ in tissue maturity and senescence from older matrix in terms of cross-link formation. Additionally, newly synthesized matrix in osteoporotic patients or diabetic patients may not necessarily be as well-made as age-matched healthy subjects. Data have accumulated that collagen cross-link formation affects not only the mineralization process but also microdamage formation. Consequently, collagen cross-linking is thought to affect the mechanical properties of bone. Furthermore, recent basic and clinical investigations of collagen cross-links seem to face a new era. For instance, serum or urine pentosidine levels are now being used to estimate future fracture risk in osteoporosis and diabetes. In this review, we describe age-related changes in collagen cross-links in bone and abnormalities of cross-links in osteoporosis and diabetes that have been reported in the literature.     

Bone fragility in male glucocorticoid-induced osteoporosis is not defined by bone mineral density

Summary  

Eighty-seven male Japanese subjects taking prednisolone ≥5 mg for more than 6 months and 132 age- and body mass index (BMI)-matched control subjects were examined. Multiple regression analysis adjusted for age and BMI showed that spinal bone mineral density (BMD) in the prednisolone group was not associated with prevalent vertebral fractures (VFs).     

Vertebral bone quality score predicts fragility fractures independently of bone mineral density

BackgroundCurrent evidence suggests that dual-energy x-ray absorptiometry (DXA) scans, the conventional method defining osteoporosis, is underutilized and, when used, may underestimate patient risk for skeletal fragility. It has recently been suggested that other imaging modalities may better estimate bone quality, such as the magnetic resonance imaging (MRI)-based vertebral bone quality (VBQ) score which also may assess vertebral compression fracture risk in patients with spine metastases.PurposeTo evaluate whether VBQ score is predictive of fragility fractures in a population with pre-existing low bone density and at high-risk for fracture.Study Design/SettingRetrospective single-center cohort.Patient SamplePatients followed at a metabolic bone clinic for osteopenia and/or osteoporosis.Outcome MeasuresRadiographically-documented new-onset fragility fracture.MethodsPatients with a DXA and MRI scans at the time of consultation and ≥2-year follow-up were included. Details were gathered about patient demographics, health history, current medication use, and serological studies of kidney function and bone turnover. For each patient, VBQ score was calculated using T1-weighted lumbar MRI images. Univariable and multivariable analyses were used to identify the independent predictors of a new fragility fracture. To support the construct validity of VBQ, patient VBQ scores were compared to those in a cohort of 45 healthy adults.ResultsSeventy-two (39.1%) study participants suffered fragility fractures, the occurrence of which was associated with higher VBQ score (3.50 vs. 3.01; p<.001), chronic glucocorticoid use (30.6% vs. 15.2%; p=.014), and a history of prior fragility fracture (36.1% vs. 21.4%; p=.030). Mean VBQ score across all patients in the study cohort was significantly higher than the mean VBQ score in the healthy controls (p<.001). In multivariable analysis, new-onset fracture was independently associated with history of prior fracture (OR=6.94; 95% confidence interval [2.48–19.40]; p<.001), higher VBQ score (OR=2.40 per point; [1.30–4.44]; p=.003), higher body mass index (OR=1.09 per kg/m²; [1.01–1.17]; p=.03), and chronic glucocorticoid use (OR=2.89; [1.03–8.17]; p=0.043). Notably, DXA bone mineral density (BMD) was not found to be significantly predictive of new-onset fractures in the multivariable analysis (p=.081).ConclusionsHere we demonstrate the novel, MRI-derived VBQ score is both an independent predictor of fragility fracture in at-risk patients and a superior predictor of fracture risk than DXA-measured BMD. Given the frequency with which MRIs are obtained by patients undergoing spine surgery consultation, we believe the VBQ score could be a valuable tool for estimating bone quality in order to optimize the management of these patients.     

Effects of osteoporosis medications on bone quality

In clinical practice, the quantitative evaluation of bone tissue relies on dual-energy X-ray absorptiometry (DXA) measurements of bone mineral density (BMD) values, which are closely associated with the risk of osteoporotic fracture. However, only a small fraction of the antifracture effect of bone resorption inhibitors is ascribable to BMD gains (4% with raloxifene and 16-28% with alendronate and risedronate). Bone quality encompasses a number of bone tissue properties that govern mechanical resistance, such as bone geometry, cortical properties, trabecular microarchitecture, bone tissue mineralization, quality of collagen and bone apatite crystal, and presence of microcracks. All these properties are dependent on bone turnover and its variations. In populations, the decreases in bone resorption markers achieved with resorption inhibitors may predict in part the decrease in fracture risk. At the spine, however, this correlation exists down to a 40% fall in bone resorption markers; larger drops did not provide further protection against fractures in patients taking risedronate in one evaluation of this relationship. Osteoporosis medications can exert favorable effects on bone size and cortical thickness. Such effects have been documented with teriparatide (PTH 1-34), which is the unique purely anabolic treatment for osteoporosis available to date. More surprising are the favorable effects on bone size seen with some of the bone resorption inhibitors such as neridronate in adults with osteogenesis imperfecta. Similarly, estrogens and alendronate can increase femoral neck size in postmenopausal women. Preservation of the trabecular microarchitecture was demonstrated first with risedronate and subsequently with alendronate. In placebo-controlled studies, a deterioration in trabecular microarchitecture occurred within 1 to 3 years in the placebo groups but not in the bisphosphonate groups. Teriparatide, in contrast, improves trabecular microarchitecture, in particular by increasing connectivity and improving the plate-rod distribution. The minerals within trabecular or cortical bone can be evaluated using microradiography or synchrotron micro-computed tomography. Marked or prolonged secondary mineralization may result in poor bone quality. Increased bone mineralization is among the key effects of bone resorption inhibitors, most notably bisphosphonates. Prolonged use of the most potent bisphosphonates may lead to unwanted effects related to excessive mineralization. Microcracks may play a physiological role; however, a large number of microcracks may be deleterious via an effect on osteocytes. Excessive mineralization may promote the development of multiple microcracks. Studies of bone crystal and collagen properties with several bone resorption inhibitors, including risedronate and raloxifene, showed no harmful effects. An increasing number (several hundreds) of mandibular osteonecrosis associated with bisphosphonate therapy has been reported. The typical patient was receiving injectable bisphosphonate therapy for bone cancer and had undergone dental work shortly before bisphosphonate administration. The mechanism of this adverse effect is poorly understood.     

Effect of disuse osteoporosis on bone composition: the fate of bone matrix

Disuse bone atrophy was induced in 10 adult dogs by means of brachial plexus section and/or elbow disarticulation. After 9 to 12 weeks of disuse intact humeri were examined by X-ray, and their physical properties determined. Thewhole humeri were isolated, defatted, dried to constant weight, and their mineral and collagen content determined.Eight out of 10 experimental (non-used) humeri demonstrated evidence of decreased radiodensity. The non-used limb demonstrated parallel loss in dry, fat-free weight (–23.2%), in collagen (–25.3%), and in mineral (–26.1%), as compared to the normal limb. The data indicated that the major portion of the lost bone tissue in disuse osteoporosis is replaced by water, fat, and other unidentified organic materials rather than fibrous tissue, and that collagen is lost in equal proportion to mineral. The proportionatelly greater loss of collagen and mineral than of dry, fat-free weight appears to be due to an increase of non-collagenous, non-lipid organic material, presumably protein.This investigation was supported in part by Public Health Service Grants Tl-AM-5437 and HD-00669, and in part by the Rainbow Hospital Research Fund and Easter Seal Research Foundation.     

Sustained-release rhBMP-2 increased bone mass and bone strength in an ovine model of postmenopausal osteoporosis

Objective  

The purpose of this study was to analyze the local treatment effects of rhBMP-2 combined with fibrin sealant (FS) on bone mineral density, microarchitectural and mechanical properties in osteoporotic ovine spine.     

Bone quality: A determinant for certain risk factors for bone fragility

Low bone quantity alone is insufficient cause for fragility fractures. This paper examines the role of bone quality in the fracture risk associated with age, sex, and race. Aspects of bone quality to be considered are bone architecture, matrix, mineralization, and fatigue damage. The trabecular network becomes progressively disconnected and weaker with age. Death of old osteocytes leads to hypermineralization and brittleness of bone. The stability of bone collagen declines with age, and unremodeled bone accumulates fatigue damage. The lower bone fragility rates in males than in females may be due to a combination of the larger male skeleton, greater cortical bone density after age 60 years, and greater bone turnover which would replace fatigue damaged bone. Fragility fracture rates in American and African blacks are lower than in whites, bone mineral density (BMD) is greater in American but not in African blacks (except for hip BMD), and American blacks have lower and African blacks higher bone turnover compared to whites. In South African blacks, trabeculae are thicker and better connected and trabecular bone undergoes less destructive age changes than in whites. To reconcile the disparate findings in American and African blacks we suggest that both groups have a genetic tendency to greater BMD than whites; American blacks realize this potential and African blacks do not, possibly because of calcium deficiency. Consequent high turnover removes fatigue damage and so improves bone quality. Weight-bearing activity in African blacks may be responsible for good hip bone density and thick trabeculae. American and African blacks have lower fragility fracture rates than whites for different reasons: American blacks because of higher BMD, and African blacks because of higher bone turnover, better hip BMD, and sturdier trabeculae.Presented at the NIA Workshop on Aging and Bone Quality, September 3–4, 1992, Bethesda, Maryland     

Emerging views about "osteoporosis", bone health,strength, fragility,and their determinants

 Recent articles by Drs. Lanyon, Raisz, Seeman, and Skerry summarized some emerging views about the causes and nature of some effects of mechanical loading on bones and “osteoporosis”, the causes of fractures in that condition, and the causes of increased bone fragility and age-related bone loss. This article would supplement theirs with further evidence and ideas. This includes a definition of bone health that suggests currently popular classifications of “osteoporosis” and “osteopenia” could fail to distinguish healthy differences from normal averages from true bone diseases. This definition also suggests a classification of osteoporotic fractures that could question some current methods and uses of noninvasive absorptiometry. This article emphasizes concepts and generalities, and leaves resolution of any devils in the details to other places, times, and people. Received: March 29, 2002 / Accepted: May 28, 2002 Offprint requests to: H.M. Frost     

Genetic perturbations that impair functional trait interactions lead to reduced bone strength and increased fragility in mice

Functional adaptation may complicate the choice of phenotype used in genetic studies that seek to identify genes contributing to fracture susceptibility. Often, genetic variants affecting one trait are compensated by coordinated changes in other traits. Bone fracture is a prototypic example because mechanical function of long bones (stiffness and strength) depends on how the system coordinately adjusts the amount (cortical area) and quality (tissue-mineral density, TMD) of bone tissue to mechanically offset the natural variation in bone robustness (total area/length). We propose that efforts aimed at identifying genes regulating fracture resistance will benefit from better understanding how functional adaptation contributes to the genotype–phenotype relationship. We analyzed the femurs of C57BL/6J–Chr^A/J/NaJ Chromosome Substitution Strains (CSSs) to systemically interrogate the mouse genome for chromosomes harboring genes that regulate mechanical function. These CSSs (CSS-i, i = the substituted chromosome) showed changes in mechanical function on the order of −26.6 to +11.5% relative to the B6 reference strain after adjusting for body size. Seven substitutions showed altered robustness, cortical area, or TMD, but no effect on mechanical function (CSS-4, 5, 8, 9, 17, 18, 19); six substitutions showed altered robustness, cortical area, or TMD, and reduced mechanical function (CSS-1, 2, 6, 10, 12, 15); and one substitution also showed reduced mechanical function but exhibited no significant changes in the three physical traits analyzed in this study (CSS-3). A key feature that distinguished CSSs that maintained function from those with reduced function was whether the system adjusted cortical area and TMD to the levels needed to compensate for the natural variation in bone robustness. These results provide a novel biomechanical mechanism linking genotype with phenotype, indicating that genes control function not only by regulating individual traits, but also by regulating how the system coordinately adjusts multiple traits to establish function.     

Effects of long-term risedronate on bone quality and bone turnover in women with postmenopausal osteoporosis

The effects of 3 years of oral risedronate treatment on bone quality and remodeling were assessed in women with postmenopausal osteoporosis. Transiliac bone biopsies were obtained at baseline and after treatment with placebo or risedronate 5 mg/day in 55 women (placebo, n = 27; risedronate 5 mg, n = 28); these pairs of samples allowed comparison of treatment effects vs. both baseline values and between treatment groups. A further 15 women (placebo, n = 6; risedronate 5 mg, n = 9) had measurements from a posttreatment biopsy, but not from a baseline biopsy. Samples were examined for qualitative changes (e.g., osteomalacia, peritrabecular fibrosis, and woven bone); no histological abnormalities were found to be associated with treatment. Among women with both baseline and posttreatment biopsies, risedronate-treated women experienced a moderate and expected reduction from baseline in bone turnover, which was reflected in mean decreases in mineralizing surface of 58% and in activation frequency of 47%. Histomorphometrical parameters indicated that bone formation rate decreased significantly from baseline with risedronate treatment, reflecting a decrease in bone turnover; bone mineralization was normal following treatment. Basic multicellular unit (BMU) balance tended to improve in the risedronate-treated women, whereas it tended to worsen in the placebo-treated women, although these changes were not statistically significant. There were no significant changes in structural parameters with treatment. The effects of 3 years of risedronate treatment on bone histology and histomorphometry reflect the antiresorptive mechanism of action, and are consistent with the antifracture efficacy and favorable bone safety profile demonstrated in large clinical trials.     

Experimental stimulation of osteogenesis induced by bone matrix

Bone gaps in 20 rabbits were filled with decalcified homologous bone. Direct currents, intravenous calcium, and anabolic steroids were administered for stimulation of osteogenesis. The shape and microscopic structure of the newly formed bone, together with the velocity of the osteogenesis, were investigated. Results were assessed by microscopic and radiographic analyses. In the group of calcium posttreatment, irregular shape and callosities were characteristic. Anabolic steroids failed to improve consolidation significantly; best results were seen after electrical stimulation of the grafted areas. In the group with electrical stimulation, fair shape, together with a more regular microscopic structure of the newly formed bone, were characteristic 4 weeks after surgery. Ungrafted gaps, together with defects filled with undecalcified cortical bone, failed to heal within the examined period of time.     

Chemical and morphologic alterations of rabbit bone induced by adriamycin

Long term, low dose administration of adriamycin (ADR) to young growing rabbits resulted in significant alterations in bone structure and chemistry. Morphologic changes were most pronounced at epiphyseal and metaphyseal areas of long bones. Epiphyseal cartilage plates were thin and there was derangement of growth zones. Areas of primary and secondary spongiosa were deficient in trabeculae, osteoblasts and osteoclasts. Analysis of femora, humeri and lumbar vertebrae from ADR-treated rabbits revealed increased water and fat content and significant decreases in bone density compared to age-matched controls. Cortices of long bones were roentgenographically thin and contained large irregular spaces evident microscopically. Evaluation of bone ash from ADR treated rabbits revealed significant increases in the percentage of calcium and phosphorus, although Ca/P ratios were not different from controls. Results ofin vitro studies indicate that ADR binds readily to nondemineralized, but not demineralized, fresh cortical bone powder. The findings of decreased bone density, histopathologic alterations, and a paucity of osteogenic cells in ADR treated rabbits are interpreted as retardation of bone maturation. It is suggested that ADR affects adversely both the organic and inorganic fractions of bone. Due to its unique characteristics of cytostatic action, binding to metal cations and orange-red fluorescence, ADR is a novel chemical agent that may be useful in experimental bone studies.     

The affinity of bone to hydroxyapatite and alumina in experimentally induced osteoporosis

The authors studied how bone reacts to hydroxyapatite (HAP) and alumina (Al2O3) in osteoporosis experimentally induced in a rat animal model by resection of the sciatic nerve. Sixteen and 32 weeks after resection of the sciatic nerve, implants of HAP and Al2O3 were inserted into rat tibias. The reaction of bone to HAP was compared with its reaction to Al2O3, which is bioinert, as a control. The results were analyzed using the affinity index (the length of bone directly opposed to the implant without an intervening fibrous membrane/total length of the bone-implant interface x 100%). In the rats left for 16 weeks after resection of the sciatic nerve the index values 24 weeks after insertion of HAP and Al2O3 were 96.9 +/- 2.4% (N = 8) and 75.2 +/- 22.2% (N = 8), respectively. The index value of HAP was 97.2 +/- 2.6% (N = 12) and of Al2O3 was 86.9 +/- 15.4% (N = 12) at 24 weeks after insertion, when the rats were first left for 32 weeks, after sciatic nerve resection. Bone was demonstrated to have a superior affinity to HAP, compared with Al2O3 (P less than .05).