Bone quality: where do we go from here?

Age- and sex-related changes in vertebral trabecular bone architecture in Neolithic and Mediaeval populations from Poland

This paper investigates trabecular bone ontogenetic changes in two different Polish populations, one prehistoric and the other historical. The studied populations are from the Brześć Kujawski region in Kujawy (north-central Poland), one from the Neolithic Period (4500-4000 BC) and one from the Middle Ages (twelfth-sixteenth centuries AD), in total 62 vertebral specimens (32 males, 30 females). Eight morphometric parameters acquired from microCT scan images were analysed. Two-way ANOVA after Box-Cox transformation and multifactorial regression model were calculated. A significant decrease in percentage bone volume fraction (BV/TV; [%]) with age at death was observed in the studied sample; Tb.N (trabecular number) was also significantly decreased with age; trabecular separation (Tb.Sp) increased with advancing age; connectivity density (Conn.D) was negatively correlated with biological age and higher in the Neolithic population. These data are found to be compatible with data from the current biomedical literature, while no loss of horizontal trabeculae was recorded as would be expected based on modern osteoporosis.

Association of trabecular bone score and bone mineral apparent density with the severity of bone fragility in children and adolescents with osteogenesis imperfecta: A cross-sectional study

Osteogenesis imperfecta (OI) is a hereditary skeletal disease characterized by bone fragility. Areal bone mineral density (BMD), evaluated by dual-energy X-ray absorptiometry (DXA), is used to assess bone brittleness. The height-adjusted BMD Z-score (BMDHAZ) is calculated in children and adolescents with OI to reduce the confounding factor of short stature. However, even with the BMDHAZ, severity evaluation in children and adolescents with OI is challenging because certain abnormalities in bone quality cannot be accurately assessed by BMD analysis. The trabecular bone scores (TBS) and bone mineral apparent density (BMAD), which represent the structural integrity of bone and bone-size-associated BMD, respectively, are associated with fracture risk. Recently, age- and sex-specific reference ranges have been reported, enabling the calculation of Z-scores for children. To evaluate which density measurements show the highest correlation with fracture risk, we analyzed the associations between the Z-scores of TBS, BMAD, and BMDHAZ, fracture rate, and genetic variants. We retrospectively reviewed 42 participants with OI aged 5 to 20 years who underwent DXA. COL1A1/2 pathogenic variants were detected in 41 of the 42 participants. In participants with nonsense and frameshift variants (n = 17) resulting in haploinsufficiency and mild phenotype, the TBS Z-score was negatively correlated with fracture rate (FR) (r = -0.50, p = 0.042). In participants with glycine substitution (n = 9) causing the severe phenotype, the BMAD Z-scores were negatively correlated with FR (r = -0.74, p = 0.022). No correlation between the BMDHAZ and FR was observed in both groups. These findings suggest that the TBS and BMAD are useful in assessing children and adolescents with OI with specific genetic variants.

Bone structure and composition in a hyperglycemic, obese, and leptin receptor-deficient rat: Microscale characterization of femur and calvarium

Metabolic abnormalities, such as diabetes mellitus and obesity, can impact bone quantity and/or bone quality. In this work, we characterize bone material properties, in terms of structure and composition, in a novel rat model with congenic leptin receptor (LepR) deficiency, severe obesity, and hyperglycemia (type 2 diabetes-like condition). Femurs and calvaria (parietal region) from 20-week-old male rats are examined to probe bones formed both by endochondral and intramembranous ossification. Compared to the healthy controls, the LepR-deficient animals display significant alterations in femur microarchitecture and in calvarium morphology when analyzed by micro-computed X-ray tomography (micro-CT). In particular, shorter femurs with reduced bone volume, combined with thinner parietal bones and shorter sagittal suture, point towards a delay in the skeletal development of the LepR-deficient rodents. On the other hand, LepR-deficient animals and healthy controls display analogous bone matrix composition, which is assessed in terms of tissue mineral density by micro-CT, degree of mineralization by quantitative backscattered electron imaging, and various metrics extrapolated from Raman hyperspectral images. Some specific microstructural features, i.e., mineralized cartilage islands in the femurs and hyper-mineralized areas in the parietal bones, also show comparable distribution and characteristics in both groups. Overall, the altered bone microarchitecture in the LepR-deficient animals indicates compromised bone quality, despite the normal bone matrix composition. The delayed development is also consistent with observations in humans with congenic Lep/LepR deficiency, making this animal model a suitable candidate for translational research.

Bone quality in endocrine diseases: determinants and clinical relevance

PURPOSE

Bone is one of the main targets of hormones and endocrine diseases are frequent causes of secondary osteoporosis and fractures in real-world clinical practice. However, diagnosis of skeletal fragility and prediction of fractures in this setting could be a challenge, since the skeletal alterations induced by endocrine disorders are not generally captured by dual-energy X-ray absorptiometry (DXA) measurement of bone mineral density (BMD), that is the gold standard for diagnosis of osteoporosis in the general population. The aim of this paper is to review the existing evidence related to bone quality features in endocrine diseases, proposing assessment with new techniques in the future.

METHODS

A comprehensive search within electronic databases was performed to collect reports of bone quality in primary hyperparathyroidism, hypoparathyroidism, hyperthyroidism, hypercortisolism, growth hormone deficiency, acromegaly, male hypogonadism and diabetes mellitus.

RESULTS

Using invasive and non-invasive techniques, such as high-resolution peripheral quantitative computed tomography or DXA measurement of trabecular bone score (TBS), several studies consistently reported altered bone quality as predominant determinant of fragility fractures in subjects affected by chronic endocrine disorders.

CONCLUSIONS

Assessment of skeletal fragility in endocrine diseases might take advantage from the use of techniques to detect perturbation in bone architecture with the aim of best identifying patients at high risk of fractures.

Long non-coding RNA H19 regulates matrisome signature and impacts cell behavior on MSC-engineered extracellular matrices

BACKGROUND

The vast and promising class of long non-coding RNAs (lncRNAs) has been under investigation for distinct therapeutic applications. Nevertheless, their role as molecular drivers of bone regeneration remains poorly studied. The lncRNA H19 mediates osteogenic differentiation of Mesenchymal Stem/Stromal Cells (MSCs) through the control of intracellular pathways. However, the effect of H19 on the extracellular matrix (ECM) components is still largely unknown. This research study was designed to decode the H19-mediated ECM regulatory network, and to reveal how the decellularized siH19-engineered matrices influence MSC proliferation and fate. This is particularly relevant for diseases in which the ECM regulation and remodeling processes are disrupted, such as osteoporosis.

METHODS

Mass spectrometry-based quantitative proteomics analysis was used to identify ECM components, after oligonucleotides delivery to osteoporosis-derived hMSCs. Moreover, qRT-PCR, immunofluorescence and proliferation, differentiation and apoptosis assays were performed. Engineered matrices were decellularized, characterized by atomic force microscopy and repopulated with hMSC and pre-adipocytes. Clinical bone samples were characterized by histomorphometry analysis.

RESULTS

Our study provides an in-depth proteome-wide and matrisome-specific analysis of the ECM proteins controlled by the lncRNA H19. Using bone marrow-isolated MSC from patients with osteoporosis, we identified fibrillin-1 (FBN1), vitronectin (VTN) and collagen triple helix repeat containing 1 (CTHRC1), among others, as having different pattern levels following H19 silencing. Decellularized siH19-engineered matrices are less dense and have a decreased collagen content compared with control matrices. Repopulation with naïve MSCs promotes a shift towards the adipogenic lineage in detriment of the osteogenic lineage and inhibits proliferation. In pre-adipocytes, these siH19-matrices enhance lipid droplets formation. Mechanistically, H19 is targeted by miR-29c, whose expression is decreased in osteoporotic bone clinical samples. Accordingly, miR-29c impacts MSC proliferation and collagen production, but does not influence ALP staining or mineralization, revealing that H19 silencing and miR-29c mimics have complementary but not overlapping functions.

CONCLUSION

Our data suggest H19 as a therapeutic target to engineer the bone ECM and to control cell behavior.

3D printed trabeculae conditionally reproduce the mechanical properties of the actual trabeculae - A preliminary study

Three-dimensional (3D) printing has been used to fabricate synthetic trabeculae models and to test mechanical behavior that cannot be recognized in the actual sample, but the extent to which 3D printed trabeculae replicate the mechanical behavior of the actual trabeculae remains to be quantified. The aim of this study was to evaluate the accuracy of 3D printed trabeculae in reproducing the mechanical properties of the corresponding actual trabeculae. Twelve human trabecular cubes (5 × 5 × 5 mm) were scanned by micro-CT to form the trabecular 3D model. Each trabecular 3D model was scaled ×2-, ×3-, ×4- and ×5-fold and then printed twice at a layer thickness of 60 μm using poly (lactic acid) (PLA). The actual trabecular cubes and the 3D-printed trabecular cubes were first compressed under a loading rate of 1 mm/min; another replicated stack of 3D-printed trabecular cubes was compressed under a strain rate of 0.2/min. The results showed that the stiffness of the printed cubes tended to increase, while the strength tended to converge when the magnification increased under the two loading conditions. The strain rate effect was found in the printed cubes. The correlation coefficient (R²) of the mechanical properties between the printed and actual trabeculae can reach up to 0.94, especially under ×3-, ×4- and ×5-fold magnification. In conclusion, 3D printing could be a potential tool to evaluate the mechanical behavior of actual trabecular tissue in vitro and may help in the future to predict the risk of fracture and even personalize the treatment evaluation for osteoporosis and other trabecular bone pathologies.

Bone Quality in Relation to HIV and Antiretroviral Drugs

PURPOSE OF REVIEW

People living with HIV (PLWH) are at an increased risk for osteoporosis, a disease defined by the loss of bone mineral density (BMD) and deterioration of bone quality, both of which independently contribute to an increased risk of skeletal fractures. While there is an emerging body of literature focusing on the factors that contribute to BMD loss in PLWH, the contribution of these factors to bone quality changes are less understood. The current review summarizes and critically reviews the data describing the effects of HIV, HIV disease-related factors, and antiretroviral drugs (ARVs) on bone quality.

RECENT FINDINGS

The increased availability of high-resolution peripheral quantitative computed tomography has confirmed that both HIV infection and ARVs negatively affect bone architecture. There is considerably less data on their effects on bone remodeling or the composition of bone matrix. Whether changes in bone quality independently predict fracture risk, as seen in HIV-uninfected populations, is largely unknown. The available data suggests that bone quality deterioration occurs in PLWH. Future studies are needed to define which factors, viral or ARVs, contribute to loss of bone quality and which bone quality factors are most associated with increased fracture risk.

Fabrication and Optimisation of Ti-6Al-4V Lattice-Structured Total Shoulder Implants Using Laser Additive Manufacturing

This work aimed to study one of the most important challenges in orthopaedic implantations, known as stress shielding of total shoulder implants. This problem arises from the elastic modulus mismatch between the implant and the surrounding tissue, and can result in bone resorption and implant loosening. This objective was addressed by designing and optimising a cellular-based lattice-structured implant to control the stiffness of a humeral implant stem used in shoulder implant applications. This study used a topology lattice-optimisation tool to create different cellular designs that filled the original design of a shoulder implant, and were further analysed using finite element analysis (FEA). A laser powder bed fusion technique was used to fabricate the Ti-6Al-4V test samples, and the obtained material properties were fed to the FEA model. The optimised cellular design was further fabricated using powder bed fusion, and a compression test was carried out to validate the FEA model. The yield strength, elastic modulus, and surface area/volume ratio of the optimised lattice structure, with a strut diameter of 1 mm, length of 5 mm, and 100% lattice percentage in the design space of the implant model were found to be 200 MPa, 5 GPa, and 3.71 mm⁻¹, respectively. The obtained properties indicated that the proposed cellular structure can be effectively applied in total shoulder-replacement surgeries. Ultimately, this approach should lead to improvements in patient mobility, as well as to reducing the need for revision surgeries due to implant loosening.

Bone fragility in diabetes: novel concepts and clinical implications

Increased fracture risk represents an emerging and severe complication of diabetes. The resulting prolonged immobility and hospitalisations can lead to substantial morbidity and mortality. In type 1 diabetes, bone mass and bone strength are reduced, resulting in up to a five-times greater risk of fractures throughout life. In type 2 diabetes, fracture risk is increased despite a normal bone mass. Conventional dual-energy x-ray absorptiometry might underestimate fracture risk, but can be improved by applying specific adjustments. Bone fragility in diabetes can result from cellular abnormalities, matrix interactions, immune and vascular changes, and musculoskeletal maladaptation to chronic hyperglycaemia. This Review summarises how the bone microenvironment responds to type 1 and type 2 diabetes, and the mechanisms underlying fragility fractures. We describe the value of novel imaging technologies and the clinical utility of biomarkers, and discuss current and future therapeutic approaches that protect bone health in people with diabetes.

Digital panoramic radiography as a tool for analyzing the quality of trabecular bone microarchitecture

Abstract Introduction Osteoporosis is a metabolic disease characterized by reduced bone mineral density, often accompanied by loss of quality of trabecular bone microarchitecture. Objective To assess the quality or degradation of trabecular bone microarchitecture in digital panoramic radiography to better predict the risk of fragility fractures. Material and method The sample included 68 female patients, age-matched, and divided into three groups according to densitometric results. Trabecular Bone Score values were measured and digital panoramic radiographs were taken. Fractal analysis with box counting was conducted in the region of premolars and angle of the mandible, with regions of interest measuring 64×64 and 80×120 pixels. In the statistical analysis, Pearson’s correlation was applied between the Trabecular Bone Score and fractal analysis results obtained in each group, using age as a control variable and assigning individualized age ranges within groups. Result A moderate correlation was identified in the regions of interest of 64×64 and 80×120 pixels at the angle of the mandible in the osteoporosis group and in the normal group. A moderate correlation was also obtained using age as a control variable in the 64x64 pixel regions of interest in the premolar region. Considering age range, the within-group analysis presented a strong correlation in the osteoporosis group and moderate correlation in the osteopenia and normal groups. Conclusion Fractal analysis in digital panoramic radiographs was shown to be a promising predictive instrument of bone microarchitecture quality.

Time-resolved in situ synchrotron-microCT: 4D deformation of bone and bone analogues using digital volume correlation

Digital volume correlation (DVC) in combination with high-resolution micro-computed tomography (microCT) imaging and in situ mechanical testing is gaining popularity for quantifying 3D full-field strains in bone and biomaterials. However, traditional in situ time-lapsed (i.e., interrupted) mechanical testing cannot fully capture the dynamic strain mechanisms in viscoelastic biological materials. The aim of this study was to investigate the time-resolved deformation of bone structures and analogues via continuous in situ synchrotron-radiation microCT (SR-microCT) compression and DVC to gain a better insight into their structure-function relationships. Fast SR-microCT imaging enabled the deformation behaviour to be captured with high temporal and spatial resolution. Time-resolved DVC highlighted the relationship between local strains and damage initiation and progression in the different biostructures undergoing plastic deformation, bending and/or buckling of their main microstructural elements. The results showed that SR-microCT continuous mechanical testing complemented and enhanced the information obtained from time-lapsed testing, which may underestimate the 3D strain magnitudes as a result of the stress relaxation occurring in between steps before image acquisition in porous biomaterials. Altogether, the findings of this study highlight the importance of time-resolved in situ experiments to fully characterise the time-dependent mechanical behaviour of biological tissues and biomaterials and to further explore their micromechanics under physiologically relevant conditions. STATEMENT OF SIGNIFICANCE: Time-resolved synchrotron X-ray tomography in combination with in situ mechanical testing provided the first four-dimensional analysis of the mechanical deformation of bone and bone analogues. To unravel the interplay of damage initiation and progression with local deformation, digital volume correlation was used to map the local strain field while microstructural changes were tracked with high temporal and spatial resolution. The results highlighted the importance of fast imaging and time-resolved in situ experiments to capture the real deformation of complex porous materials to fully characterize the local strain-damage relationship. The findings are notably improving the understanding of time-dependent mechanical behaviour of bone tissue, with the potential to be extend to highly viscoelastic biomaterials and soft tissues.

On challenges in clinical assessment of hip fracture risk using image-based biomechanical modelling: a critical review

INTRODUCTION

Hip fracture is a common health risk among elderly people, due to the prevalence of osteoporosis and accidental fall in the population. Accurate assessment of fracture risk is a crucial step for clinicians to consider patient-by-patient optimal treatments for effective prevention of fractures. Image-based biomechanical modeling has shown promising progress in assessment of fracture risk, and there is still a great possibility for improvement. The purpose of this paper is to identify key issues that need be addressed to improve image-based biomechanical modeling.

MATERIALS AND METHODS

We critically examined issues in consideration and determination of the four biomechanical variables, i.e., risk of fall, fall-induced impact force, bone geometry and bone material quality, which are essential for prediction of hip fracture risk. We closely inspected: limitations introduced by assumptions that are adopted in existing models; deficiencies in methods for construction of biomechanical models, especially for determination of bone material properties from bone images; problems caused by separate use of the variables in clinical study of hip fracture risk; availability of clinical information that are required for validation of biomechanical models.

RESULTS AND CONCLUSIONS

A number of critical issues and gaps were identified. Strategies for effectively addressing the issues were discussed.

Peak trabecular bone microstructure predicts rate of estrogen-deficiency-induced bone loss in rats

Postmenopausal osteoporosis affects a large number of women worldwide. Reduced estrogen levels during menopause lead to accelerated bone remodeling, resulting in low bone mass and increased fracture risk. Both peak bone mass and the rate of bone loss are important predictors of postmenopausal osteoporosis risk. However, whether peak bone mass and/or bone microstructure directly influence the rate of bone loss following menopause remains unclear. Our study aimed to establish the relationship between peak bone mass/microstructure and the rate of bone loss in response to estrogen deficiency following ovariectomy (OVX) surgery in rats of homogeneous background by tracking the skeletal changes using in vivo micro-computed tomography (μCT) and three-dimensional (3D) image registrations. Linear regression analyses demonstrated that the peak bone microstructure, but not peak bone mass, was highly predictive of the rate of OVX-induced bone loss. In particular, the baseline trabecular thickness was found to have the highest correlation with the degree of OVX-induced bone loss and trabecular stiffness reduction. Given the same bone mass, the rats with thicker baseline trabeculae had a lower rate of trabecular microstructure and stiffness deterioration after OVX. Moreover, further evaluation to track the changes within each individual trabecula via our novel individual trabecular dynamics (ITD) analysis suggested that a trabecular network with thicker trabeculae is less likely to disconnect or perforate in response to estrogen deficiency, resulting a lower degree of bone loss. Taken together, these findings indicate that the rate of estrogen-deficiency-induced bone loss could be predicted by peak bone microstructure, most notably the trabecular thickness. Given the same bone mass, a trabecular bone phenotype with thin trabeculae may be a risk factor toward accelerated postmenopausal bone loss.

A Review on Multiscale Bone Damage: From the Clinical to the Research Perspective

The investigation of bone damage processes is a crucial point to understand the mechanisms of age-related bone fractures. In order to reduce their impact, early diagnosis is key. The intricate architecture of bone and the complexity of multiscale damage processes make fracture prediction an ambitious goal. This review, supported by a detailed analysis of bone damage physical principles, aims at presenting a critical overview of how multiscale imaging techniques could be used to implement reliable and validated numerical tools for the study and prediction of bone fractures. While macro- and meso-scale imaging find applications in clinical practice, micro- and nano-scale imaging are commonly used only for research purposes, with the objective to extract fragility indexes. Those images are used as a source for multiscale computational damage models. As an example, micro-computed tomography (micro-CT) images in combination with micro-finite element models could shed some light on the comprehension of the interaction between micro-cracks and micro-scale bone features. As future insights, the actual state of technology suggests that these models could be a potential substitute for invasive clinical practice for the prediction of age-related bone fractures. However, the translation to clinical practice requires experimental validation, which is still in progress.

A multiscale study of structural and compositional changes in a natural nanocomposite: Osteoporotic bone with chronic endogenous steroid excess

Glucocorticoid (or steroid) induced osteoporosis (GIOP) is the leading form of secondary osteoporosis, affecting up to 50% of patients receiving chronic glucocorticoid therapy. Bone quantity (bone mass) changes in GIOP patients alone are inadequate to explain the increased fracture risk, and bone material changes (bone quality) at multiple levels have been implicated in the reduced mechanics. Quantitative analysis of specific material-level changes is limited. Here, we combined multiscale experimental techniques (scanning small/wide-angle X-ray scattering/diffraction, backscattered electron imaging, and X-ray radiography) to investigate these changes in a mouse model (Crh^-120/+) with chronic endogenous steroid production. Nanoscale degree of orientation, the size distribution of mineral nanocrystals in the bone matrix, the spatial map of mineralization on the femoral cortex, and the microporosity showed significant changes between GIOP and the control, especially in the endosteal cortex. Our work can provide insight into the altered structure-property relationship leading to lowered mechanical properties in GIOP. SIGNIFICANCE STATEMENT: As a natural nanocomposite with a hierarchical structure, bone undergoes a staggered load transfer mechanism at the nanoscale. Disease and age-related deterioration of bone mechanics are caused by changes in bone structure at multiple length scales. Although clinical tools such as dual-energy X-ray absorptiometry (DXA) can be used to assess the reduction of bone quantity in these cases, little is known about how altered bone quality in diseased bone can increase fracture risk. It is clear that high-resolution diagnostic techniques need to be developed to narrow the gap between the onset and diagnosis of fracture-related changes. Here, by combining several scanning probe methods on a mouse model (Crh^-120/+) of glucocorticoid-induced osteoporosis (GIOP), we developed quantitative and spatially resolved maps of ultrastructural changes in collagen fibrils and mineral nanocrystals, mineralization distribution (microscale), and morphology (macroscale) across femoral osteoporotic bone. Our results indicate that the altered bone remodelling in GIOP leads to 1) heterogeneous bone structure and mineralization, 2) reduced degree of orientation of collagen fibrils and mineral nanocrystals, and 3) reduced length and increased thickness of mineral nanocrystals, which contribute to mechanical abnormalities. The combined multiscale experimental approach presented here will be used to understand musculoskeletal degeneration in aging and osteoporosis.

Bone Tissue Composition in Postmenopausal Women Varies With Glycemic Control From Normal Glucose Tolerance to Type 2 Diabetes Mellitus

The risk of fragility fracture increases for people with type 2 diabetes mellitus (T2DM), even after controlling for bone mineral density, body mass index, visual impairment, and falls. We hypothesize that progressive glycemic derangement alters microscale bone tissue composition. We used Fourier-transform infrared (FTIR) imaging to analyze the composition of iliac crest biopsies from cohorts of postmenopausal women characterized by oral glucose tolerance testing: normal glucose tolerance (NGT; n = 35, age = 65 ± 7 years, HbA1c = 5.8 ± 0.3%), impaired glucose tolerance (IGT; n = 26, age = 64 ± 5 years, HbA1c = 6.0 ± 0.4%), and overt T2DM on insulin (n = 25, age = 64 ± 6 years, HbA1c = 9.13 ± 0.6). The distributions of cortical bone mineral content had greater mean values (+7%) and were narrower (-10%) in T2DM versus NGT groups (p < 0.05). The distributions of acid phosphate, an indicator of new mineral, were narrower in cortical T2DM versus NGT and IGT groups (-14% and -14%, respectively) and in trabecular NGT and IGT versus T2DM groups (-11% and -10%, respectively) (all p < 0.05). The distributions of crystallinity were wider in cortical NGT versus T2DM groups (+16%) and in trabecular NGT versus T2DM groups (+14%) (all p < 0.05). Additionally, bone turnover was lower in T2DM versus NGT groups (P1NP: -25%, CTx: -30%, ucOC: -24%). Serum pentosidine was similar across groups. The FTIR compositional and biochemical marker values of the IGT group typically fell between the NGT and T2DM group values, although the differences were not always statistically significant. In summary, worsening glycemic control was associated with greater mineral content and narrower distributions of acid phosphate, an indicator of new mineral, which together are consistent with observations of lower turnover; however, wider distributions of mineral crystallinity were also observed. A more mineralized, less heterogeneous tissue may affect tissue-level mechanical properties and in turn degrade macroscale skeletal integrity. In conclusion, these data are the first evidence of progressive alteration of bone tissue composition with worsening glycemic control in humans. © 2020 American Society for Bone and Mineral Research (ASBMR).

Deciphering the Relevance of Bone ECM Signaling

Bone mineral density, a bone matrix parameter frequently used to predict fracture risk, is not the only one to affect bone fragility. Other factors, including the extracellular matrix (ECM) composition and microarchitecture, are of paramount relevance in this process. The bone ECM is a noncellular three-dimensional structure secreted by cells into the extracellular space, which comprises inorganic and organic compounds. The main inorganic components of the ECM are calcium-deficient apatite and trace elements, while the organic ECM consists of collagen type I and noncollagenous proteins. Bone ECM dynamically interacts with osteoblasts and osteoclasts to regulate the formation of new bone during regeneration. Thus, the composition and structure of inorganic and organic bone matrix may directly affect bone quality. Moreover, proteins that compose ECM, beyond their structural role have other crucial biological functions, thanks to their ability to bind multiple interacting partners like other ECM proteins, growth factors, signal receptors and adhesion molecules. Thus, ECM proteins provide a complex network of biochemical and physiological signals. Herein, we summarize different ECM factors that are essential to bone strength besides, discussing how these parameters are altered in pathological conditions related with bone fragility.

Bone Geometry, Density, and Microarchitecture in the Distal Radius and Tibia in Adults With Marfan Syndrome Assessed by HR-pQCT

Marfan syndrome (MFS) is a hereditary disorder of connective tissue caused by mutations in the fibrillin-1 gene. Studies have shown that patients with MFS have lower bone mass, but little is known about the other constituents of bone strength. We hypothesize that patients with MFS will have larger bone area and compromised cortical microarchitecture compared with non-MFS individuals. A total of 74 adult patients with MFS and 145 age- and sex-matched non-MFS reference individuals were included in this study. High-resolution peripheral quantitative computed tomography (HR-pQCT) at the distal radius and distal tibia and dual-energy X-ray absorptiometry of total hip and the lumbar spine were performed, and bone turnover and sex hormones were measured. Patients with MFS had significantly lower areal bone mineral density (BMD) at the total spine (-13%) and total hip (-7%) when compared with the reference group. Patients with MFS had significantly larger total bone area at both the radius (+27%) and tibia (+34%). Volumetric BMD at both measured sites showed significantly reduced total, trabecular, and cortical volumetric BMD in patients with MFS compared with the reference group. The microarchitectural parameters at the radius and tibia were compromised in patients with MFS with significantly reduced trabecular number and thickness, leading to a higher trabecular separation and significantly reduced cortical thickness and increased cortical porosity compared with the reference group. The differences in bone density, geometry, or microarchitecture were not explained by increased bone turnover markers or circulating levels of sex hormones. We conclude patients with MFS have altered bone geometry, altered bone microstructure, and lower bone mass (lower areal BMD and volumetric BMD at all sites) compared with healthy reference individuals. Future studies should focus on fracture rates and fracture risk in adult and aging patients with MFS. © 2020 American Society for Bone and Mineral Research (ASBMR).

The first step in an investigation of quantitative ultrasound as a technique for evaluating infant bone strength

This study's purpose is to evaluate whether bone speed of sound (SOS) data, a parameter of quantitative ultrasound, collected from an infant autopsy sample are comparable to data collected from healthy, living infants. We hypothesize that SOS values obtained from deceased term-born infants will fall within the normal range for healthy, living infants. The study sample consists of 351 deceased infants between the ages of 30 weeks gestation at birth to 1 year postnatal at the time of death receiving autopsies at the Harris County Institute of Forensic Sciences or Texas Children's Hospital in Houston, TX. Various multivariate and univariate statistics were used to examine the relationship between SOS and age, prematurity, and chronic illness. The results of an ANOVA comparing the study sample data to published data from healthy, living infants indicate the SOS data are comparable. Additionally, a MANOVA indicated significant differences in SOS related to prematurity (p = 0.001) and age (p < 0.001). Mean SOS was significantly greater among term-born infants (M = 3065.66, SD =165.05) than premature infants (M = 2969.71, SD =192.72). Age had a significant polynomial (cubic) relationship with SOS for both the premature and term groups (p < 0.001). Results suggest that bone from an infant autopsy sample is an appropriate surrogate to examine the relationship between SOS and determinants of bone strength. Therefore, future research will use this study sample to investigate the relationship between SOS and determinants of bone strength in infants.

Breaking new ground in mineralized tissue: Assessing tissue quality in clinical and laboratory studies

Mineralized tissues, such as bone and teeth, have extraordinary mechanical properties of both strength and toughness. This mechanical behavior originates from deformation and fracture resistance mechanisms in their multi-scale structure. The term quality describes the matrix composition, multi-scale structure, remodeling dynamics, water content, and micro-damage accumulation in the tissue. Aging and disease result in changes in the tissue quality that may reduce strength and toughness and lead to elevated fracture risk. Therefore, the capability to measure the quality of mineralized tissues provides critical information on disease progression and mechanical integrity. Here, we provide an overview of clinical and laboratory-based techniques to assess the quality of mineralized tissues in health and disease. Current techniques used in clinical settings include radiography-based (radiographs, dual energy x-ray absorptiometry, EOS) and x-ray tomography-based methods (high resolution peripheral quantitative computed tomography, cone beam computed tomography). In the laboratory, tissue quality can be investigated in ex vivo samples with x-ray imaging (micro and nano-computed tomography, x-ray microscopy), electron microscopy (scanning/transmission electron imaging (SEM/STEM), backscattered scanning electron microscopy, Focused Ion Beam-SEM), light microscopy, spectroscopy (Raman spectroscopy and Fourier transform infrared spectroscopy) and assessment of mechanical behavior (mechanical testing, fracture mechanics and reference point indentation). It is important for clinicians and basic science researchers to be aware of the techniques available in different types of research. While x-ray imaging techniques translated to the clinic have provided exceptional advancements in patient care, the future challenge will be to incorporate high-resolution laboratory-based bone quality measurements into clinical settings to broaden the depth of information available to clinicians during diagnostics, treatment and management of mineralized tissue pathologies.

Spectrum of microarchitectural bone disease in inborn errors of metabolism: a cross-sectional, observational study

BACKGROUND

Patients diagnosed with inborn errors of metabolism (IBEM) often present with compromised bone health leading to low bone density, bone pain, fractures, and short stature. Dual-energy X-ray absorptiometry (DXA) is the current gold standard for clinical assessment of bone in the general population and has been adopted for monitoring bone density in IBEM patients. However, IBEM patients are at greater risk for scoliosis, short stature and often have orthopedic hardware at standard DXA scan sites, limiting its use in these patients. Furthermore, DXA is limited to measuring areal bone mineral density (BMD), and does not provide information on microarchitecture.

METHODS

In this study, microarchitecture was investigated in IBEM patients (n = 101) using a new three-dimensional imaging technology high-resolution peripheral quantitative computed tomography (HR-pQCT) which scans at the distal radius and distal tibia. Volumetric BMD and bone microarchitecture were computed and compared amongst the different IBEMs. For IBEM patients over 16 years-old (n = 67), HR-pQCT reference data was available and Z-scores were calculated.

RESULTS

Cortical bone density was significantly lower in IBEMs associated with decreased bone mass when compared to lysosomal storage disorders (LSD) with no primary skeletal pathology at both the radius and tibia. Cortical thickness was also significantly lower in these disorders when compared to LSD with no primary skeletal pathology at the radius. Cortical porosity was significantly greater in hypophosphatasia when compared to all other IBEM subtypes.

CONCLUSION

We demonstrated compromised bone microarchitecture in IBEMs where there is primary involvement of the skeleton, as well as IBEMs where skeletal complications are a secondary outcome. In conclusion, our findings suggest HR-pQCT may serve as a valuable tool to monitor skeletal disease in the IBEM population, and provides insight to the greatly varying bone phenotype for this cohort that can be used for clinical monitoring and the assessment of response to therapeutic interventions.

Differing trabecular bone architecture in dinosaurs and mammals contribute to stiffness and limits on bone strain

The largest dinosaurs were enormous animals whose body mass placed massive gravitational loads on their skeleton. Previous studies investigated dinosaurian bone strength and biomechanics, but the relationships between dinosaurian trabecular bone architecture and mechanical behavior has not been studied. In this study, trabecular bone samples from the distal femur and proximal tibia of dinosaurs ranging in body mass from 23-8,000 kg were investigated. The trabecular architecture was quantified from micro-computed tomography scans and allometric scaling relationships were used to determine how the trabecular bone architectural indices changed with body mass. Trabecular bone mechanical behavior was investigated by finite element modeling. It was found that dinosaurian trabecular bone volume fraction is positively correlated with body mass similar to what is observed for extant mammalian species, while trabecular spacing, number, and connectivity density in dinosaurs is negatively correlated with body mass, exhibiting opposite behavior from extant mammals. Furthermore, it was found that trabecular bone apparent modulus is positively correlated with body mass in dinosaurian species, while no correlation was observed for mammalian species. Additionally, trabecular bone tensile and compressive principal strains were not correlated with body mass in mammalian or dinosaurian species. Trabecular bone apparent modulus was positively correlated with trabecular spacing in mammals and positively correlated with connectivity density in dinosaurs, but these differential architectural effects on trabecular bone apparent modulus limit average trabecular bone tissue strains to below 3,000 microstrain for estimated high levels of physiological loading in both mammals and dinosaurs.

Effect of variations in tissue-level ductility on human vertebral strength

Although the ductility of bone tissue is a unique element of bone quality and varies with age and across the population, the extent to which and mechanisms by which typical population-variations in tissue-level ductility can alter whole-bone strength remains unclear. To provide insight, we conducted a finite element analysis parameter study of whole-vertebral (monotonic) compressive strength on six human L1 vertebrae. Each model was generated from micro-CT scans, capturing the trabecular micro-architecture in detail, and included a non-linear constitutive model for the bone tissue that allowed for plastic yielding, different strengths in tension and compression, large deformations, and, uniquely, localized damage once a specified limit in tissue-level ultimate strain was exceeded. Those strain limits were based on reported (mean ± SD) values from cadaver experiments (8.8 ± 3.7% strain for trabecular tissue and 2.2 ± 0.9% for cortical tissue). In the parameter study, the strain limits were varied by ±1 SD from their mean values, for a combination of nine analyses per specimen; bounding values of zero and unlimited post-yield strain were also modeled. The main outcomes from the finite element analysis were the vertebral compressive strength and the amount of failed (yielded or damaged) tissue at the overall structure-level failure. Compared to a reference case of using the mean values of ultimate strain, we found that varying both trabecular and cortical tissue ultimate strains by ±1 SD changed the computed vertebral strength by (mean ± SD) ±6.9 ± 1.1% on average. Mechanistically, that modest effect arose because the proportion of yielded tissue (without damage) was 0.9 ± 0.3% of all the bone tissue across the nine cases and the proportion of damaged tissue (i.e. tissue exceeding the prescribed tissue-level ultimate strain) was 0.2 ± 0.1%. If the types of variations in tissue-level ductility investigated here accurately represent real typical variations in the population, the consistency of our results across specimens and the modest effect size together suggest that typical variations in tissue-level ductility only have a modest impact on vertebral compressive strength, in large part because so few trabeculae are damaged at the load capacity of the bone.

Neuropeptide Y1 receptor antagonist promotes osteoporosis and microdamage repair and enhances osteogenic differentiation of bone marrow stem cells via cAMP/PKA/CREB pathway

Osteoporosis is a common metabolic bone disorder in the elderly population. The accumulation of bone microdamage is a critical factor of osteoporotic fracture. Neuropeptide Y (NPY) has been reported to regulated bone metabolism through Y1 receptor (Y1R). In this study the effects and mechanisms of Y1R antagonist on prevention for osteoporosis were characterized. In the clinical experiment, compared with osteoarthritis (OA), osteoporosis (OP) showed significant osteoporotic bone microstructure and accumulation of bone microdamage. NPY and Y1R immunoreactivity in bone were stronger in OP group, and were both correlated with bone volume fraction (BV/TV). In vivo experiment, Y1R antagonist significantly improved osteoporotic microstructure in the ovariectomized (OVX) rats. And Y1R antagonist promoted RUNX2, OPG and inhibit RANKL, MMP9 in bone marrow. In vitro cell culture experiment, NPY inhibited osteogenesis, elevated RANKL/OPG ratio and downregulated the expression of cAMP, p-PKAs and p-CREB in BMSCs, treated with Y1R antagonist or 8-Bromo-cAMP could inhibit the effects of NPY. Together, Y1R antagonist improved the bone microstructure and reduced bone microdamage in OVX rats. NPY-Y1R could inhibit osteoblast differentiation of BMSCs via cAMP/PKA/CREB pathway. Our findings highlight the regulation of NPY-Y1R in bone metabolism as a potential therapy strategy for the prevention of osteoporosis and osteoporotic fracture.

Bone Turnover Markers After Standard and Distal Roux-en-Y Gastric Bypass: Results from a Randomized Controlled Trial

BACKGROUND

Roux-en-Y gastric bypass is associated with increased risk of bone fractures. Malabsorptive procedures may be associated with secondary hyperparathyroidism and detrimental effects on bone health. We aimed to compare the effects of standard and distal gastric bypass on bone turnover markers 2 years after surgery.

METHODS

Patients with body mass index (BMI) 50-60 kg/m² (n = 113) were randomized to standard or distal gastric bypass, 105 patients (95%) completed 2-year follow-up. Serum C-terminal telopeptide of type I collagen (CTX-1), procollagen type I N-propeptide (PINP), and bone-derived alkaline phosphatase (BALP) was measured at baseline and up to 2 years after surgery. ANCOVA and linear mixed models were used to compare groups.

RESULTS

The levels of bone turnover markers increased significantly in both groups, with no statistically significant difference between groups. Two years after standard and distal gastric bypass mean (SD) CTX-1 were 0.81 (0.32) and 0.83 (0.31) μg/L (p = 0.38), mean PINP was 77.6 (23.2) and 77.7 (29.3) μg/L (p = 0.42), and BALP 47.9 (21.9) vs. 50.7 (19.6) μg/L (p = 0.38), respectively. Multiple linear regression analyses showed that PINP and BALP correlated positively (p = 0.01 and p < 0.001) with PTH, but only BALP was significantly higher in patients with secondary hyperparathyroidism (p = 0.001). Type of surgery, vitamin D serum concentrations, and 2-year BMI were all independently associated with PTH levels.

CONCLUSION

A comparable increase in bone turnover markers 2 years after standard and distal gastric bypass was observed. There was a higher prevalence of secondary hyperparathyroidism after distal gastric bypass, but this did not impact bone turnover markers.

TRIAL REGISTRATION

Clinical Trials.gov number NCT00821197.

Decoding rejuvenating effects of mechanical loading on skeletal aging using in vivo μCT imaging and deep learning

Throughout the process of aging, dynamic changes of bone material, micro- and macro-architecture result in a loss of strength and therefore in an increased likelihood of fragility fractures. To date, precise contributions of age-related changes in bone (re)modeling and (de)mineralization dynamics to this fragility increase are not completely understood. Here, we present an image-based deep learning approach to quantitatively describe the effects of short-term aging and adaptive response to cyclic loading applied to proximal mouse tibiae and fibulae. Our approach allowed us to perform an end-to-end age prediction based on μCT imaging to determine the dynamic biological process of aging during a two week period, therefore permitting short-term bone aging analysis with 95% accuracy in predicting time points. In a second application, our deep learning analysis reveals that two weeks of in vivo mechanical loading are associated with an underlying rejuvenating effect of 5 days. Additionally, by quantitatively analyzing the learning process, we could, for the first time, identify the localization of the age-relevant encoded information and demonstrate 89% load-induced similarity of these locations in the loaded tibia with younger control bones. These data therefore suggest that our method enables identifying a general prognostic phenotype of a certain skeletal age as well as a temporal and localized loading-treatment effect on this apparent skeletal age for the studied mouse tibia and fibula. Future translational applications of this method may provide an improved decision-support method for osteoporosis treatment at relatively low cost. STATEMENT OF SIGNIFICANCE: Bone is a highly complex and dynamic structure that undergoes changes during the course of aging as well as in response to external stimuli, such as loading. Automatic assessment of "age" and "state" of the bone may lead to early prognosis of deceases such as osteoporosis and enables evaluating the effects of certain treatments. Here, we present an artificial intelligence-based method capable of automatically predicting the skeletal age from μCT images with 95% accuracy. Additionally, we utilize it to demonstrate the rejuvenation effects of in-vivo loading treatment on bones. We further, for the first time, break down aging-related local changes in bone by quantitatively analyzing "what the age assessment model has learned" and use this information to investigate the structural details of rejuvenation process.

A new approach to comprehensively evaluate the morphological properties of the human femoral head: example of application to osteoarthritic joint

Osteoarthritis affects the morphological properties of the femoral head. The goal of this study was to develop a method to elucidate whether these changes are localised to discrete regions, or if the reported trends in microstructural changes may be identified throughout the subchondral bone of the human femoral head. Whole femoral heads extracted from osteoarthritic (n = 5) and healthy controls (n = 5) underwent microCT imaging 39 μm voxel size. The subchondral bone plate was virtually isolated to evaluate the plate thickness and plate porosity. The trabecular bone region was divided into 37 volumes of interest spatially distributed in the femoral head, and bone morphometric properties were determined in each region. The study showed how the developed approach can be used to study the heterogeneous properties of the human femoral head affected by a disease such as osteoarthritis. As example, in the superior femoral head osteoarthritic specimens exhibited a more heterogeneous micro-architecture, with trends towards thicker cortical bone plate, higher trabecular connectivity density, higher trabecular bone density and thicker structures, something that could only be observed with the newly developed approach. Bone cysts were mostly confined to the postero-lateral quadrants extending from the subchondral region into the mid trabecular region. Nevertheless, in order to generalise these findings, a larger sample size should be analysed in the future. This novel method allowed a comprehensive evaluation of the heterogeneous micro-architectural properties of the human femoral head, highlighting effects of OA in the superior subchondral cortical and trabecular bone. Further investigations on different stages of OA would be needed to identify early changes in the bone.

Spaceflight-Induced Bone Tissue Changes that Affect Bone Quality and Increase Fracture Risk

PURPOSE OF REVIEW

Bone mineral density and systemic factors are used to assess skeletal health in astronauts. Yet, even in a general population, these measures fail to accurately predict when any individual will fracture. This review considers how long-duration human spaceflight requires evaluation of additional bone structural and material quality measures that contribute to microgravity-induced skeletal fragility.

RECENT FINDINGS

In both humans and small animal models following spaceflight, bone mass is compromised via reduced bone formation and elevated resorption levels. Concurrently, bone structural quality (e.g., trabecular microarchitecture) is diminished and the quality of bone material is reduced via impaired tissue mineralization, maturation, and maintenance (e.g., mediated by osteocytes). Bone structural and material quality are both affected by microgravity and may, together, jeopardize astronaut operational readiness and lead to increased fracture risk upon return to gravitational loading. Future studies need to directly evaluate how bone quality combines with diminished bone mass to influence bone strength and toughness (e.g., resistance to fracture). Bone quality assessment promises to identify novel biomarkers and therapeutic targets.

Changes in bone quality after Roux-en-Y gastric bypass: A prospective cohort study in subjects with and without type 2 diabetes

BACKGROUND

Obesity and type 2 diabetes (T2D) are associated with an increased risk of skeletal fractures despite a normal areal bone mineral density (aBMD) and low bone turnover, possibly due to reduced bone material strength. Roux-en-Y gastric bypass (RYGB) enables a substantial and persistent weight loss and resolution of obesity related comorbidities such as T2D. However, the procedure induces a decrease in aBMD and increased bone turnover and fracture rate. To our knowledge, changes in bone material strength after RYGB have not been explored. This study aimed to evaluate changes in factors influencing bone quality; bone material strength, aBMD and bone turnover markers, in a population with morbid obesity undergoing RYGB and whether these changes differed in participants with and without T2D. We also sought to assess factors associated with bone material strength and bone mineral density in obese subjects before and after RYGB.

METHODS

We examined 34 participants before and one year after RYGB, of whom 13 had T2D. Bone material strength index (BMSi) was evaluated by impact microindentation, aBMD and body composition by Dual energy X-ray absorptiometry, levels of bone turnover markers and calciotropic hormones were estimated from fasting serum samples. Participants with and without T2D were comparable before surgery, with the exception of glycosylated hemoglobin (HbA_1c).

RESULTS

Preoperatively, BMSi was inversely associated with BMI, β_unadjusted -1.1 (-1.9 to -0.28), R²=0.19, p=0.010, and this association remained significant after adjusting for age and gender. After RYGB the participants had lost a mean±SD of 33.9±10.9kg, 48.7±14.2 % of total body fat, increased physical activity, unchanged vitamin D levels, and all but one of the 13 participants with T2D were in diabetes remission. BMSi increased from 78.1±8.5 preoperatively to 82.0±6.4 one year after RYGB, corresponding to an increase of 4.0±9.8 in absolute units or 6.3±14.0 %, p=0.037. The increase was comparable in participants with and without T2D. In subjects with T2D, a larger decrease in HbA_1c was associated with a larger increase in BMSi β_unadjusted -9.2 (-16.5 to -1.9), R²=0.47, p=0.019. Bone turnover markers (CTX-1 and PINP) increased by 195.1±133.5 % and 109.5±70.6 %, respectively. aBMD decreased by 3.9±5.5 % in the lumbar spine, 8.2±4.6 % in the femoral neck, 11.6±4.9 % in total hip and 9.4±3.8 % in total body.

CONCLUSION

Our findings indicate that bone material strength improves despite an increase in bone turnover and a decrease in aBMD one year after RYGB. Trends were statistically comparable in participants with and without T2D. However, improved glucose control was associated with improved bone material strength in participants with T2D.

Skeletal response to whole body vibration and dietary calcium and phosphorus in growing pigs

The quality and strength of the skeleton is regulated by mechanical loading and adequate mineral intake of calcium (Ca) and phosphorus (P). Whole body vibration (WBV) has been shown to elicit adaptive responses in the skeleton, such as increased bone mass and strength. This experiment was designed to determine the effects of WBV and dietary Ca and P on bone microarchitecture and turnover. A total of 26 growing pigs were utilized in a 60-d experiment. Pigs were randomly assigned within group to a 2 × 2 factorial design with dietary Ca and P concentration (low and adequate) as well as WBV. The adequate diet was formulated to meet all nutritional needs according to the NRC recommendations for growing pigs. Low Ca, P diets had 0.16% lower Ca and 0.13% lower P than the adequate diet. Pigs receiving WBV were vibrated 30 min/d, 3 d/wk at a magnitude of 1 to 2 mm and a frequency of 50 Hz. On days 0, 30, and 60, digital radiographs were taken to determine bone mineral content by radiographic bone aluminum equivalency (RBAE) and serum was collected to measure biochemical markers of bone formation (osteocalcin, OC) and bone resorption (carboxy-terminal collagen crosslinks, CTX-I). At day 60, pigs were euthanized and the left third metacarpal bone was excised for detailed analysis by microcomputed tomography (microCT) to measure trabecular microarchitecture and cortical bone geometry. Maximum RBAE values for the medial or lateral cortices were not affected (P > 0.05) by WBV. Pigs fed adequate Ca and P tended (P = 0.10) to have increased RBAE max values for the medial and lateral cortices. WBV pigs had significantly decreased serum CTX-1 concentrations (P = 0.044), whereas animals fed a low Ca and P diet had increased (P < 0.05) OC concentrations. In bone, WBV pigs showed a significantly lower trabecular number (P = 0.002) and increased trabecular separation (P = 0.003), whereas cortical bone parameters were not significantly altered by WBV or diet (P > 0.05). In summary, this study confirmed the normal physiological responses of the skeleton to a low Ca, P diet. Interestingly, although the WBV protocol utilized in this study did not elicit any significant osteogenic response, decreases in CTX-1 in response to WBV may have been an early local adaptive bone response. We interpret these data to suggest that the frequency and amplitude of WBV was likely sufficient to elicit a bone remodeling response, but the duration of the study may not have captured the full extent of an entire bone remodeling cycle.

Trabecular bone score: a useful clinical tool for the evaluation of skeletal health in women of short stature

PURPOSE

Areal bone mineral density (aBMD) by DXA is underestimated in those with smaller bones and overestimated in those with larger bones. Trabecular bone score (TBS) predicts fracture risk, and is not influenced by bone size. The aim of this study was to evaluate TBS and BMD in women with short stature.

METHODS

We retrospectively analyzed DXA scans of all women aged 50-90 years with short stature (<144 cm) obtained in a single center, from 2006 to 2016. The comparison group comprised women >161 cm in height, matched for age and LS BMD, selected from the same database.

RESULTS

The study population included 342 women. The two groups were similar in age, and aBMD at the LS and total hip. Femoral neck aBMD was lower in cases than in taller women. In contrast, TBS was higher in women with short stature than in their taller counterparts (1.347 ± 0.102 vs. 1.250 ± 0.110; p < 0.001). Bone mineral apparent density (BMAD) and the LS TBS-adjusted BMD T-score were also significantly higher in shorter than in taller women. From the entire cohort, 121 women (67 cases) were osteoporotic by aBMD determinations. Among these subjects, TBS was also greater in cases (1.303 ± 0.103) than in women with standard height (1.190 ± 0.099; p < 0.001). Despite being considered osteoporotic, 36% of short women, but none of the taller ones, had a normal TBS.

CONCLUSIONS

TBS can be a useful adjunct to aBMD for assessing bone quality in short women, in whom aBMD measurement tends to read lower, and, thus could overestimate fracture risk.

Niobium pentoxide and hydroxyapatite particle loaded electrospun polycaprolactone/gelatin membranes for bone tissue engineering

Effective methods of accelerating the bone regeneration healing process are in demand for a number of bone-related diseases and trauma. This work developed scaffolds with improved properties for bone tissue engineering by electrospinning composite polycaprolactone-gelatin-hydroxyapatite-niobium pentoxide (PGHANb) membranes. Composite membranes, with average fiber diameters ranging from 123 to 156 nm, were produced by adding hydroxyapatite (HA) and varying concentrations of niobium pentoxide (Nb₂O₅) particles (0, 3, 7, and 10 wt%) to a polycaprolactone (PCL) and gelatin (GL) matrix prior to electrospinning. The morphology, mechanical, chemical and biological properties of resultant membranes were evaluated. Bioactivity was assessed using simulated body fluid (SBF) and it confirmed that the presence of particles induced the formation of hydroxyapatite crystals on the surface of the membranes. Samples were hydrophilic and cell metabolism results showed that the niobium-containing membranes were non-toxic while improving cell proliferation and differentiation compared to controls. This study demonstrated that electrospun membranes containing HA and Nb₂O₅ particles have potential to promote cell adhesion and proliferation while exhibiting bioactive properties. PGHANb membranes are promising candidates for bone tissue engineering applications.

Environmentally-Controlled Near Infrared Spectroscopic Imaging of Bone Water

We have designed an environmentally-controlled chamber for near infrared spectroscopic imaging (NIRSI) to monitor changes in cortical bone water content, an emerging biomarker related to bone quality assessment. The chamber is required to ensure repeatable spectroscopic measurements of tissues without the influence of atmospheric moisture. A calibration curve to predict gravimetric water content from human cadaveric cortical bone was created using NIRSI data obtained at six different lyophilization time points. Partial least squares (PLS) models successfully predicted bone water content that ranged from 0–10% (R = 0.96, p < 0.05, root mean square error of prediction (RMSEP) = 7.39%), as well as in the physiologic range of 4–10% of wet tissue weight (R = 0.87, p < 0.05, RMSEP = 14.5%). Similar results were obtained with univariate and bivariate regression models for prediction of water in the 0–10% range. Further, we identified two new NIR bone absorbances, at 6560 cm⁻¹ and 6688 cm⁻¹, associated with water and collagen respectively. Such data will be useful in pre-clinical studies that investigate changes in bone quality with disease, aging and with therapeutic use.

Narrowband-autofluorescence imaging for bone analysis

We present a new autofluorescence-imaging method for bone analysis. This method, based on the autofluorescence of bone, provides color images in microscopic scale. The color images are created from three monochrome images acquired with optimal excitation- and emission-wavelengths combinations. The choice of these combinations were determined from the study of two-dimensional distributions of bone-features-bispectral autofluorescence in the visible- and ultraviolet-spectral range. We demonstrate that main-bone features visualized with MG-staining method can also be visualized in the autofluorescence-color image. Furthermore, the autofluorescence-color image presents features hardly distinguished in a histological-bone section.

High-precision method for cyclic loading of small-animal vertebrae to assess bone quality

One potentially important bone quality characteristic is the response of bone to cyclic (repetitive) mechanical loading. In small animals, such as in rats and mice, cyclic loading experiments are particularly challenging to perform in a precise manner due to the small size of the bones and difficult-to-eliminate machine compliance. Addressing this issue, we developed a precise method for ex vivo cyclic compressive loading of isolated mouse vertebral bodies. The method has three key characteristics: 3D-printed support jigs for machining plano-parallel surfaces of the tiny vertebrae; pivotable loading platens to ensure uniform contact and loading of specimen surfaces; and specimen-specific micro-CT-based finite element analysis to measure stiffness to prescribe force levels that produce the same specified level of strain for all test specimens. To demonstrate utility, we measured fatigue life for three groups (n = 5–6 per group) of L5 vertebrae of C57BL/6J male mice, comparing our new method against two methods commonly used in the literature. We found reduced scatter of the mechanical behavior for this new method compared to the literature methods. In particular, for a controlled level of strain, the standard deviation of the measured fatigue life was up to 5-fold lower for the new method (F-ratio = 4.9; p < 0.01). The improved precision for this new method for biomechanical testing of small-animal vertebrae may help elucidate aspects of bone quality.

Recent advancements in the analysis of bone microstructure: New dimensions in forensic anthropology

Bone is a mechanically active, three-dimensionally (3D) complex, and dynamic tissue that changes in structure over the human lifespan. Bone tissue exists and remodels in 3D and changes over time, introducing a fourth dimension. The products of the remodelling process, secondary and fragmentary osteons, have been studied substantially using traditional two-dimensional (2D) techniques. As a result, much has been learned regarding the biological information encrypted in the histomorphology of bone, yielding a wealth of information relating to skeletal structure and function. Three-dimensional imaging modalities, however, hold the potential to provide a much more comprehensive understanding of bone microarchitecture. The visualization and analysis of bone using high-resolution 3D imaging will improve current understandings of bone biology and have numerous applications in both biological anthropology and biomedicine. Through recent technological advancements, we can hone current anthropological applications of the analysis of bone microstructure and accelerate research into the third and fourth dimensional realms. This review will explore the methodological approaches used historically by anthropologists to assess cortical bone microstructure, spanning from histology to current ex vivo imaging modalities, discuss the growing capabilities of in vivo imaging, and conclude with an introduction of novel non-histological modalities for investigating bone quality.

Effect of SR-microCT radiation on the mechanical integrity of trabecular bone using in situ mechanical testing and digital volume correlation

The use of synchrotron radiation micro-computed tomography (SR-microCT) is becoming increasingly popular for studying the relationship between microstructure and bone mechanics subjected to in situ mechanical testing. However, it is well known that the effect of SR X-ray radiation can considerably alter the mechanical properties of bone tissue. Digital volume correlation (DVC) has been extensively used to compute full-field strain distributions in bone specimens subjected to step-wise mechanical loading, but tissue damage from sequential SR-microCT scans has not been previously addressed. Therefore, the aim of this study is to examine the influence of SR irradiation-induced microdamage on the apparent elastic properties of trabecular bone using DVC applied to in situ SR-microCT tomograms obtained with different exposure times. Results showed how DVC was able to identify high local strain levels (> 10,000 µε) corresponding to visible microcracks at high irradiation doses (~ 230 kGy), despite the apparent elastic properties remained unaltered. Microcracks were not detected and bone plasticity was preserved for low irradiation doses (~ 33 kGy), although image quality and consequently, DVC performance were reduced. DVC results suggested some local deterioration of tissue that might have resulted from mechanical strain concentration further enhanced by some level of local irradiation even for low accumulated dose.

Micro-finite-element method to assess elastic properties of trabecular bone at micro- and macroscopic level

OBJECTIVE OF THE STUDY

The objective of the present study is to assess the mechanical behavior of trabecular bone based on microCT imaging and micro-finite-element analysis. In this way two methods are detailed: (i) direct determination of macroscopic elastic property of trabecular bone; (ii) inverse approach to assess mechanical properties of trabecular bone tissue.

PATIENTS

Thirty-five females and seven males (forty-two subjects) mean aged (±SD) 80±11.7 years from hospitals of Assistance publique-Hôpitaux de Paris (AP-HP) diagnosed with osteoporosis following a femoral neck fracture due to a fall from standing were included in this study.

MATERIALS AND METHODS

Fractured heads were collected during hip replacement surgery. Standardized bone cores were removed from the femoral head's equator by a trephine in a water bath. MicroCT images acquisition and analysis were performed with CTan^® software and bone volume fraction was then determined. Micro-finite-element simulations were per-formed using Abaqus 6.9-2^® software in order to determine the macroscopic mechanical behaviour of the trabecular bone. After microCT acquisition, a longitudinal compression test was performed and the experimental macroscopic Young's Modulus was extracted. An inverse approach based on the whole trabecular bone's mechanical response and micro-finite-element analysis was performed to determine microscopic mechanical properties of trabecular bone.

RESULTS

In the present study, elasticity of the tissue was shown to be similar to that of healthy tissue but with a lower yield stress.

CONCLUSION

Classical histomorphometric analysis form microCT imaging associated with an inverse micro-finite-element method allowed to assess microscopic mechanical trabecular bone parameters.

Bone morphogenetic protein signaling through ACVR1 and BMPR1A negatively regulates bone mass along with alterations in bone composition

Bone quantity and bone quality are important factors in determining the properties and the mechanical functions of bone. This study examined the effects of disrupting bone morphogenetic protein (BMP) signaling through BMP receptors on bone quantity and bone quality. More specifically, we disrupted two BMP receptors, Acvr1 and Bmpr1a, respectively, in Osterix-expressing osteogenic progenitor cells in mice. We examined the structural changes to the femora from 3-month old male and female conditional knockout (cKO) mice using micro-computed tomography (micro-CT) and histology, as well as compositional changes to both cortical and trabecular compartments of bone using Raman spectroscopy. We found that the deletion of Acvr1 and Bmpr1a, respectively, in an osteoblast-specific manner resulted in higher bone mass in the trabecular compartment. Disruption of Bmpr1a resulted in a more significantly increased bone mass in the trabecular compartment. We also found that these cKO mice showed lower mineral-to-matrix ratio, while tissue mineral density was lower in the cortical compartment. Collagen crosslink ratio was higher in both cortical and trabecular compartments of male cKO mice. Our study suggested that BMP signaling in osteoblast mediated by BMP receptors, namely ACVR1 and BMPR1A, is critical in regulating bone quantity and bone quality.

Regulatory Perspectives in Pharmacometric Models of Osteoporosis

Osteoporosis is a disorder of the bones in which they are weakened to the extent that they become more prone to fracture. There are various forms of osteoporosis: some of them are induced by drugs, and others occur as a chronic progressive disorder as an individual gets older. As the median age of the population rises across the world, the chronic form of the bone disease is drawing attention as an important worldwide health issue. Developing new treatments for osteoporosis and comparing them with existing treatments are complicated processes due to current acceptance by regulatory authorities of bone mineral density (BMD) and fracture risk as clinical end points, which require clinical trials to be large, prolonged, and expensive to determine clinically significant impacts in BMD and fracture risk. Moreover, changes in BMD and fracture risk are not always correlated, with some clinical trials showing BMD improvement without a reduction in fractures. More recently, bone turnover markers specific to bone formation and resorption have been recognized that reflect bone physiology at a cellular level. These bone turnover markers change faster than BMD and fracture risk, and mathematically linking the biomarkers via a computational model to BMD and/or fracture risk may help in predicting BMD and fracture risk changes over time during the progression of a disease or when under treatment. Here, we discuss important concepts of bone physiology, osteoporosis, treatment options, mathematical modeling of osteoporosis, and the use of these models by the pharmaceutical industry and the Food and Drug Administration.

Bone quality changes associated with aging and disease: a review

Bone quality encompasses all the characteristics of bone that, in addition to density, contribute to its resistance to fracture. In this review, we consider changes in architecture, porosity, and composition, including collagen structure, mineral composition, and crystal size. These factors all are known to vary with tissue and animal ages, and health status. Bone morphology and presence of microcracks, which also contribute to bone quality, will not be discussed in this review. Correlations with mechanical performance for collagen cross-linking, crystallinity, and carbonate content are contrasted with mineral content. Age-dependent changes in humans and rodents are discussed in relation to rodent models of disease. Examples are osteoporosis, osteomalacia, osteogenesis imperfecta (OI), and osteopetrosis in both humans and animal models. Each of these conditions, along with aging, is associated with increased fracture risk for distinct reasons.

Mutant cartilage oligomeric matrix protein (COMP) compromises bone integrity, joint function and the balance between adipogenesis and osteogenesis

Mutations in COMP (cartilage oligomeric matrix protein) cause severe long bone shortening in mice and humans. Previously, we showed that massive accumulation of misfolded COMP in the ER of growth plate chondrocytes in our MT-COMP mouse model of pseudoachondroplasia (PSACH) causes premature chondrocyte death and loss of linear growth. Premature chondrocyte death results from activation of oxidative stress and inflammation through the CHOP-ER pathway and is reduced by removing CHOP or by anti-inflammatory or antioxidant therapies. Although the mutant COMP chondrocyte pathologic mechanism is now recognized, the effect of mutant COMP on bone quality and joint health (laxity) is largely unknown. Applying multiple analytic approaches, we describe a novel mechanism by which the deleterious consequences of mutant COMP retention results in upregulation of miR-223 disturbing the adipogenesis - osteogenesis balance. This results in reduction in bone mineral density, bone quality, mechanical strength and subchondral bone thickness. These, in addition to abnormal patterns of ossification at the ends of the femoral bones likely contribute to precocious osteoarthritis (OA) of the hips and knees in the MT-COMP mouse and PSACH. Moreover, joint laxity is compromised by abnormally thin ligaments. Altogether, these novel findings align with the PSACH phenotype of delayed ossification and bone age, extreme joint laxity and joint erosion, and extend our understanding of the underlying processes that affect bone in PSACH. These results introduce a novel finding that miR-223 is involved in the ossification defect in MT-COMP mice making it a therapeutic target.

The Influence of Chronic Kidney Disease on the Structural and Mechanical Properties of Canine Bone

Background

Chronic kidney disease (CKD) is common in companion animals. Secondary hyperparathyroidism is an inevitable consequence of the disease and may have deleterious effect on the bone; however, the information regarding CKD‐associated bone abnormalities in companion animals is scarce.

Hypothesis/Objectives

Dogs with CKD have decreased bone quality compared to dogs without CKD.

Animals

Nine dogs diagnosed with naturally occurring CKD for at least 6 months and 9 age‐matched controls.

Methods

Dogs with CKD were enrolled and compared to 9 age‐, weight‐, and sex‐matched control dogs with no evidence of CKD. Samples were assessed using light microscopy, mechanical testing, and microcomputed tomography. Variables evaluated included microstructural features such as number, size, and density of Haversian canals, resorption cavities and osteocytic lacunae, bone mineral density, porosity and Young's modulus.

Results

Median lacunae size was significantly smaller in the CKD group compared to the control group (P = 0.001). Resorption cavity density was higher in the CKD compared to the control group (10 [8–14] vs. 7 [4–9]/mm², respectively, P = 0.001). Overall porosity was significantly (2.3‐fold) higher in the CKD compared to the control group. There was no difference in Young's moduli between groups.

Conclusions and Clinical Importance

Naturally occurring CKD affects bone quality in dogs, but these changes are relatively mild and likely not to be manifested clinically. The duration of the disease in dogs evaluated here is short compared to cats and human patients, likely accounting for the more subtle changes in dogs compared to other species.

Thiazides and Osteoporotic Spinal Fractures: A Suspected Linkage Investigated by Means of a Two-Center, Case-Control Study

Background

An alleged association of chronic use of thiazide diuretics with an increased risk of bone fragility fractures has been highlighted by a relatively recent prospective cohort study. However, the concept that thiazides exert a beneficial effect on osteoporosis is still a predominant view. This effect would be mediated by the decrease in renal clearance of calcium ions, a pharmacological feature recognized for a long time now to this class of drugs, as opposed to the increase in calcium urinary excretion attributed instead to loop diuretics, i.e. furosemide and similar drugs. The purpose of this retrospective study was to attempt to clarify whether regular use of thiazide diuretics as antihypertensive therapeutics is associated with a significantly increased risk of osteoporotic fractures in female patients aged 65 or over.

Methods

In this two-center retrospective study, we followed up a cohort of female patients with (n = 80) and without (n = 158) thiazide-induced hyponatremia.

Results

A total of 48 osteoporotic fractures were recorded during a median follow-up period of 57.5 months. By means of univariate regression analysis, an association was found between thiazide-induced hyponatremia and increased risk of vertebral fractures (odds ratio (OR): 7.6; 95% confidence interval (CI): 3.755 - 15.39; P < 0.0001). Multivariate regression analysis, however, showed that age (OR: 1.823; 95% CI: 1.211 - 2.743) and body mass index (OR: 0.156; 95% CI: 0.038 - 0.645) were the only independent predictors of osteoporotic fractures. No association of a history of thiazide-induced hyponatremia and risk of fracture was noticeable in the final model.

Conclusions

Because thiazide-induced hyponatremia was associated with spinal fractures in univariate but not multivariate analysis, a possible explanation is that hyponatremia may be a confounder of the relation between body mass and spinal fractures. Indeed, reduced body mass especially among elderly women with small body build may confer heightened risk of thiazide-induced hyponatremia because of decreased bone sodium available for exchange with the serum sodium. Thus, occurrence of hyponatremia could only serve as an indirect surrogate marker for osteoporosis risk.

Appendicular and whole body lean mass outcomes are associated with finite element analysis-derived bone strength at the distal radius and tibia in adults aged 40years and older

PURPOSE

The purpose of this cross-sectional study was to determine how appendicular lean mass index (ALMI), and whole body lean (LMI) and fat mass indices (FMI) associate with estimated bone strength outcomes at the distal radius and tibia in adults aged 40 years and older.

METHODS

Dual energy X-ray absorptiometry (DXA) scans were performed to determine body composition, including whole body lean and fat mass, and appendicular lean mass. ALMI (appendicular lean mass/height²), LMI (lean tissue mass/height²) and FMI (fat mass/height²) were calculated. High-resolution peripheral quantitative computed tomography (HRpQCT) scans were performed to assess bone structural properties at the distal radius and tibia. Using finite element analysis, failure load (N), stiffness (N/mm), ultimate stress (MPa), and cortical-to-trabecular load ratio were estimated from HRpQCT scans. The associations between body composition (ALMI, LMI, FMI) and estimated bone strength were examined using bivariate and multivariable linear regression analyses adjusting for age, sex, and other confounding variables.

RESULTS

In 197 participants (127 women; mean±SD, age: 69.5±10.3y, body mass index: 27.95±4.95kg/m², ALMI: 7.31±1.31kg/m²), ALMI and LMI were significantly associated with failure load at the distal radius and tibia (explained 39%-48% of the variance) and remained significant after adjusting for confounding variables and multiple testing (R²=0.586-0.645, p<0.001). ALMI, LMI, and FMI did not have significant associations with ultimate stress in our multivariable models. FMI was significantly associated with cortical-to-trabecular load ratio at the distal radius and tibia (explained 6%-12% of the variance) and remained significant after adjusting for confounders and multiple testing (R²=0.208-0.243, p<0.001). FMI was no longer significantly associated with failure load after adjusting for confounders.

CONCLUSION

These findings suggest that ALMI and LMI are important determinants of estimated bone strength, particularly failure load, at the distal radius and tibia, and may contribute to preservation of bone strength in middle-to-late adulthood.

Effects of Denosumab and Teriparatide Transitions on Bone Microarchitecture and Estimated Strength: the DATA-Switch HR-pQCT study

In postmenopausal osteoporosis, switching from teriparatide to denosumab results in continued bone mineral density (BMD) gains whereas switching from denosumab to teriparatide results in BMD loss. To assess the effects of these transitions on bone microarchitecture and strength, we performed high-resolution peripheral QCT (HR-pQCT) at the distal tibia and radius in postmenopausal osteoporotic women who received 24 months of teriparatide 20 μg daily followed by 24 months of denosumab 60 mg every 6 months, 24 months of denosumab followed by 24 months of teriparatide, or 24 months of both medications followed by 24 months of denosumab. The 77 women who completed at least one post-switch visit are included in this analysis. Tibial cortical volumetric BMD (vBMD) increased between months 24 and 48 in the teriparatide-to-denosumab (net 48-month change -0.8% ± 2.4%) and combination-to-denosumab groups (net 48-month changes +2.4% ± 4.1%) but decreased in the denosumab-to-teriparatide group (net 48-month change -3.4% ± 3.2%, p < 0.001 for all between-group comparisons). Changes in total vBMD, cortical thickness, and estimated stiffness (by micro-finite element analysis [µFEA]) followed a similar pattern, as did changes at the radius. Conversely, tibial cortical porosity remained stable between months 24 and 48 in the teriparatide-to-denosumab and combination-to-denosumab groups (net 48-month changes +7.2% ± 14.8% and -3.4% ± 12.1%, respectively) but increased in the denosumab-to-teriparatide group (net 48-month change +16.2% ± 11.5%, p < 0.05 versus other groups). Trabecular vBMD changes did not differ among groups. Together, these findings demonstrate that in women treated with denosumab, switching to teriparatide is associated with a reduction in total and cortical vBMD, cortical thickness, and estimated strength, whereas switching to denosumab from teriparatide or combination therapy results in improvements in these parameters with the greatest improvements observed in women treated with combined therapy followed by denosumab. These findings strongly suggest that the use of teriparatide after denosumab should be avoided and that the use of combined teriparatide/denosumab followed by denosumab alone may be a useful treatment strategy in those with severe osteoporosis. © 2017 American Society for Bone and Mineral Research.