Ossification in the human calcaneus: a model for spatial bone development and ossification

Benign incidental lesion of the calcaneus: the calcaneal vascular remnant

BACKGROUND

The calcaneal vascular remnant, first described by Fleming et al. in 2005, is a benign intramedullary lesion of the calcaneus with a vascular origin.

PURPOSE

To determine the prevalence and magnetic resonance imaging (MRI) characteristics of incidental calcaneal vascular remnant on routine ankle MRI.

MATERIAL AND METHODS

We retrospectively reviewed 457 ankle MRI scans for the presence of calcaneal vascular remnant. MRI was considered positive when a focal cyst-like area was seen on a T2-weighted sequence, and a low signal intensity was identified on a T1-weighted image beneath the calcaneal sulcus. Patients with calcaneal vascular remnants were further evaluated for age, gender, right or left foot location, size, and lesion characteristics.

RESULTS

The prevalence of incidental calcaneal vascular remnant was 21.7% on our consecutive ankle MR examinations. The average lesion size was 5.5 mm. No statistically significant difference was noted in the frequency of lesion detection between gender, age, and side of the lesions (P > 0.05). Multilobulated lesions were detected predominantly in women (P = 0.013) and classic type lesions were detected predominantly in men (P = 0.036).

CONCLUSION

This report is the first to determine the prevalence and MRI characteristics of calcaneal vascular remnants. Detecting and reporting this lesion on routine MRI is essential to avoid confusion with other pathologic entities.

Bone tissue and histological and molecular events during development of the long bones

The bones are of mesenchymal or ectomesenchymal origin, form the skeleton of most vertebrates, and are essential for locomotion and organ protection. As a living tissue they are highly vascularized and remodelled throughout life to maintain intact. Bones consist of osteocytes entrapped in a mineralized extracellular matrix, and via their elaborated network of cytoplasmic processes they do not only communicate with each other but also with the cells on the bone surface (bone lining cells). Bone tissue develops through a series of fine-tuned processes, and there are two modes of bone formation, referred to either as intramembranous or endochondral ossification. In intramembranous ossification, bones develop directly from condensations of mesenchymal cells, and the flat bones of the skull, the clavicles and the perichondral bone cuff develop via this process. The bones of the axial (ribs and vertebrae) and the appendicular skeleton (e.g. upper and lower limbs) form through endochondral ossification where mesenchyme turns into a cartilaginous intermediate with the shape of the future skeletal element that is gradually replaced by bone. Endochondral ossification occurs in all vertebrate taxa and its onset involves differentiation of the chondrocytes, mineralization of the extracellular cartilage matrix and vascularization of the intermediate, followed by disintegration and resorption of the cartilage, bone formation, and finally - after complete ossification of the cartilage model - the establishment of an avascular articular cartilage. The epiphyseal growth plate regulates the longitudinal growth of the bones, achieved by a balanced proliferation and elimination of chondrocytes, and the question whether the late hypertrophic chondrocytes die or transform into osteogenic cells is still being hotly debated. The complex processes leading to endochondral ossification have been studied for over a century, and this review aims to give an overview of the histological and molecular events, arising from the long bones' (e.g. femur, tibia) development. The fate of the hypertrophic chondrocytes will be discussed in the light of new findings obtained from cell tracking studies.

Bohler Angle and the Crucial Angle of Gissane in Paediatric Population

Bohler angle and the crucial angle of Gissane are used on the evaluation of calcaneus fractures. However, few authors have described the variation of the angles when the calcaneus is growing. In this study, Bohler angle and the crucial angle of Gissane in paediatric population were measured using lateral foot radiographs of 429 patients, from 0 to 16 years of age. The control group was composed of 70 adult patients. The sample had a mean Bohler angle of 35.4° ± 5.9° and a mean crucial angle of Gissane of 110.5° ± 7.4°. The greater mean difference was identified for Bohler angle (8°) in the age group of 5 to 8 years (39.6° ± 5.7°) and for the crucial angle of Gissane (5°-6°) in the age group of 0 to 4 years (115.8° ± 7.3) (P < .05). The influence of the ossification centres on the geometry of the calcaneus across age groups makes Bohler angle and the crucial angle of Gissane higher in young children. The increase in Bohler angle points out the relative development of the posterior facet in young children and the importance of the reconstruction of the posterior facet height in the intra-articular calcaneus fractures.

Level of Evidence: Diagnostic study; Level III.

An Immunohistochemical Study of Matrix Components in Early-Stage Vascular Canals Within Mandibular Condylar Cartilage in Midterm Human Fetuses

Matrix components of vascular canals (VCs) in human fetal mandibular condylar cartilage (15-16 weeks of gestation) were analyzed by immunohistochemistry. Prevascular canals (PVCs), consisting of spindle-shaped cells without capillary invasion, were observed within the cartilage. Intense immunoreactivity for collagen type I, weak immunoreactivity for aggrecan and tenascin-C, weak hyaluronan (HA) staining, and abundant argyrophilic fibers in PVCs indicated that they contain noncartilaginous fibrous connective tissues that was different from those in the perichondrium/periosteum. These structural and immunohistochemical features of PVCs are different from those of previously reported cartilage canals of the long bone. Capillaries entered the VCs from the periosteum and ascended through VCs. Following capillary invasion, loose connective tissue had formed in the lower part of VCs, and immunoreactivity for collagen types I and III, tenascin-C, and HA staining was evident in the matrix of loose connective tissue. No chondroclasts or osteogenic cells were seen at the front of capillary invasion, although small, mononuclear tartrate-resistant acid phosphatase (TRAP)-positive cells were present. Meanwhile, TRAP-positive, multinucleated chondroclasts and flattened, osteoblast-like cells were observed in the loose connective tissue at the lower part of VCs. These results may indicate slow progress of endochondral ossification in human fetal mandibular condyle. Further, unique matrix components in PVCs/VCs, which were different from those in cartilage canals in long bone, may reflect the difference of speed of endochondral ossification in cartilage canals and human fetal mandibular condyles.

Age-related differential gene and protein expression in postnatal cartilage canal and osteochondral junction chondrocytes

Wnt/β-catenin, Indian hedgehog (Ihh)/Parathyroid-related peptide (PTHrP) and retinoid signaling pathways regulate cartilage differentiation, growth, and function during development and play a key role in endochondral ossification. The objective of this study was to elucidate the gene and protein expression of signaling molecules of these regulatory pathways in chondrocytes surrounding cartilage canals and the osteochondral junction during neonatal and pre-adolescent development. This study revealed cell-specific and age-related differences in gene and protein expression of signaling molecules of these regulatory pathways. A trend for higher gene expression of PTHrP along the cartilage canals and Ihh along the osteochondral junction suggests the presence of paracrine feedback in articular-epiphyseal cartilage. Differential expression of canonical (β-catenin, Wnt-4, Lrp4, Lrp6) and noncanonical Wnt signaling (Wnt-5b, Wnt-11) and their inhibitors (Dkk1, Axin1, sFRP3, sFRP5, Wif-1) surrounding the cartilage canals and osteochondral junction provides evidence of the complex interactions occurring during endochondral ossification.

Mechanical properties of human fetal talus

Mechanical characterization of human cartilage anlagen is required to effectively model congenital musculoskeletal deformities. Such modeling can effectively explore the effect of treatment procedures and potentially suggest enhanced treatment methods. Using serial MRI, we have noted shape changes of the cartilaginous hindfoot anlagen in patients with clubfoot, suggesting they are soft and deformable. We therefore determined the stress relaxation behavior of cartilage plugs obtained from third-trimester stillborn fetuses in unconfined and confined compression geometries. The material parameters determined were the aggregate modulus H(A) = 0.15 +/- 0.07 MPa, Poisson's ratio nu = 0.4 +/- 0.06, Young's modulus E(s) = 0.06 +/- 0.03 MPa, and permeability coefficients k(0) = 2.01 +/- 0.8 x 10(-14) m(4) N(-1) s(-1) and M = 4.6 +/- 1.0. As compared with adult articular cartilage, stiffness was an order of magnitude lower than the values reported in the literature, suggesting the relative softness of the tissue, and the permeability was an order of magnitude higher, indicating relative ease of flow in the tissue. Poisson's ratio also was close to the higher end of the range reported in previous studies. Such material is expected to deform and relax to larger extents. These findings are consistent with the deformability of the cartilage anlagen during manipulation and casting for treatment of clubfoot.

Pediatric issues with cavovarus foot deformities

Cavovarus foot deformity in children has numerous etiologies with a general pathophysiologic mechanism of muscle imbalance. It is of great importance in the evaluation of a child with a cavovarus foot to determine the underlying cause of the deformity, as the most common origin is a progressive neurologic condition that may be complicated by other orthopedic problems. Treatment options typically are surgical, with limited indications for nonsurgical modalities, and must consider the age of the patient, the nature of the neurologic disease, and the severity of the deformity. Current surgical procedures can be divided into soft tissue procedures to rebalance the muscle forces, osteotomies, and triple arthrodesis. Triple arthrodesis is considered a salvage procedure reserved for the older child with severe, rigid deformity who has failed other surgical treatments.

Structure, formation and role of cartilage canals in the developing bone

In the long bones, endochondral bone formation proceeds via the development of a diaphyseal primary ossification centre (POC) and an epiphyseal secondary ossification centre (SOC). The growth plate, the essential structure for longitudinal bone growth, is located between these two sites of ossification. Basically, endochondral bone development depends upon neovascularization, and the early generation of vascularized cartilage canals is an initial event, clearly preceding the formation of the SOC. These canals form a discrete network within the cartilaginous epiphysis giving rise to the formation of the marrow space followed by the establishment of the SOC. These processes require excavation of the provisional cartilaginous matrix which is eventually replaced by permanent bone matrix. In this review, we discuss the formation of the cartilage canals and the importance of their cells in the ossification process. Special attention is paid to the enzymes required in disintegration of the cartilaginous matrix which, in turn, will allow for the invasion of new vessels. Furthermore, we show that the mesenchymal cells of the cartilage canals express bone-relevant proteins and transform into osteocytes. We conclude that the canals are essential for normal epiphyseal bone development, the establishment of the growth plate and ultimately longitudinal growth of the bones.

Bone development in the femoral epiphysis of mice: The role of cartilage canals and the fate of resting chondrocytes

In mammals, the exact role of cartilage canals is still under discussion. Therefore, we studied their development in the distal femoral epiphysis of mice to define the importance of these canals. Various approaches were performed to examine the histological, cellular, and molecular events leading to bone formation. Cartilage canals started off as invaginations of the perichondrium at day (D) 5 after birth. At D 10, several small ossification nuclei originated around the canal branched endings. Finally, these nuclei coalesced and at D 18 a large secondary ossification centre (SOC) occupied the whole epiphysis. Cartilage canal cells expressed type I collagen, a major bone-relevant protein. During canal formation, several resting chondrocytes immediately around the canals were active caspase 3 positive but others were freed into the canal cavity and appeared to remain viable. We suggest that cartilage canal cells belong to the bone lineage and, hence, they contribute to the formation of the bony epiphysis. Several resting chondrocytes are assigned to die but others, after freeing into the canal cavity, may differentiate into osteoblasts.

Identification and location of bone-forming cells within cartilage canals on their course into the secondary ossification centre

Osteoblasts and osteocytes derive from the same precursors, and osteocytes are terminally differentiated osteoblasts. These two cell types are distinguishable by their morphology, localization and levels of expression of various bone cell-specific markers. In the present study on the chicken femur we investigated the properties of the mesenchymal cells within cartilage canals on their course into the secondary ossification centre (SOC). We examined several developmental stages after hatching by means of light microscopy, electron microscopy, immunohistochemistry and in situ hybridization. Cartilage canals appeared as extensions of the perichondrium into the developing distal epiphysis and they were arranged in a complex network. Within the epiphysis an SOC was formed and cartilage canals penetrated into it. In addition, they were successively incorporated into the SOC during its growth in the radial direction. Thus, the canals provided this centre with mesenchymal cells and vessels. It should be emphasized that regression of cartilage canals could never be observed in the growing bone. Outside the SOC the mesenchymal cells of the canals expressed type I collagen and periostin and thus these cells had the characteristics of preosteoblasts. Periostin was also expressed by numerous chondrocytes. Within the SOC the synthesis of periostin was down-regulated and the majority of osteoblasts were periostin negative. Furthermore, osteocytes did not secret this protein. Tissue-non-specific alkaline phosphatase (TNAP) staining was only detectable where matrix vesicles were present. These vesicles were found around the blind end of cartilage canals within the SOC where newly formed osteoid started to mineralize. The vesicles originated from osteoblasts as well as from late osteoblasts/preosteocytes and thus TNAP was only expressed by these cells. Our results provide evidence that the mesenchymal cells of cartilage canals express various bone cell-specific markers depending on their position. We suggest that these cells differentiate from preosteoblasts into osteocytes on their course into the SOC and consider that cartilage canals are essential for normal bone development within the epiphysis. Furthermore, we propose that the expression of periostin by preosteoblasts and several chondrocytes is required for adhesion of these cells to the extracellular matrix.

Computerized Three-Dimensional Reconstruction of Cartilage Canals in Chick Tibial Chondroepiphysis

Cartilage canals have been extensively investigated, in particular as to their mode of formation, morphologic distribution, function and fate. We studied the morphological pattern of the cartilage canals of the right upper chondroepiphysis of the tibia of chick embryos, Hamburger-Hamilton stages 35-42, in serial sagittal wax sections and in reconstructions made with AutoCAD software. The spatial arrangement of the canals is presented in a series of drawings made according to computerized images. The canals were penetrated from three distinct surfaces: the anterior and superior surfaces of the tubercle and the posterior surfaces of the medial and lateral condyles. Immediately after entering, nearly all the canals were extended toward the medial or lateral aspects of the chondroepiphysis, from which no canals took their origin. All of the cartilage canals connected with the perichondrium, and their branching did not follow a specific pattern. The condylar canals did not unite with the tubercular ones.

The role of cartilage canals in endochondral and perichondral bone formation: are there similarities between these two processes?

We investigated the development of cartilage canals to clarify their function in the process of bone formation. Cartilage canals are tubes containing vessels that are found in the hyaline cartilage prior to the formation of a secondary ossification centre (SOC). Their exact role is still controversial and it is unclear whether they contribute to endochondral bone formation when an SOC appears. We examined the cartilage canals of the chicken femur in different developmental stages (E20, D2, 5, 7, 8, 10 and 13). To obtain a detailed picture of the cellular and molecular events within and around the canals the femur was investigated by means of three-dimensional reconstruction, light microscopy, electron microscopy, histochemistry and immunohistochemistry [vascular endothelial growth factor (VEGF), type I and II collagen]. An SOC was visible for the first time on the last embryonic day (E20). Cartilage canals were an extension of the vascularized perichondrium and its mesenchymal stem cell layers into the hyaline cartilage. The canals formed a complex network within the epiphysis and some of them penetrated into the SOC were they ended blind. The growth of the canals into the SOC was promoted by VEGF. As the development progressed the SOC increased in size and adjacent canals were incorporated into it. The canals contained chondroclasts, which opened the lacunae of hypertrophic chondrocytes, and this was followed by invasion of mesenchymal cells into the empty lacunae and formation of an osteoid layer. In older stages this layer mineralized and increased in thickness by addition of further cells. Outside the SOC cartilage canals are surrounded by osteoid, which is formed by the process of perichondral bone formation. We conclude that cartilage canals contribute to both perichondral and endochondral bone formation and that osteoblasts have the same origin in both processes.

Cartilage canals in the chicken embryo are involved in the process of endochondral bone formation within the epiphyseal growth plate

A detailed study of so-called communicating cartilage canals, which penetrate deeply up into the lower hypertrophic zone of the epiphyseal growth plate in the embryonic chicken femur (E20), was carried out with the aim to clarify whether or not these canals are involved in the bone-forming process. In addition, we examined the manner in which cartilage canals are formed and compare the present data with our previous data. The canals were investigated by means of light microscopy, electron microscopy, immunohistochemistry (VEGF, VEGFR2/Flk1, type I collagen), and 3D reconstruction. Some communicating canals deeply penetrate into the upper hypertrophic zone where they terminate, showing electron-dense cells at their end. Subcellular characteristics of these cells are hardly detectable and we suppose that they undergo cell death. Other canals pass down deeper into the lower hypertrophic zone. The upper segment of these canals is composed of capillaries, mesenchymal cells, and macrophage-like cells. Precursors of osteoblasts are adjacent to the canals. The lower segment of communicating canals is composed of bone matrix or osteoid, which contains type I collagen fibrils and cells having the typical subcellular features of osteoblasts. No vessels are found in these segments. Immunohistochemistry shows that the matrix of the canals labels positively for type I collagen. In addition, staining with sirius red demonstrates that bone matrix is formed in these parts. We assume that the osteoblast-like cells of the lower segments of communicating canals originate either from mesenchymal cells or even from hypertrophic chondrocytes. Our immunohistochemical data also reveal that vascular endothelial growth factor (VEGF) and the corresponding receptor VEGFR2/Flk1 (VEGF receptor 2/Flk1) are localized in cartilage canals of the reserve zone, the proliferative zone, and the hypertrophic zone. The receptor is found in the endothelial cells of the vessels. Furthermore, VEGF is present in hypertrophic chondrocytes. The results of our study suggest that cartilage canals penetrate actively into the cartilage anlage and that bone is formed in the lower segments of the communicating canals where no vessels are detectable.