Bisphosphonate treatment affects trabecular bone apparent modulus through micro-architecture rather than matrix properties

Trabecular bone microcrack accumulation in patients treated with bisphosphonates for durations up to 16 years

This study quantified the length, number, and density of microcracks in bone from patients treated with bisphosphonates as a function of duration. Anterior iliac crest bone samples from 51 osteoporotic Caucasian females continuously treated with oral bisphosphonates for 1-16 years were obtained by bone biopsy. Samples were histologically processed and analyzed for bone area, microcrack number, and microcrack length. The analyses used statistical modeling and considered patient age, bone mineral density, bone volume/total volume, trabecular thickness, and bone turnover as potential covariates. Microcrack density (number of microcracks/total examined bone area) was linearly related (p = 0.018) to bisphosphonate treatment duration. None of the analyzed covariates contributed significantly to the observed relationship between microcrack density and bisphosphonate treatment duration. Observed increases in microcrack density with increasing bisphosphonate treatment duration is important because increasing levels of microcracks may not only affect bone remodeling but also reduce elastic modulus and are suspected to adversely affect other mechanical properties that may influence fracture risk. The present findings add to our prior results showing changes in bone material properties and modulus with bisphosphonate treatment duration and thereby provide a more comprehensive assessment of the relationship between bisphosphonate treatment duration and bone quality. Statement of Clinical Significance: The present findings provide information guiding clinical use of oral bisphosphonates for post-menopausal osteoporosis therapy.

Effects of anti-resorptive treatment on the material properties of individual canine trabeculae in cyclic tensile tests

Osteoporosis is defined as a decrease of bone mass and strength, as well as an increase in fracture risk. It is conventionally treated with antiresorptive drugs, such as bisphosphonates (BPs) and selective estrogen receptor modulators (SERMs). Although both drug types successfully decrease the risk of bone fractures, their effect on bone mass and strength is different. For instance, BP treatment causes an increase of bone mass, stiffness and strength of whole bones, whereas SERM treatment causes only small (4%) increases of bone mass, but increased bone toughness. Such improved mechanical behavior of whole bones can be potentially related to the bone mass, bone structure or material changes. While bone mass and architecture have already been investigated previously, little is known about the mechanical behavior at the tissue/material level, especially of trabecular bone. As such, the goal of the work presented here was to fill this gap by performing cyclic tensile tests in a wet, close to physiologic environment of individual trabeculae retrieved from the vertebrae of beagle dogs treated with alendronate (a BP), raloxifene (a SERM) or without treatments. Identification of material properties was performed with a previously developed rheological model and of mechanical properties via fitting of envelope curves. Additionally, tissue mineral density (TMD) and microdamage formation were analyzed. Alendronate treatment resulted in a higher trabecular tissue stiffness and strength, associated with higher levels of TMD. In contrast, raloxifene treatment caused a higher trabecular toughness, pre-dominantly in the post-yield region. Microdamage formation during testing was not affected by either anti-resorptive treatment regimens. These findings highlight that the improved mechanical behavior of whole bones after anti-resorptive treatment is at least partly caused by improved material properties, with different mechanisms for alendronate and raloxifene. This study further shows the power of performing a mechanical characterization of trabecular bone at the level of individual trabeculae for better understanding of clinically relevant mechanical behavior of bone.

Fifty years of bisphosphonates: What are their mechanical effects on bone?

After fifty years of experience with several generations of bisphosphonates (BPs), and 25 years after these drugs were approved for use in humans, their mechanical effects on bone are still not fully understood. Certainly, these drugs have transformed the treatment of osteoporosis in both men and women. There is no question that they do prevent fractures related to low bone mass, and there is widespread agreement that they increase strength and stiffness of the vertebrae. There is less consensus, however, about their effects on cortical bone, or on bone tissue properties in either trabecular or cortical bone, or their effects with longer periods of treatment. The consensus of most studies, both those based on ovariectomized and intact animal models and on testing of human bone, is that long-term treatment and/or high doses with certain BPs make the bone tissue more brittle and less tough. This translates into reduced energy to fracture and potentially a shorter bone fatigue life. Many studies have been done, but Interpretation of the results of these studies is complicated by variations in which BP is used, the animal model used, dose, duration, and methods of testing. Duration effects and effects on impact properties of bone are gaps that should be filled with additional testing.

Young's modulus and hardness of human trabecular bone with bisphosphonate treatment durations up to 20 years

Bone modulus from patients with osteoporosis treated with bisphosphonates for 1 to 20 years was analyzed. Modulus increases during the first 6 years of treatment and remains unchanged thereafter.

INTRODUCTION

Bisphosphonates are widely used for treating osteoporosis, but the relationship between treatment duration and bone quality is unclear. Since material properties partially determine bone quality, the present study quantified the relationship between human bone modulus and hardness with bisphosphonate treatment duration.

METHODS

Iliac crest bone samples from a consecutive case series of 86 osteoporotic Caucasian women continuously treated with oral bisphosphonates for 1.1-20 years were histologically evaluated to assess bone turnover and then tested using nanoindentation. Young's modulus and hardness were measured and related to bisphosphonate treatment duration by statistical modeling.

RESULTS

All bone samples had low bone turnover. Statistical models showed that with increasing bisphosphonate treatment duration, modulus and hardness increased, peaked, and plateaued. These models used quadratic terms to model modulus increases from 1 to 6 years of bisphosphonate treatment and linear terms to model modulus plateaus from 6 to 20 years of treatment. The treatment duration at which the quadratic-linear transition (join point) occurred also depended upon trabecular location. Hardness increased and peaked at 12.4 years of treatment; it remained constant for the next 7.6 years of treatment and was insensitive to trabecular location.

CONCLUSIONS

Bone modulus increases with bisphosphonate treatment durations up to 6 years, no additional modulus increases occurred after 6 years of treatment. Although hardness increased, peaked at 12.4 years and remained constant for the next 7.6 years of BP treatment, the clinical relevance of hardness remains unclear.

Intrinsic material property differences in bone tissue from patients suffering low-trauma osteoporotic fractures, compared to matched non-fracturing women

Osteoporotic (low-trauma) fractures are a significant public health problem. Over 50% of women over 50yrs. of age will suffer an osteoporotic fracture in their remaining lifetimes. While current therapies reduce skeletal fracture risk by maintaining or increasing bone density, additional information is needed that includes the intrinsic material strength properties of bone tissue to help develop better treatments, since measurements of bone density account for no more than ~50% of fracture risk. The hypothesis tested here is that postmenopausal women who have sustained osteoporotic fractures have reduced bone quality, as indicated with measures of intrinsic material properties compared to those who have not fractured. Transiliac biopsies (N=120) were collected from fracturing (N=60, Cases) and non-fracturing postmenopausal women (N=60, age- and BMD-matched Controls) to measure intrinsic material properties using the nano-indentation technique. Each biopsy specimen was embedded in epoxy resin and then ground, polished and used for the nano-indentation testing. After calibration, multiple indentations were made using quasi-static (hardness, modulus) and dynamic (storage and loss moduli) testing protocols. Multiple indentations allowed the median and variance to be computed for each type of measurement for each specimen. Cases were found to have significantly lower median values for cortical hardness and indentation modulus. In addition, cases showed significantly less within-specimen variability in cortical modulus, cortical hardness, cortical storage modulus and trabecular hardness, and more within-specimen variability in trabecular loss modulus. Multivariate modeling indicated the presence of significant independent mechanical effects of cortical loss modulus, along with variability of cortical storage modulus, cortical loss modulus, and trabecular hardness. These results suggest mechanical heterogeneity of bone tissue may contribute to fracture resistance. Although the magnitudes of differences in the intrinsic properties were not overwhelming, this is the first comprehensive study to investigate, and compare the intrinsic properties of bone tissue in fracturing and non-fracturing postmenopausal women.

Stiffness and strength of bone in osteoporotic patients treated with varying durations of oral bisphosphonates

Apparent modulus and failure stress of trabecular bone structure from 45 women with osteoporosis treated with bisphosphonates for varying durations were studied using finite element analyses and statistical modeling. Following adjustments for patient age and bone volume, increasing bisphosphonate treatment duration for up to 7.3 years was associated with treatment-time-dependent increases in bone apparent modulus and failure stress. Treatment durations exceeding 7.3 years were associated with time-dependent decreases in apparent modulus and failure stress from the peak values observed.

INTRODUCTION

The purpose of this study was to clarify the relationship between bisphosphonate (BP) treatment duration and human bone quality. This study quantified changes in the apparent modulus and failure stress of trabecular bone biopsied from patients with osteoporosis who were treated with BPs for widely varying durations.

METHODS

Forty-five iliac crest bone samples were obtained from women with osteoporosis who were continuously treated with oral BPs for varying periods of up to 16 years. Micro-CT imaging was used to develop three-dimensional virtual models of the trabecular bone from these samples. Apparent modulus and failure stress of these virtual models were determined using finite element analyses (FEA). Polynomial regression and cubic splines, adjusted for relevant (age and BV/TV) covariates, were used to statistically model the data and quantify the relationships between BP treatment duration and apparent modulus or failure stress.

RESULTS

Second-order polynomial models were needed to relate apparent modulus or failure stress to BP treatment duration. These models showed that these bone quality parameters (a) increased with increasing BP treatment duration up to approximately 7.3 years, (b) reached a maximum at this (~7.3 years) time, and then (c) declined with BP treatment durations exceeding ~7.3 years. A similar result was obtained by modeling with cubic splines.

CONCLUSIONS

Changes in FEA-derived apparent stiffness and failure stress are attributable to changes in trabecular bone structure, which in turn are related to the duration of BP treatment. These relationships are evident even after adjustments are made in the statistical models for changes in age and BV/TV. According to these models, increases in trabecular bone apparent stiffness and failure stress linked to BPs cease and appear to reverse after approximately 7.3 years of treatment. Conclusions regarding optimal BP therapy duration await study of additional bone quality parameters.

PLGA-linked alendronate enhances bone repair in diaphysis defect model

Alendronate (ALN) is known as an anti-resorptive drug for the treatment of osteoporosis. Recently, ALN was found to stimulate osteogenic differentiation in mesenchymal stem cells and enhance new bone formation in calvarial bone defects. Previous in vitro and in vivo studies found that the effective concentration of ALN was approximately 1-10   μm. In the present study, a poly (lactic-co-glycolic acid) (PLGA) cross-linked ALN (PLGA-ALN) with a short-term controlled-release property for local application to enhance bone repair was developed. An in vitro drug-release kinetic test showed that PLGA-ALN microspheres released an effective concentration (50-100 nm) of ALN for 9 days. The effect of PLGA-ALN on bone repair was tested in a rat femoral bone defect model. The biomechanical study results showed that the maximal strength, stiffness and energy absorption were significantly increased in the PLGA-ALN group compared with the PLGA group. The microstructure of the newly formed bone at the defect site was analysed using microcomputed tomography. The PLGA-ALN group significantly improved the trabecular bone volume at the defect site compared with the PLGA group. The fibril collagen and immunolocalized bone morphogenetic protein 2 were evident in the newly formed trabecular bone in the PLGA-ALN group. Local use of newly developed PLGA-ALN-enhanced bone repair was attributable to increasing bone matrix formation, which improved the ultrastructure of the newly formed bone and thus increased the biomechanical properties of the repaired bone. It is suggested that PLGA-ALN may be a potential bone graft substitute to enhance bone repair. Copyright © 2016 John Wiley & Sons, Ltd.

A Computational Approximation to Model Variation in Cancellous Bone Screw Pull-Out

Cancellous bone screws are used to achieve good pull-out characteristics when connected to cancellous bone. This study examines some screw characteristics, including pitch and inner diameter, using a model of cancellous bone with a range of bone apparent densities (ADs). This was achieved using bone geometry based on microCT-scanned cancellous bone and converted into a geometric model using mimics® software. The finite element (FE) models were produced in ansys®. The calculated reaction force for pull-out of 0.2 mm shows the influence of design parameters. Change in the proximal half angle increased the stiffness by about 15% in line with the experimental findings of others. An increase in pull-out reaction force with an increase in bone AD was also observed. However, when a particular screw geometry in lower AD bone was modeled and then rotated through 180 deg on plan, a significant reduction in reaction force was noted. Further models with screws of similar geometry in the same location showed similar reductions in reaction force and hence pull-out stiffness. Examination of the geometry of the bone/screw interface indicates that in certain positions there is little cancellous bone to support the implant—leading to low pull-out reaction forces, which is very difficult to predict. The study also examined the effect of increasing the bone stiffness adjacent to the implant, and concluded that, even in bone of low AD, increases in pull-out stiffness might be achieved.

Changes in cortical bone channels network and osteocyte organization after the use of zoledronic acid

OBJECTIVE

The aim of this study was to evaluate the effects of zoledronic acid (ZA) on the cortical bone channels network (CBCN) and osteocyte organization in relation to the bone channels.

MATERIALS AND METHODS

Eighteen male Wistar rats were divided into control (CG) and test groups (TG). Twelve animals from TG received 3 ZA doses (7.5 µg/kg), and 6 animals from CG did not receive any medication. TG animals were euthanized at 14 (n = 6) and 75 (n = 6) dadys after drug injection. CBCN was analyzed in mandibles and tibias using computational routines. The osteocyte organization was qualitatively evaluated in tibias using a three-dimensional reconstruction of images from serial histological sections.

RESULTS

Significant differences in CBCN of tibia were found between the treated and untreated rats, with a wider range of sizes and shapes of the channels after the use of ZA (channels area p = 0.0063, channels area SD p = 0.0276) and less bone matrix (bone volume p = 0.0388). The alterations in the channels' morphology were more evident at 75 days after the drug injection (channels perimeter p = 0.0286). No differences were found in mandibles CBCN. The osteocyte distribution revealed more variable patterns of cell distribution in ZA groups, with non-homogeneous distribution of cells in relation to the bone channels.

CONCLUSION

Zoledronic acid induces structural changes in CBCN and modifies the osteocyte arrangement in cortical bone in the tibia; also, the variability in the morphology of bone channels became more evident after a certain time of the use of the drug.

Changes of elastic constants and anisotropy patterns in trabecular bone during disuse-induced bone loss assessed by poroelastic ultrasound

Currently, the approach most widely used to examine bone loss is the measurement of bone mineral density (BMD) using dual X-ray absorptiometry (DXA). However, bone loss due to immobilization creates changes in bone microarchitecture, which in turn are related to changes in bone mechanical function and competence to resist fracture.Unfortunately, the relationship between microarchitecture and mechanical function within the framework of immobilization and antiresorptive therapy has not being fully investigated. The goal of the present study was to investigate the structure–function relationship in trabecular bone in the real-world situations of a rapidly evolving osteoporosis(disuse), both with and without antiresorptive treatment. We evaluated the structure–function relationship in trabecular bone after bone loss (disuse-induced osteoporosis)and bisphosphonate treatment (antiresorptive therapy using risedronate) in canine trabecular bone using lCT and ultrasound wave propagation. Microstructure values determined from lCT images were used into the anisotropic poroelastic model of wave propagation in order to compute the apparent elastic constants (EC) and elastic anisotropy pattern of bone. Immobilization resulted in a significant reduction in trabecular thickness (Tb.Th) and bone volume fraction (BV/TV), while risedronate treatment combined with immobilization exhibited a lesser reduction in Tb.Th and BV/TV, suggesting that risedronate treatment decelerates bone loss, but it was unable to fully stop it. Risedronate treatment also increased the tissue mineral density (TMD), which when combined with the decrease in Tb.Th and BV/TV may explain the lack of significant differences invBMD in both immobilization and risedronate treated groups. Interestingly, changes inapparent EC were much stronger in the superior–inferior (SI) direction than in the medial–lateral (ML) and anterior–posterior (AP) anatomical directions, producing changes in elastic anisotropy patterns. When data were pooled together, vBMD was able to explain 58% of ultrasound measurements variability, a poroelastic wave propagation analytical model (i.e., BMD modulated by fabric directionality) was able to predict 81%of experimental wave velocity variability, and also explained 91% of apparent EC and changes in elastic anisotropy patterns. Overall, measurements of vBMD were unable to distinguish changes in apparent EC due to immobilization or risedronate treatment.However, anisotropic poroelastic ultrasound (PEUS) wave propagation was able to distinguish functional changes in apparent EC and elastic anisotropy patterns due to immobilization and antiresorptive therapy, providing an enhanced discrimination of anisotropic bone loss and the structure–function relationship in immobilized and risedronate-treated bone, beyond vBMD.

The use of micro-CT to study bone architecture dynamics noninvasively

High-resolution micro-CT has become a standard tool in the evaluation of bone architecture. It has recently progressed from an invasive tool for bone specimens into an in vivo tool for small animals. The combination of novel sophisticated evaluation methods, such as registration (matching) of sequential scans and computer simulation models will further evolve in vivo micro-CT into an optimal tool for small animal phenotyping and contemporary approaches for drug discovery relating to the skeleton.:

Transplantation of mesenchymal stem cells from young donors delays aging in mice

Increasing evidence suggests that the loss of functional stem cells may be important in the aging process. Our experiments were originally aimed at testing the idea that, in the specific case of age-related osteoporosis, declining function of osteogenic precursor cells might be at least partially responsible. To test this, aging female mice were transplanted with mesenchymal stem cells from aged or young male donors. We find that transplantation of young mesenchymal stem cells significantly slows the loss of bone density and, surprisingly, prolongs the life span of old mice. These observations lend further support to the idea that age-related diminution of stem cell number or function may play a critical role in age-related loss of bone density in aging animals and may be one determinant of overall longevity.

Bisphosphonate effects on bone turnover, microdamage, and mechanical properties: what we think we know and what we know that we don't know

The bisphosphonates (BPs) have been useful tools in our understanding of the role that bone remodeling plays in skeletal health. The purpose of this paper is to outline what we know, and what is still unknown, about the role that BPs play in modulating bone turnover, how this affects microdamage accumulation, and ultimately what the effects of these changes elicited by BPs are to the structural and the material biomechanical properties of the skeleton. We know that BPs suppress remodeling site-specifically, probably do not have a direct effect on formation, and that the individual BPs vary with respect to speed of onset, duration of effect and magnitude of suppression. However, we do not know if these differences are meaningful in a clinical sense, how much remodeling is sufficient, the optimal duration of treatment, or how long it takes to restore remodeling to pre-treatment levels following withdrawal. We also know that suppression is intimately tied to microdamage accumulation, which is also site-specific, that BPs impair targeted repair of damage, and that they can reduce the energy absorption capacity of bone at the tissue level. However, the BPs are clearly effective at preventing fracture, and generally increase bone mineral density and whole bone strength, so we do not know whether these changes in damage accumulation and repair, or the mechanical effects at the tissue level, are clinically meaningful. The mechanical effects of BPs on the fatigue life of bone, or BP effects on bone subject to an impact, are entirely unknown. This paper reviews the literature on these topics, and identifies gaps in knowledge that can be addressed with further research.

The effects of estrogen deficiency and bisphosphonate treatment on tissue mineralisation and stiffness in an ovine model of osteoporosis

While much research has been dedicated to understanding osteoporosis, the nature of mineral distribution and the mechanical property variation in diseased bone is poorly understood. The current study aimed to determine the effect of estrogen deficiency and bisphosphonate therapy on bone tissue properties using an ovine model of osteoporosis. Skeletally mature animals (4+ years) were divided into an ovariectomy group (ovx, n=20) and a non treatment control group (control, n=20). A zoledronic acid treated group was also included in which animals were estrogen deficient for 20 months prior to receiving treatment (Zol, n=4). Half of the control and ovx groups were euthanized 12 or 31 months post-operatively and all Zol animals were euthanised at 31 months. Individual trabeculae were removed from the proximal femur and were analysed at specific locations across the width of the trabeculae. The mineral content was measured using quantitative backscatter electron imaging and the modulus was measured using nanoindentation. The spatial distribution of tissue modulus and mineral content in bone from ovariectomised animals was similar to control. However, ovariectomy significantly reduced the overall mineral content and tissue modulus relative to the control group after 12 months. Interestingly, significant differences were not maintained 31 months post-OVX. Treatment with zoledronic acid increased the mineral content and tissue modulus relative to both the ovariectomised and control groups. Zoledronic acid was also found to alter the mineral and modulus gradients normally associated with healthy bone tissue. The current study provides evidence that both estrogen deficiency and zoledronic acid therapy significantly alter mineral content and the mechanical properties of trabecular tissue.

Bisphosphonate treatment modifies canine bone mineral and matrix properties and their heterogeneity

Bone loss and alterations in bone quality are major causes leading to bone fragility in postmenopausal women. Although bisphosphonates are well known to reduce bone turnover and prevent bone loss in postmenopausal osteoporosis, their effects on other bone properties are not fully characterized. Changes in bone mineral and matrix properties may contribute to the anti-fracture efficacy observed with bisphosphonate treatments. The aim of this work was to analyze the effect of a 1-year treatment with either alendronate or risedronate, at low and high doses, on spatially resolved bone material and compositional properties that could contribute to the fracture efficacy of these agents. Distal tibias from 30 normal beagles that had been treated daily for 1 year with oral doses of vehicle (Veh), alendronate (Aln) at 0.2 or 1 mg/kg, and risedronate (Ris) at 0.1 or 0.5 mg/kg were analyzed by Fourier Transform Infrared imaging (FTIRI) to assess the changes in both mineral and matrix properties in discrete bone areas. The widths at half maximum of the pixel histograms for each FTIRI parameter were used to assess the heterogeneity of the bone tissue. Aln and Ris increased the mineral content and the collagen maturity mainly in cancellous bone and at the endocortical surface. Significant differences were observed in the mineral content and in the hydroxyapatite crystallinity distribution in bone tissue, which can contribute to reduced ductility and micro-crack accumulation. No significant differences were observed between low and high dose nor between Aln and Ris treatments. These results show that pharmacologic suppression of bone turnover increases the mineral and matrix bone tissue maturity in normal cancellous and endocortical bone areas where bone turnover is higher. These positive effects for decreased fracture risk are also associated with a loss of bone heterogeneity that could be one factor contributing to increased bone tissue brittleness and micro-crack accumulation.

Microarchitectural adaptations in aging and osteoarthrotic subchondral bone issues

The human skeleton optimizes its microarchitecture by elaborate adaptations to mechanical loading during development and growth. The mechanisms for adaptation involve a multistep process of cellular mechanotransduction stimulating bone modelling, and remodeling resulting in either bone formation or resorption. This process causes appropriate microarchitectural changes tending to adjust and improve the bone structure to its prevailing mechanical environment. Normal individual reaches peak bone mass at age between 25 and 30 years, and thereafter bone mass declines with age in both genders. The bone loss is accompanied by microarchitectural deterioration resulting in reduced mechanical strength likely leading to fragility fractures. With aging, inevitable bone loss occurs, which is frequently the cause of osteoporosis; and inevitable bone and joint degeneration happens, which often results in osteoarthrosis. These diseases are among the major health care problems in terms of socio-economic costs. The overall goals of the current series of studies were to investigate the age-related and osteoarthrosis (OA) related changes in the 3-D microarchitectural properties, mechanical properties, collagen and mineral quality of subchondral cancellous and cortical bone tissues. The studies included mainly two parts. For human subjects: aging- (I–IV) and early OArelated (V–VI) changes in cancellous bone properties were assessed. For OA guinea pig models (VII–IX), three topics were studied: firstly, the spontaneous, age-related development of guinea pig OA; secondly, the potential effects of hyaluronan on OA subchondral bone tissues; and thirdly, the effects on OA progression of an increase in subchondral bone density by inhibition of bone remodeling with a bisphosphonate. These investigations aimed to obtain more insight into the age-related and OA-related subchondral bone adaptations.

Importance of microcracks in etiology of bisphosphonate-related osteonecrosis of the jaw: a possible pathogenetic model of symptomatic and non-symptomatic osteonecrosis of the jaw based on scanning electron microscopy findings

The aim of this study was to evaluate a possible role of microcracks in the pathogenesis of bisphosphonate-related osteonecrosis of the jaw (ONJ) and to discuss an etiological model. Bone samples from 35 patients with ONJ were analyzed. Control samples were taken from five patients with osteomyelitis (OM), ten patients with osteoradionecrosis, seven patients with osteoporosis and bisphosphonate medication without signs of ONJ, and six osteoporotic elderly patients. Samples were examined using scanning electron microscopy. In 54% of the bone samples of patients with ONJ, microcracks were seen. Inflammatory and connective tissue reactions within the microcracks were evident in 82% of the cases, indicating that these cracks were not artificial. In contrast, only 29% of samples from patients with oral bisphosphonate medication without ONJ, no sample from patients with OM, none of the osteoradionecrosis group, and only 17% from patients with osteoporosis showed microcracks. Statistically significant differences could be found between the ONJ group and the group after irradiation and the group with OM, respectively. The evidence of microcracks could be a first step in the pathogenesis of bisphosphonate-related ONJ. The accumulation of these microcracks leads to a situation that could be named "non-symptomatic ONJ". Disruptions of the mucosal integrity may then allow bacterial invasion, leading to jawbone infection with exposed bone, fistulas, and pain. This state could be called "symptomatic ONJ". Furthermore, an assumed local immunosuppression as indicated by various studies could explain the severe courses of therapy-resistant ONJ as regularly observed.

The influence of boundary conditions and loading mode on high-resolution finite element-computed trabecular tissue properties

A widely used technique for determining the material properties of trabecular tissue is to perform combined experimental and computational testing of trabecular structures in order to calibrate effective tissue properties. To better understand the nature of such properties, we tested n=25 cores of human vertebral trabecular bone under two different boundary conditions (endcap and PMMA embedding) and loading modes (compression and torsion). High-resolution (20 microm) finite element models that explicitly modeled the different experimental conditions were constructed and sensitivity studies were performed to quantify errors arising from uncertainties between model and experiment. Mean (+/-S.D.) effective tissue modulus for the four groups ranged from 9.6+/-1.9 to 11.5+/-3.5 GPa, and the overall mean was 10.3+/-2.4 GPa. For the endcap tests, mean values were the same regardless of loading mode, suggesting that the effective tissue modulus is representative of true material behavior. However, on a specimen-specific basis, the various repeated measures of effective tissue modulus were only moderately correlated with each other (R2=27% to 81%), indicating that the individual measures can be subject to appreciable random errors. The sensitivity studies on the endcap tests indicated that models using lower resolution (40 microm element size) and roller-type platens boundary conditions overestimated effective tissue modulus by 42% on average, although preliminary tests with higher-density femoral neck bone indicated less sensitivity to modeling issues. We conclude that effective tissue properties derived from micro-finite element models do have biomechanical significance if measured correctly, although individual measures of tissue properties may have poor precision.

Theoretical analysis of alendronate and risedronate effects on canine vertebral remodeling and microdamage

Bisphosphonates suppress bone remodeling activity, increase bone volume, and significantly reduce fracture risk in individuals with osteoporosis and other metabolic bone diseases. The objectives of the current study were to develop a mathematical model that simulates control and 1 year experimental results following bisphosphonate treatment (alendronate or risedronate) in the canine fourth lumbar vertebral body, validate the model by comparing simulation predictions to 3 year experimental results, and then use the model to predict potential long term effects of bisphosphonates on remodeling and microdamage accumulation. To investigate the effects of bisphosphonates on bone volume and microdamage, a mechanistic biological model was modified from previous versions to simulate remodeling in a representative volume of vertebral trabecular bone in dogs treated with various doses of alendronate or risedronate, including doses equivalent to those used for treatment of post-menopausal osteoporosis in humans. Bisphosphonates were assumed to affect remodeling by suppressing basic multicellular unit activation and reducing resorption area. Model simulation results for trabecular bone volume fraction, microdamage, and activation frequency following 1 year of bisphosphonate treatment are consistent with experimental measurements. The model predicts that trabecular bone volume initially increases rapidly with 1 year of bisphosphonate treatment, and continues to slowly rise between 1 and 3 years of treatment. The model also predicts that microdamage initially increases rapidly, 0.5-1.5-fold for alendronate or risedronate during the first year of treatment, and reaches its maximum value by 2.5 years before trending downward for all dosages. The model developed in this study suggests that increasing bone volume fraction with long term bisphosphonate treatment may sufficiently reduce strain and damage formation rate so that microdamage does not accumulate above that which is initiated in the first two years of treatment.

Effects of suppression of bone turnover on cortical and trabecular load sharing in the canine vertebral body

The relative biomechanical effects of antiresorptive treatment on cortical thickness vs. trabecular bone microarchitecture in the spine are not well understood. To address this, T-10 vertebral bodies were analyzed from skeletally mature female beagle dogs that had been treated with oral saline (n=8 control) or a high dose of oral risedronate (0.5mg/kg/day, n=9 RIS-suppressed) for 1 year. Two linearly elastic finite element models (36-mum voxel size) were generated for each vertebral body-a whole-vertebra model and a trabecular-compartment model-and subjected to uniform compressive loading. Tissue-level material properties were kept constant to isolate the effects of changes in microstructure alone. Suppression of bone turnover resulted in increased stiffness of the whole vertebra (20.9%, p=0.02) and the trabecular compartment (26.0%, p=0.01), while the computed stiffness of the cortical shell (difference between whole-vertebra and trabecular-compartment stiffnesses, 11.7%, p=0.15) was statistically unaltered. Regression analyses indicated subtle but significant changes in the relative structural roles of the cortical shell and the trabecular compartment. Despite higher average cortical shell thickness in RIS-suppressed vertebrae (23.1%, p=0.002), the maximum load taken by the shell for a given value of shell mass fraction was lower (p=0.005) for the RIS-suppressed group. Taken together, our results suggest that-in this canine model-the overall changes in the compressive stiffness of the vertebral body due to suppression of bone turnover were attributable more to the changes in the trabecular compartment than in the cortical shell. Such biomechanical studies provide an unique insight into higher-scale effects such as the biomechanical responses of the whole vertebra.

Vertebral strength changes in rheumatoid arthritis patients treated with alendronate, as assessed by finite element analysis of clinical computed tomography scans: a prospective randomized clinical trial

OBJECTIVE

Finite element analysis of clinical computed tomography (CT) scans provides a noninvasive means of assessing vertebral strength that is superior to dual x-ray absorptiometry (DXA)-measured areal bone mineral density. The present study was undertaken to compare strength changes, measured using this newer method, in rheumatoid arthritis (RA) patients who were treated with alendronate (ALN) versus those who were not.

METHODS

Thirty female RA patients without radiologic signs of L3 compression fractures or a history of osteoporosis medication were enrolled in a prospective randomized clinical trial. Patients were randomly assigned to the ALN group (5 mg orally, once daily) or the control group not receiving antiresorptive treatment. All patients were evaluated by DXA and quantitative CT at baseline and reevaluated after a mean of 12.2 months. Nonlinear finite element analysis was performed on the CT scans (n = 29 available for analysis) to compute an estimate of vertebral compressive strength and to assess strength changes associated with changes in the trabecular compartment and the outer 2 mm of bone (peripheral compartment).

RESULTS

On average, vertebral strength was significantly decreased from baseline in the control group (n = 15) (median change -10.6%; P = 0.008) but was maintained in the ALN group (n = 14) (median change +0.4%; P = 0.55), with a significant difference between the 2 groups (P < 0.01). Strength decreased more rapidly within the trabecular bone, and ALN treatment was much more effective in the peripheral than the trabecular compartment.

CONCLUSION

Our results indicate that patients with RA can lose a substantial amount of vertebral strength over a relatively short period of time, and this loss can be prevented by ALN, primarily via its positive effect on the outer 2 mm of vertebral bone.

The effects of bone remodeling inhibition by alendronate on three-dimensional microarchitecture of subchondral bone tissues in guinea pig primary osteoarthrosis

We assessed whether increase of subchondral bone density enhances cartilage stress during impact loading, leading to progressive cartilage degeneration and accelerated osteoarthrosis (OA) progression. Sixty-six male guinea pigs were randomly divided into six groups. During a 9-week treatment period, four groups received twice-weekly subcutaneous injections of alendronate (ALN) in two doses: two groups received 10 microg/kg and two groups received 50 microg/kg. The two control groups received vehicle. After 9 weeks, one 10 microg/kg ALN group, one 50 microg/kg ALN group, and one control group were killed. The remaining three groups (17-week groups) were left for an additional 8 weeks, receiving the same treatment regimen before death. The left proximal tibiae were scanned by micro-computed tomography to quantify the microarchitecture of subchondral bone, followed by mechanical testing and determination of collagen and mineral. The control groups had typical OA-related cartilage degeneration at 9 and 17 weeks, whereas the 50 microg/kg ALN group had even worse degeneration in the medial condyle. It is unclear whether there is a direct or a secondary effect of ALN on the cartilage. The 9-week ALN group had significantly greater subchondral plate thickness. The 9- and 17-week groups had similar changes of cancellous bone microarchitecture, with greater volume fraction and connectivity and an extremely plate-like structure. The 9-week ALN group had greater bone mineral concentration, and the 17-week ALN group had reduced collagen concentration and greater mineral concentration. Treatment with ALN did not significantly change the mechanical properties of the cancellous bone.

Staged-injection procedure to prevent cement leakage during vertebroplasty: an in vitro study

STUDY DESIGN

Fibrin sealant (FS) combined with or without growth factor was used to improve the micro-architectural and biomechanical properties of vertebral body in osteoporotic ovine spine.

OBJECTIVE

To analyze the treatment effects of bovine bone morphogenetic protein (bBMP) combined with FS on osteopenic ovine vertebral architecture, bone mineral density, and biomechanics in vivo.

SUMMARY OF BACKGROUND DATA

Vertebroplasty and kyphoplasty were used to treat spinal osteoporosis. They can increase strength of vertebrae physically. However, each has specific disadvantages. bBMP could rapidly increasing bone formation and suppressing bone resorption, but little is known about its effect on ovariectomized-induced osteoporosis.

METHODS

Six sheep underwent ovariectomy and were placed on a low-calcium diet. Twelve months later, according to Ladin square design, L4-L6 vertebrae in all sheep were randomly assigned to 3 treatment groups: A (30 mg bBMP/1.5 mL FS), B (30 mg bBMP) and C (1.5 mL FS). All materials were injected into the assigned vertebra transpedicularly. Animals were killed 3 months after injection, and bone mineral density (BMD), biomechanics, and histomorphometry were assessed. Analysis of variance was used to determine effects of bBMP/FS (alpha = 0.05).

RESULTS

The BMD in Group 1 was 17.1% and 14.7% higher than that in Group 2 and Group 3, respectively. The micro-CT reconstruction analysis showed that the density and connectivity of trabecular bone in bBMP/FS treated vertebrae were higher than those in control groups. The mechanical properties (yield stress, ultimate stress, energy absorption, bone modulus) of the vertebrae were also significantly higher. In this study, local bBMP/FS treatment showed a positive trend in improving BMD, histomorphometric parameters, and mechanical strength of osteoporotic vertebra. Slow release of bBMP using FS appeared to be an effective method of protein delivery.

CONCLUSION

The use of bBMP/FS in the treatment of vertebral osteoporosis in an attempt to enhance bone strength merits further study.

High-dose bisphosphonate therapy in an urgent case of spontaneous multiple vertebral fractures in a 55 year old woman

An early postmenopausal Caucasian woman aged 55 sustained multiple vertebral fractures after a minor trauma. After exclusion of any kind of secondary osteoporosis, we administered due to clinical severity combined oral and cyclic intravenous bisphosphonate therapy (oral risedronate 35 mg/week, i.v. pamidronate 30 mg quarterly) with adequate calcium and vitamin D supplementation for 28 months. We performed a transiliac bone biopsy at baseline and at month 28. The paired samples were investigated by histomorphometry, by microCT-analysis for 3d structure and by qBEI representing bone mineral density distribution. Mineralisation of the bone matrix was not influenced by supplementation of calcium and vitamin D. Parameters of bone architecture and BMD improved; and a reduction of pain and increased mobility was observed. No further osteoporotic fractures occurred during the time of investigation.

Raloxifene enhances material-level mechanical properties of femoral cortical and trabecular bone

We have previously documented that raloxifene enhances the mechanical properties of dog vertebrae independent of changes in bone mass, suggesting a positive effect of raloxifene on material-level mechanical properties. The goal of this study was to determine the separate effects of raloxifene on the material-level mechanical properties of trabecular and cortical bone from the femur of beagle dogs. Skeletally mature female beagles (n = 12 per group) were treated daily for 1 yr with oral doses of vehicle or raloxifene (0.50 mg/kg d). Trabecular bone mechanical properties were measured at the femoral neck using reduced platen compression, a method that allows the trabecular bone to be tested without coring specimens. Cortical bone properties were assessed on prismatic beam specimens machined from the femoral diaphysis using both monotonic and dynamic (cyclic relaxation) four-point bending tests. Trabecular bone from raloxifene-treated animals had significantly higher ultimate stress (+130%), modulus (+89%), and toughness (+152%) compared with vehicle-treated animals. Cortical bone from raloxifene-treated animals had significantly greater toughness (+62%) compared with vehicle, primarily as a function of increased postyield displacement (+100%). There was no significant difference between groups in the percentage of stiffness loss during cortical bone cyclic relaxation tests. These results are consistent with previous data from the vertebrae of these same animals, showing raloxifene has positive effects on biomechanical properties independent of changes in bone volume/density. This may help explain how raloxifene reduces osteoporotic fractures despite modest changes in bone mass.

Anabolic effects of bisphosphonates on peri-implant bone stock

The long-term durability of total joint replacements is critically dependent on adequate peri-implant bone stock, which can be compromised by wear debris-mediated osteolysis. This study investigated the effects of bisphosphonates on enhancing peri-implant bone in the presence of clinically relevant ultra-high molecular weight polyethylene (UHMWPE) wear debris. Fiber-mesh coated titanium-alloy plugs were implanted bilaterally in the femoral condyles of 36 New Zealand white rabbits. Implants in the left femora were covered with submicron UHMWPE particles during surgery. Rabbits were administered either no drug, subcutaneous alendronate weekly (1.0mg/kg/week) or a single dose of intravenous zoledronate (0.015mg/kg). A total of 6/12 rabbits in each group were sacrificed at 6 weeks and the remainder at 12 weeks postoperatively. Peri-implant bone stock was analyzed radiographically and histomorphometrically. Radiographically, both bisphosphonates significantly increased periprosthetic cortical thickness at 6 weeks (p<0.0001; alendronate: +18%; zoledronate: +11%) and at 12 weeks (p=0.001; alendronate: +17%; zoledronate:+19%). Histomorphometrically, alendronate and zoledronate raised peri-implant bone volume (BV/TV) up to 2-fold after 6 weeks without added wear debris and more than 3-fold when wear debris was present. Furthermore a 6-week bisphosphonate treatment increased osteoid thickness in the absence of wear debris (alendronate: +132%, p=0.007; zoledronate: +67%, p=0.51) and in the presence of wear debris (alendronate: +134%, p=0.023; zoledronate: +138%, p=0.016). In summary, alendronate and zoledronate treatment increased periprosthetic bone stock in a rabbit femoral model, particularly in the presence of UHMWPE wear debris. These new findings suggest that bisphosphonates may more than compensate for the well-documented negative effects of wear debris on peri-implant bone stock. The combined antiresorptive and osteoanabolic effects of bisphosphonates on periprosthetic bone stock may have an important role for critically improving the biological fixation and ultimate durability of total joint arthroplasty.

A computational assessment of the independent contribution of changes in canine trabecular bone volume fraction and microarchitecture to increased bone strength with suppression of bone turnover

This study addressed the effects of changes in trabecular microarchitecture induced by suppressed bone turnover-including changes to the remodeling space-on the trabecular bone strength-volume fraction characteristics independent of changes in tissue material properties. Twenty female beagle dogs, aged 1-2 years, were treated daily with either oral saline (n=10 control) or high doses of oral risedronate (0.5mg/kg/day, n=10 suppressed) for a period of 1 year, the latter designed (and confirmed) to substantially suppress bone turnover. High-resolution micro-CT-based finite element models (18-mum voxel size) of canine trabecular bone cores (n=2 per vertebral body) extracted from the T-10 vertebrae were analyzed in both compressive and torsional loading cases. The same tissue-level material properties were used in all models, thus providing measures of tissue-normalized strength due only to changes in the microarchitecture. Suppressed bone turnover resulted in more plate-like architecture with a thicker and more dense trabecular structure, but the relationship between the microarchitectural parameters and volume fraction was unaltered (p>0.05). Though the suppressed group had a greater tissue-normalized strength as compared to the control group (p<0.001) for both compressive and torsional loading, the relationship between tissue-normalized strength and volume fraction was not significantly altered for compression (p>0.13) or torsion (p>0.09). In this high-density, non-osteoporotic animal model, the increases in tissue-normalized strength seen with suppression of bone turnover were entirely commensurate with increases in bone volume fraction and thus, no evidence of microarchitecture-related or "stress-riser" effects which may disproportionately affect strength were found.

Alendronate prevents bone loss and improves tendon-to-bone repair strength in a canine model

Previously we showed a loss of bone and a concomitant decrease in mechanical properties in the first 21 days after flexor tendon insertion site injury and repair in a canine model. The goal of this short-term study was to suppress bone loss after insertion site repair using alendronate in an attempt to prevent the reduction in biomechanical properties. Flexor tendons of the second and fifth digits of the right forelimbs of canines were injured and repaired. Dogs received a daily oral dose of alendronate (2 mg/kg). One digit in each dog also received a local dose of alendronate in the bone tunnel at the time of surgery. The repair was evaluated for bone mineral density (BMD) and biomechanical properties and compared to data from a previous study in which no alendronate was used. Alendronate was effective in protecting the distal phalanx from resorption during tendon-to-bone healing (BMD was 94 and 104% of control for systemic alendronate and for systemic plus local alendronate, respectively). Alendronate treatment prevented much of the decrease in ultimate load that occurs in the first 21 days. Without treatment, ultimate load was 42% of control. With systemic alendronate treatment and systemic plus local alendronate treatment, ultimate load was 78 and 69% of control, respectively. Failure mode was significantly different when comparing alendronate treatment to repair alone. A lower incidence of suture pull through was found in alendronate treated dogs, suggesting less tendon degeneration. Ultimate load can be improved in association with preventing the bone loss that normally occurs during the early period following tendon-to-bone repair. These initial short-term data demonstrate the potential for a clinical treatment that could enhance tendon-to-bone healing.

Off-axis loads cause failure of the distal radius at lower magnitudes than axial loads: a finite element analysis

Distal radius (Colles') fractures are a common fall-related injury in older adults and frequently result in long-term pain and reduced ability to perform activities of daily living. Because the occurrence of a fracture during a fall depends on both the strength of the bone and upon the kinematics and kinetics of the impact itself, we sought to understand how changes in bone mineral density (BMD) and loading direction affect the fracture strength and fracture initiation location in the distal radius. A three-dimensional finite element model of the radius, scaphoid, and lunate was used to examine changes of +/-2% and +/-4% BMD, and both axial and physiologically relevant off-axis loads on the radius. Changes in BMD resulted in similar percent changes in fracture strength. However, modifying the applied load to include dorsal and lateral components (assuming a dorsal view of the wrist, rather than an anatomic view) resulted in a 47% decrease in fracture strength (axial failure load: 2752N, off-axis: 1448N). Loading direction also influenced the fracture initiation site. Axially loaded radii failed on the medial surface immediately proximal to the styloid process. In contrast, off-axis loads, containing dorsal and lateral components, caused failure on the dorsal-lateral surface. Because the radius appears to be very sensitive to loading direction, the results suggest that much of the variability in fracture strength seen in cadaver studies may be attributed to varying boundary conditions. The results further suggest that interventions focused on reducing the incidence of Colles' fractures when falls onto the upper extremities are unavoidable may benefit from increasing the extent to which the radius is loaded along its axis.

Effects of teriparatide and alendronate on vertebral strength as assessed by finite element modeling of QCT scans in women with osteoporosis

FE modeling was used to estimate the biomechanical effects of teriparatide and alendronate on lumbar vertebrae. Both treatments enhanced predicted vertebral strength by increasing average density. This effect was more pronounced for teriparatide, which further increased predicted vertebral strength by altering the distribution of density within the vertebra, preferentially increasing the strength of the trabecular compartment.

INTRODUCTION

Teriparatide 20 microg/day (TPTD) and alendronate 10 mg/day (ALN) increase areal, measured by DXA, and volumetric, measured by QCT, lumbar spine BMD through opposite effects on bone remodeling. Using finite element (FE) modeling of QCT scans, we sought to compare the vertebral strength characteristics in TPTD- and ALN-treated patients.

MATERIALS AND METHODS

A subset of patients (N = 28 TPTD; N = 25 ALN) from the Forteo Alendronate Comparator Trial who had QCT scans of the spine at baseline and postbaseline were analyzed. The QCT scans were analyzed for compressive strength of the L(3) vertebra using FE modeling. In addition, using controlled parameter studies of the FE models, the effects of changes in density, density distribution, and geometry on strength were calculated, a strength:density ratio was determined, and a response to bending was also quantified.

RESULTS

Both treatments had positive effects on predicted vertebral strength characteristics. At least 75% of the patients in each treatment group had increased strength of the vertebra at 6 months compared with baseline. Patients in both treatment groups had increased average volumetric density and increased strength in the trabecular bone, but the median percentage increases for these parameters were 5- to 12-fold greater for TPTD. Larger increases in the strength:density ratio were also observed for TPTD, and these were primarily attributed to preferential increases in trabecular strength.

CONCLUSIONS

These results provide new insight into the effects of these treatments on estimated biomechanical properties of the vertebra. Both treatments positively affected predicted vertebral strength through their effects on average BMD, but the magnitudes of the effects were quite different. Teriparatide also affected vertebral strength by altering the distribution of density within the vertebra, so that overall, teriparatide had a 5-fold greater percentage increase in the strength:density ratio.

Vertebral osteoporosis and trabecular bone quality

Vertebral fractures due to osteoporosis commonly occur under non-traumatic loading conditions. This problem affects more than 1 in 3 women and 1 in 10 men over a lifetime. Measurement of bone mineral density (BMD) has traditionally been used as a method for diagnosis of vertebral osteoporosis. However, this method does not fully account for the influence of changes in the trabecular bone quality, such as micro-architecture, tissue properties and levels of microdamage, on the strength of the vertebra. Studies have shown that deterioration of the vertebral trabecular architecture results in a more anisotropic structure which has a greater susceptibility to fracture. Transverse trabeculae are preferentially thinned and perforated while the remaining vertical trabeculae maintain their thickness. Such a structure is likely to be more susceptible to buckling under normal compression loads and has a decreased ability to withstand unusual or off-axis loads. Changes in tissue material mechanical properties and levels of microdamage due to osteoporosis may also compromise the fracture resistance of vertebral trabecular bone. New diagnostic techniques are required which will account for the influence of these changes in bone quality. This paper reviews the influence of the trabecular architecture, tissue properties and microdamage on fracture risk for vertebral osteoporosis. The morphological characteristics of normal and osteoporotic architectures are compared and their potential influence on the strength of the vertebra is examined. The limitations of current diagnostic methods for osteoporosis are identified and areas for future research are outlined.

Specimen-specific beam models for fast and accurate prediction of human trabecular bone mechanical properties

Direct assessment of bone competence in vivo is not possible, hence, it is inevitable to predict it using appropriate simulation techniques. Although accurate estimates of bone competence can be obtained from micro-finite element models (muFE), it is at the expense of large computer efforts. In this study, we investigated the application of structural idealizations to represent individual trabeculae by single elements. The objective was to implement and validate this technique. We scanned 42 human vertebral bone samples (10 mm height, 8 mm diameter) with micro-computed tomography using a 20 microm resolution. After scanning, direct mechanical testing was performed. Topological classification and dilation-based algorithms were used to identify individual rods and plates. Two FE models were created for each specimen. In the first one, each rod-like trabecula was modeled with one thickness-matched beam; each plate-like trabecula was modeled with several beams. From a simulated compression test, assuming one isotropic tissue modulus for all elements, the apparent stiffness was calculated. After reducing the voxel size to 40 microm, a second FE model was created using a standard voxel conversion technique. Again, one tissue modulus was assumed for all elements in all models, and a compression test was simulated. Bone volume fraction ranged from 3.7% to 19.5%; Young's moduli from 43 MPa to 649 MPa. Both models predicted measured apparent moduli equally well (R2 = 0.85), and were in excellent agreement with each other (R2 = 0.97). Tissue modulus was estimated at 9.0 GPa and 10.7 GPa for the beam FE and voxel FE models, respectively. On average, the beam models were solved in 219 s, reducing CPU usage up to 1150-fold as compared to 40 microm voxel FE models. Relative to 20 microm voxel models 10,000-fold reductions can be expected. The presented beam FE model is an abstraction of the intricate real trabecular structure using simple cylindrical beam elements. Nevertheless, it enabled an accurate prediction of global mechanical properties of microstructural bone. The strong reduction in CPU time provides the means to increase throughput, to analyze multiple loading configuration and to increase sample size, without increasing computational costs. With upcoming in vivo high-resolution imaging systems, this model has the potential to become a standard for mechanical characterization of bone.

A biomechanical perspective on bone quality

Observations that dual-energy X-ray absorptiometry (DXA) measures of areal bone mineral density cannot completely explain fracture incidence after anti-resorptive treatment have led to renewed interest in bone quality. Bone quality is a vague term but generally refers to the effects of skeletal factors that contribute to bone strength but are not accounted for by measures of bone mass. Because a clinical fracture is ultimately a mechanical event, it follows then that any clinically relevant modification of bone quality must change bone biomechanical performance relative to bone mass. In this perspective, we discuss a framework for assessing the clinically relevant effects of bone quality based on two general concepts: (1) the biomechanical effects of bone quality can be quantified from analysis of the relationship between bone mechanical performance and bone density; and (2) because of its hierarchical nature, biomechanical testing of bone at different physical scales (<1 mm, 1 mm, 1 cm, etc.) can be used to isolate the scale at which the most clinically relevant changes in bone quality occur. As an example, we review data regarding the relationship between the strength and density in excised specimens of trabecular bone and highlight the fact that it is not yet clear how this relationship changes during aging, osteoporosis development, and anti-resorptive treatment. Further study of new and existing data using this framework should provide insight into the role of bone quality in osteoporotic fracture risk.

In vivo BMP-7 (OP-1) enhancement of osteoporotic vertebral bodies in an ovine model

BACKGROUND CONTEXT

Prevention of osteoporotic vertebral fractures could help at-risk individuals avoid the pain and morbidity associated with these fractures. Currently, patients with osteoporosis are treated with systemic medications to reduce fracture risk. Although effective, these therapies do not eliminate fractures and also tend to have a gradual time-dependent effect on fracture risk. The mechanism of action of the bone morphogenetic protein (BMP) family theoretically makes these molecules candidates for rapidly enhancing local bone structure.

STUDY DESIGN

An in vivo study analyzing the effects of BMP-7 (osteogenic protein 1 [OP-1]) treatment on osteopenic ovine vertebral architecture and biomechanics.

PURPOSE

We tested the hypothesis that local injection of OP-1 into osteopenic ovine vertebrae will improve bone mass and trabecular distribution, thereby reducing bone fragility and fracture risk. We specifically evaluated compressive biomechanics and morphology of osteopenic ovine vertebral bodies 6 months after local OP-1 treatment.

STUDY DESIGN

In vivo animal study.

METHODS

Skeletally mature sheep (n=24) underwent ovariectomy and were placed on low cation relative to anion diet. These interventions reduce bone density and induce skeletal fragility. After 6 months, sheep were randomly assigned to six treatment groups based on OP-1 dose (370 mg or 0 mg) and carrier with 4 animals/treatment group. Carriers A and B were poly-L-glycolic acid (PLGA) biospheres with different release kinetics (B allowing sustained BMP release); Carrier C was carboxymethylcellulose. After creating an 8-mm-diameter defect in the midvertebral body, sheep underwent intravertebral body implantation at two nonadjacent levels. Animals were euthanized 6 months after implantation and bone mineral density (BMD), biomechanics, and histomorphometry were assessed. Two-way analysis of variance was used to determine effects of OP-1 (alpha=0.05).

RESULTS

An 81.9%, 333.2%, and 39.9% increase in stiffness was seen for OP-1 treated vertebra with Carriers A, B, and C respectively. Although these effects did not reach statistical significance, trends toward improvement were evident. Histology showed varied degrees of bony healing in the injection sites. Histomorphometrically, OP-1 treated vertebrae showed improvements in percent bone of up to 38% and star volume of up to 55% (with Carrier B). Improvements in whole vertebral body BMD were not detected for any treatment.

CONCLUSION

In this study, local OP-1 treatment showed a positive trend in improving mechanical strength and histomorphometric parameters of osteopenic vertebra, despite the absence of consistent change in BMD. Controlled slow release of OP-1 using PLGA microspheres appeared to be the most effective method of protein delivery. In conclusion, we feel that the pilot data suggest that the use of OP-1 in the treatment of vertebral osteoporosis in an attempt to enhance bone strength merits further study.

Effects of calcitonin and alendronate on distraction osteogenesis

In this experimental animal study the effects of calcitonin and alendronate on distraction osteogenesis are investigated. Forty-five mature female New Zealand type rabbits were used. Rabbits were randomized into three groups, each consisting of 15 animals. Under optimal operating conditions a pre-reconstructed circular external fixator was applied to the right tibia of rabbits, and osteotomy was performed with a Gigli saw just below the tibial tuberosity. During the ten days of distraction, a placebo was administered for group I (control group), group II received 10 U of calcitonin, and group III was treated with alendronate (0.5 mg/kg/day) gavages. Rabbits were examined histologically (at the third and eighth weeks, according to Huddlestone et al.), radiologically (at the third, sixth, and eighth weeks, according to Lane and Sandhu), and mechanically (at the eighth week, as torsional loading). During the first three weeks, the groups did not differ much with regard to radiological parameters. However, in the calcitonin and alendronate groups improved histological scores were detected compared with the control group. Radiological images obtained at the end of six weeks demonstrated improved consolidation in the calcitonin and alendronate groups compared with the control group. At the end of eight weeks postoperatively, radiological and histological parameters did not differ among the groups, while torsional failure load was found to be much improved in the calcitonin group (p=0.006). During the distraction osteogenesis period, calcitonin and alendronate affected the quality of regenerate favourably. This effect is sustained until the end of the consolidation period. However, this finding needs to be supported by experimental and human studies.

Nekrosen der Kieferknochen unter Bisphosphonattherapie

Bisphosphonates are widely used in the treatment of cancer patients with hypercalcemia and bone metastases or in osteoporosis therapy. Current reports have focused on therapy-resistant osteonecrosis of the jaws as a possible side effect of bisphosphonates. Official German drug committees have recently warned about the possibility of these side effects. So far we have experience with 12 patients showing therapy-resistant osteonecrosis of the mandible under bisphosphonate medication, three of whom received oral bisphosphonates for osteoporosis treatment. Presentation of these three cases provides more information on this clinically important side effect of oral bisphosphonate medication, also in osteoporosis therapy.

The Otto Aufranc Award: bone augmentation around and within porous implants by local bisphosphonate elution

The bisphosphonate zoledronic acid chemically and physically was bound to hydroxyapatite-coated porous tantalum implants. The zoledronic acid elution characteristics in saline were determined as a function of time and the in vivo effects of elution were quantified at 12 weeks in a canine ulnar implant model. Intramedullary implants surgically were implanted bilaterally into the ulnae of a control group of five dogs and a zoledronic acid-dosed (0.05 mg zoledronic acid) group of four dogs. Computerized image analysis of undecalcified histologic sections was used to quantify the amount of peri-implant bone within the intramedullary canal, the percentage of available pore space filled with new bone, and the number and size of the individual bone islands within the implant pores. The data were analyzed using a hierarchical analysis of variance with 95% confidence intervals. The peri-implant bone occupied a mean of 13.8% of the canal space in controls and 32.2% of the canal space in zoledronic acid-dosed dogs, a relative difference of 134% (2.34-fold) that was significant. The mean extent of bone ingrowth was 12.5% for the control implants and 19.8% for the zoledronic acid-dosed dogs, a relative difference of 58% that was statistically significant. Individual islands of new bone formation with the implant pores were similar in number in both implant groups but were 71% larger on average in the ZA-dosed group. We are the first authors to show that local elution of a bisphosphonate can cause substantial bone augmentation around and within porous orthopaedic implants. The concept represents a potential tool for restoration of bone stock and enhancement of implant fixation in primary and revision cementless joint arthroplasty surgeries in the face of compromised or deficient bone.

Reduction in normalized bone elasticity following long-term bisphosphonate treatment as measured by ultrasound critical angle reflectometry

Using an improved version of ultrasound critical angle reflectometry, the bone quality of cortical and trabecular bone was assessed in vivo by measuring elastic moduli (normalized for bone density) at both principal axes, referred to as the minimum and maximum normalized elasticities. The measurements were made in 30 normal premenopausal women, 30 normal postmenopausal women, 22 untreated postmenopausal women with osteoporosis, 74 postmenopausal women with osteoporosis or osteopenia on bisphosphonate treatment, and 32 patients with renal transplantation (16 women and 16 men) taking steroids. Cortical elasticity was higher than trabecular elasticity; both declined slightly and non-significantly with age in normal women. Among untreated postmenopausal women with osteoporosis, cortical maximum normalized elasticity (E(cmax)) remained within 95% prediction intervals of normal women. Among patients on bisphosphonate, E(cmax) was low in the majority of patients. E(cmax) was significantly more depressed among those taking the drug > or =3 years than <3 years (22.1% below normal premenopausal women versus 17.2%, P =0.001), and among those with incident non-spinal fractures than without (75.9 vs. 81.5%, P =0.008). E(cmax) was independent of bone mineral density at the calcaneus. Most patients with renal transplantation had low E(cmax), with a mean 20.8% below the normal premenopausal mean. Qualitatively similar findings were found with cortical minimum elasticity and with trabecular minimum and maximum elasticities. Thus, the material bone quality of cortical and trabecular bone may be impaired following bisphosphonate treatment, as in renal transplantation on steroids.

The use of bisphosphonates in the treatment of osteoporosis

PURPOSE OF REVIEW

The bisphosphonates alendronate and risedronate, given orally once weekly, are the cornerstone of treatment of postmenopausal osteoporosis, as well as of male and secondary osteoporosis. They reduce significantly the risk of vertebral and nonvertebral fractures; their effects appear early, within 6-12 months, and appear to be sustained. Several questions remain unanswered, however. In addition, data on a new bisphosphonate became available in 2004.

RECENT FINDINGS

The optimal duration of treatment has not been clearly established. Long-term data with alendronate are now available, indicating a persistence of alendronate effects on bone mineral density and bone turnover markers several years after stopping treatment given for 5 years. Whether these effects translate into sustained reduction of fractures needs to be further analyzed. Because of their efficacy, bisphosphonate use has been explored in other forms of osteoporosis, such as after androgen deprivation therapy for prostatic cancer. The challenge of long-term compliance with treatment of osteoporosis has triggered the use of intermittent bisphosphonate. The effects of intermittent oral and intravenous ibandronate on bone mineral density, bone turnover, and fractures have been recently reported.

SUMMARY

The mechanism by which bisphosphonates improve bone strength is not yet fully understood but probably involves complex effects on different components of bone strength, such as microarchitecture.

Kieferknochennekrosen als mögliche unerwünschte Wirkung von Bisphosphonaten

BACKGROUND

Bisphosphonates are widely used in the treatment of cancer patients with hypercalcemia and bone metastases or in osteoporosis therapy. Current reports have focused on therapy-resistant osteonecrosis of the jaws as a possible side effect of bisphosphonates. Official German drug committees have recently warned about the possibility of these side effects in the publication organs Deutsches Arzteblatt and Deutsche Apotheker Zeitung.

CASE REPORTS

So far we have had experience with seven patients showing therapy-resistant osteonecrosis of the mandible under bisphosphonate medication. The presentation of these cases is intended to call attention to this clinically important side effect of bisphosphonate medication.

Mechanical properties of femoral trabecular bone in dogs

Background

Studying mechanical properties of canine trabecular bone is important for a better understanding of fracture mechanics or bone disorders and is also needed for numerical simulation of canine femora. No detailed data about elastic moduli and degrees of anisotropy of canine femoral trabecular bone has been published so far, hence the purpose of this study was to measure the elastic modulus of trabecular bone in canine femoral heads by ultrasound testing and to assess whether assuming isotropy of the cancellous bone in femoral heads in dogs is a valid simplification.

Methods

From 8 euthanized dogs, both femora were obtained and cubic specimens were cut from the centre of the femoral head which were oriented along the main pressure and tension trajectories. The specimens were tested using a 100 MHz ultrasound transducer in all three orthogonal directions. The directional elastic moduli of trabecular bone tissue and degrees of anisotropy were calculated.

Results

The elastic modulus along principal bone trajectories was found to be 11.2 GPa ± 0.4, 10.5 ± 2.1 GPa and 10.5 ± 1.8 GPa, respectively. The mean density of the specimens was 1.40 ± 0.09 g/cm³. The degrees of anisotropy revealed a significant inverse relationship with specimen densities. No significant differences were found between the elastic moduli in x, y and z directions, suggesting an effective isotropy of trabecular bone tissue in canine femoral heads.

Discussion

This study presents detailed data about elastic moduli of trabecular bone tissue obtained from canine femoral heads. Limitations of the study are the relatively small number of animals investigated and the measurement of whole specimen densities instead of trabecular bone densities which might lead to an underestimation of Young's moduli. Publications on elastic moduli of trabecular bone tissue present results that are similar to our data.

Conclusion

This study provides data about directional elastic moduli and degrees of anisotropy of canine femoral head trabecular bone and might be useful for biomechanical modeling of proximal canine femora.