Heterogeneity of trabecular and cortical postmenopausal bone loss: a longitudinal study with pQCT

Age and sex differences in estimated tibia strength: influence of measurement site

Variability in peripheral quantitative computed tomography (pQCT) measurement sites and outcome variables limit direct comparisons of results between studies. Furthermore, it is unclear what estimates of bone strength are most indicative of changes due to aging, disease, or interventions. The purpose of this study was to examine age and sex differences in estimates of tibia strength. An additional purpose of this study was to determine which tibia site or sites are most sensitive for detecting age and sex differences in tibia strength. Self-identifying Caucasian men (n=55) and women (n=59) aged 20-59yr had their tibias measured with pQCT from 5% to 85% of limb length in 10% increments distal to proximal. Bone strength index, strength strain index (SSI), moments of inertia (Ip, Imax, and Imin), and strength-to-mass ratios (polar moment of inertia to total bone mineral content [BMC] ratio [Ip:Tot.BMC] and strength strain index to total BMC ratio [SSI:Tot.BMC]) were quantified. There were significant (p<0.01) site effects for all strength variables and strength-to-mass ratios. Site×sex interaction effects were significant (p<0.05) for all strength variables. Men had greater (p<0.01) values than women for all strength variables. Sex differences in Ip, Imax, Ip:Tot.BMC, SSI, and SSI:Tot.BMC ratios were the smallest at the 15% site and peaked at various sites, depending on variable. Site×age interactions existed for Imax, Ip:Tot.BMC, and SSI:Tot.BMC. There were significant age effects, Imax, Ip:Tot.BMC, and SSI:Tot.BMC, as values were the lowest in the 20-29 age group. Age and sex differences varied by measurement site and variable, and larger sex differences existed for moments of inertia than SSI. Strength-to-mass ratios may reflect efficiency of the whole bone architecture.

Age and sex differences in tibia morphology in healthy adult Caucasians

Variability in peripheral Quantitative Computed Tomography (pQCT) measurement sites limits direct comparisons of results between studies. Further, it is unclear what estimates of bone strength are most indicative of changes due to aging, disease, or interventions. The purpose of this study was to examine age group and sex differences in tibia morphology. Additional purposes of this study were to determine which tibia site or sites are most sensitive for detecting age and sex differences.

METHODS

Self-identifying Caucasian men (n=55) and women (n=59) ages 20-59 years and separated by decades had their non-dominant tibias measured with pQCT (Stratec XCT 3000) at every 10% of the limb length from 5% to 85% (distal to proximal). Volumetric BMD and BMC of the total, cortical and trabecular bone were determined, as well as periosteal (PeriC) and endosteal (EndoC) circumferences, and cortical thickness (CTh).

RESULTS

There were significant (p<0.01) site effects for all BMC, vBMD, PeriC and EndoC measures. Large sex differences (men>women) in Tot.BMC (21-28%) were paralleled by differences in Cort.BMC (21-25%) (p<0.01). Site∗sex interaction effects were significant (p<0.05) for BMC (peak sex difference: 5%, 15%, 25%, 85% sites) and circumference (peak sex difference: 65% site) variables. CTh and total vBMD were lowest (p<0.05) in 50-59 year group, and EndoC was highest in the 50-59 year group. Site∗age interactions existed for Cort.vBMD, Tot.BMC (85% site), and EndoC (25%, 35%, 55%-85% sites). Correcting for bone free lean body mass (BFLBM) greatly reduced sex differences, eliminating sex∗site interaction effects, but sex main effects remained significant. Correcting for BFLBM did not eliminate age effects.

CONCLUSION

The magnitude of age and sex differences in tibia variables varied by measurement site demonstrating the need for standardization of measurement sites.

The impact of accurate positioning on measurements made by peripheral QCT in the distal radius

SUMMARY

Data from pQCT sections at the forearm were examined to assess the impact of positioning on measurements. Two thousand five hundred fifty one scans were analysed. The results showed 25% of scans were not performed in the same anatomical location at follow-up when one section was scanned. These results have implications for accurate follow-up BMD measurements.

INTRODUCTION

pQCT of the distal radius is routinely performed using a single section of 2 mm thickness. Accurate positioning is essential to maximise long-term repeatability. We perform two adjacent sections which, permits us to select sections at baseline and follow-up that are in the most similar anatomical site for calculating longitudinal change. This study aimed to assess baseline and follow-up pQCT forearm data to examine variability and determine whether performing two sections, as opposed to one section, improved accuracy when monitoring long-term change in BMD.

METHODS

Two adjacent 1.2 mm pQCT radial sections were performed at: baseline n = 2,551 (1,896F:655M) and follow-up n = 335F.

RESULTS

Baseline: difference between adjacent 1.2 mm forearm sections: total BMD 19.3 mg/cm(3) (females) and 16.7 mg/cm(3) (males); trabecular BMD 3.1 mg/cm(3) (females) and 2.35 mg/cm(3) (males); CSA 16.2 mm(2) (females) and 17.7 mm(2) (males) (all significant).

FOLLOW-UP

percentage of scans at baseline and follow-up performed in the same anatomical location: one section performed-75%, two sections performed-95%.

CONCLUSION

When performing a single section at the distal radius it is difficult to perform scans in the same anatomical location at visits. Performing two or more sections can overcome this problem in some individuals and provide more accurate BMD measurements.

Age-related decline in trabecular and cortical density: a 5-year peripheral quantitative computed tomography follow-up study of pre- and postmenopausal women

This 5-year prospective study assessed changes in trabecular and cortical volumetric bone density at the non-weight-bearing radius and weight-bearing tibia among clinically healthy pre- and postmenopausal women. Altogether 79 premenopausal (mean age +/- SD at baseline 33 +/- 2 years) and 108 postmenopausal (68 +/- 2 years) women participated in the baseline and follow-up measurements. Trabecular density (TrD) of the distal radius and tibia and cortical density (CoD) of the radial and tibial shafts were assessed by peripheral quantitative computed tomography (pQCT). Repeated measures analysis of variance was used to analyze differences of means and mean changes between the age groups. As expected, TrD and CoD values were greater among premenopausal than postmenopausal women. Changes in radial TrD were similar in both age groups: mean (95% confidence interval) TrD of the distal radius declined by 3.0 mg/cm(3) (-0.9 to 7.0) and 5.1 mg/cm(3) (1.8-8.5) in the younger and older age groups, respectively. The respective declines in TrD of the distal tibia were 4.1 mg/cm(3) (2.1-6.0) and 2.8 mg/cm(3) (1.2-4.3). Decline in CoD was greater in the older than younger age group at both the radial and tibial shafts (P < 0.001). The mean absolute declines in radial CoD were 33.3 mg/cm(3) (27.9-38.7) and 49.4 mg/cm(3) (44.9-53.9) in younger and older women, and the declines in tibial CoD were 16.5 mg/cm(3) (12.6-20.2) and 28.1 mg/cm(3) (25.0-31.2), respectively. In conclusion, volumetric TrD in the weight-bearing tibia and non-weight-bearing radius showed similar age-related declines among pre- and postmenopausal women, while the decline in CoD was greater among postmenopausal women.

Trabecular bone status in ultradistal tibia under habitual gait loading: a pQCT study in postmenopausal women

This study investigated regional volumetric trabecular bone mineral density (tBMD) and bone area at the ultradistal tibia in Chinese women using peripheral quantitative computed tomography. Fifty-six postmenopausal women aged 47-62 yr participated in BMD measurements at baseline and 22 of them were followed at both 1-yr and 3-yr follow-up scans. Regional baseline tBMD, rate of annual bone loss, and trabecular bone area were determined. Baseline measurements showed that the tBMD of both the posterior (252.9+/-63.4 mg/cm(3)) and medial (226.6+/-68.9 mg/cm(3)) regions was significantly higher than that of the anterior (126.3+/-61.9 mg/cm(3)) and lateral regions (149.8+/-50.6 mg/cm(3)), respectively (p<0.001). Both the 1-yr and 3-yr follow-up measurements showed that there was significant physiological annual tBMD loss on an average of 1.61%, at the four regions. Inter-slice regional tBMD and trabecular bone area measurements demonstrated a significant linear decrease from the distal to proximal aspects (p<0.001). Findings suggest that dynamic compressive loading during the heel strike and the body weight vector shifting toward the medial aspect during the stance phase in a normal gait might account for the regional tBMD differences. Increased tBMD and bone area toward the distal tibial endplate may adapt to withstand the axial impact loading. However, the low-impact weight-bearing nature of a normal gait may not be osteogenic to prevent regional bone loss. An exercise program specific to the women at risk should be contemplated.

Ovariectomy-induced bone loss varies among inbred strains of mice

There is a subset of women who experience particularly rapid bone loss during and after the menopause. However, the factors that lead to this enhanced bone loss remain obscure. We show that patterns of bone loss after ovariectomy vary among inbred strains of mice, providing evidence that there may be genetic regulation of bone loss induced by estrogen deficiency.

INTRODUCTION

Both low BMD and increased rate of bone loss are risk factors for fracture. Bone loss during and after the menopause is influenced by multiple hormonal factors. However, specific determinants of the rate of bone loss are poorly understood, although it has been suggested that genetic factors may play a role. We tested whether genetic factors may modulate bone loss subsequent to estrogen deficiency by comparing the skeletal response to ovariectomy in inbred strains of mice.

MATERIALS AND METHODS

Four-month-old mice from five inbred mouse strains (C3H/HeJ, BALB/cByJ, CAST/EiJ, DBA2/J, and C57BL/6J) underwent ovariectomy (OVX) or sham-OVX surgery (n = 6-9/group). After 1 month, mice were killed, and microCT was used to compare cortical and trabecular bone response to OVX.

RESULTS

The effect of OVX on trabecular bone varied with mouse strain and skeletal site. Vertebral trabecular bone volume (BV/TV) declined after OVX in all strains (-15 to -24%), except for C3H/HeJ. In contrast, at the proximal tibia, C3H/HeJ mice had a greater decline in trabecular BV/TV (-39%) than C57BL/6J (-18%), DBA2/J (-23%), and CAST/EiJ mice (-21%). OVX induced declines in cortical bone properties, but in contrast to trabecular bone, the effect of OVX did not vary by mouse strain. The extent of trabecular bone loss was greatest in those mice with highest trabecular BV/TV at baseline, whereas cortical bone loss was lowest among those with high cortical bone parameters at baseline.

CONCLUSIONS

We found that the skeletal response to OVX varies in a site- and compartment-specific fashion among inbred mouse strains, providing support for the hypothesis that bone loss during and after the menopause is partly genetically regulated.

Cortical and trabecular bone density and structure in anorexia nervosa

The aim of the study was to examine bone density and architecture with three different measurement methods in a sample of young women with anorexia nervosa (AN) and in an age-matched control group of women. Three-dimensional periphery quantitative computer tomography (3D-pQCT) at the ultradistal radius, a new technology providing measures of cortical and trabecular bone density and architecture, was performed, as well as quantitative ultrasound (QUS) at the heel, and dual energy X-ray absorptiometry (DXA) at the spine and hip. Thirty-six women with AN aged 18-30 years (mean duration of AN: 5.8 years) and 30 age-matched women were assessed. Bone mineral density measured by DXA at the spine and hip, and broadband ultrasound attenuation measured by QUS at the heel were significantly lower in patients than controls. 3D-pQCT demonstrated a highly significant deficit in the absolute number of bone trabecules and a significant reduction of cortical thickness. Severity of underweight was significantly associated with bone deficits at the hip measured by DXA. 3D-pQCT revealed mostly deficits of cortical bone related with age of onset of eating disorder. Using three different methods to measure bone density and bone structure at the hip, spine, heel and ultradistal radius, significant deficits in bone mineral density both in trabecular and cortical bone, as well in trabecular structure could be demonstrated in the AN patients.

Separate assessment of forearm cortical and trabecular bone density from standard densitometry data

BACKGROUND

Cortical and trabecular bone are different bone components. Their mineral density cannot be measured directly by areal bone densitometry.

AIM

To introduce a method for assessment of pure radial cortical and trabecular bone density based on standard densitometry data.

METHOD

The study included 418 healthy females (aged 20-83 years, body mass index between 19 and 30) free of previous fractures and conditions or drugs affecting bone metabolism; as well as a group of 64 age-matched females with early menopause. Forearm bone density was measured by single X-ray absorptiometry and calculated separately for cortical and trabecular bone. Age-adjusted bone density curves were built.

RESULTS

Peak bone density was found to occur between 30 and 34 years of age and was 0.561 g/cm2 for cortical and 0.281 g/cm2 for trabecular bone. In comparison, lowest values were registered between 70 and 74 years of age; cortical bone density reduced by 26% and trabecular density by 44%. Both bone density profiles through life reflected the earlier peri- and postmenopausal (mainly trabecular) and later senile (cortical bone also involved) changes in bone mass. A step-wise pattern of trabecular bone reduction was registered with acceleration around 45, 55 and 65 years. The effects of early menopause on trabecular and cortical bone were tested in the prematurely menopausal women.

CONCLUSIONS

The ability of our model to discriminate between natural and premature menopause was moderate. Although hypothetical (based on calculations from integral densitometry data rather than on direct measurements), our method could differentiate between cortical and trabecular osteopenia and may prove helpful in assessing the type of osteoporosis, in making therapy choices and monitoring response to therapy based on forearm bone density.

Gynecological factors and body mass index as determinants of bone mass in normal postmenopausal women. A study with peripheral quantitative computed tomography (pQCT)

OBJECTIVE

This paper studied the influence of several gynecological factors (years since menopause (YSM), age at menarche and gynecological age or reproductive life) simultaneously with anthropometric factors as determinants of bone mass in 189 healthy postmenopausal women.

METHODS

Bone mass was determined by peripheral quantitative computed tomography.

RESULTS

An overall evaluation showed that YSM correlated negatively with trabecular and cortical bone density (BMDTrab and BMDCorti) (P<0.05 in both cases). Age at menarche correlated negatively with BMDCorti (P<0.05) and gynecological age correlated positively with BMDTrab (P<0.05). Classifying the women according to their body mass index (BMI), the YSM correlation persisted in those subjects whose BMI was >25 kg/m(2), and in age at menarche and gynecological age of women whose BMI was <25 kg/m(2) (P<0.05). After separating women according to their age at menarche, their gynecological age and BMI, the only significant difference that persisted was in BMDTrab which was lower in the group with gynecological age <33 years, with a BMI <25 kg/m(2) (P=0.020). Parity and smoking had no impact on our results. By multiple regression, with BMD as the dependent variable and the gynecological factors as independent variables, we only observed significance between YSM and BMDCorti (P<0.005). The same was observed after separating women according to their BMI in the >25 kg/m(2) group (P<0.05).

CONCLUSIONS

Our data stress the importance of YSM on BMDTrab and BMDCorti, of age at menarche on BMDCorti and of gynecological age on BMDTrab. However, YSM is the gynecological factor that mainly determines BMD. The differences observed between measurements taken with pQCT and other methods commonly used to estimate bone mass indicate that results obtained with one technique cannot be extrapolated to other methods.

Use of peripheral quantitative computed tomography for densitometry of the femoral neck and spine in cynomolgus monkeys (Macaca fascicularis)

Quantitative computed tomography (QCT) allows for the separate densitometric examination of cortical and cancellous bone in vivo. With the new peripheral QCT (pQCT) instrument (the Norland/Stratec XCT-3000A), we evaluated the clinically relevant axial sites of spine and femoral neck in nonhuman primates in vivo. The reproducibility was good (coefficient of variation [CV] <3% at both sites for cortical, trabecular, and total bone mineral density [BMD]; CV 3%-7% for bone mineral content [BMC] and cross-sectional bone area). One hundred sixty intact female cynomolgus monkeys (M. fascicularis) were scanned at the femoral neck. There was less variability among monkeys in cortical BMD (mean 802 mg/mL, CV 6%) as opposed to trabecular BMD (mean 334 mg/mL, CV 28%) or transition zone BMD (mean 457 mg/mL, CV 12%). Scans were performed on lumbar vertebrae (L-4, L-5, and L-6) from five monkeys in vivo and ex vivo. Removal of soft tissue increased measured BMD. Decreasing voxel size from 0.4 mm to 0.2 mm increased measured BMD by diminishing the partial volume effect. Factor analysis demonstrated the expected relationships between pQCT parameters and physical measurement of bone mass and volume ex vivo. Preliminary results in eight ovariectomized and eight reproductively intact monkeys revealed a lower transition zone BMD at the femoral neck, and lower total BMD of the vertebral body in estrogen-deficient animals.

Differential patterns of altered bone formation in different bone compartments in established osteoporosis

AIM

To investigate the level of bone formation in the different bone compartments in cases of established osteoporosis, as previous work has concentrated on trabecular bone alone.

METHODS

Bone formation rates were measured histomorphometrically, in the periosteal (P), cortical (C), subcortical (SC), and trabecular (T) compartments in iliac crest biopsies from 159 patients with established osteoporosis. The values were standardised using age and sex matched control data and patterns of differential change determined by analysis of parametric status (increased, normal, reduced).

RESULTS

Mean bone formation was reduced in all four compartments. This was more marked (4.4/4.1 standard deviations below the mean in C/T, v 2.3/0.9 in P/SC) and more frequent (reduced in 81.5%/78.3% in T/C, v 43.3%/44% in P/SC) in the trabecular and cortical compartments than in the periosteal or subcortical bone. Parametric status was equal in trabecular and cortical bone in 85.4% of cases, and in periosteal and subcortical bone in 65.7%, but in all four compartments in only 35.1%, indicating differential alteration of bone formation in the two sets of compartments (T/C v P/SC).

CONCLUSIONS

Altered trabecular bone formation is important in osteoporosis, but there are differential patterns of alteration in the other three compartments, emphasising the presence of different microenvironments in bone; thus the effect on the cortical compartment was similar to that on the trabecular, while the subcortical and periosteal compartments also showed linkage. The linkage between the two pairs was divergent, indicating different control of bone formation, with resultant different patterns of perturbation in osteoporosis.

Gender differences in normal age-dependent patterns of radial bone structure and density: a cross-sectional study using peripheral quantitative computed tomography

This cross-sectional study determines gender differences in the age-dependent patterns in radial trabecular bone structure using high-resolution peripheral quantitative computed tomography. The nondominant forearrns of 145 adult volunteers (57 men) were scanned and indices of trabecular structure (connectivity index [CI]; mean hole size [H(A)]; and maximum hole size [H(M)]) were determined at the ultradistal radius. The images were also analyzed to determine bone density. Men had significantly higher values for CI (p < 0.01), significantly lower values for H(A) (p < 0.01), and significantly greater bone density (p < 0.001) than women. Age-dependent patterns in normal trabecular structure also displayed gender differences. CI decreased significantly with age in both men (-0.8%/yr, p < 0.05) and women &lpar-2.2%/yr, p < 0.001); however, the rate of change was more pronounced in women (p < 0.001). Similarly, the age-related increase in H(A) (+2.2%/yr) and H(M) (+1.1%/yr) was significant in women (p < 0.01) but not in men. In both sexes, when expressed as an annual percentage of change, indices of trabecular bone structure changed to a greater extent than indices of bone density. The assessment of structural indices may improve our ability to identify individuals at risk for fractures of the distal radius.

Clinical evaluation of a high-resolution new peripheral quantitative computerized tomography (pQCT) scanner for the bone densitometry at the lower limbs

Precision, long-term stability, linearity and accuracy of the x-ray peripheral quantitative computerized tomographic (pQCT) bone scanner XCT 3000 (Norland-Stratec Medical Sys.) were evaluated using the European Forearm Phantom (EFP). In vivo measurements were assessed using a standardized procedure at the distal femur and the distal tibia. In the patient-scan mode, the spatial resolution of the system was 1.04 +/- 0.05 lp/mm as measured at the 10% level of the modulation transfer function (MTF). The contrast-detail diagram (CDD) yielded a minimal difference in attenuation coefficient (AC) of 0.07 cm(-1) at an object size of 0.5 mm. The effective dose for humans was calculated to be less than 1.5 microSv per scan. Short-term precision in vivo was expressed as root mean square standard deviation of paired measurements of 20 healthy volunteers (RMSSD = 0.5%). At the distal femur total volumetric density (ToD) and total cross-sectional area (ToA) were found to be less sensitive to positioning errors than at the distal tibia. Structural parameters like the polar cross-sectional moment of inertia (CSMIp) or the polar cross-sectional moment of resistance (CSMRp) showed a good short-term precision at the distal femur (RMSSD = 1.2 and 1.4%). The relation between the two skeletal sites with respect to CSMIp or CSMRp showed a high coefficient of determination (r2 = 0.77 and 0.74).

Immunolocalization and quantification of noncollagenous bone matrix proteins in methylmethacrylate-embedded adult human bone in combination with histomorphometry

The noncollagenous proteins (NCPs) in the bone matrix comprise growth factors with distinct cellular effects and a series of proteins with less clear biological actions. In order to understand the role of these proteins in bone metabolism and in bone diseases, it is crucial to determine their localization and quantity in normal and pathological bone. We have developed an immunohistochemical method to detect osteopontin, osteocalcin, bone sialoprotein, osteonectin, decorin, biglycan, and the growth factors transforming growth factor-beta, insulin-like growth factor-I, and bone morphogenetic protein-2 both in bone matrix and in bone cells of adult human bone embedded in methylmethacrylate. Immunohistochemistry and standard bone histomorphometry in adjacent sections allows the localization of the proteins to metabolically active sites in bone. The protocol works with several fixatives and with bone specimens obtained and embedded to over 20 years ago. Most importantly, we developed a procedure to specifically stain the mineralized matrix green in combination with a red staining of the NCPs. Using digital image analysis it is possible to quantify the relative amounts of NCPs (microm2 NCP area/microm2 mineralized matrix area). Within one biopsy of normal bone cut at four different heights (at a distance of 100 microm), two adjacent sections were stained either for osteopontin or osteonectin. Thirty trabecular and 20 cortical microscopic fields were measured, and the NCP:mineralized matrix ratio was calculated. Stepwise analysis of the standard error of the mean of the NCP:mineralized matrix ratios showed that measuring about 50 microscopic fields is sufficient to obtain representative data with a small confidence interval. In conclusion, the present procedure enables to quantify NCPs and to relate their presence to metabolically active sites in bone. The quantification provides the opportunity to monitor differences in distribution (e.g., cortical vs. trabecular) and differences between normal and pathological conditions and to assess changes in matrix composition during treatment. This can be done by reanalyzing bone biopsies obtained in the past, e.g., during clinical trials. Therefore, the present technique will be a valuable tool for the study of noncollagenous bone matrix proteins in human bone.