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Iliac crest bone biopsies are used to assess the mechanism of action of drug treatments, yet there are little data comparing this site to sites prone to fracture. The purpose of this study was to compare the delay and the amplitude of responses to treatment in two different bone sites. The short-term effects of zoledronic acid and teriparatide on microarchitecture, collagen crosslinks and bone remodeling were evaluated in iliac crest and lumbar vertebrae. Aged ewes (n=8/gr) received either vehicle (CTRL) or a single injection of zoledronic acid (ZOL, 10mg) or daily injections of teriparatide (TPTD, 20 μg/d) for 3 months. Blood samples were collected monthly for assessing bone turnover markers. At the end of the study, a transiliac bone biopsy (IC) and L1 lumbar vertebrae (LV1) were collected to assess bone microarchitecture; pyridinoline (PYD), deoxypyridinoline (DPD), pentosidine (PEN) content, static and dynamic parameters of bone remodeling. In CTRL, Tb-BV/TV was significantly higher in LV1 than IC (p<0.0001). This was associated with a trend of higher Tb.N, Tb.Th, DA, an inferior Conn.D and a lower bone turnover as shown by the decreases of osteoid parameters, MS/BS, Ac.f in LV1 when compared to IC. In addition, the ratio PYD/DPD was 4 times higher in LV1 than IC. After 3 months, significant decreases of sALP (p<0.001) and sCTX (p<0.001) were observed in the ZOL-group whereas in TPTD-group, after transient increases, they returned to baseline values. When compared to their respective CTRL, ZOL induced significant increases in Tb.BV/TV, Conn.D, Tb.N and Tb.Sp, in IC but not in LV1. Regardless of the site, ZOL markedly depressed the bone turnover: The static parameters of bone formation significantly decreased and the diminution of MS/BS, BFR/BS and Ac.f varied from -94 to -98% vs CTRL (p<0.01 to 0.001). It was associated with a diminution of the DPD content and the PYD/DPD ratio mainly in IC cortices. In contrast, after 3 months, TPTD did not modify the 3D structure and microarchitecture in IC and LV1, except a trend of higher Conn.D in IC, compared to IC-CTRL. TPTD treatment induced a significant increase in cortical porosity in LV1 (p<0.05) when compared to LV1-CTRL. Static parameters of bone formation and resorption were augmented in both sites, significantly only in LV1 (p<0.05) with a trend of increases in MS/BS and BFR/BS, compared to LV1-CTRL. In conclusion, in adult ewes, the bone mass, microarchitecture, remodeling and collagen crosslink content differ according to the bone site (iliac crest and vertebra). Furthermore, after 3 months, the responses to ZOL and TPTD were of different magnitude and delay between the two bone sites. The distinction of bone sites to study the early effects of anti-osteoporotic therapies appears meaningful in order to approach their site-specific anti-fracture efficacy., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Microcracks are one of the determinants of the bone strength and their accumulation may contribute to increased fracture risk. They are detected after bulk staining with various dyes, including basic fuschin, calcein and xylenol orange. The duration of staining usually varies across types of bone and species. The ewe is a large animal with a bone remodeling similar to humans, used as an animal model in bone histomorphometry studies. The aim of the present study was to determine the optimal conditions for bulk staining with xylenol orange of ewe bone. Xylenol orange 5mM in 70% ethanol was applied to iliac crest and vertebral biopsies for 2 or 15 days or 1, 2 or 3 months. After embedding, sections of 40, 50 and 80 μm thick were cut with either a precision diamond wire saw or a microtome. The staining was not visible after 2 or 15 days and was heterogeneous after 1 or 2 months. The quality of 40 and 50 μm thick sections was not preserved compared with those of 80 μm. Microcracks were suitably observed on ewe bone after bulk staining with xylenol orange for 3 months, in 80 μm thick sections. We conclude that the staining procedures should differ when examining ewe or human bone. This may be due to differences in bone matrix composition., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Unusual fractures of the femur diaphysis have been reported in patients treated with alendronate and, although no causal relationship has been established, excessive suppression of bone turnover and length of treatment with alendronate have been implicated in their pathogenesis. We report here clinical, biochemical, and radiological findings of a patient with rheumatoid arthritis and multiple risk factors for fractures who was treated with alendronate for 8 yr and developed spontaneous bilateral subtrochanteric/diaphyseal fractures. Bone biopsies obtained form the iliac crest and the femur showed decreased bone formation with histomorphometric evidence of markedly increased bone resorption at the femur. These results show for the first time that an imbalance between bone resorption and bone formation at the affected bone is associated with the occurrence of these atypical femur fractures. The cause of this imbalance is currently unknown, and further studies of the epidemiology and pathogenesis of diaphyseal femur fractures are warranted.

The amount of bone and the trabecular microarchitecture are two determinants of bone strength which can be quantified by bone histomorphometry. Among the parameters of bone microarchitecture, the Euler number developed in our laboratory (E( strut.cavity )) and trabecular bone pattern factor (TBPf) evaluate the connectivity and complexity independently of the bone quantity, and the speed of sound (SOS) measured by quantitative ultrasound (QUS) corroborates E( strut.cavity ). The aim of the present study was to validate E( strut.cavity ), TBPf, and SOS as parameters of bone microarchitecture and their contribution to bone strength. We examined 20 right os calcis taken after necropsy in 11 males and 9 females, aged 52-95 years. At the same anatomic location, we measured SOS and broadband ultrasound attenuation (BUA) using a Hologic Sahara device and bone mineral density (BMD) using a Hologic QDR 1000W. At this site a transcortical cylinder was cut for both apparent density measurement (Ap.Dens) and biomechanical tests (maximum compressive stress (sigma(max)) and Young's modulus (E)), and histomorphometry was performed with an automatic image analyzer (Visiolab, Explora Nova, France). E and sigma(max) were significantly correlated with the parameters of bone quantity, microarchitecture, and QUS. However, after adjustment for the bone quantity, E correlated only with E( strut.cavity ), TBPf, and SOS, and sigma(max) with BUA. In conclusion, the bone connectivity and complexity evaluated by E( strut.cavity ) and TBPf contribute to bone strength, independently of the bone quantity. The bone mechanical properties may be assessed, in os calcis, in the elastic domain by SOS and in the plastic domain by BUA.

In osteoporosis, bone fragility results from both bone loss and changes in trabecular microarchitecture, which can be quantified by bone histomorphometric parameters. Twenty human calcaneum were collected after necropsy. All measurements were performed at the same anatomical location. Bone histomorphometric parameters were measured on histological slides with an automatic image analyzer. The aims of our study were (1) to develop automatic measurements of four additional parameters reflecting trabecular network connectivity and complexity, i.e., trabecular bone pattern factor (TBPf), Euler number/tissue volume (Euler) according to the three definitions previously reported and to a fourth one established in the laboratory (Euler(strut.cavity)), marrow star volume, and interconnectivity index, and to determine their usefulness in microarchitecture characterization; and (2) to validate these parameters by evaluating their relationship with dual-energy X-ray absorptiometry and quantitative ultrasound (QUS) measurements performed on the same samples. The statistical analysis showed that TBPf and Euler(strut.cavity) appeared to be the most significant connectivity parameters, independently of bone quantity (bone mineral density, apparent density, cancellous bone volume). For QUS, after adjustment for bone quantity, only speed of sound (SOS) was significantly and negatively correlated to Euler(strut.cavity). Broadband ultrasound attenuation depends only on bone quantity. In conclusion, TBPf (a strut analysis parameter extrapolable in three dimensions) and Euler(strut.cavity) (the only bone connectivity parameter reflecting SOS) are two valid bone microarchitecture parameters. These new parameters were significantly correlated to the established trabecular structure parameters: trabecular thickness or trabecular spacing, being weakly correlated with SOS.

As previously reported, the age-related association between bone loss and increased marrow adipose volume may involve inhibitory effects of polyunsaturated fatty acids (PUFAs) potentially released by medullary adipocytes on osteoblastic proliferation and cell cycle progression. Because PUFAs have been reported to activate peroxisome proliferator-activated receptors (PPARs), we investigated the expression of these nuclear receptors in human primary osteoblastic (hOB) cells and examined the effects of natural PPAR ligands on hOB cell proliferation. We demonstrated basic expressions of PPARgamma and PPARbeta/delta in hOB cells at the protein level. As already shown for PUFAs, a short-term treatment with 15deoxy-Delta(12,14) -prostaglandin J2 (15dPGJ2) or prostacyclin (PGI2), which are specific ligands for PPARgamma and PPARbeta/delta, respectively, also significantly inhibited hOB cell proliferation. Given that the cell cycle withdrawal resulting from PPARgamma activation was often associated with the induction of cell differentiation, long-term effects of PUFAs and 15dPGJ2 were also assessed on the expression levels of transcription factors. PUFAs and 15dPGJ2 enhanced the expression of PPARgamma in hOB cells. It is of interest to note that PPARgamma protein level was dose-dependently increased, whereas that of Cbfal was decreased by a fatty acid-rich serum. In conclusion, this study shows that PPARgamma and beta/delta are expressed by hOB cells. The results further suggest that the short-term antiproliferative effect of PUFAs may involve PPAR activation in hOB cells, resulting in a cell cycle withdrawal favorable for the long-term differentiating effects of fatty acids. Further studies are now required to confirm the functional role of PPARs in the antiproliferative effects of PUFAs in hOB cells.

As previously reported, the association of bone loss with an increase in bone marrow adipose volume may be related to the inhibition of human osteoblastic cell proliferation in the presence of human adipocytes. In the osteoblastic supernatant, fatty acid composition varied after coculture with mature adipocytes, with a marked increase in the proportion of docosahexaenoic acid (22:6 n-3; DHA) (+90 +/- 8%). This suggests that polyunsaturated fatty acids (PUFA) may contribute to the inhibitory effect of adipocytes on osteoblastic cell proliferation. The purpose of the present study was to evaluate the effects of two PUFA, DHA and arachidonic acid (20:4 n-6; AA), on the proliferation of primary human osteoblastic (hOB) cells and human osteosarcoma cell line, MG-63. The effects of cholesterol and oleic acid, a monounsaturated FA (18:1 n-9; OA), both being present in adipocyte lipidic vacuoles, were also investigated. At between 10 and 50 micromol/L, DHA and AA induced a significant dose-dependent decrease in hOB cell proliferation (p < 0.0001 and p < 0.006 for DHA and AA, respectively) when compared with control hOB cells exposed to the vehicle (bovine serum albumin). This inhibition reached -50% with 50 micromol/L of DHA or 20 micromol/L of AA. This effect was not related to cell apoptosis, as shown by terminal deoxynucleotidyltransferase-mediated dUTP-fluorescein nick end labeling (TUNEL) and Hoechst dye staining. In contrast, OA and cholesterol had no effect on hOB cell proliferation, even at a high concentration (200 micromol/L). Similar results were observed with regard to MG-63 cell proliferation. In addition, flow cytometric analysis showed that the number of hOB cells in the S phase of the cycle was twofold lower when treated with 50 micromol/L of DHA or AA. In vitro results indicate that mature adipocytes may contribute to age-related bone loss through the release of polyunsaturated fatty acids, which impair osteoblastic proliferation.

Long-term treatment with glucocorticoids (GCs) leads to a rapid bone loss and to a greater risk of fractures. To evaluate the specific effects of this treatment on cancellous bone remodeling, structure, and microarchitecture, we compared 22 transiliac biopsy specimens taken in postmenopausal women (65 +/- 6 years) receiving GCs (> or = 7.5 mg/day, for at least 6 months) and 22 biopsy specimens taken in age-matched women with postmenopausal osteoporosis (PMOP), all untreated and having either at least one vertebral fracture or a T score < -2.5 SD. On these biopsy specimens, we measured static and dynamic parameters reflecting trabecular bone formation and resorption. Also, we performed the strut analysis and evaluated the trabecular bone pattern factor (TBPf), Euler number/tissue volume (E/TV), interconnectivity index (ICI), and marrow star volume (MaSV). Glucocorticoid-induced osteoporosis (GIOP), when compared with PMOP, was characterized by lower bone volume (BV/TV), trabecular thickness (Tb.Th), wall thickness (W.Th), osteoid thickness (O.Th), bone formation rate/bone surface (BFR/BS), adjusted mineral apposition rate/bone surface (Aj.AR/BS), and higher ICI and resorption parameters. After adjustment for BV/TV, the W.Th remained significantly lower in GIOP (p < 0.0001). The active formation period [FP(a+)] was not different. Patients with GIOP were divided into two groups: high cumulative dose GCs (HGCs; 23.7 +/- 9.7 g) and low cumulative dose GCs (LGCs; 2.7 +/- 1.2 g). HGC when compared with LGC was characterized by lower W.Th (p < 0.05), BV/TV (p < 0.001), Tb.Th (p < 0.05), trabecular number (Tb.N; p < 0.05), FP(a+)(p < 0.05), and nodes (p < 0.05), and higher E/TV (p < 0.05), ICI (p < 0.005), and TBPf (p < 0.05). When HGC was compared with PMOP, the results were similar except for the MaSV, which was significantly higher (p < 0.005). In summary, GIOP was characterized by lower formation and higher resorption than in PMOP, already present after LGC. With HGCs, these changes were associated with a more dramatic bone loss caused by a major loss of trabecular connectivity.

The mean degree of mineralization of bone (MDMB) was measured by quantitative microradiography on transiliac bone biopsies taken from 53 postmenopausal osteoporotic women who had been treated with alendronate (ALN; 10 mg/day) during 2 (9 patients) or 3 years (16 patients) or with placebo (PLA; 15 and 13 patients, respectively). In the same patients, bone mineral density (BMD) values were obtained by dual-energy X-ray absorptiometry of the lumbar spine and femoral neck at the beginning and end of treatment. Histomorphometric parameters and activation frequency of new remodeling units were also measured on the iliac biopsies. After 2 years of ALN, MDMB in compact bone was 9.3% (p = 0.0035) and in cancellous bone was 7.3% (p = 0.0009) higher, respectively, than PLA. After 3 years of ALN, MDMB in compact bone was 11.6% (p = 0.0002) and in cancellous bone was 11.4% (p = 0.0001) higher, respectively, than PLA. After 2 and 3 years of ALN, and compared with the corresponding PLA, the distribution of the degree of mineralization in compact and cancellous bone showed a clear shift toward the highest mineralization values and a decrease in the number of bone structure units having low values of mineralization. The between-group differences in MDMB were similar to those of BMD at the lumbar spine BMD (+8.7% after 2 years and +9.6% after 3 years, respectively), suggesting that MDMB augmentation probably accounted for the majority of the increase in BMD seen with ALN. The data support the hypothesis that the reduction in activation frequency caused by the antiresorptive effect of ALN is followed by a prolonged secondary mineralization that increases the percentage of bone structure units having reached a maximum degree of secondary mineralization and, through this mechanism, MDMB. That these effects contribute to improved bone strength is demonstrated by the reduction in fracture incidence previously demonstrated in these patients.

It has been shown that the bone loss occurring with aging in spongy bone is associated with a reduced osteoblastic bone formation and an increased volume of marrow adipose tissue. This observation suggests a relationship between cells from the osteoblastic and adipogenic lineages. The purpose of the present study was to evaluate the influence of mature adipocytes on osteoblastic proliferation and activity in a model of coculture. Human primary osteoblastic (hBOB) cells were derived from femoral bone explants collected in patients undergoing orthopedic surgery. Human stromal osteoblastic (hMSOB) cells were obtained from bone marrow samples collected by aspiration during orthopedic surgery. Extramedullary and medullary mature adipocytes (hAd) showing similar functions, except for their response to insulin, hAd were isolated from mammary adipose tissue collected in women undergoing tumorectomy. Cells were cocultured, with hAd being separated from osteoblastic cells (hBOB or hMSOB) by a porous membrane (0.4 microm). When hBOB cells were seeded on the upper side of the insert and hAd were floating on the lower side, cell contacts between the two cell types were possible through the pores of the membrane. At the end of the experiment, proliferation of the osteoblastic cells was evaluated by [(3)H]-thymidine incorporation and alkaline phosphatase (AP) activity was measured. After 20 h of coculture, proliferation of the hBOB cells was significantly decreased when compared with control hBOB (-40 +/- 6%, p < 0.05). To establish whether or not the influence of hAd on hBOB proliferation required intercellular communications, hAd and hBOB cells were cocultured far from the porous membrane. Six other independent experiments confirmed an inhibition of hBOB proliferation under both experimental conditions (p < 0.05): -35 +/- 7% with possible intercellular contacts, and -30 +/- 7% without any contact. In contrast, the proliferation of hMSOB cells was not significantly modified after coculture with hAd. In addition, the presence of hAd did not significantly modify the AP activity of hBOB (0.163 +/- 0.143 and 0.181 +/- 0.114 nmol/min per microgram of protein in controls and after coculture, respectively). No reproducible effect of hAd-conditioned medium was noted on hBOB- and hMSOB-cell proliferation or hBOB-cell activity. In conclusion, mature adipocytes induced an inhibition of hBOB-cells proliferation, probably mediated by a factor secreted by hAd. This effect may contribute to the age-related reduction of bone formation and bone loss.

Effects of alendronate (ALN) on bone quality and turnover were assessed in 88 patients (52 women and 36 men aged 22-75 years) who received long-term oral glucocorticoid exposure. Patients were randomized to receive oral placebo or alendronate 2.5, 5, or 10 mg/day for 1 year and stratified according to the duration of their prior glucocorticoid treatment. Transiliac bone biopsies were obtained for qualitative and quantitative analysis after tetracycline double-labeling at the end of 1 year of treatment. As previously reported in glucocorticoid-induced osteoporosis, low cancellous bone volume and wall thickness were noted in the placebo group as compared with normal values. Alendronate treatment was not associated with any qualitative abnormalities. Quantitative comparisons among the four treatment groups were performed after adjustment for age, gender, and steroid exposure. Alendronate did not impair mineralization at any dose as assessed by mineralization rate. Osteoid thickness (O.Th) and volume (OV/BV) were significantly lower in alendronate-treated patients, irrespective of the dose (P = 0.0003 and 0.01, respectively, for O.Th and OV/BV); however, mineral apposition rate was not altered. As anticipated, significant decreases of mineralizing surfaces (76% pooled alendronate group; P = 0.006), activation frequency (-72%; P = 0.004), and bone formation rate (-71%; P = 0.005) were also noted with alendronate treatment. No significant difference was noted between the changes observed with each dose. Absence of tetracycline label in trabecular bone was noted in approximately 4% of biopsies in placebo and alendronate-treated groups. Trabecular bone volume, parameters of microarchitecture, and resorption did not differ significantly between groups. In conclusion, alendronate treatment in patients on glucocorticoids decreased the rate of bone turnover, but did not completely suppress bone remodeling and maintained normal mineralization at all alendronate doses studied. Alendronate treatment did not influence the osteoblastic activity, which is already low in glucocorticoid-induced osteoporosis.

Treatment effects on bone quality and remodeling was assessed in postmenopausal women with osteoporosis treated with oral alendronate. One transiliac bone biopsy was obtained from 231 women at either 24 mo (n = 11) or 36 mo (n = 120) from the start of treatment with alendronate at doses of between 5 and 20 mg/d, or placebo. 64 biopsies at 24 mo (31 from the placebo group and 33 alendronate-treated patients) and 95 biopsies at 36 mo (40 from the placebo group and 55 alendronate-treated patients) provided adequate cancellous tissue, and were analyzed by histomorphometry. Mineral apposition rate was unaffected by treatment. At 24 and 36 mo, osteoid thickness, volume, and surface significantly decreased. At each of the doses studied, mineralizing surface and activation frequency significantly decreased at each time point (e.g., -92% and -87%, respectively, for the 10 mg daily dose after 2 yr). These diminutions were of the same magnitude for each dose at 24 mo, and for the two highest doses at 36 mo. A significant increase in wall thickness accompanied by a reduction in erosion depth was detected in biopsies obtained at 24 mo. These findings confirm that mineralization is normal, and trabecular bone turnover markedly decreased in patients receiving long-term dosing with alendronate. The findings also suggest that the observed increases in bone mineral density could result both from a reduction in the remodeling space due to a decreased activation frequency and a possible trend to a positive bone balance. In addition, further studies focused on a possible increase in the degree of mineralization of bone are required.

Primary bone cell cultures were derived from human bone explants. Cellular activity was characterized by the alkaline phosphatase (AP) activity, osteocalcin, and type I and III collagen secretions in the supernatant. The determination of bone cell activity was performed in three different wells. No significant difference was noted between wells: the coefficient of variation was 8.0 +/- 2.9% for AP activity, 18.3 +/- 1.9% for osteocalcin secretion, and 22.5 +/- 14.3% for collagen. The AP activity and osteocalcin secretion significantly decreased with the number of passages: they were the highest after the first passage. Between each subject, the coefficient of variation was 85% for AP activity and osteocalcin secretion and 63 and 57% for type I and III collagen secretion, respectively. The AP activity did not differ with the age or sex of the donor. In contrast, osteocalcin secretion was significantly lower in females than in males. In males, osteocalcin significantly decreased with the age of the donor (r = -0.61; p less than 0.05). Cellular activity did not depend on the site of the biopsy. When bone explants from one donor were cultured in two different petri dishes, the activity of cells was similar in both dishes, except in one case. Primary cell cultures derived from human bone explants are the only model providing untransformed osteoblastlike cells of human origin. Because of the experimental conditions, some factors may have influenced the cellular activity and they must be taken into account to validate further in vitro studies.

We analyzed transiliac bone biopsy specimens obtained after tetracycline double labeling from 24 patients with aluminum-related bone disease who had undergone long-term hemodialysis. The specimens were selected by the following criteria: Al deposits at the mineralization fronts, a dramatic reduction in double-labeled surfaces, reflecting a low mineralization rate, and a significant increase in osteoid volume and osteoid surfaces. The bone formation rate at the tissue level and at the basic multicellular unit level was decreased in all patients. Seventeen biopsy specimens (group 1) showed morphologic and dynamic evidence of osteomalacia, as defined by an increase in the osteoid seam thickness and a decreased mineralization rate. In one specimen from group 1, thickened osteoid seams were present only in a small part of the specimen. In seven specimens (group 2), the osteoid seam thickness index was normal, indicating "aplastic bone." Two specimens from group 2, however, showed morphologic and dynamic evidence of focal osteomalacia either in trabecular or in cortical bone. Specimens from group 2 patients differed from those in group 1 in their significantly lower values of osteoid volume and lower levels of serum alkaline phosphatase and parathyroid hormone. These data show that the absence of significant increase in osteoid seam thickness and the focal distribution of thickened osteoid seams in patients with Al overload and low rate of bone formation reflect the marked reduction of bone matrix formation at the cellular level. It is suggested that low parathyroid activity might play a role in the reduction of bone matrix formation.

Unlabelled: We studied the bone histology by histomorphometric methods in transiliac bone-biopsy specimens from seventy-seven adult patients with aseptic osteonecrosis and normal kidney function. The trabecular bone volume, trabecular osteoid volume, trabecular osteoid surfaces, thickness index of osteoid seams, total resorption surfaces, calcification rate, tetracycline-labeled surfaces, and bone-formation rate at the basic multicellular unit level and at the tissue level were determined. Histological evidence of osteomalacia was found in nine patients, of whom four were alcoholics. In the remaining sixty-eight patients--fifteen treated with corticosteroids, twenty-nine alcoholics, and twenty-four who did not have any detectable etiological factor--a common histomorphometric profile was found. This consisted morphologically of a reduction in trabecular bone volume and in the thickness of osteoid seams, and dynamically of a reduction in calcification rate and in total labeled surfaces. All of these changes suggested a marked decrease in osteoblastic appositional rate and in bone-formation rate at the cell and tissue levels. This could induce a healing defect of microfractures and thus facilitate subchondral fractures., Clinical Relevance: This histological study indicated that non-apparent bone disease--either osteoporosis or osteomalacia--may underlie aseptic osteonecrosis in almost all patients, and be found even when blood and urinary biochemical parameters, usually reflecting bone-remodeling, are normal. An iliac-crest bone biopsy with static and dynamic histomorphometric study is the appropriate method for detecting these abnormalities. These results are of importance for understanding the pathophysiological mechanisms underlying osteonecrosis as well as its prevention and treatment.

The intermethod variation in the measurement of basic bone histomorphometric parameters was evaluated on 100 undecalcified transiliac bone biopsies. Two contiguous samples were taken from 50 patients (33 females; 17 males; mean age: 52 +/- 19 years) for diagnostic purposes. The diagnoses were osteoporosis (n = 38), renal osteodystrophy (n = 18), primary hyperparathyroidism (n = 16), osteomalacia (n = 12), metastatic bone disease (n = 2), thyrotoxic bone (n = 2), fluorosis (n = 2), and 10 biopsies were considered as "normal" bone. Trabecular bone volume (TBV) was measured with both a manual integrating eyepiece and an automatic (QUANTIMET 720-Cambridge Instruments, Cambridge, England) method. Trabecular resorption surfaces (TRS), trabecular osteoid surfaces (TOS), and volume (TOV) were measured with both a manual and a semiautomatic (VIDEOPLAN-Kontron, Munich, West Germany) method. The calcification rate (CR) was measured with both a manual and a semiautomatic method in eight cases after double labeling with tetracycline. Inter- and intraobserver variations were always lower with the automatic and semiautomatic methods than with the manual method, except for TOV. For all the parameters there was a highly significant correlation between manual and computerized methods (0.98 greater than r greater than 0.90). For TBV and CR no significant difference was noted, but for TBV the QUANTIMET appeared more sensitive, that is, better able to detect low values of the structure to be measured. For TRS, the manual method underestimated low values and appeared less sensitive than the semiautomatic method. For the 100 biopsies, the VIDEOPLAN underestimated the osteoid parameters by 13% for TOS and 26% for TOV.(ABSTRACT TRUNCATED AT 250 WORDS)

A hemodialyzed patient showing x-ray and biochemical evidence of apparently pure severe hyperparathyroidism underwent a tetracycline-labeled transiliac bone biopsy. The bone biopsy not only confirmed the hyperparathyroid bone lesions but also revealed an impairment of bone mineralization induced by aluminum. This was demonstrated by a reduction of double-labeled osteoid surfaces, a significant increase in the osteoid seam thickness, and the presence of extensive aluminum deposits in bone. The planned parathyroidectomy was postponed, and deferoxamine (DFO) therapy, 2 g once a week, was initiated. A second bone biopsy, taken 6 months later, showed recovery of normal bone mineralization but the persistence of hyperparathyroid bone lesions. This was associated with a considerable reduction in the extent of aluminum deposits on trabecular bone surfaces. This observation shows that severe and apparently pure hyperparathyroidism can be associated with an impairment of bone mineralization induced by aluminum. This suggests that bone mineralization and aluminum overload should be evaluated in dialyzed patients who are being considered for parathyroidectomy.

In order to evaluate the intersample variations for bone histomorphometric parameters in various metabolic bone diseases, either for a group or for one single patient, two complete contiguous transiliac bone biopsies were taken in 55 subjects. The diagnoses were osteoporosis (OP), renal osteodystrophy (ROD), osteomalacia (OM), primary hyperparathyroidism (HPT), metastatic bone disease, fluorosis, thyrotoxic bone, and "normal" bone. The following histomorphometric parameters were measured: trabecular bone volume (TBV), trabecular osteoid surfaces (TOS) and volume (TOV), trabecular resorption surfaces (TRS), and calcification rate (CR). The thickness index of osteoid seams (TIOS) was calculated. The measurements were performed with both manual and computerized methods which give similar results according to our previous study. The differences between parameters values measured on both cores were expressed by the difference in percent of the mean and by the intrapair coefficient of variation. Moreover, for each parameter, the confidence interval for one subject was calculated from the residual mean square of a two-way analysis of variance. For each parameter, the intersample variation differs according to the diagnosis. Confidence interval (risk = 5%) for one single subject reaches 29% for TBV in OP; 16% for TOS; 26% for TOV and TIOS in OM; 25% for TRS in ROD, and 69% in HPT, but is much lower for groups of 10 and 20 patients. These variations must be taken into account when successive biopsies are performed in one individual or in groups of patients to follow the course of a disease or evaluate the effects of a therapy.

Serum aluminium concentrations and biopsy specimens of bone were examined in 56 patients with end stage chronic renal failure receiving maintenance haemodialysis. Deposits of aluminium in bone specimens were often associated with low bone formation with or without osteomalacia. Serum aluminium concentrations of greater than 3.7 mumol/l (10 micrograms/100 ml) indicated a high probability of deposits of aluminium in bone specimens, although high serum concentrations did not predict the type of renal bone disease. Biopsy of the bone is the best method of detecting aluminium intoxication of bone. A serum aluminium concentration of 3.7 mumol/l should be the threshold beyond which bone biopsy should be performed to confirm an overload of aluminium and identify histological bone changes induced by aluminium.

Serum bone Gla-protein (S-BGP) and other serum biochemical parameters, including alkaline phosphatase (S-AP) and immunoreactive PTH (S-iPTH), were measured in 42 patients undergoing chronic hemodialysis. Each patient also had a tetracycline-labeled transiliac bone biopsy, allowing correlations between the biochemical and trabecular bone histomorphometric parameters, S-BGP was markedly increased [64.0 +/- 74.8 (+/- SD) vs. 6.2 +/- 2.2 ng/ml in normal subjects] significantly correlated with S-AP (r = 0.53) and S-iPTH (r = 0.55) levels. S-BGP was significantly higher in the 14 patients with high turnover renal osteodystrophy (HT-ROD; S-BGP, 138.5 +/- 90.8 ng/ml) than in the 28 patients with low turnover (LT-ROD; S-BGP, 26.8 +/- 14.8 ng/ml). S-BGP was significantly correlated with the cellular parameters of bone resorption and formation (r = 0.57-0.69) and with the dynamic parameters of bone formation (r = 0.62-0.82). The extent of stainable bone aluminum was significantly negatively correlated with S-BGP (r = -0.51) and serum iPTH (r = -0.33), but not with S-AP. S-BGP measurement allowed better discrimination between LT-ROD and HT-ROD groups than did S-AP measurement. However, in the patients with LT-ROD, S-BGP did not discriminate between patients with or without osteomalacia. We conclude that S-BGP is a valuable marker for evaluating bone remodeling and, more specifically, the bone formation rate at the tissue level in hemodialyzed patients.

Bone formation and resorption have been measured in patients with idiopathic osteoporosis by histomorphometry of 7.5-mm trephine biopsies and in the whole body by 85Sr radiotracer methodology and calcium balances. The studies were synchronized and most were preceded by double in vivo tetracycline labeling. Correlations between histological and kinetic bone formation indices were better when better when based on the extent of double tetracycline labels than on measurements of osteoid by visible light microscopy. Correction of the kinetic data for long-term exchange, using 5 months' serial whole body counting of retained 85Sr, improved the fit of the kinetic to the histological data. A statistical analysis of the measurement uncertainties showed that the residual scatter in the best correlations (between exchange-corrected bone formation rates and double-labeled osteoid surface indices) could be attributed to measurement imprecision alone. The exchange-corrected resorption rate correlated fairly well with iliac trabecular resorption surfaces, and using a volume referent rather than a surface referent for the histological index improved the statistical fit when patients with therapeutically accelerated bone turnover were included. A much better correlation was obtained by including osteoid volume acting as an independent predictor of bone resorption in a bivariate regression with a resorption surface index. The residual errors could then be accounted for by known measurement uncertainties. Whereas osteoid taking a double label closely predicted the kinetic rate of bone formation, further analysis suggested that osteoid that took no label or a single label was more closely related to bone resorption, presumably as a secondary result of the coupling of bone formation to bone resorption. The idea that continued bone loss in some patients is associated with defective osteoblastic bone formation is supported by the low rates found in some patients by both techniques. Heuristically these studies validate both in vivo tetracycline labeling for dynamic histomorphometry and corrections for long-term exchange in kinetic studies of bone formation, providing a quantitative framework for the design and analysis of future studies of bone remodeling in the osteoporoses.