Comparable outcomes in fracture reduction and bone properties with RANKL inhibition and alendronate treatment in a mouse model of osteogenesis imperfecta.

UNLABELLED: We report a direct comparison of receptor activator of nuclear factor kappa B ligand (RANKL) inhibition (RANK-Fc) with bisphosphonate treatment (alendronate, ALN) from infancy through early adulthood in a mouse model of osteogenesis imperfecta. Both ALN and RANK-Fc decreased fracture incidence to the same degree with increases in metaphyseal bone volume via increased number of thinner trabeculae. INTRODUCTION: The potential therapeutic benefit of RANKL inhibitors in osteogenesis imperfecta (OI) is under investigation. We report a direct comparison of RANKL inhibition (RANK-Fc) with bisphosphonate treatment (ALN) from infancy through early adulthood in a model of OI, the oim/oim mouse. METHODS: Two-week-old oim/oim, oim/+, and wildtype (+/+) mice were treated with RANK-Fc 1.5 mg/kg twice per week, ALN 0.21 mg/kg/week or saline (n = 12-20 per group) for 12 weeks. RESULTS: ALN and RANK-Fc both decreased fracture incidence (9.0 ± 3.0 saline 4.4 ± 2.7 ALN, 4.3 ± 3.0 RANK-Fc fractures per mouse). Serum TRACP-5b activity decreased to 65% after 1 month in all treated mice, but increased sacrifice with RANK-Fc to 130-200% at sacrifice. Metaphyseal density was significantly increased with ALN in +/+ and oim/oim mice (p < 0.05) and tended to increase with RANK-Fc in +/+ mice. No changes in oim/oim femur biomechanical parameters occurred with treatment. Both ALN and RANK-Fc significantly increased trabecular number (3.73 ± 0.77 1/mm for oim/oim saline vs 7.93 ± 0.67 ALN and 7.34 ± 1.38 RANK-Fc) and decreased trabecular thickness (0.045 mm ± 0.003 for oim/oim saline vs 0.034 ± 0.003 ALN and 0.032 ± 0.002 RANK-Fc) and separation in all genotypes (0.28 ± 0.08 mm for oim/oim saline vs 0.12 ± 0.010 ALN and 13 ± 0.03 RANK-Fc)., with significant increase in bone volume fraction (BVF) with ALN, and a trend towards increased BVF in RANK-Fc. CONCLUSION: Treatment of oim/oim mice with either a bisphosphonate or a RANK-Fc causes similar decreases in fracture incidence with increases in metaphyseal bone volume via increased number of thinner trabeculae.

In vivo hydroxyapatite formation induced by lipids.

Proteolipids and complexed acidic phospholipids that cause in vitro hydroxyapatite formation, similarly cause hydroxyapatite deposition in 10-mu pore Millipore chambers when implanted in rabbit muscle pouches. The amount of mineral deposited during a 3-week period, based on the calcium and phosphate contents of the chambers, was directly related to the dry weight of the lipid implanted in the chamber. Chambers containing total lipid extract from rabbit bone from which the complexed acidic phospholipids had been removed, acidic phospholipids from which the the proteolipids had been removed, and empty chambers did not accumulate any detectable mineral during the course of the study. Chambers implanted with synthetic hydroxyapatite served as controls for chemical analyses. The presence of hydroxyapatite in the chambers was established 3 weeks after implantation based on electron microscopic, compositional, and wide-angle X-ray diffraction analyses of the deposits. In the cell-free chambers, lipid-induced hydroxyapatite deposition, but not bone matrix formation occurred. This study demonstrates that proteolipids and complexed acidic phospholipids can cause hydroxyapatite mineral deposition in a physiologic environment. To date, these lipids are the only materials isolated from mineralizing tissues, other than reconstituted collagen, that have been shown capable of causing in vivo mineralization in the absence of cells.

The material basis for reduced mechanical properties in oim mice bones.

Osteogenesis imperfecta (OI), a heritable disease caused by molecular defects in type I collagen, is characterized by skeletal deformities and brittle bones. The heterozygous and homozygous oim mice (oim/+ and oim/oim) exhibit mild and severe OI phenotypes, respectively, serving as controlled animal models of this disease. In the current study, bone geometry, mechanics, and material properties of 1-year-old mice were evaluated to determine factors that influence the severity of phenotype in OI. The oim/oim mice exhibited significantly smaller body size, femur length, and moment of area compared with oim/+ and wild-type (+/+) controls. The oim/oim femur mechanical properties of failure torque and stiffness were 40% and 30%, respectively, of the +/+ values, and 53% and 36% of the oim/+ values. Collagen content was reduced by 20% in the oim/oim compared with +/+ bone and tended to be intermediate to these values for the oim/+. Mineral content was not significantly different between the oim/oim and +/+ bones. However, the oim/oim ash content was significantly reduced compared with that of the oim/+. Mineral carbonate content was reduced by 23% in the oim/oim bone compared with controls. Mineral crystallinity was reduced in the oim/oim and oim/+ bone compared with controls. Overall, for the majority of parameters examined (geometrical, mechanical, and material), the oim/+ values were intermediate to those of the oim/oim and +/+, a finding that parallels the phenotypes of the mice. This provides evidence that specific material properties, such as mineral crystallinity and collagen content, are indicative and possibly predictive of bone fragility in this mouse model, and by analogy in human OI.

Synteny-defined candidate genes for congenital and idiopathic scoliosis.

Idiopathic scoliosis (IS) is a common but poorly understood syndrome. Congenital scoliosis (CS) is less common but comparably unexplored. Previous studies suggest that each has a significant genetic component. However, the occurrence of scoliosis in the presence of other hereditary connective tissue syndromes raises the possibility that IS and CS are in fact a heterogeneous group of disorders with varied pathogenetic mechanisms. Mouse mutations have proven informative in identifying genes that are important in the development of the musculoskeletal system and provided important mechanistic insights regarding their roles in human disease. We sought to identify candidate genes for human IS and CS by reviewing mouse mutations with phenotypes affecting the axial skeleton. We performed a systematic review using the Mouse Genome Database (MGD), the Genome Database (GDB), and the Online Mendelian Inheritance in Man (OMIM) world-wide-web sites with additional searches performed based on the results of this initial search. We identified approximately 400 mouse mutations, reviewed approximately 250 of these for vertebral phenotypes, assessed 45 of these for synteny conservation between mouse and man, and identified 28 mouse mutations for which 29 credible candidates for human scoliosis could be identified based on mouse phenotypic and mapping data. For each of these, we have synthesized information about the mouse mutant phenotype, mapping data, information regarding molecular pathogenesis when a specific causative gene has been identified, and information regarding plausible candidates based on map position when the causative gene has not been identified. Among these were three loci for which the mutant gene had been identified and the human homologue was known. Some of the mouse mutants have phenotypes similar to human syndromes.

Identification of the oim mutation by dye terminator chemistry combined with automated direct DNA sequencing.

The homozygous oim/oim mouse, a model of moderate-to-severe human osteogenesis imperfecta, contains a G-nucleotide deletion in the Cola-2 gene (the murine pro alpha(I) collagen gene) that results in accumulation of alpha1(I) homotrimer collagen. Although these mice have a distinctive phenotype that includes multiple fractures and deformities, genotyping is necessary to distinguish them from their wildtype (+/+) and heterozygote (oim/+) littermates. In this study, the dye primer and dye terminator chemistry methods, in combination with automated direct DNA sequencing, were compared for accuracy and ease in genotyping. A total of 82 mice from 14 litters were bred and genotyped; this resulted in 18 +/+, 35 oim/+, and 29 oim/oim mice. The dye primer and dye terminator chemistry methods worked equally well for identification of the deletion mutation and thus the genotype of all of the mice. However, the dye terminator method was found to be superior on the basis of the reduced amount of sample handling and reduced quantity of reagent required.

Antecubital central venous catheter placement complicated by a persistent left superior vena cava.

A 14-year-old female in whom we encountered a persistent left superior vena cava during placement of a central venous catheter is presented. The patient had a history of coarctation of the aorta, but the left superior vena cava was unknown. Since the incidence of persistent left superior vena cava in patients with congenital heart disease is ten times as great as those without, in this patient population it may be useful to obtain radiographic confirmation of catheter position before use.

Clinical, genetic and environmental factors associated with congenital vertebral malformations.

Congenital vertebral malformations (CVM) pose a significant health problem because they can be associated with spinal deformities, such as congenital scoliosis and kyphosis, in addition to various syndromes and other congenital malformations. Additional information remains to be learned regarding the natural history of congenital scoliosis and related health problems. Although significant progress has been made in understanding the process of somite formation, which gives rise to vertebral bodies, there is a wide gap in our understanding of how genetic factors contribute to CVM development. Maternal diabetes during pregnancy most commonly contributes to the occurrence of CVM, followed by other factors such as hypoxia and anticonvulsant medications. This review highlights several emerging clinical issues related to CVM, including pulmonary and orthopedic outcome in congenital scoliosis. Recent breakthroughs in genetics related to gene and environment interactions associated with CVM development are discussed. The Klippel-Feil syndrome which is associated with cervical segmentation abnormalities is illustrated as an example in which animal models, such as the zebrafish, can be utilized to provide functional evidence of pathogenicity of identified mutations.

An analysis of PAX1 in the development of vertebral malformations.

An analysis of PAX1 in the development of vertebral malformations. Due to the sporadic occurrence of congenital vertebral malformations, traditional linkage approaches to identify genes associated with human vertebral development are not possible. We therefore identified PAX1 as a candidate gene in vertebral malformations and congenital scoliosis due to its mutation in the undulated mouse. We performed DNA sequence analysis of the PAX1 gene in a series of 48 patients with congenital vertebral malformations, collectively spanning the entire vertebral column length. DNA sequence coding variants were identified in the heterozygous state in exon 4 in two male patients with thoracic vertebral malformations. One patient had T9 hypoplasia, T12 hemivertebrae and absent T10 pedicle, incomplete fusion of T7 posterior elements, ventricular septal defect, and polydactyly. This patient had a CCC (Pro)-->CTC (Leu) change at amino acid 410. This variant was not observed in 180 chromosomes tested in the National Institute of Environmental Health Sciences (NIEHS) single nucleotide polymorphism (SNP) database and occurred at a frequency of 0.3% in a diversity panel of 1066 human samples. The second patient had a T11 wedge vertebra and a missense mutation at amino acid 413 corresponding to CCA (Pro)-->CTA (Leu). This particular variant has been reported to occur in one of 164 chromosomes in the NIEHS SNP database and was found to occur with a similar frequency of 0.8% in a diversity panel of 1066 human samples. Although each patient's mother was clinically asymptomatic and heterozygous for the respective variant allele, the possibility that these sequence variants have clinical significance is not excluded.

Fourier transform infrared imaging spectroscopy (FT-IRIS) of mineralization in bisphosphonate-treated oim/oim mice.

Fourier transform infrared microscopy (FT-IRM) and imaging spectroscopy (FT-IRIS) are increasingly used to analyze the molecular components of mineralized tissues. A primary advantage of these techniques is the capability to simultaneously image the quantity and quality of multiple components in histological sections at 7 microm spatial resolution. In the current study, FT-IRM and FT-IRIS were used to characterize bone mineralization in a mouse model of osteogenesis imperfecta (OI) after treatment with the bisphosphonate alendronate (ALN). This application is currently relevant since recent studies have demonstrated great promise for the treatment of children with OI with bisphosphonates, but have not identified bisphosphonate-associated bone quality changes. Growing oim/oim mice, a model of moderate-to-severe OI, were treated with ALN (73 microg ALN/kg/day for 4 weeks followed by 26 mg/kg/day for 4 weeks) or saline from 6 to 14 weeks of age, and mineralization was evaluated in femoral cortical and metaphyseal bone. Infrared vibrations of the mineral (a carbonated apatite) and the matrix phases were monitored. The relative amounts of mineral and matrix present (min:matrix), the relative amount of carbonate present in the mineral (carb:min), and the crystallinity of the mineral phase were calculated. In untreated oim/oim bone, the min:matrix was greater and the crystallinity was reduced (indicative of less mature mineral) in the primary versus the secondary spongiosa, most likely due to the presence of calcified cartilage. With ALN treatment, the oim/oim mm:matrix increased in the secondary spongiosa, but the mineral crystallinity was not changed. In the cortical bone, no changes were evident with ALN treatment. These data demonstrate that in this mouse model, ALN treatment results in increased metaphyseal bone mineralization, but does not improve mineral maturity.

Changes in the bone tissue lipids in persons with steroid- and alcohol-induced osteonecrosis.

The lipids associated with osteonecrotic bone have a higher cholesterol content than those associated with normal (nondiseased) or osteoarthritic bone. A study of 18 osteonecrotic femoral heads showed elevated total lipids in the affected superolateral regions of the osteonecrotic bone as compared with both the unaffected inferomedial regions and the superolateral regions of nondiseased femoral heads. Cholesterol content was elevated in both the affected and unaffected regions of the osteonecrotic bones when contrasted with the cholesterol contents of control bones. Greatest elevations were noted for those persons with histories of combined steroid use and alcohol abuse. Seven controls and four osteoarthritic femoral heads had lower total lipid and cholesterol contents. The bone cholesterol content was correlated (r = 0.82) with the proportion of the tissue that was necrotic. The elevated cholesterol content in the necrotic tissues may contribute to cell death by altering membrane metabolism.

A genomic approach to scoliosis pathogenesis.

Genetic predisposition contributes to scoliosis in humans. Two syndromes of primary scoliosis occur--congenital scoliosis, which presents at birth, often associated with other abnormalities, and idiopathic scoliosis which becomes apparent between infancy and adolescence. Little is known regarding the genetic transmission of scoliosis risk. Data gleaned from mouse mutations provide a valuable supplement to human family studies. More than 50 mouse mutations include scoliosis, kyphosis, or tail kinks as a phenotype; the locations of the human homologues for 28 of these can be predicted on the basis of synteny conservation. Some mouse mutations are either more penetrant or more fully expressed in one sex. The mouse data provide a basis both for optimism and for caution in understanding human scoliosis. Mouse models provide insight into mechanisms underlying spinal curvature and help direct searches for genes important in human disease. Four types of defects account for most mouse scoliosis: defects of cell-cell communication, intracellular signal transduction, matrix protein synthesis, and matrix protein metabolism. Mouse data suggest that at least two types of heterogeneity complicate genetic analysis: locus heterogeneity, in which lesions of distinct genes lead to a similar phenotype, and allelic heterogeneity, in which the phenotypes arising from alleles of a single gene differ. By focusing initial studies on multiplex families with apparent simple Mendelian inheritance the effect of heterogeneity is minimized.

The incidence of protrusio acetabuli in Marfan's syndrome and its relationship to bone mineral density.

Twenty-one patients with Marfan's syndrome participated in a study to assess the incidence of and radiographic measurements significant for protrusio acetabuli. Our data show that the incidence of protrusio acetabuli in Marfan's syndrome is 31%. The most sensitive radiographic parameter to determine protrusio acetabuli is crossing of the acetabular line by the iliopectineal line. The presence of protrusio in Marfan's syndrome was not related to the bone mineral content of the hip and pelvis. Protrusio acetabuli in Marfan syndrome's also did not correlate with clinical symptoms. Based on our results, the presence of protrusio acetabuli alone is not an indication for early surgical intervention.

A controlled study of the effects of alendronate in a growing mouse model of osteogenesis imperfecta.

Recent studies have reported that bisphosphonates reduce fracture incidence and improve bone density in children with osteogenesis imperfecta (OI). However, questions still persist concerning the effect of these drugs on bone properties such as ultrastructure and quality, particularly in the growing patient. To address these issues, the third-generation bisphosphonate alendronate was evaluated in the growing oim/oim mouse, an animal model of moderate-to-severe OI. Alendronate was administered to 6-week-old mice during a period of active growth at a dosage of 73 microg alendronate/kg/day for the first 4 weeks and 26 microg alendronate/kg/day for the next 4 weeks. Positive treatment effects included a reduction in the number of fractures sustained by the alendronate-treated oim/oim mice compared with untreated oim/oim mice (2.1+/-2.0 vs 3.2+/-1.6 fractures per mouse), increased femoral metaphyseal density (0.111+/-0.02 vs 0.034+/-0.04 g/cm2), a tendency towards reduced tibial bowing (4.0+/-3.7 vs 6.1+/-5.8 degrees), and towards increased femoral diameter (1.22+/-0.12 vs 1.15+/-0.11 mm). Potential negative effects included a persistence of calcified cartilage in the treated oim/oim metaphyses compared with treated wildtype (+/+) (33.8+/-11.1 vs 22.1+/-10.2%), and significantly shorter femora compared with nontreated oim/oim mice (14.8+/-0.67 vs 15.3+/-0.37 mm). This preclinical study demonstrates that alendronate is effective in reducing fractures in a growing mouse model of OI, and is also an important indicator of potential positive and negative outcomes of third-generation bisphosphonate therapy in children with OI.