Vitamin D Deficiency in Slipped Upper Femoral Epiphysis: Time to Physeal Fusion.

BACKGROUND: Slipped upper femoral epiphysis (SUFE) has an incidence of 1 to 7 per 100,000 adolescents in the United Kingdom and its link with obesity is well established. With an increasing number of pediatric orthopaedic patients presenting with vitamin D deficiency, the aim of our study was to establish the prevalence of vitamin D deficiency in SUFE patients presenting to an orthopaedic department in the United Kingdom and whether a low vitamin D level increases the time to proximal femoral physeal fusion after surgical fixation. METHODS: A total of 27 pediatric patients, with a female to male ratio of 17:10 and a mean age of 11.5 years (SD=1.99), range 8 to 16 years, presented with a SUFE and their vitamin D level was assessed during the study period, June 2007 to July 2012 (inclusive). The majority of these patients (85.2%) were assessed as vitamin D deficient, with a serum 25-(OH)D<52 nmol/L. The time taken for >50% physeal fusion on anteroposterior radiography after surgical fixation reported in the literature is 9.6 months, with no reported vitamin D deficiency or insufficiency. RESULTS: In our study, the median time to physeal fusion in the vitamin D-deficient and vitamin D-insufficient patients was 25 months (interquartile range, 17 to 43 mo; mean of 29 mo, SD=16.8). A negative correlation was also observed between vitamin D level and the time taken for physeal fusion after surgical fixation. CONCLUSIONS: We conclude that a high prevalence of vitamin D deficiency has been observed in our SUFE patients. Comparing the time taken for physeal closure of 9.6 months in the literature with vitamin D-deficient patients, this is prolonged. Indeed, a negative correlation has been shown between vitamin D level and time to physeal fusion. This study highlights the need for regular vitamin D status assessment in SUFE patients to allow early implementation of treatment with vitamin D supplementation. The impact of vitamin D screening and supplementation on SUFE outcomes should be investigated further.

The role of estrogen receptor-α and its activation function-1 for growth plate closure in female mice.

High estradiol levels in late puberty induce growth plate closure and thereby cessation of growth in humans. In mice, the growth plates do not fuse after sexual maturation, but old mice display reduced longitudinal bone growth and high-dose estradiol treatment induces growth plate closure. Estrogen receptor (ER)-α stimulates gene transcription via two activation functions (AFs), AF-1 and AF-2. To evaluate the role of ERα and its AF-1 for age-dependent reduction in longitudinal bone growth and growth plate closure, female mice with inactivation of ERα (ERα(-/-)) or ERαAF-1 (ERαAF-1(0)) were evaluated. Old (16- to 19-mo-old) female ERα(-/-) mice showed continued substantial longitudinal bone growth, resulting in longer bones (tibia: +8.3%, P < 0.01) associated with increased growth plate height (+18%, P < 0.05) compared with wild-type (WT) mice. In contrast, the longitudinal bone growth ceased in old ERαAF-1(0) mice (tibia: -4.9%, P < 0.01). Importantly, the proximal tibial growth plates were closed in all old ERαAF-1(0) mice while they were open in all WT mice. Growth plate closure was associated with a significantly altered balance between chondrocyte proliferation and apoptosis in the growth plate. In conclusion, old female ERα(-/-) mice display a prolonged and enhanced longitudinal bone growth associated with increased growth plate height, resembling the growth phenotype of patients with inactivating mutations in ERα or aromatase. In contrast, ERαAF-1 deletion results in a hyperactive ERα, altering the chondrocyte proliferation/apoptosis balance, leading to growth plate closure. This suggests that growth plate closure is induced by functions of ERα that do not require AF-1 and that ERαAF-1 opposes growth plate closure.

Femoral head histology subsequent to ischemia, reperfusion and steroid treatment.

An episode of ischemia followed by reperfusion of the femoral head (FH) is thought to be a common pathway in the pathogenesis of femoral head necrosis (FHN). Femoral head histology was investigated after short-term high-dose steroid treatment and femoral head ischemia and reperfusion in a large animal model. Twenty-two pigs were randomized to receive methylprednisolone 20mg/day/kg bodyweight intamuscularly for 3 days followed by methylprednisolone 10mg/day/kg bodyweight for 11 days (n=11), whereas the control group (n=11) received no treatment. After 6h of unilateral hip-joint pressure increase to 250mmHg, the pressure was discontinued and reperfusion was allowed for 4h. Undecalcified histology was performed for the femoral head subchondral region, the mid-region, and the region adjacent to the growth plate. Congestion phenomena were predominantly discerned in femoral head sections of the tamponaded hips. Histomorphometry revealed fat cell hyperthrophy and reduced hemopoetic marrow cells in the femoral heads of the steroid-treated group of animals. The number of blood vessels and bone trabeculae remained unchanged. These characteristics may correlate with early-stage femoral head necrosis.

Bone growth in length and width: the Yin and Yang of bone stability.

Bone growth in length is primarily achieved through the action of chondrocytes in the proliferative and hypertrophic zones of the growth plate. Longitudinal growth is controlled by systemic, local paracrine and local mechanical factors. With regard to the latter, a feedback mechanism must exist which ensures that bone growth proceeds in the direction of the predominant mechanical forces. How this works is unknown at present. Bone growth in length is detrimental to bone stability, but this effect is counteracted by concomitant bone growth in width. This occurs through periosteal apposition, which is the responsibility of periosteal osteoblasts. The action of these cells is mainly controlled by local factors, with modulation by systemic agents. According to the mechanostat theory, periosteal apposition is regulated by mechanical requirements. An alternative model, called sizostat hypothesis, maintains that a master gene or set of genes regulate bone growth in width to reach a pre-programmed size, independent of mechanical requirements. The virtues of these two hypotheses have been the subject of much discussion, but experimental data are scarce. Future research will have to address the question how periosteal bone cells manage to integrate mechanical, hormonal and other input to shape bones that are as strong as they need to be.

Canine cancellous bone microarchitecture after one year of high-dose bisphosphonates.

We examined the effects of one-year high-dose bisphosphonates (risedronate 0.5 mg/kg/day or alendronate 1.0 mg/kg/day) on the three-dimensional (3-D) microstructural and mechanical properties of canine cancellous bone. A high-resolution micro-CT scanner was used to scan cubic specimens produced from the first lumbar vertebrae. Microstructural properties of the specimens were calculated directly from the 3-D datasets and the mechanical properties of the specimens were determined. Our data demonstrate significant microarchitectural changes in the bisphosphonate-treated cancellous bone that was typically plate-like, denser, with thicker and more trabeculae compared with those of the controls. Consistent with architectural changes, the Young's moduli of cancellous bone increased in all three directions with the greatest increase in primary axial loading (cephalo-caudal) direction after treatment. Our results suggest a bone remodeling-adaptation mechanism stimulated by bisphosphonates that increases bone volume fraction, thickens trabeculae, changes trabeculae towards more plate-like, and increases mechanical properties. The secondary degree of anisotropy contributed significantly to the explained variance in bone strength, and the primary or tertiary degree of anisotropy improved the explanation of variances for Young's moduli, i.e., 79% of strength variances or 74-83% of modulus variances could be explained by the combined anisotropy and bone volume fraction. These significant improvements of cancellous bone architecture provide a rationale for the clinical observation that fracture risk decreased by 50% in the first year of bisphosphonate therapy with only a 5% increase in bone mineral density. We conclude that bisphosphonates enhance mechanical properties and reduce fracture risk by improving architectural anisotropy of cancellous bone 3-D microarchitecture.

Production of angiogenesis inhibitors and stimulators is modulated by cultured growth plate chondrocytes during in vitro differentiation: dependence on extracellular matrix assembly.

Secretion of angiogenesis inhibitors and stimulators is modulated during in vitro differentiation of embryonic chick growth plate chondrocytes. Supernatants from dedifferentiated cells undergoing maturation to hypertrophic chondrocytes in suspension progressively inhibited vascular cell random migration and invasion of basement membrane matrix by endothelial cells. Maximal inhibition was exhibited by conditioned medium from hypertrophic chondrocytes. The same medium also repressed vascular cell migration induced by highly angiogenic Kaposi's sarcoma cell supernatants and prevented formation of an anastomosed network of tube-like structures by endothelial cells plated on matrigel. On the contrary, when the suspension culture of hypertrophic chondrocytes was supplemented with ascorbic acid, a condition leading to the formation of a mineralized tissue similar to calcified cartilage, a dramatic switch to production of angiogenic activity was observed. Medium conditioned by osteoblast-like cells derived from hypertrophic chondrocytes also induced vascular cell migration and invasion of basement membrane matrix. The presence of angiogenic activity in the conditioned medium was assessed also by an in vivo assay in mice using reconstituted basement membrane associated with heparin. Therefore, interactions of chondrocytes with their extracellular matrix are an absolute requirement for the expression of angiogenic activities by hypertrophic chondrocytes at late developmental stages.

Electron microscopy of calcification during high-density suspension culture of chondrocytes.

Chondrocyte cultures grown in centrifuge tubes with intermittent centrifugation differentiate into hypertrophic chondrocytes and form calcification. We examined chondrocytes cultured in this system electron microscopically. Rat growth-plate chondrocytes were seeded in a plastic centrifuge tube and cultured in the presence of Eagle's minimum essential medium supplemented with 10% fetal bovine serum and 50 micrograms of ascorbic acid per ml. Specimens were examined by using electron microscopy and selected-area electron-diffraction techniques. In the early stage of culture, a few chondrocytes were scattered and extracellular matrices were not observed. In the middle stage of the cultures, the chondrocytes resembled proliferative cells. Matrix vesicles appeared to be budding from the cell surfaces of chondrocytes and were observed sparsely in the extracellular matrices, which were well formed around the chondrocytes. Matrix vesicles increased substantially during the following cultures. In the mature stage of the cultures, crystal formation related to matrix vesicles was observed. In the 33-day cultures, several masses of calcified matrix were formed and it was confirmed to be apatite by selected-area electron diffraction analysis. The chondrocytes appeared hypertrophic during this same stage. The 56-day culture was similar to the 33-day culture. It was concluded that this culture system provides an extracellular-matrix mineralization which is produced by chondrocytes per se.

[99mTc]diphosphonate uptake and hemodynamics in experimental arthritis: effect of naproxen in the canine carrageenan injection model.

The impact of naproxen treatment on juxta-articular hemodynamics and bone metabolism in experimental juvenile arthritis was studied in the articular carrageenan injection model. Unilateral gonarthritis was induced for 12 weeks in eight dogs receiving naproxen (dosage, 2 mg/kg) and eight controls. Regional blood flow was assessed by the microsphere method, plasma volume by the distribution space of [125I]fibrinogen, and bone metabolism by the 2-h uptake of [99mTc]diphosphonate ([99mTc]DPD). Synovial effusion was less prominent with naproxen treatment as judged by joint fluid volume and pressure. Naproxen reduced the arthritic capsular hyperemia, almost normalized a severe blood flow increase in patella and both juxta-articular epiphyses, ameliorated an expansion of plasma volume in the patella and the distal femoral epiphysis, and normalized an increased [99mTc]DPD uptake in subchondral femoral bone and the tibial cortex. Significantly increased arteriovenous shunting in the arthritic extremity was unaffected by naproxen. The study suggests that long-term cyclooxygenase inhibition offers protection against hemodynamic and metabolic changes in juxta-articular bone secondary to synovial inflammation.

Linear bone growth of oMT1a-oGH transgenic male mice.

Linear bone growth was studied in male mice possessing a controlled ovine metallothionein 1a promoter-ovine growth hormone (oMT1a-oGH) transgene. Transgene expression was activated at weaning by the addition of 25 mM zinc sulfate to drinking water; transgenic and control mice received the zinc supplementation. The ulna, humerus, and tibia were excised at 10-day intervals until 130 days from control and from mice hemizygous for oMT1a-oGH. Bones from mice overexpressing growth hormone (GH) were 11-20% longer than those from controls (P less than 0.01) at 130 days. Transgenic mice exhibited both an enhanced rate of bone growth and a growth period of greater duration, i.e., the ulna, tibia, and humerus from oMT1a-oGH mice grew at an accelerated rate for an additional 20-40 days relative to the same bones from control mice. The bones from both groups were characterized by isometric growth patterns. Genetic size scaling revealed that the observed differences in bone growth were directly related to the mature size of the bone, suggesting that the bones possess an inherent growth pattern that is followed even in the presence of elevated GH.

The effect of high calcium and/or high protein diet on bone growth in growing rats kept at high ambient temperature.

The effects of high calcium and/or high protein diet on bone growth were examined in growing rats kept at high ambient temperature. Thirty-five Wistar strain male rats aged 45 days were divided into 5 groups; room temperature, 24 degrees C and a normal diet (CN), 34 degrees C and a normal diet (HN), 34 degrees C and a high calcium diet (HCa), 34 degrees C and a high protein diet (HPr), and, 34 degrees C and a high calcium-protein diet (HCaPr). The animals were given the same amount of feed. On day 35 of experiment, blood and femurs were collected from all rats. Physical traits, calcium and phosphorus contents of right femur were measured. The number of chondrocyte and the thickness of epiphyseal growth plate were measured in distal epiphysis of left femur. Alkaline phosphatase activities and protein contents were measured in the homogenate of proximal epiphysis and diaphysis of left femur. Ultrafiltrable calcium concentrations and total concentrations of calcium and phosphorus were measured in serum. None of the treatments significantly affected the elongation and densities of calcium and phosphorus in femur. The bone growth in width was reduced at high ambient temperature and high protein diet furthermore reduced the bone growth in width at high ambient temperature. Total calcium and phosphorus concentrations were lower in serum at high ambient temperature. Total calcium concentration in serum was increased by high calcium diet and decreased by high protein diet in hot environment, while ultrafiltrable calcium concentration in serum tended to be higher at high temperature.(ABSTRACT TRUNCATED AT 250 WORDS)

Electron microscopic analysis of mineral deposits in the calcifying epiphyseal growth plate.

Early mineral deposits within calcifying rat epiphyseal growth plates were studied by bright field and selected-area dark field electron microscopy, and X-ray microanalysis. These mineral deposits were prepared in situ by high-pressure freezing, freeze substitution, and low-temperature embedding, and were examined in unstained, stained, and ethyleneglycol tetraacetic acid (EGTA)-treated stained thin sections. On unstained sections mineral rods occur within an amorphous density of calcium and phosphorus (CaP). X-ray microanalysis of stained sections reveals that the location of electron-dense deposits does not always correspond to that of the CaP mineral deposits identified in electron microscopic images. Such an analysis showed a depletion of both Ca and P in stained sections at sites corresponding to high levels of these elements in unstained sections. Staining thus demineralizes early deposition sites of CaP; at the same time lead (Pb) and uranium (U) bind to the organic components of the extracellular matrix formerly associated with Ca and P. This substitution phenomenon alters the overall fine structure of mineral sites by depleting the amorphous density of Ca and P, and by creating isolated rodlike structures that have formerly been interpreted as representing hydroxyapatite (HAP) crystals. Selected-area dark field imaging shows nascent sites of HAP crystals to be associated with the limiting membrane of matrix vesicles, but such crystals were undetectable at these sites with conventional bright field images. Dark field imaging also showed that the typical 30-80 nm crystal rods found in calcified cartilage consist of aggregates of HAP crystals.

Effects of pulsing electromagnetic fields on bone growth and articular cartilage.

Observations made during treatment of juvenile pseudarthrosis by pulsing electromagnetic fields (PEMF) suggested that bone growth might be altered. PEMF applied to immature rabbits under conditions of continuous stimulation (24 hours/day for 8 weeks) produced no major changes in bone growth. Continuous stimulation by PEMF induced a statistically significant increase (22%) in femoral articular cartilage glycosaminoglycan. Intermittent PEMF stimulation (12 hours with stimulation/12 hours without stimulation) for 18 weeks produced no significant change in bone growth or time of epiphyseal plate closure. No significant changes in the physical characteristics of growing bone were observed with any treatment.