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Effects of sex steroid receptor specificity in the regulation of skeletal metabolism.

The interaction between estrogens and androgens, with their protective effects in bone, and parathyroid hormone (PTH), a calcitropic peptide hormone, is complex but may be better understood with murine models. The purpose of this study was to characterize skeletal phenotypes of mice deficient in estrogen receptor alpha (ERalpha), androgen receptor (AR, mutant tfm), or both, and determine if ERalpha and AR alter osteoblast differentiation and/or PTH response in vitro. Loss of ERalpha resulted in increased long bone length in females, but reduced length in males, suggesting loss of ERalpha reversed sex steroid-dependent skeletal dimorphism. The AR deficient tfm mice (genetically male but phenotypically female) had the longest bones and, similar to males, lengths were reduced with loss of ERalpha. Loss of AR and/or ERalpha resulted in a reduction in femoral bone mineral density (BMD) compared to male wildtype (WT) mice, suggesting tfm mice follow the female sex for BMD. In males or tfm mice, but not females, loss of AR and/or ERalpha caused a reduction in cortical width of the tibia compared to male WT mice. Reduced trabecular bone was found in tibiae of female and tfm mice versus male littermates, suggesting that tfm mice follow the female sex for trabecular bone but loss of ERalpha did not alter trabecular bone levels. Primary calvarial osteoblasts of male WT mice were less responsive to PTH stimulation of cAMP than all other genotypes, suggesting the female chromosomal sex and/ or loss of ERalpha or AR results in increased sensitivity to PTH. In conclusion, tfm mice follow the male pattern of long bone development, but imitate females in bone density and trabecular bone. Loss of ERalpha and/or AR results in increased osteoblast sensitivity to PTH and may explain actions of PTH noted in hypogonadal humans.

Animals↗

Bone mass of asian adolescents in China: influence of physical activity and smoking.

INTRODUCTION/PURPOSE: Research addressing the role of biology and behavior on bone development during times of peak bone acquisition in adolescence is limited. The present investigation was conducted to address the influence of body composition (lean body mass, fat mass), menarche, leisure physical activity, sports team participation, smoking, and second-hand smoke on skeletal mass of a unique sample of Asian adolescents in China. METHODS: A total of 166 girls and 300 boys (ages 12-16 yr) participated in this study. Bone mineral density (BMD) and content (bone mineral content (BMC)) of the forearm and the os calcis were measured using dual energy x-ray absorptiometry (DXA); lean body mass (LBM) and fat mass were estimated by bioelectrical impedance analysis (BIA); grip strength was measured by isometric dynamometry. Menarche, leisure physical activity, sports team participation, and active and passive smoking were determined using questionnaire. RESULTS: In girls, a total of 44% of the variance in forearm BMC was attributed to a model which included LBM (32%), time since menarche (10%), and age (2%); heel BMC was best predicted by LBM alone (42%), with no significant contribution by other variables. In boys, a total of 39% of the variance in forearm BMC was attributed to a model which included LBM (28%), age (5%), sports team participation (4%), height (1%), and fat mass (1%); heel BMC was best predicted by LBM (50%) and height (3%), accounting for 53% of the variance. CONCLUSION: The findings of this study suggest that lean body mass is the primary determinant of bone mass in Chinese adolescents. Menarche is also an important contributor in girls, whereas age and sports team participation are secondary predictors of bone mass in boys.

Absorptiometry, Photon↗

Evaluation of bone mineral density in chronic glue sniffers.

Although acute and chronic toxic effects of inhalant (glue) abuse have been well demonstrated on many organ systems, the effects on the skeletal system and bone mineral content of young people with this addiction have, to our knowledge, not yet been investigated by bone mineral density measurement. In the present study bone mineral density was measured by the dual-energy X-ray absorptiometry method in 25 children and adolescents with inhalant abuse and compared with that of a control group (n=30) to detect whether there was any delay in bone development or any decrease in bone mass. Chronological age, height and weight, serum calcium, phosphorus and alkaline phosphatase levels of the study group were not significantly different from those of the control group (p>0.05), whereas bone mineral density was significantly reduced in the study group (p=0.001). Teenagers with glue vapor abuse may carry an increased risk of future fracture even though the exact mechanism(s) responsible for the toxicitiy of glue vapor on bone metabolism remains to be determined. To ascertain the exact component of glue responsible for bone demineralisation may be of value in proposing a change in the composition of the glue. Education and/or rehabilitation programs currently have the greatest importance in preventing and overcoming the harmful effects of this public health problem which is so common in young children and adolescents.

Absorptiometry, Photon↗

Phenotypic alterations in fos-transgenic mice correlate with changes in Fos/Jun-dependent collagenase type I expression. Regulation of mouse metalloproteinases by carcinogens, tumor promoters, cAMP, and Fos oncoprotein.

Using specific cDNAs isolated from mouse fibroblasts we determined tissue-specific expression of different matrix metalloproteinase genes: both stromelysin-1 and collagenase IV are highly expressed in heart and lung, whereas collagenase I is expressed most abundantly in skeletal muscle, kidney, and bone. High basal level expression of stromelysin-2 is found in heart and kidney. Like in man and rat, the expressions of collagenase I, stromelysin-1, and stromelysin-2 are regulated by the tumor promoter 12-O-tetradecanoyl-phorbol 13-acetate and by UV irradiation, but not by cAMP. In contrast, the expression of the 72-kDa collagenase IV is not affected by either stimuli. We and others have shown previously that under cell culture conditions, the regulation of human collagenase I is regulated by the transcription factor Fos/Jun (AP-1). Here we show that in c-fos transgenic mice transcription of collagenase I is induced in thymus, spleen, and, most dominantly, in bone upon overexpression of Fos. Neither collagenase IV nor stromelysin-1 or stromelysin-2 expression is affected by c-Fos. The sites of induced collagenase I expression correlate with the sites of Fos-induced long-term cellular alterations in transgenic mice including bone remodeling and T cell development. In fact, in the developing bone tumors strongly enhanced levels of collagenase I transcripts were detectable. These results identify collagenase I as a Fos-regulated gene in vivo and suggest a possible role for Fos/Jun heterodimers in establishing the pathological phenotype of c-fos transgenic mice.

3T3 Cells↗

The PERK eukaryotic initiation factor 2 alpha kinase is required for the development of the skeletal system, postnatal growth, and the function and viability of the pancreas.

Phosphorylation of eukaryotic initiation factor 2 alpha (eIF-2 alpha) is typically associated with stress responses and causes a reduction in protein synthesis. However, we found high phosphorylated eIF-2 alpha (eIF-2 alpha[P]) levels in nonstressed pancreata of mice. Administration of glucose stimulated a rapid dephosphorylation of eIF-2 alpha. Among the four eIF-2 alpha kinases present in mammals, PERK is most highly expressed in the pancreas, suggesting that it may be responsible for the high eIF-2 alpha[P] levels found therein. We describe a Perk knockout mutation in mice. Pancreata of Perk(-/-) mice are morphologically and functionally normal at birth, but the islets of Langerhans progressively degenerate, resulting in loss of insulin-secreting beta cells and development of diabetes mellitus, followed later by loss of glucagon-secreting alpha cells. The exocrine pancreas exhibits a reduction in the synthesis of several major digestive enzymes and succumbs to massive apoptosis after the fourth postnatal week. Perk(-/-) mice also exhibit skeletal dysplasias at birth and postnatal growth retardation. Skeletal defects include deficient mineralization, osteoporosis, and abnormal compact bone development. The skeletal and pancreatic defects are associated with defects in the rough endoplasmic reticulum of the major secretory cells that comprise the skeletal system and pancreas. The skeletal, pancreatic, and growth defects are similar to those seen in human Wolcott-Rallison syndrome.

Animals↗

The cyclin-dependent kinase inhibitor p57(Kip2) mediates proliferative actions of PTHrP in chondrocytes.

Parathyroid hormone-related peptide (PTHrP) is a positive regulator of chondrocyte proliferation during bone development. In embryonic mice lacking PTHrP, chondrocytes stop proliferating prematurely, with accelerated differentiation. Because the bone phenotype of mice lacking the cyclin-dependent kinase inhibitor p57(Kip2) is the opposite of the PTHrP-null phenotype, we hypothesized that PTHrP's proliferative actions in chondrocytes might be mediated by opposing p57. We generated p57/PTHrP-null embryos, which showed partial rescue of the PTHrP-null phenotype. There was reversal of the loss of proliferative chondrocytes in most bones, with reversal of the accelerated differentiation that occurs in the PTHrP-null phenotype. p57 mRNA and protein were upregulated in proliferative chondrocytes in the absence of PTHrP. Metatarsal culture studies confirmed the action of PTHrP to decrease p57 mRNA and protein levels in a model in which parathyroid hormone (PTH), used as an analog of PTHrP, increased chondrocyte proliferation rate and the length of the proliferative domain. PTH treatment of p57-null metatarsals had no effect on proliferation rate in round proliferative chondrocytes but still stimulated proliferation in columnar chondrocytes. These studies suggest that the effects of PTHrP on both the rate and extent of chondrocyte proliferation are mediated, at least in part, through suppression of p57 expression.

Animals↗

Postnatal development of dependence on thyroid hormones for growth and differentiation of rat skeletal structures.

We have studied the development of thyroid hormone dependence for growth and differentiation of rat skeletal tissues. The radius, tail tip or xiphoid process from 1-day-old rats was transplanted in its entirety under the kidney capsule of euthyroid or hypothyroid (TX) adult syngeneic virgin rats and grown there for 3, 6, 9, 12 or 15 days. Pieces of the sternum or calvarium were treated similarly. Growth of transplanted radius and sternum in TX hosts showed significant retardation by day 3, and that of transplanted calvarium, tail tip and xiphoid showed significant inhibition by day 6 post transplantation. Tissue differentiation of all of the transplants was inhibited in TX hosts and the appearance of epiphyseal ossification centers was significantly delayed. Injection of Propylthiouracil (PTU) in solvent into the neonatal rats from day 1 to day 15 post partum inhibited tail length increase by day 7, and body weight gain by day 9, as compared to the growth of solvent injected littermate pups. Our results indicate that the growth and differentiation of endochondral bones are more dependent on TH levels than are those of membranous bones and cartilage. Endochondral bones develop TH dependence for growth and differentiation before day 4 post partum, while the membranous bones and cartilage develop this dependence at the end of the first week.

Aging↗

Single-dose radiotherapy (6 Gy): palliation in painful bone metastases.

Approximately 50% of patients with cancer develop bone metastases and these have an important influence on the quality of life. PURPOSE OF THE STUDY. To evaluate a lower dose than the one already proven to be effective (8 Gy) in the palliation of painful bone metastases. METHODS AND MATERIALS. In a prospective study we analyzed the pain relief, after a single dose of 6 Gy, in 170 patients with painful bone metastases. This was assessed by a questionnaire. RESULTS. A degree of pain relief, was achieved in 88% of the treatments and there was complete relief in 39%. When the treatment was given to the vertebrae, infield spinal cord compression developed in 9%, and when given to the pelvis or femur, infield fractures developed in 8%. CONCLUSION. We concluded that a single dose of 6 Gy was very effective in the palliation of painful bone metastases.

Bone Neoplasms↗

Anabolic effect of aminoterminally truncated fibroblast growth factor 4 (FGF4) on bone.

Fibroblast growth factor 4 (FGF4), a member of the FGF family, plays several important roles in bone development during embryogenesis. Systemic administration of FGF4 increases bone mass in rats, which suggests the potential therapeutic usefulness of this growth factor in treatment for osteopenia and in bone regeneration. We investigated the length of FGF4 required to exert its anabolic effects, because this information may be useful in developing new molecules to mimic the effects of FGF4. Because the active site of FGF family molecules is in the carboxylterminal region, we produced aminoterminally truncated recombinant human FGF4s (rhFGF4s) of different sizes. Human FGF4 cDNA containing almost the full length of the coding region (573 bp, 191 amino acid residues) was inserted into pUC18 vector and then deleted from the 5' end using the ExoIII system. Each of the deleted FGF4 cDNAs was subcloned into a pET29(+) expression vector. Differently sized recombinant proteins were expressed in the BL21(DE3)pLysS Escherichia coli strain and then purified. The growth-stimulative effects on NIH3T3 cells of each recombinant protein were examined by means of MTT colorimetric assay. Full-length and the shortened recombinant proteins, which stimulated NIH3T3 cell growth, were then subcutaneously administered into male ddY mice (6 weeks old) every day for 2 weeks. Bone mineral density (BMD) was measured using dual-energy X-ray absorptiometry (DEXA) and peripheral quantitative computed tomography (pQCT). The rhFGF4 of 134 amino acid residues, the region homologous to other members of the FGF family, exerted a growth-stimulative effect on NIH3T3 cells comparable to the full-length version of FGF4; however, the shortest version, with 111 amino acid residues, showed a limited growth-stimulative effect. Systemic administration of the rhFGF4 of 134 amino acid residues increased the bone mineral density (BMD) of femurs at a dose of 0.1 mg/kg, which was comparable to that of the full-length rhFGF4. DEXA analysis, pQCT analysis, soft X-ray photos, and contact microradiographs revealed an increase in femoral trabecular bone in FGF4-treated animals; an increase in bone formation was also evident upon histomorphometric analysis. These results indicate that the region of FGF4 that is homologous to other FGF family members provides a sufficient anabolic effect in bone and that this recombinant protein is potentially useful as a therapeutic agent in bone.

3T3 Cells↗

Correlation between loss of alkaline phosphatase activity and accumulation of calcium during matrix vesicle-mediated mineralization.

Activity of the bone/liver/kidney isozyme of alkaline phosphatase (AP) is known to be critical for mineralization in developing bone, although its role is unclear. The work now reported explores changes in the activity of this Zn2+-containing enzyme that occur during Ca2+ accumulation by matrix vesicles (MV). A marked loss (up to 65-70%) in AP activity was found to accompany Ca2+ accumulation by MV. These two events were highly correlated, both temporally and quantitatively. Investigation into possible causes revealed that the decline in AP activity during Ca2+ uptake was not due to action of proteases but rather resulted from interaction with the developing mineral phase, loss of metal ions (Zn2+ and Mg2+) from the active site of the enzyme, and concomitant irreversible denaturation of the enzyme. Protease inhibitors did not protect AP from loss of activity during mineralization; in contrast, protease treatments, which progressively destroyed the ability of MV to accumulate Ca2+ actually reduced loss of AP activity. These findings clearly demonstrate that AP is present at the site of MV mineralization and that its catalytic activity is profoundly reduced by the mineralization process.

Alkaline Phosphatase↗

Understanding treatments for bone loss and bone metastases in patients with prostate cancer: a practical review and guide for the clinician.

Prostate cancer patients are at risk for developing bone loss and bone metastases. Clinicians prescribing ADT should appreciate the potential effects of ADT on BMD as well as the morbidity and mortality that can result from osteoporotic fractures. Measures to address the evaluation of patients and when to treat patients with significant bone loss have been discussed. Bisphosphonates effectively prevent loss of BMD in prostate cancer patients. Treatment of prostate cancer patients with established bone metastases with zoledronic acid should be considered strongly based on the results of the Saad study and other studies of patients with bone metastases with other malignancies. Zoledronic acid is approved by the US FDA for use in men with metastatic hormone-refractory prostate cancer and in the European Union for any patient with bone metastases, including prostate cancer patients,because of the beneficial impact of zoledronic acid on skeletal-related events. There is no validated method to determine which patients might benefit most from bisphosphonate therapy in this setting. Many questions about the use of bisphosphonate therapy in men with prostate cancer must be addressed, both in terms of the use in bone loss and bone metastases. These questions include: What is the optimal timing of therapy? Which bisphosphonate is best? What is the best dose and dose schedule? Do bisphosphonates effectively decrease skeletal fracture rates in patients with osteoporosis? How long should patients receive therapy? Are bisphosphonate "holidays" warranted? What are the long-term skeletal and renal toxicities? Is there a role for sequencing bisphosphonate therapy either before or after chemotherapy? Is bisphosphonate therapy synergistic with certain chemotherapy or other bone-targeted therapies? Which patients are the most likely to benefit from bisphosphonate therapy? What are clinically significant endpoints of bisphosphonate trials in patients with metastatic disease? Does inhibiting bone turnover also inhibit formation of bone metastases? Preliminary work in these areas has been completed, but more questions than answers are available. Given the rising costs of health care, it is imperative that these questions be addressed to best use the health care dollar while offering high-risk patients the best available therapy. At present, no data suggest that bisphosphonates should be used routinely to prevent BMD loss in men with normal BMD or to prevent the development of bone metastases in men with biochemical relapse. Continuing trials may give us guidance in the future.

Age Distribution↗

Bone and haematopoietic defects in mice lacking c-fos.

The proto-oncogene c-fos is the cellular homologue of v-fos originally isolated from murine osteosarcoma. Fos protein is a major component of the AP-1 transcription factor complex, which includes members of the jun family. Stable expression of c-fos in mice has been demonstrated in developing bones and teeth, haematopoietic cells, germ cells and in the central nervous system. It has been proposed that c-fos has an important role in signal transduction, cell proliferation and differentiation. We have previously demonstrated that overexpression of c-fos in transgenic and chimaeric mice specifically affects bone, cartilage and haematopoietic cell development. To understand better the function of c-fos in vivo, we used gene targeting in embryonic stem cells to generate cells and mice lacking c-fos. Here we report that heterozygous fos +/- mice appear normal, although females exhibit a distorted transmission frequency. All homozygous fos -/- mice are growth-retarded, develop osteopetrosis with deficiencies in bone remodelling and tooth eruption, and have altered haematopoiesis. These data define the c-Fos protein as an essential molecule for the development of specific cellular compartments.

Animals↗

A chick bone model for evaluating radial bone growth. 1. Effects of vitamin D3 deficiency.

Vitamin D3 is essential for calcification and normal bone development in chicks. In its absence, calcification is reduced but the volume (and mass) of bone increases. In vitamin D3-deficient chicks, this study shows the major defect to be in bone resorption rather than formation. Bone formation measured serially by the apposition of periosteal matrix was normal, whereas bone resorption measured by dissolution at the endosteal surface was dramatically reduced. Bone cells, therefore, would appear to retain their capacity to synthesize a collagenous matrix in the absence of vitamin D3 but lose their capacity to resorb bone. Calcification and its putative dependence on bone resorption (and vitamin D) remain to be elucidated. The vitamin D3-deficient chick provides a convenient and easily quantifiable model in which the morphological and biochemical effects of vitamin D3 can be further studied.

Animals↗

Role of cartilage-derived anti-angiogenic factor, chondromodulin-I, during endochondral bone formation.

OBJECTIVE: Cartilage is a typical avasclar tissue that exhibits powerful resistance to angiogenesis or vascular invasion. We previously identified a cartilage-specific 25 kDa glycosylated protein, chondromodulin-I (ChM-I), as anti-angiogenic factor. Taking advantage of ectopic bone formation and xenograft tumour model by human chondrosarcoma cell line OUMS-27, we examined how ChM-I is involved in switching of angiogenesis in cartilage. DESIGN: Gene expression pattern of ChM-I was examined in 4-week-old mice and mouse embryos by northern blot analysis and in situ hybridization. To evaluate the effect of ChM-I on ectopic bone formation, guanidine extracts of demineralized bone matrix were mixed with the ChM-I-bound heparin-Sepharose beads and were implanted onto the fasciae of back muscle of 6-week old nude mice. To analyse the effect of ChM-I on tumour angiogenesis, the level of ChM-I mRNA in cartilaginous tumours was assessed by competitive PCR, and compared with that of articular cartilage. Then, human chondrosarcoma OUMS-27 cells were inoculated into the back of nude mice to form a tumour about 45 mm3 in size. Recombinant ChM-I protein was administrated into OUMS-27 xenograft tumours for the initial 5 days to study its effect against tumour-angiogenesis. RESULTS: ChM-I gene was specifically expressed in cartilage of 4-week-old mice. Eye and thymus were also identified as minor expression sites. However, during endochondral bone development, cartilage changes its character from anti-angiogenic into angiogenic prior to the replacement of calcified cartilage by bone. In embryos, ChM-I mRNA was expressed in proliferative and upper hypertrophic cartilage zones in the developing cartilaginous bone rudiments, but completely abolished in lower hypertrophic and calcified cartilage zones. Purified ChM-I protein apparently inhibited vascular invasion into cartilage induced by the implantation of demineralized bone matrix in nude mice, leading to the inhibition of replacement of cartilage. The level of ChM-I transcripts in the lower-grade chondrosarcomas was substantially reduced to several hundreds or less in the lower-grade chondrosarcomas, compared with that of articular cartilage or other benign cartilage tumours. The local administration of recombinant human ChM-I almost completely blocked tumour angiogenesis and growth in the human chondrosarcoma xenografts in mice. CONCLUSIONS: ChM-I is involved in the anti-angiogenic property of cartilage and its absence creates a permissive microenvironment for vascular invasion into cartilage under physiological and pathological conditions.

Animals↗

Bone marrow necrosis in two patients with acute promyelocytic leukemia during treatment with all-trans retinoic acid.

All-trans retinoic acid has been used for the treatment of acute promyelocytic leukemia (APL) with encouraging results. However, it has recently been associated with a number of potentially serious complications including the retinoic acid syndrome. We describe two patients with APL who were begun on all-trans retinoic acid therapy (45 mg/m2), but who developed leukocytosis which was treated with hydroxyurea. Both patients demonstrated clinical and laboratory findings of disseminated intravascular coagulation, massive cell lysis manifested by marked increases in serum lactic dehydrogenase, and rapid clinical deterioration. Both patients developed bone marrow necrosis within viable, noninfarcted bone trabeculae. We postulate that the development of bone marrow necrosis in these two patients was not a chance occurrence. Rather, the specific combination of cytotoxic and differentiating agents used in these patients (hydroxyurea with all-trans retinoic acid) caused massive cell lysis and death. The absence of bone marrow necrosis in the setting of induction therapy for APL both with and without all-trans retinoic acid therapy suggests that the addition of hydroxyurea was critical to the development of marrow necrosis. We, therefore, recommend caution in the use of hydroxyurea and all-trans retinoic acid in the treatment of APL.

Adult↗

Differences in gene expression between wild type and Hoxa1 knockout embryonic stem cells after retinoic acid treatment or leukemia inhibitory factor (LIF) removal.

Homeobox (Hox) genes encode a family of transcription factors that regulate embryonic patterning and organogenesis. In embryos, alterations of the normal pattern of Hox gene expression result in homeotic transformations and malformations. Disruption of the Hoxa1 gene, the most 3' member of the Hoxa cluster and a retinoic acid (RA) direct target gene, results in abnormal ossification of the skull, hindbrain, and inner ear deficiencies, and neonatal death. We have generated Hoxa1(-/-) embryonic stem (ES) cells (named Hoxa1-15) from Hoxa1(-/-) mutant blastocysts to study the Hoxa1 signaling pathway. We have characterized in detail these Hoxa1(-/-) ES cells by performing microarray analyses, and by this technique we have identified a number of putative Hoxa-1 target genes, including genes involved in bone development (e.g. Col1a1, Postn/Osf2, and the bone sialoprotein gene or BSP), genes that are expressed in the developing brain (e.g. Nnat, Wnt3a, BDNF, RhoB, and Gbx2), and genes involved in various cellular processes (e.g. M-RAS, Sox17, Cdkn2b, LamA1, Col4a1, Foxa2, Foxq1, Klf5, and Igf2). Cell proliferation assays and Northern blot analyses of a number of ES cell markers (e.g. Rex1, Oct3/4, Fgf4, and Bmp4) suggest that the Hoxa1 protein plays a role in the inhibition of cell proliferation by RA in ES cells. Additionally, Hoxa1(-/-) ES cells express high levels of various endodermal markers, including Gata4 and Dab2, and express much less Fgf5 after leukemia inhibitory factor (LIF) withdrawal. Finally, we propose a model in which the Hoxa1 protein mediates repression of endodermal differentiation while promoting expression of ectodermal and mesodermal characteristics.

Animals↗

[Establishment of fetal limb bud culture model of mouse].

In order to study the development of bone and the effect of each single factor on the metabolism of bone during gestation age, a self-made rotating apparatus was designed. The limb bud of fetal mouse at the 16th day of gestation was examined with the techniques of X-roentgenography and histological slices. Comparing with the uncultued control limbs, the test limb cultured for six days showed longer bone length and higher bone density. The cultured bone cells showed active differentiation, proliferation and increased bone trabecula by histological examination. It is concluded that the cultured bone continued developing and differentiating, which confirming the feasibility and reliability of the method.

Animals↗

Metaphyseal peg in geroderma osteodysplasticum: a new genetic bone marker and a specific finding?

We describe two sibs with geroderma osteodysplasticum (GO) who, in addition to the known clinical and radiologic manifestations of the disorder, presented a metaphyseal peg indenting the epiphysis of the long bones, particularly at the knees. The peg was visible only at the age of 4 to 5 years but was invisible in infancy and following physeal closure. This may explain why this anomaly was not described in previous reports of 23 patients in 11 families with GO. The metaphyseal peg is an abnormality of bone development so far unknown to us. We speculate that it represents a primary, agedependent alteration of bone shape and hence a new genetic bone marker apparently specific to GO.

Abnormalities, Multiple↗