Bone

BackgroundPalliative radiation therapy (RT) for metastatic spine disease significantly increases the risk of vertebral fractures. However, the temporal mechanisms underlying radiation-induced vertebral bone fragility remain poorly understood. ObjectiveTo evaluate the longitudinal effects of a single high-dose irradiation, simulating palliative RT, on vertebral bone mechanical, architectural, and compositional properties in a healthy, skeletally mature rat model. MethodsThirty-one male Sprague Dawley rats received a single 15 Gy lumbar spine irradiation (IR). L4 vertebrae were assessed across all groups (irradiation: 7, 14, and 28 days post-IR, controls: at 0 and 28 days post-IR) for compressive strength and stiffness, micro-CT-derived bone composition and trabecular indices, serum bone turnover markers (NTX and BAP) and advanced glycation endproducts (AGEs). ResultsIrradiation induced progressive deterioration of vertebral bone mechanical properties, with strength decreasing up to 44% and stiffness up to 38% by 28 days post-IR, compared to 0- day controls. Trabecular bone exhibited reduced BMD, BV/TV, and Tb.N with increased Tb.Sp, a shift toward a more rod-like structure. Early post-IR changes suggested disrupted bone remodeling, characterized by elevated NTX and AGEs, but decreased BAP. Multivariable regression demonstrated that Tb.Th and AGEs were independent predictors of stiffness, collectively explaining 61% of its variance. DiscussionHigh-dose irradiation induces sustained temporal degradation of vertebral mechanical properties driven by both trabecular architectural deterioration and alterations in bone matrix quality. Measures of bone composition and non-enzymatic bone turnover suggest this early damage was driven by disruption of bone cellular homeostasis, favoring increased resorption over formation. These findings support that radiation impairs both structural integrity and pre-yield mechanical behavior, providing mechanistic insight into the elevated fracture risk observed clinically after irradiation for metastatic spine disease. Lay summaryThis study used a rat model to mimic palliative radiation therapy for cancer that has spread to the spine and evaluated the changes in bone quality up to 28 days post-therapy. We found that irradiation progressively weakened the structural integrity and composition of the bones in the spine and disrupted the normal balance of bone breakdown and repair, leading to greater bone loss and fragility. Our findings provide insight into the increased risk of fractures observed in patients receiving radiation therapy to the spine and may support efforts to better protect bone health during treatment.

Fracture nonunion remains a major cause of morbidity, yet patient-specific factors associated with impaired healing remain incompletely characterized. Anemia has been associated with adverse orthopaedic outcomes, but its relationship with fracture nonunion is poorly understood. We examined whether pre-fracture anemia, anemia burden, and clinically relevant anemia subtypes were associated with nonunion following tibial or femoral fractures. Using commercial and Medicare fee-for-service claims from 2016 through 2023, we identified adults aged 19 years or older with a tibial or femoral fracture, continuous enrollment during the preceding year and for at least six months after fracture, and no baseline cancer. Pre-fracture anemia was evaluated as any anemia, the number of distinct anemia diagnoses, and nutritional, hemolytic, aplastic, and other anemia subgroups. Nonunion occurring six to eighteen months after fracture was assessed using incidence rates and multivariable-adjusted hazard models. Among 326,673 adults, 149,704 had pre-fracture anemia and 176,969 did not. The crude incidence of nonunion was 42% higher among individuals with anemia than among those without anemia (incidence rate ratio, 1.42; 95% confidence interval, 1.32 to 1.53) and increased with greater anemia burden. After adjustment for demographic and clinical characteristics, including prior fractures at other anatomical sites, pre-fracture anemia remained associated with nonunion following tibial and femoral fractures, with hazard ratios of 1.83 (95% confidence interval, 1.54 to 2.18) and 1.38 (95% confidence interval, 1.26 to 1.50), respectively. Associations were also observed for nutritional and other anemias, whereas estimates for hemolytic and aplastic anemias were limited by few nonunion events. Within the femur, the association was strongest for distal fractures. These findings demonstrate that pre-fracture anemia is independently associated with nonunion. The increase in risk with greater anemia burden and findings across evaluable subgroups suggest that pre-fracture anemia may help identify patients at increased risk of impaired fracture healing.

Low-intensity vibration (LIV) is a non-invasive mechanical stimulus capable of regulating skeletal adaptation and cellular signaling pathways involved in bone remodeling. Despite growing interest in LIV, substantial methodological heterogeneity persists in the selection of experimental vibration parameters such as frequency, expressed in Hertz (Hz) and intensity, defined as earth's gravitational field (g) (9.81 m/s2). Focusing on micro-computed tomography (CT) derived trabecular bone volume fraction (BV/TV) as the main outcome measure, this study sought to synthesize the effects of different LIV frequency and intensity on BV/TV in small rodents (mice and rats) as they remain as the most studied pre-clinical model. To accomplish this, we performed a systematic review searching for publications in English on PubMed, Web of Science, CINAHL, and Embase databases. Two independent investigators followed inclusion criteria to select only peer-reviewed studies with mature mice, using whole-body vibration experiments without other co-variables. We further restricted to include studies that analyzed non-fractured bones and compared pre- and post-intervention or control values. In addition to these core criteria, a detailed hierarchical screening framework was applied during full-text review. The two independent investigators extracted data independently and considered the characteristics of the study, animals' characteristics, intervention characteristics, and results. For this study we considered load-bearing hindlimbs, femur and tibia, separately but did not include vertebrae in the analysis. A Bayesian network meta-analysis and a revised SYRCLE risk of bias (RoB) tool were used to evaluate the risk of bias across included studies. Seven studies met the inclusion criteria. Results showed that an LIV regime applied at 45Hz at 2g presented higher chances to increase trabecular BV/TV of the mouse tibia (estimated effect 3.22 [CrI 1.98, 4.45]), while LIV regimes applied to the femur at 90Hz and 1.4g (estimated effect 3.08 [CrI -1.99, 7.97]) present better chances to increase trabecular BV/TV results compared to other interventions but with no significant differences. Finally, we applied 45Hz at 0.2g LIV to 5 month old male C57BL/6 for 5 weeks (n=10/group) which showed significantly increased Trabecular Thickness (Tb.Th) for both the tibia (10%, p<0.01) and femur (17%, p<0.001), with the femur showing further increases in trabecular BV/TV (32%, p<0.05) compared to non-LIV controls. We conclude that changes in the microarchitectures of the tibia and femur respond differently to the same application of LIV (45Hz, 0.2g) in mice and rats.

Accurate evaluation of extracellular matrix (ECM) mineralization at the nano-scale is essential for establishing relevant in vitro bone models. This is particularly important with the development and increased application of three-dimensional (3D) cell models for biological research. Transmission electron microscopy (TEM) allows to perform ultra-structural analysis of cells and ECM organization, but its application in in vitro bone models remains limited, due to the potential alteration or loss of the mineral phase during sample preparation. In this study, we compared two TEM sample preparation methods - the conventional chemical fixation and the anhydrous methods - to evaluate their ability to preserve the mineralized ECM in MC3T3-E1 cells cultured as monolayers and as alginate-encapsulated bone spheroids. Chemical fixation preserved cellular ultra-structure and collagen organization, allowing for detailed assessment of cells and ECM organization. Although mineral deposits were detected and their needle-like morphology assessed, characterization of more immature deposits was partially limited by the effects of uranyl acetate and the overall sample preparation process, which could lead to alteration or loss of less stable mineral phases. The anhydrous preparation method resulted in limited preservation of cellular and ECM morphology and did not allow reliable identification of mineral deposits. When applied to spheroids, the chemical fixation method preserved the 3D architecture, collagen-rich ECM and inner mineral deposits, confirming spheroids as a relevant model for bone studies. Overall, these results highlight the need for optimized sample preparation strategies that preserve both ultra-structure and mineral components for accurate nano-scale characterization of bone mineralization.

PurposeEstrogen deficiency drives bone loss through interacting endocrine, oxidative, inflammatory and bone-remodeling disturbances. Ergothioneine (EGT) is a diet-derived thiol/thione antioxidant whose effects on the estrogen-deficient skeleton are unknown. We evaluated whether EGT, alone or combined with vitamin K2, vitamin D3 and magnesium L-threonate, attenuates the skeletal and systemic consequences of ovariectomy (OVX) in mice. MethodsForty-eight female C57BL/6J mice underwent sham surgery or OVX and received daily oral gavage for 12 weeks of vehicle, alendronate (1.53 mg/kg), EGT (30 mg/kg/day), EGT with vitamin K2 (40 {micro}g/kg/day) and vitamin D3 (500 IU/kg/day), or EGT with vitamin K2, magnesium L-threonate (350 mg/kg/day) and vitamin D3 (n = 5-6 analysed per group). Outcomes included the uterine index, tibial micro-computed tomography, distal-femoral histology, and serum bone turnover markers (CTX-I, PINP, osteocalcin), sex hormones, TNF-, IL-6, SOD and MDA. OVX lowered the uterine index and induced tibial trabecular deterioration, with increased CTX-I, decreased PINP and osteocalcin, elevated TNF- and IL-6, reduced SOD and increased MDA (all P < 0.01 vs sham). Alendronate restored tibial micro-CT bone-volume fraction (BV/TV) and trabecular number (P < 0.01 vs OVX). The EGT-based regimens did not significantly restore tibial micro-CT BV/TV, trabecular thickness or trabecular number (all P > 0.05 vs OVX), but significantly increased trabecular area on distal-femoral histology (OVX 7.6% vs 14.2-15.0% across regimens; P < 0.05 vs OVX) and lowered CTX-I, TNF-, IL-6 and MDA while raising SOD and partially restoring PINP and osteocalcin (P < 0.05-0.01 vs OVX). Because the histological and micro-CT endpoints were assessed at different skeletal sites, structural interpretation is cautious. Apparent increases in serum estradiol were assay-dependent and are regarded as exploratory. Ergothioneine-based nutritional regimens improved the systemic oxidative, inflammatory and bone-turnover environment of estrogen-deficient bone loss and preserved distal-femoral trabecular area on histology, although tibial three-dimensional microarchitecture by micro-CT was not restored. Because the histological and micro-CT endpoints were assessed at different skeletal sites, the structural interpretation is necessarily cautious. These findings support further evaluation of EGT as a dietary adjunct, with mechanistic and dose-optimization studies warranted.

Objectives: To investigate the biological and clinical relevance of knee alignment in osteoarthritis by integrating population-scale imaging, genome-wide association, and functional genetic analyses. Methods: Femorotibial angle was derived from dual-energy X-ray absorptiometry scans in UK Biobank using machine-learning methods. Associations with knee and hip osteoarthritis outcomes were assessed. A genome-wide association study of mean femorotibial angle was performed, followed by fine-mapping and pathway enrichment analyses. Mendelian randomization was used to explore potential causal relationships. Results: Varus alignment was strongly and progressively associated with knee pain, knee osteoarthritis, and total knee replacement (HR 3.42 [95% CI 2.92, 4.02]), with no association observed for hip osteoarthritis. GWAS identified 20 independent loci associated with femorotibial angle, enriched for pathways related to skeletal development, cartilage biology, and endochondral ossification. Post-GWAS analyses demonstrated regulatory effects across fetal and adult joint tissues, supporting life course influences on alignment. Genetic correlation analyses showed shared architecture between femorotibial angle and knee osteoarthritis. Causal analyses suggested that genetic liability to osteoarthritis reduces femorotibial angle ({beta} -0.11 [-0.16, -0.06]), while evidence for an overall causal effect of femorotibial angle on osteoarthritis risk was limited (OR 0.93 [0.79, 1.10]). Conclusions: Knee alignment and susceptibility to knee osteoarthritis are partially genetically determined. At the population level, these genetic determinants support a causal effect of osteoarthritis on knee alignment, whereas evidence for a causal effect of alignment on knee osteoarthritis was limited. Furthermore, this study identifies novel genetic loci linking knee alignment with pathways involved in skeletal development and cartilage biology relevant to osteoarthritis.

Abstract Introduction: Proximal humerus fractures account for approximately 5-6% of all adult fractures and are primarily managed nonoperatively. Healing is conventionally monitored with radiographs, with radiopaque callus formation indicating healing. Visible radiographic callus appears weeks after biological union begins. Ultrasound provides a dynamic, radiation-free, and cost-effective method that can detect early callus formation before x-ray visibility. Although ultrasound has demonstrated utility for fracture healing in the clavicle and humeral shaft, its role in proximal humerus fractures remains unclear. Methods: This single-centre prospective study will be conducted in two phases. The pilot phase will measure inter-rater reliability for ultrasound detection of early callus formation at 2 and 4 weeks post-injury. Ten patients with proximal humerus fractures treated nonoperatively will undergo standardized anterior and lateral scans. Each patient will generate four saved images (short- and long-axis views), producing forty anonymized images independently reviewed by two raters. The prospective cohort phase will recruit approximately thirty additional patients. Results: Reliability will be quantified using Cohens kappa. A power calculation will be performed after pilot analysis. Results from the prospective cohort phase will help determine the association and predictive value of early ultrasound-detected bridging callus for radiographic and clinical union at three and six months. Patient reported outcome measures will be assessed using the Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) questionnaire. Discussion: This study will develop and validate a standardized ultrasound protocol for assessing early fracture healing in proximal humerus fractures. By establishing both inter-rater reliability and predictive value, the findings may support ultrasound as a reproducible, radiation-free adjunct to conventional imaging and enable earlier identification of union status.

This protocol describes a standardized and reproducible minimally invasive approach for establishing mouse models of bisphosphonate-related osteonecrosis of the jaw (BRONJ) and osteoradionecrosis of the jaw (ORNJ). The method combines a unified low-trauma oral surgical procedure with disease-specific injury induction strategies to generate robust and clinically relevant models of jaw osteonecrosis. For BRONJ, systemic zoledronic acid administration is coupled with mandibular first molar extraction using tape-assisted mouth opening and customized bent micro-forceps, minimizing soft tissue damage and reducing procedural variability. For ORNJ, a customized lead-shielding platform enables precise, noninvasive mandible-targeted irradiation, producing reproducible bone injury while limiting off-target radiation exposure. Together, these complementary models provide a consistent and minimally invasive framework for investigating jaw osteonecrosis arising from distinct etiologies. The protocol supports comprehensive downstream analyses, including micro-computed tomography, histology, and immunofluorescence, and facilitates mechanistic studies of disease pathogenesis, bone regeneration, and therapeutic intervention.

Multiple myeloma causes devastating osteolytic bone disease. Current antiresorptive therapies slow bone loss but fail to rebuild the skeleton. Consequently, patients continue to fracture and suffer the associated morbidity and mortality. Targeting the Wnt inhibitor sclerostin, with romosozumab, increases bone mass in osteoporosis but has not been leveraged in cancer. We hypothesised that romosozumab would safely restore bone mass in multiple myeloma. In a murine model of myeloma, romosozumab was safe, demonstrating no impact on tumour progression while significantly increasing bone density. We subsequently conducted a Phase IIa proof-of-concept study in 12 multiple myeloma patients refractory to bisphosphonate therapy. Romosozumab was safe, it was well-tolerated and did not promote clinical or clonal myeloma progression. Treatment induced an early, significant rise in serum bone formation markers whilst resorption remained unchanged. This was coupled with significant gains in bone mineral density throughout the skeleton. Additionally, we observed radiological evidence of repair to pre-existing osteolytic lesions and, critically, a reduction in the skeletal morbidity rate from 2.5 to 0.11 events per patient-year. Longitudinal single-cell transcriptomics revealed that romosozumab transiently reprograms the osteoblast lineage to upregulate matrix synthesis and mineralisation programmes. These findings demonstrate that sclerostin inhibition safely rebuilds bone, providing clinical and mechanistic rationale for further randomised studies to restore bone health in myeloma patients.

Background Alveolar bone assessment in periodontal practice relies on radiography and clinical probing, both of which have well-documented limitations in precision. Intraoral high-frequency ultrasonography (US) offers a radiation-free alternative with potential for sub-millimeter resolution, the validity and precision for detecting minute osseous changes have not been established. The purpose of this study was to evaluate the concurrent validity and measurement precision of intraoral US for detecting alveolar bone-level changes in patients undergoing crown lengthening and osseous surgery, thereby enabling its translation to monitor osseous changes in patients with periodontitis. Methods Ten patients (28 tooth sites) undergoing crown lengthening or osseous surgery at a USC Advanced Grad Perio clinic were enrolled in this prospective observational study. Distance from the cementoenamel junction (CEJ) to the Alveolar bone crest (ABC) was measured at pre- and post-operative time points using a 40 MHz handheld intraoral US transducer and, intraoperatively, by standardized clinical photography. Agreement was assessed by Pearson correlation and Bland-Altman analysis. Measurement precision was quantified using the standard error of measurement (SEM) and minimum detectable change (MDC). Results Preoperative agreement between methods was excellent (r = 0.977; Bland-Altman bias = -0.009 mm; 95% limits of agreement [LoA]: +-0.40 mm). Post-operative correlation remained strong (r = 0.912; bias = 0.123 mm; LoA: -0.85 to +1.10 mm). Both methods detected statistically significant post-surgical increases in the ABC-to-CEJ distance (p < 0.001), as anticipated. US demonstrated substantially superior precision: preoperative SEM 0.058 mm with US versus 0.128 mm clinically, yielding MDC values of 0.160 mm (US) versus 0.354 mm (clinical), providing a 2.2-fold precision advantage. Conclusions Intraoral US demonstrated strong concurrent validity with clinical photography and a reproducible precision advantage in detecting alveolar bone-level changes in patients with periodontitis. These findings support its clinical utility as a radiation-free, high-sensitivity bone monitoring tool. Larger longitudinal studies with CBCT validation are warranted.

Sutures are the primary sites of cranial bone growth, allowing the skull to accommodate the growing brain. External mechanical stimulus has been shown to delay suture fusion and induce tissue remodelling. Recent studies suggest that in vivo cyclic bone loading increased proliferation of mesenchymal stem cells (MSC) in the coronal suture. The overall aim of this study was to understand how many loading sessions (exposure-response) and how long after loading (time-course) did MSC proliferation increase in the coronal suture. In the exposure-response analysis, mice underwent 1, 3, or 5 loading sessions between Postnatal day 7 (P7) and P11, and in the time-course analysis, treated mice underwent 10 loading sessions between P7 and P21. Loading sessions were 10 minutes at a frequency of 1 Hz and a force of 10 g (0.1 N). The loading tip was positioned on the posterior aspect of the left frontal bone, dorsal to the coronal suture. The EdU marker shows a statistically significant increase in proliferation after one loading session and a decrease after three loading sessions. The PCNA marker shows a statistically significant increase after three and five loading sessions. The exposure-response analysis showed that when the results of both markers are combined, levels of proliferation cannot be interpreted until at least five loading sessions have been completed, after which a clear increase in proliferation was observed. In the time-course analysis, proliferation was highest immediately after the final treatment session and 24 hours after the final loading session the effects of mechanical bone loading gradually returned to baseline.

Purpose The application of machine learning (ML) to osteoporosis prediction has expanded rapidly, yet no comprehensive meta-analysis has synthesized the discriminative performance of these models across all ML categories, data types, and validation strategies. This systematic review and meta-analysis aimed to evaluate the diagnostic and predictive accuracy of ML and deep learning models for osteoporosis prediction in adult populations. Methods Systematic searches of PubMed, Embase, Web of Science, and IEEE Xplore were conducted for studies published between January 2020 and February 2026. Studies developing, validating, or applying ML models for predicting osteoporosis, low bone mineral density, or osteoporotic fractures in adults were included. Methodological quality was assessed using the Prediction Model Risk of Bias Assessment Tool (PROBAST). Area under the receiver operating characteristic curve (AUC) values were pooled using random-effects meta-analysis with logit transformation. Subgroup analyses were performed by data type, ML category, external validation status, and population type. The review followed PRISMA 2020 guidelines. Results Thirty-three studies were included in the qualitative synthesis and 27 in the meta-analysis. The pooled AUC was 0.879 (95% CI: 0.853 0.901), with substantial heterogeneity (I = 99.5%). Imaging-based models outperformed clinical data models (AUC = 0.905 vs. 0.872). Deep learning achieved the highest pooled AUC (0.909), followed by ensemble methods (0.874) and traditional ML (0.840). Externally validated models showed lower performance than internally validated ones (AUC = 0.868 vs. 0.897). PROBAST assessment rated 32 of 33 studies (97.0%) as low risk of bias, though this proportion should be interpreted cautiously given that PROBAST was designed for traditional prediction models and may not fully capture ML-specific sources of bias. Egger's test indicated significant publication bias (p < 0.001). Explainable AI methods were employed in 60.6% of studies, identifying age, body weight, and alkaline phosphatase as the most frequent top predictive features. Conclusions Machine learning models demonstrate overall good discriminative performance for osteoporosis prediction, albeit with substantial heterogeneity across studies (I = 99.5%), and show potential as complementary screening tools, particularly in settings with limited DXA access. Deep learning models applied to imaging data and ensemble methods using clinical variables achieved the strongest subgroup estimates. However, extreme heterogeneity, evidence of publication bias, and limited prospective validation warrant cautious interpretation of the pooled estimate. Future research should prioritise multi-centre external validation, standardised reporting following TRIPOD+AI guidelines, and prospective clinical trials to establish real-world clinical impact.

Purpose: Pathogenic variants in NFIX cause Marshall-Smith syndrome and Malan syndrome (MALNS). We identified a severe subtype of MALNS characterized by adolescent-onset musculoskeletal deterioration and investigated functional consequences of underlying variants. Methods: Clinical data were collected from seven individuals with pathogenic NFIX variants. Wild-type and mutated recombinant NFIX DNA-binding domains (DBDs) were evaluated using biochemical, structural, and DNA-binding assays. Results: Six individuals carrying R116W, R116P, K125E, or G147E NFIX substitutions developed progressive muscle wasting, markedly reduced body mass index, and rapidly progressive scoliosis after the typical childhood features of MALNS; two died from disease-related complications. A seventh individual with R116G did not develop this severe phenotype. Functional studies on recombinant NFIX DBDs showed complete or near-complete loss of DNA-binding activity for R116W, R116P, K125E, and G147E despite preserved protein folding, consistent with disrupted DNA recognition and a potential dominant-negative mechanism. In contrast, R116G exhibited a 7.7{degrees}C decrease in thermal stability, which may support haploinsufficiency mediated by protein degradation. Conclusion: Specific NFIX missense variants define a severe subtype of MALNS associated with progressive musculoskeletal deterioration. In vitro functional studies support variant-specific disruption of DNA binding, providing a mechanistic basis of genotype-phenotype correlations and informing prognosis, clinical surveillance, and therapy development.

ABSTRACT Background: Metallic implants such as orthopedic screws, prostheses, and dental hardware produce beam-hardening, photon-starvation, and streak artifacts that degrade computed tomography (CT) image quality, and the metal artifact reduction (MAR) methods developed to mitigate them require objective, reproducible benchmarking. Purpose: Objective evaluation of MAR algorithms in CT is hindered by the absence of phantoms that simultaneously provide anatomically realistic backgrounds, embedded implants of known geometry, and controllable, ground-truth--referenced artifact intensity. We present a dual-filament, voxel-level three-dimensional (3D) printing method that fulfills these requirements and demonstrate its capabilities on a clinically representative cervical spine case with embedded orthopedic spinal screws. Methods: The proposed method extends the PixelPrint framework, a fused-deposition-modeling (FDM) workflow that converts clinical Digital Imaging and Communications in Medicine (DICOM) data directly into 3D-printer Geometric code (G-code) without intermediate segmentation or surface meshing, to interleaved, voxel-level deposition of two filaments: a calcium-doped polylactic acid (PLA) for soft tissue and bone, and a higher-attenuation metal-doped PLA for metallic implants. For demonstration, anonymized DICOM data of a healthy cervical spine were used to design and fabricate three matched phantoms, each with six embedded spinal screws at C4--C6: a 0% metal-infill ground-truth phantom, a 50% medium-metal-infill phantom, and an 85% high-metal-infill phantom. All phantoms were scanned on a clinical spectral CT system at 120 kVp and 1000 mAs, reconstructed at 0.67 mm slice thickness with virtual monoenergetic imaging (VMI) across 50--190 keV. Method performance was characterized by region of interest (ROI)-based Hounsfield Unit (HU) agreement with the source patient data and by the noise-independent Gumbel-distribution p-index metric. Results: The dual-filament method reproduced patient anatomy, soft-tissue contrast, and screw geometry with high fidelity. ROI HU values agreed with patient data within {+/-}25 HU for soft tissue and trabecular bone; cortical regions were underestimated owing to the current ceiling of the calcium-doped PLA used in this study. The tunable-artifact behavior was quantified as follows: the Gumbel location parameter scaled monotonically from 46.7 HU (no-metal background) to 57.1 HU (50% infill) to 90.5 HU (85% infill) for the VMI 70 keV with standard filter. High-keV VMI reconstructions substantially reduced streak and beam-hardening artifacts while preserving anatomic detail. Conclusions: The proposed dual-filament, voxel-level PixelPrint method enables the fabrication of patient-specific, multi-material CT phantoms with embedded metallic implants and controllable, ground-truth--referenced artifact intensity. Although demonstrated here in a single cervical-spine case, the workflow is anatomy- and implant-agnostic by construction and could in principle be adapted to other musculoskeletal sites (e.g., knee, hip, dental) and implant materials, providing a reproducible methodological foundation for benchmarking MAR algorithms, characterizing spectral CT performance, and validating emerging photon-counting detector systems. Keywords: 3D printing methodology; fused deposition modeling; voxel-level multi-material printing; spectral computed tomography; metal artifact reduction; phantom design; orthopedic implants; dual filament; PixelPrint.

Introduction: Critical-sized bone defects cannot heal spontaneously, requiring additional, often burdensome, treatment. Thus, various synthetic substitute materials have been investigated regarding their treatment capacity. Poly-L-lactic acid (PLLA) and polyglycolic acid (PGA) have emerged as promising biodegradable scaffold materials. The addition of inorganic materials such as calcium carbonate (CC) has also been shown to be advantageous. This study investigates the effect on bone regeneration of PLLA-PGA-CC scaffolds in critical-sized bone defects over a two-year observation period using sheep as an animal model. Methods: Critical-sized mandible angle defects were created in twelve female merino sheep. Mandibular defects were reconstructed with PLLA-PGA-CC scaffolds in four sheep, while the remaining eight served as negative control (defects left empty). The scaffolds were manufactured using computer-aided design and manufacturing, incorporating an interconnected porous structure and fixated with polyether ether ketone cages. Bone regeneration was evaluated using computed tomography (CT) imaging at 3, 12, and 24 months postoperatively. Bone volume was assessed quantitatively. Additionally, a histological analysis was performed. Results: Surgical procedures were successful and without major complications. CT assessment showed more bone regeneration in the scaffold group (mean volume: 7,472 mm3) than in the control group (4,168 mm3, p = 0.1) at 24 months postoperatively. Resorption of the scaffolds and formation of compact lamellar bone tissue were confirmed by histological analysis. However, the osteoconductive properties of the scaffolds were limited, with only minimal ingrowth of bone tissue into the porous structure. In both groups, fibrous tissue infiltration and the formation of cyst-like cavities in the defect region were observed. Conclusion: PLLA-PGA-CC scaffolds were found to be biocompatible and enhanced bone regeneration compared to the control group. Due to fibrous tissue infiltration and the lack of osteoconductivity, the suitability of the material for critical-sized bone defect reconstruction is limited.

The osteocyte network in bone is believed to play an important role for how bone tissues sense and respond to mechanical stimulation. Yet, bone adaptation to mechanical loads is often conceptualised as a simple response to mechanical stimuli, such as Wolffs law, which is based on mechanical variables only and takes no account of the cellular basis of mechanosensation. Wolffs law presumes the existence of a reference mechanical stimulus, the mechanical setpoint, above which bone is consolidated, and under which bone is removed. In this paper, we develop a theory of bone tissue sensing and adaptation based on osteocytes to provide new understanding of the role played by osteocyte signals in mechanical adaptation. In this theory, the mechanical setpoint of Frosts mechanostat is explicitly embodied as osteocyte properties involved in mechanotransduction. The mechanical setpoint is allowed to adapt due to the replacement of osteocytes during remodelling, making the setpoint space and time dependent. We propose a mathematical model to implement this new theory of bone adapation and present numerical simulations of this model to explore how mechanobiological response curves (effective Wolffs laws) are modulated by setpoint adaptation during remodelling. By accounting for varying osteocyte populations within bone tissue, we explore bone adaptation under osteocyte disruptions, which is particularly relevant to age-related bone loss. Our model suggests that biological disruptions of remodelling balance cannot always be compensated by mechanical feedback, and that setpoint adaptation during remodelling may have significant observable consequences, such as hysteresis in bone response signatures that resemble lazy zones.

Osteoporosis is a prevalent skeletal disorder characterized by deterioration of bone microarchitecture and loss of bone mineral density, leading to increased fracture risk and substantial health and economic burdens, particularly among older adults. Bone remodeling is orchestrated by a complex interplay of systemic and local regulators, among which vitamin D plays a central role in maintaining skeletal homeostasis. Although numerous studies have examined the effects of vitamin D on bone metabolism, outcomes have been inconsistent across populations, dosing regimens, and experimental models. To clarify the net skeletal impact of vitamin D, we investigated its effects in postmenopausal osteoporosis (PMO). Vitamin D (1,25-dihydroxyvitamin D3- active form of vitamin D) supplementation effectively prevented bone loss in ovariectomized mice, at both lower and higher concentrations. Mechanistically, vitamin D promoted osteoclast differentiation in vitro, consistent with its RANKL-dependent pro-osteoclastogenic activity, yet paradoxically conferred bone protection in vivo. This discrepancy was explained by vitamin Ds profound immunomodulatory effects, which reshaped both innate and adaptive immune responses to suppress osteoclast formation and function. Concurrently, vitamin D improved intestinal barrier integrity and restored gut microbial composition, thereby stabilizing the gut-immune-bone axis and reducing pro-resorptive inflammatory signaling. Together, these findings demonstrate that vitamin D prevents bone loss through the coordinated regulation of immune and gut homeostasis, reconciling its apparent pro-resorptive effects in vitro with its overall anti-resorptive outcomes in vivo. This integrated mechanism highlights immune-gut microbial modulation as a key mediator of vitamin D-induced bone preservation and supports the development of vitamin D as an immunotherapeutic adjunct for the prevention and management of PMO. Altogether, our findings for the first time dissect the paradox surrounding the osteoprotective property of vitamin D supplementation.

Osteoblastic bone metastasis, in which disseminated tumor cells drive net bone formation, is a clinically distinct and mechanistically underexplored form of skeletal disease that is enriched in hormone receptor-positive breast cancers. Preclinical models of bone metastasis from breast cancer predominantly rely on immunodeficient hosts inoculated with osteolytic human breast cancer cell lines, limiting the study of immune-dependent mechanisms of bone remodeling. Here we describe the development and characterization of an immunocompetent, syngeneic osteoblastic bone metastasis model using intratibial injection of PyMT-CK(OB), a luciferase-expressing derivative of the MMTV-PyMT mammary carcinoma cell line, in FVB/N mice. PyMT-CK(OB) cells produced detectable bioluminescent signal after intratibial injection, enabling longitudinal monitoring of tumor progression. Micro-computed tomography (microCT) revealed significant increases in trabecular bone volume fraction and trabecular number at three and four weeks post-injection, consistent with osteoblastic remodeling. Histological analysis confirmed dense bone lesion formation in tumor-bearing bones. Critically, this osteoblastic phenotype was entirely absent in immunodeficient NOD SCID hosts, despite robust tumor growth, supporting a role for immune competence in tumor-induced bone formation. Loss of bioluminescent signal in immunocompetent mice reflected either immune pressure on reporter gene expression or limited space for cancer cell expansion in the bone, rather than tumor regression or hypoxia, as confirmed by hypoxia imaging and histological endpoint analysis. In contrast, a second PyMT cell subline, PyMT-CF, maintained sustained bioluminescent signal and produced predominantly osteolytic lesions, providing a complementary syngeneic model of osteolytic disease from the same parental background. In vitro hydrogel coculture experiments and protein array analysis of conditioned media revealed that the PyMT sublines have differing impact on MC3T3 osteoblast mineralization, identifying candidate mediators of divergent bone remodeling phenotypes. R7 mammary carcinoma cells derived from MMTV-RON transgenic mouse mammary tumors did not induce measurable bone remodeling under equivalent experimental conditions. Together, these models provide a validated, immunologically intact framework for studying the mechanistic basis of osteoblastic bone metastasis and evaluating therapeutic interventions targeting the tumor-bone microenvironment.

1.Cancer-induced bone pain (CIBP) occurs in a majority of patients when primary or metastatic cancer develops within the bone. This pain has a significant impact on quality of life, yet there are limited effective treatment options available. Nerve sprouting is a complex mechanism that has been implicated in CIBP. Netrin-1 is a neuronal guidance molecule that is produced by numerous cell types, including cancer cells. In this study we aimed to determine whether netrin-1 inhibition (with NP137 - a humanized IGg1 monoclonal antibody) could ameliorate nerve sprouting, and nociception by extension, in three models of CIBP - osteosarcoma, metastatic breast cancer, and metastatic prostate cancer. Sustained administration of NP137 failed to produce an anti-nociceptive effect in these models, but a delayed onset was observed in the osteosarcoma model. NP137 did not produce a disease-modifying effect, as micro-computed tomography did not reveal reduced bone destruction in the NP137-treated groups. Additionally, there was no nerve fibre density reduction in any of the groups at the late-stage of the disease, suggesting that nerve sprouting occurs in early- to mid-stage CIBP development. Investigation of NP137 exposure indicated that serum levels of NP137 were comparable between the sham and cancer groups. Our study indicates that netrin-1 may play a role in early-stage CIBP development, but inhibition of this mechanism does not produce robust anti-nociception.

High-resolution 3D imaging is an important strategy for visualizing and analysing complex skeletal tissue architecture and the bone marrow microenvironment. However, multicolor immunolabeling and imaging of intact skeletal tissues are technologically challenging. The current immunolabeling and clearing methods for intact skeletal elements are very limited, time-consuming and generate low-resolution data or depend on the use of reporter mice. Here, we describe a protocol for efficient clearing and immunolabeling of intact calcified tissues that enables superfast, single-cell resolution, and quantitative 3D light-sheet imaging of intact skeletal elements and teeth. A key aspect of our protocol is the addition of a collagenase digestion step after fixation and decalcification. This step enhances antibody penetration, resulting in deep, comprehensive staining throughout immunostained bones and other calcified tissues. The protocol includes soft tissue removal, fixation, decalcification, bone dehydration, and bleaching, followed by antigen retrieval and permeabilization before the collagenase digestion step. This procedure is performed to prepare the samples for the tissue clearing process that improves bone tissue transparency prior to light-sheet imaging. The entire protocol, from bone collection to image analysis and quantification, takes about 4 days to complete, thus offering significant improvements over previous methods. This protocol is broadly applicable to the visualization of bone microstructure, bone marrow analysis, vascular and neural network mapping, and the study of signaling molecules in bone development and growth. The protocol requires experience with standard tissue processing and immunostaining techniques, and prior experience in tissue clearing and light-sheet imaging is beneficial but not essential. Key pointsO_LIA protocol for efficient clearing and immunolabeling of intact calcified tissues that enables superfast, high-resolution, and quantitative 3D imaging of various intact bones and teeth. C_LIO_LIThe entire protocol takes only 4 days to complete the comprehensive staining and perfect transparency throughout the intact bones, offering significant improvements over previous methods. C_LI Key referencesBiswas, L. et al. Cell 186, 382-397.e24 (2023): https://doi.org/10.1016/j.cell.2022.12.031