JOURNAL OF BONE AND MINERAL RESEARCH

Volume 20, Number 7, 2005

Published online on February 21, 2005; doi: 10.1359/JBMR.050213
2005 American Society for Bone and Mineral Research

Effects of Intravenous Pamidronate Treatment in Infants With

Osteogenesis Imperfecta: Clinical and Histomorphometric Outcome
Craig FJ Munns,1,2 Frank Rauch,1 Rose Travers,1 and Francis H Glorieux1

ABSTRACT: Clinical and histomorphometric outcome was compared between children with OI who had
received pamidronate since infancy and age-matched patients who had never received pamidronate. Pamidronate was associated with improved vertebral shape and mass, higher cortical width, increased cancellous
bone volume, and suppressed bone turnover.
Introduction: Observations in small patient series indicate that infants with severe osteogenesis imperfecta
(OI) benefit from treatment with cyclical intravenous pamidronate. However, detailed analyses of outcome
are lacking for this age group.
Materials and Methods: Clinical outcome was evaluated in 29 children with OI types I (n 3), III (n 14),
or IV (n 12) who started pamidronate therapy before 2 years of age (age at treatment onset: median, 6
months; range, 2 weeks to 23 months) and who had completed 3 years of treatment (total annual pamidronate
dose, 9 mg/kg). They were compared with a historical control group of 29 untreated children with severe OI
who were matched for OI type and age at the 3-year treatment time-point. In addition, iliac bone histomorphometry was compared between 24 pamidronate-treated patients and 24 age-matched OI patients who had
not received pamidronate.
Results: Morphometric evaluation of lumbar vertebrae (L1L4) showed that the shape of vertebral bodies was
better preserved in pamidronate-treated patients. This was accompanied by significantly higher lumbar spine
areal and volumetric BMD (+110 and +96%, respectively) and a larger vertebral bone volume (+26%) on
densitometry. Regarding mobility function, the Pediatric Evaluation of Disability Inventory gross motor score
was 50% greater in the pamidronate group (p < 0.001). Iliac bone histomorphometry showed 61% higher
cortical width and 89% higher cancellous bone volume in pamidronate-treated patients. Bone formation rate
per bone surface in the pamidronate group was only 17% that of untreated patients.
Conclusions: In conclusion, this study suggests that cyclical pamidronate treatment started in infancy leads to
improved bone strength and better gross motor function but also suppresses bone turnover markedly. It is
therefore prudent to reserve pamidronate treatment to infant OI patients who present with a moderate to
severe phenotype.
J Bone Miner Res 2005;20:12351243. Published online on February 21, 2005; doi: 10.1359/JBMR.050213
Key words: bisphosphonate, bone fragility, histomorphometry, osteoporosis, pediatric

INTRODUCTION

STEOGENESIS IMPERFECTA (OI) is a genetic disorder

with increased bone fragility and low bone mass. The
most commonly used classification distinguishes four clinical types.(1) OI type I comprises patients with absence of
bone deformities. Type II is lethal in the perinatal period.
OI type III is the most severe form that is compatible with
life. These patients have extremely short stature and limb
and spinal deformities secondary to multiple fractures. Patients with mild to moderate bone deformities and variable
short stature are classified as OI type IV. In the majority of

The authors have no conflict of interest.

patients with OI, the disease can be linked to mutations in

one of the two genes coding for collagen type I chains
(COL1A1 and COL1A2).(2)
Cyclical intravenous therapy with the bisphosphonate
pamidronate has been reported to be beneficial in children
and adolescents with moderate to severe forms of OI.(35)
Several investigators have observed that this treatment increases lumbar spine areal BMD and metacarpal cortical
width, decreases fracture rate, and improves mobility.(35)
Histomorphometric studies of iliac bone samples showed
that the main effect of pamidronate treatment was to increase cortical thickness.(6) The amount of trabecular bone
also increased during pamidronate therapy, because the
number of trabeculae increased.
Most of the patients described in these studies were >2

1
Genetics Unit, Shriners Hospital for Children and McGill University, Montral, Qubec, Canada; 2Current Address: The Childrens
Hospital at Westmead; Westmead, New South Wales, Australia.

1235

1236

MUNNS ET AL.

years of age when pamidronate treatment was started. In a

congenital disease such as OI, it seems logical to start treatment as early as possible. Promising results have indeed
been reported in severely affected OI patients who received
pamidronate in the first 2 years of life.(711) However, the
scope of these observations was limited, as only nine of the
reported patients were followed for >12 months. None of
these reports presented information on what effects cyclical
intravenous pamidronate therapy has on the bone tissue of
patients who start treatment in infancy.
In this study, we describe the effects of 3 years of pamidronate therapy in OI patients who started treatment before 2 years of age and provide histomorphometric data on
the treatment effect in this young age group.

MATERIALS AND METHODS

Subjects
This study was comprised of patients with a diagnosis of
OI type I, III, or IV who had received pamidronate therapy
at the Shriners Hospital for Children in Montreal before 2
years of age. Patients were eligible for this observational
trial if they had long bone deformities or had suffered more
than three fractures (including vertebrae).(3,7) This applies
to all patients with OI types III and IV and to the most
severe cases of OI type I.
As per study protocol, patients underwent anthropometric, radiological, biochemical, and functional assessment at
regular intervals during the study. Histomorphometric
analysis was to be performed after 2 years of therapy, if
feasible. To maximize the amount of histomorphometric
information in this report, the criteria for including patients
in these analyses were different for the anthropometric,
radiological, biochemical, and functional evaluation (clinical studies) than they were for histomorphometric assessment (histomorphometric studies).
The clinical study group was comprised of all 29 OI patients who had started pamidronate treatment before 2
years of age and had completed 3 years of treatment (Table
1). Collagen type I mutations were found in 27 of these
patients. In two patients, no collagen type I mutation was
detectable by sequence analysis of the entire coding region.
Results after 3 years of treatment were compared with
those of 29 patients who were matched for OI type and age
and who had not received pamidronate before the examinations reported here (Table 1). Collagen type I mutations
were found in 19 of these patients. In one patient, no collagen type I mutation was detectable by sequence analysis
of the entire coding region, and in nine patients the mutation testing had not been performed.
The histomorphometric study included patients who had
received pamidronate treatment for at least 1 year before
undergoing iliac bone biopsy. As mentioned earlier, the
protocol called for bone biopsies to be performed after 2
years of treatment. However, because the biopsy specimens
were preferably obtained during elective orthopedic procedures such as rodding of long bones, the actual timing of the
biopsy often deviated from the treatment protocol. In pa-

TABLE 1. CHARACTERISTICS OF PATIENTS INCLUDED

CLINICAL STUDIES

OI type (I/III/IV)
Sex (male/female)
Family history of OI
Blue sclera
Dentinogenesis imperfecta
Wormian bones
Age (years)
Height (cm)
Weight (kg)
Lumbar spine densitometry
BMC (g)
Areal BMD (g/cm2)
Volumetric BMD
(mg/cm3)
Vertebral volume (cm3)

IN

Pamidronatetreated group
(n 29)

Control
group
(n 29)

3/14/12
15/14
4
20
23
29
3.7 (0.6)
84.1 (9.4)
12.1 (2.7)

3/14/12
12/17
3
21
20
28
3.7 (0.9)
80.1 (11.1)
10.7 (2.5)

0.43
0.90
0.93
0.40
0.31
0.87
0.14
0.05

8.2 (2.2)
0.40 (0.06)

3.4 (1.7)
0.19 (0.05)

<0.001
<0.001

88 (12)
93 (23)

45 (11)
74 (28)

<0.001
0.009

Values are n or mean (SD). p values were calculated either by 2 test or

by unpaired t-test, as appropriate.

tients who did not require orthopedic interventions but

weighed >10 kg and did not present an elevated anesthetic
risk, specimens were obtained under general anesthesia in a
procedure performed exclusively for this purpose. Patients
were included in this evaluation if iliac bone samples of
sufficient quality were obtained.
In 49 patients, pamidronate therapy had been started before the age of 2 years and had been given for at least 1
year. At the time of this evaluation, bone biopsies had not
been obtained in 17 of these patients, and in 8 patients,
biopsy specimens were inadequate for analysis. Thus, 24
patients were included in this study. Collagen type I mutations were present in 21 of these patients. In two patients,
no collagen type I mutation was detectable by sequence
analysis, and one patient had not been tested.
Histomorphometric results in the study group were compared with those of two age-matched control groups: a cohort of children who were free from metabolic bone disorders and a group of OI patients who had not received
bisphosphonate therapy before biopsy. The healthy control
group was comprised of 10 children (4 girls and 6 boys)
between 1.6 and 5.2 years of age, as described earlier.(7)
These children had undergone iliac bone biopsies during
unrelated orthopedic procedures. The OI control group
consisted of 24 children (age at biopsy, 1.45.3 years). Collagen type I mutations were found in 21 of these patients, in
one patient, no collagen type I mutation was detectable by
sequence analysis, and two patients had not been tested.
The study was approved by the Shriners Hospital Institutional Review Board, and informed consent was obtained
from the legal guardians.

Treatment
Pamidronate was administered intravenously on 3 consecutive days in all patients. As previously reported, the
timing and dosage of these 3-day cycles varied with age,

PAMIDRONATE IN INFANTS WITH OI

1237

because the clinical effect of a pamidronate infusion, especially on bone pain, was more short-lived in infants than in
older children.(7) Patients received 0.25 mg/kg on the first
day of the first cycle, 0.5 mg/kg on days 2 and 3 of the first
cycle, and 0.5 mg/kg daily on all 3 days in subsequent cycles.
Cycles were repeated every 2 months. After the second
birthday, treatment was continued with cycles of 0.75 mg/kg
pamidronate daily on 3 successive days that were repeated
every 3 months. Above 3.0 years of age, the pamidronate
dose was 1 mg/kg daily for 3 days, and cycles were repeated
every 4 months. Thus, the yearly dose of the drug was the
same at all ages (9 mg/kg). Each dose was diluted in 0.9%
saline solution and administered slowly over 4 h.
Calcium intake was maintained adequate according to
the recommended daily allowance in all patients. All patients underwent physiotherapy and occupational therapy
evaluation and support, including exercises and the provision of special devices for transportation and sitting. In children with significant lower limb deformity, intramedullary
rodding procedures were performed when the child was
able to pull up to stand. The entire multidisciplinary treatment approach has recently been described in detail.(12)

Anthropometry
Height was measured using a Harpenden stadiometer
(Holtain Limited, Crymych, UK). Infants and children unable to stand were measured in the supine position; others
were measured standing. In cases of leg length discrepancy
or contractures, the longest leg was measured. Weight was
determined using digital electronic scales for infants and
mechanical scales for children (Healthometer).

Function
Occupational therapists and physiotherapists experienced in the care of children with OI assessed the subjects
before the start of pamidronate therapy and at each subsequent treatment cycle. The Pediatric Evaluation of Disability Inventory (PEDI) was used to assess gross motor and
self-care abilities.(13) Mobility was assessed using a modification of the Bleck score as follows: 0 (does not walk), 1
(able to walk during therapy sessions only), 2 (walking only
within the house), and 3 (able to walk within the community).(14)

Radiological measurements
All radiographs were taken using standardized techniques with a Siemens Multix H radiological unit (Siemens
AG, Erlangen, Germany) onto Kodak medical film (Eastman Kodak Co., Rochester, NY, USA). Radiographs were
taken as part of a skeletal survey performed at the start of
pamidronate treatment and annually thereafter.
Postero-anterior radiographs of the left hand were evaluated by pediatric radiologists to calculate bone age using
the method described by Greulich and Pyle.(15) From these
same radiographs, a single observer (CM) measured second
metacarpal length, midshaft periosteal diameter, and endocortical diameter, as described,(16) using a dial reading caliper with a 0.04-mm resolution (General Tools). From these

FIG. 1. Method of vertebral morphometry. Six points per vertebra, corresponding to the four corners of the vertebral body and
the midpoints of the end plates, were marked and anterior height
(AH), posterior height (PH), midheight (MH), upper length
(UL), and lower length (LL) of each vertebra were measured.
Two examples are shown to illustrate morphometry in an untreated child (pre-Rx) and in a child who received 3 years of
pamidronate (post-Rx).

measurements, combined cortical thickness, cross-sectional

cortical bone area, and percent cortical area were derived.(16)
Vertebral morphometry was performed on lateral spine
radiographs as described by Smith-Bindman et al.(17) Six
points were marked on each of the vertebral bodies L1 to
L4, which corresponded to the four corners of the vertebral
body and the midpoints of the end plates (Fig. 1). From
these points, the anterior height, posterior height, midheight, upper length, and lower length of each vertebra was
calculated. To account for magnification, all measurements
were expressed relative to lower vertebral length, because
this is the measure that is probably least influenced by compression fractures. All radiographs were evaluated by a
single observer (CM).

Bone densitometry
Bone densitometry was performed in the anteroposterior direction at the lumbar spine (L1L4) using a Hologic QDR 2000W or 4500A device (Hologic). Areal BMD
results were transformed to age-specific z scores combining
reference data from Salle et al.(18) and data provided by the
densitometer manufacturer. Volumetric BMD and bone
volume were derived mathematically as described.(19)

1238

MUNNS ET AL.

Biochemical measurements
Serum concentrations of total calcium, inorganic phosphate, alkaline phosphatase, creatinine, 25-hydroxyvitamin
D, 1,25-dihydroxyvitamin D, PTH, and TRACP, and urinary levels of the bone resorption marker cross-linked Ntelopeptide of type I collagen (NTx), creatinine, and calcium were measured on fasting samples using methodology
recently described.(20)

Bone biopsy and histomorphometry

Whenever possible, labeling was performed before biopsy using demeclocycline (1520 mg/kg per day taken
orally during two 2-day periods separated by a 10-day free
interval). Twenty patients in the treatment group, 22 of the
untreated OI patients, and all 10 children in the healthy
control group completed this labeling course before the
biopsy procedure. Transiliac bone samples were collected 4
or 5 days after the labeling using a Bordier trephine (5-mm
core diameter) from a site located 2 cm dorsal of the anterior superior iliac spine. No side effects of this procedure
were noted other than transient local discomfort.
Biopsy preparation and histomorphometric analyses
were performed as described previously.(7) Bone samples
were included in this analysis when cancellous bone per
tissue volume was measurable. Thus, samples with a
crushed cancellous compartment were excluded from
analysis. Wall thickness was not measured, because reversal
lines are difficult to visualize in severe OI. Consequently,
activation frequency could not be determined. Osteoclast
diameter was measured as the largest diameter of each cell.
Mineralized cartilage was distinguished from mineralized
bone on the basis of differences in staining (Fig. 2). Measurements were carried out using a digitizing table with
Osteomeasure software (Osteometrics, Atlanta, GA,
USA). Nomenclature and abbreviations follow the recommendations of the American Society for Bone and Mineral
Research.(21)

Statistical analysis
Variables were tested for normal distribution using the
Kolmogorov-Smirnov test. Normally distributed data were
expressed as mean and SD. Geometric means and geometric SD were calculated for nonnormally distributed variables. These variables were log-transformed before performing tests that require normal distribution. Differences
between the three patient groups were tested for significance using ANOVA. Posthoc comparisons were performed using Bonferronis adjustment. The difference between results of treated and untreated OI patients was
tested for significance using Students unpaired t-test. The
difference in the frequency of categorical measures between the pamidronate and control groups was evaluated
using the 2 test. All tests were two-tailed, and throughout
the study, p < 0.05 was considered significant. These calculations were performed using the SPSS software, version
11.5 for Windows (SPSS, Chicago, IL, USA).

FIG. 2. Trabeculae containing (A) low, (B) middle, and (C) high
proportions of calcified cartilage. In these Goldner-stained nondecalcified sections, mineralized bone stains dark green or blue;
calcified cartilage stains light green or light blue. Mineralized cartilage is brittle and therefore can disintegrate during the sectioning process, resulting in a nonstaining (white) area. The size bar
corresponds to 200 m.

RESULTS
Clinical studies
In the treatment group, pamidronate therapy was started
at 0.7 0.6 (SD) years of age (range, 2 weeks to 23 months).
Results after 3 years of treatment were compared with
those of a control group of patients who had not received
pamidronate and who were matched for OI type and age

PAMIDRONATE IN INFANTS WITH OI

1239

FIG. 3. Lateral lumbar spine radiographs of

two children 3.3 years of age with OI type III.
The child in the left panel never received
pamidronate, whereas the child in the right
panel received 3 years of pamidronate
therapy.

(Table 1). The two groups were not significantly different

for height, whereas there was a trend toward an increased
weight in the pamidronate group. Vertebral shape was better preserved in pamidronate-treated patients (Figs. 3 and
4). This was accompanied by significantly higher lumbar
spine areal and volumetric BMD (+110% and +96%, respectively) and a larger vertebral bone volume (+26%;
Table 1).
After 3 years of cyclical pamidronate treatment, biochemical markers of bone turnover (alkaline phosphatase
and urinary NTx/creatinine) were significantly reduced
(Table 2). Serum creatinine was also slightly lower in the
pamidronate cohort, whereas the other biochemical parameters were similar between the two groups.
Cortical thickness and percent cortical area of the second
metacarpal bone were significantly greater after 3 years of
pamidronate therapy, whereas outer bone diameter was
similar between groups (Table 3). The control group had a
significant delay in bone age compared with chronological
age (bone age 3.2 1.2 years versus chronological age 3.7
1.0 years; p 0.004). No such delay was evident in the
pamidronate-treated group (bone age 3.7 1.2 years versus
chronological age 3.9 0.8 years; p 0.08). Fracture incidence could not be compared between the two groups because of insufficient data in the control group.
Both the PEDI gross motor score and the mobility score
were significantly greater in the pamidronate group (p <
0.001; Table 4).

Histomorphometric studies
Results from 24 pamidronate-treated OI patients were
compared with data from 24 age-matched patients who had
not received pamidronate (Table 5). Quantitative histomorphometric measures in treated and untreated OI patients
were also compared with a group of age-matched children
without metabolic bone disease. In the treated group, pamidronate had been started at a median age of 6 months
(range, 2 weeks to 23 months). Age at the time of the bone
biopsy ranged from 1.6 to 5.5 years, when pamidronate had
been given for 2.5 0.8 years (range, 1.04.0 years). Anthropometric and densitometric results in patients included

FIG. 4. Schematic representation of average vertebral body

shape as determined by vertebral morphometry. Mean results for
anterior height (AH), midheight (MH), and posterior height (PH)
relative to lower vertebral length (see Fig. 1) are shown for the
control and the pamidronate treated groups; n 28 for the pamidronate group and n 27 for the control group. Significant differences between corresponding measures in the two groups are
indicated: *p < 0.05; **p < 0.01; ***p < 0.001.

1240
TABLE 2. SERUM

MUNNS ET AL.
AND

URINE BIOCHEMICAL DATA

OF

PATIENTS WHO HAD RECEIVED 3 YEARS

OF CONTROL PATIENTS

OF

PAMIDRONATE TREATMENT

AND

Reference range

Pamidronatetreated group
(n = 29)

Control group
(n = 29)

2.252.63
150300
1.231.62
44.288.4
3491
65134
2.610
3.07.0

2.44 (0.17)
185 (45)
1.61 (0.21)
36.0 (7.6)
65 (17)
86 (36)*
6.70 (2.10)
6.6 (1.7)

2.41 (0.14)
274 (63)
1.63 (0.22)
50.3 (6.3)
61 (23)
80 (49)
6.23 (2.26)
5.9 (1.8)

0.44
<0.001
0.68
<0.001
0.50
0.64
0.41
0.16

<1.13

0.63 (0.60)
399 (132)

0.96 (0.92)
850 (301)

0.10
<0.001

Serum
Total calcium (mM)
Alkaline phosphatase (U/liter)
Inorganic phosphate (mM)
Creatinine (M)
25-hydroxyvitamin D (nM)
1,25-dihydroxyvitamin D (nM)
PTH (pM)
TRACP (M/min/liter)
Urine
Calcium/creatinine (mM/mM)
NTx/creatinine (nM/mM)

Values are mean (SD). Reference ranges are indicated as established in the authors laboratory for children. p values were calculated by unpaired t-test.
* n 20.

n 27.

TABLE 3. EVALUATION OF THE SECOND METACARPAL IN

PATIENTS WHO HAD RECEIVED 3 YEARS OF PAMIDRONATE
TREATMENT AND IN CONTROL PATIENTS

Length (mm)
Outer diameter (mm)
Inner diameter (mm)
Combined cortical
thickness (mm)
Cortical area (mm2)
Percent cortical area

Pamidronatetreated group
(n = 27)

Control
group
(n = 29)

32.5 (4.6)
4.37 (0.61)
2.65 (0.64)

32.2 (4.6)
4.42 (0.72)
3.07 (0.70)

0.80
0.79
0.02

1.72 (0.35)
9.48 (3.47)
61.7 (13.4)

1.35 (0.32)
7.97 (3.67)
50.2 (16.2)

0.02
0.12
0.005

Values are mean (SD). p values were calculated by unpaired t-test.

TABLE 4. FUNCTIONAL EVALUATIONS AND AGE

LIMB RODDING PROCEDURE

PEDI gross motor

PEDI self-care
Mobility score

AT

FIRST LOWER

Pamidronatetreated group

Control
group

29
29
29

36 (13)
45 (12)
2.3 (1.0)

25
25
29

24 (12)
41 (12)
0.8 (1.0)

<0.001
0.26
<0.001

Values are mean (SD). p values were calculated by unpaired t-test.

in the histomorphometric study were similar to those obtained in the clinical study (data not shown).
Qualitative assessment of iliac bone specimens showed
that the proportion of samples containing marrow fibrosis
was significantly (p < 0.01) lower in the pamidronatetreated group (8 [33%] samples) compared with untreated
OI patients (18 [75%] samples). Woven bone was not detected in any of the samples. Double labels were present in
all bone specimens from patients who had received two
courses of tetracycline before biopsy.
External bone size (core width) was similarly low in
treated and untreated OI patients (Fig. 5; Table 5). How-

ever, average cortical width and cancellous bone volume

were 61% and 89% higher, respectively, in the patients who
had received pamidronate (Table 5). The difference in cancellous bone volume was caused by the presence of a large
number of thin trabeculae in the pamidronate group. In
patients receiving pamidronate, cartilage volume on average made up 0.6% of the cancellous compartment, corresponding to 4.7% of the cancellous bone volume (Fig. 2). In
contrast, only traces of cartilage were found in untreated OI
patients or healthy children.
As to parameters of cancellous bone turnover, osteoid
thickness was not different between the two groups of OI
patients (Table 6). However, all bone surface based formation parameters were lower in the pamidronate-treated
group. In particular, average bone formation rate per bone
surface in the pamidronate group was only 17% that of
untreated OI patients and 25% that of healthy controls. In
addition, the fraction of osteoid seam length showing mineralizing activity was smaller and mineral apposition rate
was lower in the treated group compared with untreated OI
patients. Therefore, mineralization lag time was considerably prolonged in the treated patients.
As to bone resorption parameters, the number and surface extent of osteoclasts were not significantly different
between groups. Average osteoclast diameter was similar
in the pamidronate group and in OI controls (37 8 versus
34 4 m; p 0.12). However, eroded surface was highest
in children receiving pamidronate.

DISCUSSION
The results of this study suggest that cyclical pamidronate
treatment started in infancy was associated with improvements in vertebral shape, size, and BMD, metacarpal and
ilial cortical thickness, trabecular number, and gross motor
function. On the down side, the treatment suppressed bone
turnover and led to some accumulation of mineralized
growth plate material in secondary bone.

PAMIDRONATE IN INFANTS WITH OI

1241

TABLE 5. HISTOMORPHOMETRIC STUDY: PATIENT CHARACTERISTICS

Variable

Pamidronatetreated group

Gender (girls/boys)
OI types (I/III/IV)
Age (years)
Core width (mm)
Cortical width (mm)
Bone volume per tissue volume (%)
Trabecular thickness (m)
Trabecular number (mm)
Cartilage volume per tissue volume (%)*
Cartilage volume per bone volume (%)*

24
24
24
19
23
24
24
24
24
24

11/13
4/10/10
3.3 (1.0)
2.9 (1.0)
515 (240)
14.9 (7.2)
68 (18)
2.3 (1.2)
0.6 (0.011.1)
4.7 (0.035.4)

AND

STRUCTURAL HISTOMORPHOMETRIC PARAMETERS

OI control
group

24
20
24
24
24
24
24
24

12/12
5/7/12
3.3 (1.1)
3.2 (1.1)
319 (151)
7.9 (3.5)
88 (23)
1.0 (0.6)
0.0 (0.00.1)
0.0 (0.00.6)

Healthy
control
group

10
10
10
10
10
10
10
10

6/4

3.2 (1.1)
5.3 (1.4)
703 (277)
17.7 (2.6)
101 (11)
1.8 (0.3)
0.0 (0.00.0)
0.0 (0.01.2)

<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001

Values are mean (SD) unless otherwise indicated. p values represent the significance of the difference between the three groups (ANOVA).
* Median (range) is given, and the p value is calculated by Kruskal-Wallis test.
The results of the posthoc test (Bonferroni adjustment) between individual groups: significant difference (p < 0.05) to pamidronate-treated group;

significant difference (p < 0.05) to OI control group; significant difference (p < 0.05) to healthy group.

FIG. 5. (A) Iliac bone sample from a 2.8year-old boy with OI type IV who had not
received pamidronate. Cortical width is 274
m, cancellous bone volume per tissue volume is 4.3%. (B) Sample from a 3.8-year-old
boy with OI type IV who had received pamidronate for 3.6 years (cortical width is 832
m, cancellous bone volume per tissue volume is 12.8%).

Our structural histomorphometric findings suggest that

the increase in vertebral bone mass and BMD during pamidronate treatment is mostly because of thicker cortices and
a higher amount of cancellous bone. Cortical thickness also
increased at the midshaft of the second metacarpal. It
seems that cortical thickening at that site occurred through
endocortical rather than periosteal apposition, because
pamidronate-treated patients had a smaller inner bone diameter but a similar outer bone diameter than controls. We
have made similar observations in iliac bone samples of
older OI patients.(6)
The increase in trabecular number during pamidronate is
probably caused by the effect of the drug on endochondral
bone growth. Endochondral growth is normally characterized by the production of a large number of thin primary
trabeculae, most of which are rapidly resorbed during the
conversion of primary into secondary spongiosa.(22) Pamidronate therapy increases the number of trabeculae, presumably because fewer primary trabeculae are resorbed.(23)
Because primary trabeculae are thinner than secondary trabeculae, this mechanism also may account for the observation that trabecular thickness was lower in pamidronatetreated patients.

It is plausible that thicker cortices and a higher amount of

cancellous bone contribute to make vertebrae stronger.
This is confirmed by the vertebral morphometry data that
document improvements in vertebral shape and size, suggesting that pamidronate prevents vertebral crush fractures
and allows for a more normal vertebral growth.
The results of this study suggest that pamidronate treatment of infants is associated with functional gains. Better
gross motor skills and mobility may have resulted from a
reduction in bone pain, lower fracture rates, and increased
muscle strength, all of which have been previously associated with pamidronate treatment in OI.(3,7,8,10) These same
factors may also have allowed for more active physiotherapy and occupational therapy input. It remains to be seen
whether these gains will be maintained and whether they
result in improved self-care and independence.
With regard to safety considerations, pamidronate treatment did not adversely affect growth rate, progression of
bone age, calcium homeostasis, and renal function. However, pamidronate therapy was associated with a significant
reduction in bone turnover, as indicated both by biochemical bone turnover markers and by histomorphometry. Low
bone turnover may explain why more iliac bone samples

1242

MUNNS ET AL.
TABLE 6. HISTOMORPHOMETRIC PARAMETERS

Variable
Bone formation
Osteoid thickness (m)
Osteoid surface per bone surface (%)
Osteoblast surface per bone surface (%)*
Mineralizing surface per bone surface (%)*
Mineralizing surface per osteoid surface (%)*
Mineral apposition rate (m/day)
Mineralization lag time (day)*
Bone formation rate per bone surface (m3/m2/y)
Bone resorption
Osteoclast number per bone perimeter (#/mm)
Osteoclast surface per bone surface (%)
Eroded surface per bone surface (%)

OF

CANCELLOUS BONE TURNOVER

Pamidronatetreated group

24
24
24
20
20
19
19
19
24
24
24

Healthy
control
group

5.1 (1.7)
48 (14)
19.6 [1.8]
24.8 (9.1)
53 (20)
0.77 (0.17)
14 [1.7]
70 (31)

10
10
10
10
10
10
10
10

5.8 (1.4)
34 (7)
7.5 [1.7]

12.5 (4.5)

38 (13)
1.04 (0.17)
16 [1.4]
48 (19)

0.08
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001

0.37 [2.1]
1.4 (1.1)
22 (10)

9
10
10

0.27 [2.1]
1.1 (0.7)
15 (4)

0.08
0.45
<0.001

OI control
group

4.7 (0.9)
33 (13)
6.2 [2.4]
5.6 (4.9)
17 (12)
0.57 (0.14)
62 [2.8]
12 (9)

24
24
21
21
21
22
21
21

0.49 [2.0]
1.6 (1.1)
30 (14)

21
21
23

Values are mean (SD).

* Geometric mean [geometric SD] are given. p values represent the significance of the difference between the three groups (ANOVA).
The results of the posthoc test (Bonferroni adjustment) between individual groups: significant difference (p < 0.05) to pamidronate-treated group;

significant difference (p < 0.05) to OI control group; significant difference (p < 0.05) to healthy group.

contained calcified cartilage during pamidronate treatment.

Growth plate cartilage probably is not completely removed
during the conversion of primary to secondary spongiosa
when turnover is low. It has been suggested that this residual growth plate cartilage might cause bone fragility.(24)
We have no indication at present that the increased amount
of calcified cartilage caused clinical problems in our patients.
Similar to our previous histomorphometric studies in
older OI patients, none of the participants of this study had
signs of a mineralization defect.(6) Mineralization lag time
was prolonged during therapy, but there was no accumulation of osteoid. The prolonged mineralization lag time is
therefore a sign of sluggish remodeling activity rather than
of a mineralization defect.
It may come as a surprise that pamidronate-treated patients did not have significantly lower osteoclast numbers
than untreated patients. However, osteoclast indices have a
large interindividual variability. Therefore, larger sample
numbers may be required to find statistically significant differences between groups. In addition, pamidronate may
render osteoclasts dysfunctional without causing apoptosis,
and therefore it is likely that the osteoclast counts do not
reflect resorptive function.(25) Similarly, the elevated readings for eroded surface may reflect bone surfaces that were
abandoned by inactivated resorptive cells after pamidronate treatment was started and were not subsequently
smoothed out by osteoblasts, because bone turnover was
suppressed by therapy.
Whereas pamidronate infusions were generally well tolerated, we have observed cases of acute respiratory compromise in babies with pre-existing pulmonary problems
who received their first pamidronate treatment cycle.(26)
This highlights the requirement for close monitoring of infants who receive pamidronate.
In conclusion, this study suggests that cyclical pamidronate treatment started in infancy can lead to improved bone
strength and better gross motor function. However, bone

turnover is markedly suppressed during pamidronate treatment. It is possible that the suppression of bone turnover
leads to the accumulation of microdamage.(27) Given the
long persistence of bisphosphonates in the skeleton, it can
not be excluded that such an effect might increase bone
fragility years or even decades later. It is therefore prudent
to reserve pamidronate treatment to infant OI patients who
present with a moderate to severe phenotype.

ACKNOWLEDGMENTS
This study would not have been possible without the tremendous support of the nursing staff and the departments
of occupational therapy and physiotherapy at the Shriners
Hospital for Children. The authors thank Guy Charette and
Jose Dpot for technical assistance with biopsy sample
processing and Mark Lepik for preparing the figures. We
are indebted to Dr Peter Roughley and Dr Liljana Lalic for
performing sequence analyses. This study was supported by
the Shriners of North America.

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Address reprint requests to:

Frank Rauch, MD
Genetics Unit
Shriners Hospital for Children
1529 Cedar Avenue
Montral, Qubec H3G 1A6, Canada
E-mail: frauch@shriners.mcgill.ca
Received in original form August 25, 2004; revised form February
3, 2005; accepted February 18, 2005.