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OSTEOMALACIA-A COMMON DISEASE IN ELDERLY WOMEN

J. CHALMERS, EDINBURGH, W. D. H. CONACHER, BANGOUR, SCOTLAND,

D. L. GARDNER, LONDON, and P. J. SCOTT, EXETER, ENGLAND

From the South-East Region (Scotland)

Osteomalacia is not generally regarded as a common disease in western countries and the

condition consequently receives scant treatment in many of the standard medical textbooks.

It is well recognised as a complication of intestinal malabsorption, gastric surgery and renal

tubular defects, and most of the cases reported from Europe and the United States fall into

these categories. Dietary deficiency of vitamin D has not been regarded as an important cause

(Albright, Burnett, Parson, Reifenstein and Roos 1946; Sherman 1950; Salvesen and B#{246}e1953).

ln the past four years we have observed thirty-seven cases of osteomalacia, thirty-one

presenting in an orthopaedic and geriatric service in the South-Eastern region of Scotland and

six in other regions. Our experience suggests that the disease is in fact quite common,

particularly in elderly women.

These cases of osteomalacia bear a superficial resemblance to senile osteoporosis and it is

probable that the latter diagnosis is too readily accepted. A distinction between these two

diseases is very important because treatment is highly effective in osteomalacia but not in

osteoporosis.

The purposes of this paper are, therefore, to indicate the frequency of osteomalacia and

to describe and evaluate some diagnostic features with particular reference to the points which

distinguish it from osteoporosis, and to outline the treatment. The thirty-seven cases of our

series are reviewed against the background of previously published work in an attempt to

assess these aspects of the disease.

CLINICAL FEATURES OF OSTEOMALACIA

In this series there were thirty-four women and three men (Table I). The mean age was

seventy-two years, ranging from thirty-nine to eighty-nine. The increased incidence of

osteomalacia among women has been found by others. Strang (1951) in a review of the

literature collected fifty-six cases of varying etiology. Of these, fifty-one were female with a

mean age of 50.5 years.

Our interest in osteomalacia was first aroused by recognising the disease in patients after

gastric surgery and by reports of this association appearing in the literature (Pyrah and Smith

1956, Baird and Oleesky 1957). Screening of all patients attending our clinical departments

who gave a history of previous gastric surgery led to the diagnosis in nineteen patients; some

of these were early cases without significant symptoms. Men who had had gastrectomy were

subjected to the same scrutiny, but only two were found to have osteomalacia.

Although the association of osteomalacia and gastric surgery has received much publicity

(Clark 1962; Jones, Cox, Cooke, Williams, Meynell and Stammers 1962; Harvald, Krogsgaard

and Lous 1962; Deller, Ibbotson and Crompton 1964) the true incidence of this association is

probably very low. Morgan, Paterson, Pulvertaft, Woods and Fourman (1965) examined 1,228

patients after a variety of gastric operations and found only six with osteomalacia. These all

occurred after partial or total gastrectomy. There were four women (an incidence of 3 per cent)

but only two men from a total of 681 men.

There is no doubt that the recognition that gastric surgery has an association with

osteomalacia and the closer study that these patients received has caused a bias in the selection

VOL. 49 B, NO. 3, AUGUST 1967 403

FIG. 1 FIG. 2 FIG. 3 FIG. 4Radiographs showing the development of a Looser’s zone from a “ stress fracture “ of the ulna. Figure 1 showsa hairline crack in the ulna on December 18, 1963. Figures 2 and 3 show the development of a typical Looser’szone (May 12 and June 6, 1964, respectively) and a crack has appeared in the radius. After vitamin D treatment

rapid healing took place (Fig. 4, October 2, 1964).

FIG. 5 FIG. 6 FIG. 7

A fracture of the surgical neck of the humerus which failed to show radiological union and was still painfulafter three years; Figure 5, December 1961; Figure 6, February 1965. Figure 7-One month after vitamin D

had been started the fracture was healing well and was painless.

404 J. CHALMERS, W. D. H. CONACHER. D. L. GARDNER AND P. J. SCOTT

THE JOURNAL OF BONE AND JOINT SURGERY

of cases in our series. With increasing experience the recognition of osteomalacia in patients

without gastrectomy is steadily rising.

Three of the younger patients, aged thirty-nine, forty-one and fifty-four, suffered from

idiopathic steatorrhoea but, if the patients with recognisable malabsorption are excluded, the

remaining thirty-four formed a homogeneous group. There was little difference in clinical

presentation and biochemical findings between the patients with a history of gastric surgery

and those without: the mean age of the patients after operation was slightly lower (sixty-nine

years), whereas the remaining patients had a mean age of eighty years.

The main symptoms of which these patients complained were skeletal pain and progressive

muscular weakness. In fourteen patients a fracture caused the first attendance at hospital.

Muscular weakness-Muscular weakness was a striking feature in several patients and produced

a typical flat-footed, springless gait which one patient’s family aptly described as “mother’s

penguin walk.” Rising from a chair was difficult for those severely affected, and in one instance

the patient was confined to bed by the severity of the weakness. Many patients who had not

specifically complained of muscular weakness before treatment volunteered that they felt

stronger and more vigorous after treatment than they had been for years.

OSTEOMALACIA-A COMMON DISEASE IN ELDERLY WOMEN 405

VOL. 49 B, NO. 3, AUGU5T 1967

Skeletal pain-Most patients, including several with fractures, gave a history of skeletal pain

which had progressed over several years. The pain occurred commonly in the thorax, shoulder

girdles and thighs, forearms and feet and was less common in the axial skeleton, in contrast

to osteoporosis. The painful sites were usually tender and were localised to bone rather than

tojoints-a point which helps to distinguish this disease from rheumatoid arthritis, with which

it had been previously confused in several of our patients. The tender areas could often be

felt as thickenings in superficial bones such as ribs and ulnae and, on radiography, Looser’s

zones were sometimes seen at these sites.

Fractures in osteomalacia-Eleven patients presented with complete fractures, ten in the

proximal femur and one in the surgical neck of humerus. The distribution and pattern of

these fractures resembled the fracture pat-

terns commonly seen in old age and usually

associated with osteoporosis. In addition

to those presenting with complete fractures,

several patients were seen with stress frac-

tures occurring in ribs, necks of femur or

forearm bones which progressed to typical

Looser’s zones (Figs. 1 to 4). Stress fractures

occurring in elderly patients should therefore

be regarded as evidence of osteomalacia

unless proved otherwise. If osteomalacia is

left untreated, fractures are very slow to

show radiological evidence of union. Figures

5 to 7 show the radiographs of a patient who

sustained a fracture of the surgical neck of

humerus in 1961, which fracture was still

ununited and painful three years later.

Within a month after starting vitamin D FIG. 8

therapy, abundant mineralisation of the � adultsh�e examples

callus was apparent. It is probable that such such as this all occurring in the tibia and fibula.

fractures are in fact “healed” by callus,

but that this callus, lacking mineral, is not demonstrable radiologically. Delay of radiological

union of a fracture which would normally be expected to heal rapidly merits further

investigation regarding the possibility of osteomalacia. Conversely, rapid healing of a fracture

excludes any likelihood of osteomalacia and is quite characteristic of osteoporosis.

Greenstick fractures were seen in three patients (Fig. 8) and are regarded as virtually

diagnostic when occurring in adults. They are not found in osteoporosis where fractures are

typically complete.

SPECIAL INVESTIGATIONS

While the diagnosis is often suggested by the clinical features, confirmation requires further

investigation. Biochemical, radiological and histological studies are important.

Biochemical changes in osteomalacia-Lowering of the plasma calcium and inorganic phosphate

levels has long been recognised to be a feature of osteomalacia and diagnostic significance

has been attached particularly to the product of these two values. Howland (1923) pointed

out that a product of less than 30 milligrams per 100 millilitres was usually found, while others

(Salvesen and B#{246}e1953) have suggested that values of less than 27 were more diagnostic.

By this latter standard, twenty-seven of our patients were in the diagnostic range but eight

were “normal.” Figures 9 to 11 indicate the range of levels found in the cases reported here

together with the corresponding values for a randomly selected group of senile osteoporotic

cases in whom calcium and phosphate levels might be expected to be normal.

OSTEOMALACIA OSTEOPOROSIS

I

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OSTEOMALACIA OSTEOPOROSiS

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PLASMA PLASMAINORGANIC

CALCIUM 11�- PHOSPHORUS“lILLIGRAMS MILLIGRAMS

PER CENT10� PER CENT

9- ... 4

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FIG. 9 FIG. 10

Distribution of the plasma calcium and phosphorus levelsin the osteomalacic patients with the correspondingvalues of a randomly selected group of osteoporotic patients.

OSTEOMALACIA OSTEOPOROSIS 65�- OSTEOMALACIA OSTE0�RQ5I560 - #{149} PLASMA

PLASMA ALKALINE 5O�-

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FIG. 11 FIG. 12

Distribution of the calcium phosphorus products and the plasma alkaline phosphatase levels in the osteomalacicpatients with the corresponding values of a randomly selected group of osteoporotic patients.

not exclude the disease. Likewise, two of the osteoporotic controls had plasma calcium and

phosphate products below 27 milligrams per 100 millilitres. It follows, therefore, that low

plasma calcium and phosphate values are not necessarily diagnostic of osteomalacia; they

406 J. CHALMERS. W. D. H. CONACHER, D. L. GARDNER AND P. J. SCOTT


Although there was a relationship between the severity of the biochemical changes and

the severity of the disease as judged by other means, a significant proportion of osteomalacic

patients had normal levels of plasma calcium and phosphate. Normal biochemical tests did


VOL. 49 B, NO. 3, AUGUST 1967

indicate the need for further investigation and should be part of the routine investigation of

all patients presenting with diminished density of bone or pathological fracture in old age.

Similarly, normal values do not exclude the possibility of osteomalacia.

Elevation ofplasma alkaline phosphatase is a common finding in osteomalacia. Figure 12

shows the results for this series together with values obtained in a random sample of

osteoporotic patients. Thirty-one of thirty-five osteomalacic patients had values above 12

King-Armstrong units, compared with six of thirty-six osteoporotic patients. Alkaline

phosphatase levels may, of course, be raised by other conditions such as Paget’s disease,

hyperparathyroidism, liver failure, widespread skeletal metastases or recent fracture but,

when these have been excluded, a raised alkaline phosphatase level suggests the diagnosis of

osteomalacia.

Urinary calcium excretion is usually much reduced in osteomalacia and can be valuable

in distinguishing this disease from osteoporosis in which normal or slightly elevated values

are the rule. In seventeen patients in this series the twenty-four-hour urinary calcium values

ranged from 10 to 125 milligrams with a mean 34 milligrams (normal range 75 to 300 milligrams

per 24 hours).

Another biochemical investigation which was not used in the present series but which

has been found of value by others is the induced hypercalcaemia test of Nordin and Fraser

(1956). Anderson et al. (1966) found this the most consistently diagnostic biochemical

investigation in their series of osteomalacia occurring in elderly women.

Radiographic changes in osteomalacia-Diminished radiographic density of bone is a feature

common to osteomalacia, osteoporosis and hyperparathyroidism. In osteomalacia the change

is caused by insufficient mineralisation of bone matrix whereas in the other diseases it is due

to a reduction in bone mass. This feature, therefore, has limited diagnostic significance,

although the distribution of the changes may be suggestive. Typically, senile osteoporosis

starts in the spine; involvement of the peripheral skeleton is delayed and seldom as marked as

the spinal involvement. In osteomalacia the opposite distribution is seen, the peripheral

changes being more characteristic. Indeed, it has been suggested (Nordin 1965) that vertebral

FIG. 15 FIG. 16Figure 15-Indrawing of the mid-thorax producing an “hour-glass” deformity was present in sixteen patients.Figure 16-Buckling of the pubic rami was seen in seven patients-the deformity was usually mild, as shown here.

408 J. CHALMERS, W. D. H. CONACHER, D. L. GARDNER AND P. J. SCOTT


density may actually be increased in osteomalacia. Small changes in density of the spine are

notoriously difficult to assess radiologically, and we have observed increased density in our

series only once (Fig. I 3). However, an apparently normal lumbar spine in patients with

marked radiolucency of their peripheral bones was often seen. Kyphosis was present in

most patients but this, being common to both osteoporosis and osteomalacia, is no help in

differential diagnosis. A few patients, who showed collapse and biconcavity of the lumbar

vertebrae, may have suffered from both osteoporosis and osteomalacia; this was confirmed in

the biopsy material.

Slight obscurity of trabecular arrangement and poor definition of individual trabeculae

in areas of cancellous bone is another suggestive radiological feature of osteomalacia. These

changes are often well seen in the ischium (Fig. 14).

Skeletal deformities are strongly suggestive of osteomalacia. The most common are an

“hour-glass” thorax found in sixteen patients (Fig. 15) and buckling of the pubic rami found

in seven cases (Fig. 16). Deformity without fracture does not occur in osteoporosis; the other

diseases which have skeletal deformity as a feature, such as Paget’s disease, fibrous dysplasia

and osteogenesis imperfecta, have clinical and radiological features which easily distinguish

them. The deformities of osteomalacia in this series were usually slight and not readily

detected on clinical examination.

Looser’s zones-Translucent bands or pseudofractures involving part of the cortex or extending

completely across bones are the most typical radiological signs of osteomalacia and are

virtually diagnostic (Steinbach and Noetzli 1964). Looser (1920) gave the classical description

of this feature. Typically, the pseudofractures are several millimetres in thickness and quite

sharply defined from the adjoining mineralised bone. Histological examination has shown

that they consist of unmineralised fracture callus with a variable content of fibrous tissue

(Figs. 35 and 36). This evidence suggests that the Looser’s zones start as minor fractures

(Albright et al. 1946, Ball 1960). Looser’s zones often show a remarkable symmetry-a

feature which Looser noted but which was redescribed some years later by Milkman (1930).

In English literature “Milkman’s syndrome” receives undeserved prominence.

In this series Looser’s zones were recognised in thirty patients. Typical examples are

shown in Figures 17 to 25. Individual patients had from one to twenty-four lesions. Figure 26

FIG. 17

I

FIG. 18

Figure 17-An incomplete Looser’s zone in the second metacarpal bone. This lesion is diagnostic ofosteomalacia. Figure 18-Symmetry of Looser’s zones is a characteristic feature of osteomalacia.

FIG. 19

Symmetrical Looser’s zones in the axillary borders of scapulae.


VOL. 49 B, NO. 3. AUGUST 1967

FIG. 20 FIG. 21

Figure 20-Lesions in ribs are not seen easily on routine chest radiographs. The radiograph on the right is of thesame patient as that on the left but taken with a different exposure: it shows several Looser’s zones in the ribswhich cannot be seen in the normally exposed radiograph. Figure 21-Rib lesions are often best seen on

spinal radiographs as in this case.

FIG. 22

Symmetrical Looser’s zones in both superior pubic rami and another in the right greater sciatic notchare shown here, as is the buckling of the inferior pubic rami.

FIG. 23

At a casual glance the femoral neck fractures might have been accepted as osteoporotic lesions but theclear Looser’s zones in the pubic rami are sufficient to establish the diagnosis of osteomalacia.



shows the skeletal distribution of these lesions in all cases. It can be seen that 86 per cent of

all Looser’s zones can be shown in two radiographs-a penetrated view of the chest which

includes the shoulder girdles and a radiograph of the pelvis including upper femurs. Where

facilities for a more complete skeletal survey are limited, these two views disclose the great

majority of cases. Looser’s zones in ribs may not be seen in normal chest films but may be

clearly visible in films taken to show the bone structure (Figs. 20 and 21).

/

FIG. 24Another typical lesion below the lesser trochanter.

FIG. 25

This Looser’s zone in the femoral neck healed with Vitamin D therapy alone. The patient remainedweight bearing. Internal fixation is not required unless a complete fracture develops.



The localisation of Looser’s zones has aroused some speculation. LeMay and Blunt (1949)

and Steinbach, Kolb and Gilfillan (1954) suggested that they develop at sites where blood

vessels are closely related to bone. However, the theory of Looser (1920) and of Camp and

McCullough (1941) that their localisation depends upon mechanical factors seems more

acceptable.

It is interesting that many of the zones

observed in this series and in those reported

by others (Steinbach and Noetzli 1964) have

occurred at sites such as the medial cortex

of the upper femur, the pubic rami and the

axillary border of the scapula which are

subjected to great compression stress.

Ascenzi and Bonucci (1964) have shown

that the mineral matrix of bone does not

affect its tensile strength, which depends

largely on the quality and orientation of

the collagen fibres. The mechanical function

of the mineral matrix is to provide resistance

to compression. The deficiency of the

mineral matrix in osteomalacia may explain

the localisation of many of the Looser’s

zones. The concept that they start as slight

fractures in bones which are pathologically

weakened is acceptable, and their symmetry

may be explained by the fact that many of

the habitual stresses such as breathing or

walking are likely to affect both sides of the

body similarly. Several patients in the present series had Looser’s zones that progressed

to complete fractures.

Pathological changes in osteomalacia-An excess of unmineralised bone or osteoid is the

essential pathological feature of osteomalacia and bone biopsy provides the most convincing

evidence of the disease. It is sometimes possible to detect the presence of osteoid in decalcified

sections of bone stained with haematoxylin and eosin (Meyer 1956), but this is an unsatisfactory

index of deficient mineralisation because even the most careful decalcification may mask the

zones of unmineralised marginal osteoid. For routine diagnostic purposes it is preferable to

prepare undecalcified sections of bone and stain for bone mineral by the Von Kossa technique.

U-



Preparation of undecalcified bone sections-Biopsy material which has a predominance of

cancellous bone is preferred because cancellous bone shows the changes of osteomalacia

clearly and because it is easier to prepare undecalcified sections of this material. In this series

several plugs of bone were removed with a 6 millimetre trephine from the anterior iliac crest,

under local anaesthesia. Undecalcified bone sections were prepared after fixing the small blocks

of bone in formol saline for twelve to twenty-four hours. The fixed material was washed and

dehydrated with alcohol. Progression through acetone

allowed the blocks to be placed overnight in a solution

of methacrylate* for one to seven days. The resin is

hardened at 56 degrees Centigrade when embedding is

complete.

Eight to ten 1u sections are cut with a Jung rotary

microtome after softening the surface of the methacrylate

block with 50 per cent acetone. Sections are placed in

distilled water for one hour, and transferred to 2’S per

cent silver nitrate exposed to a light source, for twenty-four

hours. The sections are then washed in distilled water and- 19 fixed in 4 per cent sodium thiosulphate. After further� - - - � - 19 washing, the material is counterstained in 10 per cent

carbol fuchsin, washed and mounted, after blotting dry,

in Canada balsam.Histological assessment of osteomalacia-The assessment

of bone mineralisation was based on a subjective micro-

scopic study, comparing the extent of silver deposits upon

the trabeculae ofcancellous bone with that on control bone

from persons of the same age and sex. In the normal

young and middle-aged adult almost all trabeculae are

fully mineralised (Figs. 27 and 28). Occasionally, there

are small, incomplete marginal zones where a band of

pink-staining uncalcified bone matrix can be detected.

Where these margins are extensive, wide or both wide

and extensive, a fault in bone mineralisation is confirmed.

Osteomalacia, recognised in this way, was assessed

FIG. 26 , empirically on a simple scale, ranging from 0 (no osteo-Distribution of Looser’s zones lfl the

thirty cases showing these features. malacia) through 1, 2 and 3 to 4 to 5, which representedthe most severe form of disease. Figures 30 to 34

illustrate the grades of osteomalacia which were recognised in the present series of cases.

It is not surprising in this group of elderly women to find that osteomalacia and

osteoporosis frequently co-existed. Osteoporosis, identified by a reduction in the total mass

of bone, and osteoid present in a particular sample, was recognised in nine patients (Figs. 33

and 34). Severe osteoporosis may exist with or without osteomalacia while evidence of

defective mineralisation may, by contrast, be found in examples of renal osteodystrophy in

which there is osteosclerosis. There is no evidence in the present material that the severity of

osteomalacia in any way influences the severity of osteoporosis or vice versa.

Other workers have applied more sophisticated diagnostic techniques by measuring the

thickness of osteoid seams, the amount of bone surface covered by osteoid or by relating the

� Pure methacrylate is prepared by removing hydroquinone stabiliser from N-butyl methacrylate and methyl

methacrylate with excess 5 per cent sodium hydroxide. The materials are shaken in a separating funnel and thesodium hydroxide decanted. The final preparation is washed eight times with distilled water and dried oversilica gel. Pure methacrylate then comprises one part of N-butyl methacrylate and two parts of methylmethacrylate. To polymerise the methacrylate benzoyl peroxide is used as a catalyst and is incorporated inthe methacrylate before embedding.

FIG.27

Figure 27-Normal bone. This undecalcified section shows normal trabeculae of cancellous bone. In the lowerleft part of the field non-mineralised osteoid appears red. This relative amount of osteoid is regarded as normal.(Von Kossa and carhol fuchsin, x 30.) Figure 28-Very slight osteoporosis. By comparison with the size andextent of the trabeculae of the bone in Figure 27, those in this field are slender and sparse. The proportion of

unmineralised osteoid remains normal. (Von Kossa and carbol fuchsin, x 30.)



FIG. 29 FIG. 30

Figure 29-Osteoporosis. The cancellous bone trabeculae are thin, attenuated and sparse. There is no excessof unmineralised osteoid. (Von Kossa and carbol fuchsin, x 30.) Figure 30-Very slight osteomalacia. Theproportion of bone trabeculae near the cortex of this sample, which are bordered by narrow, unmineralisedosteoid seams, is greater than normal. However, this degree of diminished calcification is difficult to interpretin this situation and an assessment based on a study of less superficial, cancellous bone is desirable. (Von Kossa

and carbol fuchsin, x 30.)

FIG. 31 FIG. 32

Figure 31 -Osteomalacia, grade 1. The extent of the bone margins which are lined by red-staining, unmineralisedosteoid is significantly greater than is the normal for any age: osteomalacia can be diagnosed confidently.(Von Kossa and carbol fuchsin, - 30.) Figure 32-Severe osteomalacia, grade 3. The proportions ofunmineralised and of mineralised bone are approximately equal. (Von Kossa and carbol fuchsin, -. 30.)



FIG. 33 FIG. 34

Figure 33-Very severe osteomalacia, grade 4. The proportion of unmineralised bone exceeds that ofmineralised. (Von Kossa and carbol fuchsin, �-: 30.) Figure 34-Osteoporosis and osteomalacia. The twodiseases are encountered together in the elderly. The bone trabeculae are slender and sparse, and incompletely

mineralised. (Von Kossa and carbol fuchsin, x 30.)

II

FIG. 35 FIG. 36Figure 35-Looser’s zone. Laminae of new bone forming in the subcortical region of an osteornalacic bonefollowing incomplete fracture. Repair is incomplete and delayed; the new bone is incompletely rnineralised.(Haematoxylin and cosin, - 30.) Figure 36-Looser’s zone. Higher power view of part of the field shown inFigure 35. Both the islands of new bone (left) and the margins of the compact cortical bone (rig/it) areincompletely calcified: the more basophilic, central zones are normally mineralised. (Haematoxylin and

eosin, 110.)



area ofosteoid to the area ofmineralised bone (Ball 1960, Frost 1962, Wood 1965). There is,

however, no generally accepted standard for the amount of osteoid necessary to justify the

diagnosis of osteomalacia. The visual method of grading used in this series has proved an

adequate diagnostic guide for routine clinical use.

The histological changes as assessed above were used as the standard by which borderline

cases were included or excluded from the series. Three of the accepted cases were diagnosed

by biopsy alone, the biochemical and radiological findings being normal.

ETIOLOGY OF OSTEOMALACIA

Dietary deficiency of vitamin D is not generally considered a common cause of

osteomalacia, except in the unusual circumstances such as those which prevailed in Europe

during the two world wars (Looser 1920: Justin-Besan#{231}on 1942; S#{232}ze,Monni#{233} and

Ordonneau 1943; Gennes, Mahoudeau, Bricaire and S#{233}n#{233}cal1943) and in famine conditions

in India and China (Maxwell 1935).

A detailed dietary history was obtained in ten of the patients of this series (Table I) and

three of these had diets which were grossly deficient in vitamin D-that is, less than 60

international units a day. This suggests that dietary factors may play a part in some of the

patients in this series. There is no doubt that certain sections of the community, particularly

at the extremes of life, live on diets of marginal adequacy; nutritional osteomalacia and rickets

have recently been reported from other centres in this country (Gough, Lloyd and Wills 1964:

Dunnigan and Smith 1965). On the other hand, many of our osteoporotic patients who showed

no signs of osteomalacia had diets containing less than 50 international units of vitamin D

a day. More information is needed concerning the nutritional requirements of old people

before the importance of this factor can be fully assessed.

The importance of the endogenous production of vitamin D by the action of sunlight on the

skin can be inferred from the high incidence of osteomalacia among women who, for religious

reasons or traditional custom, are almost totally covered by clothing (Scott 1916, Herold 1944).

416


J. CHALMERS, W. D. H. CONACHER, D. L. GARDNER AND P. J. SCOTT

TABLE IDETAILS OF FINDINGS IN THIRTY-SEVEN PATIENTS WITH OSTEOMALACIA

Biochemistry

AlkalineCasenumber Sex Presenting symptoms Plasma Plasma phosphatase.� 24-hourcalcium phosphorus Calcium X King- IIflfl3i3�

(milligrams 1 (milligrams phosphorus Am�ong calcium(milligrams)per cent) per cent) units

1 Female 89 Subtrochanteric 80 25 200 23fracture .

Transcervical fracture10-6 3-4 36-0 142 Female 85 neck of femur

Fracture neck of femur. 9.4 2-1 19-7 193 Female 76 Skeletal pain

Skeletal pain. 39 23-0 24 30-04 Female 72 Weakness

��

5 Female 82 Fracture neck of femur. 125 34 2508-9 1-4Rheumatism”

6 Female 73 Hip pain 8-2 27 22-1 8 180

�

7 Female 81 Skeletal pain 10-4 3-2 33-3 23 27-0

Skeletal pain. 9-4 20 1888 Female 76 Weakness 21 -

Greenstick 96 27 25-99 Female 87 fractures

10 Female 65 Foot pain 9-6 2-3 22-1

11 Female 74 Skeletal pain. 81 3-3 267Weakness

14 340

25

20

l2� Female 41 Weakness.Skeletal pain

13 Female 86 Fracture neck of femur

14 Female 74 Fracture neck of femur

15 Female 69 Skeletal pain�

16 Female 72 Skeletal pain

17 Male 62 Skeletal pain

10.5 38�

39.9 35 32-0

81 2-7 219 15 420

89 i 3-0 267 38 270

89 3.7 329 28 510

100 28 280 13 10-2

107 34 364 8

Skeletalpain.18 Female 78 Weakness. Bedridden

Multiple19 Female 80 greenstick

fractures

86 20 172 14

97 33�

§ Patients with idiopathic steatorrhoea.

417OSTEOMALACIA-A COMMON DISEASE IN ELDERLY WOMEN

TABLE I-continuedDETAILS OF FINDINGS IN THIRTY-SEVEN PATIENTS WITH OSTEOMALACIA

Previous �gastric surgery �

Type � Interval �� (years) �

Diet. � RadiologyDaily intake � � �

Looser’s zones �� VitaminD � � �

Calcium � (international I Other features(milligrams) � units) Part � Number �

Biopsy-

Grade of� osteo-� malaciat�

I �

None �

� �

I

1,000 109

�

Clavicle . .

Scapulae . .

Ribs . . .

Femoral shaft .

Pubicrami. .

I I� 2I 16� I

2

Thoracic sulcusand kyphosis.

Pelvic buckling�

6�Partial �gastrectomy � Ribs. . . 8�Thoracic sulcus

and kyphosis 2

Partial � 6 �gastrectomy

� �

Scapulae . .

Ribs . . .

Femoral neck .

Femoral shaft .

210

1� 1

Thoracic kyphosis 2

None

I

Pubic rami . .

Femoral neck .

Femoral shaft .

Thoracic sulcus2 and kyphosis.I Secondary2 hyperparathyroidism

3

None��

Ulna. . .

Clavicle . .

Ribs . . .

Pubic rami . .

Femoral shaft .

1I I7 Thoracic sulcus41

Partial 30gastrectomy

800 101�

Femoral neck.

Thoracic sulcus1 and kyphosis. I

Pelvic buckling1

Gastro- 6enterostomy I974 136 Metatarsal bones. 2 NoneI

2

Gastro- 40 Ienterostomy Ribs. . .�

Thoracic sulcus1 and kyphosis 31

None

�

None

�

I Thoracic sulcus.Bowing femur and tibia.Four greenstick fractures:

of tibia and fibula

24

�

Partial :8gastrectomy 1,319 : 130 Metatarsal bone .�

:

1 NoneI

:

:

�

Partial 6gastrectomy I :

Ulna . . .

640 212 I Pubic rami. .

Femoral neck .

12 None1 :

I

��

None

�

: Scapulae . .

Ribs. . .

Pubic rami. .

: Femoral neck .

Femoral shaft .

2 Thoracic sulcusI 12

4 I and kyphosis.1 Secondary� hyperparathyroidism

:

I

:

None Pubic ramus .

Thoracic kyphosis.I Lumbar collapse 2I

3:�_______

:

�Partial

gastrectomy�

UlnaeRibs . . .

ScapulaPubicrami. .

: 25 Thoracic sulcus

: 1 and kyphosis3

Partial13gastrectomy

:

Radius . .

Ulnae . .689 48 Ribs . . .

Pubic rami . .

1 Thoracic sulcus2 and kyphosis.3 Secondary3 hyperparathyroidism

:4�

NoneRibs . . .Femoral neck .

8 Thoracic sulcus1 and kyphosis

Partial6gastrectomy 1,423 117 None

:

: None

:

2t

Partialgastrectomy 10

:

:

None

Scapula . .

Ribs . . .

Femoral neck .

Femoral shaft

I16 Thoracic sulcus1 and kyphosis

I I31

I

:

I

�

:

Clavicle . .

Scapula . .

Ribs . . #{149}Pubic rami . .

Femoral shaft .

1 Thoracic sulcus.1 Lumbar collapse.

: 2 : Pelvic buckling.2 : Greenstick fractures1 tibia (2), fibula (3)

2��

* All cases showed diminished radiological density of the skeleton in addition to the features detailed in this column.

� For explanation of grading see text. � Osteoporosis also present.


B


TABLE I-continuedDETAILS OF FINDINGS IN THIRTY-SEVEN PATIENTS WITH OSTEOMALACIA

I�

I

n��er Sex�

��

Biochemistry

� Alkaline I 24-hourAge Presenting symptoms Plasma Plasma phosphatase.:

(years) calcium phosphorus I Calcium x King.. Iiflfl�IY

: (milligrams I (milligrams phosphorus I Armstrong calciumper cent) per cent) I

units I (milligrams)

20 Female 78� Fracture neck of femur 94 24 226 14 1250

21 Female 56 Chest pain 76 �: 26 I 198 I 18 240

:

22 : Female

I I

Weakness.83 Skeletal pain 8’7 2�4 20’9 24

23 : MaleI

63 Fracture humerus : 92 30I

276 12 II

24 Female

25 Female

IWeakness. :

Skeletal pain. 85 2656 Greenstick I

I fracture of tibia I

I

I

�

221 16 360I�

I

46 Backache I 92 : 28 258

26� FemaleSkeletal pain. 77 19

54 Weakness I

Skeletal pain. I80 Weakness. 67 29

Fracture femoral neck

I

146 25 410

27 FemaleI

�

:

194 52I

28 §

29

Female

Female

39

I

Skeletal pain. 82 15Weakness I

123 32 240

85Subtrochanteric fracture.i 87 19

Difficulty in walking 147 33

30 FemaleMuscular weakness- I 76 22 16786 inability to walk

�.

31

31 Female 76 Skeletal pain. 93 24 223 : 29Weakness I

I

32 Female 78 Skeletal pain :� 84 36 302 15

33 Female 75� Skeletal pain 98 6

34 Female82� Skeletal pain 110 16 176 16

I Skeletal pain. 1

35 Male 64 Weakness 8�4 2�l l76 23 220

36 Female 74 Muscular weakness 92 I 24 I 220 65 I

:

Skeletal pain. : I I I

Female 57 Subtrochanteric 98 27 265 I 45fracture femur : II I

§ Patients with idiopathic steatorrhoea.



TABI.E I-continued

DETAILS OF FINDINGS IN THIRTY-SEVEN PATIENTS WITH OSTEOMALACIA

Previous � Diet. � Radiology I

gastric surgery Daily intake � � ------- � Biopsy-

� ---��-------� 1 Looser’s zones I Grade of

Type IInterval Calcium I Vitamin D � � Other features* � osteo-� (years) � (milligrams) � (international I Part � Number � malaciat

units) � �

Partial � � Femoral neck .

gastrectomy � 2 � I Metatarsals .

2� 4 Lumbar collapse

Partial I I �

gastrectomy � � � �

I

None � � 1,052 � 57

I ��

Partial �gastrectomy � � �

Ribs .

Femoral shaft .

5� 2 Pelvic buckling 2

Ulnae . .

Neck humerus .

Pubic rami . .Ribs . . .

Femoral neck .

Femoral shaft .

2� 1

� 26I I� 2

Thoracic sulcus.

SecondaryThoracic collapse.hyperparathyroidism

NoneI� None 2

I

Partialgastrectomy 10

:

None

I�

Thoracic kyphosis.Lumbar collapse.Pelvic buckling.

Greenstick fracture tibia

Partial � 6gastrectomy �

Metacarpal bone .

Ribs . . .

Pubic ramiLesse� trochanter.Fibula neck .

1� 4I 2� 1� 1

Pelvic buckling.Secondary

hyperparathyroidism

None �Ulna. . .

Ribs . . .

Metatarsal bone .

1� 1� 1

None 4�

None � 800 133 ��

Neck radius .

Ribs . . .Scapulae . .

Pubic rami . .

Femoral neck .

1

I 7 I� 2

- 4� 1

Thoracic sulcus.Pelvic buckling

None �

��

Metacarpal bone .

Scapulae . .

Ribs . . .

Pubic rami . .

Sciatic notch .

Fibula neck .

Metatarsal bones .

12

� 5� 4

� 1I 1� 6

Slight bucklingpubic rami.Secondary

hyperparathyroidism

:

None �I

Ribs. . .

Femoral shaft .

10I 1 None 3

None � None None I 34

None :

� �

Ulnae . .

Femoral neck .

Tibiae . .

2� 1

2Thoracic sulcus I

�

Partial �gastrectomy � �

1,108 88Ribs . . .

Femoral neck .

Femoral shaft .

5� 1� I

Thoracic kyphosis � 2-3t�

None � None None � 2-3t

None � None None � 2t

Partial � �gastrectomy �

Femoral neck .

Greatertrochanter1

� 1INone �

-

: �

None :

I� I

� �

Ulnae . .

Radius . .

Clavicle . .

Scapula . .

Pubic ramus .

Femoral neck .

Femoral shaft .

3 I

I II

� I I

� 1I 1 I

22 � I

Partial � I Femoral neck .

gastrectomy � � I � I Femoral shaft .

I� I � None

a All cases showed diminished radiological density of the skeleton in addition to the features detailed in this column.

t For explanation of grading see text. � Osteoporosis also present.



We have been unable to assess how much our patients were exposed to sunshine but it is

interesting that several volunteered that their symptoms diminished in the summer months.

This feature has also been reported by Albright et a!. (1946). Certainly, the more disabled the

patients become as a result of the disease the more likely they are to be deprived of sunshine.

It might be argued that a particularly unfavourable climate could account for the frequency

of the disease in this region but three patients collected by one of us (P. J. S.) in the sunnier

counties of Cornwall and Devon discount this suggestion.

Evidence of intestinal malabsorption-Rickets and osteomalacia are familiar complications of

steatorrhoea of all types, and malabsorption is generally regarded as the commonest cause of

these diseases in this country. Both the malabsorption of vitamin D and the formation of

non-absorbable calcium soaps with excess fat in the gut may be important. This mechanism

has been invoked also to explain those cases that have appeared after gastrectomy (Deller et al.

1964). Malabsorption after gastrectomy has long been recognised. Various workers have

described impaired absorption of fat, calcium, iron, vitamin B12, folic acid, proteins and

carbohydrates (Jones et a!. 1962, Deller et a!. 1964). One of the curious and unexplained

features of osteomalacia after gastrectomy is the higher incidence of affected elderly women

among the reported cases and in our present series. As women undergo gastrectomy much

less often than men, this suggests that factors other than gastrectomy alone are important.

Three of the younger patients in this series were found to have idiopathic steatorrhoea, but

many of the remainder had evidence of malabsorption. Absorption of dextro-xylose using a

25 gramme oral dose was impaired in each of the twenty patients in whom it was estimated.

Low amounts of vitamin B I 2 in the serum were found in ten patients and low folate in four.

Four other patients were having supplements of vitamin B12 or folic acid when they first

attended. Complete studies of absorption were carried out only in the younger patients,

however, and the information available for the remainder is limited. Such evidence as was

obtained demonstrated little difference of malabsorption between those patients with and

without previous gastrectomy. Severe malabsorption was not found, but limited malabsorption

affecting calcium and vitamin D remains a possible etiological factor; further studies of this

aspect of the disease are being pursued. Anderson et a!. (1966) found sixteen cases of

osteomalacia in an investigation of 200 elderly women attending a geriatric assessment unit.

Defective dietary intake of vitamin D and lack of exposure to sunlight were thought to be

the etiological factors in their cases.

Other possible causes of osteomalacia, such as renal tubular defect, chronic renal failure

and hypophosphatasia, were not found in this series.

Secondary hyperparathyroidism-Parathyroid stimulation by the low serum calcium level in

osteomalacia might be expected to produce changes of secondary hyperparathyroidism and

this has been described (Steinbachand Noetzli 1964, Goughetal. 1964). Suggestive radiographic

appearances of hyperparathyroidism were seen in the hand in six patients of the present series.

TREATMENT

The treatment of osteomalacia is simple and effective. Adequate supplements of vitamin D

and calcium produce relief of skeletal pain and healing of pseudofractures within four to eight

weeks (Figs. 1 to 7 and 25). Plasma calcium and phosphate values promptly return to normal

but a fall in alkaline phosphatase is usually delayed (Fig. 37). Selection of the correct dose

of vitamin D presents some difficulty. Vitamin D in excessive dosage produces toxic effects

similar to hyperparathyroid secretion causing elevation of serum calcium and, if sustained,

severe renal damage.

If dietary deficiency alone is the cause of the disease, then correction of diet and small

supplements of vitamin D in a physiological dose in the order of 200 international units per

day should be adequate. If malabsorption is responsible then larger doses may be required




by mouth or small doses administered parenterally. In the various forms of resistant rickets

and osteomalacia, not encountered in this series, very large doses ofvitamin D may be required.

Clearly, ideal therapy depends on precise knowledge of the etiology of the disease which, as

indicated in this report, can be extremely hard to obtain.

We have adopted a routine treatment which has proved satisfactory in practice. Vitamin D

is given as calciferol, l25 milligrams (50,000 international units) daily by mouth. The plasma

phosphate, calcium and urea levels are checked initially at monthly intervals and thereafter

three monthly. The dose is adjusted according to the clinical or biochemical response (Fig. 37).

45Ca xP

40- � 40

� s�J � 35

30- ‘�‘�-� � 30

25- � \ PHOSPHATE PRODUCT 25

�. I � �:5 PHOSPHATASE

0

mg#{176}/o11

10

9 /5 PLASMA CALCIUM

8 /

7x

6

4 -*---------e---------- � I

3 /�o�ooo PLASMA PHOSPHATE51Uf DAY

2 � VITAMIN D BY MOUTH

r/// 50,000 I.U./ DAY 50,000 [U/DAY

� �‘/ �

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

MONTHS

FIG. 37

The chart ofa woman aged 69 years with osteomalacia after gastrectomy shows thebiochemical response to vitamin D therapy which provides a reliable means ofcontrolling dosage. The return of alkaline phosphatase to normal levels is usuallyslower than is the response of plasma calcium and phosphate, and a rise in alkalinephosphatase can be a sensitive index of inadequate therapy, as shown here.

A rise in plasma calcium above 11 milligrams per 100 millilitres or an elevation of blood

urea indicates overdosage. Usually, after clinical cure has been obtained, the dose may be

reduced to, say, 50,000 international units a week. However, unless the etiological factors

can be rectified, supplements will be necessary for the rest of the patient’s life. Morgan et a!.

(1965) have shown that 1,000 international units administered by weekly injection or 40,000

international units by monthly injection are also adequate and safe methods of treatment.

Calcium supplements are needed in the early stages of treatment because of enormous

initial deficit of mineral. We have given supplements of one to two grammes of calcium daily

in the form of effervescent tablets of calcium gluconate (Calcium Sandoz) each containing

0�38 grammes elemental calcium. The need for calcium supplement diminishes with time, but

in severe cases it should be maintained for at least a year.

422 i. CHALMERS, W. D. H. CONACHER, D. L. GARDNER AND P. J. SCOTT

Associated anaemia should be investigated and treated with appropriate supplements.

Large Looser’s zones which threaten the strength of a long bone may require protection from

weight bearing for the first few weeks of treatment but internal fixation is not required unless

complete fracture of the upper femur has occurred (Fig. 25).

SUMMARY

1 . The clinical features, diagnosis and treatment of osteomalacia are discussed in relation to

thirty-seven recently recognised cases. It is suggested that this disease is not uncommon in

elderly women, among whom it is liable to be confused with senile osteoporosis. Osteomalacia

may be distinguished by, firstly, the history, in which persistent skeletal pain of long duration

and muscular weakness are typical of osteomalacia, but not ofosteoporosis in which transient

episodes of pain usually associated with a fracture are more characteristic. There is a high

incidence of previous gastric surgery in the osteomalacia patients. Secondly, the physical

examination shows skeletal tenderness in osteomalacia but this is not a particular feature of

osteoporosis. A shuffling “ penguin gait “ suggests osteomalacia. Thirdly, the biochemistry

shows a low plasma calcium and phosphate, and raised alkaline phosphatase levels commonly

in osteomalacia but these are usually normal in osteoporosis. Reduced twenty-four-hour

urinary calcium is characteristic of osteomalacia but not of osteoporosis. Fourthly, radiology

will show diminished bone density which is common to both diseases, but if the changes are

more marked in the peripheral bones than in the axial skeleton osteomalacia is suggested ; the

opposite is typical of osteoporosis. Skeletal deformity without fracture suggests osteomalacia,

as do stress fractures and greenstick fractures in the elderly. Looser’s zones are diagnostic

of osteomalacia in which they are the most important radiological feature. Finally, histology

will show the presence ofexcess osteoid tissue in undecalcified sections ofbone in osteomalacia.

This may be the earliest and most sensitive index of the disease and biopsy is indicated in all

doubtful cases.

2. The etiology is discussed and it is suggested that a dietary deficiency of vitamin D, limited

exposure to sunlight and mild degrees of malabsorption may all be important either alone or

in combination. No satisfactory explanation is offered for the predominant female incidence.

3. A practical method of treatment is given and the dangers of uncontrolled administration

of vitamin D indicated.

4. Treatment of osteomalacia is rapidly and consistently successful, and well justifies a

thorough screening of all elderly patients presenting with weakness, skeletal pain, pathological

fractures or with diminished radiographic density of bone.

It is a pleasure to acknowledge the help of our colleagues in the South-East Region (Scotland) who have madetheir patients available to us. These include Professor J. I. P. James, Mr D. W. Lamb, Mr G. P. Mitchell,Mr W. M. McQuillan, Dr James Robson, Mr D. L. Savill, Mr J. H. S. Scott and Mr T. B. Whiston. Mr J. Piggot(Belfast), Mr R. Owen (Oswestry) and Dr Douglas Grant (Irvine) have kindly allowed access to records ofpatients under their care. We are most grateful to Mr T. C. Dodds, Mr J. Paul and Mr C. Shepley for theirskilland care in preparing the illustrations.

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