OSTEOMALACIA-A

COMMON

J. CHALMERS,

W.

EDINBURGH,

D. L. GARDNER,

Osteomalacia

is not

It is well

defects,

and

these categories.
(Albright,
Burnett,
ln

the

six

four

in an

in

other

of intestinal
reported

years

diseases

the

is very

in western

the

of

and

experience

suggests

bear

a superficial

the

cases

in the

the

and

States

of osteomalacia,
region

disease

renal

fall

into

as an important
cause
Salvesen
and B#{246}e
1953).

South-Eastern

that

the

textbooks.

surgery

United

regarded
1950;

and

medical

gastric

Europe

thirty-seven

service

countries

standard

malabsorption,
from

observed

geriatric

thirty-one
of Scotland

is in fact

quite

and

common,

women.

of osteomalacia

that

disease

of vitamin
D has not been
and Roos 1946; Sherman

have

and
Our

in elderly

probable

we

orthopaedic

cases

cases

deficiency
Reifenstein

regions.

particularly
These

of the

ENGLAND

(Scotland)

in many

most

WOMEN
SCOTLAND,

EXETER,

as a common

treatment

as a complication
Dietary
Parson,

past

presenting

Region

ELDERLY

BANGOUR,

P. J. SCOTT,

South-East

scant

IN

H. CONACHER,

and

regarded

receives

recognised

tubular

the

generally

consequently

D.

LONDON,
From

condition

DISEASE

latter

diagnosis

important

is too

because

resemblance

readily

treatment

to senile

accepted.

osteoporosis

A distinction

is highly

effective

and

between

it is

these

in osteomalacia

but

two
not

in

osteoporosis.
The

purposes

to describe

of this

and

it from

distinguish
series

are

assess

these

paper

evaluate

are,

some

osteoporosis,

reviewed
aspects

therefore,

diagnostic
and

against

the

of the

disease.

to

In

this

series

osteomalacia

were

age
Our

collected
of 50.5

FEATURES

thirty-four

ranging

among

literature
mean

there

years,

from

women

fifty-six

the
of

has

cases

women

been

of varying

The

three

(Table

men

to

eighty-nine.

by

others.

Of these,

in osteomalacia

was

first

aroused

by

recognising

the

Men

early

cases

without

subjected
to the same scrutiny,
Although
the association
and

Lous

probably
patients

Jones,

1962;
very
after
after

but

two

only
There

osteomalacia
VOL.

49 B,

Deller,
low.

Cooke,

of gastric

cases

of our

attempt

to

mean

age

was

incidence

in

a review

were

from

a total

doubt

that

closer
1967

Crompton

of 681

study

of

the

of

female

with

and
1964)

and

found
were

who

Stammers
the

true
and

only
four

clinical

in nineteen

to have
surgery

Woods

There

our

in patients

(Pyrah

incidence
six

of this

with

women

Harvald,
(1965)

Fourman

departments

incidence

some
were

publicity

Krogsgaard
association

is

1,228

examined

osteomalacia.
(an

Smith

patients;

had had gastrectomy

osteomalacia.
has received
much
1962;

after

and

all

These
of 3 per

cent)

men.

recognition
that

attending

found
gastric

Pulvertaft,

operations

the

were
and

disease

in the literature

symptoms.

Meynell

gastrectomy.

men

AUGUST

and

Paterson,

is no

3,

Williams,

Ibbotson

or total

the

significant

but only two

of osteomalacia

Morgan,

partial

and
NO.

Cox,

a variety

occurred

The

fifty-one

of these

1962;

an

increased

(1951)

Strang

etiology.

I).

The

diagnosis

(Clark

in

which

OSTEOMALACIA

and

were

work

and

points

years.

interest
surgery

osteomalacia
to the

thirty-seven

published

by reports
of this association
appearing
1956, Baird
and
Oleesky
1957).
Screening
of all patients
who gave
a history
of previous
gastric
surgery
led to the

gastric

of

reference

treatment.

and

found

frequency

particular

previously

OF

thirty-nine

the

indicate
with

outline

background

CLINICAL

seventy-two

to

features

these

that
patients

gastric

surgery

received

has

has
caused

an
a bias

association
in the

with
selection
403

J. CHALMERS,

404

W.

D. H. CONACHER.

D. L. GARDNER

AND

P. J.

SCOTT

FIG.
1
FIG. 2
FIG. 3
FIG.
4
Radiographs
showing
the development
of a Loosers
zone from a stress fracture

of the ulna. Figure 1 shows

a hairline crack in the ulna on December
18, 1963. Figures
2 and 3 show the development
of a typical Loosers
zone (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
of the surgical
neck of the humerus
which failed to show radiological
union and was still painful
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.

A fracture
after three

of

cases

in our

without

With

series.

gastrectomy
Three

of

the

younger

idiopathic

steatorrhoea

but,

remaining

thirty-four

formed

presentation
and

and

those

years),
muscular

the
the

main

weakness.
weakness-Muscular
flat-footed,
walk.

patient

specifically
stronger

from

more

vigorous

recognition

of osteomalacia

in patients

patients

a chair

to

bed

of

muscular
after

by

a mean

was

was

difficult

the

feature

for

weakness

before
they

of

skeletal
first

severely

surgery
(sixty-nine

and

progressive

at hospital.
and

described

affected,

treatment

THE

pain

Many

been

gastric

patients

aptly

weakness.
had

the

in clinical

lower

attendance

in several

family

those

of the
than

the

patients

a history
slightly

from

excluded,

years.

were

caused

severity

treatment

of eighty

a striking
one

suffered
are

difference

was

complained

a fracture

which

with

operation
age

fifty-four,

little

was

patients

after

patients

and
malabsorption

There

the

patients

these

gait

group.

had

patients

forty-one

recognisable

between

of the

weakness

complained
and

with

findings
age

fourteen

confined

the

thirty-nine,

a homogeneous

springless
Rising

was

patients

of which
In

a typical
penguin

aged

if the

remaining

Muscular

the

patients,

mean

symptoms

experience

rising.

biochemical

without:

whereas

The

increasing

is steadily

as

and

in one

patients

who

that

volunteered
for

JOURNAL

produced
mothers
instance

had

not

they

felt

years.
OF

BONE

AND

JOINT

SURGERY

OSTEOMALACIA-A

Skeletal
pain-Most
which had progressed
girdles

and

patients,
including
over several
years.

thighs,

forearms

to osteoporosis.

The

tojoints-a

COMMON

point

and

painful

which

feet

sites

helps

zones

were

sometimes

Fractures

femur

these

fractures

terns

commonly

and

tures

presenting

forearm
Loosers

with
in

bones
zones

occurring

in elderly

unless

proved

humerus

in

ununited

and

Within

of

that

this

union

of

the

surgical

investigation
excludes

three

after

diagnostic

the

likelihood

in

the

pattern

of

of

later.
D

vitamin

of

adultshe
such

is not

as this all occurring

demonstrable

be

normally

seen

in

in adults.

and

is quite
patients

They

are

Delay

to

heal

Conversely,

three

in the tibia

radiologically.

expected

of osteomalacia.

of osteomalacia
were

FIG.

the

that such
by callus,

would

occurring

the

diagnosis

levels

changes

has

long

not

merits

healing

in osteoporosis

further

of a fracture

characteristic
of osteoporosis.
(Fig.
8) and are regarded
found

fibula.

of radiological

rapidly

rapid

examples
and

as

where

virtually

fractures

are

been

attached

out

that

a product

(Salvesen

latter

together

with

NO.

to

standard,

to
have

9 to

corresponding

calcium
3,

AUGU5T

and

the

1967

a feature

features,

that
of

our

the
for
levels

confirmation

studies
plasma

are

two

values.
was

values

of

less

patients

were

range

of levels

a randomly
might

in

further

inorganic

usually

significance

(1923)
found,

27 were

the

diagnostic

found

in the
group

to be

phosphate

diagnostic
Howland

than

selected
be expected

and
and

100 millilitres

requires

important.

calcium

osteomalacia

of these

per

11 indicate
values

of

product

suggested

phosphate

clinical

histological
of the

be

twenty-seven

Figures
the

by the

and

30 milligrams

than

B#{246}e1953)

in whom
49 B,

recognised
of less

normal.

suggested

radiological

particularly

and

INVESTIGATIONS

in osteomalacia-Lowering

been

has

this

is often

Biochemical,

Biochemical

VOL.

ten
and

complete.

While

cases

fractures,

distribution

still

years

possibility

fractures

investigation.

were

complete
The

is

SPECIAL

By

with

humerus.

who

mineral,

regarding

when

typically

lacking
which

any

of

to

was

starting

fracture

Greenstick

often
be
Loosers

or

neck

fracture

painful

callus,
a

areas
could
radiography,

than
which

Figures

therapy,
abundant
mineralisation
callus was apparent.
It is probable
fractures
are in fact healed
but

with

frac-

femur

of union.

which

month

arthritis,

rheumatoid

usually

of a patient

of

1961,

rather

addition

If osteomalacia
are very slow

evidence

a fracture

in contrast

to bone

should
therefore
of osteomalacia

radiographs

sustained

skeleton,

progressed
to typical
1 to 4). Stress fractures

fractures
the

from

axial

localised

pat-

stress

necks

evidence

radiological

disease

were

fractures,

with

otherwise.

untreated,

and

presented
neck

fracture
In

patients

as

5 to 7 show

surgical

complete

ribs,

this

in the

common

tender

a history
of skeletal
pain
in the thorax,
shoulder

sites.

age and

seen

which
(Figs.

regarded

the

the

were

occurring

show

these

osteoporosis.

patients

less

patients

in

in old

seen

with

several

left

at

resembled

associated
to those

one

was

usually

405

WOMEN

in several
of our patients.
The tender
bones
such as ribs and ulnae
and, on

in osteomalacia-Eleven

proximal

be

seen

and

to distinguish

been previously
confused
as thickenings
in superficial

IN ELDERLY

several
with fractures,
gave
The pain occurred
commonly

were

it had

felt

DISEASE

more

of senile

others

diagnostic.

range

cases

normal.

pointed

while
but

reported
osteoporotic

eight

here

406

J. CHALMERS.

Although
the

there

severity

patients

of the

had

W.

was

H.

CONACHER,

a relationship

disease

normal

D.

between

as judged

levels

by

of plasma

OSTEOMALACIA

D.

other

the
and

PER

AND

severity

means,

calcium

a significant

I
.1
:;:

changes

proportion

phosphate.

and

of osteomalacic

Normal

biochemical

tests

did

OSTEOPOROSiS

PLASMA
INORGANIC
PHOSPHORUS
MILLIGRAMS

.555

CENT10

biochemical

OSTEOMALACIA

.ss.
isis

11-

P. J. SCOTT

of the

OSTEOPOROSIS

PLASMA
CALCIUM
lILLIGRAMS

L. GARDNER

PER

CENT
S..

is

9-

...

8-

.111

.115

#{149}1

.il.

..I.

II

2-

#{149}

6-

5-

FIG.
9
Distribution of the plasma calcium and phosphorus levelsin the osteomalacic
values of a randomly
selected
group of osteoporotic

65-

OSTEOPOROSIS

OSTEOMALACIA

60

#{149}

PLASMA

#{149}

PHOSPHATASE

PLASMA
X SO

PHOSPHORUS

K.A.Un,ts

40

with

the corresponding

OSTEOMALACIA

OSTE0RQ5I5

5O-

ALKALINE

CALCIUM

10

FIG.

patients
patients.

45-

4O-

S..

S.

#{149}a::

.#{149}
#{149}

35-

#{149}.S
S..

_,

4#{149}

5#{149}

#{149}

...$.

30-

#{149}

20b
25

55

20H

01_

#{149}:

15-

#{149}:

#{149}:::

50-

11
Distribution
of the calcium
phosphorus
patients
with the corresponding

FIG.

FIG.

not

exclude

phosphate
plasma

the

disease.

products
calcium

Likewise,
below

and

phosphate

27

products
values

two

of the

milligrams

per

values

12

and the plasma alkaline

phosphatase
levels
of a randomly
selected
group of osteoporotic

are

not

osteoporotic

100

controls

millilitres.

necessarily

had

THE

plasma

It follows,
diagnostic
JOURNAL

calcium

therefore,
of

OF

in the osteomalacic
patients.

BONE

osteomalacia;
AND

and

that

JOINT

low
they

SURGERY

OSTEOMALACIA-A

indicate

the

need

all patients

for

Similarly,

normal

do

ofplasma

the

results

osteoporotic

patients.
levels

these

may,

of

been

IN

should

be

with

with

excluded,

of

raised

a raised

by

investigation

fracture

in

of

in old

age.

patients

other

had

conditions

values

such
or

level

as

of

above

12

Alkaline

Pagets

recent

disease,

fracture

suggests

12

sample

patients.

metastases

phosphatase

Figure

random

osteoporotic

skeletal

alkaline

routine

in osteomalacia.

obtained

thirty-six

widespread

the

finding

values

osteomalacic

six

be

of

of osteomalacia.

is a common

of thirty-five

course,

part

407

WOMEN

or pathological

possibility

together

failure,

ELDERLY

of bone

phosphatase

series

liver

have

the

exclude

compared

hyperparathyroidism,

when

not

Thirty-one

units,

phosphatase

density

this

DISEASE

and

diminished

alkaline

for

King-Armstrong

investigation

with

values

Elevation
shows

further

presenting

COMMON

the

but,

diagnosis

of

osteomalacia.

Urinary
in distinguishing
are

the

calcium
this

In seventeen

rule.

ranged

from

per

24 hours).

has

been

of

et

in their

Radiographic

is caused

by

the

49

B,

bone

NO.

more
3,

mass.

this

not

AUGUST

In

characteristic.
1967

used

the

most

in

the

consistently

feature,

matrix

therefore,

may

of the peripheral
osteomalacia

Indeed,

the
it has

skeleton
opposite
been

series

of

but

Nordin

and

diagnostic
density

whereas

has

of

in the

bone

limited

other

is a feature

is delayed

the
diseases

diagnostic

Typically,
is
(Nordin

seldom
seen,

1965)

change
it is due

significance,

senile

and

distribution
suggested

which
Fraser

biochemical

In osteomalacia

be suggestive.

values

women.

radiographic

changes

present
test

in elderly

calcium

75 to 300 milligrams

range

hyperparathyroidism.

of bone

can be valuable
elevated
values

urinary

(normal

hypercalcaemia

occurring
and

This

of the

involvement

involvement.

being

found

and
slightly

twenty-four-hour

was

induced

of osteomalacia

mineralisation

distribution

in the spine;
spinal

changes
VOL.

in

is the

the

34 milligrams

which

others

(1966)

series

a mean

osteoporosis

insufficient

the

al.

reduced
in osteomalacia
in which
normal
or

in osteomalacia-Diminished

changes
to osteomalacia,

a reduction

by

series

common

starts

in this
with

investigation

value

Anderson

although

patients

biochemical
found

investigation

to

is usually
much
from
osteoporosis

10 to 125 milligrams

Another

(1956).

excretion
disease

osteoporosis
as marked
the
that

peripheral
vertebral

as

408

J. CHALMERS,

FIG.

1 5-Indrawing
16-Buckling

Figure

Figure

density

may

series

only

most

once

patients

vertebrae,

may

biopsy
Slight
are
Skeletal

well

in seven

cases

diseases

which

The

completely

osteoporosis

across

and

osteomalacia,

and

osteomalacia;

poor

definition

here.

spine

are

in

our

in patients
was

with

present
is no

biconcavity

and

patients

in

help

in

of the lumbar
was confirmed
in

this

bands
are

Typically,
from

consist

of

36).

in Figures

15) and

fracture

clinical and

in

individual

trabeculae

of osteomalacia.

of osteomalacia.

does
such

as a feature,

series

The
buckling

These

common
pubic

are

rami

in osteoporosis;
disease,
fibrous

features

were

most
of the

not occur
as Pagets

radiological

this

most

and

Noetzli

which

usually

evidence

17 to 25.

radiological

1964).
are

fracture
suggests

an

found

the

other

dysplasia

easily distinguish

slight

zones
Individual

syndrome
were

callus

and

not

readily

receives

recognised
patients

had

show

in thirty

and

as

later

quite

has
of

start

are

description

in thickness

shown

fibrous

minor

a remarkable

years

undeserved

from

and

classical

content

zones

some

or extending

examination

a variable

often

redescribed

cortex

osteomalacia
the

millimetres

Loosers

zones

of
gave

Histological

with
the

of the

signs

several

bone.
that

part

(1920)

Looser

mineralised

1960).
Loosers
but which
was

Milkmans

involving

typical

pseudofractures

adjoining

unmineralised
This

or pseudofractures

the

the
the

et al. 1946,
Ball
which
Looser
noted
literature

of

feature

14).
(Fig.

without

of osteomalacia

(Steinbach

defined

35 and

suggestive

have

radiological

(Fig.

strongly

deformity

bones

feature.

and

suggestive

ischium

Deformity

In this series Loosers

shown

Kyphosis

patients.

density

spine

seen.

collapse

of the

increased

lumbar

osteoporosis

in sixteen

mild, as shown

examination.

diagnostic

In English

in density

observed

often

showed

in sixteen

imperfecta,

on clinical

(Albright
feature

are

deformities

zones-Translucent

they

both

arrangement

in the

skeletal

Loosers

(Figs.

seen

16).

have

detected

that

both

changes

normal
was

present

was usually

have

apparently

who

is another

found

(Fig.

osteogenesis

this

patients,
from

we

bones
to

trabecular

deformities
thorax

sharply

an

peripheral
common

bone

often

hour-glass

of

16

was

deformity

Small
and

However,

being

of

changes

virtually

in osteomalacia.

their

suffered

obscurity
of cancellous

and

P. J. SCOTT

material.

in areas

them.

AND

deformity

patients-the

radiologically,

A few

have

an hour-glass

rami was seen in seven

I 3).

diagnosis.

producing

increased

of
this,

D. L. GARDNER

FIG.

assess

(Fig.
but

differential
the

be
to

radiolucency

CONACHER,

H.

15

of the pubic

difficult

marked

D.

of the mid-thorax

actually

notoriously

W.

tissue
fractures

symmetry-a

by Milkman

(1930).

prominence.

patients.

Typical

one

to twenty-four

THE

JOURNAL

OF

examples

lesions.
BONE

AND

are

Figure
JOINT

SURGERY

26

OSTEOMALACIA-A

COMMON

DISEASE

IN

ELDERLY

409

WOMEN

17
incomplete
Loosers
Figure
18-Symmetry
FIG.

Figure
17-An
osteomalacia.

18

FIG.

zone

in the

of

Loosers

second
zones

metacarpal
is

19
in the axillary

bone.
characteristic

This

lesion

feature

is diagnostic
of

of

osteomalacia.

FIG.

Symmetrical

FIG.
Figure
same

which

VOL.

Loosers

zones

49 B,

be seen

NO.

3.

in the normally

AUGUST

1967

of scapulae.

20

FIG.

20-Lesions
in ribs are not seen easily
on routine
patient
as that on the left but taken
with a different

cannot

borders

21

chest
radiographs.
The radiograph
on
exposure:
it shows
several
Loosers

exposed
radiograph.
Figure
21-Rib
spinal radiographs
as in this case.

lesions

are

the right is of the

zones
in the ribs

often

best

seen

on

410

J. CHALMERS,

of these lesions

the skeletal distribution

shows

all

D. H. CONACHER,

W.

Loosers

includes

zones

be shown

in

girdles and

can

the shoulder

D. L. GARDNER
in

of

Loosers

clear

glance

Loosers

the femoral

zones

facilities for a more

majority

of

cases.

in

the

complete
Loosers

clearly visible in films

pelvis

taken

neck

fractures

pubic

rami

might
are

to show

in

ribs

the

may

bone

the chest
femurs.

of

upper

cent

of

which
Where

in the right greater

pubic rami.

sciatic

notch

23

have

sufficient

skeletal survey
zones

view

including

zones in both superior

pubic
rami and another
are shown here, as is the buckling
of the inferior

FIG.

At a casual

penetrated

the

86 per

that

22

FIG.

Symmetrical

P. J. SCOTT

It can be seen

all cases.

radiographs-a

two

radiograph

AND

been
to

accepted
establish

are limited,
not

be

structure

seen

diagnosis

views

in normal

chest

20 and
JOURNAL

lesions
of

these two

(Figs.
THE

as osteoporotic
the

but the

osteomalacia.

disclose
films

but

the great
may

21).
OF

BONE

AND

JOINT

SURGERY

be

OSTEOMALACIA-A

The
and

localisation

of Loosers

Steinbach,

vessels

Kolb

are

closely

zones

has

Gilfillan

and

related

(1941)

McCullough

COMMON

to

that

their

aroused

(1954)

bone.

DISEASE

IN ELDERLY

some

suggested

However,

the

localisation

speculation.
that

they

theory

depends

of

LeMay
develop

and

at

sites

(1920)

Looser

upon

411

WOMEN

mechanical

and

Blunt

(1949)

where

blood

of Camp

factors

and

seems

more

acceptable.

It is interesting

that

observed

in this

by others

(Steinbach

occurred
of

at

the

Ascenzi

border

of

to

great

and

that

the

such

as

zones

1964)

the

medial

pubic

rami

the

scapula

have
cortex

and

are
stress.

(1964)

have

of

the

which

compression

matrix

reported

Noetzli

Bonucci

mineral

of the

in those

the

femur,

subjected

many

and
and

sites

upper

axillary

series

shown

bone

does

not

affect

its tensile
strength,
which
depends
largely on the
quality
and orientation
of
the

collagen

of the
to

fibres.

mineral

compression.

mineral
the

fractures
weakened
may

explained

of

that

they

which

are

walking

by
stresses

are

likely

to affect

similarly.
complete

Several

the

Loosers

start

as slight

their

fact

such

the

explain

pathologically

and
the

of
may

many

bones

habitual

body

deficiency

is acceptable,

be

the

of
concept

in

function
resistance

in osteomalacia

localisation
The

mechanical

is to provide
The

matrix

zones.

to

The

matrix

symmetry

that

many

as

breathing

both

sides

patients

of
Another

changes

essential

pathological

evidence

of the

in

in

the

present

osteomalacia-An

feature

disease.

the

series

had

Loosers

lesser

zones

excess

of osteomalacia

It is sometimes

of

and

possible

bone

unmineralised
biopsy

to detect

bone
provides

that

the

presence

or
the

trochanter.
progressed

stained

zones
prepare

of unmineralised
undecalcified
NO.

3,

with

mineralisation

AUGUST

haematoxylin
because

marginal
osteoid.
sections
of bone and
1967

and
even

For
stain

is the

convincing
in decalcified

25

of bone
deficient

osteoid

most

of osteoid

zone in the femoral

neck healed with Vitamin
D therapy
alone.
The
bearing.
Internal
fixation
is not required
unless a complete
fracture

of

49 B,

below

Loosers
weight

index

VOL.

lesion

of the

FIG.

sections

typical

fractures.

Pathological

This

24

FIG.

or

eosin
the

(Meyer
most

1956),

careful

routine
diagnostic
for bone mineral

but

patient
remained
develops.

this is an unsatisfactory

decalcification

may

mask

purposes
it is preferable
by the Von Kossa
technique.

the
to

412

J. CHALMERS,

Preparation
cancellous
clearly
and

W. D. H. CONACHER,

D. L. GARDNER

AND

P. J. SCOTT

of undecalcified
bone sections-Biopsy
material
which
has a predominance
of
bone
is preferred
because
cancellous
bone
shows
the changes
of osteomalacia
because
it is easier to prepare
undecalcified
sections
of this material.
In this series

several
plugs of bone were removed
under local anaesthesia.
Undecalcified
of bone in formol
saline for twelve

with a 6 millimetre
trephine
from the anterior
iliac crest,
bone sections
were prepared
after fixing the small blocks
to twenty-four
hours.
The fixed material
was washed
and
dehydrated

with

alcohol.

Progression

through

acetone

allowed
the blocks
to be placed
overnight
of methacrylate*
for one to seven
days.

in a solution
The resin
is

hardened

embedding

at

56

degrees

Centigrade

when

is

complete.
Eight
microtome

- - -

block

to ten 1u sections
are cut
after softening
the surface

with

50 per

19

of bone

young
fully

placed

in

in
after

After
further
10 per cent
blotting
dry,

assessment

mineralisation

and

of osteomalacia-The
was

based

assessment

on a subjective

micro-

comparing
the extent
of silver deposits
upon
ofcancellous
bone with that on control
bone
of the same age and sex.
In the normal
middle-aged

mineralised

(Figs.

adult

almost

27 and

28).

all

trabeculae

are

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

U-

and

FIG.

26

of Loosers

illustrate

are

balsam.

scopic
study,
the trabeculae
from
persons

cases

Sections

fixed in 4 per cent sodium

thiosulphate.
washing,
the material
is counterstained
carbol
fuchsin,
washed
and mounted,

19

Histological

thirty

acetone.

distilled
water
for one hour,
and transferred
to 2S per
cent silver nitrate
exposed
to a light source,
for twenty-four
hours.
The sections
are then washed
in distilled
water and

in Canada

Distribution

cent

with a Jung
rotary
of the methacrylate

showing

the

grades

empirically

zones

these

lfl

the

on

a simple

malacia)
through
the most
severe

features.

of

extensive,
a fault in bone
Osteomalacia,
recognised

osteomalacia

which

were

mineralisation
in this way,

scale,

ranging

is confirmed.
was assessed

from

1, 2 and 3 to 4 to 5, which
form
of disease.
Figures
recognised

in the

present

0 (no

osteo-

represented
30 to

series

34

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
defective
mineralisation
may,
which
there is osteosclerosis.
osteomalacia
Other
thickness
Pure

in any way
workers
have
of osteoid

seams,

may exist with

or without
osteomalacia
by contrast,
be found
in examples
of renal
There
is no evidence
in the present
material

influences
applied
the

the
more

amount

severity
of osteoporosis
sophisticated
diagnostic
of bone

surface

while
evidence
osteodystrophy
that the severity

or vice versa.
techniques
by measuring

covered

by osteoid

of
in
of
the

or by relating

the

methacrylate

is prepared
by removing
hydroquinone
stabiliser
from N-butyl
methacrylate
and methyl
5 per cent sodium
hydroxide.
The materials
are shaken in a separating
funnel and the
sodium
hydroxide
decanted.
The final preparation
is washed
eight times with distilled
water and dried over
silica gel.
Pure methacrylate
then comprises
one part of N-butyl
methacrylate
and two parts of methyl
methacrylate.
To polymerise
the methacrylate
benzoyl
peroxide
is used as a catalyst
and is incorporated
in
the methacrylate
before embedding.

methacrylate

with excess

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

OSTEOMALACIA-A

COMMON

DISEASE

IN

ELDERLY

413

WOMEN

FIG.27
Figure 27-Normal
bone.
This undecalcified
section shows normal
trabeculae
of cancellous
bone.
In the lower
left 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 and
extent of the trabeculae
of the bone in Figure 27, those in this field are slender and sparse.
The proportion
of
unmineralised

FIG.

Figure 29-Osteoporosis.
of unmineralised
osteoid.
proportion

of

osteoid
seams,
in this situation

VOL.

49 B,

NO.

bone

osteoid

remains

normal.

(Von

29
The cancellous
bone trabeculae
(Von Kossa and carbol
fuchsin,

trabeculae

near

the

cortex

of

this

Kossa

and

carbol

fuchsin,

FIG.

are thin,
x 30.)

sample,

which

attenuated
and
Figure
30-Very
are

30
sparse.
slight

bordered

is greater
than normal.
However,
this degree of diminished
calcification
and an assessment
based on a study of less superficial,
cancellous
bone
and carbol fuchsin,
x 30.)

3,

AUGUST

1967

x 30.)

by

There is no excess
osteomalacia.
The

narrow,

is difficult
is desirable.

unmineralised

to interpret
(Von Kossa

414

J. CHALMERS,

FIG.
Figure
osteoid

31 -Osteomalacia,
is significantly

(Von
Kossa
unmineralised

H.

CONACHER,

D.

L. GARDNER

AND

31

and carbol
fuchsin,
and of mineralised

33-Very

D.

P. J. SCOTT

FIG.

32

grade 1. The extent of the bone margins which are lined by red-staining,
greater
than
is the normal
for any age: osteomalacia
can be diagnosed

FIG.
Figure

W.

severe

30.)
Figure
32-Severe
bone are approximately
-

osteomalacia,
equal.
(Von

grade
3.
The
Kossa
and carbol

33

osteomalacia,

FIG.
grade

mineralised.
(Von Kossa and carbol
fuchsin,
diseases
are encountered
together
in the elderly.
mineralised.
(Von

4.

The

proportion

of

unmineralised

confidently.
proportions
of
fuchsin,
-. 30.)

34

unmineralised

bone

exceeds

30.)
Figure
34-Osteoporosis
and osteomalacia.
The bone trabeculae
are slender and sparse, and
Kossa and carbol fuchsin,
x 30.)

-:

THE

JOURNAL

OF

BONE

AND

that

of

The two
incompletely

JOINT

SURGERY

OSTEOMALACIA-A

COMMON

DISEASE

IN ELDERLY

415

WOMEN

FIG.
35
FIG.
Figure
35-Loosers
zone.
Laminae
of new bone forming
in the subcortical
region
following
incomplete
fracture.
Repair
is incomplete
and delayed;
the new bone is
(Haematoxylin
and cosin,
- 30.)
Figure 36-Loosers
zone.
Higher
power view of
Figure
35.
Both the islands
of new bone (left)
and the margins
of the compact
incompletely
calcified:
the more
basophilic,
central
zones
are normally
mineralised.

eosin,

area ofosteoid
however,
no

to the
generally

area ofmineralised
accepted
standard

diagnosis

of osteomalacia.

adequate

diagnostic

The
cases

histological

were

for

changes

included

by biopsy

The

guide
or

alone,

the

visual

method

from

biochemical

and

deficiency

osteomalacia,

except

during
the
Ordonneau

two
1943;

in

were

series.

OF

vitamin

the

unusual

circumstances

wars
(Looser
Mahoudeau,

in India and China

(Maxwell
1935).
A detailed dietary history was

is

have

Dunnigan
no

of life,

recently
and

signs

of

a day.

More

before

been

1920:

obtained

the
The

osteomalacia

49 B,

importance
importance

NO.

had

information

skin can be inferred

reasons
or traditional
VOL.

On the other

3,

AUGUST

diets

is needed

of this factor
of the endogenous

and

in ten

from the
custom,
1967

proved

an

being

which

cases

borderline

were

diagnosed

normal.

considered

as those

patients

cause

prevailed

of

in Europe

S#{232}ze,Monni#{233} and

1942;

S#{233}n#{233}cal
1943)
of the

common

which

and

in famine

of this

series

conditions

(Table

I) and

deficient
in vitamin
D-that
is, less than
60
dietary
factors
may play a part in some of the
certain
sections
of the community,
particularly

hand,

containing
concerning

can

has

by

accepted

Justin-Besan#{231}on

Bricaire

live on diets of marginal

from other centres

1965).

series

standard

the

generally
such

reported

Smith

as the
of

findings

not

three
of these
had diets
which
were grossly
international
units a day.
This suggests
that
patients
in this series.
There
is no doubt
that
at the extremes

in this

is,
the

OSTEOMALACIA

of

world
Gennes,

used

used

Three

radiological

ETIOLOGY
Dietary

part of the field shown in

cortical
bone (rig/it)
are
(Haematoxylin
and

use.

above
the

bone

rnineralised.

Frost
1962, Wood
1965).
There
of osteoid
necessary
to justify

of grading

clinical

as assessed

excluded

incompletely

110.)

bone (Ball 1960,

for the amount

routine

36
of an osteornalacic

be fully
production

adequacy;

in this
many
less
the

nutritional

country

osteomalacia

(Gough,

Lloyd

of our osteoporotic
than
50 international
nutritional

assessed.
of vitamin

patients
units

requirements

D by the action

high incidence
of osteomalacia
among
are almost
totally
covered
by clothing

and

and

Wills

rickets

1964:

who showed
of vitamin
D
of

old

of sunlight

people

on the

women
who, for religious
(Scott
1916, Herold
1944).

416

J. CHALMERS,

W. D. H. CONACHER,

D. L. GARDNER

TABLE
DETAILS

OF

FINDINGS

IN

THIRTY-SEVEN

AND P. J. SCOTT

I
PATIENTS

WITH

OSTEOMALACIA

Biochemistry
Case
number

Alkaline
Sex

symptoms

Presenting

Female

89

Female

85

Female

76

Female

72

Female

82

Female

73

Female

81

Female

76

Female

87

10

Female

65

11

Female

74

Skeletal
pain.
Weakness

l2

Female

41

Weakness.
Skeletal
pain

13

Female

86

Fracture

neck

14

Female

74

Fracture

neck

15

Female

69

Skeletal

pain

16

Female

72

Skeletal
Skeletal

17

Male

62

18

Female

78

19

Female

80

Subtrochanteric
fracture

Transcervical
fracture
neck of femur

Fracture

neck of femur.
Skeletal
pain

Skeletal

neck of femur.
Rheumatism

Hip

Plasma
phosphorus

(milligrams
per cent)

1 (milligrams
per cent)

pain

Calcium
phosphorus

phosphatase.
KingAmong
units

24-hour
IIflfl3i3
calcium
(milligrams)

25

200

23

10-6

3-4

36-0

14

9.4

2-1

19-7

19

39

23-0

24

30-0

8-9

1-4

125

34

250

8-2

27

22-1

180

23

27-0

Skeletal

pain

10-4

3-2

33-3

Skeletal

pain.

9-4

20

188

Weakness

80

pain.

Weakness

Fracture

Plasma
calcium

21

Greenstick

96

27

25-9

Foot

9-6

2-3

22-1

25

81

3-3

267

20

10.5

38

39.9

35

32-0

of femur

81

2-7

219

15

420

of femur

89

3-0

267

38

270

89

3.7

329

28

510

pain

100

28

280

13

10-2

pain

107

34

364

86

20

172

14

fractures

pain

Skeletal pain.

Weakness.

Bedridden

Multiple
greenstick
fractures

14

with

idiopathic

340

33

97

Patients

steatorrhoea.

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

OSTEOMALACIA-A

COMMON

DETAILS

Previous
gastric
surgery

OF

FINDINGS

IN

Daily

Diet.
intake

DISEASE

THIRTY-SEVEN

PATIENTS

Interval
(years)

(milligrams)

zones

Part

Clavicle
109

Ribs

shaft

Femoral

Pubicrami.

Partial
gastrectomy

Ribs.
Scapulae
Ribs
Femoral
Femoral

Pubic
None
I

Partial
gastrectomy

30

101

Femoral

I
2

Gastroenterostomy

974

40

136

10

neck
shaft

Thoracic

.
.
.

Thoracic

Partial
gastrectomy

640

130

Metatarsal

Ulna
.
.
I Pubic
rami.
Femoral
neck
Scapulae
.

212

bone

Ribs.

None

greenstick
tibia
and

None

None
:

.
.

neck
shaft

Pubic

2
12
4
1

Thoracic
I

ramus

Ulnae
Ribs
.
Scapula
Pubicrami.

Partial
gastrectomy

Partial
gastrectomy

13

689

Ribs
Femoral

None

:
.

.
.

.
.

neck

sulcus

and kyphosis.
Secondary
hyperparathyroidism

Thoracic
Lumbar

2
5

Thoracic

and

kyphosis.
collapse

1
2
3
3

Thoracic
sulcus
and kyphosis.
Secondary
hyperparathyroidism

8
1

sulcus
kyphosis

Radius
Ulnae
Ribs
.
Pubic rami

48

None

24

fractures:
fibula
:

2
1

rami.

Femoral
Femoral

Pubic

31

Thoracic
sulcus.
Bowing femur and tibia.
Four

1,319

Thoracic
sulcus
and kyphosis

sulcus

None

None

Thoracic
sulcus
and kyphosis.
Pelvic
buckling

of

Partial
gastrectomy

None

kyphosis

Thoracic sulcus
and kyphosis.
Secondary
hyperparathyroidism

I
7
4
1

bones.

Ribs.

malaciat

Thoracic
sulcus
and kyphosis

2
I
2

neck

Metatarsal

features

Thoracic
sulcus
and kyphosis.
Pelvic
buckling

Gastro-

enterostomy

800

16

Ulna.
.
Clavicle
.
Ribs
.
.
Pubic
rami .
Femoral
shaft

None

I
I

neck
shaft
rami

Femoral
Femoral

Other

Number
.

Scapulae

Partial
gastrectomy

Grade of
osteoI

units)

1,000

OSTEOMALACIA

Biopsy-

None

WITH

VitaminD
(international

Calcium

417

WOMEN

Radiology
Loosers

Type

IN ELDERLY

I-continued

TABLE

_______
:

Thoracic sulcus
and kyphosis
:

Partial
gastrectomy

Partial
gastrectomy

1,423

117
Scapula
Ribs .
Femoral

10

None

All

cases

showed

diminished
For

49 B,

VOL.

NO.

3,

AUGUST

radiological
explanation

1967

of

.
.

I
.

.
.

#{149}:
.

Femoral

shaft

of the

skeleton

grading

see

text.

16
1

density

:
*

shaft

Clavicle
Scapula
Ribs
.
Pubic rami

2t

None

neck

Femoral
:

None

Thoracic
sulcus
and kyphosis

1
1
2
2
1

in addition
Osteoporosis

31
I

Thoracic sulcus.
Lumbar
collapse.
Pelvic buckling.
Greenstick
fractures
tibia (2), fibula
(3)

to the
also

features
present.

detailed

in this

column.

J. CHALMERS,

418

W.

D.

H.

CONACHER,

D.

OF

FINDINGS

IN

AND

P. J. SCOTT

I-continued

TABLE
DETAILS

L. GARDNER

THIRTY-SEVEN

PATIENTS

WITH

OSTEOMALACIA

Biochemistry

Age
ner

Sex

Presenting

symptoms

Plasma
calcium
(milligrams

(years)
:

per

20

Female

78

21

Female

56

Fracture

neck

of femur

Chest

Plasma
phosphorus
(milligrams

cent)

per

94

pain

76

cent)

I Calcium
x
phosphorus
I

units

24

226

26

Alkaline
phosphatase.:
King..
I Armstrong

198

24-hour

IiflflIY

calcium
I (milligrams)

14

1250

18

240

22

23

Female

Weakness.

83

Skeletal

63

Male

Fracture

pain

87

humerus

92

Weakness.

fracture

I
I

24

30

276

12

I
I
I

Skeletal pain.
Greenstick

56

Female

209

I
I

24

24

85

26
221

of tibia

16

360

I
I

25

Female

46

26

Female

54

27

Female

80

Backache

92

Skeletal pain.
Weakness

Skeletal

77

Fracture

pain.

19

25

146

410

67

femoral

258

Weakness.

28

29

194

15

123

32

147

33

167

31

neck

52

28

Female

Skeletal
pain.
Weakness

39

29

Female

85

30

Female

86

Subtrochanteric

inability

fracture.i

Difficulty
Muscular

82

87

19

76

22

in walking
weakness-

to walk

240

31

Female

76

Skeletal
pain.
Weakness

29

93

24

223

84

36

302

15

16

32

Female

78

Skeletal

pain

33

Female

75

Skeletal

pain

98

34

Female

82

Skeletal
Skeletal

pain
pain.

110

16

176

35

Male

64

84

2l

l76

23

36

Female

74

220

65

Weakness

Muscular

weakness

92

24

220

Skeletal
Female

57

pain.

Subtrochanteric
fracture
femur

98

27

265

II

45

BONE

AND

Patients

with

idiopathic

steatorrhoea.
THE

JOURNAL

OF

JOINT

SURGERY

OSTEOMALACIA-A

COMMON
TABI.E

DETAILS

OF FINDINGS

Previous
gastric
surgery

Daily

I Interval
(years)

Partial
gastrectomy
Partial
gastrectomy

Calcium
(milligrams)

PATIENTS

Diet.
intake

units)

zones

57

5
2

Pubic
Ribs

Partial

Pelvic

humerus
rami

neck
shaft

Ribs

bone

Thoracic

Ulna.
Ribs

None

None

notch

Fibula

neck

Ulnae

Partial

1,108

gastrectomy

Ribs
Femoral

88

neck

1
I

Pelvic

sulcus.
buckling

Slight
buckling
pubic
rami.
Secondary

hyperparathyroidism

10

None

34

.
.

neck

5
1

shaft

Femoral

Thoracic

sulcus

Thoracic

kyphosis

2-3t

None

None

None

2-3t

None

None

None

2t

Femoral

Partial

gastrectomy

Ulnae
Radius

Clavicle

None

Scapula
Pubic
ramus

I
I

Partial
gastrectomy
cases

I
I

showed

NO.

diminished

t
49 B,

neck

1
1

Greatertrochanter

VOL.

Thoracic

None
.

Femoral

None

None

tibia

hyperparathyroidism

2
5
4

shaft

Tibiae

a All

Sciatic

bones

fracture

Ribs

None

None

72
4
1

Metacarpal
Scapulae
rami

Greenstick

Femoral

Ribs.

None

Pubic
rami
.
Femoral
neck

Metatarsal
:

Pubic

None

bone

collapse.

buckling.

Pelvic
buckling.
Secondary

1
1

radius

kyphosis.

Pelvic

4
2

bone

Ribs
.
Scapulae

133

800

Metatarsal

Neck

trochanter.
neck

rami

Fibula

sulcus.

Lumbar

Metacarpal
Pubic
Lesse

buckling

None

None

collapse

Secondarycollapse.
Thoracic
hyperparathyroidism

Partial
gastrectomy

3,

For

AUGUST

radiological
explanation

1967

density
of grading

neck

Femoral

shaft

Femoral

neck

Femoral

shaft

of the

skeleton

None

3
I
I

Femoral

see text.

of

osteomalaciat

10

features*

Thoracic

26
I

None

gastrectomy

Lumbar

shaft

Ulnae
Neck
Femoral
Femoral

2
4

Ribs
Femoral

Other

Number

neck

Grade

Part

Femoral

Partial
gastrectomy

OSTEOMALACIA

Biopsy-

Loosers

I (international
Vitamin
D

1,052

WITH

Radiology

I Metatarsals

None

419

-------

2
I

WOMEN

I-continued

IN THIRTY-SEVEN

---------Type

DISEASE IN ELDERLY

I
I

2
2

in addition
Osteoporosis

I
I

None
to the
also

features
present.

detailed

in this

column.

420

J. CHALMERS,

We have
interesting

been

that

unable

several

H.

to assess

feature

patients

become
as a result
It might be argued
that
disease

D.

also

been

in this

CONACHER,

how

volunteered

This

of the

has

W.

of the disease
a particularly
but

three

of Cornwall

and

Evidence

of intestinal

malabsorption-Rickets

of all types,

Devon

and

patients

the more
unfavourable

discount

AND

were

likely they
climate

collected

this

P. J. SCOTT

exposed

to sunshine

but

it is

in the summer
months.
the more disabled
the

are to be deprived
of sunshine.
could account
for the frequency

by one

of us (P. J. S.) in the

sunnier

suggestion.

and

malabsorption

these diseases
in this country.
non-absorbable
calcium
soaps
has been invoked
also to explain
1964).
Malabsorption
after
described
impaired
absorption
carbohydrates
(Jones
et a!.

our

L. GARDNER

symptoms
diminished
et a!. (1946).
Certainly,

patients

counties

steatorrhoea

much

that their
by Albright

reported

region

D.

osteomalacia

is generally

Both the malabsorption

with excess
fat in the
those cases that have

are

regarded

familiar

complications

as the commonest

of

cause

of

of vitamin
D and the formation
of
gut may be important.
This mechanism
appeared
after gastrectomy
(Deller
et al.

gastrectomy
has long been recognised.
Various
workers
have
of fat, calcium,
iron,
vitamin
B12, folic acid,
proteins
and
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

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.
however,
obtained
without
affecting

Complete
studies
and the information

of absorption
available
for

demonstrated

difference

previous
calcium

little

gastrectomy.
and vitamin

of

were carried
the remainder

out only in the younger

is limited.
Such evidence

malabsorption

Severe malabsorption
D remains
a possible

between

those

patients,
as was

patients

was not found,

but limited
etiological
factor;
further

with

and

malabsorption
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,

and hypophosphatasia,
were not found
Secondary
hyperparathyroidism-Parathyroid
osteomalacia
this

has

might
been

appearances

be expected

described

such
in this

to produce

(Steinbachand

were

tubular

defect,

by the

low

chronic
serum

renal

calcium

failure
level

in

changes
of secondary
hyperparathyroidism
and
1964, Goughetal.
1964). Suggestive
radiographic

Noetzli

of hyperparathyroidism

as renal

series.
stimulation

seen

in the hand

in six patients

of the present

series.

TREATMENT
The

treatment

and calcium
weeks (Figs.
but a fall
of vitamin
similar

to

severe

renal

of osteomalacia

produce
relief of skeletal
1 to 7 and 25). Plasma
in alkaline
D presents
hyperparathyroid

should

and

effective.

Adequate

phosphatase
is usually
delayed
(Fig. 37).
some difficulty.
Vitamin
D in excessive
secretion

supplements

of vitamin

pain and healing

of pseudofractures
within
four to eight
calcium
and phosphate
values
promptly
return
to normal

causing

elevation

Selection
of the
dosage
produces

of serum

calcium

correct
toxic

and,

dose
effects

if sustained,

damage.

If dietary
deficiency
supplements
of vitamin
day

is simple

be adequate.

alone
is the cause
D in a physiological
If malabsorption

of the disease,
then correction
of diet
dose in the order
of 200 international
is responsible

then
THE

larger

JOURNAL

doses
OF

BONE

may
AND

and small
units per
be required

JOINT

SURGERY

OSTEOMALACIA-A

by mouth
and

or small

doses

osteomalacia,

Clearly,

ideal

not

COMMON

administered

parenterally.

encountered

therapy

in this

depends

series,

on precise

as calciferol,

phosphate,
three

l25

calcium

monthly.

The

and

urea

is adjusted

ELDERLY

large

of the

to obtain.
has proved

levels

according

forms

of resistant

ofvitamin

etiology

D may

of the

satisfactory
units)

disease

by mouth.

which,

as

Vitamin

The

intervals

or biochemical

rickets

be required.

in practice.

daily

at monthly

to the clinical

421

WOMEN

various

doses

(50,000
international
are checked
initially

milligrams

dose

hard
which

IN

In the
very

knowledge

indicated
in this report,
can be extremely
We have adopted
a routine
treatment
is given

DISEASE

and
response

plasma

thereafter
(Fig.

37).

45
Ca xP

40-

40

sJ
30-

35
30

25-

PHOSPHATE

25

PRODUCT

PHOSPHATASE

0
mg#{176}/o11
10

/5

PLASMA

CALCIUM

PLASMA

PHOSPHATE

7x
6

-*---------e----------

/oooo
51Uf DAY

VITAMIN

r///

50,000

D BY

MOUTH

I.U./ DAY

50,000

[U/DAY

10 11 12 13

14

15

16

17

18

19

MONTHS

37

FIG.

The

chart
biochemical
controlling

slower

ofa

woman
aged 69 years
with osteomalacia
response
to vitamin
D therapy
which
dosage.
The return
of alkaline
phosphatase

than

is the response

phosphatase

rise

in

plasma

can

be

calcium

of plasma

a sensitive

above

11

calcium
index

after gastrectomy
provides
a reliable
to normal
levels

and phosphate,

of

inadequate

milligrams

100

per

shows
the
means
of
is usually

and a rise in alkaline

therapy,

millilitres

as

shown

or an

here.

elevation

of blood

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 patients
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.
urea

initial

Calcium
deficit

in the

form

supplements
of mineral.
of effervescent

038 grammes
elemental
in severe
cases it should
VOL.

49 B,

NO.

are needed
in the early
We have given supplements

3,

AUGUST

tablets

of calcium

calcium.
The
be maintained
1967

stages
of treatment
because
of enormous
of one to two grammes
of calcium
daily

gluconate

(Calcium

need for calcium

supplement
for at least a year.

Sandoz)
diminishes

each
with

containing
time,

but

422

i.

CHALMERS,

Associated
Large
weight

anaemia

Loosers
bearing

complete

W.

should

zones which
for the first

fracture

D.

of the

H.

CONACHER,

D.

be

investigated

and

threaten
the strength
few weeks
of treatment

upper

femur

has

L. GARDNER

AND

treated

P. J. SCOTT

with

appropriate

supplements.

of a long bone may require

protection
but internal
fixation
is not required

occurred

(Fig.

from
unless

25).

SUMMARY

The

clinical

features,

diagnosis

and

treatment

thirty-seven
recently
recognised
cases.
elderly
women,
among
whom
it is liable
be distinguished

may

and

muscular

episodes

of

incidence

pain

of

usually

in osteomalacia
urinary

will

show

more
opposite

the

discussed

not

are

more

skeletal

pain

ofosteoporosis
patients.

to
in

of long

duration

in which

transient

characteristic.

osteomalacia

in relation
uncommon
Osteomalacia

There

Secondly,

is a high

the

physical
of

are

usually

normal

in osteoporosis.

of osteomalacia

bone

density

in the peripheral

is typical

persistent
but

a fracture
in

are

this disease
is not
senile osteoporosis.

tenderness
in osteomalacia
but this is not a particular
feature
penguin
gait
suggests
osteomalacia.
Thirdly,
the biochemistry
and phosphate,
and raised alkaline
phosphatase
levels commonly

these

diminished

in which

with

surgery

is characteristic

marked

history,

that
with

of osteomalacia,

associated
gastric

but

calcium

the

typical

shows
skeletal
A shuffling
plasma
calcium

low

are

previous

examination
osteoporosis.
shows

by, firstly,

weakness

of osteomalacia

It is suggested
to be confused

which

bones

of osteoporosis.

but

not

is common

than

to both

in the axial

Skeletal

Reduced

Fourthly,

diseases,

skeleton

deformity

twenty-four-hour

of osteoporosis.

but

osteomalacia

without

fracture

radiology

if the

changes

are

is suggested

suggests

; the

osteomalacia,

do stress
fractures
and greenstick
fractures
in the elderly.
Loosers
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
as

doubtful
2.

cases.

The

etiology

exposure
in

is discussed

to sunlight
No

combination.

4. Treatment
of
thorough
screening
or with

It is a pleasure

their

M.

it is suggested

degrees

of treatment

diminished
the

to us.

patients
under their care.
skilland care in preparing

and

deficiency

may
for

the

of vitamin

all be important

the

dangers

predominant

D,

either
female

of uncontrolled

limited

alone

or

incidence.

administration

is rapidly
and consistently
successful,
and well justifies
patients
presenting
with weakness,
skeletal
pain, pathological

help

These

McQuillan,
Dr James
Mr R. Owen
(Oswestry)

a dietary

is offered

is given

radiographic

to acknowledge

that

of malabsorption

explanation

osteomalacia
of all elderly

available

patients

Mr W.
(Belfast),

mild

satisfactory

3. A practical
method
of vitamin
D indicated.

fractures

and

and

density

of our

Robson,
and

of bone.

colleagues

include

in the

Professor

South-East

Region

J. I. P. James,

Mr

Mr D. L. Savill,
Mr J. H. S. Scott
Dr Douglas
Grant
(Irvine)
have

We are most

grateful

to Mr T. C. Dodds,

(Scotland)

D. W. Lamb,

who

have

made

Mr G. P. Mitchell,

and Mr T. B. Whiston.
kindly
allowed
access

Mr J. Piggot
to records
of

Mr J. Paul

and

Mr C. Shepley

for their

and

A. (1946): Osteomalacia

the illustrations.

REFERENCES
F., BURNE1-r,

ALBRIGHT,

Late Rickets. Medicine,

I., CAMPBELL,

ANDERSON,

Scottish
BAIRD,

I. Mci.,

BALL,

J. (1960):
Harrison.
Radiology,

CLARK,

pp.

DUNN,

The

S. (1957):
Advances

A.,

and

J. B.

RUNCIMAN,

Ultimate

Tensile

Osteomalacia

in Pathology.

J. & A. Churchill

MCCULLOUGH,

36,

C. G.

Tract,

E. (1964):

In Recent

and

Jun.,

Roos,

and

M. (1966): Osteomalacia

in Elderly

Women.

11, 429.

OLEESKY,

London:

J. D.,

CAMP,

and

E. C.,

REIFENSTEIN,

399.

25,

A. E. R.,

Medical Journal,
and BONUCCI,

A.,

ASCENZI,

W.,

C. H., PARSON,

J. A.

Strength

Following
Seventh

of Single

Gastric

edition.

Osteons.

Surgery.

Chap.

9, pp.

Acta

Anatomica,

58,

Gastroentero/ogy,

33,

293-338.

by

Edited

160.
284.
C. V.

Ltd.
L. (1941):

Pseudofractures

in Diseases

Affecting

the

Skeletal

System.

the

Gastro-Intestinal

651.

(1962):

Metabolic

Consequences

76-79.

Edited

by A. N. Smith.

of Gastric Surgery.

Edinburgh:

Royal

Surgical

Physiology

College

of Surgeons.

THE

JOURNAL

OF

of

BONE

AND

JOINT

SURGERY

OSTEOMALACIA-A
D.

DELLER,

J.,

Special

Part

M.

Scottish

G.,

M.

Bulletins
K.

R.,

J.

Acid

Deficiency

(1965):

C.,

Cox,

and

The

H.,

H#{243}pitaux de Paris,
and

SeNCAL,

W.

Ober

J. P. (1935):

5, 225.
in Pakistani

R.

Beings.

Clinical
: Sur

deux

59,

408.

Hdpitaux

(1964):

de Paris,

Nutritional

P. (1962):

Pathogenesis
T.,

Gastrectomy
and

with
the

Children

of

de

Orthopaedics,
cas

Bones.

in Glasgow.

Deficiency

Lance,,
Following

: Milkmannsche

Rickets.

Metabolic

Bulletins

J.,

and

famine.

ii, 1261.
Gastrectomy.

und Milkmannsches

F. A.

STAMMERS,

of Gastric

et

de

2, 349.

M.

Consequences

famine.

175.

Partial

Krankheit

Medicine,

MEYNELL,

25,

dost#{233}opathie

Osteomalacia.

Calcium

J. A.,

WILLIAMS,

and

J.

W.,

of

Clinical

Jun.

(1949):
und

Factor

M#{233}moires

Surgery.

de

Ia

R.

(1962):

Lancet,

ii, 425.

Soci#{233}t#{233}
M#{233}dicale des

the

of

Pseudofractures

rontgenologische

f#{252}rChirurgie,

ofOsteomalacia

Identification

Location

in

521.
Klinische,

Zeitschr,ft

Conception

Histological

Determining

28,

Osteomalacia.

Deutsche

A Modem

Investigation,

Spdtrachitis

The

Partial

Metabolism

328.

Untersuchungen.

Journal,
49, 47.
MEYER,
P. C. (1956):

of

J. (1943)

Spontanfrakturen
13.

Suppi.

Lostdopathie

58,

(1920):

M.

and

COOKE,

Journal

anatomische
MAXWELL,

497.

Etiology

BLUNT,

Osteomalacia.
E.

172,
Acta,

(1942):

Effects

Gut,
Rickets

of Late

423

WOMEN

in Calcium

to Anaemia.

in Human

and

LoUs,

Haematological

L.

JUSTIN-BESANCON,

M.,

and

schleichende

Ulceration-Some

Metabolic

I : Changes

Aetiology

Seams

WILLIS,

R.,

Medica

E. V.,

(1964):
Part

The

BRICAIRE,

Symmetrische

J. (1923):

Peptic

and

of Osteoid

152,

Its Importance

Tissue.

und

pathologisch-

210.
to China.

Journal

Chinese

ofPathology

and

Medical

Bacteriology,

325.
L. A.

MILKMAN,

(1930)

: Pseudofractures

of Roentgenology,
D.

MORGAN,

24,

B.,

NORDIN,

B. E. C. (1965):
B. E. C.,

and

of Osteomalacia.
L. N.,

PYRAH,

H.

SALVESEN,

C.

R.,

in 1228 Patients

NORDIN,

and
A.,

Personal

Late

Rickets,

Osteomalacia).

Americaiz

Journal

C.

N.,

Gastrectomy

G.

WOODS,

and

Other

C.,

and

Operations

FOURMAN,

P.

(1965):

on the Stomach.

Search

Lancet,

ii,

for
1085.

communication.
R. (1956):

Lancet,

1, 823.

A Contribution

A Calcium-Infusion

Osteomalacia

I. B. (1956):

B#{246}E,J. (1953):

A. C. (1916):

Osteopathy,

PULVERTAFT,

after

FRASER,

SMITH,

and

(Hunger

29.

PATERSON,

Osteomalacia

Scorr,

Acid.

IN ELDERLY

1.

A.

Helvetica

C. T.,

71,

Folic

of Osteoid

Scandinavica,

(1944):

HOWLAND,

LOOSER,

M.

D.,

0.

LLOYD,

Medica

LEMAY,

Folic

C.

Thickness

KROGSGAARD,

Syndrom.
JONES,

of

10,

B.

CROMPTON,

and

SMITH,

MAHOUDEAU,

B.,

Acta

and

DISEASE

et M#{233}moires de Ia Soci#{233}t#{233}
M#{233}dicale des

HARVALD,

HEROLD,

and

(1962):

L. DE,

GOUGH,

N.,

Calcium

MedicalJournal,

H.

FROST,
GENNES,

to

The Contribution

II :

DUNNIGAN,

R.

IBBOTSON,

Reference

COMMON

Osteomalacia

Test.

1. Urinary

Gastrectomy.
Acta Medica
of Osteomalacia
in India.

Following

in Sprue.

to the Study

Excretion
Lancet,

Data

for

i, 935.

Scandinavica,

146,

Indian

of Medical

Journal

Recognition

290.
Research,

4, 140.

(1943): Trois observations

dost#{233}opathies de famine avec pseudo-fractures
Bulletins et M#{233}moires
de la Soci#{233}t#{233}
M#{233}dicale
des Hdpitaux de Paris, 59, 427.
M. S. (1950):
Osteomalacia.
Journal
of Bone and Joint
Surgery,
32-A,
193.
H. L., KOLB, F. 0., and GILFILLAN,
R. (1954):
A Mechanism
of the Production
of Pseudofractures

S. DE, MONNIE

SEZE,

du

bassin

SHERMAN,
STE1NBACH,

du

and

type

in Osteomalacia

American
Journal

VOL.

G.

49 B,

Syndrome).
M.

NOETZLI,

The

of Surgery,
C. (1965):

NO.

3,

Looser-Milkman
38,

Personal

AUGUST

489.
communication.

1967

Radiology,

Roentgen

(1964):

Journal of Roentgenology,

C. (1951):

STRANG,

Woon,

(Milkmans

H. L., and

STEINBACH,

ORDONNEAU

Looser.

91,

62,

Appearance

388.

of the Skeleton

in Osteomalacia

and

Rickets.

955.

Syndrome,

Occurrence

in a

Case of Idiopathic

Steatorrhoea.

British