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Bone

Bone is a rigid, dynamic connective tissue that constitutes the primary structural component of the vertebrate skeleton, providing support, protection, and enabling movement.^[1] It is composed of an organic matrix, predominantly type I collagen fibers that offer tensile strength and flexibility, embedded with an inorganic mineral phase mainly consisting of hydroxyapatite crystals (calcium phosphate) that confer compressive strength and rigidity.^[2] Bone tissue is categorized into two main types: compact (cortical) bone, which forms the dense outer layer and accounts for about 80% of skeletal mass, and cancellous (trabecular or spongy) bone, which creates a porous inner lattice for lightweight support and metabolic functions.^[1] The primary functions of bone include mechanical support for the body, protection of vital organs such as the brain and heart, and facilitation of locomotion through muscle attachments and joint formation.^[1] Additionally, bone serves as a reservoir for essential minerals like calcium and phosphate, regulating their homeostasis in the bloodstream via hormonal controls such as parathyroid hormone and calcitonin.^[2] It also houses bone marrow, the site of hematopoiesis for red and white blood cells, and acts as an endocrine organ by producing hormones like osteocalcin that influence energy metabolism and other systemic processes.^[2] Bone's cellular components are critical to its maintenance and remodeling, a lifelong process that adapts to mechanical stress and repairs damage. Osteoblasts, derived from mesenchymal stem cells, are responsible for bone formation by secreting the organic matrix and initiating mineralization.^[1] Osteocytes, the most abundant cells (comprising 90-95% of bone cells), are mature osteoblasts embedded in the matrix that sense mechanical loads and coordinate remodeling through signaling pathways.^[2] Osteoclasts, multinucleated cells from the monocyte-macrophage lineage, resorb bone by dissolving minerals and degrading the organic matrix, ensuring a balance with formation to maintain skeletal integrity.^[1] This dynamic equilibrium, influenced by factors like mechanical loading, hormones, and growth factors, allows bone to strengthen in response to activity while preventing excessive density or fragility.^[2]

Structure and Composition

Macroscopic Structure

Bone tissue at the macroscopic level is organized into distinct layers and compartments that provide structural integrity, support metabolic functions, and facilitate nutrient exchange. Compact bone, also known as cortical bone, forms the dense outer layer of most bones and constitutes approximately 80% of the total skeletal mass in adults.^[3] This layer offers primary mechanical strength and protection against external forces, appearing solid and smooth to the naked eye.^[4] In contrast, cancellous bone, or trabecular bone, comprises the porous inner network within bones, characterized by a lattice of interconnected struts and plates that create a spongy architecture.^[5] This structure is optimized for metabolic exchange due to its high surface area-to-volume ratio, while remaining lightweight to reduce overall skeletal weight.^[4] The interior of bones contains marrow cavities that house different types of bone marrow depending on location and age. Red marrow, which is actively involved in hematopoiesis, is primarily found in the cavities of flat bones such as the pelvis and sternum, as well as in the epiphyses of long bones.^[6] Yellow marrow, consisting mainly of adipose tissue for fat storage, occupies the medullary cavities of the diaphyses in long bones, particularly in adults where it replaces much of the red marrow over time.^[7] These cavities are lined by a thin membrane that separates the marrow from the surrounding bone tissue. Vascular supply to bone is essential for its nourishment and maintenance, entering through specific anatomical openings. Nutrient arteries, the primary blood supply for the inner bone, penetrate the cortical layer via nutrient foramina—small openings typically located on the diaphysis of long bones—and branch into the medullary cavity to irrigate cancellous bone and marrow.^[1] Periosteal vessels, arising from the outer surface, provide additional blood flow to the compact bone layer through a network of capillaries and anastomoses.^[8] Venous drainage parallels this arterial system, exiting via similar foramina to return deoxygenated blood to the systemic circulation.^[9] The outer and inner surfaces of bone are covered by specialized connective tissue layers that contribute to its overall organization. The periosteum is a dense, fibrous membrane enveloping the external surface of bones, excluding areas of articulation, and serves as the site for attachment of tendons, ligaments, and muscles while housing blood vessels and nerves.^[8] Internally, the endosteum lines the marrow cavities, trabecular surfaces, and vascular canals within compact bone, forming a thin layer that interfaces with the bone matrix.^[10]

Microscopic Structure

Bone tissue exhibits distinct microscopic architectures that vary between cortical and trabecular regions, enabling specialized mechanical and metabolic functions. Cortical bone, also known as compact bone, consists of densely packed cylindrical units called osteons or Haversian systems, each featuring a central Haversian canal that houses blood vessels and nerves running parallel to the bone's long axis.^[5] These canals are surrounded by concentric lamellae, which are layered sheets of mineralized matrix approximately 3-7 micrometers thick, providing structural integrity through organized deposition.^[11] Between osteons, interstitial lamellae fill the spaces, formed from remnants of older osteons and contributing to the overall solidity of the tissue.^[5] In contrast, trabecular bone, or spongy bone, displays a porous, lattice-like structure composed of interconnected trabeculae that form rods and plates, creating an open network of irregular cavities filled with bone marrow.^[12] Unlike cortical bone, trabecular bone lacks organized osteons; instead, its trabeculae align along principal stress lines to optimize strength while minimizing mass, with a porosity often exceeding 50-90%.^[5] Nutrient diffusion occurs through canaliculi connecting to adjacent marrow spaces and vascular elements, supporting the metabolic demands of this highly vascularized tissue.^[12] The bone matrix, which constitutes about 90% of bone tissue by volume, is organized into lamellae where type I collagen fibers are arranged in parallel bundles, conferring tensile strength and flexibility to withstand mechanical loads.^[13] Hydroxyapatite mineral crystals, primarily plate-like and 20-100 nanometers in length, align along the collagen fibrils within these lamellae, enhancing compressive resistance through a composite structure that mimics fiber-reinforced materials.^[14] The ground substance interspersed among these fibers includes proteoglycans and glycoproteins, which bind water to maintain hydration, facilitate nutrient diffusion, and regulate matrix assembly.^[15] Bone types differ microscopically in maturity and organization: woven bone, an immature form, features randomly oriented collagen fibers in a disorganized, basket-weave pattern, resulting in lower mechanical strength and higher remodeling rates.^[16] Lamellar bone, the mature variant predominant in adults, exhibits highly ordered, layered collagen arrangements in concentric or parallel patterns, providing superior durability and resistance to fracture.^[17] Osteocytes reside within lacunae embedded in the matrix, connected via canaliculi to vascular canals for nutrient exchange.^[5]

Cellular Components

Bone tissue is maintained by a dynamic population of specialized cells that orchestrate its formation, resorption, and homeostasis. The primary cellular components include osteoblasts, osteocytes, osteoclasts, bone-lining cells, and progenitor stem cells, each derived from distinct lineages and contributing uniquely to bone integrity. These cells interact within the bone microenvironment to ensure structural support and metabolic balance.^[18] Osteoblasts are the bone-forming cells responsible for synthesizing and mineralizing the organic bone matrix. Derived from mesenchymal stem cells, they originate from osteoprogenitor precursors and differentiate under the influence of factors such as bone morphogenetic proteins (BMPs), RUNX2, and Osterix.^[18]^[19] These mononuclear cells feature prominent Golgi apparatus and rough endoplasmic reticulum, enabling robust protein synthesis. Osteoblasts secrete osteoid, an unmineralized matrix primarily composed of type I collagen (about 90%) along with non-collagenous proteins, which they subsequently mineralize by depositing hydroxyapatite crystals via matrix vesicles containing alkaline phosphatase.^[18]^[19] Upon completion of matrix deposition, osteoblasts may undergo apoptosis, flatten into bone-lining cells, or become embedded in the matrix as osteocytes.^[18] Osteocytes represent the most abundant cell type in mature bone, comprising over 90-95% of all bone cells, and serve as mature, terminally differentiated osteoblasts entrapped within the mineralized matrix. They reside in lacunae and extend dendritic processes through a network of canaliculi, forming gap junctions that facilitate intercellular communication, nutrient diffusion, and mechanotransduction.^[19]^[20] Osteocytes act as mechanosensors, detecting mechanical loading and regulating mineral homeostasis by secreting factors like fibroblast growth factor 23 (FGF-23) and sclerostin to modulate bone remodeling and phosphate levels.^[18] With a lifespan of up to 25 years in humans, osteocytes are among the longest-lived cells in the body, enabling sustained oversight of bone tissue integrity.^[21]^[20] Osteoclasts are multinucleated giant cells specialized for bone resorption, essential for calcium mobilization and skeletal remodeling. They derive from the monocyte-macrophage lineage of hematopoietic stem cells, where precursor monocytes fuse to form these large cells containing 5-20 nuclei.^[18]^[19] During resorption, osteoclasts attach to the bone surface via a sealing zone, forming a ruffled border that creates an isolated resorption compartment. They acidify this space using vacuolar H+-ATPase proton pumps to dissolve hydroxyapatite and secrete lysosomal enzymes, notably cathepsin K, to degrade the organic matrix.^[18]^[19] Degraded products are transcytosed across the cell and released at the functional secretory domain, preventing intracellular accumulation.^[18] Bone-lining cells are flattened, quiescent osteoblasts that cover inactive bone surfaces, comprising a thin layer that modulates ion exchange between bone and extracellular fluid without active matrix production. Derived from osteoblasts that have ceased formation activity, they prevent direct contact between osteoclasts and the mineralized matrix during periods of low remodeling.^[18]^[19] These cells express receptors for hormones and growth factors, enabling rapid activation into osteoblasts when bone formation is required.^[19] Mesenchymal stem cells (MSCs) serve as multipotent progenitors for the osteoblast lineage within the bone marrow stroma and other connective tissues. These self-renewing cells differentiate into osteoblasts, adipocytes, chondrocytes, and other mesenchymal derivatives under specific signaling cues like BMPs and Wnt pathways.^[18]^[19] In bone, MSCs commit to the osteoblastic pathway via osteoprogenitors, providing a renewable source for ongoing tissue maintenance and repair.^[18]

Chemical Composition

Bone tissue comprises an organic matrix, an inorganic mineral phase, and water, which together determine its structural integrity and biomechanical performance. By dry weight, the organic components constitute approximately 30-35% of bone mass, providing flexibility and resilience, while the inorganic phase accounts for 65-70%, imparting rigidity and hardness.^[22]^[23] Water makes up 10-20% of the total bone volume, facilitating molecular diffusion, nutrient transport, and the plastic deformation necessary for absorbing mechanical stress without fracture.^[23] The organic matrix is dominated by type I collagen, which forms about 90% of the total protein content and assembles into fibrils that confer elasticity and tensile strength to bone. These collagen fibrils serve as a scaffold, with their periodic banding pattern directing the oriented deposition of mineral crystals. Non-collagenous proteins, comprising the remaining 10% of the matrix proteins, include osteocalcin and bone sialoprotein, which regulate mineralization by binding calcium ions and initiating crystal nucleation at specific sites along collagen fibers. Glycosaminoglycans, such as chondroitin sulfate, are minor constituents that enhance matrix hydration, modulate collagen fibril assembly, and contribute to bone toughness by influencing mineral distribution and preventing excessive brittleness.^[22]^[24]^[25] The inorganic phase primarily consists of hydroxyapatite crystals, with the chemical formula \ce{Ca10(PO4)6(OH)2}, which embed within the organic matrix to provide compressive strength and overall stiffness. These nanoscale platelets, approximately 50-100 nm long and 20-50 nm wide, align parallel to collagen fibrils, optimizing load transfer. Trace elements, including magnesium and fluoride, substitute for calcium in the hydroxyapatite lattice or adsorb onto crystal surfaces, thereby influencing crystal size, solubility, and growth kinetics; for instance, magnesium inhibits excessive crystal perfection to maintain some solubility for remodeling, while fluoride promotes denser crystal formation but can reduce mechanical toughness at high levels.^[26]^[27] The interplay of these components yields distinct biomechanical properties, such as a Young's modulus of 10-20 GPa for cortical bone, reflecting its stiffness under elastic deformation. Bone exhibits anisotropic behavior, with compressive strength (up to 170 MPa) exceeding tensile strength (about 120 MPa) due to the composite architecture, where mineral reinforces collagen against buckling while the organic phase resists crack propagation.^[28] Mineral deposition in bone follows a tightly regulated process beginning with nucleation on collagen fibrils, particularly at hole zones within the fibril structure, where non-collagenous proteins like bone sialoprotein concentrate ions to form initial amorphous calcium phosphate clusters. This is followed by epitaxial growth, where crystals expand along the collagen axis, transforming into mature hydroxyapatite plates. Alkaline phosphatase, an enzyme secreted by osteoblasts, plays a crucial role by hydrolyzing inorganic pyrophosphate—a potent mineralization inhibitor—thereby elevating local phosphate levels to drive crystal formation and prevent pathological calcification elsewhere.^[29]^[30]

Development and Growth

Embryonic Development

The embryonic skeleton originates from distinct mesodermal populations that establish the basic body plan. The axial skeleton, including vertebrae and ribs, derives from the paraxial mesoderm, which segments into somites during early gastrulation around the third week of development.^[31] In contrast, the appendicular skeleton, comprising the limbs and girdles, arises from the lateral plate mesoderm, which migrates to form limb buds.^[32] Hox genes, a family of homeobox transcription factors, play a crucial role in regulating segment identity along the anterior-posterior axis, ensuring proper patterning of both axial and appendicular elements by specifying regional identities in these mesodermal derivatives.^[33] Following patterning, mesenchymal precursor cells from these mesodermal sources undergo condensation, aggregating into dense clusters that serve as templates for future skeletal elements. This process is orchestrated by signaling molecules such as fibroblast growth factors (FGFs), which promote cell proliferation and migration to initiate aggregation, and bone morphogenetic proteins (BMPs), which induce differentiation within the condensates.^[34]^[35] These condensations typically occur between weeks 5 and 7, forming the foundational anlagen for most bones. Early differentiation of these mesenchymal condensates primarily follows the path of chondrogenesis, where cells commit to the chondrocyte lineage under the control of the transcription factor Sox9, which is essential for activating cartilage-specific genes like those for type II collagen and aggrecan.^[36] This results in the formation of hyaline cartilage templates, or models, that outline the prospective long bones, vertebrae, and other endochondral elements. Exceptions include the cranial vault bones, such as the parietal and frontal, which differentiate directly into bone via intramembranous pathways without a cartilaginous intermediate, relying instead on neural crest-derived mesenchyme.^[37] In the developing limbs, patterning of the appendicular skeleton involves interactions between the apical ectodermal ridge (AER), a thickened epithelium at the limb bud distal margin that drives proximodistal outgrowth through FGF signaling, and the zone of polarizing activity (ZPA) in the posterior mesenchyme, which establishes anteroposterior polarity via Sonic hedgehog (Shh) gradients.^[38]^[39] Skeletal anlagen become visible by the end of week 5 in human embryos, with limb bud condensations and early vertebral precursors emerging around Carnegie stage 18. By birth, the fetal skeleton consists of approximately 275 distinct cartilaginous and membranous precursors, many of which fuse postnatally to form the 206 bones of the adult skeleton.^[40] This embryonic phase sets the stage for subsequent ossification, where cartilage templates begin to mineralize.

Ossification Processes

Ossification is the process by which bone tissue is formed, primarily through two distinct mechanisms: intramembranous ossification and endochondral ossification. These processes transform mesenchymal precursors derived from embryonic development into mature bone structures, enabling the skeletal system's mechanical support and growth. Intramembranous ossification occurs directly within mesenchymal condensations without a cartilaginous intermediate, while endochondral ossification involves the replacement of a hyaline cartilage model by bone tissue.^[41] Intramembranous ossification is the direct differentiation of mesenchymal cells into osteoblasts, forming flat bones such as those of the skull, clavicle, and mandible. Mesenchymal progenitor cells cluster into ossification centers, where they proliferate and differentiate into osteoblasts that secrete osteoid, which subsequently mineralizes into woven bone. This process begins around the sixth to seventh week of embryonic development and progresses radially from the ossification centers, with osteoblasts organizing into trabeculae that mature into compact and spongy bone layers. Vascular invasion supports the recruitment of additional osteoprogenitor cells and osteoclasts, facilitating bone remodeling within these sites.^[41]^[42]^[43] Endochondral ossification, the predominant mechanism for forming long bones like the femur and humerus, replaces a preformed cartilage model with bone through a multistep process. It initiates in the embryonic cartilage anlage, where chondrocytes in the diaphysis hypertrophy, promoting matrix calcification and attracting vascular invasion from the periosteum. This vascular ingrowth delivers osteoprogenitor cells and osteoclasts, forming the primary ossification center in the diaphysis, where calcified cartilage is resorbed and replaced by woven bone deposited by osteoblasts. Secondary ossification centers emerge in the epiphyses after birth, following a similar sequence but leaving the epiphyseal growth plate intact for longitudinal growth.^[44]^[41]^[45] The epiphyseal growth plate, or metaphysis, orchestrates longitudinal bone elongation through distinct zones of chondrocyte activity: resting, proliferative, hypertrophic, and calcifying. In the proliferative zone, chondrocytes divide and elongate the cartilage template; in the hypertrophic zone, they swell and secrete factors that induce matrix mineralization. A critical negative feedback loop involving Indian hedgehog (Ihh) from prehypertrophic and hypertrophic chondrocytes and parathyroid hormone-related protein (PTHrP) from periarticular cells regulates this progression, maintaining a balance between proliferation and differentiation to sustain controlled growth. Ihh stimulates PTHrP expression, which in turn inhibits hypertrophic differentiation, ensuring a steady pool of proliferative chondrocytes.^[46]^[47]^[48] Angiogenesis plays an indispensable role in both ossification types by supplying oxygen, nutrients, and cells essential for bone formation. In endochondral ossification, hypertrophic chondrocytes express vascular endothelial growth factor (VEGF), which recruits blood vessels into the calcified matrix, enabling the invasion of osteoprogenitor cells from the perichondrium and the activity of osteoclasts for cartilage resorption. Similarly, in intramembranous ossification, vascularization within mesenchymal condensations supports osteoblast differentiation and matrix deposition. Without adequate vascular support, ossification stalls, as seen in conditions disrupting VEGF signaling.^[49]^[50]^[51] Defects in endochondral ossification, such as achondroplasia—the most common form of dwarfism—arise from gain-of-function mutations in the fibroblast growth factor receptor 3 (FGFR3) gene, which hyperactivate inhibitory signaling in chondrocytes. These mutations, most frequently G380R, disrupt the growth plate by accelerating hypertrophic differentiation and reducing proliferative zone expansion, leading to shortened long bones while sparing intramembranous bones like the skull. This highlights FGFR3's role as a negative regulator of endochondral growth, with impaired Ihh-PTHrP feedback contributing to the phenotype.^[52]^[53]^[54]

Postnatal Growth and Maturation

Postnatal bone growth involves two primary mechanisms: longitudinal elongation and appositional expansion, which together contribute to the achievement of skeletal maturity. Longitudinal growth occurs through endochondral ossification at the epiphyseal growth plates of long bones, where chondrocytes proliferate, hypertrophy, and are replaced by bone tissue.^[55] This process is primarily regulated by growth hormone (GH) and insulin-like growth factor-1 (IGF-1), which stimulate chondrocyte activity and overall bone lengthening during childhood and adolescence.^[55] Growth continues until the growth plates close, typically between ages 18 and 25, with females generally completing closure earlier (by around age 19) than males (by age 21), marking the end of linear expansion.^[56] Epiphyseal fusion events, such as the union of the distal femur epiphysis, occur around ages 16 to 18 in males and slightly earlier in females, permanently halting further elongation at those sites.^[57] Appositional growth enables circumferential expansion of bones, primarily through the activity of osteoblasts on the periosteal surface, which deposit new bone layers outward, increasing bone diameter and strength.^[58] This outward addition is balanced by endosteal resorption on the inner surface, preventing excessive thickening and allowing for marrow cavity development.^[58] Bone modeling, distinct from later adult remodeling, involves uncoupled resorption and formation processes that shape bone contours during growth; for instance, differential endosteal resorption widens the marrow cavity while periosteal formation maintains structural integrity.^[3]^[59] The culmination of these processes is the attainment of peak bone mass, with approximately 90% accrued by age 18 to 20, after which gains plateau into early adulthood.^[60] Genetics play a dominant role, accounting for 50% to 80% of variability in peak bone mass through heritability of bone mineral density.^[61] Pubertal timing significantly influences accrual, as earlier onset may shorten the window for bone building, while sex differences result in males achieving higher peak bone density due to prolonged growth and greater overall skeletal mass.^[62]^[63]

Classification of Bones

By Shape

Bones are classified by their gross morphology into five main categories: long, short, flat, irregular, and sesamoid, each adapted to specific mechanical demands in the body.^[64]^[65] This classification emphasizes external shape and overall form rather than internal tissue composition, reflecting their primary roles in support, protection, and movement.^[66] Long bones are elongated structures longer than they are wide, typically featuring a cylindrical shaft called the diaphysis surrounded by two broader ends known as epiphyses, connected by the metaphysis.^[64]^[65] Examples include the femur in the thigh, humerus in the upper arm, and bones of the forearm and lower leg such as the radius, ulna, tibia, and fibula.^[66] These bones primarily provide leverage and support for body weight, facilitating movement through attachments for muscles and ligaments.^[65] Short bones exhibit a compact, cube-like shape with roughly equal dimensions in length, width, and thickness, designed for stability and some shock absorption.^[64]^[66] Representative examples are the carpals of the wrist and tarsals of the ankle.^[65] Their morphology allows for gliding movements while maintaining structural integrity in areas subject to compression.^[66] Flat bones are thin, broad, and often slightly curved plates that serve protective functions and provide extensive surfaces for muscle attachment.^[64]^[65] Common examples include the bones of the skull such as the parietal and frontal, the scapulae, sternum, and ribs.^[66] This shape enables them to shield vital organs like the brain and thoracic contents while accommodating red bone marrow in their internal spaces.^[64] Irregular bones possess complex, asymmetrical shapes that do not fit neatly into the long, short, or flat categories, tailored to specialized roles such as articulation and support.^[65]^[66] Examples encompass the vertebrae of the spine, certain facial bones like the mandible and maxilla, and the hip bones (pelvis).^[64] Their intricate forms allow for protection of structures like the spinal cord and facilitation of joint movements.^[66] Sesamoid bones are small, rounded structures embedded within tendons, resembling sesame seeds, which develop to reduce friction and alter the angle of tendon pull during movement.^[65]^[66] The patella, or kneecap, is the largest and most prominent example, located anterior to the knee joint.^[64] These bones vary in presence and number among individuals, often forming through endochondral ossification in response to mechanical stress.^[65]^[66]^[67]

By Structure and Density

Bones are classified by their internal structure and density into primary types—compact (cortical) bone and spongy (trabecular or cancellous) bone—each exhibiting distinct architectural organizations that influence mechanical properties and physiological roles. Compact bone predominates in regions requiring high mechanical strength, such as the diaphyses of long bones and the outer tables of flat bones, where its dense matrix provides robust load-bearing capacity.^[68]^[69] This tissue features an apparent density of 1.8–2.0 g/cm³ and low porosity of less than 10%, enabling it to withstand compressive and tensile forces effectively while minimizing weight.^[70]^[71] In contrast, spongy bone is prevalent in the epiphyses of long bones, the interiors of short and irregular bones, and the inner tables of flat bones, where its porous lattice supports metabolic activities such as hematopoiesis and mineral storage with reduced mass.^[68]^[69] Characterized by an apparent density ranging from 0.2 to 1.0 g/cm³ and porosity of 50–90%, spongy bone's trabecular network distributes loads across a larger surface area, optimizing lightweight structural support.^[72]^[73] Within these categories, bone tissue subtypes differ in organization and maturity: woven bone, an immature form with disorganized collagen fibers and high cellular turnover, forms rapidly during early development or healing and exhibits lower mineral density compared to mature forms.^[74]^[16] Lamellar bone, the stable mature subtype, features orderly layered collagen and mineral deposition, providing greater strength and reduced remodeling rates.^[74]^[16] Bone density and structure display heterogeneity across regions, with gradients often higher at sites experiencing tensile stresses to enhance resistance, as seen in the varying mineral content from periosteum to endosteum.^[75] Regional adaptations further illustrate this, such as pneumatic bones in birds, where air-filled cavities reduce overall density for weight minimization while preserving structural integrity.^[76]^[77] Bone mineral density (BMD) is quantitatively assessed using dual-energy X-ray absorptiometry (DXA), a non-invasive technique that measures areal BMD in g/cm² to evaluate structural integrity and density variations.^[78]^[79]

Functions

Mechanical Functions

Bone serves as the primary structural framework of the vertebrate body, bearing the weight of the organism and maintaining posture against gravitational forces. In the axial skeleton, such as the vertebrae and long bones of the legs, cortical and trabecular bone distribute compressive loads efficiently, with trabecular architecture aligning along principal stress trajectories to optimize load-bearing capacity. This adaptation follows Wolff's law, which posits that bone remodels in response to mechanical usage, increasing density and strength in areas of high stress while resorbing in low-stress regions, thereby enhancing overall structural integrity.^[80]^[81] In addition to support, bone provides critical protection for vital organs by encasing them within rigid enclosures. The cranium, composed of flat bones fused into a vault, safeguards the brain from traumatic impacts, while the ribcage—formed by 12 pairs of curved ribs articulating with the thoracic vertebrae and sternum—shields the heart and lungs from external forces. These protective functions are particularly evident in flat bones, which possess broad, thin structures that dissipate energy from blows, reducing the risk of internal injury.^[82]^[83] Bone also enables locomotion and manipulation by functioning as rigid levers that amplify muscle forces. Long bones, such as the femur and humerus, serve as attachment sites for skeletal muscles, with their elongated shafts providing mechanical advantage during contraction to produce movement at synovial joints. Articulations between bones, reinforced by ligaments, allow controlled rotation, flexion, and extension, while sesamoid bones—small, rounded nodules embedded within tendons, like the patella in the quadriceps tendon—optimize force transmission by reducing friction and altering tendon angles for efficient pull.^[84] The biomechanical prowess of bone arises from its hierarchical, composite structure, exhibiting anisotropic properties that confer direction-dependent strength. Bone is significantly stronger in compression (withstanding up to 170 MPa in cortical regions) than in tension (around 125 MPa), reflecting the oriented arrangement of collagen fibers and hydroxyapatite crystals along the longitudinal axis. This material demonstrates viscoelastic behavior, where time-dependent deformation under load provides energy dissipation and fatigue resistance, preventing crack propagation during cyclic stresses like walking. Furthermore, the collagen-mineral nanocomposite imparts fracture toughness, with collagen offering ductility to bridge microcracks and minerals providing stiffness, resulting in a toughness value of approximately 2-10 MPa·m^{1/2} that rivals engineering composites.^[72]^[85]^[86] Bone's ability to adapt mechanically involves piezoelectric effects, where deformation generates electric potentials across the tissue, influencing cellular activity and directing remodeling. This phenomenon, originating from the oriented collagen fibrils, produces streaming potentials under stress that stimulate osteoblasts and osteoclasts, promoting bone deposition in loaded areas as per Wolff's adaptive principles. First demonstrated in bone specimens, these bioelectric signals underscore bone's dynamic responsiveness to mechanical environments.^[87]^[88]

Metabolic Functions

Bone serves as the primary reservoir for calcium in the human body, storing over 99% of total body calcium, which amounts to approximately 1-2 kg in adults, primarily in the form of hydroxyapatite crystals within the skeletal matrix.^[89] During periods of hypocalcemia, osteoclast-mediated bone resorption releases calcium ions into the bloodstream to restore serum levels and support essential physiological processes such as muscle contraction, nerve signaling, and blood clotting.^[90] In addition to calcium, bone functions as a major storage site for phosphate, containing about 85% of the body's phosphate reserves integrated into hydroxyapatite structures.^[91] This storage enables bone to buffer systemic phosphate concentrations, ensuring availability for critical cellular functions including energy metabolism via ATP synthesis, nucleic acid formation, and cellular signaling.^[92] Bone also contributes to acid-base homeostasis through its carbonate ions, which are mobilized during bone resorption to neutralize excess acids in conditions of metabolic acidosis, thereby helping to maintain blood pH balance.^[93] Beyond mineral storage, bone exhibits endocrine functions; osteoblasts secrete osteocalcin, a hormone that enhances insulin sensitivity in peripheral tissues and promotes testosterone biosynthesis in Leydig cells, linking skeletal metabolism to glucose regulation and male reproductive health.^[94] Osteocytes produce fibroblast growth factor 23 (FGF23), which acts on the kidneys to inhibit phosphate reabsorption in the proximal tubules, thereby preventing hyperphosphatemia and supporting mineral balance.^[95] These metabolic roles integrate with systemic regulation: parathyroid hormone (PTH) stimulates osteoclast activity to promote bone resorption and calcium release, while calcitonin inhibits this process to limit calcium mobilization; active vitamin D (calcitriol) synergizes by enhancing intestinal calcium absorption to complement bone-derived supplies.^[90]^[96]^[97]

Hematopoietic Functions

The bone marrow, housed within the spongy bone of the skeleton, serves as the primary site for hematopoiesis, the process of blood cell formation, integrating anatomical structure with physiological function to sustain blood production throughout life.^[98] In adults, active red bone marrow is predominantly located in the axial skeleton, including the vertebrae, pelvis, sternum, ribs, and skull, as well as the proximal ends of long bones such as the femurs and humeri.^[99] This distribution supports efficient hematopoiesis while minimizing interference with mechanical bone functions. During postnatal development, hematopoietic activity shifts from peripheral sites, such as the distal long bones and limbs, to more central axial locations, accompanied by the gradual conversion of red marrow to inactive yellow marrow in peripheral regions.^[100] Hematopoiesis occurs through hematopoietic stem cells (HSCs) residing in specialized marrow niches, which differentiate into erythrocytes, leukocytes, and platelets under the influence of cytokines; for instance, erythropoietin stimulates red blood cell production from erythroid progenitors.^[101] Stromal cells, including osteoblasts and endothelial cells, form these niches: the endosteal niche near the bone surface maintains quiescent HSCs via factors like CXCL12, while the vascular niche promotes HSC proliferation and mobilization through interactions with sinusoidal endothelium.^[102] In adults, much of the marrow converts to yellow marrow, characterized by adipocyte accumulation that replaces hematopoietic tissue, though this process is reversible under physiological stress such as chronic anemia, allowing reconversion to red marrow to meet increased demand.^[103] The total bone marrow volume in adults is approximately 2.6 liters, generating around 500 billion blood cells daily to maintain homeostasis.^[104] Clinically, bone marrow biopsies are commonly performed at the posterior iliac crest to assess hematopoietic function, providing samples for microscopic evaluation of cell morphology and composition.^[105] This marrow activity also links to broader metabolic roles, as released platelets require calcium ions—stored in the bone matrix—for effective blood clotting.^[98]

Remodeling and Homeostasis

Remodeling Process

Bone remodeling is a lifelong process that maintains skeletal integrity by replacing old or damaged bone tissue with new bone, primarily through the coordinated activity of osteoclasts and osteoblasts within temporary anatomical structures known as basic multicellular units (BMUs).^[106] These BMUs consist of osteoclasts leading the resorption front, followed by reversal cells and osteoblasts at the formation tail, all encased in a bone-remodeling compartment formed by overlying canopy cells.^[106] The process ensures calcium homeostasis and adaptation to mechanical stresses without net change in bone mass during adulthood under normal conditions.^[107] The remodeling cycle unfolds in five sequential phases: activation, resorption, reversal, formation, and quiescence. In the activation phase, mechanical loading or microdamage sensed by osteocytes triggers signaling pathways that recruit pre-osteoclasts to the bone surface via factors such as receptor activator of nuclear factor kappa-B ligand (RANKL).^[106] This is followed by the resorption phase, where mature osteoclasts attach to the bone surface, secrete acid and enzymes to dissolve the mineral and organic matrix, creating characteristic Howship's lacunae; this phase lasts approximately 2-4 weeks.^[106] The reversal phase then couples resorption to formation, with mononuclear cells clearing debris and releasing coupling signals like RANKL and osteoprotegerin (OPG) to prepare the site for osteoblasts.^[106] During the formation phase, osteoblasts deposit unmineralized osteoid matrix, which subsequently mineralizes into mature lamellar bone over 2-3 months, restoring the resorbed volume.^[106] Finally, the quiescence phase (or termination) sees the site return to a resting state, with excess osteoblasts becoming osteocytes or bone-lining cells, until the next cycle begins.^[106] On average, about 10% of the adult skeleton undergoes remodeling annually, with rates varying by bone type: trabecular bone turns over at 25-28% per year due to its higher surface area, while cortical bone remodels more slowly at 3-5%.^[108]^[109] This turnover occurs at specific sites, including intracortical (Haversian) remodeling within osteons for repairing fatigue damage, trabecular remodeling along plate-like surfaces for metabolic adaptation, and envelope-specific activity on periosteal (outer) and endosteal (inner) surfaces for shape maintenance.^[110]^[111] Remodeling activity peaks during childhood and adolescence to support rapid skeletal growth, with high rates of both resorption and formation contributing to bone elongation and strengthening.^[108] After peak bone mass is achieved around age 30, remodeling intensity declines progressively, leading to a negative balance where resorption outpaces formation and results in gradual net bone loss.^[108]

Regulation of Remodeling

Bone remodeling is tightly regulated by a balance of hormonal, mechanical, and molecular signals that coordinate osteoclast-mediated resorption and osteoblast-driven formation to maintain skeletal homeostasis. Intermittent pulses of parathyroid hormone (PTH) promote bone formation by activating osteoblasts through Wnt signaling and inhibiting sclerostin, while continuous PTH exposure enhances resorption via increased osteoclast activity.^[112] Estrogen inhibits osteoclast differentiation and activity primarily by suppressing RANKL expression in osteoblasts and stromal cells, thereby reducing bone resorption and preserving density.^[113] Growth hormone (GH) and insulin-like growth factor-1 (IGF-1) stimulate osteoblast proliferation and differentiation via the PI3K/AKT/mTOR pathway, supporting longitudinal bone growth and remodeling balance.^[114] Mechanical loading plays a crucial role in regulating remodeling through osteocyte-mediated sensing of strain, which activates anabolic pathways to favor bone formation. Osteocytes detect mechanical stress and respond by downregulating sclerostin expression, thereby enhancing Wnt/β-catenin signaling to promote osteoblast activity and inhibit resorption.^[115] Exercise-induced loading suppresses sclerostin release from osteocytes, leading to increased bone formation rates and adaptation to physical demands.^[116] At the molecular level, the RANKL/RANK/OPG system is central to osteoclast regulation, where RANKL binding to RANK on osteoclast precursors drives differentiation and activation, while osteoprotegerin (OPG) acts as a decoy receptor to block this interaction and maintain remodeling equilibrium.^[117] The Wnt/β-catenin pathway supports osteoblast differentiation by stabilizing β-catenin, which translocates to the nucleus to upregulate osteogenic genes and OPG, countering resorption.^[118] Transforming growth factor-β (TGF-β), released from the bone matrix during resorption, couples the processes by recruiting mesenchymal stem cells to resorptive sites and stimulating osteoblast proliferation via SMAD signaling.^[119] Systemic factors further modulate remodeling dynamics. Active vitamin D (1,25-dihydroxyvitamin D) enhances intestinal calcium absorption and directly boosts osteoblast activity while upregulating RANKL to fine-tune osteoclastogenesis.^[117] Pro-inflammatory cytokines like interleukin-6 (IL-6) promote resorption by activating JAK/STAT signaling in osteoclast precursors, increasing RANKL sensitivity during inflammatory states.^[117] Feedback mechanisms ensure precise control, including the calcium-sensing receptor (CaSR) on osteoclasts, which detects elevated extracellular calcium from resorption and inhibits further osteoclast activity to prevent excessive bone loss.^[120] Circadian rhythms regulate remodeling temporally, with osteoblast and osteoclast activities peaking at distinct times of day, influenced by clock genes that modulate RANKL/OPG expression and hormonal pulses.^[121]

Clinical Significance

Fractures and Injuries

Bone fractures occur when the mechanical loading on a bone exceeds its capacity to absorb energy, resulting in a break in the continuity of the bone tissue. These injuries are classified based on several criteria, including the relationship to the skin, the extent of the break, and the pattern of the fracture line. A closed fracture, also known as a simple fracture, involves a break in the bone without disruption of the overlying skin, whereas an open fracture, or compound fracture, occurs when the broken bone pierces the skin, increasing the risk of infection.^[122]^[123] Complete fractures extend through the entire bone, separating it into distinct segments, while incomplete fractures involve only partial disruption, such as in greenstick fractures common in children where the bone bends and cracks but does not fully separate.^[124]^[125] Fracture patterns further describe the morphology and often indicate the mechanism of injury, particularly in long bones like the femur or tibia. Transverse fractures result from forces perpendicular to the bone's long axis, typically from direct impact, creating a horizontal break across the bone. Oblique fractures arise from angled forces combining compression and shear, producing a diagonal fracture line. Comminuted fractures involve the bone shattering into three or more fragments, usually from high-energy trauma such as motor vehicle accidents. Spiral fractures are caused by twisting or torsional forces, resulting in a helical pattern along the bone, often seen in sports injuries or assaults. Stress fractures, distinct from acute traumatic breaks, develop from repetitive low-level loading that accumulates microdamage over time, leading to insufficiency fractures in weakened bone or fatigue fractures in normal bone under overuse, such as in runners.^[124]^[126]^[123] Biomechanically, long bones are primarily subjected to axial compression, bending moments, and torsional loads during daily activities and trauma. In bending, the bone's convex side experiences tension while the concave side undergoes compression, with failure often initiating at the tensile surface where bone is weaker; this explains transverse or oblique patterns in falls or impacts. Torsional forces generate shear stresses that propagate along the bone's length, leading to spiral fractures when the applied torque exceeds the bone's shear strength. Energy absorption at the fracture site is limited by the bone's material properties, with cortical bone dissipating energy through microcracking before macroscopic failure, but high-velocity impacts can overwhelm this capacity, resulting in comminuted injuries.^[127]^[128]^[129] The healing of bone fractures follows a well-orchestrated biological process involving overlapping stages that restore structural integrity. Immediately after injury (days 1-5), hematoma formation occurs as disrupted blood vessels release blood that clots at the fracture site, providing a provisional scaffold rich in growth factors and recruiting mesenchymal stem cells. This transitions into the inflammatory phase (days 5-14), where granulation tissue forms through angiogenesis and influx of inflammatory cells, stabilizing the site and initiating fibrocartilage production. By weeks 2-6, a soft callus of fibrocartilage and hyaline cartilage bridges the gap, offering initial mechanical stability. The hard callus stage (weeks 6-12) involves endochondral ossification, where the soft callus mineralizes into woven bone, bridging the fracture. Finally, remodeling (months to years) reshapes the callus into organized lamellar bone through osteoclastic resorption and osteoblastic deposition, adapting to mechanical stresses.^[130]^[131]^[132] Several factors influence the rate and success of fracture healing, with complications like non-union (failure to form bridging callus) or malunion (healing in a misaligned position) occurring in 5-10% of cases. Advanced age slows healing due to reduced cellular activity and vascularity, often prolonging the process by weeks to months in the elderly. Nutritional deficiencies impair collagen synthesis and mineralization; for instance, vitamin C is essential for hydroxylation in collagen formation, while vitamin D and calcium support ossification. Smoking delays healing by vasoconstriction and reduced oxygen delivery, increasing non-union risk by up to 2-4 times through impaired angiogenesis and osteoblast function. Other contributors include poor blood supply, infection, and excessive motion at the site, all of which disrupt the inflammatory and callus formation stages.^[130]^[133]^[134] Initial management of fractures prioritizes stabilization to promote healing and prevent further damage. First aid involves immobilizing the injured limb using splints or slings to minimize movement, applying ice to reduce swelling, and elevating the area while seeking immediate medical evaluation. Non-surgical immobilization with casts—made of plaster or fiberglass—maintains alignment for stable fractures, allowing natural healing over 6-8 weeks in adults. For unstable or displaced fractures, open reduction and internal fixation (ORIF) is employed, where surgery realigns the bone fragments under direct visualization and secures them with plates, screws, or intramedullary nails to provide rigid stability and facilitate early mobilization.^[126]^[135]^[136]

Bone Diseases and Disorders

Bone diseases and disorders encompass metabolic, infectious, and inflammatory conditions that compromise bone integrity without involving acute trauma or neoplasia, often resulting from imbalances in remodeling, nutrient deficiencies, infections, or autoimmune processes. These disorders lead to structural weakening, pain, deformities, and heightened susceptibility to complications, with diagnosis typically relying on clinical evaluation, imaging, and biochemical markers. Osteoporosis is defined by reduced bone mass and microarchitectural deterioration, which increases bone fragility and the risk of low-trauma fractures. The condition is diagnosed via dual-energy X-ray absorptiometry (DXA) when the T-score falls below -2.5 at key sites such as the lumbar spine, hip, or distal forearm. Primary osteoporosis manifests as postmenopausal type (driven by estrogen deficiency in women) or senile type (age-related in both sexes over 70 years), whereas secondary forms arise from underlying causes like long-term glucocorticoid therapy, which suppresses osteoblast activity and promotes resorption. This distinction guides targeted screening, with postmenopausal cases accelerating after menopause due to hormonal shifts. Osteomalacia and rickets represent disorders of impaired bone mineralization, predominantly stemming from vitamin D deficiency that disrupts calcium and phosphate homeostasis. In adults, osteomalacia causes bone softening, muscle weakness, and diffuse pain, while in growing children, rickets leads to skeletal deformities such as bowing of the legs (genu varum), widened growth plates, and delayed walking. These conditions arise from inadequate sunlight exposure, dietary insufficiency, or malabsorption, with biochemical hallmarks including low serum 25-hydroxyvitamin D levels and elevated parathyroid hormone. Paget's disease of bone, synonymous with osteitis deformans, features focal excessive bone remodeling where hyperactive osteoclasts resorb bone, followed by disorganized osteoblast-driven replacement, yielding a characteristic mosaic pattern of woven and lamellar bone under microscopy. This results in enlarged, deformed, and weakened bones, often in the pelvis, skull, or long bones, with elevated serum alkaline phosphatase reflecting heightened turnover. A severe complication occurs in about 1% of cases, involving sarcomatous transformation of pagetic bone, which carries poor prognosis. Osteomyelitis constitutes a key infectious bone disorder, typically bacterial and dominated by Staphylococcus aureus as the causative pathogen in both hematogenous and contiguous forms. Acute osteomyelitis presents with fever, localized pain, and swelling within weeks of onset, progressing to chronic stages if untreated, marked by persistent drainage, sequestrum formation, and bone necrosis. Spread occurs hematogenously from distant sites like skin infections or directly via trauma, surgery, or adjacent soft tissue involvement, necessitating prompt antimicrobial therapy to prevent systemic spread. Inflammatory bone diseases include ankylosing spondylitis, an autoimmune spondyloarthropathy strongly linked to HLA-B27, which targets the sacroiliac joints and axial skeleton through chronic enthesitis and synovitis. This leads to erosions, sclerosis, and eventual ankylosis (fusion) of the sacroiliac joints and spine, causing stiffness, pain, and kyphotic deformity. Autoimmune mechanisms involve T-cell driven inflammation and cytokine dysregulation, distinguishing it from infectious or metabolic etiologies. Diabetes mellitus exerts a detrimental effect on bone health, where chronic hyperglycemia accelerates osteoclast-mediated resorption and impairs collagen quality via advanced glycation end products, thereby elevating fracture risk by 2- to 4-fold relative to non-diabetic populations despite sometimes normal bone density. This risk stems from disrupted remodeling balance and vascular complications, with type 2 diabetes showing particularly pronounced effects due to insulin resistance and prolonged exposure.

Bone Tumors and Cancer

Bone tumors encompass a range of neoplasms originating from bone tissue or metastatic spread to bone, classified as benign or malignant, primary or secondary. Primary bone tumors arise directly within the skeletal system, while metastatic tumors represent secondary involvement from distant primary cancers. Benign tumors generally do not metastasize but can cause local complications, whereas malignant ones exhibit aggressive growth, invasion, and potential for distant spread.^[137] Benign bone tumors include osteomas, which are characterized by compact bone overgrowth typically occurring on the skull or facial bones through subperiosteal ossification.^[138] Osteochondromas represent the most common benign bone tumor, comprising 20-50% of cases, and manifest as cartilage-capped bony exostoses primarily on the surface of long bones such as the femur or tibia.^[137] Enchondromas are intramedullary benign tumors of hyaline cartilage origin, often asymptomatic and located within the medullary cavity of small tubular bones like those in the hands and feet.^[139] Primary malignant bone tumors are rare but aggressive, with osteosarcoma being the most common, predominantly affecting adolescents and originating in the metaphyses of long bones where it produces malignant osteoid matrix.^[140] The five-year survival rate for localized osteosarcoma is approximately 60-70%, influenced by factors such as tumor stage and response to neoadjuvant therapy.^[141] Chondrosarcoma typically occurs in adults, frequently involving the pelvis or proximal femur, and is notable for its resistance to chemotherapy due to low vascularity and sparse dividing cells.^[142] Ewing sarcoma primarily affects children and adolescents, arising in the diaphyses of long bones and characterized histologically by uniform small round blue cells with high nuclear-to-cytoplasmic ratios.^[143] Metastatic bone cancer commonly originates from primary sites such as breast, prostate, or lung, accounting for the majority of bone malignancies and exhibiting either lytic patterns (bone destruction, as in breast and lung cancers) or blastic patterns (excessive bone formation, as in prostate cancer).^[144] Osteolytic metastases from these primaries can lead to hypercalcemia through excessive bone resorption and release of calcium into the bloodstream.^[145] The pathophysiology of bone tumors involves genetic mutations that drive uncontrolled proliferation, such as TP53 alterations in osteosarcoma, which impair tumor suppression and promote genomic instability.^[146] In Ewing sarcoma, the EWSR1-FLI1 gene fusion, resulting from t(11;22) translocation, acts as an oncogenic driver by dysregulating transcription and cell cycle control.^[147] Tumor progression is further facilitated by angiogenesis, enabling nutrient supply to growing masses, and degradation of the extracellular bone matrix via enzymes like matrix metalloproteinases (MMPs).^[148] These processes often hijack normal bone remodeling mechanisms, leading to pathological bone resorption or formation.^[149] Diagnosis of bone tumors relies on a multidisciplinary approach, beginning with imaging such as MRI for soft tissue extension and CT for bony details, followed by biopsy to confirm histology and molecular features.^[150] Treatment for primary malignant tumors typically involves neoadjuvant chemotherapy, surgical resection with wide margins, and adjuvant radiation, particularly for Ewing sarcoma.^[143] For metastatic disease, systemic therapies targeting the primary cancer are combined with localized interventions like radiation for pain control, and bisphosphonates to inhibit osteoclast activity and prevent skeletal-related events.^[151]

Regenerative Medicine

Regenerative medicine in bone repair has advanced significantly in recent years, focusing on innovative therapies to enhance osteogenesis and address critical defects that natural healing cannot fully resolve. Mesenchymal stem cells (MSCs) play a central role in these approaches due to their ability to differentiate into osteoblasts and promote bone formation. A 2025 study from Northwestern University demonstrated that deforming the nuclei of MSCs using microstructured scaffolds triggers regenerative signals, improving bone healing efficiency in preclinical models by modulating mechanotransduction pathways.^[152] Functionalization strategies, such as gene editing or biomaterial coatings, further enhance MSC therapeutic potential by increasing their survival and osteogenic differentiation in vivo.^[153] Three-dimensional (3D) bioprinting has emerged as a key technology for creating scaffolds that mimic the extracellular matrix (ECM) of bone, incorporating bioinks composed of hydroxyapatite and growth factors like bone morphogenetic protein-2 (BMP-2). These constructs support cell adhesion, proliferation, and vascularization, making them suitable for repairing critical-sized bone defects where traditional grafts fail. Progress in 2024-2025 includes the development of pre-vascularized 3D-printed scaffolds using biodegradable polymers, which integrate endothelial cells and osteogenic factors to promote angiogenesis-osteogenesis coupling and accelerate integration with host tissue.^[154]^[155] Bone organoids, derived from induced pluripotent stem cells (iPSCs), offer advanced 3D models for studying bone pathophysiology and screening regenerative therapies. These organoids recapitulate multicellular interactions in bone tissue, enabling disease modeling for conditions like osteoporosis and high-throughput drug testing. Recent 2025 research highlights the synergistic activation of BMP and Wnt signaling pathways to mature iPSC-derived bone organoids, enhancing mineralization and structural complexity for more accurate in vitro simulations.^[156]^[157] Novel discoveries in skeletal progenitor cells have expanded regenerative potential. In 2025, researchers at the University of California, Irvine identified a new skeletal tissue termed "lipocartilage," which exhibits hybrid properties of lipid storage and cartilage resilience, offering promise for engineered grafts in load-bearing repairs. Additionally, fibro-adipogenic progenitors (FAPs), particularly the Prg4+ subset, have been shown to critically support endochondral bone repair by transitioning from muscle to skeletal lineages, enhancing regeneration in injury models.^[158]^[159] Gene editing via CRISPR-Cas9 targeting RUNX2, a master regulator of osteoblast differentiation, has enabled precise modulation of osteogenic pathways, with activation strategies increasing bone formation markers in stem cell cultures.^[160] Clinical translation of these advances is progressing through trials and approved therapies. Recombinant human BMP-2 (rhBMP-2) received FDA approval in 2002 for spinal fusions and continues to demonstrate superior fusion rates in anterior lumbar interbody fusion procedures, with ongoing multicenter trials confirming its efficacy at low doses for up to 100% radiographic fusion by 12 months. Emerging AI-optimized implants, leveraging machine learning for patient-specific design, improve fit and biocompatibility, potentially reducing rejection risks by minimizing mismatch-induced inflammation in orthopedic applications.^[161]^[162]^[163]

Bone Health and Maintenance

Nutritional Factors

Calcium is a primary mineral essential for bone formation and maintenance, constituting approximately 99% of the body's calcium stores in the form of hydroxyapatite crystals within the bone matrix.^[164] The recommended dietary allowance (RDA) for calcium is 1,000 mg per day for adults aged 19–50 years and 1,200 mg per day for women over 51 years and men over 70 years.^[164] Dietary sources include dairy products such as milk and yogurt, as well as leafy green vegetables like kale and broccoli.^[164] Calcium absorption in the intestines occurs primarily through vitamin D-dependent active transport at lower intake levels, with parathyroid hormone regulating serum calcium levels by mobilizing bone reserves when dietary intake is insufficient.^[164] Deficiency in calcium can lead to secondary hyperparathyroidism, where elevated parathyroid hormone promotes bone resorption to maintain blood calcium homeostasis, ultimately weakening bone structure.^[164] Vitamin D plays a crucial role in bone health by facilitating calcium and phosphate absorption and supporting mineralization processes.^[165] The RDA for vitamin D is 600 IU (15 mcg) per day for adults aged 19–70 years and 800 IU (20 mcg) per day for those over 70 years.^[165] It is synthesized in the skin upon exposure to UVB sunlight or obtained from dietary sources such as fatty fish like salmon and fortified foods.^[165] The active form, 1,25-dihydroxyvitamin D (calcitriol), enhances intestinal uptake of calcium and phosphate while promoting osteoblast activity for bone formation.^[165] Other micronutrients contribute to bone integrity through various mechanisms. Phosphorus, with an RDA of 700 mg per day for adults, forms hydroxyapatite alongside calcium and is sourced from dairy products and meats.^[91] Magnesium, required at 310–320 mg per day for adult women and 400–420 mg for men, supports bone quality and is found in nuts, seeds, and leafy greens.^[166] Vitamin K, particularly phylloquinone (vitamin K1), has an adequate intake of 90 mcg per day for women and 120 mcg for men; it serves as a cofactor for the gamma-carboxylation of osteocalcin, a bone protein that binds calcium to promote mineralization, with sources including green leafy vegetables.^[167] Vitamin C, with an RDA of 75 mg per day for women and 90 mg for men, is vital for collagen synthesis in the bone matrix and is obtained from fruits and vegetables.^[168] Protein provides amino acids necessary for the organic matrix of bone, including collagen, and adequate intake supports bone mineral density. The RDA is 0.8 g per kg of body weight per day, though intakes of 1.0–1.2 g/kg may benefit bone health, particularly from high-quality animal sources like meat and dairy.^[169] Nutrient interactions can influence bone health outcomes. Oxalates in spinach and phytates in grains inhibit calcium absorption by forming insoluble complexes in the gut.^[170] Excessive alcohol consumption impairs osteoblast function and disrupts bone remodeling, leading to reduced bone density.^[171]

Lifestyle and Prevention

Regular physical activity plays a pivotal role in optimizing bone mass and reducing fracture risk through non-dietary means. Weight-bearing exercises, such as brisk walking for at least 30 minutes per day, along with resistance training, apply mechanical loads to the skeleton that stimulate bone formation via mechanotransduction, where osteocytes sense and respond to these stresses to promote osteogenesis.^[172] These interventions have strong evidence for preserving bone density and reducing fracture risk in older adults when performed consistently.^[173] Avoiding harmful behaviors further supports bone health. Smoking cessation can mitigate the dose-dependent bone loss associated with tobacco use, with former smokers showing improved bone mineral density compared to current smokers.^[174] Limiting alcohol intake to fewer than two standard drinks per day prevents the bone resorption linked to chronic heavy consumption, which otherwise elevates fracture risk.^[175] In the elderly, balance training programs, such as tai chi or targeted exercises performed several times weekly, significantly lower fall rates and subsequent fracture incidence by improving postural stability.^[176] For high-risk individuals, pharmacological prevention is an option alongside lifestyle measures. Bisphosphonates, including alendronate, are first-line agents for postmenopausal women at elevated fracture risk, as they inhibit osteoclast activity to maintain bone density and reduce vertebral and non-vertebral fractures.^[177] Denosumab, a monoclonal antibody that inhibits RANKL to suppress bone resorption, is indicated for severe osteoporosis cases in postmenopausal women and men to prevent fractures.^[178] Screening facilitates early intervention to preserve bone health. Dual-energy X-ray absorptiometry (DXA) scans are recommended starting at age 65 for women and 70 for men, or earlier for those with risk factors like prior fractures or glucocorticoid use, to assess bone mineral density.^[179] The FRAX tool integrates clinical risk factors and femoral neck BMD to estimate 10-year probability of major osteoporotic or hip fracture, guiding decisions on preventive therapy.^[180] Public health initiatives underscore these strategies for broader impact. The World Health Organization promotes lifestyle approaches, including physical activity and risk avoidance, as core elements of osteoporosis prevention to curb fragility fractures globally.^[181] Disparities in access to screening and preventive care, however, disproportionately affect low-income groups, resulting in lower DXA utilization and higher untreated fracture risks among these populations.^[182]

Comparative and Evolutionary Aspects

Bone in Other Animals

In teleost fish, bone is characteristically acellular, lacking osteocytes embedded within the matrix, a feature that distinguishes it from cellular bone in other vertebrates and is thought to facilitate mineral homeostasis through alternative mechanisms like periosteal regulation.^[183]^[184] This acellular structure supports the lightweight endoskeleton necessary for aquatic buoyancy, allowing efficient movement in water. In contrast, chondrichthyans exhibit hypermineralized tissues in their jaws; for example, holocephalans such as chimaeras have pleromin layers in tooth plates that enhance durability for crushing prey without relying on a fully bony skeleton.^[185] Some amphibians, such as certain anurans, exhibit porous cortical bone similar to that in reptiles, which facilitates extensive remodeling to accommodate growth and environmental stresses.^[186] In crocodilians, a secondary bony palate formed by fused palatal bones provides additional structural reinforcement to the skull, aiding in powerful biting and aquatic lifestyles.^[187] Birds have evolved pneumatic bones, which are permeated by extensions of the respiratory air sacs, significantly reducing skeletal mass to facilitate flight; the humerus, for instance, contains foramina that connect to these sacs for efficient gas exchange and weight minimization.^[188] Additionally, avian bones undergo rapid calcium turnover, with medullary bone deposits resorbed to supply up to 40% of the calcium needed for eggshell formation during reproduction.^[189] Rodents exhibit continuous bone growth in structures like incisors, which serve as key models for studying odontogenesis and regeneration due to their persistent eruption.^[190] In elephants, tusks represent modified incisors that are largely avascular in their erupted portions and dominated by dentin, providing tools for foraging and defense while minimizing vascular demands.^[191] Invertebrates lack true bone, instead relying on analogs such as the chitinous exoskeletons of arthropods, which offer external support and protection but differ fundamentally in composition and cellular embedding from vertebrate bone.^[192]

Evolutionary Development

The evolutionary origins of bone tissue date to approximately 500 million years ago in the Cambrian period, when agnathans—jawless fish—developed acellular dermal bone as a lightweight, protective exoskeleton lacking embedded cells. This innovation provided structural defense without the metabolic cost of cellular maintenance, forming the basis for subsequent skeletal complexity. Ostracoderms, an early group of extinct agnathans from the Ordovician to Devonian periods, exhibited elaborate calcified armor composed of this bone type, which covered their bodies and heads in plated structures adapted to predatory pressures in ancient aquatic environments.^[193]^[194] The advent of jawed vertebrates around 420 million years ago marked a major diversification, with placoderms pioneering an endoskeleton that integrated bony elements into cartilaginous frameworks, facilitating greater mobility and jaw function essential for predation. This shift from purely cartilaginous supports to ossified structures was orchestrated by Runx transcription factors, which initially regulated cartilage formation and later drove its endochondral replacement by bone in gnathostomes, enhancing durability and load-bearing capacity.^[195]^[196] In post-Devonian tetrapods, emerging around 360 million years ago, limb bones evolved specialized adaptations for terrestrial weight-bearing, such as thickened cortices and reinforced articulations to withstand gravitational stresses during the fish-to-amphibian transition. The evolution of endothermy around 300 million years ago in the common ancestors of mammals, birds, and crocodylians elevated bone remodeling rates through heightened vascularization and osteoblast-osteoclast activity, supporting rapid skeletal adjustments to elevated metabolic demands.^[197]^[198] Critical innovations further refined bone's functionality: osteocytes, specialized cells for mechanosensing and mineral regulation, appeared by about 400 million years ago in early osteichthyans, allowing bone to dynamically respond to mechanical loads as evidenced by fossilized cellular structures with modern-like metabolic traits. Hematopoietic marrow, enabling intraskeletal blood cell production, originated in synapsids around 300 million years ago during the Carboniferous-Permian transition, linking skeletal evolution to advanced immune and oxygen transport systems in mammalian ancestors.^[199]^[200] These developments underscore profound genetic conservation across metazoans, exemplified by bone morphogenetic protein (BMP) homologs such as decapentaplegic (dpp) in Drosophila melanogaster, which governs embryonic patterning in ways analogous to BMP's role in vertebrate skeletogenesis. Recent studies (as of 2025) indicate that the evolution of skeletal cell types, such as osteoblasts and hypertrophic chondrocytes, follows trends of co-opting key regulatory genes across vertebrates.^[201]^[202] Fossil records illuminate these shifts, as seen in Australopithecus afarensis specimen "Lucy" (dated to 3.2 million years ago), whose lower limb bones display elevated trabecular density and robusticity adapted for habitual bipedalism, reflecting selective pressures for efficient terrestrial weight distribution.^[203]

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Bone Health: Part 2, Physical Activity - PMC - NIH
Physical activity transmits mechanical loads to the skeleton that are vital for maintaining or enhancing bone strength.
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Bone Health in Athletes: The Role of Exercise, Nutrition, and ...
There is strong evidence that exercise benefits bone health at every age and is a critical factor in osteoporosis prevention and treatment.
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A Meta-Analysis of the Effects of Cigarette Smoking on Bone Mineral ...
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There is tenuous evidence that moderate alcohol consumption may protect bone. But human and animal studies clearly indicate that chronic heavy drinking, ...
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Effectiveness of exercise interventions on fall prevention in ...
Several studies (23–28) have concluded that strength, balance, and aerobic-based training is effective in reducing falls among older adults in general and up to ...
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Alendronate, ibandronate, risedronate, and zoledronate are considered today a treatment of first choice in postmenopausal osteoporosis.
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THE osseous endoskeletons of the higher orders of teleost fish are noteworthy in that they are totally devoid of enclosed osteocytes (Fig. 1)1,2.
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A New Mechanistic Scenario for the Origin and Evolution of ...
Runx genes are key regulators of both cartilage and bone development in jawed vertebrates. During embryogenesis all three gnathostome Runx paralogs, Runx1,2 ...
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