Osteogenesis Imperfecta

Article Author:
Surabhi Subramanian
Article Editor:
Vibhu Krishnan Viswanathan
Updated:
2/3/2019 12:14:51 PM
PubMed Link:
Osteogenesis Imperfecta

Introduction

Osteogenesis imperfecta (OI) is a genetic disorder of connective tissues caused by an abnormality in the synthesis or processing of type I collagen.[1][2] It is also called brittle bone disease. It is characterized by an increased susceptibility to bone fractures and decreased bone density. Other manifestations include blue sclerae, dentinogenesis imperfecta, short stature, as well as deafness in adulthood. There are also reports of valvular insufficiencies and aortic root dilation. Milder manifestations include generalized laxity, easy bruising, hernias, and excess sweating.[3] Clinical manifestations range from mild with a nearly asymptomatic form to most severe forms (involving infants presenting with crumpled ribs, fragile cranium, and long bone fractures incompatible with life) resulting in perinatal mortality.[4]

Etiology

Osteogenesis imperfecta is a rare genetic disease. In the majority of cases, it occurs secondary to mutations in the COL1A1 and COL1A2 genes. More recently, there has been the identification of diverse mutations related to OI.[5]

OI classification according to International Society of Skeletal Dysplasias on the basis of mode of inheritance and genes involved.[6]

Osteogenesis Imperfecta / Type / Inheritance / Genes

Nondeforming OI (Type I) / AD / COL1A1, COL1A2 / X-linked / PLS3

Perinatal (type II) / AD, AR / COL1A1, COL1A2, CRTAP, LEPRE1, PPIB, BMP1   

Progressively deforming (type III) / AD, AR / COL1A1, COL1A2, CRTAP, LEPRE1, PPIB, FKBP10, SERPINH1, SERINF1, WNT1

Moderate (type IV) / AD, AR / COL1A1, COL1A2, CRTAP, FKBP10, SP7, SERPINF1, WNT1, TMEM38B

Calcification of interosseous membrane or hypertrophic callus (type V) / AD / IFITM5

Epidemiology

Osteogenesis imperfecta is a rare disease occurring in 1 in 15,000 to 20,000 births.[4] The population frequencies of type I OI has been reported to range between 2.35 to 4.7 in 100000 worldwide. Reports of the incidence of type II OI range between 1 in 40,000 to 1.4 in 100000 live births. The exact incidence of types III and IV OI is not known, although the incidence is much less common than type I.[7][8][9] In Shapiro's study,[10][11] the incidence of types congenita A, congenita B, tarda A, and tarda B were approximately 19%, 31%, 25%, and 25%, respectively.

Pathophysiology

Two pro-alpha-1 chains and one pro-alpha-2 chain make up type I collagen, which forms the main protein of extracellular membrane of skin, bones, tendons, etc., which creates a rigid triple helix structure. Each alpha chain consists of an amino-terminal pro-peptide and carboxyl-terminal pro-peptide and a central pro-peptide consisting of 338 repeats of glycine. Glycine is the smallest residue that can occupy the axial position of the triple helix.[12] Triple helix structure of type I collagen is possible because of the presence of glycine at every third amino acid residue. 

At least 90% of OI patients have a genetic defect resulting in quantitative and qualitative (or both) abnormalities in type I collagen molecule. This disorder is inheritable in an autosomal dominant, autosomal recessive or a spontaneous mutation pattern.[12][13] The autosomal dominant forms are caused by direct defects in type 1 collagen, while autosomal recessive forms are caused by non-collagenous proteins, which take part in post-translational modifications or triple helix formation.[4]

Defects involving type 1 collagen molecules: 

Frameshift mutations (involving premature stop codon in the affected allele) can result in a quantitative decrease in the amount of structurally normal type 1 collagen. When a patient is heterozygous for this condition, he may secrete half the normal amount of type 1 collagen [haplo-insufficiency; as seen in type IA OI in Sillence Classification].[9] Alternatively, errors in substitution or deletion involving a glycine peptide residue along the polypeptide chain can result in the production of structurally or qualitatively abnormal or less effectual collagen. The phenotypic expression of these defects depends on the position of substitution whether glycine substitutes at carboxy-terminal (severe form) or amino terminal (milder form) of the polypeptide chains.[14] Substitutions at the carboxy end of the peptide are potentially more serious owing to cross-linking of the triple helix beginning at the carboxy terminus of polypeptide chains. These patients with mutations of glycine residues affecting the quality of collagen chains (commonly identified defect in Sillence types II, III and IV types) develop more severe skeletal manifestations than patients with haploinsufficiency defects.[15]

Other mutations: 

Apart from type I collagen mutations, other genetic mutations producing autosomal recessive types of OI (types VI, VII, VIII, IX, X and XI) have also been described. These mutations may involve components that encode collagen 3-hydroxylation complex, which helps in the assembling of the triple helix. These recessive mutational types account for less than 5% of the cases of OI collectively.[15]

Histopathology

Generally, the defects involving decreased collagen type 1 secretion or secretion of abnormal collagen result in insufficient osteoid production.[16] Both enchondral and intramembranous ossification are affected. Thin, poorly organized bony trabeculae and collagen matrix, scanty spongiosa, a relative abundance of osteoblasts and osteoclasts, increased bone turnover; and broad, irregular physis with disorganized proliferative and hypertrophic zones, as well as thinned calcified zone are typical histological features.[17]

Toxicokinetics

History and Physical

Two clinically useful classification systems of osteogenesis imperfecta have been described by Sillence et al.  and Shapiro et al.[7][18][10] In 1979, Sillence and Danks initially described four types of OI based on the clinical and genetic basis. They originally identified types I and IV as autosomal dominant and types II and III as autosomal recessive inheritance. More recent literature, however, has shown that true autosomal recessive inheritance is quite rare. Based on further research on the genetic defects involved, Cole further added types V to XI to the original Sillence Classification (type V with autosomal dominant and types VI to XI with autosomal recessive transmissions).[12][4]

Osteogenesis imperfecta classification based on phenotypic characteristics and mode of inheritance modified from Sillence et al. [9][6]:

Type I: Autosomal dominant (COL1A1 gene does not produce viable mRNA for procollagen); collagen amount is 50% reduced, however, the molecule is structurally normal. General manifestation shows generalized osteoporosis, abnormal bone fragility (fractures typically during the ambulatory years of child development and reduce bone maturity), blue sclera, conductive deafness, and mild stunting. IA (Normal Teeth), IB/IC(Dentinogenesis Imperfecta).

Type II: Originally classified as autosomal recessive; however recent work indicates that it follows a dominant negative inheritance (7% risk of disease in subsequent pregnancies), often as a result of spontaneous mutation. This form results in severe disruption in the qualitative function of the collagen molecule: perinatal lethal form. General manifestation demonstrates extreme bone fragility (accordion femur), delayed skull ossification, blue sclera, and perinatal death. Type IIA  has short and wide long bone with fractures, wide ribs with sparse fractures. II-B manifests with short and widened long bones with fractures, ribs with sparse fractures. II-C presents with thin long bones with fractures, thin ribs.[19][12]

Type III: Autosomal recessive or dominant negative inheritance; type I collagen alteration is both qualitative and quantitative. Most children with severe clinical manifestations belong to this category. General manifestation presents with blue sclera in infancy and returns to normal hue in adolescence. Moderate to severe bone fragility, coxa vara, multiple fractures and marked long bone deformities (more severe than type I with greater ambulation difficulties). These patients require intramedullary nailing prophylactically. Other specific features: Early onset scoliosis, triangular facies, frontal bossing, basilar invagination and extremely short stature.[3][20][13][21][22]

Type IV: Heterogenous group; autosomal dominant that also has qualitative and quantitative changes in type I collagen. More severe clinical manifestations than type I OI. General manifestation shows normal sclera, moderate to severe bone fragility and deformity of the long bones and spinal column, moderate to severe growth stunting. Type IV A presents with normal teeth while Type IV B shows dentinogenesis imperfecta.

Type V: Autosomal dominant; mutation in the gene encoding interferon-induced transmembrane protein-5 (IFITM5); histologically demonstrates a mesh-like appearance of the lamellar bone. It presents with mild to moderate degrees of severity. Specific features include normal sclera, the absence of dental involvement, calcification of interosseous membrane especially the forearm that can lead to secondary dislocation of radius, hypertrophic callus and a radiodense band near long bone physis are specific characteristics of this type.[23][24][25]

Type VI: Mutation involving SERPINF1 gene; characteristic histological presentation includes lamellar bone with fish scale pattern under a polarized light microscope and severe mineralization defects. This type presents with moderate to severe skeletal manifestations, normal sclera, and absence of dental involvement.

Types VII, VIII and IX[4][26][27]:

Common features: 1.A defect in prolyl 3-hydroxylation complex in the endoplasmic reticulum (ER) (which helps in the assembly of the triple helix). 2.Autosomal Recessive.

Specific defects include cartilage associated protein defects (CRTAP) - type VII, prolyl 3-hydroxylase (LEPRE1) - type VIII and peptidyl-prolyl cis-trans isomerase B (PPIB) - type IX.

General Manifestation: 

Type VII: Moderate to severe. Associated with rhizomelia and coxa vara.

Type VIII: Severe to lethal. It is associated with rhizomelia.

Type IX: Similar to types VII and VII; however no rhizomelia.

Types X and XI[27][28]

Common features: 1.A defect in collagen chaperones which accompany procollagen molecules from ER to Golgi apparatus. 2.Autosomal Recessive.

Specific defects: SERPINH1 - type X, FKBP10 - type XI.

General Manifestation: 

Type X: Severe bone dysplasia, dentinogenesis imperfecta, transient skin bullae, blue sclera, pyloric stenosis, and renal stones.

Type XI: Bone dysplasia, ligamentous laxity, scoliosis, and platyspondyly. Normal sclera and absence of dental involvement.

The pitfall of Sillence Classification: Significant variability in the severity of deformities and fractures within different classification categories. Less prognostic relevance.

Looser et al. (1906):

Classified OI into two types - OI congenita (presence of numerous fractures at birth); and OI tarda (fractures occur after perinatal period).

Shapiro's modification of Looser classification (4 types): Excellent practical application regarding prognostication for survival and ambulation.[10]

Congenita A (Incompatible with life) - Sustain fractures in utero or at birth; Radiographically, present with crumpled long bones, crumpled ribs, rib cage deformity, fragile skull.

Congenita B (Compatible with survival) - Sustain fractures in utero or at birth; Radiographically, present with more tubular long bones with funnelization in the metaphysis, normally formed ribs and no rib cage deformity.

Tarda A - Fractures before walking; Age of onset of fractures - not prognostic for ambulation.

Tarda B - First fracture after walking age; All patients usually ambulate.

Evaluation

It is of foremost importance to rule out non-accidental trauma in these patients presenting with multiple fractures.[29][30]

Diagnosis: Based on clinical and family history, bone mineral density (lumbar vertebra), bone biochemistry and radiographic features.[31]

The most common clinical finding is bone fragility present in a majority of OI types. Most of them have specific features as described by Van Dijk and Sillence.[32]

Four Major Clinical Features:

  • Decreased bone mass, increased bone fragility
  • Blue Sclera
  • Dentinogenesis imperfecta (Normal enamel with dentin abnormality)
  • Hearing loss
  • Other features include ligament laxity and increased joint mobility, short stature, and easy bruising.

Fractures in OI: Earlier the onset of fractures, the prognosis is poor.[33] [34] There is a possibility of hypertrophic callus during fracture healing (which may resemble osteosarcoma); however, the fractures on most occasions heal at the usual rate. Bony deformities can occur secondary to fractures: protrusio acetabuli, proximal varus or anterolateral bowing (femur), anterior bow (tibia), cubitus varus and other proximal forearm deformities are known to occur.[35] 

Facies in OI: Elfin facies, helmet head appearance.

Manifestations depend on the type of OI.

Laboratory: No commercially available diagnostic test is available due to a wide variety of genetic mutations. Laboratory values are typically within normal range — mildly elevated alkaline phosphatase (ALP).

Plain Radiograph: 

  • Head, neck, and Spine: wormian bones, basilar invagination, kyphoscoliosis (39 to 100%), platyspondyly
  • Chest: pectus excavatum or carinatum
  • Pelvis: protusio acetabuli, coxa vara
  • General: osteoporosis, lack of funneling of long bones, cortical thinning, hypertrophic callus formation, popcorn calcifications involving metaphysis and epiphysis, pseudoarthrosis at the site of fractures

Prenatal ultrasound: decreased calvarial ossification, shortened and angulated long bones, multiple bone fractures, a beaded appearance of ribs, polyhydramnios.[36]

Computed Tomography (CT)[37]:

  • Wormian bone
  • Basilar invagination
  • Otosclerosis
  • Long bone fractures

Magnetic Resonance Imaging (MRI): to evaluate basilar invagination

Fibroblast culturing to analyze type I collagen (positive in 80% of type IV) is used for confirmation of diagnosis in equivocal cases

Biopsy: 

  • Collagen analysis of a punch biopsy
  • Iliac crest biopsy which demonstrates a decrease in cortical widths and the volume of cancellous bone, with increased bone remodeling

Treatment / Management

Management varies with age, severity and functional status of patients.[38][39]

  • Mild disease: subtle restriction, avoid contact sports, treated for any fractures
  • Moderate to Severe disease: rehabilitation and orthopedic interventions, management of acute fractures and scoliosis
  • Severe form: an intramedullary rod with osteotomy used to correct severe bowing of long bones

Medical Management[40][41][42][43][44][45][46]

  • Sex hormones, sodium fluoride, calcium, calcitonin, magnesium oxide, vitamins C and D - attempted in the past with no or mixed results 
  • Bisphosphonates (intravenous pamidronate, oral alendronate) - have been demonstrated to be useful (decrease fracture risk, improve bone mineral density, improved ambulatory status) through their ability to reduce the osteoclastic resorption of bone in children with OI
  • Gene therapy (to correct defective COL1A1, COL1A2 genes) - still not available

Orthopedic management:

Goals - 

To ameliorate patient functional status, prevent deformity and disability, correct deformities and monitor for complications.

1. Orthotic treatment: orthosis, walking aids, wheelchairs

2. Management of long bone fractures

3. Management of long bone deformities: 

A. Infants and children[47][48][49][50]:  

  • Closed osteoclasis without intramedullary fixation
  • Closed osteoclasis with percutaneous intramedullary fixation
  • Open osteotomy with internal fixation (Sofield and Millar procedure) - Rush nail, Williams rod

B. Young adult patients

  • External fixation with circular or uniplanar constructs with osteotomy.

4. Prophylactic intramedullary rod for children who repeatedly fracture their long bones. Different types of rods according to bone size and skeletal maturity:

  • Osteotomy and fixation with telescoping rod (Bailey-Dubow rod, Sheffield rod, Fassier-Duval rod)
  • Osteotomy and fixation with a non-telescoping rod (Kirschner wire, Steinmann pin, Williams rod, push rod, other fixed-length rods)

5. Management of spinal deformities: basilar invagination, kyphoscoliosis, spinal fractures

Differential Diagnosis

Major differentials[29][30][51][52]

1. Congenital hypophosphatasia

2. Achondroplasia

3. Pyknodysostosis

4. Diffuse osteopenia in early stages of leukemia

5. Idiopathic juvenile osteoporosis

6. Child abuse or battered child syndrome

Prognosis

Varied across the diverse spectrum of the disease (previously discussed).[10]

Shapiro's classification (more than Sillence classification) is a good prognostic indicator (previously discussed). 

Age of onset of long bone fractures has been demonstrated as an important prognostic indicator for ambulatory ability (previously discussed).

Survival: The most significant indicators include the location of fractures, the severity of fractures and general radiographic appearance of the skeleton.

Engelbert et al. demonstrated that children who achieved independent sitting or standing or both by 12 years of age, were finally able to ambulate. 

Engelbert and co-workers also found that children who could achieve independent sitting or standing, or both, by the age of 12 months were likely to be able to walk.[53]

Complications

The following complication may present with osteogenesis imperfecta[54][55][56][57]

  1. Hyperplastic callus formation: Rare; differential diagnosis: osteogenic sarcoma - Management: conservative, palliative radiotherapy (caution: secondary malignancy), bisphosphonates
  2. Tumors: Osteogenic sarcoma
  3. Basilar invagination: Cranial nerve involvement, direct brain stem compression, altered cerebrospinal fluid (CSF) dynamics
  4. Malignant hyperthermia: Both the surgeon and anesthesiologist should keep in mind the possibility of malignant hyperthermia during anesthesia

Deterrence and Patient Education

It is of vital importance to educate the parent regarding the likelihood of survival; and what to expect regarding deformity, disability, and ambulatory capacity. Genetic counseling and prenatal screening (including ultrasonography) may be necessary during future pregnancies.  The parents should also receive counsel that the children, despite their orthopedic impairments, have normal intelligence and social abilities. Parents should also receive information regarding the need for caution against falls, to obviate recurrent fragility fractures.[58]

Antenatal diagnosis[3]:

Antenatal ultrasound - can demonstrate OI Sillence type II by 16 weeks of fetal age. Based on the severity of disease expression, Sillence types I, III and IV can also be diagnosable on imaging. 

Parents with a history of a fetus affected by OI type II carry a 2% to 7% risk of a similarly affected fetus in future pregnancies. Antenatal diagnosis can be made in such scenarios by DNA analysis of chorionic villus samples obtained by ultrasonographic imaging.

Enhancing Healthcare Team Outcomes

The management of osteogenesis imperfecta is challenging and complex.[58] The primary reason underlying the complexity of management is the wide variation in the phenotypic expression across the different spectra of the disease. The significant role of early diagnosis (clinical, imaging, biochemical, and genetic evaluation) and early risk stratification in the long-term management of the child can never be understated. The importance of multidisciplinary interventions over long term involving a family physician, pediatrician, endocrinologist, radiologist, orthopedic surgeon, neurosurgeon, anesthesiologist, orthotic expert, occupational therapist, physiotherapist, and nurse practitioner over different stages of management needs to be understood. The orthopedic surgeon gets involved in the prevention and management of fractures and deformities of extremities. Medical management with bisphosphonates can prevent fractures in children with recurrent fractures. A neurosurgeon may be involved in the management of upper cervical spine/craniocervical junction compressive pathologies or spinal deformities. The role of parent education on what to expect at different stages of disease management is also extremely significant. Nurse practitioners can play a vital role in imparting of holistic care to the patient, as well as provide needed support to the caregivers. Such interdisciplinary care can aid in meeting basic goals in the management of OI including melioration of patient's functional status, prevention of deformity and disability, correction of existing deformities and monitoring for possible complications.

Most of the current knowledge on the subject of OI has its basis in available level 3 to 5 evidence.


References

[1] Uttarilli A,Shah H,Bhavani GS,Upadhyai P,Shukla A,Girisha KM, Phenotyping and genotyping of skeletal dysplasias: Evolution of a center and a decade of experience in India. Bone. 2018 Nov 6;     [PubMed PMID: 30408610]
[2] Nicol L,Morar P,Wang Y,Henriksen K,Sun S,Karsdal M,Smith R,Nagamani SCS,Shapiro J,Lee B,Orwoll E, Alterations in non-type I collagen biomarkers in osteogenesis imperfecta. Bone. 2018 Oct 2;     [PubMed PMID: 30290234]
[3] Ablin DS, Osteogenesis imperfecta: a review. Canadian Association of Radiologists journal = Journal l'Association canadienne des radiologistes. 1998 Apr;     [PubMed PMID: 9561014]
[4] Forlino A,Cabral WA,Barnes AM,Marini JC, New perspectives on osteogenesis imperfecta. Nature reviews. Endocrinology. 2011 Jun 14;     [PubMed PMID: 21670757]
[5] Valadares ER,Carneiro TB,Santos PM,Oliveira AC,Zabel B, What is new in genetics and osteogenesis imperfecta classification? Jornal de pediatria. 2014 Nov-Dec;     [PubMed PMID: 25046257]
[6] Warman ML,Cormier-Daire V,Hall C,Krakow D,Lachman R,LeMerrer M,Mortier G,Mundlos S,Nishimura G,Rimoin DL,Robertson S,Savarirayan R,Sillence D,Spranger J,Unger S,Zabel B,Superti-Furga A, Nosology and classification of genetic skeletal disorders: 2010 revision. American journal of medical genetics. Part A. 2011 May;     [PubMed PMID: 21438135]
[7] Sillence D, Osteogenesis imperfecta: an expanding panorama of variants. Clinical orthopaedics and related research. 1981 Sep;     [PubMed PMID: 7285446]
[8] Stoltz MR,Dietrich SL,Marshall GJ, Osteogenesis imperfecta. Perspectives. Clinical orthopaedics and related research. 1989 May;     [PubMed PMID: 2650946]
[9] Sillence DO,Senn A,Danks DM, Genetic heterogeneity in osteogenesis imperfecta. Journal of medical genetics. 1979 Apr;     [PubMed PMID: 458828]
[10] Shapiro F, Consequences of an osteogenesis imperfecta diagnosis for survival and ambulation. Journal of pediatric orthopedics. 1985 Jul-Aug;     [PubMed PMID: 4019761]
[11] Jain M,Tam A,Shapiro JR,Steiner RD,Smith PA,Bober MB,Hart T,Cuthbertson D,Krischer J,Mullins M,Bellur S,Byers PH,Pepin M,Durigova M,Glorieux FH,Rauch F,Lee B,Sutton VR,Nagamani SCS, Growth characteristics in individuals with osteogenesis imperfecta in North America: results from a multicenter study. Genetics in medicine : official journal of the American College of Medical Genetics. 2018 Jul 4;     [PubMed PMID: 29970925]
[12] Cole WG, The Nicholas Andry Award-1996. The molecular pathology of osteogenesis imperfecta. Clinical orthopaedics and related research. 1997 Oct;     [PubMed PMID: 9345229]
[13] Minch CM,Kruse RW, Osteogenesis imperfecta: a review of basic science and diagnosis. Orthopedics. 1998 May;     [PubMed PMID: 9606696]
[14] Makareeva E,Mertz EL,Kuznetsova NV,Sutter MB,DeRidder AM,Cabral WA,Barnes AM,McBride DJ,Marini JC,Leikin S, Structural heterogeneity of type I collagen triple helix and its role in osteogenesis imperfecta. The Journal of biological chemistry. 2008 Feb 22;     [PubMed PMID: 18073209]
[15] Rauch F,Lalic L,Roughley P,Glorieux FH, Relationship between genotype and skeletal phenotype in children and adolescents with osteogenesis imperfecta. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 2010 Jun;     [PubMed PMID: 19929435]
[16] Hoyer-Kuhn H,Netzer C,Semler O, Osteogenesis imperfecta: pathophysiology and treatment. Wiener medizinische Wochenschrift (1946). 2015 Jul;     [PubMed PMID: 26055811]
[17] Doty SB,Mathews RS, Electron microscopic and histochemical investigation of osteogenesis imperfecta tarda. Clinical orthopaedics and related research. 1971 Oct;     [PubMed PMID: 5133325]
[18] Sillence DO,Rimoin DL,Danks DM, Clinical variability in osteogenesis imperfecta-variable expressivity or genetic heterogeneity. Birth defects original article series. 1979;     [PubMed PMID: 393318]
[19] Sanguinetti C,Greco F,De Palma L,Specchia N,Falciglia F, Morphological changes in growth-plate cartilage in osteogenesis imperfecta. The Journal of bone and joint surgery. British volume. 1990 May;     [PubMed PMID: 2187879]
[20] Cole WG,Jaenisch R,Bateman JF, New insights into the molecular pathology of osteogenesis imperfecta. The Quarterly journal of medicine. 1989 Jan;     [PubMed PMID: 2687927]
[21] Nicholls AC,Oliver J,Renouf DV,Keston M,Pope FM, Substitution of cysteine for glycine at residue 415 of one allele of the alpha 1(I) chain of type I procollagen in type III/IV osteogenesis imperfecta. Journal of medical genetics. 1991 Nov;     [PubMed PMID: 1770532]
[22] Aarabi M,Rauch F,Hamdy RC,Fassier F, High prevalence of coxa vara in patients with severe osteogenesis imperfecta. Journal of pediatric orthopedics. 2006 Jan-Feb;     [PubMed PMID: 16439896]
[23] Cho TJ,Lee KE,Lee SK,Song SJ,Kim KJ,Jeon D,Lee G,Kim HN,Lee HR,Eom HH,Lee ZH,Kim OH,Park WY,Park SS,Ikegawa S,Yoo WJ,Choi IH,Kim JW, A single recurrent mutation in the 5'-UTR of IFITM5 causes osteogenesis imperfecta type V. American journal of human genetics. 2012 Aug 10;     [PubMed PMID: 22863190]
[24] Glorieux FH,Rauch F,Plotkin H,Ward L,Travers R,Roughley P,Lalic L,Glorieux DF,Fassier F,Bishop NJ, Type V osteogenesis imperfecta: a new form of brittle bone disease. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 2000 Sep;     [PubMed PMID: 10976985]
[25] Semler O,Garbes L,Keupp K,Swan D,Zimmermann K,Becker J,Iden S,Wirth B,Eysel P,Koerber F,Schoenau E,Bohlander SK,Wollnik B,Netzer C, A mutation in the 5'-UTR of IFITM5 creates an in-frame start codon and causes autosomal-dominant osteogenesis imperfecta type V with hyperplastic callus. American journal of human genetics. 2012 Aug 10;     [PubMed PMID: 22863195]
[26] Morello R,Bertin TK,Chen Y,Hicks J,Tonachini L,Monticone M,Castagnola P,Rauch F,Glorieux FH,Vranka J,Bächinger HP,Pace JM,Schwarze U,Byers PH,Weis M,Fernandes RJ,Eyre DR,Yao Z,Boyce BF,Lee B, CRTAP is required for prolyl 3- hydroxylation and mutations cause recessive osteogenesis imperfecta. Cell. 2006 Oct 20;     [PubMed PMID: 17055431]
[27] van Dijk FS,Nesbitt IM,Zwikstra EH,Nikkels PG,Piersma SR,Fratantoni SA,Jimenez CR,Huizer M,Morsman AC,Cobben JM,van Roij MH,Elting MW,Verbeke JI,Wijnaendts LC,Shaw NJ,Högler W,McKeown C,Sistermans EA,Dalton A,Meijers-Heijboer H,Pals G, PPIB mutations cause severe osteogenesis imperfecta. American journal of human genetics. 2009 Oct;     [PubMed PMID: 19781681]
[28] Christiansen HE,Schwarze U,Pyott SM,AlSwaid A,Al Balwi M,Alrasheed S,Pepin MG,Weis MA,Eyre DR,Byers PH, Homozygosity for a missense mutation in SERPINH1, which encodes the collagen chaperone protein HSP47, results in severe recessive osteogenesis imperfecta. American journal of human genetics. 2010 Mar 12;     [PubMed PMID: 20188343]
[29] Augarten A,Laufer J,Szeinberg A,Passwell J, Child abuse, osteogenesis imperfecta and the grey zone between them. Journal of medicine. 1993;     [PubMed PMID: 8409779]
[30] Knight DJ,Bennet GC, Nonaccidental injury in osteogenesis imperfecta: a case report. Journal of pediatric orthopedics. 1990 Jul-Aug;     [PubMed PMID: 2358497]
[31] Trejo P,Rauch F, Osteogenesis imperfecta in children and adolescents-new developments in diagnosis and treatment. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2016 Dec;     [PubMed PMID: 27492436]
[32] Van Dijk FS,Sillence DO, Osteogenesis imperfecta: clinical diagnosis, nomenclature and severity assessment. American journal of medical genetics. Part A. 2014 Jun;     [PubMed PMID: 24715559]
[33] Gamble JG,Rinsky LA,Strudwick J,Bleck EE, Non-union of fractures in children who have osteogenesis imperfecta. The Journal of bone and joint surgery. American volume. 1988 Mar;     [PubMed PMID: 3346270]
[34] Moorefield WG Jr,Miller GR, Aftermath of osteogenesis imperfecta: the disease in adulthood. The Journal of bone and joint surgery. American volume. 1980 Jan;     [PubMed PMID: 7351402]
[35] Wenger DR,Abrams RA,Yaru N,Leach J, Obstruction of the colon due to protrusio acetabuli in osteogenesis imperfecta: treatment by pelvic osteotomy. Report of a case. The Journal of bone and joint surgery. American volume. 1988 Aug;     [PubMed PMID: 3403582]
[36] Renaud A,Aucourt J,Weill J,Bigot J,Dieux A,Devisme L,Moraux A,Boutry N, Radiographic features of osteogenesis imperfecta. Insights into imaging. 2013 Aug;     [PubMed PMID: 23686748]
[37] Heimert TL,Lin DD,Yousem DM, Case 48: osteogenesis imperfecta of the temporal bone. Radiology. 2002 Jul;     [PubMed PMID: 12091678]
[38] Montpetit K,Palomo T,Glorieux FH,Fassier F,Rauch F, Multidisciplinary Treatment of Severe Osteogenesis Imperfecta: Functional Outcomes at Skeletal Maturity. Archives of physical medicine and rehabilitation. 2015 Oct;     [PubMed PMID: 26140741]
[39] Lin TY,Yang CY,Liu SC, Corrective osteotomy with retrograde Fassier-Duval nail in an osteogenesis imperfecta patient with bilateral genu valgum: A case report. Medicine. 2017 Nov;     [PubMed PMID: 29381920]
[40] Aeschlimann MI,Grunt JA,Crigler JF Jr, Effects of sodium fluoride on the clinical course and metabolic balance of an infant with osteogenesis imperfecta congenita. Metabolism: clinical and experimental. 1966 Oct;     [PubMed PMID: 5923526]
[41] Castells S,Inamdar S,Baker RK,Wallach S, Effects of porcine calcitonin in osteogenesis imperfecta tarda. The Journal of pediatrics. 1972 May;     [PubMed PMID: 5062955]
[42] Nishi Y,Hamamoto K,Kajiyama M,Ono H,Kihara M,Jinno K, Effect of long-term calcitonin therapy by injection and nasal spray on the incidence of fractures in osteogenesis imperfecta. The Journal of pediatrics. 1992 Sep;     [PubMed PMID: 1517930]
[43] Lee YS,Low SL,Lim LA,Loke KY, Cyclic pamidronate infusion improves bone mineralisation and reduces fracture incidence in osteogenesis imperfecta. European journal of pediatrics. 2001 Nov;     [PubMed PMID: 11760017]
[44] Fujiwara I,Ogawa E,Igarashi Y,Ohba M,Asanuma A, Intravenous pamidronate treatment in osteogenesis imperfecta. European journal of pediatrics. 1998 Mar;     [PubMed PMID: 9537501]
[45] Gerber LH,Binder H,Berry R,Siegel KL,Kim H,Weintrob J,Lee YJ,Mizell S,Marini J, Effects of withdrawal of bracing in matched pairs of children with osteogenesis imperfecta. Archives of physical medicine and rehabilitation. 1998 Jan;     [PubMed PMID: 9440417]
[46] Gerber LH,Binder H,Weintrob J,Grange DK,Shapiro J,Fromherz W,Berry R,Conway A,Nason S,Marini J, Rehabilitation of children and infants with osteogenesis imperfecta. A program for ambulation. Clinical orthopaedics and related research. 1990 Feb;     [PubMed PMID: 2295183]
[47] Morel G,Houghton GR, Pneumatic trouser splints in the treatment of severe osteogenesis imperfecta. Acta orthopaedica Scandinavica. 1982 Aug;     [PubMed PMID: 7102270]
[48] Frost RB,Middleton RW,Hillier LG, A stereotaxic device for the closed exchange of intramedullary rods, using image-intensified X-rays, in children with osteogenesis imperfecta. Engineering in medicine. 1986 Jul;     [PubMed PMID: 3527804]
[49] Ryöppy S,Alberty A,Kaitila I, Early semiclosed intramedullary stabilization in osteogenesis imperfecta. Journal of pediatric orthopedics. 1987 Mar-Apr;     [PubMed PMID: 3558793]
[50] Sijbrandij S, Percutaneous nailing in the management of osteogenesis imperfecta. International orthopaedics. 1990;     [PubMed PMID: 2373568]
[51] Swischuk LE,Hayden CK Jr, Rickets: a roentgenographic scheme for diagnosis. Pediatric radiology. 1979 Oct;     [PubMed PMID: 514674]
[52] Marlowe A,Pepin MG,Byers PH, Testing for osteogenesis imperfecta in cases of suspected non-accidental injury. Journal of medical genetics. 2002 Jun;     [PubMed PMID: 12070242]
[53] Engelbert RH,Uiterwaal CS,Gulmans VA,Pruijs H,Helders PJ, Osteogenesis imperfecta in childhood: prognosis for walking. The Journal of pediatrics. 2000 Sep;     [PubMed PMID: 10969267]
[54] Mrosk J,Bhavani GS,Shah H,Hecht J,Krüger U,Shukla A,Kornak U,Girisha KM, Diagnostic strategies and genotype-phenotype correlation in a large Indian cohort of osteogenesis imperfecta. Bone. 2018 May;     [PubMed PMID: 29499418]
[55] Cheung MS,Glorieux FH,Rauch F, Natural history of hyperplastic callus formation in osteogenesis imperfecta type V. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 2007 Aug;     [PubMed PMID: 17451374]
[56] Takahashi S,Okada K,Nagasawa H,Shimada Y,Sakamoto H,Itoi E, Osteosarcoma occurring in osteogenesis imperfecta. Virchows Archiv : an international journal of pathology. 2004 May;     [PubMed PMID: 15214333]
[57] Engelbert RH,Gerver WJ,Breslau-Siderius LJ,van der Graaf Y,Pruijs HE,van Doorne JM,Beemer FA,Helders PJ, Spinal complications in osteogenesis imperfecta: 47 patients 1-16 years of age. Acta orthopaedica Scandinavica. 1998 Jun;     [PubMed PMID: 9703404]
[58] Paterson CR,Ogston SA,Henry RM, Life expectancy in osteogenesis imperfecta. BMJ (Clinical research ed.). 1996 Feb 10;     [PubMed PMID: 8611834]