BASIC SCIENCE
Bone formation, remodelling
and healing
Nick Little
Benedict Rogers
Mark Flannery
Abstract
Bone is one of the largest organs in the body receiving 5–10% of the
cardiac output. Bone formation starts early in the first trimester in
utero and throughout life, it is continuously resorbed and formed,
a process known as remodelling. Bone (fracture) healing is a process
closely linked with both formation and remodelling. This article explores
the basic structure of bone and provides the current understanding of
intramembranous and endochondral bone formation, remodelling and
primary and secondary bone healing.
Keywords Bone formation; bone remodelling; bone structure; fracture
healing
Introduction
Bone formation starts early in the first trimester in-utero.
Throughout life, bone is continuously resorbed and formed,
a process known as remodelling. Bone (fracture) healing is closely
linked with both formation and remodelling. However, a basic
knowledge of the constituents and structure of bone is needed to
help understand bone formation, remodelling and healing.
What is bone?
Bone, being one of the largest organs in the body, receives
approximately 5e10% of the cardiac output. It plays a role in
providing biomechanical support, allowing locomotion,
haematopoiesis and calcium homeostasis. It is a visco-elastic
composite biomaterial consisting of cells (10%) held within
a matrix (90%). The matrix has both organic and inorganic
components.
Nick Little MB ChB MSc FRCS (Orth) is a Specialist Registrar in Trauma and
Orthopaedics at the Royal Surrey County Hospital, Guildford, UK.
Conflicts of interest: none declared.
Benedict Rogers MA MSc MRCGP FRCS (Orth) is an Orthopaedic Fellow at
Mount Sinai Hospital, Toronto, Ontario, Canada. Conflicts of interest:
none declared.
Mark Flannery MBBS FRCS (Ed) is a Consultant in Trauma and Orthopae-
dics at the Royal Surrey County Hospital, Guildford, UK. Conflicts of
interest: none declared.
SURGERY 29:4
Cellular component
There are three main types of bone cell: osteoblasts, osteocytes
and osteoclasts.
Osteoblasts (OB): these are bone-forming cells and originate from
undifferentiated mesenchymal stem cells. Their major function is
to make organic matrix. When entrapped in mineralized matrix
they become osteocytes. They have receptors for parathyroid
hormone (PTH), 1,25-vitamin D3, glucocorticoids, prostaglandins
and oestrogen. More recently they have been found to be directly
stimulated by osteoclasts1 and act in conjunction with them to
remodel bone. OBs take up technetium 99 (radioisotope bone
scan) and lay it onto mineralized bone. Therefore hot spots in the
delayed phase on a bone scan signal high activity of osteoblasts.
Osteocytes: these are mature osteoblasts whose primary function
is to maintain bone. They make up 90% of the cellular content of
bone. They have a higher nucleus-to-cytoplasm ratio than oste-
oblasts as they produce less matrix. They are also important in
controlling extra cellular concentrations of calcium and phos-
phorous. They are stimulated by calcitonin and inhibited by PTH.
Osteoclasts (OC): these are bone-resorbing cells and originate
from haematopoietic stem cells. These multinucleated, irregu-
larly shaped cells are formed from the fusion of monocyte
progenitor cells (the macrophages of bone). They possess
a ruffled (brush) border which is made up of invagination of the
plasma membrane. This increases the surface area of the
resorption site. Resorption occurs in pits (depressions) known as
Howships lacunae and is closely linked with formation.
Once activated the OC bonds (fixes) to bone via surface
proteins (intergrins). These seal the brush border of the OC to the
surface of bone. Hþ is released (via carbonic anhydrase system)
to lower the pH which in turn increases the solubility of the
inorganic matrix. The osteoclast then produces a variety of
proteolytic enzymes (e.g. tartrate-resistant acid phosphatase) to
degrade the organic matrix. OCs are stimulated by OBs and
regulated by calcitonin, interleukin-10 and oestrogen.
Matrix: organic
Approximately 40% of the dry weight of bone. It is composed of:
1. Type I collagen. 90% of the organic matrix. It consists of
a triple helix of two a-1 and one a-2 polypeptide chains
arranged in a quarter staggered array to form a 3-D structure.
There are multiple intra- and inter-molecular crosslinks
which increase strength. Calcification occurs in the gaps
between the ends (hole zones) and sides (pore zones) of
molecules. It is primarily responsible for the tensile strength
of bone.
2. Proteoglycans. Complex hydrophilic protein structures
increasing compressive strength of bone.
3. Non-collagenous matrix proteins. These are bone-specific
and include osteopontin, osteonectin and osteocalcin.
4. Others. Matrix metalloproteinases and tissue inhibitors of
metalloproteinases. These can be activated/inactivated to
help in the turnover of the organic matrix.
5. Growth factors and cytokines.
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 BASIC SCIENCE
Matrix: inorganic (mineralized)
This makes up 60% of the dry weight of bone and is predomi-
nantly made up of calcium hydroxyapatite (Ca10(PO4)6(OH)2)
crystals. It also contains calcium phosphate and makes up 99%
of the body’s calcium. It provides compressive strength for bone.
Types of bone
This is broadly split into immature and mature bones. Immature
bone is predominantly known as woven bone. Collagen fibrils
are haphazardly laid down by osteoblasts reducing strength but
increasing flexibility. It is isotropic, that is it exhibits universal
properties in all directions on loading. It is found in embryonic
bone, the immature skeleton, fracture healing and pathological
bone (tumour or infection with high levels of bone turnover)
conditions.
Mature bone can either be cortical (lamellar) bone or
cancellous bone (see Figure 1). Cortical bone makes up 80% of
bone and is characterized by Haversian systems or osteons.
These are highly organized parallel collagen fibrils mineralized
forming rings around a central canal (Haversian canal). Osteo-
cytes trapped inside lacunae communicate with one another and
the Haversian canal through canaliculi (cytoplasmic extensions).
The Haversian canal contains a neurovascular bundle. Cement
lines separate individual osteons. Volkmann’s canals run
perpendicular to the Haversian canal and join the periosteal
blood supply to the central supply.
Trabecular and cortical bone
a 1. Reserve zone. This contains undifferentiated cells next to the
Trabecular bone
b a haphazard arrangement. The perichondral arterioles
Cortical bone d a
e b
f
g c
a: osteoclast. b: osteoblast. c: osteocyte. d: concentric lamellae.
e: capillaries in Haversian canal. f: capillary in Volkmann's canal.
g: interstitial lamellae.
Figure 1
SURGERY 29:4
Cancellous, trabecular bone is the honeycomb of bone. It is
a 3-D lattice of interconnecting trabeculae. As in cortical bone,
osteocytes lie in lacunae and are interconnected by canaliculi.
There are however no Haversian systems. It is less dense than
cortical bone and hence is more elastic. It is found in areas of
high stress, commonly found in the epiphysis and metaphysis of
mature bone.
Bone formation
Bone formation occurs in one of two ways; enchondral or
intramembranous bone formation.
Enchondral bone formation
This type of bone formation occurs in embryonic long bone, the
growth plate (physis) of immature bones, and in fracture healing.
Undifferentiated mesenchymal cells secrete a cartilage like
matrix and in turn differentiate into chondrocytes. The matrix is
mineralized and the chondrocytes undergo apoptosis. The matrix
is invaded by vascular buds which bring osteoclasts and osteo-
blasts to the area. The osteoclasts absorb the calcified matrix and
it is the osteoblasts that lay down new bone. In essence, a carti-
lage matrix is replaced by bone.
Growth plate (physis)
Two types of growth plate exist in immature long bones: hori-
zontal and spherical. The horizontal growth plate is responsible
for longitudinal growth and spherical growth plate allows for
growth of the epiphysis. The spherical growth plate has the same
arrangement as the horizontal physis but is less organized.
The growth plate is divided into the following zones (see
Figure 2)
epiphysis within an abundant matrix. The cells are rich in
lipids, glycogen and proteoglycans and are found in
penetrate this layer without giving off any end vessels and
therefore the oxygen tension is low.2
The physis
1
2
3
c
4 d
a: resting zone. b: proliferative zone. c: hypertrophic zone. d: primary and
secondary spongiosa. 1: epiphysis. 2: physis. 3: metaphysis. 4: diaphysis
Figure 2
142 Ó 2011 Elsevier Ltd. All rights reserved.
 BASIC SCIENCE

2. Proliferative zone. This zone functions in cellular prolifera-

tion and matrix production. The cells arrange themselves in Cutting cones crossing the fracture site in primary
columns in the axis of growth of the long bone. The top cell bone healing
(Mother cell) divides forming columns of chondrocytes,
Fracture line
resulting in longitudinal growth. Perichondral arterioles
terminate here producing high oxygen tension. High
concentrations of proteoglycans (in the matrix) and the high
oxygen tension prevent calcification. The proliferation and
differentiation of chondrocytes are regulated by a variety of
endocrine, paracrine, and autocrine agents, such as growth, Mature osteon
thyroid and sex hormones, bone morphogenetic proteins, remodelling bone
insulin-like growth factor, nitric oxide, transforming growth
factor beta and vitamin D metabolites. However, the most
significant factor in stimulating cell proliferation is para-
thyroid hormone-related protein (PTHrP). Further PTHrP Cutting cone
delays transformation of proliferating chondrocytes into pre- crossing
hypertrophic and hypertrophic chondrocytes.3,4 fracture line
3. Hypertrophic zone. This can be subdivided into three zones:
maturation, degeneration and provisional calcification.
(a) Maturation zone. Chondrocytes swell in size (5e10 The cutting cone basic multicellular unit (BMU) is fronted by activated
osteoclasts followed a network of capillaries and a line of osteoblasts.
times their original size) and the membrane-to-cyto-
plasm ratio decreases. Up to 60% of longitudinal
growth is attributable to this zone.5 Figure 3
(b) Degeneration zone. As well as swelling due to an
increase in osmotic pressure chondrocytes accumulate bone formation matches bone resorption resulting in no net loss
calcium in their mitochondria,6 reducing oxygen of bone mass. Bone remodelling occurs via basic multicellular
tension and a series of programmed cellular events units (BMUs). Each unit consists of a group of cells that remodel
results in cell death. bone in response to a variety of biological and mechanical
(c) Provisional calcification. The dying chondrocytes stimuli.
release calcium from their mitochondria into the BMUs are headed by OCs that act as cutting cones, removing
surrounding matrix forming calcified cartilaginous trenches or tunnels of bone from the surfaces of trabecular and
bars.4 The oxygen tension is lowest here. cortical bone.1 These are followed by a capillary bed and a lining
4. Primary and secondary spongiosa. The metaphyseal arterial of OBs that fill in the trenches by laying down new bone matrix
system invades the calcified cartilaginous bars of the in them (see Figure 3). This is similar to the process in primary
hypertrophic zone. Chondroclasts and osteoclasts break- and secondary spongiosa in the physis.
down the cartilaginous bars and osteoblasts lay down woven
bone. This is then remodelled via osteoclasts and osteoblasts
into cortical and cancellous bone.
5. Periphery of the physis.
(a) Groove of Ranvier. This wedge-shaped area of chro-
RANK – RANK-L activation of osteoclasts
drocyte progenitor cells is found at the lateral edge of
the physis and is responsible for lateral growth.7 Immature Osteoclast
(b) Perichondral ring of LaCroix. A dense fibrous network
that anchors the physis to the metaphysis at the periphery.
PTHrP
Intramembranous ossification Vit D3
+ RANK-L Activated
Bone is formed without the mediation of a cartilaginous phase. PGE2 OPG osteoclast
Ossification occurs within areas of condensed primitive mesen- IL1
IL2 RANK
chymal tissue. Mesenchymal stem cells differentiate into OBs
which secrete a haphazard osteoid matrix. This is calcified into
woven bone and finally remodelled into lamellar bone.
Examples of intramembranous bone formation include
embryonic flat bone formation (clavicle, skull and pelvis), Bone resorption
Osteoblast
increases in radial growth of long bones in the periosteal cambial
layer (appositional ossification) and fracture healing. Parathyroid hormone-related peptide (PTHrP), vitamin D3 (Vit D3),
prostaglandin E2 (PGE2) and interleukins 1 and 2 (IL1 and IL2) all stimulate the
expression of RANK on the surface of osteoblasts.
Bone remodelling
Bone in the adult skeleton is renewed continuously in response
to a variety of stimuli by the process of bone remodelling. Ideally, Figure 4

SURGERY 29:4 143 Ó 2011 Elsevier Ltd. All rights reserved.

 BASIC SCIENCE
Activated osteoblasts stimulate osteoclasts to resorb bone via
the RANKeRANK-L pathway. OBs produce RANK-L (also known
as osteoclast differentiation factor) in response to PTHrP, vitamin
prostaglandin E2 (PGE2), interleukins 1 and 2 (IL1 and IL2).
RANK-L binds to a receptor (RANK) on immature osteoclasts to
stimulate osteoclastic differentiation and osteoclastic bone
resorption (see Figure 4). OBs also produce osteoprotegerin (OPG)
which acts as a decoy receptor for RANK-L therefore limiting
osteoclastic differentiation.8 However, regulation of the complex
autocrine, paracrine and endocrine pathways are still not fully
understood.
Mechanical and electrical stimuli
Bone remodelling is sensitive to its mechanical and piezo-elec-
trical environment. In the late 19th century Wolff stated that
bone remodels in response to its mechanical environment, so
called ‘form follows function’. In mature bone, increasing
mechanical stress on a bone increases bone formation. Goodship
et al. demonstrated that when the ulna of a weight-bearing pig
was removed, the radius remodels (hypertrophies) in response to
the extra load applied.9
In immature bone, the remodelling responds differently to
mechanical stress. The HuetereVolkmann law states that
compression (increased stress) at the growth plate reduces bone
growth and to a lesser extent, distraction (tension/decreased
stress)) at the growth plate increases it.10 This may play a role in
the progression of deformity in paediatric scoliosis and Blount’s
disease.
Piezo-electrical charges on bone cause an opposite effect on
bone remodelling to those seen in immature bone. The
compression side of bone is electro-negative, stimulating osteo-
blasts and bone formation. The tension side is electro-positive,
stimulating osteoclasts and therefore bone resorption.
The type of force applied to bone can also affect the type of
bone formation. Compressive forces stimulate endochondral
ossification, tensile forces stimulate intramembranous ossifica-
tion and shear forces stimulate fibrous tissue formation.11 This is
also important in bone/fracture healing.
Bone healing
Bone healing (repair) can occur by different mechanisms
dependent on both the mechanical and biological environments.
Primary (direct) bone healing
This occurs when there has been anatomical reduction of the
fragments with direct cortical contact. Further, there is inter-
fragmentary compression and no movement between the frac-
tures surfaces. This leads to absolute stability.12e15
In this context there is no callus formation and the bone heals
by remodelling using BMUs and cutting cones (see Figure 3).
Rigid plate fixation of fractures is an example of primary bone
healing. If the gap between the fractured surfaces is too large
then the BMUs may not be able to cross it and the fracture may
not unite.
Secondary (indirect) bone healing
This occurs when there is movement at the fracture site and the
bone heals via callus formation. There are several stages to
indirect bone healing first described by Dupuytren in 1847.15e18
SURGERY 29:4
Fracture callus during the repair stage of fracture
healing
a
b
c c
d
b
a
a: exosteal bridging callus. b: periosteal callus. c: fracture ends.
d: endosteal callus
Figure 5
(a) Haematoma and inflammation (hours to days). Bleeding
from the bone and soft tissues leads to the formation of
a haematoma and a fibrinous blood clot. This acts as
a reservoir for the release of growth factors, and cytokines
(IL-1, IL-6, transforming growth factor-b, bone morphoge-
netic proteins, platelet-derived growth factor, fibroblast
growth factor and insulin-like growth factor). These stimu-
late angiogenesis to the area and migration of macrophages,
PNMs, mesenchymal stem cells and fibroblasts. Haematoma
is gradually replaced with fibrous tissue and the bone ends
are resorped by osteoclasts.
(b) Repair (see Figure 5). Primary callus occurs with 2 weeks.
Intramembranous bone forms at the periosteal layer. Type I
collagen is laid down from primary osteoblasts found within
the periosteal cambial layer, but does not bridge the fracture
(see Figure 5). Endochondral bone formation forms in the
bridging callus. This joins the fracture ends and is produced
by mesenchymal stem cells differentiating into chondroclasts
and changing the fibrous network into a cartilaginous matrix
(soft callus). This is calcified and invaded by blood vessels
and osteoblasts which secrete osteoid. The cartilaginous
matrix is changed into woven bone (hard callus).
(c) Remodelling. Woven bone is remodelled into hard lamellae
bone by BMUs. It assumes a configuration based on the
stresses applied to it (Wolff’s law).
Factors affecting bone healing
Mechanical environment
Movement at the fracture site results in mechanical strain. Strain
is defined as the change in length over the original length. For
example at a fracture site, a large fracture gap can afford a larger
movement at the fracture to have the same strain as a fracture
with a smaller gap.
As a fracture heals the callus changes from fibrous to carti-
laginous to woven bone. Each of these tissues is able to tolerate
a varying amount of strain. The amount of strain at the fracture
144 Ó 2011 Elsevier Ltd. All rights reserved.
 BASIC SCIENCE

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SURGERY 29:4 145 Ó 2011 Elsevier Ltd. All rights reserved.