THE EFFECT OF ETHANOL ON BONE MINERAL Raymond 0. Pierce, Jr, MD, and Alonza Perry, PhD Indianapolis, Indiana
Chronic alcoholics frequently have osteopenia. This usually leads to an increase in long bone fractures. The exact cause of these changes is unknown. They could be caused by a change in the calcium metabolism or a change in the organic phase of bone. To elucidate the exact mechanism by which these changes occur, the following study was done. Forty-six Sprague-Dawley rats were divided into four groups. Two groups received alcohol, and two groups served as control. One set of each group received a fracture to the leg in order to study any change that might occur in the organic phase of bone. Our findings in these animals demonstrated that alcohol causes osteopenia due to a change in calcium metabolism and does not appear to effect the organic phase of bone. (J Nati Med Assoc. 1991;83:505-508.) Key words * osteopenia * alcohol * calcium metabolism The chronic alcoholic is plagued with an increased incidence of long bone fractures.'13 These injuries result not only from the increased likelihood of falling From the Department of Orthopaedic Surgery, Indiana University Medical Center, Indianapolis. Requests for reprints should be addressed to Dr Raymond 0. Pierce, Jr, Indiana University Medical Center, Department of Orthopaedic Surgery, Clinical Bldg, Rm 600, 541 Clinical Dr, Indianapolis, IN 46223. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 6
associated with acute intoxication but also from the decrease in the structural integrity of bone which these individuals are likely to have.4-8 Bony strength is dependent on the mineral content of bone and its architectural make up. This decrease in bony strength can be due either to a lack of bone mineral or to a deficiency in the organic or protein phase of bone. The purpose of this study was to see if we could demonstrate in the laboratory model the exact mechanism by which alcohol causes a decrease in bony strength. The feedback mechanism whereby serum calcium and phosphorous are kept in a steady state is complex. It is dependent not only on adequate intake of these elements in the diet and excretion in the urine but also on the interaction of several hormones (vitamin D, calcitonin, and parathyroid hormone). The interplay between serum calcium and bone crystal, which is ultimately responsible for the bony strength, can take a prolonged period of time to study. However, in fracture healing, calcium metabolism with new bone formation is greatly accelerated. Hence, we used a fracture healing model in this study.
MATERIALS AND METHODS One of the reasons for using the Sprague-Dawley rat was because the animal did not have an aversion to alcohol and took it freely when given along with water and his diet. This ensured an adequate intake of the drug by the animals. We also used this animal because this laboratory had a vast amount of experience in studying the effect of trauma on its musculoskeletal system. 505
ETHANOL & BONE MINERAL
Finding Initial rat weight (g) Final rat weight (g) Bone wet weight (g) Bone dry weight (g) Bone dry defatted weight (g) Bone ash weight (g) Percent water Percent fat Percent ash dry
TABLE 1. BIOCHEMICAL FINDINGS Group 2: Group 1: Alcohol Alcohol Unfractured Fractured 313.6 321 425.6 419.9 .7699 1.2779 .5051 .7753 .4904 .7354 .3003 .4179 34.34 38.4528 1.881 3.1637 61.22 56.8282
4~~~
Figure 1. Photomicrograph of primary bone healing in Group I (alcohol fractured).
Forty-six male Sprague-Dawley rats, weighing between 300 g and 325 g, were used in this study. All 46 rats were weighed on arrival and allowed to acclimate to their surroundings (one rat per cage) for a period of 1 week. Any animal that lost weight in the first 2 days was immediately replaced. After the period of acclimation, animals were randomly assigned to their respective groups using a Fisher table of random numbers. These rats were divided into four groups of 10 each, and six rats were used as spares. Group 1 (alcohol fractured) rats received standard laboratory chow ad libitum and a free choice of water, 20% alcohol, and a fractured right tibia. Group 2 (alcohol unfractured) rats received the same diet and alcohol content as group one, but received no fracture. Group 3 (water fractured) rats received Purina standard animal chow, ad lib, and water, and received a fracture of their right tibia. Group 4 (water unfractured) rats received the same freedom as Group 3 animals but received no fracture. The spares were divided into two for each fracture group and one for each non-fracture group. All animals were anesthetized with sodium pentobarbital (Nembutal 50 mg/mL) 506
Group 3: Water Fractured 317.7 423.4 1.1912 .7662 .7212 .4099 35.68 3.749 56.88
Group 4: Water Unfractured 332 429.9 .8100 .5312 .5157 .3179 34.42 1.92 61.65
using a dose of 30 mg/kg of rat weight. The fracture groups were fractured by placing the right tibia between the thumb and forefinger of each hand so as to have the thumb of each hand at midshaft to create a midshaft fracture. Rats from the two unfractured groups were returned to their cages without a fracture. Daily alcohol consumption was recorded. Alcohol was administered ad lib by the use of Richter flask with a capacity of 100 mL and was refilled at 3-day intervals. No attempt was made to record water or food intake. All animals were followed for a period of 5 weeks. At the end of 5 weeks, each rat was sacrificed with an overdose of sodium pentobarbital anesthesia. Each tibia was carefully dissected free, and the strength of the healing fracture and the normal tibia were measured by breaking the bone on an ostensiometer designed for measuring the breaking strength of rat long bones. Immediately after testing, each bone was placed in a tarred weighing bottle and its weight obtained on an analytical balance. After obtaining the wet weight of all bones, the bones were allowed to dry for a period of 3 days at a temperature of 1060 C in a laboratory oven. The bones were reweighed to obtain a dry weight. The dry bones were placed in a mixture of chloroform/ methanol 2/1 VV for 3 days with daily changes to ascertain the fat content. The bones were reweighed. The dry, defatted bones were ashed in a muffle furnace at 7000 C for 6 hours to obtain the ash weight. One rat from each group was predesignated for histological observation and was not subjected to dry, defatted, or ash analysis. All results were subjected to statistical analysis using the student's t test for
significance.
RESULTS None of the animals in this study were lost due to alcohol toxicity or other causes. The amount of alcohol and water consumed was similar in all groups. The JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 6
ETHANOL & BONE MINERAL
Finding Breaking strength in mm deflection Breaking 100 g rat weight 100 g bone/wet 100 g bone/dry 100 g bone/defatted 100 g ash
TABLE 2. BIOMECHANICAL FINDINGS Group 3: Group 2 Group 1: Water Alchohol Alcohol Fractured Unfractured Fractured 112.7 110 128.9
30.7337
26.45
26.128
1.0426 1.6815 1.7741 3.1188
1.4663 2.2305 2.2966 3.7479
.9218 1.4307 1.5194 2.675
amount of weight gained was greater in animals in Group 3 (the water fractured) than in Group 2 (the alcohol unfractured). The weight was very similar in the two remaining groups. Biochemically, it was found that animals in Group 2 (the alcohol unfractured) had a decrease in the wet weight, dry weight, and dry defatted weight as well as bone ash when compared to the other groups (Table 1). The percentage of water was essentially the same in the animals in Group 2 (alcohol unfractured) and Group 4 (water unfractured) (3.43 vs 3.44). Also, the percentage of fat was essentially the same in Group 2 (alcohol unfractured group) versus Group 4 (water unfractured) (1.88 vs 1.92). The alcohol consumption was essentially the same in both groups. The 100-g ash was 3.74 in Group 2 (alcohol unfractured) versus 2.67 in Group 3 (water fractured). The ash dry ratio was not significantly different in any of the groups. Biomechanically, the breaking strength of bone was found to be greatest in Group 1 (alcohol fractured) compared to the other three groups (Table 2). There was no significant difference in the category of bone breaking strength per 100 g, per 100 mm bone weight, or per 100 g of bone defatted weight. Histological evaluation was rather remarkable because it demonstrated that the animals on alcohol that had received a fracture, Group 1 (alcohol fractured), heeled their fractures by primary bone healing (Figure 1). This was in marked contrast to the animals on water in Group 3 (water fractured) that had a fracture and healed their fractures with a cartilage callus that had to undergo metaplasia to bone (Figure 2). The latter is the usual method of healing in the laboratory animal at this time.
DISCUSSION Paul Saville noted that chronic alcoholics had a bone mass very similar to individuals who were much older or who had osteoporosis.9 He then demonstrated in the JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 6
Group 4: Water Unfractured 118
1.45 2.22 2.288
Figure 2. Photomicrograph of fracture healing in Group 3 (water fractured). rat model that the density in the tibia and femur in these
animals was a linear function of the animal's weight and that the decrease in density in these bones could be explained by the difference in weight between the two groups.°l0Il He did not demonstrate that alcohol played any role in these differences. Smith worked with white rats and found that alcohol caused an increased urinary excretion of calcium due to an increased stimulation of the adrenal cortex. 12 In addition, he found that the increase in adrenal cortical function could be increased with the alcohol dose and worked by way of the pituitary axis. Yu was able to produce a state of chronic alcoholism in dogs. 13 He studied these animals for a total of 8 months. He concluded that there was a decrease in bone mineral in these animals despite adequate diet and the absence of body weight loss. 13 Lau et al studied the direct effect of ethanol on the embryonic chief calvarium cells. 14 They concluded that ethanol had a biphasic time and dose-dependent effect on bone cell proliferation. They found that low concentration of ethanol increased bone proliferation in 507
ETHANOL & BONE MINERAL
bone remodeling but had no apparent effect on bone formation in the organ culture system. Lau et al also found that alcohol decreased bone cell responsiveness to agents that increase bone formation; this suggested that alcohol might interfere with the normal remodeling process in bone. In our study, we attempted to use the fracture model to study the effect of ethanol on the apparent decrease in bone mineral. We used the fracture model because in this model there is an increased bone turnover giving the investigator an opportunity to study the effect of the agent on bone. In the initial phase of the work it is seen that there was a definite decrease in the bone mineral in Group 2 (alcohol unfractured) animals. This occurred despite the short period of time in which the study was undertaken. It is not known whether this would be a transitory effect in these animals or whether this is reversible over a period of time on this drug. A study of the breaking strength per 100 g of ash revealed that Group 2 (alcohol unfractured) had a higher increase in bone mineral than both Group 1 (alcohol fractured) and Group 3 (water fractured). The only possible explanation for this would be a contribution of fat immobilization mineral turnover. The increase in breaking strength was by far the greatest in Group 1 (alcohol fractured). This corresponds very well with the histological findings that revealed these groups of animals healed their fractures primarily by bone healing. This is a superior form of healing than healing by cartilage callus. We cannot explain why Group 1 (alcohol fractured) healed by primary bone formation. This type of repair is usually reserved for those cases when there is "absolute firm immobilization of the fracture." One explanation might be that the animals on alcohol were less active, thereby decreasing the amount of motion at their fracture site.
CONCLUSION We have been able to demonstrate in a very limited
508
group of animals that alcohol given to laboratory animals causes a decrease in bone mineral in a short period of time. With the addition of a fracture that causes mobilization of calcium as well as an increased production of ground substance, it appears as though alcohol does not cause any derangement in the production of the ground substance. Therefore, it would appear as though the changes in the animals on alcohol resulted from a derangement in calcium metabolism. Literature Cited 1. Snell W. The chronic alcoholic and his fractures. J Bone Joint Surg. 1971 ;53A:1 655. Abstract. 2. Kristensson J, Lunden A, Nilsson BE. Fracture incidence and diagnostic roentgen in alcoholics. Acta Scand. 1 980;51 :205-207. 3. Honkanen R, Ertama L, Kuosmanen P, et al. The role of alcohol in accidental falls. J Stud Alcohol. 1983;44:231-245. 4. Johnell 0, Nilsson BE, Wiklund PF Bone morphometry in alcoholics. Clin Orthop. 1982;165:253-258. 5. Lalor B, Counihan TB. Metabolic bone disease in heavy drinkers. Clin Sci. 1982;63:43. Abstract. 6. Pierce RO. Bone changes in alcoholics. J Natl Med Assoc. 1979;71:1213-1216. 7. Oppenheim WL. The battered alcoholic syndrome. J Trauma. 1977;1 7:850-856. 8. Nilsson BE, Weslin NE. Changes in bone mass in alcoholics. Clin Orthop. 1973;90:229-232. 9. Saville PD. Changes in bone mass with age and alcoholism. J Bone Joint Surg. 1 965;47A:492-499. 10. Saville PD, Lieber CS. Effect of alcohol on growth bone density and muscle magnesium in the rat. J Nutr 1965;87:477484. 11. Saville PD. Alcohol-related skeletal disorders. Ann NY Acad Sci. 1975;252:287-291. 12. Smith JJ. The effect of alcohol on the adrenal ascorbic acid and cholesterol in rats. J Clin Invest. 1951;1 1:792-802. 13. Yu WY. Photon absorpiometry, the effect of alcohol on the mineral content of bone. An experimental study. Orthopaedic Transactions. 1977;1:32. 14. Lau JR, Farley R, Fitzsimmons AK. An in vitro investigation of effects of ethanol on bone formation and bone resorption. Orthopaedic Research Society. 1985;9:278-279.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 6
Chronic alcoholics frequently have osteopenia. This usually leads to an increase in long bone fractures. The exact cause of these changes is unknown. They could be caused by a change in the calcium metabolism or a change in the organic phase of bone. To elucidate the exact mechanism by which these changes occur, the following study was done. Forty-six Sprague-Dawley rats were divided into four groups. Two groups received alcohol, and two groups served as control. One set of each group received a fracture to the leg in order to study any change that might occur in the organic phase of bone. Our findings in these animals demonstrated that alcohol causes osteopenia due to a change in calcium metabolism and does not appear to effect the organic phase of bone. (J Nati Med Assoc. 1991;83:505-508.) Key words * osteopenia * alcohol * calcium metabolism The chronic alcoholic is plagued with an increased incidence of long bone fractures.'13 These injuries result not only from the increased likelihood of falling From the Department of Orthopaedic Surgery, Indiana University Medical Center, Indianapolis. Requests for reprints should be addressed to Dr Raymond 0. Pierce, Jr, Indiana University Medical Center, Department of Orthopaedic Surgery, Clinical Bldg, Rm 600, 541 Clinical Dr, Indianapolis, IN 46223. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 6
associated with acute intoxication but also from the decrease in the structural integrity of bone which these individuals are likely to have.4-8 Bony strength is dependent on the mineral content of bone and its architectural make up. This decrease in bony strength can be due either to a lack of bone mineral or to a deficiency in the organic or protein phase of bone. The purpose of this study was to see if we could demonstrate in the laboratory model the exact mechanism by which alcohol causes a decrease in bony strength. The feedback mechanism whereby serum calcium and phosphorous are kept in a steady state is complex. It is dependent not only on adequate intake of these elements in the diet and excretion in the urine but also on the interaction of several hormones (vitamin D, calcitonin, and parathyroid hormone). The interplay between serum calcium and bone crystal, which is ultimately responsible for the bony strength, can take a prolonged period of time to study. However, in fracture healing, calcium metabolism with new bone formation is greatly accelerated. Hence, we used a fracture healing model in this study.
MATERIALS AND METHODS One of the reasons for using the Sprague-Dawley rat was because the animal did not have an aversion to alcohol and took it freely when given along with water and his diet. This ensured an adequate intake of the drug by the animals. We also used this animal because this laboratory had a vast amount of experience in studying the effect of trauma on its musculoskeletal system. 505
ETHANOL & BONE MINERAL
Finding Initial rat weight (g) Final rat weight (g) Bone wet weight (g) Bone dry weight (g) Bone dry defatted weight (g) Bone ash weight (g) Percent water Percent fat Percent ash dry
TABLE 1. BIOCHEMICAL FINDINGS Group 2: Group 1: Alcohol Alcohol Unfractured Fractured 313.6 321 425.6 419.9 .7699 1.2779 .5051 .7753 .4904 .7354 .3003 .4179 34.34 38.4528 1.881 3.1637 61.22 56.8282
4~~~
Figure 1. Photomicrograph of primary bone healing in Group I (alcohol fractured).
Forty-six male Sprague-Dawley rats, weighing between 300 g and 325 g, were used in this study. All 46 rats were weighed on arrival and allowed to acclimate to their surroundings (one rat per cage) for a period of 1 week. Any animal that lost weight in the first 2 days was immediately replaced. After the period of acclimation, animals were randomly assigned to their respective groups using a Fisher table of random numbers. These rats were divided into four groups of 10 each, and six rats were used as spares. Group 1 (alcohol fractured) rats received standard laboratory chow ad libitum and a free choice of water, 20% alcohol, and a fractured right tibia. Group 2 (alcohol unfractured) rats received the same diet and alcohol content as group one, but received no fracture. Group 3 (water fractured) rats received Purina standard animal chow, ad lib, and water, and received a fracture of their right tibia. Group 4 (water unfractured) rats received the same freedom as Group 3 animals but received no fracture. The spares were divided into two for each fracture group and one for each non-fracture group. All animals were anesthetized with sodium pentobarbital (Nembutal 50 mg/mL) 506
Group 3: Water Fractured 317.7 423.4 1.1912 .7662 .7212 .4099 35.68 3.749 56.88
Group 4: Water Unfractured 332 429.9 .8100 .5312 .5157 .3179 34.42 1.92 61.65
using a dose of 30 mg/kg of rat weight. The fracture groups were fractured by placing the right tibia between the thumb and forefinger of each hand so as to have the thumb of each hand at midshaft to create a midshaft fracture. Rats from the two unfractured groups were returned to their cages without a fracture. Daily alcohol consumption was recorded. Alcohol was administered ad lib by the use of Richter flask with a capacity of 100 mL and was refilled at 3-day intervals. No attempt was made to record water or food intake. All animals were followed for a period of 5 weeks. At the end of 5 weeks, each rat was sacrificed with an overdose of sodium pentobarbital anesthesia. Each tibia was carefully dissected free, and the strength of the healing fracture and the normal tibia were measured by breaking the bone on an ostensiometer designed for measuring the breaking strength of rat long bones. Immediately after testing, each bone was placed in a tarred weighing bottle and its weight obtained on an analytical balance. After obtaining the wet weight of all bones, the bones were allowed to dry for a period of 3 days at a temperature of 1060 C in a laboratory oven. The bones were reweighed to obtain a dry weight. The dry bones were placed in a mixture of chloroform/ methanol 2/1 VV for 3 days with daily changes to ascertain the fat content. The bones were reweighed. The dry, defatted bones were ashed in a muffle furnace at 7000 C for 6 hours to obtain the ash weight. One rat from each group was predesignated for histological observation and was not subjected to dry, defatted, or ash analysis. All results were subjected to statistical analysis using the student's t test for
significance.
RESULTS None of the animals in this study were lost due to alcohol toxicity or other causes. The amount of alcohol and water consumed was similar in all groups. The JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 6
ETHANOL & BONE MINERAL
Finding Breaking strength in mm deflection Breaking 100 g rat weight 100 g bone/wet 100 g bone/dry 100 g bone/defatted 100 g ash
TABLE 2. BIOMECHANICAL FINDINGS Group 3: Group 2 Group 1: Water Alchohol Alcohol Fractured Unfractured Fractured 112.7 110 128.9
30.7337
26.45
26.128
1.0426 1.6815 1.7741 3.1188
1.4663 2.2305 2.2966 3.7479
.9218 1.4307 1.5194 2.675
amount of weight gained was greater in animals in Group 3 (the water fractured) than in Group 2 (the alcohol unfractured). The weight was very similar in the two remaining groups. Biochemically, it was found that animals in Group 2 (the alcohol unfractured) had a decrease in the wet weight, dry weight, and dry defatted weight as well as bone ash when compared to the other groups (Table 1). The percentage of water was essentially the same in the animals in Group 2 (alcohol unfractured) and Group 4 (water unfractured) (3.43 vs 3.44). Also, the percentage of fat was essentially the same in Group 2 (alcohol unfractured group) versus Group 4 (water unfractured) (1.88 vs 1.92). The alcohol consumption was essentially the same in both groups. The 100-g ash was 3.74 in Group 2 (alcohol unfractured) versus 2.67 in Group 3 (water fractured). The ash dry ratio was not significantly different in any of the groups. Biomechanically, the breaking strength of bone was found to be greatest in Group 1 (alcohol fractured) compared to the other three groups (Table 2). There was no significant difference in the category of bone breaking strength per 100 g, per 100 mm bone weight, or per 100 g of bone defatted weight. Histological evaluation was rather remarkable because it demonstrated that the animals on alcohol that had received a fracture, Group 1 (alcohol fractured), heeled their fractures by primary bone healing (Figure 1). This was in marked contrast to the animals on water in Group 3 (water fractured) that had a fracture and healed their fractures with a cartilage callus that had to undergo metaplasia to bone (Figure 2). The latter is the usual method of healing in the laboratory animal at this time.
DISCUSSION Paul Saville noted that chronic alcoholics had a bone mass very similar to individuals who were much older or who had osteoporosis.9 He then demonstrated in the JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 6
Group 4: Water Unfractured 118
1.45 2.22 2.288
Figure 2. Photomicrograph of fracture healing in Group 3 (water fractured). rat model that the density in the tibia and femur in these
animals was a linear function of the animal's weight and that the decrease in density in these bones could be explained by the difference in weight between the two groups.°l0Il He did not demonstrate that alcohol played any role in these differences. Smith worked with white rats and found that alcohol caused an increased urinary excretion of calcium due to an increased stimulation of the adrenal cortex. 12 In addition, he found that the increase in adrenal cortical function could be increased with the alcohol dose and worked by way of the pituitary axis. Yu was able to produce a state of chronic alcoholism in dogs. 13 He studied these animals for a total of 8 months. He concluded that there was a decrease in bone mineral in these animals despite adequate diet and the absence of body weight loss. 13 Lau et al studied the direct effect of ethanol on the embryonic chief calvarium cells. 14 They concluded that ethanol had a biphasic time and dose-dependent effect on bone cell proliferation. They found that low concentration of ethanol increased bone proliferation in 507
ETHANOL & BONE MINERAL
bone remodeling but had no apparent effect on bone formation in the organ culture system. Lau et al also found that alcohol decreased bone cell responsiveness to agents that increase bone formation; this suggested that alcohol might interfere with the normal remodeling process in bone. In our study, we attempted to use the fracture model to study the effect of ethanol on the apparent decrease in bone mineral. We used the fracture model because in this model there is an increased bone turnover giving the investigator an opportunity to study the effect of the agent on bone. In the initial phase of the work it is seen that there was a definite decrease in the bone mineral in Group 2 (alcohol unfractured) animals. This occurred despite the short period of time in which the study was undertaken. It is not known whether this would be a transitory effect in these animals or whether this is reversible over a period of time on this drug. A study of the breaking strength per 100 g of ash revealed that Group 2 (alcohol unfractured) had a higher increase in bone mineral than both Group 1 (alcohol fractured) and Group 3 (water fractured). The only possible explanation for this would be a contribution of fat immobilization mineral turnover. The increase in breaking strength was by far the greatest in Group 1 (alcohol fractured). This corresponds very well with the histological findings that revealed these groups of animals healed their fractures primarily by bone healing. This is a superior form of healing than healing by cartilage callus. We cannot explain why Group 1 (alcohol fractured) healed by primary bone formation. This type of repair is usually reserved for those cases when there is "absolute firm immobilization of the fracture." One explanation might be that the animals on alcohol were less active, thereby decreasing the amount of motion at their fracture site.
CONCLUSION We have been able to demonstrate in a very limited
508
group of animals that alcohol given to laboratory animals causes a decrease in bone mineral in a short period of time. With the addition of a fracture that causes mobilization of calcium as well as an increased production of ground substance, it appears as though alcohol does not cause any derangement in the production of the ground substance. Therefore, it would appear as though the changes in the animals on alcohol resulted from a derangement in calcium metabolism. Literature Cited 1. Snell W. The chronic alcoholic and his fractures. J Bone Joint Surg. 1971 ;53A:1 655. Abstract. 2. Kristensson J, Lunden A, Nilsson BE. Fracture incidence and diagnostic roentgen in alcoholics. Acta Scand. 1 980;51 :205-207. 3. Honkanen R, Ertama L, Kuosmanen P, et al. The role of alcohol in accidental falls. J Stud Alcohol. 1983;44:231-245. 4. Johnell 0, Nilsson BE, Wiklund PF Bone morphometry in alcoholics. Clin Orthop. 1982;165:253-258. 5. Lalor B, Counihan TB. Metabolic bone disease in heavy drinkers. Clin Sci. 1982;63:43. Abstract. 6. Pierce RO. Bone changes in alcoholics. J Natl Med Assoc. 1979;71:1213-1216. 7. Oppenheim WL. The battered alcoholic syndrome. J Trauma. 1977;1 7:850-856. 8. Nilsson BE, Weslin NE. Changes in bone mass in alcoholics. Clin Orthop. 1973;90:229-232. 9. Saville PD. Changes in bone mass with age and alcoholism. J Bone Joint Surg. 1 965;47A:492-499. 10. Saville PD, Lieber CS. Effect of alcohol on growth bone density and muscle magnesium in the rat. J Nutr 1965;87:477484. 11. Saville PD. Alcohol-related skeletal disorders. Ann NY Acad Sci. 1975;252:287-291. 12. Smith JJ. The effect of alcohol on the adrenal ascorbic acid and cholesterol in rats. J Clin Invest. 1951;1 1:792-802. 13. Yu WY. Photon absorpiometry, the effect of alcohol on the mineral content of bone. An experimental study. Orthopaedic Transactions. 1977;1:32. 14. Lau JR, Farley R, Fitzsimmons AK. An in vitro investigation of effects of ethanol on bone formation and bone resorption. Orthopaedic Research Society. 1985;9:278-279.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 6
