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Inhibition of bone resorption and stimulation of formation by mechanical loading of the modeling rat ulna in vivo.

During normal growth of the rat ulna, bone is resorbed from the medial periosteal surface. This occurs as part of the modeling process by which the bone achieves its adult shape. By attaching strain gauges to the ulnae of rats in vivo, we measured the strains imposed on that surface of the bone during normal locomotion. We then applied mechanical loads to the ulnae of other rats in vivo for 6 consecutive days, inducing strains approximately double those we had measured. Fluorochromes were given on the 1st and 5th days. The histology of the medial ulnar periosteal surface was correlated with the amount of fluorochrome incorporation and tartrate resistant acid phosphatase (TRAP) activity in serial sections. In the nonloaded ulnae, the surfaces were lined with bone resorbing cells. Corresponding areas of the loaded bones were lined with osteoid and osteoblasts. There was insignificant label incorporation in the nonloaded bones but almost continuous label incorporation in the corresponding regions of the loaded bones, which was significantly different from the nonloaded bones. TRAP activity of the periosteal cells in the loaded bones was significantly less than in the nonloaded limbs. It is widely acknowledged that loading induces bone formation, and this implies that it also has the ability to inhibit resorption. However, to date there has been little direct evidence for the inhibition of resorption in vivo by mechanical loading. The changes we have observed are similar to the sequence of cellular events that occur during the reversal phase of bone remodeling, in which osteoclastic resorption ceases and osteoblasts are recruited and begin formation. This model may help increase understanding of that process.

Acid Phosphatase↗

Age-dependence of bone material quality shown by the measurement of frequency of resonance in the ulna.

In women before and after the age of peak bone mass, identical values of bone mineral density (BMD) can be obtained. However, there is a much higher incidence of osteoporotic fractures in older women. We investigated whether a deterioration of bone material quality with increasing age might contribute to this phenomenon. Material properties of bone tissue can be characterized by the modulus of elasticity, which is correlated to the square of sound transmission velocity. In this study, sound transmission velocity was determined in cortical bone by measuring the frequency of resonance in the ulna in the direction of the bone's longitudinal axis and correcting the values by multiplying by ulna length. Validation of this method indicated acceptable reproducibility: interobserver variability determined as the mean coefficient of variation was 1.82%. In a clinical study, 21 young women (22.5 +/- 1.2 years old) were compared with 21 middle-aged women (52.9 +/- 2.7 years old). Pairs were matched that had identical values of BMD in the nondominant forearm at a location representing mainly cortical bone (SPA). The product of ulna length and frequency of resonance in the ulna in the younger women was found to be 61.4 +/- 5.8 m/second, and in the middle-aged women 55.7 +/- 4.5 m/second. The difference was highly significant with P < 0.005. Our results confirm recent findings indicating a deterioration of bone material quality independent of BMD with increasing age.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

[Fracture of the distal ulna accompanying fracture of the distal radius. Minimally invasive treatment with elastic stable intramedullary nailing (ESIN)].

The distal radius is one of the commonest sites of fracture, and this injury is sometimes associated with fracture of the distal ulna. In recent years, surgical treatment of distal radius fractures has consisted increasingly in internal fixation with locking plates followed by early functional postoperative treatment. The associated injury to the distal ulna has so far not received much attention in the literature. Various techniques have veen described for its treatment: Kirscher wire fixation, tension band wiring, and internal fixation with screws and plates. Following positive results with elastic stable intramedullary nailing (ESIN) in the treatment of shaft fractures in children this technique was also applied in in fractures in adults (forearm, clavicle). Use of this technique for stabilisation of distal ulnar fractures has not previously been reported. In the course of a prospective longitudinal study (EBM level II), in 26 patients with an average age of 73.6 (42-88 years), bone healing in anatomical position was achieved in all cases within 6-12 weeks after closed reduction and anterograde ESIN with subsequent treatment that did not involve immobilization. No length differences of more than 2 mm and no functionally relevant deviations of the ulnar axis were observed. Apart from 3 cases of nail perforation at the distal end of the ulna, which had no clinical manifestations, there were no complications. ESIN offers a minimally invasive option for the treatment of unstable fractures of the distal ulna associated with distal radius fractures; it allows functional aftertreatment and can be regarded at least as an alternative to open reduction with internal fixation.

Adult↗

Contoured LCDC plating of the proximal ulna.

Comminuted fractures of the proximal ulna, particularly in combination with dislocation of the radial head, represent complex injuries which threaten both elbow and forearm motion. Thirty-seven complex proximal ulna fractures were treated with a dorsally applied, limited-contact titanium plate, contoured to fit the anatomy of the olecranon and proximal ulna. Twenty-four patients had Monteggia fracture/dislocations, and 13 had isolated but complex fractures of the proximal ulna. After an average follow up of 24 months, good or excellent functional results were achieved in 27 patients.

Adolescent↗

Cross-sectional geometrical properties and bone mineral contents of the human radius and ulna.

The mechanical strength of the human radius and ulna depends on their geometrical and material properties. This study quantifies the cortical bone cross-sectional properties of the adult radius and ulna (cross-sectional area, thickness, centroids, area moments of inertia and section moduli) using computerized tomographic (CT) scanning coupled with image processing along the lengths of eight human cadaveric forearms. Bone mineral mass and apparent ash density were also quantified at serial locations. Sites of significant variation of selected geometric and mineral properties along the length of each forearm bone were determined. Our results show that interpolation of CT measurements made at 10 and 30% of the radial length in the radius and 30 and 90% of the radial length in the ulna can provide approximate geometric values over the 10-90% region. This information can be used to develop a protocol using the fewest sites to clinically assess changes in forearm bone geometry. Regression analyses did not show significant linear relationships between geometric properties and apparent cortical ash density. Thus, CT derived geometric properties are not helpful in estimating the extent of changes in bone density. Area moment of inertia results suggest that the junction of the middle and distal third of the radius, and the ulnar shaft region may have increased vulnerability to fractures. The former is likely due to the change in moment of inertia values, whereas the latter is due to the relatively small magnitude of cross-sectional moments along the ulnar shaft as compared to the proximal or distal ends. This is consistent with fracture patterns observed clinically when a single forearm bone is fractured: Galeazzi fracture of the radius and nightstick fracture of the ulna.

Biomechanical Phenomena↗

Extensor carpi ulnaris and flexor carpi ulnaris tenodesis of the unstable distal ulna.

A procedure for stabilizing the distal ulna using the extensor carpi ulnaris and flexor carpi ulnaris is described. Seven patients who had sustained posttraumatic distal ulnar dorsal instability and articular degeneration and one patient with instability caused by rheumatoid arthritis were operated on. All eight obtained stable ulnae with mean motion of 62 degrees of supination and 86 degrees of pronation (mean increase of 32 degrees of supination and 43 degrees of pronation). Follow-up averaged 28 months (range, 18 to 63 months). The tenodesis, using a weave of a distally-based slip of flexor carpi ulnaris and a proximally-based slip of extensor carpi ulnaris combined with a Darrach procedure, is a reliable, reproducible salvage procedure for stabilizing the degenerated distal radioulnar joint and for salvaging the symptomatic unstable ulna after excessive distal ulna resection.

Adult↗

Matched distal ulna resection for posttraumatic disorders of the distal radioulnar joint.

In 1985 we published the results of the matched ulna resection in 44 patients, the majority of whom had rheumatoid arthritis. The matched ulna resection maintains the continuity of the distal ulna to the ulnar sling mechanism, including the triangular fibrocartilage complex (TFCC), and resects the distal ulna in a smooth, curved, convex fashion to match the contour of the radius throughout forearm rotation. This article presents the results of the procedure in patients with posttraumatic and mechanical disorders of the distal radioulnar joint. Good to excellent results were noted in 24 of 32 patients. The outcome was related to the severity of the patient's initial problem.

Adolescent↗

Condylar blade plate fixation of unstable fractures of the distal ulna associated with fracture of the distal radius.

PURPOSE: To review the results of condylar blade plate fixation of unstable fractures of the distal ulna associated with fracture of the distal radius. METHODS: Twenty-four patients in whom a minicondylar blade plate was used to repair an unstable fracture of the distal ulna associated with a fracture of the distal radius were reviewed retrospectively an average of 26 months (range, 12-50 months) after injury. According to the Q modifier of the Comprehensive Classification of Fractures, there were 1 simple fracture of the ulnar neck (Q2), 20 comminuted fractures of the ulnar neck (Q3), and 3 fractures of the head and neck (Q5). Subsequent surgeries included repeat fixation and autogenous cancellous bone grafting in 2 patients with nonunion of the distal radius and 1 with nonunion of the distal ulna. Seven patients had a second operation to remove the ulnar plate secondary to discomfort from plate prominence. RESULTS: The final average motion was as follows: degrees of flexion (range, 30 degrees-80 degrees), 52 degrees of extension (range, 40 degrees-90 degrees), 76 degrees of pronation (range, 45 degrees-90 degrees), and 70 degrees of supination (range, 45 degrees-90 degrees). Grip strength averaged 64% of the contralateral, uninjured extremity (range, 35%-100%). Final radiographic measurements included an average palmar tilt of the distal articular surface of the radius of 8 degrees (range, 0 degrees-20 degrees of palmar tilt), ulnar inclination of 21 degrees (range, 15 degrees-25 degrees), and ulnar positive variance of 1 mm (range, 0-4 mm). There were no problems related to the distal radioulnar joint. According to the system of Gartland and Werley as modified by Sarmiento, there were 6 excellent, 15 good, and 4 fair results at final evaluation. CONCLUSION: For unstable fractures of the distal ulna associated with fracture of the distal radius, condylar blade plate fixation can achieve healing with good alignment, satisfactory function, and an acceptable rate of secondary surgery.

Adolescent↗

Corrective osteotomies of the radius and ulna for supination contracture of the pediatric and adolescent forearm secondary to neurologic injury.

PURPOSE: To present the authors' experience with internal fixation of the radius and ulna as a surgical option for correction of supination contracture of the forearm. METHODS: Twelve patients (13 limbs) had an osteotomy of the radius and ulna for a supination deformity secondary to a residual brachial plexus or spinal cord injury. Surgery consisted of proximal ulna and distal radius osteotomies combined with plate fixation. RESULTS: The average age of the patients at the time of surgery was 11 years. Five limbs had fixed supination deformities and 8 limbs lacked pronation beyond neutral. The average preoperative supination deformity (either fixed or measured at midarc) was 76 degrees. The average intraoperative correction was 86 degrees. The average follow-up period was 16 months. The average midrange resting position maintained at final follow-up evaluation was 2 degrees of pronation. All limbs ultimately obtained radiographic and clinical union of the osteotomy sites. Complications included 6 plate fractures; however, only 1 patient required revision internal fixation. CONCLUSIONS: The combination of a proximal ulna and distal radius osteotomy with internal fixation can provide excellent correction, but the implant must be strong enough to hold the osteotomies rigidly in the corrected position during the time needed for union. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.

Adolescent↗

The load-bearing characteristics of the forearm: pattern of axial and bending force transmitted through ulna and radius.

A biomechanical study was performed on 12 cadaveric arms to define the normal profiles of force transmission through the ulna and radius and demonstrate the effect on these of simulated injury of the distal radioulnar joint (DRUJ). Strain gauges were used to measure the axial and bending forces transmitted through each bone. Axial force transmitted through the ulna is, broadly, reciprocal to that seen in the radius, with the greatest force seen in supination. In all 12 arms, axial loading of the hand created an anterior bending force (to create a posterior convexity) in the distal radius. Axial loading of the hand created an anterior bending force in the distal ulna for half the specimens and a posterior bending force in the remaining half. Division and division with reconstruction of either the volar or the dorsal distal radioulnar ligament (DRUL) had no significant effect on force transmission through the ulna and radius, while excision of the ulnar head significantly disrupted the profiles of the axial and bending forces.

Aged↗

[The step-cut shortening osteotomy of the shaft of the ulna, technique and results].

Step-cut shortening osteotomy of the ulna for impingment of the distal ulna relies on the principles enunciated by Desanfans 1953. We recommend the plate be placed on either the palmar or the dorsal aspect of the ulna. Used since 1990 this technique has enabled primarily bony healing by 6 months in all the 18 cases operated upon. A significant clinical improvement as measured by the scoring system of Chun and Palmer was noted at a median follow-up of 95.7 months. Shortening did not unfortunately, appear to stabilize the distal ulna and those patients with residual clinical radioulnar instability had significantly worse results. We conclude that the technique presented gives reliable bone healing. It is a versatile and simple technique that requires no special instrumentation but does demand skill and precision.

Adult↗

[Hemi-epiphyseal lengthening of the ulna in Kienboeck's disease].

The authors report the first results of a hemiepiphyseal lengthening of the ulna in a case of Kienböck's disease. Only the articular portion of the inferior epiphysis of the ulna is lengthened, the position of the styloid ulna being left untouched. The results of 17 cases are analysed. There were no cases of pseudarthrosis. The risk of conflict between the styloid ulna and the triquetrum is avoided.

Adolescent↗

Segmental shortening of the ulna in some malunions of the distal radius.

In patients who have a malunion of the distal part of the radius with a shortened radius, the ulna is too long. A discrepancy between the ulna and the lower radius, and between the ulna and the carpal bones occurs, compromising the mobility and appearance of the wrist. We reviewed ten such patients in whom the ulna was shortened by performing a resection of a diaphysar cylinder followed by a plate osteosynthesis. This method restored the normal anatomy of the distal radio-ulnar joint, markedly reduced the patient's pain and improved pronation and supination. When performed in young patients, when the radial deformity is not very important, this procedure has most satisfying functional results.

Adolescent↗

Stress distribution in the ulna following a hinged elbow arthroplasty. A finite element analysis.

The failure rates for total elbow arthroplasty, in comparison to those for hip arthroplasty, are quite high, and a precise understanding of the underlying causes still remains elusive. The presence of abnormal stresses is a known factor that accelerates loosening of hip and knee arthroplasties. Although a large number of biomechanical studies have led to a better understanding of elbow joint kinetics, very little is known about the stress distribution in this joint. The implantation of a Coonrad humeral component increases stresses in the bone and cement adjacent to the stem tip and hinge regions. An analysis of implanted ulnar stresses and a comparison of those stresses to implanted humeral stresses would improve our understanding of hinged elbow arthroplasty. For this reason, the distribution of mechanical stresses in the ulna are investigated in this study. Using a specially developed casting and sectioning technique, three-dimensional finite element meshes were obtained from an intact human cadaver ulna and an ulna fitted with a Coonrad prosthesis. The material properties were derived from values presented in the literature. Stress distributions in response to axial compression, axial torque, and anteroposterior (AP) force were computed. The cancellous bone and cement regions adjacent to the stem tip of the prosthesis exhibited higher stresses than those in the same regions of the intact case. The higher stresses in the ulna with an implanted prosthesis, as compared to the intact model, might initiate loosening or failure of the prosthesis. The stresses in the cortical bone region adjacent to the prosthesis head were decreased. This is consistent with the clinical observations of bone atrophy following total elbow arthroplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

Modulation of appositional and longitudinal bone growth in the rat ulna by applied static and dynamic force.

Appositional and longitudinal growth of long bones are influenced by mechanical stimuli. Using the noninvasive rat ulna loading model, we tested the hypothesis that brief-duration (10 min/day) static loads have an inhibitory effect on appositional bone formation in the middiaphysis of growing rat ulnae. Several reports have shown that ulnar loading, when applied to growing rats, results in suppressed longitudinal growth. We tested a second hypothesis that load-induced longitudinal growth suppression in the growing rat ulna is proportional to time-averaged load, and that growth plate dimensions and chondrocyte populations are reduced in the loaded limbs. Growing male rats were divided into one of three groups receiving daily 10 min bouts of static loading at 17 N, static loading at 8.5 N, or dynamic loading at 17 N. Periosteal bone formation rates, measured 3 mm distal to the ulnar midshaft, were suppressed significantly (by 28-41%) by the brief static loading sessions despite normal (dynamic) limb use between the daily loading bouts. Static loading neither suppressed nor enhanced endocortical bone formation. Dynamic loading increased osteogenesis significantly on both surfaces. At the end of the 2 week loading experiment, loaded ulnae were approximately 4% shorter than the contralateral controls in the 17 N static and dynamic groups, and approximately 2% shorter than the control side in the 8.5 N static group, suggesting that growth suppression was proportional to peak load magnitude, regardless of whether the load was static or dynamic. The suppressed growth in loaded limbs was associated with thicker distal growth plates, particularly in the hypertrophic zone, and a concurrent retention of hypertrophic cell lacunae. Negligible effects were observed in the proximal growth plate. The results demonstrate that, in growing animals, even short periods of static loading can significantly suppress appositional growth; that dynamic loads trigger the adaptive response in bone; and that longitudinal growth suppression resulting from compressive end-loads is proportional to load magnitude and not average load.

Animals↗

Strain rate as a controlling influence on adaptive modeling in response to dynamic loading of the ulna in growing male rats.

To test the hypothesis that the rate of change of strain to which a bone is subjected is an important determinant to the subsequent functionally adaptive modeling response, the ulnae of growing male rats were subjected to dynamic axial loading in vivo for a short period each day over 2 weeks. Due to the longitudinal curvature of the ulna, such axial loading leads to both compression and bending. The left ulna in three groups of rats was loaded cyclically between 1 and 20 N in a trapezoidal pattern to produce dynamic, longitudinal compressive strains of -0.004 (-4000 microstrain) at the medial midshaft with one of three strain rates: low (+/-0.018 sec(-1); n = 7); moderate (+/-0.030 sec(-1); n = 7); and high (+/-0.100 sec(-1); n = 8). These strain rates span the range recorded from strain gauges bonded to the bone at this site during a variety of normal activities. At the end of the experiment, the loaded ulnae were slightly, but significantly, shorter than their contralateral controls (2.7% to 5.6% mean change in length; p < 0.0001). This effect was most marked at lower strain rates, associated with an increased load-bearing time. The pattern of adaptive modeling along the bone shaft was similar for all groups, each showing a reduced rate of periosteal expansion proximally, and increased periosteal new bone production distally. This distal increase was achieved through enhanced periosteal bone formation on the lateral (tension) cortex, and arrest of resorption, with conversion to formation on the medial (compression) surface. The modeling response to axial loading therefore involves complex location-dependent increases and decreases in both formation and resorption. The high-strain-rate group demonstrated a 54% greater osteogenic response than the moderate-strain-rate group, which in turn showed a 13% larger response than the low-strain-rate group. Rate of strain change is therefore a major determinant of the adaptive osteogenic/antiresorptive response to mechanical load. Across the physiological range, a high rate of strain change provides a greater osteogenic stimulus than the same peak strain achieved more slowly.

Adaptation, Physiological↗

[Partial resection of the ulna as a diaphyseal bone defect model in the dog].

A 25-mm periosteal cylinder was removed from the middle of the ulna in fully grown mongrel dogs. A silastic block was interposed and the defect was fixed by a plate. Eight weeks later, the block was removed. During the following 24 weeks, spontaneous bone regeneration was evaluated by radiologic and histomorphometric evidence. In a second series, three screws were placed transversely to the longitudinal axis from the ulna into the radius to stabilize the partial resected ulna. The observation period after silastic removal was 16 weeks. Evaluation was based on radiology and on Indian ink stain of the vessels. Plate fixation provides an essentially stable defect model, with partly considerable bone apposition to the proximal area of resection. This is explained by the entry of the only nutrient artery into the proximal diaphyseal third. No instance of spontaneous defect healing following plate fixation was observed. The transverse fixation of the ulna revealed early radiologic signs of instability.

Animals↗

The anatomic basis of a free vascularized bone graft based on the canine distal ulna.

The anatomy of the canine distal ulna was evaluated to determine its potential as a free vascularized bone graft. Twelve cadavers were studied by gross dissection and nonselective and selective angiography. The caudal interosseous artery consistently served as a source artery to the distal ulnar periosteal vasculature in all dogs. The diameters of the caudal interosseous artery and venae comitantes were large enough to permit microvascular anastomoses. Nonselective perfusions of the brachial artery demonstrated large barium-filled vessels within soft tissues surrounding the ulna with anastomotic connections between medullary and periosteal vasculature. Grafts selectively perfused through the caudal interosseous artery (periosteal circulation only) had barium-filled vessels within the muscular cuff, periosteum, cortical bone, and medullary canal of the ulna. A surgical approach to remove the distal ulna along with an intact musculoperiosteal cuff and its associated vasculature is described.

Angiography↗