MMed (Orthopaedic Surgery), Faculty of Health Sciences, University of the Witwatersrand / Intramedullary nail insertion into a fractured bone allows stabilisation of the fracture with minimal intervention through the zone of injured tissue. This study aimed to assess whether intramedullary nailing of the forearm bones (radius and/or ulna) is a safe and effective form of management of these often complex fractures. A prospective case series was followed from presentation to fracture union. Between April 2006 and February 2008, 21 patients were enrolled in the study. The fracture union rate was high and complication rate was low. There was no increased risk of sepsis. The use of intramedullary nailing for diaphyseal fractures was successful but metaphyseal fractures, particularly with shortening, may be problematic. The use of intramedullary nailing for radius/ulna fractures is safe and effective, however the widespread use of this technique may be limited by the cost of the implant.

No description available.

Currently Dual energy X-ray Absorptiometry (DXA) and Quantitative Ultrasound (QUS) are used readily in the clinical environment for the assessment of bone quality. However, neither measure is a direct mechanical measure of bone. A Mechanical Resonance Tissue Analyzer (MRTA) has been developed that looks at the ulna’s deformation curve to vibration to achieve the measure of EI, cross sectional bending stiffness. This study investigated the relationships between MRTA to that of QUS and DXA. Regression analysis found significant linear correlations between EI to BMD and BMC, however, no significant relationships were found between EI and the variables of QUS. However, this technology is seen to have a potential for the assessment of in vivo bone quality. Furthermore, an improved configuration of the MRTA device is described, in addition to how preliminary results correspond to theoretical results.

Currently Dual energy X-ray Absorptiometry (DXA) and Quantitative Ultrasound (QUS) are used readily in the clinical environment for the assessment of bone quality. However, neither measure is a direct mechanical measure of bone. A Mechanical Resonance Tissue Analyzer (MRTA) has been developed that looks at the ulna’s deformation curve to vibration to achieve the measure of EI, cross sectional bending stiffness. This study investigated the relationships between MRTA to that of QUS and DXA. Regression analysis found significant linear correlations between EI to BMD and BMC, however, no significant relationships were found between EI and the variables of QUS. However, this technology is seen to have a potential for the assessment of in vivo bone quality. Furthermore, an improved configuration of the MRTA device is described, in addition to how preliminary results correspond to theoretical results.

Thesis (MSc.(Anatomy)--Faculty of Health Sciences)-University of Pretoria, 2008. / Summary in English and Afrikaans. Includes bibliographical references.

Investigation of activated remodelling in the healing of experimental stress fractures and the influence of anti-inflammatory treatments Lisa Jane Kidd Abstract Targeted and focal remodelling are important processes in bone homeostasis and pathology. However, the factors that initiate and direct remodelling to repair microcracks, or respond to excess loading are still poorly understood. The rat ulna-loading (RUL) model has been widely used to examine modelling and remodelling responses to axial cyclic loading. However the model has not yet been fully characterised. Stress fractures are common amongst athletes, dancers and military recruits, but there is almost no information available on the mechanism of healing of these fractures. Although cyclooxygenase-2 (COX-2) is a key mediator of bone resorption and bone formation, very little information is available on the effect of non-steroidal antiinflammatories (NSAIDs) on stress fracture healing. Remodelling may play a role in the pathogenesis of stress fractures, and there is growing interest in the potential use of bisphosphonates to prevent them. Nonetheless, the effect of bisphosphonates on stress fracture healing is not known. PMX53 is a C5a receptor antagonist developed as a novel anti-inflammatory agent. It is effective against inflammatory arthritis, but has not been tested in any fracture models. The aims of this study were to undertake a detailed examination of the histology, histomorphometry and gene expression of the healing and remodelling process initiated by RUL, and to use this model to determine the effects of selective and non-selective NSAIDs, a bisphosphonate and PMX53 on stress fracture healing. To characterise the RUL model, fatigue fractures were created by loading ulnae until displacement was observed to increase by between 4% and 50%. Ulnae were bulk-stained in basic fuchsin and processed for undecalcified histology. For all remaining experiments, loading was stopped when the displacement had increased by 10%. For detailed histology and histomorphometry, ulnae were decalcified, paraffin embedded and stained with toluidine blue, saffranin-O or for tartrate resistant acid phosphatase (TRAP). Ulnae were examined at 1, 2, 4, 6, 8, and 10 weeks after loading. The effects of DFU (a selective COX-2 inhibitor, 2 mg/kg po), ibuprofen (a non-selective NSAID, 30 mg/kg po) and PMX53 (10 mg/kg po) were examined at 2, 4 and 6 weeks after loading. Effects of risedronate (a bisphosphonate) were examined at a high (1.0 mg/kg po) and low dose (0.1 mg/kg po) at 2, 6 and 10 weeks after loading. RUL did not create isolated intracortical microcracks, but curvilinear fatigue fractures that occurred at a standard position in the medial cortex of the distal ulna diaphysis. These stress fractures induced rapid periosteal woven bone formation and direct intracortical remodelling along the fracture line that originated at the periosteum and progressed towards the medullary cavity. Basic multicellular units (BMUs) could be followed through serial sections extending along the fracture line towards the centre of the bone. Quantitative, real-time PCR was performed at 4 hours, 24 hours, 4 days, 7 days and 14 days after fatigue fracture. Following each period, bones were dissected and mRNA was extracted using standard protocols. Gene expression was compared between loaded and unloaded ulnae and to an unloaded control group. Four hours after loading, there was a marked, 220-fold increase (P<0.0001) in expression of Interleukin-6 (IL-6). There were also prominent peak increases in mRNA expression for Osteoprotegerin (OPG), cyclooxygenase-2 (COX-2), and vascular endothelial growth factor (VEGF) (all P<0.0001). At 24 hours there was a peak increase in mRNA expression for IL-11 (73-fold increase, P<0.0001). At 4 days there was a significant increase in mRNA expression for Bcl-2, COX-1, bone morphogenic protein (BMP)-2, insulin-like growth factor (IGF)-1, osteopontin (OPN), and stromal cell derived factor SDF-1. At 7 days there was a significant increase in mRNA expression of Receptor activator of nuclear factor kappa β ligand (RANKL) and OPN. The dramatic, early up-regulation of IL-6 and IL-11 suggests they play a central role in initiating signalling events for stress fracture healing. Treatment with PMX53 did not affect any measures of woven bone formation or stress fracture remodelling. There were no treatment effects of Ibuprofen or DFU on the area of woven bone. DFU treatment resulted in a significant reduction in the area of porosity (resorption) and BMU area along the fracture line at 2 weeks after fracture. Ibuprofen treatment resulted in a significant reduction in length and area of BMUs and new bone formation along the fracture line at 6 weeks (p < 0.05). This is the first report to demonstrate a negative effect on stress fracture healing of both a selective COX-2 inhibitor and a non-selective NSAID. These data confirm the importance of cyclooxygenase in bone resorption and formation during remodelling. Bisphosphonates are potent inhibitors of osteoclastic bone resorption Two, 6 and 10 weeks after loading, measures of resorption and new bone formation were significantly reduced along the fracture line by high dose risedronate treatment, but not by the low dose. Only the porosity along the fracture line 2 weeks after loading was significantly reduced by the low dose risedronate. The low dose more closely resembles the clinical dose used to treat patients. Woven bone formation and consolidation were not affected by the low or high doses of risedronate. In conclusion, fatigue fractures in the rat ulna are highly reproducible, induce exuberant periosteal woven bone formation, and heal by direct remodelling along the fracture line. Remodelling is associated with gene expression for molecules typically associated with bone resorption and formation, angiogenesis and cell signalling. Remodelling of the stress fracture line was adversely affected by treatment with selective and non-selective COX inhibitors, by high dose treatment with risedronate, but not by PMX53, a C5a antagonist.

Bone mineral content (BMC) and bone mineral density (BMD), measured by dual x-ray absorptiometry are used clinically to diagnose osteoporosis and estimate risk for fragility fractures. Bone mineral explains up to 70% of bone strength; however, it does not take into account bone geometry. Mechanical Response Tissue Analysis is a method of non-invasively measuring the bending stiffness (EI) of bone which is determined by the product of Young's modulus of elasticity (E) and the areal cross sectional moment of inertia (I). The aim of the current study was to determine if high intensity strength training will increase ulnar bending stiffness in young women. Forty-nine women aged 19.9 ± 1.7 yrs, trained their nondominant arm either concentrically or eccentrically in the Isokinetic modality on the Biodex® system III 3d/wk for 32 wks. The dominant arm served as the control limb (untrained). Analysis of all subjects regardless of training mode demonstrated a significant increase in ulnar EI (22% ↑, P=0.01) with no significant difference in the untrained arm. When EI results were assessed by training mode, subjects who trained eccentrically showed a significant increase for ulnar EI in the trained limb (40% ↑, P=0.01) with no significant effect on the untrained limb while concentric training demonstrated no significant gain in either the trained or untrained arm. There was no effect of time x mode of training interaction for either the trained or untrained limb. Bone mineral density and bone mineral content of the ulna increased significantly in the trained arm in both concentric and eccentric training modes (P<0.05). These findings suggest support for the hypothesis that a critical threshold of mechanical bending loads may be necessary to effect an adaptation in bone strength and thus, eccentric training may be a novel approach to increase ulnar EI in young women. / Master of Science

A utilização de enxertos ósseos vem aumentando bastante em pequenos animais, entretanto, em aves esta utilização é menor devido à dificuldade de conseguir autoenxerto em quantidades adequadas. Sendo assim, o objetivo do projeto foi avaliar três tipos de enxertos em aves. Foram utilizadas 30 galinhas separadas em três grupos: grupo aloenxerto congelado em ultrafreezer (GUF) por duas semanas; grupo aloenxerto congelado em nitrogênio líquido (GNL) e grupo enxerto sintético de hidroxiapatita deficiente em cálcio (GHA). Os enxertos foram aplicados em defeito ósseo de aproximadamente 20mm na ulna das aves e fixados ao leito receptor com uma placa e quatro parafusos bloqueados. Os animais foram acompanhados por meio de avaliação clínica, radiográfica, histológica e biomecânica. A consolidação radiográfica ocorreu em 90% nos animais do GNL, 70% nos do GUF e 60% nos do GHA, com média de 47,14±13,50 dias no GUF, 61,67±21,79 dias no GNL e aos 70±18,17 dias no GHA, havendo diferença significativa entre o GUF e GHA. Histologicamente os enxertos do GUF apresentavam-se em processo de consolidação mais avançada, com remodelação óssea e a presença de osteoclastos. Na avaliação clínica todas as ulnas operadas tinham estabilidade, sem sinal de inflamação/contaminação, articulações preservadas, sem dor e sem desvios angulares graves na asa. Na análise biomecânica houve diferença significativa (p<0,05) entre o GNL e o GHA na resistência, já na avaliação de flexão máxima, observou-se diferença estatística entre o GHA e o GNL e entre o GHA e o GUF. Sendo assim, é possível concluir que os três enxertos testados podem ser utilizados em defeitos ósseos em aves, mas o melhor deles foi o GNL por apresentar mais vantagens na preparação, confecção, aplicação dos enxertos e resistência biomecânica, com maior taxa de consolidação óssea. / The use of bone grafts is increasing considerably in small animals, however, in poultry this use is less due to the difficulty of obtaining autograft in adequate quantities. Therefore, the objective of the project was to test three types of grafts, evaluating their best results over a period of 90 days. For this purpose, 30 chickens were divided into three groups: frozen ultra freezer allograft group (UFG) for two weeks; allograft frozen in liquid nitrogen group (LNG) and synthetic grafts of calcium deficient hydroxyapatite group (HAG). Grafts were applied to a bone defect of approximately 20 mm in the ulna of birds, in all three groups the grafts were fixed to the recipient bed with plates blocked and 4 screws locked. The animals were followed up by serial radiographs, histological examination, clinical orthopedic evaluation and biomechanical flexion assay. Radiographic consolidation occurred in 90% of the LNG, 70% in the GUF and 60% in the GHA, mean of 47.14 ± 13.50 days without UFG, 61.67 ± 21.79 days non LNG and at 70 ± 18.17 days without HAG, with a significant difference between UFG and HAG. Histologically, UFG grafts were in a more advanced consolidation process, presenting bone remodeling with a presence of osteoclasts In the clinical review, all of them were operated with stability, with no sign of inflammation / contamination, preserved joints, no pain and no angular deviations, graves in the nail. In the biomechanics, there was a significant difference (p <0.05) between LNG and HAG in the resistance, already in the evaluation of maximum flexion, it was observed statistical difference not HAG with LNG and HAG with UFG grafts. Thus, it is possible to conclude that the three grafts tested are feasible to be used in bone loss in birds, where the LNG was superior because it presented more advantages in the preparation, preparation and application of the grafts, presenting a higher rate of bone consolidation.

A utilização de enxertos ósseos vem aumentando bastante em pequenos animais, entretanto, em aves esta utilização é menor devido à dificuldade de conseguir autoenxerto em quantidades adequadas. Sendo assim, o objetivo do projeto foi avaliar três tipos de enxertos em aves. Foram utilizadas 30 galinhas separadas em três grupos: grupo aloenxerto congelado em ultrafreezer (GUF) por duas semanas; grupo aloenxerto congelado em nitrogênio líquido (GNL) e grupo enxerto sintético de hidroxiapatita deficiente em cálcio (GHA). Os enxertos foram aplicados em defeito ósseo de aproximadamente 20mm na ulna das aves e fixados ao leito receptor com uma placa e quatro parafusos bloqueados. Os animais foram acompanhados por meio de avaliação clínica, radiográfica, histológica e biomecânica. A consolidação radiográfica ocorreu em 90% nos animais do GNL, 70% nos do GUF e 60% nos do GHA, com média de 47,14±13,50 dias no GUF, 61,67±21,79 dias no GNL e aos 70±18,17 dias no GHA, havendo diferença significativa entre o GUF e GHA. Histologicamente os enxertos do GUF apresentavam-se em processo de consolidação mais avançada, com remodelação óssea e a presença de osteoclastos. Na avaliação clínica todas as ulnas operadas tinham estabilidade, sem sinal de inflamação/contaminação, articulações preservadas, sem dor e sem desvios angulares graves na asa. Na análise biomecânica houve diferença significativa (p<0,05) entre o GNL e o GHA na resistência, já na avaliação de flexão máxima, observou-se diferença estatística entre o GHA e o GNL e entre o GHA e o GUF. Sendo assim, é possível concluir que os três enxertos testados podem ser utilizados em defeitos ósseos em aves, mas o melhor deles foi o GNL por apresentar mais vantagens na preparação, confecção, aplicação dos enxertos e resistência biomecânica, com maior taxa de consolidação óssea. / The use of bone grafts is increasing considerably in small animals, however, in poultry this use is less due to the difficulty of obtaining autograft in adequate quantities. Therefore, the objective of the project was to test three types of grafts, evaluating their best results over a period of 90 days. For this purpose, 30 chickens were divided into three groups: frozen ultra freezer allograft group (UFG) for two weeks; allograft frozen in liquid nitrogen group (LNG) and synthetic grafts of calcium deficient hydroxyapatite group (HAG). Grafts were applied to a bone defect of approximately 20 mm in the ulna of birds, in all three groups the grafts were fixed to the recipient bed with plates blocked and 4 screws locked. The animals were followed up by serial radiographs, histological examination, clinical orthopedic evaluation and biomechanical flexion assay. Radiographic consolidation occurred in 90% of the LNG, 70% in the GUF and 60% in the GHA, mean of 47.14 ± 13.50 days without UFG, 61.67 ± 21.79 days non LNG and at 70 ± 18.17 days without HAG, with a significant difference between UFG and HAG. Histologically, UFG grafts were in a more advanced consolidation process, presenting bone remodeling with a presence of osteoclasts In the clinical review, all of them were operated with stability, with no sign of inflammation / contamination, preserved joints, no pain and no angular deviations, graves in the nail. In the biomechanics, there was a significant difference (p <0.05) between LNG and HAG in the resistance, already in the evaluation of maximum flexion, it was observed statistical difference not HAG with LNG and HAG with UFG grafts. Thus, it is possible to conclude that the three grafts tested are feasible to be used in bone loss in birds, where the LNG was superior because it presented more advantages in the preparation, preparation and application of the grafts, presenting a higher rate of bone consolidation.

A utilização de enxertos ósseos vem aumentando bastante em pequenos animais, entretanto, em aves esta utilização é menor devido à dificuldade de conseguir autoenxerto em quantidades adequadas. Sendo assim, o objetivo do projeto foi avaliar três tipos de enxertos em aves. Foram utilizadas 30 galinhas separadas em três grupos: grupo aloenxerto congelado em ultrafreezer (GUF) por duas semanas; grupo aloenxerto congelado em nitrogênio líquido (GNL) e grupo enxerto sintético de hidroxiapatita deficiente em cálcio (GHA). Os enxertos foram aplicados em defeito ósseo de aproximadamente 20mm na ulna das aves e fixados ao leito receptor com uma placa e quatro parafusos bloqueados. Os animais foram acompanhados por meio de avaliação clínica, radiográfica, histológica e biomecânica. A consolidação radiográfica ocorreu em 90% nos animais do GNL, 70% nos do GUF e 60% nos do GHA, com média de 47,14±13,50 dias no GUF, 61,67±21,79 dias no GNL e aos 70±18,17 dias no GHA, havendo diferença significativa entre o GUF e GHA. Histologicamente os enxertos do GUF apresentavam-se em processo de consolidação mais avançada, com remodelação óssea e a presença de osteoclastos. Na avaliação clínica todas as ulnas operadas tinham estabilidade, sem sinal de inflamação/contaminação, articulações preservadas, sem dor e sem desvios angulares graves na asa. Na análise biomecânica houve diferença significativa (p<0,05) entre o GNL e o GHA na resistência, já na avaliação de flexão máxima, observou-se diferença estatística entre o GHA e o GNL e entre o GHA e o GUF. Sendo assim, é possível concluir que os três enxertos testados podem ser utilizados em defeitos ósseos em aves, mas o melhor deles foi o GNL por apresentar mais vantagens na preparação, confecção, aplicação dos enxertos e resistência biomecânica, com maior taxa de consolidação óssea. / The use of bone grafts is increasing considerably in small animals, however, in poultry this use is less due to the difficulty of obtaining autograft in adequate quantities. Therefore, the objective of the project was to test three types of grafts, evaluating their best results over a period of 90 days. For this purpose, 30 chickens were divided into three groups: frozen ultra freezer allograft group (UFG) for two weeks; allograft frozen in liquid nitrogen group (LNG) and synthetic grafts of calcium deficient hydroxyapatite group (HAG). Grafts were applied to a bone defect of approximately 20 mm in the ulna of birds, in all three groups the grafts were fixed to the recipient bed with plates blocked and 4 screws locked. The animals were followed up by serial radiographs, histological examination, clinical orthopedic evaluation and biomechanical flexion assay. Radiographic consolidation occurred in 90% of the LNG, 70% in the GUF and 60% in the GHA, mean of 47.14 ± 13.50 days without UFG, 61.67 ± 21.79 days non LNG and at 70 ± 18.17 days without HAG, with a significant difference between UFG and HAG. Histologically, UFG grafts were in a more advanced consolidation process, presenting bone remodeling with a presence of osteoclasts In the clinical review, all of them were operated with stability, with no sign of inflammation / contamination, preserved joints, no pain and no angular deviations, graves in the nail. In the biomechanics, there was a significant difference (p <0.05) between LNG and HAG in the resistance, already in the evaluation of maximum flexion, it was observed statistical difference not HAG with LNG and HAG with UFG grafts. Thus, it is possible to conclude that the three grafts tested are feasible to be used in bone loss in birds, where the LNG was superior because it presented more advantages in the preparation, preparation and application of the grafts, presenting a higher rate of bone consolidation.