Static vs dynamic loads as an influence on bone remodelling

Remodelling activity in the avian ulna was assessed under conditions of disuse alone, disuse with a superimposed continuous compressive load, and disuse interrupted by a short daily period of intermittent loading. The ulnar preparation consisted of the 110mm section of the bone shaft between two submetaphyseal osteotomies. Each end of the preparation was transfixed by a stainless steel pin and the shaft either protected from normal functional loading with the pins joined by external fixators, loaded continuously in compression by joining the pins with springs, or loaded intermittently in compression for a single 100s period per day by engaging the pins in an Instron machine. Similar loads (525 N) were used in both static and dynamic cases. The strains engendered were determined by strain gauges, and at their maximum around the bone's midshaft were -0.002. The intermittent load was applied at a frequency of 1 Hz as a ramped square wave, with a rate of change of strain during the ramp of 0.01 s-1. Peak strain at the midshaft of the ulna during wing flapping in the intact bone was recorded from bone bonded strain gauges in vivo as -0.0033 with a maximum rate of change of strain of 0.056 s-1. Examination of bone sections from the midpoint of the preparation after an 8 week period indicated that in both non-loaded and statically loaded bones there was an increase in both endosteal diameter and intra cortical porosity. These changes produced a decrease in cross sectional area which was similar in the two groups (-13%).(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Effects of loading frequency on mechanically induced bone formation

The anabolic effect of mechanical loading on bone tissue is modulated by loading frequency. The objective of this study was to characterize the new bone formation on the periosteal and endocortical surfaces of the ulnar diaphysis in adult, female rats in response to controlled dynamic loading and to examine the interactions between strain magnitude, loading frequency, and bone formation rate (BFR/BS) for frequencies ranging from 1 to 10 Hz. Cyclic, compressive loading was applied to the ulnas of 60 adult, female rats divided into 12 loading groups. Loading was applied for 360 cycles/day with peak loads ranging from 4.3 to 18N at frequencies of 1, 5, and 10 Hz. After 2 weeks of loading, bone formation on the periosteal and endocortical surfaces of the ulna was quantified using double-label histomorphometry on transverse sections obtained at the middiaphysis. Periosteal bone formation increased in a dose-response manner with peak load at each of the three loading frequencies tested. Loading frequency significantly affected the x intercepts and slopes of the peak strain versus BFR/BS (p < 0.001) and peak strain versus mineralizing surface (MS/BS; p < 0.001) curves. Periosteal osteogenesis was best predicted by a mathematical model that assumed: (1) bone cells are activated by fluid shear stresses and (2) that stiffness of the bone cells and the extracellular matrix near the cells increases at higher loading frequencies because of viscoelasticity. Consequently, mechanotransduction appears to involve a complex interaction between extracellular fluid forces and cellular mechanics.

Prediction of adult height from height, bone age, and occurrence of menarche, at ages 4 to 16 with allowance for midparent height

Multiple regression equations for predicting the adult height of boys and girls from height and bone age at ages 4 and upwards are presented. There is a separate equation for each half year of chronological age; and for pre- and postmenarcheal girls at ages 11 to 14. These are based on longitudinal data from 116 boys and 95 girls of the Harpenden Growth Study and the London group of the International Children's Centre longitudinal study. The bone age used is the revised version of the Tanner-Whitehouse standards, omitting the score for carpal bones (RUS age, TW 2 system). Boys aged 4 to 12 are predicted in 95% of instances to within plus or minus 7 cm of true height, and at ages 13 and 14 to within plus or minus 6 cm. Girls ages 4 to 11 are predicted to within plus or minus 6 cm; premenarcheal girls aged 12 and 13 to within plus or minus 5 and plus or minus 4 cm, respectively; and postmenarcheal girls aged 12 and 13 to within plus or minus 4 and plus or minus 3 cm, respectively. Prediction can be somewhat imporved by allowing for midparent height. One-third of the amount that midparent height differs from mean midparent height is added or subtracted. An alternative system of equations which are based on initial classification by bone age rather than chronological age is given. These have about the same accuracy as the equations based on initial classification by chronological age, but allowance for bone age retardation is less. It is not clear which system is preferable. The equations probably apply to girls complaining of tall stature and boys or girls complaining of shortness and needing reassurance as to normality. In clearly pathological children, such as those with endocrinopathies, they do not apply.

The role of the resting zone in growth plate chondrogenesis

In mammals, growth of long bones occurs at the growth plate, a cartilage structure that contains three principal layers: the resting, proliferative, and hypertrophic zones. The function of the resting zone is not well understood. We removed the proliferative and hypertrophic zones from the rabbit distal ulnar growth plate in vivo, leaving only the resting zone. Within 1 wk, a complete proliferative and hypertrophic zone often regenerated. Next, we manipulated growth plates in vivo to place resting zone cartilage ectopically alongside the proliferative columns. Ectopic resting zone cartilage induced a 90-degree shift in the orientation of nearby proliferative zone chondrocytes and seemed to inhibit their hypertrophic differentiation. Our findings suggest that resting zone cartilage makes important contributions to endochondral bone formation at the growth plate: 1) it contains stem-like cells that give rise to clones of proliferative chondrocytes; 2) it produces a growth plate-orienting factor, a morphogen, that directs the alignment of the proliferative clones into columns parallel to the long axis of the bone; and 3) it may also produce a morphogen that inhibits terminal differentiation of nearby proliferative zone chondrocytes and thus may be partially responsible for the organization of the growth plate into distinct zones of proliferation and hypertrophy.

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.

Bone typology and growth rate: testing and quantifying 'Amprino's rule' in the mallard (Anas platyrhynchos)

Periosteal bone histology expresses its rate of deposition. This fundamental relationship between bone structure and growth dynamics, first assumed by Amprino many decades ago, was quantified in preliminary studies, but never statistically tested. Moreover, the precise typological characters of bone tissue linked to growth rate remained poorly known. Here, we present the first statistical analysis of 'Amprino's rule', measured on comprehensive growth series of the mallard, Anas platyrhynchos. Growth rates were assessed by fluorescent labelling. Bone typology was described according to Ricqlès' typological classification. Results show that the presence and proportion of primary osteons, two consequences of bone initial porosity at the time of its deposit, are strongly related to bone growth rate. However, no significant relationship between primary osteons orientation and bone growth rate could be detected, at least for osteonal orientations (longitudinal, laminar and reticular) and growth rates values observed in mallard long bones. These results suggest that Amprino's rule holds for some major typological characters of primary compact bone tissues (i.e. primary osteons presence and proportion). However, it is irrelevant to some other characters (i.e. osteonal orientation), the meaning of which remains to be discovered.

Influence of puberty on muscle area and cortical bone area of the forearm in boys and girls

The aim of the current study is to analyze the interaction of the muscle and bone system (muscle-bone unit) during puberty in males and females by computed tomography of the nondominant forearm. The data presented here are the first results from 318 healthy children (159 boys and 159 girls), aged 6-22 yr, and 336 adults (parents) participating in the DONALD Study (Dortmund Nutritional and Anthropometric Longitudinally Designed Study). Cortical area (CA) of the radius representing bone strength and muscle area (MA) representing muscle strength were measured with peripheral quantitative computed tomography (XCT 2000; Stratec, Pforzheim, Germany). A single slice measurement at a site corresponding to 65% of the ulnar length proximal to the radial endplate was used. MA and CA of the radius have been determined by a built-in software algorithm using density differences. There was a strong correlation between MA (x) and CA (y) in all children, adolescents, and adults (y = 0.019x + 10.93; r2 = 0.77). Before puberty, boys and girls displayed a similar relation between MA and CA. CA in relation to MA was greater in girls than in boys during puberty. Analysis of covariance was performed investigating the dependency of CA on MA, five pubertal stages, sex, and interaction of sex and pubertal stages. MA representing muscle strength was the strongest predictor of CA (P < 0.001) representing bone mass. Pubertal stage (P < 0.001) and interaction of pubertal stage*sex (P = 0.002) also had a significant influence on CA. r2 of the model was 0.85. These data suggest that in pubertal girls and women rather than in pubertal boys and men an additional factor shifts the relationship between MA and CA to higher values of cortical area. The present data confirm previous studies of the influence of puberty and estrogens or related factors on the muscle-bone interaction.

Multiple roles of Hoxa11 and Hoxd11 in the formation of the mammalian forelimb zeugopod

Mutations in the 5' or posterior murine Hox genes (paralogous groups 9-13) markedly affect the formation of the stylopod, zeugopod and autopod of both forelimbs and hindlimbs. Targeted disruption of Hoxa11 and Hoxd11 or Hoxa10, Hoxc10 and Hoxd10 result in gross mispatterning of the radius and ulna or the femur, respectively. Similarly, in mice with disruptions of both Hoxa13 and Hoxd13, development of the forelimb and hindlimb autopod is severely curtailed. Although these examples clearly illustrate the major roles played by the posterior Hox genes, little is known regarding the stage or stages at which Hox transcription factors intersect with the limb development program to ensure proper patterning of the principle elements of the limb. Moreover, the cellular and/or molecular bases for the developmental defects observed in these mutant mice have not been described. In this study, we show that malformation of the forelimb zeugopod in Hoxa11/Hoxd11 double mutants is a consequence of interruption at multiple steps during the formation of the radius and ulna. In particular, reductions in the levels of Fgf8 and Fgf10 expression may be related to the observed delay in forelimb bud outgrowth that, in turn, leads to the formation of smaller mesenchymal condensations. However, the most significant defect appears to be the failure to form normal growth plates at the proximal and distal ends of the zeugopod bones. As a consequence, growth and maturation of these bones is highly disorganized, resulting in the creation of amorphous bony elements, rather than a normal radius and ulna.

The effects of dynamic axial loading on the rat growth plate

Longitudinal bone growth can be suppressed by compressive loading. In this study, we applied three different magnitudes (17, 8.5, and 4N) of compressive force to growing rat ulnas 10 minutes/day for 8 days and investigated the effects on the distal growth plate biology. Further, to investigate growth rate recovery after cessation of loading, we examined rats 7 days after the loading period. Longitudinal growth of the ulna was suppressed in a dose-dependent manner by applied compressive force. In the 17N group, the longitudinal mineralization rate (LMR) at the distal growth plate was suppressed completely by loading and did not recover. However, in the 8.5N and 4N groups, LMR suppression recovered in 1 week. In the 17N group, growth plate height and hypertrophic zone height were significantly greater than control; the number of hypertrophic chondrocytes was increased; and some traumatic changes such as cracks in the growth plate were found. In addition, 17N loading suppressed cartilage mineralization and capillary invasion beneath the growth plate, although the number of chondrocytes synthesizing vascular endothelial growth factor (VEGF) was increased. Our study shows longitudinal growth suppression caused by axial loading of the ulna, which is proportional to the magnitude of load. Only the largest load (17N) caused morphological changes in the distal growth plate cartilage. There was no association found between mineralization and type X collagen localization or capillary invasion and VEGF expression.

Alendronate affects long bone length and growth plate morphology in the oim mouse model for Osteogenesis Imperfecta

Alendronate, a bisphosphonate drug, has shown promise in reducing remodeling and bone loss in postmenopausal osteoporosis. Alendronate acts directly on the osteoclast, inhibiting its resorption capability. This inhibition of osteoclast activity has led to the use of bisphosphonates in the treatment of the osteogenesis imperfecta condition. Treatment of osteogenesis imperfecta with bisphosphonates enhances bone strength, but the consequences on linear bone growth are not well defined. Using the oim mouse model for type III osteogenesis imperfecta, two doses of alendronate, low (0.125 mg/kg/wk) and high (2.5 mg/kg/wk) were administered weekly via intraperitoneal injection starting at 4 weeks of age and ending at 12 weeks of age to assess the effects of alendronate on humerus and ulna length. The higher dose of alendronate reduced humerus and ulna length in the oim/wt and wt/wt genotypes for both sexes (P < 0.05). The oim/oim humerus and ulna were not significantly affected by the higher dose of alendronate in females, but reduced bone length in males (P < 0.0085). Proximal humerus growth plate area was affected by both genotype and alendronate dose and growth plate diameter was increased at the chondro-osseous junction by both alendronate doses (P < 0.011). Genotype and alendronate dose affected growth plate height. The oim/oim genotype displayed taller growth plates. The high dosage of alendronate increased overall growth plate height, particularly within the hypertrophic zone, which suggests a failure of vascular invasion-induced apoptosis in the hypertrophic cells. In conclusion, these results indicate that high doses of alendronate (>2.5 mg/kg/wk) inhibit long bone length in mice through alteration of the growth plate and possibly reduced resorption at the chondro-osseous junction.

Skeletal growth of the protohistoric Arikara

The longitudinal growth of the long bones and growth in breadth of the ilium are assessed for a population of protohistoric Arikara Indians from South Dakota through the correlation of skeletal measurements with estimates of chronological age at death. Comparison of the Arikara growth data with those from other Indian samples (Indian Knoll and Late Woodland, Illinois) reveals similar rates of bone growth, when compensation is made for methodological variation. As predicted from documented variation in adult statures, the Indian samples indicate slower growth rates than those of Whites but faster than those of Eskimos.

Short term, low dose estradiol accelerates ulnar growth in boys

We previously described a biphasic dose-response curve for ethinyl estradiol on short term growth in patients with Turner's syndrome. To investigate whether there is a similar phenomenon in boys, we measured the 3-week ulnar growth velocity (TUG) after administration of different doses of estradiol to five prepubertal or early pubertal boys. Basal TUG was determined initially. Subsequently, the boys received a 4-day iv infusion of estradiol at each of three doses (4, 20, and 90 micrograms/day) given double blind in a randomized sequence. TUG was determined before and after each infusion and was allowed to return to baseline before giving the second and third infusions. Mean TUG increased from 0.45 +/- 0.11 (+/- SEM) to 1.38 +/- 0.51 mm/3 weeks after the 4 micrograms/day infusion (P less than 0.05), from 0.49 +/- 0.11 to 1.0 +/- 0.4 mm/3 weeks after the 20 micrograms/day infusion (P = NS), and from 0.46 +/- 0.1 to 0.84 +/- 0.12 mm/3 weeks after the 90 micrograms/day infusion (P = NS). The mean serum estradiol level was 10 +/- 2.3 pg/ml during the 4 micrograms/day infusion, 16 +/- 2.3 pg/ml during the 20 micrograms/day infusion, and 96 +/- 12 pg/ml during the 90 micrograms/day infusion. Mean serum somatomedin-C levels were significantly higher only after the 20 and 90 micrograms/day estradiol infusions. We conclude that low dose estrogen can stimulate ulnar growth in boys and may play a role in the male pubertal growth spurt.

Growth in revascularized bone grafts in young puppies

The results of microvascular transfers of growing ulnas in puppy forelegs have been studied. These transfers were carried out both heterotopically and orthotopically. The growth in the revascularized bone grafts has been compared to that in heterotopic, nonvascularized ulna transfers and to normal ulnar growth. The growth in the vascularized bone grafts was significantly greater than in the nonvascularized grafts, but significantly less than in normal ulnar growth. A metaphyseal contribution to the blood supply of the growing portion of long bones is suggested.

Remodelling after distal forearm fractures in children. I. The effect of residual angulation on the spatial orientation of the epiphyseal plates

The effect of residual fracture angulation on the distal radial and ulnar epiphyseal plates was studied in children aged 1 to 15 years. Thirty-eight fractures located in the distal fifth of the forearm bones were observed for 1 to 25 months after the fractures had healed. The forearms were examined radiographically on two to five occasions and the inclinations of the epiphyseal plates in relation to the long axis of the proximal fragments were measured. The results showed that an abnormal inclination of the epiphyseal plate after healing of a distal forearm fracture induced an alteration of growth in the epiphyseal plate. The redistribution of growth tended to correct the abnormal inclination. The rate of correction followed an exponential course. The age of the child at the time of the fracture and the distance from the fracture to the epiphyseal plate did not influence the capacity for correction.

Skeletal maturation and craniofacial growth

The purpose of this study was to assess the relevance of hand-wrist radiographs to craniofacial growth and clinical orthodontics. Serial annual cephalometric and hand-wrist radiographs and standing height measurements were obtained from a sample of 47 girls (ages 10 through 15 years) and 39 boys (ages 11 through 16 years) from the Bolton-Brush data base. Four skeletal linear measurements showing statistically significant increases were analyzed: SN, GoGn, SGo, and NMe. The hand-wrist radiographs were scored by the Tanner-Whitehouse TW2 RUS method of skeletal maturity assessment. The results of the study indicated that statural height and hand-wrist skeletal maturation in both sexes are significantly related. The children demonstrated a large variety of growth patterns, and growth spurts could not be consistently observed on an individual basis. Because of low statistical correlations, the relationship between acceleration and deceleration in growth of the specific craniofacial dimensions and statural height or skeletal maturity was not deemed clinically significant for prediction. However, it may be used as a factor for consideration in diagnosis and treatment planning of an individual case.

Growth rate rather than gender determines the size of the adaptive response of the growing skeleton to mechanical strain

To determine whether male and female skeletons are equally responsive to mechanical load, the left ulnae in a group of juvenile male (n = 7), and age-matched female (n = 9) rats received a short daily period of controlled dynamic loading in vivo (1200 cycles at 2 Hz each day for 10 days) in addition to their normal exercise. Axial loads for each group were adjusted to engender a peak dynamic strain of -4000 microstrain at the medial face of the ulna midshaft, applied and released at a rate of +/-30,000 microstrain/sec. Fluorescent labels were administered at the start and finish of the loading period. Over the course of daily loading, the body mass of the male rats increased 2.5 times faster than that of the females (6.3 g/day vs. 2.5 g/day). The increase in periosteal interlabel bone area due to growth and normal exercise was also 2.5 times greater in the males than in the females. Both genders showed statistically significant (p < 0.05) increases in periosteal new bone deposition in the ulna of their loaded compared with their control limb. The pattern of osteogenic response was similar in males and females and featured increased mineral apposition rate on the lateral surface of the ulna, and arrest of modeling-drift-related resorption with its reversal to bone formation on the medial surface. In males, the absolute loading-related increase in bone area was six times greater than that in females. However, when the absolute size of the loading-related change in periosteal interlabel new bone deposition was expressed relative to that due to growth, there was no difference between males and females (Mean +/- SEM: 37 +/- 12% for males, 34 +/- 12% for females). These data confirm that the ulna of young actively growing rats of both genders responds to a short daily period of loading with an altered modeling response that involves increased bone formation and decreased resorption. Although the absolute amount of new bone formation stimulated by loading is greater in males than in females there is no difference between genders following correction for the higher rate of bone deposition seen in the males in association with their faster rate of growth.

Curve Progression in Adolescent Idiopathic Scoliosis Does Not Match Skeletal Growth

BACKGROUND

Determining the peak growth velocity of a patient with adolescent idiopathic scoliosis (AIS) is important for timely treatment to prevent curve progression. It is important to be able to predict when the curve-progression risk is greatest to maximize the benefits of any intervention for AIS. The distal radius and ulna (DRU) classification has been shown to accurately predict skeletal growth. However, its utility in predicting curve progression and the rate of progression in AIS is unknown.

QUESTIONS/PURPOSES

(1) What is the relationship between radius and ulna grades to growth rate (body height and arm span) and curve progression rate? (2) When does peak curve progression occur in relation to peak growth rate as measured by months and by DRU grades? (3) How many months and how many DRU grades elapse between peak curve progression and plateau?

METHODS

This was a retrospective analysis of a longitudinally maintained dataset of growth and Cobb angle data of patients with AIS who presented with Risser Stages 0 to 3 and were followed to maturity at Risser Stage 5 at a single institute with territory-wide school screening service. From June 2014 to March 2016, a total of 513 patients with AIS fulfilled study inclusion criteria. Of these, 195 were treated with bracing at the initial presentation and were excluded. A total of 318 patients with AIS (74% girls) with a mean age of 12 ± 1.5 years were studied. For analysis, only data from initial presentation to commencement of intervention were recorded. Data for patients during the period of bracing or after surgery were not used for analysis to eliminate potential interventional confounders. Of these 318 patients, 192 were observed, 119 were braced, and seven underwent surgery. Therefore 192 patients (60.4%) who were observed were followed up until skeletal maturity at Risser Stage 5; no patients were lost to followup. The mean curve magnitude at baseline was 21.6 ± 4.8. Mean followup before commencing intervention or skeletal maturity was 4.3 ± 2.3 years. Standing body height, arm span, curve magnitude, Risser stage, and DRU classification were studied. A subgroup analysis of 83 patients inclusive of acceleration, peak, and deceleration progression phases for growth and curve progression was studied to determine any time lag between growth and curve progression. Results were described in mean ± SD.

RESULTS

There was positive correlation between growth rate and curve progression rate for body height (r = 0.26; p < 0.001) and arm span (r = 0.26; p < 0.001). Peak growth for body height occurred at radius grade (R) 6 (0.56 ± 0.29 cm/month) and ulna grade (U) 4 (0.65 ± 0.31 cm/month); peak change in arm span occurred at R5 (0.67 ± 0.33 cm/month) and U3 (0.67 ± 0.22 cm/month); and peak curve progression matched with R7 (0.80 ± 0.89 cm/month) and U5 (0.84 ± 0.78 cm/month). Subgroup analysis confirmed that peak curve progression lagged behind peak growth rate by approximately 7 months or one DRU grade. The mean time elapsed between the peak curve progression rate and the plateau phase at R9 U7 was approximately 16 months, corresponding to two DRU grades.

CONCLUSIONS

By using a standard skeletal maturity parameter in the DRU classification, this study showed that the maximal curve progression occurs after the peak growth spurt, suggesting that the curve should be monitored closely even after peak growth. In addition, the period of potential curve continuing progression extends nearly 1.5 years beyond the peak growth phase until skeletal maturity. Future studies may evaluate whether by observing the trend of growth and curve progression rates, we can improve the outcomes of interventions like bracing for AIS.

LEVEL OF EVIDENCE

Level II, prognostic study.

Which morphologies of synovial folds result from degeneration and/or aging of the radiohumeral joint: an anatomic study with cadavers and embryos

The synovial folds of the radiohumeral joints in cadaveric elbows from 179 elderly subjects and 40 embryos were investigated macroscopically and histologically to determine any morphologic changes caused by aging or degeneration. The anterior and posterior folds found in the elderly population shared characteristics of folds seen in embryos, with some modifications, and were thought to originate from the primitive septum. Proportionally, the length, width, and thickness of these folds were consistent between adults and embryos. However, the embryonic folds showed a homogenous morphology. In contrast, in the adult the anterior fold was characterized by a shorter and narrower villous pattern, and the posterior fold tended to be wider. Lateral extension of the anterior or posterior folds was also observed. Moreover, the lateral fold, never seen in embryos, was present and characterized by a hard plicate pattern in the adult. These derived or specific morphologies in adults probably result from alterations in the movement of the radial head caused by aging.

Free microvascular epiphyseal transplantation: an experimental study in dogs

Orthopic and heterotopic microvascular epiphyseal transplants based on periosteal blood supply were performed in 2 experiments. Heterotopic transplants averaged 69 per cent of growth of non-operated control bones. Orthopic transplants achieved a better result but the number of dogs available for evaluation was too small to be conclusive. The question is raised whether additional blood supply to the epiphyseal side of the transplant could improve the results.

Assessing bone microstructure at the distal radius in children and adolescents using HR-pQCT: a methodological pilot study

We examined the use of high-resolution peripheral quantitative computed tomography (HR-pQCT [XtremeCT; Scanco Medical, Switzerland]) to assess bone microstructure at the distal radius in growing children and adolescents. We examined forearm radiographs from 37 children (age 8-14 yr) to locate the position of the ulnar and radial growth plates. We used HR-pQCT to assess bone microstructure in a region of interest (ROI) at the distal radius that excluded the growth plate (as determined from the radiographs) in all children (n=328; 9-21 yr old). From radiographs, we determined that a ROI in the distal radius at 7% of bone length excluded the radial growth plate in 100% of participants. We present bone microstructure data at the distal radius in children and adolescents. From the HR-pQCT scans, we observed active growth plates in 80 males (aged 9.5-20.7 yr) and 92 females (aged 9.5-20.2 yr). The ulnar plate was visible in 9 male and 17 female participants (aged 11.2 ± 1.9yr). The HR-pQCT scan required 3 min with a relatively low radiation dose (<3 μSv). Images from the radial ROI were free of artifacts and outlined cortical and trabecular bone microstructure. There is currently no standard method for these measures; therefore, these findings provide insight for investigators using HR-pQCT for studies of growing children.