Surgical treatment of hamstring injuries and disorders – the clinical spectrum from chronic tendinopathy to complete rupture

Hamstring muscle injuries and tendon disorders are common, especially in sports. They can be severe and difficult to treat, often resulting in impaired athletic performance and long rehabilitation times. Previous studies considering treatment of these problems are scarce. The current study was designed to investigate the effect of surgery on different types of hamstring muscle injuries and on proximal hamstring tendinopathy. In addition, we wanted to study the typical histopathological findings relating to proximal hamstring tendinopathy. In the study of complete (all three muscles torn) proximal hamstring avulsions (41 patients), our results showed that early operative treatment gives significantly better results than late surgery, and is therefore recommended. Despite this, considerable improvement of symptoms could also be achieved in chronic cases. In the study of partial (one or two muscles torn) proximal hamstring tears (47 patients), we observed that these injuries can cause significant functional deficit and impaired performance in athletes. The main finding was that after surgical repair most of the patients were able to return to their pre-injury level of sports. In the study of distal hamstring tears (18 patients), the results showed that surgical treatment had a good effect in the majority of these cases. In proximal hamstring tendinopathy, the main problem is pain which limits sports. In this study (90 patients), we found that after unsuccessful conservative treatment, surgery was a good treatment option resulting in full return to sports in most cases. In tendinopathic hamstring tendons, the morphological changes of tendinosis were largely identical to those previously described in other common (e.g. Achilles and patellar) tendinopathies. In chronic proximal hamstring avulsions, and also in reoperations, a large defect between distally retracted tendons and the ischial tuberosity may occasionally prevent anatomic reinsertion. We have described a reconstruction method using fascia lata autograft augmentation to be used in these most challenging repairs. This technique was utilized in the treatment of five patients, with encouraging results.

Pikkuvarsojen ojentajajänteen repeämä

Summary: Rupture of the common digital extensor in neonatal foals

Kosteuden ja lämpötilan vaikutus kartonkimassojen muovattavuuteen

Työn tavoitteena oli kartoittaa yleisesti kartongin valmistukseen käytettävien massatyyppien muovattavuuspotentaali. Muovattuvuuteen eniten vaikuttava tekijänä pidettiinmassojen murtovenymää. Työssä tutkittiin kosteuden ja lämpötilan sekä vetonopeuden vaikutusta mekaanisten ja sellumassojen ominaisuuksiin laboratorio-olosuhteissa. Kirjallisuusosassa tarkastellaan paperin lasisiirtymälämpötilaa muovauksen kannalta oleellisena tekijä. Lisäksi käydään läpi tapoja, joilla murtovenymää voidaan kasvattaa. Kartongin keskikerroksen aallotuksessa ja valmistettaessa paperipohjaisia tuotteita syvävedolla, käytetään hyväksi paperin pehmenemistä lämpötilan ja kosteuden alaisena. Niiden olosuhteita tarkastellaan lyhyesti. Lisäksi luodaan katsaus lämpötilan, kosteuden ja nopeuden vaikutuksistapaperin mekaanisiin ominaisuuksiin. Työn kokeellisessa osassa massojen mekaanisia ominaisuuksia testattiin erilaisissa kosteuspitoisuuksissasekä lämpötiloissa eri vetonopeuksilla. Kokeiden perusteella pyrittiin löytämään olosuhteet kullekin massalle, joissa niillä on paras murtovenymä. Lisäksi selvitettiin kuidun kihartamisen, sellumassojen jauhatuksen sekä arkin vapaan kuivumisen vaikutusta murtovenymään. Erilaiset massat saavuttavat parhaan murtovenymän erilaisissa kosteus- ja lämpötilaolosuhteissa. Sellumassoilla paras murtovenymä saadaan huoneenlämpötilassa ja paperin kosteuspitoisuuden ollessa välillä 11...12%. CTMP-massojen paras murtovenymä saadaan vedellä kyllästetyllä paperilla kohotetussa lämpötilassa. Lämpötila riippuu CTMP-massan valmistustavasta ja raaka-aineesta. Sellumassoilla on parempi kokonaisvenymä, kuin ligniinipitoisilla massoilla. Vetonopeuden vaikutus murtovenymään riippuu massasta sekä kosteudesta. Alhaisessa kosteudessa suurempi vetonopeus antaa aina pienemmän venymän. Kosteuden noustessa riippuu massasta, miten vetonopeus vaikuttaa murtovenymään. Plastinen osa tietystä venymästä on riippumaton massasta, jauhatusasteesta ja kuivatustavasta. Ainut vaikuttava muuttuja on kosteus. Kosteuden kasvu kasvattaa plastista venymää.

Imaging of the Vulnerable Atherosclerotic Plaque. Pre-Clinical Evaluation of PET Tracers for Vascular Inflammation

Atherosclerosis is a vascular inflammatory disease causing coronary artery disease, myocardial infarct and stroke, the leading causes of death in Finland and in many other countries. The development of atherosclerotic plaques starts already in childhood and is an ongoing process throughout life. Rupture of a plaque and the following occlusion of the vessel is the main reason for myocardial infarct and stroke, but despite extensive research, the prediction of rupture remains a major clinical problem. Inflammation is considered a key factor in the vulnerability of plaques to rupture. Measuring the inflammation in plaques non-invasively is one potential approach for identification of vulnerable plaques. The aim of this study was to evaluate tracers for positron emission tomography (PET) imaging of vascular inflammation. The studies were performed with a mouse model of atherosclerosis by using ex vivo biodistribution, autoradiography and in vivo PET and computed tomography (CT). Several tracers for inflammation activity were tested and compared with the morphology of the plaques. Inflammation in the atherosclerotic plaques was evaluated as expression of active macrophages. Systematic analysis revealed that the uptake of 18F-FDG and 11C-choline, tracers for metabolic activity in inflammatory cells, was more prominent in the atherosclerotic plaques than in the surrounding healthy vessel wall. The tracer for αvβ3 integrin, 18Fgalacto- RGD, was also found to have high potential for imaging inflammation in the plaques. While 11C-PK11195, a tracer targeted to receptors in active macrophages, was shown to accumulate in active plaques, the target-to-background ratio was not found to be ideal for in vivo imaging purposes. In conclusion, tracers for the imaging of inflammation in atherosclerotic plaques can be tested in experimental pre-clinical settings to select potential imaging agents for further clinical testing. 18F-FDG, 18F-galacto-RGD and 11C-choline choline have good properties, and further studies to clarify their applicability for atherosclerosis imaging in humans are warranted.

Generation and Characterization of Knockout Mice and Analysis of Patient Material Demonstrates a Role for Tissue Inhibitor of Metalloproteinases 4 (Timp4) in the Cardiovascular System and Tumor Metastasis

This thesis focuses on tissue inhibitor of metalloproteinases 4 (TIMP4) which is the newest member of a small gene and protein family of four closely related endogenous inhibitors of extracellular matrix (ECM) degrading enzymes. Existing data on TIMP4 suggested that it exhibits a more restricted expression pattern than the other TIMPs with high expression levels in heart, brain, ovary and skeletal muscle. These observations and the fact that the ECM is of special importance to provide the cardiovascular system with structural strength combined with elasticity and distensibility, prompted the present molecular biologic investigation on TIMP4. In the first part of the study the murine Timp4 gene was cloned and characterized in detail. The structure of murine Timp4 genomic locus resembles that in other species and of the other Timps. The highest Timp4 expression was detected in heart, ovary and brain. As the expression pattern of Timp4 gives only limited information about its role in physiology and pathology, Timp4 knockout mice were generated next. The analysis of Timp4 knockout mice revealed that Timp4 deficiency has no obvious effect on the development, growth or fertility of mice. Therefore, Timp4 deficient mice were challenged using available cardiovascular models, i.e. experimental cardiac pressure overload and myocardial infarction. In the former model, Timp4 deficiency was found to be compensated by Timp2 overexpression, whereas in the myocardial infarct model, Timp4 deficiency resulted in increased mortality due to increased susceptibility for cardiac rupture. In the wound healing model, Timp4 deficiency was shown to result in transient retardation of re-epithelialization of cutaneous wounds. Melanoma tumor growth was similar in Timp4 deficient and control mice. Despite of this, lung metastasis of melanoma cells was significantly increased in Timp4 null mice. In an attempt to translate the current findings to patient material, TIMP4 expression was studied in human specimens representing different inflammatory cardiovascular pathologies, i.e. giant cell arteritis, atherosclerotic coronary arteries and heart allografts exhibiting signs of chronic rejection. The results showed that cardiovascular expression of TIMP4 is elevated particularly in areas exhibiting inflammation. The results of the present studies suggest that TIMP4 has a special role in the regulation of tissue repair processes in the heart, and also in healing wounds and metastases. Furthermore, evidence is provided suggesting the usefulness of TIMP4 as a novel systemic marker for vascular inflammation.

Detection of the Vulnerable Atherosclerotic Plaque. Pre-Clinical Evaluation of Novel PET Imaging Probes With Experimental Models

Atherosclerosis is a life-long vascular inflammatory disease and the leading cause of death in Finland and in other western societies. The development of atherosclerotic plaques is progressive and they form when lipids begin to accumulate in the vessel wall. This accumulation triggers the migration of inflammatory cells that is a hallmark of vascular inflammation. Often, this plaque will become unstable and form vulnerable plaque which may rupture causing thrombosis and in the worst case, causing myocardial infarction or stroke. Identification of these vulnerable plaques before they rupture could save lives. At present, in the clinic, there exists no appropriated, non-invasive method for their identification. The aim of this thesis was to evaluate novel positron emission tomography (PET) probes for the detection of vulnerable atherosclerotic plaques and to characterize, two mouse models of atherosclerosis. These studies were performed by using ex vivo and in vivo imaging modalities. The vulnerability of atherosclerotic plaques was evaluated as expression of active inflammatory cells, namely macrophages. Age and the duration of high-fat diet had a drastic impact on the development of atherosclerotic plaques in mice. In imaging of atherosclerosis, 6-month-old mice, kept on high-fat diet for 4 months, showed matured, metabolically active, atherosclerotic plaques. [18F]FDG and 68Ga were accumulated in the areas representative of vulnerable plaques. However, the slow clearance of 68Ga limits its use for the plaque imaging. The novel synthesized [68Ga]DOTA-RGD and [18F]EF5 tracers demonstrated efficient uptake in plaques as compared to the healthy vessel wall, but the pharmacokinetic properties of these tracers were not optimal in used models. In conclusion, these studies resulted in the identification of new strategies for the assessment of plaque stability and mouse models of atherosclerosis which could be used for plaque imaging. In the used probe panel, [18F]FDG was the best tracer for plaque imaging. However, further studies are warranted to clarify the applicability of [18F]EF5 and [68Ga]DOTA-RGD for imaging of atherosclerosis with other experimental models.

Epävarmuustarkastelun soveltaminen deterministisissä turvallisuusanalyyseissä

Tässä diplomityössä esitetään selvitys käytössä olevista deterministisistä turvallisuusanalyysimenetelmistä. Deterministisillä turvallisuusanalyyseillä arvioidaan ydinvoimalaitosten turvallisuutta eri käyttötilojen aikana. Voimalaitoksen turvallisuusjärjestelmät mitoitetaan deterministisen turvallisuusanalyysin tulosten perusteella. Deterministiset turvallisuusanalyysit voidaan laatia konservatiivista tai tilastollista menetelmää käyttäen. Konservatiivinen menetelmä pyrkii mallintamaan tarkasteltavan tilanteen siten, että laitoksen todellinen käyttäytyminen on hyvällä varmuudella lievempää kuin analyysitulos. Konservatiivisessa menetelmässä analyysin epävarmuudet huomioidaan konservatiivisilla oletuksilla. Tilastollinen menetelmä perustuu parhaan arvion menetelmään eli pyrkimykseen mallintaa laitoksen käyttäytyminen mahdollisimman todenmukaisesti. Tilastollisessa menetelmässä analyysin epävarmuudet määritetään systemaattisesti tilastomatematiikan keinoin. Työssä painotetaan tilastollisen analyysin epävarmuuksien määritykseen käytettäviä epävarmuustarkastelumenetelmiä. Diplomityön laskennallisessa osassa vertaillaan deterministisen turvallisuusanalyysin laadintaan käytettäviä menetelmiä termohydraulisen turvallisuusanalyysiesimerkin laskennan kautta. Laskennassa tarkasteltavana onnettomuutena on Olkiluoto 3-laitosyksikössä tapahtuva primäärijäähdytepiirin putkikatkosta aiheutuva jäähdytteenmenetysonnettomuus. Lasketun esimerkkitapauksen perusteella tilastollista ja konservatiivista menetelmää voidaan pitää vaihtoehtoisina turvallisuusanalyysin laadintaan. Molemmat analyysit tuottivat hyväksyttäviä ja toisilleen verrannollisia tuloksia, joiden suuruusluokka on sama.

Eri MAG-hitsausprosessien ja -parametrien vaikutus suurlujuusteräksestä valmistetun otsapienahitsin äärikestävyyteen, muodonmuutoskykyyn ja vauriomuotoon

Työssä tutkittiin Ruukki Oyj:n suorasammutetusta S960QC-teräksestä valmistetun kuormaakantavan levyjen ristiliitoksen pienahitsien lujuutta, muodonmuutoskykyä ja vaurioitumismekanismia laajaan kokeelliseen aineistoon perustuen. Tärkeimpänä muuttujana koematriisissa olivat eri MAG-hitsausprosessit. Perinteisen kuumakaarihitsauksen vertailukohteena oli Kemppi Oy:n uusi adaptiivinen valokaaren pituutta säätävä WiseFusion-hitsaustoiminto kuuma- ja pulssikaarihitsauksessa. Näiden kolmen hitsausprosessin rinnalla varioitiin erisuuruisia a-mittoja, eri hitsauslisäaineita ja hitsin erikylkisyyttä. Lisäksi juuritunkeuman estämisen vaikutusta hitsien käyttäytymiseen tutkittiin täydentävällä koesarjalla, jossa tunkeuman muodostuminen estettiin levyjen väliin asetetulla volframilevyllä. Työn perimmäisenä tavoitteena oli selvittää syy aiemmassa tutkimuksessa havaitulle pienahitsien vaurioitumiselle leikkautumalla sularajaa pitkin. Sularajan suhteellista pituutta saadaan kasvatettua estämällä hitsin juuritunkeuma ja absoluuttista pituutta saadaan lisää kateettipoikkeaman avulla. Lisäksi tutkimuksessa oli tarkoitus tuoda esille suurlujuusteräksisen liitoksen eri mitoituslähtökohdat (mm. lämmöntuonnin kontrollointi). Tämän vuoksi hitsausparametrit mitattiin jännitteen ja virran hetkellisiin arvoihin perustuen, jolloin kuuma- ja pulssikaarihitsauksen laskennalliset hitsaustehot ovat vertailukelpoisia. Koehitseistä valmistettiin hieet hitsien tarkan geometrian määrittämiseksi ja liitoksen mekaaniset ominaisuudet tutkittiin vetokokeella. Tulosten perusteella sularajavaurio aktivoituu pulssikaarella hitsatuissa koekappaleissa. Tämä aiheutunee pulssi- ja kuumakaarihitsauksen sularajan mikrorakenteiden eroavaisuudesta. Sularajavaurio näyttää huonontavan hitsien muodonmuutoskykyä, mutta jatkokokeita tuloksen verifioimiseksi on tehtävä. S960QC-teräkselle ominaisen pehmenneen vyöhykkeen vaurio ei aktivoitunut, vaikka Ruukin antamat jäähtymisaikasuositukset ylitettiin reilusti.

Computational modeling of stented coronary arteries

The application of computational fluid dynamics (CFD) and finite element analysis (FEA) has been growing rapidly in the various fields of science and technology. One of the areas of interest is in biomedical engineering. The altered hemodynamics inside the blood vessels plays a key role in the development of the arterial disease called atherosclerosis, which is the major cause of human death worldwide. Atherosclerosis is often treated with the stenting procedure to restore the normal blood flow. A stent is a tubular, flexible structure, usually made of metals, which is driven and expanded in the blocked arteries. Despite the success rate of the stenting procedure, it is often associated with the restenosis (re-narrowing of the artery) process. The presence of non-biological device in the artery causes inflammation or re-growth of atherosclerotic lesions in the treated vessels. Several factors including the design of stents, type of stent expansion, expansion pressure, morphology and composition of vessel wall influence the restenosis process. Therefore, the role of computational studies is crucial in the investigation and optimisation of the factors that influence post-stenting complications. This thesis focuses on the stent-vessel wall interactions followed by the blood flow in the post-stenting stage of stenosed human coronary artery. Hemodynamic and mechanical stresses were analysed in three separate stent-plaque-artery models. Plaque was modeled as a multi-layer (fibrous cap (FC), necrotic core (NC), and fibrosis (F)) and the arterial wall as a single layer domain. CFD/FEA simulations were performed using commercial software packages in several models mimicking the various stages and morphologies of atherosclerosis. The tissue prolapse (TP) of stented vessel wall, the distribution of von Mises stress (VMS) inside various layers of vessel wall, and the wall shear stress (WSS) along the luminal surface of the deformed vessel wall were measured and evaluated. The results revealed the role of the stenosis size, thickness of each layer of atherosclerotic wall, thickness of stent strut, pressure applied for stenosis expansion, and the flow condition in the distribution of stresses. The thicknesses of FC, and NC and the total thickness of plaque are critical in controlling the stresses inside the tissue. A small change in morphology of artery wall can significantly affect the distribution of stresses. In particular, FC is the most sensitive layer to TP and stresses, which could determine plaque’s vulnerability to rupture. The WSS is highly influenced by the deflection of artery, which in turn is dependent on the structural composition of arterial wall layers. Together with the stenosis size, their roles could play a decisive role in controlling the low values of WSS (<0.5 Pa) prone to restenosis. Moreover, the time dependent flow altered the percentage of luminal area with WSS values less than 0.5 Pa at different time instants. The non- Newtonian viscosity model of the blood properties significantly affects the prediction of WSS magnitude. The outcomes of this investigation will help to better understand the roles of the individual layers of atherosclerotic vessels and their risk to provoke restenosis at the post-stenting stage. As a consequence, the implementation of such an approach to assess the post-stented stresses will assist the engineers and clinicians in optimizing the stenting techniques to minimize the occurrence of restenosis.

Mathematical modeling and optimal control of malaria

Malaria continues to infect millions and kill hundreds of thousands of people worldwide each year, despite over a century of research and attempts to control and eliminate this infectious disease. Challenges such as the development and spread of drug resistant malaria parasites, insecticide resistance to mosquitoes, climate change, the presence of individuals with subpatent malaria infections which normally are asymptomatic and behavioral plasticity in the mosquito hinder the prospects of malaria control and elimination. In this thesis, mathematical models of malaria transmission and control that address the role of drug resistance, immunity, iron supplementation and anemia, immigration and visitation, and the presence of asymptomatic carriers in malaria transmission are developed. A within-host mathematical model of severe Plasmodium falciparum malaria is also developed. First, a deterministic mathematical model for transmission of antimalarial drug resistance parasites with superinfection is developed and analyzed. The possibility of increase in the risk of superinfection due to iron supplementation and fortification in malaria endemic areas is discussed. The model results calls upon stakeholders to weigh the pros and cons of iron supplementation to individuals living in malaria endemic regions. Second, a deterministic model of transmission of drug resistant malaria parasites, including the inflow of infective immigrants, is presented and analyzed. The optimal control theory is applied to this model to study the impact of various malaria and vector control strategies, such as screening of immigrants, treatment of drug-sensitive infections, treatment of drug-resistant infections, and the use of insecticide-treated bed nets and indoor spraying of mosquitoes. The results of the model emphasize the importance of using a combination of all four controls tools for effective malaria intervention. Next, a two-age-class mathematical model for malaria transmission with asymptomatic carriers is developed and analyzed. In development of this model, four possible control measures are analyzed: the use of long-lasting treated mosquito nets, indoor residual spraying, screening and treatment of symptomatic, and screening and treatment of asymptomatic individuals. The numerical results show that a disease-free equilibrium can be attained if all four control measures are used. A common pitfall for most epidemiological models is the absence of real data; model-based conclusions have to be drawn based on uncertain parameter values. In this thesis, an approach to study the robustness of optimal control solutions under such parameter uncertainty is presented. Numerical analysis of the optimal control problem in the presence of parameter uncertainty demonstrate the robustness of the optimal control approach that: when a comprehensive control strategy is used the main conclusions of the optimal control remain unchanged, even if inevitable variability remains in the control profiles. The results provide a promising framework for the design of cost-effective strategies for disease control with multiple interventions, even under considerable uncertainty of model parameters. Finally, a separate work modeling the within-host Plasmodium falciparum infection in humans is presented. The developed model allows re-infection of already-infected red blood cells. The model hypothesizes that in severe malaria due to parasite quest for survival and rapid multiplication, the Plasmodium falciparum can be absorbed in the already-infected red blood cells which accelerates the rupture rate and consequently cause anemia. Analysis of the model and parameter identifiability using Markov chain Monte Carlo methods is presented.

Simulation and material calibration of ultra high strength steel (UHSS) S960 welded joint under static tensile test utilizing finite element method (FEM)

The aim of this work was to calibrate the material properties including strength and strain values for different material zones of ultra-high strength steel (UHSS) welded joints under monotonic static loading. The UHSS is heat sensitive and softens by heat due to welding, the affected zone is heat affected zone (HAZ). In this regard, cylindrical specimens were cut out from welded joints of Strenx® 960 MC and Strenx® Tube 960 MH, were examined by tensile test. The hardness values of specimens’ cross section were measured. Using correlations between hardness and strength, initial material properties were obtained. The same size specimen with different zones of material same as real specimen were created and defined in finite element method (FEM) software with commercial brand Abaqus 6.14-1. The loading and boundary conditions were defined considering tensile test values. Using initial material properties made of hardness-strength correlations (true stress-strain values) as Abaqus main input, FEM is utilized to simulate the tensile test process. By comparing FEM Abaqus results with measured results of tensile test, initial material properties will be revised and reused as software input to be fully calibrated in such a way that FEM results and tensile test results deviate minimum. Two type of different S960 were used including 960 MC plates, and structural hollow section 960 MH X-joint. The joint is welded by BöhlerTM X96 filler material. In welded joints, typically the following zones appear: Weld (WEL), Heat affected zone (HAZ) coarse grained (HCG) and fine grained (HFG), annealed zone, and base material (BaM). Results showed that: The HAZ zone is softened due to heat input while welding. For all the specimens, the softened zone’s strength is decreased and makes it a weakest zone where fracture happens while loading. Stress concentration of a notched specimen can represent the properties of notched zone. The load-displacement diagram from FEM modeling matches with the experiments by the calibrated material properties by compromising two correlations of hardness and strength.