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.

Reconstruction of cranial bone defects with fiber-reinforced composite–bioactive glass implants

A cranial bone defect may result after an operative treatment of trauma, infection, vascular insult, or tumor. New biomaterials for cranial bone defect reconstructions are needed for example to mimic the biomechanical properties and structure of cranial bone. A novel glass fiber-reinforced composite implant with bioactive glass particulates (FRC–BG, fiber-reinforced composite–bioactive glass) has osteointegrative potential in a preclinical setting. The aim of the first and second study was to investigate the functionality of a FRC–BG implant in the reconstruction of cranial bone defects. During the years 2007–2014, a prospective clinical trial was conducted in two tertiary level academic institutions (Turku University Hospital and Oulu University Hospital) to evaluate the treatment outcome in 35 patients that underwent a FRC–BG cranioplasty. The treatment outcome was good both in adult and pediatric patients. A number of conventional complications related to cranioplasty were observed. In the third study, a retrospective outcome evaluation of 100 cranioplasty procedures performed in Turku University Hospital between years 2002–2012 was conducted. The experimental fourth study was conducted to test the load-bearing capacity and fracture behavior of FRC–BG implants under static loading. The interconnective bars in the implant structure markedly increased the load-bearing capacity of the implant. A loading test did not demonstrate any protrusions of glass fibers or fiber cut. The fracture type was buckling and delamination. In this study, a postoperative complication requiring a reoperation or removal of the cranioplasty material was observed in one out of five cranioplasty patients. The treatment outcomes of cranioplasty performed with different synthetic materials did not show significant difference when compared with autograft. The FRC–BG implant was demonstrated to be safe and biocompatible biomaterial for large cranial bone defect reconstructions in adult and pediatric patients.

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.

Spondyloosi hevosen rintarangan etuosassa : tapausselostus

Summary: Spondylosis in the equine cranial thoracic spine : case report

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.

Repair of segmental bone defects with fiber-reinforced composite: a study of material development and an animal model on rabbits

The Repair of segmental defects in load-bearing long bones is a challenging task because of the diversity of the load affecting the area; axial, bending, shearing and torsional forces all come together to test the stability/integrity of the bone. The natural biomechanical requirements for bone restorative materials include strength to withstand heavy loads, and adaptivity to conform into a biological environment without disturbing or damaging it. Fiber-reinforced composite (FRC) materials have shown promise, as metals and ceramics have been too rigid, and polymers alone are lacking in strength which is needed for restoration. The versatility of the fiber-reinforced composites also allows tailoring of the composite to meet the multitude of bone properties in the skeleton. The attachment and incorporation of a bone substitute to bone has been advanced by different surface modification methods. Most often this is achieved by the creation of surface texture, which allows bone growth, onto the substitute, creating a mechanical interlocking. Another method is to alter the chemical properties of the surface to create bonding with the bone – for example with a hydroxyapatite (HA) or a bioactive glass (BG) coating. A novel fiber-reinforced composite implant material with a porous surface was developed for bone substitution purposes in load-bearing applications. The material’s biomechanical properties were tailored with unidirectional fiber reinforcement to match the strength of cortical bone. To advance bone growth onto the material, an optimal surface porosity was created by a dissolution process, and an addition of bioactive glass to the material was explored. The effects of dissolution and orientation of the fiber reinforcement were also evaluated for bone-bonding purposes. The Biological response to the implant material was evaluated in a cell culture study to assure the safety of the materials combined. To test the material’s properties in a clinical setting, an animal model was used. A critical-size bone defect in a rabbit’s tibia was used to test the material in a load-bearing application, with short- and long-term follow-up, and a histological evaluation of the incorporation to the host bone. The biomechanical results of the study showed that the material is durable and the tailoring of the properties can be reproduced reliably. The Biological response - ex vivo - to the created surface structure favours the attachment and growth of bone cells, with the additional benefit of bioactive glass appearing on the surface. No toxic reactions to possible agents leaching from the material could be detected in the cell culture study when compared to a nontoxic control material. The mechanical interlocking was enhanced - as expected - with the porosity, whereas the reinforcing fibers protruding from the surface of the implant gave additional strength when tested in a bone-bonding model. Animal experiments verified that the material is capable of withstanding load-bearing conditions in prolonged use without breaking of the material or creating stress shielding effects to the host bone. A Histological examination verified the enhanced incorporation to host bone with an abundance of bone growth onto and over the material. This was achieved with minimal tissue reactions to a foreign body. An FRC implant with surface porosity displays potential in the field of reconstructive surgery, especially regarding large bone defects with high demands on strength and shape retention in load-bearing areas or flat bones such as facial / cranial bones. The benefits of modifying the strength of the material and adjusting the surface properties with fiber reinforcement and bone-bonding additives to meet the requirements of different bone qualities are still to be fully discovered.

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.