Introdução: Os corticosteroides intra-articulares (IA) são amplamente utilizados no tratamento da osteoartrite (OA) de joelho, porém é desconhecido qual dentre estes agentes é o mais eficaz. Objetivo: O objetivo do presente estudo foi comparar a eficácia das infiltrações IA de triancinolona hexacetonida (TH) e de acetato de metilprednisolona (AM) na OA de joelho. Pacientes e Métodos: Pacientes com OA sintomática de joelho, graus II ou III de Kellgren-Lawrence, foram randomizados para receber uma única infiltração IA com 40mg de TH ou AM. As avaliações clínicas foram realizadas nas semanas 4, 12 e 24. O desfecho primário do estudo foi a melhora da dor do joelho pelo paciente por escala visual analógica (EVA) da visita basal à semana 4. Os desfechos secundários incluíram a avaliação global da doença pelo paciente e pelo médico, o questionário de osteoartrite Western Ontario and McMaster Universities (WOMAC), o índice de Lequesne e o critério de resposta Outcome Measures in Rheumatology and Osteoarthritis Research Society International (OMERACT-OARSI). Na análise estatística, foram empregadas equações de estimativa generalizada, com estatística de Wald para contrastes do tipo 3 e ajustes de Tukey-Kramer para comparações múltiplas. Resultados: Cem pacientes foram incluídos na população com intenção de tratar, 50 em cada braço do estudo. Uma melhora significativa na dor pela EVA foi observada na semana 4 para ambos os grupos (P < 0,0001), não havendo diferença entre eles (P=0,352). Esta melhora foi sustentada até a semana 24. Uma melhora significativa em relação à avaliação basal foi observada na avaliação global da doença pelo paciente e pelo médico, no questionário WOMAC e no índice de Lequesne, não havendo diferença entre os grupos. A melhora nos desfechos secundários de avaliação foi sustentada durante o estudo, exceto para a avaliação global da doença pelo paciente. O critério de resposta OMERACT-OARSI foi alcançado por 74% e 72% dos pacientes dos grupos TH e AM, respectivamente. Conclusão: TH e AM são igualmente eficazes na OA de joelho, e a melhora na dor e na função física pode ser sustentada por até 24 semanas / Introduction: Intra-articular (IA) corticosteroid injections are broadly used in the treatment of knee osteoarthritis (OA), but it is unknown which of these agents is the most effective. Objective: The aim of the present study was to compare the efficacy of triamcinolone hexacetonide (TH) and methylprednisolone acetate (MA) IA injections in knee OA. Patients and Methods: Patients with symptomatic knee OA, Kellgren-Lawrence grades II or III, were randomized to receive a single IA injection with 40mg of TH or MA. Evaluations were performed at 4, 12 and 24 weeks. The primary outcome of the study was to evaluate the improvement in the patient\'s knee pain by visual analogue scale (VAS) from baseline to week 4. Secondary outcomes included the global assessment of the disease by the patient and the physician, the Western Ontario and McMaster Universities osteoarthritis questionnaire (WOMAC), the Lequesne index and the Outcome Measures in Rheumatology and Osteoarthritis Research Society International (OMERACT-OARSI) criteria of response. Generalized estimating equations with Wald statistics for type 3 contrasts and Tukey-Kramer multiple comparison adjustment were employed in statistical analysis. Results: The intention-to-treat population included one hundred patients; 50 in each study arm. A significant improvement in pain by VAS was observed at week 4 for both groups (P<0.0001), with no difference between them (P=0.352). This improvement was sustained up to week 24. A significant improvement from the baseline was observed for the patients\' and the physicians\' global assessments, WOMAC questionnaire, and Lequesne index, with no differences between the groups. Improvements in the secondary outcomes were sustained during the study, except for the patients\' global assessment of disease. OMERACT-OARSI criteria of response was achieved by 74% and 72% of patients in the TH and the MA groups, respectively. Conclusion: TH and MA are equally effective in knee OA and improvement in pain and physical function can be sustained for up to 24 week

Objetivo: Investigar se há associação entre a diminuição da amplitude de movimento da articulação coxofemoral e a lesão por não-contato do ligamento cruzado anterior em jogadores de futebol. Método: Neste estudo de casos e controles, 50 jogadores de futebol, com lesão por nãocontato do ligamento cruzado anterior do joelho, confirmada por cirurgia, tiveram suas articulações coxofemorais examinadas e comparadas com o grupo controle. Os achados foram estatisticamente analisados, de acordo com dois pontos de corte (70° e 80°, na soma total de rotação interna e rotação externa), em ambos os grupos. Resultados: Uma significativa diminuição na amplitude de movimento da articulação coxofemoral foi encontrada em 38% de todos os indivíduos estudados no menor ponto de corte (70°) e 64% no maior ponto de corte (80°). A diminuição da amplitude de movimento do quadril foi maior no grupo com ruptura de LCA do que no grupo controle, com pequena diferença entre os dois pontos de corte (70° e 80°). A diferença entre pacientes e controles foi estatisticamente significativa (p = 0, 001). Conclusão: Houve uma forte associação entre a diminuição da amplitude de movimento da articulação do quadril e a ruptura de LCA em jogadores de futebol, não somente, mas, principalmente, devido à diminuição da rotação interna. Apesar da falta de comparação com outros esportes, o resultado mostrou um maior aumento da diminuição de amplitude de movimento do quadril no grupo de jogadores de futebol, quando comparado com a população em geral. / Purpose: To investigate whether there is an association between decreased hip range of motion and noncontact anterior cruciate ligament (ACL) injuries in soccer players. Methods: In this case-control study, 50 soccer players with noncontact ACL injuries confirmed by surgery had their hips examined and compared with those of a control group. Findings were statistically analyzed according to cutoff points (70 and 80 degrees of total internal-external rotation sum) for both groups. Results: A significant decrease in hip range of motion was found in 38% of all individuals studied at the lower cutoff point (70 degrees) and 64% at the upper cutoff point (80 degrees). The decrease in hip range of motion was greater in the group with ruptured ACL than in controls, with little difference between the two cutoff points (70 and 80 degrees). The difference between patients and controls was statistically significant (p < 0,001). Conclusions: There was strong association between decreased hip range of motion and ACL ruptures in soccer players, not only but mainly due to internal rotation lessening. Despite lacking comparison with other sports, our findings showed a higher decrease of hip range of motion in the group of soccer players when compared with the general population.

<p>Intra-articular glucocorticoid injection therapy is frequently used to relieve symptoms of arthritis, but there is considerable variation in injection routines among physicians. One issue of debate concerns the importance of synovial fluid aspiration during the injection procedure. In the present randomised controlled study of patients with rheumatoid arthritis (RA), a significantly reduced risk for arthritis relapse was observed when arthrocentesis was included in the intra-articular injection procedure of the knee. </p><p>Furthermore, there is no consensus about the post-injection regimes. Previous studies have shown beneficial effects of post-injection rest of the knee, but also injection routines for other joints often include such recommendations. The present randomised controlled trial showed that 48-hour rest in elastic orthosis after intra-articular injection in the wrist did not improve the outcome. Thus, the effect of post-injection rest varies between different joints. </p><p>The improved treatment result of post-injection rest of the knee is supposed to be caused by retarded steroid resorption from the joint. In order examine the metabolic effects in cartilage, bone and the hypothalamic-piuitary-adrenal (HPA)-axis, resting and mobile RA patients were studied after intra-articular knee injections. Serum levels of the injected glucocorticoid, triamcinolone hexacetonide (THA), were analysed, as well as cartilage oligomeric matrix protein (COMP) as a marker of cartilage turnover, osteocalcin for bone formation and deoxypyridinoline for bone resorption. The HPA-axis was assessed using serum levels of cortisol and adrenocorticotropine hormone. The result showed a short term and reversible suppression of the HPA-axis and bone formation, whereas bone resorption was unaffected. No differences between mobile and resting patients were observed. In both groups reduction of COMP levels were seen, but these were significantly more pronounced in resting patients, suggesting a cartilage-protective effect. The THA levels increased similarly in both groups, indicating that rest did not affect glucocorticoid resorption. </p><p>Consequently, another explanation for the beneficial effects of postinjection rest of knee synovitis should be considered. In the present material the incidence of infectious complications of intra-articular treatment was less than 1/12,000 injections. </p><p>The findings in this thesis can be applied in the clinical practice and should be considered when new guidelines for intra-articular glucocorticoid therapy are created.</p>

Intra-articular glucocorticoid injection therapy is frequently used to relieve symptoms of arthritis, but there is considerable variation in injection routines among physicians. One issue of debate concerns the importance of synovial fluid aspiration during the injection procedure. In the present randomised controlled study of patients with rheumatoid arthritis (RA), a significantly reduced risk for arthritis relapse was observed when arthrocentesis was included in the intra-articular injection procedure of the knee. Furthermore, there is no consensus about the post-injection regimes. Previous studies have shown beneficial effects of post-injection rest of the knee, but also injection routines for other joints often include such recommendations. The present randomised controlled trial showed that 48-hour rest in elastic orthosis after intra-articular injection in the wrist did not improve the outcome. Thus, the effect of post-injection rest varies between different joints. The improved treatment result of post-injection rest of the knee is supposed to be caused by retarded steroid resorption from the joint. In order examine the metabolic effects in cartilage, bone and the hypothalamic-piuitary-adrenal (HPA)-axis, resting and mobile RA patients were studied after intra-articular knee injections. Serum levels of the injected glucocorticoid, triamcinolone hexacetonide (THA), were analysed, as well as cartilage oligomeric matrix protein (COMP) as a marker of cartilage turnover, osteocalcin for bone formation and deoxypyridinoline for bone resorption. The HPA-axis was assessed using serum levels of cortisol and adrenocorticotropine hormone. The result showed a short term and reversible suppression of the HPA-axis and bone formation, whereas bone resorption was unaffected. No differences between mobile and resting patients were observed. In both groups reduction of COMP levels were seen, but these were significantly more pronounced in resting patients, suggesting a cartilage-protective effect. The THA levels increased similarly in both groups, indicating that rest did not affect glucocorticoid resorption. Consequently, another explanation for the beneficial effects of postinjection rest of knee synovitis should be considered. In the present material the incidence of infectious complications of intra-articular treatment was less than 1/12,000 injections. The findings in this thesis can be applied in the clinical practice and should be considered when new guidelines for intra-articular glucocorticoid therapy are created.

Bioreactors are devices used for the growth of tissues in a laboratory environment. They exist in many different forms, each designed to enable the production of high-quality tissues. The dynamic environment within bioreactors is known to significantly affect the growth and development of the tissue. Chondrocytes, the building blocks of articular cartilage, for example, are stimulated by mechanical stresses such as shear, as compared with those in tissues grown under static incubation conditions. On the other hand, high shear can damage cells. Consequently the shear-stress level has to be controlled in order to optimize the design and the operating conditions of bioreactors. Spinner flasks have been used for the production of articular cartilage in vitro. Assuming the existence of a relation between the cellular glycosaminoglycan (GAG) synthesis and the local shear stresses on the construct surfaces, this research focuses on the development of a model for cartilage growth in such devices. The flow produced in a model spinner flask is characterized experimentally using particle-image velocimetry (PIV). A computational fluid dynamic (CFD) model validated with respect to the laboratory measurements is constructed in order to predict the local shear stresses on the construct surfaces. Tissue growth experiments conducted in the prototype bioreactor permit construct histologies and GAG contents to be analyzed and then correlated with the shear-stress predictions. The integration of this relation into the CFD model enables the prediction of GAG synthesis through convective effects. Coupling this convective model to an existing diffusive model produces a complete cartilage-growth model for use in aiding the optimization of existing bioreactors, and in the design of new ones.

Solute diffusion is critical to maintenance of cellular function and matrix integrity in articular cartilage. Nutrient deficiency due to transport limitations is thought to be one of the causes of the pathological degeneration of the cartilage tissue. Thus, a study of diffusion within cartilage will lead to a better understanding of the causes of cartilage degeneration. To accurately estimate diffusion coefficients in cartilage and other hydrated medium, we developed a finite-element based method, the Direct Diffusion Simulation Parameter Estimation method (DDSPE), to be used for quantitative determination of solute diffusivities from Fluorescence Recovery After Photobleaching data. Analyses of simulated and experimental FRAP data demonstrated that this method was more accurate than existing analytical methods, including having a low sensitivity to variations in the spot radius. Subsequently, the roles of extracellular matrix (ECM) composition and tissue orientation in solute diffusion within immature bovine cartilage were explored. Diffusivities were measured through the cartilage depth and in two different orientations (radial and transverse). Diffusivities were then correlated with ECM components. Matrix water content was found to be the best predictor of solute diffusion rates in immature cartilage. Although no specific experiments were done to measure the effect of structure, our results suggested that matrix structure did indeed modulate transport. Diffusional anisotropy, defined as the ratio of the diffusivities in both orientations, was observed to be significant in all the immature cartilage zones. As a consequence, the differences in solute diffusion between immature and mature bovine cartilage were investigated. Diffusion rates and diffusional anisotropy decreased in the mature cartilage superficial zone. The decrease in diffusivities observed in mature cartilage suggests that there may be a reduction in nutrient and growth factor supply to the cells. Nevertheless, healthy adult cartilage can still maintain its normal function even with a reduction in solute diffusion rates as nutrient diffusion distances are shorter in mature cartilage. However, any disruption in the mechanical or biological environment could cause an imbalance in tissue homeostasis, which when combined with decreased diffusivities, could trigger matrix degeneration. Thus, decreased diffusivity may be a necessary but not a sufficient prerequisite of matrix degeneration.

L’objectif de cette étude est de vérifier si un ciment ostéoconducteur résorbable utilisé comme technique de fixation de greffons ostéochondraux permet d'obtenir une stabilité initiale supérieure à celle obtenue avec la technique de mosaicplastie originalement décrite. Il s’agit d’une étude biomécanique effectuée sur des paires de fémurs cadavériques bovins. Pour chaque paire de fémurs, des greffons ostéochondraux autologues ont été insérés et stabilisés au moyen d’un ciment biorésorbable (Kryptonite, DRG inc.) sur un fémur alors qu’au fémur controlatéral, les greffons ont été implantés par impaction selon la technique usuelle de mosaicplastie. Des greffons uniques ainsi que des greffons en configuration groupée ont été implantés et soumis à une évaluation biomécanique. Les charges axiales nécessaires pour enfoncer les greffons de 1, 2 et 3 mm ont été comparées en fonction de la technique de stabilisation utilisée, ciment ou impaction, pour chaque configuration de greffons. Les résultats démontrent que les greffons ostéochondraux cimentés uniques et groupés ont une stabilité initiale supérieure à celle de greffons non cimentés sur des spécimens cadavériques bovins. L’obtention d’une plus grande stabilité initiale par cimentation des greffons ostéochondraux pourrait permettre une mise en charge précoce post-mosaicplastie et mener à une réhabilitation plus rapide. / The objective of this project is to compare the primary stability of osteochondral autografts stabilized with a resorbable osteoconductive bone cement to that of bottomed press fit grafts inserted according to the original mosaicplasty technique. Biomechanical testing was conducted on pairs of cadaveric bovine femurs. For each femoral pair, osteochondral grafts were inserted and stabilized with an osteoconductive bone cement (Kryptonite, DRG inc.) on one bone whereas on the controlateral femur, grafts were inserted in a press fit fashion. Grafts were inserted in 2 different configurations, single grafts as well as groups of 3 adjacent grafts, and submitted to biomechanical testing. Axial loads needed to sink the grafts to 1, 2 and 3 millimeters below cartilage level were recorded and compared according to the fixation technique, cement or press-fit impaction, for each graft configuration. According to those results, cemented osteochondral autografts appear more stable than press fit grafts for both single and 3-in-a-row configurations. Using such a cementation technique could potentially prevent the initial loss of stability that has been shown to occur with osteochondral grafts in the post-operative period, allowing patients to perform early weight bearing and rehabilitation.

Articular cartilage which covers the surfaces of synovial joints is designed to allow smooth contact between long bones and to absorb shock induced during joint movement. Tissue engineering, a means of combining cells, biomaterials, bioreactors and bioactive agents to produce functional tissue replacements suitable for implantation, represents a potential long-term strategy for cartilage repair. The interplay between environmental factors, however, gives rise to complex culture conditions that influence the development of tissue-engineered constructs. A fibrous capsule that is composed of abundant type I collagen molecules and resembles fibrocartilage usually forms at the outer edge of neocartilage, yet the understanding of its modulation by environmental cues is still limited. Therefore, this dissertation was aimed to characterize the capsule formation, development and function through manipulation of biochemical parameters present in a hydrodynamic environment while a chemically reliable media preparation protocol for hydrodynamic cultivation of tissue-engineered cartilage was established. To this end, a novel wavy-wall bioreactor (WWB) that imparts turbulent flow-induced shear stress was employed as the model system and polyglycolic acid scaffolds seeded with bovine primary chondrocytes were cultivated under varied biochemical conditions. The results demonstrated that tissue morphology, biochemical composition and mechanical strength of hydrodynamically engineered cartilage were maintained as the serum content decreased by 80% (from 10% to 2%). Transient exposure of the low-serum constructs to exogenous insulin-like growth factor-1 (IGF-1) or transforming growth factor-β1 (TGF-β1) further accelerated their development in comparison with continuous treatment with the same bioactive molecules. The process of the capsule formation was found to be activated and modulated by the concentration of serum which contains soluble factors that are able to induce fibrotic processes and the capsule development was further promoted by fluid shear stress. Moreover, the capsule formation in hydrodynamic cultures was identified as a potential biphasic process in response to concentrations of fibrosis-promoting molecules such as TGF-β. Comparison between the capsule-containing and the capsule-free constructs, both of which had comparable tissue properties and were produced by utilizing the WWB system in combination with IGF-1 and TGF-β1, respectively, showed that the presence of the fibrous capsule at the construct periphery effectively improved the ability of engineered cartilage to integrate with native cartilage tissues, but evidently compromised its tissue homogeneity. Characterization of the fibrous capsule and elucidation of the conditions under which it is formed provide important insights for the development of tissue engineering strategies to fabricate clinically relevant cartilage tissue replacements that possess optimized tissue homogeneity and properties while retaining a minimal capsule thickness required to enhance tissue integration.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2005. / Härtill 5 uppsatser.

Hyaline cartilage is a highly specialized tissue, which plays an important role in the articulating joints of an individual. It provides the joints with a nearly frictionless, impact resisting surface to protect the ends of the articulating bones. Articular cartilage has a poor self-repair capacity and, therefore, it rarely heals back to normal after an injury. Overweight, injuries, overloading and genetic factors may initiate a degenerative disease of the joint called osteoarthritis. Osteoarthiritis is a major global public health issue. Currently, the most used treatment for large articular cartilage defects is joint replacement surgery. However, possibilities to replace this highly invasive operation with strategies based on tissue engineering are currently investigated. The idea of the tissue engineering is to optimize the use of the cells, biomaterials and culture conditions to regenerate a new functional tissue for the defect site. The goal of this thesis was to manufacture cartilage tissue in cell culture conditions in vitro. Bovine primary chondrocytes isolated from the femoral condyles were used in all the experiments for neocartilage production. The samples were collected for histology, gene expression level quantifications, and analyses of proteoglycan (PG) content and quality. The histological sections were stained for type II collagen and PGs, the quantitative RT-PCR was used to observe the relative expressions of aggrecan, Sox9, procollagen α2(I) and procollagen α1(II) genes. The PGs were quantified using a spectrophotometric method, and agarose gel electrophoresis was used to separate the PGs according to their size. In the two first studies, we optimized the culture conditions of in vitro scaffold-free culture technique to produce the native-type hyaline cartilage of a good quality. We found out that high glucose concentration and hypertonic medium at 20% oxygen tension promoted the best hyaline-like neocartilage tissue production. Glucosamine sulfate supplementation, low oxygen tension, 5 mM glucose concentration and a transient TGF-β3 supplementation were not beneficial for the neocartilage formation in the scaffold-free cell culture system. In the third study, we used these newly defined, optimized culture conditions to produce the neocartilage tissues in the HyStem™ and the HydroMatrix™ scaffold materials and we compared these tissues to the ones grown as scaffold-free control cultures. We noticed that there was no difference between the controls and the scaffolds, and occasionally the scaffold-free controls had produced better quality cartilage than the ones with the scaffolds. Overall, the neocartilage tissues were of good hyaline-like quality in the third study. Their extracellular matrix contents were close to the native cartilage, although the neotissues lacked the zonal organization typical to the normal articular cartilage. The tissues had the right components, but their ultrastructure differed from the native cartilage. In conclusion, we were able to optimize our in vitro neocartilage culture method further, and discovered a good combination of the culture conditions to produce hyaline-like cartilage of good quality. Surprisingly, the scaffold materials were not beneficial for the cartilage formation. / Lasi- eli hyaliinirusto on pitkälle erikoistunutta kudosta, jolla on erittäin tärkeä rooli yksilön nivelten toiminnassa. Kudos suojaa ruston alapuolista luuta muodostamalla lähes kitkattoman ja joustavan liikkumista helpottavan pinnan. Lasiruston oma uusiutumiskyky on hyvin heikko, ja näin ollen kudos vain harvoin paranee alkuperäisen kaltaiseksi vaurion jälkeen. Ylipaino, vammat, liiallinen kuormitus tai geneettiset tekijät voivat käynnistää rustokudoksen rappeutumisen. Tätä tilaa kutsutaan nivelrikoksi. Nivelrikko on valtava kansanterveydellinen ongelma. Keinonivelleikkaus on nykyisellään ainoa hoitokeino pinta-alaltaan laajojen nivelruston vaurioiden hoitoon. Vaihtoehtoja tämän suuren ja invasiivisen kirurgisen operaation korvaamiseksi tutkitaan kuitenkin koko ajan ympäri maailmaa. Kudosteknologian ajatuksena on optimoida solujen, biomateriaalien ja erilaisten kasvatusolosuhteiden käyttö uuden, alkuperäisen kaltaisen toiminnallisen kudoksen luomiseksi vauriokohtaan. Väitöskirjan kaikissa kolmessa osatutkimuksessa uudisrustokudoksia tuotettiin käyttäen naudan polven rustosta eristettyjä primäärisiä rustosoluja. Näytteet kerättiin histologisia analyysejä, geenin ilmentymistutkimuksia ja proteoglykaanisisällön ja -jakauman (PG) analyyseja varten. Histologisista leikkeistä värjättiin tyypin II kollageeni ja PG:t, ja kvantitatiivista RT-PCR -menetelmää käytettiin aggrekaani-, Sox9-, prokollageeni α2(I)- ja prokollageeni α1(II)-geenien suhteellisten ilmentymistasojen määrittämiseen. Proteoglykaanisisältö analysoitiin käyttäen spektrofotometristä menetelmää, ja PG:t eroteltiin kokonsa perusteella agaroosigeelielektroforeesia käyttäen. Kahdessa ensimmäisessä osatutkimuksessa optimoitiin tukirakenteetta kasvattujen uudisrustojen kasvatusolosuhteita natiivin kaltaisen lasiruston tuottamiseksi. Havaitsimme, että korkea glukoosipitoisuus ja hypertoninen elatusaine yhdistettynä 20 % happiosapaineeseen tuotti parhaimman laatuista uudisrustokudosta tutkituista yhdistelmistä. Glukosamiinisulfaatin lisäys, matala happiosapaine, 5 mM glukoosi konsentraatio tai TGF-β3:n lisääminen alkuvaiheessa eivät edesauttaneet uudisrustokudosten muodostumisessa. Kolmannessa osatutkimuksessa otettiin käyttöön uudet, hyväksi havaitut kasvatusolosuhteet yhdistettynä HyStem™ and HydroMatrix™ -tukimateriaaleihin, ja niitä verrattiin tukirakenteettomaan kasvatusmenetelmään. Tutkimuksessa havaittiin, ettei tukirakenteettoman kontrollin tai tukimateriaalien välillä ollut mitään eroa, ja että kontrollikasvatukset tuottivat ajoittain jopa parempaa rustoa kuin tukimateriaalein kasvatetut. Kaiken kaikkiaan kaikki tuotetut uudiskudokset muistuttivat laadullisesti lasiruston kaltaista kudosta. Molekyylisisältö lähenteli natiivia rustoa, vaikkakin uudiskudoksista puuttui normaalille nivelrustolle tyypillinen vyöhykkeinen järjestäytyminen. Kudoksissa oli parhaimmillaan oikea määrä oikeita komponentteja, mutta ne eivät vain olleet järjestäytyneet oikealla tavalla. Onnistuimme optimoimaan uudisrustokudosten kasvatusmenetelmäämme. Löysimme hyvän kasvatusolosuhteiden yhdistelmän, jonka avulla kykenimme tuottamaan lasiruston kaltaista uudisrustokudosta. Hivenen yllättäenkin, tukimateriaalit eivät olleet avuksi tutkimuksessamme uudisrustokudoksia muodostettaessa.