<p><strong>Syfte</strong>: Syftet var att finna skillnader och samband i self-efficacy (SE) – med avseende på typ av artroplastik, kön och ålder – inför två förflyttningar. Detta för att se vilka patienter som kan vara i större behov av att stärka SE postoperativt.</p><p><strong>Metod:</strong> Studien gjordes på inneliggande patienter som genomgått en höft- eller knäartroplastik. Ett för undersökningen framställt frågeformulär undersökte de 117 deltagarnas SE inför att sätta sig upp på sängkanten samt gå med hjälpmedel. Deltagarna skattade SE inför förflyttningarna första eller andra dagen efter operationen.</p><p><strong>Resultat</strong>: Deltagare som hade genomgått en knäartroplastik skattade signifikant högre SE inför att sätta sig upp på sängkanten än de som hade genomgått en höftartroplastik. Männen skattade signifikant högre SE inför båda momenten jämfört med kvinnorna. Det fanns en låg korrelation mellan stigande ålder och låg SE inför att gå med hjälpmedel.</p><p><strong>Konklusion:</strong> Resultaten tyder på att SE inför förflyttningarna skiljer sig mellan patienter. Detta bör behandlande sjukvårdspersonal ta hänsyn till i ett postoperativt skede för att undvika immobiliseringskomplikationer hos patienterna.</p>

Biocompatible sensors have been demonstrated using traditional microfabrication techniques modified for polymer substrates and utilize only materials suitable for implantation or bodily contact. Sensor arrays for the measurement of the load condition of polyethylene spacers in the total knee arthroplasty (TKA) prosthesis have been developed. Arrays of capacitive sensors are used to determine the three-dimensional strain within the polyethylene prosthesis component. Data from these sensors can be used to give researchers a better understanding of component motion, loading, and wear phenomena for a large range of activities. This dissertation demonstrates both analytically and experimentally the fabrication of these sensor arrays using biocompatible polymer substrates and dielectrics while preserving industry-standard microfabrication processing for micron-level resolution. An array of sensors for real-time measurement of pressure profiles is the long-term goal of this research. A custom design using capacitive-based sensors is an excellent selection for such measurement, giving high spatial resolution across the sensing surface and high load resolution for pressures applied normal to that surface while operating at low power.

This dissertation describes the development and results of a physiological rigid body forward solution mathematical model that can be used to predict normal knee and total knee arthroplasty (TKA) kinematics and kinetics. The simulated activities include active extension and weight-bearing deep knee bend. The model includes both the patellofemoral and tibiofemoral joints. Geometry of the normal or implanted knee is represented by multivariate polynomials and modeled by constraining the velocity of lateral and medial tibiofemoral and patellofemoral contact points in a direction normal to the geometry surface. Center of mass, ligament and muscle attachment points and normal knee geometry were found using computer aided design (CAD) models built from computer tomography (CT) scans of a single subject. Quadriceps forces were the input for this model and were adjusted using a unique controller to control the rate of flexion, embedded with a controller which stabilizes the patellofemoral joint. The model was developed first using normal knee parameters. Once the normal knee model was validated, different total knee arthroplasty (TKA) designs were virtually implanted. The model was validated using in vivo data obtained through fluoroscopic analysis. In vivo data of the extension and deep knee bend activities from five non-implanted knees were used to validate the normal model kinematics. In vivo kinematic and kinetic data from a telemetric TKA with a tibia component instrumented with strain gauges was used to validate the kinematic and kinetic results of the model implanted with the TKA geometry. The tibiofemoral contact movement matched the trend seen in the in vivo data from the one patient available with this implant. The maximum axial tibiofemoral force calculated with the model was in 3.1% error with the maximum force seen in the in vivo data, and the trend of the contact forces matched well. Several other TKA designs were virtually implanted and analyzed to determine kinematics and bearing surface kinetics. The comparison between the model results and those previously assessed under in vivo conditions validates the effectiveness of the model and proves that it can be used to predict the in vivo kinematic and kinetic behavior of a TKA.

The principal aim of the present thesis was to prospectively follow (clinical status and ultrasound + Doppler findings) the patellar tendons in the young elite volleyball players at the Swedish National Centre for high school volleyball in Falköping. In an Olympic weightlifter with chronic painful jumper´s knee, the effects of treatment with sclerosing injections followed by early instituted very heavy weightlifting training, was also evaluated. First, in a prevalence study, we demonstrated that the clinical diagnosis patellar tendinopathy-jumper’s knee, together with structural tendon changes and vascularisation in the painful area of the tendon, was demonstrated in 12/114 tendons in Swedish junior elite volleyball players, but not in any tendons of individually matched (age, height and weight) not regularly sports active controls. Structural tendon changes alone was demonstrated among the volleyball players but also among the controls. In a 7 months prospective study of a total of 120 tendons, we demonstrated that the clinical diagnosis patellar tendinopathy-jumper’s knee was associated with neovessels/vascularity in the area with structural tendon changes in 17/19 tendons. Seventy tendons that at start were clinically normal, and had normal ultrasound + Doppler findings, remained clinically normal after 7 months with intensive training and playing volleyball. In a 3-year prospective study it was demonstrated that normal clinical tests and normal ultrasound + Doppler findings at school start, indicated a low risk (8%) for these players to sustain patellar tendinopathy-jumper’s knee during the 3 school years with intensive training and playing. In a case study, involving an Olympic elite weightlifter with chronic painful patellar tendinopathy-jumper’s knee, successful treatment with ultrasound and Doppler-guided injection of the sclerosing agent polidocanol, allowed for pain-free very heavy weight training two weeks after treatment. Further heavy weightlifting training on a daily basis, preparing for European Championships, was done without causing tendon rupture and/or pain. Key words: Jumper’s knee, Patellar tendinopathy, Chronic pain, Ultrasonography, Doppler, Neovascularisation, Volleyball, Weightlifting

Towards understanding regional meniscus characteristics important for tissue engineering efforts, meniscus cells were characterized biomechanically and an effective method for isolating these cells for tissue engineering was determined. It was found that the meniscus contains cells that are biomechanically distinct, with outer meniscus cells showing higher stiffness than inner cells. It was also determined that meniscus cells as a whole were more biomechanically similar to ligament cells than to articular chondrocytes, indicating that tissue properties may correlate with cellular mechanics. In addition to showing regionally distinct biomechanical properties, enzymatic isolation of meniscus cells was found to cause varying phenotypic changes in cells from the inner, middle, and outer regions. A comparison of isolation techniques also indicated that sequential digestion of meniscus tissue with pronase and collagenase was able to yield more cells with higher viability than other techniques tested, and those isolated cells created stiffer and more glycosaminoglycan (GAG) rich constructs when used in a tissue engineering modality than cells isolated using only collagenase. The identification of an effective mode of isolating meniscus cells is of great use to tissue engineering efforts, as they often require a large cell numbers. These findings illustrate that known regional variations in meniscus cell phenotype and biochemical composition are also evident in cellular mechanics, and phenotypic responses of these cells to isolation are varied and distinct. To be successful tissue replacements, tissue engineered meniscus constructs must not elicit an immune response and must have sufficient mechanical properties to survive when implanted. To determine if allogeneic or xenogeneic implantation of scaffold-free meniscus constructs could be feasible, the immunogenicity of bovine and leporine meniscus cells and articular chondrocytes were determined in an in vitro model system. It was found that neither bovine nor leporine meniscus cells or articular chondrocytes caused activation of leporine immune cells, suggesting that they may serve as allogeneic or xenogeneic cell sources for meniscus engineering. Additional analysis of the mechanical role of meniscus GAGs indicated that they are mechanically important in all regions of the meniscus, but especially in the inner region where the relatively high GAG content affects both compressive and tensile properties. Therefore, tissue engineering efforts should try to recapitulate GAG content and distribution to enhance the functionality of meniscus replacements. As a major obstacle for meniscus engineering is the identification of an abundant cell source, this thesis also investigated the use of skin cells as an alternative to primary cells for tissue engineering. Previously identified chondroinducible dermis cells were found to have multilineage differentiation capacity, and were subsequently termed dermis isolated adult stem cells (DIAS). DIAS cells were also able to be expanded in monolayer without losing chondroinductive capacity, and were able to create constructs with cartilaginous properties which could be varied with growth factor application. Given the ease of expansion and ability of DIAS cells to form fibrocartilaginous tissue, these cells present an abundant cell source for meniscus tissue engineering.

Study Design: Cross-sectional. Background: Although decreased hip abduction and lateral rotation strength has been found in females with patellofemoral pain syndrome (PFPS), few studies have included males. Aim: To determine if hip abduction and lateral rotation strength is decreased in males with PFPS. Methods: Eight males participated. Isometric hip abduction and external rotation strength was measured with a hand-held dynamometer. Four subjects had unilateral patellofemoral pain (mean age = 26.5 ± 7.5 years) and 4 asymptomatic subjects were controls (mean age = 23 ± 6.4 years). The recorded measurements from the symptomatic legs were compared with the asymptomatic legs, and also with the controls. Results: No significant differences in hip abduction or lateral rotation strength were found between the symptomatic and asymptomatic legs of male subjects with PFPS. The PFPS subjects did not have generally weaker hip strength compared with the asymptomatic controls. Conclusion: Males with PFPS do not appear to have decreased hip abduction and lateral rotation strength. However, the sample size was too small for conclusions to be drawn. This study can be used as a preliminary step in gathering evidence about factors affecting PFPS in males, which may in turn shed light on appropriate clinical treatments.

Neuromuscular control is believed to play an essential role during dynamic knee joint stabilisation. Evaluation of voluntary muscle action can be delineated as support strategies against external loading moments (Lloyd & Buchanan, 2001). The aim of this study was to determine if males and females exhibit differences in knee muscle action and cocontraction during voluntary isometric closed kinetic chain force generation in various directions in the horizontal plane representative of applied loads transverse to the long axis of the shank. Twenty-six healthy young adults (13 male, 13 female) stood with their dominant leg in a boot fixed to a force platform. A force target matching protocol required subjects to position a cursor (projected on a video screen) over a target and maintain the position for one second. To control the cursor, loads were applied against the force platform with their dominant leg to produce various combinations of anterior-posterior, medial-lateral loads while maintaining constant inferior-superior loads. A successful target match required a normalised force magnitude of equal effort for each subject and target location which triggered the recording of electromyography (EMG) for eight muscles crossing the knee joint. EMG was normalised to percent maximum voluntary isometric contraction. A mean magnitude of muscle activation, mean direction of muscle activation and a muscle specificity index was determined using EMG vectors. In addition, cocontraction indices were also computed for antagonist muscle pairs. Based on similar previous research, it was hypothesised that females would have greater quadriceps and hamstrings coactivation, greater muscle activation magnitudes, lower specificity for the quadriceps than males and no difference in hamstring characteristics. In our study, females significantly cocontracted their vastus lateralis and lateral gastrocnemius muscles to a greater degree than males (p=0.001). No significant differences were observed across sexes for the cocontraction of quadriceps and hamstrings or the lateral quadriceps and gastrocnemius muscles. Females displayed significantly lower specificity than males in their semitendinosus (p=0.025) and tensor fascia lata (p=0.012) activity patterns, greater magnitude of muscle activation in their lateral gastrocnemius (p=0.002) and tensor fascia lata (p<0.003) and no statistical difference in the other muscles. Furthermore, the activation patterns in our study grossly differed from previous open kinetic chain force target matching. These findings indicate that healthy young males and females have differences in their knee muscle control strategies and that knee muscle recruitment patterns differ during weight bearing and non-weight bearing tasks.

This quality study was carried out with seven semi-structured interviews and five of them were with elite women´s football coaches. What has been studied is how elite women’s football coaches are working with injury prevention training to their knees for the women’s football players. An anterior cruciate ligament injury in elite women’s football is both common and serious knee injury. This is a major problem area of ​​the anterior cruciate ligament injuries in women's football. In a squad of 20 women's football players occur an anterior cruciate ligament injury every two years. Injury prevention training is important to prepare the women's football players for the physical stresses that will arise during the season[1].  In this study includes, for example, theories of loss prevention training and risk factors for elite women’s football player to suffer an ACL injury. The interview guide has been focusing on the coach’s work and why they have chosen to use loss prevention training and how it can be planned and executed. This is to get information on how the elite women coaches working with the training to give the elite women football players the best position possible to prevent an ACL injury. The elite coaches have the help of physiotherapists, doctors and / or physiological coach with the loss prevention training must include for different exercises, and then determine the elite coaches themselves when it will be done during training week. In addition to interviews with the elite women coaches have also been interviewed by a physiotherapist and a doctor. This interview has been used to get information about the problem area with an ACL injury in elite women football. After that question I also touched on how and why the elite women’s football players should prevent this knee injury. The elite women’s football coaches all think the injury prevention training is important to use. This is to prepare women football players for the loads and stresses which will occur during the season. The loss prevention training is somewhat different in the five elite women´s football team that is part of my study. Any association uses a knee control program more than others, and cardio and strength training workouts vary in number. What unites them is that they all use a combination and the pulsation of the training. That is, they use both low and high intensity training and other training is a combination of different exercises and exercise. And they all have the injury prevention training scheduled throughout the season. [1] Martin Hagglund physiotherapist, interview February 8 2012, Markus Waldén orthopedic, interview  February 3 2012

Neuromuscular control is believed to play an essential role during dynamic knee joint stabilisation. Evaluation of voluntary muscle action can be delineated as support strategies against external loading moments (Lloyd & Buchanan, 2001). The aim of this study was to determine if males and females exhibit differences in knee muscle action and cocontraction during voluntary isometric closed kinetic chain force generation in various directions in the horizontal plane representative of applied loads transverse to the long axis of the shank. Twenty-six healthy young adults (13 male, 13 female) stood with their dominant leg in a boot fixed to a force platform. A force target matching protocol required subjects to position a cursor (projected on a video screen) over a target and maintain the position for one second. To control the cursor, loads were applied against the force platform with their dominant leg to produce various combinations of anterior-posterior, medial-lateral loads while maintaining constant inferior-superior loads. A successful target match required a normalised force magnitude of equal effort for each subject and target location which triggered the recording of electromyography (EMG) for eight muscles crossing the knee joint. EMG was normalised to percent maximum voluntary isometric contraction. A mean magnitude of muscle activation, mean direction of muscle activation and a muscle specificity index was determined using EMG vectors. In addition, cocontraction indices were also computed for antagonist muscle pairs. Based on similar previous research, it was hypothesised that females would have greater quadriceps and hamstrings coactivation, greater muscle activation magnitudes, lower specificity for the quadriceps than males and no difference in hamstring characteristics. In our study, females significantly cocontracted their vastus lateralis and lateral gastrocnemius muscles to a greater degree than males (p=0.001). No significant differences were observed across sexes for the cocontraction of quadriceps and hamstrings or the lateral quadriceps and gastrocnemius muscles. Females displayed significantly lower specificity than males in their semitendinosus (p=0.025) and tensor fascia lata (p=0.012) activity patterns, greater magnitude of muscle activation in their lateral gastrocnemius (p=0.002) and tensor fascia lata (p<0.003) and no statistical difference in the other muscles. Furthermore, the activation patterns in our study grossly differed from previous open kinetic chain force target matching. These findings indicate that healthy young males and females have differences in their knee muscle control strategies and that knee muscle recruitment patterns differ during weight bearing and non-weight bearing tasks.

Wear of the polyethylene (PE) bearing surface and wear particle-induced osteolysis (bone resorption) can lead to failure of modular total knee replacements and make expensive revision surgery necessary. Gamma-in-air sterilization of the PE insert and having a modular tibial component are both risk factors for excessive backside wear that contribute to osteolysis and implant failure. The overall wear (backside and topside) of modular total knee replacements has been subjected to considerable research in order to avoid such implant failure. The investigations reported in the present thesis evaluated both the clinical and in vitro wear performance of modular total knee replacements. The clinical investigations included damage assessment of retrieved PE inserts. A semi-quantitative grading method was developed and used to assess backside surface damage on 52 PE inserts retrieved from contemporary total knee replacement surgeries. Statistical analyses, such as univariate and multiple linear regression analysis, were performed to identify factors that influence backside damage including implant design features and patient characteristics. The damage features on the retrieved tibial PE inserts were also assessed with surface characterization techniques, such as scanning electron microscopy, energy dispersive X-ray analysis, and surface profilometry. To reduce surface damage and thus wear, PE inserts should be either gas-plasma or ethylene-oxide sterilized, used with polished tibial trays and held in place with a partial-peripheral locking mechanism. Synovial fluid samples were aspirated from a total of twenty patients and some basic biochemical analyses were performed. The total protein concentration, protein constituent fractions, the level of osmolality, and trace element concentrations were measured and compared with the same characteristics of four serum lubricants that were frequently used in simulator wear testing to mimic synovial fluid. In vitro investigations were conducted to explore the effects of some major constituents of the serum lubricants on the wear rate using a knee simulator apparatus. Increased protein constituent degradation led to increased wear. Such findings suggested that a protein layer acted as a boundary lubricant to protect the PE surfaces of knee implants. The protein constituent fractions of alpha calf serum (ACS) were similar to those measured for synovial fluid. These ACS lubricants were used in further wear studies in which hyaluronic acid (HA) and phosphate buffer solution (PBS) were successively added. The PBS was used in place of the distilled water to generate a serum lubricant with a clinically relevant level of osmolality. The thermal stability of the ACS lubricants and synovial fluid were measured. The thermal stability of the ACS lubricant that contained HA and PBS was about the same as that of human synovial fluid. The simulator wear rate of PE was significantly influenced by both HA and PBS. In further investigations, sodium azide, which has been used to inhibit microbial growth in simulator wear testing, was shown to be highly ineffective. Microbial contamination was recognized and the organism responsible was identified using standard microbiological methods. The use of an antibiotic-antimycotic mixture as the microbial inhibitor in the ACS + PBS + HA lubricant created a sterile environment and thus very clinically relevant environment for wear testing. The content of this thesis represents a comprehensive data collection on retrieval analysis and lubricant-specific knee simulator wear testing of modular total knee replacements. A more clinically relevant lubricant composition for simulator wear testing was proposed (U.S. patent Serial number 60/899,894; pending since February 9th, 2007) that improved upon the current guideline from the International Standards Organization for knee simulator wear testing. The present thesis should serve as a guide for the surgeon, researcher and the implant manufacturer to evaluate retrieved implant components and to select lubricant additives for wear testing that closely mimics the in vivo wear conditions.