The overall aim of this thesis on congenital clubfoot was to estimate the incidence with a national perspective, analyse residual deformities and their management, and evaluate patient reported long-term quality of life and foot function. Paper I was a prospective, nationwide sampling of 280 children with congenital clubfoot during 1995-96. The average incidence was 1.4‰. There was regional heterogeneity but no seasonal variation. Paper II evaluated ultrasonography on 54 newborn, prospectively followed up to 12 months of age. Significant increase of medial malleolus to navicular distance (MM-N-distance) and of soft tissue thickness with increasing age was seen and with acceptable reliability. Paper III assessed 35 children (47 feet) after previous posterior release, mean age of 4.5 years, and the MM-N-distance was shorter in unilateral clubfeet (21 patients) than in contralateral normal feet. No association between navicular position and forefoot adduction (FFA) was determined. Smaller FFA yielded better subjective and functional outcome. Paper IV reviewed distraction treatment with Ilizarov External Fixator in seven patients (10 feet), 6-15 years of age, with relapsed deformities. All patients, except one, reported satisfaction with the overall result but less stiffness was experienced in only 4/10 feet. Paper V evaluated self-estimated outcome in 83 patients (63 males, 20 females), mean age of 64 years, through SF-36 and EQ-5D, and through AAOS foot and ankle score. Age and gender adjusted norm groups were used. Female patients scored worse than male patients did. Both males and females reported negative influence on foot and ankle function. Conclusion: The incidence of congenital clubfoot in Sweden is higher than in previous Scandinavian studies. Ultrasonography is reliable for describing pathoanatomy of the talo-navicular joint in clubfeet and can detect "spurious" (false) correction. Distraction treatment with the Ilizarov External Fixator yields subjective improvement but stiffness remains. Long-term influence on daily life activities is limited to foot and ankle function for both genders, but only female patients report negative influence on physical aspects of quality of life.

In orthopaedic practice, fractures are usually stabilised with metal screws or rods. This is done in order to keep the fracture parts in place during the rather slow healing process. The healing time can potentially be reduced by local- or systemic treatment with different bone promoting drugs. In later years, lithium, otherwise used to treat bipolar disease, has shown promise to be such a drug.   The aim of this master thesis was to find a way to coat metal bone screws with lithium and to characterise the coating. The coating was to be designed in such a way that it could release lithium to the surrounding bone tissue.   Lithium chloride was incorporated into a titanate sol-gel and attached to silicon wafers and stainless steel screws by dip coating. Wafers were used for initial in vitro studies of how lithium changed coating characteristics. This was studied using ellipsometry, AFM and SEM. Lithium is most probably physisorbed and not incorporated into the network building up the sol-gel. Coating structure is changed as more lithium is incorporated. For large amounts of lithium, the nanoparticles normally formed when curing the sol-gel are inhibited. One effect of this is reduced bioactivity, seen as a reduced ability for calcium phosphate crystals to nucleate on the coating when immersed in simulated body fluid. Lithium release was investigated using AAS. Lithium is released from the coating, showing a burst effect. By changing the number of coating layers used, the release profile can be partly altered. The coating was also applied to screws, showing good attachment, and the lithium release profile was similar to the one seen from wafers. Finally, a screw model was used in rats to assess the effect of local lithium treatment from screws and systemic lithium treatment on fracture healing. In the model, a screw was inserted in tibia, mimicking a fracture. When the bone around the screw was healed, a pullout test was performed, giving information about the strength of the bone surrounding the screw. No significant difference could be found for either local- or systemic lithium treatment compared to control. However, when evaluating the strength of intact bone in a similar way, a positive effect of systemic lithium treatment could be seen. Therefore, it is still likely that lithium has a positive effect on bone and further studies are needed to fully evaluate its role in fracture healing. / Vid behandling av benbrott stabiliseras vanligtvis frakturen internt med metallskruvar och metallstavar. Detta görs för att hålla brottbitarna på plats under den relativt långsamma läkprocessen. Det är möjligt att minska tiden för frakturläkning genom att lokalt eller systemiskt behandla med olika läkemedel som främjar bentillväxt. På senare år har det presenterats bevis för att litium, som annars används som psykofarmaka, fungerar som ett sådant läkemedel.   Syftet med detta examensarbete var att hitta en metod för att fästa litium på benimplantat. Litium skulle fästas på ett sådant sätt att frisläppning till omgivande vävnad blev möjlig.   Litiumklorid inkorporerades i en titanat-solgel och lager av detta lades på kiselytor och rostfria skruvar genom s.k. ”dip-coating”. Kiselytorna användes för initiala in vitro-studier av hur litium ändrade beläggningens egenskaper. Litium sitter antagligen fast på ytan av det tredimensionella nätverk som utgör solgelen, istället för att sitta inbundet i nätverket. Lagerstrukturen ändras ju mer litium som inkorporeras och vid stora mängder skapas inte de nanopartiklar som vanligtvis finns i en solgel-baserad beläggning. En följd av detta är reducerad bioaktivitet för beläggningen, dvs. en minskad förmåga för kalciumfosfatkristaller att bildas på ytan. Litium frisläpps från beläggningen, dock sker denna frisläppning snabbt. Genom att belägga ytan med flera lager av solgel kan frisläppningskinetiken delvis ändras. Solgelen kunde också med god vidhäftning appliceras på skruvar och frisläppningskinetiken från en skruv är liknande den från en kiselyta. Slutligen användes en skruvmodell i råtta för att undersöka vilken effekt lokal respektive systemisk litiumbehandling har på frakturläkning. I modellen efterliknas ett benbrott genom att en skruv sätts in i skenbenet.  När benvävnaden runt skruven har läkt görs ett utdragstest på skruven vilket ger information om benets styrka. Ingen signifikant skillnad i skruvens utdragskraft kunde ses mellan de båda försöksgrupperna och kontrollgruppen. Däremot hade gruppen som fick systemisk litiumbehandling fått starkare ben totalt, vilket indikerar att litium har effekt på intakt ben. På grund av dessa resultat finns det fortfarande skäl att tro att litium har en positiv påverkan på ben, varför dess effekt på frakturläkning bör undersökas ytterligare.

Matrix metalloproteinases (MMPs), such as collagenases, are a family of enzymes capable of degrading most constituents of the extracellular matrix. MMPs are thought to be involved in the aetiopathogenesis of tendon rupture. Additionally, failure of healing has in some instances been associated with elevated levels of MMPs. We have studied (a) the effects of the MMP-inhibitor doxycycline on healing of tendons and intestines in experimental models and (b) systemic levels of MMPs and their endogenous inhibitors (TIMPs) in patients with tendon rupture. In the first study, systemic doxycycline treatment lead to weakened rat Achilles tendons during healing after injury. Subsequently, systemic doxycycline was shown to improve biomechanical properties of tendon suture fixation in the rat Achilles tendon. Sutures were also coated with doxycycline, leading to similar improvement in mechanical strength of the suture construct during healing. In the third study, doxycycline-coated sutures improved the strength of healing intestinal anastomoses in an experimental model. Finally, we showed that patients with a history of Achilles tendon rupture had elevated levels of MMP-2, MMP-7 and TIMP-2 in serum. In addition, MMP-7 correlated inversely to mechanical strength of the tendon during healing. In conclusion, MMP-inhibitors can be administered systemically and locally to manipulate healing of tendons and intestines. Generalised alterations in the MMP-TIMP system may be involved in the pathogenesis of Achilles tendon rupture and associated with differences in outcome of healing.

No description available.

The aim of this thesis was to investigate some methods for quantitative analysis of bone structure, particularly techniques which might ultimately be applied post-operatively following orthopaedic reconstruction operations. Initially it was decided to explore the efficacy of MRI in quantifying the bone structure at high resolution by comparing high resolution MRI against 'gold standards' such as Scanning Electron Microscopy (SEM) and optical histology. This basic study provided a measure of the distortions in the morphological bone parameters derived from MR images due to susceptibility artefacts and partial volume effects. The study of bone architecture was then extended to a model of advanced renal osteodystrophy in a growing rat. For this study, high-resolution micro computed tomography (microCT) was used and as a result of the high resolution images obtained, three new bone morphological parameters were introduced to characterise the bone structure. The desire to study bone architecture post-operatively in hip replacements led to a preliminary study on ex-vivo sheep acetabulae following total hip replacement, to determine the extent that the bone architecture could be investigated around the acetabulum. The motivation for studying the acetabulum was based on the high occurrence of debonding at the bone / prosthesis interface. This study demonstrated the superior nature of 3D MRI over conventional x-ray radiographs in early quantitation of fibrous membranes located between the host bone and the non-metallic implant and/or the bone cement. The presence of such fibrous membranes is strongly indicative of failure of the prosthesis. When using clinical MRI to image post-operative hip replacement, the image quality is severely affected by the presence of the metallic implant. The head of the prosthesis is shaped like a metal sphere and is located in the acetabular cup. This problem was investigated by performing simulations of MR images in the presence of the field perturbation induced by the presence of a metal sphere, with the effects of slice excitation and frequency encoding incorporated into the simulations. The simulations were compared with experimental data obtained by imaging a phantom comprising a stainless steel ball bearing immersed in agarose gel. The simulations were used to predict the effects of changing imaging parameters that influence artefact size and also to show how current metal artefact reduction techniques such as view angle tilting (VAT) work and to identify their limitations. It was shown that 2D SE and VAT imaging techniques should not be used when metallic prosthesis are present due to extreme slice distortion, whereas 3D MRI provided a method that has no slice distortion, although the effects of using a frequency encoding gradient still remain.

Biotribology, the study of lubrication, wear and friction within the body, has become a topic of high importance in recent times as we continue to encounter debilitating diseases and trauma that destroy function of the joints. A highly successful surgical procedure to replace the joint with an artificial equivalent alleviates dysfunction and pain. However, the wear of the bearing surfaces in prosthetic joints is a significant clinical problem and more patients are surviving longer than the life expectancy of the joint replacement. Revision surgery is associated with increased morbidity and mortality and has a far less successful outcome than primary joint replacement. As such, it is essential to ensure that everything possible is done to limit the rate of revision surgery. Past experience indicates that the survival rate of the implant will be influenced by many parameters, of primary importance, the material properties of the implant, the composition of the synovial fluid and the method of lubrication. In prosthetic joints, effective boundary lubrication is known to take place. The interaction of the boundary lubricant and the bearing material is of utmost importance. The identity of the vital active ingredient within synovial fluid (SF) to which we owe the near frictionless performance of our articulating joints has been the quest of researchers for many years. Once identified, tribo tests can determine what materials and more importantly what surfaces this fraction of SF can function most optimally with. Surface-Active Phospholipids (SAPL) have been implicated as the body’s natural load bearing lubricant. Studies in this thesis are the first to fully characterise the adsorbed SAPL detected on the surface of retrieved prostheses and the first to verify the presence of SAPL on knee prostheses. Rinsings from the bearing surfaces of both hip and knee prostheses removed from revision operations were analysed using High Performance Liquid Chromatography (HPLC) to determine the presence and profile of SAPL. Several common prosthetic materials along with a novel biomaterial were investigated to determine their tribological interaction with various SAPLs. A pin-on-flat tribometer was used to make comparative friction measurements between the various tribo-pairs. A novel material, Pyrolytic Carbon (PyC) was screened as a potential candidate as a load bearing prosthetic material. Friction measurements were also performed on explanted prostheses. SAPL was detected on all retrieved implant bearing surfaces. As a result of the study eight different species of phosphatidylcholines were identified. The relative concentrations of each species were also determined indicating that the unsaturated species are dominant. Initial tribo tests employed a saturated phosphatidylcholine (SPC) and the subsequent tests adopted the addition of the newly identified major constituents of SAPL, unsaturated phosphatidylcholine (USPC), as the test lubricant. All tribo tests showed a dramatic reduction in friction when synthetic SAPL was used as the lubricant under boundary lubrication conditions. Some tribopairs showed more of an affinity to SAPL than others. PyC performed superior to the other prosthetic materials. Friction measurements with explanted prostheses verified the presence and performance of SAPL. SAPL, in particular phosphatidylcholine, plays an essential role in the lubrication of prosthetic joints. Of particular interest was the ability of SAPLs to reduce friction and ultimately wear of the bearing materials. The identification and knowledge of the lubricating constituents of SF is invaluable for not only the future development of artificial joints but also in developing effective cures for several disease processes where lubrication may play a role. The tribological interaction of the various tribo-pairs and SAPL is extremely favourable in the context of reducing friction at the bearing interface. PyC is highly recommended as a future candidate material for use in load bearing prosthetic joints considering its impressive tribological performance.

Metal ions released from implantable biomaterials have been associated with adverse biological reactions that can limit implant longevity. Previous studies have shown that, in macrophages, Co2+, Cr3+, and Ni2+ can activate the NLR family pyrin domain-containing protein 3 (NLPR3) inflammasome, which is responsible for interleukin(IL)-1β production through caspase-1. Furthermore, these ions are known to induce oxidative stress, and inflammasome priming is known to involve nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) signaling. However, the mechanisms of inflammasome activation by metal ions remain largely unknown. The objectives of this thesis were to determine if, in macrophages: 1. IL-1β release induced by metal ions is caspase-1-dependent; 2. caspase-1 activation and IL-1β release induced by metal ions are oxidative stress-dependent; and 3. IL-1β release induced by metal ions is NF-κB signaling pathway-dependent. Lipopolysaccharide (LPS)-primed murine bone-marrow-derived macrophages were exposed to Co2+, Cr3+, or Ni2+, with or without an inhibitor of caspase-1, oxidative stress, or NF-κB. Culture supernatants were analyzed for active caspase-1 (immunoblotting) and/or IL-1β (ELISA). Overall, results showed that while both Cr3+ and Ni2+ may be inducing inflammasome activation, Cr3+ is likely a more potent activator, acting through oxidative stress and the NF-κB signaling pathway. Further elucidation of the activation mechanisms may facilitate the development of therapeutic approaches to modulate the inflammatory response to metal ions, and thereby increase implant longevity.

Aim: The aim of this thesis is to evaluate patients’ satisfaction with prosthetic device and service on lower limb amputations in Danang, Vietnam and to implement comparisons between the subgroups gender, living area, amputation cause and level. Method: A cross-sectional study design was conducted using the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST) 2.0 questionnaire to measure patients’ satisfaction. Fifty patients were recruited through the International Committee of the Red Cross (ICRC) and the data collection was performed in the patients own homes with an interpreter. The collected data was statistically analyzed with suitable tests using Statistical Package for the Social Sciences (SPSS). Result: The patients were quite satisfied with their prosthetic devices (mean 4.16 SD ± 0.561) and more or less satisfied with their given services (mean 2.83 SD ± 1.213). Significant differences were found between genders regarding the patients’ satisfaction with prosthetic device. There were no significant differences between the remaining subgroups; living area, amputation cause and amputation level. Conclusion: This thesis demonstrates that the patients in Danang appear to be quite satisfied with their prosthetic device, even though they reported problems with the durability of the device. Furthermore, the patients were more or less satisfied with their prosthetic services. The findings in this thesis also reveals that women were less satisfied compared to men regarding the prosthetic device. These conclusions should however be taken with caution, since the reliability and validity was lower than desired and it’s difficult to generalize the results to the population. / Syfte: Syftet med denna studie är att evaluera patienters nöjdhet med deras utgivna protes och service på nedre extremitetsamputerade i Danang, Vietnam och att implementera jämförelser mellan subgrupperna kön, bostadsområde, amputations- orsak och nivå. Metod: En cross-sectional studiedesign blev utförd genom användning av Quebec User Evaluation of Satisfaction with assistive Technology (QUEST) 2.0 enkäten för att mäta patienters nöjdhet. Femtio patienter blev rekryterade genom International Committee of the Red Cross (ICRC) och datainsamlingen blev utförd i patienternas egna hushåll med en tolk. Den insamlade datan blev statistiskt analyserad med lämpliga tester genom användning av Statistical Package for the Social Sciences (SPSS). Resultat: Patienterna var ganska nöjda med deras utgivna proteser (medelvärde 4,16 SD ± 0,561) och mer eller mindre nöjda med deras utgivna service (medelvärde 2,83 SD ± 1,213). Signifikanta skillnader hittades mellan kön gällande patienters nöjdhet med deras utgivna protes. Det fanns inga signifikanta skillnader mellan de resterande subgrupperna; bostadsområde, amputationsorsak och amputationsnivå. Slutsats: Den här studien demonstrerar att patienterna i Danang verkar vara ganska nöjda med deras utgivna proteser, fastän de rapporterade problem med protesens hållbarhet. Dessutom var patienterna mer eller mindre nöjda med deras utgivna service. Fynden i denna studie påvisar också att kvinnorna var mindre nöjda gällande protesen jämfört med männen. Dessa slutsatser skall dock tas med aktsamhet, eftersom reliabiliteten och validiteten blev lägre än önskat och det var svårt att generalisera resultaten till populationen.

Bakgrund: För att uppnå en god barnanpassad vård inom ortopedteknik krävs information om hur barn uppfattar mötet på en ortopedteknisk avdelning. Genom att ta del av barns tankar, åsikter och förslag kan verksamheter i framtiden lättare argumentera för exempelvis hur lokaler bör inredas och hur man bör bemöta barn.   Syfte: Syftet med denna studie är att undersöka hur barn upplever mötet på en ortopedteknisk avdelning i avseendet vårdmiljö och möte med ortopedingenjören.   Metod: En kvalitativ metod där deltagarna får rita och berätta kallad “Draw and tell” och åtta intervjuer med barn mellan 6 till 12 år om deras upplevelse efter besöket hos en ortopedingenjör genomfördes. Intervjuerna transkripterades och en innehållsanalys genomfördes.   Resultat: Vissa gemensamma faktorer hittades i intervjuerna så som att det ansågs att det samtalades för mycket utan att engagera barnet samt att aktiviteter som fanns sågs som bra då det kunde bli lite väntan under besöket. Det fanns flera förslag på andra aktiviteter som önskades under väntan och speglade barnens egna intressen så som datorspel och böcker.   Slutsats: Denna studie visar att det som ortopedingenjören är viktigt att engagera barnen vid mötena samt att aktiviteter finns till hands under långa väntetider.   Nyckelord: Barns upplevelser, ortopedteknik, ortopedingenjör, bemötande, miljö / Background: To achieve good child centered care in the field of prosthetics/orthotics, information about how children perceive a meeting with a prosthetist/orthotist is needed. Knowing children’s thoughts, opinions and suggestions about the situation can help increase knowledge about how to set up the environment and meetings. Aim: The aim of this study is to investigate how children experience the interactions with health professionals and the environment when meeting a prosthetist or orthotist. Method: A qualitative method called “draw and tell” was used. Eight children aged between 6 to 12 years were interviewed after a meeting with a prosthetist/orthostist. The interviews were transcribed and a content analysis was performed. Result: Too much talk without engaging the child and long waiting times were found as negative factors and activities such as books and toys and that the prosthetist/orthotist was kind were found as positive factors during the meeting. Multiple suggestions were given about what kinds of activity could be available to children when waiting these included computer games and books. Conclusion:  This study shows that it is important for a prosthetist/orthoptist to engage children in the meetings and that possibilities for activities are available when children are waiting to see the clinician.   Keywords: Children’s experience, Prosthetics, Orthotics,  Enviroment, Consultation

O aparelho propulsor mandibular é utilizado na odontologia para modular o crescimento da cartilagem condilar, por meio de forças geradas pela alteração postural da musculatura. Neste estudo foi avaliado o papel de integrinas ligantes de fibronectina (FN) na transdução das forças mecânicas geradas pelo aparelho, em ratos. Por meio de imuno-histoquímica e PCR em tempo real verificou-se que, in vivo, o uso do aparelho modulou a expressão das subunidades <font face=\"symbol\">1, <font face=\"symbol\">5, e <font face=\"symbol\">v de integrinas, FN e PCNA, um marcador de proliferação celular. In vitro, forças distensivas cíclicas aplicadas sobre células da cartilagem condilar aumentaram a expressão de mRNA para FN, fatores de crescimento IGF-I e IGF-II e PCNA. A adição do peptídeo GRGDSP, que bloqueia a ligação de algumas integrinas à FN, inibiu todos os efeitos, exceto na expressão de IGF-II. Esses resultados sugerem que integrinas ligantes de FN desempenham papel importante na mecano-transdução neste sistema e contribuem para o entendimento das bases moleculares envolvidas na ortopedia funcional dos maxilares / The mandibular propulsor appliance is widely used in dentistry to modulate the growth of the condylar cartilage, through forces generated by postural changes in the orofacial musculature. The aim of this study was to evaluate the role of fibronectin (FN)-binding integrins in the transduction of mechanical forces generated by the appliance in rats. By immunohistochemistry and real time PCR it was observed that, in vivo, the appliance´s use modulated the expression of the integrin subunits <font face=\"symbol\">1, <font face=\"symbol>\"5, and <font face=\"symbol\">v, FN and PCNA, a cell proliferation marker. In vitro, the application of cyclic distension forces on condylar cartilage cells increased the expression of FN, IGF-I, IGF-II and PCNA mRNA. Addition of the peptide GRGDSP, which blocks the binding of some integrins to FN, inhibited all the effects except the increase in IGF-II mRNA. These results suggest that FN-binding integrins play an important role in mechanotransduction in this system, contributing to the understanding of the molecular basis involved in maxillary functional orthopedic therapy.