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An Investigation on Biological Modulation on Anterior Cruciate Ligament 
Reconstruction- treatments with Intra-operative L-ascorbate and Post-operative 
Glycyl-Histydyl-Lysine Tripeptide 
FU, Sai Chuen 
A Thesis Submitted in Partial Fulfillment 
of the Requirements for the Degree of 
Doctor of Philosophy 
in 
Orthopaedics and Traumatology 
The Chinese University of Hong Kong 
August 2013 
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Thesis/ Assessment Committee 
Professor Qin Ling (Chair) 
Professor Chan, Kai-Ming (Thesis Supervisor) 
Professor Hung, Leung-Kim (Thesis Co-supervisor) 
Professor Li, Gang (Committee Member) 
Professor Yung, Shu-Hang Patrick (Committee Member) 
Professor Feng, Hua (External Examiner) 
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Abstract of thesis entitled: 
An  investigation  on  biological  modulation  on  anterior  cruciate  ligament 
reconstruction-  Treatments  with  intra-operative  L-ascorbate  and  post-operative 
Glycyl-Histydyl-Lysine tripeptide 
Submitted by FU, Sai-Chuen 
For the degree of Doctor of Philosophy 
at The Chinese University of Hong Kong (June 2013) 
Abstract: 
Anterior  cruciate  ligament  (ACL)  rupture  is  a  very  common  sport  injury 
resulting in an unstable knee. As a ruptured ACL does not heal, ACL reconstruction 
(ACLR) is the standard treatment to restore knee function. Poor graft healing is the 
major cause  leading  to  ACLR  failure  and  excessive  knee  laxity.  There  is  ample 
emphasis on "mechanical" solutions to ACLR, but the biological healing process 
would be more deterministic for ultimate graft incorporation. If this process can be 
further enhanced, it will reduce the time of maturation of the graft, and hence 
earlier returns to full activities and sports. In the present study, the possibilities of 
biological augmentation of graft healing in ACLR were investigated. 
In the first part of the study, research focus was put on the establishment of 
validated functional outcomes with good clinical relevance in a rat model of ACLR. 
We developed the measurement of anterior-posterior (AP) translational knee laxity 
for the rat model of ACLR. Moreover, measurement of limb idleness during walking 
was developed to measure functional impairments due to ACL deficiency in rats, 
such as knee pain.   
In the second part, the effect of biological modulation of anterior cruciate 
ligament  reconstruction  was  investigated  in  the  same  rat  model.  As  the  graft 
degeneration  during  post-operative  inflammatory  phase  and  graft  remodeling 
(ligamentization) are the key processes that affect the graft integrity in ACLR, we 
propose to modulate graft degeneration by intra-operative irrigation of L-ascorbate 
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ii 
(vitamin C) saline; and for the post-inflammatory phase, we also tested the effect of 
Glycyl-Histydyl-Lysine tripeptide (GHK), a well-known activator of tissue remodeling, 
to modulate tissue remodeling in ACLR. 
From the result of vitamin C study, vitamin C irrigation at all tested doses 
significantly reduced the extent of post-operative inflammation. At day 42 post-op, 
the  restoration  of  AP  knee  laxity  was  significantly  improved  with  less  graft 
degeneration by 3 mg/ml vitamin C irrigation. There was no significant difference in 
limb idleness among different groups at day 28 and 42 post injury. From the result of 
the GHK-Cu study, we found that a treatment regime of 4 weekly intra-articular 
injections of 50 μl GHK-Cu (0.3mg/ml, week 2-5) could significantly improve AP knee 
laxity at 6 week post-op, but the failure load of the graft complex was not altered. At 
a longer time  point (12 week post-op), knee laxity in both control and  GHK-Cu 
groups were improved but the group difference was no longer significant. Although 
GHK  treatment  did  not  affect  limb  idleness  as  compared  to  control,  repeated 
intra-articular  injections  caused  significant  increase  in  limb  idleness.  Combined 
treatments of effective doses of vitamin C (intra-op) and GHK-Cu (2-5 week post op) 
did not yield further improvement. 
Because of the high safety profile, ease of application and potential benefits, 
further investigations for the clinical use of vitamin C irrigation saline and GHK-Cu 
supplementation to promote graft healing in ACLR are well supported by the results 
of this study. (Word count: 480) 
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iii 
論文標題: 
在前交叉韌带重建中促進生物癒合的研究 
-有關手術中L-抗壞血酸與手術後藍銅勝肽的效用 
論文摘要: 
前交叉韌带缺損是一種十分常見的運動創傷,能導致膝關節不穩定,影響傷者
的活動能力。由於前交叉韌带不會自行癒合,前交叉韌带重建手術是恢復膝功
能的標準療法。手術雖然有效,但植入腱的生物癒合不良是導致手術失敗和膝
關節過度鬆弛的重要原因。過往運動醫學較為重視裝好植入腱的機械性條件,
但對於更為關鍵的生物性癒合條件卻未予以足夠重視。如果我們能促進前交叉
韌带重建中的生物癒合過程,植入腱的嫁接及成熟時間將能縮短,從而有機會
讓傷者能回復活動能力,儘早返回運動場上。故此,我們將研究在前交叉韌带
重建中促進生物癒合的可能性。 
我們首先建立一個前交叉韌带重建的大鼠動物模型,並研發具臨床意義的
康復評估指標,作為測試新法療效的工具。這些指標包括量度膝關節前後鬆緊
度的方法,以及利用動物步態分析去評估功能性康復的障礙,例如膝關節疼痛
可能導致步行時懶用受傷一側肢體的情況。由於發炎期植入腱退化和植入腱的
組織重塑(即韌帶化)是生物癒合成功與否的關鍵,我們嘗試利用手術中給予 L-
抗坏血酸(即維生素 C)去減輕植入腱退化,以及利用手術後在關節腔內注射藍
銅勝肽去促進組織重塑,以期達致提升生物癒合的目標。 
實驗結果表明,含3 mg/ml  維生素C的手術沖洗液能有效舒緩術後發炎情
況,在術後 6 週時減輕植入腱退化,並明顯改善膝關節的前後鬆緊度。不過,
植入腱的機械強度無法進一步提升,而大鼠的步態和懶用肢體的情況並無明顯
分別。術後2-5周維持每周注射0.3mg/ml藍銅勝肽也能有效改善膝關節前後鬆
緊度,但植入腱的機械強度仍然無法增加。此外,重複進行關節腔內注射可能
增加懶用肢體的情況。結合維生素 C 和藍銅勝肽使用並不能進一步提高促進生
物癒合的效能。 
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iv 
這項研究顯示,L-抗坏血酸和藍銅勝肽 都能促進前交叉韌带重建的生物癒
合。由於兩種藥物都十分安全,進一步轉化成臨床使用的前景看好。  (字數: 744) 
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Acknowledgements 
I would like to thank my supervisor Prof. Chan Kai-Ming and co-supervisor Prof. 
Hung Leung-Kim for their encouragement and guidance to me for the pursuit of a 
PhD degree. I am also grateful to Prof. Qin Ling and Dr. Simon Lee for their kind 
support to me throughout the PhD study. For the past 18 years working in the 
Department  of  Orthopaedics  and  Traumatology,  I  received  much  help  from  all 
colleagues  and  I  am  very  happy  to  work  in  a  department  with  a  big  family 
atmosphere. 
The research projects involved in this PhD study were financially supported by a 
grant of Innovation and Technology Fund and a grant of General Research Fund. I 
am indebted to the research assistants who carried out most of the experimental 
work in these projects. Without the help by Tom Cheng, Emily Mok and Maggie 
Cheuk, I would not be able to complete the projects on time and devoted my efforts 
in writing proposals, devising new measurement methods, performing data analysis 
and writing up the thesis. I appreciate the team work and the leadership by the 
professors who set the research direction for the team. 
I would also like to express my gratitude to the panel of examiners, including Prof. 
Feng Hua, Prof. Chan Kai-Ming, Prof. Hung Leung-Kim, Prof. Qin Ling, Prof. Li Gang 
and Prof. Yung Shu-Hang. 
Last but not least, I would like to thank my family, especially my wife Maggie, who 
helps me a lot in office and at home, shares the happy and difficult times with me, 
and we shall enjoy the challenges and wonders in our life ahead. 
vi 
Table of content 
Preface 
Chapter 1 
Background 
1.1   
Definition of ligament∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  4 
1.2   
History∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  5 
1.3   
Anatomy, structure and functions of ACL∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  10 
1.4   
ACL injuries∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  14 
1.5   
Treatment of ACL injuries∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  17 
1.6   
Chapter summary∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  21 
Chapter 2 Biological healing process in ACL reconstruction∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  22 
2.1   
General scheme of healing processes of connective tissue∙∙∙∙∙∙∙∙∙∙∙∙  22 
2.2   
Natural healing of ACL injuries∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  24 
2.3   
Bone healing∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  26 
2.4   
Bone tendon junction healing∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  27 
2.5   
Natural healing process in ACLR∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  30 
2.6   
Graft-tunnel interface healing∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  32 
2.7   
Ligamentization∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  34 
2.8   
Chapter summary∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  35 
Chapter 3 
Literature review on biological modulation on ACLR∙∙∙∙∙∙∙∙∙∙∙∙∙∙  36 
3.1   
Methodology of systematic review∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  37 
3.2   
Search results and methodological assessment∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  39 
3.3   
Summary of selected studies∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  48 
3.4 
Meta-synthesis of treatments to modulate biological healing in 
ACLR∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 
49 
3.5   
Chapter Summary∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  52 
vii 
Chapter 4 
Objectives and Research plan∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  53 
4.1
Objectives∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  53 
4.2
Building up an animal model of ACLR∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  54 
4.3
The effect of intra-operative supplementation of vitamin C to 
promote healing in ACLR∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 
60 
4.4
The effect of post-operative intra-articular injection of GHK-Cu∙∙∙  62 
4.5
Chapter summary∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  64 
Chapter 5 
Experimental design and research methods∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  65 
5.1   
Experimental design∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  65 
5.2   
Methods∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  71 
5.3   
Statistical analyses∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  92 
5.4   
Chapter summary∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  92 
Chapter 6 
Results of building up a rat model of ACLR∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  94 
6.1   
Determination of initial graft tension for ACLR in a rat model∙∙∙∙∙∙∙  94 
6.2 
Histological evaluation of the temporal changes in graft healing 
in the rat model of ACLR∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 
102 
6.3 
Establishment of gait analysis to monitor functional deficit 
related to ACL deficiency∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 
109 
6.4   
Chapter summary∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  115 
Chapter 7 
Results of treatment effects∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  117 
7.1   
Effect of vitamin C irrigation saline on ACLR∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  117 
7.2   
Effect of GHK-Cu on ACLR∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  128 
7.3   
Chapter summary∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  137 
Chapter 8 
Discussions∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  138 
8.1   
Validity of animal model and outcome measure∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  138 
viii 
8.2   
Possible mechanisms of treatment effects∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  146 
8.3   
Limitations of the studies∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  149 
8.4   
Clinical relevance∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  154 
8.5   
Chapter summary∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  159 
Chapter 9 
Further investigations∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  160 
9.1   
Effect of combined treatments∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  160 
9.2   
Exploration of possible mechanisms of treatment effects∙∙∙∙∙∙∙∙∙∙∙∙∙  165 
9.3 
Phase I clinical trial on intra-operative local supplementation of 
vitamin C irrigation saline during anterior cruciate ligament 
reconstruction∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 
165 
9.4   
Biomaterials for controlled delivery∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  166 
9.5   
Chapter summary∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  167 
Chapter 10  Conclusion∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  168 
Responses to examiners’ comments∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  169 
Bibliography∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  173 
List of publication and related research output∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  196 
Appendices∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙  197 
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