Primary stability in cementless total hip replacement: measurement techniques and aided-surgery

Primary stability of stems in cementless total hip replacements is recognized to play a critical role for long-term survival and thus for the success of the overall surgical procedure. In Literature, several studies addressed this important issue. Different approaches have been explored aiming to evaluate the extent of stability achieved during surgery. Some of these are in-vitro protocols while other tools are coinceived for the post-operative assessment of prosthesis migration relative to the host bone. In vitro protocols reported in the literature are not exportable to the operating room. Anyway most of them show a good overall accuracy. The RSA, EBRA and the radiographic analysis are currently used to check the healing process of the implanted femur at different follow-ups, evaluating implant migration, occurance of bone resorption or osteolysis at the interface. These methods are important for follow up and clinical study but do not assist the surgeon during implantation. At the time I started my Ph.D Study in Bioengineering, only one study had been undertaken to measure stability intra-operatively. No follow-up was presented to describe further results obtained with that device. In this scenario, it was believed that an instrument that could measure intra-operatively the stability achieved by an implanted stem would consistently improve the rate of success. This instrument should be accurate and should give to the surgeon during implantation a quick answer concerning the stability of the implanted stem. With this aim, an intra-operative device was designed, developed and validated. The device is meant to help the surgeon to decide how much to press-fit the implant. It is essentially made of a torsional load cell, able to measure the extent of torque applied by the surgeon to test primary stability, an angular sensor that measure the relative angular displacement between stem and femur, a rigid connector that enable connecting the device to the stem, and all the electronics for signals conditioning. The device was successfully validated in-vitro, showing a good overall accuracy in discriminating stable from unstable implants. Repeatability tests showed that the device was reliable. A calibration procedure was then performed in order to convert the angular readout into a linear displacement measurement, which is an information clinically relevant and simple to read in real-time by the surgeon. The second study reported in my thesis, concerns the evaluation of the possibility to have predictive information regarding the primary stability of a cementless stem, by measuring the micromotion of the last rasp used by the surgeon to prepare the femoral canal. This information would be really useful to the surgeon, who could check prior to the implantation process if the planned stem size can achieve a sufficient degree of primary stability, under optimal press fitting conditions. An intra-operative tool was developed to this aim. It was derived from a previously validated device, which was adapted for the specific purpose. The device is able to measure the relative micromotion between the femur and the rasp, when a torsional load is applied. An in-vitro protocol was developed and validated on both composite and cadaveric specimens. High correlation was observed between one of the parameters extracted form the acquisitions made on the rasp and the stability of the corresponding stem, when optimally press-fitted by the surgeon. After tuning in-vitro the protocol as in a closed loop, verification was made on two hip patients, confirming the results obtained in-vitro and highlighting the independence of the rasp indicator from the bone quality, anatomy and preserving conditions of the tested specimens, and from the sharpening of the rasp blades. The third study is related to an approach that have been recently explored in the orthopaedic community, but that was already in use in other scientific fields. It is based on the vibration analysis technique. This method has been successfully used to investigate the mechanical properties of the bone and its application to evaluate the extent of fixation of dental implants has been explored, even if its validity in this field is still under discussion. Several studies have been published recently on the stability assessment of hip implants by vibration analysis. The aim of the reported study was to develop and validate a prototype device based on the vibration analysis technique to measure intra-operatively the extent of implant stability. The expected advantages of a vibration-based device are easier clinical use, smaller dimensions and minor overall cost with respect to other devices based on direct micromotion measurement. The prototype developed consists of a piezoelectric exciter connected to the stem and an accelerometer attached to the femur. Preliminary tests were performed on four composite femurs implanted with a conventional stem. The results showed that the input signal was repeatable and the output could be recorded accurately. The fourth study concerns the application of the device based on the vibration analysis technique to several cases, considering both composite and cadaveric specimens. Different degrees of bone quality were tested, as well as different femur anatomies and several levels of press-fitting were considered. The aim of the study was to verify if it is possible to discriminate between stable and quasi-stable implants, because this is the most challenging detection for the surgeon in the operation room. Moreover, it was possible to validate the measurement protocol by comparing the results of the acquisitions made with the vibration-based tool to two reference measurements made by means of a validated technique, and a validated device. The results highlighted that the most sensitive parameter to stability is the shift in resonance frequency of the stem-bone system, showing high correlation with residual micromotion on all the tested specimens. Thus, it seems possible to discriminate between many levels of stability, from the grossly loosened implant, through the quasi-stable implants, to the definitely stable one. Finally, an additional study was performed on a different type of hip prosthesis, which has recently gained great interest thus becoming fairly popular in some countries in the last few years: the hip resurfacing prosthesis. The study was motivated by the following rationale: although bone-prosthesis micromotion is known to influence the stability of total hip replacement, its effect on the outcome of resurfacing implants has not been investigated in-vitro yet, but only clinically. Thus the work was aimed at verifying if it was possible to apply to the resurfacing prosthesis one of the intraoperative devices just validated for the measurement of the micromotion in the resurfacing implants. To do that, a preliminary study was performed in order to evaluate the extent of migration and the typical elastic movement for an epiphyseal prosthesis. An in-vitro procedure was developed to measure micromotions of resurfacing implants. This included a set of in-vitro loading scenarios that covers the range of directions covered by hip resultant forces in the most typical motor-tasks. The applicability of the protocol was assessed on two different commercial designs and on different head sizes. The repeatability and reproducibility were excellent (comparable to the best previously published protocols for standard cemented hip stems). Results showed that the procedure is accurate enough to detect micromotions of the order of few microns. The protocol proposed was thus completely validated. The results of the study demonstrated that the application of an intra-operative device to the resurfacing implants is not necessary, as the typical micromovement associated to this type of prosthesis could be considered negligible and thus not critical for the stabilization process. Concluding, four intra-operative tools have been developed and fully validated during these three years of research activity. The use in the clinical setting was tested for one of the devices, which could be used right now by the surgeon to evaluate the degree of stability achieved through the press-fitting procedure. The tool adapted to be used on the rasp was a good predictor of the stability of the stem. Thus it could be useful for the surgeon while checking if the pre-operative planning was correct. The device based on the vibration technique showed great accuracy, small dimensions, and thus has a great potential to become an instrument appreciated by the surgeon. It still need a clinical evaluation, and must be industrialized as well. The in-vitro tool worked very well, and can be applied for assessing resurfacing implants pre-clinically.

Studio di fenomeni d'instabilità gravitativa sui fondali marini, con particolare riferimento all'isola di Stromboli

In the last decade the interest for submarine instability grew up, driven by the increasing exploitation of natural resources (primary hydrocarbons), the emplacement of bottom-lying structures (cables and pipelines) and by the development of coastal areas, whose infrastructures increasingly protrude to the sea. The great interest for this topic promoted a number of international projects such as: STEAM (Sediment Transport on European Atlantic Margins, 93-96), ENAM II (European North Atlantic Margin, 96-99), GITEC (Genesis and Impact of Tsunamis on the European Coast 92-95), STRATAFORM (STRATA FORmation on Margins, 95-01), Seabed Slope Process in Deep Water Continental Margin (Northwest Gulf of Mexico, 96-04), COSTA (Continental slope Stability, 00-05), EUROMARGINS (Slope Stability on Europe’s Passive Continental Margin), SPACOMA (04-07), EUROSTRATAFORM (European Margin Strata Formation), NGI's internal project SIP-8 (Offshore Geohazards), IGCP-511: Submarine Mass Movements and Their Consequences (05-09) and projects indirectly related to instability processes, such as TRANSFER (Tsunami Risk ANd Strategies For the European region, 06-09) or NEAREST (integrated observations from NEAR shore sourcES of Tsunamis: towards an early warning system, 06-09). In Italy, apart from a national project realized within the activities of the National Group of Volcanology during the framework 2000-2003 “Conoscenza delle parti sommerse dei vulcani italiani e valutazione del potenziale rischio vulcanico”, the study of submarine mass-movement has been underestimated until the occurrence of the landslide-tsunami events that affected Stromboli on December 30, 2002. This event made the Italian Institutions and the scientific community more aware of the hazard related to submarine landslides, mainly in light of the growing anthropization of coastal sectors, that increases the vulnerability of these areas to the consequences of such processes. In this regard, two important national projects have been recently funded in order to study coastal instabilities (PRIN 24, 06-08) and to map the main submarine hazard features on continental shelves and upper slopes around the most part of Italian coast (MaGIC Project). The study realized in this Thesis is addressed to the understanding of these processes, with particular reference to Stromboli submerged flanks. These latter represent a natural laboratory in this regard, as several kind of instability phenomena are present on the submerged flanks, affecting about 90% of the entire submerged areal and often (strongly) influencing the morphological evolution of subaerial slopes, as witnessed by the event occurred on 30 December 2002. Furthermore, each phenomenon is characterized by different pre-failure, failure and post-failure mechanisms, ranging from rock-falls, to turbidity currents up to catastrophic sector collapses. The Thesis is divided into three introductive chapters, regarding a brief review of submarine instability phenomena and related hazard (cap. 1), a “bird’s-eye” view on methodologies and available dataset (cap. 2) and a short introduction on the evolution and the morpho-structural setting of the Stromboli edifice (cap. 3). This latter seems to play a major role in the development of largescale sector collapses at Stromboli, as they occurred perpendicular to the orientation of the main volcanic rift axis (oriented in NE-SW direction). The characterization of these events and their relationships with successive erosive-depositional processes represents the main focus of cap.4 (Offshore evidence of large-scale lateral collapses on the eastern flank of Stromboli, Italy, due to structurally-controlled, bilateral flank instability) and cap. 5 (Lateral collapses and active sedimentary processes on the North-western flank of Stromboli Volcano), represented by articles accepted for publication on international papers (Marine Geology). Moreover, these studies highlight the hazard related to these catastrophic events; several calamities (with more than 40000 casualties only in the last two century) have been, in fact, the direct or indirect result of landslides affecting volcanic flanks, as observed at Oshima-Oshima (1741) and Unzen Volcano (1792) in Japan (Satake&Kato, 2001; Brantley&Scott, 1993), Krakatau (1883) in Indonesia (Self&Rampino, 1981), Ritter Island (1888), Sissano in Papua New Guinea (Ward& Day, 2003; Johnson, 1987; Tappin et al., 2001) and Mt St. Augustine (1883) in Alaska (Beget& Kienle, 1992). Flank landslide are also recognized as the most important and efficient mass-wasting process on volcanoes, contributing to the development of the edifices by widening their base and to the growth of a volcaniclastic apron at the foot of a volcano; a number of small and medium-scale erosive processes are also responsible for the carving of Stromboli submarine flanks and the transport of debris towards the deeper areas. The characterization of features associated to these processes is the main focus of cap. 6; it is also important to highlight that some small-scale events are able to create damage to coastal areas, as also witnessed by recent events of Gioia Tauro 1978, Nizza, 1979 and Stromboli 2002. The hazard potential related to these phenomena is, in fact, very high, as they commonly occur at higher frequency with respect to large-scale collapses, therefore being more significant in terms of human timescales. In the last chapter (cap. 7), a brief review and discussion of instability processes identified on Stromboli submerged flanks is presented; they are also compared with respect to analogous processes recognized in other submerged areas in order to shed lights on the main factors involved in their development. Finally, some applications of multibeam data to assess the hazard related to these phenomena are also discussed.