New functional and biomechanical assessments for the improvement of the surgical navigation systems for joint replacement in the human lower limb

In case of severe osteoarthritis at the knee causing pain, deformity, and loss of stability and mobility, the clinicians consider that the substitution of these surfaces by means of joint prostheses. The objectives to be pursued by this surgery are: complete pain elimination, restoration of the normal physiological mobility and joint stability, correction of all deformities and, thus, of limping. The knee surgical navigation systems have bee developed in computer-aided surgery in order to improve the surgical final outcome in total knee arthroplasty. These systems provide the surgeon with quantitative and real-time information about each surgical action, like bone cut executions and prosthesis component alignment, by mean of tracking tools rigidly fixed onto the femur and the tibia. Nevertheless, there is still a margin of error due to the incorrect surgical procedures and to the still limited number of kinematic information provided by the current systems. Particularly, patello-femoral joint kinematics is not considered in knee surgical navigation. It is also unclear and, thus, a source of misunderstanding, what the most appropriate methodology is to study the patellar motion. In addition, also the knee ligamentous apparatus is superficially considered in navigated total knee arthroplasty, without taking into account how their physiological behavior is altered by this surgery. The aim of the present research work was to provide new functional and biomechanical assessments for the improvement of the surgical navigation systems for joint replacement in the human lower limb. This was mainly realized by means of the identification and development of new techniques that allow a thorough comprehension of the functioning of the knee joint, with particular attention to the patello-femoral joint and to the main knee soft tissues. A knee surgical navigation system with active markers was used in all research activities presented in this research work. Particularly, preliminary test were performed in order to assess the system accuracy and the robustness of a number of navigation procedures. Four studies were performed in-vivo on patients requiring total knee arthroplasty and randomly implanted by means of traditional and navigated procedures in order to check for the real efficacy of the latter with respect to the former. In order to cope with assessment of patello-femoral joint kinematics in the intact and replaced knees, twenty in-vitro tests were performed by using a prototypal tracking tool also for the patella. In addition to standard anatomical and articular recommendations, original proposals for defining the patellar anatomical-based reference frame and for studying the patello-femoral joint kinematics were reported and used in these tests. These definitions were applied to two further in-vitro tests in which, for the first time, also the implant of patellar component insert was fully navigated. In addition, an original technique to analyze the main knee soft tissues by means of anatomical-based fiber mappings was also reported and used in the same tests. The preliminary instrumental tests revealed a system accuracy within the millimeter and a good inter- and intra-observer repeatability in defining all anatomical reference frames. In in-vivo studies, the general alignments of femoral and tibial prosthesis components and of the lower limb mechanical axis, as measured on radiographs, was more satisfactory, i.e. within ±3°, in those patient in which total knee arthroplasty was performed by navigated procedures. As for in-vitro tests, consistent patello-femoral joint kinematic patterns were observed over specimens throughout the knee flexion arc. Generally, the physiological intact knee patellar motion was not restored after the implant. This restoration was successfully achieved in the two further tests where all component implants, included the patellar insert, were fully navigated, i.e. by means of intra-operative assessment of also patellar component positioning and general tibio-femoral and patello-femoral joint assessment. The tests for assessing the behavior of the main knee ligaments revealed the complexity of the latter and the different functional roles played by the several sub-bundles compounding each ligament. Also in this case, total knee arthroplasty altered the physiological behavior of these knee soft tissues. These results reveal in-vitro the relevance and the feasibility of the applications of new techniques for accurate knee soft tissues monitoring, patellar tracking assessment and navigated patellar resurfacing intra-operatively in the contest of the most modern operative techniques. This present research work gives a contribution to the much controversial knowledge on the normal and replaced of knee kinematics by testing the reported new methodologies. The consistence of these results provides fundamental information for the comprehension and improvements of knee orthopedic treatments. In the future, the reported new techniques can be safely applied in-vivo and also adopted in other joint replacements.

Subject-specific musculoskeletal models of the lower limbs for the prediction of skeletal loads during motion

The determination of skeletal loading conditions in vivo and their relationship to the health of bone tissues, remain an open question. Computational modeling of the musculoskeletal system is the only practicable method providing a valuable approach to muscle and joint loading analyses, although crucial shortcomings limit the translation process of computational methods into the orthopedic and neurological practice. A growing attention focused on subject-specific modeling, particularly when pathological musculoskeletal conditions need to be studied. Nevertheless, subject-specific data cannot be always collected in the research and clinical practice, and there is a lack of efficient methods and frameworks for building models and incorporating them in simulations of motion. The overall aim of the present PhD thesis was to introduce improvements to the state-of-the-art musculoskeletal modeling for the prediction of physiological muscle and joint loads during motion. A threefold goal was articulated as follows: (i) develop state-of-the art subject-specific models and analyze skeletal load predictions; (ii) analyze the sensitivity of model predictions to relevant musculotendon model parameters and kinematic uncertainties; (iii) design an efficient software framework simplifying the effort-intensive phases of subject-specific modeling pre-processing. The first goal underlined the relevance of subject-specific musculoskeletal modeling to determine physiological skeletal loads during gait, corroborating the choice of full subject-specific modeling for the analyses of pathological conditions. The second goal characterized the sensitivity of skeletal load predictions to major musculotendon parameters and kinematic uncertainties, and robust probabilistic methods were applied for methodological and clinical purposes. The last goal created an efficient software framework for subject-specific modeling and simulation, which is practical, user friendly and effort effective. Future research development aims at the implementation of more accurate models describing lower-limb joint mechanics and musculotendon paths, and the assessment of an overall scenario of the crucial model parameters affecting the skeletal load predictions through probabilistic modeling.

Evaluation of deambulation in a protected environment and in the public green in limb amputated subjects treated through a new osteointegration method

The limb amputation is one of the oldest surgical procedures performed and it still represents an event that drastically changes the life of an individual. Despite the technological progress, the difficulties related to the realization and daily use of the socket remain very common. Among the different technologies adopted in the prosthetic field, this project focused on the osseointegration technique. This technique consists in implanting a stem within the medullary canal of the amputated skeletal segment that extends outside the amputation stump with a prosthesis, later connected to the metal extension. The objective of this PhD project is to treat and to evaluate selected patients with osseointegrated prosthetic implants for the treatment of lower limb amputations. Patients are recruited at the Rizzoli Orthopaedic Institute and at the Prosthesis - INAIL center of Vigorso (Budrio) during outpatient visits, while the surgical procedure is performed by the same expert surgeon in the II Orthopaedic and Traumatology Clinic of the Rizzoli Orthopaedic Institute. The project is still ongoing, to date three patients had completed both procedures, but due to various personal problems, just one of them is included in the analysis. This patient increased his percentage of prosthesis use and the level of mobility with an overall improvement of quality of live after the procedure. The osseointegration technique represents a promising alternative method of treatment for amputees who are not satisfied with their socket prosthesis. In the coming years it will continue the collection of clinical, radiographic and kinematic data of subjects undergoing this procedure in order to perform a long-term monitoring of both clinical outcomes and quality of life.

Development of musculoskeletal models for the design and the pre-clinical validation of hip resurfacing prosthesis

Background. The surgical treatment of dysfunctional hips is a severe condition for the patient and a costly therapy for the public health. Hip resurfacing techniques seem to hold the promise of various advantages over traditional THR, with particular attention to young and active patients. Although the lesson provided in the past by many branches of engineering is that success in designing competitive products can be achieved only by predicting the possible scenario of failure, to date the understanding of the implant quality is poorly pre-clinically addressed. Thus revision is the only delayed and reliable end point for assessment. The aim of the present work was to model the musculoskeletal system so as to develop a protocol for predicting failure of hip resurfacing prosthesis. Methods. Preliminary studies validated the technique for the generation of subject specific finite element (FE) models of long bones from Computed Thomography data. The proposed protocol consisted in the numerical analysis of the prosthesis biomechanics by deterministic and statistic studies so as to assess the risk of biomechanical failure on the different operative conditions the implant might face in a population of interest during various activities of daily living. Physiological conditions were defined including the variability of the anatomy, bone densitometry, surgery uncertainties and published boundary conditions at the hip. The protocol was tested by analysing a successful design on the market and a new prototype of a resurfacing prosthesis. Results. The intrinsic accuracy of models on bone stress predictions (RMSE < 10%) was aligned to the current state of the art in this field. The accuracy of prediction on the bone-prosthesis contact mechanics was also excellent (< 0.001 mm). The sensitivity of models prediction to uncertainties on modelling parameter was found below 8.4%. The analysis of the successful design resulted in a very good agreement with published retrospective studies. The geometry optimisation of the new prototype lead to a final design with a low risk of failure. The statistical analysis confirmed the minimal risk of the optimised design over the entire population of interest. The performances of the optimised design showed a significant improvement with respect to the first prototype (+35%). Limitations. On the authors opinion the major limitation of this study is on boundary conditions. The muscular forces and the hip joint reaction were derived from the few data available in the literature, which can be considered significant but hardly representative of the entire variability of boundary conditions the implant might face over the patients population. This moved the focus of the research on modelling the musculoskeletal system; the ongoing activity is to develop subject-specific musculoskeletal models of the lower limb from medical images. Conclusions. The developed protocol was able to accurately predict known clinical outcomes when applied to a well-established device and, to support the design optimisation phase providing important information on critical characteristics of the patients when applied to a new prosthesis. The presented approach does have a relevant generality that would allow the extension of the protocol to a large set of orthopaedic scenarios with minor changes. Hence, a failure mode analysis criterion can be considered a suitable tool in developing new orthopaedic devices.

Procedura di progettazione di protesi a basso costo per l'arto inferiore

L'attività di ricerca descritta in questa tesi fornisce linee guida per la progettazione di arti protesici inferiori, con particolare riferimento alla progettazione di protesi a basso costo. La necessità di efficienti protesi a basso costo risulta infatti sentita nei Paesi in via di sviluppo ma anche dalle fasce meno abbienti dei paesi occidentali. Al fine di comprendere le strategie adottate dall'apparato locomotorio per muoversi con le protesi sono analizzati il cammino fisiologico, le protesi presenti sul mercato ed infine le modalità con cui le loro prestazioni sono valutate. Con il presente lavoro, dopo aver osservato la presenza di una scarsa strutturazione della metodologia di progettazione che riguarda specialmente il settore del basso costo, si propone una metodologia il più possibile oggettiva e ripetibile tesa ad individuare quali sono gli aspetti essenziali di una protesi per garantire al paziente una buona qualità di vita. Solo questi aspetti dovranno essere selezionati al fine di ottenere la massima semplificazione della protesi e ridurre il più possibile i costi. Per la simulazione delle attività di locomozione, in particolare del cammino, è stato elaborato un apposito modello spaziale del cammino. Il modello proposto ha 7 membri rigidi (corrispondenti a piedi, tibie, femori e bacino) e 24 gradi di libertà. Le articolazioni e l'appoggio dei piedi al suolo sono modellati con giunti sferici. La pianta del piede consente tre possibili punti di appoggio. I criteri di realizzazione delle simulazioni possono comprendere aspetti energetici, cinematici e dinamici considerati come obiettivo dall'apparato locomotorio. In questa tesi vengono trattati in particolare gli aspetti cinematici ed è mostrata un'applicazione della procedura nella quale vengono dapprima identificati i riferimenti fisiologici del cammino e quindi simulato il cammino in presenza di una menomazione al ginocchio (eliminazione della flessione in fase di appoggio). Viene quindi lasciato a sviluppi futuri il completamento della procedura e la sua implementazione in un codice di calcolo.

Development of motion analysis protocols based on inertial sensors

The aim of this thesis was to describe the development of motion analysis protocols for applications on upper and lower limb extremities, by using inertial sensors-based systems. Inertial sensors-based systems are relatively recent. Knowledge and development of methods and algorithms for the use of such systems for clinical purposes is therefore limited if compared with stereophotogrammetry. However, their advantages in terms of low cost, portability, small size, are a valid reason to follow this direction. When developing motion analysis protocols based on inertial sensors, attention must be given to several aspects, like the accuracy of inertial sensors-based systems and their reliability. The need to develop specific algorithms/methods and software for using these systems for specific applications, is as much important as the development of motion analysis protocols based on them. For this reason, the goal of the 3-years research project described in this thesis was achieved first of all trying to correctly design the protocols based on inertial sensors, in terms of exploring and developing which features were suitable for the specific application of the protocols. The use of optoelectronic systems was necessary because they provided a gold standard and accurate measurement, which was used as a reference for the validation of the protocols based on inertial sensors. The protocols described in this thesis can be particularly helpful for rehabilitation centers in which the high cost of instrumentation or the limited working areas do not allow the use of stereophotogrammetry. Moreover, many applications requiring upper and lower limb motion analysis to be performed outside the laboratories will benefit from these protocols, for example performing gait analysis along the corridors. Out of the buildings, the condition of steady-state walking or the behavior of the prosthetic devices when encountering slopes or obstacles during walking can also be assessed. The application of inertial sensors on lower limb amputees presents conditions which are challenging for magnetometer-based systems, due to ferromagnetic material commonly adopted for the construction of idraulic components or motors. INAIL Prostheses Centre stimulated and, together with Xsens Technologies B.V. supported the development of additional methods for improving the accuracy of MTx in measuring the 3D kinematics for lower limb prostheses, with the results provided in this thesis. In the author’s opinion, this thesis and the motion analysis protocols based on inertial sensors here described, are a demonstration of how a strict collaboration between the industry, the clinical centers, the research laboratories, can improve the knowledge, exchange know-how, with the common goal to develop new application-oriented systems.

Analysis of human body kinematics using a hybrid markerless video acquisition and processing

A main objective of the human movement analysis is the quantitative description of joint kinematics and kinetics. This information may have great possibility to address clinical problems both in orthopaedics and motor rehabilitation. Previous studies have shown that the assessment of kinematics and kinetics from stereophotogrammetric data necessitates a setup phase, special equipment and expertise to operate. Besides, this procedure may cause feeling of uneasiness on the subjects and may hinder with their walking. The general aim of this thesis is the implementation and evaluation of new 2D markerless techniques, in order to contribute to the development of an alternative technique to the traditional stereophotogrammetric techniques. At first, the focus of the study has been the estimation of the ankle-foot complex kinematics during stance phase of the gait. Two particular cases were considered: subjects barefoot and subjects wearing ankle socks. The use of socks was investigated in view of the development of the hybrid method proposed in this work. Different algorithms were analyzed, evaluated and implemented in order to have a 2D markerless solution to estimate the kinematics for both cases. The validation of the proposed technique was done with a traditional stereophotogrammetric system. The implementation of the technique leads towards an easy to configure (and more comfortable for the subject) alternative to the traditional stereophotogrammetric system. Then, the abovementioned technique has been improved so that the measurement of knee flexion/extension could be done with a 2D markerless technique. The main changes on the implementation were on occlusion handling and background segmentation. With the additional constraints, the proposed technique was applied to the estimation of knee flexion/extension and compared with a traditional stereophotogrammetric system. Results showed that the knee flexion/extension estimation from traditional stereophotogrammetric system and the proposed markerless system were highly comparable, making the latter a potential alternative for clinical use. A contribution has also been given in the estimation of lower limb kinematics of the children with cerebral palsy (CP). For this purpose, a hybrid technique, which uses high-cut underwear and ankle socks as “segmental markers” in combination with a markerless methodology, was proposed. The proposed hybrid technique is different than the abovementioned markerless technique in terms of the algorithm chosen. Results showed that the proposed hybrid technique can become a simple and low-cost alternative to the traditional stereophotogrammetric systems.

Reconstructive Microsurgery and Tissue Engineering in Musculo-Skeletal Oncology - Innovative Techniques

Tumors involving bone and soft tissues are extremely challenging situations. With the recent advances of multi-modal treatment, not only the type of surgery has moved from amputation to limb-sparing procedures, but also the survivorship has improved considerably and reconstructive techniques have the goal to allow a considerably higher quality of life. In bone reconstruction, tissue engineering strategies are the main area of research. Re-vascularization and re-vitalisation of a massive allograft would considerably improve the outcome of biological reconstructions. Using a rabbit animal model, in this study we showed that, by implanting a vascular pedicle inside a weight bearing massive cortical allograft, the bone regeneration inside the allograft was higher compared to the non-vascularized implants, given the patency of the vascular pedicle. Improvement in the animal model and the addition of Stem Cells and Growth factors will allow a further improvement in the results. In soft tissue tumors, free and pedicled flaps have been proven to be of great help as reconstruction strategies. In this study we analyzed the functional and overall outcome of 14 patients who received a re-innervated vascularized flap. We have demonstrated that the use of the innovative technique of motor re-innervated muscular flaps is effective when the resection involves important functional compartments of the upper or lower limb, with no increase of post-operative complications. Although there was no direct comparison between this type of reconstruction and the standard non-innervated reconstruction, we underlined the remarkable high overall functional scores and patient satisfaction following this procedure.

Cell-free cryopreserved arterial allografts from multiorgan donors: a new strategy to fabricate artificial blood vessels suited for peripheral vascular surgery

Critical lower limb ischemia is a severe disease. A common approach is infrainguinal bypass. Synthetic vascular prosthesis, are good conduits in high-flow low-resistance conditions but have difficulty in their performance as small diameter vessel grafts. A new approach is the use of native decellularized vascular tissues. Cell-free vessels are expected to have improved biocompatibility when compared to synthetic and are optimal natural 3D matrix templates for driving stem cell growth and tissue assembly in vivo. Decellularization of tissues represent a promising field for regenerative medicine, with the aim to develop a methodology to obtain small-diameter allografts to be used as a natural scaffold suited for in vivo cell growth and pseudo-tissue assembly, eliminating failure caused from immune response activation. Material and methods. Umbilical cord-derived mesenchymal cells isolated from human umbilical cord tissue were expanded in advanced DMEM. Immunofluorescence and molecular characterization revealed a stem cell profile. A non-enzymatic protocol, that associate hypotonic shock and low-concentration ionic detergent, was used to decellularize vessel segments. Cells were seeded cell-free scaffolds using a compound of fibrin and thrombin and incubated in DMEM, after 4 days of static culture they were placed for 2 weeks in a flow-bioreactor, mimicking the cardiovascular pulsatile flow. After dynamic culture, samples were processed for histological, biochemical and ultrastructural analysis. Discussion. Histology showed that the dynamic culture cells initiate to penetrate the extracellular matrix scaffold and to produce components of the ECM, as collagen fibres. Sirius Red staining showed layers of immature collagen type III and ultrastructural analysis revealed 30 nm thick collagen fibres, presumably corresponding to the immature collagen. These data confirm the ability of cord-derived cells to adhere and penetrate a natural decellularized tissue and to start to assembly into new tissue. This achievement makes natural 3D matrix templates prospectively valuable candidates for clinical bypass procedures

The use of expandable megaprostheses for reconstruction of the distal femur in pediatric patients after bone tumor resection

Expandable prostheses are becoming increasingly popular in the reconstruction of children with bone sarcomas of the lower limb. Since the introduction of effective chemotherapy in the treatment of these pathologies, in the 70s, there has been need for new limb salvage techniques. In children, limb salvage of the lower limbs is particularly challenging, not in the last place, because of the loss of growth potential. Therefore, expandable prostheses have been developed. However, the first experiences with these implants were not very successful. High complication rates and unpredictable outcomes raised major concerns on this innovative type of reconstruction. The rarity of the indication is one of the main reasons why there has been a relatively slow learning curve and implant development regarding this type of prosthesis. This PhD thesis, gives an overview of the introduction, the development, the current standards, and the future perspectives of expandable prostheses for the reconstruction of the distal femur in children.

Physical activity and osseointegration: "step forward" to improve the quality of life of a trans-femoral amputee person

Lower limb amputation is an event that inevitably changes the lifestyle of the person with a significant impact on quality of life. The socket-type prosthesis entails that the residual limb is in direct contact with the socket which often implies numerous disadvantages. Osseointegrated prosthesis is a solution that avoids skin problems because not include the presence of the socket. In this type of prosthesis, a stem is surgically inserted inside the medullary canal and connected with the external prosthetic limb. Therefore, this thesis aims to highlight and explore the main strengths and problems of osseointegrated prostheses and to examine the role of physical activity, with attention to functional capacity and bone quality. The objectives of the thesis will be developed through 5 studies: (I) A gait analysis of a 44 years-old male patient who underwent surgery for the implantation of an osseointegrated prosthesis; (II) A systematic review to investigate the state of stump bone quality in patients with limb amputations; (III) A systematic review of the technologies involved in such devices has been carried out to identify the most fruitful ones in improving bone quality; (IV) A systematic review investigating the topic of physical activity and bone turnover biomarkers; (V) A systematic review to investigate the effects of physical activity interventions combined with drug treatments on bone biomarkers in people with osteopenia and osteoporosis. The integrated prosthesis is a good solution for people with lower limb amputation who cannot use their traditional socket-type prosthesis. Although many objectives have already been achieved, there are still many aspects that we can improve. These include the creation of a multidisciplinary path that support patients along their path, with particular attention to the pre-surgery and the post-rehabilitation phase that is still lacking even if of fundamental impact in determining the quality of life.

Skeletal variability of the fibular ends and evolutionary implications

This thesis investigates the morphological variations of fibular extremities in humans and non-human hominids using a 3D Geometric Morphometric approach. The study has three objectives: (1) to assess the shape, form, and size variations of fibular epiphyses within the human species, highlighting sexually dimorphic features; (2) to explore interpopulation variability of fibular extremities from the Upper Paleolithic to the 20th century, comparing subsistence, mobility, and lifestyles; and (3) to examine interspecific variations in fibular ends, testing potential associations with locomotor and positional behavior among extant hominid taxa. In terms of intraspecific variations, sex-related differences in fibular form and size were observed, suggesting distinct functional requirements for the lower limb between sexes. Interpopulation variations revealed a decline in activity level over time, influenced by terrain and footwear use. Hunter-gatherer groups exhibited greater joint mobility, loading, and range of motion compared to sedentary pre- and post-industrial populations. Interspecific variations demonstrated significant morphological differences among hominid taxa, indicating functional implications related to both phylogeny and specific loading patterns on the lower limb. The study identified features indicative of bipedalism in humans, as well as shared characteristics among non-human great apes. Furthermore, distinguishing features were found between Asian and African apes, along with unique morphological signals associated with distinct positional behavior in each hominid taxa. By comprehensively analyzing fibular morphology, this research sheds light on the importance of this bone in knee support, ankle stabilization, and overall locomotor function. The findings contribute to our understanding of the evolutionary and functional aspects of the fibula across human populations and non-human hominids throughout history.

Medial Artery Calcification (MAC) e Small Artery Disease (SAD) nei pazienti con ischemia critica degli arti inferiori: definizione dei fattori predisponenti, svilup-po di uno score prognostico, definizione istopatologica e valutazione dei risultati dell'arterializzazione delle vene dell'arto inferiore come tecnica di rivascolarizzazione

Questo studio si concentra sull'ischemia critica cronica dell'arto inferiore (CLTI), una patologia globale con gravi complicanze e impatto sociale elevato. Recentemente, la "Medial Artery Calcification" (MAC) è emersa come fattore prognostico significativo nei pazienti con CLTI e malattia grave dei vasi del piede, ma le informazioni sono principalmente retrospettive. Questa tesi esplora la relazione tra MAC e CLTI in tre sezioni. Nella sezione clinica, 248 pazienti sono stati divisi in gruppi MAC per valutare l'impatto prospettico sulla guarigione e sul salvataggio dell'arto. Nella sezione isto-patologica, campioni arteriosi di 26 pazienti sottoposti ad amputazione maggiore sono stati analizzati per comprendere la relazione tra MAC, aterosclerosi e occlusione vascolare. Nella sezione di arterializzazione, 16 pazienti sottoposti all'arterializzazione delle vene del piede (AVP) sono stati esaminati per valutare i risultati clinici prospettici. I risultati della sezione clinica indicano che la presenza di MAC severa è associata a risultati clinici peggiori nei pazienti affetti da CLTI. L'analisi isto-patologica mostra una prevalenza elevata di MAC rispetto all'aterosclerosi, con una associazione importante tra MAC e iperplasia intimale. L'AVP presenta risultati promettenti nei pazienti affetti da CLTI. In conclusione, la MAC influisce sui risultati clinici della CLTI, e l'AVP potrebbe essere una strategia efficace di trattamento.

Alpha oscillations index the functionality and the plastic changes of the visual system

Alpha oscillations are linked to visual awareness and to the periodical sampling of visual information, suggesting that alpha rhythm reflect an index of the functionality of the posterior cortices, and hence of the visual system. Therefore, the present work described a series of studies investigating alpha oscillations as a biomarker of the functionality and the plastic modifications of the visual system in response to lesions to the visual cortices or to external stimulations. The studies presented in chapter 5 and 6 showed that posterior lesions alter alpha oscillations in hemianopic patients, with reduced alpha reactivity at the eyes opening and decreased alpha functional connectivity, especially in right-lesioned hemianopics, with concurrent dysfunctions in the theta range, suggesting a specialization of the right hemisphere in orchestrating alpha oscillations and coordinating complex interplays among different brain rhythms. The study presented in chapter 7 investigated a mechanism of rhythmical attentional sampling of visual information in healthy participants, showing that perceptual performance is influenced by a rhythmical mechanism of attentional allocation, occurring at lower-alpha frequencies (i.e., 7 Hz), when a single spatial location is monitored, and at lower frequencies (i.e., 5 Hz), when attention is allocated to two spatial locations. Moreover, the right hemisphere seemed to have a dominance in this rhythmical attentional sampling, distributing attentional resources to the entire visual field. Finally, the study presented in chapter 8 showed that prolonged visual entrainment induce long-term modulations of resting-state alpha activity in healthy participants, suggesting that persistent modifications in the functionality of the visual system are possible. Altogheter, these findings show that functional processes and plastic changes of the visual system are reflected in alpha oscillatory patterns. Therefore, investigating and promoting alpha oscillations may contribute to the development of rehabilitative protocols to ameliorate the functionality of the visual system, in brain lesioned patients.