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.

Letteratura postmoderna e comunicazione pubblicitaria, problemi teorici e analisi testuali

Premise: In the literary works of our anthropological and cultural imagination, the various languages and the different discursive practices are not necessarily quoted, expressly alluded to or declared through clear expressive mechanisms; instead, they rather constitute a substratum, a background, now consolidated, which with irony and intertextuality shines through the thematic and formal elements of each text. The various contaminations, hybridizations and promptings that we find in the expressive forms, the rhetorical procedures and the linguistic and thematic choices of post-modern literary texts are shaped as fluid and familiar categories. Exchanges and passages are no longer only allowed but also inevitable; the post-modern imagination is made up of an agglomeration of discourses that are no longer really separable, built up from texts that blend and quote one another, composing, each with its own specificities, the great family of the cultural products of our social scenario. A literary work, therefore, is not only a whole phenomenon, delimited hic et nunc by a beginning and an ending, but is a fragment of that complex, dense and boundless network that is given by the continual interrelations between human forms of communication and symbolization. The research hypothesis: A vision is delineated of comparative literature as a discipline attentive to the social contexts in which texts take shape and move and to the media-type consistency that literary phenomena inevitably take on. Hence literature is seen as an open systematicity that chooses to be contaminated by other languages and other discursive practices of an imagination that is more than ever polymorphic and irregular. Inside this interpretative framework the aim is to focus the analysis on the relationship that postmodern literature establishes with advertising discourse. On one side post-modern literature is inserted in the world of communication, loudly asserting the blending and reciprocal contamination of literary modes with media ones, absorbing their languages and signification practices, translating them now into thematic nuclei, motifs and sub-motifs and now into formal expedients and new narrative choices; on the other side advertising is chosen as a signification practice of the media universe, which since the 1960s has actively contributed to shaping the dynamics of our socio-cultural scenarios, in terms which are just as important as those of other discursive practices. Advertising has always been a form of communication and symbolization that draws on the collective imagination – myths, actors and values – turning them into specific narrative programs for its own texts. Hence the aim is to interpret and analyze this relationship both from a strictly thematic perspective – and therefore trying to understand what literature speaks about when it speaks about advertising, and seeking advertising quotations in post-modern fiction – and from a formal perspective, with a search for parallels and discordances between the rhetorical procedures, the languages and the verifiable stylistic choices in the texts of the two different signification practices. The analysis method chosen, for the purpose of constructive multiplication of the perspectives, aims to approach the analytical processes of semiotics, applying, when possible, the instruments of the latter, in order to highlight the thematic and formal relationships between literature and advertising. The corpus: The corpus of the literary texts is made up of various novels and, although attention is focused on the post-modern period, there will also be ineludible quotations from essential authors that with their works prompted various reflections: H. De Balzac, Zola, Fitzgerald, Joyce, Calvino, etc… However, the analysis focuses the corpus on three authors: Don DeLillo, Martin Amis and Aldo Nove, and in particular the followings novels: “Americana” (1971) and “Underworld” (1999) by Don DeLillo, “Money” (1984) by Martin Amis and “Woobinda and other stories without a happy ending” (1996) and “Superwoobinda” (1998) by Aldo Nove. The corpus selection is restricted to these novels for two fundamental reasons: 1. assuming parameters of spatio-temporal evaluation, the texts are representative of different socio-cultural contexts and collective imaginations (from the masterly glimpses of American life by DeLillo, to the examples of contemporary Italian life by Nove, down to the English imagination of Amis) and of different historical moments (the 1970s of DeLillo’s Americana, the 1980s of Amis, down to the 1990s of Nove, decades often used as criteria of division of postmodernism into phases); 2. adopting a perspective of strictly thematic analysis, as mentioned in the research hypothesis, the variations and the constants in the novels (thematic nuclei, topoi, images and narrative developments) frequently speak of advertising and inside the narrative plot they affirm various expressions and realizations of it: value ones, thematic ones, textual ones, urban ones, etc… In these novels the themes and the processes of signification of advertising discourse pervade time, space and the relationships that the narrator character builds around him. We are looking at “particle-characters” whose endless facets attest the influence and contamination of advertising in a large part of the narrative developments of the plot: on everyday life, on the processes of acquisition and encoding of the reality, on ideological and cultural baggage, on the relationships and interchanges with the other characters, etc… Often the characters are victims of the implacable consequentiality of the advertising mechanism, since the latter gets the upper hand over the usual processes of communication, which are overwhelmed by it, wittingly or unwittingly (for example: disturbing openings in which the protagonist kills his or her parents on the basis of a spot, former advertisers that live life codifying it through the commercial mechanisms of products, sons and daughters of advertisers that as children instead of playing outside for whole nights saw tapes of spots.) Hence the analysis arises from the text and aims to show how much the developments and the narrative plots of the novels encode, elaborate and recount the myths, the values and the narrative programs of advertising discourse, transforming them into novel components in their own right. And also starting from the text a socio-cultural reference context is delineated, a collective imagination that is different, now geographically, now historically, and from comparison between them the aim is to deduce the constants, the similarities and the variations in the relationship between literature and advertising.

Fiscal Constitutions: An Empirical Approach

The overarching question of this dissertation is: “why does the public debt grow, and why are fiscal (debt) crises repetitive and so widespread?” A special focus in answering this question is given to a fiscal constitution, which contains a country-specific set of laws, rules and regulations, and guides decision making in the area of fiscal policy. By shaping incentives and limiting arbitrariness, the fiscal constitution determines the course of fiscal policy and fiscal outcomes in the long term. This dissertation does not give, however, an exhaustive response to the overarching question. Instead it asks much narrower questions, which are selected after reviewing and identifying the main weaknesses and gaps in the modern literature on fiscal constitutions.