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.

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.

Cross-layer optimizations in multi-hop ad hoc networks

Unlike traditional wireless networks, characterized by the presence of last-mile, static and reliable infrastructures, Mobile ad Hoc Networks (MANETs) are dynamically formed by collections of mobile and static terminals that exchange data by enabling each other's communication. Supporting multi-hop communication in a MANET is a challenging research area because it requires cooperation between different protocol layers (MAC, routing, transport). In particular, MAC and routing protocols could be considered mutually cooperative protocol layers. When a route is established, the exposed and hidden terminal problems at MAC layer may decrease the end-to-end performance proportionally with the length of each route. Conversely, the contention at MAC layer may cause a routing protocol to respond by initiating new routes queries and routing table updates. Multi-hop communication may also benefit the presence of pseudo-centralized virtual infrastructures obtained by grouping nodes into clusters. Clustering structures may facilitate the spatial reuse of resources by increasing the system capacity: at the same time, the clustering hierarchy may be used to coordinate transmissions events inside the network and to support intra-cluster routing schemes. Again, MAC and clustering protocols could be considered mutually cooperative protocol layers: the clustering scheme could support MAC layer coordination among nodes, by shifting the distributed MAC paradigm towards a pseudo-centralized MAC paradigm. On the other hand, the system benefits of the clustering scheme could be emphasized by the pseudo-centralized MAC layer with the support for differentiated access priorities and controlled contention. In this thesis, we propose cross-layer solutions involving joint design of MAC, clustering and routing protocols in MANETs. As main contribution, we study and analyze the integration of MAC and clustering schemes to support multi-hop communication in large-scale ad hoc networks. A novel clustering protocol, named Availability Clustering (AC), is defined under general nodes' heterogeneity assumptions in terms of connectivity, available energy and relative mobility. On this basis, we design and analyze a distributed and adaptive MAC protocol, named Differentiated Distributed Coordination Function (DDCF), whose focus is to implement adaptive access differentiation based on the node roles, which have been assigned by the upper-layer's clustering scheme. We extensively simulate the proposed clustering scheme by showing its effectiveness in dominating the network dynamics, under some stressing mobility models and different mobility rates. Based on these results, we propose a possible application of the cross-layer MAC+Clustering scheme to support the fast propagation of alert messages in a vehicular environment. At the same time, we investigate the integration of MAC and routing protocols in large scale multi-hop ad-hoc networks. A novel multipath routing scheme is proposed, by extending the AOMDV protocol with a novel load-balancing approach to concurrently distribute the traffic among the multiple paths. We also study the composition effect of a IEEE 802.11-based enhanced MAC forwarding mechanism called Fast Forward (FF), used to reduce the effects of self-contention among frames at the MAC layer. The protocol framework is modelled and extensively simulated for a large set of metrics and scenarios. For both the schemes, the simulation results reveal the benefits of the cross-layer MAC+routing and MAC+clustering approaches over single-layer solutions.

Percezione della direzione del proprio movimento: dalla registrazione dell'attività corticale al modello computazionale.

The main aim of this thesis is strongly interdisciplinary: it involves and presumes a knowledge on Neurophysiology, to understand the mechanisms that undergo the studied phenomena, a knowledge and experience on Electronics, necessary during the hardware experimental set-up to acquire neuronal data, on Informatics and programming to write the code necessary to control the behaviours of the subjects during experiments and the visual presentation of stimuli. At last, neuronal and statistical models should be well known to help in interpreting data. The project started with an accurate bibliographic research: until now the mechanism of perception of heading (or direction of motion) are still poorly known. The main interest is to understand how the integration of visual information relative to our motion with eye position information happens. To investigate the cortical response to visual stimuli in motion and the integration with eye position, we decided to study an animal model, using Optic Flow expansion and contraction as visual stimuli. In the first chapter of the thesis, the basic aims of the research project are presented, together with the reasons why it’s interesting and important to study perception of motion. Moreover, this chapter describes the methods my research group thought to be more adequate to contribute to scientific community and underlines my personal contribute to the project. The second chapter presents an overview on useful knowledge to follow the main part of the thesis: it starts with a brief introduction on central nervous system, on cortical functions, then it presents more deeply associations areas, which are the main target of our study. Furthermore, it tries to explain why studies on animal models are necessary to understand mechanism at a cellular level, that could not be addressed on any other way. In the second part of the chapter, basics on electrophysiology and cellular communication are presented, together with traditional neuronal data analysis methods. The third chapter is intended to be a helpful resource for future works in the laboratory: it presents the hardware used for experimental sessions, how to control animal behaviour during the experiments by means of C routines and a software, and how to present visual stimuli on a screen. The forth chapter is the main core of the research project and the thesis. In the methods, experimental paradigms, visual stimuli and data analysis are presented. In the results, cellular response of area PEc to visual stimuli in motion combined with different eye positions are shown. In brief, this study led to the identification of different cellular behaviour in relation to focus of expansion (the direction of motion given by the optic flow pattern) and eye position. The originality and importance of the results are pointed out in the conclusions: this is the first study aimed to investigate perception of motion in this particular cortical area. In the last paragraph, a neuronal network model is presented: the aim is simulating cellular pre-saccadic and post-saccadic response of neuron in area PEc, during eye movement tasks. The same data presented in chapter four, are further analysed in chapter fifth. The analysis started from the observation of the neuronal responses during 1s time period in which the visual stimulation was the same. It was clear that cells activities showed oscillations in time, that had been neglected by the previous analysis based on mean firing frequency. Results distinguished two cellular behaviour by their response characteristics: some neurons showed oscillations that changed depending on eye and optic flow position, while others kept the same oscillations characteristics independent of the stimulus. The last chapter discusses the results of the research project, comments the originality and interdisciplinary of the study and proposes some future developments.

La Pace Calda. La nascita del movimento antinucleare negli Stati Uniti e in Gran Bretagna, 1957-1963

The aim of this proposal is to offer an alternative perspective on the study of Cold War, since insufficient attention is usually paid to those organizations that mobilized against the development and proliferation of nuclear weapons. The antinuclear movement began to mobilize between the 1950s and the 1960s, when it finally gained the attention of public opinion, and helped to build a sort of global conscience about nuclear bombs. This was due to the activism of a significant part of the international scientific community, which offered powerful intellectual and political legitimization to the struggle, and to the combined actions of the scientific and organized protests. This antinuclear conscience is something we usually tend to consider as a fait accompli in contemporary world, but the question is to show its roots, and the way it influenced statesmen and political choices during the period of nuclear confrontation of the early Cold War. To understand what this conscience could be and how it should be defined, we have to look at the very meaning of the nuclear weapons that has deeply modified the sense of war. Nuclear weapons seemed to be able to destroy human beings everywhere with no realistic forms of control of the damages they could set off, and they represented the last resource in the wide range of means of mass destruction. Even if we tend to consider this idea fully rational and incontrovertible, it was not immediately born with the birth of nuclear weapons themselves. Or, better, not everyone in the world did immediately share it. Due to the particular climate of Cold War confrontation, deeply influenced by the persistence of realistic paradigms in international relations, British and U.S. governments looked at nuclear weapons simply as «a bullet». From the Trinity Test to the signature of the Limited Test Ban Treaty in 1963, many things happened that helped to shift this view upon nuclear weapons. First of all, more than ten years of scientific protests provided a more concerned knowledge about consequences of nuclear tests and about the use of nuclear weapons. Many scientists devoted their social activities to inform public opinion and policy-makers about the real significance of the power of the atom and the related danger for human beings. Secondly, some public figures, as physicists, philosophers, biologists, chemists, and so on, appealed directly to the human community to «leave the folly and face reality», publicly sponsoring the antinuclear conscience. Then, several organizations leaded by political, religious or radical individuals gave to this protests a formal structure. The Campaign for Nuclear Disarmament in Great Britain, as well as the National Committee for a Sane Nuclear Policy in the U.S., represented the voice of the masses against the attempts of governments to present nuclear arsenals as a fundamental part of the international equilibrium. Therefore, the antinuclear conscience could be defined as an opposite feeling to the development and the use of nuclear weapons, able to create a political issue oriented to the influence of military and foreign policies. Only taking into consideration the strength of this pressure, it seems possible to understand not only the beginning of nuclear negotiations, but also the reasons that permitted Cold War to remain cold.

Per un'indagine comparata della relazione voce-movimento nel performer

The present study investigates the principles that effect the relationship between voice and movement in performance. The topic stresses a contemporary tendency, which emerges from the work of numerous artits and looks into a research field that has not yet been well explored. The research arises from what I observed and experienced during my performance practical work and what I deepened after theorical studies: expression through movement and voice reflects constant principles. The first two chapters of the former study analyze the compared lines of the inquiry, from a theoretical point of view (interior and exterior voice-movement spatial patterns, and temporal patterns) and a practical point of view referring to body, action and relation. The third one is a survey on 'vocal gesture' as devised by Francesca della Monica, a topic that finds here the first academic investigation, built after nine years sudies with the artist on the oral sources of her teaching. The research is based on practical and theorical sources (especially philosophical studies of Giovanni Piana, Carlo Serra, Merleau-Ponty; performing studies of Grotowski, Laban, Dalcroze, Tomatis; ancient greek philosophy and literature; bodywork tecqniques as Kineseology, Body-mind centering, Alexander, Feldenkrais). The purpose of the study is to theorize, sistematyze and expose clear lines of compared investigation awakening the performer's interest on a central issue of his work and drawing the researcher's attention to make further focusing on the matter. Abstract (Italian) La ricerca va incontro a una tendenza che la contemporaneità pone in risalto con l'opera di numerosi artisti, investigando un campo ancora poco visitato a livello critico. Essa teorizza, sistematizza ed espone le costanti riscontrate nella relazione tra voce e movimento. L'indagine deriva dal presupposto, a me suggerito dalla pratica e dallo scambio con maestri e performer, e qui approfondito e restituito a livello teorico, che nella danza e nel canto, nell'espressione attraverso il movimento o attraverso la voce, si riflettono gli stessi principi. La tesi è articolata in tre capitoli: i primi due sviluppano le linee di indagine comparata, prima da un punto di vista filosofico e poi da un punto di vista pratico, il terzo porta alla luce il concetto di gesto-vocale come inteso da Francesca della Monica, di cui questo studio rappresenta il primo contributo scientifico, aprendo una ricerca nuova agli studi di settore. Il primo capitolo, 'Risonanze', sviluppa le premesse filosofiche della questione, introduce il corpo come veicolo di voce e movimento, affronta il tema del movimento della voce nello spazio interno del corpo e nello spazio di relazione. Legge poi il movimento in termini temporali, secondo i concetti di istante, ritmo, forma e flusso. Il secondo capitolo, 'Costanti', espone le costanti concrete della relazione voce-movimento in riferimento allo spazio interno del corpo, all'azione, allo spazio esterno di relazione. Il terzo capitolo, 'Confini', analizza il gesto vocale, come inteso da Francesca della Monica, concetto sintesi dell'intera ricerca poiché integra, nella sua essenza, il movimento fisico e vocale, restituendo e approfondendo lo spettro di riflessioni emerse nei primi due capitoli. Il gesto vocale, nella sua accezione espressiva, così come il lavoro di Francesca della Monica, è ancora estraneo agli studi di settore e trova in questo studio un primo contributo accademico. Le fonti sono quelle dell'insegnamento orale di Francesca della Monica, che ho seguito per nove anni, fino a desumerne una mia personale sistematizzazione, integrata con altri punti di vista critici. Analizzo i diversi livelli di profondità del gesto vocale scandendo il tema secondo la categoria della relazione: relazioni motorie, relazioni materiche, relazioni spaziali, temporali, compositive e sinestesiche. Le fonti della ricerca sono scaturite da due sorgenti, quella sul campo, e quella della teoria, confluite qui in un unico flusso. Le fonti 'in presa diretta' sono state avvalorate e confrontate con le fonti relative agli studi di settore (in particolare per la filosofia Giovanni Piana, Carlo Serra, Merleau-Ponty, per il teatro, il canto e la danza Grotowski, Laban, Dalcroze, Tomatis) e le bodywork techniques (Kinesiologia, Body-mind centering, metodo Alexander, metodo Feldenkrais). Ampio spazio viene dato alla grecità antica, che propone sull'espressione di voce e movimento un pensiero integrato carico di speculazioni che racchiudono in nuce i principi sviluppati. Lo studio tenta di offrire un livello di lettura idoneo a suscitare l'interesse del performer, e a valere come momento di indagine per lo studioso, che possa da queste basi operare approfondimenti sulle connessioni proposte. L'obiettivo è restituire la conoscenza, intuita in virtù della pratica, elaborata ed arricchita grazie alla teoria, su un nodo fondamentale per gli studi teatrali e recente oggetto di attenzione da parte di critici e artisti.