Biomechanical modelling of human knee during living activities

The knee joint is a key structure of the human locomotor system. The knowledge of how each single anatomical structure of the knee contributes to determine the physiological function of the knee, is of fundamental importance for the development of new prostheses and novel clinical, surgical, and rehabilitative procedures. In this context, a modelling approach is necessary to estimate the biomechanic function of each anatomical structure during daily living activities. The main aim of this study was to obtain a subject-specific model of the knee joint of a selected healthy subject. In particular, 3D models of the cruciate ligaments and of the tibio-femoral articular contact were proposed and developed using accurate bony geometries and kinematics reliably recorded by means of nuclear magnetic resonance and 3D video-fluoroscopy from the selected subject. Regarding the model of the cruciate ligaments, each ligament was modelled with 25 linear-elastic elements paying particular attention to the anatomical twisting of the fibres. The devised model was as subject-specific as possible. The geometrical parameters were directly estimated from the experimental measurements, whereas the only mechanical parameter of the model, the elastic modulus, had to be considered from the literature because of the invasiveness of the needed measurements. Thus, the developed model was employed for simulations of stability tests and during living activities. Physiologically meaningful results were always obtained. Nevertheless, the lack of subject-specific mechanical characterization induced to design and partially develop a novel experimental method to characterize the mechanics of the human cruciate ligaments in living healthy subjects. Moreover, using the same subject-specific data, the tibio-femoral articular interaction was modelled investigating the location of the contact point during the execution of daily motor tasks and the contact area at the full extension with and without the whole body weight of the subject. Two different approaches were implemented and their efficiency was evaluated. Thus, pros and cons of each approach were discussed in order to suggest future improvements of this methodologies. The final results of this study will contribute to produce useful methodologies for the investigation of the in-vivo function and pathology of the knee joint during the execution of daily living activities. Thus, the developed methodologies will be useful tools for the development of new prostheses, tools and procedures both in research field and in diagnostic, surgical and rehabilitative fields.

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.

Spatial mechanisms for modelling the human ankle passive motion

Knowledge on how ligaments and articular surfaces guide passive motion at the human ankle joint complex is fundamental for the design of relevant surgical treatments. The dissertation presents a possible improvement of this knowledge by a new kinematic model of the tibiotalar articulation. In this dissertation two one-DOF spatial equivalent mechanisms are presented for the simulation of the passive motion of the human ankle joint: the 5-5 fully parallel mechanism and the fully parallel spherical wrist mechanism. These mechanisms are based on the main anatomical structures of the ankle joint, namely the talus/calcaneus and the tibio/fibula bones at their interface, and the TiCaL and CaFiL ligaments. In order to show the accuracy of the models and the efficiency of the proposed procedure, these mechanisms are synthesized from experimental data and the results are compared with those obtained both during experimental sessions and with data published in the literature. Experimental results proved the efficiency of the proposed new mechanisms to simulate the ankle passive motion and, at the same time, the potentiality of the mechanism to replicate the ankle’s main anatomical structures quite well. The new mechanisms represent a powerful tool for both pre-operation planning and new prosthesis design.

Sviluppo, implementazione e valutazione funzionale di un nuovo modello protesico di caviglia

Total ankle arthroplasty (TAA) is still not as satisfactory as total hip and total knee arthroplasty. For the TAA to be considered a valuable alternative to ankle arthrodesis, an effective range of ankle mobility must be recovered. The disappointing clinical results of the current generation of TAA are mostly related to poor understanding of the structures guiding ankle joint mobility. A new design (BOX Ankle) has been developed, uniquely able to restore physiologic ankle mobility and a natural relationship between the implanted components and the retained ligaments. For the first time the shapes of the tibial and talar components in the sagittal plane were designed to be compatible with the demonstrated ligament isometric rotation. This resulted in an unique motion at the replaced ankle where natural sliding as well as rolling motion occurs while at the same time full conformity is maintained between the three components throughout the flexion arc. According to prior research, the design features a spherical convex tibial component, a talar component with radius of curvature in the sagittal plane longer than that of the natural talus, and a fully conforming meniscal component. After computer-based modelling and preliminary observations in several trial implantation in specimens, 126 patients were implanted in the period July 2003 – December 2008. 75 patients with at least 6 months follow-up are here reported. Mean age was 62,6 years (range 22 – 80), mean follow-up 20,2 months. The AOFAS clinical score systems were used to assess patient outcome. Radiographs at maximal dorsiflexion and maximal plantar flexion confirmed the meniscalbearing component moves anteriorly during dorsiflexion and posteriorly during plantarflexion. Frontal and lateral radiographs in the patients, show good alignment of the components, and no signs of radiolucency or loosening. The mean AOFAS score was observed to go from 41 pre-op to 74,6 at 6 month follow-up, with further improvement at the following follow-up. These early results reveal satisfactory clinical scores, with good recovery of range of motion and reduction of pain. Radiographic assessment reveals good osteointegration. All these preliminary results confirm biomechanical studies and the validity of this novel ligamentcompatible prosthesis design. Surely it will be important to re-evaluate these patients later.

Skeletal Markers of Activity: Methodological and Interpretative Reflections after the study of the whole Frassetto Sassari identified skeletal collection

Entheses (skeletal attachment sites of muscles and ligaments) and their pathologic modifications (enthesopathies) have long been used as skeletal markers of activity in bioarchaeological (reconstruction of past populations lifestyle) and forensic (personal identification) contexts. However, a functional interpretation of these markers have to deal critically with the multifactorial etiology of the same. Factors such as sex, age, genetic factors, mechanical stress, metabolic conditions, etc.. can compete to produce the observed morphological variability at each attachment site. The aim of this thesis has drawn on the ongoing debate about the informativeness of entheseal modifications as skeletal markers of activity and represent a deepening of the actual knowledge about the relationship between these characters and sex, age and physical activity. For this purpose, the whole "Frassetto” identified skeletal collection of Sassari (Sardinia, Italy) was analyzed. The collection includes the skeletal remains of about 600 individuals died in the late 19th and early 20th century for whom information regarding sex, age at death and, in many cases the occupation are known The results obtained highlight the great age importance on the entheseal modifications. The differences observed between sexes may reflect differences in the level or type of activity performed in life, but could also be related to a different bone tissue response to mechanical stress due to hormonal factors and different growth rates. The role of biomechanical stress related to professional activities remains doubtful. This is probably partly attributable to the analyzed sample characteristics (preponderance of farmers compared with other professions, different mean age of the considered professional subsamples), which has hampered the analysis of samples homogenous with regard to age, which is very influential on the entheses and enthesopathies expression.

Ruolo dei glicosaminoglicani su struttura e funzione dei crimps nei tendini e nei legamenti

The biomechanical roles of both tendons and ligaments are fulfilled by extracellular matrix of these tissues. In particular, tension is mainly transmitted and resisted by fibrous proteins (collagen, elastin), whereas compressive load is absorbed by water-soluble glycosaminoglycans (GAGs). GAGs spanning the interfibrillar spaces and interacting with fibrils also seem to play a part in transmitting and resisting tensile stresses. Apart from different functional roles and collagen array, tendons and ligaments share the same basic structure showing periodic undulations of collagen fibers or crimps. Each crimp is composed of many knots of each single fibril or fibrillar crimps. Fibrillar and fiber crimps act as shock absorbers during the initial elongation of both tendons and ligaments and assist the elastic recoil of fibrils and fibers when the tensile stress is removed. The aim of this thesis was to evaluate whether GAGs directly affect the 3D microstructural integrity of fibrillar crimp and fiber crimps in both tendons and ligaments. Achilles tendons and medial collateral ligaments of the knee from eight female Sprague-Dawley rats (90 days old) were digested with chondroitinase ABC to remove GAGs and observed under a scanning electron microscope (SEM). In addition, isolated fibrils from these tissues obtained by mechanical homogenization were analyzed by a transmission electron microscope (TEM). Both samples digested with chondroitinase ABC or mechanically disrupted still showed crimps and fibrillar crimps comparable to tissues with a normal GAGs content. All fibrils in the fibrillar crimp region always twisted leftwards, thus changing their running plane, and then sharply bent, changing their course on a new plane. These data suggest that GAGs do not affect structural integrity or fibrillar crimps functions that seem mainly related to the local fibril leftward twisting and the alternating handedness of collagen from a molecular to a supramolecular level.

Biomechanics of sprint running: a methodological contribution

Sports biomechanics describes human movement from a performance enhancement and an injury reduction perspective. In this respect, the purpose of sports scientists is to support coaches and physicians with reliable information about athletes’ technique. The lack of methods allowing for in-field athlete evaluation as well as for accurate joint force estimates represents, to date, the main limitation to this purpose. The investigations illustrated in the present thesis aimed at providing a contribution towards the development of the above mentioned methods. Two complementary approaches were adopted: a Low Resolution Approach – related to performance assessment – where the use of wearable inertial measurement units is exploited during different phases of sprint running, and a High Resolution Approach – related to joint kinetics estimate for injury prevention – where subject-specific, non-rigid constraints for knee joint kinematic modelling used in multi-body optimization techniques are defined. Results obtained using the Low Resolution Approach indicated that, due to their portability and inexpensiveness, inertial measurement systems are a valid alternative to laboratory-based instrumentation for in-field performance evaluation of sprint running. Using acceleration and angular velocity data, the following quantities were estimated: trunk inclination and angular velocity, instantaneous horizontal velocity and displacement of a point approximating the centre of mass, and stride and support phase durations. As concerns the High Resolution Approach, results indicated that the length of the anterior cruciate and lateral collateral ligaments decreased, while that of the deep bundle of the medial collateral ligament increased significantly during flexion. Variations of the posterior cruciate and the superficial bundle of the medial collateral ligament lengths were concealed by the experimental indeterminacy. A mathematical model was provided that allowed the estimate of subject-specific ligament lengths as a function of knee flexion and that can be integrated in a multi-body optimization procedure.

New mechanisms for modelling the motion of the human ankle complex

The relevance of human joint models was shown in the literature. In particular, the great importance of models for the joint passive motion simulation (i.e. motion under virtually unloaded conditions) was outlined. They clarify the role played by the principal anatomical structures of the articulation, enhancing the comprehension of surgical treatments, and in particular the design of total ankle replacement and ligament reconstruction. Equivalent rigid link mechanisms proved to be an efficient tool for an accurate simulation of the joint passive motion. This thesis focuses on the ankle complex (i.e. the anatomical structure composed of the tibiotalar and the subtalar joints), which has a considerable role in human locomotion. The lack of interpreting models of this articulation and the poor results of total ankle replacement arthroplasty have strongly suggested devising new mathematical models capable of reproducing the restraining function of each structure of the joint and of replicating the relative motion of the bones which constitute the joint itself. In this contest, novel equivalent mechanisms are proposed for modelling the ankle passive motion. Their geometry is based on the joint’s anatomical structures. In particular, the role of the main ligaments of the articulation is investigated under passive conditions by means of nine 5-5 fully parallel mechanisms. Based on this investigation, a one-DOF spatial mechanism is developed for modelling the passive motion of the lower leg. The model considers many passive structures constituting the articulation, overcoming the limitations of previous models which took into account few anatomical elements of the ankle complex. All the models have been identified from experimental data by means of optimization procedure. Then, the simulated motions have been compared to the experimental one, in order to show the efficiency of the approach and thus to deduce the role of each anatomical structure in the ankle kinematic behavior.

Valutazione della psoriasi ungueale come fattore di rischio per lo sviluppo di artropatia psoriasica - studio pilota

Scopo della tesi è verificare se i pazienti affetti da psoriasi puramente ungueale sviluppano psoriasi artropatica e se esistono parametri clinici che possano permettere di predire lo sviluppo del danno articolare. Viene inoltre valutato l'impatto che la psoriasi ungueale, associata alla psoriasi artropatica, determina sulla qualità di vita dei nostri pazienti. L'artrite psoriasica è spesso associata a psoriasi ungueale, che è più frequente nei pazienti con artrite psoriasica rispetto ai pazienti con psoriasi cutanea. Vi è una stretta relazione funzionale tra l'unghia e l'articolazione interfalangea distale, i tendini e i legamenti: lo sviluppo di entesite della falange distale è infatti associato ad una infiammazione dell'apparato ungueale. Riportiamo i dati preliminari emersi dal nostro studio pilota, che conferma come siano necessari e doverosi ulteriori studi su popolazioni più ampie per determinare la relazione che sussiste fra psoriasi ungueale e psoriasi artropatica