Funzionalizzazione della mandibola dopo ricostruzione con lembo libero rivascolarizzato di fibula "single strut". Al di là del deficit di verticalità.

Obiettivi: Valutare la modalità  più efficace per la riabilitazione funzionale del limbo libero di fibula "single strut", dopo ampie resezioni per patologia neoplastica maligna del cavo orale. Metodi: Da una casistica di 62 ricostruzioni microvascolari con limbo libero di fibula, 11 casi sono stati selezionati per essere riabilitati mediante protesi dentale a supporto implantare. 6 casi sono stati trattati senza ulteriori procedure chirurgiche ad eccezione dell'implantologia (gruppo 1), affrontando il deficit di verticalità  della fibula attraverso la protesi dentaria, mentre i restanti casi sono stati trattati con la distrazione osteogenetica (DO) della fibula prima della riabilitazione protesica (gruppo 2). Il deficit di verticalità  fibula/mandibola è stato misurato. I criteri di valutazione utilizzati includono la misurazione clinica e radiografica del livello osseo e dei tessuti molli peri-implantari, ed il livello di soddisfazione del paziente attraverso un questionario appositamente redatto. Risultati: Tutte le riabilitazioni protesiche sono costituite da protesi dentali avvitate su impianti. L'età  media è di 52 anni, il rapporto uomini/donne è di 6/5. Il numero medio di impianti inseriti nelle fibule è di 5. Il periodo massimo di follow-up dopo il carico masticatorio è stato di 30 mesi per il gruppo 1 e di 38.5 mesi (17-81) di media per il gruppo 2. Non abbiamo riportato complicazioni chirurgiche. Nessun impianto è stato rimosso dai pazienti del gruppo 1, la perdita media di osso peri-implantare registrata è stata di 1,5 mm. Nel gruppo 2 sono stati riportati un caso di tipping linguale del vettore di distrazione durante la fase di consolidazione e un caso di frattura della corticale basale in assenza di formazione di nuovo osso. L'incremento medio di osso in verticalità è stato di 13,6 mm (12-15). 4 impianti su 32 (12.5%) sono andati persi dopo il periodo di follow-up. Il riassorbimento medio peri-implantare, è stato di 2,5 mm. Conclusioni: Le soluzioni più utilizzate per superare il deficit di verticalità  del limbo libero di fibula consistono nell'allestimento del lembo libero di cresta iliaca, nel posizionare la fibula in posizione ideale da un punto di vista protesico a discapito del profilo osseo basale, l'utilizzo del lembo di fibula nella versione descritta come "double barrel", nella distrazione osteogenetica della fibula. La nostra esperienza concerne il lembo libero di fibula che nella patologia neoplastica maligna utilizziamo nella versione "single strut", per mantenere disponibili tutte le potenzialità  di lunghezza del peduncolo vascolare, senza necessità  di innesti di vena. Entrambe le soluzioni, la protesi dentale ortopedica e la distrazione osteogenetica seguita da protesi, entrambe avvitate su impianti, costituiscono soluzioni soddisfacenti per la riabilitazione funzionale della fibula al di là  del suo deficit di verticalità . La prima soluzione ha preso spunto dall'osservazione dei buoni risultati della protesi dentale su impianti corti, avendo un paragonabile rapporto corona/radice, la DO applicata alla fibula, sebbene sia risultata una metodica con un numero di complicazioni più elevato ed un maggior livello di riassorbimento di osso peri-implantare, costituisce in ogni caso una valida opzione riabilitativa, specialmente in caso di notevole discrepanza mandibulo/fibulare. Decisiva è la scelta del percorso terapeutico dopo una accurata valutazione di ogni singolo caso. Vengono illustrati i criteri di selezione provenienti dalla nostra esperienza.

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.

Tuzla City (BiH): an example of geohazard induced by salt extraction

Salt deposits characterize the subsurface of Tuzla (BiH) and made it famous since the ancient times. Archeological discoveries demonstrate the presence of a Neolithic pile-dwelling settlement related to the existence of saltwater springs that contributed to make the most of the area a swampy ground. Since the Roman times, the town is reported as “the City of Salt deposits and Springs”; "tuz" is the Turkish word for salt, as the Ottomans renamed the settlement in the 15th century following their conquest of the medieval Bosnia (Donia and Fine, 1994). Natural brine springs were located everywhere and salt has been evaporated by means of hot charcoals since pre-Roman times. The ancient use of salt was just a small exploitation compared to the massive salt production carried out during the 20th century by means of classical mine methodologies and especially wild brine pumping. In the past salt extraction was practised tapping natural brine springs, while the modern technique consists in about 100 boreholes with pumps tapped to the natural underground brine runs, at an average depth of 400-500 m. The mining operation changed the hydrogeological conditions enabling the downward flow of fresh water causing additional salt dissolution. This process induced severe ground subsidence during the last 60 years reaching up to 10 meters of sinking in the most affected area. Stress and strain of the overlying rocks induced the formation of numerous fractures over a conspicuous area (3 Km2). Consequently serious damages occurred to buildings and infrastructures such as water supply system, sewage networks and power lines. Downtown urban life was compromised by the destruction of more than 2000 buildings that collapsed or needed to be demolished causing the resettlement of about 15000 inhabitants (Tatić, 1979). Recently salt extraction activities have been strongly reduced, but the underground water system is returning to his natural conditions, threatening the flooding of the most collapsed area. During the last 60 years local government developed a monitoring system of the phenomenon, collecting several data about geodetic measurements, amount of brine pumped, piezometry, lithostratigraphy, extension of the salt body and geotechnical parameters. A database was created within a scientific cooperation between the municipality of Tuzla and the city of Rotterdam (D.O.O. Mining Institute Tuzla, 2000). The scientific investigation presented in this dissertation has been financially supported by a cooperation project between the Municipality of Tuzla, The University of Bologna (CIRSA) and the Province of Ravenna. The University of Tuzla (RGGF) gave an important scientific support in particular about the geological and hydrogeological features. Subsidence damage resulting from evaporite dissolution generates substantial losses throughout the world, but the causes are only well understood in a few areas (Gutierrez et al., 2008). The subject of this study is the collapsing phenomenon occurring in Tuzla area with the aim to identify and quantify the several factors involved in the system and their correlations. Tuzla subsidence phenomenon can be defined as geohazard, which represents the consequence of an adverse combination of geological processes and ground conditions precipitated by human activity with the potential to cause harm (Rosenbaum and Culshaw, 2003). Where an hazard induces a risk to a vulnerable element, a risk management process is required. The single factors involved in the subsidence of Tuzla can be considered as hazards. The final objective of this dissertation represents a preliminary risk assessment procedure and guidelines, developed in order to quantify the buildings vulnerability in relation to the overall geohazard that affect the town. The historical available database, never fully processed, have been analyzed by means of geographic information systems and mathematical interpolators (PART I). Modern geomatic applications have been implemented to deeply investigate the most relevant hazards (PART II). In order to monitor and quantify the actual subsidence rates, geodetic GPS technologies have been implemented and 4 survey campaigns have been carried out once a year. Subsidence related fractures system has been identified by means of field surveys and mathematical interpretations of the sinking surface, called curvature analysis. The comparison of mapped and predicted fractures leaded to a better comprehension of the problem. Results confirmed the reliability of fractures identification using curvature analysis applied to sinking data instead of topographic or seismic data. Urban changes evolution has been reconstructed analyzing topographic maps and satellite imageries, identifying the most damaged areas. This part of the investigation was very important for the quantification of buildings vulnerability.