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.

Riconoscimento di gesti: estensione a movimenti fini su spazi limitati. Teoria e implementazione

Riconoscere un gesto, tracciarlo ed identificarlo è una operazione complessa ed articolata. Negli ultimi anni, con l’avvento massivo di interfacce interattive sempre più sofisticate, si sono ampliati gli approcci nell’interazione tra uomo e macchina. L’obiettivo comune, è quello di avere una comunicazione “trasparente” tra l’utente e il computer, il quale, deve interpretare gesti umani tramite algoritmi matematici. Il riconoscimento di gesti è un modo per iniziare a comprendere il linguaggio del corpo umano da parte della macchina. Questa disciplina, studia nuovi modi di interazione tra questi due elementi e si compone di due macro obiettivi : (a) tracciare i movimenti di un particolare arto; (b) riconoscere tale tracciato come un gesto identificativo. Ognuno di questi due punti, racchiude in sé moltissimi ambiti di ricerca perché moltissimi sono gli approcci proposti negli anni. Non si tratta di semplice cattura dell’immagine, è necessario creare un supporto, a volte molto articolato, nel quale i dati grezzi provenienti dalla fotocamera, necessitano di filtraggi avanzati e trattamenti algoritmici, in modo tale da trasformare informazioni grezze, in dati utilizzabili ed affidabili. La tecnologia riguardo la gesture recognition è rilevante come l’introduzione delle interfacce tattili sui telefoni intelligenti. L’industria oggi ha iniziato a produrre dispositivi in grado di offrire una nuova esperienza, la più naturale possibile, agli utenti. Dal videogioco, all’esperienza televisiva gestita con dei piccoli gesti, all’ambito biomedicale, si sta introducendo una nuova generazione di dispositivi i cui impieghi sono innumerevoli e, per ogni ambito applicativo, è necessario studiare al meglio le peculiarità, in modo tale da produrre un qualcosa di nuovo ed efficace. Questo lavoro di tesi ha l’obiettivo di apportare un contributo a questa disciplina. Ad oggi, moltissime applicazioni e dispositivi associati, si pongono l’obiettivo di catturare movimenti ampi: il gesto viene eseguito con la maggior parte del corpo e occupa una posizione spaziale rilevante. Questa tesi vuole proporre invece un approccio, nel quale i movimenti da seguire e riconoscere sono fatti “nel piccolo”. Si avrà a che fare con gesti classificati fini, dove i movimenti delle mani sono compiuti davanti al corpo, nella zona del torace, ad esempio. Gli ambiti applicativi sono molti, in questo lavoro si è scelto ed adottato l’ambito artigianale.

Analisi della dinamica nel gesto sportivo della battuta nel tennis

Creazione di un protocollo tramite il pacchetto software SMART-D BTS per l'analisi della dinamica dell'arto superiore durante il servizio del tennis e comparazione dei risultati ottenuti di tre atleti normodotati e di un atleta con disabilità

Studio e sviluppo di un prototipo di un meccanismo per l'azionamento di una mano protesica cinematica

Lo studio si prefigge di verificare la fattibilità di un nuovo meccanismo per l'azionamento di una mano protesica e inoltre di costruirne un prototipo. Questo nuovo meccanismo andrebbe a sostituire le molle azionate da tiranti delle attuali protesi cinematiche, evitando all'amputato vistosi movimenti del corpo atti ad azionare la mano protesica. Tramite confronto tra le forze calcolate tramite modellazione del meccanismo e quelle realmente fornite dal paziente, si può dichiarare che il meccanismo funziona correttamente. Il prototipo costruito inoltre rispetta i vincoli dimensionali che deve avere una protesi per arto superiore.

Analisi delle caratteristiche di dispositivi per il brain computer interface

La brain computer interface sono state create per sopperire ai problemi motori e di linguistica nei pazienti che, a causa di malattie neurodegenerative o in seguito a traumi, sono paralizzate o non riescono a parlare. Vengono prese in questione le caratteristiche di un sistema per le BCI analizzando ogni blocco funzionale del sistema. Si fa visione delle applicazioni tra le quali la possibilità di far muovere un arto bionico a una donna tetraplegica e la possibilità di far scrivere una parola su uno schermo a un paziente non in grado di comunicare verbalmente. Si mettono in luce i problemi annessi a questo campo e i possibili sviluppi.

Cinematica della corsa con stampelle tramite sensori inerziali: Analisi di soggetti della Nazionale Italiana di Calcio Amputati

L’analisi del movimento umano mira alla raccolta di informazioni quantitative riguardo la meccanica del sistema muscolo-scheletrico durante l’esecuzione di un compito motorio. All’interno di questo contesto, la cinematica del passo rappresenta uno strumento d’indagine tra i più usati. Tra i diversi protocolli di analisi cinematiche si è affermato recentemente l’uso di sensori magnetico-inerziali. Il principale vantaggio di questi dispositivi rispetto alla tecnica tradizionalmente impiegata (la stereofotogrammetria) è che possono essere utilizzati al di fuori di un ambiente di laboratorio, rendendo meno vincolante la scelta del task motorio da analizzare. Lo stato dell’arte offre una molteplicità di studi basati sull’analisi del cammino e della corsa di atleti, professionisti o dilettanti, utilizzando sensori inerziali; nulla, però, è stato dedicato alla corsa con stampelle. In questo lavoro di tesi è stata dunque analizzata la corsa su stampelle di soggetti amputati (in particolare di atleti della Nazionale Italiana di Calcio Amputati). Dalla letteratura sono stati individuati tre metodi, ideati principalmente per la corsa di soggetti normodotati e in questa situazione riadattati per la corsa di soggetti con amputazione/malformazione di un arto inferiore, con i quali è stato possibile ricavare parametri temporali relativi al ciclo del passo; è stato inoltre progettato un nuovo metodo che permette di ricavare parametri temporali della corsa attraverso le fasi delle stampelle. L’elemento che contraddistingue questo studio è la presenza di un gold standard, dato da un riferimento video, con il quale sarà possibile determinare con più affidabilità quale metodo risulti più adeguato per l’analisi di questo tipo di corsa.

Determination of Language Dominance: Wada Test and fMRI Compared Using a Novel Sentence Task

This study aimed to develop a new linguistic based functional magnetic resonance imaging (fMRI)-sentence decision task that reliably detects hemispheric language dominance.

Spike-triggered reaction-time EEG as a possible assessment tool for driving ability

The impact of interictal epileptic activity (IEA) on driving is a rarely investigated issue. We analyzed the impact of IEA on reaction time in a pilot study. Reactions to simple visual stimuli (light flash) in the Flash test or complex visual stimuli (obstacle on a road) in a modified car driving computer game, the Steer Clear, were measured during IEA bursts and unremarkable electroencephalography (EEG) periods. Individual epilepsy patients showed slower reaction times (RTs) during generalized IEA compared to RTs during unremarkable EEG periods. RT differences were approximately 300 ms (p < 0.001) in the Flash test and approximately 200 ms (p < 0.001) in the Steer Clear. Prior work suggested that RT differences >100 ms may become clinically relevant. This occurred in 40% of patients in the Flash test and in up to 50% in the Steer Clear. When RT were pooled, mean RT differences were 157 ms in the Flash test (p < 0.0001) and 116 ms in the Steer Clear (p < 0.0001). Generalized IEA of short duration seems to impair brain function, that is, the ability to react. The reaction-time EEG could be used routinely to assess driving ability.

Differences between RNA and DNA due to RNA editing in temporal lobe epilepsy

To investigate whether alterations in RNA editing (an enzymatic base-specific change to the RNA sequence during primary transcript formation from DNA) of neurotransmitter receptor genes and of transmembrane ion channel genes play a role in human temporal lobe epilepsy (TLE), this exploratory study analyzed 14 known cerebral editing sites in RNA extracted from the brain tissue of 41 patients who underwent surgery for mesial TLE, 23 with hippocampal sclerosis (MTLE+HS). Because intraoperatively sampled RNA cannot be obtained from healthy controls and the best feasible control is identically sampled RNA from patients with a clinically shorter history of epilepsy, the primary aim of the study was to assess the correlation between epilepsy duration and RNA editing in the homogenous group of MTLE+HS. At the functionally relevant I/V site of the voltage-gated potassium channel Kv1.1, an inverse correlation of RNA editing was found with epilepsy duration (r=-0.52, p=0.01) but not with patient age at surgery, suggesting a specific association with either the epileptic process itself or its antiepileptic medication history. No significant correlations were found between RNA editing and clinical parameters at other sites within glutamate receptor or serotonin 2C receptor gene transcripts. An "all-or-none" (≥95% or ≤5%) editing pattern at most or all sites was discovered in 2 patients. As a secondary part of the study, RNA editing was also analyzed as in the previous literature where up to now, few single editing sites were compared with differently obtained RNA from inhomogenous patient groups and autopsies, and by measuring editing changes in our mouse model. The present screening study is first to identify an editing site correlating with a clinical parameter, and to also provide an estimate of the possible effect size at other sites, which is a prerequisite for power analysis needed in planning future studies.

Placebo effect characteristics observed in a single, international, longitudinal study in Huntington's disease

BACKGROUND Classically, clinical trials are based on the placebo-control design. Our aim was to analyze the placebo effect in Huntington's disease. METHODS Placebo data were obtained from an international, longitudinal, placebo-controlled trial for Huntington's disease (European Huntington's Disease Initiative Study Group). One-hundred and eighty patients were evaluated using the Unified Huntington Disease Rating Scale over 36 months. A placebo effect was defined as an improvement of at least 50% over baseline scores in the Unified Huntington Disease Rating Scale, and clinically relevant when at least 10% of the population met it. RESULTS Only behavior showed a significant placebo effect, and the proportion of the patients with placebo effect ranged from 16% (first visit) to 41% (last visit). Nondepressed patients with better functional status were most likely to be placebo-responders over time. CONCLUSIONS In Huntington's disease, behavior seems to be more vulnerable to placebo than overall motor function, cognition, and function

Muscle metabolites: functional MR spectroscopy during exercise imposed by tetanic electrical nerve stimulation

Permission from the ethics committee and informed consent were obtained. The purpose of this study was to prospectively evaluate a method developed for the noninvasive assessment of muscle metabolites during exercise. Hydrogen 1 magnetic resonance (MR) spectroscopy peaks were measured during tetanic isometric muscle contraction imposed by supramaximal repetitive nerve stimulation. The kinetics of creatine-phosphocreatine and acetylcarnitine signal changes (P < .001) could be assessed continuously before, during, and after exercise. The control peak (trimethylammonium compounds), which served as an internal reference, did not change. This technique-that is, functional MR spectroscopy-opens the possibility for noninvasive diagnostic muscle metabolite testing in a clinical setting.

Syncope

Syncope is defined as an acute, brief and transient loss of consciousness and postural tone with spontaneous and complete recovery. Neurovascular ultrasound has contributed to elucidate the underlying mechanism of different types of syncope. In routine diagnostic work-up of patients with syncope, however, neurovascular ultrasound is not among the first line tools. In particular, an ultrasound search for occlusive cerebro-vascular disease is of limited value because cerebral artery obstruction is a very rare and questionable cause of syncope. Transcranial Doppler sonography monitoring of the cerebral arteries is useful in the diagnostic work-up of patients with suspicion of postural related, cerebrovascular, cough and psychogenic syncope, and in some cases for differentiating focal epileptic seizures from transient ischemic attacks and migraine with aura.

Sleep and wakefulness disturbances in Swiss pharmacy customers

BACKGROUND AND OBJECTIVE: Sleep disturbances are prevalent but often overlooked or underestimated. We suspected that sleep disorders might be particularly common among pharmacy customers, and that they could benefit from counselling. Therefore, we described the prevalence and severity of symptoms associated with sleep and wakefulness disorders among Swiss pharmacy customers, and estimated the need for counselling and treatment. METHODS: In 804 Swiss pharmacies (49% of all community pharmacies) clients were invited to complete the Stanford Sleep Disorders Questionnaire (SDQ), and the Epworth Sleepiness Scale (EPW). The SDQ was designed to classify symptoms of sleep and wakefulness into the four most prevalent disorders: sleep apnoea syndrome (SAS), insomnia in psychiatric disorders (PSY), periodic leg movement disorders/restless legs (RLS) and narcolepsy (NAR). Data were entered into an internet-linked database for analysis by an expert system as a basis for immediate counselling by the pharmacist. RESULTS: Of 4901 participants, 3238 (66.1%) were female, and 1663 (33.9%) were male. The mean age (SD) of females and males was 52.4 (18.05), and 55.1 (17.10) years, respectively. The percentages of female and male individuals above cut-off of SDQ subscales were 11.4% and 19.8% for sleep apnoea, 40.9% and 38.7% for psychiatric sleep disorders, 59.3% and 46.8% for restless legs, and 10.4% and 9.4% for narcolepsy respectively. The prevalence of an Epworth Sleepiness Scale score >11 was 16.5% in females, and 23.9% in males. Reliability assessed by Cronbach's alpha was 0.65 to 0.78 for SDQ subscales, and for the Epworth score. CONCLUSIONS: Symptoms of sleep and wakefulness disorders among Swiss pharmacy customers were highly prevalent. The SDQ and the Epworth Sleepiness Scale score had a satisfactory reliability to be useful for identification of pharmacy customers who might benefit from information and counselling while visiting pharmacies. The internet-based system proved to be a helpful tool for the pharmacist when counselling his customers in terms of diagnostic classification and severity of symptoms associated with the sleeping and waking state.

Brain activation during string playing

This chapter attempts to integrate data from both functional magnetic resonance imaging (fMRI) and electroencephalography (EEG) to elucidate the activation of the cortical areas in musical performance for both execution and imagination of music during string playing. In both fMRI and EEG experiments, playing the music was compared with imagining the music. This allowed separation of the areas mainly involved in motor execution from those involved in imagining, planning, and working memory, thus differentiating musical from purely motor areas.

On how high performers keep cool brains in situations of cognitive overload

What happens in the brain when we reach or exceed our capacity limits? Are there individual differences for performance at capacity limits? We used functional magnetic resonance imaging (fMRI) to investigate the impact of increases in processing demand on selected cortical areas when participants performed a parametrically varied and challenging dual task. Low-performing participants respond with large and load-dependent activation increases in many cortical areas when exposed to excessive task requirements, accompanied by decreasing performance. It seems that these participants recruit additional attentional and strategy-related resources with increasing difficulty, which are either not relevant or even detrimental to performance. In contrast, the brains of the high-performing participants "keep cool" in terms of activation changes, despite continuous correct performance, reflecting different and more efficient processing. These findings shed light on the differential implications of performance on activation patterns and underline the importance of the interindividual-differences approach in neuroimaging research.