In silico methods to evaluate Fracture Risk and Bone Mineral Density changes in patients undergoing Total Hip Replacement

La sostituzione totale d’anca è uno degli interventi chirurgici con le più alte percentuali di successo. Esistono due varianti di protesi d’anca che differiscono in base al metodo di ancoraggio all’osso: cementate (fissaggio tramite cemento osseo) e non cementate (fissaggio tramite forzamento). Ad oggi, i chirurghi non hanno indicazioni quantitative di supporto per la scelta fra le due tipologie di impianto, decidendo solo in base alla loro esperienza. Due delle problematiche che interessano le protesi non cementate sono la possibilità di frattura intra-operatoria durante l’inserimento forzato e il riassorbimento osseo nel periodo di tempo successivo all’intervento. A partire da rilevazioni densitometriche effettuate su immagini da TC di pazienti sottoposti a protesi d’anca non cementata, sono stati sviluppati due metodi: 1) per la valutazione del rischio di frattura intra-operatorio tramite analisi agli elementi finiti; 2) per la valutazione della variazione di densità minerale ossea (tridimensionalmente attorno alla protesi) dopo un anno dall’operazione. Un campione di 5 pazienti è stato selezionato per testare le procedure. Ciascuno dei pazienti è stato scansionato tramite TC in tre momenti differenti: una acquisita prima dell’operazione (pre-op), le altre due acquisite 24 ore (post 24h) e 1 anno dopo l’operazione (post 1y). I risultati ottenuti hanno confermato la fattibilità di entrambi i metodi, riuscendo inoltre a distinguere e a quantificare delle differenze fra i vari pazienti. La fattibilità di entrambe le metodologie suggerisce la loro possibilità di impiego in ambito clinico: 1) conoscere la stima del rischio di frattura intra-operatorio può servire come strumento di guida per il chirurgo nella scelta dell’impianto protesico ottimale; 2) conoscere la variazione di densità minerale ossea dopo un anno dall’operazione può essere utilizzato come strumento di monitoraggio post-operatorio del paziente.

Effectiveness and Cost-effectiveness of Outpatient Physiotherapy After Knee Replacement for Osteoarthritis: Study Protocol for a Randomised Controlled Trial

Background: Primary total knee replacement is a common operation that is performed to provide pain relief and restore functional ability. Inpatient physiotherapy is routinely provided after surgery to enhance recovery prior to hospital discharge. However, international variation exists in the provision of outpatient physiotherapy after hospital discharge. While evidence indicates that outpatient physiotherapy can improve short-term function, the longer term benefits are unknown. The aim of this randomised controlled trial is to evaluate the long-term clinical effectiveness and cost-effectiveness of a 6-week group-based outpatient physiotherapy intervention following knee replacement. Methods/design: Two hundred and fifty-six patients waiting for knee replacement because of osteoarthritis will be recruited from two orthopaedic centres. Participants randomised to the usual-care group (n = 128) will be given a booklet about exercise and referred for physiotherapy if deemed appropriate by the clinical care team. The intervention group (n = 128) will receive the same usual care and additionally be invited to attend a group-based outpatient physiotherapy class starting 6 weeks after surgery. The 1-hour class will be run on a weekly basis over 6 weeks and will involve task-orientated and individualised exercises. The primary outcome will be the Lower Extremity Functional Scale at 12 months post-operative. Secondary outcomes include: quality of life, knee pain and function, depression, anxiety and satisfaction. Data collection will be by questionnaire prior to surgery and 3, 6 and 12 months after surgery and will include a resource-use questionnaire to enable a trial-based economic evaluation. Trial participation and satisfaction with the classes will be evaluated through structured telephone interviews. The primary statistical and economic analyses will be conducted on an intention-to-treat basis with and without imputation of missing data. The primary economic result will estimate the incremental cost per quality-adjusted life year gained from this intervention from a National Health Services (NHS) and personal social services perspective. Discussion: This research aims to benefit patients and the NHS by providing evidence on the long-term effectiveness and cost-effectiveness of outpatient physiotherapy after knee replacement. If the intervention is found to be effective and cost-effective, implementation into clinical practice could lead to improvement in patients’ outcomes and improved health care resource efficiency.

Improving Patients’ Experience and Outcome of Total Joint Replacement: the RESTORE Programme

BACKGROUND: Total hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected. OBJECTIVE: To undertake a programme of research studies to work towards improving patient outcomes after THR and TKR. METHODS: We used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement. RESULTS: Systematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test. CONCLUSIONS: The RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.

Durability performance of self-compacting concrete (SCC) with binary and ternary mixes of fly ash and limestone filler

The basic objective of this work is to evaluate the durability of self-compacting concrete (SCC) produced in binary and ternary mixes using fly ash (FA) and limestone filler (LF) as partial replacement of cement. The main characteristics that set SCC apart from conventional concrete (fundamentally its fresh state behaviour) essentially depend on the greater or lesser content of various constituents, namely: greater mortar volume (more ultrafine material in the form of cement and mineral additions); proper control of the maximum size of the coarse aggregate; use of admixtures such as superplasticizers. Significant amounts of mineral additions are thus incorporated to partially replace cement, in order to improve the workability of the concrete. These mineral additions necessarily affect the concrete's microstructure and its durability. Therefore, notwithstanding the many well-documented and acknowledged advantages of SCC, a better understanding its behaviour is still required, in particular when its composition includes significant amounts of mineral additions. An ambitious working plan was devised: first, the SCC's microstructure was studied and characterized and afterwards the main transport and degradation mechanisms of the SCC produced were studied and characterized by means of SEM image analysis, chloride migration, electrical resistivity, and carbonation tests. It was then possible to draw conclusions about the SCC's durability. The properties studied are strongly affected by the type and content of the additions. Also, the use of ternary mixes proved to be extremely favourable, confirming the expected beneficial effect of the synergy between LF and FA.

Aortic valve replacement through the upper ministernotomy. Preliminary experience with modified technique

Minimally invasive approach for aortic valve surgery has been developed since 1995, reducing the complications related to the full sternotomy. We have introduced a new method for central cannulation that reduces the length of surgical incision for the aortic valve replacement through upper mini-sternotomy. To improve the surgical view without enlargement of the incision, two small additional incisions are performed for both arterial and atrial cannulation. We have used the modified technique in 60 patients without sternal infection or other surgical complications and with good cosmetic results. Cardiac surgery - Aortic valve replacement - Minimally invasive approach.

A petrographic investigation into the durability of common replacement sandstones to the crystallisation of de-icing salts

Scottish sandstone buildings are now suffering the long-term effects of salt-crystallisation damage, owing in part to the repeated deposition of de-icing salts during winter months. The use of de-icing salts is necessary in order to maintain safe road and pavement conditions during cold weather, but their use comes at a price. Sodium chloride (NaCl), which is used as the primary de-icing salt throughout the country, is a salt known to be damaging to sandstone masonry. However, there remains a range of alternative, commercially available de-icing salts. It is unknown however, what effect these salts have on porous building materials, such as sandstone. In order to protect our built heritage against salt-induced decay, it is vital to understand the effects of these different salts on the range of sandstone types that we see within the historic buildings of Scotland. Eleven common types of sandstone were characterised using a suite of methods in order to understand their mineralogy, pore structure and their response to moisture movement, which are vital properties that govern a stone’s response to weathering and decay. Sandstones were then placed through a range of durability tests designed to measure their resistance to various weathering processes. Three salt crystallisation tests were undertaken on the sandstones over a range of 16 to 50 cycles, which tested their durability to NaCl, CaCl2, MgCl2 and a chloride blend salt. Samples were primarily analysed by measuring their dry weight loss after each cycle, visually after each cycle and by other complimentary methods in order to understand their changing response to moisture uptake after salt treatment. Salt crystallisation was identified as the primary mechanism of decay across each salt, with the extent of damage in each sandstone influenced by environmental conditions and pore-grain properties of the stone. Damage recorded in salt crystallisation tests was ultimately caused by the generation of high crystallisation pressures within the confined pore networks of each stone. Stone and test-specific parameters controlled the location and magnitude of damage, with the amount of micro-pores, their spatial distribution, the water absorption coefficient and the drying efficiency of each stone being identified as the most important stone-specific properties influencing salt-induced decay. Strong correlations were found between the dry weight loss of NaCl treated samples and the proportion of pores <1µm in diameter. Crystallisation pressures are known to scale inversely with pore size, while the spatial distribution of these micro-pores is thought to influence the rate, overall extent and type of decay within the stone by concentrating crystallisation pressures in specific regions of the stone. The water absorption determines the total amount of moisture entering into the stone, which represents the total amount of void space for salt crystallisation. The drying parameters on the other hand, ultimately control the distribution of salt crystallisation. Those stones that were characterised by a combination of a high proportion of micro-pores, high water absorption values and slow drying kinetics were shown to be most vulnerable to NaCl-induced decay. CaCl2 and MgCl2 are shown to have similar crystallisation behaviour, forming thin crystalline sheets under low relative humidity and/or high temperature conditions. Distinct differences in their behaviour that are influenced by test specific criteria were identified. The location of MgCl2 crystallisation close to the stone surface, as influenced by prolonged drying under moderate temperature drying conditions, was identified as the main factor that caused substantial dry weight loss in specific stone types. CaCl2 solutions remained unaffected under these conditions and only crystallised under high temperatures. Homogeneous crystallisation of CaCl2 throughout the stone produced greater internal change, with little dry weight loss recorded. NaCl formed distinctive isometric hopper crystals that caused damage through the non-equilibrium growth of salts in trapped regions of the stone. Damage was sustained as granular decay and contour scaling across most stone types. The pore network and hydric properties of the stones continually evolve in response to salt crystallisation, creating a dynamic system whereby the initial, known properties of clean quarried stone will not continually govern the processes of salt crystallisation, nor indeed can they continually predict the behaviour of stone to salt-induced decay.

Rheology of fresh mortar

Resumen: Los materiales basados en cementos presentan una enorme importancia tecnológica. Para una correcta utilización es necesario que sea posible su transporte y conformado en un estado “fresco”, por lo que es fundamental controlar su comportamiento reológico. En esta conferencia se describe el comportamiento reológico de morteros y productos relacionados, en situaciones prácticas, donde se tratarán casos concretos, y se discutirán las principales características de cada comportamiento. Además, se presentarán los nexos de unión entre la reología y la tecnología de los materiales de la construcción. Abstract: Cement-based materials are of enormous technological importance and their satisfactory performance depends on being able to transport and mould them in the freshly mixed state. This conference describes the rheology of mortars and related products in the context of practical situations, and deals with testing and measurement, together with the main features of their behaviour. It explores the links between rheology and technology.

A Replacement Technique to Maximize Task Reuse in Reconfigurable Systems

Dynamically reconfigurable hardware is a promising technology that combines in the same device both the high performance and the flexibility that many recent applications demand. However, one of its main drawbacks is the reconfiguration overhead, which involves important delays in the task execution, usually in the order of hundreds of milliseconds, as well as high energy consumption. One of the most powerful ways to tackle this problem is configuration reuse, since reusing a task does not involve any reconfiguration overhead. In this paper we propose a configuration replacement policy for reconfigurable systems that maximizes task reuse in highly dynamic environments. We have integrated this policy in an external taskgraph execution manager that applies task prefetch by loading and executing the tasks as soon as possible (ASAP). However, we have also modified this ASAP technique in order to make the replacements more flexible, by taking into account the mobility of the tasks and delaying some of the reconfigurations. In addition, this replacement policy is a hybrid design-time/run-time approach, which performs the bulk of the computations at design time in order to save run-time computations. Our results illustrate that the proposed strategy outperforms other state-ofthe-art replacement policies in terms of reuse rates and achieves near-optimal reconfiguration overhead reductions. In addition, by performing the bulk of the computations at design time, we reduce the execution time of the replacement technique by 10 times with respect to an equivalent purely run-time one.

A non-contrast self-navigated 3-dimensional MR technique for aortic root and vascular access route assessment in the context of transcatheter aortic valve replacement: proof of concept.

OBJECTIVES: Due to the high prevalence of renal failure in transcatheter aortic valve replacement (TAVR) candidates, a non-contrast MR technique is desirable for pre-procedural planning. We sought to evaluate the feasibility of a novel, non-contrast, free-breathing, self-navigated three-dimensional (SN3D) MR sequence for imaging the aorta from its root to the iliofemoral run-off in comparison to non-contrast two-dimensional-balanced steady-state free-precession (2D-bSSFP) imaging. METHODS: SN3D [field of view (FOV), 220-370 mm(3); slice thickness, 1.15 mm; repetition/echo time (TR/TE), 3.1/1.5 ms; and flip angle, 115°] and 2D-bSSFP acquisitions (FOV, 340 mm; slice thickness, 6 mm; TR/TE, 2.3/1.1 ms; flip angle, 77°) were performed in 10 healthy subjects (all male; mean age, 30.3 ± 4.3 yrs) using a 1.5-T MRI system. Aortic root measurements and qualitative image ratings (four-point Likert-scale) were compared. RESULTS: The mean effective aortic annulus diameter was similar for 2D-bSSFP and SN3D (26.7 ± 0.7 vs. 26.1 ± 0.9 mm, p = 0.23). The mean image quality of 2D-bSSFP (4; IQR 3-4) was rated slightly higher (p = 0.03) than SN3D (3; IQR 2-4). The mean total acquisition time for SN3D imaging was 12.8 ± 2.4 min. CONCLUSIONS: Our results suggest that a novel SN3D sequence allows rapid, free-breathing assessment of the aortic root and the aortoiliofemoral system without administration of contrast medium. KEY POINTS: • The prevalence of renal failure is high among TAVR candidates. • Non-contrast 3D MR angiography allows for TAVR procedure planning. • The self-navigated sequence provides a significantly reduced scanning time.

Aproveitamento de resíduos minerais na formulação de argamassas para a construção civil

Current environmental concerns include the excessive consumption and inefficient use of non-renewable natural resources. The construction industry is considered one of the largest consumers of natural raw materials, significantly contributing to the environmental degradation of the planet. The use of calcareous quarry (RPPC) and porcelain tile polishing residues (RPP) as partial replacements of the cement in mortars is an interesting alternative to minimize the exploration of considerably large amounts of natural resources. The present study aimed at investigating the properties of fresh and hardened mortars produced using residues to replace cement. The residues used were fully characterized to determine their specific mass, unitary mass, particle size distribution and morphology, and composition. The performance of the mortars was compared to that of reference compositions, prepared without residues. A total of 18 compositions were prepared, 16 using residues and 2 reference ones. The mortars were prepared using Portland CP II F 32 cement, CH I hydrated lime, river sand and tap water. The compositions of the mortars were 1:1:6 and 1:0.5:4.5 (vol%), and water to cement ratios of 1.87 and 1.45 were used, respectively. The mortars in the fresh state were evaluated by consistency index, water retention, density of mass and incorporated air content tests. In their hardened state, the mortars were evaluated by apparent mass density, modulus of elasticity, flexural tensile strength, compressive strength and water absorption by capillarity. The mortars were also analyzed by scanning electron microscopy, energy dispersive spectroscopy, X-ray diffraction and fluorescence. Finally, they were classified according to NBR 13281 standards. The mortars prepared using residues partially replacing the cement exhibited lower modulus of elasticity compared to the reference compositions, thus improving the performance in their intended use. On the downside, the water absorption by capillarity was affected by the presence of residues and both the tensile and compressive strength were reduced. However, from the overall standpoint, the replacement of cement by calcareous quarry or porcelain tile polishing residues did not result in significant changes in the properties of the mortars. Therefore, compositions containing these residues can be used in the construction industry

Dispersion and optimization of a calcium sulfoaluminate mortar prepared with superplasticizer

Calcium sulfoaluminate (CSA) cements/mortars are receiving increasing attention since their manufacture produces less CO2 than ordinary Portland cement (OPC) (up to 22% of decrease depending on its composition). These systems are complex and there are many parameters affecting their hydration mechanism, such as water-to-cement (w/c) ratio, type and amount of sulfate source, and so on. Low w/c ratios, within certain limits, may reduce the porosity and consequently, improve the mechanical strengths. However, it is accompanied by an increasing of viscosity and lack of both workability and homogeneity, with the consequent negative effect on the mechanical properties. The dispersion of the particles through the adsorption of the right amount and type of additives, such as superplasticizers, is a key point to improve the workability of mortars allowing both the preparation of homogeneous mixtures and the reduction of the amount of mixing water. This work deals with the preparation and optimization of homogeneous CSA-mortars with improved mechanical strengths. The optimum amount of superplasticizer was optimized through rheological measurements. The effect of different amounts of the superplasticizer on the viscosity of the mortars, its hydration mechanism and corresponding mechanical properties has been studied and will be discussed.

Effect of milling time on mechanical properties of fly ash incorporated cement mortars

Abstract. Currently, thermal energy generation through coal combustion produces ash particles which cause serious environmental problems and which are known as Fly Ash (FA). FA main components are oxides of silicon, aluminum, iron, calcium and magnesium in addition, toxic metals such as arsenic and cobalt. The use of fly ash as a cement replacement material increases long term strength and durability of concrete. In this work, samples were prepared by replacing cement by ground fly ash in 10, 20 and 30% by weight. The characterization of raw materials and microstructure was obtained by Scanning Electron Microscopy (SEM) and X-ray diffraction (XRD). The final results showed that the grinding process significantly improves the mechanical properties of all samples when compared replacing a mortar made with cement by ground fly ash and the reference samples without added fly ash. The beneficial effect of the ground fly ash can increase the use of this product in precast concrete industry

Aplicación de residuos en la fabricación de morteros industriales

La presente Tesis Doctoral estudia el uso de la fracción fina de los residuos de construcción y demolición (RCD) en la fabricación de morteros de albañilería. El principal uso de los áridos reciclados de RCD es la construcción de rellenos o firmes de carreteras, aunque su uso como áridos para la fabricación de hormigones o morteros le daría un mayor valor añadido. A nivel internacional existen numerosos estudios sobre la utilización de la fracción gruesa de los áridos reciclados de RCD en la fabricación de hormigones. Sin embargo son escasos los trabajos llevados a cabo para valorizar la fracción fina. Actualmente en España la fracción fina de los áridos reciclados de RCD está infrautilizada y en la mayoría de los casos depositada sin uso en los vertederos de las Plantas de reciclaje. En este trabajo se han utilizado dos tipos de áridos reciclados, uno procedente de residuos de hormigón (FRCA) y otro de residuos mixtos de tabiquería con un alto porcentaje de ladrillo rojo cerámico (FMRA). Todos los materiales han sido caracterizados desde un punto de vista físico, químico y mineralógico para justificar el efecto de su incorporación a la fabricación de morteros industriales de albañilería. En una primera fase se estudiaron las propiedades del mortero fresco y endurecido fabricado con FRCA y cinco niveles de sustitución volumétrica de arena natural y FRCA: 0%, 5%, 10%, 20% y 40%.Se utilizó un cemento puzolánico tipo CEM-IV y se evaluaron las propiedades a corto y largo plazo de morteros de baja resistencia (M5) En una segunda fase, se utilizó un cemento tipo CEM-II y se fabricaron morteros de mayor resistencia (M-10) utilizando FRMA. En esta etapa se llevaron a cabo sustituciones de arena natural por arena reciclada de 0%, 25%, 50%, 75% y 100%. El residuo fue evaluado medioambientalmente mediante el test de conformidad antes y después de ser ligado con cemento (lixiviación). Los resultados fueron completados con estudios de durabilidad. Con el objetivo de completar los estudios anteriores, se llevó a cabo una tercera fase, donde se sustituyó hasta un 100% de arena natural por FRCA, utilizando un cemento tipo CEM-II para fabricar un mortero tipo M-10, dosificado de manera similar al empleado en la segunda fase de este trabajo. Como conclusión general de esta tesis, se puede decir que pueden admitirse tasas de sustitución de hasta un 50% de arena natural por árido reciclado en morteros industriales de albañilería para usos de interior sin que sus propiedades puedan verse afectadas significativamente. Los resultados obtenidos contribuyen a reducir la extracción de arena natural de canteras y ríos, minimizar el consumo de energía y emisiones de CO2, mitigar el calentamiento global y evitar el depósito en vertedero de la fracción fina de RCD.