Mandibular bone segmentation from CT scans: Quantitative and qualitative comparison among software.

OBJECTIVES: Nowadays, a wide variety of software for 3D reconstruction from CT scans is available; they differ for costs, capabilities, a priori knowledge, and, it is not trivial to identify the most suitable one for specific purposes. The article is aimed to provide some more information, having set up various metrics for the evaluation of different software's performance. METHODS: Metrics include software usability, segmentation quality, geometric accuracy, mesh properties and Dice Similarity Coefficient (DSC). Five different software have been considered (Mimics, D2P, Blue Sky Plan, Relu, and 3D Slicer) and tested on four cases; the mandibular bone was used as a benchmark. RESULTS: Relu software, being based on AI, was able to solve some very intricate geometry and proved to have a very good usability. On the other side, the time required for segmentation was significantly higher than other software (reaching over twice the time required by Mimics). Geometric distances between nodes position calculated by different software usually kept below 2.5 mm, reaching 3.1 mm in some very critical area; 75th percentile q75 is generally less than 0.5 mm, with a maximum of 1.11 mm. Dealing with consistency among software, the maximum DSC value was observed between Mimics and Slicer, D2P and Mimics, and D2P and Slicer, reaching 0.96. SIGNIFICANCE: This work has demonstrated how mandible segmentation performance among software was generally very good. Nonetheless, differences in geometric accuracy, usability, costs and times required can be significant so that information here provided can be useful to perform an informed choice.

Parametrization of the Calcaneus and Medial Cuneiform to Aid Potential Advancements in Flatfoot Surgery.

INTRODUCTION: Flatfoot is a condition commonly seen in children; however, there is general disagreement over its incidence, characterization and correction. Painful flatfoot accompanied with musculoskeletal and soft tissue problems requires surgery to avoid arthritis in adulthood, the most common surgical approach being two osteotomies to the calcaneus and medial cuneiform bones of the foot. OBJECTIVES: This study focuses on the parametrization of these two bones to understand their bone morphology differences in a population sample among 23 normal subjects. Population differences could help in understanding whether bone shape may be an important factor in aiding surgical planning and outcomes. METHODS: A total of 45 sets of CT scans of these subjects were used to generate surface meshes of the two bones and converted to be iso-topological meshes, simplifying the application of Generalized Procrustes Analysis and Principal Component Analysis, allowing the main sources of variation between the subjects to be quantified. RESULTS: For the calcaneus, 16 Principal Components (PCs) and, for the medial cuneiform, 12 PCs were sufficient to describe 90% of the dataset variability. The quantitative and qualitative analyses confirm that for the calcaneus PC1 describes the Achilles attachment location and PC2 largely describes the anterior part of the bone. For the medial cuneiform, PC1 describes the medial part of the bone, while PC2 mainly describes the superior part. CONCLUSION: Most importantly, the PCs did not seem to describe the osteotomy sites for both bones, suggesting low population variability at the bone cutting points. Further studies are needed to evaluate how shape variability impacts surgical outcomes. Future implications could include better surgical planning and may pave the way for complex robotic surgeries to become a reality.

Multiscale Mechanical Characterization of Polyether-2-ketone (PEKK) for Biomedical Application.

Polyether-ether-2-ketone (PEKK) is a high-performance thermoplastic polymer used in various fields, from aerospace to medical applications, due to its exceptional mechanical and thermal properties. Nonetheless, the mechanical behavior of 3D-printed PEKK still deserves to be more thoroughly investigated, especially in view of its production by 3D printing, where mechanical properties measured at different scales are likely to be correlated to one another and to all play a major role in determining biomechanical properties, which include mechanical strength on one side and osteointegration ability on the other side. This work explores the mechanical behavior of 3D-printed PEKK through a multiscale approach, having performed both nanoindentation tests and standard tensile and compression tests, where a detailed view of strain distribution was achieved through Digital Image Correlation (DIC) techniques. Furthermore, for specimens tested up to failure, their fractured surfaces were analyzed through Scanning Electron Microscopy (SEM) to clearly outline fracture modes. Additionally, the internal structure of 3D-printed PEKK was explored through Computed Tomography (CT) imaging, providing a three-dimensional view of the internal structure and the presence of voids and other imperfections. Finally, surface morphology was analyzed through confocal microscopy. The multiscale approach adopted in the present work offers information about the global and local behavior of the PEKK, also assessing its material properties down to the nanoscale. Due to its novelty as a polymeric material, no previous studies have approached a multiscale analysis of 3D-printed PEKK. The findings of this study contribute to a comprehensive understanding of 3D-printed PEKK along with criteria for process optimization in order to customize its properties to meet specific application requirements. This research not only advances the knowledge of PEKK as a 3D-printing material but also provides insights into the multifaceted nature of multiscale material characterization.

Form Factors as Potential Imaging Biomarkers to Differentiate Benign vs. Malignant Lung Lesions on CT Scans.

Indeterminate lung nodules detected on CT scans are common findings in clinical practice. Their correct assessment is critical, as early diagnosis of malignancy is crucial to maximise the treatment outcome. In this work, we evaluated the role of form factors as imaging biomarkers to differentiate benign vs. malignant lung lesions on CT scans. We tested a total of three conventional imaging features, six form factors, and two shape features for significant differences between benign and malignant lung lesions on CT scans. The study population consisted of 192 lung nodules from two independent datasets, containing 109 (38 benign, 71 malignant) and 83 (42 benign, 41 malignant) lung lesions, respectively. The standard of reference was either histological evaluation or stability on radiological followup. The statistical significance was determined via the Mann-Whitney U nonparametric test, and the ability of the form factors to discriminate a benign vs. a malignant lesion was assessed through multivariate prediction models based on Support Vector Machines. The univariate analysis returned four form factors (Angelidakis compactness and flatness, Kong flatness, and maximum projection sphericity) that were significantly different between the benign and malignant group in both datasets. In particular, we found that the benign lesions were on average flatter than the malignant ones; conversely, the malignant ones were on average more compact (isotropic) than the benign ones. The multivariate prediction models showed that adding form factors to conventional imaging features improved the prediction accuracy by up to 14.5 pp. We conclude that form factors evaluated on lung nodules on CT scans can improve the differential diagnosis between benign and malignant lesions.

In Silico Meta-Analysis of Boundary Conditions for Experimental Tests on the Lumbar Spine.

The study of the spine range of motion under given external load has been the object of many studies in literature, finalised to a better understanding of the spine biomechanics, its physiology, eventual pathologic conditions and possible rehabilitation strategies. However, the huge amount of experimental work performed so far cannot be straightforwardly analysed due to significant differences among loading set-ups. This work performs a meta-analysis of various boundary conditions in literature, focusing on the flexion/extension behaviour of the lumbar spine. The comparison among range of motions is performed virtually through a validated multibody model. Results clearly illustrated the effect of various boundary conditions which can be met in literature, so justifying differences of biomechanical behaviours reported by authors implementing different set-up: for example, a higher value of the follower load can indeed result in a stiffer behaviour; the application of force producing spurious moments results in an apparently more deformable behaviour, however the respective effects change at various segments along the spine due to its natural curvature. These outcomes are reported not only in qualitative, but also in quantitative terms. The numerical approach here followed to perform the meta-analysis is original and it proved to be effective thanks to the bypass of the natural variability among specimens which might completely or partially hinder the effect of some boundary conditions. In addition, it can provide very complete information since the behaviour of each functional spinal unit can be recorded. On the whole, the work provided an extensive review of lumbar spine loading in flexion/extension.

Ex vivo biomechanical evaluation of polyester and polyblend suture techniques to perform equine laryngoplasty.

OBJECTIVE: To validate the use of a polyblend tape suture in equine laryngoplasty (PL). STUDY DESIGN: Experimental study. ANIMALS: Thirty-two cadaveric larynges. METHODS: Each larynx was randomly assigned to 1 of 4 groups: PL with polyblend tape suture (TigerTape), without (TT) or with a cannula (TTC) in the muscular process of the arytenoid cartilage, and PL with polyester suture (Ethibond), without (EB) or with a cannula (EBC). Construct stiffness, total migration, creep, and drift values were measured after 3000 cycles. The specimens were then loaded to failure to assess their residual properties: load at failure, total energy, displacement, and 2 stiffness coefficients. RESULTS: After cyclic testing, the total migration and creep were lower in TTC (6.36 ± 1.20 mm; 1.35 ± 0.38 mm/s) than in EB (11.12 ± 4.20 mm; 3.39 ± 2.68 mm/s) and in the TT constructs (11.26 ± 1.49 mm; 3.20 ± 0.54 mm/s); however, no difference was found with EBC (9.19 ± 3.18 mm; 2.14 ± 0.99). A correlation was found between total migration and creep (R = .85). The TTC constructs failed at higher loads (129.51 ± 33.84 N) than EB (93.16 ± 18.21 N) and EBC (81.72 ± 13.26 N) whereas the EB and EBC constructs were less stiff than TT and TTC (P < .001). CONCLUSION: Biomechanical properties were generally superior for the TTC constructs tested under cyclical loading. The TT and TTC constructs failed at a higher load than EB and EBC constructs. The cannula in TTC and EBC reduced the failure at the muscular process. CLINICAL SIGNIFICANCE: These results provide evidence to support the in vivo evaluation of the polyblend tape suture with or without a cannula in the muscular process for laryngoplasty in horses.

Colour and Texture Descriptors for Visual Recognition: A Historical Overview.

Colour and texture are two perceptual stimuli that determine, to a great extent, the appearance of objects, materials and scenes. The ability to process texture and colour is a fundamental skill in humans as well as in animals; therefore, reproducing such capacity in artificial ('intelligent') systems has attracted considerable research attention since the early 70s. Whereas the main approach to the problem was essentially theory-driven ('hand-crafted') up to not long ago, in recent years the focus has moved towards data-driven solutions (deep learning). In this overview we retrace the key ideas and methods that have accompanied the evolution of colour and texture analysis over the last five decades, from the 'early years' to convolutional networks. Specifically, we review geometric, differential, statistical and rank-based approaches. Advantages and disadvantages of traditional methods vs. deep learning are also critically discussed, including a perspective on which traditional methods have already been subsumed by deep learning or would be feasible to integrate in a data-driven approach.

Impact of Lesion Delineation and Intensity Quantisation on the Stability of Texture Features from Lung Nodules on CT: A Reproducible Study.

Computer-assisted analysis of three-dimensional imaging data (radiomics) has received a lot of research attention as a possible means to improve the management of patients with lung cancer. Building robust predictive models for clinical decision making requires the imaging features to be stable enough to changes in the acquisition and extraction settings. Experimenting on 517 lung lesions from a cohort of 207 patients, we assessed the stability of 88 texture features from the following classes: first-order (13 features), Grey-level Co-Occurrence Matrix (24), Grey-level Difference Matrix (14), Grey-level Run-length Matrix (16), Grey-level Size Zone Matrix (16) and Neighbouring Grey-tone Difference Matrix (five). The analysis was based on a public dataset of lung nodules and open-access routines for feature extraction, which makes the study fully reproducible. Our results identified 30 features that had good or excellent stability relative to lesion delineation, 28 to intensity quantisation and 18 to both. We conclude that selecting the right set of imaging features is critical for building clinical predictive models, particularly when changes in lesion delineation and/or intensity quantisation are involved.

Design of a loading system for cyclic test on sutured organs.

The design of loading systems to test biologic samples is often challenging, due to shape variability and non-conventional loading set-ups. In addition to this, large economic investments would not be justified since the loading set up is usually designed for one single or for a limited range of applications. The object of this work is the development of a loading set-up finalised to on-site testing of sutures whose main function is applying a localised tensile load. The main challenges of this design process can be so summarized:•Applying cyclic tensile loads on the suture wire, mimicking the physiologic condition where both suture anchorage points have a certain compliance;•Designing a loading system as versatile as possible, in order to be able to accommodate organs with different geometries and sizes;•Keeping low both the complexity and costs of realization.All these considerations and the design calculi are here reported in detail, discussing the novelty of the system, and its main advantages.

Dynamic Characterization of the Biomechanical Behaviour of Bovine Ovarian Cortical Tissue and Its Short-Term Effect on Ovarian Tissue and Follicles.

The ovary is a dynamic mechanoresponsive organ. In vitro, tissue biomechanics was reported to affect follicle activation mainly through the Hippo pathway. Only recently, ovary responsiveness to mechanical signals was exploited for reproductive purposes. Unfortunately, poor characterization of ovarian cortex biomechanics and of the mechanical challenge hampers reproducible and effective treatments, and prevention of tissue damages. In this study the biomechanical response of ovarian cortical tissue from abattoir bovines was characterized for the first time. Ovarian cortical tissue fragments were subjected to uniaxial dynamic testing at frequencies up to 30 Hz, and at increasing average stresses. Tissue structure prior to and after testing was characterized by histology, with established fixation and staining protocols, to assess follicle quality and stage. Tissue properties largely varied with the donor. Bovine ovarian cortical tissue consistently exhibited a nonlinear viscoelastic behavior, with dominant elastic characteristics, in the low range of other reproductive tissues, and significant creep. Strain rate was independent of the applied stress. Histological analysis prior to and after mechanical tests showed that the short-term dynamic mechanical test used for the study did not cause significant tissue tear, nor follicle expulsion or cell damage.

Mechanical Behavior of Elastic Self-Locking Nails for Intramedullary Fracture Fixation: A Numerical Analysis of Innovative Nail Designs.

Intramedullary nails constitute a viable alternative to extramedullary fixation devices; their use is growing in recent years, especially with reference to self-locking nails. Different designs are available, and it is not trivial to foresee the respective in vivo performances and to provide clinical indications in relation to the type of bone and fracture. In this work a numerical methodology was set up and validated in order to compare the mechanical behavior of two new nailing device concepts with one already used in clinic. In detail, three different nails were studied: (1) the Marchetti-Vicenzi's nail (MV1), (2) a revised concept of this device (MV2), and (3) a new Terzini-Putame's nail (TP) concept. Firstly, the mechanical behavior of the MV1 device was assessed through experimental loading tests employing a 3D-printed component aimed at reproducing the bone geometry inside which the device is implanted. In the next step, the respective numerical model was created, based on a multibody approach including flexible parts, and this model was validated against the previously obtained experimental results. Finally, numerical models of the MV2 and TP concepts were implemented and compared with the MV1 nail, focusing the attention on the response of all devices to compression, tension, bending, and torsion. A stability index (SI) was defined to quantify the mechanical stability provided to the nail-bone assembly by the elastic self-locking mechanism for the various loading conditions. In addition, results in terms of nail-bone assembly stiffness, computed from force/moment vs. displacement/rotation curves, were presented and discussed. Findings revealed that numerical models were able to provide good estimates of load vs. displacement curves. The TP nail concept proved to be able to generate a significantly higher SI (27 N for MV1 vs. 380 N for TP) and a greater stiffening action (up to a stiffness difference for bending load that ranges from 370 Nmm/° for MV1 to 1,532 Nmm/° for TP) than the other two devices which showed similar performances. On the whole, a demonstration was given of information which can be obtained from numerical simulations of expandable fixation devices.

On-site testing of sutured organs: An experimental set up to cyclically tighten sutures.

A number of surgical practices are aimed to compensate for tissue relaxation or weakened/atrophied muscles by means of suture prostheses/thread lifts. The success rate of these procedures is often very good in the short term, while it is quite variable among subjects and techniques in the middle-long term. Middle-long term failures are mostly related to suture distraction, loosening or wear, coming from repeated loading cycles. In this work, an experimental device to perform ex vivo tests on prosthetic sutures has been set up. An equine laryngoplasty has been used as a benchmark, being representative of sutures aimed to compensate for atrophied muscles. The peculiarity of this experimental set up is that the suture is on-site and it has been tightened with known, repeated loads, which do not depend on thread deformation at different load levels. Preliminary tests have been performed applying over 3000 load cycles and finally a tensile test up to rupture. Force/displacement curves obtained with this experimental set up have been reported and parameters useful to classify the biomechanical performance of sutures versus time (mainly its creep behaviour), have been outlined. Results have outlined that the organ-suture system undergoes significant creep over 3000 cycles, and this should be taken into account in order to foresee its long-term behaviour; in addition, the suture anchorage to cartilage should be improved. The experimental set up can be used to perform on-site testing of sutures, taking into account the compliance and creep response at both suture anchorage ends, in order to compare different surgeries and different kinds of thread.

Data from cyclic tensile tests on sutured organs to evaluate creep behaviour, distraction, and residual thread strength.

A number of applications in the surgical practice are based on tensile sutures aimed to keep soft tissues in place and compensate the exit of neuropathies, prolapses or general tissue relaxation. Long-term behaviour of these constructs need to be carefully examined in order to define tensile forces to be applied and to compare different suture anchors. Data here reported refer to equine laryngoplasties, where a suitable loading system has been designed in order to be able to test sutures in-sito, applying known forces ("On-site testing of sutured organs: an experimental set up to cyclically tighten sutures" (Pascoletti et al., 2020 [1])). The loading protocol was made of two steps: in the first step, 3000 loading cycles have been performed; in the following step, a tensile test up to rupture was performed. Cyclic load/displacement curves allow evaluating suture distraction, as a consequence of suture migration and/or soft tissues creep. Tensile curves allow evaluating the residual thread strength and its ultimate displacement. These data can provide a detailed insight of long-term suture behaviour and can be a reference to compare different threads and/or suture anchors.

Multibody Models for the Analysis of a Fall From Height: Accident, Suicide, or Murder?

The final subject position is often the only evidence in the case of the fall of a human being from a given height. Foreseeing the body trajectory and the respective driving force may not be trivial due to the possibility of rotations and to an unknown initial position and momentum of the subject. This article illustrates how multibody models can be used for this aim, with specific reference to an actual case, where a worker fell into a stair well, prior to stair mounting, and he was found in an unexpected posture. The aim of the analysis was establishing if this worker was dead in that same place, if he had been pushed, and which was his initial position. A multibody model of the subject has been built ("numerical android"), given his stature and his known mass. Multiple simulations have been performed, following a design of experiments where various initial positions and velocity as well as pushing forces have been considered, while the objective function to be minimized was the deviation of the numerical android position from the actual worker position. At the end of the analysis, it was possible to point how a very limited set of conditions, all including the application of an external pushing force (or initial speed), could produce the given final posture with an error on the distance function equal to 0.39 m. The full analysis gives a demonstration of the potentiality of multibody models as a tool for the analysis of falls in forensic inquiries.

Prosthetic Hip ROM from Multibody Software Simulation.

The pre-operative planning of a hip arthroplasty entails the choice of the prosthetic hip model and of the position of both joint components with reference to bone. Assessing the impact of geometrical factors on the final hip range of motion (ROM) is not trivial, since it requires performing 3D evaluations. Nonetheless, it deserves to be studied since hip impingement and dislocation are still relevant complications in hip arthroplasty. This work pertains a numerical model for the assessment of the hip ROM in relation to cotyle position. External/internal rotation is considered as a benchmark, and multiple combinations of acetabular anteversion/inclination are considered. According to results, over two hundred different geometric configurations can be examined in few minutes, and the cotyle position can be so optimized with relevant benefits in term of hip ROM.

Numerical Simulation of an Intramedullary Elastic Nail: Expansion Phase and Load-Bearing Behavior.

The Marchetti-Vicenzi's nail is an intramedullary device where six curved nails are kept straight by a closing ring in order to allow their insertion into the medullary canal of a long bone; in a following step, these nails stabilize the fracture due to the ring withdrawal and to the consequent elastic expansion of the nails. Pre-clinical testing of this sort of device is strongly advocated in order to be able to foresee their stability inside the medullary canal and to quantify their stiffening action on a broken bone. In this numerical work, an MB (Multi Body) model of the device has been developed, with the dual purpose of evaluating forces between the bone and the system components during its progressive opening and verifying the behavior of the stabilized bone when it undergoes external loading. Different solutions, for flexible body modeling (discretization with lumped parameters, "flexible body," "FE Part"), have been analyzed and compared in terms of accuracy of results and required computational resources. Contact parameters have been identified and criteria to simplify geometries and therefore to reduce simulation times have been given. Results have allowed to demonstrate how a moderate lateral force is able to dislocate the fracture and how the final position of the retention nut can be optimized. On the whole, a tool for the pre-clinical testing of elastic intramedullary nails has been given.

Clinical Assessment of Dental Implant Stability During Follow-Up: What Is Actually Measured, and Perspectives.

The optimization of loading protocols following dental implant insertion requires setting up patient-specific protocols, customized according to the actual implant osseointegration, measured through quantitative, objective methods. Various devices for the assessment of implant stability as an indirect measure of implant osseointegration have been developed. They are analyzed here, introducing the respective physical models, outlining major advantages and critical aspects, and reporting their clinical performance. A careful discussion of underlying hypotheses is finally reported, as is a suggestion for further development of instrumentation and signal analysis.

Modal analysis for implant stability assessment: Sensitivity of this methodology for different implant designs.

OBJECTIVE: To investigate the influence of implant design on the change in the natural frequency of bone-implant system during osseointegration by means of a modal 3D finite element analysis. METHODS: Six implants were considered. Solid models were obtained by means of reverse engineering techniques. The mandibular bone geometry was built-up from a CT scan dataset through image segmentation. Each implant was virtually implanted in the mandibular bone. Two different models have been considered, differing in the free length of the mandibular branch ('long branch' and 'short branch') in order to simulate the variability of boundary conditions when performing vibrometric analyses. Modal analyses were carried out for each model, and the first three resonance frequencies were assessed with the respective vibration modes. RESULTS: With reference to the 'long branch' model, the first three modes of vibration are whole bone vibration with minimum displacement of the implant relative to bone, with the exception of the initial condition (1% bone maturation) where the implant is not osseointegrated. By contrast, implant displacements become relevant in the 'short branch' model, unless osseointegration level is beyond 20%. The difference between resonance frequency at whole bone maturation and resonance frequency at 1% bone maturation remained lower than 6.5% for all modes, with the exception of the third mode of vibration in the 'D' implant where this difference reached 9.7%. With reference to the 'short branch', considering the first mode of vibration, 61-68% of the frequency increase was achieved at 10% osseointegration; 72-79% was achieved at 20%; 89-93% was achieved at 50% osseointegration. The pattern of the natural frequency versus the osseointegration level is similar among different modes of vibration. SIGNIFICANCE: Resonance frequencies and their trends towards osseointegration level may differ between implant designs, and in different boundary conditions that are related to implant position inside the mandible; tapered implants are the most sensitive to bone maturation levels, small implants have very little sensitivity. Resonance frequencies are less sensitive to bone maturation level beyond 50%.