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Contents

Issue No.45 l Aeronautica ultural l Biomedical l ral Agric ar Mine l Aeronautical Mechanica edica ultura uter Nucle ical Civiln l Chem are Comp Mineral Agric autical Biom l Aeron l Mechanica inability Desig nics Softw Nuclear and ical Photoare Computer ral Agricultural Biomedica Civil Susta Electrical ms Softw Nuclear Minel Aeronautica l Chemical ity Design Biomechan Syste anica Systems ical uter Agricultura Photonics Electronics l Mech Civil Sustainabil ral Electronics echanicalSoftware Comp ical and ms Biomechan are ical l Biomedica ar Mine n Electr Softw ical and Systems Biom anical Chemity Desig Electronics SystePhotonics Nuclear Photonics uter Nucle l Aeronautica n Electr ity Desig and Electronics uter echanical are Comp ultura l edical Mech Sustainabil ical and echanical ical ms Biom nics Softw Mineral Agricautical Biom Sustainabil ical CivilDesign Electr Systems Biom Software Comp Agricultura l Chem ical Civil ity Design Electr nics ity onics Syste ical Photo MineralAeronautical 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inability Desig onics Systeical Photonics Nuclear Mine autical l Chemical ity Design Electr l Mech Sustainability and Electr echanical Photo uter Nucle l Syste uter Electr echan ultura Photo Aeron are edica Electr uter l ical and Susta anica inabil Biom Agric echan Civil Biom are Comp Agricultura l ral AgricBiomedical Mech Electronics echanicalSoftware Comp ical Civil n Electrical and ms Biom Software Compral Agriculturaedical Mech Civil Susta n Electrical Systems Photonics Softwar MineralAeronautical l Chemical ity Design Electr Systems Biom l ar Mine ical and Systems Biom nics Softw Mineral autica l anica anical Chemity Desig Electronics SystePhotonics Nuclear Mine autical Biomanical Chemicalinability Desigand Electronics echanical Photonics uter Nucle l Aeronautica n Electr uter Nucle Electronics ical Photouter Nuclear ultural Aeron edical Sustainabil Agriculturaedical Mech ity Desig and Electronics echanical are Comp ultura ical and Biomechan edical Mech Sustainabil ical and 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Publication of the Chamber of Engineers

Cover Image The latest breakthroughs in biomechanical research have given engineers a better insight on biological systems.

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May 2013

www.coe.org.mt

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From the Editor

From the President

Editor Ing. John Pace

BOV’s Ongoing Green Initiatives

Editorial Board Ing. John Pace Ing. Paul Refalo Ing. Ray Vassallo Prof. Robert Ghirlando

Engineering Material Challenges for Human Joint Replacements

Technology; the only cure for our healthcare systems

The 2013 Engineering Conference Highlights

Engineering the Brain - Deep Brain Stimulation

Biomechanics at the Mechanical Engineering Department

Authors

© Chamber of Engineers 2013. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopy, recording or otherwise, without the prior permission of the Chamber of Engineers – Malta. Opinions expressed in Engineering Today are not necessarily those of the Chamber of Engineers – Malta. All care has been taken to ensure truth and accuracy, but the Editorial Board cannot be held responsible for errors or omissions in the articles, pictographs or illustrations.

Chamber of Engineers, Professional Centre, Sliema Road, Gzira, GZR 1633, Malta Tel: +356 2133 4858 Fax: +356 2134 7118 Email: info@coe.org.mt Web: www.coe.org.mt

Design by:

A member of:

www.darkdragonmedia.com

From the editor by Ing. John Pace

Young people rarely discuss health issues, a favourite topic for their elders. Being in the latter category I recently had occasion to sample the facilities at Mater Dei hospital. I knew of CT scan machines, as these had been regular features in the UK stand at the old Malta Trade Fair, together with ceiling high models of the DNA double spiral and the hovercraft, all British inventions. Now I encountered the real thing. The machine had the form of a large vertical doughnut and I was asked to lie on a bed on the axis of the doughnut and a needle was inserted in my arm to inject a dye. The machine was started and the bed slid inside the doughnut. After a short calibration there was a sound of a big vacuum cleaner and a voice asked me to take a big breath. The bed moved in and out for a few seconds as the scanning X-rays were taken, and all was over. Back at the consultantâ&#x20AC;&#x2122;s office the result of the scan was immediately available on the hospital network. Using the mouse the doctor could see various slices of my body. His practiced eye could see that there were no tumours, which put my mind at rest. CT scans, and more recent developments like the MRI and PET scanners are marvels of technology, a synthesis of medicine, precision engineering and computation. Doctors can see the inside of a person in a way previously only possible post mortem. Listening through a stethoscope and thumping on the chest are no longer the sole diagnostic means available. Ultrasonic echo scans show accurate pictures of the condition and working of the heart. Ultrasound is a non invasive and risk free method of inspecting the insides of the body,

May 2013

Issue No. 45

as every expectant mother knows. Doppler ultrasound can measure the flow of blood and detect circulation problems. Technology also provides tools for endoscopic examinations by inserting a camera through a body cavity and directing it to the various organs. Keyhole surgery is possible thanks to video and manipulative probes being inserted through small incisions. In his conference paper (to be published in the next issue) Ing. Carl Azzopardi describes the use of capsule endoscopy, where a capsule is swallowed and transmits video information as it travels through the alimentary system. These are only a small sample of the techniques that technology has made available to the medical field, from laser treatment in ophthalmic cases, to artificial joints and prostheses and the treatment of neurological conditions. Even the private person may have several medical gizmos in his household, as explained by Simon Attard in his paper. Engineering is nowadays the backbone of healthcare, as was the apt theme of the annual Engineering Conference held on 25 April. The present issue of Engineering Today is dedicated to the papers presented at the conference, which principally come from researchers and practicing professionals in the medical engineering field. Recent issues of Engineering Today also included articles related to medical technology. Medical engineering has taken off. I remember the days when the engineering staff at St Lukeâ&#x20AC;&#x2122;s hospital consisted of one engineer and a handful of technicians. This would be unthinkable at Mater Dei hospital which is bristling with all the gadgets. Visiting a patient at the ITU is like

entering the cockpit of an airliner, the patient being wired to a plethora of monitors charting every imaginable condition of the body. Behind the scenes are the persons involved in research and development, and the papers at the conference give an indication of the breadth

Ing. John Pace Editor, Engineering Today

of the subject. Medicine has made huge advances in recent years, making us live longer, but also improving the quality of life of persons afflicted by some medical condition. Engineers have participated in these advances in cooperation with persons from other professions. ET

From the President by Ing. Saviour Baldacchino

Dear Colleagues... The annual general meeting (AGM) of the Chamber was held according to statute during the last week of February as announced earlier on. This year postal voting was introduced and the number of members who took part in the voting process was about six times larger than traditional voting during the AGM. The Council is thus becoming a more realistic representation of the Chamber members’ preference. A sincere thank you goes to all colleague members who gave a very positive sign of co-operation with their support and participation. Those members who did not cast their vote this year, are cordially encouraged to do so in next year’s election. Your vote matters to our profession as it gives more voice to your representatives with stakeholders. I would like to thank engineers Matthew Galea and Godfrey Muscat who held the posts of Membership Secretary and Treasurer respectively in the previous Council. Matthew’s enthusiasm and motivation were key to deliver his duties with pride and to contribute in many other ways to important Council assignments. Godfrey tried his best consistently despite demanding professional commitments during the last term. They both merit a word of recognition for the voluntary work they gave to the Chamber and to the profession. I would like to welcome on board engineers Neal Borg and Jason Vella who are the newly elected Council members. Neal was assigned the duties of Treasurer while Jason was appointed Public Relations Officer. Neal and Jason are dedicated colleagues who are willing to contribute some of their time and bring with them new energy and ideas to the Council. Also elected during this year’s election were engineers Johan Psaila, Daniel Micallef and the

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undersigned, all of whom served on Council in previous years. Last but not least, special thanks go to all nominees who showed interest in serving on Council and encourage them to continue to take an active part in the Chamber’s initiatives aimed at raising the stature of the profession. This year’s annual conference, “Engineering: The backbone of healthcare” was held on the 25th April 2013 at the Grand Hotel Excelsior. The event was opened by the Honourable Dr Edward Zammit Lewis, Parliamentary Secretary for Competitiveness and Economic Growth, on behalf of the Prime Minister. Very often innovation is linked with science. However, an important link in the chain between the two is engineering. Engineers are the proud designers of sophisticated and innovative technologies used by surgeons, doctors and nurses, to make peoples’ lives better, as we saw during this year’s annual conference. Supporting medical equipment and related instruments is very important for correct diagnoses and treatment of diseases. The event was characterised by presentations covering the subject from wide perspectives including the latest oncology treatment equipment providing on-demand radiation, deep brain stimulation technology, new materials used for prosthesis and many more related topics on state-of-the-art research and innovation taking place both locally and abroad. Some of the presentations will be featured in this issue of Engineering Today. Some others are going to be featured in the next issue. During the closing ceremony of the conference, the Chamber signed collaboration agreements with Bank of Valletta and Citadel Insurance. It

is very encouraging for the Chamber to form alliances with such prestigious organisations. All parties stand to gain and augment respect in their respective operating communities. Chamber members will be benefitting directly from special packages offered by both organisations. Further details will be announced shortly. Engineering is a wide horizontal discipline that cuts across other sectors. Healthcare is one such application, but there are others including sports, energy, communications, information technology, manufacturing, environment, education, transport and our homes, within which engineering features prominently. This yearâ&#x20AC;&#x2122;s conference was a successful attempt to illustrate how engineering is the backbone of healthcare. In the years to come, I hope that there will be other similar opportunities to demonstrate the value of engineering in other sectors. The Chamber is looking forward to participate and contribute to the celebration of the 50th anniversary of the launch of the first engineering degree in Malta. We feel that this is of utmost importance for a number of reasons. One of the factors that is crucial for the sustained development of the profession, is the academic formation of students to become future engineers. The body of practicing engineers, consultants and researchers regulated by professional ethics, form the main working force of the engineering profession which drives technology. The third factor is the participation of engineers in management who lead organisations and have an active part in the strategic direction of organisations. This role has a significant bearing on safeguarding the future of the profession.

Two weeks ago the Executive Council met Honourable Minister Joe Mizzi, whose portfolio includes the Engineering Board. During the courtesy visit at his parliament office in Valletta, a number of issues were briefly discussed in a cordial atmosphere. One of the matters raised during the meeting was the possible participation of the Chamber in the Engineering Board, which has not yet been constituted following the change in government. So long as we continue to find our membersâ&#x20AC;&#x2122; support, the Executive Council will continue to dedicate its time and effort voluntarily for the benefit of the profession. Those members who would like to assist us in achieving this mission, are encouraged to come forth with new ideas for consideration. Please send us your feedback on info@coe.org.mt on anything you would like to see happening at the Chamber. We wish our engineering student members good luck in their examinations. ET 5th May 2013 Yours Sincerely,

Ing. Saviour M. Baldacchino

president@coe.org.mt - www.coe.org.mt

Ing. Saviour Baldacchino President, Chamber of Engineers

May 2013

Issue No. 45

BOV CARDS LOYALTY REWARDS PROGRAMME

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BOV’s Ongoing Green Initiatives The Bank of Valletta is offering an exclusive package for COE members as part of the partnership agreement with the Chamber. However, BOV’s activities are not restricted to banking, as John Paul Abela, Manager, Media and Community Relations, explains. By conducting environmental reviews of

this initiative, the environment stands to

its current operations and taking tangible

gain substantially. The Bank will double the

action, Bank of Valletta wants to lead by

amount of PV panels on the BOV buildings

example.

in the coming years.

Last year Bank of Valletta appointed an

The Bank also installed a communication

Environment Manager, Mark Marmara,

hub known as WebBox for the solar panels

specifically to focus on “Green Initiatives”

to constantly monitor the panels’ output to

and

environmental

ensure maximum efficiency with a view to

opportunities to ensure that the Bank’s

launch

new

increase the number of panels in its bid to

investment minimises the Bank’s carbon

become carbon neutral.

footprint.

Besides sprearheading the planting of over 850 trees around the islands, over 200,000

By end of this year, the Bank is aiming to

printed statements were avoided as the

It is not enough to teach customers about

reduce its energy consumption by a fifth

use of internet banking continued to grow

their environmental responsibilities and

through a combination of PV panels and

among customers.

promote ‘green initiatives’ if, on the other

more energy-saving air-conditioning units,

hand, the organisation itself does not

more efficient lighting and changes to

Bank of Valletta has also appointed 60

pursue a stringent policy to that effect.

its IT systems. The reduction of 700 light

staff members as green leaders, who have

fittings at the Bank’s head office and the

the responsibility to act as ambassadors

It is for this purpose that the Bank has

installation of motion-sensitive lighting

to promote an environmentally-friendly

drawn up a roadmap to direct its impact

in less frequented areas will save some

culture, complementing the Bank’s ongoing

on the environment and it is committed to

55,000kg of CO2 emissions.

green initiatives. They will identify bank

treading carefully along this ‘green’ path.

practices which can become greener and The Bank has also embarked on a server and

also encourage the staff and customers

The Bank has embarked on a large-scale

storage consolidation exercise as well as

to contribute towards reducing waste and

carpeting of the roof space of some of its

an investment in virtualisation technology

energy saving.

branches with photovoltaic cells to generate

which has brought power and cooling costs

120,000 units of electricity.

down by 30 per cent, helping to reduce the

BOV has also sponsored a number of

Bank’s carbon footprint.

environmental initiatives aimed at the

The

exercise

started

off

with

environmental education of the community.

comprehensive study of all branches to see

Throughout last year, BOV also worked

Over 7,000 trees were planted at St Aloysius

where it was feasible and efficient to install

hard to enhance its green credentials in

College with the help of the bank. This

the panels, taking into account surrounding

the community. For example, it continued

project, now in its 7th year, engages

buildings that could have masked direct

to promote its ECO personal loan. This

students in the whole process from making

sunlight. It was concluded that some of

product encourages customers to opt for

their own compost to re-potting the plants.

the buildings cannot house these devices

more eco-friendly equipment making this

because they are dwarfed between higher

ideal solution for customers who invest in

Through

buildings or are in complete shade.

anything which will reduce the negative

proven that it is serious about being eco-

these

initiatives,

BOV

has

environmental impact. On the same lines,

effective, managing its direct impact on the

Phase 1 of this project included the

BOV joined forces with the Chamber for

environment, as well as addressing some

installation of circa 300 PV panels in 16

Small and Medium Entreprises - GRTU to

of the environmental impacts generated

branches. This has saved 104,000kg of CO2

unveil an interest-free loan that customers

by those using its service and as a result

emissions. When one takes in consideration

could use to finance solar and sun-powered

contributing to a reduction of Malta’s

that one tree absorbs 7.05kg of CO2 per

water heaters.

environmental deficit.

year, it is immediately apparent that through

Engineering Material Challenges for Human Joint Replacements

by Prof. Peter A Dearnley

More than 50,000 patients per year receive total joint replacement in the UK. 1. Introduction This paper provides a brief overview of the current status of materials used in human joint replacements and indicates there is a clear need for advanced surface engineered alternatives to increase the durability of bearing and the Trunnion/Morse taper surfaces that presently undermine the success rate of present day modular designs.

were until circa 2000 made from the austenitic stainless steel Ortron 90 (an Fe-20Cr-10Ni2.5Mo-0.4N alloy) [3].

2. Discussion More than 50,000 patients per year receive total joint replacements in the UK [1, 2]. Such surgical procedures provide alleviation from the debilitating pain caused by the advanced stages of osteoarthritis. These remarkable clinical procedures were originally made possible through the pioneering work on total hip replacements (THRs) carried out by Sir John Charnley during the 1960s. This success led to developments in total knee replacements (TKRs) and other joint replacement devices. Basic designs of THR and TKR mobile joints are shown in Fig 1. The femoral components for both devices are frequently made from special metallic alloys, typically cast or wrought CoCr-Mo alloys [3] or more recently in the USA from oxygen diffusion hardened Zr-2.5Nb alloy [4, 5] (with the proprietary name “Oxinium”). The counterface bearing for both is typically manufactured from ultra-high-molecularweight-polyethylene (UHMWPE), which is frequently nowadays given extra wear durability by stimulating cross-linking via irradiation. Additionally, femoral components for THRs can be made from Alumina [3] or Zirconium Toughened Alumina, but these are not practical for TKRs since they are prohibitively costly to make in such relatively large sizes. Due to cost constraints in the UK, femoral THR components

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Issue No. 45

Figure 1 – Depiction of the main components of popular TJRs

Although very successful, there are various factors that limit the lifetime use of total joint replacements. Of most concern to the implant manufacturer is the susceptibility or not of the bearing surfaces to the production of particulate debris and/or the release (solution) of metal ions into surrounding tissues. Both effects have been linked to the formation of pseudotumours (causing pain) and the loss of bone stock (due to bone cell death – via Osteolysis). The latter leads to aseptic implant loosening which requires prompt revision surgery. The examination of worn joint replacements (explants) reveals evidence of multiple direction scratching of metallic bearing surfaces [6] in-vivo (Fig 2a). Associated with the scratch grooves are protruding scratch ‘lips’ that cause considerable plastic deformation of the apposing UHMWPE counter surfaces, via microasperity cutting and shearing which creates a significant source of particulate debris. Many of the metallic scratch lips become sheared

off [7] and contribute to the overall volume of wear debris that collects in tissue surrounding the implant. Metal ion solution also takes place evidenced by raised ion concentrations in the human body following surgical implantation of THR and TKR devices. Ceramic bearing materials based on Al2O3 or Zirconia toughened alumina suffer less intense scratching and result in less wear debris and ion dissolution into surrounding body tissues. A view of another Co-Cr-Mo femoral head bearing surface (after 20 years use in the body – “in-vivo”) is shown in Fig 2b. Here, the surface has been severely damaged at some point – possibly by a surgical instrument, by bone fragments or bone cement. It is important to note that at some point during use, some of the mechanical damage has become removed by a polishing action, whereas, in this example, the metal carbides contained in the Co-Cr-Mo alloy matrix, have become lightly etched (Fig 2b). Both features are indicative of material being removed via anodic dissolution/corrosion releasing potentially “toxic” metal (Co and Cr) ions into the surrounding anatomy of the body.

Figure 2 – Scanning electron microscope images of bearing surfaces: (a) micro-abrasion scratching of Co-Cr femoral head after 15 years; (b) “polishing” of a prior scratch region, caused by dissolution of cobalt and chromium ions, after 20 years of implantation

Given the highlighted problems of mechanical and chemical degradation actions of joint replacement bearing surfaces it seems possible to improve performance though “Surface Engineering”. In principle surfaces can be made more resistant to scratch damage by making them harder; to make them more resistant to metal dissolution they could also be made less chemically active. This idea began to be explored in the past 30 years. From such work, important lessons can be learnt how to evolve a better materials design. TiN coated Ti-6Al4V femoral heads for THRs was the subject of an early (1992) patent application by Pappas [8] and there are 2 reports on the surface condition of similar TiN coated components retrieved (removed) after several years human implantation (Harmen et al [9], Raimondi and Pietrabiss [10]). Here coating delamination, via localised fracture along the coating-substrate interface was evident. In later work, Taeger et al [11] reported an SEM examination of diamondlike-carbon (DLC) coated Ti-6Al-4V femoral heads recovered from several active patients who had begun to experience problems. A number of the used DLC coated femoral head components (feature “A” in Fig 1a) showed numerous circular patches caused by a very localised coating removal. It has since been shown that these features are attributable to in-vivo blistering of the DLC coating, initiated by corrosion at the coating-substrate interface (via “pin-hole” defects in the coating), which is followed by mechanical removal of the blister “caps” during sliding contact (during joint articulation) with the femoral cup component (feature “B” in Fig 1b). Such combined actions of corrosion and wear are termed corrosionwear or sometimes tribo-corrosion and have been reproduced successfully in laboratory experiments In fact there are three important basic types [12] of corrosion-wear mechanism relevant to TJRs (total joint replacements):

May 2013

Issue No. 45

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Engineering Material Challenges for Human Joint Replacements (cont.)

• Type I: The removal of the coating passive film during sliding contact and its subsequent regeneration. • Type II: corrosion attack of the substrate leading to blistering and removal of the blister cap during sliding contact (as initially discussed above). • Type III: Galvanic attack of the bearing surface, causing it to roughen and subsequently abrade any apposing surface with which it makes contact – not discussed here but a potential threat to the durability of some bio-medical joint designs. Type I corrosion-wear is pervasive in most joint replacement bearing surfaces, and is probably responsible for the polishing effect observed in the uncoated Co-Cr-Mo explant shown in Fig 2b. This enables the release of metal ions into the recipient’s blood stream. This effect has recently been linked to the formation of pseudo-tumours in anatomical regions adjacent the joint replacement, which cause intense pain and necessitate removal and revision of the TJR. Recently, the latter effect has also been argued [13] to be additionally caused by micro-metre motion between the internal surface of metallic modular femoral head components (the ball – “A” in Fig 1a) surface and the metallic partner trunion surface of the neck/stem component to which it is connected. Type II corrosion-wear of DLC coated femoral head components (above) could be moderated by doping them with up to 3 at.% Si, according to the laboratory tests conducted by Kim et al [14]. It should be noted, however, that at the time of writing, very few non-doped DLC coated implant materials remain in clinical use. It is a matter of surmise that such devices have not been successful enough to warrant their further use.

A clinically, more successful surface engineered material design is that of oxygen diffusion hardened Zr-2.5 Nb [15, 16] – which has been given the proprietary name of “Oxinium”. Human implantation of knee joint replacement components made of this material commenced in circa 1995, and increased markedly (in North America) between 2000 and 2010. Given its comparative newness, it is only recently that reports of used oxinium components (explants) have appeared in academic literature. Heyes et al [15] report a reduced incidence of scratching, of the condyle bearing surfaces compared to uncoated Co-Cr alloy components, used for similar time intervals. Significantly, however, they reported pitting of the condylar surfaces of six retrieved ODH Zr-2.5 Nb TKR femoral components, whereas no pitting was observed in another 9 explants. The latter were smoothly worn, indicative of micro-abrasion, whilst the micro-pitting suggests Type II corrosion-wear (enabling some Zr metal ion release to take place). The work of Heyes et al, was based on a small cohort of components retrieved after a maximum implantation time of 46 months. Until very recently, there was a resurgence in the use of metal-on-metal (MOM) THRs, using a Co-Cr alloy hade and cup components.. These have also been associated with high levels of metal ion solution in the surrounding body tissues., and the surgical community has begun to withdraw their use. Nevertheless, if other work is to be believed, the use of Co-Ct metal femoral head (ball) components coated with ~8-12 µm thick layers of CrN may have a better future. Laboratory hip joint simulator tests have demonstrated cobalt metal ion release during articulation is at least 7 times lower when using PVD-CrN coated Co-Cr-Mo femoral heads compared to standard uncoated components [1]. This work also indicates that CrN coated Co-Cr-Mo gives better overall performance in terms of wear resistance. To date, no laboratory

May 2013

Issue No. 45

Engineering Material Challenges for Human Joint Replacements (cont.)

test comparisons have been made between CrN coated Co-Cr-Mo and Oxinium treated Zr2.5Nb femoral components. This is essential future work given the widespread use of the latter’s use in the USA and Canada. 3. Conclusions While it is fair to say that total joint replacements (TJRs) are largely very successful bio-medical engineering devices, a number of bio-medical engineering problems persist at this time: 1. For designs that utilise metal on polymer bearing couples, too much wear debris is created (due to micro-abrasion) that leads to bone cell death and eventual aseptic loosening of the implant; this requires the device to be replaced in the medium to long term (typically after 1015 years). Total hip replacement designs that utilize a modular Co-Cr-Mo femoral head that is mechanically connect to a titanium alloy stem, via a Morse taper, have been recently shown to lead to painful pseudotumour formation, in a relatively high number of individuals, after quite short implantation times (over the initial 5 years of implantation). The latter effect is associated with very high levels of cobalt and chromium metal ions in the tissues that surround the implant. This unacceptable outcome is traumatic for the patient and costly to the health service provider. 2. For ceramic materials, there is a small risk of catastrophic failure due to brittle fracture, particularly in very active patients; such components are also very costly to manufacture, compared to metals and polymers.

Looking ahead to the next 10 to 20 years there are good prospects for advanced surface engineered metals. In clinical use today there is only one joint replacement that utilizes such a material design – thermally oxidized zirconium alloy (Zr-2.5Nb); this has been almost exclusively used in North America where it has displayed favourable outcomes. The disadvantage of these devices is, however, that they remain relatively expensive compared to Co-Cr and stainless steels. It is clear a more cost effective and novel surface engineered equivalent, probably utilizing Co-Cr and/or stainless steel substrates, would prove very attractive for use by the UK and other EC member state health services. To achieve this bio-engineering aim, a series of well funded research projects must be immediately implemented at the National and International level. ET Acknowlegdements The author wishes to thank Professor Wood, Director of the National Centre of Tribology at Southampton for his personal interest and support for this work. References [1] J. Fisher, X. Q. Hu, J. L. Tipper, T. D. Stewart, S. Williams, M. H. Stone, C. Davies, P. Hatto, J. Bolton,M. Riley, C. Hardaker, G. H. Isaac, G. Berry and E. Ingham: J. Eng. Med. (UK), 2002, 216, 219–230. [2] S. Williams, J. L. Tipper, E. Ingham, M. H. Stone and J. Fisher: J. Eng. Med., 2003, 217, 155–163. [3] P. A. Dearnley: Proc. Inst. Mech. Eng., 1999, 213, (H), 107–135.

May 2013

Issue No. 45

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Engineering Material Challenges for Human Joint Replacements (cont.)

[4] J. A. Davidson: ‘Zirconium oxide coated prostheses for wear and corrosion resistance’, US Patent 5037438, 1991. [5] J. A. Davidson “Ceramic Coatings for Orthopaedic Bearing Surfaces” in Ceramics in Substitutive and Reconstructive Surgery, P. Vincenzini (Editor), Elsevier Science Publishers BV, 1991, pp 157-166. [6] K. L. Dahm, I. Anderson and P. A. Dearnley: Surf. Eng., 1995, 11, (2), 138–144. [7] H. Minakawa, M. Stone, B. Wroblewski and J. Fisher, Journal of Bone and Joint Surgery (British volume) 80 (5) 894-899, 1998. [8] M. J. Pappas and F. F. Buechel: ‘Prosthesis with biologically inert wear resistant surface’, European Patent Application EP 0573694 A2, 1992. [9] M. K. Harman, S. A. Banks and W. A. Hodge: J. Arthoplasty, 1997, 12, 838–845.

[12] P. A. Dearnley and G. Aldrich-Smith: “Corrosion-wear mechanisms of hard coated austenitic 316L stainless steels Wear, 256/5 (2004) 491-499. [13] R.B. Cook et al, “Pseudotumour formation due to tribocorrosion” The Journal of Arthroplasty (2013), published on-line, Elsevier, 2013. [14] J-G Kim, K-R Lee, S-J Yang “Wear corrosion performance of Si-DLC coatings on Ti-6Al-4V” Journal of Biomedical Materials Research 86A, pp41-47, 2008. [15] C. D. C Burnell, J-M Brandt. M J Petrak and R B Bourne, “Posterior Condyle Surface Damage on Retrieved Femoral Knee Components” The Journal of Arthroplasty, (2012), published online, Elsevier, 2012. [16] T J Heyse, D X Chen and N. Kelly, “Matchedpair total knee arthroplasty retrieval analysis: Oxidized Zirconium vs. CoCrMo” THE KNEE 18 (6) 448-452, 2011.

[10] M. T. Raimondi and R. Pietrabissa: Biomaterials, 2000, 21, 907–913. [11] G. Taeger et al., “Comparison of diamond like carbon and alumina articulating with polyethylene in total hip arthroplasty”, Mattwiss. U. Werkstofftech., vol. 34, No 12, 2003, 1094-110.

Prof. Peter A Dearnley

National Centre for Advanced Tribology, Engineering Sciences, University of Southampton, United Kingdom

May 2013

Issue No. 45

Technology; the only cure for our healthcare systems

by Simon Attard

Despite the huge advancements in human health during the last century, healthcare systems nowadays face a different set of challenges. Abstract With the help of innovative technological solutions, healthcare can be made cheaper, more efficient and more accurate and safe (yes, currently healthcare is not very safe; pharmaceutical drugs claim more lives than traffic accidents every year). This study presents several innovative technologies which have the potential to help alleviate some of today’s healthcare issues. These technologies can be split into three main categories; i) Innovative Devices, ii) the Internet and iii) Genomics and Data. There are two types of innovative medical devices which will have an impact on the future of healthcare. First, there are wearable sensors which will enable patients to monitor their vital signs continuously throughout the day. Then there are other disruptive medical devices which will offer the functionality of complex medical equipment, at a much cheaper price. Many industries (banking, retail, etc.) have embraced the power of the internet and used it to revolutionise the way they deliver their service. This did not happen in the healthcare industry; but it soon will. There are several companies building websites and mobile apps enabling them to deliver online healthcare services with a difference. Apart from these, there are also social networking sites which are specifically for the medical community and for patients to connect with others who are going through the same experience. Studies show that these web-sites can have a very beneficial psychological impact on patients. DNA sequencing technology has improved significantly since the year 2000, when the first human Genome was sequenced. We have computing machines which can process and

store huge amounts of data in fractions of a second. These advancements in technology will lead to the ability of practicing personalised medicine. This will reduce medical inefficiencies and medical errors significantly. Introduction Over the last few years, we have seen remarkable technological breakthroughs in healthcare. Paralyzed people were given the ability to move an artificial arm using just their thoughts. People who were short of hearing were given the ability to hear again with the help of cochlear implants. We have even arrived to the point where we are able to restore some light in blind people. These are all demonstrations of remarkable engineering skills which are having a huge positive impact on people’s lives. However, these are not the only type of technologies which are needed to help healthcare systems in the challenges they are facing today. The major challenge being faced by healthcare systems today is cost. Almost every country in the world is spending more and more money on healthcare, but it is failing to see much improvement in the health of the public in general. Healthcare systems are offering more services, but the risks and side effects of overtreatment and over-screening are outweighing the benefits. Another problem with modern health systems is their inefficiencies. One reason for inefficient systems is that we focus on treating the sick, rather than on keeping people healthy. This makes me wonder why we call our systems “healthcare systems”, because they are actually sick-care systems! The second reason for healthcare inefficiencies is that we practice population based medicine, rather than personalized medicine i.e. two patients with the

May 2013

Issue No. 45

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Technology; the only cure for our healthcare systems (cont.)

same disease are usually treated in the exact same manner, even though they have different medical history, genetic codes and so on… this is not efficient at all. The third problem with modern healthcare systems is inaccuracy. I am sure some people reading this article had the experience where two different doctors gave them completely different advice for the same medical condition. This is because healthcare can be very inaccurate and sometimes doctors take blind uninformed guesses when it comes to patient care. This is why many compare modern healthcare with the story of the “elephant and the blind men”. Fortunately, healthcare systems will soon have better solutions to tackle these issues. Up to now the medical community has not yet taken advantage of modern digital and wireless technologies and used them to their full potential. With the help of innovative medical devices, with the help of the Internet and with the help of Genomics and Data, healthcare will be made cheaper, more efficient and more accurate and safe. Innovative Devices Currently, many of us use our smart phones to check the news, our emails and our social networks to find out what our friends are up to. It won’t take long before we can look at our phones to check what our body is up to! Today there are many wireless wearable sensors which can monitor vital signs such as cardiac activity, blood pressure, body temperature, body activity, calorie usage, sleep quality, galvanic skin response (stress levels) and so on. The Basis wrist band, shown in Figure 1, is a stylish wearable device, in the form of a wrist watch, which has multiple embedded sensors. It can sense body activity and calorie usage, cardiac activity, body temperature, galvanic skin

response and sleep quality. When you combine all this data together, you have very informative insights on your body and your health. The strength of this device is its accompanying software which is capable to display the data in an easily understandable format. It shows a person’s daily habits, what he is doing well and what needs to be improved. Another similar device called LarkLife, can give real time advice to the user on his smartphone. For example if it detects that the user did not have enough sleep, it will suggest the user to eat a protein fuelled breakfast, so that he has enough energy to keep him going through the day. That is very helpful. It is like having a virtual personal fitness assistant available 24 hours a day.

(a)

(b)

Figure 1. (a) The Basis wrist band; (b) The LarkLife wrist band Being healthy is not just about monitoring your vital signs. The team behind a product called LUMOback wanted to tackle lower back pain problems which are becoming increasingly common. They designed a sleek device which is worn on the lower back underneath the clothes and which can detect bad body posture. As soon as it detects that the user is slouching, it will vibrate to remind him to sit in a good posture. Diabetes is a major chronic condition which affects the lives of millions of people. People who suffer from this condition need to sample

May 2013

Issue No. 45

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Technology; the only cure for our healthcare systems (cont.)

their blood glucose levels regularly by pinching their fingers to draw small samples of blood. This is a very inconvenient process, and thus most diabetics end up not doing it frequently enough. Fortunately, continuous glucose monitors are becoming more common. These consist of a small device which is worn on the body and an external device which acts as a display of the glucose value. In the very near future, the external device wonâ&#x20AC;&#x2122;t be needed because glucose levels will be displayed on smart phones. Being able to monitor glucose levels in real time will allow diabetics to control better their blood glucose and to adjust their lifestyle accordingly. The Piix ECG monitor is a small device which can monitor cardiac rhythm for up to seven days, without the need for the patients to visit the hospital. This device will transmit all the data to the cloud, so that a physician can review it from anywhere he wants. As you can see from Figure 2, the Piix ECG monitor is a much more comfortable solution than the Holter monitor which is usually used for ECG monitoring. It is also better because a patient can put it on himself, and does not need to visit a doctor.

(a)

doctors can now keep an ultrasound device in their pockets so that they can use them whenever they want. Doctors might not be walking around with stethoscopes anymore. They would use one of these pocket-sized devices to look into their patients, not just listen to their sounds! The device in Figure 3(b) is a smartphone based ECG recorder. It comes in the form of an iPhone cover, with two electrodes at the back. Patients who suffer from short episodes of cardiac pain usually have to be monitored for a long time, just to detect the ECG signal during the actual pain. With this device, the patient can record his ECG immediately as soon as he feels the pain. This is much more convenient and less expensive both for the patient and for the caregiver.

(a)

(b)

Figure 2. (a) A conventional Holter monitor; (b) An innovative wireless ECG monitor by Corventis Innovative healthcare devices do not only include wearable sensors. The device in Figure 3(a) is a smartphone-based ultra sound device. This device shows the direction medical technology is taking. Instead of being an expensive complex machine in a hospital,

Figure 3. (a) A smartphone-based ultrasound device; (b) A smartphonebased ECG monitor The last smartphone-based device to be described is a urine analyser. This is called uCheck. A patient dips a test strip in urine. The test strip changes colour according to the contents of the urine. Then, instead of having to go to a doctor to look at the test strip, the patient takes a photo of the test strip and the

May 2013

Issue No. 45

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Technology; the only cure for our healthcare systems (cont.)

iPhone application will automatically do the diagnosis. This is much more convenient and cheap for the patient because the test strips cost a few cents and the iPhone application costs just $1. An important point to mention is that except for the smartphone based ultrasound, all the other devices are targeted to be used directly by the patients away from hospitals and without much involvement from medical professionals. This is in fact what innovative health technology is all about. It empowers the patients and enables them to take better care of their own health. The Internet The internet has disrupted several industries such as banking, retail, entertainment, education and so on. This has not yet happened in the healthcare industry. Since the inception of the Internet, healthcare service delivery has remained relatively the same. Nowadays we can find several websites which offer very accurate health information. The most popular is called WebMD. This website alone gets over 80 million unique monthly visitors. This shows that people do search for medical information online. Websites like WebMD are controlled by medical professionals so the information they provide can be considered as reliable. Also, all information is available for free. Another website, called Health Tap offers a platform where anyone can ask online questions to medical professionals. Every question and answer is posted publicly and doctors receive ratings based on the answers they provide. This means that doctors have to be very careful about the quality of their answers, otherwise their reputation will suffer. This ensures that all the information available on the website is reliable and accurate. Apart from websites which offer free medical knowledge and information, there are other

companies which are offering online health services for their users. Sherpaa.com is a website which offers a pool of medical professionals who are available 24/7 and who are ready to assist the users immediately when they need assistance. For just a small annual fee, users can rest assured that when they need medical assistance, it is just an email or a call away. They offer many types of assistance such as medical advice, medication prescription and patient referral to more advanced treatment. DirectDermatology.com uses a similar concept but it is only focused on dermatological problems. People who have dermatological issues can take a picture of their infected area using their smartphone and send it to a dermatologist on this site. A certified dermatologist will then diagnose the patient and offer assistance by giving advice, prescribe some medication or arranging a proper clinical visit if the issue is serious. Nowadays, one cannot talk about the internet without mentioning online social networking. Fortunately, this modern obsession is playing its role in healthcare as well. There are several online social networks which are purposely built for patients. They allow patients to communicate with others who are experiencing the same symptoms and who are going through the same difficult experience. These platforms allow patients to share their experiences together and this has a very positive psychological impact. Also, patients can share together useful tips, so these social networks act as unofficial data hubs! In my opinion, every modern medical practitioner should advice his/her patients to subscribe to one of these social networks, because they are very beneficial and above all, they are free! Genomics and Data Many refer to genomics as the art of â&#x20AC;&#x153;digitising humansâ&#x20AC;?. This is because in gene sequencing,

May 2013

Issue No. 45

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Technology; the only cure for our healthcare systems (cont.)

all characteristics of a human body are encoded in a very complex combination of four letters; A, C, G and T. By sequencing a patient’s genome, one gets a lot of information about that particular patient. This enables better practice of personalized medicine and better prediction of disease risk and treatment response. The first ever human DNA sequence was published in the year 2000. This process took 10 years, with multiple labs working together and the cost was billions of US dollars. In 2008, a company called Knome was offering DNA sequencing services for $250,000. The price dropped to $100,000 in less than a year. Today, we are fast approaching the “$1000 genome”. Currently one can get full DNA sequencing for around $6000. Apart from that, a US company called 23AndMe is offering personal genotyping (a simplified form of gene sequencing) for $100! The way this company works is very effective. After you create an online account with this company, they send you a small box by post which contains a small container as shown in Figure 4 (a). You put some saliva into the container and send it back. After a few days, you can log into your account again and you can see all your genotyped information. The information they provide is mainly related to the person’s disease risk, carrier status and drug response. Another company called Oxford Nanopore Technologies, is taking genomics to a new level by building a USB powered genome sequencer shown in Figure 4 (b). This device will cost less than $1000 and will be able to sequence about 150 million base pairs in just 6 hours. Clearly, DNA sequencing technology is improving at a very fast rate. However DNA sequencing and genomics would not be useful at all if we are not capable of storing and processing large amounts of data quickly and efficiently. Nowadays computing power has reached a remarkable level but we still have not seen the medical community take advantage of this.

(a)

(b)

Figure 4. (a) 23AndMe personal genome test kit; (b) MinION USB powered DNA sequencer Medical information can take lots of formats; genomic data, medical images, data from wearable sensors and so on. At the moment, it is almost impossible for a caregiver to consume all this information and use it to make informed decisions. We need Artificially Intelligent (AI) systems which are capable of consuming large amounts of data and present it in a summarized, simplified and easy-to-understand format. These systems would then help care-givers in making better and more informed decisions about their patients. Some of you might think that these types of systems are something which will happen in the distant future. However, the IBM Watson supercomputer is already being used to help diagnose and offer treatment advice to patients with lung cancer. This system uses information supplied about the patient as well as literature

May 2013

Issue No. 45

The PV Market in Malta INTERVIEW Andrea Bozzetto

Key Account Manager at Conergy, Italia

1. What are your thoughts on the PV market in Malta, particularly the commercial side? Malta has blooming potential for solar development. Although it is unfortunate that this development seems to have only just begun, I suspect that the market will develop at a very fast rate. The fact that Germany and Italy account for nearly 60% of global market growth is unsustainable so markets like Malta will become very important for the rest of Europe. Obviously, this strongly depends on government policies which are inevitable influencers.

Thanks to ElectroFix, during the meeting I had the opportunity to demonstrate Conergy’s full range of products for highperformance solar solutions. I was able to illustrate very well how our products work, their high-level and the significant strengths.

3. What can you tell us about Solar Farms in general and how these would benefit Malta? Solar farms (Photovoltaic plants) are becoming increasingly inexpensive. In contrast, the prices for electricity from conventional power plants are rocketing all around the world, especially in Europe.

I believe Malta will find that renewable energy, particularly the PV market, will play a significant part in its economy in general. With the proper policy in place, market development and continuous industry innovation, the PV market should mark a remarkable growth rate over the short-, medium- and long term.

This is making the solar farm market segment progressively more lucrative for financially strong investors, but also a strong investment for everyone and anyone who wants to save money on their electricity bill. Photovoltaic plants, definitely offer a profitable, long-term investment with comparatively low risk.

2. What response did you receive from Maltese engineers present at the Malta Group of Professional Engineers meeting?

In Malta’s case, solar farms may be an investors dream with ample sun and the need to increase renewable energy production due to EU requirements.

Once the engineers understood that Conergy is a bankable PV panel manufacturer rated in Tier 1* by Bloomberg and that investing in Conergy systems is strongly matched to investing in Apple’s shares on the international stock exchange, their interest was increasingly positive.

4. What future do you see for Conergy in Malta?

A PV, whether for residential or commercial use, is an investment for which the engineer is highly responsible. Conergy never compromise quality; each component, type of material, supplier is carefully checked. Consistent quality is never achieved by chance, and it is for this reason that we gain engineers’ trust.

Additionally I also see Malta as a potential hub for the Mediterranean and North African region. There is a niche market that definitely could provide expertise and support services in this field to larger markets in this region. Andrea Bozzetto is Key Account Manager at Conergy, Italia. He manages B2B international sales and B2C negotiations, giving technical as well as commercial support to all the dealers, agents etc. etc. His role involves strategic planning, relationship management and negotiations, leadership and innovative development of opportunities. Additionally, Andrea identifies new potential clients. ElectroFix are the sole authorized Conergy distributors in Malta. ElectroFix has established itself as one of the leaders in the energy efficiency market in Malta, handling installations in some of the largest private enterprises as well as government organizations on the Island. *Tier 1: highest ranking for financial security & investments and superior product quality.

I definitely see a bright future for Conergy in Malta, which understandably must be paired with a stable market environment, achieved only if a long-term support scheme is put in place to allow a sustainable and competitive development of the local market. Through ElectroFix, Conergy’s authorized distributor, Conergy’s name has already been well established in Malta. Conergy panels have been used for important projects, not only because of its superior quality, but because it is the most suited panel for Malta’s Mediterranean climate.

Debbie Schembri, Director, ElectroFix Ltd. and Andrea Bozzetto, Key Account Manager, Conergy, Italy at the Malta Group of Professional Engineers meeting

ElectroFix Ltd. Valletta Road, Qormi Tel: 21675353 Email: engineering@electrofixenergy.com

www.electrofixenergy.com

Technology; the only cure for our healthcare systems (cont.)

and data which is found on the internet to arrive at conclusions about lung cancer diagnosis and treatments. An article which was published a few weeks ago on Wired magazine states that â&#x20AC;&#x153;Watson is better than humans at diagnosing cancerâ&#x20AC;?. Conclusion I hope that after reading this article you are convinced that technology has the potential to positively impact healthcare. The main role of engineers in the future of healthcare is to provide practical solutions to the challenges that are currently being faced by this sector. We have arrived at a point where technological solutions are as important as medical solutions in healthcare. In Malta we are very fortunate to have a very compact healthcare system. I believe that we have the potential to be leaders in adopting innovative health technology solutions. In my opinion these are three areas which we need to

invest in first, we need to make use of wearable technologies which help educate our people and motivate them to stay healthy. Prevention is better than cure. Second, with the current bed-shortage crisis in our hospitals, we should start to make use of remote patient monitoring technologies so that some patients can be monitored remotely while they are at home, rather than having to stay in hospital. Thirdly, we need better technology to help us store, share and process medical data. This makes medical processes much more efficient and accurate. We have very good engineering talent in Malta. I believe that with the right investments from the government and from private companies, we can make the Maltese healthcare system more cost effective, more efficient and more accurate and safe! ET Please contact the author on: contact@simonattard.com

Simon Attard

BEng Hons (University of Malta), MSc Biomed. Eng. (Imperial College London)

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Issue No. 45

Engineering, The Backbone of Healthcare Parliamentary Secretary Dr. Edward Zammit Lewis makes the introductory address

The event was hosted by television presenter Stephanie Spiteri, shown here discussing a point with Simon Attard regarding biomedical gadgets Chamber president Ing. Saviour Baldacchino welcomes the participants

Radiotherapy is now faster and safer, according to Joannis Pantalos

Dr. Zdenka Sant describes her work on thoraco-lumbar spinal implants

Ms. Damaris Lofaro describes how Deep Brain Stimulation can change the life of a person afflicted with neurological movement disorders

Andrew Falzon, who was diagnosed with early onset Parkinsonâ&#x20AC;&#x2122;s disease at the age of 24, demonstrates how a deep brain stimulation implant has cured many of his symptoms

Prof. Peter A Dearnley speaks about human joint replacement materials

Former president Alex Galea explains a point during the break

Ing. Carl Azzopardi describes how to analyse the results of Capsule Endoscopy

Ms. Marcelle Abela and Dr. Daniel Micallef worked hard to make the Conference a success

Dr. Tracy Camilleri explains how sleep EEG patterns are analysed

Ing. Stefania Cristina explains the secrets of communicating by eye gaze

Prof. Paul Micallef asks a question

Ms. May Agius describes a case study on the use of Assistive Technology for persons with learning difficulties

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Engineering the Brain Deep Brain Stimulation

by Damaris Lofaro

The brain may be viewed as the CPU of the body. Abstract The brain's functions are essential to life and cannot be substituted. It does fail, and when it does, mortality usually draws near. In view of this, ongoing research attempts to find ways of overcoming the debilitating conditions associated with disorders that stem from the brain. 2012 marked the 25th anniversary of the birth of modern Deep Brain Stimulation (DBS). DBS is the application of high frequency stimulation to a very defined area of the brain. Implantable electrical devices supply the required electrical energy which is applied via very thin electrodes implanted within the brain. Nowadays, DBS is an established and effective treatment for movement disorders like Parkinson’s Disease (PD), Essential Tremor (ET) and Dystonia. It has a proven safety profile and is well-tolerated in the long-term. The therapy is completely reversible and does not have any side effects normally associated with pharmaceuticals. Treatment with DBS significantly improves quality of life for patients and their caregivers. This paper will first give a brief overview of the history of DBS, followed by a general description of how DBS is performed in Malta, the effect of DBS and its applications. Finally, a patient’s experience is recounted which clearly illustrates how this groundbreaking technology changed his life.

organ. On these lines, electrical stimulation has been used since ancient times to interact with the nervous system. In the 19th Century, peripheral applications of electrical current had become common for anesthesia (pain relief) and a variety of medical ailments. In 1887, the first electrocorticography for epilepsy was performed. Horsley performed cortical ablations of the pyramidal system for movement disorders. Another signification contribution was that by Meyers who was the first who tested lesions of the basal ganglia to alleviate movement disorders in 1939. Until the 1950’s, lesioning (causing scars in otherwise intact tissue) was the common practice. 1947 was revolutionary for neuroscience as Spiegel developed a rudimentary stereotactic frame. As early as 1951, electrical stimulation was used to determine the proximity of vital structures and thereby avoid them whilst creating stereotactic lesions. In the late 1950’s, there was an explosion of stereotactic functional neurosurgery. In the following decade, DBS was conceived and the drug Levo-dopa discovered. By the early 1970s, there were reports of chronic deep brain stimulation (DBS) systems implanted into the thalamus for chronic pain. Medtronic (Minneapolis, MN) established its Neurological Division Division in 1976, focusing on device development for DBS to treat chronic pain. Studies led to the approval of Medtronic’s Activa system for thalamic DBS for essential tremor and tremor related to PD in 1997.

History of DBS Neurostimulation is the fruit of decades of both technical and scientific advances in the field of basic neuroscience and functional neurosurgery. The first major steps in such progress were the realizations that the brain is in fact an electrical

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Issue No. 45

In 1987, the discovery by Benabid that highfrequency deep brain stimulation was able to mimic, in a reversible and adjustable manner, the effects of ablation of functional targets, revived functional neurosurgery for movement disorders. Initially, Benabid et al treated

tremor with DBS of the ventral intermediate nucleus (Vim) of the thalamus. The subsequent extension of DBS to the subthalamic nucleus (STN), demonstrating its efficacy on virtually all symptoms of advanced Parkinson’s disease, sparked an era of intense clinical and research activity, eventually transcending PD and movement disorders to encompass mood and mind. Due to the superior safety of GPi and Vim DBS over pallidotomy and thalamotomy, there has been a gradual abandonment of lesional techniques in favor of DBS (Figure 1).

The central surgical technique is called stereotaxis, a method useful for very precisely approaching deep brain targets though a small skull opening. For stereotactic surgery, a rigid MRI proof frame is attached to the patient’s head just before surgery (Figure 3), after the skin is anesthetized with local anesthetic.

Figure 1 - DBS target sites for movement disorders DBS Implant Procedure Several surgical methods are available. Below is an outline of how a procedure is typically carried out locally (Figure 2).

Figure 2 - DBS Implant Procedure

Figure 3 – Leksell Multi-purpose Arc permits full flexibility in terms of access to all intracranial targets A brain imaging MRI study is then obtained with the frame in place. The images of the brain and frame are used to calculate the position of the desired brain target. This information is transferred onto a planning system, where the target coordinates are calculated on a computer. The patient is then taken to the operating room where the arc is mounted on the frame still attached to the patient’s head in the original position. The electrode is inserted through a targeting channel mounted on the arc. After

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Call 144 WWW.BUSINESSFIRST.COM.MT

Engineering the Brain - Deep Brain Stimulation

the correct target site is confirmed with a second MRI, the permanent DBS electrode is anchored to the skull with a plastic cap, and the scalp is closed with sutures. The stereotactic headframe is removed. At the end, the pulse generator is then placed in a pocket fashioned on the chest wall whilst the connector wires are tunneled between the brain electrode and the pulse generator unit. The pulse generator can then be programmed externally via a portable PDA-like programmer (Figure 4) that allows the doctor to alter the amplitude, pulse width and rate of the electrical stimulation to find the right parameters for each patient whilst conserving as much battery capacity as possible. Patients may also be given limited control over their stimulation via a hand-held patient programmer.

What does DBS do? The exact mechanism by which the constant frequency stimulation pulse affects nearby brain cells has not been yet determined. The mechanisms could be the inhibition of the cell firing, the excitation of cells and surely of fibers, the possible retrograde activation of other neural structures, which would in turn inhibit the primary target. This could be a jamming, confusing the neuronal message and making it not transferable, particularly when it is abnormal and leading to symptoms. It could be also at the synaptic level â&#x20AC;&#x201C; the exhaustion of the neurotransmitters availability leading to a functional inhibition The idea of jamming is to produce a flow of information that does not convey any valid semantic message, which does not further allow the network to trigger an action, making it unable to transfer further information. Neurotransmitter depletion at the level of the synapse is also an intermediate mechanism able to produce a functional inhibition following the excitation of neural elements, even at high frequency. Applications of DBS DBS is used most widely to treat Movement Disorders. Movement Disorders are neurological conditions characterized by too much or too little movement, beyond the control of the sufferer.

Figure 4 - Doctor using a DBS programmer to set the right parameters on the DBS implant

Parkinsonâ&#x20AC;&#x2122;s Disease is the most widely known movement disorder, Essential Tremor is the most common, whilst Dystonia is the third most common movement disorders, and can be life threatening.

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Engineering the Brain - Deep Brain Stimulation

Parkinson’s disease is a progressive and degenerative disorder. Symptoms are caused by reduced production of Dopamine. The most characteristic symptom of PD is shaking (70%). The most obvious symptoms are movement related – shaking, rigidity and slowness of movement. Most commonly it affects the elderly, although 15% of patients are diagnosed before the age of 50. Essential Tremor (ET) is also a progressive disease characterized by rhythmic movements produced by involuntary muscle contractions. The typical symptom is a slow tremor affecting hands, head and voice. Average onset is 4050 years with the exact cause being unknown, although half of these patients have a family history of ET. Dystonia is a debilitating movement disorder characterized by involuntary muscle contractions that force the body into abnormal postures. It can affect any part of the body and symptoms may be distributed. Together, PD, ET and Dystonia affect over 3 million people across Europe. Recently, DBS has also been approved for Obsessive Compulsive Disorder (OCD). Progressive movement impairment is a huge burden on patient and caregiver’s quality of life as they can be distressing and disabling. Below, a first-hand experience by a very young Maltese patient who has undergone the first DBS surgery in Malta follows. Andrew Falzon – DBS Patient experience (Figure 5) “I was diagnosed with early onset Parkinson’s disease in 2002 at the age of 24 but had been

living with some annoying symptoms for nearly two years. I carried on normally with my life for as long as possible, I worked as a physical education teacher then as a program animator for an educational foundation. Eventually I had to stop working because it became increasingly difficult to move. Except for when I took Levodopa, I could hardly speak, smiling took effort, breathing was difficult, simply making a cup of tea (on a good day) used to take me three quarters of an hour. On the 18th of July 2011, I underwent surgery and a deep brain stimulator was implanted. Now I can speak, I can walk and I can eat on my own. My overall health has improved immensely, I exercise, socialize and I am a second year student of Gestalt psychotherapy. I plan on furthering my studies abroad and running my own clinic in the future.”

Figure 5 - Consultant Neurosurgeon Mr. Ludvic Zrinzo (right) testing the DBS implant on Mr. Andrew Falzon (left) Conclusion High-freqency stimulation is a surgical tool applicable to an increasing number of targets and diseases, the list of which will depend on technical and scientific advances. The adaptability and reversibility of high-frequency stimulation make it globally safe and allow

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Engineering the Brain - Deep Brain Stimulation

it to be tried in situations that could not be envisioned before. This stresses the careful ethical approach that must underlie any new development in this field. The mechanism of action is not yet clearly understood and may consist of several types of submechanisms from electrophysiology to molecular biology. Its understanding will provide new insights in neurophysiology, as well as in the understanding of the mechanism of some functional disorders. Nanotechnologies will play a prominent role in the evolution of this field, both in solving hardware problems, as well as in opening new horizons, such as deficit compensation. Ethical issues should dominate the theme of brain stimulation, including its availability to all classes of society, particularly in emerging countries. ET References Hariz MI, Zrinzo L: Deep brain stimulation between 1947 and 1987: the untold story. Neurosurg Focus 29 (2): E1 1-7, 2010 Benabid AL: What the future holds for deep brain stimulation. Expert Rev. Med. Devices 4(6): 896-903, 2007 Hariz, MI: Twenty-Five Years of Deep Brain Stimulation: Celebrations and Apprehensions.

Movement Disorders (0): 3-5, 2012 Coffey, RJ: Deep Brain Stimulation Devices:A Brief Technical History and Review. Artif Organs 33(3): 208-220, 2009 Awan RN, Lozano A, Hamani C: Deep brain stimulation: current and future perspectives. Neurosurg Focus 27 (1): E2 1-8, 2009 Blomstedt P, Hariz M: Deep brain stimulation for movement disorders before DBS for movement disorders. Parkinsonism and Related Disorders 16: 429-433, 2010 Collins KL, Lehmann EM, Patil PG: Deep brain stimulation for movement disorders. Neurobiology of Disease 38: 338-345, 2010 Schwalb JM, Hamani C: The History and Future of Deep Brain Stimulation. Neurotherapeutics 5 (1): 3-13 Okun, MS: Deep-Brain Stimulation for Parkinsonâ&#x20AC;&#x2122;s Disease. The New England Journal of Medicine 367: 1529-38, 2012 Liker MA, Won DS. Rao VY, Hua SE: Deep Brain Stimulation: An Evolving Technology. Proceedings of the IEEE 96(7): 1129-41 Zrinzo L. Pitfalls in precision stereotactic surgery. Surg Neurol Int:;3, Suppl S1:53-61,2012

Damaris Lofaro B.Sc. (Hons.), Sales Executive, Technoline Ltd.

May 2013

Issue No. 45

Biomechanics at the Mechanical Engineering Department

by Dr. Zdenka Sant

Biomechanical research is a relatively new area at the Mechanical Engineering department compared to the other traditional engineering fields. Abstract I would like to talk about our first experience and progress in this multidisciplinary area of Bioengineering.

which forms the interface of the intervertebral disc and vertebra. The CT scans of a healthy and degenerated spine were obtained to compare their behaviour. The FEA model of the healthy spinal segment was created from CT scans and the intervertebral disc (IVD) was modeled as a two phase structure. The results were presented at the TRECOP conference. At the present time we are working in collaboration with VUT, Austria where they developed the method how to assign a new material model that corresponds to patient specific bone density recorded on CT scan to existing FE model. Introduction

Figure 1 – USS implant

The work in biomechanics can be carried out either ‘in vivo’ or ‘in vitro’. That means the physical testing in the laboratory or simulation ‘in silica’. The simulation seemed to be the best option that provides the least expensive way to start new research. The computer and FEA software necessary to this approach were available so the task to investigate the biomechanical feedback of a specific implant for thoraco-lumbar spine was the first work done at Mechanical Engineering department. The work on the USS thoraco-lumbar spinal implant was carried out as a part of the research project at BUT, Czech Republic. A new spinal segment was created, a few years later, upon the request from medical community with the aim to obtain additional information about the behaviour of endplates,

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What is biomechanics and how does biomechanics contribute to bioengineering? The word ‘Biomechanics’ originates from Ancient Greek words ‘βίος’ and ‘μηχανική’ meaning ‘life’ and ‘mechanics’. Thus “Biomechanics is the study of the structure and function of biological systems by means of the methods of mechanics.” How does it affect our lives? What has been done here in Malta so far? Starting point is coupled to my former department of Solid Body Mechanics, Mechatronics, and Biomechanics at BUT that obtained a request by orthopaedic specialists to explore, predict, and compare the behaviour of various spinal implants. The analyses have to be carried out for a specific physiological situation to provide the clinicians with comparison of the different implants. There are two major ways how to obtain more information about the implants’ performance. The first one ‘in vivo’ is based on clinical observation and measurements using telemetric external device if possible. The second approach is laboratory testing that is based on the tests carried out on a physical model by means of a test rig, or testing via computational simulation, which is gaining more popularity due to effective way to obtain better insight about the implants’ behaviour in a relatively short time. The major

advantage of this approach is the reusability of models as their mechanical and geometrical properties remain the same so they are suitable for comparative studies. Another advantage lies in the possibility of rapid application of new knowledge to the existing model. Method To run the simulation we need a finite element (FE) model, that is usually created by segmentation of the 3D object, and definition of mechanical properties characterizing the material behaviour, definition of the load simulating the selected physical activity of the object, and definition of kinematic constrains, which control the behaviour of the object. All necessary information acquired from medical doctor must be ‘translated’ into: Geometry model: Creation of the model is the most time-consuming activity during the simulation process. The first model was created from data obtained in form of ‘keypoints’ outlining the surface of vertebra. All researchers simulating different implants had the same data thus the effect of shape and size variation of the vertebra was eliminated.

material consisting of collagen and hydroxyapatite, thus it exhibits non-linear viscoelastic behaviour. The bone tissue exists in the mature bone in two forms. The cortical bone has a highly organized dense architecture while the cancellous bone tissue is less dense with the architecture dependent on the stress trajectories. The bone tissue demonstrates linear behaviour within relatively very small strain up to 2% according to the loading direction. The mechanical properties of bone tissue vary depending on the function of bone as indicated in Wolff’s Law. Model of the material is idealized due to lack of data describing properties of vertebral bone so an isotropic properties represented by Young’s modulus and Poisson’s ratio were assigned to the both models of bone [1]. The model of cortical bone having E = 14.1 GPa was assigned to all external areas of vertebra except of the superior and inferior endplates assuming constant 1 mm thickness of cortical/subchondral bone. The model of material properties of endplates correspondes to mechanical properties of cartilage and subchondral bone. The volume enclosed by the cortical bone was filled with material characterized by E = 160 MPa that corresponds to properties of trabecular bone. The material properties for USS implant were received from the manufacturer of USS implant. Load model: The model of spinal load used for simulation is based on the work by Arjmand & Shirazi, which was published in [2] using values corresponding to the load on vertebra L3. The load is comprised of a normal compressive force, shear force acting in posterior direction, and sagittal flexion moment at the mid-plane of the intervertebral disc.

Figure 2 – First geometry model

Material model: The bone tissue is an inhomogeneous, anisotropic composite

Finite Element model: The FE model was created via free and mapped meshing to obtain suitable mesh. This complex system of bodies with different mesh requires setting the contact pairs so as to allow transfer of loads between

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Biomechanics at the Mechanical Engineering Department (cont.)

the bone and screw, screw and positioning rod, rod and the locking sleeve and between inferior endplate and the bone graft model was possible.

Figure 3 â&#x20AC;&#x201C; Finite element model

Results The analysis of results had two major outcomes in mind. The first objective was controlled by the contracting medical professionals with their interest related to healing process. The second aim of the analysis is stress-strain distibution within the implant, which is primarily interesting for the manufacturer while for the doctor it demonstrates the limit related to physical activity.

Healing process factors: Number of factors that promote fast healing process can be categorised into three groups; the local factors, system factors, and stimulators. Mechanical factors are represented in the first group by mechanical stability and mechanical load, which is translated into the micro-motion factor, and the stress-strain factor at healing site. Stress shielding must be avoided so the loosening of the implant is prevented and the system was stable. The strain in lamellar bone tissue is tolerated up to 2% while the higher level 10-30 % will induce resorption. Our analysis revealed that the strain at the fusion site varies within the desired limit even for situation when the upper torso reaches flexion 650 and load 180N is applied. At the region bone - implant interface the present stress distribution does not provide any indication of under- or overloaded section. The majority of interface area is located between the implant and trabecular bone where the stress might vary according to the micro-structure of bone. Therefore further investigation via sub-modelling on micro-scale level is necessary and the bone properties of a specific patient must be available on microscale level. Stresses developed within the implant: The function of the implant is to stabilise the spine, ensure load transfer from superior to

Figure 4 - Stress distribution at the bone-screw interface position (a) 00- 0N, (b) 650- 180N

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Biomechanics at the Mechanical Engineering Department (cont.)

inferior vertebra, and maintain the mechanical condition for successful fusion. Thus the implant must permit dynamical behaviour of the segment while providing the axial and torsional stability. Stresses developed within the system must be lower than the yield limit 400 MPa. Provided analyses showed stress at the screw opening contact with the rod that reached the yield limit.

the disc and behaviour of endplates. The emergence of new technologies and methods of modeling set another challenge to create multi-scale model. To be able to create model that will capture the behaviour of the segment on different levels, we need more information related to behaviour of the bone on micro- and nano-level, which requires more investment and human resources.

Figure 5 - Stress distribution developed within the implant due to flexion 650 and 180 N load Model second generation

Conclusion

The use of FEA in biomechanics simulation is growing very fast thus the continuation of the presented work requires new model of a spinal segment based on the human vertebra. The first attempt to build a vertebra via laser scan was done by an enthusiastic student from final year as his final project who manage to overcome number of diffculties and delivered model, which had to be smoothened. Unfortunately there was no modelling software available at that time. Later on another student in her final year used the CT scans and created a segment, which is now used and subjected to further work by other students. The new segment includes an intervertebral disc modelled as a two-phase structure with varying material properties so we are able to analyse the load transfer through

The simulation provided more insight about the implantsâ&#x20AC;&#x2122; behaviour but we have to keep in mind that model is not reality and every model is created with assumptions and idealization of very complex structures or behaviours. Thus the results must be interpreted very carefuly. This type of work provides a good oportunity to compare different implants or techniques. To create a predictive model we need to consider the real vertebra with improved material model. At the moment the new segment undergoes updating of the model of bone tissue, which is based on the CT scans. This part of the project is carried out in collaboration with VUT, Austria where the multi-scale bone model was developed and validated. Task to provide more information

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AASK Enterprises Ltd

in Uganda with SOS Malta promoting Development through CSR AASK offered its skills and expertise to improve the living conditions of the poor in Africa as part of its celebrations marking the 10th anniversary from its foundation in 2003. SOS Malta welcomed AASK’s offer and organised our trip to Uganda to work closely with the team on the ground in Jinja during the month of April. Our involvement in SOS Malta’s varied projects was exciting and challenging but the greatest satisfaction was the Ugandan’s appreciation Malta’s contribution to the sustainable development of Jinja.

Our main task was to install the Solar Pump System on the Fish Farm which was entering into the second phase of implementation and to help out in the building, wiring and equipping of the Chicken House. Fish Farming in Uganda is now being introduced as a means to improve household incomes and for nutrition. We were amazed with the potential this project has to help feed many of Uganda’s rural people who live far from main fish markets and routes. Our experience was incredible and it is hard to find words to give

justice to all we gained from working with the people in Jinja. While volunteering we had countless experiences that were very emotional. We saw both happiness and sadness in the eyes of the children and the women – our minds were flooded with such a mix of emotions. We soon realised we are not just Kevin, Darren and Sammy in Malta but in this world and that our life is about exploring, learning and sharing with the people and environment that surround us. Being in Uganda made us realise this and that is why we know we must return.

About Us A.A.S.K Enterprises Ltd (AASK) is one of Malta’s leading turnkey Mechanical and Electrical contractors. It has since its inception grown from a company that deals in domestic plumbing and electrical installation works to a main contractor / turnkey type nature offering a one stop holistic building services approach. AASK today enjoys its share of market within the industrial and commercial projects. AASK also specialises in building management and intelligent systems. AASK Enterprises Ltd - Triq il-Kappillan Mifsud, Hamrun HMR1857 Tel: +(356) 2122 8200 - Email: info@aask.com.mt - Website: www.aask.com.mt

Biomechanics at the Mechanical Engineering Department (cont.)

about the behavior of implant has provided new possibilities of application of engineering techniques on the multidisciplinary field, which is still developing very fast eventhough it has a long history behind. Modelling techniques are applied in various fields of biology, chemistry, and initiative to create a virtual human so the outcome of surgery, physiotherapy, or drug effect can be predicted might be a dream that will come true in a very near future.

with available resources. The new model was created form CT scans obtained from Radiology department with the kind permission of Head of Radiology. All works were done in accordance to regulation and data protection act covered by approval from UREC. ET Reference Langton C. M., Njeh C. F., The Physical Measurement of Bone., IOP Publishing Ltd., 2004, ISBN 0-7503-0838-9 Arjmand N., Shirazi-Adl A., Model and in vivo studies on human trunk load partitioning and stability in isometric forward flexions., J. Biomechanics, 39, 2006

Figure 6 â&#x20AC;&#x201C; Investigation of endplate and intervertebral disc behaviour with different level of degeneration

Novitskaya E., & comp., Anisotropy in the compressive mechanical properties of bovine cortical bone and the mineral and protein constituents., Acta Biomaterialia, Vol.7, Issue 8, pg. 3170-3177 Email: zdenka.sant@um.edu.mt; Tel.: 23403056

Acknowledgements The work would not start without collaborating partner BUT, Czech Republic. The continuation of work by modelling other musculo-skeletal systems is possible thanks to enthusiastic students in their final year and their hard work to deliver their thesis and create the best model

Dr. Zdenka Sant

Mechanical Engineering Department, University of Malta

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Issue No. 45

Authors

Professor Peter Dearnley is a Fellow of the Institute of Materials and a member of the founding team of academics who created the journal Surface Engineering first published in 1995. He served on its Editorial Panel for more than 20 years. Since that time he has held several Fellowships and Lectureships at Cambridge, Auckland, Leeds and most recently Southampton University where he was appointed Visiting Professor in 2011 within the National Centre for Advanced Triboloy His career highlights include: recipient of the 1987 Institute of Materials (London) Pfeil Medal for his work on Metal Machining Tools for Titanium Alloys, Editor of Cutting Tool News, published by Elsevier (1997-2001), Codiscoverer of “S-phase” and the first person to unequivocally corroborate the existence of this material outside Japan (1988) and the first scientist to synthesise novel coating materials for machining titanium alloys (British Patent – 2004). His interests in bio-materials for joint replacements began in Auckland, New Zealand, in 1991 since when he has evaluated the limitations of existing bio-materials and argued for their replacement with novel coated bio-metal variants.

Dr. Inġ. Zdenka SANT nee Krejcarova. Was born in Brno, Czech Republic where she obtained her education M.Sc. and Ph.D. in Mechanical Engineering with specialization in “ Applied Mechanics - Biomechanics”. She started her professional life as a researcher at IBZKG Brno, Czech republic and in 1986 she joined Department of Solid Body Mechanics at Mechanical Engineering Faculty, BUT, Czech republic as a lecturer where she worked till 1994. In 1997 she joined the University of Malta, Dept. of Mechanical Engineering on part-time basis, and full-time in 2001. Her main research area is biomechanics that was introduced to students as an introduction to bioengineering.

Ms. Damaris Lofaro started working for Technoline Ltd. as a Sales Executive in 2004 after 2 years working at St. Luke’s Hospital as a Speech and Language Pathologist. Her work there, had mostly to do with adults following a CVA (Cerebro-Vascular Accident) or MVA (Motor Vehicle Accident) as well as with children with speech and language delays and / or disorders. For the past 9 years, Damaris has focused on expanding her knowledge in Cardiology and Neurology. She has attended several training programmes and conferences which enabled her to introduce new technologies on the local market. Her work focuses mainly on supporting doctors using the devices supplied by Technoline Ltd, amongst which are devices related to DBS.

Mr. Simon Attard is a healthcare technology enthusiast. He obtained his Electrical Engineering degree from the University of Malta and his MSc in Biomedical Engineering from Imperial College London. He was awarded the Imperial College Ash Prize for his work at Imperial College. He is an avid follower of the innovative health technology scene. His main interests are mHealth and eHealth systems, especially wearable sensors, remote patient monitoring and online medical service systems.