Periacetabular osteotomy through the pararectus approach: technical feasibility and control of fragment mobility by a validated surgical navigation system in a cadaver experiment.

PURPOSE: The pararectus approach has been validated for managing acetabular fractures. We hypothesised it might be an alternative approach for performing periacetabular osteotomy (PAO). METHODS: Using four cadaver specimens, we randomly performed PAO through either the pararectus or a modified Smith-Petersen (SP) approach. We assessed technical feasibility and safety. Furthermore, we controlled fragment mobility using a surgical navigation system and compared mobility between approaches. The navigation system's accuracy was tested by cross-examination with validated preoperative planning software. RESULTS: The pararectus approach is technically feasible, allowing for adequate exposure, safe osteotomies and excellent control of structures at risk. Fragment mobility is equal to that achieved through the SP approach. Validation of these measurements yielded a mean difference of less <1 mm without statistical significance. CONCLUSION: Experimental data suggests the pararectus approach might be an alternative approach for performing PAO. Clinical validation is necessary to confirm these promising preliminary results.

Hierarchical segmentation-assisted multimodal registration for MR brain images.

Information theory-based metric such as mutual information (MI) is widely used as similarity measurement for multimodal registration. Nevertheless, this metric may lead to matching ambiguity for non-rigid registration. Moreover, maximization of MI alone does not necessarily produce an optimal solution. In this paper, we propose a segmentation-assisted similarity metric based on point-wise mutual information (PMI). This similarity metric, termed SPMI, enhances the registration accuracy by considering tissue classification probabilities as prior information, which is generated from an expectation maximization (EM) algorithm. Diffeomorphic demons is then adopted as the registration model and is optimized in a hierarchical framework (H-SPMI) based on different levels of anatomical structure as prior knowledge. The proposed method is evaluated using Brainweb synthetic data and clinical fMRI images. Both qualitative and quantitative assessment were performed as well as a sensitivity analysis to the segmentation error. Compared to the pure intensity-based approaches which only maximize mutual information, we show that the proposed algorithm provides significantly better accuracy on both synthetic and clinical data.

3D face reconstruction from 2D pictures: first results of a web-based computer aided system for aesthetic procedures.

The human face is a vital component of our identity and many people undergo medical aesthetics procedures in order to achieve an ideal or desired look. However, communication between physician and patient is fundamental to understand the patient's wishes and to achieve the desired results. To date, most plastic surgeons rely on either "free hand" 2D drawings on picture printouts or computerized picture morphing. Alternatively, hardware dependent solutions allow facial shapes to be created and planned in 3D, but they are usually expensive or complex to handle. To offer a simple and hardware independent solution, we propose a web-based application that uses 3 standard 2D pictures to create a 3D representation of the patient's face on which facial aesthetic procedures such as filling, skin clearing or rejuvenation, and rhinoplasty are planned in 3D. The proposed application couples a set of well-established methods together in a novel manner to optimize 3D reconstructions for clinical use. Face reconstructions performed with the application were evaluated by two plastic surgeons and also compared to ground truth data. Results showed the application can provide accurate 3D face representations to be used in clinics (within an average of 2 mm error) in less than 5 min.

Comparative evaluation of pelvic allograft selection methods.

This paper presents a firsthand comparative evaluation of three different existing methods for selecting a suitable allograft from a bone storage bank. The three examined methods are manual selection, automatic volume-based registration, and automatic surface-based registration. Although the methods were originally published for different bones, they were adapted to be systematically applied on the same data set of hemi-pelvises. A thorough experiment was designed and applied in order to highlight the advantages and disadvantages of each method. The methods were applied on the whole pelvis and on smaller fragments, thus producing a realistic set of clinical scenarios. Clinically relevant criteria are used for the assessment such as surface distances and the quality of the junctions between the donor and the receptor. The obtained results showed that both automatic methods outperform the manual counterpart. Additional advantages of the surface-based method are in the lower computational time requirements and the greater contact surfaces where the donor meets the recipient.

Population-based design of mandibular fixation plates with bone quality and morphology considerations.

In this paper we present a new population-based implant design methodology, which advances the state-of-the-art approaches by combining shape and bone quality information into the design strategy. The method may enhance the mechanical stability of the fixation and reduces the intra-operative in-plane bending which might impede the functionality of the locking mechanism. The computational method is presented for the case of mandibular locking fixation plates, where the mandibular angle and the bone quality at screw locations are taken into account. The method automatically derives the mandibular angle and the bone thickness and intensity values at the path of every screw from a set of computed tomography images. An optimization strategy is then used to optimize the two parameters of plate angle and screw position. The method was applied to two populations of different genders. Results for the new design are presented along with a comparison with a commercially available mandibular locking fixation plate (MODUS(®) TriLock(®) 2.0/2.3/2.5, Medartis AG, Basel, Switzerland). The proposed designs resulted in a statistically significant improvement in the available bone thickness when compared to the standard plate. There is a higher probability that the proposed implants cover areas of thicker cortical bone without compromising the bone mineral density around the screws. The obtained results allowed us to conclude that an angle and screw separation of 129° and 9 mm for females and 121° and 10 mm for males are more suitable designs than the commercially available 120° and 9 mm.

Statistical model based shape prediction from a combination of direct observations and various surrogates: application to orthopaedic research.

In computer-assisted orthopaedic surgery, recovering three-dimensional patient-specific anatomy from incomplete information has been focus of interest due to several factors such as less invasive surgical procedures, reduced radiation doses, and rapid intra-operative updates of the anatomy. The aim of this paper is to report results obtained combining statistical shape modeling and multivariate regression techniques for predicting bone shape from clinically and surgically relevant predictors, including sparse observations of the bone surface but also morphometric and anthropometric information. Different state of the art methods such as partial least square regression, principal component regression, canonical correlation analysis, and non-parametric kernel-based regression are compared. Clinically relevant surrogate variables and combinations are investigated on a database of 142 femur and 154 tibia shapes obtained from CT images. The results are evaluated using cross validation to quantify the prediction error. The proposed approach enables to characterize the added value of different predictors in a quantitative and localized fashion. Results indicate that complementary sources of information can be efficiently exploited to improve the accuracy of shape prediction.

Population-based design of mandibular plates based on bone quality and morphology.

In this paper we present a new population-based implant design methodology, which advances the state-of-the-art approaches by combining shape and bone quality information into the design strategy. The method enhances the mechanical stability of the fixation and reduces the intra-operative in-plane bending which might impede the functionality of the locking mechanism. The method is presented for the case of mandibular locking fixation plates, where the mandibular angle and the bone quality at screw locations are taken into account. Using computational anatomy techniques, the method automatically derives, from a set of computed tomography images, the mandibular angle and the bone thickness and intensity values at the path of every screw. An optimisation strategy is then used to optimise the two parameters of plate angle and screw position. Results for the new design are presented along with a comparison with a commercially available mandibular locking fixation plate. A statistically highly significant improvement was observed. Our experiments allowed us to conclude that an angle of 126 degrees and a screw separation of 8 mm is a more suitable design than the standard 120 degrees and 9 mm.

Minimization of intra-operative shaping of orthopaedic fixation plates: a population-based design.

In this paper we present a new population-based method for the design of bone fixation plates. Standard pre-contoured plates are designed based on the mean shape of a certain population. We propose a computational process to design implants while reducing the amount of required intra-operative shaping, thus reducing the mechanical stresses applied to the plate. A bending and torsion model was used to measure and minimize the necessary intra-operative deformation. The method was applied and validated on a population of 200 femurs that was further augmented with a statistical shape model. The obtained results showed substantial reduction in the bending and torsion needed to shape the new design into any bone in the population when compared to the standard mean-based plates.

A navigation system for percutaneous needle interventions based on PET/CT images: design, workflow and error analysis of soft tissue and bone punctures.

Percutaneous needle intervention based on PET/CT images is effective, but exposes the patient to unnecessary radiation due to the increased number of CT scans required. Computer assisted intervention can reduce the number of scans, but requires handling, matching and visualization of two different datasets. While one dataset is used for target definition according to metabolism, the other is used for instrument guidance according to anatomical structures. No navigation systems capable of handling such data and performing PET/CT image-based procedures while following clinically approved protocols for oncologic percutaneous interventions are available. The need for such systems is emphasized in scenarios where the target can be located in different types of tissue such as bone and soft tissue. These two tissues require different clinical protocols for puncturing and may therefore give rise to different problems during the navigated intervention. Studies comparing the performance of navigated needle interventions targeting lesions located in these two types of tissue are not often found in the literature. Hence, this paper presents an optical navigation system for percutaneous needle interventions based on PET/CT images. The system provides viewers for guiding the physician to the target with real-time visualization of PET/CT datasets, and is able to handle targets located in both bone and soft tissue. The navigation system and the required clinical workflow were designed taking into consideration clinical protocols and requirements, and the system is thus operable by a single person, even during transition to the sterile phase. Both the system and the workflow were evaluated in an initial set of experiments simulating 41 lesions (23 located in bone tissue and 18 in soft tissue) in swine cadavers. We also measured and decomposed the overall system error into distinct error sources, which allowed for the identification of particularities involved in the process as well as highlighting the differences between bone and soft tissue punctures. An overall average error of 4.23 mm and 3.07 mm for bone and soft tissue punctures, respectively, demonstrated the feasibility of using this system for such interventions. The proposed system workflow was shown to be effective in separating the preparation from the sterile phase, as well as in keeping the system manageable by a single operator. Among the distinct sources of error, the user error based on the system accuracy (defined as the distance from the planned target to the actual needle tip) appeared to be the most significant. Bone punctures showed higher user error, whereas soft tissue punctures showed higher tissue deformation error.

Allograft selection for transepiphyseal tumor resection around the knee using three-dimensional surface registration.

Transepiphyseal tumor resection is a common surgical procedure in patients with malignant bone tumors. The aim of this study is to develop and validate a computer-assisted method for selecting the most appropriate allograft from a cadaver bone bank. Fifty tibiae and femora were 3D reconstructed from computed tomography (CT) images. A transepiphyseal resection was applied to all of them in a virtual environment. A tool was developed and evaluated that compares each metaphyseal piece against all other bones in the data bank. This is done through a template matching process, where the template is extracted from the contralateral healthy bone of the same patient. The method was validated using surface distance metrics and statistical tests comparing it against manual methods. The developed algorithm was able to accurately detect the bone segment that best matches the patient's anatomy. The automatic method showed improvement over the manual counterpart. The proposed method also substantially reduced computation time when compared to state-of-the-art methods as well as the manual selection. Our findings suggest that the accuracy, robustness, and speed of the developed method are suitable for clinical trials and that it can be readily applied for preoperative allograft selection.

ECM versus ICP for point registration.

Iterative Closest Point (ICP) is a widely exploited method for point registration that is based on binary point-to-point assignments, whereas the Expectation Conditional Maximization (ECM) algorithm tries to solve the problem of point registration within the framework of maximum likelihood with point-to-cluster matching. In this paper, by fulfilling the implementation of both algorithms as well as conducting experiments in a scenario where dozens of model points must be registered with thousands of observation points on a pelvis model, we investigated and compared the performance (e.g. accuracy and robustness) of both ICP and ECM for point registration in cases without noise and with Gaussian white noise. The experiment results reveal that the ECM method is much less sensitive to initialization and is able to achieve more consistent estimations of the transformation parameters than the ICP algorithm, since the latter easily sinks into local minima and leads to quite different registration results with respect to different initializations. Both algorithms can reach the high registration accuracy at the same level, however, the ICP method usually requires an appropriate initialization to converge globally. In the presence of Gaussian white noise, it is observed in experiments that ECM is less efficient but more robust than ICP.

2D/3D reconstruction of a scaled lumbar vertebral model from a single fluoroscopic image.

Accurate three-dimensional (3D) models of lumbar vertebrae can enable image-based 3D kinematic analysis. The common approach to derive 3D models is by direct segmentation of CT or MRI datasets. However, these have the disadvantages that they are expensive, time-consuming and/or induce high-radiation doses to the patient. In this paper, we present a technique to reconstruct a scaled 3D lumbar vertebral model from a single two-dimensional (2D) lateral fluoroscopic image and a statistical shape model of the lumbar vertebrae. Four cadaveric lumbar spine segments (totally twelve lumbar vertebrae) were used to validate the technique. To evaluate the reconstruction accuracy, the surface models reconstructed from the lateral fluoroscopic images were compared to the associated ground truth data derived from a 3D CT-scan reconstruction technique. For each case, a surface-based matching was first used to recover the scale and the rigid transformation between the reconstructed surface models and the ground truth model before the distances between the two discrete surface models were computed. An average error of 1.0 mm was found when the present technique was used to reconstruct the surface models of all twelve lumbar vertebrae.

Multimodal target correction by local bone registration: a PET/CT evaluation.

PET/CT guidance for percutaneous interventions allows biopsy of suspicious metabolically active bone lesions even when no morphological correlation is delineable in the CT images. Clinical use of PET/CT guidance with conventional step-by-step technique is time consuming and complicated especially in cases in which the target lesion is not shown in the CT image. Our recently developed multimodal instrument guidance system (IGS) for PET/CT improved this situation. Nevertheless, bone biopsies even with IGS have a trade-off between precision and intervention duration which is proportional to patient and personnel exposure to radiation. As image acquisition and reconstruction of PET may take up to 10 minutes, preferably only one time consuming combined PET/CT acquisition should be needed during an intervention. In case of required additional control images in order to check for possible patient movements/deformations, or to verify the final needle position in the target, only fast CT acquisitions should be performed. However, for precise instrument guidance accounting for patient movement and/or deformation without having a control PET image, it is essential to be able to transfer the position of the target as identified in the original PET/CT to a changed situation as shown in the control CT.

Computer aided surgery for percutaneous nephrolithotomy: Clinical requirement analysis and system design.

Percutaneous nephrolithotomy (PCNL) for the treatment of renal stones and other related renal diseases has proved its efficacy and has stood the test of time compared with open surgical methods and extracorporeal shock wave lithotripsy. However, access to the collecting system of the kidney is not easy because the available intra-operative image modalities only provide a two dimensional view of the surgical scenario. With this lack of visual information, several punctures are often necessary which, increases the risk of renal bleeding, splanchnic, vascular or pulmonary injury, or damage to the collecting system which sometimes makes the continuation of the procedure impossible. In order to address this problem, this paper proposes a workflow for introduction of a stereotactic needle guidance system for PCNL procedures. An analysis of the imposed clinical requirements, and a instrument guidance approach to provide the physician with a more intuitive planning and visual guidance to access the collecting system of the kidney are presented.

Automated detection of fiducial screws from CT/DVT volume data for image-guided ENT surgery.

This paper presents an automated solution for precise detection of fiducial screws from three-dimensional (3D) Computerized Tomography (CT)/Digital Volume Tomography (DVT) data for image-guided ENT surgery. Unlike previously published solutions, we regard the detection of the fiducial screws from the CT/DVT volume data as a pose estimation problem. We thus developed a model-based solution. Starting from a user-supplied initialization, our solution detects the fiducial screws by iteratively matching a computer aided design (CAD) model of the fiducial screw to features extracted from the CT/DVT data. We validated our solution on one conventional CT dataset and on five DVT volume datasets, resulting in a total detection of 24 fiducial screws. Our experimental results indicate that the proposed solution achieves much higher reproducibility and precision than the manual detection. Further comparison shows that the proposed solution produces better results on the DVT dataset than on the conventional CT dataset.

Integrating optical fiber force sensors into microforceps for ORL microsurgery.

The delicate anatomy of the ear require surgeons to use great care when operating on its internal structures. One example for such an intervention is the stapedectomy, where a small crook shaped piston is placed in the oval window of the cochlea and connected to the incus through crimping thus bypassing the diseased stapes. Performing the crimp process with the correct force is necessary since loose crimps poorly transmit sound whereas tight crimps will eventually result in necrosis of the incus. Clinically, demand is high to reproducibly conduct the crimp process through a precise force measurement. For this reason, we have developed a fiber Bragg grating (FBG) integrated microforceps for use in such interventions. This device was calibrated, and tested in cadaver preparations. With this instrument we were able to measure for the first time forces involved in crimping a stapes prosthesis to the incus. We also discuss a method of attaching and actuating such forceps in conjunction with a robot currently under development in our group. Each component of this system can be used separately or combined to improve surgical accuracy, confidence and outcome.

Anatomically-driven soft-tissue simulation strategy for cranio-maxillofacial surgery using facial muscle template model.

We propose a computationally efficient and bio-mechanically relevant soft-tissue simulation method for cranio-maxillofacial (CMF) surgery. A template-based facial muscle reconstruction was introduced to minimize the efforts on preparing a patient-specific model. A transversely isotropic mass-tensor model (MTM) was adopted to realize the effect of directional property of facial muscles in reasonable computation time. Additionally, sliding contact around teeth and mucosa was considered for more realistic simulation. Retrospective validation study with postoperative scan of a real patient showed that there were considerable improvements in simulation accuracy by incorporating template-based facial muscle anatomy and sliding contact.

A new soft-tissue simulation strategy for cranio-maxillofacial surgery using facial muscle template model.

We propose a computationally efficient, bio-mechanically relevant soft-tissue simulation method for cranio-maxillofacial (CMF) surgery. Special emphasis is given to comply with the current clinical workflow. A template-based facial muscle prediction was introduced to avoid laborious segmentation from medical images. In addition, transversely isotropic mass-tensor model (MTM) was applied to realize the directional behavior of facial muscles in short computation time. Finally, sliding contact was incorporated to mimic realistic boundary condition in error-sensitive regions. Mechanical simulation result was compared with commercial finite element software. And retrospective validation study with post-operative scan of four CMF cases was performed.

A feasibility study of computer-assisted bone graft implantation for tissue-engineered replacement of the human ankle joint.

OBJECTIVE: Computer-assisted graft implantation may contribute to achieving biological joint replacement in the future. The purpose of this experimental study was to evaluate the feasibility and accuracy of a series of computer-assisted graft implantations into human cadaver ankle joints. METHODS: Three-dimensional graft models of virtually planned corresponding tibial and talar defects were created from bovine cancellous bone. A platform for computer-assisted surgery (CAS) was set up to implant the grafts. Registration was performed by pair-point matching with anatomical landmarks. In the case of insufficient registration accuracy, artificial landmarks were used for registration. Eight grafts (four tibial, four talar) were implanted in four human cadaver ankle joints. Postoperative CT was used for outcome analysis. The following criteria of accuracy were defined: macroscopic quality of implant fit; quality of the sagittal and coronar joint surface; and quality of the undersurface of the graft in relation to the base of the defect. RESULTS: No technical complications were observed during computer-assisted graft implantation. Clinically acceptable accuracy was achieved in 6 of 8 graft implantations, with implant failure occurring at the tibial and talar location in one ankle joint. In total, 25 of 32 criteria of accuracy were achieved: 6/8 for macroscopic implant fit; 5/8 for quality of the sagittal joint surface; 7/8 for quality of the coronar joint surface; and 7/8 for quality of the undersurface of the graft. Registration with anatomical landmarks did not achieve sufficient accuracy in 4 of 8 cases, whereas registration with artificial landmarks was successful in all these cases. CONCLUSIONS: We demonstrated the feasibility and accuracy of computer-assisted graft implantation for tissue-engineered replacement of the human ankle joint. However, we cannot recommend the present type of registration by pair-point matching with anatomical landmarks due to the considerable inaccuracies. The focus should be on the improvement of non-invasive registration techniques and methods for evaluating postoperative outcome.

Augmented reality endoscopic system (ARES): preliminary results.

OBJECTIVES: During endoscopic surgery, it is difficult to ascertain the anatomical landmarks once the anatomy is fiddled with or if the operating area is filled with blood. An augmented reality system will enhance the endoscopic view and further enable surgeons to view hidden critical structures or the results of preoperative planning. METHOD: The skull and endoscope are fixed with optical markers that are used as dynamic reference bases for tracking. A small optical tracking device, the easyTrack 200, which is connected to a computer, calculates the positions of the markers. The endoscope is calibrated and registered for augmenting its video with a 3D model. Images of a black and white checkerboard pattern, with 2.5 mm sized squares, are used for calibration with a Matlab based calibration toolbox. Standard modalities of overlay have been developed, including a CT viewer displaying it as an overlay in the endoscopic video stream, and a 3D viewer to render 3D models of preoperatively segmented structures. The accuracy of the augmented reality system was assessed on a plastic skull. RESULTS: The accuracy is calculated by looking at the difference in pixels of several contours in both a real and an overlay image, obtaining a mean of 3-4 pixels that correspond to sub-millimeter accuracy (pixel to mm ratio calculated previously). Mean error was consistently 1-2 [+/- 0.3] mm. CONCLUSIONS: A novel augmented reality system for endoscopic surgery is presented. Highlighting hidden structures or CT overlays in the endoscope will give more information in difficult situations and enhance the operation quality.