Branislav Jaramaz

Imaging and Navigation Measurement of Acetabular Component Position in THA

There are six different definitions of acetabular position based on observed inclination and anteversion made in either the (1) anterior pelvic plane or (2) coronal planes and based on whether each of the observations made in one of these two planes is (1) anatomic, (2) operative, or (3) radiographic. Anteroposterior pelvic tilt is the angle between the anterior pelvic plane and the coronal plane of the body. The coronal plane is a functional plane and the anterior pelvic plane is an anatomic pelvic plane. A cup may be in the “safe zone” by one definition but may be out of the “safe zone” by another definition. We reviewed published studies, analyzed the difference in varying definitions, evaluated the influence of the anterior pelvic tilt, and provided methods to convert from one definition to another. We recommend all inclination and anteversion measurements be converted to the radiographic inclination and anteversion based on the coronal plane, which is equivalent to the inclination and anteversion on the anteroposterior pelvic radiograph.

Ultrasound Registration of the Bone Surface for Surgical Navigation

Objective: To allow non-invasive registration of the bone surface for computer-assisted surgery (CAS), this investigation reports the development and evaluation of intraoperative registration using 2D ultrasound (US) images. This approach employs automatic segmentation of the bone surface reflection from US images tagged with the 3D position to enable the application of CAS to minimally invasive procedures. Methods: The US-based registration method was evaluated in comparison to point-based registration, which is the predominant method in current clinical use. The absolute accuracy of the US-based registration was determined using a phantom pelvis, with fiducial registration providing the ground truth. The relative accuracy was determined by an intraoperative study comparing the US registration to the point-based registration obtained as part of the HipNav™ experimental protocol. Results: The phantom pelvis study demonstrated equivalent accuracy between point-and US-based registration under in vitro conditions. In the intraoperative study, the US-based registration was sufficiently consistent with the point-based registration to warrant larger-scale clinical trials of this non-invasive registration method. Conclusion: Ultrasound-based registration eliminates the need for physical contact with the bone surface as in point-based registration. As a result, non-invasive registration could fully unlock the potential of computer-assisted surgery, enabling development of the next generation of minimally invasive surgical procedures.

Functional pelvic orientation measured from lateral standing and sitting radiographs.

We prospectively obtained preoperative and 3-month postoperative lateral pelvic radiographs in the standing and sitting positions from 84 patients who underwent total hip arthroplasty. We measured pelvic orientation (flexion extension) using the anterior pelvic plane as defined by the anterior superior iliac spines and pubic tubercles as references. There was a trend towards upright pelvic alignment when standing, with a mean anterior pelvic plane angle of 1.2° (range, −22°-+27°). In the sitting position the pelvis tended to extend posteriorly, with a mean anterior pelvic plane angle of −36.2° (range, −64°-+4°). There was a wide variation in the arc of pelvic flexion extension as patients moved from standing to sitting, with arc of pelvic motion in some patients as mobile as 70° and in others as stiff as 5°. There was no significant variation between males and females or between preoperative and postoperative pelvic flexion extension. There were substantial variations in pelvic orientation when comparing standing and sitting for an individual patient and between different patients. This variation can be unpredictable, and may influence implant alignment and stability after total hip arthroplasty.Level of Evidence: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Cup alignment error model for total hip arthroplasty.

Almost all computer-assisted orthopaedic surgery systems that rely on the anterior pelvic plane definition, such as in computed tomography and magnetic resonance image-based, fluoroscopy-based, and nonimage total hip replacement approaches, are derived from identifying two pairs of pelvic bony landmarks: anterior superior iliac spines and the pubic tubercles. Although these systems strive to achieve cup alignment accuracy of approximately 1°, even a minor failure to correctly identify these anatomic landmarks can lead to higher inaccuracies in the final cup alignment. This study shows how to examine the effects of these inaccuracies on the final acetabular cup implant orientation during total hip replacement by generating a kinematic model, which then is simulated. Simulation results indicate that, for example, a total error of 4 mm in measuring the anterior superior iliac spine and the pubic tubercles would result in a final cup orientation of 47° and 27° in abduction and version respectively, resulting in a 2° abduction error and 7° error in version when targeting 45° abduction and 20° version results. These calculations can be repeated for any error values.

Computer-Assisted Orthopaedic Surgery

Over the last decade, orthopaedics has been one of the most active and diverse areas of development in computer-assisted surgery. Orthopaedics has been a specially challenging area of development as many orthopaedic surgeons consider the outcomes of conventional procedures generally successful. There is significant pressure to improve the efficiency and ergonomics, reduce cost and dependence on more expensive medical imaging modalities, and simplify the use and interfaces. Increasing emphasis on less invasive and minimally invasive procedures could give a significant boost to the adoption of computer-assisted surgery. In this paper, we present the overview of different approaches using a classification scheme that relies on two important criteria: 1) the autonomy of clinical action permitted to the system and 2) the imaging requirements

Variations in acetabular anatomy with reference to total hip replacement

Three-dimensional surface models of the normal hemipelvis derived from volumetric CT data on 42 patients were used to determine the radius, depth and orientation of the native acetabulum. A sphere fitted to the lunate surface and a plane matched to the acetabular rim were used to calculate the radius, depth and anatomical orientation of the acetabulum. For the 22 females the mean acetabular abduction, anteversion, radius and normalised depth were 57.1 degrees (50.7 degrees to 66.8 degrees ), 24.1 degrees (14.0 degrees to 33.3 degrees ), 25 mm (21.7 to 30.3) and 0.79 mm (0.56 to 1.04), respectively. The same parameters for the 20 males were 55.5 degrees (47.7 degrees to 65.9 degrees ), 19.3 degrees (8.5 degrees to 32.3 degrees ), 26.7 mm (24.5 to 28.7) and 0.85 mm (0.65 to 0.99), respectively. The orientation of the native acetabulum did not match the safe zone for acetabular component placement described by Lewinnek. During total hip replacement surgeons should be aware that the average abduction angle of the native acetabulum exceeds that of the safe zone angle. If the concept of the safe zone angle is followed, abduction of the acetabular component should be less than the abduction of the native acetabulum by approximately 10 degrees .

Measurements of acetabular cup position and pelvic spatial orientation after total hip arthroplasty using computed tomography/radiography matching

This study presents a clinical validation of postoperative measurements of acetabular cup alignment following total hip arthroplasty (THA). The methodology was based on concurrent anatomic three-dimensional (3D) measurements of both the acetabular cup alignment and pelvic orientation, using an original CT/X-ray matching algorithm named Xalign. The subjects were 19 patients who had undergone bilateral THA using CT-based surgical navigation. All patients had postoperative pelvic CT scans and multiple antero-posterior (AP) pelvic X-rays. Using a proprietary software algorithm, the X-rays included in the study were matched with the corresponding postoperative CT scans. The goal of this method was to allow 3D anatomic pelvic and acetabular measurements on two-dimensional AP X-rays. The postoperative cup abduction, version and pelvic flexion angles were determined in three different ways: using CT images directly, applying the Xalign method, and finally by performing conventional (abduction only) measurements on AP pelvic X-rays. The cup orientation measured on CT images was taken as the ground truth. The Xalign measurement errors were defined as the difference between the CT cup values and those obtained by applying the matching method. The mean cup abduction error was 0.85° ± 1.3° (± standard deviation) and the mean version error was 0.01° ± 1.99°. Conventionally measured cup abduction ranged from 44° to 62° and correlated significantly (p = 0.001, r = −0.5) with pelvic flexion angle, proving the linear negative correlation between pelvic flexion and the error in conventional radiographic cup measurements. The Xalign method offered reasonable accuracy for cup orientation, and allowed cup and pelvic 3D anatomic measurements at different times.

A Multi-Image Shape-from-Shading Framework for Near-Lighting Perspective Endoscopes

This article formulates a near-lighting shape-from-shading problem with a pinhole camera (perspective projection) and presents a solution to reconstruct the Lambertian surface of bones using a sequence of overlapped endoscopic images, with partial boundaries in each image. First we extend the shape-from-shading problem to deal with perspective projection and near point light sources that are not co-located with the camera center. Secondly we propose a multi-image framework which can align partial shapes obtained from different images in the world coordinates by tracking the endoscope. An iterative closest point (ICP) algorithm is used to improve the matching and recover complete occluding boundaries of the bone. Finally, a complete and consistent shape is obtained by simultaneously re-growing the surface normals and depths in all views. In order to fulfill our shape-from-shading algorithm, we also calibrate both geometry and photometry for an oblique-viewing endoscope that are not well addressed before in the previous literatures. We demonstrate the accuracy of our technique using simulations and experiments with artificial bones.

Precision Freehand Sculpting of Bone

The Precision Freehand Sculptor (PFS) is a compact, handheld, intelligent tool to assist the surgeon in accurately cutting bone. A retractable rotary blade on the PFS allows a computer to control what bone is removed. Accuracy is ensured even though the surgeon uses the tool freehand. The computer extends or retracts the blade based on data from an optical tracking camera. Three users used each of three PFS prototype concepts to cut a faceted shape in wax. The results of this experiment were analyzed to identify the largest sources of error.

Biomechanics for preoperative planning and surgical simulations in orthopaedics

Surgical simulations are particularly appropriate for the large volume and expense of joint replacement procedures in orthopaedics. A first generation surgical simulator has been developed to model the implantation procedure for cementless acetabular and femoral components in total hip replacement surgery. The simulator is based upon finite element analysis and predicts the early postoperative mechanical environment that results from a proposed surgery. Since the short- and long-term clinical success of cementless hip replacement components is very dependent upon the initial mechanics of the bone-implant system, such simulations can help orthopaedic surgeons to develop better preoperative plans.