Geert J. Streekstra

Removal of bone in CT angiography of the cervical arteries by piecewise matched mask bone elimination

In maximum intensity projection (MIP) images of CT angiography (CTA) scans, the arteries are often obscured by bone. A bone removal method is presented that uses an additional, nonenhanced scan to create a mask of the bone by thresholding and dilation. After registration of the CTA scan and the additional scan, the bone in the CTA scan is masked. As the cervical area contains bones that can move with respect to each other, these bones are separated first using a watershed algorithm, and then registered individually. A phantom study was performed to evaluate and quantify the tradeoff between the removal of the bone and the preservation of the arteries contiguous to the bone. The influence of algorithm parameters and scan parameters was studied. The method was clinically evaluated with data sets of 35 patients. Best results were obtained with a threshold of 150 HU and a dilation of 8 in-plane voxels and two out-of-plane voxels. The mean width of the soft tissue layer, which is also masked, was approximately 1 mm. The mAs value of the nonenhanced scan could be reduced from 250 mAs to 65 mAs without a loss of quality. In 32 cases the bones were registered correctly and removed completely. In three cases the bone separation was not completely successful, and consequently the bone was not completely removed. The piecewise matched mask bone elimination method proved to be able to obtain MIP images of the cervical arteries free from overprojecting bone in a fully automatic way and with only a slight increase of radiation dose.

Computer-Assisted Planning and Navigation for Corrective Distal Radius Osteotomy, Based on Pre- and Intraoperative Imaging

Malunion after a distal radius fracture is very common and if symptomatic, is treated with a so-called corrective osteotomy. In a traditional distal radius osteotomy, the radius is cut at the fracture site and a wedge is inserted in the osteotomy gap to correct the distal radius pose. The standard procedure uses two orthogonal radiographs to estimate the two inclination angles and the dimensions of the wedge to be inserted into the osteotomy gap. However, optimal correction in 3-Dspace requires restoring three angles and three displacements. This paper introduces a new technique that uses preoperative planning based on 3-D images. Intraoperative 3-D imaging is also used after inserting pins with marker tools in the proximal and distal part of the radius and before the osteotomy. Positioning tools are developed to correct the distal radius pose in six degrees of freedom by navigating the pins. The method is accurate (derr <; 1.2 mm, φerr <; 0.9°, mTRE = 1.7 mm), highly reproducible (SEd <; 1.0 mm, SEφ ≤ 1.4°, SEmTRE = 0.7 mm), and allows intraoperative evaluation of the end result. Small incisions for pin placement and for the osteotomy render the method minimally invasive.

In-vivo three-dimensional carpal bone kinematics during flexion-extension and radio-ulnar deviation of the wrist: Dynamic motion versus step-wise static wrist positions

An in-vivo approach to the measurement of three-dimensional motion patterns of carpal bones in the wrist may have future diagnostic applications, particularly for ligament injuries of the wrist. Static methods to measure carpal kinematics in-vivo only provide an approximation of the true kinematics of the carpal bones. This study is aimed at finding the difference between dynamically and statically acquired carpal kinematics. For eight healthy subjects, static and a dynamic measurements of the carpal kinematics were performed for a flexion-extension and a radio-ulnar deviation movement. Dynamic scans were acquired by using a four-dimensional X-ray imaging system during an imposed cyclic motion. To assess static kinematics of the wrists, three-dimensional rotational X-ray scans were acquired during step-wise flexion-extension and radio-ulnar deviation. The helical axis rotations and the rotation components. i.e. flexion-extension, radio-ulnar deviation and pro-supination were the primary parameters. Linear mixed model statistical analysis was used to determine the significance of the difference between the dynamically and statically acquired rotations of the carpal bones. Small and in most cases negligible differences were observed between the dynamic motion and the step-wise static motion of the carpal bones. The conclusion is that in the case of individuals without any pathology of the wrist, carpal kinematics can be studied either dynamically or statically. Further research is required to investigate the dynamic in-vivo carpal kinematics in patients with dynamic wrist problems.

Computer-assisted and patient-specific 3-D planning and evaluation of a single-cut rotational osteotomy for complex long-bone deformities

Malunion after long bone fracture results in an incorrect position of the distal bone segment. This misalignment may lead to reduced function of the limb, early osteoarthritis and chronic pain. An established treatment option is a corrective osteotomy. For complex malunions, a single-cut rotational osteotomy is sometimes preferred in cases of angular deformity in three dimensions. However, planning and performing this type of osteotomy is relatively complex. This report describes a computer-assisted method for 3-D planning and realizing a single-cut rotational osteotomy with a patient-specific cutting guide for orienting the osteotomy and an angled jig for adjusting the rotation angle. The accuracy and reproducibility of the method is evaluated experimentally using plastic bones. In addition, complex rotational deformities are simulated by a computer to investigate the relation between deformity and correction parameters. The computed relation between deformity and correction parameters enables the surgeon to judge the feasibility of a single-cut rotational osteotomy. This appears possible for deformities combining axial misalignment with sufficient axial rotation. The proposed 3-D method of preoperative planning and transfer with a patient-specific cutting guide and angled jig renders the osteotomy procedure easily applicable, accurate, reproducible, and is a good alternative for complex and expensive navigation systems.

Statistical descriptions of scaphoid and lunate bone shapes

Diagnosing of injuries of the wrist bones is problematic due to a highly complex and variable geometry. knowledge of variations of healthy bone shapes is essential to detect wrist pathologies, developing prosthetics and investigating biomechanical properties of the wrist joint. In previous literature various methods have been proposed to classify different scaphoid and lunate types. These classifications were mainly qualitative or were based on a limited number of manually determined surface points. The purposes of this study are to develop a quantitative, standardized description of the variations in the scaphoid and lunate and to investigate whether it is feasible to divide carpal bones in isolated shape categories based on statistical grounds. The shape variations of the scaphoid and lunate were described by constructing a statistical shape model (SSM) of healthy bones. SSM shape parameters were determined that describe the deviation of each shape from the mean shape. The first five modes of variation in the SSMs describe 60% of the total variance of the scaphoid and 57% of the lunate. Higher modes describe less than 5% of the variance per mode. The distributions of the parameters that characterize the bone shape variations along the modes do not significantly differ from a normal distribution. The SSM provides a description of possible shape variations and the distribution of scaphoid and lunate shapes in our population at an accuracy of approximately the voxel size (0.3x0.3x0.3mm(3)). The developed statistical shape model represents the previously qualitatively described variations of scaphoid and lunate. However, strict classifications based on shape differences are not feasible on statistical grounds.

Cochlear implant electrode array insertion monitoring with intra-operative 3D rotational X-ray

• During cochlear implantation surgery, we use a mobile C‐arm with 3D functionality to acquire per‐operative 3D X‐ray images.

Three-dimensional assessment of bilateral symmetry of the radius and ulna for planning corrective surgeries.

PURPOSE The contralateral unaffected side is often used as a reference in planning a corrective osteotomy of a malunited distal radius. Two-dimensional radiographs have proven unreliable in assessing bilateral symmetry, so we assessed 3-dimensional configurations to assess bilateral symmetry. METHODS We investigated bilateral symmetry using 3-dimensional imaging techniques. A total of 20 healthy volunteers without previous wrist injury underwent a volumetric computed tomography of both forearms. The left radius and ulna were segmented to create virtual 3-dimensional models of these bones. We selected a distal part and a larger proximal part from these bones and matched them with a mirrored computed tomographic image of the contralateral side. This allowed us to calculate the relative displacements (Δx, Δy, Δz) and rotations (Δφx, Δφy, Δφz) for aligning the left bone with the right bone segments. We investigated the relation between longitudinal length differences in radiuses and ulnas. RESULTS Relative differences of the radiuses were (Δx, Δy, Δz): -0.81 ± 1.22 mm, -0.01 ± 0.64 mm, and 2.63 ± 2.03 mm; and (Δφx, Δφy, Δφz): 0.13° ± 1.00°, -0.60° ± 1.35°, and 0.53° ± 5.00°. The same parameters for the ulna were (Δx, Δy, Δz): -0.22 ± 0.82 mm, 0.52 ± 0.99 mm, 2.08 ± 2.33 mm; and (Δφx, Δφy, Δφz): -0.56° ± 0.96°, -0.71° ± 1.51°, and -2.61° ± 5.58°. There is a strong relation between absolute length differences (Δz) between the radiuses and ulnas of individuals. CONCLUSIONS We observed substantial length and rotational differences around the longitudinal bone axis in healthy individuals. Surgical planning using the unaffected side as a reference may not be as useful as previously assumed. However, including the length difference of the adjacent forearm bones can be useful in improving length correction in computer-assisted planning of radius or ulna osteotomies and in other reconstructive surgery procedures. CLINICAL RELEVANCE Bilateral symmetry is important in reconstructive surgery procedures where the contralateral unaffected side is often used as a reference for planning and evaluation.

Removal of bone in CT angiography by multiscale matched mask bone elimination

For clear visualization of vessels in CT angiography (CTA) images of the head and neck using maximum intensity projection (MIP) or volume rendering (VR) bone has to be removed. In the past we presented a fully automatic method to mask the bone [matched mask bone elimination (MMBE)] for this purpose. A drawback is that vessels adjacent to bone may be partly masked as well. We propose a modification, multiscale MMBE, which reduces this problem by using images at two scales: a higher resolution than usual for image processing and a lower resolution to which the processed images are transformed for use in the diagnostic process. A higher in-plane resolution is obtained by the use of a sharper reconstruction kernel. The out-of-plane resolution is improved by deconvolution or by scanning with narrower collimation. The quality of the mask that is used to remove bone is improved by using images at both scales. After masking, the desired resolution for the normal clinical use of the images is obtained by blurring with Gaussian kernels of appropriate widths. Both methods (multiscale and original) were compared in a phantom study and with clinical CTA data sets. With the multiscale approach the width of the strip of soft tissue adjacent to the bone that is masked can be reduced from 1.0 to 0.2 mm without reducing the quality of the bone removal. The clinical examples show that vessels adjacent to bone are less affected and therefore better visible. Images processed with multiscale MMBE have a slightly higher noise level or slightly reduced resolution compared with images processed by the original method and the reconstruction and processing time is also somewhat increased. Nevertheless, multiscale MMBE offers a way to remove bone automatically from CT angiography images without affecting the integrity of the blood vessels. The overall image quality of MIP or VR images is substantially improved relative to images processed with the original MMBE method.

Syllectometry: the effect of aggregometer geometry in the assessment of red blood cell shape recovery and aggregation

Syllectometry is a measuring method that is commonly used to assess red blood cell (RBC) aggregability. In syllectometry, light is incident on a layer of whole blood initially exposed to shear flow. The backscattered light is measured after abruptly stopping the driving mechanism. The resultant time-dependent intensity plot is called the syllectogram. Parameters that quantify RBC aggregability are obtained by analyzing the syllectogram. As we will show in this paper, the upstroke in the initial part of the syllectogram contains the information for measurement of RBC-shape recovery in whole blood as well. To estimate RBC-shape recovery, we extended the existing two-exponential mathematical representation of the syllectogram by a third exponent that describes the upstroke. To investigate the feasibility of RBC-shape recovery measurement from the upstroke, we derived an analytical model of the flow decay that follows after abruptly stopping the driving mechanism. The model reveals that for large gaps the flow decay may interfere with the true RBC-shape recovery process. These theoretical findings were confirmed by velocity measurements in a Couette-type aggregometer. Syllectograms obtained using large gaps differ in many respects from those obtained using small gaps. As predicted by our model large gaps show a prolonged apparent shape-recovery time-constant. Moreover, a delayed intensity peak, a reduced upstroke of the intensity peak and a considerable increase of the half-life parameter are observed. The aggregation indices for large gaps are lower than for small gaps. This paper yields a better understanding of the velocity and shear-rate decay following upon abruptly stopping the driving mechanism. A better mathematical representation of the syllectogram and recommendations for a maximum gap width enables both RBC-shape recovery and aggregation measurements in whole blood using syllectometry.

Detection of In Vivo Dynamic 3-D Motion Patterns in the Wrist Joint

We present a method for measurement dynamic in vivo carpal motion patterns. The method consists of a 4-D rotational X-ray (RX) with improved image quality and image processing for accurate detection in vivo wrist motion measurements. Dynamic 3-D imaging yields a number of volume reconstructions of the wrist at different phases of its cyclic motion. Next, the carpal reconstructions are registered to their static acquired and segmented counterpart in all phases. With this information, the relation between the applied motion and carpal kinematic behavior is acquired, i.e., the motion patterns. We investigated the precision of the image acquisition and processing and tested it on three healthy subjects. The precision of the image acquisition and image processing is in the range of submillimeters and subdegrees, respectively, which is better than existing systems and sufficient for clinical investigations. Reproducibility measurements show some more deviation (>1deg). This method was tested on four human volunteers and agrees for the greater part with previously done invasive and nondynamic measurements. In vivo motion pattern measurement with 4-D-RX imaging and processing is accurate and noninvasive. The motion patterns can reveal disorders that could not have been detected in either video fluoroscopy, computed tomography, or MRI.