Mehran Armand

Intraoperative Image-based Multiview 2D/3D Registration for Image-Guided Orthopaedic Surgery: Incorporation of Fiducial-Based C-Arm Tracking and GPU-Acceleration

Intraoperative patient registration may significantly affect the outcome of image-guided surgery (IGS). Image-based registration approaches have several advantages over the currently dominant point-based direct contact methods and are used in some industry solutions in image-guided radiation therapy with fixed X-ray gantries. However, technical challenges including geometric calibration and computational cost have precluded their use with mobile C-arms for IGS. We propose a 2D/3D registration framework for intraoperative patient registration using a conventional mobile X-ray imager combining fiducial-based C-arm tracking and graphics processing unit (GPU)-acceleration. The two-stage framework 1) acquires X-ray images and estimates relative pose between the images using a custom-made in-image fiducial, and 2) estimates the patient pose using intensity-based 2D/3D registration. Experimental validations using a publicly available gold standard dataset, a plastic bone phantom and cadaveric specimens have been conducted. The mean target registration error (mTRE) was 0.34±0.04 mm (success rate: 100%, registration time: 14.2 s) for the phantom with two images 90° apart, and 0.99±0.41 mm (81%, 16.3 s) for the cadaveric specimen with images 58.5° apart. The experimental results showed the feasibility of the proposed registration framework as a practical alternative for IGS routines.

Relationship between time- and frequency-domain analyses of angular head movements in the squirrel monkey

We used the three-dimensional magnetic search-coil recording technique to study the range of active angular head movements made by squirrel monkeys. There were two goals in this study: (1) to determine the range of angular velocities and accelerations as well as the bandwidth and other frequency characteristics of active head movements and (2) to compare analyses of transients of velocity and acceleration that are studied by residual analysis, Fourier transform, and wavelet transform of the head velocity signal.The residual analysis showed that the shape and duration of the transients affected the bandwidth. During the time after the head had begun to accelerate, the frequency content of the head movement extended into the range of 6 to 12 Hz. When considering all three planes of rotation, approximately 75% of the transients had peak acceleration between 2,000 and 10,000 deg/s2 and a peak velocity of 50 to 400 deg/s. A peak acceleration of >10,000 deg/s2 was recorded in 10% of the transients.These findings indicate that active head movements in squirrel monkeys cover a higher range of frequencies, accelerations, and velocities than have typically been used in previous eye-movement and neuronal studies of the reflexes that control gaze. We further conclude that the choice of a method for analyzing transient, time-varying biological signals is dependent on the desired information. Residual analysis provides detailed resolution in the time domain, but estimation of the frequency content of the signal is dependent on the portions selected for analysis and the choice of filters. Fourier transform provides a representation of the power spectrum in the frequency domain but without any inherent temporal resolution. We show that the wavelet transform, a novel method as applied to the signal analysis goals of this study, is the most useful technique for relating time- and frequency-domain information during a continuous signal.

Design of a new cable-driven manipulator with a large open lumen: Preliminary applications in the minimally-invasive removal of osteolysis

A dexterous manipulator (DM) with a large open lumen is presented. The manipulator is designed for surgical applications with a preliminary focus on the removal of osteolysis formed behind the acetabular shell of primary total hip arthroplasties (THAs). The manipulator is constructed from two nested superelastic nitinol tubes enabling lengthwise channels for drive cables. Notches in the nested assembly provide reliable bending under applied cable tension producing kinematics that can be effectively modeled as a series of rigid vertebrae connected using pin joints. The manipulator is controlled in plane with two independently actuated cables in a pull-pull configuration. For the purpose of the procedure, the manipulator is mounted on a Z-θ stage adding a translational and rotational degree of freedom (DOF) along the axis of the manipulator. Preliminary experimental results demonstrate the initial modeling and control of the manipulator.

Three-dimensional mechanical evaluation of joint contact pressure in 12 periacetabular osteotomy patients with 10-year follow-up

Background and purpose Because of the varying structure of dysplastic hips, the optimal realignment of the joint during periacetabular osteotomy (PAO) may differ between patients. Three-dimensional (3D) mechanical and radiological analysis possibly accounts better for patient-specific morphology, and may improve and automate optimal joint realignment. Patients and methods We evaluated the 10-year outcomes of 12 patients following PAO. We compared 3D mechanical analysis results to both radiological and clinical measurements. A 3D discrete-element analysis algorithm was used to calculate the pre- and postoperative contact pressure profile within the hip. Radiological angles describing the coverage of the joint were measured using a computerized approach at actual and theoretical orientations of the acetabular cup. Quantitative results were compared using postoperative clinical evaluation scores (Harris score), and patient-completed outcome surveys (q-score) done at 2 and 10 years. Results The 3D mechanical analysis indicated that peak joint contact pressure was reduced by an average factor of 1.7 subsequent to PAO. Lateral coverage of the femoral head increased in all patients; however, it did not proportionally reduce the maximum contact pressure and, in 1 case, the pressure increased. This patient had the lowest 10-year q-score (70 out of 100) of the cohort. Another hip was converted to hip arthroplasty after 3 years because of increasing osteoarthritis. Interpretation The 3D analysis showed that a reduction in contact pressure was theoretically possible for all patients in this cohort, but this could not be achieved in every case during surgery. While intraoperative factors may affect the actual surgical outcome, the results show that 3D contact pressure analysis is consistent with traditional PAO planning techniques (more so than 2D analysis) and may be a valuable addition to preoperative planning and intraoperative assessment of joint realignment.

Outcome of periacetabular osteotomy: Joint contact pressure calculation using standing AP radiographs, 12 patients followed for average 2 years

Background Due to wide variations in acetabular structure of individuals with hip dysplasia, the measurement of the acetabular orientation may not be sufficient to predict the joint loading and pressure distribution across the joint. Addition of mechanical analysis to preoperative planning, therefore, has the potential to improve the clinical outcome. We analyzed the effect of periacetabular osteotomy on hip dysplasia using computeraided simulation of joint contact pressure on regular AP radiographs. The results were compared with the results of surgery based on realignment of acetabular angles to the normal hip. Patients and methods We studied 12 consecutive periacetabular osteotomies with no femoral head deformity. The median age of patients, all females, was 35 (20–50) years. The median follow-up was 2 years (1.3–2.2). Patient outcome was measured with the total score of a self-administered questionnaire (q-score) and with the Harris hip score. The pre- and postoperative orientation of the acetabulum was defined using reconstructed 3D CT-slices to measure angles in the three anatomical planes. Peak contact pressure, weight-bearing area, and the centroid of the contact pressure distribution (CP-ratio) were calculated. Results While 9 of 12 cases showed decreased peak pressure after surgery, the mean changes in weight-bearing area and peak contact pressure were not statistically significant. However, CP-ratio changed (p < 0.001, paired t-test) with surgery. For the optimal range of CP-ratio (within its mid-range 40–60%), the mechanical outcome improved significantly. Interpretation Verifying the correlation between the optimal CP-ratio and the outcome of the surgery requires additional studies on more patients. Moreover, the anatomically measured angles were not correlated with the ranges of CP-ratio, suggesting that they do not always associate with objective mechanical goals of realignment osteotomy. Mechanical analysis, therefore, can be a valuable tool in assessing two-dimensional radiographs in hip dysplasia.

Evaluation of a computerized measurement technique for joint alignment before and during periacetabular osteotomy

Periacetabular osteotomy (PAO) is intended to treat a painful dysplastic hip. Manual radiological angle measurements are used to diagnose dysplasia and to define regions of insufficient femoral head coverage for planning PAO. No method has yet been described that recalculates radiological angles as the acetabular bone fragment is reoriented. In this study, we propose a technique for computationally measuring the radiological angles from a joint contact surface model segmented from CT-scan data. Using oblique image slices, we selected the lateral and medial edge of the acetabulum lunate to form a closed, continuous, 3D curve. The joint surface is generated by interpolating the curve, and the radiological angles are measured directly using the 3D surface. This technique was evaluated using CT data for both normal and dysplastic hips. Manual measurements made by three independent observers showed minor discrepancies between the manual observations and the computerized technique. Inter-observer error (mean difference +/- standard deviation) was 0.04 +/- 3.53 degrees for Observer 1; -0.46 +/- 3.13 degrees for Observer 2; and 0.42 +/- 2.73 degrees for Observer 3. The measurement error for the proposed computer method was -1.30 +/- 3.30 degrees . The computerized technique demonstrates sufficient accuracy compared to manual techniques, making it suitable for planning and intraoperative evaluation of radiological metrics for periacetabular osteotomy.

Design of a new independently-mobile reconfigurable modular robot

A new self-reconfigurable robot is presented. The robot is a hybrid chain/lattice design with several novel features. An active mechanical docking mechanism provides inter-module connection, along with optical and electrical interface. The docking mechanisms function additionally as driven wheels. Internal slip rings provide unlimited rotary motion to the wheels, allowing the modules to move independently by driving on flat surfaces, or in assemblies negotiating more complex terrain. Modules in the system are mechanically homogeneous, with three identical docking mechanisms within a module. Each mechanical dock is driven by a high torque actuator to enable movement of large segments within a multi-module structure, as well as low-speed driving. Preliminary experimental results demonstrate locomotion, mechanical docking, and lifting of a single module.

Preliminary development of a workstation for craniomaxillofacial surgical procedures: introducing a computer-assisted planning and execution system.

IntroductionFacial transplantation represents one of the most complicated scenarios in craniofacial surgery because of skeletal, aesthetic, and dental discrepancies between donor and recipient. However, standard off-the-shelf vendor computer-assisted surgery systems may not provide custom features to mitigate the increased complexity of this particular procedure. We propose to develop a computer-assisted surgery solution customized for preoperative planning, intraoperative navigation including cutting guides, and dynamic, instantaneous feedback of cephalometric measurements/angles as needed for facial transplantation and other related craniomaxillofacial procedures. MethodsWe developed the Computer-Assisted Planning and Execution (CAPE) workstation to assist with planning and execution of facial transplantation. Preoperative maxillofacial computed tomography (CT) scans were obtained on 4 size-mismatched miniature swine encompassing 2 live face-jaw-teeth transplants. The system was tested in a laboratory setting using plastic models of mismatched swine, after which the system was used in 2 live swine transplants. Postoperative CT imaging was obtained and compared with the preoperative plan and intraoperative measures from the CAPE workstation for both transplants. ResultsPlastic model tests familiarized the team with the CAPE workstation and identified several defects in the workflow. Live swine surgeries demonstrated utility of the CAPE system in the operating room, showing submillimeter registration error of 0.6 ± 0.24 mm and promising qualitative comparisons between intraoperative data and postoperative CT imaging. ConclusionsThe initial development of the CAPE workstation demonstrated that integration of computer planning and intraoperative navigation for facial transplantation are possible with submillimeter accuracy. This approach can potentially improve preoperative planning, allowing ideal donor-recipient matching despite significant size mismatch, and accurate surgical execution for numerous types of craniofacial and orthognathic surgical procedures.

Constrained workspace generation for snake-like manipulators with applications to minimally invasive surgery

Osteolysis is a debilitating condition that can occur behind the acetabular component of total hip replacements due to wear of the polyethylene liner. Conventional treatment techniques suggest replacing the component, while less-invasive approaches attempt to access and clean the lesion through the screw holes in the component. However, current rigid tools have been shown to access at most 50% of the lesion. Using a recently developed dexterous manipulator, we have adapted a group-theoretic convolution framework to define the manipulators workspace and its ability to fully explore a lesion. We compared this with the experimental exploration of a printed model of the lesion. This convolution approach successfully contains the experimental results and shows over 98.8% volumetric coverage of a complex lesion. The results suggest this manipulator as a possible solution to accessing much of the area unreachable to the conventional less-invasive technique.

Overcoming cross-gender differences and challenges in Le Fort-based, craniomaxillofacial transplantation with enhanced computer-assisted technology.

BackgroundSex-specific anthropometrics, skin texture/adnexae mismatch, and social apprehension have prevented cross-gender facial transplantation from evolving. However, the scarce donor pool and extreme waitlist times are currently suboptimal. Our objective was to (1) perform and assess cadaveric facial transplantation for each sex-mismatched scenario using virtual planning with cutting guide fabrication and (2) review the advantages/disadvantages of cross-gender facial transplantation. MethodsCross-gender facial transplantation feasibility was evaluated through 2 mock, double-jaw, Le Fort–based cadaveric allotransplants, including female donor-to-male recipient and male donor-to-female recipient. Hybrid facial-skeletal relationships were investigated using cephalometric measurements, including sellion-nasion-A point and sellion-nasion-B point angles, and lower-anterior-facial-height to total-anterior-facial-height ratio. Donor and recipient cutting guides were designed with virtual planning based on our team’s experience in swine dissections and used to optimize the results. ResultsSkeletal proportions and facial-aesthetic harmony of the transplants (n = 2) were found to be equivalent to all reported experimental/clinical sex-matched cases by using custom guides and Mimics technology. Cephalometric measurements relative to Eastman Normal Values are shown. ConclusionsOn the basis of our results, we believe that cross-gender facial transplantation can offer equivalent, anatomical skeletal outcomes to those of sex-matched pairs using preoperative planning and custom guides for execution. Lack of literature discussion of cross-gender facial transplantation highlights the general stigmata encompassing the subject. We hypothesize that concerns over sex-specific anthropometrics, skin texture/adnexae disparity, and increased immunological resistance have prevented full acceptance thus far. Advantages include an increased donor pool with expedited reconstruction, as well as size-matched donors.