Robert S. Armiger

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.

A New Interpretation of the Mechanism of Ankle Fracture

BACKGROUND Researchers have found it difficult to recreate a Lauge-Hansen supination-external rotation-type ankle fracture in experimental settings. We hypothesized that a pronation-external rotation mechanism could cause both distal, short oblique and high fibular fractures and that the fracture type would be affected by associated, laterally directed forces applied to the foot. Methlods: Twenty-three cadaver ankles were subjected to fracture loading that replicated the Lauge-Hansen pronation-external rotation mechanism with or without applying an external lateral force. In Phase I, an axial load was applied to fifteen specimens mounted on a materials testing machine. Each foot was rotated externally to failure. In Phase II, eight specimens were tested according to the Phase-I protocol, but external forces were applied laterally at the foot to increase the abduction moment at the ankle. Load and position versus time curves were recorded and were correlated with video image data to establish the sequence of failure of specific anatomic structures. RESULTS Eight specimens tested in Phase I sustained an oblique fracture of the distal end of the fibula with both medial and posterior injuries that occurred after the fibular fracture. Increasing the external lateral force and hence the abduction moment within the ankle (Phase II) resulted in three of eight specimens sustaining a high fibular fracture with a reversed fracture line (anterosuperior to posteroinferior) and/or a comminuted high fibular fracture. The distribution of traditional pronation-external rotation-type fractures differed significantly between Phase I and Phase II (p=0.032). CONCLUSIONS This study generated counterexamples to the Lauge-Hansen classification system by showing that a short oblique fracture of the distal end of the fibula can occur with the foot in the pronated position. Furthermore, a high fibular fracture was recreated by increasing the abduction moment at the ankle.

Individual finger control of a modular prosthetic limb using high-density electrocorticography in a human subject

OBJECTIVE We used native sensorimotor representations of fingers in a brain-machine interface (BMI) to achieve immediate online control of individual prosthetic fingers. APPROACH Using high gamma responses recorded with a high-density electrocorticography (ECoG) array, we rapidly mapped the functional anatomy of cued finger movements. We used these cortical maps to select ECoG electrodes for a hierarchical linear discriminant analysis classification scheme to predict: (1) if any finger was moving, and, if so, (2) which digit was moving. To account for sensory feedback, we also mapped the spatiotemporal activation elicited by vibrotactile stimulation. Finally, we used this prediction framework to provide immediate online control over individual fingers of the Johns Hopkins University Applied Physics Laboratory modular prosthetic limb. MAIN RESULTS The balanced classification accuracy for detection of movements during the online control session was 92% (chance: 50%). At the onset of movement, finger classification was 76% (chance: 20%), and 88% (chance: 25%) if the pinky and ring finger movements were coupled. Balanced accuracy of fully flexing the cued finger was 64%, and 77% had we combined pinky and ring commands. Offline decoding yielded a peak finger decoding accuracy of 96.5% (chance: 20%) when using an optimized selection of electrodes. Offline analysis demonstrated significant finger-specific activations throughout sensorimotor cortex. Activations either prior to movement onset or during sensory feedback led to discriminable finger control. SIGNIFICANCE Our results demonstrate the ability of ECoG-based BMIs to leverage the native functional anatomy of sensorimotor cortical populations to immediately control individual finger movements in real time.

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.

Conveying Tactile Feedback in Sensorized Hand Neuroprostheses Using a Biofidelic Model of Mechanotransduction

One approach to conveying tactile feedback from sensorized neural prostheses is to characterize the neural signals that would normally be produced in an intact limb and reproduce them through electrical stimulation of the residual peripheral nerves. Toward this end, we have developed a model that accurately replicates the neural activity evoked by any dynamic stimulus in the three types of mechanoreceptive afferents that innervate the glabrous skin of the hand. The model takes as input the position of the stimulus as a function of time, along with its first (velocity), second (acceleration), and third (jerk) derivatives. This input is filtered and passed through an integrate-and-fire mechanism to generate a train of spikes as output. The major conclusion of this study is that the timing of individual spikes evoked in mechanoreceptive fibers innervating the hand can be accurately predicted by this model. We discuss how this model can be integrated in a sensorized prosthesis and show that the activity in a population of simulated afferents conveys information about the location, timing, and magnitude of contact between the hand and an object.

A real-time virtual integration environment for the design and development of neural prosthetic systems

We have developed a virtual integration environment (VIE) for the development of neural prosthetic systems. The VIE is a software environment that modularizes the core functions of a neural prosthetic system — receiving signals, decoding signals and controlling a real or simulated device. Complete prosthetic systems can be quickly assembled by linking pre-existing modules together through standard interfaces. Systems can be simulated in real-time, and simulated components can be swapped out for real hardware. This paper is the first of two companion papers that describe the VIE and its use. In this paper, we first describe the architecture of the VIE and review implemented modules. We then describe the use of the VIE for the real-time validation of neural decode algorithms from pre-recorded data, the use of the VIE in closed loop primate experiments and the use of the VIE in the clinic.

Air-Guitar Hero: A real-time video game interface for training and evaluation of dexterous upper-extremity neuroprosthetic control algorithms

We developed an interface to the commercial video game Guitar Heroreg III using surface electromyography (EMG) to create a novel training and evaluation device for upperextremity amputees. Rather than pressing the keys with onepsilas fingers as in the normal game, in our modified version a user merely flexes his or her index, middle, or ring finger muscles, and the resulting myoelectric activity is recorded using six or more EMG electrodes placed around the forearm. The acquired data is processed in real-time using pattern recognition algorithms to derive intended motion, and the results are used to control the game. Performance metrics reported by the gamepsilas built-in scoring system are used to evaluate classifier performance. To confirm the functionality of the system, three non-amputee users evaluated the EMG-controlled game (called ldquoAir-Guitar Herordquo) and reported that it was effective, fun, and engaging. Ultimately, we intend to use this system as a performance assay for different types of motor decoding algorithms for dexterous control of upper-extremity neuroprostheses.

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.

Prediction of Three-Dimensional Contact Stress and Ligament Tension in the Ankle During Stance Determined from Computational Modeling

Background: Our goal was to quantify and visualize the three-dimensional loading relationship between the ligaments and articular surfaces of the ankle to identify and determine the stabilizing roles of these anatomical structures during the stance phase of gait. Materials and Methods: We applied discrete element analysis to computationally model the three-dimensional contact characteristics and ligament loading of the ankle joint. Physiologic loads approximating those at five positions in the stance phase of a normal walk cycle were applied. We analyzed joint contact pressures and periankle ligament tension concurrently. Results: Most ankle joint loading during the stance phase occurred across the articular surfaces of the joint, and the amount of ligament tension was small. The tibiotalar articulation showed full congruency throughout most of the stance phase, with peak pressure developing anteriorly toward the toe-off frame. Of the periankle ligaments, the deep deltoid ligament transferred the most force during the stance phase (57.2%); the superficial deltoid ligament transferred the second-most force (26.1%). The anterior talofibular ligament transferred force between the talus and fibula continuously, whereas the calcaneofibular ligament did not carry force during gait. The distal tibiofibular ligaments and the interosseous membrane were loaded throughout the stance phase. Conclusion: Force transmission through the ankle joint during the stance phase is predominantly through the articular surfaces, and the periankle ligaments do not play a major stabilizing role in constraining ankle motion. The medial ligaments have a more important role than do the lateral ligaments in stabilizing the ankle joint. Clinical Relevance: In addition to ligament insufficiency, other factors, such as varus tilt of the tibial plafond, may be important in the development of recurrent instability. Continuous loading of syndesmosis ligaments provides a theoretical basis for evidence of syndesmosis screw breakage or loosening. The analysis method has potential applications for clarifying ankle joint function and providing a basis for comparison between normal and abnormal joint conditions.

WiiEMG: A real-time environment for control of the Wii with surface electromyography

We have developed a hardware and software platform, the WiiEMG, for controlling the Wii™ video game console with surface electromyography (EMG). WiiEMG is intended to assist with training and performance assessment of myoelectric control of upper arm prostheses. For this application, a player wears skin surface electrodes over myoelectric control sites. A real-time signal analysis system acquires amplified EMG signals and classifies the activity patterns associated with different motions. In addition, the amplitude of this pattern is used as a velocity signal, which is differentiated to give acceleration. Finally, a scaled version of this acceleration value is input as an analog voltage into a modified Wiimote™ in place of the normal accelerometer, and the Wiimote communicates the data to the console. To evaluate the systems performance, six able-bodied subjects were used to test the WiiEMG by playing the game Wii Tennis™ using myoelectric control. Results are reported that show how users develop improved EMG control after only a few brief trials. Improved muscle and EMG control has the potential to benefit myoelectric limb use as well as motor skills rehabilitation.