computer assisted image processing and …sheet „ 1993-94 canada “with the development of of...
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Prof. Dr. Endre Varga Balázs Erdőhelyi
University of Szeged Albert Szent-Györgyi Clinical Center
Department of Trauma Surgery and
Department of Image Processing and Computer Graphics
Computer Assisted Image Processing and Navigation Systems for Trauma
Surgery (Making our life easier)
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Our duty
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Sheet
„
Once upon a time…1956
What they had?
Huge practise
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Sheet
„
Once upon a time…
What they had?
Huge practise More respect?
„„„
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Sheet
„
1993-94 Canada
“With the development of of image control guidance systems, percutaneous fixation of the unstable posterior pelvic ring injury will become safer and will, I believe, become the method of choice for early stabilization.”
(Marvin Tile, Foreword. Injury, Supplement, Pelvic Ring Injuries, Part II, 1996, Vol.27, Suppl. 2)
„„„
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Sheet
„
Today - what else?
„
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Sheet
„
Today - what else?
• Good light • Good power tools (Light, oscillating drills)
llii ht
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Sheet
„
Today - imaging
• Conventional x-ray • 3-D C-arm • CT scan • Spiral CT scan • MRI • Ultrasound • Arthroscopy (optical imaging) • Radioisotope scan • Navigation • Preop. Planning
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History
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Take home
10
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Literature
new challenge, different evidence levels
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Smartphones/tablets
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Today trends
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Offer an Idea
Last 19 years TEAM work IT experts (software designers) medical doctors engineers
focused education
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Planning softwares on the market
Non competitive
No FEA
No animation
Not 3D
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Maybe the plan was wrong? - Interactive 3D-plan
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Should be plan!
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What are the strengths of ?
•Team with same interest (common language)
•AO trained clinicians and mathematicians
•The Trauma Department, U of Szeged is a dedicated AOTrauma Educational Center - aim to be an AO Research Site as well
•Surgeons and computer experts are working “hand in hand”
•Wide international connections
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Endre Varga, MD, PhD. Professor of Trauma Surgery, University of Szeged, HungaryLevel I Trauma Center
general-, trauma-, orthopedic- & hand-surgeonPresident of Hungarian Trauma SocietyAO TrusteePresident of the AOTrauma Hungarian ChapterChair of ATLS HungaryHungarian delegate of ESTES
87 Fellowship, Martin Luther University, Halle, Germany93-94 Fellowship at Sunnybrook Health Science Centre, Toronto, Canada (Biomechanical research)96 AO Fellowship at Carolinas Medical Center, Charlotte NC, USA
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ARI Research Fellowship
Balázs Bagó Szeged, Hungary Computer Science
Fellowship March 2011 - December 2011
Endre Varga jr. DMD Szeged, Hungary Doctor in Dentistry
Fellowship March 2010 - March 2011
Balázs Erdőhelyi Szeged, Hungary Computer Science
Fellowship August 2010 - January 2011 Co-worker 11 August 2011- June 2012
more than 3 years!!!
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CT 3D Biomech.
Segmented
Image
3D Surface
model
Implants
Surgical
Plan
Mechanical
data
Biomech.
model
CT image
FEA
Analysis
Operating Room Navigation
The whole idea
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CT 3D Biomech.
Segmented
Image
3D Surface
model
Implants
Surgical
Plan
Mechanical
data
Biomech.
model
CT image
FEA
Analysis
Operating Room Navigation
The idea
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Segmen-tation
SurfaceExtraction
MechanicalModel
Generation
ResultEvaluation
Analysis
Surgical Planning
CT
JMed
FEA
System Overview - CT
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Segmen-tation
SurfaceExtraction
MechanicalModel
Generation
ResultEvaluation
Analysis
Surgical Planning
CT
JMed
FEA
System Overview - Segmentation
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Marching Cubes ~800k triangles
ss
Simplification ~100k triangles
Segmen-tation
SurfaceExtraction
MechanicalModel
Generation
ResultEvaluation
Analysis
Surgical Planning
CT
JMed
FEA
System Overview – Surface Extraction
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Segmen-tation
SurfaceExtraction
MechanicalModel
Generation
ResultEvaluation
Analysis
Surgical Planning
CT
JMed
FEA
System Overview – Surgical Planning
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Segmen-tation
SurfaceExtraction
MechanicalModel
Generation
ResultEvaluation
Analysis
Surgical Planning
CT
JMed
FEA
System Overview – Mechanical Model
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Segmen-tation
SurfaceExtraction
MechanicalModel
Generation
ResultEvaluation
Analysis
Surgical Planning
CT
JMed
FEA
System Overview – Result
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SzE, 50yFemale
Fall from high
Acetabulum
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Acetabulum
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Intraop
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TraumArt on the screen
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low profile plates
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Case presentation (planning and procedure)
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Segmen-tation
SurfaceExtraction
MechanicalModel
Generation
ResultEvaluation
Analysis
Surgical Planning
CT
JMed
FEA
Planning
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1. Register and login. 2. Create a Study. 3. Pre-operative survey. 4. Upload DICOM files. 5. View results. 6. Post-operative survey.
Service and clinical trial http://www.inf.u-szeged.hu/~medsys/service.php
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• Users: 25 different countries
• Countries: Europe and Australia, USA, Columbia, Saudi Arabia, Canada.
Present status
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Italian Case
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Italian Case
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Italian Case with VCP
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Italian Case with juxtaartic-LCP
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It. Case with 2 col dorsal plates
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Italian Case VA-LCP
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Case VA-LCP
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VA-LCP focused on key screws
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Postoperative Xrays
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Postoperative Xrays
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Spine16y/ female/ horseriding No neurological compl.
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Spine
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Spine
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Spine
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CMF - case
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Glider Truck crush
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Glider Truck crush
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Glider Truck crush
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Glider Truck crush
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Intermediate splint - rapid prototype
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Human
CT
image
FEA
Analysis
Educational platform first step
Animation
AO Surgery reference
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Simplify the question Injury animation - surgery reference
Be a surgeon! Play with forces
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Straddle fx
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Bucket handle fx
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AP (B1) HD Risk ++
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LC (B2) H/D Risk +/-
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VS (C) H/D Risk ++/-
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Injury animation - surgery reference
On site support
Sequential introduction
International development with experts involvement
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Bone defect allograft library
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Implant design
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Injury animation - surgery referenceCooperation with ARI
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PublicationsB Erdőhelyi, E Varga and A Kuba (2007) Surgical Planning Tool with Biomechanical Simulation. Int J CARS 2 (Suppl 1):S246–S272
E. Varga, B. Dudás, and M. Tile (2008) Putitative prorioceptive function of the pelvic ligaments: Biomechanical and histological studies Injury Vol.39, pp. 858-864.
E. Varga, B. Erdőhelyi (2010) Severe Pelvic Bleeding: The Role of Primary Internal Fixation European Journal of Trauma and Emergency Surgery, NO.2 pp. 107-116
ncycy
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• 1. EDUCATION: Implementing the program into the AOSurgery Reference (animations)
• 2. CLINICAL: Validate the Program with the help of German Trauma Registry cases (C. Krettek - 20T/20 CMF- pilot)
• Evaluate webclinical feedbacks
• 3. R&D: Further development in cooperation with the ARI
Future steps
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EU Grant GOP 1.1.1. Siemens ARCADIS ISO C 3D Image Intensifire, BrainLab IO Navigation Unit.
Pelvis, Acetabulum, Spine, Joints surgeries
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TRAUMA TEAM
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Sheet
„
What is different in the OR?
„
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Sheet
„
Light…
„
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MonitorMonitor
Carbon/ARCADIS/BrainLab/Carbon op table
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Sheet
„
Today - imaging
• Conventional x-ray • 3-D C-arm • CT scan • Spiral CT scan • MRI • Ultrasound • Arthroscopy (optical imaging) • Radioisotope scan • Navigation • Preop. Planning
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Sheet
„
Today - what else?
• Good light • Good power tools (Light, oscillating drills)
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SummaryVarious imaging modalities exist…
• Conventional x-ray: adequate for most bone injuries • 3-D C-arm: intraoperative assessment of reduction and
fixation • CT scan: imaging of complex intraarticular fractures • Spiral CT scan: polytrauma • MRI: deep soft-tissue lesions
• IO Navigation and CT and • 3D Virtual Planning improved patient
care
Modalities
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Sheet
„
Conventional X-ray (Image intensifire)
Limits Some fractures and subluxations difficult to see Poor visualization of soft tissues Potentially insufficient information for planning
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Sheet
„
Conventional X-ray (Image intensifire)
„
Limits Some fractures and subluxations difficult to see Poor visualization of soft tissues Potentially insufficient information for planning
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Monitor
Modified C-Arm with a motor unit allows steady orbital rotation around 190° arc
Modified C-Arm with a motorttststssteaeaeaeadddydydydy ooo o bbrbrbrbrbitititittit llalalaal rrr r ttotototot ttatataatiiioiooionnnn araraarouououou
13 cm³
Intraoperative ISO C 3D ARCADIS
Modified C-Arm with a motor unit allows steady orbital rotation
Computerized special work station for intra-operative visualization
Imaging starts with rotation of 190° around the object to be studied
Inatraoperative 3D Imaging with Mobile Isocentric C-Arm
Siemens ARCADIS IsoC-3D
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During this movement, a set of 2D projections in fixed angular steps is recorded in normal or HD quality
DeviceInatraoperative 3D Imaging with Mobile Isocentric C-Arm
Siemens ARCADIS IsoC-3D
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During this movement, a set of 2D projections in fixed angular steps is recorded in normal or HD quality
DeviceInatraoperative 3D Imaging with Mobile Isocentric C-Arm
Siemens ARCADIS IsoC-3D
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During this movement, a set of 2D projections in fixed angular steps is recorded in normal or HD quality
DeviceInatraoperative 3D Imaging with Mobile Isocentric C-Arm
Siemens ARCADIS IsoC-3D
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Monitor
Navigation Unit
Siremobil Iso-C-3D
Navi with IsoC-3D
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Monitor
Carbon/ARCADIS/BrainLab
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Monitor
Carbon/ARCADIS/BrainLab
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Monitor
ARCADIS/BrainLab
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Monitor
ARCADIS/BrainLab
Monitor
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Monitor
59y, female, MVA
Monitor
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Monitor
C-arm setup
MMoMooMMoMMMMM niniiiinnn tototootoooooooot rrrrrrrrr
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Monitor
Arcadis ISO-C 3D
MMMoMoMoooMoMooooMMoooMMoMooMoooMMoooooMMoooonnniniiiiiiiiniinin ttotttttttt rrrrr
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Monitor
Legs’ rotation
MMMMMMMMMMoMoMoMMMMoooMooMoMoMMMoMoMoMMM ininninnininniininnnin totootoooottotoootottoottoootoootoorrrrrrrrrrrrr
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Monitor
“High Tech” - reduction tricks
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Monitor
PIB removal
MoMoMoMoooMMoMoMMMMoooMMMoooMoooonnnninininnnnnniinnnnnininnnnniinninnnininittoootootttoottoooottoototooottotoottoorrrrrrrrrrrr
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Monitor
PS reduction
MMMMMoMoMoMoMMoniniinnininiin tottotoootttooooototooorrrrrrr
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Monitor
TEN
MoMMMoMM ninnnin totototorr
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Monitor
PS Plating
MMMMMMoMMMMMoMoMMMMMoooMMMMMMMMoooooMMMMMMMMoooooMMMMMooooMMMooooMoMMMMooo iiinninnnnnninnnnninnnnniinininnnnittttttttoooottoooootototooototototorrrrrrrrrrrrrrrr
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Monitor
Navigaton markers
MMoMMooooMoM nniiinininn tottoooootoootoooot rrrrrrrr
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Monitor
Infracamera
MMoMooooM nninin totooorrrr
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Monitor
“Arcadischeck”
MoMoMoMMoMooMooMoniinninninininitotttotototototototototot rrrrrrrrrrrr
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Monitor
“Pointer”
MMoMMMMMooooMoMoMoMoooooMoMMooooonnininnniinnnniinnnnninnnninnnnniinnnnnniitttototottotttototoototorrrrrrrr
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Monitor
Planning (80/48 mm/10mm
MoMoMoMoMoMoMMoMoMoMMMMoMooonninininininniininniniitototototootoooooottttoooottoooottooottotorrrrrrrrrrrrrrrrrr
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Monitor
Calibration
MoMMoo inininiitototot rrr
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Monitor
K-wires/drill/tap
MMMoMooooMMooMoMooMoMMoMoMoMooMoooMMoooonnniinniniinnninininininnniittttotooottottooorrrrrrrr
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Monitor
SI screw insertion
MMMMMMMMooMMMooMMoMMMooMoMMMoooMMoMMMMMMMooooMMoooonnniininnniniinnininnitottoooooooooottttoorrrrrrrrrr
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Monitor
Arcadis check
MoMM ninnin totototorrrr
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Monitor
59y, female, MVA
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Monitor
Variations in sacral morphology
MoMoMoMoniiininittttotottorrrrr
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AH, 33é, nőbeteg, AO 41C3
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AH, 33é, nőbeteg, AO 41C3
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Tibia plateu navi
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Tibia plateu navi
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• 3D Virtual Planning with prediction of stability that will lead to improved patient care
• Biomechanical lab • Application fields
– Clinical practice
– Education – Research
Take home...
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Monitor
Novel techniques
Feasible
Enables the surgeon:
to evaluate fracture type
to judge reduction & implant position
intra-operative validation
ittoooooorr
The use of intraoperative three-dimensional imaging (ISO-C-3D) in fixation of intraarticular fractures K Atesok, J Finkelstein, A Khoury, A Peyser, Y Weil… - Injury, 2007 - Elsevier
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Monitor
Novel techniques
MMoMoMoMoMoMoMo inininininininittototototototorrrrrrrM it
Feasible
Enables the surgeon:
to evaluate fracture type
to judge reduction & implant position
intra-operative validation
More safe, (anatomical variations!)Computer-assisted trauma surgery K Atesok, EH Schemitsch - Journal of the American …, 2010 - Am Acad Ortho Surgeons
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Sheet
„
Take home…
Severeal new “toys” exsist
“High Tech” is a better chance
The surgeon has to be remain “the doctor”
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136
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E. Varga EISSF