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Chan HHL, Nayak P, Alshaygy I, Gundle KR, Tsoi K, Daly MJ, Irish JC, Ferguson PC, Wunder JS. Does Freehand, Patient-specific Instrumentation or Surgical Navigation Perform Better for Allograft Reconstruction After Tumor Resection? A Preclinical Synthetic Bone Study. Clin Orthop Relat Res 2024:00003086-990000000-01620. [PMID: 38813958 DOI: 10.1097/corr.0000000000003116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 04/12/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Joint-sparing resection of periarticular bone tumors can be challenging because of complex geometry. Successful reconstruction of periarticular bone defects after tumor resection is often performed with structural allografts to allow for joint preservation. However, achieving a size-matched allograft to fill the defect can be challenging because allograft sizes vary, they do not always match a patient's anatomy, and cutting the allograft to perfectly fit the defect is demanding. QUESTIONS/PURPOSES (1) Is there a difference in mental workload among the freehand, patient-specific instrumentation, and surgical navigation approaches? (2) Is there a difference in conformance (quantitative measure of deviation from the ideal bone graft), elapsed time during reconstruction, and qualitative assessment of goodness-of-fit of the allograft reconstruction among the approaches? METHODS Seven surgeons used three modalities in the same order (freehand, patient-specific instrumentation, and surgical navigation) to fashion synthetic bone to reconstruct a standardized bone defect. National Aeronautics and Space Administration (NASA) mental task load index questionnaires and procedure time were captured. Cone-beam CT images of the shaped allografts were used to measure conformance (quantitative measure of deviation from the ideal bone graft) to a computer-generated ideal bone graft model. Six additional (senior) surgeons blinded to modality scored the quality of fit of the allografts into the standardized tumor defect using a 10-point Likert scale. We measured conformance using the root-mean-square metric in mm and used ANOVA for multipaired comparisons (p < 0.05 was significant). RESULTS There was no difference in mental NASA total task load scores among the freehand, patient-specific instrumentation, and surgical navigation techniques. We found no difference in conformance root-mean-square values (mean ± SD) between surgical navigation (2 ± 0 mm; mean values have been rounded to whole numbers) and patient-specific instrumentation (2 ± 1 mm), but both showed a small improvement compared with the freehand approach (3 ± 1 mm). For freehand versus surgical navigation, the mean difference was 1 mm (95% confidence interval [CI] 0.5 to 1.1; p = 0.01). For freehand versus patient-specific instrumentation, the mean difference was 1 mm (95% CI -0.1 to 0.9; p = 0.02). For patient-specific instrumentation versus surgical navigation, the mean difference was 0 mm (95% CI -0.5 to 0.2; p = 0.82). In evaluating the goodness of fit of the shaped grafts, we found no clinically important difference between surgical navigation (median [IQR] 7 [6 to 8]) and patient-specific instrumentation (median 6 [5 to 7.8]), although both techniques had higher scores than the freehand technique did (median 3 [2 to 4]). For freehand versus surgical navigation, the difference of medians was 4 (p < 0.001). For freehand versus patient-specific instrumentation, the difference of medians was 3 (p < 0.001). For patient-specific instrumentation versus surgical navigation, the difference of medians was 1 (p = 0.03). The mean ± procedural times for freehand was 16 ± 10 minutes, patient-specific instrumentation was 14 ± 9 minutes, and surgical navigation techniques was 24 ± 8 minutes. We found no differences in procedures times across three shaping modalities (freehand versus patient-specific instrumentation: mean difference 2 minutes [95% CI 0 to 7]; p = 0.92; freehand versus surgical navigation: mean difference 8 minutes [95% CI 0 to 20]; p = 0.23; patient-specific instrumentation versus surgical navigation: mean difference 10 minutes [95% CI 1 to 19]; p = 0.12). CONCLUSION Based on surgical simulation to reconstruct a standardized periarticular bone defect after tumor resection, we found a possible small advantage to surgical navigation over patient-specific instrumentation based on qualitative fit, but both techniques provided slightly better conformance of the shaped graft for fit into the standardized post-tumor resection bone defect than the freehand technique did. To determine whether these differences are clinically meaningful requires further study. The surgical navigation system presented here is a product of laboratory research development, and although not ready to be widely deployed for clinical practice, it is currently being used in a research operating room setting for patient care. This new technology is associated with a learning curve, capital costs, and potential risk. The reported preliminary results are based on a preclinical synthetic bone tumor study, which is not as realistic as actual surgical scenarios. CLINICAL RELEVANCE Surgical navigation systems are an emerging technology in orthopaedic and reconstruction surgery, and understanding their capabilities and limitations is paramount for clinical practice. Given our preliminary findings in a small cohort study with one scenario of standardized synthetic periarticular bone tumor defects, future investigations should include different surgical scenarios using allograft and cadaveric specimens in a more realistic surgical setting.
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Affiliation(s)
- Harley H L Chan
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- TECHNA Institute, Guided Therapeutics (GTx) Program, University Health Network, Toronto, Ontario, Canada
| | - Prakash Nayak
- Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, India
| | - Ibrahim Alshaygy
- Department of Orthopaedics, College of Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Kenneth R Gundle
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Kim Tsoi
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Surgical Oncology, University Health Network, Toronto, Ontario, Canada
| | - Michael J Daly
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- TECHNA Institute, Guided Therapeutics (GTx) Program, University Health Network, Toronto, Ontario, Canada
| | - Jonathan C Irish
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- TECHNA Institute, Guided Therapeutics (GTx) Program, University Health Network, Toronto, Ontario, Canada
- Department of Surgical Oncology, University Health Network, Toronto, Ontario, Canada
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Peter C Ferguson
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Surgical Oncology, University Health Network, Toronto, Ontario, Canada
| | - Jay S Wunder
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Surgical Oncology, University Health Network, Toronto, Ontario, Canada
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Wang C, Huang S, Yu Y, Liang H, Wang R, Tang X, Ji T. Fluoroscopically calibrated 3D-printed patient-specific instruments improve the accuracy of osteotomy during bone tumor resection adjacent to joints. 3D Print Med 2024; 10:15. [PMID: 38656431 PMCID: PMC11041006 DOI: 10.1186/s41205-024-00216-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 04/15/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Inadequate surface matching, variation in the guide design, and soft tissue on the skeletal surface may make it difficult to accurately place the 3D-printed patient-specific instrument (PSI) exactly to the designated site, leading to decreased accuracy, or even errors. Consequently, we developed a novel 3D-printed PSI with fluoroscopy-guided positioning markers to enhance the accuracy of osteotomies in joint-preserving surgery. The current study was to compare whether the fluoroscopically calibrated PSI (FCPSI) can achieve better accuracy compared with freehand resection and conventional PSI (CPSI) resection. METHODS Simulated joint-preserving surgery was conducted using nine synthetic left knee bone models. Osteotomies adjacent to the knee joint were designed to evaluate the accuracy at the epiphysis side. The experiment was divided into three groups: free-hand, conventional PSI (CPSI), and fluoroscopically Calibrated PSI (FCPSI). Post-resection CT scans were quantitatively analyzed. Analysis of variance (ANOVA) was used. RESULT FCPSI improved the resection accuracy significantly. The mean location accuracy is 2.66 mm for FCPSI compared to 6.36 mm (P < 0.001) for freehand resection and 4.58 mm (P = 0.012) for CPSI. The mean average distance is 1.27 mm compared to 2.99 mm (p < 0.001) and 2.11 mm (p = 0.049). The mean absolute angle is 2.16° compared to 8.50° (p < 0.001) and 5.54° (p = 0.021). The mean depth angle is 1.41° compared to 8.10° (p < 0.001) and 5.32° (p = 0.012). However, there were no significant differences in the front angle compared to the freehand resection group (P = 0.055) and CPSI (P = 0.599) group. The location accuracy observed with FCPSI was maintained at 4 mm, while CPSI and freehand resection exhibited a maximum deviation of 8 mm. CONCLUSION The fluoroscopically calibrated 3D-printed patient-specific instruments improve the accuracy of osteotomy during bone tumor resection adjacent to joint joints compared to conventional PSI and freehand resection. In conclusion, this novel 3D-printed PSI offers significant accuracy improvement in joint preserving surgery with a minimal increase in time and design costs.
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Affiliation(s)
- Chen Wang
- Peking University People's Hospital, Musculoskeletal Tumor Center, Beijing, China
| | - Siyi Huang
- Peking University People's Hospital, Musculoskeletal Tumor Center, Beijing, China
| | - Yue Yu
- LDK Medical Co., Ltd., R&D, Beijing, China
| | - Haijie Liang
- Peking University People's Hospital, Musculoskeletal Tumor Center, Beijing, China
| | - Ruifeng Wang
- Peking University People's Hospital, Musculoskeletal Tumor Center, Beijing, China
| | - Xiaodong Tang
- Peking University People's Hospital, Musculoskeletal Tumor Center, Beijing, China
| | - Tao Ji
- Peking University People's Hospital, Musculoskeletal Tumor Center, Beijing, China.
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Hill D, Williamson T, Lai CY, Leary M, Brandt M, Choong P. Automated elaborate resection planning for bone tumor surgery. Int J Comput Assist Radiol Surg 2023; 18:553-564. [PMID: 36319922 PMCID: PMC9939503 DOI: 10.1007/s11548-022-02763-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 09/19/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Planning for bone tumor resection surgery is a technically demanding and time-consuming task, reliant on manual positioning of planar cuts in a virtual space. More elaborate cutting approaches may be possible through the use of surgical robots or patient-specific instruments; however, methods for preparing such a resection plan must be developed. METHODS This work describes an automated approach for generating conformal bone tumor resection plans, where the resection geometry is defined by the convex hull of the tumor, and a focal point. The resection geometry is optimized using particle swarm, where the volume of healthy bone collaterally resected with the tumor is minimized. The approach was compared to manually prepared planar resection plans from an experienced surgeon for 20 tumor cases. RESULTS It was found that algorithm-generated hull-type resections greatly reduced the volume of collaterally resected healthy bone. The hull-type resections resulted in statistically significant improvements compared to the manual approach (paired t test, p < 0.001). CONCLUSIONS The described approach has potential to improve patient outcomes by reducing the volume of healthy bone collaterally resected with the tumor and preserving nearby critical anatomy.
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Affiliation(s)
- Dave Hill
- Centre for Additive Manufacturing, School of Engineering, RMIT University, 58 Cardigan St, Carlton, 3001, Australia
| | - Tom Williamson
- Centre for Additive Manufacturing, School of Engineering, RMIT University, 58 Cardigan St, Carlton, 3001, Australia.
| | - Chow Yin Lai
- Department of Electronic and Electrical Engineering, University College London, Malet Place and Torrington Place, Roberts Building, Level 7, London, WC1E 7JE, UK
| | - Martin Leary
- Centre for Additive Manufacturing, School of Engineering, RMIT University, 58 Cardigan St, Carlton, 3001, Australia
| | - Milan Brandt
- Centre for Additive Manufacturing, School of Engineering, RMIT University, 58 Cardigan St, Carlton, 3001, Australia
| | - Peter Choong
- Department of Surgery, University of Melbourne, Level 2, Clinical Sciences Building, 29 Regent Street, Fitzroy, 3065, Australia
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He G, Dai AZ, Mustahsan VM, Shah AT, Li L, Khan JA, Bielski MR, Komatsu DE, Kao I, Khan FA. A novel method of light projection and modular jigs to improve accuracy in bone sarcoma resection. J Orthop Res 2022; 40:2522-2536. [PMID: 35245391 DOI: 10.1002/jor.25300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 02/04/2023]
Abstract
We developed a novel method using a combined light-registration/light-projection system along with an off-the-shelf, instant-assembly modular jig construct that could help surgeons improve bone resection accuracy during sarcoma surgery without many of the associated drawbacks of 3D printed custom jigs or computer navigation. In the novel method, the surgeon uses a light projection system to precisely align the assembled modular jig construct on the bone. In a distal femur resection model, 36 sawbones were evenly divided into 3 groups: manual-resection (MR), conventional 3D-printed custom jig resection (3DCJ), and the novel projector/modular jig (PMJ) resection. In addition to sawbones, a single cadaver experiment was also conducted to confirm feasibility of the PMJ method in a realistic operative setting. The PMJ method improved resection accuracy when compared to MR and 3DCJ, respectively: 0.98 mm versus 7.48 mm (p < 0.001) and 3.72 mm (p < 0.001) in mean corner position error; 1.66 mm versus 9.70 mm (p < 0.001) and 4.32 mm (p = 0.060) in mean maximum deviation error; 0.79°-4.78° (p < 0.001) and 1.26° (p > 0.999) in mean depth angle error. The PMJ method reduced the mean front angle error from 1.72° to 1.07° (p = 0.507) when compared to MR but was slightly worse compared to 0.61° (p = 0.013) in 3DCJ. The PMJ method never showed an error greater than 3 mm, while the maximum error of other two control groups were almost 14 mm. Similar accuracy was found with the PMJ method on the cadaver. A novel method using a light projector with modular jigs can achieve high levels of bone resection accuracy, but without many of the associated drawbacks of 3D printed jigs or computer navigation technology.
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Affiliation(s)
- Guangyu He
- Department of Mechanical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Amos Z Dai
- Department of Orthopedics, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Vamiq M Mustahsan
- Department of Mechanical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Aadit T Shah
- Department of Orthopedics, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Liming Li
- Department of Mechanical Engineering, Stony Brook University, Stony Brook, New York, USA
| | | | - Michael R Bielski
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - David E Komatsu
- Department of Orthopedics, Stony Brook University Hospital, Stony Brook, New York, USA
| | - Imin Kao
- Department of Mechanical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Fazel A Khan
- Department of Orthopedics, Stony Brook University Hospital, Stony Brook, New York, USA
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He G, Dai AZ, Mustahsan VM, Shah AT, Li L, Khan JA, Bielski MR, Komatsu DE, Kao I, Khan FA. A novel intraoperative method to project osteotomy lines for accurate resection of primary bone sarcomas. J Orthop 2022; 32:60-67. [DOI: 10.1016/j.jor.2022.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/01/2022] [Accepted: 04/28/2022] [Indexed: 10/18/2022] Open
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Evrard R, Schubert T, Paul L, Docquier PL. Quality of resection margin with patient specific instrument for bone tumor resection. J Bone Oncol 2022; 34:100434. [PMID: 35601663 PMCID: PMC9115318 DOI: 10.1016/j.jbo.2022.100434] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 05/02/2022] [Accepted: 05/03/2022] [Indexed: 11/19/2022] Open
Abstract
Patient-specific instruments (PSI) improve surgical orthopaedic interventions. Resection margins are all safe for oncologic resections in our series. All types of bone tumour were included. Planification margins can be shortened to 5 mm thanks to their accuracy. The correlation index between planned and obtained margins is excellent.
Background Patient Specific Instruments (PSI) is currently a proven technique for bone tumor resection. In a previous publication, we analyzed the quality of margin resection of pelvic sarcoma resections with the use of PSI (by pathologic evaluation of the margins). In this new study, we compare preoperative resection planning and actual resection margins by MRI analysis of the resection specimens. Methods Between 2011 and 2020, 31 patients underwent bone tumor resection with the use of PSI. Preoperatively, the margins were planned with a software and PSI were made according to these margins. Postoperatively, the surgical resection specimens were analyzed with MRI. Resection margins were measured with the same software used in the preoperative planning. Results All margins were safe (free of tumor). The differences between preoperative planned margins and the obtained ones were within the range −5 to +5 mm. The correlation between planned margin and the obtained one was excellent (R2 = 0.841; p < 0.0001). Conclusions This study demonstrates the accuracy of PSI. In our series, all resection margins were safe. A minimal 5 mm-margin has to be planned but a larger sample is needed to give recommendations.
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Affiliation(s)
- Robin Evrard
- Secteur des Sciences de la Santé, Institut de Recherche Expérimentale et Clinique, Neuro Musculo Skeletal Lab (NMSK), Université catholique de Louvain, Avenue Mounier 53, B-1200 Brussels, Belgium
- Service d’orthopédie et de traumatologie de l’appareil locomoteur, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, B-1200 Brussels, Belgium
- Institut Roi Albert II, cancérologie et hématologie, cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium
- Corresponding author at: Secteur des Sciences de la Santé, Institut de Recherche Expérimentale et Clinique, Neuro Musculo Skeletal Lab (NMSK), Université catholique de Louvain, Avenue Mounier 53, B-1200 Brussels, Belgium.
| | - Thomas Schubert
- Secteur des Sciences de la Santé, Institut de Recherche Expérimentale et Clinique, Neuro Musculo Skeletal Lab (NMSK), Université catholique de Louvain, Avenue Mounier 53, B-1200 Brussels, Belgium
- Service d’orthopédie et de traumatologie de l’appareil locomoteur, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, B-1200 Brussels, Belgium
- Institut Roi Albert II, cancérologie et hématologie, cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Laurent Paul
- 3D-Side, André Dumont, 5, 1435 Mont-Saint-Guibert, Belgium
| | - Pierre-Louis Docquier
- Secteur des Sciences de la Santé, Institut de Recherche Expérimentale et Clinique, Neuro Musculo Skeletal Lab (NMSK), Université catholique de Louvain, Avenue Mounier 53, B-1200 Brussels, Belgium
- Service d’orthopédie et de traumatologie de l’appareil locomoteur, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, B-1200 Brussels, Belgium
- Institut Roi Albert II, cancérologie et hématologie, cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium
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He G, Dai AZ, Mustahsan VM, Blum CL, Kao I, Khan FA. A Novel 3D Light Assisted Drawing (3D-LAD) Method to Aid Intraoperative Reproduction of Osteotomy Lines Surrounding a Bone Tumor During Wide Resection: An Experimental Study. Orthop Res Rev 2022; 14:101-109. [PMID: 35422661 PMCID: PMC9005132 DOI: 10.2147/orr.s349240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/22/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Computer navigation and customized 3D-printed jigs improve accuracy during bone tumor resection, but such technologies can be bulky, costly, and require intraoperative radiation, or long lead time to be ready in OR. Methods We developed a method utilizing a compact, inexpensive, non-X-ray based 3D surface light scanner to provide a visual aid that helps surgeons accurately draw osteotomy lines on the surface of exposed bone to reproduce a well-defined preoperative bone resection plan. We tested the accuracy of the method on 18 sawbones using a distal femur hemimetaphyseal resection model and compared it with a traditional, freehand method. Results The method significantly reduces the positional error from 2.53 (±1.13) mm to 1.04 (±0.43) mm (p<0.001), and angular error of the front angle from 2.10° (±0.83°) to 0.80° (±0.66°) (p=0.001). The method also reduces the mean maximum deviation of the bone resection, with respect to the preoperative path, from 3.75mm to 2.69mm (p=0.003). However, no increased accuracy was observed at the back side of the bone surface where this method would not be expected to provide information. Discussion In summary, we developed a novel 3D-LAD navigation technology. From the experimental study, we demonstrated that the method can improve the ability of surgeons to accurately draw the preoperative osteotomy lines and perform resection of a primary bone sarcoma, with comparison to traditional methods, using 18 sawbones.
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Affiliation(s)
- Guangyu He
- Department of Mechanical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Amos Z Dai
- Department of Orthopedics, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Vamiq M Mustahsan
- Department of Mechanical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Christopher L Blum
- Department of Orthopedics, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Imin Kao
- Department of Mechanical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Fazel A Khan
- Department of Orthopedics, Stony Brook University Hospital, Stony Brook, NY, USA
- Correspondence: Fazel A Khan, Email
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Arnold MCA, Zhao S, Doyle RJ, Jeffers JRT, Boughton OR. Power-Tool Use in Orthopaedic Surgery: Iatrogenic Injury, Its Detection, and Technological Advances: A Systematic Review. JB JS Open Access 2021; 6:JBJSOA-D-21-00013. [PMID: 34841185 PMCID: PMC8613350 DOI: 10.2106/jbjs.oa.21.00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Power tools are an integral part of orthopaedic surgery but have the capacity to cause iatrogenic injury. With this systematic review, we aimed to investigate the prevalence of iatrogenic injury due to the use of power tools in orthopaedic surgery and to discuss the current methods that can be used to reduce injury.
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Affiliation(s)
| | - Sarah Zhao
- The MSk Lab, Imperial College London, London, United Kingdom
| | - Ruben J Doyle
- Department of Mechanical Engineering, Imperial College London, London, United Kingdom
| | - Jonathan R T Jeffers
- Department of Mechanical Engineering, Imperial College London, London, United Kingdom
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Fox O, Kanawati A. 3D printed composite model of pelvic osteochondroma and nerve roots. 3D Print Med 2021; 7:31. [PMID: 34564778 PMCID: PMC8466893 DOI: 10.1186/s41205-021-00121-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND 3D-printing has become increasingly utilized in the preoperative planning of clinical orthopaedics. Surgical treatment of bone tumours within the pelvis is challenging due to the complex 3D bone structure geometry, as well as the proximity of vital structures. We present a unique case where a composite bone and nerve model of the lower lumbar spine, pelvis and accompanying nerve roots was created using 3D-printing. The 3D-printed model created an accurate reconstruction of the pelvic tumour and traversing nerves for preoperative planning and allowed for efficient and safe surgery. CASE PRESENTATION We present a unique case where a composite bone and nerve model of the lower lumbar spine, pelvis and accompanying nerve roots was created using 3D-printing. The bony pelvis and spine model was created using the CT, whereas the nerve roots were derived from the MRI and printed in an elastic material. 3D-printed model created an accurate reconstruction of the pelvic tumour and traversing nerves for preoperative planning and allowed for efficient and safe surgery. Pelvic tumour surgery is inherently dangerous due to the delicate nature of the surrounding anatomy. The composite model enabled the surgeon to very carefully navigate the anatomy with a focused resection and extreme care knowing the exact proximity of the L3 and L4 nerve roots. CONCLUSION The patient had complete resection of this tumour, no neurological complication and full resolution of his symptoms due to careful, preoperative planning with the use of the composite 3D model.
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Affiliation(s)
- Olivia Fox
- Department of Orthopaedics, Westmead Hospital, Hawkesbury Road, Westmead, NSW 2145 Australia
| | - Andrew Kanawati
- Department of Orthopaedics, Westmead Hospital, Hawkesbury Road, Westmead, NSW 2145 Australia
- Harbour Spine Surgeons, 207 Pacific Highway, St Leonards, NSW 2065 Australia
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Schileo E, Feltri P, Taddei F, di Settimi M, Di Martino A, Filardo G. A taper-fit junction to improve long bone reconstruction: A parametric In Silico model. J Mech Behav Biomed Mater 2021; 124:104790. [PMID: 34530302 DOI: 10.1016/j.jmbbm.2021.104790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/26/2021] [Accepted: 08/21/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE Critical size long bone defects represent a clinical challenge in orthopaedic surgery. Various grafting techniques have been developed through the years, but they all present several downsides. A key requirement of all grafting techniques is the achievement of a continuous interface between host bone and graft to enhance both biological processes and mechanical stability. This study used a parametric in silico model to quantify the biomechanical effect of the inaccuracies inherent to current osteotomy techniques, and to test a new concept of accurate taper-fit junction that may improve the biomechanical parameters of the reconstruction under load. METHODS A population-based in-silico 3D model of the reconstruction of a long bone defect was built to represent a defect of the femoral mid-diaphysis. To fix the reconstruction a titanium plate was placed on the lateral aspect of the reconstruction. The model was modified to (i) quantify the biomechanical consequences of actual inaccuracies in the realization of a flat host-graft interface, (ii) compare the contact behaviour and bone strains among different taper angles of the new design and the current host-graft flat interface, (iii) evaluate the robustness of the taper-fit design to inter-subject variability in bone geometry and defect length. RESULTS The influence of 2° single-plane misalignments of the host-graft interface is highly dependent on the misalignment orientation with respect to the metal plate. For some misalignment orientations, tangential micromotions of contact interfaces exceeded alert thresholds. When the angle of the taper-fit host-graft junction is changed from 10° to 30° and the results obtained are compared with the planar case, the overall stiffness is almost preserved, the bone strains are almost unchanged with safety factors higher than five, and full contact closure around the host-graft junction is achieved at 20°. Similarly, contact pressures decrease almost linearly with a 20% decrease at 30°. The host-graft micro motions are almost unchanged in both value and distribution up to 20° and never exceed the warning threshold of 50 μm. CONCLUSIONS The present in silico study developed quantitative biomechanical evidence that an osteotomy performed with attention to the perpendicularity of the cut planes is needed to reduce the risk of mismatch and possible complications of long bone reconstructions, and that a new concept of a taper-fit junction may improve the biomechanical environment of the interface between the graft and the host bone. The optimal taper-fit configuration is suggested to be around a 20° taper angle. These results will serve as an input to conduct exvivo experiments to further corroborate the proposed taper-fit junction concept and to refine its surgical implementation.
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Affiliation(s)
- Enrico Schileo
- Bioengineering and Computing Laboratory, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, IT, Italy
| | - Pietro Feltri
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, 6900 Lugano, CH Switzerland.
| | - Fulvia Taddei
- Bioengineering and Computing Laboratory, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, IT, Italy
| | | | - Alessandro Di Martino
- Second Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, IT, Italy
| | - Giuseppe Filardo
- Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, IT, Italy
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Gao H, Liu Z, Wang G, Wang B. A New Accurate, Simple and Less Radiation Exposure Device for Distal Locking of Femoral Intramedullary Nails. Int J Gen Med 2021; 14:4145-4153. [PMID: 34377014 PMCID: PMC8349542 DOI: 10.2147/ijgm.s321005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Due to the metal elasticity of intramedullary nails (IMs) and irregularities of the long bone marrow cavity and other reasons, one of the greatest challenges for surgeons is to position the distal locking screw. Therefore, a novel laser guiding navigation device was designed for the distal locking of femoral IMs. The purpose of this study was to compare the effectiveness of the novel device and freehand technique for distal locking of IMs in the femoral model. Methods The laser guiding navigation device (laser group) and freehand technique (freehand group) were used in the distal locking of the IMs in the femoral model. All operations were performed by surgeons of the same level. The differences between the two groups were compared in terms of operative time, radiation exposure time, first success rate, deviation angle between ideal trajectory and actual trajectory, and learning curve. Results The distal locking of the IMs in the femoral model was performed 40 times in each group. The results showed that the laser group was better than the freehand group in terms of operative time (345±165 VS 212±105 seconds, t=4.27, P<0.001), radiation exposure time (164±57 VS 41±15 seconds, t=13.15, P<0.001) and first successrate (χ 2=21.36, P<0.001). Compared with the freehand group, the actual trajectory of the laser group was closer to the ideal trajectory in coronal and horizontal planes. Furthermore, the learning curve time of the laser group was shorter. Conclusion Compared with traditional freehand technique, the novel laser guiding navigation device can shorten the operative time and reduce radiation exposure invitro. In addition, it is easy to master with more accuracy and a higher first success rate in vitro.
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Affiliation(s)
- Hua Gao
- Department of Orthopaedics, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Zhenyu Liu
- Department of Orthopaedics, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Gang Wang
- Department of Orthopaedics, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Baojun Wang
- Department of Orthopaedics, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
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12
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Christensen DD, Beynnon BD, Daniels SD, Salinas CJ, Blankstein M, Nelms NJ. Comparison of Tip- Versus Hub-Oscillating Saw Blade Control in a Total Knee Arthroplasty Model. J Arthroplasty 2020; 35:3300-3304. [PMID: 32631728 DOI: 10.1016/j.arth.2020.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/07/2020] [Accepted: 06/10/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Oscillating saws are commonly used for bone preparation in total knee arthroplasty but can cause injury to the posterior neurovascular bundle during tibial resection. Tip-oscillating saw blades are a recent innovation that could improve saw control due to decreased excursion; however, the tactile feedback to the surgeon is different. METHODS To compare traditional hub and new tip-oscillating saw blades, 16 participants of varying levels of experience were video-recorded during composite tibial bone model resections to measure posterior saw blade plunge. Subjective perceptions of saw control and preference were also surveyed. RESULTS Saw blade design and level of surgical experience did not produce a significant difference in posterior saw blade plunge (P > .05). Independent of saw blade design, subjects with no previous saw experience had significantly decreased posterior tibial plunge over subsequent resections. Tip-oscillating saw blades were perceived to be easier to use and control by less experienced participants (P = .0163). CONCLUSION Tip-oscillating saw blades do not alter the risk of posterior tibial saw plunge compared with traditional saw blades.
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Affiliation(s)
- David D Christensen
- Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, VT
| | - Bruce D Beynnon
- Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, VT
| | | | | | - Michael Blankstein
- Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, VT
| | - Nathaniel J Nelms
- Department of Orthopaedics and Rehabilitation, University of Vermont, Burlington, VT
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13
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Müller DA, Stutz Y, Vlachopoulos L, Farshad M, Fürnstahl P. The Accuracy of Three-Dimensional Planned Bone Tumor Resection Using Patient-Specific Instrument. Cancer Manag Res 2020; 12:6533-6540. [PMID: 32801891 PMCID: PMC7397560 DOI: 10.2147/cmar.s228038] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 06/23/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction Although treatment of bone tumors is multidisciplinary, the complete surgical resection of bone tumors remains the mainstay of the treatment. Patient-specific instruments (PSI) are personalized tools, which help the surgeon to perform tumor resections accurately. The aim of this study is to evaluate how precise the planned resection can be intraoperatively executed with the use of PSI. Patients and Methods Eleven patients who underwent a resection of bone tumor using PSI were analyzed. A preoperative model of the tumor and the affected bone was created from acquired CT scans and MRI. After defining the resection planes, PSI were produced by a 3D printer. The resected piece of bone was scanned and imported in the original planning model enabling the assessment of the distance between the planned resection plane and the realized osteotomy in every direction. Results In overall, the combined error of an osteotomy ranges from 0.74 ± 0.96 mm to 3.60 ± 2.46 mm. The average errors observed in situations with one resection plane (simple osteotomy) are lower than in complex curved osteotomies with multiple planes, in which we also found a greater variance. Conclusion 3D planned bone tumor resections using PSI show promising results for precise resection at different anatomical regions. Even if the found error range in this series is slightly higher than reported, PSI remain a valuable tool to facilitate complex bone tumor resections.
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Affiliation(s)
- Daniel A Müller
- Department of Orthopedic Surgery, Balgrist University Hospital, Zürich 8008, Switzerland
| | - Yannik Stutz
- Department of Orthopedic Surgery, Balgrist University Hospital, Zürich 8008, Switzerland
| | - Lazaros Vlachopoulos
- Department of Orthopedic Surgery, Balgrist University Hospital, Zürich 8008, Switzerland
| | - Mazda Farshad
- Department of Orthopedic Surgery, Balgrist University Hospital, Zürich 8008, Switzerland
| | - Philipp Fürnstahl
- Computer Assisted Research & Development Group, Balgrist University Hospital, Zürich 8008, Switzerland
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14
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Abstract
The field of robotic surgery has progressed from small teams of researchers repurposing industrial robots, to a competitive and highly innovative subsection of the medical device industry. Surgical robots allow surgeons to perform tasks with greater ease, accuracy, or safety, and fall under one of four levels of autonomy; active, semi-active, passive, and remote manipulator. The increased accuracy afforded by surgical robots has allowed for cementless hip arthroplasty, improved postoperative alignment following knee arthroplasty, and reduced duration of intraoperative fluoroscopy among other benefits. Cutting of bone has historically used tools such as hand saws and drills, with other elaborate cutting tools now used routinely to remodel bone. Improvements in cutting accuracy and additional options for safety and monitoring during surgery give robotic surgeries some advantages over conventional techniques. This article aims to provide an overview of current robots and tools with a common target tissue of bone, proposes a new process for defining the level of autonomy for a surgical robot, and examines future directions in robotic surgery.
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15
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Fotouhi J, Unberath M, Song T, Hajek J, Lee SC, Bier B, Maier A, Osgood G, Armand M, Navab N. Co-localized augmented human and X-ray observers in collaborative surgical ecosystem. Int J Comput Assist Radiol Surg 2019; 14:1553-1563. [PMID: 31350704 DOI: 10.1007/s11548-019-02035-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 07/18/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Image-guided percutaneous interventions are safer alternatives to conventional orthopedic and trauma surgeries. To advance surgical tools in complex bony structures during these procedures with confidence, a large number of images is acquired. While image-guidance is the de facto standard to guarantee acceptable outcome, when these images are presented on monitors far from the surgical site the information content cannot be associated easily with the 3D patient anatomy. METHODS In this article, we propose a collaborative augmented reality (AR) surgical ecosystem to jointly co-localize the C-arm X-ray and surgeon viewer. The technical contributions of this work include (1) joint calibration of a visual tracker on a C-arm scanner and its X-ray source via a hand-eye calibration strategy, and (2) inside-out co-localization of human and X-ray observers in shared tracking and augmentation environments using vision-based simultaneous localization and mapping. RESULTS We present a thorough evaluation of the hand-eye calibration procedure. Results suggest convergence when using 50 pose pairs or more. The mean translation and rotation errors at convergence are 5.7 mm and [Formula: see text], respectively. Further, user-in-the-loop studies were conducted to estimate the end-to-end target augmentation error. The mean distance between landmarks in real and virtual environment was 10.8 mm. CONCLUSIONS The proposed AR solution provides a shared augmented experience between the human and X-ray viewer. The collaborative surgical AR system has the potential to simplify hand-eye coordination for surgeons or intuitively inform C-arm technologists for prospective X-ray view-point planning.
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Affiliation(s)
- Javad Fotouhi
- Computer Aided Medical Procedures, Johns Hopkins University, Baltimore, USA. .,Department of Computer Science, Johns Hopkins University, Baltimore, USA.
| | - Mathias Unberath
- Computer Aided Medical Procedures, Johns Hopkins University, Baltimore, USA.,Department of Computer Science, Johns Hopkins University, Baltimore, USA
| | - Tianyu Song
- Computer Aided Medical Procedures, Johns Hopkins University, Baltimore, USA
| | - Jonas Hajek
- Computer Aided Medical Procedures, Johns Hopkins University, Baltimore, USA.,Pattern Recognition Lab, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Sing Chun Lee
- Computer Aided Medical Procedures, Johns Hopkins University, Baltimore, USA.,Department of Computer Science, Johns Hopkins University, Baltimore, USA
| | - Bastian Bier
- Computer Aided Medical Procedures, Johns Hopkins University, Baltimore, USA.,Pattern Recognition Lab, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Andreas Maier
- Pattern Recognition Lab, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Greg Osgood
- Department of Orthopedic Surgery, Johns Hopkins Hospital, Baltimore, USA
| | - Mehran Armand
- Applied Physics Laboratory, Johns Hopkins University, Baltimore, USA.,Department of Orthopedic Surgery, Johns Hopkins Hospital, Baltimore, USA
| | - Nassir Navab
- Computer Aided Medical Procedures, Johns Hopkins University, Baltimore, USA.,Department of Computer Science, Johns Hopkins University, Baltimore, USA.,Computer Aided Medical Procedures, Technische Universität München, Munich, Germany
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16
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Can Navigation Improve the Ability to Achieve Tumor-free Margins in Pelvic and Sacral Primary Bone Sarcoma Resections? A Historically Controlled Study. Clin Orthop Relat Res 2019; 477:1548-1559. [PMID: 31107331 PMCID: PMC6999970 DOI: 10.1097/corr.0000000000000766] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anatomic and surgical complexity make pelvic and sacral bone sarcoma resections challenging. Positive surgical margins are more likely to occur in patients with pelvic and sacral bone sarcomas than in those with extremity sarcomas and are associated with an increased likelihood of local recurrence. Intraoperative navigation techniques have been proposed to improve surgical accuracy in achieving negative margins, but available evidence is limited to experimental (laboratory) studies and small patient series. Only one small historically controlled study is available. Because we have experience with both approaches, we wanted to assess whether navigation improves our ability to achieve negative resection margins. QUESTIONS/PURPOSES Are navigated resections for pelvic and sacral primary bone sarcomas better able to achieve adequate surgical margins than nonnavigated resections? METHODS Thirty-six patients with pelvic or sacral sarcomas treated with intraoperative navigation were retrospectively compared with 34 patients undergoing resections without navigation. All patients underwent resections between 2000 and 2017 with the intention to achieve a wide margin. Patients in the navigation group underwent surgery between 2008 and 2017; during this period, all resections of pelvic and sacral primary bone sarcomas with the intention to achieve a wide margin were navigation-assisted by either CT fluoroscopy or intraoperative CT. Patients in the control group underwent surgery before 2008 (when navigation was unavailable at our institution), to avoid selection bias. We did not attempt to match patients to controls. Nonnavigated resections were performed by two senior orthopaedic surgeons (with 10 years and > 25 years of experience). Navigated resections were performed by a senior orthopaedic surgeon with much experience in surgical navigation. The primary outcome was the bone and soft-tissue surgical margin achieved, classified by a modified Enneking system. Wide margins (≥ 2 mm) and wide-contaminated margins, in which the tumor or its pseudocapsule was exposed intraoperatively but further tissue was removed to achieve wide margins, were considered adequate; marginal (0-2 mm) and intralesional margins were considered inadequate. RESULTS Adequate bone margins were achieved in more patients in the navigated group than in the nonnavigation group (29 of 36 patients [81%] versus 17 of 34 [50%]; odds ratio, 4.14 [95% CI, 1.43-12.01]; p = 0.007). With the numbers available, we found no difference in our ability to achieve adequate soft-tissue margins between the navigation and nonnavigation group (18 of 36 patients [50%] versus 18 of 34 [54%]; odds ratio, 0.89 [95% CI, 0.35-2.27]; p = 0.995). CONCLUSIONS Intraoperative guidance techniques improved our ability to achieve negative bony margins when performing surgical resections in patients with pelvic and sacral primary bone sarcomas. Achieving adequate soft-tissue margins remains a challenge, and these margins do not appear to be influenced by navigation. Larger studies are needed to confirm our results, and longer followup of these patients is needed to determine if the use of navigation will improve survival or the risk of local recurrence. LEVEL OF EVIDENCE Level III, therapeutic study.
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17
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Evrard R, Schubert T, Paul L, Docquier PL. Resection margins obtained with patient-specific instruments for resecting primary pelvic bone sarcomas: A case-control study. Orthop Traumatol Surg Res 2019; 105:781-787. [PMID: 30982774 DOI: 10.1016/j.otsr.2018.12.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/17/2018] [Accepted: 12/21/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Limb salvage surgery for pelvic bone sarcoma carries a very high risk of local recurrence. Patient-specific instruments (PSIs) have shown promise for obtaining tumour-free resection margins. However, no data are available on medium-term outcomes including local recurrence rates after PSI-guided resection. The objectives of this case-control study were to determine whether PSI-guided resection: 1) was associated with a lower local recurrence rate, 2) allowed a shorter operative time, 3) was associated with better-quality allograft reconstruction. HYPOTHESIS PSI-guided resection decreases the local recurrence rate by improving the resection margins in patients with primary pelvic bone sarcomas. PATIENTS AND METHODS PSI-guided resection was performed in 9 consecutive patients (cases) with primary pelvic sarcomas (chondrosarcoma, n=3; Ewing's sarcoma, n=3; osteosarcoma, n=1; fibrosarcoma, n=1; and radiation-induced sarcoma, n=1). Age ranged from 11 to 63 years. Outcomes were compared to those in a historical control group of 19 patients with primary bone sarcomas who underwent resection surgery in the same hospital without PSI guidance. The case and control groups were similar regarding age, sex distribution, and follow-up duration. The local recurrence rate and operative time were compared between the two groups. Resection margins were classified as R0, R1, or R2. The quality of allograft reconstruction, which was performed in 7 of the 9 cases, was assessed. RESULTS After a mean follow-up of 52 months (range, 30-90 months), none of the cases had experienced local bone or soft-tissue recurrences, compared to 7 of the 19 controls (p=0.03), in whom mean follow-up was 62 months (range, 24-134 months). Bone resection margins were R0 in 8 cases; in the remaining patient, R1 resection was performed deliberately to preserve an S1 root. All 9 cases had R0 soft-tissue resection margins. In the control group, bone resection margins were R0 in 13 patients, R1 in 5 patients, and R2 in 1 patient (p=0.47). Mean operative time was similar in the cases (612 minutes [range, 435-854 minutes]) and controls (633 minutes [range, 420-990 minutes]) (p=0.87). In the 7 patients who underwent pelvic allograft reconstruction, allograft contact in the defect and osteosynthesis stability were deemed satisfactory by the surgeon. DISCUSSION The lower local recurrence rate in the cases demonstrates that the improved resection accuracy provided by PSIs directly influences the risk of local recurrence. In addition, the R0 bone margins in 8 cases establishes that PSIs are effective in improving resection accuracy. LEVEL OF EVIDENCE III, case-control study.
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Affiliation(s)
- Robin Evrard
- Neuro Musculo-Skeletal Laboratory (NMSK), secteur des sciences de la santé, institut de recherche expérimentale et clinique, université catholique de Louvain, avenue Mounier 53, 1200 Brussels, Belgium; Service d'orthopédie et de traumatologie de l'appareil locomoteur, cliniques universitaires Saint-Luc, avenue Hippocrate 10, 1200 Brussels, Belgium; Cancérologie et hématologie, institut Roi-Albert-II, cliniques universitaires Saint-Luc, avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Thomas Schubert
- Neuro Musculo-Skeletal Laboratory (NMSK), secteur des sciences de la santé, institut de recherche expérimentale et clinique, université catholique de Louvain, avenue Mounier 53, 1200 Brussels, Belgium; Service d'orthopédie et de traumatologie de l'appareil locomoteur, cliniques universitaires Saint-Luc, avenue Hippocrate 10, 1200 Brussels, Belgium; Cancérologie et hématologie, institut Roi-Albert-II, cliniques universitaires Saint-Luc, avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Laurent Paul
- 3D-Side, 5, rue André-Dumont, Mont-Saint-Guibert, Belgium
| | - Pierre-Louis Docquier
- Neuro Musculo-Skeletal Laboratory (NMSK), secteur des sciences de la santé, institut de recherche expérimentale et clinique, université catholique de Louvain, avenue Mounier 53, 1200 Brussels, Belgium; Service d'orthopédie et de traumatologie de l'appareil locomoteur, cliniques universitaires Saint-Luc, avenue Hippocrate 10, 1200 Brussels, Belgium; Cancérologie et hématologie, institut Roi-Albert-II, cliniques universitaires Saint-Luc, avenue Hippocrate 10, 1200 Brussels, Belgium.
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18
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A Cadaveric Comparative Study on the Surgical Accuracy of Freehand, Computer Navigation, and Patient-Specific Instruments in Joint-Preserving Bone Tumor Resections. Sarcoma 2018; 2018:4065846. [PMID: 30538600 PMCID: PMC6260549 DOI: 10.1155/2018/4065846] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 10/17/2018] [Indexed: 12/16/2022] Open
Abstract
Orthopedic oncologic surgery requires preservation of a functioning limb at the essence of achieving safe margins. With most bone sarcomas arising from the metaphyseal region, in close proximity to joints, joint-salvage surgery can be challenging. Intraoperative guidance techniques like computer-assisted surgery (CAS) and patient-specific instrumentation (PSI) could assist in achieving higher surgical accuracy. This study investigates the surgical accuracy of freehand, CAS- and PSI-assisted joint-preserving tumor resections and tests whether integration of CAS with PSI (CAS + PSI) can further improve accuracy. CT scans of 16 simulated tumors around the knee in four human cadavers were performed and imported into engineering software (MIMICS) for 3D planning of multiplanar joint-preserving resections. The planned resections were transferred to the navigation system and/or used for PSI design. Location accuracy (LA), entry and exit points of all 56 planes, and resection time were measured by postprocedural CT. Both CAS + PSI- and PSI-assisted techniques could reproduce planned resections with a mean LA of less than 2 mm. There was no statistical difference in LA between CAS + PSI and PSI resections (p=0.92), but both CAS + PSI and PSI showed a significantly higher LA compared to CAS (p=0.042 and p=0.034, respectively). PSI-assisted resections were faster compared to CAS + PSI (p < 0.001) and CAS (p < 0.001). Adding CAS to PSI did improve the exit points, however not significantly. In conclusion, PSI showed the best overall surgical accuracy and is fastest and easy to use. CAS could be used as an intraoperative quality control tool for PSI, and integration of CAS with PSI is possible but did not improve surgical accuracy. Both CAS and PSI seem complementary in improving surgical accuracy and are not mutually exclusive. Image-based techniques like CAS and PSI are superior over freehand resection. Surgeons should choose the technique most suitable based on the patient and tumor specifics.
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19
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Nakano N, Audenaert E, Ranawat A, Khanduja V. Review: Current concepts in computer-assisted hip arthroscopy. Int J Med Robot 2018; 14:e1929. [DOI: 10.1002/rcs.1929] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 05/13/2018] [Accepted: 05/13/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Naoki Nakano
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital; Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Emmanuel Audenaert
- Department of Orthopaedic Surgery and Traumatology; Ghent University Hospital; Ghent Belgium
| | - Anil Ranawat
- Department of Orthopaedics, Hospital for Special Surgery; New York USA
| | - Vikas Khanduja
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital; Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
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20
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Sternheim A, Kashigar A, Daly M, Chan H, Qiu J, Weersink R, Jaffray D, Irish JC, Ferguson PC, Wunder JS. Cone-Beam Computed Tomography-Guided Navigation in Complex Osteotomies Improves Accuracy at All Competence Levels: A Study Assessing Accuracy and Reproducibility of Joint-Sparing Bone Cuts. J Bone Joint Surg Am 2018; 100:e67. [PMID: 29762285 DOI: 10.2106/jbjs.16.01304] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The objective of this study was to assess the accuracy and reproducibility of a novel cone-beam computed tomography (CBCT)-guided navigation system designed for osteotomies with joint-sparing bone cuts. METHODS Eighteen surgeons participated in this study. First, 3 expert tumor surgeons resected bone tumors in 3 Sawbones tumor models identical to actual patient scenarios. They first performed these osteotomies without navigation and then performed them using a navigation system and 3-dimensional (3D) planning tools based on CBCT imaging. The 2 sets of measurements were compared using image-based measurements from post-resection CBCT. Next, 15 residents, fellows, and orthopaedic staff surgeons were instructed on the use of the system, and their navigated resections were compared with navigated resections performed by the 3 expert tumor surgeons. RESULTS One hundred and twenty-six navigated cuts done by the orthopaedic oncologists were compared with 126 non-navigated cuts by the same surgeons. The cuts violated the tumor in 22% (6) of the 27 non-navigated resections compared with none of the 27 navigated resections. The navigated cuts were significantly more accurate in terms of entry point, pitch, and roll (p < 0.001). The variation among the 3 surgeons when they used navigation was <0.6 mm for the entry cut and, on average, 1.5° for pitch and roll. All 18 surgeons then completed a total of 144 navigated cuts. The level of experience did not result in a significant difference among groups with regard to cut accuracy. Two cuts went into the tumor. The mean distance from the planned bone cuts to the actual entry points into bone was 1.5 mm (standard deviation [SD] = 1.4 mm) for all users. The mean difference in pitch and roll between the planned and actual cuts was 3.5° (SD = 2.8°) and 3.7° (SD = 3.2°) for all users. CONCLUSIONS Even in expert hands, navigated cuts were significantly more accurate than non-navigated cuts. When the osteotomies were aided by navigation, their accuracy did not differ according to the level of professional experience. CBCT-based metrics enable intraoperative assessments of cut accuracy and reconstruction planning. CLINICAL RELEVANCE CBCT-guided navigated osteotomies can improve accuracy regardless of surgeon experience and decrease the variability among different surgeons.
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Affiliation(s)
- Amir Sternheim
- National Unit of Orthopaedic Oncology, Tel Aviv Medical Center, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aidin Kashigar
- Division of Orthopaedic Surgery, Queen's University, Kingston, Ontario, Canada
| | - Michael Daly
- Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Harley Chan
- Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Jimmy Qiu
- Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - Robert Weersink
- Techna Institute, University Health Network, Toronto, Ontario, Canada
| | - David Jaffray
- Techna Institute, University Health Network, Toronto, Ontario, Canada.,Department of Radiation Physics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Ontario Cancer Institute, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Jonathan C Irish
- Techna Institute, University Health Network, Toronto, Ontario, Canada.,Department of Surgical Oncology, University Health Network, Toronto, Ontario, Canada.,Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Peter C Ferguson
- Department of Surgical Oncology, University Health Network, Toronto, Ontario, Canada.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Jay S Wunder
- Department of Surgical Oncology, University Health Network, Toronto, Ontario, Canada.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada
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21
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Sallent A, Vicente M, Reverté MM, Lopez A, Rodríguez-Baeza A, Pérez-Domínguez M, Velez R. How 3D patient-specific instruments improve accuracy of pelvic bone tumour resection in a cadaveric study. Bone Joint Res 2017; 6:577-583. [PMID: 29054990 PMCID: PMC5715211 DOI: 10.1302/2046-3758.610.bjr-2017-0094.r1] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 07/31/2017] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES To assess the accuracy of patient-specific instruments (PSIs) versus standard manual technique and the precision of computer-assisted planning and PSI-guided osteotomies in pelvic tumour resection. METHODS CT scans were obtained from five female cadaveric pelvises. Five osteotomies were designed using Mimics software: sacroiliac, biplanar supra-acetabular, two parallel iliopubic and ischial. For cases of the left hemipelvis, PSIs were designed to guide standard oscillating saw osteotomies and later manufactured using 3D printing. Osteotomies were performed using the standard manual technique in cases of the right hemipelvis. Post-resection CT scans were quantitatively analysed. Student's t-test and Mann-Whitney U test were used. RESULTS Compared with the manual technique, PSI-guided osteotomies improved accuracy by a mean 9.6 mm (p < 0.008) in the sacroiliac osteotomies, 6.2 mm (p < 0.008) and 5.8 mm (p < 0.032) in the biplanar supra-acetabular, 3 mm (p < 0.016) in the ischial and 2.2 mm (p < 0.032) and 2.6 mm (p < 0.008) in the parallel iliopubic osteotomies, with a mean linear deviation of 4.9 mm (p < 0.001) for all osteotomies. Of the manual osteotomies, 53% (n = 16) had a linear deviation > 5 mm and 27% (n = 8) were > 10 mm. In the PSI cases, deviations were 10% (n = 3) and 0 % (n = 0), respectively. For angular deviation from pre-operative plans, we observed a mean improvement of 7.06° (p < 0.001) in pitch and 2.94° (p < 0.001) in roll, comparing PSI and the standard manual technique. CONCLUSION In an experimental study, computer-assisted planning and PSIs improved accuracy in pelvic tumour resections, bringing osteotomy results closer to the parameters set in pre-operative planning, as compared with standard manual techniques.Cite this article: A. Sallent, M. Vicente, M. M. Reverté, A. Lopez, A. Rodríguez-Baeza, M. Pérez-Domínguez, R. Velez. How 3D patient-specific instruments improve accuracy of pelvic bone tumour resection in a cadaveric study. Bone Joint Res 2017;6:577-583. DOI: 10.1302/2046-3758.610.BJR-2017-0094.R1.
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Affiliation(s)
- A Sallent
- Department of Orthopedic Surgery, Hospital Vall d'Hebron, Barcelona, Spain and Vall d'Hebron Research Institute (VHIR), Universitat Autonoma de Barcelona, Barcelona, Spain
| | - M Vicente
- Department of Orthopedic Surgery, Hospital Vall d'Hebron, Barcelona, Spain
| | - M M Reverté
- Department of Orthopedic Surgery, Hospital Vall d'Hebron, Barcelona, Spain
| | - A Lopez
- Musculoskeletal Tissue Engineering Department, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - A Rodríguez-Baeza
- Department of Morphological Science, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - M Pérez-Domínguez
- Department of Orthopedic Surgery, Hospital Vall d'Hebron, Barcelona, Spain
| | - R Velez
- Department of Orthopedic Surgery, Hospital Vall d'Hebron, Barcelona, Spain and Vall d'Hebron Research Institute (VHIR), Universitat Autonoma de Barcelona, Spain
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22
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Cartiaux O, Jenny JY, Joskowicz L. Accuracy of Computer-Aided Techniques in Orthopaedic Surgery: How Can It Be Defined, Measured Experimentally, and Analyzed from a Clinical Perspective? J Bone Joint Surg Am 2017; 99:e39. [PMID: 28419041 DOI: 10.2106/jbjs.15.01347] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Surgical accuracy is multifactorial. Therefore, it is crucial to consider all influencing factors when investigating the accuracy of a surgical procedure, such as the surgeon's experience, the assistive technologies that may be used by the surgeon, and the patient factors associated with the specific anatomical site. For in vitro preclinical investigations, accuracy should be linked to the concepts of trueness (e.g., distance from the surgical target) and precision (e.g., variability in relation to the surgical target) to gather preclinical, quantitative, objective data on the accuracy of completed surgical procedures that have been performed with assistive technologies. The clinical relevance of improvements in accuracy that have been observed experimentally may be evaluated by analyzing the impact on the risk of failure and by taking into account the level of tolerance in relation to the surgical target (e.g., the extent of the safety zone). The International Organization for Standardization (ISO) methodology enables preclinical testing of new assistive technologies to quantify improvements in accuracy and assess the benefits in terms of reducing the risk of failure and achieving surgical targets with tighter tolerances before the testing of clinical outcomes.
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Affiliation(s)
- Olivier Cartiaux
- 1Computer Assisted and Robotic Surgery, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium 2Centre de Chirurgie Orthopédique et de la Main, Les Hôpitaux Universitaires de Strasbourg, Illkirch, France 3The Rachel and Selim Benin School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem, Israel
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23
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Sternheim A, Daly M, Qiu J, Weersink R, Chan H, Jaffray D, Irish JC, Ferguson PC, Wunder JS. Navigated pelvic osteotomy and tumor resection: a study assessing the accuracy and reproducibility of resection planes in Sawbones and cadavers. J Bone Joint Surg Am 2015; 97:40-6. [PMID: 25568393 DOI: 10.2106/jbjs.n.00276] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND This Sawbones and cadaver study was performed to assess the accuracy and reproducibility of pelvic bone cuts made with use of a novel navigation system with a navigated osteotome and oscillating saw. METHODS Using a novel navigation system and a three-dimensional planning tool, we navigated pelvic bone cuts that were representative of typical cuts made in pelvic tumor resections. The system includes a prototype mobile C-arm for intraoperative cone-beam computed tomography, real-time optical tracking (Polaris), and three-dimensional visualization software. Three-dimensional virtual radiographs were utilized in addition to triplanar (axial, sagittal, and coronal) navigation. In part one of the study, we navigated twenty-four sacral bone cuts in Sawbones models and validated our results in sixteen similar cuts in cadavers. In part two, we developed three Sawbones models of pelvic tumors based on actual patient scenarios and compared three navigated resections with three non-navigated resections for each tumor model. Part three assessed the accuracy of the system with multiple users. RESULTS There were ninety navigated cuts in Sawbones that were compared with fifty-four non-navigated cuts. In the navigated Sawbones cuts, the mean entry and exit cuts were 1.4 ± 1 mm and 1.9 ± 1.2 mm from the planned cuts, respectively. In comparison, the entry and exit cuts in Sawbones that were not navigated were 2.8 ± 4.9 mm and 3.5 ± 4.6 mm away from the planned osteotomy site. The navigated cuts were significantly more accurate (p ≤ 0.01). In the cadaver study, navigated entry and exit cuts were 1.5 ± 0.9 mm and 2.1 ± 1.5 mm from the planned cuts. The variation among three different users was 1 mm on both the entry and exit cuts. CONCLUSIONS Navigation to guide pelvic bone cuts is accurate and feasible. Three-dimensional radiographs should be used for improved accuracy. Navigated cuts were significantly more accurate than non-navigated cuts were. A margin of 5 mm between the target tumor volume and the planned cut plane would result in a negative margin resection in more than 95% of the cuts. CLINICAL RELEVANCE The accuracy of pelvic bone tumor resections and pelvic osteotomies can be improved with navigation to within 5 mm of the planned cut.
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Affiliation(s)
- Amir Sternheim
- Division of Orthopaedic Surgery, Mount Sinai Hospital, 600 University Avenue, Room 476, Toronto, ON M5G 1X5, Canada. E-mail address for A. Sternheim: . E-mail address for J.S. Wunder:
| | - Michael Daly
- GTx Core-Techna Institute, University Health Network, 101 College Street, 7-1001, Toronto Medical Discovery Tower, Toronto, ON M5G 1L7, Canada. E-mail address for M. Daly: . E-mail address for J. Qiu: . E-mail address for R. Weersink: . E-mail address for H. Chan:
| | - Jimmy Qiu
- GTx Core-Techna Institute, University Health Network, 101 College Street, 7-1001, Toronto Medical Discovery Tower, Toronto, ON M5G 1L7, Canada. E-mail address for M. Daly: . E-mail address for J. Qiu: . E-mail address for R. Weersink: . E-mail address for H. Chan:
| | - Robert Weersink
- GTx Core-Techna Institute, University Health Network, 101 College Street, 7-1001, Toronto Medical Discovery Tower, Toronto, ON M5G 1L7, Canada. E-mail address for M. Daly: . E-mail address for J. Qiu: . E-mail address for R. Weersink: . E-mail address for H. Chan:
| | - Harley Chan
- GTx Core-Techna Institute, University Health Network, 101 College Street, 7-1001, Toronto Medical Discovery Tower, Toronto, ON M5G 1L7, Canada. E-mail address for M. Daly: . E-mail address for J. Qiu: . E-mail address for R. Weersink: . E-mail address for H. Chan:
| | - David Jaffray
- Ontario Cancer Institute, 610 University Avenue, 5-631, Toronto, ON M5G 1X5, Canada. E-mail address:
| | - Jonathan C Irish
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Cancer Centre, 610 University Avenue, 3-954, Toronto, ON M5G 2M9, Canada. E-mail address:
| | - Peter C Ferguson
- Department of Surgery, Mount Sinai Hospital, 600 University Avenue, Suite 476G, Toronto, ON M5G 1X5, Canada. E-mail address:
| | - Jay S Wunder
- Division of Orthopaedic Surgery, Mount Sinai Hospital, 600 University Avenue, Room 476, Toronto, ON M5G 1X5, Canada. E-mail address for A. Sternheim: . E-mail address for J.S. Wunder:
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Abstract
Computer-assisted orthopedic surgery (CAOS) was introduced, developed, and implemented in musculoskeletal tumor surgery recently to enhance surgical precision in resecting malignant and benign tumors. The origins of computer-assisted surgery were in other subspecialties including maxillofacial surgery, spine surgery, and arthroplasty. Early studies have shown that CAOS can also be used safely for bone tumor resection surgery. Additional technological improvements may allow use of CAOS in soft tissue tumor surgery. It has the potential to improve surgical precision and accuracy, but more study is needed to evaluate clinical efficacy and long term results.
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Affiliation(s)
- Robert L Satcher
- Department of Orthopaedic Oncology, MD Anderson Cancer Center, 1400 Pressler Street, Unit 1448, Houston, TX 77030, USA.
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Improved accuracy with 3D planning and patient-specific instruments during simulated pelvic bone tumor surgery. Ann Biomed Eng 2013; 42:205-13. [PMID: 23963884 DOI: 10.1007/s10439-013-0890-7] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 08/07/2013] [Indexed: 10/26/2022]
Abstract
In orthopaedic surgery, resection of pelvic bone tumors can be inaccurate due to complex geometry, limited visibility and restricted working space of the pelvis. The present study investigated accuracy of patient-specific instrumentation (PSI) for bone-cutting during simulated tumor surgery within the pelvis. A synthetic pelvic bone model was imaged using a CT-scanner. The set of images was reconstructed in 3D and resection of a simulated periacetabular tumor was defined with four target planes (ischium, pubis, anterior ilium, and posterior ilium) with a 10-mm desired safe margin. Patient-specific instruments for bone-cutting were designed and manufactured using rapid-prototyping technology. Twenty-four surgeons (10 senior and 14 junior) were asked to perform tumor resection. After cutting, ISO1101 location and flatness parameters, achieved surgical margins and the time were measured. With PSI, the location accuracy of the cut planes with respect to the target planes averaged 1 and 1.2 mm in the anterior and posterior ilium, 2 mm in the pubis and 3.7 mm in the ischium (p < 0.0001). Results in terms of the location of the cut planes and the achieved surgical margins did not reveal any significant difference between senior and junior surgeons (p = 0.2214 and 0.8449, respectively). The maximum differences between the achieved margins and the 10-mm desired safe margin were found in the pubis (3.1 and 5.1 mm for senior and junior surgeons respectively). Of the 24 simulated resection, there was no intralesional tumor cutting. This study demonstrates that using PSI technology during simulated bone cuts of the pelvis can provide good cutting accuracy. Compared to a previous report on computer assistance for pelvic bone cutting, PSI technology clearly demonstrates an equivalent value-added for bone cutting accuracy than navigation technology. When in vivo validated, PSI technology may improve pelvic bone tumor surgery by providing clinically acceptable margins.
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Ritacco LE, Milano FE, Farfalli GL, Ayerza MA, Muscolo DL, Aponte-Tinao LA. Accuracy of 3-D planning and navigation in bone tumor resection. Orthopedics 2013; 36:e942-50. [PMID: 23823054 DOI: 10.3928/01477447-20130624-27] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Surgical precision in oncologic surgery is essential to achieve adequate margins in bone tumor resections. Three-dimensional preoperative planning and bone tumor resection by navigation have been introduced to orthopedic oncology in recent years. However, the accuracy of preoperative planning and navigation is unclear. The purpose of this study was to evaluate the accuracy of preoperative planning and the navigation system. A total of 28 patients were evaluated between May 2010 and February 2011. Tumor locations were the femur (n=17), pelvis (n=6), sacrum (n=2), tibia (n=2), and humerus (n=1). All resections were planned in a virtual scenario using computed tomography and magnetic resonance imaging fusion. A total of 61 planes or osteotomies were performed to resect the tumors. Postoperatively, computed tomography scans were obtained for all surgical specimens, and the specimens were 3-dimensionally reconstructed from the scans. Differences were determined by finding the distances between the osteotomies virtually programmed and those performed. The global mean of the quantitative comparisons between the osteotomies programmed and those obtained through the resected specimen was 2.52±2.32 mm for all patients. Differences between osteotomies virtually programmed and those achieved by navigation intraoperatively were minimal.
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Affiliation(s)
- Lucas E Ritacco
- Department of Health Informatics, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
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Abstract
BACKGROUND Accurate reproduction of the preoperative plan at the time of surgery is critical for wide resection of primary bone tumors. Robotic technology can potentially help the surgeon reproduce a given preoperative plan, but yielding control of cutting instruments to a robot introduces potentially serious complications. We developed a novel passive ("haptics") robot-assisted resection technique for primary bone sarcomas that takes advantage of robotic accuracy while still leaving control of the cutting instrument in the hands of the surgeon. QUESTIONS/PURPOSES We asked whether this technique would enable a preoperative resection plan to be reproduced more accurately than a standard manual technique. METHODS A joint-sparing hemimetaphyseal resection was precisely outlined on the three-dimensionally reconstructed image of a representative Sawbones femur. The indicated resection was performed on 12 Sawbones specimens using the standard manual technique on six specimens and the haptic robotic technique on six specimens. Postresection images were quantitatively analyzed to determine the accuracy of the resections compared to the preoperative plan, which included measuring the maximum linear deviation of the cuts from the preoperative plan and the angular deviation of the resection planes from the target planes. RESULTS Compared with the manual technique, the robotic technique resulted in a mean improvement of 7.8 mm of maximum linear deviation from the preoperative plan and 7.9° improvement in pitch and 4.6° improvement in roll for the angular deviation from the target planes. CONCLUSIONS The haptic robot-assisted technique improved the accuracy of simulated wide resections of bone tumors compared with manual techniques. CLINICAL RELEVANCE Haptic robot-assisted technology has the potential to enhance primary bone tumor resection. Further bench and clinical studies, including comparisons with recently introduced computer navigation technology, are warranted.
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Abstract
BACKGROUND Hip arthroscopy is rapidly becoming the mainstay of treatment for femoroacetabular impingement (FAI), but remains technically demanding and has its limitations. The failures of arthroscopic FAI surgery due to inaccurate and inadequate resection are reported to be increasing. Computer-assisted surgery (CAS) can theoretically improve the accuracy and precision of the osseous resections required to treat FAI. It does so by providing a preoperative assessment tool, an intraoperative tracking device, and a robotic-assisted cutting instrument. QUESTIONS/PURPOSES The purpose of this review is to discuss the evolution of CAS to address the current limitations of arthroscopic FAI surgery and propose the features required of the ideal CAS solution for FAI. METHODS A computerized keyword search of MEDLINE was performed for studies that investigated the use of computer assistance in FAI surgery. Data was collected on preoperative assessment tools, intraoperative navigation programs, and robotic-assisted execution of FAI surgery. RESULTS Sixty-one articles were identified after the keyword search. Nineteen studies met our inclusion criteria. Thirteen studies were selected to address our study questions: three studies were analyzed for preoperative planning, six for navigated osseous resection, and four for robotic-assisted execution. CONCLUSION Navigation and robotic-assisted surgery can preoperatively plan and execute osseous resection with greater accuracy compared to freehand techniques, although the clinical success and cost-effectiveness has yet to be demonstrated. The ideal CAS solution must be able to virtually plan a resection, guide the surgeon towards accurate execution of the plan, and facilitate post-resection assessment of the adequacy of resection.
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Cartiaux O, Banse X, Paul L, Francq BG, Aubin CÉ, Docquier PL. Computer-assisted planning and navigation improves cutting accuracy during simulated bone tumor surgery of the pelvis. ACTA ACUST UNITED AC 2012; 18:19-26. [PMID: 23176154 DOI: 10.3109/10929088.2012.744096] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Resection of bone tumors within the pelvis requires good cutting accuracy to achieve satisfactory safe margins. Manually controlled bone cutting can result in serious errors, especially due to the complex three-dimensional geometry, limited visibility, and restricted working space of the pelvic bone. This experimental study investigated cutting accuracy during navigated and non-navigated simulated bone tumor cutting in the pelvis. METHODS A periacetabular tumor resection was simulated using a pelvic bone model. Twenty-three operators (10 senior and 13 junior surgeons) were asked to perform the tumor cutting, initially according to a freehand procedure and later with the aid of a navigation system. Before cutting, each operator used preoperative planning software to define four target planes around the tumor with a 10-mm desired safe margin. After cutting, the location and flatness of the cut planes were measured, as well as the achieved surgical margins and the time required for each cutting procedure. RESULTS The location of the cut planes with respect to the target planes was significantly improved by using the navigated cutting procedure, averaging 2.8 mm as compared to 11.2 mm for the freehand cutting procedure (p < 0.001). There was no intralesional tumor cutting when using the navigation system. The maximum difference between the achieved margins and the 10-mm desired safe margin was 6.5 mm with the navigated cutting process (compared to 13 mm with the freehand cutting process). CONCLUSIONS Cutting accuracy during simulated bone cuts of the pelvis can be significantly improved by using a freehand process assisted by a navigation system. When fully validated with complementary in vivo studies, the planning and navigation-guided technologies that have been developed for the present study may improve bone cutting accuracy during pelvic tumor resection by providing clinically acceptable margins.
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Affiliation(s)
- Olivier Cartiaux
- Center for Research in Computer Assisted and Robotic Surgery, Institute of Experimental and Clinical Research, Université catholique de Louvain, Brussels, Belgium.
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Potential use of computer navigation in the treatment of primary benign and malignant tumors in children. Curr Rev Musculoskelet Med 2012; 5:83-90. [PMID: 22488037 DOI: 10.1007/s12178-012-9124-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The treatment of benign and malignant primary bone tumors has progressed over time from relatively simple practice to complex resection and reconstruction techniques. Recently, computer-assisted orthopaedic surgery (CAOS) has been used to assist surgeons to enhance surgical precision in order to achieve these goals. Initially, software developed for CT-based spinal applications was used to perform simple intraoperative point localization. With advances in technique and software design, oncology surgeons have now performed joint sparing complex multiplanar osteotomies using combined CT and MRI image data with precision and accuracy. The purpose of this paper is to provide a review of the clinical progress to date, the different types of navigation available, methods for error management, and limitations of CAOS in the treatment of pediatric benign and malignant primary bone tumors.
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Rossi MD. An Overview of Total Knee Replacement and the Role of the Strength and Conditioning Professional. Strength Cond J 2011. [DOI: 10.1519/ssc.0b013e318215d363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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