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)
Our duty
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Once upon a time…1956
What they had?
Huge practise
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Once upon a time…
What they had?
Huge practise More respect?
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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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Today - what else?
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Today - what else?
• Good light • Good power tools (Light, oscillating drills)
llii ht
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Today - imaging
• Conventional x-ray • 3-D C-arm • CT scan • Spiral CT scan • MRI • Ultrasound • Arthroscopy (optical imaging) • Radioisotope scan • Navigation • Preop. Planning
History
Take home
10
Literature
new challenge, different evidence levels
Smartphones/tablets
Today trends
Offer an Idea
Last 19 years TEAM work IT experts (software designers) medical doctors engineers
focused education
Planning softwares on the market
Non competitive
No FEA
No animation
Not 3D
Maybe the plan was wrong? - Interactive 3D-plan
Should be plan!
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
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
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!!!
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
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
Segmen-tation
SurfaceExtraction
MechanicalModel
Generation
ResultEvaluation
Analysis
Surgical Planning
CT
JMed
FEA
System Overview - Segmentation
Marching Cubes ~800k triangles
ss
Simplification ~100k triangles
Segmen-tation
SurfaceExtraction
MechanicalModel
Generation
ResultEvaluation
Analysis
Surgical Planning
CT
JMed
FEA
System Overview – Surface Extraction
Segmen-tation
SurfaceExtraction
MechanicalModel
Generation
ResultEvaluation
Analysis
Surgical Planning
CT
JMed
FEA
System Overview – Surgical Planning
Segmen-tation
SurfaceExtraction
MechanicalModel
Generation
ResultEvaluation
Analysis
Surgical Planning
CT
JMed
FEA
System Overview – Mechanical Model
Segmen-tation
SurfaceExtraction
MechanicalModel
Generation
ResultEvaluation
Analysis
Surgical Planning
CT
JMed
FEA
System Overview – Result
SzE, 50yFemale
Fall from high
Acetabulum
Acetabulum
Intraop
TraumArt on the screen
low profile plates
Case presentation (planning and procedure)
Segmen-tation
SurfaceExtraction
MechanicalModel
Generation
ResultEvaluation
Analysis
Surgical Planning
CT
JMed
FEA
Planning
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
• Users: 25 different countries
• Countries: Europe and Australia, USA, Columbia, Saudi Arabia, Canada.
Present status
Italian Case
Italian Case
Italian Case with VCP
Italian Case with juxtaartic-LCP
It. Case with 2 col dorsal plates
Italian Case VA-LCP
Case VA-LCP
VA-LCP focused on key screws
Postoperative Xrays
Postoperative Xrays
Spine16y/ female/ horseriding No neurological compl.
Spine
Spine
Spine
CMF - case
Glider Truck crush
Glider Truck crush
Glider Truck crush
Glider Truck crush
Intermediate splint - rapid prototype
Human
CT
image
FEA
Analysis
Educational platform first step
Animation
AO Surgery reference
Simplify the question Injury animation - surgery reference
Be a surgeon! Play with forces
Straddle fx
Bucket handle fx
AP (B1) HD Risk ++
LC (B2) H/D Risk +/-
VS (C) H/D Risk ++/-
Injury animation - surgery reference
On site support
Sequential introduction
International development with experts involvement
Bone defect allograft library
Implant design
Injury animation - surgery referenceCooperation with ARI
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
• 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
EU Grant GOP 1.1.1. Siemens ARCADIS ISO C 3D Image Intensifire, BrainLab IO Navigation Unit.
Pelvis, Acetabulum, Spine, Joints surgeries
TRAUMA TEAM
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What is different in the OR?
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Light…
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MonitorMonitor
Carbon/ARCADIS/BrainLab/Carbon op table
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Today - imaging
• Conventional x-ray • 3-D C-arm • CT scan • Spiral CT scan • MRI • Ultrasound • Arthroscopy (optical imaging) • Radioisotope scan • Navigation • Preop. Planning
Sheet
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Today - what else?
• Good light • Good power tools (Light, oscillating drills)
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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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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Conventional X-ray (Image intensifire)
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Limits Some fractures and subluxations difficult to see Poor visualization of soft tissues Potentially insufficient information for planning
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
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
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
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
Monitor
Navigation Unit
Siremobil Iso-C-3D
Navi with IsoC-3D
Monitor
Carbon/ARCADIS/BrainLab
Monitor
Carbon/ARCADIS/BrainLab
Monitor
ARCADIS/BrainLab
Monitor
ARCADIS/BrainLab
Monitor
Monitor
59y, female, MVA
Monitor
Monitor
C-arm setup
MMoMooMMoMMMMM niniiiinnn tototootoooooooot rrrrrrrrr
Monitor
Arcadis ISO-C 3D
MMMoMoMoooMoMooooMMoooMMoMooMoooMMoooooMMoooonnniniiiiiiiiniinin ttotttttttt rrrrr
Monitor
Legs’ rotation
MMMMMMMMMMoMoMoMMMMoooMooMoMoMMMoMoMoMMM ininninnininniininnnin totootoooottotoootottoottoootoootoorrrrrrrrrrrrr
Monitor
“High Tech” - reduction tricks
Monitor
PIB removal
MoMoMoMoooMMoMoMMMMoooMMMoooMoooonnnninininnnnnniinnnnnininnnnniinninnnininittoootootttoottoooottoototooottotoottoorrrrrrrrrrrr
Monitor
PS reduction
MMMMMoMoMoMoMMoniniinnininiin tottotoootttooooototooorrrrrrr
Monitor
TEN
MoMMMoMM ninnnin totototorr
Monitor
PS Plating
MMMMMMoMMMMMoMoMMMMMoooMMMMMMMMoooooMMMMMMMMoooooMMMMMooooMMMooooMoMMMMooo iiinninnnnnninnnnninnnnniinininnnnittttttttoooottoooootototooototototorrrrrrrrrrrrrrrr
Monitor
Navigaton markers
MMoMMooooMoM nniiinininn tottoooootoootoooot rrrrrrrr
Monitor
Infracamera
MMoMooooM nninin totooorrrr
Monitor
“Arcadischeck”
MoMoMoMMoMooMooMoniinninninininitotttotototototototototot rrrrrrrrrrrr
Monitor
“Pointer”
MMoMMMMMooooMoMoMoMoooooMoMMooooonnininnniinnnniinnnnninnnninnnnniinnnnnniitttototottotttototoototorrrrrrrr
Monitor
Planning (80/48 mm/10mm
MoMoMoMoMoMoMMoMoMoMMMMoMooonninininininniininniniitototototootoooooottttoooottoooottooottotorrrrrrrrrrrrrrrrrr
Monitor
Calibration
MoMMoo inininiitototot rrr
Monitor
K-wires/drill/tap
MMMoMooooMMooMoMooMoMMoMoMoMooMoooMMoooonnniinniniinnninininininnniittttotooottottooorrrrrrrr
Monitor
SI screw insertion
MMMMMMMMooMMMooMMoMMMooMoMMMoooMMoMMMMMMMooooMMoooonnniininnniniinnininnitottoooooooooottttoorrrrrrrrrr
Monitor
Arcadis check
MoMM ninnin totototorrrr
Monitor
59y, female, MVA
Monitor
Variations in sacral morphology
MoMoMoMoniiininittttotottorrrrr
AH, 33é, nőbeteg, AO 41C3
AH, 33é, nőbeteg, AO 41C3
Tibia plateu navi
Tibia plateu navi
• 3D Virtual Planning with prediction of stability that will lead to improved patient care
• Biomechanical lab • Application fields
– Clinical practice
– Education – Research
Take home...
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
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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Take home…
Severeal new “toys” exsist
“High Tech” is a better chance
The surgeon has to be remain “the doctor”
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E. Varga EISSF
