SummerSchool.ppt [Mode de compatibilité] Summer School... · 2007. 9. 10. · Title: Microsoft...

10/09/2007

1

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

10/09/2007

2

« Perform 3D actions in a 3D space on a 3D Object: a human being »Introduction

Basics

History

Therapeutic objects = Targets

TKA

HTO

THA

ACL

Conclusion Therapeutic objects Targets

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

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3

Frame based Stereotaxy : Clarke et Horsley - 1806

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

Introduction

Basics

History

Pedicular screwingTKA

HTO

THA

ACL

Conclusion

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4

First generation : ROBODOC and CASPAR

Introduction

Basics

History

First generation : ROBODOC and CASPAR

Femoral drilling

Out of business

Cost

TKA

HTO

THA

ACL

ConclusionCost

Invasiveness

No added value

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

6223

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5

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

The Perception – Decision – Action loop

PRE-OPIntroduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

PER-OP

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6

PASSIVE SYSTEMSNavigation systems

Introduction

Basics

History

Guiding systems

Navigation systems

3D localizers

TKA

HTO

THA

ACL

Conclusion

Real-time feed back on the location of :

-Therapeutic objects

- Surgical instruments

SEMI-ACTIVE SYSTEMSThe surgeon is guided in a

Introduction

Basics

History

The surgeon is guided in a restricted volume

Padyc

Guiding systems

TKA

HTO

THA

ACL

Conclusion

Synergistic robots

Collaborative robots

Impeachment robots

http://www-timc.imag.fr/

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7

ACTIVE SYSTEMSActive robots which performs

Introduction

Basics

History

Active robots which performsPart of the surgical procedure

Active robots

Guiding systems

TKA

HTO

THA

ACL

Conclusion

Perform parts of the procedure

Based on per-op planning

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

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Introduction

Basics

History

3D Localizers

TKA

HTO

THA

ACL

Conclusion

Localization : non deformable Objects

• Bones or surgical tools

Introduction

Basics

History

Bones or surgical tools•Location•Orientation

Refrb

TKA

HTO

THA

ACL

Conclusion

Ref.abscamera 3D rotation matrix and the translation

matrix to compute the transformation from Refabs to Refrb

rb

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Non deformable Objects

Bony structures : therapeutic objects

Introduction

Basics

History

• Dynamic reference base(DRB)

•Bony structures : therapeutic objects

•Surgical toolsTKA

HTO

THA

ACL

Conclusion

DRB attached to :

Non deformable Objects

• Dynamic reference base(DRB)Introduction

Basics

History

•DRB attached to :

•Bony structures : therapeutic objects

•Surgical tools

TKA

HTO

THA

ACL

Conclusion

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10

Optical localizer with two 2 Dimensional sensors

Localizer = 1 Source + 1 Sensor

Introduction

Basics

History

Line of sight

DRB

•Optical localizer with two 2 Dimensional sensors TKA

HTO

THA

ACL

Conclusion

Polaris :

Localizer = 1 Source + 1 Sensor

Introduction

Basics

History

•Polaris :TKA

HTO

THA

ACL

Conclusion

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Infra red sensors

Optical systems

Introduction

Basics

History

•Infra-red sensors

Basics

Emitted by the DRB

Reflected by the DRB

TKA

HTO

THA

ACL

Conclusion

Wave length 880 nm

In the OR one can find70 000 Lux 400 et 500 nm

Active systems

Optical systems

Introduction

Basics

History

•Active systems

DrawbacksCables on the operating field

Batteries

TKA

HTO

THA

ACL

Conclusion

Active emission of light= source of energy Weight

Sterilization issues

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Passive systemDrawbacks

Si l

Optical systems

Introduction

Basics

History

•Passive system Single use

Sensitive to surrounding light

Passive = reflectorsTKA

HTO

THA

ACL

Conclusion

ProsCheap

Light

Can be set on any type of instrument

Vision of the camera

Optical systems

Introduction

Basics

History

•Vision of the camera

Vision of the optical system

TKA

HTO

THA

ACL

Conclusion

Surgical scene

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13

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

40 000 TKA / Year / France

8 000 Uni / Year / France

• The challenges : two faces

Introduction

Basics

History

•Geometric challenge•Align the implants with respect to mechanical axes

•Functional challenge•Perform a good ligament balance

TKA

HTO

THA

ACL

Conclusion

•Enough mobility

•Enough stability

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•Mechanical axes :


Introduction

Basics

History

•Mechanical axes :TKA

HTO

THA

ACL

Conclusion

7°


Introduction

Basics

History

•Geometric challenge•Align the implants with respect to mechanical axes

•Functional challenge•Perform a good ligament balance

TKA

HTO

THA

ACL

Conclusion

•Enough mobility

•Enough stability

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• Functional challenge

•Ligament balancing

Introduction

Basics

History

•Ligament balancingTKA

HTO

THA

ACL

Conclusion



Introduction

Basics

History

•Ligament balancingTKA

HTO

THA

ACL

Conclusion

•Lift-off = wear •Instability

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16



• Well align knee (HKA ~ 180°): Good cuts• Well align knee (HKA ~ 180 ): Good cuts



• Well align knee (HKA ~ 180°): Excessive cuts

• Gap

• Well align knee (HKA ~ 180 ): Excessive cuts

p

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• Well align knee (HKA ~ 180°): Excessive cuts

• Gap

• Well align knee (HKA ~ 180 ): Excessive cuts

p

• Laxity in extension

• Increase PE.



• Well align knee (HKA ~ 180°): Insufficient cuts• Well align knee (HKA ~ 180 ): Insufficient cuts

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• Well align knee (HKA ~ 180°): Insufficient cuts• Well align knee (HKA ~ 180 ): Insufficient cuts

• Excessive constraint



• Misalignment (Varus or Valgus):

• Distraction

g ( g )

• Retraction• Laxity

• Constraint

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• Misalignment (Varus or Valgus):• Misalignment (Varus or Valgus):

• Retraction• Release




• Risks•Unbalance knee•Residual laxity / Excessive constraints•Overcorrection / Hypocorrection


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Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

The solutions

Build a SPECIFIC model of the patient under surgery

•Build the specific GEOMETRY of this patient

Introduction

Basics

History

•Build the specific GEOMETRY of this patient•Align the prosthesis with respect to the patient axes

•Hip center

•Knee center

TKA

HTO

THA

ACL

Conclusion

•Ankle center

•Localize in 3D the joint centers•Build reference planes

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Build a SPECIFIC model of the patient under surgery

•Build the specific MORPHOLOGY of this patient

Introduction

Basics

History

•Build the specific MORPHOLOGY of this patient

Local adjustment to the bonesLigament balance can only be made with local data

TKA

HTO

THA

ACL

Conclusion

Pros and Cons

•CT based approach

Introduction

Basics

History

CT based approach •Pre-operative planning•Cost – Radio protection issues•Archiving and communication of images : PACS•No increasing time for acquisition and planning

•CT including Hip – Knee - Ankle•Setup time•Intra-operative registration (time consuming/accuracy issues)

TKA

HTO

THA

ACL

Conclusion

Registration

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•Non image based systemPros and Cons

Introduction

Basics

History

g y

•Simple•Low cost – No radiation•Integration of intra-operative data•No registration issue

•Increase the operative time

TKA

HTO

THA

ACL

Conclusion

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

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•No pre-operative images

B ild ifi d l f th ti t A i iti

Introduction

Basics

History

•Build a specific model of the patient : Acquisition

•Geometric data•Axes

•Hip center•Knee center•Ankle center

TKA

HTO

THA

ACL

Conclusion

•Morphologic data•Bone surfaces

•Digitization of points with a 3D probe

•None image based approach

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

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24


Kinematics approach

Introduction

Basics

History

Rpolaris

Ta1

Tb1Tc1

•Search of a point C of Rfem with the minimum trajectory during the acquisiton motion

-Kinematics approachTKA

HTO

THA

ACL

Conclusion

Hip Center

Rfemur

Tc1

Td1

Ta0

Tb0Tc0 Td0


Morphologic approach

Introduction

Basics

History

Rpolaris

-Morphologic approachTKA

HTO

THA

ACL

Conclusion

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25

•Percutaneous digitization of points


Geometric approach

Introduction

Basics

History

•Percutaneous digitization of points -Geometric approachTKA

HTO

THA

ACL

Conclusion


Geometric approach

Introduction

Basics

History

•Error

•Slope

•Varus

-Geometric approachTKA

HTO

THA

ACL

Conclusion

•Valgus

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-Geometric approach

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

E. STINDEL, et Al., The center of the ankle in ct less based navigation system.

What is really important to detect? CAOS Santa fee 19-22 Juin 2002.


Introduction

Basics

History

0,2

0,3

0,4

0,5

0,6SsMI – SsME – Consequences on the slopeError in °

TKA

HTO

THA

ACL

Conclusion

-0,2

-0,1

0

0,1

0 10 20 30 40 50 60

Patient

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27

•Femoral and tibial shape : Bone morphing

U f t ti ti l d f bl d l

Introduction

Basics

History

•Use of statistical deformable modelsTKA

HTO

THA

ACL

Conclusion

A i iti D f ti Q lit t l

•Femoral shape : Bone morphing

Introduction

Basics

History

•Acquisition – Deformation – Quality controlTKA

HTO

THA

ACL

Conclusion

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d ( llé ) h h l d f h

•Femoral shape : Bone morphing

Introduction

Basics

History

•Quadtree (Lavallée) : hierarchical division of the 3D volume to apply global and local deformationTKA

HTO

THA

ACL

Conclusion

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

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•Level 1 : based on morphologic data

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

•Level 2 : based on dynamic per-operative dataSensor

Introduction

Basics

History

Spacer

Software

• Alignment

• Quantitative data on GAPS

TKA

HTO

THA

ACL

Conclusiondata on GAPS

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30

•Level 2 : based on dynamic per-operative data

Introduction

Basics

History

• Test residual laxity•Varus Max.•Valgus Max.

• If the residual laxity is over a threshold

TKA

HTO

THA

ACL

Conclusion


• Loop until the threshold is reached

Introduction

Basics

History

p

TKA

HTO

THA

ACL

Conclusion

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• Loop until the threshold is reached

Introduction

Basics

History

p

TKA

HTO

THA

ACL

Conclusion

• Courtesy of Christophe Marmignon and Philippe Cinquin – TIMC - Grenoble

•Level 3 : Integration of quality control in the decision loop

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

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•Femoral planning

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

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Active system : robotsIntroduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

Passive system : navigation

•Freehand

•Tools are localized in the 3D space in real time with respect to the bones

•Robotized cutting guides

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

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34

•Robotized milling guides

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

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Navigation of cutting guidesIntroduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

Navigation of cutting guidesIntroduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

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Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

7 000 cases / Year / France

•Integration of bricksIntroduction

Basics

History

-Hip center : Same brick

-Knee center : Specific solution

-Ankle center : Same brick

TKA

HTO

THA

ACL

Conclusion

-3D Planning

Computer Assisted Surgical Protocol - CASP

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37

•Knee center

-No access to the joint-Mixed approach-Man / Machine synergy

Introduction

Basics

History

Man / Machine synergy

SOMMER, H.J., Determination of first and second order instant screw parameters from landmark trajectories.

Mechanical Design, 1990: p. 141-142.

TKA

HTO

THA

ACL

Conclusion

•Knee center

-No access to the joint-Mixed approach-Man / Machine synergy

Introduction

Basics

History

y gy

TKA

HTO

THA

ACL

Conclusion

Expert steering

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•In the ORIntroduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

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•Anterior Cruciate Ligament Replacement

•The challenges

I t

Introduction

Basics

History

•Isometry

•Avoid impingementTKA

HTO

THA

ACL

Conclusion

•Planning

• Projection of the tibial point / Femoral notch projection• Compute the anisometry map

Introduction

Basics

History

•Anterior Cruciate Ligament Replacement

TKA

HTO

THA

ACL

Conclusion

•For a specific tibial point choose the best location of the femoral point

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•Action

•Anterior Cruciate Ligament ReplacementIntroduction

Basics

History

• Take the usual guide

• Attache a rigid body

•Perform the calibration

• Drill the tunnels with the

TKA

HTO

THA

ACL

Conclusion• Drill the tunnels with the help of the GUI

•Impingement

•Anterior Cruciate Ligament ReplacementIntroduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

• Digitized the anterior fiber of the graft

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Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

100 000 cases / Year / France

•Total Hip ArthroplastyIntroduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

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Length -


Basics

History

TKA

HTO

THA

ACL

Conclusion

Length +


Basics

History

TKA

HTO

THA

ACL

Conclusion

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Offset


Basics

History

TKA

HTO

THA

ACL

Conclusion

Offset +


Basics

History

TKA

HTO

THA

ACL

Conclusion

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Offset -


Basics

History

TKA

HTO

THA

ACL

Conclusion

-Length -Centre of rotation-Offset -Stability


Basics

History

• Anteversion of the cupTKA

HTO

THA

ACL

Conclusion

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•Total Hip Arthroplasty

-Reference planeIntroduction

Basics

History

• Not an absolute reference

• Can be define on an X-Ray

•Change in supine position

•Influence anteversion values

α

Vert

ical

TKA

HTO

THA

ACL

Conclusionα

-Reference plane


35

Introduction

Basics

History

0

5

10

15

20

25

30

TKA

HTO

THA

ACL

Conclusion

-50 0,5 1 1,5 2 2,5 3 3,5 4 4,5 5

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•View of the acetabulum fossa before reaming

-Local bone morphing instead of global


Basics

History

FossaTKA

HTO

THA

ACL

Conclusion



Basics

History

TKA

HTO

THA

ACL

Conclusion

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Basics

History

TKA

HTO

THA

ACL

Conclusion

• Final hip center location

-Fine tunning of the implants


Basics

History

TKA

HTO

THA

ACL

Conclusion

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-Fine tunning of the implantsIntroduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

Introduction

Basics

History

TKA

HTO

THA

ACL

Conclusion

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Introduction

Basics

History

Blind surgery or quantitative surgery ?

TKA

HTO

THA

ACL

Conclusion

SummerSchool.ppt [Mode de compatibilité] Summer School... · 2007. 9. 10. · Title: Microsoft...

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Transcript of SummerSchool.ppt [Mode de compatibilité] Summer School... · 2007. 9. 10. · Title: Microsoft...