Mixed Reality has the potential to improve accuracy and reduce required dissection for the performance of peri-acetabular osteotomy. The current work assesses initial proof of concept of MR guidance for PAO. A PAO planning module, based on preoperative computed tomography (CT) imaging, allows for the planning of PAO cut planes and repositioning of the acetabular fragment. 3D files (holograms) of the cut planes and native and planned acetabulum positions are exported with the associated spatial information. The files are then displayed on mixed reality head mounted device (HoloLens2, Microsoft) following intraoperative registration using an FDA-cleared mixed reality application designed primary for hip arthroplasty (HipInsight). PAO was performed on both sides of a bone model (Pacific Research). The osteotomies and acetabular reposition were performed in accordance with the displayed holograms. Post-op CT imaging was performed for analysis. Cutting plane-accuracy was evaluated using a best-fit plane and 2D angles (°) between the planned and achieved supra (SA)- and retroacetabular (RA) osteotomy and retroacetabular and ischial osteotomies (IO) were measured. To evaluate the accuracy of acetabular reorientation, we digitized the acetabular rim and calculated the acetabular opening plane. Absolute errors of planned and achieved operative inclination and anteversion (°) of the acetabular fragment, as well as 3D lateral-center-edge (LCE) angles were calculated. The mean absolute difference between the planned and performed osteotomy angles was 3 ± 3°. The mean absolute error between planned and achieved operative anteversion and inclination was 1 ± 0° and 0 ± 0° respectively. Mean absolute error between planned and achieved 3D LCE angle was 0.5 ± 0.7°. Mixed-reality guidance for the performance of pelvic osteotomies and acetabular fragment reorientation was feasible and highly accurate. This solution may improve the current standard of care by enabling reliable and precise reproduction of the desired acetabular realignment.
Navigation of acetabular component orientation is still not commonly performed despite repeated studies that show that more than ½ of acetabular components placed during hip arthroplasty are significantly mal-positioned and that intra-operative radiographic assessment is unreliable. The current study uses postoperative CT to assess the accuracy of a smart mechanical navigation instrument system for cup alignment. Thirty seven hip replacements performed using a smart mechanical navigation device (the HipXpert System) had post-operative CT studies available for analysis. These post-operative CT studies were performed for pre- operative planning of the contralateral side, one to three years following the prior surgery. An application specific software module was developed to measure cup orientation using CT (HipXpert Research Application, Surgical Planning Associates Inc., Boston, Massachusetts). The method involves creation of a 3D surface model from the CT data and then determination of an Anterior Pelvic Plane coordinate system. A multiplaner image viewer module is then used to create an image through the CT dataset that is coincident with the opening plane of the acetabular component. Points in this plane are input and then the orientation of the cup is calculated relative to the AP Plane coordinate space according to Murray's definitions of operative anteversion and operative inclination. The actual cup orientation was then compared to the goal of cup orientation recorded when the surgery was performed using the system for acetabular component alignment.Introduction
Patients and Methods
Cup malpositioning remains a common cause of dislocation, wear, osteolysis, and revision. The concept of a “Safe Zone” for acetabular component orientation was introduced more than 35 years ago1. The current study assesses CT studies of replaced hips to assess the concept of a safe zone for acetabular orientation by comparing the orientation of acetabular components revised due to recurrent instability and to a series of stable hip replacements. Cup orientation in 50 hips revised for recurrent instability was measured using CT. These hips were compared to a group of 184 stable hips measured using the same methods. Femoral anteversion in the stable hips was also measured. Images to assess femoral anteversion in the unstable group were not available. An application specific software modules was developed to measure cup orientation using CT (HipSextant Research Application 1.0.13 Surgical Planning Associates Inc., Boston, Massachusetts). The cup orientation was determined by first identifying Anterior Pelvic Plane Coordinate system landmarks on a 3D surface model. A multiplanar reconstruction module then allowed for the creation of a plane parallel with the opening plane of the acetabulum. The orientation of the cup opening plane in the AP Plane coordinate space was calculated according to Murray's definitions of operative anteversion and operative inclination2. Both absolute cup position relative to the APP and tilt-adjusted cup position3 were calculated.Introduction
Methods
Cup malpositioning remains a common cause of dislocation, wear, osteolysis, and revision. The concept of a “Safe Zone” for acetabular component orientation was introduced more than 35 years ago1. The current study assesses CT studies of replaced hips to assess the concept of a safe zone for acetabular orientation by comparing the orientation of acetabular components revised due to recurrent instability and to a series of stable hip replacements. Cup orientation in 30 hips revisedin 27patients for recurrent instability was measured using CT. These hips were compared to a group of 115 stable hips measured using the same methods. Femoral anteversion in the stable hips was also measured. Images to assess femoral anteversion in the unstable group were not available. An application specific software modules was developed to measure cup orientation using CT (HipSextant Research Application 1.0.13 Surgical Planning Associates Inc., Boston, Massachusetts). The cup orientation was determined by first identifying Anterior Pelvic Plane Coordinate system landmarks on a 3D surface model. A multiplanar reconstruction module then allowed for the creation of a plane parallel with the opening plane of the acetabulum. The orientation of the cup opening plane in the AP Plane coordinate space was calculated according to Murray's definitions of operative anteversion and operative inclination2. Both absolute cup position relative to the APP and tilt-adjusted cup position3 were calculated.INTRODUCTION
METHODS
Cup malpositioning remains a common cause of dislocation, wear, osteolysis, and revision. The concept of a “Safe Zone” for acetabular component orientation was introduced more than 35 years ago. The current study assesses CT studies of replaced hips to assess the concept of a safe zone for acetabular orientation. We assessed the orientation of acetabular components revised due to recurrent instability and compared the results to a series of stable hip replacements.BACKGROUND
PURPOSE
Studies show that cup malpositioning using conventional techniques occurs in 50 to 74% of cases defined. Assessment of the utility of improved methods of placing acetabular components depends upon the accuracy of the method of measuring component positioning postoperatively. The current study reports on our preliminary experience assessing the accuracy of EOS images and application specific software to assess cup orientation as compared to CT. Eighteen patients with eighteen unilateral THA had pre-operative EOS images were obtained for preoperative assessment of leg-length difference and standing pelvic tilt. All of these patients also had preoperative CT imaging for surgical navigation of cup placement. This allows us to compare cup orientation as measured by CT to cup orientation as measured using the EOS images. Application specific software modules were developed to measure cup orientation using both CT and EOS images (HipSextant Research Application 1.0.13 Surgical Planning Associates Inc., Boston, Massachusetts). Using CT, cup orientation was determined by identifying Anterior Pelvic Plane coordinate system landmarks on a 3D surface model. A multiplanar reconstruction module allows for creation of a plane parallel with the opening plane of the acetabulum and subsequent calculation of plane orientation in the AP Plane coordinate space according to Murray's definitions of operative anteversion and operative inclination. Using EOS DICOM images, spatial information from the images were used to reconstruct the fan beam projection model. Each image pair is positioned inside this projection model. Anterior Pelvic Plane coordinate points are digitized on each image and back-projected to the fan beam source. Corresponding beams are then used to compute the 3D intersection points defining the 3D position and orientation of the Anterior Pelvic Plane. Ellipses with adjustable radii were then used to define the cup border in each EOS image. By respecting the fan beam projection model, 3D planes defining the projected normal of the ellipse in each image are computed. 3D implant normal was estimated by determining 3D plane intersection lines for each image pair. Implant center points are defined by using the back-projected and intersected ellipse center beams in the image pairs (Figure 1).Introduction
Methods
Cup malposition in hip arthroplasty and hip resurfacing is associated with instability, accelerated wear, and the need for revision. A recent study measuring cup orientation on conventional radiodiographs demonstrated an incidence of cup malpositioning of 50% according to the safe zone that they defined 1,2. A prior study of 105 conventionally placed cups using CT demonstrated a cup malpositioning incidence of 74%3. The current study similarly assesses the variation in cup position using conventional techniques as measured by CT. CT studies of 123 hips in 119 patients with total hip arthroplasties performed using conventional techniques were used for this study. The indications for the CT studies were for CT-based surgical navigation of the contralateral side or for assessment of periprosthetic osteolysis. An application specific software modules was developed to measure cup orientation using CT (HipSextant Research Application 1.0.13 Surgical Planning Associates Inc., Boston, Massachusetts). The cup orientation was determined by first identifying Anterior Pelvic Plane Coordinate system landmarks on a 3D surface model. A multiplanar reconstruction module then allowed for the creation of a plane parallel with the opening plane of the acetabulum. The orientation of the cup opening plane in the AP Plane coordinate space was calculated according to Murray's definitions of operative anteversion and operative inclination. Since these studies including images through the femoral condyles, femoral anteversion could be measured on these hips as well (Osirix v5.6, Pixmeo SARL, Bernex, Switzerland).Introduction
Methods
Cup malposition leads to increased incidences of dislocation, impingement, wear, and revision. The HipSextant navigation system is a smart mechanical navigation device designed to indicate correct cup orientation at surgery. The current study assesses the effect of deliberately mis-docking the device on clinical accuracy. Ten patients (5 men and 5 women) presenting for total hip arthroplasty were assessed. Planning for the HipSextant Navigation System (Surgical Planning Associates, Inc., Boston, MA) was performed as usual. This is done by first creating a 3D surface model from CT imaging, establishing an Anterior Pelvic Plane coordinate system, and then creating a patient-specific HipSextant coordinate system. This coordinate system is defined by three points. The first point, called the basepoint, is located just behind the posterior wall of the acetabulum a fixed distance above the infracotyloid notch. The second point is located on the lateral aspect of the anterior superior iliac spine. The third point is located on the surface of the ilium and equally distant from the other two points. These three points define a patient-specific coordinate system that is known relative to the APP. Clinically, the instrument is then docked according to the plan and two protractors on the top of the instrument allow a direction indicator to point in the direction of desired cup orientation. For each of the hips, after the HipSextant plan was created (Figure 1), two additional plans were created: one where the basepoint was docked 5 mm closer to and one 5 mm further from the infracotyloind notch. The effect of the deliberate mis-docking was measured in degrees of operative anteversion and operative inclination.Introduction:
Methods:
Wear, wear-associated osteolysis, and instability are the most common reasons for revision total hip arthroplasty. These failures have been shown to be associated with acetabular component malpositioning. However, optimal acetabular component orientation on a patient-specific basis is currently unknown. The current study uses CT to assess acetabular orientation in a group of unstable hips as compared to a control group of stable hips. Our institutional database of CT studies performed in the region of the hip beginning in February of 1998 (41,975 CT studies) was compared against our institutional database of revision total hip arthroplasties beginning in August of 2003 (2262 Revision THA) to identify CT studies of any hip treated for recurrent instability by revision of the acetabular component. Twenty hips in 20 patients with suitable CT studies were identified for the study group. Our control group consisted of 99 hips in 93 patients who had CT studies either for computer-assisted surgery on the contralateral side or for assessment of osteolysis. Using the CT data, the AP plane (APP) was defined, supine pelvic tilt was measured, and cup orientation was calculated by fitting a best fit plane to 6 points on the rim of the acetabular component. Cup orientation was calculated in degrees of operative anteversion and operative inclination according to the definitions of Murray. Both absolute cup position relative to the APP and tilt-adjusted cup position1 were calculated.Introduction:
Methods:
Cup malposition in hip arthroplasty and hip resurfacing is associated with instability, accelerated wear, and the need for revision. A recent study measuring cup orientation on conventional radiodiographs demonstrated an incidence of cup malpositioning of 50% according to the safe zone that they defined1,2. A prior study of 105 conventionally placed cups using CT demonstrated a cup malpositioning incidence of 74%3. The current study similarly assesses the variation in cup position using conventional techniques as measured by CT. We have performed CT-based navigation of hip arthroplasty and revision arthroplasty on a routine basis since 2003 and also use CT imaging to quantify periprosthetic osteolysis. In our image database from these, we have identified 98 hips and y patients who had a previously conventionally-placed cup on CT imaging. For each hip, cup orientation was determined in operative anteversion and operative inclination (according to the definitions of Murray) using an application specific software application (HipSextant Research Application 1.0.7, Surgical Planning Associates Inc., Boston, Massachusetts). This application allows for determination of the Anterior Pelvic Plane coordinates from a 3D surface model. A multiplanar reconstruction module allows for creation of a plane parallel with the opening plane of the acetabulum and subsequent calculation of plane orientation in the AP Plane coordinate space.Introduction:
Methods:
While more than ½ of acetabular components placed during hip arthroplasty are significantly malpositioned, traditional surgical navigation and robotoics have not been widely adopted. This may be due to the additional time, expense, and complexity associated with this technology. As an alternative, smart mechanical navigation instruments, adjusted on a patient-specific basis, have been introduced to address the problem of cup malorientation. The current study assesses the accuracy of acetabular component alignment using a mechanical navigation instrument. The acetabular component was aligned in 58 consecutive hips in 58 patients using the HipSextant Mechanical Navigation System (Surgical Planning Associates, Inc. Boston, MA). The technique involves using a patient-specific plan and associated software. In planning for surgery, CT data are used to create a 3D model and to define the anterior pelvic plane (APP). A patient-specific HipSextant docking coordinate system is then determined by three points: one just behind the posterior acetabular rim, a second on the lateral side of the ASIS, and a third on the surface of the ilium (Figure 1). The HipSextant itself has two adjustable orthogonal protractors (in-plane and off-plane angle) and two adjustable arms so that the instrument is adjusted for each patient based on their specific anatomy. The instrument docks directly to the pelvis so the recommended orientation of the acetabular component is based on the actual position of the pelvis at the time of component implantation. A direction indicator points in the direction of the planned cup orientation (Figure 2). Cup alignment was further enhanced with the use of a parallel guide to improve parallel visualization (Figure 3). Postoperative cup orientation was measured using a validated two-dimensional/three-dimensional matching method [3,5].Background:
Patients and Methods:
Conventional methods of aligning the acetabular component during hip arthroplasty and hip resurfacing often rely upon anatomic information available to the surgeon. Such anatomical information includes the transverse acetabular ligament and the locations of the pubis, ischium and ilium. The current study assesses the variation in orientation of the plane defined by the pubis, ischium and ilium on a patient-specific basis as measured by CT. To assess the reliability of anatomical landmarks in surgery, we assessed 54 hips in 51 patients (32 male, 22 female) who presented for CT-based surgical navigation of total hip arthroplasty. The HipSextant Research Application (version 1.0.7, Surgical Planning Associates Inc., Boston, Massachusetts) was used to perform the calculations. This application allows for determination of the Anterior Pelvic Plane coordinates from a 3D surface model. Standardized points on the ilium, ischium, and pubis were entered. These three points defined a plane and the orientation of the plane in the AP Plane coordinate system was calculated in degrees of operative anteversion and operative inclination according to the definitions of Murray1.Introduction:
Methods:
Half of all acetabular components placed using conventional methods are malpositioned1. The HipSextant™ Navigation System (Surgical Planning Associates, Boston, MA) is a mechanical navigation system, adjusted on a patient-specific basis, designed to achieve appropriate cup alignment as simply and rapidly as possible. The current study assesses the surgeon's ability to register and track the pelvis and align the cup using the system. A bioskills model pelvis (Pacific Research Laboratories, Inc., Vashon, WA) was prepared by placing screws to mark the anterior pelvic plane points and by inserting a long cup alignment pin, simulating a cup insertion handle, into the acetabulum. The bone model was then scanned using CT. The HipSextantTM Navigation System Planning Application was then used to plan the use of the HipSextant for the surgery. This is accomplished by creating a 3D model, designating the AP plane (marked by the screws), and then determining the HipSextant docking points. One of these three points is behind the posterior wall of the acetabulum (the basepoint). The second of these three points is on the lateral aspect of the anterior superior iliac spine. The third point, the landing point, is located on the surface of the ilium and equally distant from the other two points (Figure 1). The two protractors on the HipSextant planning application were then adjusted to be parallel with the cup alignment pin on the bone model. A surgeon and assistant were then asked to dock the HipSextant on the bone model and to visually align the direction indicator to be parallel with the cup alignment pin. The two protractor angles on the instrument were recorded. This allowed for calculation of error in operative anteversion and operative inclination between the plan and the actual alignment that was accomplished. Four pairs of surgeon and assistant each performed the docking and alignment procedure 10 times for a total of 40 measurements.Introduction
Methods
Acetabular component malpositioning is the most common reason for instability and wear resulting in revision total hip arthroplasty (THA). The current study aimed to assess a novel mechanical navigation device which was designed to simply and efficiently indicate appropriate cup orientation during surgery. The accuracy was compared to a series of hip arthroplasties performed using CT-based computer-assisted cup placement. The study group consisted of 70 THAs performed using the mechanical device. The control group consisted of 146 THAs performed using CT-based computer navigation. Postoperative cup positioning was measured using a validated 2D/3D-matching method. An outlier was defined outside a range of ± 10 degrees from the planned inclination or anteversion. In the study group the mean accuracy for inclination was 1.3 ± 3.4 (-6.6 – 8.2) and 1.0 ± 4.1 (-8.8 – 9.5) for anteversion with no outliers for either parameter. In the control group the accuracy for anteversion (3.0 ± 5.8 [-11.8 - 19.6]; p=0.6%) and the percentage of outliers (6.8%; p=3.3%) differed significantly. The accuracy for inclination (3.5 ± 4.1 [-12.7 - 9.5]; p=21.4%) and the percentage of ouliers (4.8%; p=9.9%) did not differ significantly. The use of this mechanical navigation device can result in similar accuracy of acetabular cup orientation compared with CT-based surgical navigation. All cups were placed within a zone of ± 10 degree range of inclination and anteversion. This mechanical navigation device allows accurate cup navigation with minimal additional time and equipment.
