Reproducibly achieving proper implant alignment is a critical step in total hip arthroplasty procedures that has been shown to substantially affect patient outcome. In current practice, correct alignment of the acetabular cup is verified in C-arm x-ray images that are acquired in an anterior–posterior (AP) view. Favorable surgical outcome is, therefore, heavily dependent on the surgeon’s experience in understanding the 3-D orientation of a hemispheric implant from 2-D AP projection images. This work proposes an easy to use intraoperative component planning system based on two C-arm x-ray images that are combined with 3-D augmented reality (AR) visualization that simplifies impactor and cup placement according to the planning by providing a real-time RGBD data overlay. We evaluate the feasibility of our system in a user study comprising four orthopedic surgeons at the Johns Hopkins Hospital and report errors in translation, anteversion, and abduction as low as 1.98 mm, 1.10 deg, and 0.53 deg, respectively. The promising performance of this AR solution shows that deploying this system could eliminate the need for excessive radiation, simplify the intervention, and enable reproducibly accurate placement of acetabular implants.
The state of the art approaches that provide guidance using image-less or image-based methods have certain drawbacks. Image-less methods require complex navigation and may provide unreliable registration @cite_13 . Image-based solutions rely on pre-operative CT scans or intra-operative fluoroscopy and often use external navigations systems for tracking @cite_23 @cite_0 . Systems based on external navigation are expensive and increase the operative time due to the added complexity. Use of pre-operative CT scans increases the radiation exposure and cost to the patient. Moreover, many of the methods used for registering CT to patient seek to solve ill-posed problems that require manual interaction either for initialization or landmark identification and, thus, disrupt the surgical workflow. Manual annotations can take between 3 to 5 minutes during the intervention for image registration @cite_7 . Although proven beneficial for the surgical outcome, neither of these costly and labor-intensive navigation techniques were widely adopted in clinical practice.
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Intraoperative patient registration may significantly affect the outcome of image-guided surgery (IGS). Image-based registration approaches have several advantages over the currently dominant point-based direct contact methods and are used in some industry solutions in image-guided radiation therapy with fixed X-ray gantries. However, technical challenges including geometric calibration and computational cost have precluded their use with mobile C-arms for IGS. We propose a 2D 3D registration framework for intraoperative patient registration using a conventional mobile X-ray imager combining fiducial-based C-arm tracking and graphics processing unit (GPU)-acceleration. The two-stage framework 1) acquires X-ray images and estimates relative pose between the images using a custom-made in-image fiducial, and 2) estimates the patient pose using intensity-based 2D 3D registration. Experimental validations using a publicly available gold standard dataset, a plastic bone phantom and cadaveric specimens have been conducted. The mean target registration error (mTRE) was 0.34±0.04 mm (success rate: 100 , registration time: 14.2 s) for the phantom with two images 90° apart, and 0.99±0.41 mm (81 , 16.3 s) for the cadaveric specimen with images 58.5° apart. The experimental results showed the feasibility of the proposed registration framework as a practical alternative for IGS routines. Recent years have seen exciting advances in Computer Assisted Surgery (CAS). CAS systems are currently in use which provide data to the surgeon, provide passive feedback and motion constraint, and even automate parts of the surgery by manipulating cutters and endoscopic cameras. For most of these systems, accurate registration between the patient's anatomy and the CAS system is crucial: if the position of the surgical target is not known with sufficient accuracy, therapies cannot be applied precisely, and treatment efficacy falls. This thesis presents a system for recovering the position and orientation of the target anatomy in 3D space based on iterative comparison of 2D planar radiographs with preoperative CT data. More specifically, this system uses X-ray images acquired at the time of treatment, and iteratively compares them with synthetic images, known as Digitally Reconstructed Radiographs (DRRs), in order to estimate the position and orientation of the target anatomy. An intermediate data representation called a Transgraph is presented. The Transgraph is similar to the Lumigraph, or Light Field, and extends the computer graphics field called image-based rendering to transmission imaging. This representation speeds up computation of DRRs by over an order of magnitude compared to ray-casting techniques, without the use of special graphics hardware. A hardware based volume rendering technique is also presented. This approach is based on new texture mapping techniques which enable DRR generation using off the shelf consumer grade computer graphics hardware. These techniques permit computation of full resolution (512 x 512) DRRs based on 256 x 256 x 256 CT data in roughly 70 ms. The registration system is evaluated for application to frameless stereotactic radiosurgery, and phantom studies are presented demonstrating accuracy comparable to state of the art immobilization systems. Additional phantom studies are presented in which the registration system is used to measure implant orientation following total hip replacement surgery, improving on current practice by a factor of two. Abstract A new information-theoretic approach is presented for finding the registration of volumetric medical images of differing modalities. Registration is achieved by adjustment of the relative position and orientation until the mutual information between the images is maximized. In our derivation of the registration procedure, few assumptions are made about the nature of the imaging process. As a result the algorithms are quite general and can foreseeably be used with a wide variety of imaging devices. This approach works directly with image data; no pre-processing or segmentation is required. This technique is, however, more flexible and robust than other intensity-based techniques like correlation. Additionally, it has an efficient implementation that is based on stochastic approximation. Experiments are presented that demonstrate the approach registering magnetic resonance (MR) images with computed tomography (CT) images, and with positron-emission tomography (PET) images. Surgical applications of the registration method are described. We present a framework for robustly estimating registration between a 3D volume image and a 2D projection image and evaluate its precision and robustness in spine interventions for vertebral localization in the presence of anatomical deformation. The framework employs a normalized gradient information similarity metric and multi-start covariance matrix adaptation evolution strategy optimization with local-restarts, which provided improved robustness against deformation and content mismatch. The parallelized implementation allowed orders-of-magnitude acceleration in computation time and improved the robustness of registration via multi-start global optimization. Experiments involved a cadaver specimen and two CT datasets (supine and prone) and 36 C-arm fluoroscopy images acquired with the specimen in four positions (supine, prone, supine with lordosis, prone with kyphosis), three regions (thoracic, abdominal, and lumbar), and three levels of geometric magnification (1.7, 2.0, 2.4). Registration accuracy was evaluated in terms of projection distance error (PDE) between the estimated and true target points in the projection image, including 14 400 random trials (200 trials on the 72 registration scenarios) with initialization error up to ±200 mm and ±10°. The resulting median PDE was better than 0.1 mm in all cases, depending somewhat on the resolution of input CT and fluoroscopy images. The cadaver experiments illustrated the tradeoff between robustness and computation time, yielding a success rate of 99.993 in vertebral labeling (with 'success' defined as PDE <5 mm) using 1,718 664 ± 96 582 function evaluations computed in 54.0 ± 3.5 s on a mid-range GPU (nVidia, GeForce GTX690). Parameters yielding a faster search (e.g., fewer multi-starts) reduced robustness under conditions of large deformation and poor initialization (99.535 success for the same data registered in 13.1 s), but given good initialization (e.g., ±5 mm, assuming a robust initial run) the same registration could be solved with 99.993 success in 6.3 s. The ability to register CT to fluoroscopy in a manner robust to patient deformation could be valuable in applications such as radiation therapy, interventional radiology, and an assistant to target localization (e.g., vertebral labeling) in image-guided spine surgery.