Yonsei Med J.  2018 Aug;59(6):769-780. 10.3349/ymj.2018.59.6.769.

CT-based Navigation System Using a Patient-Specific Instrument for Femoral Component Positioning: An Experimental in vitro Study with a Sawbone Model

Affiliations
  • 1Department of Robotics Engineering, Daegu Gyeongbuk Institute of Science and Technology, Daegu, Korea.
  • 2Department of Orthopaedic Surgery, Daegu Catholic University College of Medicine, Daegu, Korea. dr.junyoung@gmail.com
  • 3Department of Orthopedic Surgery, Kyungpook National University Hospital, Daegu, Korea.

Abstract

PURPOSE
The intraoperative version of the femoral component is usually determined by visual appraisal of the stem position relative to the distal femoral condylar axis. However, several studies have suggested that a surgeon's visual assessment of the stem position has a high probability of misinterpretation. We developed a computed tomography (CT)-based navigation system with a patient-specific instrument (PSI) capable of three-dimensional (3D) printing and investigated its accuracy and consistency in comparison to the conventional technique of visual assessment of the stem position.
MATERIALS AND METHODS
A CT scan of a femur sawbone model was performed, and pre-experimental planning was completed. We conducted 30 femoral neck osteotomies using the conventional technique and another 30 femoral neck osteotomies using the proposed technique. The femoral medullary canals were identified in both groups using a box chisel.
RESULTS
For the absolute deviation between the measured and planned values, the mean two-dimensional anteversions of the proposed and conventional techniques were 1.41° and 4.78°, while their mean 3D anteversions were 1.15° and 3.31°. The mean θ 1, θ 2, θ 3, and d, all of which are parameters for evaluating femoral neck osteotomy, were 2.93°, 1.96°, 5.29°, and 0.48 mm for the proposed technique and 4.26°, 3.17°, 4.43°, and 3.15 mm for the conventional technique, respectively.
CONCLUSION
The CT-based navigation system with PSI was more accurate and consistent than the conventional technique for assessment of stem position. Therefore, it can be used to reduce the frequency of incorrect assessments of the stem position among surgeons and to help with accurate determination of stem anteversion.

Keyword

Total hip replacement; computer-assisted surgery; 3D printing

MeSH Terms

Arthroplasty, Replacement, Hip
Femur
Femur Neck
In Vitro Techniques*
Osteotomy
Printing, Three-Dimensional
Surgeons
Surgery, Computer-Assisted
Tomography, X-Ray Computed

Figure

  • Fig. 1 Experimental steps of the proposed technique. (A) Fixation of the Steinmann pin (red circle) around the greater trochanter. (B) Attachment of the Steinman pin with a marker. (C) Patient-specific instrument positioning on the planned surface. (D) Femoral neck osteotomy using an oscillating saw. (E) Cross-section of the proximal portion after the osteotomy. (F) Alignment of the tool orientation using the navigation system. (G) Femoral medullary canalizing. (H) Cross-section of the distal portion after femoral medullary canalizing. (I) Evaluation.

  • Fig. 2 Planning of stem anteversion. (A) Points around the femoral neck (red) were set and used to define a center point. (B) A different center point (blue) on the femoral head was set. (C) The reference line (red line) was determined using the two center points. (D) Three anatomical landmarks (both condyles and the lesser trochanter, blue points) were set. (E) The three landmarks were used to define a coronal plane, and femoral anteversion was measured based on the plane and reference line.

  • Fig. 3 Geometric relationship between 2D anteversion (θ2D) and 3D anteversion (θ3D). 2D, two-dimensional; 3D, three-dimensional.

  • Fig. 4 Patient-specific instrument (PSI) design and preregistration. (A) Four lines (L1, L2, L3, and L4) were manually defined in the coronal view. θ1, θ2, and d were defined using the lines. (B) PSI was made with several virtual landmarks; in this study, θ1, θ2, and d were set to 135°, 45°, and 10 mm, respectively. The cutting plane was parallel to nc, which means that θ3 was set to 0. (C) Preregistration was performed to obtain the transformation matrix (T1PM) representing the transformation from {I} to {PM}, where {PM} and {I} are coordinate systems of the PSI-attached marker and virtual femur model, respectively.

  • Fig. 5 One-click image-to-patient registration. {O}, {I}, {PM}, and {SM} represent coordinate systems of the optical tracking system, virtual femur model, patient-specific instrument (PSI)-attached marker, and Steinmann pin-attached marker, respectively. TOPM, TOSM, and T1PM are transformation matrixes representing transformation from {O} to {PM}, from {O} to {SM}, and from {I} to {PM}, respectively. Image-to-patient registration was simply performed using the three matrices.

  • Fig. 6 Evaluation of the proposed technique. (A) The coordinate system used in the evaluation step is the same with that determined in the planning step. ns, na, and nc are the basis vectors of the coordinate system. (B) Femoral anteversion evaluation in which lproj was defined as a line passing through two edge points (green dots) of the rectangular hole (white dashed line) made from bone marrow tunneling and two-dimensional anteversion, θ2D, was measured using lproj and ns. (C) Osteotomy evaluation in the coronal view in which θ1, θ2, and d were measured using manually drawn lines (L1, L2, L3, and L4). (D) Osteotomy evaluation in the sagittal view, in which θ3 was measured using a manually drawn line (L5) and nc.

  • Fig. 7 Scatter plot and Bland-Altman diagram of measurements of 2D and 3D anteversion. (A) Scatter plot of the 2D anteversion measurements with and without the navigation system. (B) Bland-Altman diagram of the 2D anteversion measurements with and without the navigation system. (C) Scatter plot of the 3D anteversion measurements with and without the navigation system. (D) Bland-Altman diagram of 3D anteversion measurements with and without the navigation system. 2D, two-dimensional; 3D, three-dimensional.

  • Fig. 8 Scatter plot and Bland-Altman diagram of measurements of θ1, θ2, d, and θ3. (A) Scatter plot of the θ1 measurements with and without the patient-specific instrument (PSI); (B) Bland-Altman diagram of the θ1 measurements with and without the PSI; (C) Scatter plot of the θ2 measurements with and without the PSI; (D) Bland-Altman diagram of the θ2 measurements with and without the PSI; (E) Scatter plot of the d measurements with and without the PSI; (F) Bland-Altman diagram of d measurements with and without the PSI; (G) Scatter plot of θ3 measurements with and without the PSI; (H) Bland-Altman diagram of the θ3 measurements with and without the PSI.


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