Virtual Reality Aided Mobile C-arm Positioning for Image-Guided Surgery

Image-guided surgery (IGS) is the minimally invasive procedure based on the pre-operative volume in conjunction with intra-operative X-ray images which are commonly captured by mobile C-arms for the confirmation of surgical outcomes. Although currently some commercial navigation systems are employed, one critical issue of such systems is the neglect regarding the radiation exposure to the patient and surgeons. In practice, when one surgical stage is finished, several X-ray images have to be acquired repeatedly by the mobile C-arm to obtain the desired image. Excessive radiation exposure may increase the risk of some complications. Therefore, it is necessary to develop a positioning system for mobile C-arms, and achieve one-time imaging to avoid the additional radiation exposure. In this dissertation, a mobile C-arm positioning system is proposed with the aid of virtual reality (VR). The surface model of patient is reconstructed by a camera mounted on the mobile C-arm. A novel registration method is proposed to align this model and pre-operative volume based on a tracker, so that surgeons can visualize the hidden anatomy directly from the outside view and determine a reference pose of C-arm. Considering the congested operating room, the C-arm is modeled as manipulator with a movable base to maneuver the image intensifier to the desired pose. In the registration procedure above, intensity-based 2D/3D registration is used to transform the pre-operative volume into the coordinate system of tracker. Although it provides a high accuracy, the small capture range hinders its clinical use due to the initial guess. To address such problem, a robust and fast initialization method is proposed based on the automatic tracking based initialization and multi-resolution estimation in frequency domain. This hardware-software integrated approach provides almost optimal transformation parameters for intensity-based registration. To determine the pose of mobile C-arm, high-quality visualization is necessary to locate the pathology in the hidden anatomy. A novel dimensionality reduction method based on sparse representation is proposed for the design of multi-dimensional transfer function in direct volume rendering. It not only achieves the similar performance to the conventional methods, but also owns the capability to deal with the large data sets

Automatic image analysis of C-arm Computed Tomography images for ankle joint surgeries

Open reduction and internal fixation is a standard procedure in ankle surgery for treating a fractured fibula. Since fibula fractures are often accompanied by an injury of the syndesmosis complex, it is essential to restore the correct relative pose of the fibula relative to the adjoining tibia for the ligaments to heal. Otherwise, the patient might experience instability of the ankle leading to arthritis and ankle pain and ultimately revision surgery. Incorrect positioning referred to as malreduction of the fibula is assumed to be one of the major causes of unsuccessful ankle surgery. 3D C-arm imaging is the current standard procedure for revealing malreduction of fractures in the operating room. However, intra-operative visual inspection of the reduction result is complicated due to high inter-individual variation of the ankle anatomy and rather based on the subjective experience of the surgeon. A contralateral side comparison with the patient’s uninjured ankle is recommended but has not been integrated into clinical routine due to the high level of radiation exposure it incurs. This thesis presents the first approach towards a computer-assisted intra-operative contralateral side comparison of the ankle joint. The focus of this thesis was the design, development and validation of a software-based prototype for a fully automatic intra-operative assistance system for orthopedic surgeons. The implementation does not require an additional 3D C-arm scan of the uninjured ankle, thus reducing time consumption and cumulative radiation dose. A 3D statistical shape model (SSM) is used to reconstruct a 3D surface model from three 2D fluoroscopic projections representing the uninjured ankle. To this end, a 3D SSM segmentation is performed on the 3D image of the injured ankle to gain prior knowledge of the ankle. A 3D convolutional neural network (CNN) based initialization method was developed and its outcome was incorporated into the SSM adaption step. Segmentation quality was shown to be improved in terms of accuracy and robustness compared to the pure intensity-based SSM. This allows us to overcome the limitations of the previously proposed methods, namely inaccuracy due to metal artifacts and the lack of device-to-patient orientation of the C-arm. A 2D-CNN is employed to extract semantic knowledge from all fluoroscopic projection images. This step of the pipeline both creates features for the subsequent reconstruction and also helps to pre-initialize the 3D-SSM without user interaction. A 2D-3D multi-bone reconstruction method has been developed which uses distance maps of the 2D features for fast and accurate correspondence optimization and SSM adaption. This is the central and most crucial component of the workflow. This is the first time that a bone reconstruction method has been applied to the complex ankle joint and the first reconstruction method using CNN based segmentations as features. The reconstructed 3D-SSM of the uninjured ankle can be back-projected and visualized in a workflow-oriented manner to procure clear visualization of the region of interest, which is essential for the evaluation of the reduction result. The surgeon can thus directly compare an overlay of the contralateral ankle with the injured ankle. The developed methods were evaluated individually using data sets acquired during a cadaver study and representative clinical data acquired during fibular reduction. A hierarchical evaluation was designed to assess the inaccuracies of the system on different levels and to identify major sources of error. The overall evaluation performed on eleven challenging clinical datasets acquired for manual contralateral side comparison showed that the system is capable of accurately reconstructing 3D surface models of the uninjured ankle solely using three projection images. A mean Hausdorff distance of 1.72 mm was measured when comparing the reconstruction result to the ground truth segmentation and almost achieved the high required clinical accuracy of 1-2 mm. The overall error of the pipeline was mainly attributed to inaccuracies in the 2D-CNN segmentation. The consistency of these results requires further validation on a larger dataset. The workflow proposed in this thesis establishes the first approach to enable automatic computer-assisted contralateral side comparison in ankle surgery. The feasibility of the proposed approach was proven on a limited amount of clinical cases and has already yielded good results. The next important step is to alleviate the identified bottlenecks in the approach by providing more training data in order to further improve the accuracy. In conclusion, the new approach presented gives the chance to guide the surgeon during the reduction process, improve the surgical outcome while avoiding additional radiation exposure and reduce the number of revision surgeries in the long term

IMPROVED IMAGE QUALITY IN CONE-BEAM COMPUTED TOMOGRAPHY FOR IMAGE-GUIDED INTERVENTIONS

In the past few decades, cone-beam computed tomography (CBCT) emerged as a rapidly developing imaging modality that provides single rotation 3D volumetric reconstruction with sub-millimeter spatial resolution. Compared to the conventional multi-detector CT (MDCT), CBCT exhibited a number of characteristics that are well suited to applications in image-guided interventions, including improved mechanical simplicity, higher portability, and lower cost. Although the current generation of CBCT has shown strong promise for high-resolution and high-contrast imaging (e.g., visualization of bone structures and surgical instrumentation), it is often believed that CBCT yields inferior contrast resolution compared to MDCT and is not suitable for soft-tissue imaging. Aiming at expanding the utility of CBCT in image-guided interventions, this dissertation concerns the development of advanced imaging systems and algorithms to tackle the challenges of soft-tissue contrast resolution. The presented material includes work encompassing: (i) a comprehensive simulation platform to generate realistic CBCT projections (e.g., as training data for deep learning approaches); (ii) a new projection domain statistical noise model to improve the noise-resolution tradeoff in model-based iterative reconstruction (MBIR); (iii) a novel method to avoid CBCT metal artifacts by optimization of the source-detector orbit; (iv) an integrated software pipeline to correct various forms of CBCT artifacts (i.e., lag, glare, scatter, beam hardening, patient motion, and truncation); (v) a new 3D reconstruction method that only reconstructs the difference image from the image prior for use in CBCT neuro-angiography; and (vi) a novel method for 3D image reconstruction (DL-Recon) that combines deep learning (DL)-based image synthesis network with physics-based models based on Bayesian estimation of the statical uncertainty of the neural network. Specific clinical challenges were investigated in monitoring patients in the neurological critical care unit (NCCU) and advancing intraoperative soft-tissue imaging capability in image-guided spinal and intracranial neurosurgery. The results show that the methods proposed in this work substantially improved soft-tissue contrast in CBCT. The thesis demonstrates that advanced imaging approaches based on accurate system models, novel artifact reduction methods, and emerging 3D image reconstruction algorithms can effectively tackle current challenges in soft-tissue contrast resolution and expand the application of CBCT in image-guided interventions