Computer Aided Tools for the Design and Planning of Personalized Shoulder Arthroplasty

La artroplastia de hombro es el tercer procedimiento de reemplazo articular más común, después de la artroplastia de rodilla y cadera, y actualmentees el de más rápido crecimiento en el campo ortopédico. Las principales opciones quirúrgicas incluyen la artroplastia total de hombro (TSA), en la quese restaura la anatomía articular normal, y, para pacientes con un manguito rotador completamente desgarrado, la artroplastia inversa de hombro (RSA), en la que la bola y la cavidad de la articulación glenohumeral se cambian. A pesar del progreso reciente y los avances en el diseño, las tasas de complicaciones reportadas para RSA son más altas que las de la artroplastia de hombro convencional. Un enfoque específico para el paciente, en el que los médicos adaptan el tratamiento quirúrgico a las características del mismo y al estado preoperatorio, por ejemplo mediante implantes personalizados y planificación previa, puede ayudar a reducir los problemas postoperatorios y mejorar el resultado funcional. El objetivo principal de esta tesis es desarrollar y evaluar métodos novedosos para RSA personalizado, utilizando tecnologías asistidas por ordenador de última generación para estandarizar y automatizar las fases de diseño y planificación.Los implantes personalizados son una solución adecuada para el tratamiento de pacientes con pérdida extensa de hueso glenoideo. Sin embargo, los ingenieros clínicos se enfrentan a muchas variables en el diseño de implantes (número y tipo de tornillos, superficie de contacto, etc.) y una gran variabilidad anatómica y patológica. Actualmente, no existen herramientas objetivas para guiarlos a la hora de elegir el diseño óptimo, es decir, con suficiente estabilidad inicial del implante, lo que hace que el proceso de diseño sea tedioso, lento y dependiente del usuario. En esta tesis, se desarrolló una simulación de Virtual Bench Test (VBT) utilizando un modelo de elementos finitos para evaluar automáticamente la estabilidad inicial de los implantes de hombro personalizados. A través de un experimento de validación, se demostró que los ingenieros clínicos pueden utilizar el resultado de Virtual Bench Test como referencia para respaldar sus decisiones y adaptaciones durante el proceso de diseño del implante.Al diseñar implantes de hombro, el conocimiento de la morfología y la calidad ósea de la escápula en toda la población es fundamental. En particular, se tienen en cuenta las regiones con la mejor reserva ósea (hueso cortical) para definir la posición y orientación de los orificios de los tornillos, mientras se busca una fijación óptima. Como alternativa a las mediciones manuales, cuya generalización está limitada por el análisis de pequeños subconjuntos de pacientes potenciales, Statistical Shape Models (SSMs) se han utilizado comúnmente para describir la variabilidad de la forma dentro de una población. Sin embargo, estos SSMs normalmente no contienen información sobre el grosor cortical.Por lo tanto, se desarrolló una metodología para combinar la forma del hueso escapular y la morfología de la cortical en un SSM. Primero, se presentó y evaluó un método para estimar el espesor cortical, a partir de un análisis de perfil de Hounsfield Unit (HU). Luego, utilizando 32 escápulas sanas segmentadas manualmente, se creó y evaluó un modelo de forma estadística que incluía información de la cortical. La herramienta desarrollada se puede utilizar para implantar virtualmente un nuevo diseño y probar su congruencia dentro de una población virtual generada, reduciendo así el número de iteraciones de diseño y experimentos con cadáveres.Las mediciones del alargamiento de los músculos deltoides y del manguito rotador durante la planificación quirúrgica pueden ayudar a los médicos aseleccionar un diseño y una posición de implante adecuados. Sin embargo, tal evaluación requiere la indicación de puntos anatómicos como referencia para los puntos de unión de los músculos, un proceso que requiere mucho tiempo y depende del usuario, ya que a menudo se realiza manualmente. Además, las imágenes médicas, que se utilizan normalmente para la artroplastia de hombro,contienen en su mayoría solo el húmero proximal, lo que hace imposible indicarlos puntos de unión de los músculos que se encuentran fuera del campo de visión de la exploración. Por lo tanto, se desarrolló y evaluó un método totalmente automatizado, basado en SSM, para medir la elongación del deltoides y del manguito rotador. Su aplicabilidad clínica se demostró mediante la evaluación del rendimiento de la estimación automatizada de la elongación muscular para un conjunto de articulaciones artríticas del hombro utilizadas para la planificación preoperatoria de RSA, lo que confirma que es una herramienta adecuada para los cirujanos a la hora de evaluar y refinar las decisiones clínicas.En esta investigación, se dio un paso importante en la dirección de un enfoque más personalizado de la artroplastia inversa de hombro, en el que el manejo quirúrgico, es decir, el diseño y la posición del implante, se adapta a las características específicas del paciente y al estado preoperatorio. Al aplicar tecnologías asistidas por computadora en la práctica clínica, el proceso de diseño y planificación se puede automatizar y estandarizar, reduciendo así los costos y los plazos de entrega. Además, gracias a los métodos novedosos presentados en esta tesis, esperamos en el futuro una adopción más amplia del enfoque personalizado, con importantes beneficios tanto para los cirujanos como para los pacientes.Shoulder arthroplasty is the third most common joint replacement procedure, after knee and hip arthroplasty, and currently the most rapidly growing one in the orthopaedic field. The main surgical options include total shoulder arthroplasty (TSA), in which the normal joint anatomy is restored, and, for patients with a completely torn rotator cuff, reverse shoulder arthroplasty (RSA), in which the ball and the socket of the glenohumeral joint are switched. Despite the recent progress and advancement in design, the reported rates of complication for RSA are higher than those of conventional shoulder arthroplasty. A patient-specific approach, in which clinicians adapt the surgical management to patient characteristics and preoperative condition, e.g. through custom implants and pre-planning, can help to reduce postoperative problems and improve the functional outcome. The main goal of this thesis is to develop and evaluate novel methods for personalized RSA, using state-of-the-art computer aided technologies to standardize and automate the design and planning phases. Custom implants are a suitable solution when treating patients with extensive glenoid bone loss. However, clinical engineers are confronted with an enormous implant design space (number and type of screws, contact surface, etc.) and large anatomical and pathological variability. Currently, no objective tools exist to guide them when choosing the optimal design, i.e. with sufficient initial implant stability, thus making the design process tedious, time-consuming, and user-dependent. In this thesis, a Virtual Bench Test (VBT) simulation was developed using a finite element model to automatically evaluate the initial stability of custom shoulder implants. Through a validation experiment, it was shown that the virtual test bench output can be used by clinical engineers as a reference to support their decisions and adaptations during the implant design process. When designing shoulder implants, knowledge about bone morphology and bone quality of the scapula throughout a certain population is fundamental. In particular, regions with the best bone stock (cortical bone) are taken into account to define the position and orientation of the screw holes, while aiming for an optimal fixation. As an alternative to manual measurements, whose generalization is limited by the analysis of small sub-sets of the potential patients, Statistical Shape Models (SSMs) have been commonly used to describe shape variability within a population. However, these SSMs typically do not contain information about cortical thickness. Therefore, a methodology to combine scapular bone shape and cortex morphology in an SSM was developed. First, a method to estimate cortical thickness, starting from a profile analysis of Hounsfield Unit (HU), was presented and evaluated. Then, using 32 manually segmented healthy scapulae, a statistical shape model including cortical information was created and assessed. The developed tool can be used to virtually implant a new design and test its congruency inside a generated virtual population, thus reducing the number of design iterations and cadaver labs. Measurements of deltoid and rotator cuff muscle elongation during surgical planning can help clinicians to select a suitable implant design and position. However, such an assessment requires the indication of anatomical landmarks as a reference for the muscle attachment points, a process that is time-consuming and user-dependent, since often performed manually. Additionally, the medical images, which are normally used for shoulder arthroplasty, mostly contain only the proximal humerus, making it impossible to indicate those muscle attachment points which lie outside of the field of view of the scan. Therefore, a fully-automated method, based on SSM, for measuring deltoid and rotator cuff elongation was developed and evaluated. Its clinical applicability was demonstrated by assessing the performance of the automated muscle elongation estimation for a set of arthritic shoulder joints used for preoperative planning of RSA, thus confirming it a suitable tool for surgeons when evaluating and refining clinical decisions. In this research, a major step was taken into the direction of a more personalized approach to Reverse Shoulder Arthroplasty, in which the surgical management, i.e. implant design and position, is adapted to the patient-specific characteristics and preoperative condition. By applying computer aided technologies in the clinical practice, design and planning process can be automated and standardized, thus reducing costs and lead times. Additionally, thanks to the novel methods presented in this thesis, we expect in the future a wider adoption of the personalized approach, with important benefits both for surgeons and patients.<br /

Integration of cortical thickness data in a statistical shape model of the scapula

Knowledge about bone morphology and bone quality of the scapula throughout the population is fundamental in the design of shoulder implants. In particular, regions with the best bone stock (cortical bone) are taken into account when planning the supporting screws, aiming for an optimal fixation. As an alternative to manual measurements, statistical shape models (SSMs) have been commonly used to describe shape variability within a population. However, explicitly including cortical thickness information in an SSM of the scapula still remains a challenge. Therefore, the goal of this study is to combine scapular bone shape and cortex morphology in an SSM. First, a method to estimate cortical thickness, based on HU (Hounsfield Unit) profile analysis, was developed and validated. Then, based on the manual segmentations of 32 healthy scapulae, a statistical shape model including cortical information was created and evaluated. Generalization, specificity and compactness were calculated in order to assess the quality of the SSM. The average cortical thickness of the SSM was 2.0¿±¿0.63¿mm. Generalization, specificity and compactness performances confirmed that the combined SSM was able to capture the bone quality changes in the population. In this work we integrated information on the cortical thickness in an SSM for the scapula. From the results we conclude that this methodology is a valuable tool for automatically generating a large population of scapulae and deducing statistics on the cortex. Hence, this SSM can be useful to automate implant design and screw placement in shoulder arthroplasty

Evaluation of bone quality using novel image analyses and mechanical testing methods.

Osteoporosis has become a growing health threat with rising social and economic consequences. The understanding of the relationship between bone mechanical strength and bone structural quality is important for the diagnosis of osteoporosis and the evaluation of osteoporosis treatments. A novel cancellous bone segmentation method was developed to separate cancellous bone from cortical bone automatically. The segmentation was based on the three-dimensional images. The basic idea of the method is that a contiguous three-dimensional non-bone region that is located inside the whole bone region of interest can be defined as the marrow region. Any bone material that is surrounded by the marrow region is considered cancellous bone while bone that is outside of the marrow region is cortical bone. This method is more objective, more accurate and more precise than a manual method and an established computer method (Helterbrand method). Twenty-four female Sprague-Dawley rats, 7-8 weeks old, were used in a study of various osteoporosis drugs. After 8 weeks drug treatment, alendronate had more positive effects on cancellous bone volume fraction than 17 ß-Estradiol2, raloxifene and PTH. This striking result may be explained by the age of the rat model because the young animals are still growing rapidly and it is possible that the ovariectomy (OVX) operation results in higher remodeling rate in young animals. When an anti-resorptive drug is given, the individuals with high baseline remodeling rate have more positive response than those with low baseline remodeling rate. 120 female Sprague-Dawley rats, 5.5 months or 6 months old, were used in three studies of experimental drugs. In the Pradama studies, sensitivity analyses and linear regression analyses were conducted. Drug effect analyses were also conducted, but this research did not focus on that. A new mechanical indentation test was developed. The three-point breaking test and the calculation of volume fraction were also established during the research. By focusing on only Sham group and OVX group, the sensitivity analyses showed that these three new methods were much more sensitive than more traditional methods (Archimedes\u27 density measurements and three-point bending tests). The linear regression analyses were conducted to explore if the image processing methods can be correlated to the mechanical test methods, such as indentation testing and three-point breaking testing. The analyses showed that the volume fraction calculated from image processing methods explained most of the bone strength, but not all. The R 2 of the correlation between the indentation force and the cancellous bone volume fraction (0.542) was a little lower than that between the indentation force and the whole bone volume fraction (0.588). The correlations between the mechanical results from three-point breaking testing and the volume fractions (cancellous bone and whole bone) were in the range of 0.504~0.552. So it is better to combine both image analysis and mechanical tests to understand osteoporosis in bone properties and structures

Evaluating osteological ageing from digital data

YesAge at death estimation of human skeletal remains is one of the key issues in constructing a biological profile both in forensic and archaeological contexts. The traditional adult osteological methods evaluate macroscopically the morphological changes that occur with increasing age of specific skeletal indicators, such as the cranial sutures, the pubic bone, the auricular surface of the ilium and the sternal end of the ribs. Technologies such as CT and laser scanning are becoming more widely used in anthropology, and several new methods have been developed. This review focuses on how the osteological age-related changes have been evaluated in digital data. Firstly, the 3D virtual copies of the bones have been used to mimic the appearance of the dry bones and the application of the traditional methods. Secondly, the information directly extrapolated from CT scan has been used to qualitatively or quantitatively assess the changes of the trabecular bones, the thickness of the cortical bones, and to perform morphometric analyses. Lastly, the most innovative approach has been the mathematical quantification of the changes of the pelvic joints, calculating the complexity of the surface. The importance of new updated reference datasets, created thanks to the use of CT scanning in forensic settings, is also discussed.CV was supported from the Danish Council for Independent Research (DFF – 4005-00102B – FTP

Finite Element Analysis of Hollow-stemmed Shoulder Implants in Different Bone Qualities Derived from a Statistical Shape and Density Model

The incidence of total shoulder arthroplasty procedures (TSA) to treat osteoarthritis has experienced the most rapid growth among all human joint replacements. However, stress shielding of proximal bone following its reconstruction is a complication of TSA triggering unfavorable adaptive bone remodeling, especially for osteoporotic patients. A better understanding of how the shape and density of the shoulder vary among members of a population can help design more effective population-based orthopedic implants. Therefore, finite element models representing healthy, osteopenic, and osteoporotic bone qualities in a population were developed using our statistical shape and density model. Bones were reconstructed with hollow- and solid-stemmed implants and resulting changes in bone stresses were calculated. We concluded that the use of more compliant stems, such as hollow stems, could marginally mitigate the effect of stress shielding at the proximal humerus. Further increasing the compliance of stems by making them porous could improve bone-implant mechanics

Trabecular architecture and joint loading of the proximal humerus in extant hominoids, Ateles, and Australopithecus africanus

Objectives: Several studies have investigated potential functional signals in the trabecular structure of the primate proximal humerus but with varied success. Here we apply for the first time a ìwhole-epiphysesî approach to analysing trabecular bone in the humeral head with the aim of providing a more holistic interpretation of trabecular variation in relation to habitual locomotor or manipulative behaviors in several extant primates and Australopithecus africanus. Materials and Methods: We use a ìwhole-epiphysisî methodology in comparison to the traditional volume of interest (VOI) approach to investigate variation in trabecular structure and joint loading in the proximal humerus of extant hominoids, Ateles and A. africanus (StW 328). Results: There are important differences in the quantification of trabecular parameters using a ìwhole-epiphysisî versus a VOI-based approach. Variation in trabecular structure across knucklewalking African apes, suspensory taxa, and modern humans was generally consistent with predictions of load magnitude and inferred joint posture during habitual behaviors. Higher relative trabecular bone volume and more isotropic trabeculae in StW 328 suggest A. africanus may have still used its forelimbs for arboreal locomotion. Discussion: A whole-epiphysis approach to analysing trabecular structure of the proximal humerus can help distinguish functional signals of joint loading across extant primates and can provide novel insight into habitual behaviors of fossil hominins

Biomechanical evolution of solid bones in large animals: a microanatomical investigation

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