DYNAMIC MEASUREMENT OF THREE-DIMENSIONAL MOTION FROM SINGLE-PERSPECTIVE TWO-DIMENSIONAL RADIOGRAPHIC PROJECTIONS

The digital evolution of the x-ray imaging modality has spurred the development of numerous clinical and research tools. This work focuses on the design, development, and validation of dynamic radiographic imaging and registration techniques to address two distinct medical applications: tracking during image-guided interventions, and the measurement of musculoskeletal joint kinematics. Fluoroscopy is widely employed to provide intra-procedural image-guidance. However, its planar images provide limited information about the location of surgical tools and targets in three-dimensional space. To address this limitation, registration techniques, which extract three-dimensional tracking and image-guidance information from planar images, were developed and validated in vitro. The ability to accurately measure joint kinematics in vivo is an important tool in studying both normal joint function and pathologies associated with injury and disease, however it still remains a clinical challenge. A technique to measure joint kinematics from single-perspective x-ray projections was developed and validated in vitro, using clinically available radiography equipmen

Augmented Reality and Artificial Intelligence in Image-Guided and Robot-Assisted Interventions

In minimally invasive orthopedic procedures, the surgeon places wires, screws, and surgical implants through the muscles and bony structures under image guidance. These interventions require alignment of the pre- and intra-operative patient data, the intra-operative scanner, surgical instruments, and the patient. Suboptimal interaction with patient data and challenges in mastering 3D anatomy based on ill-posed 2D interventional images are essential concerns in image-guided therapies. State of the art approaches often support the surgeon by using external navigation systems or ill-conditioned image-based registration methods that both have certain drawbacks. Augmented reality (AR) has been introduced in the operating rooms in the last decade; however, in image-guided interventions, it has often only been considered as a visualization device improving traditional workflows. Consequently, the technology is gaining minimum maturity that it requires to redefine new procedures, user interfaces, and interactions. This dissertation investigates the applications of AR, artificial intelligence, and robotics in interventional medicine. Our solutions were applied in a broad spectrum of problems for various tasks, namely improving imaging and acquisition, image computing and analytics for registration and image understanding, and enhancing the interventional visualization. The benefits of these approaches were also discovered in robot-assisted interventions. We revealed how exemplary workflows are redefined via AR by taking full advantage of head-mounted displays when entirely co-registered with the imaging systems and the environment at all times. The proposed AR landscape is enabled by co-localizing the users and the imaging devices via the operating room environment and exploiting all involved frustums to move spatial information between different bodies. The system's awareness of the geometric and physical characteristics of X-ray imaging allows the exploration of different human-machine interfaces. We also leveraged the principles governing image formation and combined it with deep learning and RGBD sensing to fuse images and reconstruct interventional data. We hope that our holistic approaches towards improving the interface of surgery and enhancing the usability of interventional imaging, not only augments the surgeon's capabilities but also augments the surgical team's experience in carrying out an effective intervention with reduced complications

Image-Guided Interventions Using Cone-Beam CT: Improving Image Quality with Motion Compensation and Task-Based Modeling

Cone-beam CT (CBCT) is an increasingly important modality for intraoperative 3D imaging in interventional radiology (IR). However, CBCT exhibits several factors that diminish image quality — notably, the major challenges of patient motion and detectability of low-contrast structures — which motivate the work undertaken in this thesis. A 3D–2D registration method is presented to compensate for rigid patient motion. The method is fiducial-free, works naturally within standard clinical workflow, and is applicable to image-guided interventions in locally rigid anatomy, such as the head and pelvis. A second method is presented to address the challenge of deformable motion, presenting a 3D autofocus concept that is purely image-based and does not require additional fiducials, tracking hardware, or prior images. The proposed method is intended to improve interventional CBCT in scenarios where patient motion may not be sufficiently managed by immobilization and breath-hold, such as the prostate, liver, and lungs. Furthermore, the work aims to improve the detectability of low-contrast structures by computing source–detector trajectories that are optimal to a particular imaging task. The approach is applicable to CBCT systems with the capability for general source–detector positioning, as with a robotic C-arm. A “task-driven” analytical framework is introduced, various objective functions and optimization methods are described, and the method is investigated via simulation and phantom experiments and translated to task-driven source–detector trajectories on a clinical robotic C-arm to demonstrate the potential for improved image quality in intraoperative CBCT. Overall, the work demonstrates how novel optimization-based imaging techniques can address major challenges to CBCT image quality

AUGMENTED REALITY AND INTRAOPERATIVE C-ARM CONE-BEAM COMPUTED TOMOGRAPHY FOR IMAGE-GUIDED ROBOTIC SURGERY

Minimally-invasive robotic-assisted surgery is a rapidly-growing alternative to traditionally open and laparoscopic procedures; nevertheless, challenges remain. Standard of care derives surgical strategies from preoperative volumetric data (i.e., computed tomography (CT) and magnetic resonance (MR) images) that benefit from the ability of multiple modalities to delineate different anatomical boundaries. However, preoperative images may not reflect a possibly highly deformed perioperative setup or intraoperative deformation. Additionally, in current clinical practice, the correspondence of preoperative plans to the surgical scene is conducted as a mental exercise; thus, the accuracy of this practice is highly dependent on the surgeon’s experience and therefore subject to inconsistencies. In order to address these fundamental limitations in minimally-invasive robotic surgery, this dissertation combines a high-end robotic C-arm imaging system and a modern robotic surgical platform as an integrated intraoperative image-guided system. We performed deformable registration of preoperative plans to a perioperative cone-beam computed tomography (CBCT), acquired after the patient is positioned for intervention. From the registered surgical plans, we overlaid critical information onto the primary intraoperative visual source, the robotic endoscope, by using augmented reality. Guidance afforded by this system not only uses augmented reality to fuse virtual medical information, but also provides tool localization and other dynamic intraoperative updated behavior in order to present enhanced depth feedback and information to the surgeon. These techniques in guided robotic surgery required a streamlined approach to creating intuitive and effective human-machine interferences, especially in visualization. Our software design principles create an inherently information-driven modular architecture incorporating robotics and intraoperative imaging through augmented reality. The system's performance is evaluated using phantoms and preclinical in-vivo experiments for multiple applications, including transoral robotic surgery, robot-assisted thoracic interventions, and cocheostomy for cochlear implantation. The resulting functionality, proposed architecture, and implemented methodologies can be further generalized to other C-arm-based image guidance for additional extensions in robotic surgery

Serious Games and Mixed Reality Applications for Healthcare

Virtual reality (VR) and augmented reality (AR) have long histories in the healthcare sector, offering the opportunity to develop a wide range of tools and applications aimed at improving the quality of care and efficiency of services for professionals and patients alike. The best-known examples of VR–AR applications in the healthcare domain include surgical planning and medical training by means of simulation technologies. Techniques used in surgical simulation have also been applied to cognitive and motor rehabilitation, pain management, and patient and professional education. Serious games are ones in which the main goal is not entertainment, but a crucial purpose, ranging from the acquisition of knowledge to interactive training.These games are attracting growing attention in healthcare because of their several benefits: motivation, interactivity, adaptation to user competence level, flexibility in time, repeatability, and continuous feedback. Recently, healthcare has also become one of the biggest adopters of mixed reality (MR), which merges real and virtual content to generate novel environments, where physical and digital objects not only coexist, but are also capable of interacting with each other in real time, encompassing both VR and AR applications.This Special Issue aims to gather and publish original scientific contributions exploring opportunities and addressing challenges in both the theoretical and applied aspects of VR–AR and MR applications in healthcare

Towards markerless orthopaedic navigation with intuitive Optical See-through Head-mounted displays

The potential of image-guided orthopaedic navigation to improve surgical outcomes has been well-recognised during the last two decades. According to the tracked pose of target bone, the anatomical information and preoperative plans are updated and displayed to surgeons, so that they can follow the guidance to reach the goal with higher accuracy, efficiency and reproducibility. Despite their success, current orthopaedic navigation systems have two main limitations: for target tracking, artificial markers have to be drilled into the bone and calibrated manually to the bone, which introduces the risk of additional harm to patients and increases operating complexity; for guidance visualisation, surgeons have to shift their attention from the patient to an external 2D monitor, which is disruptive and can be mentally stressful. Motivated by these limitations, this thesis explores the development of an intuitive, compact and reliable navigation system for orthopaedic surgery. To this end, conventional marker-based tracking is replaced by a novel markerless tracking algorithm, and the 2D display is replaced by a 3D holographic Optical see-through (OST) Head-mounted display (HMD) precisely calibrated to a user's perspective. Our markerless tracking, facilitated by a commercial RGBD camera, is achieved through deep learning-based bone segmentation followed by real-time pose registration. For robust segmentation, a new network is designed and efficiently augmented by a synthetic dataset. Our segmentation network outperforms the state-of-the-art regarding occlusion-robustness, device-agnostic behaviour, and target generalisability. For reliable pose registration, a novel Bounded Iterative Closest Point (BICP) workflow is proposed. The improved markerless tracking can achieve a clinically acceptable error of 0.95 deg and 2.17 mm according to a phantom test. OST displays allow ubiquitous enrichment of perceived real world with contextually blended virtual aids through semi-transparent glasses. They have been recognised as a suitable visual tool for surgical assistance, since they do not hinder the surgeon's natural eyesight and require no attention shift or perspective conversion. The OST calibration is crucial to ensure locational-coherent surgical guidance. Current calibration methods are either human error-prone or hardly applicable to commercial devices. To this end, we propose an offline camera-based calibration method that is highly accurate yet easy to implement in commercial products, and an online alignment-based refinement that is user-centric and robust against user error. The proposed methods are proven to be superior to other similar State-of- the-art (SOTA)s regarding calibration convenience and display accuracy. Motivated by the ambition to develop the world's first markerless OST navigation system, we integrated the developed markerless tracking and calibration scheme into a complete navigation workflow designed for femur drilling tasks during knee replacement surgery. We verify the usability of our designed OST system with an experienced orthopaedic surgeon by a cadaver study. Our test validates the potential of the proposed markerless navigation system for surgical assistance, although further improvement is required for clinical acceptance.Open Acces