Assessment of Normal Knee Kinematics Using High-Speed Stereo-Radiography System

The measurement of dynamic joint kinematics in vivo is important in order to understand the effects of joint injuries and diseases as well as for evaluating the treatment effectiveness. Quantification of knee motion is essential for assessment of joint function for diagnosis of pathology, such as tracking and progression of osteoarthritis and evaluation of outcome following conservative or surgical treatment. Total knee arthroplasty (TKA) is an invasive treatment for arthritic pain and functional disability and it is used for deformed joint replacement with implants in order to restore joint alignment. It is important to describe knee kinematics in healthy individuals for comparison in diagnosis of pathology and understanding treatment to restore normal function. However measuring the in vivo dynamic biomechanics in 6 degrees of freedom with an accuracy that is acceptable has been shown to be technically challenging. Skin marker based methods, commonly used in human movement analysis, are still prone to large errors produced by soft tissue artifacts. Thus, great deal of research has been done to obtain more accurate data of the knee joint by using other measuring techniques like dual plane fluoroscopy. The goal of this thesis is to use high-speed stereo radiography (HSSR) system for measuring joint kinematics in healthy older adults performing common movements of daily living such as straight walking and during higher demand activities of pivoting and step descending in order to establish a useful baseline for the envelope of healthy knee motion for subsequent comparison with patients with TKA. Prior to data collection, validation and calibration techniques as well as dose estimations were mandatory for the successful accomplishment of this study

Assessment of Wear in Total Knee Arthroplasty Using Advanced Radiographic Techniques

Total knee arthroplasty (TKA) has become the gold standard approach for treating advanced osteoarthritis of the knee. Although the surgery continues to be very successful at relieving pain and restoring joint function, its longevity is challenged by wear and loosening of the implant components. This requires the patient to undergo a revision surgery to replace the implant, a much more challenging operation than primary arthroplasty. Wear of the polyethylene tibial inserts from TKA is assessed in vitro using mechanical wear simulator testing and by examining failed implants retrieved from patients during revision surgery, as well as with direct in vivo measurements. Current in vitro measurement tools provide only a global estimate of wear (failing to describe whether the wear has occurred on the articulating or backside surfaces, or stabilizing post), or are qualitative measurements, or lack resolution. Current in vivo measurement techniques are performed statically or quasi-statically, leading to the potential for an underestimation of wear volume as the contact area of the implant components change throughout flexion. The purpose of this thesis was to describe, validate, and utilize new advanced imaging techniques to measure TKA implant wear for both in vitro and in vivo applications. Micro-computed tomography (micro-CT), a non-destructive, high resolution imaging technique was utilized to provide detailed images of the geometry of tibial inserts used in wear simulator trials or retrieved from patients, and create surface deviation maps to accurately quantify wear. Ways to create an unworn reference geometry, for use in comparing to a worn retrieved tibial insert when the pre-wear geometry is unknown, were evaluated and a best practice approach was determined. These methods were then applied to study a group of tibial inserts retrieved from patients during revision surgery, which were found to be well functioning with a yearly wear rate equivalent to other contemporary implant designs. Finally, a pilot study to evaluate the use of dynamic single-plane flat panel digital radiography for use in measuring TKA implant wear in vivo was conducted. The system was determined to have a measurement accuracy and precision sufficient to begin a pilot clinical study with patients

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

Biplanar Fluoroscopic Analysis of in vivo Hindfoot Kinematics During Ambulation

The overall goal of this project was to develop and validate a biplanar fluoroscopic system and integrated software to assess hindfoot kinematics. Understanding the motion of the foot and ankle joints may lead to improved treatment methods in persons with foot and ankle pathologies. During gait analysis, skin markers are placed on the lower extremities, which are defined as four rigid-body segments with three joints representing the hip, knee and ankle. This method introduces gross assumptions on the foot and severely limits the analysis of in depth foot mechanics. Multi-segmental models have been developed, but are susceptible to skin motion artifact error. Intra-cortical bone pins studies provide higher accuracy, but are invasive. This dissertation developed and validated a noninvasive biplane fluoroscopy system to overcome the skin motion artifacts and rigid-body assumptions of conventional foot motion analysis. The custom-built biplane fluoroscopy system was constructed from two fluoroscopes separated by 60°, attached to a custom walkway with an embedded force plate. Open source software was incorporated to correct the image distortion and calibrate the capture volume. This study was the first that quantified the cross-scatter contamination in a biplane fluoroscopic system and its effects on the accuracy of marker-based tracking. A cadaver foot study determined the static and dynamic error of the biplane fluoroscopic system using both marker-based and model-based tracking algorithms. The study also developed in vivo 3D kinematic models of the talocrural and subtalar joints during the stance phase of gait. Cross-scatter degradation showed negligible effects in the smallest phantom, suggesting negligible motion tracking error due to cross scatter for distal extremities. Marker-based tracking error had a maximum absolute mean error of 0.21 (± 0.15) in dynamic trials. Model-based tracking results compared to marker-based had an overall dynamic RMS average error of 0.59 mm. Models were developed using custom algorithms to determine talocrural and subtalar joint 3D kinematics. The models offer a viable, noninvasive method suitable for quantifying hindfoot kinematics. Patients with a variety of adult and pediatric conditions which affect foot and ankle dynamics during walking may benefit from this work

3D reconstruction of cerebral blood flow and vessel morphology from x-ray rotational angiography

Three-dimensional (3D) information on blood flow and vessel morphology is important when assessing cerebrovascular disease and when monitoring interventions. Rotational angiography is nowadays routinely used to determine the geometry of the cerebral vasculature. To this end, contrast agent is injected into one of the supplying arteries and the x-ray system rotates around the head of the patient while it acquires a sequence of x-ray images. Besides information on the 3D geometry, this sequence also contains information on blood flow, as it is possible to observe how the contrast agent is transported by the blood. The main goal of this thesis is to exploit this information for the quantitative analysis of blood flow. I propose a model-based method, called flow map fitting, which determines the blood flow waveform and the mean volumetric flow rate in the large cerebral arteries. The method uses a model of contrast agent transport to determine the flow parameters from the spatio-temporal progression of the contrast agent concentration, represented by a flow map. Furthermore, it overcomes artefacts due to the rotation (overlapping vessels and foreshortened vessels at some projection angles) of the c-arm using a reliability map. For the flow quantification, small changes to the clinical protocol of rotational angiography are desirable. These, however, hamper the standard 3D reconstruction. Therefore, a new method for the 3D reconstruction of the vessel morphology which is tailored to this application is also presented. To the best of my knowledge, I have presented the first quantitative results for blood flow quantification from rotational angiography. Additionally, the model-based approach overcomes several problems which are known from flow quantification methods for planar angiography. The method was mainly validated on images from different phantom experiments. In most cases, the relative error was between 5% and 10% for the volumetric mean flow rate and between 10% and 15% for the blood flow waveform. Additionally, the applicability of the flow model was shown on clinical images from planar angiographic acquisitions. From this, I conclude that the method has the potential to give quantitative estimates of blood flow parameters during cerebrovascular interventions

Reconstruction of coronary arteries from X-ray angiography: A review.

Despite continuous progress in X-ray angiography systems, X-ray coronary angiography is fundamentally limited by its 2D representation of moving coronary arterial trees, which can negatively impact assessment of coronary artery disease and guidance of percutaneous coronary intervention. To provide clinicians with 3D/3D+time information of coronary arteries, methods computing reconstructions of coronary arteries from X-ray angiography are required. Because of several aspects (e.g. cardiac and respiratory motion, type of X-ray system), reconstruction from X-ray coronary angiography has led to vast amount of research and it still remains as a challenging and dynamic research area. In this paper, we review the state-of-the-art approaches on reconstruction of high-contrast coronary arteries from X-ray angiography. We mainly focus on the theoretical features in model-based (modelling) and tomographic reconstruction of coronary arteries, and discuss the evaluation strategies. We also discuss the potential role of reconstructions in clinical decision making and interventional guidance, and highlight areas for future research

Towards a Digital Twin of Coronary Stenting: A Suitable and Validated Image-Based Approach for Mimicking Patient-Specific Coronary Arteries

Considering the field of application involving stent deployment simulations, the exploitation of a digital twin of coronary stenting that can reliably mimic the patient-specific clinical reality could lead to improvements in individual treatments. A starting step to pursue this goal is the development of simple, but at the same time, robust and effective computational methods to obtain a good compromise between the accuracy of the description of physical phenomena and computational costs. Specifically, this work proposes an approach for the development of a patient-specific artery model to be used in stenting simulations. The finite element model was generated through a 3D reconstruction based on the clinical imaging (coronary Optical Coherence Tomography (OCT) and angiography) acquired on the pre-treatment patient. From a mechanical point of view, the coronary wall was described with a suitable phenomenological model, which is consistent with more complex constitutive approaches and accounts for the in vivo pressurization and axial pre-stretch. The effectiveness of this artery modeling method was tested by reproducing in silico the stenting procedures of two clinical cases and comparing the computational results with the in vivo lumen area of the stented vessel

Statistical Modeling to Investigate Anatomy and Function of the Knee

The natural knee is a hinge joint with significant functional requirements during activities of daily living; as a result, acute and chronic injuries can occur. Pathologies are influenced by joint anatomy and may include patellar maltracking, cartilage degeneration (e.g. osteoarthritis), or acute injuries such as meniscal or ligamentous tears. Population variability makes broadly applicable conclusions about etiology of these conditions from small-scale investigations challenging. The work presented in this dissertation is a demonstration of statistical modeling approaches to evaluate population variability in anatomy of the knee and function of its tibiofemoral (TF) and patellofemoral (PF) joints. Three-dimensional (3D) computational models of the bone and cartilage in the knee were characterized using a principal component analysis (PCA) algorithm to understand the primary sources of variability in shape and motion and make predictions from sparse data. Statistical models were used to investigate relationships between natural knee anatomy and kinematics and make predictions of both shape and function from sparse data. A whole-joint characterization study identified key correlations between shape and function of the TF and PF joints, successfully recreating results from multiple studies and introducing new relationships under one unified approach. Results from this study were used in a subsequent investigation to build a statistical model of two-dimensional (2D) shape and alignment measures and 6 degree-of-freedom (DOF) kinematics to identify the key measures capable of predicting PF joint motion. The ability to reconstruct the 3D implanted patellar bone of a subject with a total knee replacement (TKR) was evaluated by a statistical shape model of the patella and simulated 2D edge profiles in a custom optimization algorithm. Lastly, a validated predictive algorithm was employed to assess the accuracy of subject-specific knee articular cartilage predictions from bony geometry. The utility of statistical modeling is elucidated by the population-based evaluations of the musculoskeletal system described in this work and could continue to inform characteristics related to pathological conditions and large-scale computational evaluations of implant performance

3D reconstruction of coronary arteries from angiographic sequences for interventional assistance

Introduction -- Review of literature -- Research hypothesis and objectives -- Methodology -- Results and discussion -- Conclusion and future perspectives