Navigation system for robot-assisted intra-articular lower-limb fracture surgery

Purpose In the surgical treatment for lower-leg intra-articular fractures, the fragments have to be positioned and aligned to reconstruct the fractured bone as precisely as possible, to allow the joint to function correctly again. Standard procedures use 2D radiographs to estimate the desired reduction position of bone fragments. However, optimal correction in a 3D space requires 3D imaging. This paper introduces a new navigation system that uses pre-operative planning based on 3D CT data and intra-operative 3D guidance to virtually reduce lower-limb intra-articular fractures. Physical reduction in the fractures is then performed by our robotic system based on the virtual reduction. Methods 3D models of bone fragments are segmented from CT scan. Fragments are pre-operatively visualized on the screen and virtually manipulated by the surgeon through a dedicated GUI to achieve the virtual reduction in the fracture. Intra-operatively, the actual position of the bone fragments is provided by an optical tracker enabling real-time 3D guidance. The motion commands for the robot connected to the bone fragment are generated, and the fracture physically reduced based on the surgeon’s virtual reduction. To test the system, four femur models were fractured to obtain four different distal femur fracture types. Each one of them was subsequently reduced 20 times by a surgeon using our system. Results The navigation system allowed an orthopaedic surgeon to virtually reduce the fracture with a maximum residual positioning error of 0.95±0.3mm (translational) and 1.4∘±0.5∘ (rotational). Correspondent physical reductions resulted in an accuracy of 1.03 ± 0.2 mm and 1.56∘±0.1∘, when the robot reduced the fracture. Conclusions Experimental outcome demonstrates the accuracy and effectiveness of the proposed navigation system, presenting a fracture reduction accuracy of about 1 mm and 1.5∘, and meeting the clinical requirements for distal femur fracture reduction procedures

Image-Guided Surgical Robotic System for Percutaneous Reduction of Joint Fractures

Complex joint fractures often require an open surgical procedure, which is associated with extensive soft tissue damages and longer hospitalization and rehabilitation time. Percutaneous techniques can potentially mitigate these risks but their application to joint fractures is limited by the current sub-optimal 2D intra-operative imaging (fluoroscopy) and by the high forces involved in the fragment manipulation (due to the presence of soft tissue, e.g., muscles) which might result in fracture malreduction. Integration of robotic assistance and 3D image guidance can potentially overcome these issues. The authors propose an image-guided surgical robotic system for the percutaneous treatment of knee joint fractures, i.e., the robot-assisted fracture surgery (RAFS) system. It allows simultaneous manipulation of two bone fragments, safer robot-bone fixation system, and a traction performing robotic manipulator. This system has led to a novel clinical workflow and has been tested both in laboratory and in clinically relevant cadaveric trials. The RAFS system was tested on 9 cadaver specimens and was able to reduce 7 out of 9 distal femur fractures (T- and Y-shape 33-C1) with acceptable accuracy (≈1 mm, ≈5°), demonstrating its applicability to fix knee joint fractures. This study paved the way to develop novel technologies for percutaneous treatment of complex fractures including hip, ankle, and shoulder, thus representing a step toward minimally-invasive fracture surgeries

Image-Based Robotic System for Enhanced Minimally Invasive Intra-Articular Fracture Surgeries

Abstract: Robotic assistance can bring significant improvements to orthopedic fracture surgery: facilitate more accurate fracture fragment repositioning without open access and obviate problems related to the current minimally invasive fracture surgery techniques by providing a better clinical outcome, reduced recovery time, and health-related costs. This paper presents a new design of the robot-assisted fracture surgery (RAFS) system developed at Bristol Robotics Laboratory, featuring a new robotic architecture, and real-time 3D imaging of the fractured anatomy. The technology presented in this paper focuses on distal femur fractures, but can be adapted to the larger domain of fracture surgeries, improving the state-of-the-art in robot assistance in orthopedics. To demonstrate the enhanced performance of the RAFS system, 10 reductions of a distal femur fracture are performed using the system on a bone model. The experimental results clearly demonstrate the accuracy, effectiveness, and safety of the new RAFS system. The system allows the surgeon to precisely reduce the fractures with a reduction accuracy of 1.15 mm and 1.3°, meeting the clinical requirements for this procedure

Intra-operative fiducial-based CT/fluoroscope image registration framework for image-guided robot-assisted joint fracture surgery

Purpose Joint fractures must be accurately reduced minimising soft tissue damages to avoid negative surgical outcomes. To this regard, we have developed the RAFS surgical system, which allows the percutaneous reduction of intra-articular fractures and provides intra-operative real-time 3D image guidance to the surgeon. Earlier experiments showed the effectiveness of the RAFS system on phantoms, but also key issues which precluded its use in a clinical application. This work proposes a redesign of the RAFS’s navigation system overcoming the earlier version’s issues, aiming to move the RAFS system into a surgical environment. Methods The navigation system is improved through an image registration framework allowing the intra-operative registration between pre-operative CT images and intra-operative fluoroscopic images of a fractured bone using a custom-made fiducial marker. The objective of the registration is to estimate the relative pose between a bone fragment and an orthopaedic manipulation pin inserted into it intra-operatively. The actual pose of the bone fragment can be updated in real time using an optical tracker, enabling the image guidance. Results Experiments on phantom and cadavers demonstrated the accuracy and reliability of the registration framework, showing a reduction accuracy (sTRE) of about 0.88 ±0.2mm (phantom) and 1.15±0.8mm (cadavers). Four distal femur fractures were successfully reduced in cadaveric specimens using the improved navigation system and the RAFS system following the new clinical workflow (reduction error 1.2±0.3mm, 2±1∘). Conclusion Experiments showed the feasibility of the image registration framework. It was successfully integrated into the navigation system, allowing the use of the RAFS system in a realistic surgical application

RAFS: A computer-assisted robotic system for minimally invasive joint fracture surgery, based on pre- and intra-operative imaging

The integration of minimally invasive robotic assistance and image-guidance can have positive impact on joint fracture surgery, providing a better clinical outcome with respect to the current open procedure. In this paper, a new design of the RAFS surgical system is presented. The redesign of the robotic system and its integration with a novel 3D navigation system through a new clinical workflow, overcomes the drawbacks of the earlier prototype. This makes the RAFS surgical system more suitable to clinical scenarios in the operating theatre. System accuracy and effectiveness are successfully demonstrated through laboratory trials and preliminary cadaveric trials. The experimental results demonstrate that the system allows the surgeon to reduce a 2-fragment distal femur fracture in a cadaveric specimen, with a reduction accuracy of up to 0.85 mm and 2.2°. Preliminary cadaveric trials also provided a positive and favorable outcome pointing to the usability and safety of the RAFS system in the operating theatre, potentially enhancing the capacity of joint fracture surgeries

Robot-Bone Attachment Device for Robot-Assisted Percutaneous Bone Fragment Manipulation

The treatment of joint-fractures is a common task in orthopaedic surgery causing considerable health costs and patient disabilities. Percutaneous techniques have been developed to mitigate the problems related to open surgery (e.g. soft tissue damage), although their application to joint-fractures is limited by the sub-optimal intra-operative imaging (2D-fluoroscopy) and by the high forces involved. Our earlier research toward improving percutaneous reduction of intra-articular fractures has resulted in the creation of a robotic system prototype, i.e. RAFS (Robot-Assisted Fracture Surgery) system. We propose a robot-bone attachment device for percutaneous bone manipulation, which can be anchored to the bone fragment through one small incision, ensuring the required stability and reducing the “biological cost” of the procedure. The device has been evaluated through the reduction of 9 distal femur fractures on human cadavers using the RAFS system

Recent trends, technical concepts and components of computer-assisted orthopedic surgery systems: A comprehensive review

Computer-assisted orthopedic surgery (CAOS) systems have become one of the most important and challenging types of system in clinical orthopedics, as they enable precise treatment of musculoskeletal diseases, employing modern clinical navigation systems and surgical tools. This paper brings a comprehensive review of recent trends and possibilities of CAOS systems. There are three types of the surgical planning systems, including: systems based on the volumetric images (computer tomography (CT), magnetic resonance imaging (MRI) or ultrasound images), further systems utilize either 2D or 3D fluoroscopic images, and the last one utilizes the kinetic information about the joints and morphological information about the target bones. This complex review is focused on three fundamental aspects of CAOS systems: their essential components, types of CAOS systems, and mechanical tools used in CAOS systems. In this review, we also outline the possibilities for using ultrasound computer-assisted orthopedic surgery (UCAOS) systems as an alternative to conventionally used CAOS systems.Web of Science1923art. no. 519

Medical Robotics

The first generation of surgical robots are already being installed in a number of operating rooms around the world. Robotics is being introduced to medicine because it allows for unprecedented control and precision of surgical instruments in minimally invasive procedures. So far, robots have been used to position an endoscope, perform gallbladder surgery and correct gastroesophogeal reflux and heartburn. The ultimate goal of the robotic surgery field is to design a robot that can be used to perform closed-chest, beating-heart surgery. The use of robotics in surgery will expand over the next decades without any doubt. Minimally Invasive Surgery (MIS) is a revolutionary approach in surgery. In MIS, the operation is performed with instruments and viewing equipment inserted into the body through small incisions created by the surgeon, in contrast to open surgery with large incisions. This minimizes surgical trauma and damage to healthy tissue, resulting in shorter patient recovery time. The aim of this book is to provide an overview of the state-of-art, to present new ideas, original results and practical experiences in this expanding area. Nevertheless, many chapters in the book concern advanced research on this growing area. The book provides critical analysis of clinical trials, assessment of the benefits and risks of the application of these technologies. This book is certainly a small sample of the research activity on Medical Robotics going on around the globe as you read it, but it surely covers a good deal of what has been done in the field recently, and as such it works as a valuable source for researchers interested in the involved subjects, whether they are currently “medical roboticists” or not