This paper describes a proposed CAD graphics application that analyze digital radiography image for preoperative surgery in shoulder hemiarthroplasty.The purpose of designing this application is to aid orthopedic surgeon in preoperative planning phase before surgery, in terms of selecting suitable implant and manipulating the digital radiograph by using various facilities or tools available in

the application. Therefore, digital templating and image processing play important roles in this research. Basically this application will support a few types of image file including jpg, gif, bmp and etc to be loaded. It will allow image enhancement and also enable measurement tools to be used by surgeon during the preoperative phase. A user will only need to do 5 simple steps in order to get the appropriate template and finally generate reports that he requires

Abdullah, Suhail

Lee, Thian Seng

Mohd Kassim, Abdul Yazid

Mohd Zin, Indra

Sulaiman, Riza

UUM Repository

 Computer Aided Preoperative Planning Application for Shoulder Hemiarthroplasty  Lee Thian Senga, Indra Mohd Zina, Abdul Yazid Mohd Kassimb, Suhail Abdullahb, Riza Sulaimana  a Dept. of Industrial Computing, Faculty of Information Science and Technology, National University Malaysiab Dept. of Orthopaedics and Traumatology, Faculty of Medicine, National University Malaysiathianseng01@yahoo.com, indrazin@yahoo.com.my, yamani42@yahoo.com, suhail69@yahoo.com, rs@ftsm.ukm.myABSTRACTThis paper describes a proposed CAD graphics application  that  analyze  digital  radiography  image  for  preoperative  surgery  in  shoulder  hemiarthroplasty.  The  purpose  of  designing this application is  to  aid orthopedic surgeon in  preoperative  planning  phase  before  surgery,  in  terms  of  selecting  suitable  implant  and  manipulating  the  digital  radiograph by using various facilities or tools available in the  application.  Therefore,  digital  templating  and  image processing play important roles in this research. Basically  this  application  will  support  a  few  types  of  image  file  including jpg, gif,  bmp and etc to be loaded. It will  allow image enhancement and also enable measurement tools to be used by surgeon during the preoperative phase. A user will  only need to do 5 simple steps in order to get the appropriate  template and finally generate reports that he requires. Keywords  Digital  Templating,  Preoperative  Planning,  Shoulder  Hemiarthroplasty1.0 INTRODUCTIONThis is an on-going research between orthopedic surgeons and programmers on developing a pre-operative templating and planning application for orthopedic procedures.  In the past,  templating  has  been  performed  by  overlaying magnified rulers and transparent outlines of implants on the X-ray  film  (King,  Craig,  Boreham,  Majeed  &  Moran, 2008). It is aimed that this application will  takes away the ability  to  do  routine  pre-surgical  templating,  and  enable surgeons  to  plan  operations  on-screen  and  facilitate  the completely  film-free  orthopedic  department  in  the  most efficient and simple way. 1.1 ShoulderThe shoulder is a ball-and-socket joint that allows the arm to be raised, twisted, bent, and moved forward, to the side and backward. The head of the upper arm bone (humerus) is the ball, and a circular cavity (glenoid) in the shoulder blade (scapula) is the socket. A soft-tissue rim (labrum) surrounds and  deepens  the  socket.  The  head  of  the humerus is  also covered  with  a  smooth,  tough  tissue  (articular  cartilage); and the joint, also called the acromioclavicular (AC) joint, has a thin inner lining (synovium) that facilitates movement while  surrounding  muscles  and  tendons  provide  stability and  support.  Most  shoulder  problems  involve  the  soft tissues, muscles, ligaments, and tendons, rather than bones. And most of these problems fall into three major categories, tendinitis  or  bursitis,  injury  or  instability  and  arthritis (Florian, Bernhard, & Juerg, 2008; William & Steven, 2005; Wiater, 2007). Either surgical or nonsurgical treatment will be  suggested  by  specialist  depending  on  how serious  the illness is. One of the common treatments will be shoulder arthroplasty. 1.2 Shoulder ArthroplastyMany people know someone with an artificial knee or hip joint. Shoulder replacement is less common. But it is just as successful  in  relieving  joint  pain.  It  is  being  used  as  a treatment for severe shoulder fractures. Over the years, this surgery  has  come  to  be  used  for  many  other  painful conditions  of  the  shoulder (Wiater,  2007). Shoulder arthroplasty reliably relieves pain and improves function in the  majority  of  patients  with  painful  arthritic  shoulders. Shoulder  prostheses  are  now  commonly  used.  Clinical results and patient’s satisfaction level are usually good. The most  commonly  used types are humeral  hemiarthroplasty, unconstrained  total  shoulder  arthroplasty,  and semiconstrained  inversed  shoulder  prosthesis. Complications  of  shoulder  arthroplasty  depend  on  the prosthesis  type  used.  Osteoarthritis,  rheumatoid  arthritis, complex  fractures  of  the proximal  humerus,  osteonecrosis of  the  humeral  head,  irreparable  tears  of  the  rotator  cuff with or  without  arthropathy  (“cuff  tear  arthropathy”),  and revisions of failed prosthesis are the most common reasons to  perform  shoulder  arthroplasty   (Florian  et  al.,  2008; William et al., 2005; Michael, 2004).1.3 Shoulder HemiarthroplastyShoulder arthroplasty involves replacement of humeral and glenoid components. Shoulder hemiarthroplasty is a process where  the  fractured  humeral  head  is  replaced  with  a modular  prosthesis.  The  procedure  aims  at  an  adequate reconstruction of shape and function of the shoulder (Ernst, Ulrich, Sandra,  & Wolf, 2004). There are studies showing that  most  of the patients who suffered from shoulder pain felt relief as well as experienced improvement in abduction, internal rotation and external rotation (Matthew, Charles, & Bradford, 2008; Ian, Robert, & Sharon, 2005). Therefore a mandatory technique to choose a suitable implant for joint replacement  is  vital.  And  the  technique  that  will  be discussed  here  is  digital  templating  which  is  the  famous technique implement  in most  of the preoperative planning software today.1.4 Digital TemplatingA  complete  shoulder  arthroplasty  process  includes preoperative  planning,  intraoperative  surgery  and postoperative rehabilitation,  each phase plays an important role,  lacking  in  any  of  these  would  be  considered  as  an imperfection.  Preoperative  templating  is  advised  as  an important part of patient assessment whereby the operating surgeon will gain an idea beforehand of the optimal implant size and restore anatomy (Hossain, Lewis, & Sinha, 2008). Optimal  implant  size  is  essential  for  success  of  joint arthroplasty. The correct implant size will help in soft tissue balancing  and  optimal  load  transmission  through the  new joint (Lewis,  Hossain,  Mustafa,  &  Sinha,  2008). Digital preoperative planning enables the surgeon to select from a library of templates and electronically overlay them on an image.  The  surgeon  can  then  perform  the  necessary measurements critical  to  the  templating and  preoperative planning process in a digital environment. The preoperative planning process  is fast,  precise  and  cost-efficient,  and  it provides  a  permanently archived  record  of  the  templating process (James,  2004). This  is  becoming  increasingly important  due to the large range of implants available and the  limitations  of  any  one  hospital  unit  in  stocking  large inventories  of  implants  (SP  &  DL,  2005). Without  the ability to template radiographs there is a danger that during the operation the surgeon will select an unsuitable implant, use the incorrect size of implant, or discover that the correct size is not available (King et al., 2008).2.0  ISSUE  ON  ANALOGUE  VS  DIGITAL TEMPLATINGThe issue about precision of analogue or acetate and digital preoperative planning is nothing new. However, each of the techniques  has  its  own  researches  output  that  proved  its efficiency. So there is no specific theory that shows either digital  or  analogue  templating  is  more  efficient.  Some studies claimed that analogue preoperative planning yielded more  predictable  results  than  digital  planning  and  would give more accurate  results if it is done by an experienced surgeon (Lewis  et  al.,  2008;  SP  et  al.,  2005;  Valle, Fernando,  Nicole,  & Eduardo,  2007). On the  other  hand, some  studies  showed that  digital  templating  proved  to be statistically,  significantly  more  accurate  compared  to analogue  templating.  Combining  digital  radiography  with digital  templating  has  the  potential  to  eliminate  errors associated  with  the  manual  manipulation  of  acetate templates  and  analog  radiographs.  Digital  templating  was determined to be acceptably safe for preoperative planning in these studies (Hossain et al., 2008; Iorio, Siegel, Specht, Tilzey,  Hartman,  & Healy,  2008). Most  of  the references found are related to knee and hip arthroplasty, but the main concept  of digital  and acetate  templating are the same for shoulder, knee and hip during preoperative planning stage. So  we  can  assume  that  the  findings  for  comparison  of digital  and  plain  radiography  preoperative  templating  for shoulder, hip and knee are the same.3.O APPLICATION DESIGNTo  develop  a  suitable  and  effective  digital  templating application,  we have  interviewed few specialists  from the orthopedic  department  (National  University  of  Malaysia Medical  Center).  Techniques and tools needed to measure prosthesis for humeral head and humeral stem are identified through discussions with orthopedic specialists and also via literature reviews (King et al., 2008; Michael, 2004; Ernst et al., 2004; Matthew et al., 2008; James & Tom, 2003; Field, Fabian,  Peter,  &  Russell,  1998). The  results  were  then implemented in the proposed application. The magnification issue  is  something  that  we  couldn’t  miss  in  digital templating,  so the measurement  involved in the system is very important. Calibration will be done at the development phase  to get  the  correct  measurement (Valle  et  al.,  2007; (Todsaporn,  Amnach,  &  Mitsuhashi,  2008;  Nofrini,  La Palombara, Marcacci, Martelli, & F. Iacono, 2000). Figure 1 shows  the  proposed  framework  of  the  computer  aided preoperative planning application. Start Load Image Image Enhancement Measure Apply Templates Report End Figure 1: Framework WorkflowBasically,  the application that  will  be built  allows user to load  image,  followed  by  image  enhancement  with  the support  of  a few image processing  tools.  Next,  user  only needs  to  perform  five  simple  steps  in  order  to  get  the appropriate template. The system will automatically process inputs made by user and select an output template with the closest  fit  in size  according  to  the  calculation  result,  and display  it  on  the  screen  (all  the  template  sizes  available would  be  stored  in a  database  and  the  application  would automatically  generate  the  template  only  after  user  had given  the  complete  set  of  dimensions  needed).  Once  a template is chosen, it can be easily scaled and manipulated manually by the user through the facilities available in the application. Finally, the user can choose to print out a report that will show the x-ray together with the digital template as well  as  information  such  as  patient  details,  template  size chosen, and surgeon’s name.3.1 Load Image2D x-ray data from file type jpg, Gif, bmp and etc. can be imported to the application. After the image is successfully loaded, the next stage will be image enhancement.3.2 Image EnhancementAt this  stage,  a  best  view of  the  x-ray on screen  will  be adjusted  to  enhance  x-ray  visibility  and  increase  the accuracy  of measurement  by user.  To get the perfect  way for setting best view, a test is done on an x-ray image by using  image  processing  functions  in  Photoshop.  It  is observed that to get the best quality and clear view so that the  structure  of  the  bone  will  be  more  visible,  color inverting  on  X-ray  image  is  required.  Figure  2a  and  2b show  the  difference  before  and  after  inverting  an  x-ray image.  Therefore,  color  inverting  on  X-ray  image  is suggested before moving to the next stage, this is because after the inverting process, the user can easily locate parts of shoulder  anatomy  such  as  greater  and  lower  tuberosities, humeral  head,  clavicle  and  etcetera  for  accurate measurements.  The  rest  of  image  enhancement  will  be dependent  on  user’s  requirement  in  adjusting  scale, brightness, hue/saturation, color editing and etcetera. Figure 2a: X-ray image before invert colorFigure 2b: X-ray image after invert color3.3 MeasureUseful  measurement  tools  include  distance,  angles  and pattern matching (Thian Seng, Abdul Yazid,  & al.,  2008). These  are  preliminary  planning  phases  for  choosing  a prosthesis template. Figure 3 shows measurements involve in  getting  the  accurate  implant  for  humeral  head  and humeral  stem.  In  the  picture,  number  1-5  show  the  five steps  that  a  user  needs  to  perform in order  to get  proper template. First, user needs to draw a line across greater and lower tuberosities (no. 1 to 2 or vice versa). The system will automatically generate a semicircle once it registers the line (the  semicircle  indicates  the  round  surface  of  humeral head). Next, the user will adjust the size of semicircle until it best fits the humeral head (as indicated by no. 1 and 2 in Figure 3). Finally user needs to draw two lines (lines 4 and 5) to get the humeral stem template.Figure 3: Five steps to get the template3.4 Apply TemplateOnce  user  has  finished  providing  the  required  inputs,  the application will search the preloaded database and display the  most  appropriate  template  that  is  available  in  the database. User can then easily edit the template to best fit his needs.3.5 ReportThe  final  step in the  workflow will  be  report  generation. The  application  allows  user  to  generate  a  comprehensive report,  including  a  preoperative  planning  image  produced by  the  system,  annotations  by  the  surgeon  on  the  image using  tools  available  in  the  application  in  the  planning phase, and patient’s details. The report can be either kept in softcopy or printed out as hardcopy for future reference.4.0 CONCLUSIONThis  paper  describes  a  proposed  application  for  digital preoperative  planning,  begins  with  some  general introductions of related topics in this research, followed by the some issue on digital templating regarding the reliability of  analogue  and  digital  templating.  It  then  described  the proposed application design and a workflow of the proposed application was shown in that case. AcknowledgementsThis is an ongoing research under a research group; there are currently two other similar researches on knee and hip arthroplasty.  The  proposed  application  will  be  developed and then used and tested by orthopedic surgeon to evaluate its efficiency, accuracy and flexibility.REFERENCESErnst, W., Ulrich, B., Sandra, H., & Wolf, M. (2004). Hemiarthroplasty  for  Humeral  Head  Fractures. 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Computer aided preoperative planning application for shoulder hemiarthroplasty

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