Robotic hand surgery: current insights and future directions

Robotic surgery is a rapidly evolving field that will potentially play a pivotal role in future patient care. There are specific challenges that needs circumventing for each surgical specialty. This article discusses the current robotic surgical systems that have been developed or are currently in development for its application in hand surgery, which has its own unique complexity of comprising both bony and soft tissue procedures. Although robotics has been applied to a wide range of surgical specialties, its precise role in hand surgery remains a subject of further research. We delve into how this new technology is changing the landscape of the management of hand conditions, in both bony and microsurgical procedures, and future directions of this evolving field.

Navigated laparoscopic ultrasound in abdominal soft tissue surgery: technological overview and perspectives

PURPOSE

Two-dimensinal laparoscopic ultrasound (LUS) is commonly used for many laparoscopic procedures, but 3D LUS and navigation technology are not conventional tools in the clinic. Navigated LUS can help the user understand and interpret the ultrasound images in relation to the laparoscopic view and preoperative images. When combined with information from MRI or CT, navigated LUS has the potential to provide information about anatomic shifts during the procedure. In this paper, we present an overview of the ongoing technological research and development related to LUS combined with navigation technology, The purpose of this overview is threefold: (1) an introduction for those new to the field of navigated LUS; (2) an overview for those working in the field and; and (3) as a reference for those searching for literature on technological developments related to navigation in ultrasound-guided laparoscopic surgery.

METHODS

Databases were searched to identify relevant publications from the last 10 years.

RESULTS

We were able to identify 18 key papers in the area of navigated LUS for the abdomen, originating from about 10-11 groups. We present the literature overview, including descriptions of our own experience in the field, and a discussion of the important clinical and technological aspects related to navigated LUS.

CONCLUSIONS

LUS integrated with miniaturized tracking technology is likely to play an important role in guiding future laparoscopic surgery.

3D ultrasound reconstruction algorithms from analog and digital data

Freehand 3D ultrasound is increasingly being introduced in the clinic for diagnostics and image-assisted interventions. Various algorithms exist for combining 2D images of regular ultrasound probes to 3D volumes, being either voxel-, pixel- or function-based. Previously, the most commonly used input to 3D ultrasound reconstruction has been digitized analog video. However, recent scanners that offer access to digital image frames exist, either as processed or unprocessed data. To our knowledge, no comparison has been performed to determine which data source gives the best reconstruction quality. In the present study we compared both reconstruction algorithms and data sources using novel comparison methods for detecting potential differences in image quality of the reconstructed volumes. The ultrasound scanner used in this study was the Sonix RP from Ultrasonix Medical Corp (Richmond, Canada), a scanner that allow third party access to unprocessed and processed digital data. The ultrasound probe used was the L14-5/38 linear probe. The assessment is based on a number of image criteria: detectability of wire targets, spatial resolution, detectability of small barely visible structures, subjective tissue image quality, and volume geometry. In addition we have also performed the more "traditional" comparison of reconstructed volumes by removing a percentage of the input data. By using these evaluation methods and data from the specific scanner, the results showed that the processed video performed better than the digital scan-line data, digital video being better than analog video. Furthermore, the results showed that the choice of video source was more important than the choice of tested reconstruction algorithms.

A Navigated Mechatronic System with Haptic Features to Assist in Surgical Interventions

OBJECTIVE

In orthopaedic surgery, the development of new computer-based technologies such as navigation systems and robotics will facilitate more precise, reproducible results in surgical interventions. There are already commercial systems available for clinical use, though these still have some limitations and drawbacks. This paper presents an alternative approach to a universal modular surgical assistant system for supporting less or minimally invasive surgery.

MATERIALS AND METHODS

The position of a mechatronic arm, which is part of the system, is controlled by a navigation system so that small patient movements are automatically detected and compensated for in real time. Thus, the optimal tool position can be constantly maintained without the need for rigid bone or patient fixation. Furthermore, a force control mode of the mechatronic assistant system, based on a force-torque sensor, not only increases safety during surgical interventions but also facilitates hand-driven direct positioning of the arm.

RESULTS

A prototype has been successfully tested in clinical applications at the Orthopadische Universitätsklinik Frankfurt. For the first time worldwide, implantation of the cup prosthesis in total hip replacement surgery has been carried out with the assistance of a mechatronic arm. According to measurements by the digitizing system, operating tool angle deviation remained below 0.5 degrees, relative to the preoperative planning.

CONCLUSION

The presented approach to a new kind of surgical mechatronic assistance system supports the surgeon as needed by optimal positioning of the surgical instruments. Due to its modular design, it is applicable to a wide range of tasks in surgical interventions, e.g., endoscope guidance, bone preparation, etc.

CASPER, a Computer ASsisted PERicardial puncture system: first clinical results

Pericardial puncture is the percutaneous insertion of a needle into the pericardial space to drain a pathological pericardial effusion. The challenge for the operating surgeon is to reach percutaneously a target zone in the vicinity of the mobile heart, in a soft-tissue environment. The surgeon's ability to accomplish this depends on his own mental picture of the effusion. CASPER is a navigation software using an optical localizer which assists the surgeon by enhancing the representation of the effusion and guiding the needle's progress. Using a localized and calibrated echographic probe, the surgeon acquires a set of images in the region of interest. This zone is then manually segmented on each image, a common zone is computed, and the surgeon defines a trajectory for the needle. During the puncture procedure, the surgeon follows the position of the localized needle on a computer monitor. After initial validation on an experimental phantom, a feasibility study was performed using canine and porcine models. The optical localization device was changed from an Optotrak to a Polaris device for easier use in the clinical setting. Prior to clinical application, various tests were performed concerning the mobility of the thoracic cage, the reproducibility of the thoracic position over several apneas, and the stability of anatomic structures relative to the thoracic cage. Finally, a first clinical application was successfully performed using this system. The present paper reports on these last two stages.

Computer- und Robotertechnik für die bildgeführte Orthopädische Chirurgie (Computer and Robot Technology for Image guided Orthopaedic Surgery)

Seit einigen Jahren hält die Computer- und auch Robotertechnologie in der Orthopädischen Chirurgie Einzug, wird jedoch teilweise sehr kontrovers diskutiert. Wo liegen Vorteile und Probleme der Automatisierungstechnik für den chirurgischen Einsatz? In diesem Beitrag sollen Möglichkeiten und Techniken im Überblick dargestellt werden. Entwicklungspotentiale insbesondere im Hinblick auf robotische Unterstützungssysteme sollen am Beispiel des CRIGOS-Parallelrobotersystems aufgezeigt werden.

The future of robotics in hand surgery

Robotics has spread over many surgical fields over the last decade: orthopaedic, cardiovascular, urologic, gynaecologic surgery and various other types of surgery. There are five different types of robots: passive, semiactive and active robots, telemanipulators and simulators. Hand surgery is at a crossroad between orthopaedic surgery, plastic surgery and microsurgery; it has to deal with fixing all sorts of tissues from bone to soft tissues. To our knowledge, there is not any paper focusing on potential clinical applications in this realm, even though robotics could be helpful for hand surgery. One must point out the numerous works on bone tissue with regard to passive robots (such as fluoroscopic navigation as an ancillary for percutaneous screwing in the scaphoid bone). Telemanipulators, especially in microsurgery, can improve surgical motion by suppressing physiological tremor thanks to movement demultiplication (experimental vascular and nervous sutures previously published). To date, the robotic technology has not yet become simple-to-use, cheap and flawless but in the future, it will probably be of great technical help, and even allow remote-controlled surgery overseas.

Cross-correlation-based image acquisition technique for manually-scanned optical coherence tomography

We present a novel image acquisition technique for Optical Coherence Tomography (OCT) that enables manual lateral scanning. The technique compensates for the variability in lateral scan velocity based on feedback obtained from correlation between consecutive A-scans. Results obtained from phantom samples and biological tissues demonstrate successful assembly of OCT images from manually-scanned datasets despite non-uniform scan velocity and abrupt stops encountered during data acquisition. This technique could enable the acquisition of images during manual OCT needle-guided biopsy or catheter-based imaging, and for assembly of large field-of-view images with hand-held probes during intraoperative in vivo OCT imaging.

Comparison between analog and digital neural network implementations for range-finding applications

A neural network (NN) was developed in order to increase the distance range of a phase-shift laser range finder and to achieve surface recognition, by using two photoelectrical signals issued from the measurement system. The NN architecture consists of a multilayer perceptron (MLP) with two inputs, three neurons in the hidden layer, and one output. Depending on the application, the NN output has to resolve the ambiguity due to phase-shift measurement by linearizing the inverse of the square law, or to indicate an output voltage corresponding to the tested surface. This embedded system dedicated to optoelectronic measurements was successfully tested with an analog NN, implemented in 0.35- microm complimentary metal-oxide-semiconductor (CMOS) technology, resulting in a threefold increase in the distance range with respect to the one limited by the phase-shift measurement, and by discriminating four types of surfaces (a plastic surface, glossy paper, a painted wall, and a porous surface), at a remote distance between the range finder and the target varying from 0.5 m up to 1.25 m and with a laser beam angle varying between -pi/6 and pi/6 with respect to the target. In this type of application, NN analog implementation provides many advantages, notably use of a small silicon area, low power consumption and no analog-to-digital conversions (ADCs). Nevertheless, digital implementation allows ease of conception and reconfigurability and an embedded weight and bias update. This paper presents the complete measurement system and a comparison between both types of implementation, by developing the advantages and drawbacks relative to each method. An optimized mixed architecture, using both techniques, is then proposed and discussed at the end of the paper.

Navigation in laparoscopy--prototype research platform for improved image-guided surgery

The manipulation of the surgical field in laparoscopic surgery, through small incisions with rigid instruments, reduces free sight, dexterity, and tactile feedback. To help overcome some of these drawbacks, we present a prototype research and development platform, CustusX, for navigation in minimally invasive therapy. The system can also be used for planning and follow-up studies. With this platform we can import and display a range of medical images, also real-time data such as ultrasound and X-ray, during surgery. Tracked surgical tools, such as pointers, video laparoscopes, graspers, and various probes, allow surgeons to interactively control the display of medical images during the procedure. This paper introduces navigation technologies and methods for laparoscopic therapy, and presents our software and hardware research platform. Furthermore, we illustrate the use of the system with examples from two pilots performed during laparoscopic therapy. We also present new developments that are currently being integrated into the system for future use in the operating room. Our initial results from pilot studies using this technology with preoperative images and guidance in the retroperitoneum during laparoscopy are promising. Finally, we shortly describe an ongoing multicenter study using this surgical navigation system platform.

Freehand 3D ultrasound reconstruction algorithms--a review

Three-dimensional (3D) ultrasound (US) is increasingly being introduced in the clinic, both for diagnostics and image guidance. Although dedicated 3D US probes exist, 3D US can also be acquired with the still frequently used two-dimensional (2D) US probes. Obtaining 3D volumes with 2D US probes is a two-step process. First, a positioning sensor must be attached to the probe; second, a reconstruction of a 3D volume can be performed into a regular voxel grid. Various algorithms have been used for performing 3D reconstruction based on 2D images. Up till now, a complete overview of the algorithms, the way they work and their benefits and drawbacks due to various applications has been missing. The lack of an overview is made clear by confusions about algorithm and group names in the existing literature. This article is a review aimed at explaining and categorizing the various algorithms into groups, according to algorithm implementation. The algorithms are compared based on published data and our own laboratory results. Positive and practical uses of the various algorithms for different applications are discussed, with a focus on image guidance.

MBARS: mini bone-attached robotic system for joint arthroplasty

A report on a new active, miniature bone-attached, robotic system including its design, high level and low level control, is given together with a description of the system implementation and first experimental use. The system is capable of preparing the bone cavity for an implant during joint arthroplasty procedures. Without loss of generality, the report describes the implementation of the system for a Patellofemoral Joint Replacement procedure. The system is image-free and all planning is performed intra-operatively in the robot coordinate system, eliminating the need for external tracking systems in the operating room. Experiments were conducted using the first robot prototype and the results supported the feasibility of the concept. The methodology which is presented can be modified to other orthopaedic procedures and could improve the results in terms of accuracy and operational time. Moreover, it enables minimally invasive procedures and use of the next generation of more anatomically shaped implants.

Guiding the surgical gesture using an electro-tactile stimulus array on the tongue: a feasibility study

Under conventional "open-" surgery, the physician has to take care of the patient, interact with other clinicians and check several monitoring devices. Nowadays, the computer assisted surgery proposes to integrate 3-D cameras in the operating theatre in order to assist the surgeon in performing minimally invasive surgical punctures. The cameras localize the needle and the computer guides the surgeon towards an intracorporeal clinically defined target. A visualization system (screen) is employed to provide the surgeon with indirect visual spatial information about the intracorporeal positions of the needle. The present work proposes to use another sensory modality to guide the surgeon, thus keeping the visual modality fully dedicated to the surgical gesture. For this, the sensory substitution paradigm using the Bach-y-Rita's "Tongue Display Unit" (TDU) is exploited to provide to the surgeon information of the position tool. The TDU device is composed of a 6 x 6 matrix of electrodes transmitting electrotactile information on the tongue surface. The underlying idea consists in transmitting information about the deviation of the needle movement with regard to a preplanned "optimal" trajectory. We present an experiment assessing the guidance effectiveness of an intracorporeal puncture under TDU guidance with respect to the performance evidenced under a usual visual guidance system.

Three-dimensional reconstruction of registered and fused Chinese Visible Human and patient MRI images

Radiological images are commonly used as important tools in medical diagnoses and treatment. Different modalities of medical images provide uniquely different content. Hence, it is natural and desirable to combine different image modalities to obtain additional new information to enhance clinical assessment. However, given the current technology, radiological images are not always sufficiently informative to permit diagnosis and treatment. In order to address this problem, we fused selected portions of the Chinese Visible Human (CVH) dataset with MRI images from a patient. Specifically, we segmented the caudate nucleus, the lentiform nucleus, and the thalamus in the CVH dataset and then registered and fused this dataset with corresponding MRI images using both rigid and nonrigid registration techniques. After rigid and nonrigid registration, the CVH and MRI images largely coincided with each other. The shape, relationship, and position of focal areas and neural structures were clearly displayed. Using volume and surface rendering, these images were three-dimensionally reconstructed to display the neural structures of interest within the brain. These structures can be rotated at will and observed from different angles. Our research indicates that the fusion of CVH and patients' MRI images can enhance the amount of neural information available to physicians and lay a foundation for the clinical use of the CVH dataset.

A review of calibration techniques for freehand 3-D ultrasound systems

Three-dimensional (3-D) ultrasound (US) is an emerging new technology with numerous clinical applications. Ultrasound probe calibration is an obligatory step to build 3-D volumes from 2-D images acquired in a freehand US system. The role of calibration is to find the mathematical transformation that converts the 2-D coordinates of pixels in the US image into 3-D coordinates in the frame of reference of a position sensor attached to the US probe. This article is a comprehensive review of what has been published in the field of US probe calibration for 3-D US. The article covers the topics of tracking technologies, US image acquisition, phantom design, speed of sound issues, feature extraction, least-squares minimization, temporal calibration, calibration evaluation techniques and phantom comparisons. The calibration phantoms and methods have also been classified in tables to give a better overview of the existing methods.

A review of calibration techniques for freehand 3-D ultrasound systems

Three-dimensional (3-D) ultrasound (US) is an emerging new technology with numerous clinical applications. Ultrasound probe calibration is an obligatory step to build 3-D volumes from 2-D images acquired in a freehand US system. The role of calibration is to find the mathematical transformation that converts the 2-D coordinates of pixels in the US image into 3-D coordinates in the frame of reference of a position sensor attached to the US probe. This article is a comprehensive review of what has been published in the field of US probe calibration for 3-D US. The article covers the topics of tracking technologies, US image acquisition, phantom design, speed of sound issues, feature extraction, least-squares minimization, temporal calibration, calibration evaluation techniques and phantom comparisons. The calibration phantoms and methods have also been classified in tables to give a better overview of the existing methods.

An Image-Guided System Based on Custom Templates: Case Reports

BACKGROUND

With the use of computer-assisted surgery and other modern imaging technologies, the surgeon's procedures have been modified.

PURPOSE

The purpose of these case reports is to show the clinical predictability of dental implant placement using an image-guided system.

MATERIAL AND METHODS

An acrylic template is made on the patient model. After computed tomographic examination, a treatment plan is established with appropriate software. To fabricate the surgical template, it is necessary to use a dedicated drilling machine. The first osteotomy is achieved through the template with a 2 mm twist drill. The template is then removed, and the osteotomy is completed, followed by implant placement with standard clinical procedures.

RESULTS

An excellent predictability was observed between the planned implants and those placed in the two maxillary cases presented: a full upper screw-retained bridge and two single units.

CONCLUSIONS

This new technology improves the treatment outcome and optimizes the surgical procedure.

Precision of transfer of preoperative planning for oral implants based on cone-beam CT-scan images through a robotic drilling machine

In this study, an image-guided system for oral implant placement was assessed. A specially designed mechanical tool has been elaborated to transfer the preoperative implant axis planned on 3-dimensional imagery into a surgical template by a numerically controlled drilling machine. The main drawback of image-guiding systems is the use of preoperative computed tomography, which is expensive and delivers high radiation doses. Therefore, in this study the image-guiding system was coupled with a cone-beam tomograph that significantly decreased both cost and radiation doses. Three edentulous models were used. To determine the accuracy of the system, the ability of a 1.8-mm diameter drill to enter a 2.0-mm diameter, 10-mm-long titanium tube inserted on the model with no contact was verified. Because the drill entered the tubes with no contact and went beyond the end of the tube, the transfer error was less than 0.2 mm for translation and less than 1.1 degrees for rotation. The method presented here is low cost and high precision compared to other technological solutions such as tracking. Further assessment in the surgical field should lead to daily use of this system for flapless surgery, to prepare a prosthesis prior to surgery for immediate loading, to reduce risk of injuring critical anatomical structures and to eliminate manual placement error.

Computer-assisted neurosurgery by using a noninvasive vacuum-affixed dental cast that acts as a reference base: another step toward a unified approach in the treatment of brain tumors

OBJECT

The purpose of the study was to evaluate the use of the Vogele-Bale-Hohner (VBH) mouthpiece, which is attached to the patient's upper jaw by negative pressure, for patient-image registration and for tracking the patient's head during image-guided neurosurgery.

METHODS

A dynamic reference frame (DRF) is reproducibly mounted on the mouthpiece. Reference points, optimally distributed and attached to the mouthpiece, are used for registration in the patient's absence on the day before surgery. In the operating room, the mouthpiece and DRF are precisely repositioned using a vacuum, and the patient's anatomical structures are automatically registered to corresponding ones on the image. Experimental studies and clinical experiences in 10 patients confirmed repeated (rigid body) localization accuracy in the range of 0 to 2 mm, throughout the entire surgery despite movements by the patient.

CONCLUSIONS

Because of its noninvasive, rigid, reliable, and reproducible connection to the patient's head, the VBH vacuum-affixed mouthpiece grants the registration device an accuracy comparable to invasive fiducial markers.

Virtual image navigation: a new method to control intraoperative bleeding in neuroendoscopic surgery. Technical note

In this neuroendoscopic study the authors tested the newly developed "red-out module" of their visual navigation system that enables the neurosurgeon to achieve hemostasis if total visualization is lost due to hemorrhage ("red out") within the visual field. An optical position measurement system connected to the endoscope guarantees that digitized endoscopic images are coupled with the accurate endoscopic position. Computerized images are simultaneously stored with their respective position data, and this creates a virtual anatomical landscape. The system was tested in in vivo bleeding conditions in a rat model. Artificial endoscopic cavities were created in the inguinal, pelvic, and jugular regions in rats to imitate the conditions of the human ventricular system. Two experimental settings were tested: Technique I, in which a computer landmark has been previously determined at the point where the vessel will be lesioned; and Technique II, in which a landmark has been previously set in the surrounding area of the vessel. Immediately after hemorrhage obscures the visual field (red out), the computer automatically displays the virtual images on a separate monitor. The previously set landmarks and the graphic overlay of the coagulation fiber enable the surgeon to navigate within the operative field based on the virtual images and to perform coagulation at the site of the lesion. A total of 175 vessels were coagulated: 43 arteries and 132 veins. In using Technique I, 130 (90.9%) of 143 vessels and in using Technique II, 26 (81.2%) of 32 arteries were successfully coagulated. The authors' data revealed that virtual image guidance has the potential to be a helpful tool in neuroendoscopy.

A novel mechatronic tool for computer-assisted arthroscopy

This paper describes a novel mechatronic tool for arthroscopy, which is at the same time a smart tool for traditional arthroscopy and the main component of a system for computer-assisted arthroscopy. The mechatronic arthroscope has a cable-actuated servomotor-driven multi-joint mechanical structure, is equipped with a position sensor measuring the orientation of the tip and with a force sensor detecting possible contact with delicate tissues in the knee, and incorporates an embedded microcontroller for sensor signal processing, motor driving and interfacing with the surgeon and/or the system control unit. When used manually, the mechatronic arthroscope enhances the surgeon's capabilities by enabling him/her to easily control tip motion and to prevent undesired contacts. When the tool is integrated in a complete system for computer-assisted arthroscopy, the trajectory of the arthroscope is reconstructed in real time by an optical tracking system using infrared emitters located in the handle, providing advantages in terms of improved intervention accuracy. The computer-assisted arthroscopy system comprises an image processing module for segmentation and three-dimensional reconstruction of preoperative computer tomography or magnetic resonance images, a registration module for measuring the position of the knee joint, tracking the trajectory of the operating tools, and matching preoperative and intra-operative images, and a human-machine interface that displays the enhanced reality scenario and data from the mechatronic arthroscope in a friendly and intuitive manner. By integrating preoperative and intra-operative images and information provided by the mechatronic arthroscope, the system allows virtual navigation in the knee joint during the planning phase and computer guidance by augmented reality during the intervention. This paper describes in detail the characteristics of the mechatronic arthroscope and of the system for computer-assisted arthroscopy and discusses experimental results obtained with a preliminary version of the tool and of the system.

Computer-aided surgery in the petrous bone

OBJECTIVE

We demonstrate that computer-assisted frameless stereotactic navigation with the ISG/ELEKTA Viewing Wand system in the petrous bone is routinely possible with sufficient application accuracy.

METHODS

High-resolution computed tomography imaging is done with a dedicated structure attached to the mouthpiece of the Vogele-Bale-Hohner (VBH) head holder, an integral part of our intraoperative patient fixation. The patient image registration can be reliably performed before surgery in an unsterile environment with the registration structure of the mouthpiece. For intraoperative navigation either the position-sensitive articulated arm or the optical three-dimensional digitizer of the ISG/ELEKTA system is used.

RESULTS

In the operations of the petrous bone performed so far, i.e., mastoidectomy, cholesteatoma surgery, and lateral skull base revision surgery, the clinical value of three-dimensional navigation was clearly demonstrated with an application accuracy, constant throughout surgery, mostly limited only by the resolution of the computed tomography.

Accurate guidance for percutaneous access to a specific target in soft tissues: preclinical study of computer-assisted pericardiocentesis

In the field of percutaneous access to soft tissues, our project was to improve classical pericardiocentesis by performing accurate guidance to a selected target, according to a model of the pericardial effusion acquired through three-dimensional (3D) data recording. Required hardware is an echocardiographic device and a needle, both linked to a 3D localizer, and a computer. After acquiring echographic data, a modeling procedure allows definition of the optimal puncture strategy, taking into consideration the mobility of the heart, by determining a stable region, whatever the period of the cardiac cycle. A passive guidance system is then used to reach the planned target accurately, generally a site in the middle of the stable region. After validation on a dynamic phantom and a feasibility study in dogs, an accuracy and reliability analysis protocol was realized on pigs with experimental pericardial effusion. Ten consecutive successful punctures using various trajectories were performed on eight pigs. Nonbloody liquid was collected from pericardial effusions in the stable region (5 to 9 mm wide) within 10 to 15 minutes from echographic acquisition to drainage. Accuracy of at least 2.5 mm was demonstrated. This study demonstrates the feasibility of computer-assisted pericardiocentesis. Beyond the simple improvement of the current technique, this method could be a new way to reach the heart or a new tool for percutaneous access and image-guided puncture of soft tissues. Further investigation will be necessary before routine human application.

Applications of computer modelling for the design of orthopaedic, dental and cardiovascular biomaterials

Biomaterials do not escape from the general trend present in all contemporary science and technology towards increasing use of computers and information technology. In this paper the use of computer modelling for the design of biomaterials is discussed. The word 'biomaterials' is interpreted in its broadest sense, i.e. referring to any foreign object brought into the body for temporary or permanent use. Computer modelling will first be discussed as a tool to model biological structures (bones, arteries) or to investigate and simulate biological interactions at implant-host interfaces. It will then be illustrated how computer modelling, using insights gained from the modelling of the biological structures themselves, is used in the design process of dental, orthopaedic and cardiovascular prostheses. The area of computer modelling for biomaterials applications has become so vast that an exhaustive overview is impossible in the framework of one paper. Rather, some illustrative case studies will be discussed which are, in the opinion of the authors, representative of general trends in this challenging domain of science on the boundary between engineering and medicine.

Systematic distortions in magnetic position digitizers

Medical devices equipped with position sensors enable applications like image guided surgical interventions, reconstruction of three-dimensional 3D ultrasound (US) images, and virtual or augmented reality systems. The acquisition of three-dimensional position data in real time is one of the key technologies in this field. The systematic distortions induced by various metals, surgical tools, and US scan probes in different commercial electromagnetic tracking systems were assessed in the presented work. A precise nonmetallic six degree-of-freedom measurement rack was built that allowed a quantitative comparison of different electromagnetic trackers. Also, their performance in the presence of large metallic structures was quantified in a phantom study on an acrylic skull model in an operating room (OR). The trackers used were alternating current (ac) and direct current (dc) based systems. The ac trackers were, on average, distorted by 0.7 mm and 0.5 degree by metallic objects positioned at a distance greater than 120 mm between the geometrical center of the sample and the sensor. In the OR environment, the ac system exhibits mean errors of 3.2 +/- 2.4 mm and 2.9 degrees +/- 1.9 degrees. The dc trackers are more sensitive to distortions caused by ferromagnetic materials (averaged value: 1.6 mm and 0.5 degree beyond a distance of 120 mm). The dc tracker shows no distortions from other conductive materials but was less accurate in the OR environment (typical error: 6.4 +/- 2.5 mm and 4.9 degrees +/- 2.0 degrees). At distances smaller than approximately 100 mm between sample and sensor error increases quickly. It is also apparent from our measurements that the influence of US scan probes is governed by their shielding material. The results show that surgical instruments not containing conductive material are to be preferred when using an ac tracker. Nonferromagnetic instruments should be used with dc trackers. Static distortions caused by the OR environment have to be compensated by precise calibration methods.

Computer assisted orthopaedic surgery with image based individual templates

Recent developments in computer assisted surgery offer promising solutions for the translation of the high accuracy of the preoperative imaging and planning into precise intraoperative surgery. Broad clinical application is hindered by high costs, additional time during intervention, problems of intraoperative man and machine interaction, and the spatially constrained arrangement of additional equipment within the operating theater. An alternative technique for computerized tomographic image based preoperative three-dimensional planning and precise surgery on bone structures using individual templates has been developed. For the preoperative customization of these mechanical tool guides, a desktop computer controlled milling device is used as a three-dimensional printer to mold the shape of small reference areas of the bone surface automatically into the body of the template. Thus, the planned position and orientation of the tool guide in spatial relation to bone is stored in a structural way and can be reproduced intraoperatively by adjusting the position of the customized contact faces of the template until the location of exact fit to the bone is found. No additional computerized equipment or time is needed during surgery. The feasibility of this approach has been shown in spine, hip, and knee surgery, and it has been applied clinically for pelvic repositioning osteotomies in acetabular dysplasia therapy.

Three-dimensional image-guided endonasal surgery with a microdebrider

We report the first intraoperative use of a microdebrider as a stereotactic three-dimensional (3D) navigation instrument in paranasal and frontobasal surgery. The microdebrider uses rotating blades and an integrated suction device for controlled removal of tissue under video-endoscopic view. The ISG Viewing Wand uses the patient's computed tomography/magnetic resonance (CT/MR) data and a 3D reconstruction thereof and a high-precision position-sensitive mechanical arm for intraoperative three-dimensional navigation. We have linked the microdebrider to the Viewing Wand to transform it into a continuously available intraoperative stereotactic localizing device. We discuss the problems related to this extension of the Viewing Wand and demonstrate the practical use in an exemplary polypectomy.

Computer-assisted surgery in the frontal and maxillary sinus

We report the intraoperative use of bent probes for 3-dimensional computer-assisted navigation in ENT surgery with the ISG Viewing Wand. Probe calibration is standardized and the new probes comply with the overall application accuracy of the navigation system. The bent probes permit an easy access to the remotest locations of the maxillary and the frontal sinus and are beneficial for application in paranasal sinus surgery. We present our clinical experiences with these probes.