Fast and automatic periacetabular osteotomy fragment pose estimation using intraoperatively implanted fiducials and single-view fluoroscopy

Accurate and consistent mental interpretation of fluoroscopy to determine the position and orientation of acetabular bone fragments in 3D space is difficult. We propose a computer assisted approach that uses a single fluoroscopic view and quickly reports the pose of an acetabular fragment without any user input or initialization. Intraoperatively, but prior to any osteotomies, two constellations of metallic ball-bearings (BBs) are injected into the wing of a patient's ilium and lateral superior pubic ramus. One constellation is located on the expected acetabular fragment, and the other is located on the remaining, larger, pelvis fragment. The 3D locations of each BB are reconstructed using three fluoroscopic views and 2D/3D registrations to a preoperative CT scan of the pelvis. The relative pose of the fragment is established by estimating the movement of the two BB constellations using a single fluoroscopic view taken after osteotomy and fragment relocation. BB detection and inter-view correspondences are automatically computed throughout the processing pipeline. The proposed method was evaluated on a multitude of fluoroscopic images collected from six cadaveric surgeries performed bilaterally on three specimens. Mean fragment rotation error was 2.4 ± 1.0 degrees, mean translation error was 2.1 ± 0.6 mm, and mean 3D lateral center edge angle error was 1.0 ± 0.5 degrees. The average runtime of the single-view pose estimation was 0.7 ± 0.2 s. The proposed method demonstrates accuracy similar to other state of the art systems which require optical tracking systems or multiple-view 2D/3D registrations with manual input. The errors reported on fragment poses and lateral center edge angles are within the margins required for accurate intraoperative evaluation of femoral head coverage.

Automatic annotation of hip anatomy in fluoroscopy for robust and efficient 2D/3D registration

PURPOSE

Fluoroscopy is the standard imaging modality used to guide hip surgery and is therefore a natural sensor for computer-assisted navigation. In order to efficiently solve the complex registration problems presented during navigation, human-assisted annotations of the intraoperative image are typically required. This manual initialization interferes with the surgical workflow and diminishes any advantages gained from navigation. In this paper, we propose a method for fully automatic registration using anatomical annotations produced by a neural network.

METHODS

Neural networks are trained to simultaneously segment anatomy and identify landmarks in fluoroscopy. Training data are obtained using a computationally intensive, intraoperatively incompatible, 2D/3D registration of the pelvis and each femur. Ground truth 2D segmentation labels and anatomical landmark locations are established using projected 3D annotations. Intraoperative registration couples a traditional intensity-based strategy with annotations inferred by the network and requires no human assistance.

RESULTS

Ground truth segmentation labels and anatomical landmarks were obtained in 366 fluoroscopic images across 6 cadaveric specimens. In a leave-one-subject-out experiment, networks trained on these data obtained mean dice coefficients for left and right hemipelves, left and right femurs of 0.86, 0.87, 0.90, and 0.84, respectively. The mean 2D landmark localization error was 5.0 mm. The pelvis was registered within [Formula: see text] for 86% of the images when using the proposed intraoperative approach with an average runtime of 7 s. In comparison, an intensity-only approach without manual initialization registered the pelvis to [Formula: see text] in 18% of images.

CONCLUSIONS

We have created the first accurately annotated, non-synthetic, dataset of hip fluoroscopy. By using these annotations as training data for neural networks, state-of-the-art performance in fluoroscopic segmentation and landmark localization was achieved. Integrating these annotations allows for a robust, fully automatic, and efficient intraoperative registration during fluoroscopic navigation of the hip.

Pose Estimation of Periacetabular Osteotomy Fragments With Intraoperative X-Ray Navigation

OBJECTIVE

State-of-the-art navigation systems for pelvic osteotomies use optical systems with external fiducials. In this paper, we propose the use of X-ray navigation for pose estimation of periacetabular fragments without fiducials.

METHODS

A two-dimensional/three-dimensional (2-D/3-D) registration pipeline was developed to recover fragment pose. This pipeline was tested through an extensive simulation study and six cadaveric surgeries. Using osteotomy boundaries in the fluoroscopic images, the preoperative plan was refined to more accurately match the intraoperative shape.

RESULTS

In simulation, average fragment pose errors were 1.3 ° /1.7 mm when the planned fragment matched the intraoperative fragment, 2.2 ° /2.1 mm when the plan was not updated to match the true shape, and 1.9 ° /2.0 mm when the fragment shape was intraoperatively estimated. In cadaver experiments, the average pose errors were 2.2  ° /2.2 mm, 3.8 ° /2.5 mm, and 3.5  ° /2.2 mm when registering with the actual fragment shape, a preoperative plan, and an intraoperatively refined plan, respectively. Average errors of the lateral center edge angle were less than 2 ° for all fragment shapes in simulation and cadaver experiments.

CONCLUSION

The proposed pipeline is capable of accurately reporting femoral head coverage within a range clinically identified for long-term joint survivability.

SIGNIFICANCE

Human interpretation of fragment pose is challenging and usually restricted to rotation about a single anatomical axis. The proposed pipeline provides an intraoperative estimate of rigid pose with respect to all anatomical axes, is compatible with minimally invasive incisions, and has no dependence on external fiducials.

Plan in 2-D, execute in 3-D: an augmented reality solution for cup placement in total hip arthroplasty

Reproducibly achieving proper implant alignment is a critical step in total hip arthroplasty procedures that has been shown to substantially affect patient outcome. In current practice, correct alignment of the acetabular cup is verified in C-arm x-ray images that are acquired in an anterior-posterior (AP) view. Favorable surgical outcome is, therefore, heavily dependent on the surgeon's experience in understanding the 3-D orientation of a hemispheric implant from 2-D AP projection images. This work proposes an easy to use intraoperative component planning system based on two C-arm x-ray images that are combined with 3-D augmented reality (AR) visualization that simplifies impactor and cup placement according to the planning by providing a real-time RGBD data overlay. We evaluate the feasibility of our system in a user study comprising four orthopedic surgeons at the Johns Hopkins Hospital and report errors in translation, anteversion, and abduction as low as 1.98 mm, 1.10 deg, and 0.53 deg, respectively. The promising performance of this AR solution shows that deploying this system could eliminate the need for excessive radiation, simplify the intervention, and enable reproducibly accurate placement of acetabular implants.

Fathers make a difference: positive relationships with mother and baby in relation to infant colic

BACKGROUND

Maternal psychological factors like depression, anxiety and stress have been associated with infant fussiness or colic. However, little research exists on whether positive factors such as social support and the happiness of the mother-partner relationship are associated with lower rates of infant fussiness or colic.

OBJECTIVES

We investigated the association between infant colic and three types of maternal support: general maternal social support (during pregnancy and post partum), the happiness of the mother-partner relationship (during pregnancy and post partum) and partner involvement in caring for the newborn.

METHODS

Participants were 3006 women in the First Baby Study, a prospective study of the effect of mode of first delivery on subsequent childbearing. Women were interviewed by telephone during pregnancy and 1 month after first childbirth and asked about social support and if their baby had a variety of problems since birth, including 'Colic - crying or fussiness three or more hours a day'. Multivariable logistic regression models were used to model the association between maternal support and infant colic, controlling for confounders, including maternal race or ethnicity, insurance, marital status, smoking, mode of delivery, maternal post-partum depression, breastfeeding, other neonatal illnesses and newborn gestational age.

RESULTS

Infant colic was reported by 11.6% of new mothers. High general maternal social support (in comparison with low), measured during pregnancy, was associated with lower reported infant colic (adjusted odds ratio (AOR), 0.55, 95% confidence interval (CI), 0.40-0.75) and measured post partum (AOR, 0.51, 95% CI, 0.39-0.67); high relationship happiness (in comparison with low), measured during pregnancy (AOR, 0.71, 95% CI, 0.54-0.93), and measured post partum (AOR, 0.22, 95% CI, 0.12-0.40); and high partner involvement with newborn care (in comparison with low) (AOR, 0.60, 95% CI, 0.44-0.81).

CONCLUSION

Higher levels of maternal social support during pregnancy and post partum are associated with lower rates of maternal reported infant colic.

The ability of Sos1 to oligomerize the adaptor protein LAT is separable from its guanine nucleotide exchange activity in vivo

The activation of the small guanosine triphosphatase Ras by the guanine nucleotide exchange factor (GEF) Sos1 (Son of Sevenless 1) is a central feature of many receptor-stimulated signaling pathways. In developing T cells (thymocytes), Sos1-dependent activation of extracellular signal-regulated kinase (ERK) is required to stimulate cellular proliferation and differentiation. We showed that in addition to its GEF activity, Sos1 acted as a scaffold to nucleate oligomerization of the T cell adaptor protein LAT (linker for activation of T cells) in vivo. The scaffold function of Sos1 depended on its ability to bind to the adaptor protein Grb2. Furthermore, the GEF activity of Sos1 and the Sos1-dependent oligomerization of LAT were separable functions in vivo. Whereas the GEF activity of Sos1 was required for optimal ERK phosphorylation in response to T cell receptor (TCR) stimulation, the Sos1-dependent oligomerization of LAT was required for maximal TCR-dependent phosphorylation and activation of phospholipase C-γ1 and Ca(2+) signaling. Finally, both of these Sos1 functions were required for early thymocyte proliferation. Whereas transgenic restoration of either the GEF activity or the LAT oligomerization functions of Sos1 alone failed to rescue thymocyte development in Sos1-deficient mice, simultaneous reconstitution of these two signals in the same cell restored normal T cell development. This ability of Sos1 to act both as a RasGEF and as a scaffold to nucleate Grb2-dependent adaptor oligomerization may also occur in other Grb2-dependent pathways, such as those activated by growth factor receptors.

A phospholipase C-γ1-independent, RasGRP1-ERK-dependent pathway drives lymphoproliferative disease in linker for activation of T cells-Y136F mutant mice

Mice expressing a germline mutation in the phospholipase C-γ1-binding site of linker for activation of T cells (LAT) show progressive lymphoproliferation and ultimately die at 4-6 mo age. The hyperactivated T cells in these mice show defective TCR-induced calcium flux but enhanced Ras/ERK activation, which is critical for disease progression. Despite the loss of LAT-dependent phospholipase C-γ1 binding and activation, genetic analysis revealed RasGRP1, and not Sos1 or Sos2, to be the major Ras guanine exchange factor responsible for ERK activation and the lymphoproliferative phenotype in these mice. Analysis of isolated CD4(+) T cells from LAT-Y136F mice showed altered proximal TCR-dependent kinase signaling, which activated a Zap70- and LAT-independent pathway. Moreover, LAT-Y136F T cells showed ERK activation that was dependent on Lck and/or Fyn, protein kinase C-θ, and RasGRP1. These data demonstrate a novel route to Ras activation in vivo in a pathological setting.

Vesicular monoamine transporter-1 (VMAT-1) mRNA and immunoreactive proteins in mouse brain

OBJECTIVE

Vesicular monoamine transporter 1 (VMAT-1) mRNA and protein were examined (1) to determine whether adult mouse brain expresses full-length VMAT-1 mRNA that can be translated to functional transporter protein and (2) to compare immunoreactive VMAT-1 proteins in brain and adrenal.

METHODS

VMAT-1 mRNA was detected in mouse brain with RT-PCR. The cDNA was sequenced, cloned into an expression vector, transfected into COS-1 cells, and cell protein was assayed for VMAT-1 activity. Immunoreactive proteins were examined on western blots probed with four different antibodies to VMAT-1.

RESULTS

Sequencing confirmed identity of the entire coding sequences of VMAT-1 cDNA from mouse medulla oblongata/pons and adrenal to a Gen-Bank reference sequence. Transfection of the brain cDNA into COS-1 cells resulted in transporter activity that was blocked by the VMAT inhibitor reserpine and a proton ionophore, but not by tetrabenazine, which has a high affinity for VMAT-2. Antibodies to either the C- or N- terminus of VMAT-1 detected two proteins (73 and 55 kD) in transfected COS-1 cells. The C-terminal antibodies detected both proteins in extracts of mouse medulla/pons, cortex, hypothalamus, and cerebellum but only the 73 kD protein and higher molecular weight immunoreactive proteins in mouse adrenal and rat PC12 cells, which are positive controls for rodent VMAT-1.

CONCLUSIONS

These findings demonstrate that a functional VMAT-1 mRNA coding sequence is expressed in mouse brain and suggest processing of VMAT-1 protein differs in mouse adrenal and brain.

Congenital hepatic arteriovenous malformation: an unusual cause of neonatal persistent pulmonary hypertension

Congenital hepatic arteriovenous malformations are rare anomalies, which typically present in infancy with congestive heart failure, anemia, and hepatomegaly. Morbidity and mortality is high if the condition is not recognized and treated promptly. Hepatic arteriovenous malformation associated with persistent pulmonary hypertension of the newborn has been reported in two cases in the literature. We report a neonate who was referred for management of persistent pulmonary hypertension and was subsequently diagnosed with a large hepatic arteriovenous malformation. He underwent coil embolization following which pulmonary hypertension resolved.

Massive powder aspiration in a toddler

We report a case of aspiration of calcium carbonate powder by a toddler. Bronchoscopic removal of aspirated contents resulted in favourable outcome.