计算机辅助导航技术在骨科中应用

,计算机辅助导航技术在骨科应用,既往骨科手术：术前看片、计划、手术,现在骨科手术：术前读片+手术设计+精确=精准医疗,未来手术？,第一PPT模板网，PPT素材下载/sucai/,人,机器人,机械,融合,广义导航,基本概念,计算机辅助骨科导航手术(computer assistedo rthopedics surgery，CAOS)即利用各种影象设备如CT、MRI、PET、DSA、US等结合导航系统，对人体骨骼解剖结构及手术器械进行显示和定位，通过计算机制订手术计划，在术中进行操作干预的一项技术。最早应用于神经外科领域的立体定位，肿瘤切除化疗等。其最大的优势是：简化了手术操作，缩短了手术时间，减少了手术创伤，减弱了术中放射线的照射，使骨科手术变的更安全、更准确、更微创。,骨科计算机辅助导航技术简史,1991,1992,1995,Roberts声波数字化仪跟踪手术器械应用于神经外科手术,日本的Wanatabe和美国的Pell相继发明了遥控机械臂定位系统，可以不受瞄准线约束。但因其体积过大，使医生的操作受限.,1992年，使用红外线跟踪技术的影像导航系统在美国开始应用于临床。这是世界上首台光学手术导航系统，由于其精度较高，所以成为目前市场上的主流产品,1995年，Gunkel推出了电磁感应型导航系统，但由于手术室各种金属器械及仪器都会影响电磁场，从而影响其精度，所以未能很好推广,1999年首台完全针对骨科的手术导航系统进入市场。X线透视和红外线跟踪技术、计算机定点手术技术的结合提供了一种新颖的术中影像导航的方法,1999,1986,计算机辅助导航系统组成及工作原理,Image,Action,Navigation,Basic principle,基本设备,不同的导航系统有不同的设备，但其中最基本的设备是一致的。大概有以下三种分类：（1）SO（surgical object）:手术操作实体，在骨科领域，主要是骨骼及相关联的组织结构。（2）VO（virtual object）成像设备。现在常用的CT，X线，MRI ，PET，DSA 等影象设备，可以实时准确地提供图象及数据。（3）NAV（navigator）：导航仪。即在SO 和VO 之间的连接装置。获取操作器械在人体的定位和方向。,Tool Set Spine,4 chisels Pelvis Fragment Calibration Pointer VK,同时可跟随9件器械,Tool Set Pelvis,Tool Set Hip Prosthetics,SurgiGATE Components,easy setup, mobile, only 80 x 80 cm each,Shield,Infrared,Camera,LED,Surgical instruments are tracked by a camera,High precision long and compact tools Many objects tracked multiple tools and bones Large Field of View (FOV) needed for C-Arm and other applications,Best tracking technology,三个条件,1校准（calibration）：对于描述骨骼的几何形状校准是必需的。即在操作器械上安装跟踪器，是提高图象配准精度及定位精度的第一步。2配准(registration)：其目的是在VO和术前图象的基础上对手术器械定位，提供相对应的定位显象。3参照(reference)：动态参照系统（dynamic reference bases,DRB）可以弥补由于导航仪和骨骼位置的移动带来的误差。,Automatic compensation of patient and camera motion.,Reference coordinate system is attached anywhere on patient.,Referencing,Define Landmark in Image,Find Landmark on Patient,Matching,The transformation between the patient world and the CT image world is found,Methods: Paired-Point Matching Surface Matching,Digitization of points,Matching methods,Image,Patient,Surgical Navigation,工作模式,医生通过术前或术中x线CTMRI对人体手术部位进行显示，定位，然后规划模拟，术中手持装有跟踪器的操作器械对患者实施操作，手术工具的空间立体定位及瞄准过程均在跟踪器的实时控制之下，跟踪器能够精确地给出术中解剖部位与多模图像之间的位置关系，经过相应坐标转换(平移、旋转等)的配准过程控制手术器械到达要求的部位，从而实施相应的手术操作。,Reference coordinate system is attached anywhere on patient.,Step 1: Placement of the Reference Base,Step 2: Shoot images,Image stored in the computer,Action,Image,Step 3: Navigate,OR Setup,基本类型,CT依赖的导航系统,基于X线透视图像导航系统,三维X线透视导航系统（Iso-C）,非图像依赖导航系统,4,1,2,3,1、CT依赖的导航系统,最早应用于神经外科，目前在骨科应用比较广泛，最早应用于脊柱椎弓根螺钉固定系统。目前典型的系统有DiGioia等开发的Hipnav系统，Langlotz等开发的脊柱导航系统。术前将获得CT扫描图像，并将患者的模拟仿真数据导人计算机中；术中，通过定位跟踪器获得手术工具与解剖结构之间的空间位置关系，并与术前的CT图像进行配准，在计算机中实时显示手术工具在仿真模型中的位置关系，以指导医生实施手术操作。配准是其最关键的技术，有过去的点匹配和现在的面匹配。该导航最大的优点是可以获得良好的三维图象，有利于术前计划和模拟。其缺点是，需要严格的配准和参照才能获得更好的图象，而且无法实时显象，图象无法更新。，现在已经广泛应用于全髋置换和全膝置换，DHS，锁式髓针，十字韧带重建等。,2、基于X线透视图像导航系统,C臂现在已经成为骨科手术的基本设备。其最大的特点是实时迅速的显象，无须术前模拟。在手术器械上和传感器上安装两套光发射二级管（LEDS）通过显示屏来配准。其配准过程包括X线的建模和补偿由于C臂转动带来的图象变形。示踪器安放在C臂上，可以计算控制功能参数，最先被ofsteterr使用。通过C臂的转动获得图象，是一对多的图象，相当于使用了多个C臂，这是2维显象的一个优势。另一个优势是图象可以更新，随时可以获得最新的图象，有利于复杂骨折的复位。现在2维依赖的导航已经广泛应用于关节置换、锁式髓针，DHS，十字韧带重建中。,3、三维X线依赖的导航,1999年，3维依赖的导航开始应用于临床 （德国西门子公司）。其配置了特殊的发动机和旋转程序来实现高清晰的围绕骨骼旋转轨迹的图象。大约可以旋转190度。可以达到CT一样的显象效果。每一次旋转可以获得50200套2维图象。把骨骼放在C臂中心，通过图象数据综合，来获得高分解的3维图象数据，其中容量扫描的准确性是成功的关键。3维X线依赖的导航还可以实时显象，所以前景非常广阔，是计算机导航的发展方向。,非图像依赖导航系统,这种导航没有具体的图象，而是通过示踪系统作用于不同的骨性结构和参照标记建立起来的。最早应用于前交叉韧带的重建。其最大的特色是旋转程序，严格的人体机械定位和数据优化来计算运动参数，决定特殊关节的运动特征。最大的优点是骨骼变形技术。必须建立骨骼解剖模型数据库，需要大量的高分解的容积图象、数据参数和表面形态，以及尸体模型。在术中通过个解剖区的点数据对应来达到导航作用。要作到微创很难，必须借助2维和3维图象来获得所有必要的解剖标记。因此适合于那些解剖结构暴露比较充分的手术，典型的如ACL重建，全膝关节置换，全髋关节置换等。Dessenne等于1995年最早应用于交叉韧带重建。,临床应用,脊柱手术,最早在实验室应用于椎弓根螺钉系统，由于设备技术的限制，以前仅限于腰椎的应用，现已拓展到颈椎和胸椎。最常用的导航是依赖CT的导航。如椎弓根螺钉的置入，术前通过CT对手术部位脊柱进行三维重建，制定手术方案，然后在脊柱上确定36个术中可分辨的标记点。术中通过带有动态参考系统的操作器械进行点对点匹配。当二者完全匹配时再钻孔置入螺钉。由于CT良好的三维图象，最常用于颈椎和胸椎上段。在计算机导航系统引导下的颈椎离体实验中，C1、2经关节螺钉与经椎弓螺钉的使用都是安全的,而且有很高的精确性以依赖X 线的导航：术中通过X线获得图象，然后通过计算机工作中心设计引导下置入椎弓根螺钉。不需要术前模拟，而且术中图象可以更新，但是无法得到良好的三维图象。所以更广泛应用于腰椎和下胸椎，不过也有人开始应用于颈椎和上胸椎。目前的脊柱外科的研究热点是如何进行经皮螺钉植入和脊柱内窥镜技术。,Advanced pre-op planning,Current positionTarget position,Guidance,Future penetrationsCurrent position,Realtime Trajectory,Kotani等回顾性分析 32 例（416 根椎弓根螺钉）脊柱侧弯患者,Rajasekaran 进行了一项 31 例（242 颗螺钉）胸椎骨折患者的随机临床研究,创伤骨科,随着微创的要求变高和X线的局限性，计算机导航在在创伤骨科的应用将更加广泛，主要集中在骨盆骨折和长骨骨折。骨盆骨折有些位置比较深而且移位比较小，X片不容易发现，而且手术入路比较困难，很难达到坚强固定。用以CT依赖的导航则变的简单方便，将参考架固定于病人骨折肢体表面，术前进行CT扫描，手术模拟入路位置术中导航仪帮助引导，配准，经皮即可到达理想部位，达到坚强准确固定骨折。锁式髓钉的应用。主要应用与远端锁钉的固定，关键有两步：首先准确的控制锁钉入孔，在髓针进入髓腔以后，远端的锁钉必须准确。其次术中钻孔需要跟踪实时显象DHS的应用。首先复位用克氏针临时固定，然后将动态参考系统固定在斯氏针上插入股骨近端。C臂照射，将图象传到投射计算机工作站，通过设计轨迹和引导进行螺钉置入。,Insertion of IM Nails Fragment Reduction K-Wire Placement Near Joint Surgery Distal Locking of IM Nails,ApplicationsTrauma,Realtime mode,Fragment motion,关节外科,包括髋关节置换（TKA）和膝关节置换(THA)。髋关节置换的应用比较早。最主要的问题是确定假体的位置和轴线。计算机辅助骨科技术系统可以在术前用CT或X线对关节进行扫描及三维重建，设计假体的位置、大小，通过计算机计算出力学轴线和截骨平面，模拟匹配，模拟关节活动。术中通过导航系统指导医生在合适的位置安放假体。Leenders的一项临床随机研究表明CAOS对于假体安放位置要优于传统手术。减少了全髋置换中由于位置不合适而造成的假体脱位。,optimal implantoptimal placement,Cup Planning,Execution Phase,Execution Phase,骨肿瘤,如何能够精确的切除靶区肿瘤组织，进行化疗和放疗，这是医学界的一大难题。计算机导航在此方面优势明显。CAOS通过CT定位系统能够对高度不规则肿瘤制订精确的三维立体显象，提供肿瘤的实际形状，能够严格的区分肿瘤与周围的正常组织。以达到准确切除和最佳照射角度和放射野来避开重要组织器官，并使放射计划的剂量分布更为精确合理。它不仅对放射治疗的计划设计和照射质量的提高有明显作用，而且将显著提高存某些肿瘤的控制率和病人生存率.,计算机辅助导航技术存在的问题,减少患者及医务人员的辐射暴露,增加了手术的安全性减少手术的风险,减少手术时间,患者体位必须严格固定不能移动,术者需要 严格培训，学习曲线长,设备昂贵，增加患者手术费用,发展趋势,更简单的注册,多种导航方法融合，图像注册更准确,与导航设备相配套的手术室建立，影像设备更加合理布局，更加便捷的图像数据传输,各种手术机器人结合导航设备引用于现代骨科手术,极大的节约医疗卫生成本，更加充分利用专家资源,数字化手术室建立,手术机器人应用,远程医疗发展,计算机辅助导航系统已经使骨科手术迅速、安全、准确。随着计算机和电脑图像处理系统的发展，该技术将会辅助医生完成更多骨科疑难与复杂手术。 计算机辅助导航技术的发展必将日益高科技化，应用领域也将多样化。,Thank You!,,How do I incorporate my logo to a slide that will apply to all the other slides? 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