增强现实导航引导的股骨头坏死核心减压
1China-Japan Friendship School of Clinical Medicine,Peking University, 2Graduate School of Beijing University of Chinese Medicine, 3Department of Orthopedic Surgery, Beijing Key Lab of Immunes-Mediated Inflammatory Disease,China-Japan Friendship Hospital, 4Beijing Normal University, 5State Key Laboratory of Virtual Reality Technology and Systems,Beihang University
Summary
将增强现实技术应用于股骨头坏死的核心减压，实现该外科手术的实时可视化。该方法可有效提高岩心减压的安全性和精度。
Abstract
股骨头坏死（ONFH）是中青年患者中常见的关节疾病，严重负担他们的生活和工作。对于早期ONFH，核心减压手术是一种经典而有效的髋关节保护疗法。在Kirschner线核心减压的传统程序中，仍然存在许多问题，例如X射线暴露，反复穿刺验证以及对正常骨组织的损伤。穿刺过程的盲目性和无法提供实时可视化是这些问题的关键原因。
为了优化这一程序，我们的团队在增强现实（AR）技术的基础上开发了一种术中导航系统。该手术系统可以直观地显示手术区域的解剖结构，并将术前图像和虚拟针头实时渲染到术中视频中。在导航系统的引导下，外科医生可以准确地将Kirschner导线插入目标病变区域，并将附带损伤降至最低。我们用这个系统进行了10例核心减压手术。与传统程序相比，定位和透视的效率大大提高，穿刺的准确性也得到了保证。
Introduction
股骨头坏死（ONFH）是一种常见的致残性疾病，发生在年轻人中1。临床上，有必要根据 X 线、CT 和 MRI 确定 ONFH 的分期，以决定治疗策略（图 1）。对于早期ONFH，通常采用髋关节保留疗法2。核心减压（CD）手术是ONFH最常用的髋关节保留方法之一。已有报道，联合或不联合骨移植的核心减压治疗早期 ONFH 的某些疗效，可避免或延迟后续全髋关节置换术 （THA）3，4，5。然而，在以前的研究中，有或没有骨移植的克罗恩病的成功率报告不同，从64%到95%6，7，8，9。手术技术，特别是钻孔位置的准确性，对于髋关节保留的成功非常重要10。由于穿刺和定位程序的失明，传统的CD技术存在几个问题，例如更多的透视时间，使用Kirschner线反复穿刺以及正常骨组织11，12的损伤。
近年来，增强现实（AR）辅助方法已在骨科手术中引入13。AR技术可以直观地显示手术场的解剖结构，指导外科医生规划手术程序，从而降低手术难度。AR技术在椎弓根螺钉植入和关节关节置换术中的应用已有14，15，16，17的报道。在这项研究中，我们的目标是将AR技术应用于CD程序，并验证其在临床实践中的安全性，准确性和可行性。
系统硬件组件
基于AR的导航手术系统的主要部件包括：（1）安装在手术区域正上方的深度摄像头（图2A）;视频从中拍摄并发送回工作站，以便与成像数据进行注册和协作。（2）穿刺装置（图2B）和非侵入性体表标记框架（图2C），均带有被动红外反射器。红外设备可以捕获标记球的特殊反射涂层（图3），以实现对手术区域内手术设备的精确跟踪。（3）红外定位装置（图2D）负责跟踪手术区域的标记物，高精度匹配体表标记框和穿刺装置（图4）。（4）主机系统（图2E）是一个64位工作站，安装了自主研发的AR辅助骨科手术系统。髋关节和股骨头穿刺手术的增强现实显示可以在其辅助下完成。
Protocol
本研究经中日友好医院伦理委员会批准（批准号：2021-12-K04）。以下所有步骤均按照标准化程序进行，以避免对患者和外科医生造成伤害。本研究获得了患者的知情同意。外科医生必须熟练掌握传统的核心减压程序，以确保在导航不准确或其他意外情况下，手术可以以传统方式进行。 1. ONFH的术前诊断和分级 识别具有ONFH临床症状的患者;典型症状，例如腹?…
Representative Results
操作特点手术导航系统应用于9例患者的连续10个髋关节。手术平均总定位时间为10.1分钟（中位数9.5分钟，范围8.0-14.0分钟）。平均C-ARM透视率为5.5倍（中位数为5.5倍，范围为4-8倍）。穿刺精度的平均误差为1.61 mm（中位数为1.2 mm，范围为-5.76-19.73 mm; 表 1）。结果表明，与传统程序相比，定位时间和透视时间明显缩短。 临床结局评估入…
Discussion
虽然THA近年来发展迅速，成为ONFH的有效终极方法，但髋关节保存疗法在治疗早期ONFH18，19中仍然起着重要作用。CD是一种基础有效的髋关节保留手术，它可以释放髋关节疼痛，延缓股骨头塌陷20的发生。局灶性坏死的穿刺定位是克罗恩病的关键程序，因为它决定了手术的成功或失败。然而，传统的穿刺定位方法仍然含有一些盲点，可能?…
Declarações
The authors have nothing to disclose.
Acknowledgements
本研究由北京市自然科学基金（7202183）、国家自然科学基金（81972107）和北京市科委（D171100003217001）资助。
Materials
| AR-assisted Orthopedic Surgery System | Self development | None | An operating software that implements AR for orthopedic surgery |
| Depth camera | Stereolabs | ZED depth camera(ZED mini) | shoot video and sent back to the workstation. |
| Image processing software | Adobe Systems Incorporated | Adobe Photoshop CS6 | Image processing software |
| Infrared positioning device | Northern Digital Inc. | NDI Polaris Spectra optical tracking device | Tracking markers in the surgical area. |
| Puncture device | Stryker | Stryker System 7 Cordless driver and Sabo | Insert kirschner wire into the necrotic area. |
Referências
- Cohen-Rosenblum, A., Cui, Q. Osteonecrosis of the femoral head. Orthopedic Clinics of North America. 50 (2), 139-149 (2019).
- Migliorini, F., et al. Prognostic factors in the management of osteonecrosis of the femoral head: A systematic review. The Surgeon: journal of the Royal Colleges of surgeons of Edinburgh and Ireland. (21), 00199 (2022).
- Mont, M. A., Jones, L. C., Hungerford, D. S. Nontraumatic osteonecrosis of the femoral head: ten years later. The Journal of Bone and Joint Surgery. American Volume. 88 (5), 1117-1132 (2006).
- Wang, L., Tian, X., Li, K., Liu, C. Combination use of core decompression for osteonecrosis of the femoral head: A systematic review and meta-analysis using Forest and Funnel Plots. Computational and Mathematical Methods in Medicine. , 1284149 (2021).
- Hua, K. C., et al. The efficacy and safety of core decompression for the treatment of femoral head necrosis: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 14 (1), 306 (2019).
- Ganz, R., Krushell, R. J., Jakob, R. P., Küffer, J. The antishock pelvic clamp. Clinical Orthopaedics and Related Research. 267, 71-78 (1991).
- Yoshikawa, K., et al. Training with hybrid assistive limb for walking function after total knee arthroplasty. Journal of Orthopaedic Surgery and Research. 13 (1), 163 (2018).
- Wu, C. T., Yen, S. H., Lin, P. C., Wang, J. W. Long-term outcomes of Phemister bone grafting for patients with non-traumatic osteonecrosis of the femoral head. International Orthopaedics. 43 (3), 579-587 (2019).
- Mont, M. A., Marulanda, G. A., Seyler, T. M., Plate, J. F., Delanois, R. E. Core decompression and nonvascularized bone grafting for the treatment of early stage osteonecrosis of the femoral head. Instructional Course Lectures. 56, 213-220 (2007).
- Wang, W., et al. Patient-specific core decompression surgery for early-stage ischemic necrosis of the femoral head. PLoS One. 12 (5), 0175366 (2017).
- Hoffmann, M. F., Khoriaty, J. D., Sietsema, D. L., Jones, C. B. Outcome of intramedullary nailing treatment for intertrochanteric femoral fractures. Journal of Orthopaedic Surgery and Research. 14 (1), 360 (2019).
- Dennler, C., et al. Augmented reality-based navigation increases precision of pedicle screw insertion. Journal of Orthopaedic Surgery and Research. 15 (1), 174 (2020).
- Yonezawa, H., et al. Low-grade myofibroblastic sarcoma of the levator scapulae muscle: a case report and literature review. BMC Musculoskeletal Disorders. 21 (1), 836 (2020).
- Tsukada, S., et al. Augmented reality- vs accelerometer-based portable navigation system to improve the accuracy of acetabular cup placement during total hip arthroplasty in the lateral decubitus position. The Journal of Arthroplasty. 37 (3), 488-494 (2021).
- Raymond, J., et al. Pharmacogenetics of direct oral anticoagulants: a systematic review. Journal of Personalized Medicine. 11 (1), 37 (2021).
- Bhatt, F. R., et al. Augmented reality-assisted spine surgery: an early experience demonstrating safety and accuracy with 218 screws. Global Spine Journal. , (2022).
- Weiss, H. R., Nan, X., Potts, M. A. Is there an indication for surgery in patients with spinal deformities? – A critical appraisal. The South African Journal of Physiotherapy. 77 (2), 1569 (2021).
- Boontanapibul, K., Amanatullah, D. F., Huddleston, J. I., Maloney, W. J., Goodman, S. B. Outcomes of cemented total knee arthroplasty for secondary osteonecrosis of the knee. The Journal of Arthroplasty. 36 (2), 550-559 (2021).
- Bakircioglu, S., Atilla, B. Hip preserving procedures for osteonecrosis of the femoral head after collapse. J Clin Orthop Trauma. 23, 101636 (2021).
- Ma, H. Y., et al. Core decompression with local administration of zoledronate and enriched bone marrow mononuclear cells for treatment of non-traumatic osteonecrosis of femoral head. Orthopaedic Surgery. 13 (6), 1843-1852 (2021).
- Hu, L., et al. Comparison of intramedullary nailing and plate fixation in distal tibial fractures with metaphyseal damage: a meta-analysis of randomized controlled trials. Journal of Orthopaedic Surgery and Research. 14 (1), 30 (2019).
- Pierannunzii, L. Endoscopic and arthroscopic assistance in femoral head core decompression. Arthroscopy Techniques. 1 (2), 225-230 (2012).
- Salas, A. P., et al. Hip arthroscopy and core decompression for avascular necrosis of the femoral head using a specific aiming guide: a step-by-step surgical technique. Arthroscopy Techniques. 10 (12), 2775-2782 (2021).
- Beer, A. J., Dijkgraaf, I. Editorial European journal of nuclear medicine and molecular imaging. European Journal of Nuclear Medicine and Molecular Imaging. 44 (2), 284-285 (2017).
- Negrillo-Cárdenas, J., Jiménez-Pérez, J. R., Feito, F. R. The role of virtual and augmented reality in orthopedic trauma surgery: From diagnosis to rehabilitation. Computer Methods and Programs in Biomedicine. 191, 105407 (2020).
- Brookes, M. J., et al. Surgical Advances in Osteosarcoma. Cancers. 13 (3), 388 (2021).
- Cho, H. S., et al. Can augmented reality be helpful in pelvic bone cancer surgery? an in vitro study. Clinical Orthopaedics and Related Research. 476 (9), 1719-1725 (2018).
Tags
Citar este artigo
Wang, Q., Wang, Q., Ding, R., Yao, Y., Pan, J., Wang, W. Augmented Reality Navigation-Guided Core Decompression for Osteonecrosis of Femoral Head. J. Vis. Exp. (182), e63806, doi:10.3791/63806 (2022).