Name: augmented reality navigation-guided core decompression for osteonecrosis of femoral head
Uploaded: 2022-04-12T14:00:00
Description: Watch this Scientific Journal Video about Augmented Reality Navigation-Guided Core Decompression for Osteonecrosis of Femoral Head at JoVE.com

This work was supported by Beijing Natural Science Foundation(7202183), National Natural Science Foundation of China(81972107), and Beijing Municipal Science and Technology Commission(D171100003217001).

This study was approved by the ethics committee of the China-Japan Friendship Hospital (approval number: 2021-12-K04). All of the following steps were performed according to standardized procedures to avoid injury to the patients and the surgeons. Informed patient consent was obtained for this study. The surgeon must be skilled in conventional core decompression procedures to ensure that the surgery can be performed in a traditional way in case of inaccurate navigation or other unexpected situations.
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<ol>
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Although THA has developed rapidly in recent years and become an effective ultimate method for ONFH, hip preservation therapy still plays an important role in treating early-stage ONFH18,19. CD is a basic and effective hip preservation surgery, which can release hip pain and delay the development of femoral head collapse20. The puncture positioning of the focal necrosis is the crucial procedure of CD, as it determines the success or failur...

Osteonecrosis of the femoral head (ONFH) is a common disabling disease occurring in young adults1. Clinically, it is necessary to determine the staging of ONFH based on X-ray, CT, and MRI to decide the treatment strategy (Figure 1). For early-stage ONFH, hip preservation therapy is usually adopted2. Core decompression (CD) surgery is one of the most frequently used hip preservation methods for ONFH. Certain curative effects of core decompression with or without bone grafting in treating early-stage ONFH have been reported, which can avoid or delay subsequent total hip arthroplasty (THA) for a long time3,4,5. However, the success rate of CD with or without bone grafting was reported differently among previous studies, from 64% to 95%6,7,8,9. The surgical technique, especially the accuracy of drilling position, is important for the success of hip preservation10. Due to the blindness of the puncture and positioning procedure, the traditional techniques of CD have several problems, such as more fluoroscopy time, repeated puncture using Kirschner wire, and injury of normal bone tissue11,12.
In recent years, the augmented reality (AR)-assisted method has been introduced in orthopedic surgery13. The AR technique can visually show the anatomy of the surgical field, guide the surgeons in planning the operating procedure, and consequently reduce the difficulty of the operation. The applications of the AR technique in pedicle screw implantation and joint arthroplasty surgery have been reported earlier14,15,16,17. In this study, we aim to apply the AR technique to the CD procedure and verify its safety, accuracy, and feasibility in clinical practice.
System hardware components 
The main components of the AR-based navigation surgical system include the following: (1) A depth camera (Figure 2A) installed directly above the surgical area; the video is shot from this and sent back to the workstation for registration and cooperation with the imaging data. (2) A puncture device (Figure 2B) and a non-invasive body surface marking frame (Figure 2C), both with passive infrared reflectors. A special reflective coating of marking balls (Figure 3) can be captured by infrared equipment to achieve accurate tracking of surgical equipment in the surgical area. (3) An infrared positioning device (Figure 2D) is responsible for tracking markers in the surgical area, matching the body surface marking frame and puncture device with high accuracy (Figure 4). (4) The host system (Figure 2E) is a 64-bit workstation, installed with the independently developed AR-assisted orthopedic surgery system. Augmented reality display of hip joint and femoral head puncture operation can be completed with its assistance.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>AR-assisted Orthopedic Surgery System</td>
			<td>Self development</td>
			<td>None</td>
			<td>An operating software that implements AR for orthopedic surgery</td>
		</tr>
		<tr>
			<td>Depth camera</td>
			<td>Stereolabs</td>
			<td>ZED depth camera(ZED mini)</td>
			<td>shoot video and sent back to the workstation.</td>
		</tr>
		<tr>
			<td>Image processing software</td>
			<td>Adobe Systems Incorporated</td>
			<td>Adobe Photoshop CS6</td>
			<td>Image processing software</td>
		</tr>
		<tr>
			<td>Infrared positioning device</td>
			<td>Northern Digital Inc.</td>
			<td>NDI Polaris Spectra optical tracking device</td>
			<td>Tracking markers in the surgical area.</td>
		</tr>
		<tr>
			<td>Puncture device</td>
			<td>Stryker</td>
			<td>Stryker System 7 Cordless driver and Sabo</td>
			<td>Insert kirschner wire into the necrotic area.</td>
		</tr>
	</tbody>
</table>

augmented reality navigation-guided core decompression for osteonecrosis of femoral head

Osteonecrosis of the femoral head (ONFH) is a common joint disease in young and middle-aged patients, which seriously burdens their lives and work. For early-stage ONFH, core decompression surgery is a classical and effective hip preservation therapy. In traditional procedures of core decompression with Kirschner wire, there are still many problems such as X-ray exposure, repeated puncture verification, and damage to normal bone tissue. The blindness of the puncture process and the inability to provide real-time visualization are crucial reasons for these problems.
To optimize this procedure, our team developed an intraoperative navigation system on the basis of augmented reality (AR) technology. This surgical system can intuitively display the anatomy of the surgical areas and render preoperative images and virtual needles to intraoperative video in real-time. With the guide of the navigation system, surgeons can accurately insert Kirschner wires into the targeted lesion area and minimize the collateral damage. We conducted 10 cases of core decompression surgery with this system. The efficiency of positioning and fluoroscopy is greatly improved compared to the traditional procedures, and the accuracy of puncture is also guaranteed.

Operation characteristics 
The surgical navigation system was applied in continuative 10 hips of nine patients. The average total positioning time of the surgery was 10.1 min (median 9.5 min, range 8.0-14.0 min). The mean C-ARM fluoroscopies was 5.5 times (median 5.5 times, range 4-8 times). The mean error of puncture accuracy was 1.61 mm (median 1.2 mm, range -5.76-19.73 mm; Table 1). The results show that the positioning time and fluoroscopy times are obviously shortened compared ...

Watch this Scientific Journal Video about Augmented Reality Navigation-Guided Core Decompression for Osteonecrosis of Femoral Head at JoVE.com

Augmented Reality Navigation-Guided Core Decompression for Osteonecrosis of Femoral Head

Augmented reality technology was applied to core decompression for osteonecrosis of the femoral head to realize real-time visualization of this surgical procedure. This method can effectively improve the safety and precision of core decompression.

Osteonecrosis of the femoral head (ONFH) is a common joint disease in young and middle-aged patients, which seriously burdens their lives and work. For ...

Our system can improve the success rate and the efficiency in core decompression surgery for femoral head necrosis. It also significantly reduces the intraoperative positioning time and the fluoroscope source. With VR technology, we can utilize the puncture process, reduce the difficulty of the operation, and it cause less additional damage to the patient than traditional surgical results.The system can be extended to other orthopedic surgery involving puncture procedures. It has been used to get percutaneous endoscopic transforaminal discectomy procedure. This system is specially designed for the early osteonecrosis of the femoral head, since traditional surgery is not precise enough, and may bring more secondary damage to the patient, such as normal tissue damage or excessive radiation.The protocol should be and the operation carefully observed to understand the principles and the steps of the system, to minimize the risk indication. And the technical points of core decompression of the femoral head will prove helpful for successful excursion. Begin by dividing the planned surgical frontal area into upper and lower levels.This spatial information will be automatically entered into the software system. Allocate every level with 10 matching points and divide it into three equal parts with two parts having three points each, and the remaining part having four points. Ask the assistant to place the noninvasive body surface marking frame according to the points.Once done, click on match. The system's special image for registration will be automatically super imposed on the marking frame. Move the puncture device randomly in the surgical area to detect the matching degree of virtual needle and tracking delay.In the operating room, ask the patient to lie down in a supine position and fix the lower limb of the affected side. Prepare the surgical site with iodine and 75%alcohol. Move the C-arm fluoroscope to the side of the operating table and position the source above the hip joint.Align the source with the depth camera and record the position of the surgical table as position one. In the AR-assisted orthopedic surgery system, click file front x-ray image and select image one. The system will automatically identify the marking frame and superimpose this image to the hip joint in the surgical video.Using the AR display of the x-ray image and based on the real time video, plan the puncture path. Stand on the affected side for performing the procedure, hold the puncture device, and determine the best insertion angle. Mark the insertion point on the skin surface, guided by the virtual Kirschner wire and the x-ray image of the hip joint in the surgical video.Using a Kirschner wire, pierce through the insertion point. Observe the insertion depth and angle in the video, and adjust it timely. When the virtual needle has reached the target area of necrosis, stop the puncture process and retain the screenshot as image two for subsequent puncture accuracy evaluation.After the puncture, pull out the drill, leaving the Kirschner wires in the bone temporarily. Move the operating table to position one for the second fluoroscopy to verify the actual puncture condition of the Kirschner wire. Record the image file.Puncture is successful when the location of the Kirschner wire meets all of the surgeon's requirements. Then, use the Lancet to cut the skin around the needle and separate every level of soft tissue until the subtrochanter bone is exposed to approximately a depth of three centimeters. Drill into the necrotic area along the Kirschner wire with a five millimeter trephine to complete the subsequent operations.After finishing all the procedures, close the skin with three oh silk thread and cover it with sterile dressing. The surgical navigation system was applied in continuative ten hips of nine patients. With an average total positioning time of 10.1 minutes during the surgery, the mean C-arm fluoroscopies were 5.5 times.The mean error of puncture accuracy was 1.61 millimeters. By the hips evaluated, two hips were in ARCO I stage, four hips were in ARCO IIA stage, and four in ARCO IIB stage. The mean preoperative VAS score was six, and the mean postoperative score was 3.75.The average preoperative Harris score was 77.5, and the mean postoperative score was 85.5. No postoperative complications such as infection, hematoma, or nerve damage were found. It is also possible to combine the procedure with CT three dimensional reconstruction technology so that the puncture can be realized from a three dimensional perspective, which is our future work.We provide an innovative idea of combining AI technology and orthopedic surgery. This idea can also be used to improve the precision of other orthopedic operations in the future.

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