Name: a teleoperated robotic system-assisted percutaneous transiliac-transsacral screw fixation technique
Uploaded: 2023-01-06T14:00:00
Description: Watch this Scientific Journal Video about A Teleoperated Robotic System-Assisted Percutaneous Transiliac-Transsacral Screw Fixation Technique at JoVE.com

该机器人技术的应用得到了华中科技大学同济医学院同济医院伦理委员会的批准，符合2013年修订的1975年《赫尔辛基宣言》。
1.术前计划
<ol><li>通过插入两个Schanz针，使用透视板底座（见 材料表）将尸体骨盆固定在仰卧位。在仰卧位，将两个髂后上棘同时放在平板上，腰椎平行于地板。 注：捐赠的尸体由华中科技大学同济医学院解剖学与研究系?...

<ol>
	<li>Bargar, W. L., Bauer, A., B&#246;rner, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Primary+and+revision+total+hip+replacement+using+the+Robodoc+system.">Primary and revision total hip replacement using the Robodoc system.</a> Clinical Orthopaedics and Related Research. (354), 82-91 (1998).</li><li>Jacofsky, D. J., Allen, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotics+in+arthroplasty:+A+comprehensive+review.">Robotics in arthroplasty: A comprehensive review.</a> Journal of Arthroplasty. 31 (10), 2353-2363 (2016).</li><li>Perfetti, D. C., Kisinde, S., Rogers-LaVanne, M. P., Satin, A. M., Lieberman, I. 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J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+percutaneous+cannulated+screw+fixation+of+femoral+neck+fractures:+Preliminary+clinical+results.">Robot-assisted percutaneous cannulated screw fixation of femoral neck fractures: Preliminary clinical results.</a> Orthopaedic Surgery. 11 (1), 34-41 (2019).</li><li>Lei, H., Sheng, L., Manyi, W., Junqiang, W., Wenyong, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+biplanar+robot+navigation+system+for+the+distal+locking+of+intramedullary+nails.">A biplanar robot navigation system for the distal locking of intramedullary nails.</a> International Journal of Medical Robotics and Computer Assisted Surgery. 6 (1), 61-65 (2010).</li><li>Oszwald, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotized+access+to+the+medullary+cavity+for+intramedullary+nailing+of+the+femur.">Robotized access to the medullary cavity for intramedullary nailing of the femur.</a> Technology and Health Care. 18 (3), 173-180 (2010).</li><li>Hung, S. S., Lee, M. Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Functional+assessment+of+a+surgical+robot+for+reduction+of+lower+limb+fractures.">Functional assessment of a surgical robot for reduction of lower limb fractures.</a> International Journal of Medical Robotics and Computer Assisted Surgery. 6 (4), 413-421 (2010).</li><li>Dagnino, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Image-guided+surgical+robotic+system+for+percutaneous+reduction+of+joint+fractures.">Image-guided surgical robotic system for percutaneous reduction of joint fractures.</a> Annual Review of Biomedical Engineering. 45 (11), 2648-2662 (2017).</li><li>Garcia, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Trauma+Pod:+A+semi-automated+telerobotic+surgical+system.">Trauma Pod: A semi-automated telerobotic surgical system.</a> International Journal of Medical Robotics and Computer Assisted Surgery. 5 (2), 136-146 (2009).</li><li>Gaensslen, A., M&#252;ller, M., Nerlich, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Acetabular Fractures: Diagnosis, Indications, Treatment Strategies. , (2017).</li><li>LBR Med: A collaborative robot for medical applications. KUKA Available from: <a target="_blank" href="https://www.kuka.com/en-cn/industries/health-care/kuka-medical-robotics/lbr-med">https://www.kuka.com/en-cn/industries/health-care/kuka-medical-robotics/lbr-med</a> (2023)</li><li>Gras, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=2D-fluoroscopic+navigated+percutaneous+screw+fixation+of+pelvic+ring+injuries--A+case+series.">2D-fluoroscopic navigated percutaneous screw fixation of pelvic ring injuries--A case series.</a> BMC Musculoskeletal Disorders. 11, 153 (2010).</li><li>Innocenti, B., Bori, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotics+in+orthopaedic+surgery:+Why,+what+and+how.">Robotics in orthopaedic surgery: Why, what and how.</a> Archives of Orthopaedic and Trauma Surgery. 141 (12), 2035-2042 (2021).</li><li>Chen, A. F., Kazarian, G. S., Jessop, G. W., Makhdom, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+technology+in+orthopaedic+surgery.">Robotic technology in orthopaedic surgery.</a> Journal of Bone and Joint Surgery. 100 (22), 1984-1992 (2018).</li><li>D'Souza, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+spine+surgery:+History,+efficacy,+cost,+and+future+trends.">Robotic-assisted spine surgery: History, efficacy, cost, and future trends.</a> Robotic surgery. 6, 9-23 (2019).</li><li>Dagnino, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Navigation+system+for+robot-assisted+intra-articular+lower-limb+fracture+surgery.">Navigation system for robot-assisted intra-articular lower-limb fracture surgery.</a> International Journal for Computer Assisted Radiology and Surgery. 11 (10), 1831-1843 (2016).</li><li>F&#252;chtmeier, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reduction+of+femoral+shaft+fractures+in+vitro+by+a+new+developed+reduction+robot+system+'RepoRobo.">Reduction of femoral shaft fractures in vitro by a new developed reduction robot system 'RepoRobo.</a> Injury. 35, 113-119 (2004).</li><li>Schuijt, H. J., Hundersmarck, D., Smeeing, D. P. J., vander Velde, D., Weaver, M. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+fracture+fixation+in+orthopaedic+trauma+surgery:+A+systematic+review.">Robot-assisted fracture fixation in orthopaedic trauma surgery: A systematic review.</a> OTA International. 4 (4), 153 (2021).</li><li>Wang, J. Q., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+sacroiliac+screw+placement:+A+prospective+randomized+comparison+of+robot-assisted+navigation+procedures+with+a+conventional+technique.">Percutaneous sacroiliac screw placement: A prospective randomized comparison of robot-assisted navigation procedures with a conventional technique.</a> Chinese Medical Journal. 130 (21), 2527-2534 (2017).</li><li>Zhu, Z. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=TiRobot-assisted+percutaneous+cannulated+screw+fixation+in+the+treatment+of+femoral+neck+fractures:+A+minimum+2-year+follow-up+of+50+patients.">TiRobot-assisted percutaneous cannulated screw fixation in the treatment of femoral neck fractures: A minimum 2-year follow-up of 50 patients.</a> Orthopaedic Surgery. 13 (1), 244-252 (2021).</li><li>Gardner, M. J., Routt, M. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transiliac-transsacral+screws+for+posterior+pelvic+stabilization.">Transiliac-transsacral screws for posterior pelvic stabilization.</a> Journal of Orthopaedic Trauma. 25 (6), 378-384 (2011).</li><li>Verhey, J. T., Haglin, J. M., Verhey, E. M., Hartigan, D. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Virtual,+augmented,+and+mixed+reality+applications+in+orthopedic+surgery.">Virtual, augmented, and mixed reality applications in orthopedic surgery.</a> International Journal of Medical Robotics and Computer Assisted Surgery. 16 (2), 2067 (2020).</li></ol>

无论机器人的类型如何，机器人在骨科中的核心应用都为外科医生提供了提高手术准确性的先进工具。然而，手术机器人的出现并不能替代医生。进行机器人手术的外科医生可能在手术室，也可能不在手术室。手术机器人一般包括计算机控制系统、负责手术的机械臂和负责跟踪的导航系统。根据机器人和外科医生的交互方式，机器人系统分为三类，包括半主动、被动和主动系统14</sup...

骨科手术中使用的第一个机器人应用是1992年采用的ROBODOC系统1。从那时起，机器人辅助手术系统迅速发展。机器人辅助手术通过增强外科医生恢复肢体对齐和关节生理运动学的能力来改善关节成形术2.在脊柱手术中，使用机器人放置椎弓根螺钉是安全准确的;它还减少了外科医生的辐射暴露3。然而，由于创伤性骨科疾病的异质性，对机器人辅助手术的研究受到限制。现有骨科创伤机器人手术研究主要集中在骨盆环骨折的机器人辅助骶髂关节螺钉和耻骨螺钉固定4，股骨颈空心螺钉固定5，髓内钉的入口点和远端锁定螺栓6，7，经皮骨折复位8，9，以及军事领域重伤患者的治疗10。
经皮螺钉技术可以使用 2D 和 3D 导航支持进行。骶髂螺钉、前柱、后柱螺钉、髋臼上螺钉和魔术螺钉是盆腔和髋臼护理最常见的经皮技术11.经皮经髂-经骶螺钉技术对外科医生来说仍然具有挑战性。该手术需要了解骨盆解剖结构和 X 射线透视、准确定位和长期手部稳定性。遥控机器人系统可以很好地满足这些要求。本研究利用远程操作机器人系统完成骨盆环骨折的经皮经髂骨-骶骨螺钉固定。该协议的详细信息和工作流程如下所示。
机器人系统 主从骨定位引导系统（MSOPGS）主要由三部分组成：具有七自由度（DOF）的手术机器人（从机械手），具有力反馈的主机械手和控制台。该系统有四种操作模式：手动牵引、主从操作、远程运动中心 （ROM） 和紧急。 图 1 显示了 MSOPPG;其主要组成部分简要说明如下。
手术机器人（见 材料表）是一个七自由度机械手，经过预先认证，可集成到医疗产品中12。机器人具有力反馈传感器，可以检测力的变化。机械臂可以手动或远程操作。扭矩传感器安装在尖端并映射到“主机械手”，从而实现实时力反馈。机械臂上的最大负载足以抵抗软组织力并减少手术器械的颤动。机器人连接到移动平台，以获得可操作的工作场所并确保稳定性。底座连接到“主机械手”和操作系统，可以处理来自操作系统的指令。
“主机械手”专为医疗保健行业设计，用于精确控制机器人。该器件提供七个有源自由度，包括高精度力反馈抓取功能。它的末端执行器涵盖了人手的自然运动范围。采用增量控制策略实现对机械臂的直观控制。
该操作系统提供四种控制机械臂的方法：手动牵引、主从操作模式、远程运动中心 （RCM） 和紧急情况。操作系统将外科医生和机器人连接起来，并提供安全警报。手动牵引模式允许机械手在特定的工作范围内自由拖动。机器人在停止5秒后自动锁定。在主从模式下，外科医生可以使用“主机械手”来控制机械臂的运动。RCM 模式允许手术器械围绕器械末端旋转。RCM 模式最适合在通道的轴向透视视图上重新定向，例如髋臼上通道的放射影像泪滴征和经髂-经骶骨通路的真实骶视图。机械手可用于任何位置的紧急制动。 图 2 显示了系统的工作流程。

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>160-slice CT</td>
			<td>United Imaging Healthcare Surgical Technology Co. Ltd</td>
			<td>uCT780</td>
			<td>Acquire the prescise image and DICOM data</td>
		</tr>
		<tr>
			<td>Electric bone drill</td>
			<td>YUTONG Medical</td>
			<td>None</td>
			<td>Power system</td>
		</tr>
		<tr>
			<td>Fluoroscopic plate base</td>
			<td>None</td>
			<td>None</td>
			<td>Fix the cadaveric pelves to operating table</td>
		</tr>
		<tr>
			<td>K-wire</td>
			<td>None</td>
			<td>2.5mm</td>
			<td>Guidewire</td>
		</tr>
		<tr>
			<td>Master-Slave Orthopaedic Positioning and Guidance System</td>
			<td>United Imaging Healthcare Surgical Technology Co. Ltd</td>
			<td>None</td>
			<td>A teleoperated robotic system that positions screws for orthopaedic surgery</td>
		</tr>
		<tr>
			<td>Mimics Innovation Suite</td>
			<td>Materialise</td>
			<td>Mimics Medical 21</td>
			<td>Preoperative planning software &#160;&#160;</td>
		</tr>
		<tr>
			<td>Mobile C-arm</td>
			<td>United Imaging Healthcare Surgical Technology Co. Ltd</td>
			<td>uMC560i</td>
			<td>Low Dose CMOS Mobile C-arm</td>
		</tr>
		<tr>
			<td>Operating table&#160;</td>
			<td>KELING</td>
			<td>DL&#183;C-I</td>
			<td>Fluoroscopic surgical table</td>
		</tr>
		<tr>
			<td>Schanz pins</td>
			<td>Tianjin ZhengTian Medical Instrument Co.,Ltd.</td>
			<td>5.0mm</td>
			<td>Fix the cadaveric pelves</td>
		</tr>
		<tr>
			<td>Semi-threaded screw</td>
			<td>Tianjin ZhengTian Medical Instrument Co.,Ltd.</td>
			<td>7.3mm</td>
			<td>Transiliac-Transsacral Screw</td>
		</tr>
		<tr>
			<td>Seven DOF manipulator</td>
			<td>KUKA, Germany</td>
			<td>LBR Med 7 R800</td>
			<td>Device for performing surgical operations</td>
		</tr>
	</tbody>
</table>

a teleoperated robotic system-assisted percutaneous transiliac-transsacral screw fixation technique

经髂骨-骶部螺钉固定在临床实践中具有挑战性，因为螺钉需要突破六层皮质骨。经髂骨螺钉提供更长的杠杆臂，以承受垂直垂直剪切力。然而，螺杆通道太长，微小的差异会导致医源性神经血管损伤。医疗机器人的发展提高了手术的精度。本协议描述了如何使用新的远程操作机器人系统来执行经髂骨-经骶骨螺钉固定。机器人被远程操作以定位入口点并调整套筒的方向。使用术后计算机断层扫描（CT）评估螺钉位置。所有螺钉均已安全植入，如术中透视检查所证实的那样。术后CT证实所有螺钉都在松质骨中。该系统将医生的主动性与机器人的稳定性相结合。可以远程控制此过程。与传统方法相比，机器人辅助手术具有更高的位置保持能力。与主动机器人系统相比，外科医生可以完全控制手术。机器人系统与手术室系统完全兼容，不需要额外的设备。

一位高级整形外科医生使用所述程序完成了手术。所有螺钉（S1 中的三个和 S2 中的两个）都已固定。插入五个螺钉中的每一个所花费的时间（从第一次X射线透视到插入螺钉）分别为32分钟，28分钟，26分钟，20分钟和23分钟。每个螺杆的荧光透视时间约为5分钟。尽管所有螺钉在术中透视图像上都位于正确的位置，但有几篇文章强调了术后CT扫描以评估螺钉放置的必要性。术后CT扫描中没有螺钉穿透?...

Watch this Scientific Journal Video about A Teleoperated Robotic System-Assisted Percutaneous Transiliac-Transsacral Screw Fixation Technique at JoVE.com

A Teleoperated Robotic System-Assisted Percutaneous Transiliac-Transsacral Screw Fixation Technique

远程手术机器人系统辅助经皮经髂-经骶螺钉固定是一种可行的技术。由于机械臂具有出色的移动自由度和稳定性，因此可以高精度地实现螺杆通道。

一种远程操作机器人系统辅助经皮经髂骶螺钉固定技术

Transiliac-transsacral screw fixation is challenging in clinical practice as the screws need to break through six layers of cortical bone. ...

经髂骨-经骶部螺钉固定在临床实践中是一项具有挑战性的任务。远程手术机器人系统辅助手术为经髂骨-经骶部螺钉放置的困难提供了解决方案。使用这种技术，外科医生可以在手术室外进行手术，从而避免辐射暴露的危险。此外，与传统方法相比，机器人辅助手术具有更高的位置保持能力。该技术可以与 3D 导航、虚拟现实、增强现实和混合现实技术相结合，用于在骨盆髋臼中进行经皮螺钉放置。为了有效固定，医生在使用该技术之前，应熟练地在透视下徒手放置骶髂螺钉。首先，通过插入两个 Schanz 针穿过股骨，使用透视板底座将尸体骨盆固定在仰卧位。仰卧位时，将髂后上棘同时放在平板上，腰椎平行于地板。使用术前计划软件的 Med CAD 模块，创建骨盆图像的圆柱体，并通过输入直径和长度来定义圆柱体的大小。将圆柱体放入 S1 或 S2 椎体中，并在轴向和冠状图像上调整圆柱体中线的方向。检查每个图像中圆柱体边缘与皮质骨之间的关系。将骨盆固定在透视手术台上的仰卧位置。然后将机器人放置在与手术台成 45 度的同侧，C 型臂垂直于对侧的手术台。接下来，将主机械手的工作站放在手术室外。用胶带将网格定位器固定在同侧。通过骶骨真实侧视图上的网格位置标记选择目标区域。确保选择并启动控制台上的手动牵引模式，将机械臂拖动到 S1 或 S2 经髂-经骶螺钉入口点的一般区域。可视化骶骨的真实侧视图，在主从操作模式下操作主机械手，并将远端套筒的尖端调整为位于导丝入口区域。选择远程运动中心或 RCM 模式后，继续 C 臂透视以获得骶侧视图。将导丝套的中心调整为同心圆，以与螺钉通道一致。锁定机械臂，并使用电钻将 2.5 毫米导丝插入对侧回肠。然后在手动牵引模式下卸下机器人。将 C 型臂转向入口和出口角度，检查导丝是否已突破，或接触骶骨内侧和后部皮层以及骶神经管。沿导丝将 7.3 毫米半螺纹螺钉插入对侧髂皮层。评估螺钉在骨盆入口、出口和侧位图中的位置。将采集到的CT扫描数据以DICOM格式导入术前计划软件，以获得骨盆冠状、矢状和轴向图像中的螺钉位置。术后CT重建图像和X线检查显示，没有螺钉穿透皮质骨，所有螺钉都完全在松质骨中。中线部位的矢状面CT重建图像提示螺钉位于S1中，并未进入骶管，如重新切片轴向图像所示。此外，螺钉是安全的，如重新切片冠状 CT 重建图像所示。骶骨的真实侧视图显示，螺钉完全位于骨骼内，并且在入口和出口图像上与前骶骨皮质和后骶神经管保持安全距离。可以远程控制此过程。该协议的关键是主从操作模式和RCM模式的准确性和稳定性。这种方法有望成为未来远程医疗的重要组成部分。

Research

JoVE Journal

Engineering

Time Multiplexing Super Resolving Technique for Imaging from a Moving Platform

时间复用超解析技术成像的运动平台

We propose a method for increasing the resolution of an object and overcoming the diffraction limit of an optical system installed on top of a moving ...

科研

工程学

Prescribed 3-D Direct Writing of Suspended Micron/Sub-micron Scale Fiber Structures via a Robotic Dispensing System

暂停规定微米/亚微米尺度的纤维结构的3-D直写经全自动点胶系统

A 3-axis dispensing system is utilized to control the initiating and terminating fiber positions and trajectory via the dispensing software. The polymer ...

Ohmic Contact Fabrication Using a Focused-ion Beam Technique and Electrical Characterization for Layer Semiconductor Nanostructures

欧姆接触制造用聚焦离子束技术和电气特性的半导体层的纳米结构

Layer semiconductors with easily processed two-dimensional (2D) structures exhibit indirect-to-direct bandgap transitions and superior transistor ...

Light Enhanced Hydrofluoric Acid Passivation: A Sensitive Technique for Detecting Bulk Silicon Defects

光增强氢氟酸钝化：一个敏感的技术检测散装硅缺陷

A procedure to measure the bulk lifetime (&#62;100 &#181;sec) of silicon wafers by temporarily attaining a very high level of surface passivation when ...

A Robotic Platform to Study the Foreflipper of the California Sea Lion

机器人平台研究加州海狮的Foreflipper

The California sea lion (Zalophus californianus), is an agile and powerful swimmer. Unlike many successful swimmers (dolphins, tuna), they generate most ...

Magnet Assisted Composite Manufacturing: A Flexible New Technique for Achieving High Consolidation Pressure in Vacuum Bag/Lay-Up Processes

磁铁辅助复合制造: 真空袋/糊化过程中实现高固结压力的一种柔性新技术

This work demonstrates a protocol to improve the quality of composite laminates fabricated by wet lay-up vacuum bag processes using the recently developed ...

Design and Implementation of a Bespoke Robotic Manipulator for Extra-corporeal Ultrasound

一种用于体外超声的自定义机器人机械手的设计与实现

With the potential for high precision, dexterity, and repeatability, a self-tracked robotic system can be employed to assist the acquisition of real-time ...

Robotic Sensing and Stimuli Provision for Guided Plant Growth

机器人传感和刺激为引导植物生长提供

Robot systems are actively researched for manipulation of natural plants, typically restricted to agricultural automation activities such as harvest, ...

Twin-Screw Extrusion Process to Produce Renewable Fiberboards

双螺丝挤压工艺，以生产可再生纤维板

A versatile twin-screw extrusion process to provide an efficient thermo-mechano-chemical pre-treatment on lignocellulosic biomass before using it as ...