骨科机器人及导航技术研究进展

随着微创外科技术、精准医疗的不断发展,骨科机器人及其导航技术引起了人们的广泛关注。凭着智能、微创、精准等基本特性,骨科机器人在应用中展现出巨大的应用价值,有力地改善了传统骨科手术损伤大、辐射量高、操作不精确等状况。骨科机器人从早期的基于工业化机器人改造逐渐发展为专用骨科机器人,体积由大到小,功能由简单到复杂,智能化程度不断提高,甚至实现了远程遥控操作。骨科机器人的操作离不开导航技术的引导,各种导航技术不断涌现,产生了基于CT、2D透视、3D透视、无图像、超声、电磁等导航系统,以及多模态导航。由此,本文主要对骨科机器人及其导航技术的基本特征、分类进行总结。     

机器人在普通外科的应用进展

一、机器人技术的发展概况 手术机器人的灵感来源于工业机器人的成功应用,1985年工业机器人Puma首次被用于神经外科的定位取样.经历最初的内镜光学定位外科机器人系统（AESOP）、辅助手术操作的宙斯（Zeus）机器人的发展后,结合美国航天航空局（National Aeronautics and Space Administration,NASA）和众多研究机构先进技术的达芬奇手术机器人系统（da Vinci Surgical System,DVSS）于1997年登上了历史舞台,它集成了图像导航技术、机器人定位、遥控操作等多项先进技术,为微创外科提供了一个全新、高效、精准的操作平台,并于2000年被美国食品和药物管理局（Food and Drug Administration,FDA）批准应用于临床.     

神经导航定位下显微外科手术治疗脑深部肿瘤的护理

神经导航手术定位系统近年来迅速发展成为微侵袭神经外科的重要部分。它集立体定向、计算机影像学、红外线信号追踪和机器人自动化技术等高科技手段于一体 ,术前对病变进行精确定位 ,术中实时导航 ,从而提高病变的全切除率并降低手术并发症。我科自 2 0 0 0年 1 1月至 2 0 0 1年 5月 ,在导航辅助下采用显微手术技术治疗脑深部肿瘤 2 5例 ,效果良好 ,现将护理报告如下。1　临床资料2 5例中 ,男 1 6例、女 9例 ,年龄 1 9～ 5 7岁 ,平均 3 9.0岁。脑膜瘤 6例 ,颅咽管瘤 4例 ,皮样囊肿 3例 ,室管膜瘤 4例 ,脉络丛乳头状瘤 5例 ,星形细胞瘤 3例。…     

CT/MRI导航机器人系统用于微创诊疗研究进展

影像学引导下微创诊疗技术在临床工作中的价值日益凸显,但CT/MRI引导下经皮穿刺存在依赖操作者经验、存在辐射或易受呼吸影响而发生位移等问题。影像学导航机器人系统的发展大大提升了微创诊疗过程的精准度及安全性。本文针对CT/MRI导航机器人系统用于微创诊疗研究进展进行综述。     

关节外科机器人的现状与思考

随着精准化、微创化、个性化及快速康复等理念的推广,个性化导板、计算机辅助导航、机器人辅助骨科手术、压力衬垫、3D打印、人工智能等一系列新技术应用于关节置换术中,以期获得精准的假体位置、减少磨损,并尽可能改善关节功能和延长假体寿命。目前,在机器人辅助关节置换术领域,机器人辅助技术具有精准性、可重复性的优势,理论上能够解决传统关节置换术无法精准实现目标假体定位的痛点,然而其作为一种新技术,也存在成本高、效率低、占用空间、有学习曲线、可能出现故障、软件问题等不足,且其中长期随访未显示明显优势。关节外科医师应当对机器人辅助技术有深入的了解,衡量其优势与不足,而不是盲目追捧,在使用的过程中进行改进,研制符合中国医师习惯的国产化机器人。     

超声微泡造影剂在膀胱肿瘤中的研究进展

膀胱肿瘤是泌尿系统最常见的肿瘤。目前膀胱肿瘤诊断、治疗及预后主要通过膀胱镜检查、经尿道膀胱肿瘤电切术(TURB-t)、术后化疗及长期随访等方法而实现。因此,如何精准进行术前定位定性诊断、术中操作以及术后治疗是降低肿瘤复发率甚至彻底根治的关键。靶向纳米微泡造影剂具有器官或组织靶向性、血管穿透性及显像聚集性的特点。膀胱肿瘤靶向纳米微泡造影剂能够特异性地结合肿瘤组织,并在肿瘤组织聚集,从而提高膀胱肿瘤的显像分辨率,为膀胱肿瘤早期精准定位定性诊断提供可能。膀胱肿瘤靶向纳米微泡造影剂还可携带基因、药物穿过内皮间隙结合肿瘤组织并且诱导释放,从而使得在分子水平对膀胱肿瘤进行治疗成为可能,最终提高治疗水平、降低药物不良反应。     

主动式骨科手术机器人

正骨科手术机器人是手术机器人领域的一个分支,其发展源于20世纪90年代初。目前应用的骨科手术机器人导航方式都需要使用外部的标志点或者具有光学性质的标志点进行手术图像和手术空间的标定。按照在术中是否对手术器械进行主动的跟踪定位可分为主动和被动两类。基于主动导航的骨科手术机器人系统,要求使用某类医学图像进行手术规划和手术机器人定位,据此进一步划分为二维图像导航和三维图像导航。对于骨科手术,常用的二维导航图像为X射线图像。针对X射线图像的引导是指在术中使用X射线获取术中透视图     

三轴直角坐标系立体定位CT导航辅助经皮椎间孔镜手术治疗腰椎间盘突出症的疗效分析

正经皮椎间孔镜下髓核摘除术(percutaneous transforaminal endoscopic discectomy,PTED)目前已成熟应用于腰椎间盘突出症(lumbar disc herniation,LDH),并取得较好疗效~([1-2]),但需充分依靠影像学导航技术进行精准的定位,引导其抵达靶点位置~([3])。本课题组尝试将三轴直角坐标系立体定位CT导航应用于PTED手术中,取得了较好效果。1资料与方法1.1一般资料随机选择2014年1月-2016年1     

导航机器人系统在肿瘤微创治疗中的临床应用进展

肿瘤治疗模式已向着微创化、精准化、个体化方向发展,导航机器人系统的发展和进步对这一理念的实现起着至关重要的作用。本文对近年来导航系统和机器人系统的应用进展做一综述。     

可视化经皮穿刺乳腺病灶定位标记夹的临床应用

可视化经皮乳腺病灶定位标记夹(简称乳腺Marker)是一类可置入乳腺肿瘤及区域转移病灶的标记物,目前可分如下两类:纯金属Marker和聚合物涂覆的Marker,主要用于乳腺可疑小肿瘤或不可触及乳腺癌的定位、新辅助化疗病灶的评估及腋窝可疑转移淋巴结的标记。目前,国内外对于新辅助化疗时乳腺Marker的放置时机和数目仍存在争议。乳腺Marker相关安全问题包括可能造成影像学局部伪像、Marker移位和丢失等。乳腺Marker是帮助提升乳腺精准外科水平的有效工具,可用于活检标记,术前精准定位、随访追踪和新辅助疗效评估,具有不错的安全性,但仍存在术前术中再定位的问题。     

Percutaneous radiofrequency ablation of virtual tumours in canine kidney using Global Positioning System-like technology

What's known on the subject? and What does the study add? We have previously shown that percutaneous radiofrequency ablation guided by image‐fusion technology allows for precise needle placement with real time ultrasound superimposed with pre‐loaded imaging, removing the need for real‐time CT or MR guidance. Emerging technology also allows real‐time tracking of a treatment needle within an organ in a virtually created 3D format. To our knowledge, this is the first study utilising a sophisticated ultrasound‐based navigation system that uses both image‐fusion and real‐time probe‐tracking technologies for in‐vivo renal ablative intervention.

OBJECTIVES

• ? To evaluate the feasibility, accuracy and efficacy of ultrasonography (US)‐guided percutaneous radiofrequency ablation (RFA) in the canine kidney model using novel Global Positioning System‐like probe tracking technology.
• ? Virtual tumours in the canine kidney were ablated in vivo by percutaneous RFA guided exclusively by two‐dimensional (2D) US and a virtual navigation system.

MATERIALS AND METHODS

• ? Gold fiducial markers were inserted into renal parenchyma to serve as centres of virtual tumours.
• ? After capturing 2D US images, navigation software created a three‐dimensional planning model of the kidney, and superimposed it onto the live US image.
• ? Percutaneous RFA was guided by multiplanar navigation, showing real‐time probe positions within the superimposed images, to treat each virtual tumour with a single treatment.
• ? Navigator software predicted the percentage of tumour treated; treated kidney specimens were examined to evaluate projection and targeting accuracy.

RESULTS

• ? In total, 32 virtual tumours (median diameter 16 mm, range 10–24 mm) were treated in 16 canine kidneys.
• ? Median (range) error between ‘fiducial tumour centre’ and ‘treated area centre’ was 1.8 (0–25) mm.
• ? Targeting accuracy improved with experience: median (range) error decreased from 6.3 (2–25) mm in an initial 12 tumours to 1.3 (0–9.0) mm in the last 20 tumours (P= 0.008).
• ? The percentage (range) of tumour actually treated improved significantly from the initial series at 23% (0–100%) to 100% (51–100%) (P < 0.001).
• ? Overall, navigator‐reported and pathologically confirmed treatment percentages were correlated significantly (r= 0.5; P= 0.006).

CONCLUSIONS

• ? Percutaneous renal RFA guided exclusively by real‐time 2D US with multiplanar Global Positioning System‐like probe tracking is feasible and accurate.
• ? Near‐future technologies, including elastic fusion overlay and anticipation of soft‐tissue deformation, will further augment this guidance system.

     

Development of micro-CT protocols for in vivo follow-up of mouse bone architecture without major radiation side effects

In vivo micro-computed tomography (micro-CT) will offer unique information on the time-related changes in bone mass and structure of living mice, provided that radiation-induced side effects are prevented. Lowering the radiation dose, however, inevitably decreases the image quality. In this study we developed and validated a protocol for in vivo micro-CT imaging of mouse bone architecture that retains high quality images but avoids radiation-induced side effects on bone structure and hematological parameters.The left hindlimb of male C57Bl/6 mice was scanned in vivo at 3 consecutive time points, separated each time by a 2-week interval. Two protocols for in vivo micro-CT imaging were evaluated, with pixel sizes of 9 and 18 μm and administered radiation doses of 434 mGy and 166 mGy per scan, respectively. These radiation doses were found not to influence trabecular or cortical bone architecture in pre-pubertal or adult mice. In addition, there was no evidence for hematological side effects as peripheral blood cell counts and the colony-forming capacity of hematopoietic progenitor cells from bone marrow and spleen were not altered. Although the images obtained with these in vivo micro-CT protocols were more blurred than those obtained with high resolution (5 μm) ex vivo CT imaging, longitudinal follow-up of trabecular bone architecture in an orchidectomy model proved to be feasible using the 9 μm pixel size protocol in combination with a suitable bone segmentation technique (i.e. local thresholding). The image quality of the 18 μm pixel size protocol was too degraded for accurate bone segmentation and the use of this protocol is therefore restricted to monitor marked changes in bone structure such as bone metastatic lesions or fracture healing.In conclusion, we developed two micro-CT protocols which are appropriate for detailed as well as global longitudinal studies of mouse bone architecture and lack noticeable radiation-induced side effects.     

Accuracy and precision of lumbar bone mineral content by dual-energy X-ray absorptiometry in live female monkeys

Summary Dual-energy X-ray absorptiometry (DXA) was used to determine thein vivo bone mineral content (BMC) of lumbar vertebrae in 20 feral adult female cynomolgus macaques (Macaca fascicularis). The ash weight of the third lumbar vertebra (L3) was compared to the measured L3BMC of thein vivo DXA analyses. Correlation between the estimated L3BMC by DXA and the actual ash weight was significant (r=0.965,P<0.01); however, DXA methodology underestimated ash weight on the average of 6.2%. Correlation was significant between two sequentialin vivo DXA scans (r=0.988,P<0.001). Noninvasivein vivo DXA was a fast, precise, and effective method for measuring the lumbar BMC in female cynomolgus macaques.     

Lentiviral Transduction of Human Postnatal Skeletal (Stromal, Mesenchymal) Stem Cells: In Vivo Transplantation and Gene Silencing

Systems for gene transfer and silencing in human skeletal stem cells (hSSCs, also stromal or mesenchymal stem cells) are important for addressing critical issues in basic hSSC and skeletal biology and for developing gene therapy strategies for treatment of skeletal diseases. Whereas recent studies have shown the efficacy of lentiviral transduction for gene transfer in hSSCs in vitro, no study has yet proven that lentivector-transduced hSSCs retain their distinctive organogenic potential in vivo, as probed by in vivo transplantation assays. Therefore, in addition to analyzing the in vitro growth and differentiation properties of hSSCs transduced with advanced-generation lentivectors, we ectopically transplanted LV-eGFP-transduced hSSCs (along with an osteoconductive carrier) in the subcutaneous tissue of immunocompromised mice. eGFP-transduced cells formed heterotopic ossicles, generating osteoblasts, osteocytes, and stromal cells in vivo, which still expressed GFP at 2 months after transplantation. eGFP-expressing cells could be recovered from the ossicles 8 weeks posttransplantation and reestablished in culture as viable and proliferating cells. Further, we investigated the possibility of silencing individual genes in hSSCs using lentivectors encoding short hairpin precursors of RNA interfering sequences under the control of the Pol-III-dependent H1 promoter. Significant long-term silencing of both lamin A/C and GFP (an endogenous gene and a transgene, respectively) was obtained with lentivectors encoding shRNAs. These data provide the basis for analysis of the effect of gene knockdown during the organogenesis of bone in the in vivo transplantation system and for further studies on the silencing of alleles carrying dominant, disease-causing mutations.     

A multi‐modality tracking,navigation and calibration for a flexible robotic drill system for total hip arthroplasty

Background

This paper presents a novel multi‐modality tracking and navigation system that provides a unique capability to guild a flexible drill tip inside the bone with accurate curved tunnelling.

Methods

As the flexible drill tip cannot be tracked optically inside the bone, this research focuses on developing a hybrid tracking and navigation system for tracking a flexible drill tip by using both optical and kinematic tracking. The tracking information is used to guide the THA (total hip arthroplasty) procedure, providing a real‐time virtual model of the flexible drill.

Results

The flexible and steerable drill tip system is then tested on total hip arthroplasty followed by evaluation of the positioning and orientation of femoral stem placement by femoral milling.

Conclusions

Based on this study, we conclude that the tracking and navigation system is able to guide the flexible drill to mill inside femoral canal.     

Expression and Secretion of RANTES (CCL5) in Granulomatous Calcified Tissue before and after Lipopolysaccharide Treatment In Vivo

RANTES (regulated on activation, normal T cell-expressed and secreted) is a CC chemokine appearing to be involved in the recruitment of leukocytes at inflammation sites. RANTES is produced by CD8⁺ T cells, epithelial cells, fibroblasts, and platelets. It acts in vitro in leukocyte activation and human immunodeficiency virus suppression, but its role in vivo is still uncertain. In our study, we established the involvement of RANTES in an in vivo model of chronic inflammation induced by potassium permanganate, leading to calcified granulomas. In our rat model, RANTES expression (mRNA and protein) was significantly upregulated in granulomatous tissue; RANTES expression was further increased upon i.p. injection of lipopolysaccharide (LPS), while it was kept at basal levels by dexamethasone (Dex) given 18 hours before sacrifice. LPS and Dex increased and decreased, respectively, the recruitment of mononuclear cells in granulomatous tissue compared with control granulomas from phosphate-buffered saline (PBS)-treated animals. In granuloma tissue, levels of RANTES were higher in LPS-treated rats and lower in the Dex group compared to controls. RANTES was also found in the conditioned medium of granuloma tissue from treated (LPS or Dex) and untreated (PBS) rats. When LPS was added in vitro for 18 hours, RANTES was further increased, except in the Dex group (P > 0.05). On serum analysis, RANTES levels were higher in the LPS group and lower in the Dex group compared to controls. This study shows for the first time that RANTES is produced in vivo in chronic, experimental inflammatory states, an effect increased by LPS and inhibited by Dex.     

Accuracy and precision of in vivo bone mineral measurements in sheep using dual-energy X-ray absorptiometry

We evaluated the precision and accuracy of in vivo measurements of spine bone mineral density (BMD) and bone mineral content (BMC) in five ewes using dual-energy X-ray absorptiometry (DXA, Lunar DPX-L). The short-term in vivo reproducibility expressed as the coefficient of variation (CV) varied from 0.9 to 1.6% for spine BMD and from 1 to 3.1% for spine BMC. The ex vivo measurements, performed in 20 cm of water to simulate soft tissue thickness, correlated closely with the in vivo measurements, yielding an r value of 0.98 and 0.97 for spine BMD and BMC, respectively. The accuracy was determined by comparing the total BMC of each vertebra measured in vivo with the corresponding ash weight. The correlation coefficient between the two measurements was r = 0.98, with an accuracy error of 5.6%. We concluded that the DXA allows a precise and accurate measurement of spine bone mineral in live ewes using the methodology designed for humans. Received: 19 March 1999 / Accepted: 26 July 1999     

Biological and Genetic Characteristics of Tumor-Initiating Cells in Colon Cancer

Background Human prominin-1 (PROM1, CD133) was used as a marker to detect stem cells (progenitor cells) and cancer stem cells (tumor-initiating cells) in various tissues. The purpose of this study was to investigate the biological and genetic characteristics of tumor-initiating cells in colon cancer with both in vitro and in vivo analyses. Methods The CD133 expression of 12 colon cancer cell lines was evaluated. CD133⁺ cells were isolated by flow cytometry and examined for in vivo tumor formation, in vitro proliferation, colony formation, and invasion ability. Additionally, we used microarray analysis to compare gene expression profiles between CD133⁺ and CD133^– isolated cells. Results CD133⁺ cells were found in 5 of 12 colon cancer cell lines. Isolated CD133⁺ cells from the HT29 colon cancer cell line exhibited a higher tumorigenic potential than CD133^– cells in the in vivo tumor formation assay. Furthermore, it was shown that CD133⁺ cells are more proliferative and have higher colony-forming and invasive abilities than CD133^– cells in vitro. Microarray analysis found differential gene expression correlating with CD133 expression. Conclusions It was confirmed that CD133⁺ cells in colon cancer are useful markers for the detection of tumor-initiating cells. Intimate biological and genetic features of CD133⁺ cells in colon cancer cell lines were also revealed. The biological characteristics of CD133⁺ cells and differentially expressed genes in these cells will help elucidate more details of tumor-initiating cells in colon cancer. Electronic supplementary material The online version of this article (doi: ) contains supplementary material, which is available to authorized users     

A comparative ultrahistochemical study of glycosaminoglycans with cuprolinic blue in bone formedin vivo andin vitro

Summary Histochemical and morphological studies have shown that proteoglygans (PG) are involved in mineralization processin vivo but such studies have not yet been conductedin vitro. A comparative histochemical study in electronic microscopy of the localization, organization, and morphology of the PG was performed with bones of calvaria rat formedin vivo and bone nodules formedin vitro from osteoblastic cells in culture. For this investigation, we used a cationic phthalocyanin dye, cuprolinic blue, in a critical electrolyte concentration which simultaneously stained the glycosaminoglycans and demineralized the bone. This histochemical technique demonstrated (1) osteoblast cellsin vitro synthesized PG which were included in the matrix formed. (2) These PG were found in the calcified and uncalcified matrix bothin vivo andin vitro. In the uncalcified matrix, PG were either free with a granular or rodlike structure or tightly connected to the periphery of the collagen fiber. Contrarily, in the calcified matrix, PG formed dense filamentous reticular patches between the collagen fibers. (3) Similarities in localization, organization, and morphology were noted in PG of bone formedde novo in vitro andin vivo with the exception of the mineralization front, where the stainingin vivo compared within vitro was faint or absent.     

Anatomically Shaped Breast Prosthesis <Emphasis Type="Italic">in Vivo</Emphasis>: A Change of Dimension?

Background In addition to the already existing round cohesive gel-filled breast prostheses, anatomically shaped breast prostheses were introduced in 1990 to provide a more natural shape to the augmented or reconstructed breast. To date, however, it is unclear whether the anatomic configuration of the prostheses is maintained after subpectoral implantation. Recently, a three-dimensional (3D) magnetic resonance imaging (MRI) technique became available, offering a precise visualization of the prosthesis in vivo. Using this 3D MRI technique, this study aimed to compare the shape of commercially available round and anatomically shaped silicone gel-filled breast prostheses before and after implantation. Methods Using 3D MRI, 6 conventionally round and 12 symmetrically shaped silicone gel-filled prostheses were scanned in vitro. Scans were made in vivo 6 weeks after subpectoral implantation of these prostheses in nine patients. The in vivo 3D images were compared with the in vitro 3D images. Results Overall, a 3.5% decrease in projection was found on the in vivo images, as compared with the in vitro images. On the craniocaudally oriented images, a slight lateral shift of the cohesive gel was observed in the majority of the prostheses. Inamed Style 510 prostheses showed the best in vivo preservation of their configuration. Conclusions The results show that both the round and the anatomically shaped silicone prostheses in vivo largely maintain their original in vitro configuration after subpectoral implantation. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.