数字化技术在口腔种植中的应用研究进展

近年来数字化技术持续发展,在医学领域中数字化技术的应用也越发广泛,推动了口腔医学发 展,特别是口腔种植医学领域。基于高精度的影像学诊断作为支持,能够为后续的个性化治疗方案的设计 以及精准的手术导航等提供支持,数字化技术的应用可以有效提升口腔种植的成功率以及患者的满意度, 高效解决患者的口腔问题,改善患者的生活质量。本文重点探讨了口腔种植技术中数字化技术的发展与应 用,以期为口腔种植领域的研究和临床应用提供一定参考。     

Assessment of Australian osteopathic learners' clinical competence during workplace learning

The literature about the overarching assessment strategy and the tools used to assess learners' clinical competence in the workplace in the allied health disciplines is less extensive than in medicine. In particular, there is very little published about the assessment of osteopathic learner's ability to deliver osteopathic health care. We show cause for the need for a body of work to explore the validity, reliability, fairness and efficacy of the various osteopathic assessment tools to determine an osteopathic learner's clinical competence, capacity and capability in the workplace. We contend future research into assessments tools and practices will assist in confirming an osteopathic student's clinical competence in general as well as during multiple episodes of patient care.     

Real-time 3D image reconstruction guidance in liver resection surgery

Background

Minimally invasive surgery represents one of the main evolutions of surgical techniques. However, minimally invasive surgery adds difficulty that can be reduced through computer technology.

Methods

From a patient’s medical image [US, computed tomography (CT) or MRI], we have developed an Augmented Reality (AR) system that increases the surgeon’s intraoperative vision by providing a virtual transparency of the patient. AR is based on two major processes: 3D modeling and visualization of anatomical or pathological structures appearing in the medical image, and the registration of this visualization onto the real patient. We have thus developed a new online service, named Visible Patient, providing efficient 3D modeling of patients. We have then developed several 3D visualization and surgical planning software tools to combine direct volume rendering and surface rendering. Finally, we have developed two registration techniques, one interactive and one automatic providing intraoperative augmented reality view.

Results

From January 2009 to June 2013, 769 clinical cases have been modeled by the Visible Patient service. Moreover, three clinical validations have been realized demonstrating the accuracy of 3D models and their great benefit, potentially increasing surgical eligibility in liver surgery (20% of cases). From these 3D models, more than 50 interactive AR-assisted surgical procedures have been realized illustrating the potential clinical benefit of such assistance to gain safety, but also current limits that automatic augmented reality will overcome.

Conclusions

Virtual patient modeling should be mandatory for certain interventions that have now to be defined, such as liver surgery. Augmented reality is clearly the next step of the new surgical instrumentation but remains currently limited due to the complexity of organ deformations during surgery. Intraoperative medical imaging used in new generation of automated augmented reality should solve this issue thanks to the development of Hybrid OR.     

Mixed Reality Combined with Three‐Dimensional Printing Technology in Total Hip Arthroplasty: An Updated Review with a Preliminary Case Presentation

Three‐dimensional (3D) printing technology, virtual reality, and augmented reality technology have been used to help surgeons to complete complex total hip arthroplasty, while their respective shortcomings limit their further application. With the development of technology, mixed reality (MR) technology has been applied to improve the success rate of complicated hip arthroplasty because of its unique advantages. We presented a case of a 59‐year‐old man with an intertrochanteric fracture in the left femur, who had received a prior left hip fusion. After admission to our hospital, a left total hip arthroplasty was performed on the patient using a combination of MR technology and 3D printing technology. Before surgery, 3D reconstruction of a certain bony landmark exposed in the surgical area was first performed. Then a veneer part was designed according to the bony landmark and connected to a reference registration landmark outside the body through a connecting rod. After that, the series of parts were made into a holistic reference registration instrument using 3D printing technology, and the patient's data for bone and surrounding tissue, along with digital 3D information of the reference registration instrument, were imported into the head‐mounted display (HMD). During the operation, the disinfected reference registration instrument was installed on the selected bony landmark, and then the automatic real‐time registration was realized by HMD through recognizing the registration landmark on the reference registration instrument, whereby the patient's virtual bone and other anatomical structures were quickly and accurately superimposed on the real body of the patient. To the best of our knowledge, this is the first report to use MR combined with 3D printing technology in total hip arthroplasty.     

Augmented reality in minimally invasive spine surgery: early efficiency and complications of percutaneous pedicle screw instrumentation

BACKGROUND CONTEXTAugmented reality (AR) employs an optical projection directly onto the user's retina, allowing complex image overlay on the natural visual field. In general, pedicle screw accuracy rates have improved with increasingly use of technology, with navigation-based instrumentation described as accurate in 89%–100% of cases. Emerging AR technology in spine surgery builds upon current spinal navigation to provide 3-dimensional imaging of the spine and powerfully reduce the impact of inherent ergonomic and efficiency difficulties.PURPOSEThis publication describes the first known series of in vivo pedicle screws placed percutaneously using AR technology for MIS applications.STUDY DESIGN / SETTINGAfter IRB approval, 3 senior surgeons at 2 institutions contributed cases from June, 2020 – March, 2022. 164 total MIS cases in which AR used for placement of percutaneous pedicle screw instrumentation with spinal navigation were identified prospectively.PATIENT SAMPLE155 (94.5%) were performed for degenerative pathology, 6 (3.6%) for tumor and 3 (1.8%) for spinal deformity.  These cases amounted to a total of 606 pedicle screws; 590 (97.3%) were placed in the lumbar spine, with 16 (2.7%) thoracic screws placed.OUTCOME MEASURESPatient demographics and surgical metrics including total posterior construct time (defined as time elapsed from preincision instrument registration to final screw placement), clinical complications and instrumentation revision rates were recorded in a secure and de-identified database.METHODSThe AR system used features a wireless headset with transparent near-eye display which projects intra-operative 3D imaging directly onto the surgeon's retina. After patient positioning, 1 percuntaneous and 1 superficial reference marker are placed. Intra-operative CT data is processed to the headset and integrates into the surgeon's visual field creating a “see-through” 3D effect in addition to 2D standard navigation images. MIS pedicle screw placement is then carried out percutaneously through single line of sight using navigated instruments.RESULTSTime elapsed from registration and percutaneous approach to final screw placement averaged 3 minutes and 54 seconds per screw.  Analysis of the learning curve revealed similar surgical times in the early cases compared to the cases performed with more experience with the system.  No instrumentation was revised for clinical or radiographic complication at final available follow-up ranging from 6–24 months. A total of 3 screws (0.49%) were replaced intra-operatively. No clinical effects via radiculopathy or neurologic deficit postoperatively were noted.CONCLUSIONSThis is the first report of the use of AR for placement of spinal pedicle screws using minimally invasive techniques.   This series of 164 cases confirmed efficiency and safety of screw placement with the inherent advantages of AR technologies over legacy enabling technologies.     

腹腔镜袖状胃切除术在治疗单纯性肥胖症中的应用

肥胖目已成为当今世界日益普遍的健康问题,随着人们对于肥胖症的重视和科技的发展,减肥方式也在逐渐演变.近年来,袖状胃切除术的广泛应用使其已经成为全世界使用量排名第2位的减重手术方式.本文就有关袖状胃切除术治疗肥胖症的适应证与禁忌证、手术方式、手术效果、并发症等方面作一综述.     

Is the use of augmented reality-assisted surgery beneficial in urological education? A systematic review

Background:Google Glass is an optical head-mounted display that has been used in multiple medical and surgical settings to enhance delivery of education and training. This systematic review focuses solely on the use of this technology in urology operating theaters for the purpose of surgical education.Materials and methods:A systematic search strategy was employed using EMBASE (1996–2019), Medline (1946–2019) and PubMed. Search terms included optical head-mounted displays, Google Glass and urological surgical training. Use of this technology in a nonurological setting, nonteaching sessions, case reports, reviews, editorials, abstracts, and articles not in English were rejected. Three studies were identified following the exclusion criteria.Results:All 3 studies received positive feedback from trainees regarding this technology in relation to enhanced surgical education. In addition, in all studies the trainees felt the technology had a place for educational training in the future. All studies described disadvantages to the technology as well including battery life, comfort, and cost.Conclusions:Studies describe a big potential for Google Glass and similar head-mounted devices for the role of surgical training in urology, however, larger studies looking at more varied operations can help reinforce this viewpoint.     

From ancient to avant‐garde: a review of traditional and modern multimodal approaches to surgical anatomy education

The landscape of surgical anatomy education is progressively changing. Traditional methods, such as cadaveric dissection and didacticism are being increasingly phased out in undergraduate courses for multimodal approaches incorporating problem‐based learning, radiology and computer‐based simulations. Although effective at clinically contextualizing and integrating anatomical information, these approaches may be a poor substitute for fostering a grasp of foundational ‘pure’ anatomy. Dissection is ideal for this purpose and hence remains the cornerstone of anatomical education. However, novel methods and technological advancements continually give way to adjuncts such as cadaveric surgery, three‐dimensional printing, virtual simulation and live surgical streaming, which have demonstrated significant efficacy alone or alongside dissection. Therefore, although divergent paradigms of ‘new versus old’ approaches have engulfed and divided the community, educators should seek to integrate the ancient and avant‐garde to comprehensively satisfy all of the modern anatomy learner's educational needs.     

Challenges to the development of complex virtual reality surgical simulations

Virtual reality simulation in surgical training has become more widely used and intensely investigated in an effort to develop safer, more efficient, measurable training processes. The development of virtual reality simulation of surgical procedures has begun, but well-described technical obstacles must be overcome to permit varied training in a clinically realistic computer-generated environment. These challenges include development of realistic surgical interfaces and physical objects within the computer-generated environment, modeling of realistic interactions between objects, rendering of the surgical field, and development of signal processing for complex events associated with surgery. Of these, the realistic modeling of tissue objects that are fully responsive to surgical manipulations is the most challenging. Threats to early success include relatively limited resources for development and procurement, as well as smaller potential for return on investment than in other simulation industries that face similar problems. Despite these difficulties, steady progress continues to be made in these areas. If executed properly, virtual reality offers inherent advantages over other training systems in creating a realistic surgical environment and facilitating measurement of surgeon performance. Once developed, complex new virtual reality training devices must be validated for their usefulness in formative training and assessment of skill to be established.     

CD-ROM multimedia

Applications developed using key multimedia elements are finding their way into a number of training and information exchange environments including the laparoscopy training market. Emerging multimedia-based applications range from procedural information for patients to interactive CD-ROM-based applications used to train highly skilled surgeons. These products are designed with a high level of interactivity that allows the surgeon to plan a surgical procedure, review detailed patient information and then merge that information into the surgical planning process. Using this new technology, a surgeon now has the ability to review CD-ROM-based course materials and efficiently meet continuing education requirements. The factor found most limiting in the development of multimedia-based applications for laparoscopy training is generally not the technology, but the limits placed on the technology because of one's reluctance to think beyond what is accepted as the norm. Properly implemented, multimedia applications developed for laparoscopy training reduce the cost and time associated with learning new materials, assist a user in retaining more of the information reviewed, and in many cases make the learning experience much more enjoyable. Received: 6 February 1995/Accepted: 26 June 1995     

虚拟现实技术与新型整形外科教学

由于整形外科病种繁杂多样、临床患者特异性较高,其疾病治疗的学习缺乏可重复性。虚拟现实技术可提供三维、无风险的手术环境,使学习者可在正式手术前进行演练操作并尝试独立完成手术。但是,单纯应用虚拟现实技术进行教学仍有不足,该技术无法完全模拟临床复杂肠道、血流动力学等。若能在原本的学习循环中加入新型VR(Virtual reality)模拟技术,可借由模拟的手术环境弥补整形外科教学中存在的学习曲线长且复杂术式难以掌握的缺点,从而形成"Observation, thinking, experience, action and teaching",即"临床观摩、临床问题思考、手术操作演练、独立手术与教学"的新型循环学习模式。该模式有效突破了传统的由课堂到手术台的学习平台期,使整形外科领域能够快速且高质量地培养更多的专业医生。     

应用增强现实与混合现实导航预防腹腔镜肝切除术中出血价值研究

目的 研究应用增强现实与混合现实导航技术预防腹腔镜肝切除术中出血的价值。方法 回顾性分析2018年1月至2021年7月南方医科大学珠江医院肝胆一科收治171例行腹腔镜肝切除术治疗肝脏恶性肿瘤病人临床资料,分为增强现实与混合现实腹腔镜肝切除手术导航组（A组）和常规腹腔镜肝切除组（B组）。其中A组108例,术中采用自主研发的3D腹腔镜增强现实与混合现实手术导航系统将术前三维模型、3D腹腔镜场景进行多模图像实时融合与交互,在导航技术引导下完成腹腔镜肝切除术。B组63例,未采用手术导航技术,采用常规腹腔镜肝切除。分别采用t 检验、Wilcoxon秩和检验、χ2检验对临床数据进行统计学分析。结果 两组病人的术前资料差异均无统计学意义。术中指标中,A组术中出血量少于B组［（263.9±147.0） mL vs.（405.6±286.5） mL,P＜0.01）］,差异有统计学意义;A组术中输血率低于B组（9.3% vs. 31.7%,P＜0.01）,差异有统计学意义;两组病人均无严重并发症发生及围手术期死亡。结论 在腹腔镜肝切除中应用增强现实与混合现实导航技术出血更少,有更好的手术安全性,对术中预防出血具有重要的应用价值。     

虚拟技术对21世纪微创外科发展的影响

20世纪后期，建立在高新技术基础上的虚拟技术发展迅速，为微创外科的发展提供了强有力的手段，在微创外科领域的应用日益广泛，并对微创外科的发展产生了深远的影响。虚拟技术充实和更新了微创外科的诊疗理念，拓展了微创外科的诊疗范围，提高了微创外科的诊疗效果，并且促进了微创诊疗器械的不断发展和更新。但由于虚拟技术目前尚处于起步阶段，虚拟技术的开发不仅需要高层次复合型人才，还需要借助昂贵的设备和特殊的器械，因此将虚拟技术应用于微创外科领域时，应选择合适的手术适应证，有选择有重点的逐步开展，同时应不断加强虚拟技术的基础和应用研究，努力促使其真正成为微创或无创治疗的有效手段。     

History of the development of intraoperative spinal cord monitoring

In the early 1970s, spinal instrumentation and aggressive surgical technology came into wide use for the treatment of severe spinal deformities. This background led to the development of intraoperative spinal cord monitoring by orthopaedic spine surgeons themselves. The author's group (T.T.) and Kurokawa's group invented a technology in 1972 to utilize the spinal cord evoked potential (SCEP) after direct stimulation of the spinal cord. In the United States, Nash and his group started to use SEPs. Following these developments, the Royal National Orthopaedic Hospital group of Stanmore, UK employed spinal somatosensory evoked potential in 1983. However, all of these methods were used to monitor sensory mediated tracts in the spinal cord. The only way to monitor motor function was the Wake up test developed by Vauzelle and Stagnara. In 1980, Merton and Morton reported a technology to stimulate the brain transcranially and opened the doors for motor tract monitoring. Presently, in the operating theatre, monitoring of motor-related functions is routinely performed. We have to remember that multidisciplinary support owing to the development of hardware and, software and the evolution of anesthesiology has made this possible. Furthermore, no single method can sufficiently cover the complex functions of the spinal cord. Multimodality combinations of the available technologies are considered necessary for practical and effective intra-operative monitoring (IOM). In this article, the most notable historic events and articles that are regarded as milestones in the development of IOM are reviewed.

     

14839例儿童肢体畸形临床数据分析

目的 总结分析秦泗河矫形外科团队近40年间手术治疗的万例儿童肢体畸形病例,探讨中国儿童肢体畸形病人的疾病谱、病种分布特征、变化趋势及治疗策略,为制定中国儿童肢体畸形防治措施提供依据.方法 检索秦泗河矫形外科团队手术病例资料数据库,选取1980年4月24日至2019年12月31日手术治疗的16岁以下肢体畸形患儿共1483...     

Realigning Global Health Realities Towards Children's Surgery: Progress and Possibilities

Despite the high population of children, increasing surgical disease burden and shortage of pediatric surgeons, as well as limited infrastructure, children's surgical care in low- and middle-income countries (LMICs) has been neglected for decades. This has contributed to unacceptably high morbidity and mortality, long term disabilities and economic loss to families. The work of the global initiative for children's surgery (GICS) has raised the profile and visibility of children's surgery in the global health space. This has been achieved a philosophy of inclusiveness, LMIC participation, focus on LMIC needs and high income country (HIC) support, and driven by implementation to change on the ground situations. Children's operating rooms are being installed to strengthen infrastructure and children's surgery is being gradually included in national surgical plans to provide the policy framework to support children's surgical care. In Nigeria, pediatric surgery workforce has increased from 35 in 2003 to 127 in 2002, but the density remains low at 0.14 per 100,000 population <15 years. Education and training have been strengthened with the publication of a pediatric surgery textbook for Africa and creation of a Pan Africa pediatric surgery e-learning platform. However, financing children's surgery in LMICs remains a barrier as many families are at risk of catastrophic healthcare expenditure. The success of these efforts provides encouraging examples of what can be collectively achieve by appropriate and mutually beneficial global north-south collaborations. Pediatric surgeons need to commit their time, knowledge and skills, as well as experience and voices to strengthen children's surgery globally to impact more lives, for the overall good of more.     

Twenty Years Development of Tibial Cortex Transverse Transport Surgery in PR China

Tibial cortex transverse transport (TTT) surgery is an extension of the Ilizarov technique. Based on the law of tension‐stress, its primary function is to rebuild microcirculation which can relieve ischemic symptoms and promote wound healing. It has received more and more scholars'' attention and has experienced a series of changes for 20 years since it entered PR China. The mechanisms involved have gradually become clear, such as the reconstruction of the polarization balance of macrophages, the promotion of vascular tissue regeneration, and the mobilization and regulation of bone marrow‐derived stem cells. TTT technique is mainly used in the treatment of chronic ischemic diseases of the lower extremities. It has recently been successfully used in the treatment of primary lymphedema of the lower extremities. A series of improvements have been made in the external fixator''s style, the size of skin incision and osteotomy, and distraction method. For example, the annular external fixator has been redesigned as a unilateral external fixator, and accordion technology has been introduced. For distraction methods after surgery, there was no uniform standard in the past. The technique can also be used in combination with other treatments to achieve better effects, such as interventional therapy, negative pressure sealed drainage, 3D printing technology, traditional Chinese medicine. Nevertheless, the surgery may bring some complications, such as secondary fracture, nail infection, skin necrosis at the surgical site, etc. Reports of complications and doubts about the technique have made the TTT technique controversial. In 2020, the relevant expert consensus was published with treatment and management principles, which might guide the better application and development of this technique.     

血管介入手术机器人的腔内器械自动识别与跟踪研究进展

在血管外科领域，血管介入手术是一种高效的微创治疗方法。然而，传统的介入手术方法需要医生长时间穿戴防护铅衣，并且存在暴露于辐射的风险，这不仅为医生带来健康隐患，还可能对手术效率产生不利影响。随着血管腔内介入手术机器人（EIR）的研发应用，可在减少医生辐射暴露的同时，提供相较于传统方法更高的操作精度和稳定性。介入器械的自动识别和实时跟踪两大关键技术可以使得EIR在复杂的介入手术中拥有对器械方位的把控能力和判断能力，从而保证治疗的质量和安全。目前研究大多倾向利用介入影像实现EIR在血管结构中实时、准确地检测和定位器械，即令机器人观察图像信息进行手术。与此同时，介入器械识别技术与EIR的协同工作具有重大潜在价值。这要求机器人不仅要能精准执行命令，更需能够理解和预测医生的操作意图。随着人工智能技术的发展，有望在辅助机器人更精确地识别和跟踪器械并修改定位误差方面提供支持，实现真正的协同手术。在此，笔者分析介入器械的自动识别和实时跟踪两大技术在EIR领域的应用情况，综合讨论它们的临床应用前景，并对国内外相关技术的发展进行对比和总结。     

Innovative Surgical Planning in Resecting Soft Tissue Sarcoma of the Foot Using Augmented Reality With a Smartphone

Augmented or hybrid reality is a display technology that combines the real world with the virtual world; it permits digital images of preoperative planning information to be combined with the surgeon's view of the real world. Augmented reality (AR) can increase the surgeon's intraoperative vision by providing virtual transparency of the real patient and has been applied to a wide spectrum of orthopedic procedures, such as tumor resection, fracture fixation, arthroscopy, and component's alignment in total joint arthroplasty. We present a case of a male patient who presented with pain in the medial aspect of his left foot after he underwent an incomplete mass excision elsewhere where it turned out to be synovial sarcoma. Because the mass was small, impalpable, and deeply positioned beneath both the plantar and the medial plantar aponeuroses, it was impossible to preoperatively decide a plan for resection. We opted to use the aid of AR in the form of an application using the camera of a smartphone. We were able to excise the tumor with negative surgical margins. On 12-month follow-up, the patient is in complete remission and has optimal mobility and functionality of his foot. In conclusion, AR holds great potential for use in the future of orthopedic surgical oncology. We emphasize using it via a handheld device that we found to be optimal for planning resection of the small and relatively fixed tumor. Based on our literature review, this is the first case describing the surgical planning in resecting an impalpable synovial sarcoma of the foot using AR technology.