计算机辅助骨科手术的应用和进展

计算机辅助手术(CAS)是近年来在外科手术领域发展最为迅速的一个领域。CAS在骨科手术中的具体应用被称为计算机辅助骨科手术(CAOS)。CAOS的含义是利用当今医学领域的先进成像设备如计算机断层扫描(CT)、磁共振成像(MRI)、正电子发射断层扫描(PET)、数字血管减影(DAS、超声成像(US)以及医用机器人(MR)所得到的多模图像数据，在计算机的帮助下，对医学图像信息进行处理并结合立体定位系统，对人体骨骼的解剖结构进行显示和定位，并由计算机规划手术路径，制定合理、定量的手术方案，进行术前手术模拟，在适当的图像监视和立体定位系统下，利用一定的导引系统，在骨科手术中使用计算机和医用机器人进行手术干预，为骨科医生提供强有力的工具和方法。CAOS在提高病灶定位精度，减少手术损伤，执行复杂外科操作，提高手术成功率方面有卓越的表现，配准和定位是CAOS的核心技术。CAOS已应用在脊柱外科、人工关节置换术、创伤骨科、骨肿瘤治疗中。     

计算机辅助技术在骨科手术中的应用进展

随着近十年来人工智能技术的飞速发展,计算机辅助骨科手术(Computer assisted orthopedic surgery,CAOS)在临床手术中的应用已经较为成熟,但是相对于发达国家,其在国内的发展还处于初级阶段;CAOS最早应用于脊柱手术中,现已经逐步完善了在关节、创伤、运动医学及骨肿瘤等方面的应用.CAOS在骨科手术中的应用具有手术时间短、辐射量少、定位准确等优势,目前已经是骨科发展的重要方向.推动CAOS和自主研发的骨科手术机器人的发展,优化计算机导航技术将是骨科技术程序化、智能化和个体化的关键所在.本文针对CAOS的发展进程及未来的应用前景做一综述.     

机器人和计算机辅助骨科手术

本文旨在介绍计算机辅助外科手术在术前计划、手术模拟和术中导航的应用,以及医用自动化机械臂的引入和手术导航系统的基本原理等。手术导航要求很高的精确度,因此引入和发展医用自动化机械臂十分必要。我们简要地回顾了目前的医用机器人系统,同时也介绍了在香港中文大学所发展的机械臂系统以及在手术中的应用。导航指引下远端置入髓内钉的实验室测定显示机械臂的使用可以获得更好地可重复性和准确性。手术导航机械臂已经广泛应用于远端髓内钉的置入,经皮置入骶髂关节螺钉、髂骨螺钉、髋螺钉等骨科治疗中。医用机械臂无疑将是计算机辅助手术未来发展的主要技术之一。     

计算机辅助骨科手术在创伤骨科中的应用

计算机辅助骨科手术（computer—assisted orthopaedic surgery，CAOS）是利用计算机对数字化医学影像的高速处理及控制能力，通过虚拟手术环境为骨科医生从技术上提供支援，使手术更微创、更安全、更准确的一门新技术。正因为这是一项基于术中图像，应用相应定位手段，对手术部位及术中的手术器械进行实时跟踪、显示、引导而进行手术的技术，其工作原理犹如在航空、航海中为飞机和舰船进行导航一样，所以也有很多学者把CAOS称为影像辅助导航手术（image guidance fluoroscopic navigation surgery，IGFNS）。CAOS应用的是以计算机图像处理工作站及影像跟踪设备为核心的手术系统，此系统的基本功能是将医学影像设备提供的图像进行信息化处理，并结合立体定位系统（stereotactic localization system）对真正的人体肌肉、骨骼解剖结构进行显示和定位，     

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。     

计算机辅助骨科手术在创伤骨科的应用

目的讨论计算机辅助骨科手术（computer assisted orthopedic surgery，CAOS）在创伤骨科的应用及其意义。方法分析CAOS在创伤骨科应用的现状，总结其应用的价值及相关问题。结果目前CAOS在创伤骨科主要应用于脊柱、四肢骨折内固定物的植入和人工髋、膝关节置换以及膝关节交叉韧带的重建等，而在骨折复位方面的应用很少且技术不成熟，但已显示明显的优越性。在CAOS应用过程中应注意其缺点、临床医学评价、手术医生的地位、正确的微创观念等相关问题。结论CAOS在创伤骨科手术微创化进程中有重要意义和无可替代的价值，应处理好一些相关的问题，促进其更好地发展。     

计算机辅助骨科技术的现状与未来

近年来，计算机技术在外科领域应用日益广泛，计算机辅助骨科技术(CAOS)在神经外科导航的基础上发展迅猛，成功地应用到越来越多的骨科疾病中。它是在计算机技术支持下进行的骨科手术，包括了医学图像数据的获取、术前计划和模拟、配准、术中导航和机器人系统。它的应用提高了手术的准确性，减小了手术创伤，更好的进行手术计划和模拟，并且减少了射线的暴露量。章评述了CAOS的发展现状，提出了未来研究的设想。     

计算机导航在骨科手术中的应用与进展

计算机辅助骨科手术（Computer assisted orthopedics surgery,CAOS）即利用各种影像设备如CT、MRI、PET、DSA、US等结合导航系统,对人体骨骼解剖结构及手术器械进行显示和定位,通过计算机制订手术计划,在术中进行操作干预的一项技术.最早应用于神经外科领域的立体定位,肿瘤切除化疗等.其最大的优势是：简化了手术操作,缩短了手术时间,减少了手术创伤,减弱了术中放射线的照射,使骨科手术变得更安全、更准确、更微创。     

计算机辅助手术导航系统在脊柱外科手术中的应用进展

近年来脊柱外科手术得到了很大发展,但脊柱解剖结构复杂,毗邻重要血管神经,手术难度和风险性很高.同时脊柱手术趋向微创化、精准化,迫切需要更安全有效的技术措施辅助手术.自上世纪90年代以来,计算机辅助骨科手术(computer-assisted orthopedic surgery,CAOS)应运而生,旨在通过手术过程中应用机器人设备或者定位导航系统,从而提高术野的可视度和手术精度.自Nolte等[1]应用计算机辅助微创导航手术系统实施了第1例腰椎椎弓根螺钉内固定术后,计算机辅助手术导航系统逐渐发展,并在脊柱外科手术中广泛应用[2～7].计算机辅助手术导航系统又称图像引导手术导航系统(image-guided surgical navigation system)、图像引导外科手术(image-guided surgery)等.本文将近年来计算机辅助手术导航系统在脊柱外科手术中的应用进展综述如下.     

2007年中国骨科年度报告-创伤骨科

回顾2007年中国创伤骨科的发展,简单地说是处于发展的平台区.具有以下几个方面的特点: 一、计算机辅助骨科手术 近年来,医学影像技术、计算机图形处理技术以及外科机器人技术的进步和结合,极大地促进了计算机辅助骨科手术(computer-assisted orthopaedic surgery,CAOS)的发展.     

Geschichte und Entwicklung der computerassistierten Chirurgie in der Orthopädie

Computer assisted orthopaedic surgery (CAOS) was developed to improve the accuracy of surgical procedures. It has improved dramatically over the last years, being transformed from an experimental, laboratory procedure into a routine procedure theoretically available to every orthopaedic surgeon.The first field of application of computer assistance was neurosurgery. After the application of computer guided spinal surgery, the navigation of total hip and knee joints became available. Currently, several applications for computer assisted surgery are available. At the beginning of navigation, a preoperative CT-scan or several fluoroscopic images were necessary. The imageless systems allow the surgeon to digitize patient anatomy at the beginning of surgery without any preoperative imaging. The future of CAOS remains unknown, but there is no doubt that its importance will grow in the next 10 years, and that this technology will probably modify the conventional practice of orthopaedic surgery.     

新观念及新技术影响着创伤骨科的发展

骨折内固定理念的改变、微创手术的广泛使用、计算机技术在创伤骨科领域中的使用及循证医学对临床决策的影响给创伤骨科领域带来了技术和思想的转变。本文通过对第二届全国创伤骨科学术大会论文的评述，简要介绍目前创伤骨科领域的发展趋势。     

Evaluation of the Accuracy and Precision of a Next Generation Computer-Assisted Surgical System

BackgroundComputer-assisted orthopaedic surgery (CAOS) improves accuracy and reduces outliers in total knee arthroplasty (TKA). However, during the evaluation of CAOS systems, the error generated by the guidance system (hardware and software) has been generally overlooked. Limited information is available on the accuracy and precision of specific CAOS systems with regard to intraoperative final resection measurements. The purpose of this study was to assess the accuracy and precision of a next generation CAOS system and investigate the impact of extra-articular deformity on the system-level errors generated during intraoperative resection measurement.MethodsTKA surgeries were performed on twenty-eight artificial knee inserts with various types of extra-articular deformity (12 neutral, 12 varus, and 4 valgus). Surgical resection parameters (resection depths and alignment angles) were compared between postoperative three-dimensional (3D) scan-based measurements and intraoperative CAOS measurements. Using the 3D scan-based measurements as control, the accuracy (mean error) and precision (associated standard deviation) of the CAOS system were assessed. The impact of extra-articular deformity on the CAOS system measurement errors was also investigated.ResultsThe pooled mean unsigned errors generated by the CAOS system were equal or less than 0.61 mm and 0.64° for resection depths and alignment angles, respectively. No clinically meaningful biases were found in the measurements of resection depths (< 0.5 mm) and alignment angles (< 0.5°). Extra-articular deformity did not show significant effect on the measurement errors generated by the CAOS system investigated.ConclusionsThis study presented a set of methodology and workflow to assess the system-level accuracy and precision of CAOS systems. The data demonstrated that the CAOS system investigated can offer accurate and precise intraoperative measurements of TKA resection parameters, regardless of the presence of extra-articular deformity in the knee.     

Primary pyomyositis of the paraspinal muscles: a case report and literature review

The objectives of this study were (1) to quantify the benefit of computer assisted orthopaedic surgery (CAOS) pedicle screw insertion in a porcine cadaver model evaluated by dissection and computed tomography (CT); (2) to compare the effect on performance of four surgeons with no experience of CAOS, and varying experience of pedicle screw insertion; (3) to see if CT with extended windows was an acceptable method to evaluate the position of the pedicle screws in the porcine cadaver model, compared to dissection. This was a prospective, randomised, controlled and blinded porcine cadaver study. Twelve 6-month-old porcine (white skinned Landrace) lumbar spines were scanned pre-operatively by spiral CT, as required for the CAOS computer data set. Computer randomisation allocated the specimens to one of four surgeons, all new to CAOS but with different levels of experience in spinal surgery. The usual anatomical landmarks for the freehand technique were known to all four surgeons. Two pedicles at each vertebral level were randomly allocated between conventional free hand insertion and an electromagnetic image guided surgery (NAVITRAK^®) and 6.5 mm cancellous AO screws inserted. Post-operatively, spiral CT was blindly evaluated by an independent radiologist and the spine fellow to assess the accuracy of pedicle screw placement, by each method. The inter- and intra-observer reliability of CT was evaluated compared to dissection. The pedicle screw placement was assessed as perfect if within the pedicle along its central axis, or acceptable (within < 2 mm from perfect), and measured in millimetres from perfect thereafter. One hundred and sixty-six of 168 pedicles in 12 porcine spines were operated on. Complete data were present for 163 pedicles (81 CAOS, 82 freehand). In the CAOS group 84% of screws were deemed acceptable or perfect, compared to 75.6% with the freehand technique. Screw misplacement was significantly reduced using CAOS (P = 0.049). Seventy-nine percent of CAOS screws were ideally placed compared with 64% with a conventional freehand technique (P = 0.05). A logistic linear regression model showed that the miss placed pedicle screw rate was significantly reduced using CAOS (P = 0.047). CAOS benefited the least experienced surgeons most (the research registrars acceptable rate increased from 70 to 90% and the spine fellow from 76 to 86%). CAOS did not have a statistically significant effect on the experienced consultant spine surgeon increasing from 70 to 79% (P = 0.39). The experienced general orthopaedic surgeon did not benefit from CAOS (P = 0.5). CT compared to dissection showed an intra-observer reliability of 99.4% and inter-observer reliability of 92.6%. The conclusions of this study were as follows: (1) an increased number of pedicle screws were ideally placed using the CAOS electromagnetic guidance system compared to the conventional freehand technique; (2) junior surgeons benefited most from CAOS; (3) we believe CAOS (Navitrak^®) with porcine lumbar spines evaluated by post operative CT, represents a useful model for training junior surgeons in pedicle screw placement; (4) experienced spine surgeons, who have never used CAOS, may find CAOS less helpful than previously reported.     

Computer‐assisted Orthopaedic Surgery

Nowadays, operating rooms can be inefficient and overcrowded. Patient data and images are at times not well integrated and displayed in a timely fashion. This lack of coordination may cause further reductions in efficiency, jeopardize patient safety, and increase costs. Fortunately, technology has much to offer the surgical disciplines and the ongoing and recent operating room innovations have advanced preoperative planning and surgical procedures by providing visual, navigational, and mechanical computerized assistance. The field of computer‐assisted surgery (CAS) broadly refers to surgical interface between surgeons and machines. It is also part of the ongoing initiatives to move away from invasive to less invasive or even noninvasive procedures. CAS can be applied preoperatively, intraoperatively, and/or postoperatively to improve the outcome of orthopaedic surgical procedures as it has the potential for greater precision, control, and flexibility in carrying out surgical tasks, and enables much better visualization of the operating field than conventional methods have afforded. CAS is an active research discipline, which brings together orthopaedic practitioners with traditional technical disciplines such as engineering, computer science, and robotics. However, to achieve the best outcomes, teamwork, open communication, and willingness to adapt and adopt new skills and processes are critical. Because of the relatively short time period over which CAS has developed, long‐term follow‐up studies have not yet been possible. Consequently, this review aims to outline current CAS applications, limitations, and promising future developments that will continue to impact the operating room (OR) environment and the OR in the future, particularly within orthopedic and spine surgery.     

计算机辅助骨科导航技术面临的主要问题

计算机辅助骨科导航技术近年来发展迅速,现已几乎涉及骨科所有领域,并取得初步成果。但由于此项技术的研发及应用尚处于起步阶段,目前面临以下主要问题:①无统一的技术标准,包括设备技术标准、手术操作规范和评价标准;②临床应用中尚存不少问题,如操作繁琐、手术时间延长以及易出现操作错误和错误信息反馈;③设备昂贵、技术尚待完善。了解其面临的问题有助于我们对这项技术的深入理解,并减少经济及临床应用上的风险,避免出现一拥而上的局面。     

计算机辅助带锁髓内钉远端锁定瞄准系统的设计与实验研究

目的　测试计算机辅助带锁髓内钉远端锁定瞄准系统应用于下肢模型骨及尸体骨固定中的准确性及安全性。方法　采用 10根塑料模型胫骨 ,2 0根塑料模型股骨 (SynboneAG ,Malans,Switzerland) ,6具青年男性新鲜尸体的双下肢标本 ,随机平均分为两组 ,行胫骨、股骨带锁髓内钉内固定术 (Orthofix带锁髓内钉 ,每根针远端有 2孔 )。在远端锁钉时 ,实验组采用计算机辅助带锁髓内钉远端锁定瞄准系统 ;对照组采用Orthofix带锁髓内钉机械锁定瞄准器。两组以远端锁钉锁定的手术操作时间、在C型臂X线下暴露时间、锁定的成功率三项指标进行比较。结果　实验组锁钉锁定的手术时间、X线下暴露时间、锁定成功率分别为 (4 4 4± 2 99)min、(1 16± 0 38)min ,(10 0± 0 ) % ;对照组手术时间、X线下暴露时间、锁定成功率分别为 (10 4 2± 4 18)min ,(4 71± 3 86 )min ,(94 4 4±0 36 ) % ,两组手术与X线下暴露时间显著减少 (P <0 0 5 )。结论　计算机辅助带锁髓内钉远端瞄准系统设计合理、定位准确、操作简便、成功率高、缩短了手术时间 ,特别是在手术中对C型臂X线的依赖程度降低 ,在X线下暴露时间短 ,减少了医患人员的放射损伤。该系统能够通用于各种类型的髓内针 ,便于推广、普及。