Technical note: standardized and semiautomated Harris lines detection.

Arrest in long bone growth and the subsequent resumption of growth may be visible as radiopaque transverse lines in radiographs (Harris lines, HL; Harris, HA. 1933. Bone growth in health and disease. London: Oxford University Press). The assessment of individual age at occurrence of such lines, as part of paleopathological skeletal studies, is time-consuming and shows large intra- and interobserver variability. Thus, a standardized, automated detection algorithm would help to increase the validity of such paleopathological research. We present an image analysis application facilitating automatic detection of HL. On the basis of established age calculation methods, the individual age-at-formation can be automatically assessed with the tool presented. Additional user input to confirm the automatic result is possible via an intuitive graphical user interface. Automated detection of HL from digital radiographs of a sample of late Medieval Swiss tibiae was compared to the consensus of manual assessment by two blinded expert observers. The intra- and interobserver variability was high. The quality of the observer result improved when standardized detection criteria were defined and applied. The newly developed algorithm detected two-thirds of the HL that were identified as consensus lines between the observers. It was, however, necessary to validate the last one-third by manual editing. The lack of a large test series must be noted. The application is freely available for further testing by any interested researcher.

Interactive visuo-haptic surgical planning tool for pelvic and acetabular fractures.

Treatment of pelvic and acetabular fractures still poses a major challenge to trauma surgeons. We present a tool for intervention planning for such injuries using patient-specific models built from Computed Tomography data. The presented tool has three main parts: (1) the virtual reduction of the bone fragments, (2) the virtual adaptation of the osteosynthesis implants and (3) Finite Element Analysis (FEA) for testing mechanical behavior of the resulting intervention plan. Our tool provides an intuitive visuo-hapic interface designed to be used by trauma surgeons. The type and size of the osteosynthesis material can be determined and measurements like distances and angles relative to landmarks can be taken. First results of prospectively planned interventions show an excellent correlation and a significant gain in operation time.

Comparing a simplified FEM approach with the mass-spring model for surgery simulation.

Virtual reality based surgical simulators offer a very elegant approach to enhancing traditional training in endoscopic surgery. In this context a realistic soft tissue model is of central importance. The most accurate procedures for modeling elastic deformations of tissue use the Finite Element Method (FEM) to solve the governing mechanical equations. An alternative are mass-spring models which are a crude approximation of the real physical behavior. The main reason given when using the mass-spring approach is the computational complexity of FEM. In this study we show that an optimized linear FEM model requires computation time similar to the mass-spring approach, while giving better results.

Rendering Virtual Tumors in Real Tissue Mock-Ups Using Haptic Augmented Reality.

Haptic augmented reality (AR) is an emerging research area, which targets the modulation of haptic properties of real objects by means of virtual feedback. In our research, we explore the feasibility of using this technology for medical training systems. As a possible demonstration example, we currently examine the use of augmentation in the context of breast tumor palpation. The key idea in our prototype system is to augment the real feedback of a silicone breast mock-up with simulated forces stemming from virtual tumors. In this paper, we introduce and evaluate the underlying algorithm to provide these force augmentations. This includes a method for the identification of the contact dynamics model via measurements on real sample objects. The performance of our augmentation is examined quantitatively as well as in a user study. Initial results show that the haptic feedback of indenting a real silicone tumor with a rod can be approximated reasonably well with our algorithm. The advantage of such an augmentation approach over physical training models is the ability to create a nearly infinite variety of palpable findings.

Effects of visual-haptic asynchronies and loading-unloading movements on compliance perception.

Spring compliance is perceived by combining the sensed force exerted by the spring with the displacement caused by the action (sensed through vision and proprioception). We investigated the effect of delay of visual and force information with respect to proprioception to understand how visual-haptic perception of compliance is achieved. First, we confirm an earlier result that force delay increases perceived compliance. Furthermore, we find that perceived compliance decreases with a delay in the visual information. These effects of delay on perceived compliance would not be present if the perceptual system would utilize all force-displacement information available during the interaction. Both delays generate a bias in compliance which is opposite in the loading and unloading phases of the interaction. To explain these findings, we propose that information during the loading phase of the spring displacement is weighted more than information obtained during unloading. We confirm this hypothesis by showing that sensitivity to compliance during loading movements is much higher than during unloading movements. Moreover, we show that visual and proprioceptive information about the hand position are used for compliance perception depending on the sensitivity to compliance. Finally, by analyzing participants' movements we show that these two factors (loading/unloading and reliability) account for the change in perceived compliance due to visual and force delays.

Data-Driven Haptic Rendering-From Viscous Fluids to Visco-Elastic Solids.

In this article we present extensions of our earlier work on data-driven haptic rendering. Haptic feedback is generated directly by interpolating measured data. The selection of appropriate data dimensions is guided by the structure of the generalized Maxwell model. Material elasticity and viscosity are reproduced, including transient material effects like stress relaxation. All these properties can be nonlinear and mutually dependent. Besides visco-elastic bodies, we also apply our method to viscous fluids. We present results for several materials and compare the errors of the interpolated forces with perceptual thresholds reported in the literature. Moreover, we examine how these errors behave if different subjects perform the recordings on which the data-driven haptic feedback is based.

A morphological approach to the simulation of forearm motion.

Computer-based simulations support surgeons in preoperative planning of osteotomy and assessing the improvement of the forearm motion. To this end, an in-silico model of patient-specific forearm kinematics is required. In this paper we introduce a motion model of the forearm which is based on a patient's joint morphology, the form and shape of the joints. The morphology of the articulations is represented by 3-dimensional splines. In this way the gliding motion of the articulations is expressed analytically in a closed-form. Our algorithm was designed to work with available clinical planning data and requires minimal user interaction. This allows an integration in computer-aided planning systems that are operated by surgeons. The accuracy of the simulation results is verified via cadaver experiments.

Modeling intravasation of liquid distension media in surgical simulators.

During therapeutic hysteroscopy and transurethral resection of the prostate, intravasation of the liquid distension media into the vascular system of the patient occurs. We present a model which allows the integration of the intravasation process into surgical simulator systems. A linear network flow model is extended with a correction for non-Newtonian blood behavior in small vessels and an appropriate handling of vessel compliance. We employ a fast lookup scheme in order to allow for real-time simulation. Cutting of tissue is accounted for by adjusting pressure boundary conditions for all cut vessels. We investigate the influence of changing distention fluid pressure settings and of the position of tissue cuts. In addition, we quantify the intravasation occurring with different approaches of fluid control, and we compare the performance of direct and iterative solvers applied to the non-linear system of the compliant model. Our simulation predicts significant intravasation only on the venous side, and just in cases when larger veins are cut. The implemented methods allow the realistic control of bleeding for short-term and of the total resulting intravasation volume for long-term complication scenarios. While the simulation is fast enough to support real-time training, it is also adequate for explaining intravasation effects which were previously observed on a phenomenological level only.

Using statistical shape analysis for the determination of uterine deformation states during hydrometra.

A fundamental prerequisite of hysteroscopy is the proper distension of the uterine cavity with a fluid, also known as hydrometra. For a virtual reality based simulation of hysteroscopy, the uterus deformation process due to different pressure settings has to be modeled. In previous work we have introduced a hybrid method, which relies on precomputed deformation states to derive the hydrometra changes during runtime. However, new offline computations were necessary for every newly introduced organ mesh. This is not viable if a new surgical scene is to be generated for every training session. Therefore, we include the deformation states during hydrometra into our previously developed statistical shape model for undeformed organ instances. This allows deriving the hydrometra steps together with new undeformed uterus meshes. These can then be used during the interactive simulation for predicting uterus deformation without time-intensive precomputation steps.

Modelling intravasation of liquid distension media in surgical simulators.

We simulate the intravasation of liquid distention media into the systemic circulation as it occurs during hysteroscopy and transurethral resection of the prostate. A linear network flow model is extended with a correction for non-newtonian blood behaviour in small vessels and an appropriate handling of vessel compliance. We then integrate a fast lookup scheme in order to allow for real-time simulation. Cutting of tissue is accounted for by adjusting pressure boundary conditions for all cut vessels. We investigate the influence of changing distention fluid pressure settings and of the position of tissue cuts. Our simulation predicts significant intravasation only on the venous side, and just in cases when larger veins are cut. The implemented methods allow the realistic control of bleeding for short-term and the total resulting intravasation volume for long-term complication scenarios. While the simulation is fast enough to support real-time training, it is also adequate for explaining intravasation effects which were previously observed on a phenomenological level only.

A hybrid cutting approach for hysteroscopy simulation.

An integral element of every surgical simulator is the ability to interactively cut tissue. A number of approaches have been suggested in the past, the most important being mesh subdivision by introducing new elements and mesh adaptation by adjusting existing topology. In this paper we combine these two methods and optimize them for our training system of hysteroscopic interventions. The basic methodology is introduced in 2D, a first extension to 3D is presented and finally the integration into the simulator described.

Hydrometra simulation for VR-based hysteroscopy training.

During hysteroscopy a hydrometra is maintained, i.e. the uterus is distended with liquid media to access and visualize the uterine cavity. The pressure and flow induced by the liquid are crucial tools for he gynecologists during surgery to obtain a clear view of the operation site. This paper presents two different aspects of hydrometra simulation, namely the distension of the uterine muscle and the liquid flow simulation in the cavity. The deformation of the organ's shape is computed offline based on finite element calculations whereas the flow is approximated on the fly by solving the simplified Navier-Stokes equations. The real-time capabilities of the presented algorithms as well as the level of fidelity achieved by the proposed methods are discussed.