Personal Digital Assistant in an orthopaedic wireless ward: the HandHealth project.

Personal Digital Assistant devices are becoming a frequently used device for the bedside care of the patient. Ways of application are many, but limitations are also numerous. Input device and monitor resolution are limited by the device size. Moreover, the choice of specific programs and the amount of storable data are limited by the quantity of memory. During HandHealth project a system was developed using a different point of view. Personal Digital Assistant is only a means to access data and use functionalities that are stored in a remote server. Using that system patient ward note can be showed and collected on the handheld device but saved directly on the Hospital Information System. Medical images can be showed on the device display, but also transferred to a high-resolution monitor. Large amount of data can be dictated and translated by remote continuous speech recognition.

Multimod Data Manager: a tool for data fusion.

Nowadays biomedical engineers regularly have to combine data from multiple medical imaging modalities, biomedical measurements and computer simulations and this can demand the knowledge of many specialised software tools. Acquiring this knowledge to the depth necessary to perform the various tasks can require considerable time and thus divert the researcher from addressing the actual biomedical problems. The aim of the present study is to describe a new application called the Multimod Data Manager, distributed as a freeware, which provides the end user with a fully integrated environment for the fusion and manipulation of all biomedical data. The Multimod Data Manager is generated using a software application framework, called the Multimod Application Framework, which is specifically designed to support the rapid development of computer aided medicine applications. To understand the general logic of the Data Manager, we first introduce the framework from which it is derived. We then illustrate its use by an example--the development of a complete subject-specific musculo-skeletal model of the lower limb from the Visible Human medical imaging data to be used for predicting the stresses in the skeleton during gait. While the Data Manager is clearly still only at the prototype stage, we believe that it is already capable of being used to solve a large number of problems common to many biomedical engineering activities.

The multimod application framework: a rapid application development tool for computer aided medicine.

This paper describes a new application framework (OpenMAF) for rapid development of multimodal applications in computer-aided medicine. MAF applications are multimodal in data, in representation, and in interaction. The framework supports almost any type of biomedical data, including DICOM datasets, motion-capture recordings, or data from computer simulations (e.g. finite element modeling). The interactive visualization approach (multimodal display) helps the user interpret complex datasets, providing multiple representations of the same data. In addition, the framework allows multimodal interaction by supporting the simultaneous use of different input-output devices like 3D trackers, stereoscopic displays, haptics hardware and speech recognition/synthesis systems. The Framework has been designed to run smoothly even on limited power computers, but it can take advantage of all hardware capabilities. The Framework is based on a collection of portable libraries and it can be compiled on any platform that supports OpenGL, including Windows, MacOS X and any flavor of Unix/linux.

Support for Taverna workflows in the VPH-Share cloud platform.

BACKGROUND AND OBJECTIVE: To address the increasing need for collaborative endeavours within the Virtual Physiological Human (VPH) community, the VPH-Share collaborative cloud platform allows researchers to expose and share sequences of complex biomedical processing tasks in the form of computational workflows. The Taverna Workflow System is a very popular tool for orchestrating complex biomedical & bioinformatics processing tasks in the VPH community. This paper describes the VPH-Share components that support the building and execution of Taverna workflows, and explains how they interact with other VPH-Share components to improve the capabilities of the VPH-Share platform. METHODS: Taverna workflow support is delivered by the Atmosphere cloud management platform and the VPH-Share Taverna plugin. These components are explained in detail, along with the two main procedures that were developed to enable this seamless integration: workflow composition and execution. RESULTS: 1) Seamless integration of VPH-Share with other components and systems. 2) Extended range of different tools for workflows. 3) Successful integration of scientific workflows from other VPH projects. 4) Execution speed improvement for medical applications. CONCLUSION: The presented workflow integration provides VPH-Share users with a wide range of different possibilities to compose and execute workflows, such as desktop or online composition, online batch execution, multithreading, remote execution, etc. The specific advantages of each supported tool are presented, as are the roles of Atmosphere and the VPH-Share plugin within the VPH-Share project. The combination of the VPH-Share plugin and Atmosphere engenders the VPH-Share infrastructure with far more flexible, powerful and usable capabilities for the VPH-Share community. As both components can continue to evolve and improve independently, we acknowledge that further improvements are still to be developed and will be described.

A Computational Approach for the Prediction of Fatigue Behaviour in Peripheral Stents: Application to a Clinical Case.

Nickel-Titanium (NiTi) peripheral stents are commonly used for the treatment of diseased femoropopliteal arteries (FPA). However, cyclic deformations of the vessel, induced by limb movements affect device performance and fatigue failure may occur. Stent strut fracture has been described in the literature, and is implicated as a potential causative factor in vessel re-occlusion. In this paper, a numerical approach is proposed to predict the fatigue behaviour of peripheral NiTi stents within patient-specific arterial geometries, as additional information to aid clinician intervention planning. The procedure needs some patient-specific vessel features derived from routine clinical images but, when this information is not available, reference data from the literature may be used, obviously increasing the uncertainties of the results. In addition, specific stent material data are required and can be obtained from experimental tests. Several 3D finite element models resembling stented vessel segments are built and used for fatigue analyses. For each model, axial cyclic boundary conditions are obtained from a patient-specific lumped parameter model representing the entire artery as a series of suitable springs. This allows the simplification of stiffness changes along the vessel due to plaque and stent that affect local axial deformations. Imposed local cyclic bending values depend on the stent location along the FPA. The procedure is exemplified by its application to an actual clinical case that showed two strut fractures at 18 months follow-up. Interestingly, despite the lack of some of patient-specific information and the use of data from the literature to inform the model, the numerical approach was able to interpret the in vivo fractures.

Validation of two algorithms to evaluate the interface between bone and orthopaedic implants.

The level of fit and fill of the prosthetic stem in the femoral canal is an important parameter when planning a cementless total hip arthroplasty. However, the standard templates used in combination with radiographs are not always effective in the pre-operative evaluation of the level of fitting. For this reason, two algorithms were developed able to provide clinically relevant three-dimensional indicators of the implant fit and fill in the host femur, based on the CT data of each specific patient as collected in vivo. In this study the computational methods were described and validated using digital phantom datasets. Then the algorithms were applied for in vivo datasets and the sensitivity of each indicator was evaluated. The validation showed that the two algorithms are accurate from a computational point of view. Moreover, the in vivo testing demonstrated that the developed methods provide reasonable quantitative indicators of the stem positioning in the femoral CT dataset.

An automated method to position prosthetic components within multiple anatomical spaces.

The level of fit and fill of a stem in the host femur is the most critical factor for the mechanical stability and success of the prosthesis. It would be useful to have a simulation tool able to investigate the anatomical compatibility of a new implant in a large library of femoral anatomies in the early phases of the design process. In order to realise this tool, it is necessary to develop an automatic method for the positioning of the stem in a database of anatomies. The aim of this study was to develop and evaluate a method for the automatic positioning of the stem geometry in the anatomical CT dataset. Two different strategies were considered: a completely automatic registration technique and a semi-automatic method based on an anatomical referencing. The two procedures were compared to the manual positioning obtained by an expert surgeon in a set of nine CT datasets. For both methods in each femur the positioning and the orientation of the stem were good. The results showed a better level of fitting for the automatic method, while the shift of the hip joint centre was lower for the anatomical referencing technique. However, the anatomical referencing method requires a higher computational effort without being significantly better than the automatic method. For this reason, the automatic method should be chosen to develop the automatic positioning of a stem in a database of anatomies.

A new software for prediction of femoral neck fractures.

Femoral neck fractures are an important clinical, social and economic problem. Even if many different attempts have been carried out to improve the accuracy predicting the fracture risk, it was demonstrated in retrospective studies that the standard clinical protocol achieves an accuracy of about 65%. A new procedure was developed including for the prediction not only bone mineral density but also geometric and femoral strength information and achieving an accuracy of about 80% in a previous retrospective study. Aim of the present work was to re-engineer research-based procedures and develop a real-time software for the prediction of the risk for femoral fracture. The result was efficient, repeatable and easy to use software for the evaluation of the femoral neck fracture risk to be inserted in the daily clinical practice providing a useful tool for the improvement of fracture prediction.

JIDE: a new software for computer-aided design of hip prosthesis.

This work is aimed at developing an innovative simulation environment supporting and improving the design of standard joint implants (JPD integrated design environment (JIDE)). The conceptual workflow starts from the design of a new implant, by using conventional CAD programmes and completes with the generation of a report that summarises the goodness for a new implant against a database of human bone anatomies. For each dataset in the database, the JPD application calculates a set of quantitative indicators that will support the designer in the evaluation of its design on a statistical basis. The resulting system is thus directed to prostheses manufacturers and addresses a market segment that appears to have a steady growth in the future.

Are subject-specific musculoskeletal models robust to the uncertainties in parameter identification?

Subject-specific musculoskeletal modeling can be applied to study musculoskeletal disorders, allowing inclusion of personalized anatomy and properties. Independent of the tools used for model creation, there are unavoidable uncertainties associated with parameter identification, whose effect on model predictions is still not fully understood. The aim of the present study was to analyze the sensitivity of subject-specific model predictions (i.e., joint angles, joint moments, muscle and joint contact forces) during walking to the uncertainties in the identification of body landmark positions, maximum muscle tension and musculotendon geometry. To this aim, we created an MRI-based musculoskeletal model of the lower limbs, defined as a 7-segment, 10-degree-of-freedom articulated linkage, actuated by 84 musculotendon units. We then performed a Monte-Carlo probabilistic analysis perturbing model parameters according to their uncertainty, and solving a typical inverse dynamics and static optimization problem using 500 models that included the different sets of perturbed variable values. Model creation and gait simulations were performed by using freely available software that we developed to standardize the process of model creation, integrate with OpenSim and create probabilistic simulations of movement. The uncertainties in input variables had a moderate effect on model predictions, as muscle and joint contact forces showed maximum standard deviation of 0.3 times body-weight and maximum range of 2.1 times body-weight. In addition, the output variables significantly correlated with few input variables (up to 7 out of 312) across the gait cycle, including the geometry definition of larger muscles and the maximum muscle tension in limited gait portions. Although we found subject-specific models not markedly sensitive to parameter identification, researchers should be aware of the model precision in relation to the intended application. In fact, force predictions could be affected by an uncertainty in the same order of magnitude of its value, although this condition has low probability to occur.

Computational Horizons In Cancer (CHIC): Developing Meta- and Hyper-Multiscale Models and Repositories for In Silico Oncology - a Brief Technical Outline of the Project.

This paper briefly outlines the aim, the objectives, the architecture and the main building blocks of the ongoing large scale integrating transatlantic research project CHIC (http://chic-vph.eu/).

SOA-based digital library services and composition in biomedical applications.

Carefully collected, high-quality data are crucial in biomedical visualization, and it is important that the user community has ready access to both this data and the high-performance computing resources needed by the complex, computational algorithms that will process it. Biological researchers generally require data, tools and algorithms from multiple providers to achieve their goals. This paper illustrates our response to the problems that result from this. The Living Human Digital Library (LHDL) project presented in this paper has taken advantage of Web Services to build a biomedical digital library infrastructure that allows clinicians and researchers not only to preserve, trace and share data resources, but also to collaborate at the data-processing level.

Multimodal fusion of biomedical data at different temporal and dimensional scales.

The introduction of integrative approaches to biomedical research (integrative biology, physiome, Virtual Physiological Human, etc.) poses original problems to computer aided medicine: the need to operate with large amounts of data that are strongly heterogeneous in structure, format and even in the knowledge domain that generated them; the need to integrate all of these data into a coherent whole; the further complication imposed by the fact that more and more frequently these data are captured at very different dimensional and/or temporal scales. The present study describes a first attempt at providing an interactive visualisation environment for homogeneous biomedical data defined over radically different spatial or temporal scales. In particular, we describe new strategies for the management of the dimensional information of highly heterogeneous data types; the management of temporal multiscaling; for 3D unstructured spatial multiscale visualisation and the related interaction paradigms and user interface. Preliminary results with a prototype implementation based on the OpenMAF application framework (http://www.openmaf.org) indicate that it is possible to develop effective environments for interactive visualisation of multiscale biomedical data.

PhysiomeSpace: digital library service for biomedical data.

Every research laboratory has a wealth of biomedical data locked up, which, if shared with other experts, could dramatically improve biomedical and healthcare research. With the PhysiomeSpace service, it is now possible with a few clicks to share with selected users biomedical data in an easy, controlled and safe way. The digital library service is managed using a client-server approach. The client application is used to import, fuse and enrich the data information according to the PhysiomeSpace resource ontology and upload/download the data to the library. The server services are hosted on the Biomed Town community portal, where through a web interface, the user can complete the metadata curation and share and/or publish the data resources. A search service capitalizes on the domain ontology and on the enrichment of metadata for each resource, providing a powerful discovery environment. Once the users have found the data resources they are interested in, they can add them to their basket, following a metaphor popular in e-commerce web sites. When all the necessary resources have been selected, the user can download the basket contents into the client application. The digital library service is now in beta and open to the biomedical research community.

Effect of a virtual reality interface on the learning curve and on the accuracy of a surgical planner for total hip replacement.

The aim of this study is to evaluate the performance of a non-conventional input and output device (virtual reality) in a total hip replacement surgical planner. A test was performed asking five users to position a cup in a defined position. Every user performed the task using three different hardware configurations: (I) conventional mouse and monitor, (II) mouse and auto-stereoscopic monitor, and (III) 12-DOF tracker (haptic device) and auto-stereoscopic monitor. The results were evaluated in terms of root mean square error of the obtained position with respect to the target one and in terms of learning curve. The results showed that the examined VR technology does not show a sufficient positioning accuracy to be considered for clinical assessment.

Virtual palpation of skeletal landmarks with multimodal display interfaces.

The 3D location of skeletal landmarks on CT datasets is an important procedure, used in many research and clinical contexts. The standard procedure involves the segmentation of the CT images, the creation of a 3D surface bone model, and the location of the landmarks on this surface. However, the segmentation is time-consuming and requires skilled operators and sophisticated software. The aim of the present study is to evaluate the efficacy of a multimodal display interface to direct volumetric interactive visualization in performing a virtual palpation task. An expert operator used the CT dataset of a patient's thigh region to locate 14 femoral skeletal landmarks. This operation was repeatedly performed using different CT data representation; the accuracy and repeatability were compared to those achievable with the conventional procedure based on the segmented 3D surface. When a multimodal display interface (formed by an orthogonal slice, RXCT and interactive isosurface views) was used to perform the virtual palpation directly on the CT data, the average coordinates of the landmarks did not differ significantly from those located on the 3D surface, and the measurement repeatability was actually better with the multimodal display of the volumetric data than with the 3D surface. Thus, we can conclude that skeletal virtual palpation can be performed directly on the CT dataset, as far as the virtual palpation is performed with a multimodal display interface.

Efficacy of stereoscopic visualization and six degrees of freedom interaction in preoperative planning of total hip replacement.

The aim of this study was to assess the accuracy of a six-degrees-of-freedom application for pre-operative planning of total hip replacement in a virtual reality (VR) environment. A test was performed estimating the system inherent accuracy. The users can move objects in the VR environment with an intrinsic accuracy almost four orders of magnitude greater than the object dimension. A second unambiguous and relevant task was defined to assess the accuracy achievable with the interface in a specific planning task. The results were compared with those obtained with 2D interfaces for both the stem and the cup component. The RMSE was assumed as an indicator of the achievable accuracy. The accuracy of the immersive interface was comparable with that achievable with a standard mouse - monitor interface. The users were consistent using the VR interface, confirming the high usability of the new interface and the steep learning curve of users unfamiliar with the new environment. This study has demonstrated that the application of VR environment for pre-operative planning of total hip replacement may help to shorten the duration of the positioning and to yield consistent results even with first-time users.

Prediction of hip fracture can be significantly improved by a single biomedical indicator.

Femoral neck fractures are a relevant clinical and social problem. The aim of this study was to improve the prediction of patients at-risk of femoral neck fracture with respect to the current densitometric-based methods. In particular, finite element models were used to assess the prediction accuracy obtained by combining together data from the bone density distribution, the proximal femur anatomy, and the fall-related loading conditions. Two-dimensional finite element models were developed based on dual energy x-ray absorptiometry data. A population of 93 elder Caucasian women (half of them reporting a femoral neck fracture) were retrospectively classified both using the standard clinical protocol and Bayes' linear classifiers. This study showed that the bone mineral density in the femoral neck region dominated the fracture event (65% accuracy). Adding the subject's height and the neck-shaft angle to the bone density increased the accuracy to 77%. The classification accuracy was further improved to 82% by including the peak principal tensile strain obtained from the finite element analyses. This research demonstrated that adding one single biomechanical indicator to the standard clinical measurements improves the identification of patients at-risk of femoral neck fracture.

New aspects and approaches in pre-operative planning of hip reconstruction: a computer simulation.

BACKGROUND: All computer-aided surgery technologies assume that the surgeon knows the best position for the implant components. However, there is indirect evidence that simple anatomical information may not be sufficient for the surgeon to decide size and position of the implant in a repeatable manner. METHOD: In the present study we estimated the variability in choosing the size and position of the components of a cementless total hip replacement (THR), using template-on-radiograph as well as computed tomography (CT)-based computer-aided planning. In addition, using a computer model, we assessed the sensitivity to such variability of implant fitting, location of the joint centre, skeletal range of motion, and resting length of major hip muscles. Using templates, surgeons selected the size with variability up to 2.5 mm for the stem and up to 4 mm for the socket. A similar variability was also observed when the CT-based planning program was used. RESULTS: No major differences were found between surgeons. The standard deviation over repeated planning sessions of the selected position for each component, using the CT-based planning software, was found to be 3.9 mm and 8.9 degrees . CONCLUSION: On the basis of the computer simulation, this variability did not affect the selected biomechanical parameters in a drastic way, although some differences were observed, especially in the lever arm of the hip muscles.

Accuracy and repeatability of cementless total hip replacement surgery in patients with deformed anatomies.

The present study is aimed to assess the repeatability of orthopaedic surgeons in planning total hip replacement surgery, and the Planned-vs.-Achieved accuracy obtainable with a conventional unassisted surgical procedure. A CT-based surgical planning system called Hip-Op was used for pre-operative planning the pose of the cementless components. The study group included only patients affected by severe deformities of the hip joint. In the repeatability study three surgeons were asked to repetitively plan the same three cases in a blind way. There was agreement among surgeons and also consistency for each surgeon in planning the implant position, while the most expert surgeon was more repeatable in planning the implant orientation. For all patients of the study group, the Planned-vs.-Achieved accuracy was computed as the difference between the spatial position of both prosthetic components derived from the post-operative CT scans and that achieved by the surgeon in the pre-operative planning. The average differences for the stem were lower than 5 mm for the position, and lower than 5 degrees for the orientation. For the socket the average differences increased to 8 mm and 10 degrees. The study shows the need for a more informative planning environment and for intra-operative supports, especially when deformed anatomies are involved.