Preoperative infection risk assessment in hip arthroplasty a matched-pair study of the reliability of 3 validated risk scales.

Peri-prosthetic infection (PJI) represents one of the most devastating complications of total hip arthroplasty (THA). The aim of this study is to assess the reliability of different PJI risk assessment scales between two matched pairs of THA groups. This study included 37 patients with PJI following THA performed between 2012 and 2020 (Group A). Each patient in this group was matched, based on sex, age, and follow-up duration, with a control patient who underwent the same surgical procedure without any septic complications (Group B) during the same period. Each patient's assessment included the American Society of Anesthesiologists (ASA) score and a retrospective evaluation using three different preoperative, specific PJI risk assessment scales: the International Consensus Meeting (ICM) Preoperative Risk Calculator for PJI, the Mayo PJI Risk Score, and the KLIC-score. The two groups were statistically compared using descriptive analyses, both for binomial data and numerical variables. Statistically significant higher values were observed in the preoperative ASA score and surgical time in Group A. Statistically different higher scores were determined only with the ICM risk calculator score in Group A. No significant differences were found using the KLIC score and Mayo score between the two groups. We emphasize the reliability of the ASA score as a nonspecific preoperative assessment scale for PJI. The ICM risk calculator was confirmed as a reliable, specific preoperative assessment scale for PJI, suggesting its routine adoption in THA clinical practice.

Femoral Neck Fractures in HIV-Positive Patients: Analysis of 10 Years Short-Term Post-operative Complications.

INTRODUCTION: Aging and effect of antiretroviral therapy on bone mass could increase the risk of femoral neck fractures (FNF) in HIV patient. The aim of this study was specifically to determine whether intracapsular FNF in HIV-positive patients are more prone to short-term post-operative complications than similar fractures occurring in HIV-negative patients. MATERIALS AND METHODS: A group of 25 HIV-positive patients with intracapsular FNF were enrolled and matched to HIV-negative patient with similar fractures according to gender, age, a modified Charlson Comorbidity Index (CCI), fracture classification, surgical treatment and time interval between fracture event and surgery. For each group, length of stay, surgical time, early clinical outcomes and short-term surgical and medical complications were compared to determine the impact on the early outcome. RESULTS: At the time of the fracture occurrence, 56% of HIV-positive patients were on antiretroviral therapy and 12% started with therapy in the perioperative period. At three months follow-up, there were no statistically significant differences between the two study groups in length of stay, Harris hip score and total number of early complications. However, a statistically significant increase in urinary tract infections and longer surgical time using hip sliding screw fixation were seen in the HIV-positive group. The poorest post-operative result was seen in a patient who failed to adequately adhere to the HIV therapy protocol. CONCLUSIONS: This study failed to show any statistically significant increase in short-term complications or worse clinical outcomes for intracapsular FNF in HIV-positive patients compared to HIV-negative patients to recommend their treatment in dedicated centres.

Adaptive Mathematical Model of Tumor Response to Radiotherapy Based on CBCT Data.

Mathematical modeling of tumor response to radiotherapy has the potential of enhancing the quality of the treatment plan, which can be even tailored on an individual basis. Lack of extensive in vivo validation has prevented, however, reliable clinical translation of modeling outcomes. Image-guided radiotherapy is a consolidated treatment modality based on computed tomographic (CT) imaging for tumor delineation and volumetric cone beam CT data for periodic checks during treatment. In this study, a macroscopic model of tumor growth and radiation response is proposed, being able to adapt along the treatment course as volumetric tumor data become available. Model parameter learning was based on cone beam CT images in 13 uterine cervical cancer patients, subdivided into three groups (G1, G2, G3) according to tumor type and treatment. Three group-specific parameter sets (PS1, PS2, and PS3) on one general parameter set (PSa) were applied. The corresponding average model fitting errors were 14%, 18%, 13%, and 21%, respectively. The model adaptation testing was performed using volume data of three patients, other than the ones involved in the parameter learning. The extrapolation performance of the general model was improved, while comparable prediction errors were found for the group-specific approach. This suggests that an online parameter tuning can overcome the limitations of a suboptimal patient stratification, which appeared otherwise a critical issue.

Image guided particle therapy in CNAO room 2: implementation and clinical validation.

In this contribution we describe the implementation of a novel solution for image guided particle therapy, designed to ensure the maximal accuracy in patient setup. The presented system is installed in the central treatment room at Centro Nazionale di Adroterapia Oncologica (CNAO, Italy), featuring two fixed beam lines (horizontal and vertical) for proton and carbon ion therapy. Treatment geometry verification is based on robotic in-room imaging acquisitions, allowing for 2D/3D registration from double planar kV-images or 3D/3D alignment from cone beam image reconstruction. The calculated six degrees-of-freedom correction vector is transferred to the robotic patient positioning system, thus yielding automated setup error compensation. Sub-millimetre scale residual errors were measured in absolute positioning of rigid phantoms, in agreement with optical- and laser-based assessment. Sub-millimetre and sub-degree positioning accuracy was achieved when simulating setup errors with anthropomorphic head, thorax and pelvis phantoms. The in-house design and development allowed a high level of system customization, capable of replicating the clinical performance of commercially available products, as reported with preliminary clinical results in 10 patients.

Commissioning of an integrated platform for time-resolved treatment delivery in scanned ion beam therapy by means of optical motion monitoring.

The integrated use of optical technologies for patient monitoring is addressed in the framework of time-resolved treatment delivery for scanned ion beam therapy. A software application has been designed to provide the therapy control system (TCS) with a continuous geometrical feedback by processing the external surrogates tridimensional data, detected in real-time via optical tracking. Conventional procedures for phase-based respiratory phase detection were implemented, as well as the interface to patient specific correlation models, in order to estimate internal tumor motion from surface markers. In this paper, particular attention is dedicated to the quantification of time delays resulting from system integration and its compensation by means of polynomial interpolation in the time domain. Dedicated tests to assess the separate delay contributions due to optical signal processing, digital data transfer to the TCS and passive beam energy modulation actuation have been performed. We report the system technological commissioning activities reporting dose distribution errors in a phantom study, where the treatment of a lung lesion was simulated, with both lateral and range beam position compensation. The zero-delay systems integration with a specific active scanning delivery machine was achieved by tuning the amount of time prediction applied to lateral (14.61 ± 0.98 ms) and depth (34.1 ± 6.29 ms) beam position correction signals, featuring sub-millimeter accuracy in forward estimation. Direct optical target observation and motion phase (MPh) based tumor motion discretization strategies were tested, resulting in 20.3(2.3)% and 21.2(9.3)% median (IQR) percentual relative dose difference with respect to static irradiation, respectively. Results confirm the technical feasibility of the implemented strategy towards 4D treatment delivery, with negligible percentual dose deviations with respect to static irradiation.

Commissioning and quality assurance of an integrated system for patient positioning and setup verification in particle therapy.

In an increasing number of clinical indications, radiotherapy with accelerated particles shows relevant advantages when compared with high energy X-ray irradiation. However, due to the finite range of ions, particle therapy can be severely compromised by setup errors and geometric uncertainties. The purpose of this work is to describe the commissioning and the design of the quality assurance procedures for patient positioning and setup verification systems at the Italian National Center for Oncological Hadrontherapy (CNAO). The accuracy of systems installed in CNAO and devoted to patient positioning and setup verification have been assessed using a laser tracking device. The accuracy in calibration and image based setup verification relying on in room X-ray imaging system was also quantified. Quality assurance tests to check the integration among all patient setup systems were designed, and records of daily QA tests since the start of clinical operation (2011) are presented. The overall accuracy of the patient positioning system and the patient verification system motion was proved to be below 0.5 mm under all the examined conditions, with median values below the 0.3 mm threshold. Image based registration in phantom studies exhibited sub-millimetric accuracy in setup verification at both cranial and extra-cranial sites. The calibration residuals of the OTS were found consistent with the expectations, with peak values below 0.3 mm. Quality assurance tests, daily performed before clinical operation, confirm adequate integration and sub-millimetric setup accuracy. Robotic patient positioning was successfully integrated with optical tracking and stereoscopic X-ray verification for patient setup in particle therapy. Sub-millimetric setup accuracy was achieved and consistently verified in daily clinical operation.

Tumor tracking based on correlation models in scanned ion beam therapy: an experimental study.

Accurate dose delivery to extra-cranial lesions requires tumor motion compensation. An effective compensation can be achieved by real-time tracking of the target position, either measured in fluoroscopy or estimated through correlation models as a function of external surrogate motion. In this work, we integrated two internal/external correlation models (a state space model and an artificial neural network-based model) into a custom infra-red optical tracking system (OTS). Dedicated experiments were designed and conducted at GSI (Helmholtzzentrum für Schwerionenforschung). A robotic breathing phantom was used to reproduce regular and irregular internal target motion as well as external thorax motion. The position of a set of markers placed on the phantom thorax was measured with the OTS and used by the correlation models to infer the internal target position in real-time. Finally, the estimated target position was provided as input for the dynamic steering of a carbon ion beam. Geometric results showed that the correlation models transversal (2D) targeting error was always lower than 1.3 mm (root mean square). A significant decrease of the dosimetric error with respect to the uncompensated irradiation was achieved in four out of six experiments, demonstrating that phase shifts are the most critical irregularity for external/internal correlation models.

Mechatronic design of a fully integrated camera for mini-invasive surgery.

This paper describes the design features of an innovative fully integrated camera candidate for mini-invasive abdominal surgery with single port or transluminal access. The apparatus includes a CMOS imaging sensor, a light-emitting diode (LED)-based unit for scene illumination, a photodiode for luminance detection, an optical system designed according to the mechanical compensation paradigm, an actuation unit for enabling autofocus and optical zoom, and a control logics based on microcontroller. The bulk of the apparatus is characterized by a tubular shape with a diameter of 10 mm and a length of 35 mm. The optical system, composed of four lens groups, of which two are mobile, has a total length of 13.46 mm and an effective focal length ranging from 1.61 to 4.44 mm with a zoom factor of 2.75×, with a corresponding angular field of view ranging from 16° to 40°. The mechatronics unit, devoted to move the zoom and the focus lens groups, is implemented adopting miniature piezoelectric motors. The control logics implements a closed-loop mechanism, between the LEDs and photodiode, to attain automatic control light. Bottlenecks of the design and some potential issues of the realization are discussed. A potential clinical scenario is introduced.

Robustness of external/internal correlation models for real-time tumor tracking to breathing motion variations.

In radiotherapy, organ motion mitigation by means of dynamic tumor tracking requires continuous information about the internal tumor position, which can be estimated relying on external/internal correlation models as a function of external surface surrogates. In this work, we propose a validation of a time-independent artificial neural networks-based tumor tracking method in the presence of changes in the breathing pattern, evaluating the performance on two datasets. First, simulated breathing motion traces were specifically generated to include gradually increasing respiratory irregularities. Then, seven publically available human liver motion traces were analyzed for the assessment of tracking accuracy, whose sensitivity with respect to the structural parameters of the model was also investigated. Results on simulated data showed that the proposed method was not affected by hysteretic target trajectories and it was able to cope with different respiratory irregularities, such as baseline drift and internal/external phase shift. The analysis of the liver motion traces reported an average RMS error equal to 1.10 mm, with five out of seven cases below 1 mm. In conclusion, this validation study proved that the proposed method is able to deal with respiratory irregularities both in controlled and real conditions.

Functional evaluation and rehabilitation engineering.

Life is complex and all about movement, which allows us to interact with the environment and communicate with each other. The human nervous system is capable of performing a simultaneous and integrated control of 100-150 mechanical degrees of freedom of movement in the body via tensions generated by about 700 muscles. In its widest context, movement is carried out by a sensory motor system comprising multiple sensors (visual,auditory, and proprioceptive),multiple actuators (muscles acting on the skeletal system),and an intermediary processor that can be summarized as a multiple-input­multiple-output nonlinear dynamic time-varying control system. This grand control system is capable of responding with remarkable accuracy,speed, appropriateness,versatility, and adaptability to a wide spectrum of continuous and discrete stimuli and conditions and is certainly orders of magnitude more complex and sophisticated than the most advanced robotic systems currently available. In the last decades,a great deal of research has been carried out in the fields of functional evaluation of human performance and rehabilitation engineering. These fields combine knowledge, concepts, and methods from across many disciplines (e.g., biomechanics,neuroscience, and physiology), with the aim of developing apparatuses and methods fort he measurement and analysis of complex sensory motor performance and the ultimate goal of enhancing the execution of different tasks in both healthy people and persons with reduced capabilities from different causes (injury, disease, amputation,and neural degeneration).

Isomap transform for segmenting human body shapes.

Segmentation of the 3D human body is a very challenging problem in applications exploiting volume capture data. Direct clustering in the Euclidean space is usually complex or even unsolvable. This paper presents an original method based on the Isomap (isometric feature mapping) transform of the volume data-set. The 3D articulated posture is mapped by Isomap in the pose of Da Vinci's Vitruvian man. The limbs are unrolled from each other and separated from the trunk and pelvis, and the topology of the human body shape is recovered. In such a configuration, Hoshen-Kopelman clustering applied to concentric spherical shells is used to automatically group points into the labelled principal curves. Shepard interpolation is utilised to back-map points of the principal curves into the original volume space. The experimental results performed on many different postures have proved the validity of the proposed method. Reliability of less than 2 cm and 3° in the location of the joint centres and direction axes of rotations has been obtained, respectively, which qualifies this procedure as a potential tool for markerless motion analysis.

Method for the estimation of a double hinge kinematic model for the trapeziometacarpal joint using MR imaging.

In this paper, we propose a method to estimate the parameters of a double hinge model of the trapeziometacarpal joint (TMC) by MRI-based motion analysis. The model includes two non-orthogonal and non-intersecting rotation axes accounting for flexion-extension (F-E) and adduction-abduction (A-A). We evaluated the quality of the estimated model parameters in the prediction of the relative motion of the first metacarpal bone with respect to the trapezium. As a result, we obtained that: (a) the estimated location and orientation of the F-E and A-A axes were in agreement with previous in vitro studies, (b) the motion of the first metacarpal predicted by the 2 degrees of freedom (2DoF) model exhibits a maximum surface distance error in the range of about 2 mm and (c) four thumb postures at the boundary of the TMC range of motion are sufficient to provide a good estimation of the 2DoF TMC kinematic model and good reproducibility (~1.7 mm) of the real thumb motion at TMC level.

Bi-unicompartmental versus total knee arthroplasty: a matched paired study with early clinical results.

INTRODUCTION: The authors performed a matched paired study between two groups: bi-unicompartmental (Bi-UKR) versus total knee replacements (TKR) for the treatment of isolated bicompartmental tibio-femoral knee arthritis with an asymptomatic patello-femoral joint. The Authors believe that Bi-UKR could achieve comparable outcomes than TKR, but with a real less invasive surgery and maintaining a higher joint function. MATERIALS AND METHODS: A total of 22 patients with bicompartmental tibio-femoral knee arthritis, who underwent Bi-UKR between January 1999 and March 2003, were included in the study (group A). In all the knees the arthritic changes were graded according to the classification of Alback. All patients had an asymptomatic patello-femoral joint. All patients had a varus deformity lower than 8 degrees , a body-mass index lower than 34, no clinical evidence of ACL laxity or flexion deformity and a preoperative range of motion of a least 110 degrees . At a minimum follow-up of 48 months, every single patient in group A was matched with a patient who had undergone a computer assisted TKR between August 1999 and September 2002 (group B). In the Bi-UKR group, in two cases we registered intraoperatively the avulsion of the treated tibial spines, requiring intra-operative internal fixation and without adverse effects on the final outcome. Statistical analysis of the results was performed. RESULTS: At a minimum follow-up of 48 months there were no statistical significant differences in the surgical time while the hospital stay was statistically longer in TKR group. No statistically significant difference was seen for the Knee Society, Functional and GIUM scores between the two groups. Statistically significant better WOMAC Function and Stiffness indexes were registered for the Bi-UKR group. TKR implants were statistically better aligned with all the implants positioned within 4 degrees of an ideal hip-knee-ankle (HKA) angle of 180 degrees . CONCLUSIONS: The results of this 48 months follow-up study suggest that Bi-UKR is a viable option for bicompartmental tibio-femoral arthritis at least as well as TKR but maintaining a higher level of function.

In vivo validation of a realistic kinematic model for the trapezio-metacarpal joint using an optoelectronic system.

This article analyzes a realistic kinematic model of the trapezio-metacarpal (TM) joint in the human thumb that involves two non-orthogonal and non-intersecting rotation axes. The estimation of the model parameters, i.e. the position and orientation of the two axes with respect to an anatomical coordinate system, was carried out by processing the motion of nine retroreflective markers, externally attached to the hand surface, surveyed by a video motion capture system. In order to compute the model parameters, prototypical circumduction movements were processed within an evolutionary optimization approach. Quality and reproducibility in assessing the parameters were demonstrated across multiple testing sessions on 10 healthy subjects (both left and right thumbs), involving the complete removal of all markers and then retesting. Maximum errors of less than 5 mm in the axis position and less than 6 degrees in the orientation were found, respectively. The inter-subject mean distance between the two axes was 4.16 and 4.71 mm for right and left TM joints, respectively. The inter-subject mean relative orientation between the two axes was about 106 and 113 degrees for right and left TM joints, respectively. Generalization properties of the model were evaluated quantitatively on opposition movements in terms of distance between measured and predicted marker positions (maximum error less than 5 mm). The performance of the proposed model compared favorably with the one (maximum error in the range of 7-8 mm) obtained by applying a universal joint model (orthogonal and intersecting axes). The ability of in vivo estimating the parameters of the proposed kinematic model represents a significant improvement for the biomechanical analysis of the hand motion.

Finger kinematic modeling and real-time hand motion estimation.

This paper describes methods and experimental studies concerned with quantitative reconstruction of finger movements in real-time, by means of multi-camera system and 24 surface markers. The approach utilizes a kinematic model of the articulated hand which consists in a hierarchical chain of rigid body segments characterized by 22 functional degrees of freedom and the global roto-translation. This work is focused on the experimental evaluation of a kinematical hand model for biomechanical analysis purposes. From a static posture, a completely automatic calibration procedure, based on anthropometric measures and geometric constraints, computes axes, and centers of rotations which are then utilized as the base of an interactive real-time animation of the hand model. The motion tracking, based on automatic marker labeling and predictive filter, is empowered by introducing constraints from functional finger postures. The validation is performed on four normal subjects through different right-handed motor tasks involving voluntary flexion-extension of the thumb, voluntary abduction-adduction of the thumb, grasping, and finger pointing. Performances are tested in terms of repeatability of angular profiles, model-based ability to predict marker trajectories and tracking success during real-time motion estimation. Results show intra-subject repeatability of the model calibration both to different postures and to re-marking in the range of 0.5 and 2 mm, respectively. Kinematic estimation proves satisfactory in terms of prediction capability (index finger: maximum RMSE 2.02 mm; thumb: maximum RMSE 3.25 mm) and motion reproducibility (R (2) coefficients--index finger: 0.96, thumb: 0.94). During fast grasping sequence (60 Hz), the percentage of residual marker occlusions is less than 1% and processing and visualization frequency of 50 Hz confirms the real-time capability of the motion estimation system.

Kinematical models to reduce the effect of skin artifacts on marker-based human motion estimation.

The estimation of the skeletal motion obtained from marker-based motion capture systems is known to be affected by significant bias caused by skin movement artifacts, which affects joint center and rotation axis estimation. Among different techniques proposed in the literature, that based on rigid body model, still the most used by commercial motion capture systems, can smooth only part of the above effects without eliminating their main components. In order to sensibly improve the accuracy of the motion estimation, a novel technique, named local motion estimation (LME), is proposed. This rests on a recently described approach that, using virtual humans and extended Kalman filters, estimates the kinematical variables directly from 2D measurements without requiring the 3D marker reconstruction. In this paper, we show how such method can be extended to include the computation of the local marker displacement due to skin artifacts. The 3D marker coordinates, expressed in the corresponding local reference coordinate frames, are inserted into the state vector of the filter and their dynamics is automatically estimated, with adequate accuracy, without assuming any particular deformation function. Simulated experiments of lower limb motion, involving systematic mislocations (5, 10, 20 mm) and random errors of the marker coordinates and joint center locations (+/-5, +/-10, +/-15 mm), have shown that artifact motion can be substantially decoupled from the global skeletal motion with an effective increase of the accuracy wrt standard techniques. In particular, the comparison between the nominal kinematical variables and the one recovered from markers attached to the skin surface proved LME to be sensibly superior (50% in the worse condition) to the methods imposing marker-bone rigidity. In conclusion, while requiring further validation on real movement data, we argue that the proposed method can constitute an appropriate approach toward the improvement of the human motion estimation.

Derivation of centers and axes of rotation for wrist and fingers in a hand kinematic model: methods and reliability results.

In the field of 3D reconstruction of human motion from video, model-based techniques have been proposed to increase the estimation accuracy and the degree of automation. The feasibility of this approach is strictly connected with the adopted biomechanical model. Particularly, the representation of the kinematic chain and the assessment of the corresponding parameters play a relevant role for the success of the motion assessment. In this paper, the focus is on the determination of the kinematic parameters of a general hand skeleton model using surface measurements. A novel method that integrates nonrigid sphere fitting and evolutionary optimization is proposed to estimate the centers and the functional axes of rotation of the skeletal joints. The reliability of the technique is tested using real movement data and simulated motions with known ground truth 3D measurement noise and different ranges of motion (RoM). With respect to standard nonrigid sphere fitting techniques, the proposed method performs 10-50% better in the best condition (very low noise and wide RoM) and over 100% better with physiological artifacts and RoM. Repeatability in the range of a couple of millimeters, on the localization of the centers of rotation, and in the range of one degree, on the axis directions is obtained from real data experiments.

CT-3D rotational angiography automatic registration: a sensitivity analysis.

Preprocessing, binning and dataset subsampling are investigated with regard to simultaneous maximisation of the speed, accuracy and robustness of CT-3D rotational angiography (3DRA) registration. Clinical diagnosis and treatment can both take advantage of this integration, because 3DRA allows the shape of vessel structures to be evaluated three-dimensionally with respect to standard 2D projective angiography. The method for optimising preprocessing, binning and subsampling consisted of independent variation of the corresponding parameters to maximise robustness and speed while maintaining subvoxel accuracy; the latter was computed as the sum of the mean squared errors initially present in the registrations with the errors relative to both binning and subsampling. The results suggest the choice of 256 bins, steps between 14 mm (coarse optimisation) and 2.5 mm (fine optimisation) and bone segmentation by threshold, for binning, subsampling and preprocessing, respectively. The application of this parameter set-up to 50 CT-3DRA registrations resulted in a saving, on average, of 40% of the time with respect to the method previously used, while registration error was maintained within 2 mm (1.97 mm, 90% confidence interval) and robustness was increased, so that no manual initial realignment was needed in 48 registrations. Validation by the registration of images acquired for a head phantom showed subvoxel residual errors. In conclusion, the proposed procedure can be considered a satisfactory strategy to optimise CT-3DRA registration.

Preliminary study on the use of nonrigid registration for thoraco-abdominal radiosurgery.

The inclusion of organ deformation and movement in radiosurgery treatment planning is of increasing importance as research and clinical applications begin to take into consideration the effects of physiological processes, like breathing, on the shape and position of lesions. In this scenario, the challenge is to localize the target in toto (not only by means of marker sampling) and to calculate the dose distribution as the sum of all the contributions from the positions assumed by the target during the respiratory cycle. The aim of this work is to investigate the use of nonrigid registration for target tracking and dynamic treatment planning, i.e., treatment planning based not on one single CT scan but on multiple CT scans representative of the respiration. Twenty patients were CT scanned at end-inhale and end-exhale. An expert radiation oncologist identified the PTV in both examinations. The two CT data sets per patient were nonrigidly registered using a free-form deformation algorithm based on B-splines. The optimized objective function consisted of a weighted sum of a similarity criterion (Mutual Information) and a regularization factor which constrains the transformation to be locally rigid. Once the transformation was obtained and the registration validated, its parameters were applied to the target only. Finally, the deformed target was compared to the PTV delineated by the radiation oncologist in the other study. The results of this procedure show an agreement between the center of mass as well as volume of the target identified automatically by deformable registration and manually by the radiation oncologist. Moreover, obtained displacements were in agreement with body structure constraints and considerations usually accepted in radiation therapy practice. No significant influence of initial target volume on displacements was found. In conclusion, the proposed method seems to offer the possibility of using nonrigid registrations in radiosurgery treatment planning, even if more cases need to be investigated in order to give a statistical consistency to parameter setup and proposed considerations.