Mechanical restoration and failure analyses of a hydrogel and scaffold composite strategy for annulus fibrosus repair

Unrepaired defects in the annulus fibrosus of intervertebral disks are associated with degeneration and persistent back pain. A clinical need exists for a disk repair strategy that can seal annular defects, be easily delivered during surgical procedures, and restore biomechanics with low risk of herniation. Multiple annulus repair strategies were developed using poly(trimethylene carbonate) scaffolds optimized for cell delivery, polyurethane membranes designed to prevent herniation, and fibrin-genipin adhesive tuned to annulus fibrosus shear properties. This three-part study evaluated repair strategies for biomechanical restoration, herniation risk and failure mode in torsion, bending and compression at physiological and hyper-physiological loads using a bovine injury model. Fibrin-genipin hydrogel restored some torsional stiffness, bending ROM and disk height loss, with negligible herniation risk and failure was observed histologically at the fibrin-genipin mid-substance following rigorous loading. Scaffold-based repairs partially restored biomechanics, but had high herniation risk even when stabilized with sutured membranes and failure was observed histologically at the interface between scaffold and fibrin-genipin adhesive. Fibrin-genipin was the simplest annulus fibrosus repair solution evaluated that involved an easily deliverable adhesive that filled irregularly-shaped annular defects and partially restored disk biomechanics with low herniation risk, suggesting further evaluation for disk repair may be warranted. Statement of significance Lower back pain is the leading cause of global disability and commonly caused by defects and failure of intervertebral disk tissues resulting in herniation and compression of adjacent nerves. Annulus fibrosus repair materials and techniques have not been successful due to the challenging mechanical and chemical microenvironment and the needs to restore biomechanical behaviors and promote healing with negligible herniation risk while being delivered during surgical procedures. This work addressed this challenging biomaterial and clinical problem using novel materials including an adhesive hydrogel, a scaffold capable of cell delivery, and a membrane to prevent herniation. Composite repair strategies were evaluated and optimized in quantitative three-part study that rigorously evaluated disk repair and provided a framework for evaluating alternate repair techniques.

Fully Automatic Segmentation of Hip CT Images

Automatic segmentation of the hip joint with pelvis and proximal femur surfaces from CT images is essential for orthopedic diagnosis and surgery. It remains challenging due to the narrowness of hip joint space, where the adjacent surfaces of acetabulum and femoral head are hardly distinguished from each other. This chapter presents a fully automatic method to segment pelvic and proximal femoral surfaces from hip CT images. A coarse-to-fine strategy was proposed to combine multi-atlas segmentation with graph-based surface detection. The multi-atlas segmentation step seeks to coarsely extract the entire hip joint region. It uses automatically detected anatomical landmarks to initialize and select the atlas and accelerate the segmentation. The graph based surface detection is to refine the coarsely segmented hip joint region. It aims at completely and efficiently separate the adjacent surfaces of the acetabulum and the femoral head while preserving the hip joint structure. The proposed strategy was evaluated on 30 hip CT images and provided an average accuracy of 0.55, 0.54, and 0.50 mm for segmenting the pelvis, the left and right proximal femurs, respectively.

Automated 3D Lumbar Intervertebral Disc Segmentation from MRI Data Sets

This paper proposed an automated three-dimensional (3D) lumbar intervertebral disc (IVD) segmentation strategy from Magnetic Resonance Imaging (MRI) data. Starting from two user supplied landmarks, the geometrical parameters of all lumbar vertebral bodies and intervertebral discs are automatically extracted from a mid-sagittal slice using a graphical model based template matching approach. Based on the estimated two-dimensional (2D) geometrical parameters, a 3D variable-radius soft tube model of the lumbar spine column is built by model fitting to the 3D data volume. Taking the geometrical information from the 3D lumbar spine column as constraints and segmentation initialization, the disc segmentation is achieved by a multi-kernel diffeomorphic registration between a 3D template of the disc and the observed MRI data. Experiments on 15 patient data sets showed the robustness and the accuracy of the proposed algorithm.

Preoperative Planning of Periacetabular Osteotomy (PAO)

Pelvic osteotomies improve containment of the femoral head in cases of developmental dysplasia of the hip or in femoroacetabular impingement due to acetabular retroversion. In the evolution of osteotomies, the Ganz Periacetabular Osteotomy (PAO) is among the complex reorientation osteotomies and allows for complete mobilization of the acetabulum without compromising the integrity of the pelvic ring. For the complex reorientation osteotomies, preoperative planning of the required acetabular correction is an important step, due to the need to comprehend the three-dimensional (3D) relationship between acetabulum and femur. Traditionally, planning was performed using conventional radiographs in different projections, reducing the 3D problem to a two-dimensional one. Known disturbance variables, mainly tilt and rotation of the pelvis make assessment by these means approximate at the most. The advent of modern enhanced computation skills and new imaging techniques gave room for more sophisticated means of preoperative planning. Apart from analysis of acetabular geometry on conventional x-rays by sophisticated software applications, more accurate assessment of coverage and congruency and thus amount of correction necessary can be performed on multiplanar CT images. With further evolution of computer-assisted orthopaedic surgery, especially the ability to generate 3D models from the CT data, examiners were enabled to simulate the in vivo situation in a virtual in vitro setting. Based on this ability, different techniques have been described. They basically all employ virtual definition of an acetabular fragment. Subsequently reorientation can be simulated using either 3D calculation of standard parameters of femoroacetabular morphology, or joint contact pressures, or a combination of both. Other techniques employ patient specific implants, templates or cutting guides to achieve the goal of safe periacetabular osteotomies. This chapter will give an overview of the available techniques for planning of periacetabular osteotomy.

2D-3D Reconstruction-Based Planning of Total Hip Arthroplasty

This chapter proposed a personalized X-ray reconstruction-based planning and post-operative treatment evaluation framework called iJoint for advancing modern Total Hip Arthroplasty (THA). Based on a mobile X-ray image calibration phantom and a unique 2D-3D reconstruction technique, iJoint can generate patient-specific models of hip joint by non-rigidly matching statistical shape models to the X-ray radiographs. Such a reconstruction enables a true 3D planning and treatment evaluation of hip arthroplasty from just 2D X-ray radiographs whose acquisition is part of the standard diagnostic and treatment loop. As part of the system, a 3D model-based planning environment provides surgeons with hip arthroplasty related parameters such as implant type, size, position, offset and leg length equalization. With this newly developed system, we are able to provide true 3D solutions for computer assisted planning of THA using only 2D X-ray radiographs, which is not only innovative but also cost-effective.

A cost-effective surgical navigation solution for periacetabular osteotomy (PAO) surgery

In this chapter a low-cost surgical navigation solution for periacetabular osteotomy (PAO) surgery is described. Two commercial inertial measurement units (IMU, Xsens Technologies, The Netherlands), are attached to a patient’s pelvis and to the acetabular fragment, respectively. Registration of the patient with a pre-operatively acquired computer model is done by recording the orientation of the patient’s anterior pelvic plane (APP) using one IMU. A custom-designed device is used to record the orientation of the APP in the reference coordinate system of the IMU. After registration, the two sensors are mounted to the patient’s pelvis and acetabular fragment, respectively. Once the initial position is recorded, the orientation is measured and displayed on a computer screen. A patient-specific computer model generated from a pre-operatively acquired computed tomography (CT) scan is used to visualize the updated orientation of the acetabular fragment. Experiments with plastic bones (7 hip joints) performed in an operating room comparing a previously developed optical navigation system with our inertial-based navigation system showed no statistical difference on the measurement of acetabular component reorientation (anteversion and inclination). In six out of seven hip joints the mean absolute difference was below five degrees for both anteversion and inclination.

Effect of boundary conditions on yield properties of human femoral trabecular bone

Trabecular bone plays an important mechanical role in bone fractures and implant stability. Homogenized nonlinear finite element (FE) analysis of whole bones can deliver improved fracture risk and implant loosening assessment. Such simulations require the knowledge of mechanical properties such as an appropriate yield behavior and criterion for trabecular bone. Identification of a complete yield surface is extremely difficult experimentally but can be achieved in silico by using micro-FE analysis on cubical trabecular volume elements. Nevertheless, the influence of the boundary conditions (BCs), which are applied to such volume elements, on the obtained yield properties remains unknown. Therefore, this study compared homogenized yield properties along 17 load cases of 126 human femoral trabecular cubic specimens computed with classical kinematic uniform BCs (KUBCs) and a new set of mixed uniform BCs, namely periodicity-compatible mixed uniform BCs (PMUBCs). In stress space, PMUBCs lead to 7–72 % lower yield stresses compared to KUBCs. The yield surfaces obtained with both KUBCs and PMUBCs demonstrate a pressure-sensitive ellipsoidal shape. A volume fraction and fabric-based quadric yield function successfully fitted the yield surfaces of both BCs with a correlation coefficient R2≥0.93. As expected, yield strains show only a weak dependency on bone volume fraction and fabric. The role of the two BCs in homogenized FE analysis of whole bones will need to be investigated and validated with experimental results at the whole bone level in future studies.

Nitinol Stent Oversizing in Patients Undergoing Popliteal Artery Revascularization: A Finite Element Study

Nitinol stent oversizing is frequently performed in peripheral arteries to ensure a desirable lumen gain. However, the clinical effect of mis-sizing remains controversial. The goal of this study was to provide a better understanding of the structural and hemodynamic effects of Nitinol stent oversizing. Five patient-specific numerical models of non-calcified popliteal arteries were developed to simulate the deployment of Nitinol stents with oversizing ratios ranging from 1.1 to 1.8. In addition to arterial biomechanics, computational fluid dynamics methods were adopted to simulate the physiological blood flow inside the stented arteries. Results showed that stent oversizing led to a limited increase in the acute lumen gain, albeit at the cost of a significant increase in arterial wall stresses. Furthermore, localized areas affected by low Wall Shear Stress increased with higher oversizing ratios. Stents were also negatively impacted by the procedure as their fatigue safety factors gradually decreased with oversizing. These adverse effects to both the artery walls and stents may create circumstances for restenosis. Although the ideal oversizing ratio is stent-specific, this study showed that Nitinol stent oversizing has a very small impact on the immediate lumen gain, which contradicts the clinical motivations of the procedure.