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Three-Dimensional Virtual Reality Simulation of Periarticular Tumors Using Dextroscope Reconstruction and Simulated Surgery : a Preliminary 10 Case Study

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Three-Dimensional Virtual Reality Simulation of Periarticular Tumors Using Dextroscope Reconstruction and Simulated Surgery : a Preliminary 10 Case Study Shi et al._Opmaak 1 20/03/14 15:19 Pagina 132 Acta Orthop. Belg., 2014, 80, 132-138 ORIGINAL STUDY Three-dimensional virtual reality simulation of periarticular tumors using Dextroscope reconstruction and simulated surgery : a preliminary 10 case study JingSheng SHi, Jun Xia, YiBing WEi, SiQun WaNg, Jianguo WU, FeiYan CHEN, gangYong HUaNg, Jie CHEN From the Department of Orthopedics, Huashan Hospital of Fudan University, Shanghai 200040, China A Dextroscope® three-dimensional (3D) imaging has such as drilling and implant placement, are urgently been extensively applied for generation of virtual required. reality (Vr) workspaces for in neurosurgery and laparoscopy, though few applications in orthopedic Keywords : simulation ; virtual surgery ; reconstruc- surgery have been reported. tion ; periarticular tumor; virtual reality Patients undergoing surgery for periarticular tumors (n = 10) from oct. 2008 to Jun. 2010 were enrolled and presurgically subjected to computed tomogra- Abbreviations : virtual reality (VR) ; computed phy (cT), magnetic resonance imaging (MrI), and tomography (CT), magnetic resonance imaging MrI angiography (MrI-A). Imaging data was trans- (MRi), and magnetic resonance angiography (MRi- ferred and integrated in Dextroscope, producing a a) Vr simulation. resultant presurgical 3D anatomical reconstructions and intraoperative anatomical char- InTroDucTIon acteristics (virtual vs. actual data) and surgical approach (virtual vs. actual situation) measurement Multimodal virtual reality (VR) imaging for and subjective appearance were compared. Anatomical characteristics in the area of interest and presurgical visualization is increasingly common in tumor diameters were consistent between virtual and actual data. However, the virtual surgical situations remained inconsistent with the actual intraoperative I situation in many cases, leading to complications. The JingSheng Shi, MS. I Jun Xia*, MD. resolution of original cT, MrI, and MrI-A images I YiBing Wei, MD. directly correlated with the quality of 3D simulations, I SiQun Wang, MD. with soft tissues most poorly represented. Tumor tis- I JianGuo Wu, MS. sue imaging quality in 3D varied extensively by I FeiYan Chen, MD. tumor type. I GangYong Huang, MD. conclusions : Anatomical structures of periarticular I Jie Chen, MS tumors can be reconstructed using the Dextroscope Department of Orthopedics, Huashan Hospital of Fudan system with good accuracy in the case of simple fen- University, Shanghai 200040, China. estration, increasing individualization of treatment, Correspondence : Jun Xia Department of Orthopedics, surgical competence level, and potentially reducing Huashan Hospital of Fudan University, Middle Urumqi Road intraoperative complications. However, further spe- No. 12, Shanghai 200040, China. E-mail : [email protected] cialization of Vr tools for use in orthopedic applica- © 2014, Acta Orthopædica Belgica. tions that involve specialized tools and procedures, Acta Orthopædica Belgica, Vol. 80 - 1 - 2014 No benefits or funds were received in support of this study. Shi et al._Opmaak 1 20/03/14 15:19 Pagina 133 pERiaRTiCUlaR TUMORS iN 3D ViRTUal REaliTY 133 contemporary clinical settings (22). These techni - ques have been widely and successfully employed in neurosurgery and laparoscopy (7,12), but less than 16 cases and 23 published articles have reported orthopedic applications of VR despite the potential for improvements in surgical evaluation and plan- ning, minimization of unanticipated intraoperative variations, and improvements in patient outcomes Fig. 1. — The Dextroscope interface. 15) ( . These cases consisted primarily of acetabular (a) Single extraction of the area of interest using ‘tool kit’ (bot- fractures (21), total hip replacement (19), and arthro- tom) for automatic recognition and extraction of the area using scopic knee surgery (4), representing few of the bitmap grayscale ranges, and (b) one-by-one image selection myriad of potential orthopedic applications. and integration, including automatic and manual operation Dextroscope® is a prominent VR system for using 2- and multiple-point methods. reconstruction of two-dimensional (2D) from DiCOM data and three-dimensional (3D) stereo- scopic virtual workspaces from magnetic resonance imaging (MRi) and computed tomography (CT) tibia (1 case) were confirmed by postsurgical pathologi- cal examination. all patients were followed a minimum data (3,13,23-25,29). The 3D user interface reflects the of 12 months. The study was approved by the institu - computer-generated scenario into the user's eyes tional Review Board of the Huashan Hospital of Fudan using mirrors and time-split synchronized liquid University, and written inform consent was obtained display shutter glasses, allowing full manipulation from each patient. of the 3D workspace by hand-held pen and virtual ‘tool rack’ (8). Color, transparency, segmentation, Vr image data image fusion, and linear and volumetric measure- ments can also be manipulated and exported in all patients were subject to CT (SOMaTOM image or video format (8), allowing for complete Sensation® 64-Slice CT System ; Siemens, germany), surgical simulation. MRi (gE 3.0 Tesla Signal Horizon; gE Healthcare, periarticular tumors in 10 patients were assessed USa), and MRi angiography (MRi-a) 2 days prior to by conventional MRi and CT imaging and data was surgery using layer thickness and spacing of 2 mm. integrated with Dextroscope to produce a 3D work- Native DiCOM images were converted to Radio - Dexter version 1.0 (Volume interactions, Singapore) space to examine pathological anatomical structure. software format, preliminarily processed, loaded into the Simulated virtual and actual intraoperative anatom- Dextroscope® (Volume interactions, Singapore) 3D VR ical characteristics and surgeries were compared to environment, and observed by an operator equipped with provide a preliminary evaluation of orthopedic use liquid crystal stereoscopic glasses, transmitter (left of Dextroscope for periarticular tumor treatment. hand), and virtual pen (right hand). areas of interest were assigned (Fig. 1a) and integrated by automated or SubJecTS AnD MeTHoDS manual 2- or multiple-point selection (Fig. 1b). The operator assigned tissue colors for visualization Subjects and segmented or rotated structures. Selective removal of skin, skeleton, tumors, vessels, and neighboring Benign periarticular tumor patients (n = 10 ; M:F, anatomical and functional structures using variant seg- 4:6 ; aged 23-52 years ; mean age 39.2 years) scheduled mentation and extraction was used to reveal anatomical for curettage and artificial bone or bone cement implan- characteristics in the final reconstructions (Fig. 2). tation at the Department of Orthopedics from Oct. 2008 Resultant presurgical 3D anatomical reconstructions to Jun. 2010 were enrolled. Diagnoses of aneurysmal (virtual data) were used to generate tumor vertical, trans- bone cyst in proximal femur (5 cases), giant-cell tumor verse, and anteroposterior diameters and these values of bone in the proximal tibia (3 cases), chondroblastoma were compared to intraoperative measurements (actual in proximal humerus (1 case), and bone cyst in left distal data). Acta Orthopædica Belgica, Vol. 80 - 1 - 2014 Shi et al._Opmaak 1 20/03/14 15:19 Pagina 134 134 J.S. SHi, J. Xia, Y.B. WEi, S.Q.UN WaNg, J.g. WU, F.Y. CHEN, g.Y. HUaNg, J. CHEN tionships between relationship between lesions and neighboring tissues were examined. Subjective image assessment by the operator and surgical precision were compared with those from the intraoperative surgical sit- uation (actual situation). Standard postsurgical care was performed. Statistical analysis Statistical analyses were performed in SpSS version 16.0 (SpSS inc., USa). all continuous variables were presented as means ± standard deviations (SD) and ana- lyzed using paired t-tests. P-values less than 0.05 were considered statistically significant (p < 0.05). reSulTS Patient data and Dextroscope imaging patient data for all 10 cases are shown in Table 1. Each patient dataset yielded successful virtual and Fig. 2. — Removal of blocking structures and tissues to gener- ate reconstruction images for measurement. actual information for both data and situation. imaging resolution was determined by the resolu- tion of the original image data and was highly vari- ant between individual tissue types based on sub- Presurgical planning and surgical approach jective visual assessment. Optimal visual effects The VR workspace was used to expose lesion sites were achieved in the skeleton and skin, though according to standard surgical requirements for optimal blood vessel also exhibited relatively high-quality field of view, including soft tissue incision, bone flap reconstruction images. Conversely, low-quality fenestration, and tumor curettage, to generate individual- reconstruction was apparent in soft tissues, such as ized presurgical plans. Final output images/videos (virtu- muscles. The quality of tumor tissue reconstruction al situation) were used as surgical references, and rela- varied by tumor characteristics (data not shown). Table 1. — periarticular tumor patients examined by Dextroscope Case no. gender age Diagnosis affected location Condition* Follow-up (yrs) side (mo) 1M41 aneurysmal bone cyst l proximal femur - 12 2F43 aneurysmal bone cyst R proximal femur psoriasis 15 3M23 Chondroblastoma l proximal humerus - 26 4F35 giant-cell tumor of bone R proximal tibia - 16 5F48 Bone cyst l distal tibia Sjögren's syndrome
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