Introduction to Navigation - Robotic Total Knee Replacement

1. HISTORY of NAVIGATION and its Evolution
Dr. Kalaivanan Kanniyan

2. CAS - Computer Assisted Surgery is an innovative technology that
enhances surgical guidance since late 90s.
CAS was initially developed to locate brain tumors based on a surgical
intervention that used a three dimensional coordinate system.
computer‐assisted orthopaedic surgery (CAOS)
Advancement in Imaging modality like digital X‐rays, CT, MRI, ultrasound,
or fluoroscopy made CAS to allow surgeons to visualize more accurately
on a monitor as a real time image better than the anatomy.
CAS may provide real time operative views of surgical instruments and
their relative positioning with respect to the human anatomy and previously
existing implants.

3. CAS major advantages:
• increase the accuracy of surgical procedures
• reduce iatrogenic damage
• minimally invasive surgery
• reduce surgical time
• early post operative rehabilitation
Surgical navigation is a form of CAS and is the visualization system that
gives positional information about surgical tools or implants relative to a target
organ on a computer display

4. CAS
(i) passive systems,
(ii) semi‐active systems
(iii) active systems.
CAS: Passive
Navigation is the primary mode of passive systems, which may be CT based,
imageless, or fluoroscopic
optical 3‐D position sensor (Optotrak 3020),

5. Semi active systems perform some actions such as moving a drill guide sleeve or a
cutting jig. but no direct surgical procedure. Acrobot, allows surgeons to control a
drill bit using a robotic arm in real‐time
Active systems perform surgical actions that are programmed preoperatively.
ROBODOC, which prepares the femoral canal for prosthesis placement based on
pre surgical plans

6. “Navigation in surgery” ?
“Where is my (anatomical) target ?
“How do I reach my target safely?
“Where am I (anatomically)?
“Where and how shall I position my implant?
Neurosurgery
Stereotaxy
Frame based to frameless
1990s when David Roberts
Biggest advantage is the capability to track a surgical instrument in “real-time” and
constantly visualize its position on the preoperative CT or MRI.
This marked the inception of navigation in surgery – became image free

7. Navigation is a successor or natural evolution of frame-based stereotaxy.
• Guide the surgeon to find a specific anatomical target
• avoid areas of risk,
• offer intraoperative orientation in the absence of anatomical landmarks
• optimal alignment of implants
• 3D measurement system.
navigation system is in some way the same as a commonly used navigation
system in a car, Both attempt to localize or determine a position in space in the
context of its surroundings.
Difference is surgical navigation doesn’t use triangulation like a GPS - global
positioning system with the help of several geostationary satellites.

8. Modern surgical navigation systems use a stereoscopic camera emitting
infrared light which can determine a 3D position of prominent structures, like
reflective marker spheres. This allows for real-time tracking of the marker
spheres.
Mezger, Uli et al. “Navigation in surgery.” Langenbeck's archives of surgery vol. 398,4 (2013): 501-14.
doi:10.1007/s00423-013-1059-4

9. Modern orthopedic navigation systems are “model-based” and
work almost exclusively without information from external image sources.
No need of additional radiation, e.g., through CT or X-ray.
Instead the navigation software calculates an individual model of the patients’
anatomy based on defined landmarks on the bone which are acquired using a
navigated instrument (registration)

10. Image modalities
CT
MRI
Functional MRI
fluroscopy
Imageless
Image registration
1. Extrinsic registration methods (“gold standard”)
2. Curve methods
3. Surface methods
4. Moment and Principal Axes methods
5. Correlation methods
6. Atlas methods
7. Maximized mutual information-based methods
8. Wavelet-based methods
9. Artificial Neural network method (NN)
10.Genetic Algorithm (GA)
11.Fuzzy sets
12.Rough Sets
Imageless: computer constructs a digitized
anatomical model of the area of interest by
referencing the results of the patient's Orthopedic
tests, such as joint rotation angles, flexion/extension
angles, etc. Although a digital image is constructed by
the computer, there are no image-taking processes in
both the pre-operative and intra-operative stages
thereby eliminating radiation exposure, and reducing
operation time

11. Tracking of surgical tools Surgical tools are tracked by devices knows as
tracking systems. These devices measure the (Tx, Ty, Tz) coordinates of each
tool, as well as three angles (Rx, Ry, Rz) to describe the tool orientation, and
they report this information many times per second to make it possible to track
the motion of the tool
Clinical applications of computer assisted surgical navigation
Arthroplasty
spine surgery
Arthroscopy
Tumour surgery
Fracture surgery
Mavrogenis AF, Mimidis G, Koulalis D, Papagelopoulos PJ. Computer-
assisted navigation in orthopaedics. OA Orthopaedics 2014 Apr 15;2(1):8.

14. Brain LaB - Navigation - TKR

16. Thanks all Dr. Kalaivanan Kanniyan

21. ZHA Academy
CRMKR ( www.casereportmaker.com)
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