The glenohumeral joint is an important joint with large mobility of the human upper extremity. In shoulder arthroplasty patients often has an unsatisfactory outcome. In order to understand the biomechanical complexity of the shoulder, a novel computer controlled experimental shoulder simulator with an innovative muscle control were constructed. The main component of the simulator includes the active pneumatic muscles to replicate the deltoid and the rotator-cuff function and two springs as passive muscle. The aim of this study is to evaluate the impact of a variation of shoulder joint geometries on shoulder biomechanics in the basis of motion analysis. The radius of the glenoid cavity varied from 28–33mm with 2.5mm increment while the radius the humeral head are varied from 20.1–25.1 with 2.5mm increment. The “teach-in” function of the simulator allows an operator to assign the movement to the simulator where the lengths of the pneumatic muscles are recorded. Then the simulator repeats the assigned movement according to the recorded muscles length. The daily living activities includes abduction/adduction, internal/external rotation with adducted arm, and circumduction. The results show promising repeatability of the simulator with minor deviation. However, damage on the surface of the humeral head has been found which should be further studied for both shoulder behavior investigation and the shoulder simulator optimisation. Therefore, this study is a decent initial study toward the verification of the simulator and lead to a better understanding of shoulder biomechanical behavior to cope with the clinical problems in the future.

The sagittal orientation of the pelvis commonly called pelvic tilt has an effect on the orientation of the cup in total hip arthroplasty (THA). Pelvic tilt is different between individuals and changes during activities of daily living. In particular the pelvic tilt in standing position should be considered during the planning of THA to adapt the target angles of the cup patient-specifically to minimise wear and the risk of dislocation. Methods to measure pelvic tilt require an additional step in the planning process, may be time consuming and require additional devices or x-ray imaging.

In this study the relationship between three functional parameters describing the sagittal pelvic orientation in standing position and seven morphological parameters of the pelvis was investigated. Correlations might be used to estimate the pelvic tilt in standing position by the morphology of the pelvis in order to avoid additional measuring techniques of pelvic tilt in the planning process of THA. For 18 subjects a semi-automatic process was established to match a 3D-reconstruction of the pelvis from CT scans to orthogonal EOS imaging in standing position and to calculate the morphological and functional parameters of the pelvis subsequently.

The two strongest correlations of the linear correlation analysis were observed between morphological pelvic incidence and functional sacral slope (r = 0.78; p = 0.0001) and between morphological pubic symphysis-posterior superior iliac spines-ratio and functional tilt of anterior pelvic plane (r = −0.59; p = 0.0098). The results of this study suggest that patient-specific adjustments to the orientation of the cup in planning of THA without additional measurement of the sagittal pelvic orientation in standing position should be based on the correlation between morphological pelvic incidence and functional sacral slope.

Nowadays, foot switches are used in almost every operating theatre to support the interaction with medical devices. Foot switches are especially used to release risk-sensitive functions of e.g. the drilling device, the high-frequency device or the X-ray C-arm. In general, the use of foot switches facilitates the work, since they enable the surgeon to use both hands exclusively for the manipulation within the operation procedures. Due to the increasing number of (complex) devices controlled by foot switches, the surgeons face a variety of challenges regarding usability and safety of these human-machine-interfaces.

In the future, the approach of integrated medical devices in the OR on the basis of the open communication standard IEEE 11073 gives the opportunity to provide a central surgical cockpit with a universal foot switch for the surgeon, enabling the interaction with various devices different manufacturers. In the framework of the ongoing OR.NET initiative founded on the basis of the OR.NET research project (2012–2016) a novel concept for a universal foot switch (within the framework of a surgical workstation) has been developed in order to optimise the intraoperative workflow for the OR-personnel.

Here, we developed three wireless functional models of a universal foot switch together with a standardised modular interface for visual feedback via a central surgical cockpit display. Within the development of our latest foot switch, the requirements have been inter alia to provide adequate functionalities to cover the needs for the interventions in the medical disciplines orthopaedic surgery, neurosurgery and ENT.

The evaluation has been conducted within an interaction-centered usability analysis with surgeons from orthopaedics, neurosurgery and ENT. By using the Thinking Aloud technique in a Wizard-of-Oz experiment the usability criteria effectiveness, learnability and user satisfaction have been analysed.

Regarding learnability 83.25% of the subjects stated that the usage of the universal foot switch is easy to learn. An average of 77,2% of users rated the usability of the universal foot switch between good and excellent on the SUS scale. The intuitiveness of the graphical user interface has been approved with 91.75% and the controllability with 83.25%. Finally, 86% of the subjects stated a high user satisfaction.

Total knee arthroplasty (TKA) is widely accepted as a successful surgical intervention to treat osteoarthritis and other degenerative diseases of the knee. However, present statistics on limited survivorship and patient-satisfaction emphasise the need for an optimal endoprosthetic care. Although, the implant design is directly associated with the clinical outcome comprehensive knowledge on the complex relationship between implant design (morphology) and function is still lacking.

The goal of this study was to experimentally analyse the relationship between the trochlear groove design of the femoral component (iTotal CR, ConforMIS, Inc., Bedford, MA, USA) and kinematics in an in vitro test setup based on rapid prototyping of polymer-based replica knee implants.

The orientation of the trochlear groove was modified in five different variations in a self-developed computational framework. On the basis of the reference design, one was medially tilted (−2°) and four were laterally tilted (+2°, +4°, +6°, +8°). For manufacturing, we used rapid prototyping to produce synthetic replicates made of Acrylnitril-Butadien-Styrol (ABS) and subsequent post-processing with acetone vapor. The morpho-functional analysis of the replicates was performed in our experimental knee simulator. Tibiofemoral and patellofemoral kinematics were recorded with an optical tracking system during a semi-active flexion/extension (∼10° to 90°) motion.

Looking at the results, the patellofemoral kinematics, especially the medial/lateral translation and internal/external rotation were mainly affected. During low flexion, the patella had a more laterally position relative to the femur with increasing lateral trochlear orientation. The internal/external rotation initially differentiated and converged with flexion. Regarding the tibiofemoral kinematics, only the tibial internal/external rotation showed notable differences between the modified replica implants.

We presented a workflow for an experimental morpho-functional analysis of the knee and demonstrated its feasibility on the example of the trochlear groove orientation which might be used in the future for comprehensive implant design parameter optimisation, especially in terms of image based computer assisted patient-specific implants.

Demographic changes will increase the number of surgical procedures in the next years. Therefore, quality assurance of clinical processes, such as the reprocessing of surgical instruments as well as intraoperative workflows will be of increasing importance to ensure patient safety. Surgical procedures are often complex and may involve risks for the patient. For fixation of screws, e.g. in case of pedicle screws, osteosynthesis plates or revision joint replacement surgery implants, the application of defined torques may be crucial in order to achieve optimal therapeutic results and minimal complication rates. In many cases a subjective rating of the surgeon is necessary as no adequate instrumentation is available. With the same subjective feeling, hammering or screwing in are performed to implant e.g. the acetabular component in THA.

Our actual work is dedicated to the implementation of a functional prototypes of sensor- integrated instruments for specific types of intervention (especially in traumatology) and the evaluation of the sensor integrated surgical instruments in combination with RFID technology for smart process optimisation in the operating room as well as for reprocessing of surgical instruments and surgical management in combination with a knowledge-based planning, control and documentation system. Complementary (preferably wireless) sensors such for instrument identification, tracking or more complex measurements such as forces, torques, temperature or impacts during surgery as well as during reprocessing of reusable instruments could enable computer network based quality assurance in a much broader and comprehensive manner.

Within the framework of the OR.NET initiative we follow the approach to integrate wireless sensors for measurement of temperature, force-torque as well as inertial sensors for orientation and impact control, depending on the specific type of application for monitoring of workflows during surgery as well as during reprocessing of reusable instruments and devices. The integration of smart surgical instruments into an open networked operating room based on the open communication standard IEEE 11073 knowledge-based workflow system, can help to improve the process and quality management.

In total knee arthroplasty (TKA) the implant design is one key factor for a proper functional restoration of the diseased knee. Therefore, detailed knowledge on the shape (morphology) is essential to guide the design process. In literature, the morphology has been extensively studied revealing differences, e.g. between ethnicity and gender. However, it is still unclear in which way gender-specific morphological differences are sexual dimorphism or explained by differences in size.

The aim of this study was to investigate the morphology of the distal femur under gender-specific aspects for a large group of patients. Statistical analysis was used to reveal significant differences and subsequent correlation analysis to normalise the morphology.

A dataset of n=363 segmented distal femoral bone surface reconstructions (229 female, 134 male) were randomly collected from a database of patients which underwent TKA. In total, 34 morphological features (distances, angles), quantifying the distal femoral geometry, were determined full automatically. Subsequently, graphs and descriptive statistics were used to check normality and gender-specific differences were analysed by calculating the 95% confidence intervals for women and men separately. Finally, significant differences were normalised by dividing each feature by appropriate distance measurements and confidence intervals were recalculated.

Looking at the confidence 95% intervals, 6 of 34 features did not show any significant differences between genders. Remarkably, this primarily involves angular (relative) features whereas distance (absolute) measurements were mostly gender dependent. Then, we normalised all distance measurements and radii according to their direction of measurement: Features defined in medial/lateral (ML) direction were divided by the overall ML width and those following the anterior/posterior direction were normalised based on the overall AP length. The results demonstrated that gender-specific differences mostly disappear by using an adequate normalisation term.

In conclusion, implant sizes (femoral components) should not be linearly scaled according to one dimension. Instead, ML and AP directions should be regarded separately (non-isotropic scaling). Taking this into consideration, gender- specific differences might be neglected.

Proper component alignment is crucial for a successful total hip arthroplasty (THA). Some studies found safe cup orientations and corresponding stem antetorsions based on a defined desired range of motion (ROM) suitable for activities of daily living. These studies either used complex and time consuming 3D simulations or more simple mathematical formulas which cannot be extended to combined motions.

With the method introduced in this work, any arbitrary motion can be applied. The ROM specified as the ROM of the femur relative to the pelvis is transformed into the ROM of the prosthesis neck relative to the cup for each cup orientation. For this transformation, the orientation and design of the stem are considered. The comparison of the neck and cup orientations is done using a 2D mapping of a 3D spherical surface which reduces the complexity of the calculation.

We found that the femoral antetorsion as well as the neutral stem flexion and adduction have an influence on the resulting safe zone. The result is not just a combined anteversion but a combined orientation. For validating the plausibility of the algorithm, the resulting safe zones are compared to literature. Same results can be achieved using the same input data. Using this technique, a patient-specific safe zone based on the ROM can be derived and adjusted to the stem orientation.

Robotic surgical systems reduce the cognitive workload of the surgeon by assisting in guidance and operational tasks. As a result, higher precision and a decreased surgery time are achieved, while human errors are minimised. However, most of robotic systems are expensive, bulky and limited to specific applications.

In this paper a novel semi-automatic robotic system is evaluated, that offers the high accuracies of robotic surgery while remaining small, universally applicable and easy to use. The system is composed of a universally applicable handheld device, called Smart Screwdriver (SSD) and an application specific kinematic chain serving as a tool guide. The guide mechanism is equipped with motion screws. By inserting the SSD into a screw head, the screw is identified automatically and the required number of revolutions is executed to achieve the desired pose of the tool guide.

The usability of the system was evaluated according to IEC 60601-1-6 using pedicle screw implementation as an example. The achieved positioning accuracies of the drill sleeve were comparable to those of fully automatic robotic systems with −0.54 ± 0.93 mm (max: − 2.08 mm) in medial/lateral-direction and 0.17 ± 0.51 mm (max: 1.39 mm) in cranial/caudal- direction in the pedicle isthmus. Additionally, the system is cost-effective, safe, easy to integrate in the surgical workflow and universally applicable to applications in which a static position in one or more DOF is to be adjusted.

The consideration of the individual knee ligament attachments is crucial for the application of patient specific musculoskeletal models in the clinical routine, e.g. in knee arthroplasty. Commonly, the pre-operative planning is based on CT images, where no soft tissue information is available. The goal of this study was to evaluate the accuracy of a full automatic and robust mesh morphing method that estimates locations of cruciate ligament attachments on the basis of training data.

The cruciate ligament attachments from 6 (n=6) different healthy male subjects (BH 184±6cm, BW 90±10kg) were identified in MRI-datasets by a clinical expert. The insertion areas were exported as point clouds and the centres of gravitation served as approximations of the attachments. These insertion points were used to annotate mean shapes of femur and tibia.

The mean shapes were built up from 332 training data sets each. The surface data were obtained from CT scans by performing an automatic segmentation followed by manual cleaning steps. The mean shapes were computed by selecting a data set randomly and aligning this reference rigidly to each of the remaining data sets. The data were fitted using the non-rigid ICP variant (N-ICP-A). Due to this morphing step, point correspondences were established.

By morphing a mean shape to the target geometries, including the cruciate ligament attachments, the distribution of the insertions on the original mean shape was obtained. Subsequently, a statistical mean was computed (annotated mean). The annotated mean shape was again morphed to the target data sets and the deviations of the respective predicted insertion points from the measured insertion points were computed.

The training data was successfully morphed to all 6 subjects in an automatic manner with virtually no distance error (10-5 mm). The mean distance between the measured and morphed ligament attachments was highest for the ACL in the femur (4.26±1.48 mm) and lowest for PCL in the tibia (1.63±0.36 mm). The highest deviation was observed for femoral ACL (6.93 mm).

In this study, a morphing based approach was presented to predict origins and insertions of the knee ligaments on the basis of CT-data, exemplarily shown for the cruciate ligaments. It has been demonstrated, that the N-ICP-A is applicable to predict the attachments automatic and robust with a high accuracy. This might help to improve patient-specific biomechanical models and their integration in the clinical routine.

For a proper functional restoration of the knee following knee arthroplasty, a comprehensive understanding of bony and soft tissue structures and their effects on biomechanics of the individual patient is essential. A systematic description of morphological knee joint parameters and a study of their effects could beneficial for an optimal patient-specific implant design.

The goal of this study was the development of a full parametric model for a comprehensive analysis of the distal femoral morphology also enabling a systematic parameter variation in the context of a patient specific multi-parameter optimisation of the knee implant shape.

The computational framework was implemented in MATLAB and tested on 20 CT-models which originated from pathological right knees. The femora were segmented semi-automatically and exported in STL-format.

First, a 3D surface model was imported, visualised and reference landmarks were defined. Cutting planes were rotated around the transepicondylar axis and ellipses were fitted in the cutting contour using pattern recognition. The portions between the ellipses were approximated by using a piecewise cubic hermite interpolation polynom such that a closed contour was obtained following the characteristics of the real bone model. At this point the user could change the parameters of the ellipses in order to manipulate the approximated contour for e.g. higher-level biomechanical analyses. A 3D surface was generated by using the lofting technique. Finally, the parameter model was exported in STL-format and compared against the original 3D surface model to evaluate the accuracy of the framework

The presented framework could be successfully applied for automatic parameterisation of all 20 distal femur surface data-sets. The mean global accuracy was 0.09±0.62 mm with optimal program settings which is more accurate than the optimal resolution of the CT based data acquisition. A systematic variation of the femoral morphology could be proofed based on several examples such as the manipulation of the medial/lateral curvature in the frontal plane, contact width of the condyles, J-Curve and trochlear groove orientation.

In our opinion, this novel approach might offer the opportunity to study the effect of femoral morphology on knee biomechanics in combination with validated biomechanical simulation models or experimental setups. New insights could directly be used for patient-specific implant design and optimisation.

For a successful total knee arthroplasty (TKA) and long prosthesis lifespan, correct alignment of the implant components as well as proper soft tissue balancing are of major importance. In order to overcome weaknesses of existing imaging modalities for TKA planning such as radiation exposure and lack of soft tissue visualisation (X-ray and CT) and high cost, long acquisition times and geometric distortion (MRI), it is investigated if ultrasound (US) imaging is a suitable alternative.

Currently, a reconstruction method of the bony knee morphology based on US imaging is developed at our research institute. For capturing the mechanical axis, being crucial for TKA planning, different approaches could be implemented. This work investigates whether a weight-bearing full leg X-ray registered with the local 3D-US knee dataset can be used for this purpose. Also, the impact of incorrect calibration data (i.e. uncalibrated X-rays) on the accuracy of the estimated mechanical axis is investigated.

A 3D-2D projective, feature-based registration algorithm was used to spatially align the 3D US-based model to the 2D X-ray image before transferring the mechanical axis from the X-ray to the model. For validation, a CT-based local model and its projection were used and an initial error in translation and rotation was added. Also, calibration parameters such as the centre ray position and the source-to-image-detector distance were altered. The estimation error of the mechanical axis was less than 1°, the median error lower than 0.1° in the frontal plane. Even if the calibration data is not available, the accuracy remains sufficient for TKA planning. In this study, idealised 2D and 3D image information was used. In the future, this method should be tested using clinical X-ray images and 3D-US data.

For a proper rehabilitation of the knee following knee arthroplasty, a comprehensive understanding of bony and soft tissue structures and their effects on biomechanics of the individual patient is essential. Musculoskeletal models have the potential, however, to predict dynamic interactions of the knee joint and provide knowledge to the understanding of knee biomechanics. Our goal was to develop a generic musculoskeletal knee model which is adaptable to subject-specific situations and to use in-vivo kinematic measurements obtained under full-weight bearing condition in a previous Upright-MRI study of our group for a proper validation of the simulation results.

The simulation model has been developed and adapted to subject-specific cases in the multi-body simulation software AnyBody. For the implementation of the knee model a reference model from the AnyBody Repository was adapted for the present issue. The standard hinge joint was replaced with a new complex knee joint with 6DoF. The 3D bone geometries were obtained from an optimized MRI scan and then post-processed in the mesh processing software MeshLab. A homogenous dilation of 3 mm was generated for each bone and used as articulating surfaces.

The anatomical locations of viscoelastic ligaments and muscle attachments were determined based on literature data. Ligament parameters, such as elongation and slack length, were adjusted in a calibration study in two leg stance as reference position.

For the subject-specific adaptation a general scaling law, taking segment length, mass and fat into account, was used for a global scaling. The scaling law was further modified to allow a detailed adaption of the knee region, e.g. align the subject-specific knee morphology (including ligament and muscle attachments) in the reference model.

The boundary conditions were solely described by analytical methods since body motion (apart from the knee region) or force data were not recorded in the Upright-MRI study. Ground reaction forces have been predicted and a single leg deep knee bend was simulated by kinematic constraints, such as that the centre of mass is positioned above the ankle joint. The contact forces in the knee joint were computed using the force dependent kinematic algorithm.

Finally, the simulation model was adapted to three subjects, a single leg deep knee bend was simulated, subject-specific kinematics were recorded and then compared to their corresponding in-vivo kinematic measurements data.

We were able to simulate the whole group of subjects over the complete range of motion. The tibiofemoral kinematics of three subjects could be simulated showing the overall trend correctly, whereas absolute values partially differ.

In conclusion, the presented simulation model is highly adaptable to an individual situation and seems to be suitable to approximate subject-specific knee kinematics without consideration of cartilage and menisci. The model enables sensitivity analyses regarding changes in patient specific knee kinematics following e.g. surgical interventions on bone or soft tissue as well as related to the design and placement of partial or total knee joint replacement. However, model optimisation, a higher case number, sensitivity analyses of selected parameters and a semi-automation of the workflow are parts of our ongoing work.

Currently, standard total knee arthroplasty (TKA) procedures focus on axial and rotational alignment of the prosthesis components and ligament balancing. Even though TKA has been constantly improved, TKA patients still experience a significantly poorer functional outcome than total hip arthroplasty patients.

Among others, complications can occur when knee kinematics (active/passive) after TKA do not correspond with the physiological conditions. We hypothesised that the Q-angle has a substantial impact on active joint kinematics and should be taken into account in TKA. The Q-angle can be influenced by the position of the tibial tuberosity (TT). A pathological position of the TT is commonly related to patellofemoral pain and knee instability. A clinically well accepted surgical treatment is the TT medialisation which causes a change in the orientation of the patella tendon and thus alters the biomechanics of the knee. If active and passive knee kinematics differs, this aspect should be considered for implant design and positioning. Therefore we investigated the sensitivity of active knee kinematics related to the position of the TT by using a complex multi-body model with a dynamic simulation of an entire gait cycle.

The validated model has been implemented in the multi-body simulation software AnyBody and was adapted for the present issue. The knee joint is represented by articulating surfaces of a standard prosthesis and contains 6 degrees of freedom. Intra-articular passive structures are implemented and the muscular apparatus consists of 159 muscles per leg. As input parameter for the sensitivity analysis, the TT was translated medially 9 mm and laterally 15 mm from the initial position in equidistant steps of 3 mm.

The Q-angle was about 10° in the initial position, which lies in the physiological range. It changed approximately 2.5° with a gradual shift of 3 mm, confirming the impact of the individual TT position on active knee kinematics. The tibiofemoral kinematics, particularly the internal/external rotation of the tibia was significantly affected. Lateralisation of the TT decreased the external rotation of the tibia, whereas a medialisation caused an increase. During contralateral toe off the external rotation was +7.5° for a medial transfer of 9 mm and −1.4° for a lateral transfer of 15 mm, respectively. The differences in external rotation were almost zero for low flexion angles, correlating with the activation pattern of the quadriceps muscle: the higher the activation of the quadriceps, the greater were the changes in kinematics.

In conclusion, knee kinematics are strongly affected by the Q-angle which is directly associated with the position of the TT. As active kinematics may show significant differences to passive kinematics, intraoperative ligament balancing may result in a suboptimal ligament situation during active motion. Since the Q-angle varies widely between gender and patients, the individual situation should be considered. The optimisation of the model and further experimental validation is one aspect of our ongoing work.

Knee biomechanics after total knee arthroplasty (TKA) has received more attention in recent years. One critical biomechanical aspect involved in the workflow of present TKA strategies is the intraoperative optimisation of ligament balancing. Ligament balancing is usually performed with passive flexion-extension in unloaded situations. Medial and lateral ligaments strains after TKA differ in loaded flexion compared to unloaded passive flexion making the passive unloaded ligament balancing for TKA questionable. To address this problem, the development of detailed and specific knowledge on the biomechanical behaviour of loaded knee structures is essential. Stress MRI techniques were introduced in previous studies to evaluate loaded joint kinematics. Previous studies captured the knee movement either in atypical loading supine positions, or in upright positions with help of inclined supporting backrests being insufficient for movement capture under full body weight-bearing conditions.

In this work, we proposed a combined MR imaging approach for measurement and assessment of knee kinematics under full body weight-bearing in single legged stance as a first step towards the understanding of complex biomechanical aspects of bony structures and soft tissue envelope. The proposed method is based on registration of high resolution static MRI data (supine acquisition) with low resolution data, quasi-static upright-MRI data (loaded flexion positions) and was applied for the measurement of tibio-femoral kinematics in 10 healthy volunteers. The high resolution MRI data were acquired using a 1.5T Philips-Intera system, while the quasi-static MRI data (full bodyweight-bearing) was obtained with a 0.6T Fonar-Upright™ system. Contours of femur, tibia, and patella from both MRI techniques were extracted using expert manual segmentation. Anatomical surface models were then obtained for the high resolution static data.

The upright-MRI acquisition consisted of Multi-2D, quasi-static sagittal scans each including 4 slices for each flexion angle. Starting with full knee extension, the subjects were asked to increase the flexion in 4–5 steps to reach the maximum flexion angle possible under space and force limitations. Knees were softly padded for stabilisation in lateral-medial direction only in order to reduce motion artifacts. During the upright acquisition the subjects were asked to transfer their bodyweight onto the leg being imaged and maintain the predefined flexion position in single legged stance. The acquisition at every flexion angle was obtained near the scanner's isocenter and takes ∼39 seconds.

The anatomical surface models of the static data were each registered to their corresponding contours from the weight-bearing scans using an iterative closest point (ICP) based approach. A reference registration step was carried out to register the surface models to the full extension loaded position. The registered surfaces from this step were then considered as initial conditions for next ICP registration step. This procedure was similarly repeated to ensure successful registrations between subsequent flexion acquisitions.

The tibio-femoral kinematics was calculated using the joint coordinate system (JCS). The combined MR imaging approach allows the non-invasive measurement of kinematics in single legged stance and under physiological full weight-bearing conditions. We believe that this method can provide valuable insights for TKA for the validation of patient-specific biomechanical models.

Total hip replacement is one of the standard procedures in orthopedic surgery. Due to various reasons revision surgery (RTHR) has to be performed. In case of the revision of a cemented prosthesis stem, the bone cement has to be removed from the femoral cavity.

Conventionally the cement removal is done manually using a hammer, chisel or burr under X-ray control, causing a considerable radiation exposure for patient and the surgeon. Furthermore the risk of undesirable bone damage is high due to bad sight and access conditions, leading to complications and prolongation of the intervention. Different approaches addressing the mentioned problems were proposed, but did not achieve acceptance in clinical practice due to disadvantages concerning process controllability. Another possibility is to use a robot guided milling tool. However, to be able to control it typically a 3D reconstruction of the cement volume to be removed is necessary. Existing approaches use computed tomography based measurements combined with previously implanted markers, fluoroscopy or ultrasound based measurements, all requiring additional process steps prior to the surgery or to the actual cement removal.

The ICOS project (Impedance Controlled Surgical Instrumentation, Chair of Medical Engineering, RWTH Aachen University) investigates the approach of electrical impedance controlled, robot assisted bone cement removal, based on real time cement detection during the removal process without radiation exposure or the necessity of prior imaging or marker implanting steps. Therefore the electrical impedance is measured between the milling head mounted on the surgical mini-robot MINARO and one or more electrodes attached to the skin of the patient's thigh. An impedance variation mainly results from decreasing thickness of bone cement near the milling head contact point due to material removal. Hence the proposed method does not generate a 3D volume allowing for a milling path generation prior to the process. It requires a strategy for real time path generation using only the limited local information. Up to now, only the differentiation between bone cement and bone, and thus the cement-bone interface breakthrough, is reliably detectable. To efficiently use this information for the tool path generation, generic a-priori knowledge of the bone cement shape after removal of the prosthesis stem is used.

The concept for impedance controlled milling has been verified in first lab trials. For impedance measurements during the cement removal process the robots milling tool has been modified to achieve electrical insulation of the milling head. A strategy for online adaptive robot path planning has been implemented and tested in a Matlab/Simulink based process simulation. For all data sets a cement removal rate of about 90% with a bone removal of approximately 3% was achieved. These results confirm that it is generally possible to use only the limited local information for automated cement removal. Future work aims for a practical evaluation of the algorithm using real impedance measurement values.

This work has been funded by the German Ministry for Education and Research (BMBF) in the framework of the ICOS project under grant No. BMBF 13EZ1005.

Musculoskeletal loading plays an important role in the primary stability of THA. There are about 210,000 primary THA interventions p.a. in Germany. Consideration of biomechanical aspects during computer-assisted orthopaedic surgery is recommendable in order to obtain satisfactory long-term results. For this purpose simulation of the pre- and post-operative magnitude of the resultant hip joint force R and its orientation is of interest. By means of simple 2D-models (Pauwels, Debrunner, Blumentritt) or more complex 3D-models (Iglič), the magnitude and orientation of R can be computed patient-individually depending on their geometrical and anthropometrical parameters. In the context of developing a planning module for computer-assisted THA, the objective of this study was to evaluate the mathematical models. Therefore, mathematical model computations were directly compared to in-vivo measurements obtained from instrumented hip implants.

With patient-specific parameters the magnitude and orientation of R were model-based computed for three patients (EBL, HSR, KWR) of the OrthoLoad-database. Their patient-specific parameters were acquired from the original patient X-rays. Subsequently, the computational results were compared with the corresponding in-vivo telemetric measurements published in the OrthoLoad-database. To obtain the maximum hip joint load, the static single-leg-stance was considered. A reference value for each patient for the maximum hip load under static conditions was calculated from OrthoLoad-data and related to the respective body weights (BW).

On average there are large deviations of the results for the magnitude (Ø=147%) and orientation (Ø=14.35° too low) of R obtained by using Blumentritt's model from the in-vivo results/measurements. The differences might be partly explained by the supplemental load of 20% BW within Blumentritt's model which is added to the input parameter BW in order to consider dynamic gait influences. Such a dynamic supplemental load is not applied within the other static single-leg-stance models. Blumentritt's model assumptions have to be carefully reviewed due to the deviations from the in-vivo measurement data.

Iglič's 3D-model calculates the magnitude (Ø17%) and the orientation (Ø49%) of R slightly too low. For the magnitude one explanation could be that his model considers nine individual 3D-sets of muscle origins and insertion points taken from literature. This is different from other mathematical models. The patient-individual muscle origin and insertion points should be used.

Pauwels and Debrunner's models showed the best results. They are in the same range compared to in-vivo data. Pauwels's model calculates the magnitude (Ø5%) and the orientation (Ø28%) of R slightly higher. Debrunner's model calculates the magnitude (Ø1%) and the orientation (Ø14%) of R slightly lower.

In conclusion, for the orientation of R, all the computational results showed variations which tend to depend on the used model.

There are limitations coming along with our study: as our previous studies showed, an unambiguous identification of most landmarks in an X-ray (2D) image is hardly possible. Among the study limitations there is the fact that the OrthoLoad-database currently offers only three datasets for direct comparison of static single leg stance with in-vivo measurement data of the same patient. Our ongoing work is focusing on further validation of the different mathematical models.

Major aspects on long-term outcome in Total Knee Arthroplasty are the correct alignment of the implant with the mechanical load axis, the rotational alignment of the components as well as good soft tissue balancing. To reduce the variability of implant alignment and at the same time minimise the invasiveness different computer assisted systems have been introduced.

To achieve accuracy as high as those of a robotic system but with a pure mechanically adjustable cutting block, the Exactech GPS system has been developed. The new concept comprises a seamlessly planning and navigation screen with an integrated optical tracking system for fast and accurate acquisition and verification of anatomical landmarks within the sterile field as well as a tiny cutting guide for accurate transfer of the planned bone resections.

Using a conventional screwdriver the cutting block could be accurately aligned with the planned resection by controlling the current position of the cutting block on the navigation screen. To save time, to maximise the ease of use and to minimize the surgeon's mental workload during adjustment, a smart screwdriver (SSD) has been developed being able to automatically adjust the screws.

The basic idea of the smart screwdriver is to have a system providing an automatic transfer of the planned data to the cutting guide similar to a robotic system, but with the actuators separated from the kinematic. The use of the SSD is as simple as follows: After planning of the intervention and rigid fixation of the cutting guide on the bone, the surgeon simply connects sequentially the screwdriver to all screws of the cutting guide.

To further maximise the ease of use and to avoid a mix-up of different screws, an identification means has been integrated into the positioning screws as well as into the smart screwdriver. For an automated identification of the screws different technologies have been analysed as position tracking, optical recognition or wired/wireless electronics.

A first prototype without screw identification has been used successfully on 4 cadaver knees. All guide positions could be adjusted automatically using the SSD. However, the absence of screw identification required that the surgeon follows indications given by the computer to turn screws sequentially.

A second prototype of the smart screwdriver has successfully been built up and is able to identify the different positioning screws in less than 1s with high reliability. The identification is realised as inductive coupling of different small resonance circuits that are integrated into the screw heads and the screwdrivers tip.

To adjust the cutting guide from neutral to the planned position, the screws have to be adjusted by 5 mm in average. The rotational speed of the current SSD implementation is 2 rounds per second, resulting in a mean time of about 3.5 s for each screw adjustment. The rotational accuracy of the screwdriver is ±5°. Taking into account a thread of the positioning screws of 0.7 mm, the theoretical translational error is about ±0.01 mm. Looking at the angular accuracy, the maximum distance of the screws of the current setup of the cutting block of 15 mm results in an angular error of less than ±0.05°.

Knee biomechanics after total knee arthroplasty (TKA) has received more attention in recent years. One critical biomechanical aspect involved in the workflow of present TKA strategies is the intraoperative optimisation of ligament balancing. Ligament balancing is usually performed with passive flexion-extension in unloaded situations. Medial and lateral ligaments strains after TKA differ in loaded flexion compared to unloaded passive flexion making the passive unloaded ligament balancing for TKA questionable. To address this problem, the development of detailed and specific knowledge on the biomechanical behavior of loaded knee structures is essential. Stress MRI techniques were introduced in previous studies to evaluate loaded joint kinematics. Previous studies captured the knee movement either in atypical loading supine positions, or in upright positions with help of inclined supporting backrests being insufficient for movement capture under full body weight-bearing conditions.

In this work, we proposed a combined MR imaging approach for measurement and assessment of knee kinematics under full body weight-bearing in single legged stance as a first step towards the understanding of complex biomechanical aspects of bony structures and soft tissue envelope. The proposed method is based on registration of high resolution static MRI data (supine acquisition) with low resolution data, quasi-static upright-MRI data (loaded flexion positions) and was applied for the measurement of tibio-femoral kinematics in 10 healthy volunteers. The high resolution MRI data were acquired using a 1.5T Philips-Intera system, while the quasi-static MRI data (full bodyweight-bearing) was obtained with a 0.6T Fonar-Upright™ system. Contours of femur, tibia, and patella from both MRI techniques were extracted using expert manual segmentation. Anatomical surface models were then obtained for the high resolution static data.

The upright-MRI acquisition consisted of Multi-2D, quasi-static sagittal scans each including 4 slices for each flexion angle. Starting with full knee extension, the subjects were asked to increase the flexion in 4–5 steps to reach the maximum flexion angle possible under space and force limitations. Knees were softly padded for stabilisation in lateral-medial direction only in order to reduce motion artifacts. During the upright acquisition the subjects were asked to transfer their bodyweight onto the leg being imaged and maintain the predefined flexion position in single legged stance. The acquisition at every flexion angle was obtained near the scanner's isocenter and takes ∼39 seconds.

The anatomical surface models of the static data were each registered to their corresponding contours from the weight-bearing scans using an iterative closest point (ICP) based approach. A reference registration step was carried out to register the surface models to the full extension loaded position. The registered surfaces from this step were then considered as initial conditions for next ICP registration step. This procedure was similarly repeated to ensure successful registrations between subsequent flexion acquisitions.

The tibio-femoral kinematics was calculated using the joint coordinate system (JCS). The combined MR imaging approach allows the non-invasive measurement of kinematics in single legged stance and under physiological full weight-bearing conditions. We believe that this method can provide valuable insights for TKA for the validation of patient-specific biomechanical models.

The alignment of prostheses components has a major impact on the longevity of total knee protheses as it significantly influences the biomechanics and thus also the load distribution in the knee joint.

Knee joint loads depend on three factors: (1) geometrical conditions such as bone geometry and implant position/orientation, (2) passive structures such as ligaments and tendons as well as passive mechanical properties of muscles, and (3) active structures that are muscles. The complex correlation between implant position and clinical outcome of TKA and later in vivo joint loading after TKA has been investigated since 1977. These investigations predominantly focused on component alignment relative to the mechanical leg axis (Mikulicz-line) and more recently on rotational alignment perpendicular to the mechanical axis. In general four different approaches can be used to study the relationship between implant position and knee joint loads: In anatomical studies (1), the influence of the geometrical conditions and passive structures can be analyzed under the constraint that the properties of vital tissue are only approximated. This could be overcome with an intraoperative load measurement approach (2). Though, this set up does not consider the influence of active structures. Although post-operative in vivo load measurements (3) provide information about the actual loading condition including the influence of active structures, this method is not applicable to investigate the influence of different implant positions. Using mathematical approaches (4) including finite element analysis and multi-body-modeling, prostheses positions can be varied freely. However, there exists no systematical analysis of the influence of prosthesis alignment on knee loading conditions not only in axial alignment along and rotational alignment perpendicular to the mechanical axis but in all six degrees of freedom (DOF) with a validated mathematical model. Our goal was therefore to investigate the correlation between implant position and joint load in all six DOF using an adaptable biomechanical multi-body model.

A model for the simulation of static single leg stance was implemented as an approximation of the phase with the highest load during walking cycle. This model is based on the AnyBody simulation software (AnyBody Technology A/S, Denmark). As an initial approach, with regard to the simulation of purely static loading the knee joint was implemented as hinge joint. The patella was realised as a deflection point, a so called “ViaNode,” for the quadriceps femoris muscle. All muscles were implemented based on Hill's muscle model. The knee model was indirectly validated by comparison of the simulation results for single and also double leg stance with in-vivo measurements from the Orthoload database (www.orthoload.de). For the investigation of the correlation between implant position and knee load, major boundary conditions were chosen as follows:•

Flexion angle was set to 20° corresponding to the position with the highest muscle activity during gait cycle.

Comparing the simulation results of single and double leg stance with the in-vivo measurements from the Orthoload database, changes in knee joint forces showed similar trends and the slope of changes in torques transmitted by the joint was equal. Against the background of unknown geometrical conditions in the Orthoload measurements and the simplification (hinge joint) of the initial multi-body-model compared to real knee joints, the developed model provides a reasonable basis for further investigations already – and will be refined in future works.

As influencing parameters are very complex, a non-ambiguous interpretation of force/torque changes in the knee joint as a function of changes in component positions was in many cases hardly possible. Changes in patella force on the other hand could be traced back to geometrical and force changes in the quadriceps femoris muscle. Positional changes mostly were in good agreement with our hypotheses based on literature data when knee load and patellar forces respectively were primarily influenced by active structures, e.g. with regard to the danger of patella luxation in case of increased internal rotation of the tibial component. Whereas simulations also showed results contradicting our expectations for positional changes mainly affecting passive structures, e.g. cranial/caudal translation of the femoral component. This shows the major drawback of the implemented model: Intra-articular passive structures such as cruciate and collateral ligaments were not represented. Additionally kinematic influences on knee and patella loading were not taken into account as the simulations were made under static conditions. Implementation of relative movements of femoral, tibial and patella components and simulation under dynamic conditions might overcome this limitation. Furthermore, the boundary condition of complete muscle adaptations might be critical, as joint loads might be significantly higher shortly after operation. This could lead to a much longer and possibly ineffective rehabilitation process.

Pertrochanteric femoral fractures are common and intramedullary nailing with a proximal femoral nail (PFNA®) is an accepted method for the surgical treatment. Accurate guide wire and subsequent hardware placement in the femoral neck is believed to be essential in order to avoid mechanical failure. Malpositioned implants may lead to rotational or angular malalignment or “cut out” in the femoral neck. Hip and knee arthritis might be a potential long-term consequence. The conventional technique might require multiple guidewire passes, and relies heavily on fluoroscopy.

A computer-assisted surgical planning and navigation system based on 2D-fluoroscopy was developed in-house as an intraoperative guidance system for navigated guide wire placement in the femoral neck and head. To support the image acquisition process, the surgeon is supported by a so-called “zero-dose C-arm navigation” module. This tool enables a virtual radiation-free preview of the X-ray images of the femoral neck and head. The aim of this study was to compare PFNA® insertion using this system to conventional implantation technique. We hypothesised that guide wire and subsequent implant placement using our software decreases radiation exposure to the minimum of two images and reduces the number of drilling attempts. Furthermore, accuracy of implant placement in comparison to the conventional method might be improved and operation time shortened.

We used 24 identical intact left femoral Sawbones® to simulate reduced pertrochanteric femoral fractures. First, we performed placement of the PFNA® into 12 Sawbones using the conventional fluoroscopic technique (group 1). Secondly, we performed placement of the PFNA® into 12 Sawbones guided by the computer-assisted surgical planning software (group 2). In each group, we first performed open and secondly minimal-invasive intramedullary nailing in six sawbones each. For minimal-invasive guide wire placement, a surgical drape imitated soft tissue coverage. Conventional and navigated technique used a C-arm fluoroscope (Siemens IsoC 3D®, Erlangen, Germany) in conventional 2D mode. Guidewire and subsequent blade placement in the femoral neck was evaluated. We documented: 1: the number of fluoroscopic images; 2: the total number of drilling attempts; 3: implant placement accuracy (3.1. Tip apex distance (TAD); 3.2. visible penetrations of the femoral neck and head; 3.3. blade-corticalis bone distance in the anteroposterior and lateral plane) and the 4: operation time.

The number of fluoroscopic single shots taken to achieve an acceptable PFNA®-blade position was reduced significantly with computer-assistance by 71.5% (p<0.001) in the open and by 72,4% (p<0.001) in the minimally invasive technique. In each operation two X-rays for final documentation were taken. The average number of drilling attempts for the computer-guided system was significantly (p<0.05) less than that of the conventional technique in the minimally invasive procedure. The average number of drilling attempts showed no difference between the computer-assisted and conventional techniques in the open procedure. Accuracy of implant placement showed no difference between the computer-assisted and the conventional group. Computer assistance significantly increased the mean operation time for fixation of pertrochanteric femoral fractures with a PFNA® by 79.8% (p<0.001) in the open technique and by 54.4% (p<0.001) in the minimally invasive technique.

Use of our computer-guided system for fixation of pertrochanteric femoral fractures by a PFNA® decreases the number of fluoroscopic single shots and of suboptimal guide wire passes while maintaining blade placement accuracy that is equivalent to the conventional technique. Computer-assisted surgery with our system increases the operation time and has just been tested in non-fractured sawbones. Although these results are promising, additional studies including fractured sawbones and cadaver models with extension of the navigation process to all steps of PFNA® introduction and with the goal of reducing the operation time are indispensable before integration of this navigation system into the clinical workflow.