SURGICALLY ORIENTED MEASUREMENTS FOR THREE-DIMENSIONAL CHARACTERIZATION OF TUNNEL PLACEMENT IN ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

Transcription

1 SURGICALLY ORIENTED MEASUREMENTS FOR THREE-DIMENSIONAL CHARACTERIZATION OF TUNNEL PLACEMENT IN ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION Introduction: The human knee is composed of three bones (femur, tibia, and patella), four major ligaments (anterior cruciate, posterior cruciate, lateral collateral, and medial collateral), articular cartilage, menisci (lateral and medial), and a variety of muscular attachments(1). The ligaments function to stabilize the knee during motion and load bearing. Specifically, the anterior cruciate ligament (ACL) acts as the primary restraint to anterior tibial translation and internal tibial rotation. Disruption of the ACL is a common injury of the knee, especially in athletes. It has been estimated that nearly 175,000 ACL reconstructions are performed each year with an estimated cost of up to $1 billion(2-4). The guiding principle in modern surgical ACL reconstruction is to replace the torn ACL with a graft. Ideally, the graft is placed in the exact location of the native ACL. Placing the graft in the native ACL location is technically challenging; the current single bundle methods require drilling two tunnels: one through the femur and one through the tibia. The graft is placed in the drill tunnels between the femur and tibia, and over time grows into the healing bone. ACL reconstruction has generated increased debate due to a number of unknowns including the best method of tunnel placement and the reasons for development of late sequela osteoarthritis after this procedure. One of several reasons for revision to ACL reconstruction is poor graft tunnel placement(4). Surgical ACL reconstructions typically fall into one of two categories: single bundle and double bundle procedures. Single bundle techniques (e.g. medial portal, transtibial, two-incision approaches) involve the placement of a single graft to replace the 1

2 torn ACL, while double bundle techniques use two independent grafts to replace the functional anteromedial and posterolateral bundles of the native ACL. Traditionally, the characterization of ACL tunnels has largely concentrated on twodimensional measurements from standard radiographic views. The European Society of Sports Traumatology Knee Surgery and Arthroscopy (ESSKA) Workshop on Reconstruction of the Anterior and Posterior Cruciate Ligaments has provided guidelines for describing tunnel locations on the distal femur and proximal tibia(5). Two-dimensional tunnel evaluation studies using plain films have been performed using these guidelines and variations of them(6-10). With the advent of CT technologies, several studies have extrapolated the two-dimensional measurements to CT slices(11-13). Virtual surface model generation from CT images has also been investigated as a method of tunnel placement evaluation(14-16). Three-dimensional surface-based techniques are desirable due to their ability to visualize not only the bone but also the tunnels through the bone. However, a standardized three-dimensional measurement system does not currently exist that allows for direct translation of measurements from the laboratory to the operating room. We hypothesize that simulating the placement of surgical drill bits within surface models of the femur and tibia will allow for localiztion of ACL graft drill tunnels. Herein, we describe a reliable and flexible three-dimensional measurement system capable of characterizing ACL tunnel position and orientation. 2

3 Materials and Methods: Three-Dimensional Measurement System We have developed a three-dimensional measurement system for characterizing femoral and tibial drill tunnels from ACL reconstructions. Our ability to characterize the drill tunnels relies on simulating the positioning of the drill bit originally used to create the tunnels within the bone. Based on positioning virtual drill bits, we are able to describe the drill tunnels both angularly and spatially with respect to previously described anatomic landmarks and radiographic views. An overview of this process is outlined in Figure 1. The following sections describe the methods used to develop a standardized three-dimensional orientation, align the bone surfaces to this orientation, generate and align virtual drill bits, match virtual drill bits to drill tunnel apertures, and automatically spatially and angularly measure the virtual drill bits. Standardized Orientation To ensure accurate and reproducible measurements, a standardized orientation is required for both the femur and the tibia. We have created separate orientations for the femur and tibia based on anatomic landmarks. For the femur, the orientation is illustrated in Figure 2A. The X- axis is defined by a line through the femoral condyles such that the posterior-most aspects of the medial and lateral condyles are aligned, which correlates with a perfect lateral 2D radiograph. The Z-axis is defined by the femoral diaphysis after compensating for the approximately 7 of anatomic valgus. The Y-axis is then defined by the cross-product of the X- and Z- axes. For the tibia, the orientation is illustrated in Figure 2B. The Y-Axis is defined by the AP medial tibial plateau, and the Z-axis is defined by a line through the posterior-most aspects of the medial and 3

4 lateral condyles of the tibial plateau. The X-axis is then defined by the cross-product of the Y- and Z-axes. Estimating ACL Tunnel Position As an estimate of the drill bit used for the surgical procedure, a cylinder was generated with a diameter equivalent to that of the drill bit. For this study, all procedures were performed using a 10mm diameter drill bit; thus, a virtual drill bit with a diameter of 10mm was created. The cylinder was assigned a length to adequately traverse the entire length of the drill tunnel; a 50mm long drill bit was satisfactory for all of the specimens used in this study. To compute the position of the tunnel within the bone, the cylinder was placed within the tunnel (Figures 3A and 4A) using custom tools. Modifying the opacity of the bone surfaces allowed for proper positioning of the virtual drill bits within the tunnels. Once the virtual drill bits were aligned with the tunnels, three angles were calculated: α (Eq. 1), β (Eq. 2), and γ (Eq. 3); the angles represent the deviation of the tunnel from the X-, Y-, and Z- axes, respectively (Figures 3 and 4). α = cos 1 p 1p 2 p 1 p x (1) p 1 p 2 p 1 p x β = cos 1 p 1p 2 p 1 p y (2) p 1 p 2 p 1 p y γ = cos 1 p 1p 2 p 1 p z (3) p 1 p 2 p 1 p z where p 1 is the centroid of the endcap of the virtual drill bit closest to the knee joint, p 2 is the centroid of the endcap at the opposite end of the drill bit, p x represents p unit in the X- 4

5 direction, p y represents p unit in the Y-direction, and p z represents p unit in the Z- direction. Spatial localization of the ACL drill tunnel apertures allows for correlation of surgical tunnel positioning with respect to the anatomic ACL footprint. To estimate the tunnel apertures from the virtual drill bits, the cylindrical surface was cropped at the tunnel aperture using custom software. After the virtual drill bits were cropped to match the tunnel apertures (Figures 4 & 5), two spatial measurements for each bone were calculated: m/m and a/a for the tibia and n/n and c/c for the femur. For the tibia, the position of the aperture centroid is measured as a proportion of the distance from the anterior aspect of the tibial plateau (a) with respect to the total tibial depth (A) as shown in Figure 4A, and also as a proportion of the distance from the medial aspect of the tibial plateau (m) with respect to the total width of the tibial plateau (M) as shown in Figure 4B. For the femur, the position of the aperture centroid is measured as a proportion of the distance from the distal-most aspect of the lateral condyle (c) with respect to the total diameter of the lateral condyle (C) as shown in Figure 6A and also as the proportion of the distance from the posterior-most aspect of the lateral condyle (n) with respect to the apex of the intercondylar notch (N) as demonstrated in Figure 6B. Evaluation Using Digital Phantoms To validate the angular and spatial measurements, two digital phantoms were created. The angular measurements were validated using 9 virtual drill bits in different known orientations as shown in Figure 7A. The spatial measurements were validated using 3 virtual drill bits encased in a cube as shown in Figure 7B. The resulting angular and spatial measurements were compared to the known values used to generate the digital phantoms. 5

6 Evaluation Using Cadaveric Specimens Ten cadaveric knee joints were collected (4 left and 6 right); each specimen included the full knee joint and a portion of the proximal tibia and distal femur. Prior to scanning, a single bundle ACL reconstruction was performed by a fellowship trained orthopaedic surgeon on each specimen using either the medial portal, transtibial, or two incision technique. The 10 specimens included four medial portal operations, four transtibial operations, and two two-incision operations from six fellowship trained orthopaedic surgeons. A Siemens Sensation 64 slice CT scanner was used to collect three-dimensional voxel datasets of the knee for each specimen (matrix = 1005x512, FOV = 261mm x 133mm, KVP = 120, Current = 128mA, Exposure = 160mAs) with a 0.26mm in-plane resolution and a 0.75mm slice thickness. Slices spanning the entire specimen were obtained for each dataset. The CT datasets were resampled to 1.0mm isotropic voxels, and all left knees were mirrored along the x-axis to produce 10 right knees for analysis. The BRAINS2 software was used to manually segment the distal femur and proximal tibia(17). 3DSlicer was used to generate and smooth surface representations from the manual tracings of the 10 femur surfaces and 10 tibia surfaces. An average sized femoral and tibial surface were aligned such that the surface orientations corresponded to the standardized orientation described above. The resulting orientations were verified to match the desired standardized orientation by an experienced orthopaedic surgeon. An Iterative Closest Point surface registration using 100 iterations and 5000 landmarks was used to rigidly align the remaining specimen surfaces to the standardized orientation(18). 6

7 Four users, two biomedical engineers and two orthopaedic residents, used the proposed measurement techniques to evaluate the femoral and tibial ACL tunnels on each of the 10 specimens. Each user was independently trained and performed placement and aperture matching of virtual drill bits into the tibia and femur for the 10 cadaveric datasets on a single occasion. The resulting virtual drill bits were processed using the 3D measurement techniques described above. The reliability of the raters was evaluated by computing the intraclass correlation coefficients for the described spatial and angular measures using SAS. As a test of the robustness of our measurement system, an additional two femur surfaces from a pre-existing dataset with misplaced tunnels (i.e. tunnels that missed the lateral femoral condyle) were also evaluated by a single user. Results: We have developed a novel three-dimensional measurement system to characterize ACL tunnel placement. The digital phantom evaluation verified the measurement methods by computing angular and spatial values that matched the known values in all cases. The ten cadaveric specimens showed average values of α = 60, β = 50, γ = 56, n/n = 0.54, and c/c = 0.68 for the femur and α = 77, β = 59, γ = 34, a/a = 0.49, and m/m = 0.46 for the tibia. The intraclass correlation coefficient was calculated for the four users and found to range from 0.95 to 0.99 for the femoral and tibial measurements. Tables describing these values were not included due to space constraints. The two misplaced femoral tunnels were successfully evaluated and can be seen in Figure 8. 7

8 Discussion: We have presented a surgically oriented tunnel localization system for ACL reconstructions based on estimating the positioning of surgically generated tunnels for the tibia and femur using surface models. Our methods are intentionally designed to be of practical use in the operating room and provide measurements based on the ESSKA recommendations(5) as well as the new measurements that we have proposed. By establishing a surgically relevant orientation, the aperture spatial measurements and the tunnel angular measurements provide a novel three-dimensional method to describe this inherently three-dimensional procedure. In addition, our methods allow for measurement of misplaced tunnels that could be difficult to describe using two-dimensional methods. Our methods are widely applicable. We have demonstrated their application on single bundle ACL reconstructions including the transtibial, medial portal, and two incision techniques. Simply incorporating a second drill bit would also allow this to be a method of evaluation for double bundle ACL reconstructions. In addition, this method could be used to evaluate posterior cruciate ligament (PCL) reconstruction and other procedures involving bone tunnels for graft placement. Our methods are reliable with intraclass correlation coefficients ranging from 0.95 to 0.99 between four users with both surgical and nonsurgical backgrounds. These high values can be attributed to a small degree of variability between raters in placing the virtual drill bits and a high degree of variability in the tunnel angles themselves. Blumensaat s line (a radiopaque region of overlapping bone in the roof of the intercondylar notch of the femur) has traditionally been a radiographic landmark important in describing the placement of ACL tunnels in two dimensions. Recently, Forsythe et al.(15) and Kopf et al.(16) have demonstrated the use of three-dimensional surfaces to characterize tunnel 8

9 locations using quadrants and spatial dimensions based on Blumensaat s line; however, we found this landmark difficult to reliably define across all anatomical variants on three-dimensional surfaces. We provide an alternative measurement tool based on the diameter of the lateral femoral condyle and the diaphysis of the femur. Currently, image segmentation may be seen as a limitation of this work; however, we recently developed semi-automated methods that require less than 60 seconds of manual intervention to perform the segmentation. While this study used surfaces generated from CT images, MRI could also be used for surface generation as it is more commonly obtained for an ACL revision surgery due to tunnel misplacement. Surfaces generated from MRI scans could also act as an input to our measurement process. Our surgically oriented coordinate system does deviate from orientations that have been proposed in the past. With respect to the femur, Grood et al.(19) proposed orienting the Z-axis corresponding to the femoral mechanical axis (partially defined with the femoral head). With respect to the tibia, Grood et al.(19) proposed aligning the Z-axis with the tibial mechanical axis (partially defined with the tibial malleoli). Forsythe et al.(15) and Kopf et al.(16) based their coordinate system on the recommendations from the International Society of Biomechanics and Grood et al(19). During ACL reconstructions, the femoral head is typically draped and is difficult to reference intraoperatively. In our measurement system, we have aligned the diaphysis of the femur with the Z-axis; this allows measurements to be taken with respect to a portion of the femur directly visible during the procedure. Our X- and Y- axes are defined similarly to that described by Grood et al(19). For the tibia, instead of orienting with respect to the tibial malleoli, we have oriented the tibia with regards to surface features of the tibial plateau. 9

10 Overall, our orientations were defined by aligning the femur and tibia with landmarks visible during the operative procedure. In the future, we hope to apply our methods to evaluate ACL reconstructions and provide a three-dimensional characterization to improve patient outcomes. We also hope to apply our techniques beyond ACL reconstructions to other surgical procedures. Future improvements to our methods will include fully automated segmentation of the tibia and femur, and automated placement of the virtual drill bits into the drill tunnels to foster an automated measurement system. To promote applicability, we plan to compile our tools into a user-friendly graphical user interface. In summary, we have presented a surgically oriented three-dimensional method of evaluating tunnel placement/orientation for ACL reconstructions. Our methods are applicable to both the femur and tibia and were based on the measurement recommendations made by the ESSKA(5). We have demonstrated our methods to be reliable and applicable to multiple techniques of ACL reconstruction. In the future, we will apply these methods to study the effects of multiple factors on the variability of tunnel placement to improve patient outcomes. 10

11 References: 1. F. Cimino, B. S. Volk, D. Setter, Am. Fam. Physician 82, 917 (2010). 2. D. Endele, C. Jung, U. Becker, G. Bauer, F. Mauch, Arthroscopy 25, 1067 (2009). 3. S. Lyman et al., J. Bone Joint Surg. Am. 91, 2321 (2009). 4. D. Kendoff, M. Citak, J. Voos, A. D. Pearle, Clin. Sports Med. 28, 41 (2009). 5. A. A. Amis et al., Knee Surg. Sports Traumatol. Arthrosc. 2, 124 (1994). 6. J. Dargel et al., Knee Surg. Sports Traumatol. Arthrosc. 17, 220 (2009). 7. S. M. Howell, M. E. Gittins, J. E. Gottlieb, S. M. Traina, T. M. Zoellner, Am. J. Sports Med. 29, 567 (2001). 8. L. A. Pinczewski et al., J. Bone Joint Surg. Br. 90, 172 (2008). 9. F. Giron, P. Cuomo, P. Aglietti, A. M. Bull, A. A. Amis, Knee Surg. Sports Traumatol. Arthrosc. 14, 250 (2006). 10. P. Aglietti, G. Zaccherotti, P. P. Menchetti, P. De Biase, Knee Surg. Sports Traumatol. Arthrosc. 3, 2 (1995). 11. C. Hoser, K. Tecklenburg, K. H. Kuenzel, C. Fink, Knee Surg. Sports Traumatol. Arthrosc. 13, 256 (2005). 12. A. Bedi, B. Raphael, A. Maderazo, H. Pavlov, R. J. Williams 3rd, Arthroscopy 26, 342 (2010). 13. Y. S. Chan et al., Arthroscopy 25, 54 (2009). 14. E. S. Abebe et al., Am. J. Sports Med. 37, 1904 (2009). 15. B. Forsythe et al., J. Bone Joint Surg. Am. 92, 1418 (2010). 16. S. Kopf et al., J. Bone Joint Surg. Am. 92, 1427 (2010). 17. V. A. Magnotta et al., Comput. Med. Imaging Graph. 26, 251 (2002). 18. G. C. Sharp, S. W. Lee, D. K. Wehe, In: Proc. IEEE Int. Conf. on Robotics and Autom. 1999, 932 (1999). 19. E. S. Grood, W. J. Suntay, J. Biomech. Eng. 105, 136 (1983). 11

12 Figure 1: A flow diagram describing the measurement process. Figure 2: A) The standardized orientation of the A) femur and B) tibia. Figure 3: Tibial tunnel angles (α, β, γ) were measured based on the tunnel centerline s deviation from the A) surgically oriented coordinate system as demonstrated B) looking down the y-axis and C) looking down the x-axis. Figure 4: Femoral tunnel angles (α, β, γ) were measured based on the tunnel centerline s deviation from the A) surgically oriented coordinate system as demonstrated B) looking down the y-axis and C) looking down the x-axis. 12

13 Figure 5: A) A measurement (a/a) of the tunnel aperture centroid based on the anterior-posterior distance of the tibial plateau. B) A measurement (n/n) of the tunnel aperture centroid based on the medial-lateral distance of the tibial plateau. Figure 6: A) A measurement (c/c) of the tunnel aperture centroid based on the diameter of the lateral femoral condyle. B) A measurement (n/n) of the tunnel aperture centroid based on the height of the intercondylar notch. Figure 7: A) Nine virtual drill bits used to test the angular measurements. B) Three virtual drill bits used to test the aperture localization measurements. 13 Figure 8: Two examples of misplaced ACL tunnels. A) A case where the femoral drill tunnel penetrated the cortex. B) A case where the femoral drill tunnel missed the lateral condyle.