3-D Intraoperative Imaging Proving Invaluable for Orthopaedic Surgery

Siemens’ Artis Zeego Robotic C-arm Imaging System

Originally inspired by the needs of cardiac and vascular surgeons, Siemens’ Artis zeego® robotic C-arm imaging system quickly generates three-dimensional images with a precision and field of view that is unprecedented in the operating room. Currently, UVA is one of the first medical centers in the country applying this advanced technology to improve outcomes for orthopaedic patients.

“With Artis zeego, orthopaedic surgeons can review reduction and implant positions to confirm that they are correct and make any necessary adjustments in alignment, all before leaving the operating room,” says orthopaedic surgeon Seth Yarboro, MD.

As minimally invasive surgery becomes the norm for complicated orthopaedic conditions, the need for high-quality intraoperative imaging is ever increasing. The two-dimensional images produced by traditional fluoroscopy cannot definitively confirm the positioning of three-dimensional objects, and its narrow field of view is not as well suited for aligning long-bone fractures.

Artis zeego’s field of view is not only wider than conventional fluoroscopy but it is also greater than mobile three-dimensional technology that is sometimes used in operating rooms. In fact, the volume of the scan is so great that surgeons can compare the reduction position in a limb they have just repaired to its uninjured counterpart, which is used as a template.

Collaboration Among Disciplines
UVA’s ability to adopt Artis zeego for orthopaedic procedures is the result of two surgeons working together to seize an unexpected opportunity. UVA’s David Kahler, MD, a renowned pioneer in computer-assisted orthopaedic surgery, encouraged Yarboro to spend part of his fellowship in 2013 studying at Ulm University Hospital in Germany alongside Florian Gebhard, MD, another leader in the field. Gebhard was the first in the world to adopt Artis zeego for orthopaedic use, and he and Yarboro performed a number of procedures using the technology.

Soon after, Kahler and Yarboro discovered UVA planned to include an Artis zeego C-arm in a new hybrid operating room being constructed for vascular surgery. When they realized that one was being installed, they contacted Gilbert Upchurch, Jr., MD, division chief of vascular surgery, and began discussions to use the Artis zeego for orthopaedic surgery.

Yarboro and Kahler have since used Artis zeego to treat a range of conditions, including ankle syndesmosis injuries, fractures that have healed incompletely and acetabulum fractures. “This technology is useful whenever a condition presents particular difficulty in imaging,” Yarboro says. “It provides unparalleled confidence that we have achieved our surgical goal before leaving the operating room.”

The Next Step: Computer-Assisted Orthopaedic Surgery
Kahler’s history with intraoperative imaging and computer-assisted surgery goes back to the early 1990s. Working with UVA colleague Gwo-Jaw Wang, MD, he performed minimally invasive procedures on select patients in UVA’s CT scanner facility. Since that time, he has adopted a series of increasingly sophisticated technologies that not only produced better images in the operating room but also provided greater certainty in placing implants. In Artis zeego, Kahler sees the potential for even greater surgical precision.

“Artis zeego takes us closer to the Holy Grail of navigated surgery,” Kahler says. “That’s the ability to take a surgical navigation system with an orthopaedic implant registry and interface it with a robotic imaging system.”

Gebhard has already incorporated an automatically registering navigation system in the Artis zeego in Ulm, Germany. By merging the intraoperative three-dimensional scan with the preoperative MRI and constantly recalibrating the patient’s position in relationship to the C-arm, the navigation system can generate a guide that enables a surgeon to position and angle an implant correctly. In addition, this system reduces the need for repeated fluoroscopic images, decreasing operating staff radiation exposure.

“The next item on our agenda is to add the navigation system,” Kahler says. “This is something we have been working toward at UVA for quite some time — and we’re almost there.”