Electromagnetic Navigation for Femoral Osteotomy Using High-Accuracy X-ray-to-CT Registration

Accurate execution of preoperative plans in corrective femoral osteotomies remains challenging. Current techniques are limited by variable accuracy, invasiveness, and radiation exposure, with free-hand methods and patient-specific instrumentation (PSI) often requiring >30 and >6 fluoroscopic images, respectively. We present an integrated, electromagnetic tracking (EMT)-based navigation system for femoral osteotomies that minimizes dissection and intraoperative fluoroscopy. The system couples CT-based preoperative planning with one-time intraoperative C-arm calibration and accurate X-ray-to-CT registration from two fluoroscopic images acquired at initialization. This enables real-time, fluoroscopy-free EMT navigation of the saw blade and bone fragments relative to the preoperative plan, and is compatible with uniplanar and biplanar osteotomies. In a feasibility study using 18 synthetic femora, EMT guidance significantly outperformed free-hand execution in total angular error ($(3.05 \pm 0.75)^\circ$ vs.\ $(6.32 \pm 2.36)^\circ$, $p=0.031$), assuming the same minimal surgical exposure for both. No EMT-guided trials exceeded the >5° clinical threshold, whereas free-hand produced 4 outliers of 6 trials. The system achieved statistical equivalence ($\pm 2^\circ$, $\pm 2,\text{mm}$) to PSI for total angular ($p \le 0.02$) and total translational ($p=0.048$) errors, with no significant differences in user questionnaire scores. By transferring preoperative plans using only two fluoroscopic images while matching PSI accuracy without additional surgical exposure, the proposed system motivates subsequent cadaveric and clinical validation.

Automatic Multi-View X-Ray/CT Registration Using Bone Substructure Contours

Purpose: Accurate intraoperative X-ray/CT registration is essential for surgical navigation in orthopedic procedures. However, existing methods struggle with consistently achieving sub-millimeter accuracy, robustness under broad initial pose estimates or need manual key-point annotations. This work aims to address these challenges by proposing a novel multi-view X-ray/CT registration method for intraoperative bone registration. Methods: The proposed registration method consists of a multi-view, contour-based iterative closest point (ICP) optimization. Unlike previous methods, which attempt to match bone contours across the entire silhouette in both imaging modalities, we focus on matching specific subcategories of contours corresponding to bone substructures. This leads to reduced ambiguity in the ICP matches, resulting in a more robust and accurate registration solution. This approach requires only two X-ray images and operates fully automatically. Additionally, we contribute a dataset of 5 cadaveric specimens, including real X-ray images, X-ray image poses and the corresponding CT scans. Results: The proposed registration method is evaluated on real X-ray images using mean reprojection error (mRPD). The method consistently achieves sub-millimeter accuracy with a mRPD 0.67mm compared to 5.35mm by a commercial solution requiring manual intervention. Furthermore, the method offers improved practical applicability, being fully automatic. Conclusion: Our method offers a practical, accurate, and efficient solution for multi-view X-ray/CT registration in orthopedic surgeries, which can be easily combined with tracking systems. By improving registration accuracy and minimizing manual intervention, it enhances intraoperative navigation, contributing to more accurate and effective surgical outcomes in computer-assisted surgery (CAS).