Surgical system and method of use for ultrasound-based multiple bone positioning in computer-assisted surgery - Patents.com

Abstract

Disclosed herein is a surgical system for surgical positioning of a patient's bones relative to a surgical plan. As part of the surgical system's ability to perform surgical positioning, the system is configured to process ultrasound images of the patient's bones, the ultrasound images including bone surfaces for each of the patient's bones. The system includes a computing device including a processing device and a computer-readable medium having one or more executable instructions stored thereon. The processing device is configured to execute the one or more executable instructions. The one or more executable instructions: i) detect bone surfaces of each of the patient's bones in the ultrasound images; and ii) isolate a first point cloud of ultrasound image pixels associated with the bone surfaces of each of the patient's bones.

Description

[Technical field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims the benefit of U.S. Provisional Application No. 63 / 105,973, filed October 27, 2020, which is hereby incorporated by reference in its entirety.

[0002] FIELD OF THE DISCLOSURE The present disclosure relates to medical systems and methods of use in computer-assisted surgery, and more particularly, to surgical positioning systems and methods in computer-assisted surgery. [Background technology]

[0003] Modern orthopaedic joint replacement surgery typically involves at least some degree of preoperative planning of the surgery to increase the effectiveness and efficiency of the particular procedure. In particular, preoperative planning can increase the accuracy of bone resection and implant placement while reducing the overall time of the procedure and the time the patient's joint is open and exposed.

[0004] The use of robotic systems in the performance of orthopaedic joint replacement surgery can significantly reduce the intraoperative time of a particular procedure. More than ever, the effectiveness of a procedure can be based on the tools, systems, and methods utilized during the preoperative planning stage.

[0005] Examples of steps involved in preoperative planning may include determining implant size, location, and orientation, resection plane and depth, trajectory to access the surgical site, and others. In certain cases, preoperative planning may involve generating a three-dimensional ("3D") patient-specific model of the bone and soft tissue of the patient receiving the joint replacement. The 3D patient model may be used as a visual aid in planning various possibilities for implant size, implant orientation, implant location, and corresponding resection plane and depth, among other parameters.

[0006] However, before the robotic system can perform the joint replacement, the robotic system and navigation system need to be positioned relative to the patient. Positioning involves mapping virtual boundaries and constraints defined in the preoperative plan for the patient in physical space so that the robotic system can be accurately tracked relative to the patient and constrained to the boundaries that apply to the patient's anatomy.

[0007] While frameworks for certain aspects of surgical positioning may be known in the art, there is a need for systems and methods that further improve upon certain aspects of positioning to further increase the efficiency and effectiveness of robotic and robotic-assisted orthopaedic joint replacement surgery. Summary of the Invention

[0008] Aspects of the present disclosure may include one or a combination of a variety of neural networks that are trained to detect and optionally classify bone surfaces in ultrasound images.

[0009] Aspects of the present disclosure may also include an algorithm that can simultaneously co-locate bone surfaces of N bones (which typically form articulating joints) between an ultrasound modality and a second modality (e.g., CT / MRI, or surface reconstruction employing one or more statistical / generic models that are deformed according to the patient's anatomical data) to capture the bones by optimizing at least an Nx6 degree of freedom transformation from the ultrasound modality to the second modality, and classification information that assigns regions in the image data of the ultrasound modality to one of the N captured bones.

[0010] In certain cases, to stitch together the individual ultrasound images (capturing only slices / small portions of the bone) into one coherent 3D image dataset, the ultrasound probe is tracked relative to anatomical trackers attached to each of the N captured bones. If the scanned bones are fixed, the ultrasound images can be stitched together by tracking only the ultrasound probe.

[0011] In certain cases, the multiple localizations may be 3D point cloud / mesh based. In such a situation, the N bones may be segmented in a second modality (CT / MRI bone segmentation) to obtain a triangulated mesh.

[0012] In certain cases, the multiple registrations may be image-based. In such a situation, the classified ultrasound data is directly matched with the second modality without the need to detect bone surfaces in the ultrasound image.

[0013] Aspects of the present disclosure may include a system for surgical positioning of a patient's bone relative to a surgical plan, the surgical positioning employing ultrasound images of the patient's bone, the ultrasound images including individual ultrasound images including bone surfaces of a plurality of bones, the individual ultrasound images being generated from an ultrasound scan resulting from a single swath of an ultrasound probe across the patient's bone. In such a system, the system includes a computing device including a processing device and a computer readable medium having one or more executable instructions stored thereon. The processing device is configured to execute the one or more instructions. The one or more executable instructions include one or more neural networks trained to i) detect bone surfaces in the individual ultrasound images, and ii) classify each of the bone surfaces in the individual ultrasound images according to a bone type to arrive at a classified bone surface.

[0014] The one or more neural networks may include a convolutional network that detects bone surfaces in each ultrasound image, and depending on the embodiment, the one or more neural networks may include a pixel classification network and / or a likelihood classification network that classifies each of the bone surfaces.

[0015] Advantageously, the system can receive individual ultrasound images having bone surfaces of multiple bones, and then i) detect bone surfaces in the individual ultrasound images, and ii) classify each of the bone surfaces according to its type of bone to arrive at a classified bone surface. In other words, the system can still detect and classify bone surfaces even though the individual ultrasound images contain bone surfaces of multiple bones. Advantageously, this capability allows individual ultrasound images to be generated from ultrasound scans resulting from a single swath of the ultrasound probe over the patient's bones forming a joint. Thus, this capability allows the swath of the ultrasound probe over the patient's bones of the joint to not have to be limited to a single bone, but rather the swath can simply extend over all bones of the joint such that the resulting ultrasound image includes multiple bones, and the system can detect the bone surfaces and classify the bone surfaces as they are classified by the system.

[0016] In one version of the system, the processing device executes one or more instructions to calculate a transformation of the 2D image pixels of the classified bone surfaces of each ultrasound image to 3D points, thereby generating a classified 3D bone surface point cloud. Depending on the embodiment, in calculating the transformation of the 2D image pixels of the classified bone surfaces of each ultrasound image to 3D points, the propagation speed of ultrasound in a particular medium may be taken into account, a known set of poses of the ultrasound probe may be obtained with respect to the probe tracker relative to the ultrasound probe coordinate system, and a transformation may be calculated between the probe tracker space and the ultrasound probe coordinate system.

[0017] In one version of the system, the processing device executes one or more instructions to calculate an initial or rough positioning of the patient's bone relative to a computer model of the patient's bone.

[0018] In one embodiment of the system, in calculating the initial or rough positioning of the patient's bones to the computer model of the patient's bones, a first point cloud and a second point cloud are generated by the system, the first point cloud being for a first bone of the patient's bones and for a first tracker associated with the first bone, and the second point cloud being for a second bone of the patient's bones and for a second tracker associated with the second bone. Thus, in the context of the patient's knee, the first point cloud is for a femur of the patient's bones and for a first tracker fixed to the femur, and the second point cloud is for a tibia of the patient's bones and for a second tracker fixed to the tibia. In calculating the initial or rough positioning of the patient's bones to the computer model of the patient's bones, the system matches bone surface points of the first point cloud onto the computer model of the first bone and matches bone surface points of the second point cloud onto the computer model of the second bone.

[0019] In other embodiments of the system, in calculating the initial or rough positioning of the patient's bone to the computer model of the patient's bone, the system may employ landmark-based positioning and / or tracker pin-based positioning of the anatomical structures.

[0020] In one version of the system, the processing device executes one or more instructions to employ an initial or coarse positioning and the classified 3D bone surface point cloud to calculate a final bone positioning, where the final bone positioning achieves convergence between the classified 3D bone surface point cloud and the patient's bones. Depending on the embodiment, in calculating the final bone positioning where convergence exists between the classified 3D bone surface point cloud and the patient's bones, the system may apply the initial or coarse positioning to the classified 3D bone surface point cloud with reference to a first tracker. In the context of a knee joint, the first tracker may be attached to the femur.

[0021] Depending on the embodiment, when calculating the final multiple bone positioning where there is convergence between the classified 3D bone surface point cloud and the patient's bones, the system iteratively calculates the closest points of the classified 3D surface point cloud to a computer model of the patient's bones.

[0022] Aspects of the present disclosure may include a method of positioning a plurality of bones of a joint of a patient relative to a surgical plan. Depending on the embodiment, the method may include receiving an ultrasound image of a joint of a patient, at least a portion of which depicts a plurality of bones, employing a convolutional network to detect bone surfaces of the plurality of bones in the ultrasound image, employing at least one of a likelihood classifier network or a pixel classifier network to classify each of the bone surfaces according to its type of bone to arrive at a classified bone surface, converting the 2D ultrasound image pixels of the classified bone surface to 3D to result in a classified 3D bone surface point cloud, generating an initial rough positioning of the plurality of bones of the joint of the patient to a medical image representation of the plurality of bones of the joint of the patient, and calculating a final positioning of the plurality of bones of the joint of the patient relative to the surgical plan by applying the initial rough positioning to the classified 3D bone surface point cloud.

[0023] In one embodiment, the propagation speed of ultrasound in a particular medium may be taken into account when converting 2D ultrasound image pixels of classified bone surfaces to 3D.

[0024] In one embodiment, when converting the 2D ultrasound image pixels of the classified bone surface to 3D, the 2D ultrasound image pixels of the classified bone surface may be mapped from the 2D pixel space to a 3D metric coordinate system of the ultrasound probe coordinate system.

[0025] In one embodiment, when converting the 2D ultrasound image pixels of the classified bone surfaces to 3D, a known set of poses of the ultrasound probe may be obtained relative to the probe tracker in relation to the ultrasound probe coordinate system.

[0026] In one embodiment, in transforming the 2D ultrasound image pixels of the classified bone surfaces to 3D, a transformation may be calculated between the probe tracker space and the ultrasound probe coordinate system.

[0027] In one embodiment, in generating an initial rough positioning of multiple bones of a patient's joint onto a medical image representation of the multiple bones of the patient's joint, a first point cloud and a second point cloud may be generated, the first point cloud relating to a first bone of the multiple bones for a first tracker associated with the first bone, and the second point cloud relating to a second bone of the multiple bones for a second tracker associated with the second bone.

[0028] In one embodiment, in generating an initial rough positioning of multiple bones of a patient's joint onto a medical image representation of the multiple bones of the patient's joint, bone surface points of a first point cloud may be matched onto a computer model of the first bone and bone surface points of a second point cloud are matched onto a computer model of the second bone.

[0029] In one embodiment, landmark-based positioning may be employed in generating an initial rough positioning of multiple bones of a patient's joint onto a medical image representation of the multiple bones of the patient's joint.

[0030] In one embodiment, tracker pin based positioning of anatomical structures may be employed in generating an initial rough positioning of multiple bones of a patient's joint onto a medical image representation of the multiple bones of the patient's joint.

[0031] In one embodiment, when calculating a final bone positioning of the bones of the patient's joint relative to the surgical plan by applying an initial coarse positioning to the classified 3D bone surface point cloud, the final bone positioning achieves convergence between the classified 3D bone surface point cloud and the patient's bones. In doing so, the initial coarse positioning may be applied to the classified 3D bone surface point cloud with reference to a first tracker. Depending on the embodiment, during this final positioning, the algorithm employed may converge until the result reaches a plateau, and the algorithm may also refine the classification of the classified 3D bone surface point cloud itself, so that any initial errors in the classification may be eliminated or at least reduced. In achieving these aspects of the final positioning, the classified 3D bone surface point cloud and the initial or coarse positioning become sufficiently registered, resulting in the final bone positioning.

[0032] In one embodiment, by applying an initial rough positioning to the classified 3D bone surface point cloud, an iterative calculation of the closest points of the classified 3D surface point cloud to a computer model of the patient's bones may be performed in calculating the final bone positioning of the bones of the patient's joint relative to the surgical plan.

[0033] Aspects of the present disclosure may include a method for surgical positioning of a patient's bone relative to a surgical plan. Depending on the embodiment, the method may include receiving ultrasound images of the patient's bone, the ultrasound images including individual ultrasound images including bone surfaces of a plurality of bones, the individual ultrasound images being generated from an ultrasound scan resulting from a single swath of an ultrasound probe across the patient's bone, and employing one or more neural networks trained to detect bone surfaces in the individual ultrasound images and classify each of the bone surfaces in the individual ultrasound images according to bone type to arrive at the classified bone surfaces.

[0034] Aspects of the present disclosure may include a surgical system configured to process ultrasound images of a patient's bones, the ultrasound images including bone surfaces for each of the patient's bones. In one embodiment, the system includes a computing device including a processing device and a computer-readable medium having one or more executable instructions stored thereon. The processing device is configured to execute the one or more executable instructions. The one or more executable instructions include: i) detecting bone surfaces of each of the patient's bones in the ultrasound images; and ii) isolating a first point cloud of ultrasound image pixels associated with the bone surfaces of each of the patient's bones.

[0035] In one version of the embodiment, the detection of the bone surface may occur via an image processing algorithm forming at least a part of the one or more executable instructions. The image processing algorithm may include a machine learning model. The separation of the first point cloud may occur via a pixel classification neural network forming at least a part of the one or more executable instructions. The separation of the first point cloud may occur via an image-based classification neural network forming at least a part of the one or more executable instructions.

[0036] In one version of the embodiment, the processing device may execute one or more executable instructions to calculate a transformation of the first point cloud into a separated 3D point cloud, the separated 3D point cloud being separated such that ultrasound image pixels of the separated 3D point cloud are each correlated to a corresponding bone surface of the patient's bone. In calculating the transformation of the first point cloud into the separated 3D point cloud, the ultrasound image pixels may be calibrated to an ultrasound probe tracker, and the ultrasound probe tracker is calibrated to a tracking camera. In calibrating the ultrasound image pixels to the ultrasound probe tracker, the propagation speed of ultrasound in a particular medium may be taken into account. In calculating the transformation of the first point cloud into the separated 3D point cloud, the ultrasound image pixels may be calibrated to an ultrasound probe tracker, and the ultrasound probe tracker is calibrated to a tracking camera, and the coordinate system is relative to the bone surface via an anatomical structure tracker placed on the bone surface of the patient's bone. The separation of the first point cloud may occur via a geometric analysis of the first point cloud.

[0037] In one version of an embodiment, the one or more executable instructions may calculate an initial or rough positioning of a second point cloud acquired from the patient's bone to a bone model of the patient's bone. The second point cloud may include multiple point clouds for multiple trackers on the patient's bone. The multiple point clouds may include one point cloud positioned on one bone model of the bone model of the patient's bone and another point cloud positioned on another bone model of the bone model of the patient's bone.

[0038] The initial or coarse positioning may be landmark based. The initial or coarse positioning may be calculated from the tracker positions and orientations of the anatomical structures. In calculating the initial or coarse positioning, a third point cloud and a fourth point cloud may be generated by the system, the third point cloud being for a first bone of the patient's bones and for a first tracker associated with the first bone, and the fourth point cloud being for a second bone of the patient's bones and for a second tracker associated with the second bone.

[0039] In one version of the embodiment, when calculating the initial or rough positioning, the system may match bone surface points of the third point cloud onto a computer model of the first bone and match bone surface points of the fourth point cloud onto a computer model of the second bone.

[0040] In one version of an embodiment, the processing device may execute one or more instructions to employ the initial or rough positioning and the separated 3D point cloud to calculate a final bone positioning, which achieves a final positioning between the separated 3D point cloud and the patient's bones. In calculating the final bone positioning, where there is a final positioning between the classified 3D bone surface point cloud and the patient's bones, the system may iteratively refine the positioning of the separated 3D point cloud to a computer model of the patient's bones, and iteratively refine the separation of the separated 3D point cloud.

[0041] Aspects of the present disclosure may include a method of processing an ultrasound image of a patient's bones, the ultrasound image including a bone surface for each of the patient's bones. One embodiment of such a method may include detecting the bone surface of each of the patient's bones in the ultrasound image and isolating a first point cloud of ultrasound image pixels associated with the bone surface of each of the patient's bones.

[0042] In one version of the embodiment, the detection of the bone surface may occur via an image processing algorithm. The image processing algorithm may include a machine learning model. The separation of the first point cloud may occur via a pixel classification neural network. The separation of the first point cloud may occur via an image-based classification neural network.

[0043] In one version of an embodiment, the method further includes calculating a transformation of the first point cloud into a separated 3D point cloud, the separated 3D point cloud being separated such that ultrasound image pixels of the separated 3D point cloud are each correlated to a corresponding bone surface of the patient's bone. In calculating the transformation of the first point cloud into the separated 3D point cloud, the ultrasound image pixels may be calibrated to an ultrasound probe tracker, and the ultrasound probe tracker may be calibrated to a tracking camera. In calibrating the ultrasound image pixels to the ultrasound probe tracker, the propagation speed of ultrasound in a particular medium may be taken into account.

[0044] In one version of an embodiment, in computing a transformation of the first point cloud into a separated 3D point cloud, the ultrasound image pixels may be calibrated to an ultrasound probe tracker, which is calibrated to a tracking camera, and the coordinate system is relative to the bone surface via an anatomical tracker placed on the bone surface of the patient's bone. Separation of the first point cloud may occur via a geometric analysis of the first point cloud.

[0045] In one version of an embodiment, the method further includes calculating an initial or coarse positioning of a second point cloud acquired from the patient's bone to a bone model of the patient's bone. The second point cloud may include a plurality of point clouds for a plurality of trackers at the patient's bone. The plurality of point clouds may include one point cloud positioned at a bone model of the bone model of the patient's bone and another point cloud positioned at another bone model of the bone model of the patient's bone. The initial or coarse positioning may be landmark-based. The initial or coarse positioning may be calculated from the positions and orientations of the trackers of the anatomical structure.

[0046] In one version of the embodiment, in calculating the initial or rough positioning, a third point cloud and a fourth point cloud may be generated, the third point cloud for a first bone of the patient's bones and for a first tracker associated with the first bone, and the fourth point cloud for a second bone of the patient's bones and for a second tracker associated with the second bone. In calculating the initial or rough positioning, bone surface points of the third point cloud may be matched onto a computer model of the first bone, and bone surface points of the fourth point cloud are matched onto a computer model of the second bone.

[0047] In one version of an embodiment, the method further includes calculating a final bone positioning employing the initial or rough positioning and the separated 3D point cloud, where the final bone positioning achieves a final positioning between the separated 3D point cloud and the patient's bones. In calculating the final bone positioning, where there is a final positioning between the classified 3D bone surface point cloud and the patient's bones, the positioning of the separated 3D point cloud to the computer model of the patient's bones may be iteratively refined, and the separation of the separated 3D point cloud is iteratively refined.

[0048] The patent or application file contains at least one drawing executed in color. Copies of this patent or patent application publication with color drawing(s) will be provided by the Office upon request and payment of the necessary fee. [Brief description of the drawings]

[0049] [Figure 1] FIG. 1 is a diagram of a surgical system.

[0050] [Diagram 2] FIG. 2 is a flow chart illustrating surgical planning and performance of arthroplasty.

[0051] [Figure 3A] FIG. 3A shows haptic guidance during the performance of arthroplasty. [Figure 3B] FIG. 3B illustrates tactile guidance during the performance of the arthroplasty.

[0052] [Figure 4A] FIG. 4A is a coronal image of the knee joint showing the femur and tibia.

[0053] [Figure 4B] FIG. 4B is an axial image of the knee joint showing the femur and patella.

[0054] [Figure 4C] FIG. 4C is a sagittal image of the knee joint showing the femur, patella, and tibia.

[0055] [Figure 4D] FIG. 4D is a coronal image of the knee joint showing the femur and tibia.

[0056] [Figure 4E] FIG. 4E is a 3D joint model including 3D models of the femur, patella, and tibia.

[0057] [Figure 5A]FIG. 5A is a flow chart illustrating pre-operative and intra-operative aspects of the positioning process shown in FIG. 2, which is an ultrasound-based multiple bone positioning process.

[0058] [Figure 5B] FIG. 5B is a pictorial depiction of an embodiment of a portion of the registration process of FIG. 5A, i.e., the process of generating a classified or separated three-dimensional ("3D") bone surface point cloud from an ultrasound sweep.

[0059] [Figure 6A] FIG. 6A is a flow chart of a portion of the registration process of FIG. 5A, ie, the process of ultrasound image bone surface detection using pixel classification.

[0060] [Figure 6B] FIG. 6B is a pictorial depiction of the process of FIG. 6A.

[0061] [Figure 7A] FIG. 7A is a flow chart of a portion of the registration process of FIG. 5A, ie, the process of ultrasound image bone surface detection using likelihood classification.

[0062] [Figure 7B] FIG. 7B is a pictorial depiction of the process of FIG. 7A.

[0063] [Figure 8A] FIG. 8A is a flow chart of a portion of the positioning process of FIG. 5A, ie, the process of calculating the transformation of ultrasound two-dimensional ("2D") image pixels into 3D points.

[0064] [Figure 8B] FIG. 8B is a pictorial depiction of the process of FIG. 8A.

[0065] [Figure 9A]FIG. 9A is a flow chart of the portion of the positioning process of FIG. 5A, ie, the process of obtaining global positioning data (probe pose / landmarks) in CAD model space.

[0066] [Figure 9B] FIG. 9B is a pictorial depiction of the process of FIG. 9A.

[0067] [Figure 10A] FIG. 10A is a flow chart of the positioning process of FIG. 5A, i.e., the initial positioning is obtained intraoperatively.

[0068] [Figure 10B] FIG. 10B is a pictorial depiction of an alternative embodiment of the process of FIG. 10A. [Figure 10C] FIG. 10C is a pictorial depiction of an alternative embodiment of the process of FIG. 10A.

[0069] [Figure 11A] FIG. 11A is a flow chart of a portion of the positioning process of FIG. 5A, ie, the "one click / one pose" positioning process.

[0070] [Figure 11B] FIG. 11B is a pictorial depiction of an embodiment of the process of FIG. 11A. [Figure 11C] FIG. 11C is a pictorial depiction of an embodiment of the process of FIG. 11A.

[0071] [Figure 12] FIG. 12 is a flow chart of the localization process of FIG. 5A, ie, a portion of the process of landmark-based localization.

[0072] [Figure 13A] FIG. 13A is a flow chart of a portion of the registration process of FIG. 5A, i.e., the process of tracker pin-based registration of an anatomical structure.

[0073] [Figure 13B] FIG. 13B is a pictorial depiction of an embodiment of the process of FIG. 13A.

[0074] [Figure 14A] FIG. 14A is a flow chart of a portion of the registration process of FIG. 5A, ie, the process of calculating the final multiple bone registrations.

[0075] [Figure 14B] FIG. 14B is a pictorial depiction of an embodiment of the process of FIG. 14A. [Figure 14C] FIG. 14C is a pictorial depiction of an embodiment of the process of FIG. 14A.

[0076] [Figure 15] FIG. 15 is a diagram of a positioning system or identifying surgical targets.

[0077] [Figure 16] FIG. 16 is an example computing system having one or more computing units capable of implementing the various systems and methods discussed herein. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0078] This application incorporates by reference the following applications in their entirety: International Application No. PCT / US2017 / 049466, filed August 30, 2017, entitled "SYSTEM AND METHOD FOR INTRA-OPERATIVE PELVIS POSITIONING," International Application No. PCT / US2016 / 034847, filed May 27, 2016, entitled "PREOPERATIVE PLANNING AND ASSOCIATED INTRA-OPERATIVE POSITIONING FOR A SURGERY SYSTEM," U.S. Patent Application No. 12 / 894,071, filed September 29, 2010, entitled "SURGICAL SYSTEM FOR POSITIONING PROSTHETIC COMPONENTS AND / OR CONSTRAINING MOVEMENT OF SURGERY TOOLS," U.S. Patent Application No. 12 / 894,071, filed September 16, 2011, entitled "SYSTEM AND METHOD FOR MEASURING PARAMETERS IN JOINT REPLACEMENT SURGERY," No. 13 / 234,190, U.S. Pat. No. 11 / 357,197, filed Feb. 21, 2006, entitled "Tactile Guidance System and Method," U.S. Pat. No. 12 / 654,519, filed Dec. 22, 2009, entitled "Transmission Using First and Second Transmitting Elements," U.S. Pat. No. 12 / 644,964, filed Dec. 22, 2009, entitled "Device That Can Be Assembled By Connection," and U.S. Pat. No. 11 / 750,807, filed May 18, 2007, entitled "System and Method for Verifying Calibration of a Surgical Device."

[0079] A surgical positioning system and method of use are disclosed herein in connection with the surgical system 100. Surgical positioning requires, for example, mapping a virtual boundary determined in a preoperative plan with a working boundary in physical space. A surgical robot may be permitted to perform certain operations within the virtual boundary, such as drilling a hole or resecting a bone surface. Once the virtual boundary is mapped to the patient's physical space, the robot may drill a hole or resect a bone surface at a planned location and orientation, but may be constrained from performing such operations outside the pre-planned virtual boundary. Accurate and precise positioning of the patient's anatomy allows for accurate navigation of the surgical robot during the surgical procedure. The need for accuracy and precision in the positioning process must be balanced with the time required to perform the positioning.

[0080] In the case of robotic-assisted surgery, the virtual boundaries may be defined in the pre-operative plan. In the case of fully robotic surgery, the virtual tool paths may be defined in the pre-operative plan. In either case, the pre-operative plan may include, for example, defining the bone resection depth and identifying whether an unacceptable notch in the anterior femoral cortex is associated with the proposed bone resection depth and proposed orientation of the candidate implant. Assuming that the pre-operatively planned bone resection depth and implant orientation are free of unacceptable notches in the anterior femoral cortex and approved by the surgeon, the bone resection depth may be updated to account for the cartilage thickness by intraoperatively positioning the cartilage condyle surface of the actual patient's bone to the patient's bone model employed in the pre-operative plan. By so accounting for the cartilage thickness, the actual implant, when implanted via the surgical system 100, has a respective condyle surface positioned to function in place of the resected cartilage condyle surface of the actual patient's bone. Further description of pre-operative planning can be found in International Application No. PCT / US2016 / 034847, filed May 27, 2016, entitled "Pre-operative Planning and Associated Intra-operative Positioning for a Surgical System," which is incorporated by reference in its entirety.

[0081] Before commencing a detailed discussion of surgical positioning, an overview of the surgical system and its operation will now be given as follows.

[0082] I. Overview of the surgical system

[0083] To begin a detailed discussion of the surgical system, reference is made to Figure 1. As can be seen from Figure 1, the surgical system 100 includes a navigation system 42, a computer 50, and a haptic device 60 (also referred to as a robotic arm 60). The navigation system tracks the patient's bones (i.e., tibia 10, femur 11) and the surgical tools utilized during surgery (e.g., pointer devices, probes, cutting tools) to allow the surgeon to visualize the bones and tools on a display 56 during the osteotomy procedure.

[0084] The navigation system 42 may be any type of navigation system configured to track the pose (i.e., position and orientation) of bones. For example, the navigation system 42 may include a non-mechanical tracking system, a mechanical tracking system, or any combination of non-mechanical and mechanical tracking systems. The navigation system 42 includes a detection device 44 that obtains the pose of an object relative to a coordinate frame of reference of the detection device 44. As the object moves within the coordinate frame of reference, the detection device tracks the pose of the object to detect the movement of the object.

[0085] In one embodiment, the navigation system 42 includes a non-mechanical tracking system as shown in FIG. 1. The non-mechanical tracking system is an optical tracking system having a detection device 44 and trackable elements (e.g., navigation markers 46, 47) that are respectively placed on the tracked object (e.g., the patient's tibia 10 and femur 11) and are detectable by the detection device 44. In one embodiment, the detection device 44 includes a visible light-based detector such as a MicronTracker (Claron Technology Inc., Toronto, Canada) that detects a pattern (e.g., a checkerboard pattern) on the trackable elements. In another embodiment, the detection device 44 includes a stereo camera pair that responds to infrared radiation and is positionable in the operating room where the arthroplasty procedure is performed. The trackable elements include an array of markers that are attached to the tracked object in a fixed and stable manner and have a known geometric relationship to the tracked object. As is known, the trackable elements may be active (e.g., light emitting diodes or LEDs) or passive (e.g., reflective spheres, checkerboard patterns, etc.) and may have a unique shape (e.g., a unique geometric arrangement of markers) or, in the case of active wired or wireless markers, a unique emission pattern. In operation, the detection device 44 detects the position of the trackable elements and the surgical system 100 (e.g., detection device 44 using embedded electronics) calculates the pose of the tracked object based on the position, unique shape, and known geometric relationship of the trackable elements to the tracked object. The tracking system 42 includes a trackable element for each object the user wishes to track, such as a navigational marker 46 located on the tibia 10 and a navigational marker 47 located on the femur 11.During haptic-guided robotic-assisted surgery, the navigation system may further include haptic device markers 48 (for tracking the global or overall position of the haptic device 60), end effector markers 54 (for tracking the distal end of the haptic device 60), and freehand navigation probes 55, 57 for use in the positioning process in the form of a tracked ultrasound probe 55 and a tracked stylus 57 having a sharp tip for touching specific relevant anatomical landmarks on the patient and specific positioning locations on parts of the system 100. Additionally or alternatively, the system 100 may employ electromagnetic tracking.

[0086] Although the systems and methods disclosed herein are provided in the context of a robotically assisted surgical system employing the above-mentioned navigation system, such as that employed by Stryker's Mako surgical robot, the disclosure is readily applicable to other navigated surgical systems. For example, the systems and methods disclosed herein may additionally or alternatively be applied to bone-creating surgical procedures employing navigated arthroplasty jigs, such as in the context of Stryker's eNact Knee Navigation software. Similarly, the systems and methods disclosed herein may additionally or alternatively be applied to bone-creating surgical procedures employing navigated saws or handheld robots.

[0087] As shown in FIG. 1, the surgical system 100 further includes a processing circuit, depicted diagrammatically as a computer 50. The processing circuit includes a processor and a memory device. The processor may be implemented as a general-purpose processor, an application specific integrated circuit (ASIC), one or more field programmable gate arrays (FPGAs), a group of processing components, a special purpose processor, or other suitable electronic processing components. A memory device (e.g., memory, memory unit, storage device, etc.) is one or more devices (e.g., RAM, ROM, flash memory, hard disk storage, etc.) that store data and / or computer code that completes or facilitates the various processes, layers, and functions described herein. The memory device may be or include volatile or non-volatile memory. The memory device may include a database component, an object code component, a script component, or any other type of information structure that supports the various operations and information structures described herein. According to a preferred embodiment, the memory device is communicatively coupled to the processor via processing circuitry and includes computer code for carrying out (e.g., by the processing circuitry and / or the processor) one or more of the processes described herein.

[0088] The computer 50 is configured to communicate with the navigation system 42 and the haptic device 60. Additionally, the computer 50 may receive information related to the orthopedic / arthroplasty procedure and perform various functions related to performing the osteotomy procedure. For example, the computer 50 may have the necessary software to perform functions related to image analysis, surgical planning, positioning, navigation, image guidance, and haptic guidance. More specifically, the navigation system may operate in conjunction with an autonomous robot or a surgeon-assistance device (haptic device) in performing the arthroplasty procedure.

[0089] The computer 50 receives images of the patient's anatomy on which the arthroplasty procedure is to be performed. With reference to FIG. 2, prior to the performance of the arthroplasty procedure, the patient's anatomy may be scanned (step 801) using any known imaging technique, such as CT or MRI captured using a medical imaging machine. Although the present disclosure makes reference to medical images captured or generated using a medical imaging machine, such as a CT or MRI machine, other methods of generating medical images are possible and contemplated herein. For example, images of bones may be generated intraoperatively via a medical imaging machine, such as a handheld scanning or imaging device that scans or locates the topography of bone surfaces. As yet another example, patient anatomical data obtained from a wide variety of modalities may be used to generate medical images by deforming one or more statistical / generic models according to the patient's anatomical data, preoperatively or intraoperatively. Thus, the term medical imaging machine is intended to encompass devices of various sizes (e.g., C-arms, handheld devices) located at an imaging center or used intraoperatively, and the term medical images is intended to encompass images, models, or other anatomical representation data of a patient that are useful in planning and performing an arthroplasty procedure.

[0090] The scan data is then subsequently segmented to obtain a three-dimensional representation of the patient's anatomy. For example, prior to the performance of the knee arthroplasty, a three-dimensional representation of the femur and tibia is generated. Using the three-dimensional representation, femoral and tibial landmarks may be selected as part of the planning process, and the patient's femoral-tibial alignment is calculated along with the orientation and placement of proposed femoral and tibial implants, which may be selected for model and size via computer 50. The femoral and tibial landmarks may include, among others, the femoral head center, the distal trochlear groove, the center of the intercondylar eminence, the tibial-ankle center, and the medial tibial spine. The femoral-tibial alignment is the angle between the femoral functional axis (i.e., a line from the femoral head center to the distal trochlear groove) and the tibial functional axis (i.e., a line from the ankle center to the intercondylar eminence center). Based on the patient's current femoral-tibial alignment and the desired femoral-tibial alignment to be achieved by the arthroplasty procedure, and further including the size, model, and placement of the proposed femoral and tibial implants, including the desired extension, varus-valgus angles, and internal-external rotation associated with the implantation of the proposed implants, the computer 50 is programmed to calculate the desired implantation of the proposed implants or at least assist in pre-operative planning of the implantation of the proposed implants (step 803), including resections generated via the haptic device 60 in the process of performing the arthroplasty procedure. The pre-operative plan achieved via step 803 is provided to the surgeon for review, adjustments, and approval, and the pre-operative plan is updated as directed by the surgeon (step 802).

[0091] It should be understood that since the computer 50 is used to develop the surgical plan according to step 803, the user may interact with the computer 50 at any stage during the surgical plan to input information and modify any portion of the surgical plan. The surgical plan may include a number of planned virtual boundaries (in the case of haptic-based robotic-assisted surgery) or tool path planning (in the case of autonomous robotic surgery). The virtual boundaries or tool paths may represent holes and / or cuts to be created in the bones 10, 11 during the arthroplasty procedure. Once the surgical plan is developed, the haptic device 60 is used to assist the user in creating the planned holes and cuts in the bones 10, 11. Pre-operative planning, particularly with regard to planning bone resection depth and preventing notching of the anterior femoral shaft, is described more fully below.

[0092] The drilling of holes and the creation of cuts or resections in the bones 10, 11 may be accomplished with the assistance of a haptically guided interactive robotic system such as the haptic guidance system described in U.S. Patent No. 8,010,180, entitled "Haptic Guidance System and Method," issued August 30, 2011, and incorporated herein by reference in its entirety. As the surgeon manipulates the robotic arm to drill holes or perform cuts in the bone with a high speed drill, sagittal saw, or other suitable tool, the system provides haptic feedback to guide the surgeon in sculpting the holes and cuts to the appropriate shapes preprogrammed into the control system of the robotic arm. Haptic guidance and feedback is described more fully below.

[0093] During surgical planning, the computer 50 further receives information related to the femoral and tibial implants to be implanted during the arthroplasty procedure. For example, a user may input the parameters of the selected femoral and tibial implants into the computer 50 using the input device 52 (e.g., keyboard, mouse, etc.). Alternatively, the computer 50 may include a pre-established database of various implants and their parameters, and the user may choose the selected implant from the database. In still further embodiments, the implants may be custom designed based on the patient-specific surgical plan. The selection of the implant may occur at any stage of the surgical planning.

[0094] The surgical plan may further be based on at least one parameter of the implant or a function of the parameter of the implant. Since the implant may be selected at any stage of the surgical planning process, the implant may be selected before or after the determination of the planned virtual boundaries by the computer 50. If the implant is selected first, the planned virtual boundaries may be based at least in part on the parameters of the implant. For example, the distance (or any other relationship) between the planned virtual boundaries representing the holes or cuts to be created in the bones 10, 11 may be planned based on the desired varus-valgus femoral-tibial alignment, extension, internal-external rotation, or any other factor associated with the desired surgical outcome of the implantation of the arthroplasty implant. In this way, the implementation of the surgical plan may result in the proper alignment of the resected bone surfaces and holes to enable the selected implant to achieve the desired surgical outcome. Alternatively, the computer 50 may develop a surgical plan including the planned virtual boundaries prior to the implant selection. In this case, the implant may be selected (e.g., input, chosen, or designed) based at least in part on the planned virtual boundaries. For example, an implant can be selected based on planned virtual boundaries such that execution of the surgical plan results in proper alignment of the resected bone surfaces and holes to enable the selected implant to achieve the desired surgical outcome.

[0095] The virtual boundaries or tool paths exist in virtual space and may represent features that exist or are generated in physical (i.e., real) space. The virtual boundaries correspond to working boundaries in physical space that may interact with objects in the physical space. For example, the working boundaries may interact with a surgical tool 58 connected to a haptic device 60. Although surgical plans are often described herein as including virtual boundaries representing holes and resections, the surgical plans may include virtual boundaries that represent other modifications to the bones 10, 11. Additionally, the virtual boundaries may correspond to any working boundaries in physical space that may interact with objects in the physical space.

[0096] It should be noted that while the systems and methods disclosed herein are within the context of arthroplasty, they are readily useful in the context of surgery that does not employ implants. Thus, for example, and without limitation, navigation and haptics can be pre-planned to enable the systems disclosed herein to resect bone tumors (sarcomas) or make other types of incisions or resections in bone or soft tissue generally when performing any type of navigated surgery.

[0097] Referring again to FIG. 2, after surgical planning and prior to performing the arthroplasty procedure, the physical anatomical structures (e.g., bones 10, 11) are positioned in a virtual representation (e.g., pre-operative 3D representation) of the anatomy using positioning techniques (step 804), as described in detail below. Positioning of the patient's anatomy allows for precise navigation (step 805) during the surgical procedure, such that each of the virtual boundaries can correspond to a working boundary in physical space. For example, referring to FIGS. 3A and 3B, a virtual boundary 62 representing a resection in the tibia 10 is displayed on a computer or other display 63, where the virtual boundary 62 corresponds to a working boundary 66 in a physical space 69, such as a surgical site in an operating room. And a portion of the working boundary 66 corresponds to the location of the planned resection in the tibia 10.

[0098] The virtual boundary, and therefore the corresponding working boundary, may be of any configuration or shape. With reference to FIG. 3A, the virtual boundary 62 representing the proximal resection to be created in the tibia 10 may be of any configuration suitable for assisting a user during the creation of the proximal resection in the tibia 10. The portion of the virtual boundary 62 shown in the virtual representation of the tibia 10 represents the bone to be removed by the surgical tool. A similar virtual boundary may be created for a hole to be drilled or milled in the tibia 10 to facilitate the placement of a tibial implant in the resected tibia 10. The virtual boundary (and therefore the corresponding working boundary) may include surfaces that completely enclose and surround the three-dimensional volume. In an alternative embodiment, the virtual boundary and the working boundary do not completely enclose the three-dimensional volume, but rather include both "active" surfaces and "open" portions. For example, a virtual boundary 62 representing a proximal resection in the tibia may have a substantially rectangular box-shaped "active" surface 62a and a folding funnel or triangular box-shaped "active" surface 62b connected to the rectangular box-shaped portion with an "open" portion 64. In one embodiment, the virtual boundary 62 may be generated with a folding funnel as described in U.S. Application No. 13 / 340,668, entitled "System and Method for Selectively Activating Haptic Guide Zones," filed December 29, 2011, and incorporated herein by reference in its entirety. A working boundary 66 corresponding to the virtual boundary 62 has the same configuration as the virtual boundary 62. In other words, a working boundary 66 guiding a proximal resection in the tibia 10 may have a substantially rectangular box-shaped "active" surface 66a and a folding funnel or triangular box-shaped "active" surface 66b connected to the rectangular box-shaped portion with an "open" portion 67.

[0099] In a further embodiment, the imaginary boundary 62 representing the resection in the bone 10 includes only a substantially rectangular box-shaped portion 62a. The ends of the imaginary boundary having only a rectangular box-shaped portion may have an "open" top such that the open top of the corresponding working boundary coincides with the outer surface of the bone 10. Alternatively, as shown in Figures 3A and 3B, the rectangular box-shaped working boundary portion 66a corresponding to the imaginary boundary portion 62a may extend beyond the outer surface of the bone 10.

[0100] In some embodiments, the virtual boundary 62 representing the resection through the portion of the bone may have a substantially planar shape with or without thickness. Alternatively, the virtual boundary 62 may have a curved or irregular shape. If the virtual boundary 62 is depicted as a line or planar shape and the virtual boundary 62 also has a thickness, the virtual boundary 62 may be slightly thicker than the surgical tool used to create the resection in the bone, so that the tool may be constrained within the active plane of the working boundary 66 while within the bone. Such a line or planar virtual boundary 62 may be planned such that the corresponding working boundary 66 extends beyond the outer surface of the bone 10 in a funnel or other suitable shape to assist the surgeon as the surgical tool 58 approaches the bone 10. Haptic guidance and feedback (as described below) may be provided to the user based on the relationship between the surgical tool 58 and the active plane of the working boundary.

[0101] The surgical plan may also include automatic alignment of the surgical tool and may include virtual boundaries to facilitate moving in and out of haptic control, as described in U.S. application Ser. No. 13 / 725,348, entitled "System and Method for Haptic Control of Surgical Tools," filed Dec. 21, 2012, and incorporated herein by reference in its entirety.

[0102] A surgical plan including a virtual boundary may be developed based on information related to the patient's bone density. The density of the patient's bone is calculated using data obtained from CT, MRI, or other imaging of the patient's anatomy. In one embodiment, a calibration object representing a human bone and having a known calcium content is imaged to obtain a correspondence between the density values ​​of the image and bone density measurements. This correspondence may then be applied to convert the density values ​​of the individual images of the patient's anatomy into bone density measurements. The individual images of the patient's anatomy are then segmented and used with the corresponding map of bone density measurements to generate a three-dimensional representation (i.e., a model) of the patient's anatomy that includes the patient's bone density information. Image analysis, such as finite element analysis (FEA), may then be performed on the model to assess its structural integrity.

[0103] Being able to assess the structural integrity of the patient's anatomy improves the effectiveness of joint arthroplasty planning. For example, if a particular portion of the patient's bone is deemed less dense (i.e., osteoporosis), holes, resections, and implant placements can be planned to minimize the risk of fracture of the weakened portion of the bone. Additionally, the planned structure of the bone and implant combination after implementation of the surgical plan (e.g., post-operative bone and implant placement) can also be pre-operatively evaluated for structural integrity to improve the surgical plan. In this embodiment, holes and / or cuts are planned and the bone and implant models are manipulated to represent the patient's bone and implant placement after implementation of the joint arthroplasty and implantation procedure. Various other factors that affect the structural integrity of the post-operative bone and implant placement can be considered, such as the patient's weight and lifestyle. The structural integrity of the post-operative bone and implant placement is analyzed to determine whether the placement will be structurally sound and kinematically functional post-operatively. If the analysis reveals structural weakness or kinematic concerns, the surgical plan can be modified to achieve the desired post-operative structural integrity and function.

[0104] In one embodiment, once the surgical plan is finalized, the surgeon may perform the arthroplasty procedure with the assistance of the haptic device 60 (step 806). In one embodiment, as an alternative or in addition to the haptic device 60 (step 806), the surgical system 100 employs OrthoMap® Precision Knee navigation software from Advanced Guidance Technologies of Stryker®. The OrthoMap® Precision Knee navigation software facilitates the cutting guide being navigated into place.

[0105] In the context of an embodiment employing a haptic device 60 according to step 806, through the haptic device 60, the surgical system 100 provides haptic guidance and feedback to the surgeon to assist the surgeon in accurately executing the surgical plan. Haptic guidance and feedback during the arthroplasty procedure allows for greater control of surgical tools, resulting in more accurate alignment and placement of implants, as compared to traditional arthroplasty techniques. Furthermore, haptic guidance and feedback is intended to eliminate the need to use K-wires and fluoroscopy for planning purposes. Instead, the surgical plan is generated and confirmed using a three-dimensional representation of the patient's anatomy, with the haptic device providing guidance during the surgical procedure.

[0106] "Haptics" refers to the sense of touch, and the field of haptics relates to human interactive devices that provide tactile and / or force feedback to an operator. Haptic feedback generally includes tactile sensations, such as, for example, vibration. Force feedback (also known as "wrench") refers to feedback in the form of force (e.g., resistance to movement) and / or torque. Wrench includes, for example, feedback in the form of force, torque, or a combination of force and torque. Haptic feedback can also include overriding or modifying the amount of force provided to a surgical tool, which can provide tactile and / or force feedback to a user.

[0107] The surgical system 100 provides haptic feedback to the surgeon based on a relationship between the surgical tool 58 and at least one of the working boundaries. The relationship between the surgical tool 58 and the working boundaries may be any suitable relationship between the surgical tool 58 and the working boundaries that may be obtained by the navigation system and utilized by the surgical system 100 to provide haptic feedback. For example, the relationship may be a position, orientation, attitude, velocity, or acceleration of the surgical tool 58 relative to one or more working boundaries. The relationship may further be any combination of a position, orientation, attitude, velocity, and acceleration of the surgical tool 58 relative to one or more working boundaries. The "relationship" between the surgical tool 58 and the working boundary may also refer to a quantity or measurement that results from another relationship between the surgical tool 58 and the working boundary. In other words, the "relationship" may be a function of another relationship. As a specific example, the "relationship" between the surgical tool 58 and the working boundary may be a magnitude of a haptic force generated by a positional relationship between the surgical tool 58 and the working boundary.

[0108] During surgery, the surgeon manipulates the haptic device 60 to guide the surgical tool 58 connected to the device. The surgical system 100 provides haptic feedback to the user through the haptic device 60 to assist the surgeon during the creation of planned holes, cuts, or other modifications to the patient's bones required to facilitate the placement of femoral and tibial implants. For example, the surgical system 100 may assist the surgeon by substantially preventing or constraining the surgical tool 58 from crossing the working boundary. The surgical system 100 may constrain the surgical tool from crossing the working boundary by any number of haptic feedback mechanisms and combinations thereof, including providing haptic feedback, providing force feedback, and / or modifying the amount of force provided to the surgical tool. As used herein, "constraint" is used to describe a tendency to restrict movement. Thus, the surgical system may directly constrain the surgical tool 58 by applying an opposing force against the haptic device 60 that tends to restrict the movement of the surgical tool 58. The surgical system may also indirectly constrain the surgical tool 58 by providing haptic feedback to alert the user to modify their actions. This is because alerting the user to modify their action tends to limit the movement of the surgical tool 58. In still further embodiments, the surgical system 100 may constrain the surgical tool 58 by limiting the force on the surgical tool 58, which tends to further limit the movement of the tool.

[0109] In various embodiments, the surgical system 100 provides haptic feedback to the user as the surgical tool 58 approaches the working boundary, upon contact of the surgical tool 58 with the working boundary, and / or after the surgical tool 58 has penetrated the working boundary a predetermined depth. The surgeon may experience haptic feedback, for example, as a vibration, as a wrench that resists or actively opposes further movement of the haptic device, or as a solid "wall" that substantially prevents further movement of the haptic device. Alternatively, the user may experience haptic feedback as a tactile sensation due to a change in the force provided to the surgical tool 58 (e.g., a change in vibration), or a tactile sensation due to a cessation of the force provided to the tool. If the force on the surgical tool 58 is changed or stopped when the surgical tool 58 is drilling, cutting, or otherwise directly acting against bone, the surgeon feels haptic feedback in the form of resistance to further movement due to the tool no longer being able to drill, cut, or otherwise move through the bone. In one embodiment, upon contact between the surgical tool 58 and the working boundary, the force on the surgical tool is altered (e.g., the force on the tool is reduced) or stopped (e.g., the tool is disabled). Alternatively, the force provided to the surgical tool 58 may be altered (e.g., reduced) as the surgical tool 58 approaches the working boundary.

[0110] In another embodiment, the surgical system 100 may assist the surgeon in creating planned holes, cuts, and other modifications to the bone by providing haptic feedback to guide the surgical tool 58 toward or along the working boundary. As an example, the surgical system 100 may provide a force to the haptic device 60 based on a positional relationship between the tip of the surgical tool 58 and the closest coordinate of the working boundary. The force may move the surgical tool 58 closer to the closest working boundary. Once the surgical tool 58 is substantially close to or in contact with the working boundary, the surgical system 100 may apply a force that tends to guide the surgical tool 58 to move along a portion of the working boundary. In another embodiment, the force tends to guide the surgical tool 58 to move from one portion of the working boundary to another portion of the working boundary (e.g., from a funnel-shaped portion of the working boundary to a rectangular box-shaped portion of the working boundary).

[0111] In yet another embodiment, the surgical system 100 is configured to assist the surgeon in creating planned holes, cuts, and modifications to bone by providing haptic feedback to guide a surgical tool from one working boundary to another. For example, the surgeon may experience a force tending to pull the surgical tool 58 toward the working boundary 66 as the user guides the surgical tool 58 toward the working boundary 66. Then, when the user manipulates the haptic device 60 to remove the surgical tool 58 from the space enclosed by the working boundary 66 such that the surgical tool 58 approaches a second working boundary (not shown), the surgeon may experience a force pushing from the working boundary 66 toward the second working boundary.

[0112] Haptic feedback as described herein may operate in conjunction with modifications to the working boundary by the surgical system 100. Although discussed herein as modifications to the "working boundary," it should be understood that the surgical system 100 modifies a virtual boundary that corresponds to the working boundary. Some examples of modifications to the working boundary include 1) reconfiguring the working boundary (e.g., changing the shape or size) and 2) activating and deactivating the entire working boundary or portions of the working boundary (e.g., converting an "open" portion to an "active" surface and converting an "active" surface to an "open" portion). Similar to haptic feedback, modifications to the working boundary may be performed by the surgical system 100 based on a relationship between the surgical tool 58 and one or more working boundaries. Modifications to the working boundary further assist the user in creating holes and cuts required during an arthroplasty procedure by facilitating various actions such as moving the surgical tool 58 toward a bone and cutting the bone with the surgical tool 58.

[0113] In one embodiment, the modifications to the working boundary facilitate movement of the surgical tool 58 towards the bone 10. During the surgical procedure, as the patient's anatomy is tracked by the navigation system, the surgical system 100 moves the entire working boundary 66 in response to the movement of the patient's anatomy. In addition to this movement of the reference line, portions of the working boundary 66 may be reshaped and / or reconfigured to facilitate movement of the surgical tool 58 towards the bone 10. As an example, the surgical system may tilt the funnel-shaped portion 66b of the working boundary 66 relative to the rectangular box-shaped portion 66a during the surgical procedure based on the relationship between the surgical tool 58 and the working boundary 66. Thus, the working boundary 66 may be dynamically modified during the surgical procedure such that the surgical tool 58 remains within the space enclosed by the portion 66b of the working boundary 66 as the surgical tool 58 approaches the bone 10.

[0114] In another embodiment, the working boundary or a portion of the working boundary is activated and deactivated. Activating and deactivating the entire working boundary may assist the user as the surgical tool 58 approaches the bone 10. For example, a second working boundary (not shown) may be deactivated while the surgeon is approaching the first working boundary 66 or while the surgical tool 58 is within the space enclosed by the first working boundary 66. Similarly, the first working boundary 66 may be deactivated when the surgeon is about to create a second resection after completing the creation of a first corresponding resection. In one embodiment, the working boundary 66 may be deactivated after the surgical tool 58 enters an area within the funnel portion connected to the second working boundary, but is still outside the first funnel portion 66b. Activating a portion of the working boundary converts a previous open portion (e.g., the open top 67) into the active face of the working boundary. In contrast, by deactivating a portion of the working boundary, the previous active face of the working boundary (eg, end 66c of working boundary 66) is converted into an "open" portion.

[0115] Activation and deactivation of the entire working boundary or portions thereof may be accomplished dynamically by the surgical system 100 during a surgical procedure. In other words, the surgical system 100 may be programmed to determine the presence of factors and relationships that trigger activation and deactivation of the virtual boundary or portions of the virtual boundary during a surgical procedure. In another embodiment, a user may interact with the surgical system 100 (e.g., by using the input device 52) to indicate the start or completion of various stages of an arthroplasty procedure, thereby triggering the working boundary or portions thereof to be activated or deactivated.

[0116] With the operation and functionality of the surgical system 100 as described above in mind, the discussion will now turn to how to pre-operatively plan a surgery to be performed via the surgical system 100, followed by a detailed discussion of how to align the pre-operative plan with the actual bones of the patient, as well as applicable components of the surgical system 100.

[0117] The haptic device 60 may be described as a surgeon-assist device or tool, since the device 60 is manipulated by the surgeon to perform various resections, drill holes, and the like. In certain embodiments, the device 60 may be an autonomous robot, as opposed to a surgeon-assist. That is, as opposed to a haptic boundary, an autonomous robot may only operate along a predefined tool path, such that haptic feedback is not necessary, and a tool path may be defined to resect bone and drill holes. In certain embodiments, the device 60 may be a cutting device having at least one degree of freedom that operates in conjunction with the navigation system 42. For example, the cutting tool may include a rotating burr with a tracker on the tool. The cutting tool may be freely manipulated by the surgeon and handheld. In such a case, the haptic feedback may be limited to the burr ceasing to rotate when it intersects with a virtual boundary. Thus, the device 60 should be considered broadly to encompass any of the devices described in this application, as well as others.

[0118] After the surgical procedure is completed, immediately or after a period of time, a post-operative analysis (step 807) may be performed. The post-operative analysis may determine the accuracy of the actual surgical procedure as compared to the planned procedure. That is, the location and orientation of the actual implant placement may be compared to the planned values. Factors such as varus-valgus femoral-tibial alignment, extension, internal-external rotation, or any other factor associated with the desired surgical outcome of the implantation of arthroplasty implants may be compared to the planned values.

[0119] II. Preoperative Steps of Arthroplasty Procedure

[0120] The preoperative steps of an arthroplasty procedure may include imaging of the patient and a preoperative planning process that may include implant placement, bone resection depth determination, and anterior shaft notch evaluation, among other evaluations. Bone resection depth determination involves selecting and placing three-dimensional computer models of candidate femoral and tibial implants relative to three-dimensional computer models of the patient's distal femur and proximal tibia to determine the location and orientation of the implants that will achieve the desired surgical outcome for the arthroplasty procedure. As part of this evaluation, the depth of the required tibial and femoral resections is calculated along with the orientation of the planes of the resections.

[0121] The anterior shaft notch assessment involves determining whether the anterior flange of the 3D model of the selected femoral implant intersects with the anterior shaft of the 3D model of the patient's distal femur when the 3D implant model is positioned and oriented relative to the 3D femoral model as suggested during the bone resection depth determination. Such an intersection of the two models indicates an anterior femoral shaft notch, which must be avoided.

[0122] Determining bone resection depth and performing anterior diaphyseal notch assessment is described in International Application PCT / US2016 / 034847, filed May 27, 2016, and incorporated herein by reference in its entirety.

[0123] A. Preoperative imaging

[0124] In preparation for a surgical procedure (e.g., knee arthroplasty, hip arthroplasty, ankle arthroplasty, shoulder arthroplasty, elbow arthroplasty, spinal procedures (e.g., fusion, implantation, scoliosis correction, etc.)), a patient may undergo pre-operative imaging, for example, at an imaging center. The patient may undergo magnetic resonance imaging ("MRI"), computed tomography ("CT") scans, radiographic scans ("X-ray"), among other imaging modalities, at the operative joint. The patient's knee may undergo a CT scan, as seen in FIG. 4A, which is an exemplary coronal image scan of a patient's knee joint 102 including the femur 104, patella 105 (shown in other figures), and tibia 106. The CT scan may include a helical scan of the knee joint 102 packaged as a Digital Imaging and Communications in Medicine ("DICOM") file. From the file, slices or cross sections of the two-dimensional image may be viewed in multiple planes (e.g., coronal, sagittal, axial). As can be seen from Figures 4B, 4C, and 4D, the segmentation process can be performed on the two-dimensional image 108 by applying the spline 110 at the bone contour line. Alternatively, the segmentation process can be performed on the image 108 as a whole without the need to apply the spline 110 to the 2D image slices. Such pre-operative imaging and planning steps can be found in International Application PCT / US2019 / 066206, filed December 13, 2019, which is incorporated herein by reference in its entirety.

[0125] 4B, 4C, and 4D respectively show an axial image 108 of the femur 104 and patella 105 with splines 110 on the bone surfaces, a sagittal image 108 of the joint 102 with splines 110 on the bone surfaces of the femur 104, patella 105, and tibia 106, and a coronal image 108 of the joint 102 with splines 110 on the femur 104 and tibia 106. In certain cases, the segmentation process may be a manual process in which a person identifies the splines 110 on each two-dimensional image slice 108. In certain cases, the segmentation process may be automated, where the splines 110 are automatically applied to the bone contours in the image slices 108. In certain cases, the segmentation process may be a combination of manual and automatic processes.

[0126] After the segmentation process is complete, the segmented images 108 may be combined to generate a three-dimensional ("3D") bone model 111 of the joint 102, including a 3D femur model 112, a 3D patella model 113, and a 3D tibia model 114.

[0127] As can be seen in FIG. 4E, which is an isometric axial-coronal-sagittal view of the 3D joint model 111, the model 111 represents the joint 102, more specifically its femur 104, patella 105, and tibia 106, in a deteriorated state prior to the performance of any surgical procedure to correct the bones. From this 3D joint model 111, various steps of the pre-operative planning process can be performed. Each of these 3D bone models 112-114 can be generated relative to the coordinate system of the medical imaging system used to generate the two-dimensional image slices 108. For example, if the image slices 108 are generated via CT imaging, the 3D bone models can be generated relative to the CT coordinate system 115.

[0128] In certain cases, the 3D model 111 of the patient's joint, including 3D models 112, 113, and 114 of each bone 104, 105, and 106 of the patient's joint 102, may be generated from a statistical or generic model of the bones and joint, which is deformed or otherwise modified to approximate the bones 104, 105, and 106 of the patient's joint 102 based on certain factors without the need to segment the 2D image slices 108 with splines 110. In certain cases, the segmentation process may manually, automatically, or a combination of manually and automatically fit the 3D statistical or generic bone model to the scanned images 108 of the femur 104, patella 105, and tibia 106. In such cases, the segmentation process does not require applying splines 110 to each of the 2D image slices 108. Instead, a 3D statistical or generic bone model is fitted or deformed to the shape of the femur 104, patella 105, and tibia 106 in the scanned image 108. The deformed or fitted 3D bone model therefore requires a 3D joint model 111 as shown in FIG.

[0129] In one embodiment, the generic bone model may be the result of an analysis of a large number (e.g., thousands or tens of thousands) of medical images (e.g., CT, MRI, X-ray, etc.) of actual bones for size and shape, which is used to generate a generic bone model that is a statistical average of the large number of actual bones. In another embodiment, a statistical model is derived that describes the statistical distribution of a population of sizes, shapes, and appearance variations within the images.

[0130] In certain cases, other methods of generating a patient model may be employed. For example, a patient bone model or portion thereof may be generated intraoperatively by locating bone or cartilage surfaces within one or more areas of the bone. Such a process may generate one or more bone surface contours. Thus, the various methods described herein are intended to encompass three-dimensional bone models generated from segmented medical images (e.g., CT, MRI) as well as intraoperative imaging methods and others.

[0131] Although the imaging and subsequent steps of the method are described with respect to the knee joint 102, the teachings of the present disclosure are likewise applicable to other joints such as the hip, ankle, shoulder, wrist, elbow, and spine, among others.

[0132] B. Preoperative planning of implant selection, placement and orientation

[0133] After the 3D femoral model 112 of the patient's joint 102 is generated, the remainder of the pre-operative planning may begin. For example, the surgeon or surgical system 100 may select an appropriate implant, and the location and orientation of the implant may be determined. The selection may determine the appropriate cuts or resections to the patient's bone to accommodate the selected implant. Such pre-operative planning steps may be found in International Application PCT / US2016 / 034847, filed May 27, 2016, which is incorporated herein by reference in its entirety.

[0134] III. Surgical Procedure

[0135] After the pre-operative planning steps are completed, the surgery may begin according to plan: the surgeon may use the haptic device 60 of the surgical system 100 to perform the resections of the patient's bone, and the surgeon may implant the implant to restore function to the joint. The steps of the surgical procedure may include:

[0136] A. Positioning

[0137] Positioning is the process of mapping the pre-operative plan, including the bone models 111-114 (of FIG. 4E) and associated virtual boundaries or tool paths, to the patient's physical bones, so that the robotic arm 60 is spatially oriented relative to the patient's physical bones to accurately perform the surgical procedure. The pre-operative plan, including the bone models 111-114 and associated virtual boundaries or tool paths, may be stored on the computer 50 in a first coordinate system (x1, y1, z1). A navigation system 42, which tracks the movement of the robotic arm 60 via various tracker arrays (e.g., 48, 54), is also in communication with the computer 50. The navigation system 42 also tracks the patient's body via various tracker arrays 46, 47 located on the tibia 10 and femur 11, respectively. In this way, the positions and orientations (i.e., poses) of the robotic arm 60 and the surgical bones 10, 11 are known relative to each other in a second coordinate system (x2, y2, z2) within the computer 50. The process of mapping, transforming or registering a first coordinate system (x1, y1, z1) and a second coordinate system (x2, y2, z2) together in a common coordinate system is known as registration.

[0138] Once positioned, the bone models 111-114 and virtual boundaries or tool paths can be "locked" to the appropriate locations on the patient's physical bones such that any movement of the patient's physical bones will move the bone models 111-114 and virtual boundaries or tool paths accordingly. Thus, the robotic arm 60 can be constrained to operate along the virtual boundaries or tool paths defined in the pre-operative plan and that move with the patient's bones as they move. In this way, the robotic arm 60 has spatial awareness of the patient's physical body pose through the positioning process.

[0139] i. Generation of classified / segregated 3D bone surface point clouds from intraoperative ultrasound data

[0140] As will be discussed in detail below, the computer 50 of the surgical system 100, and more specifically, the computer's processor and memory, store and execute one or more algorithms employing one or a combination of various neural networks that are trained to detect bone surfaces in ultrasound images and classify the bone surfaces in the ultrasound images according to the anatomical structures being captured.

[0141] As will also be discussed in detail below, the computer 50 of the surgical system 100, and more specifically, the computer's processor and memory, store and execute one or more algorithms that enable simultaneous co-registration of the bone surfaces of N bones (which typically form an articulating joint) between an ultrasound modality and a second modality (e.g., CT / MRI) that captures the N bones. The co-registration of the bone surfaces of the N bones between the two modalities is achieved via one or more algorithms that optimize an Nx6 degree of freedom transformation from the ultrasound modality to the second modality, and classification information that assigns regions within the ultrasound modality image data to one of the N captured bones.

[0142] In one embodiment, the common positioning of bone faces of the N bones between two modalities can be 3D point cloud / mesh based, occurring between the 3D point cloud and the triangulated mesh. In such a situation, the N bones need to be segmented in a second modality (e.g., CT / MRI bone segmentation) to obtain the triangulated mesh, and the 3D point cloud is applied to the triangulated mesh.

[0143] In another embodiment, the common registration of the bone surfaces of the N bones between the two modalities can be image-based, in other words, by directly matching the classified ultrasound image data with the second modality without the need to detect the bone surfaces.

[0144] To begin a discussion of one or more algorithms for simultaneously co-locating bone surfaces of N bones between two modalities capturing the N bones, reference is made to Fig. 5A, which is a flow chart showing in more detail the overall positioning process (step 804) shown in Fig. 2 as employed by the surgical system 100 depicted in Fig. 1. The process depicted in Fig. 5A is an ultrasound-based multiple bone positioning process 503 employing a two-step procedure, in which the initial or coarse positioning (step 776) resulting from steps 610, 612, 776 is combined (step 900) with the classified or separated 3D bone surface point cloud (step 600) resulting from steps 512, 527, 580, 600 and generated from an ultrasound sweep acquired in the surgical target area (i.e., the patient's joint area in the context of the patient's arthroplasty). The ultrasound-based multiple bone positioning process 503 therefore has two main steps or aspects: initial positioning establishes a first guess of the positioning alignment, from which a starting point can be said to be refined by calculating a very precise alignment.

[0145] The classified or separated 3D bone surface point cloud (step 600) of the ultrasound-based multiple bone positioning process 503 starts with an intraoperative ultrasound image acquired of most, if not all, of the patient's surface area surrounding the patient's joint and each of its bones in the vicinity of the patient's joint. For example, for knee arthroplasty, an ultrasound sweep covers most, if not all, of the knee, one or more times up and down, to obtain ultrasound image data of the bone surface of each bone of the patient's knee (femur, tibia, and patella). The intraoperative ultrasound image is then algorithmically analyzed via machine learning to determine which individual points of the millions of individual points of the acquired ultrasound image points belong to each bone of the patient's joint, resulting in a classified or separated point cloud belonging to each bone. In other words, in the context of knee arthroplasty, the algorithm appropriately assigns each point or pixel of the intraoperative ultrasound image to its respective knee joint bone, such that each point or pixel can be said to be classified or separated to correspond to its respective bone, thereby resulting in a classified or separated 3D bone surface point cloud. Stated another way, each point or pixel of the intraoperative ultrasound image is converted into a classified or separated 3D bone surface point cloud such that each ultrasound image pixel or point of the classified or separated 3D bone surface point cloud is correlated to a corresponding bone surface of the patient's bone.

[0146] As can be seen from FIG. 5A, the initial or rough positioning (step 776) starts with a tracked probe 57 applied intraoperatively to the patient's knee according to a particular preoperative planned posture or set of landmarks relative to the patient's anatomy to generate a transformation that positions the physical tracked bones to a 3D CAD bone model 111 generated from segmented medical imaging (CT, MRI, etc.) of the patient's knee bone. The final positioning occurs via combination of the initial positioning algorithm of step 776 with the classified 3D bone surface point cloud of step 600, algorithmically matching each portion of the classified point cloud with the initial positioning point cloud and its respective 3D CAD bone model surface (step 900). During this final positioning, the employed algorithm converges until its result reaches a steady state, and the algorithm may also improve the classification or separation of the classified or separated 3D bone surface point cloud itself, so that any initial errors in the classification / separation may be eliminated or at least reduced. Upon achieving these aspects of the final registration, the classified or separated 3D bone surface point cloud and the initial or rough registration become fully registered, resulting in a final bone registration, which of step 900 may then be employed by the surgical system 100 in performing surgery on the patient's joint.

[0147] This ultrasound-based positioning process 503 of the surgical system 100 is efficient in that positioning can be accomplished by simply having a medical professional perform an ultrasound sweep of the patient's joint area, and then machine learning takes over to identify which points in the ultrasound sweep belong to which bone of the patient's joint, and then assigning and matching the points to the correct bone in the 3D bone model. Thus, the positioning process 503 allows all of the multiple bones of the patient's joint to be imaged via ultrasound in one go, and then the system identifies and separates points in the point cloud that belong to each bone of the joint, and then assigns / matches the points to the appropriate bone in the 3D model of the joint to complete the final positioning process, where the points are not only assigned to the appropriate bone, but are also located in the corresponding anatomical location in the bone.

[0148] As shown in Figure 5A, the ultrasound-based positioning process 503 of the surgical system 100 includes a pre-operative aspect 500 and an intra-operative aspect 502, each of which is divided into a workflow section and a data flow section. For the workflow section, a person operates a machine / tool / device / system or physically performs the execution of the identified workflow steps. For the data flow section, one or more hardware processors 1302 of a computer system 1300 associated with the surgical system 100 depicted in Figure 1 execute programs in performing the identified data flow steps, as discussed in more detail below with reference to Figure 16.

[0149] During the workflow portion of the pre-operative aspect 500, medical images are acquired of the patient's joint (step 504), as described above in section "A. Pre-operative Imaging" of this detailed description. As shown in FIG. 5A, the pre-operative aspect 500 continues to a data flow portion, where the medical images are then used to generate 3D CAD models of the patient's articulating bones (step 506), as described above in section "A. Pre-operative Imaging" of this detailed description with reference to FIGS. 4A-4E. The data flow portion of the pre-operative aspect 500 concludes with the generation of initial positioning data in CAD model space for the 3D CAD models 111-114 (FIG. 4E) of the patient's bones 104-106 of the patient's joint image 108 (FIGS. 4A-4D) (step 508). In particular, this generation of initial positioning data (step 508) includes defining the above-mentioned probe pose and anatomical landmarks in the 3D CAD model space.

[0150] Turning to the workflow portion of the intraoperative aspect 502 of the ultrasound-based multiple bone positioning process 503 of FIG. 5A, a medical professional places anatomical trackers (e.g., see 46, 47 in FIG. 1) on the patient's bones (e.g., tibia 10 and femur 11 in FIG. 1) (step 510). In a preferred embodiment, the trackers 46, 47 are typically placed on the patient's bones 10, 11 at the start of the intraoperative portion 502 of the overall positioning process 503 of FIG. 5A as shown in step 510, although in an alternative embodiment, if the target limb (e.g., leg) is sufficiently immobilized, the positioning portion may occur before the trackers 46, 47 (FIG. 1) are attached to the bones 10, 11. For example, the initial positioning (step 776) is completed, followed by generation of a classified point cloud (step 600), both of which are discussed in more detail below with respect to FIG. 5A and others. The locations of the trackers 46, 47 may then be identified and the trackers placed accordingly on the patient's bones 10, 11. The initial positioning 776 may then be repeated, after which the initial positioning of step 776 and the classified point cloud of step 600 may be combined to achieve the final positioning (step 900).

[0151] 5A, continuing with the preferred embodiment, where trackers 46, 47 are placed on the patient's bones 10, 11 according to step 510 at the start of the intraoperative portion 502 of the overall positioning process 503, the medical professional then utilizes a trackable ultrasound probe (see, e.g., 55 in FIG. 1) to record multiple ultrasound sweeps of the patient's bones across the joint region (step 512). The sweeps may be of the joint area in a general manner, capturing various bones (e.g., the femur, tibia, and patella in the context of the knee joint) in a collage of ultrasound image data points that are undefined as to which data points belong to which bone and where on the bone.

[0152] As can be seen from Figure 5B, which is a pictorial depiction of the process of generation of a classified three-dimensional ("3D") bone surface point cloud from an ultrasound sweep, the ultrasound sweep 514 resulting from step 512 of Figure 5A has ultrasound image data associated with the femur 11, patella (not shown), and tibia 10 (see, e.g., Figure 1), which are undefined as to which bones and where on the bones. Although not actually defined at this point in the process, as shown in Figure 5B, the ultrasound sweep 514 can be seen to have femur data points 516, patella data points 518, and tibia data points 520. This data may be arranged in the form of a set of 2D ultrasound images 523, including an ultrasound image of the femur 522, an ultrasound image of the patella (not shown), and an ultrasound image of the tibia 524, with data points that are undefined as to whether a particular point is part of bone or soft tissue, and undefined as to which particular bone of the joint and where on the particular bone a particular data point belongs. The surgical system 100 then converts the set of 2D ultrasound images 523, via the classification module (step 527) of FIG. 5A, into classified bone surface pixels 526, as shown in FIG. 5B. It should be noted that although 2D ultrasound images are depicted in FIG. 5B and discussed herein, the processes described herein may be readily accomplished with the use of 3D ultrasound images in lieu of or mixed with the 2D ultrasound images. Thus, throughout this disclosure, any reference to 2D ultrasound images should be understood to encompass 3D ultrasound images as well.

[0153] As shown in FIG. 5A, in one embodiment, the classified bone surface pixels 526 are generated from a set of 2D ultrasound images 523, and the classification module (step 527) may employ one of two alternative classification processes: by ultrasound image bone surface via a pixel classification neural network (step 528), or by ultrasound image bone surface detection via a likelihood classification neural network (step 530). In other embodiments, the classified bone surface pixels 526 are generated from a set of 2D ultrasound images 523, and the classification module (step 527) may employ other processes, such as, for example, not looking at the images, but only looking at the 3D placement of the various points, deriving the classification from the distance of the two navigational markers 46, 47 fixed to the bones 10, 11, and / or running a classification algorithm on the resulting point cloud itself. In still other embodiments, the classification of the point cloud is solved via other non-machine learning processes or other networks in addition to classification and convolution, such as, for example, random forests. In still further embodiments, the classification of the point cloud may be solved via non-machine learning processes. In one embodiment, the classification of the point cloud may be resolved via geometric analysis of the point cloud. For example, such geometric analysis of the point cloud may include separation of principal axes such as principal component analysis (e.g., in the context of knee arthroplasty), clustering methods such as connected component analysis (e.g., in the context of spine / vertebral procedures), and shape properties such as convex / concave / tubular / etc. Finally, without unduly limiting this disclosure, there is a classification module 527 that receives the image as an input, a classified bone point cloud is output from the classification module, and there are a number of different processes that may be part of the classification module to achieve these objectives.

[0154] FIG. 6A is a flow chart of the process of the surgical system 100 for ultrasound image bone surface detection using pixel classification (step 528), and FIG. 6B is a pictorial depiction of the process of FIG. 6A. As shown in FIG. 6A, the process employs an ultrasound image bone surface detector 532 and an ultrasound image pixel classifier 534, both of which are divided into an input section, a processing section, and an output section. As shown in FIG. 6A and FIG. 6B, the ultrasound image bone surface detector 532 receives the 2D ultrasound image 523 of FIG. 5B as input (step 536), processes it through a convolutional network to detect the presence or absence of bone surface points at each point across each ultrasound image (step 538), and outputs a binary image 540 of "zero (0) is equivalent to non-bone surface" 542 and "one (1) is equivalent to bone surface" 544 (step 546).

[0155] Similarly, the ultrasound image pixel classifier 534 receives as input the 2D ultrasound image 523 of FIG. 5B (step 548), processes it through a classification network to determine the particular type of anatomical structure present at each point across each ultrasound image (step 550), and outputs a single number 552 indicating the type of anatomical structure: "zero (0) is equivalent to the tibia," "one (1) is equivalent to the femur," and "two (2) is equivalent to the patella" (step 554). It should be noted that although the examples given in this detailed discussion are in the context of a knee joint, the concepts taught herein are similarly applicable to any type of joint, such as, for example, but not by way of limitation, the spine, shoulder, elbow, wrist, hip, ankle, etc.

[0156] FIG. 7A is a flow chart of the process of the surgical system 100 for ultrasound image bone surface detection (step 530) using likelihood classification, and FIG. 7B is a pictorial depiction of the process of FIG. 7A. The process is divided into an input section, a processing section, and an output section. As shown in FIG. 7A and FIG. 7B, a convolutional network 556 receives as input the 2D ultrasound image 523 of FIG. 5B (step 558), processes it to detect bone surface points, and classifies each point by determining the likelihood that the point belongs to a particular anatomical structure (step 560). For example, in the context of the knee, the convolutional network 556 detects bone surface points in the 2D ultrasound image 523, and then calculates the likelihood that any particular detected bone surface point belongs to the femur, tibia, or patella (step 560). The convolutional network 556 outputs N binary images 562, where N is the number of bones considered, and each pixel of each binary image is decoded with a "zero" or a "one" depending on whether the pixel represents a bone surface or not (step 563).

[0157] As can be seen from Figure 7B, in the illustrative example, the number of binary images N is 2 since the patella is ignored for this example only and the femur and tibia are present. If the patella were also used in this example, the number of binary images N would be 3 since the femur, patella, and tibia are present.

[0158] Continuing with the example where the number of binary images N is 2, the convolutional network 556 analyzes the ultrasound image 523 and classifies the image 523 according to the likelihood that it represents an image of the tibia 564 or an image of the femur 566, the classification being via an algorithmic evaluation of the ultrasound image 523 in the context of machine learning (step 562 of FIG. 7B). The pixels of each classified image 564 classified according to step 562 are then decoded as to whether each particular pixel represents a bone surface (step 568 of FIG. 7B). For example, the classified image of the tibia 564 is evaluated to identify its non-bone surface pixels 570 and its bone surface pixels 572, which are bone surface pixels 572 of the tibia (step 568). Similarly, the classified image of the femur 566 is evaluated to identify its non-bone surface pixels 574 and its bone surface pixels 576, which are bone surface pixels 576 of the femur (step 568).

[0159] Returning to Figures 5A and 5B, once classified bone surface pixels 526 have been generated from the set of 2D ultrasound images 523 via a classification module (step 527) to provide classified 2D femur bone surface pixels 526F and classified 2D tibia bone surface pixels 526T, a 2D to 3D transformation of the 2D surface pixels 526F, 526T is calculated (step 580) to convert the 2D surface pixels 526F, 526T to 3D surface pixels 578F, 578T.

[0160] FIG. 8A is a flow chart of a process (step 580) for computing the transformation of 2D surface pixels 526F, 526T to 3D surface pixels 578F, 578T, and FIG. 8B is a pictorial depiction of the process of FIG. 8A. As shown in FIGS. 8A and 8B, the process employs a temporal calibration (step 582) of the ultrasound probe, where an ultrasound scan (514 in FIG. 5B) is acquired at the bone (10, 11 in FIG. 1) via ultrasound waves 583 projected and detected via the distal tip 55A of the ultrasound probe, and the propagation speed of the ultrasound waves 583 in a particular medium / tissue is taken into account (step 584) when the trackable element 55B of the ultrasound probe is detected by the detection device 44 of the navigation system 42 as the ultrasound probe 55 is tracked intraoperatively. The distal tip 55A includes a sensor array with its own intrinsic coordinate system 586. In doing so, the 2D surface pixels 526F, 526T of the ultrasound images 522, 524 undergo a transformation 585 that maps them from 2D pixel space (2D pixel coordinate system) 586 to a 3D metric coordinate system 588, converting the 2D surface pixels 526F, 526T to 3D surface pixels 578F, 578T, and converting the 2D pixel coordinates to 3D coordinates within the native ultrasound probe coordinate system 588 (step 590).

[0161] As shown in Figure 8A and can be seen from Figure 8B, upon completion of the temporal calibration of the ultrasound probe (step 582), the process moves to calibrating the ultrasound probe relative to the probe tracker (step 592). In doing so, the system obtains a known set of poses of the ultrasound probe 55 relative to the probe detection device 44 of the navigation system 42 in relation to the native ultrasound probe coordinate system 588 (step 594). The system then completes a transformation between the probe tracker space and the native ultrasound probe coordinate system (step 596).

[0162] For further information regarding complementary and / or alternative processes associated with computing the transformation of 2D surface pixels 526F, 526T to 3D surface pixels 578F, 578T according to step 580 or a version thereof, reference is made to PCT Application No. PCT / IB2018 / 056189 (WO 2019 / 035049A1), having an international filing date of August 16, 2018, and entitled "Ultrasound Bone Localization Using Learning-Based Segmentation and Speed ​​of Sound Calibration," the entirety of which is hereby incorporated by reference into this disclosure.

[0163] Although the immediately preceding discussion has been in the context of a 2D ultrasound probe, it should be understood that the 2D ultrasound probe may be substituted for a 3D ultrasound probe to proceed with the processes disclosed in this detailed description. Thus, the processes disclosed in this detailed description should not be limited to 2D ultrasound probes and 2D pixels / points, but should be considered to include 3D ultrasound probes and any type of ultrasound pixel / point in an image coordinate system, regardless of whether the ultrasound pixel / point is 2D or 3D.

[0164] Each individual ultrasound sweep with the ultrasound probe produces an individual ultrasound image that captures a slice or small portion of the patient's bone. Multiple individual ultrasound sweeps with the ultrasound probe are typically required when ultrasound imaging the patient's bone. To combine each individual ultrasound image into one coherent 3D ultrasound image data set, the ultrasound probe is tracked relative to an anatomical tracker attached to each of the N captured bones.

[0165] The process of stitching together individual ultrasound images may be simplified if the bone being ultrasound scanned is fixed: specifically, in such a case, each individual ultrasound image may be stitched together with other individual ultrasound images by tracking only the ultrasound probe.

[0166] 5A and 5B, once the system completes step 580, it then generates a classified 3D bone surface point cloud 598 (step 600). The classified 3D bone surface point cloud 598 has femur points 602 classified as femur, patella points 604 classified as patella, and tibia points 606 classified as tibia. For further complementary or alternative aspects of the process of positioning using an ultrasound probe, reference is made to U.S. Patent Application No. 14 / 144,961, filed December 31, 2013, entitled "SYSTEM AND METHOD FOR POSITIONING USING AN ULTRASOUND PROBE," the disclosure of which is incorporated herein by reference in its entirety.

[0167] ii. Initial rough positioning

[0168] As discussed above and shown in FIG. 5A, during the workflow portion of the pre-operative aspect 500, medical images are acquired of the patient's joint (step 504), as described above in section "A. Pre-operative Imaging" of this detailed description. As shown in FIG. 5A, the pre-operative aspect 500 continues to a data flow portion, where the medical images are then used to generate 3D CAD models of the patient's articulating bones (step 506), as described above in section "A. Pre-operative Imaging" of this detailed description with reference to FIGS. 4A-4E. The data flow portion of the pre-operative aspect 500 concludes with the generation of initial positioning data in CAD model space for the 3D CAD models 111-114 (FIG. 4E) of the patient's bones 104-106 of the patient's joint image 108 (FIGS. 4A-4D) (step 508). In particular, this generation of initial positioning data (step 508) includes defining the above-mentioned probe pose and anatomical landmarks in the 3D CAD model space.

[0169] For a discussion of the pre-operative process of defining probe pose and anatomical landmarks pertaining to step 508 of FIG. 5A, reference is now made to FIG. 9A, which is a flow chart outlining the process of step 508. As shown in FIG. 9A, step 508 begins by defining an arbitrary pose P of the probe relative to the patient's anatomy to be positioned (step 700). Then, as can be seen from FIGS. 9A and 9B, a 3D CAD model (i.e., 3D CAD probe model 57M) of probe 57 (FIG. 1) is placed at the defined arbitrary pose P relative to the 3D CAD bone model 111 shown in FIG. 4E and a transformation (T プローブ対3D画像 ) 701 is recorded, and the transformation 701 is performed in the probe coordinate system CS プローブ From the 3D image coordinate space CS 3D画像 Then, the 3D CAD probe model 57M is mapped to the 3D CAD bone model 111 (step 702). Specifically, as a non-limiting example of the many possible arbitrary poses P, the 3D CAD probe model 57M is positioned so that it points perpendicular to the center of the femoral anterior cortex of the 3D CAD femur model 112 of the 3D CAD bone model 111 of the knee region 102 and is centered, as shown in FIG. 9B. Of course, any other arbitrary poses P suitable for a particular surgical application may be defined. Step 702 may be performed by a dedicated surgical planner or surgeon. The 3D CAD bone model 111 of the knee region 102 may be a volume rendering or other type of CT or medical image, or a model defined therefrom.

[0170] As shown in FIG. 5A, once the generation of initial positioning data is completed as described above with respect to step 508, the initial positioning data is acquired (step 610) as part of the workflow portion of the intraoperative aspect 502 of the ultrasound-based multiple bone positioning process 503. For a discussion of the intraoperative process of acquiring initial positioning data according to step 610 of FIG. 5A, reference is now made to FIG. 10A, which is a flow chart outlining the process of step 610. As shown in FIG. 10A, step 610 begins by positioning the tracked probe 57 relative to the patient's anatomy according to the defined pose P of step 508 (step 704). In other words, in this example, for step 704, the pose P depicted in FIG. 9B between the 3D CAD probe model 57M and the 3D CAD femur model 112 of the 3D CAD bone model 111 is reproduced intraoperatively between the actual physical probe 57 and the patient's actual femur 11. This intraoperative pose P is then recorded (step 706).

[0171] As can be seen from FIG. 10B, the recording of the intraoperative position P in step 706 is プローブ対ナビゲーションカメラ ) 705. Alternatively, as shown in FIG. 10C, recording the intraoperative position P in step 706 may be accomplished using the tracking camera 44 of the tracking system 42 to acquire the transformation (T プローブ対解剖学的構造のトラッカ This may be accomplished using the anatomical structure tracker 47 of the tracking system 42 to obtain the anatomical structure (a) 707.

[0172] The process in step 610 ends with the calculation of the initial positioning via a 4x4 matrix multiplication, T ナビゲーションカメラ対3D画像 =T プローブ対3D画像 *inv(T プローブ対ナビゲーションカメラ ), or, if an anatomical structure tracker 47 is employed as shown in FIG. 10C, T 解剖学的構造のトラッカ対3D画像 =T プローブ対3D画像 *inv(T プローブ対解剖学的構造のトラッカ(step 710). As shown in Figure 5A, this initial positioning data then enters the positioning module 612 as part of the data flow portion of the intra-operative aspect 502 of the ultrasound-based multiple bone positioning process 503.

[0173] As shown in FIG. 5A, the positioning module (step 612) may employ any of a wide variety of alternative positioning processes, such as "one click / one pose" positioning (step 614), "landmark-based" positioning (step 616), or "anatomical tracker pin-based" positioning (618), in three non-limiting examples. Any of the three applications 614, 616, 618 may establish an initial positioning (i.e., a "rough" guess) of the transformation from the anatomical tracker space to the CAD model (CT / MRI) coordinate system. Other alternative positioning processes that may be part of the positioning model (step 612) may include, for example, "probe-based" positioning, "probe mini-sweep-based" positioning, or even utilizing a calibrated digital camera to generate a picture of the patient's anatomy to be positioned and estimate the pose and location therefrom.

[0174] FIG. 11A is a flow chart of the surgical system 100 process of positioning using "one click / one pose" positioning (step 614), and FIGS. 11B and 11C are pictorial depictions of the process of FIG. 11A. As shown in FIGS. 11A and 11B, the process (step 614) begins by using the tracked probe 57 in FIGS. 1, 10B, and 10A intraoperatively to record the bone surface points of the femur 11, tibia 10, and optionally the patella to generate two point clouds 620, 622 (step 624). In this step 624, one point cloud (i.e., femoral tracker related point cloud ("FTRPC") 620 is acquired for the femoral tracker 47 in FIG. 1) and the other point cloud (i.e., tibial tracker related point cloud ("TTRPC") 622 is acquired for the tibial tracker 46) (step 624). In other words, effectively two point clouds 620, 622 are acquired, one point cloud 620 relating to the femur tracker 47 and the other point cloud 622 relating to the tibia tracker 46.

[0175] 11B, FTRPC 620 has femur data point 620F, patella data point 620P, and tibia data point 620T, none of which have been identified as such yet, but are simply data points for the overall FTRPC 620. Similarly, TTRPC 622 has femur data point 622F, patella data point 622P, and tibia data point 622T, none of which have been identified as such yet, but are simply data points for the overall TTRPC 622.

[0176] 11A and 11B, the "one click / one pose" positioning process (step 614) continues by applying a classification algorithm intraoperatively to the FTRPC 620 and TTRPC 622 to output a femur-only point cloud for the femur tracker ("FOPCRFT") 626 and a tibia-only point cloud for the tibia tracker ("TOPCRTT") 628 (step 630). This separation of the point clouds is advantageous because the knee pose in the preoperative 3D CAD bone model may differ from the intraoperative knee pose.

[0177] As can be seen from Figures 11A and 11C, after step 630, the "one click / one pose" positioning process (step 614) continues with intraoperative calculation of positioning transformations 632, 634 for the femur 11 and tibia 10, respectively (step 636). This calculation of the positioning transformations may employ a positioning algorithm (e.g., "iterative closest point"). For example, the femoral positioning (T 大腿骨のトラッカ対CAD大腿骨モデル ) is obtained by matching the bone surface points of the FOPCRFT 626 onto the femur CAD model 112 (step 638). 脛骨のトラッカ対CAD脛骨モデル The bone surface points of the TOPCRTT 628 are matched onto the tibia CAD model 114 (step 640) to obtain a tibial CAD model 114 (step 640). This "one click / one pose" positioning in step 614 is beneficial because it at least partially facilitates the intraoperative ultrasound surface capture process in step 512 in which multiple bone surfaces are simultaneously acquired via the ultrasound probe 55.

[0178] FIG. 12 is a flow chart of the surgical system 100 process of registration using landmark-based registration (step 616). As shown in FIG. 12, this process (step 616) begins by determining XYZ coordinates for three or more anatomical landmarks on each 3D CAD model of the bone in CAD model space to generate a first set of points (step 750). In this example, where the surgery is in the context of knee arthroplasty and the bones are the tibia 10 and femur 11 (see FIG. 1), this step 750 generates the first set of points by determining XYZ coordinates for three or more anatomical landmarks on each of the 3D CAD femur model 112 and the 3D CAD tibia model 114. This step 750 can be accomplished pre-operatively or intra-operatively.

[0179] After step 750, a second set of points is generated by intraoperatively digitizing the anatomical landmarks via the navigated probe 57 that acquires XYZ coordinates in the anatomical tracker space for each anatomical landmark defined in step 750 (step 755). In other words, for step 755, second points are intraoperatively digitized in the actual tibia 11 and femur 12 at landmarks in the bones that correspond to the landmarks defined in the corresponding 3D CAD tibia model 114 and 3D CAD femur model 112, respectively. For the final aspect of step 616, the first and second sets of points are matched to each other using a typical point-to-point matching algorithm to provide an initial positioning for each bone (step 760). In an alternative embodiment, the point-to-point algorithm of step 760 may be replaced by a point-to-point algorithm, and the pre-operative 3D CAD femur model 112 and 3D tibia model 114 do not have point clouds but are surface models.

[0180] 12 includes digitization of landmarks in CAD space (pre-operative planning) and anatomical tracker space (intra-operative). Having these two sets of landmarks is efficient for calculating the initial positioning that is completed via the positioning module 612 when employing landmark-based positioning 616 (see FIG. 5A).

[0181] 13A is a flow chart of the surgical system 100 process of positioning using anatomical tracker pin-based positioning (step 618). As shown in FIGS. 13A and 13B, this process (step 618) begins with the attachment of pins used to fixedly attach the anatomical trackers 46, 47 to the patient's bones (e.g., the tibia 10 and femur 11 in the context of this example, which is knee arthroplasty), which are attached in a consistent and repeatable manner for each type of surgical procedure (step 770). The navigation system 42 (FIG. 1) then tracks the anatomical trackers 46, 47 to obtain a rough estimate of the location of the patient's bones 10, 11 relative to the anatomical trackers 46, 47 (step 772).

[0182] 13A and 13B, for the final aspect of step 618, a knee joint 762 is positioned and its degrees of freedom are determined (step 774). In doing so, the patient's femur 11 and tibia 10 (FIG. 1) are intraoperatively articulated relative to one another at the knee 762, and a second point cloud 764 referencing trackers 46, 47 mounted on the patient's tibia 10 and femur 11 is bent such that a tibia portion 766 of point cloud 764 and a femoral portion 768 of point cloud 764 are articulated relative to one another at the knee joint 762. This joint is transformed into the femur model 112 and tibia model 114.

[0183] In summary, it can be said that the anatomical tracker pin based positioning 618 described in FIGS. 13A and 13B employs some assumptions regarding the typical location where the anatomical trackers are placed and how the knee is bent (e.g., the anatomical tracker pins are attached to the anterior mid-shaft and the knee is in mid-flexion (e.g., 30°-70°)). By using this knowledge, the location of the center of the knee joint in 3D space relative to the anatomical tracker pins and its orientation can be roughly estimated. Finally, this location and orientation are used to define an initial positioning transformation, which is efficient to calculate the initial positioning completed via the positioning module 612 when employing the anatomical tracker pin based positioning 618 (see FIG. 5A).

[0184] As shown in FIG. 5A, once the positioning module (step 612) completes the initial or “rough guess” positioning process via any of the three alternative positioning processes (i.e., “one click / one pose” positioning (step 614), “landmark based positioning” (step 616), or “anatomical tracker pin based” positioning (618)), the positioning module outputs the initial or “rough guess” positioning data (e.g., an estimate of the transformation from the trackers 46, 47 to the 3D CAD bone models 111, 112, 113, 114) (step 776).

[0185] iii. Calculate the final multiple bone positioning

[0186] As can be seen from Figures 5A and 5B, the initial positioning data of step 776 is utilized with the classified 3D bone surface point cloud 598 of step 600 to calculate a final bone positioning (step 900), as will now be discussed with respect to Figures 14A-14C, where Figure 14A is a process flow diagram for step 900 in Figure 5A, and Figures 14B and 14C are pictorial depictions of aspects of the process of Figure 14A. As shown in Figures 14A and 14B, the initial or coarse positioning data 902 of step 776 of Figure 5A is applied to the classified 3D point cloud 598 of step 600 of Figure 5A with reference to the femoral tracker 47 (step 904). As discussed above with respect to Figure 5B and shown in Figure 14B, the classified 3D point cloud 598 has femur points 602 classified to the femur, patella points 604 classified to the patella, and tibia points 606 classified to the tibia. As discussed above in the context of the initial positioning module of step 612 in Figure 5A and depicted in Figure 14B, the initial positioning data 902 includes a femur point cloud 912, a patella point cloud 913 (optional), and a tibia point cloud 914, each generated via any of the three initial positioning processes 614, 616, 618 of the initial positioning module of step 612, and each point cloud 912, 913, 914 is registered to the applicable 3D CAD bone model 112, 113, 114 via the initial positioning model of step 612 and the output therefrom according to step 776.

[0187] As shown in Fig. 14A, the final registration process (step 900) continues by iteratively calculating the closest points of the classified 3D point cloud 602, 604, 606 to the points of the point cloud 912, 913, 914 on the initially registered or transformed 3D CAD bone model 112, 113, 114 (step 920). More specifically, the registration transformation is updated from the CAD model space to the tracker coordinate system of the anatomical structure by matching the points of the classified 3D point cloud 602, 604, 606 to the points of the point cloud 912, 913, 914 on the initially registered or transformed 3D CAD bone model 112, 113, 114 (step 925). After step 925, the classification of the points of the classified 3D point cloud due to step 925 is updated based on a point-to-closest point distance analysis, and any bone-to-bone interferences are penalized (step 930). A check is then made (step 935) to determine whether convergence has been achieved between the classified 3D point clouds 602, 604, 606 and the point clouds 912, 913, 914 on the 3D CAD bone models 112, 113, 114. If convergence has not yet been achieved, the final multiple bone positioning calculation returns from the convergence check of step 935 to step 920. If convergence is achieved, final positioning is complete (step 940) and the converged initial or rough positioning data (e.g., 3D CAD bone models 112, 113, 114 and point clouds 912, 913, 914 thereon) are finally registered with the classified 3D point clouds 602, 604, 606, and the two sets of point clouds 912, 913, 914 and 602, 604, 606, respectively, are consistent with each other and generally coextensive with respect to the 3D CAD bone models 112, 113, 114 as depicted in FIG. 14C. Once final positioning is achieved according to step 900 of FIG. 5A, the surgical system 100 and procedure may then proceed from positioning (step 805) to navigation (step 805), etc., as shown in FIG. 2, to utilize the final positioning data from step 805 as required throughout the surgery on the patient via the surgical system 100.

[0188] As a twist on the final registration process (900) of FIG. 5A described immediately above with respect to FIGS. 14A-14C, in one embodiment, the final registration process 900 continues by iteratively calculating the closest points of the classified 3D point cloud 602, 604, 606 to the triangulated mesh bone surfaces on the initial positioned or transformed 3D CAD bone model 112, 113, 114. More specifically, the registration transformation is updated from the CAD model space to the tracker coordinate system of the anatomical structure by matching the points of the classified 3D point cloud 602, 604, 606 to the triangulated mesh bone surfaces on the initial positioned or transformed 3D CAD bone model 112, 113, 114. The final registration process 900 continues by running an optimization algorithm in which a cost function is minimized. In one embodiment, this cost function, which depends on the positioning matrix present at the time, is a weighted sum of various terms: (1) for each point of the classified 3D point cloud 602, 604, 606, a minimum distance to the nearest triangulated mesh bone surface on the 3D CAD bone model 112, 113, 114 of the initial positioning or transformation after application of the positioning matrix; (2) for each point of the classified 3D point cloud 602, 604, 606, a fixed penalty to be assigned to a 3D CAD bone model 112, 113, 114 that does not match its initial guess to prevent the 3D CAD bone model 112, 113, 114 from being swapped; (3) for each point or location on the triangulated mesh surface of each 3D CAD bone model 112, 113, 114, a minimum distance to the nearest triangulated mesh bone surface on the 3D CAD bone model 112, 113, 114 of the initial positioning or transformation after application of the positioning matrix; a fixed penalty if it is within the CAD bone model 112, 113, 114, and (4) a penalty term for the magnitude of the transformation / positioning to be applied on top of the initial positioning, for each degree of freedom of the required positioning, assuming that the initial positioning is accurate enough that there is no need to deviate from it. In one embodiment, the bone assignment is computed implicitly in the first step, so there is no need to explicitly alternate between optimizing the point cloud assignment and optimizing the transformation, as may be required when employing an iterative closest point algorithm.

[0189] The final positioning process 900 continues with a check to determine if convergence has been achieved between the classified 3D point cloud 602, 604, 606 and the triangulated mesh bone faces on the 3D CAD bone model 112, 113, 114. If convergence has not yet been achieved, the final multiple bone positioning calculation returns from the convergence check to again iteratively calculate the closest points of the classified 3D point cloud 602, 604, 606 to the triangulated mesh bone faces on the 3D CAD bone model 112, 113, 114 of the initial positioning or transformation, and continues through the remainder of the above process until convergence is again confirmed.

[0190] If convergence is achieved, final positioning is complete and the converged initial or rough positioning data (e.g., triangulated mesh bone surfaces of the 3D CAD bone models 112, 113, 114) is finally registered with the classified 3D point clouds 602, 604, 606, and the point clouds 912, 913, 914 are coincident and generally coextensive for the respective areas of the triangulated mesh bone surfaces of the 3D CAD bone models 112, 113, 114. Once final positioning is achieved according to step 900 of Figure 5A, again as shown in Figure 2, the surgical system 100 and procedure may then proceed from positioning (step 805) to navigation (step 805), etc., utilizing the final positioning data from step 805 as required throughout the surgery on the patient via the surgical system 100.

[0191] The positioning process disclosed herein is advantageous in that it does not enforce consistent positioning of a single bone with no overlapping bones in the resulting positioning. Furthermore, the process is flexible / user friendly and provides a faster workflow since it does not require medical professionals to avoid scanning multiple bones. The process is also not adversely affected by outliers from other bones.

[0192] Thus, when only one bone is located, the user does not need to avoid accidentally scanning another nearby bone.

[0193] Finally, the positioning process disclosed herein is advantageous because it is independent of the incision size of the procedure, which is not the case with positioning processes known in the art. This is particularly useful for hip and shoulder procedures, and even more so for ankle procedures, where the incisions for such procedures are very small, making it difficult to access the relevant bone surfaces with typical digitizing tools (navigated pointers, sharp probes, etc.). Advantageously, ultrasound allows access to substantially all of the bone structure of the entire bone.

[0194] Moreover, the positioning process disclosed herein is advantageous because it is not limited to fully robotic or robot-assisted applications. Specifically, the positioning process may also be any navigated surgery that employs preoperative imaging. By way of example, the positioning process may be employed in navigated cutting jig applications, navigated ACL reconstruction, and even as part of a navigated procedure to remove osteosarcoma.

[0195] IV. Positioning system to confirm surgical goals

[0196] For example, there continues to be a high interest in minimizing the risk of completing a surgical procedure on the wrong side of a patient, such as performing an arthroplasty on the patient's right knee when the surgery was intended to be performed on the left knee. Thus, there is a need for a positioning system 1500 that can be used to quickly verify or confirm that a surgical team is operating on the correct target before the surgical team takes any critical steps in performing the surgery.

[0197] FIG. 15 is a diagram of a positioning system 1500. As shown in FIG. 15, the positioning system 1500 includes a navigation or tracking system 42, a computer 50, and a positioning tool 55, 57. The navigation or tracking system 42 includes a detection device 44 that tracks the positioning tool 55, 57, and the computer 50 includes an input device and a display 56. The positioning tool, which may be in the form of a tracked ultrasound probe 55 and / or a tracked stylus 57, may be used to image and / or touch certain anatomical landmarks of the patient in the vicinity of the surgical target 1502 in positioning the patient's anatomy in a preoperatively generated patient-specific model and / or image of the patient's anatomy. All of these components of the positioning system 1500 are configured to function in much the same manner as the elements of the surgical system 100 of FIG. 1 described above.

[0198] The navigation or tracking system 42 tracks the positioning tools 55, 57 used in positioning the patient's surgical target 1502 to ensure that the surgical target is correct. In Figure 15, the surgical target 1502 is the patient's knee 1502, but could also be the shoulder, elbow, hip, ankle, spine, etc.

[0199] In operation, the positioning system 1500 may be used as a precursor to a robotic or robot-assisted surgery performed using the above-described surgical system 100 of FIG. 1 . Similarly, the positioning system 1500 may be used as a precursor to a conventional non-robotic surgery. In either case, a medical practitioner may pre-operatively utilize the positioning system 1500 on a patient to properly identify the intended surgical target 1502. For example, in the context of a knee arthroplasty or other joint arthroplasty, the positioning system 1500 may be used to distinguish the target knee 1502 from other non-target knees by scanning and / or touching landmarks on the patient's tibia 10 and / or femur 11 adjacent the target knee 1502. In the context of a spinal procedure, the positioning system 1500 may be used to identify vertebral bone borders and to identify the appropriate vertebral height that is the target of the surgery. In either case, the positioning system is employed to determine the correct location of the first incision and subsequent incisions.

[0200] In one embodiment, pre-operative positioning for surgical target confirmation purposes may occur by holding the suspected patient surgical target 1502 stationary and scanning the suspected patient surgical target 1502 with a tracked ultrasound probe. The resulting image is processed and registered to the pre-operative patient-specific image or computer model of the patient surgical target via computer 50 according to the method outlined in FIG. 5A and described in detail above. If the suspected patient surgical target 1502 is successfully registered to the pre-operative patient-specific image or computer model of the patient surgical target, this confirms that the suspected patient surgical target 1502 is in fact the correct surgical target. Robotic, robotic-assisted, or conventional surgery may then be performed at the correctly identified surgical target.

[0201] V. Preferred Computing System

[0202] 16, a detailed description of an exemplary computing system 1300 having one or more computing units that may implement the various systems and methods discussed herein is provided. The computing system 1300 may be applicable to any of the computers or systems utilized in pre-operative planning, positioning, and post-operative analysis of arthroplasty procedures, as well as other computing or network devices. It will be appreciated that the specific implementation of the device may be of different possible specific computing architectures, not all of which are specifically discussed herein but would be understood by one of ordinary skill in the art.

[0203] The computer system 1300 may be a computing system capable of executing a computer program product to execute a computer process. Data and program files may be input to the computer system 1300, which reads the files and executes the programs therein. Some of the elements of the computer system 1300 are shown in FIG. 16, including one or more hardware processors 1302, one or more data storage devices 1304, one or more memory devices 1308, and / or one or more ports 1308-1310. Additionally, other elements recognized by those skilled in the art may be included in the computing system 1300, but are not explicitly depicted in FIG. 16 or discussed further herein. The various elements of the computer system 1300 may communicate with each other by one or more communication buses, point-to-point communication paths, or other communication means not explicitly depicted in FIG. 16.

[0204] The processor 1302 may include, for example, a central processing unit (CPU), a microprocessor, a microcontroller, a digital signal processor (DSP), and / or one or more internal level caches. There may be more than one processor 1302, such that the processor 1302 comprises a single central processing unit, or multiple processing units capable of executing instructions and performing operations in parallel with each other, commonly referred to as a parallel processing environment.

[0205] The computer system 1300 may be a conventional computer, a distributed computer, or any other type of computer, such as one or more external computers made available via a cloud computing architecture. The techniques described are optionally implemented in software stored on the data storage device 1304, stored on the memory device 1306, and / or communicated via one or more of the ports 1308-1310, thereby turning the computer system 1300 in FIG. 16 into a dedicated machine that implements the operations described herein. Examples of the computer system 1300 include personal computers, terminals, workstations, mobile phones, tablets, laptops, personal computers, multimedia consoles, gaming consoles, set-top boxes, and the like.

[0206] The one or more data storage devices 1304 may include any non-volatile data storage device capable of storing data generated or employed within the computing system 1300, such as computer-executable instructions for executing computer processes, which may include instructions for both application programs and an operating system (OS) that manages the various components of the computing system 1300. Without limitation, the data storage devices 1304 may include magnetic disk drives, optical disk drives, solid-state drives (SSDs), flash drives, and the like. The data storage devices 1304 may include removable data storage media, non-removable data storage media, and / or external storage devices made available via wired or wireless network architectures with such computer program products, including one or more database management products, web server products, application server products, and / or other additional software components. Examples of removable data storage media include compact disc read only memory (CD-ROM), digital versatile disc read only memory (DVD-ROM), magnetic optical disks, flash drives, and the like. Examples of non-removable data storage media include internal magnetic hard disks, SSDs, and the like. The one or more memory devices 1306 may include volatile memory (e.g., dynamic random access memory (DRAM), static random access memory (SRAM), etc.) and / or non-volatile memory (e.g., read only memory (ROM), flash memory, etc.).

[0207] A computer program product including mechanisms for implementing the systems and methods according to the described technology may reside in data storage device 1304 and / or memory device 1306, which may be referred to as a machine-readable medium. It will be appreciated that a machine-readable medium may include any tangible, non-transitory medium that can store or encode instructions for performing any one or more of the operations of the present disclosure for execution by a machine, or that can store or encode data structures and / or modules utilized by or associated with such instructions. A machine-readable medium may include a single medium or multiple media (e.g., a centralized or distributed database and / or associated caches and servers) that store one or more executable instructions or data structures.

[0208] In some implementations, computer system 1300 includes one or more ports, such as input / output (I / O) port 1308 and communication port 1310, that communicate with other computing, network, or vehicle devices. It will be appreciated that ports 1308-1310 may be combined or separated and more or fewer ports may be included in computer system 1300.

[0209] I / O ports 1308 may be connected to I / O devices or other devices by which information may be input to or output from computing system 1300. Without limitation, such I / O devices may include one or more input devices, output devices, and / or other devices.

[0210] In one implementation, an input device converts human-generated signals, such as human voice, physical movement, physical touch or pressure, and / or the like, into electrical signals as input data to the computing system 1300 via the I / O ports 1308. Similarly, an output device may convert electrical signals received from the computing system 1300 via the I / O ports 1308 into signals that can be sensed by a human as output, such as sound, light, and / or touch. An input device may be an alphanumeric input device, including alphanumeric and other keys, that communicate information and / or command selections to the processor 1302 via the I / O ports 1308. An input device may be another type of user input device, including, but not limited to, a direction and selection control device, such as a mouse, a trackball, cursor direction keys, a joystick, and / or a wheel, one or more sensors, such as a camera, a microphone, a position sensor, an orientation sensor, a gravity sensor, an inertial sensor, and / or an accelerometer, and / or a touch-sensitive display screen ("touch screen"). Without limitation, the output device may include a display, a touch screen, a speaker, a tactile and / or haptic output device, and / or the like. In some implementations, the input device and the output device may be the same device, for example, in the case of a touch screen.

[0211] In one implementation, the communication port 1310 is connected to a network, whereby the computer system 1300 can receive network data that aids in the execution of the methods and systems described herein and the transmission of information and network configuration changes determined thereby. Stated differently, the communication port 1310 connects the computer system 1300 to one or more communication interface devices configured to transmit and / or receive information between the computing system 1300 and other devices over one or more wired or wireless communication networks or connections. Without limitation, examples of such networks or connections include Universal Serial Bus (USB), Ethernet, Wi-Fi, Bluetooth, Near Field Communication (NFC), Long Term Evolution (LTE), and the like. One or more such communication interface devices can be utilized via the communication port 1310 to communicate with one or more other machines directly over a point-to-point communication path, over a wide area network (WAN) (e.g., the Internet), over a local area network (LAN), over a cellular (e.g., third generation (3G) or fourth generation (4G)) network, or over another communication means. Additionally, the communications port 1310 may be in communication with an antenna or other link for communicating and / or receiving electromagnetic signals.

[0212] In an example implementation, patient data, bone models (e.g., generic, patient-specific), conversion software, positioning software, implant models, and other software, as well as other modules and services, may be embodied by instructions stored on the data storage device 1304 and / or memory device 1306 and executed by the processor 1302. The computer system 1300 may be integrated into or otherwise form a part of the surgical system 100.

[0213] However, the system depicted in Figure 16 is one possible example of a computer system that may employ or be configured in accordance with aspects of the present disclosure. It will be appreciated that other non-transitory, tangible, computer-readable storage media that store computer-executable instructions that implement the techniques of the present disclosure on a computing system may be utilized.

[0214] In the present disclosure, the methods disclosed herein, such as those particularly shown in Figures 5A-14C, may be implemented as a set of device-readable instructions or software. It is further understood that the specific order or hierarchy of steps in the disclosed methods is an example of an example approach. Based on design preferences, it is understood that the specific order or hierarchy of steps in the methods may be rearranged while remaining within the disclosed subject matter. The accompanying methods claim elements of the various steps in a sample order, and are not necessarily meant to be limited to the specific order or hierarchy presented.

[0215] The described disclosure, including any of the methods described herein, may be provided as a computer program product or software, which may include a non-transitory machine-readable medium having instructions stored thereon that may be used to program a computer system (or other electronic device) to perform a process according to the present disclosure. A machine-readable medium includes any mechanism for storing information in a form (e.g., software, processing application) readable by a machine (e.g., a computer). A machine-readable medium may include, but is not limited to, a magnetic storage medium, an optical storage medium, a magneto-optical storage medium, a read-only memory (ROM), a random access memory (RAM), an erasable programmable memory (e.g., EPROM and EEPROM), a flash memory, or any other type of medium suitable for storing electronic instructions.

[0216] While the present disclosure has been described with reference to various implementations, it will be understood that the implementations are exemplary and that the scope of the disclosure is not limited thereto. Numerous variations, modifications, additions, and improvements are possible. More generally, embodiments in accordance with the present disclosure have been described in the context of specific implementations. Functions may be separated or combined in blocks differently or described in different terms in various embodiments of the present disclosure. These and other variations, modifications, additions, and improvements may fall within the scope of the present disclosure as defined in the following claims.

[0217] Generally, the embodiments described herein are described with reference to specific embodiments, but modifications thereto can be made without departing from the spirit and scope of the disclosure. It should also be noted that the term "comprising" as used herein is intended to be inclusive, i.e., "including but not limited to."

[0218] The structure and arrangement of the systems and methods as shown in the various preferred embodiments are merely exemplary. Although only a few embodiments are described in detail in this disclosure, numerous modifications are possible (e.g., changes in the size, dimensions, structure, shape, and proportions of the various elements, parameter values, mounting arrangements, use of materials, colors, orientations, etc.). For example, the positions of elements may be reversed or otherwise changed, and the nature or number of individual elements or positions may be altered or changed. Accordingly, all such modifications are intended to be included within the scope of this disclosure. The order or sequence of any process or method steps may be changed or reordered according to alternative embodiments. Other substitutions, modifications, changes, and omissions may be made in the design, operating conditions, and arrangements of the preferred embodiments without departing from the scope of this disclosure. The inventions disclosed herein include the following: [Aspect 1] 1. A surgical system configured to process ultrasound images of bones of a patient, the ultrasound images including bone surfaces for each of the patient's bones, the system comprising: 1. A system comprising: a computing device including a processing device and a computer-readable medium having one or more executable instructions stored thereon, the processing device configured to execute the one or more executable instructions, the one or more executable instructions including: i) detecting the bone surfaces of each of the patient's bones in the ultrasound image; and ii) isolating a first point cloud of ultrasound image pixels associated with the bone surfaces of each of the patient's bones. [Aspect 2] 2. The system of claim 1, wherein the detection of the bone surface occurs via an image processing algorithm that forms at least a part of the one or more executable instructions. [Aspect 3] 3. The system of claim 2, wherein the image processing algorithm comprises a machine learning model. [Aspect 4] 3. The system of claim 2, wherein the separation of the first point cloud occurs via a pixel classification neural network forming at least a portion of the one or more executable instructions. [Aspect 5] 3. The system of claim 2, wherein the separation of the first point cloud occurs via an image-based classification neural network forming at least a portion of the one or more executable instructions. [Aspect 6] The system of aspect 1, wherein the processing device executes the one or more executable instructions to calculate a transformation of the first point cloud into a separated 3D point cloud, the separated 3D point cloud being separated such that the ultrasound image pixels of the separated 3D point cloud are each correlated to a corresponding bone surface of the patient's bone. [Aspect 7] The system of aspect 6, wherein in calculating the transformation of the first point cloud to the separated 3D point cloud, the ultrasound image pixels are calibrated to an ultrasound probe tracker, and the ultrasound probe tracker is calibrated to a tracking camera. [Aspect 8] 8. The system of embodiment 7, wherein the propagation speed of ultrasound in a particular medium is taken into account when calibrating the ultrasound image pixels to the ultrasound probe tracker. [Aspect 9] The system of aspect 6, wherein when calculating the transformation of the first point cloud to the separated 3D point cloud, the ultrasound image pixels are calibrated to an ultrasound probe tracker, the ultrasound probe tracker is calibrated to a tracking camera, and the coordinate system is relative to the bone surface via an anatomical structure tracker placed on the bone surface of the patient's bone. [Aspect 10] 7. The system of claim 6, wherein the separation of the first point cloud occurs via a geometric analysis of the first point cloud. [Aspect 11] The system of aspect 6, wherein the one or more executable instructions calculate an initial or rough positioning of a second point cloud obtained from the patient's bone to a bone model of the patient's bone. [Aspect 12] The system of embodiment 11, wherein the second point cloud includes a plurality of point clouds for a plurality of trackers on a bone of the patient. [Aspect 13] The system of aspect 12, wherein the multiple point clouds include one point cloud positioned on a bone model of the bone model of the patient's bone and another point cloud positioned on another bone model of the bone model of the patient's bone. [Aspect 14] The system of embodiment 11, wherein the initial or rough positioning is landmark-based. [Aspect 15] 12. The system of aspect 11, wherein the initial or rough positioning is calculated from a tracker position and orientation of the anatomical structure. [Aspect 16] The system of aspect 11, wherein when calculating the initial or rough positioning, a third point cloud and a fourth point cloud are generated by the system, the third point cloud being for a first bone of the patient's bones and for a first tracker associated with the first bone, and the fourth point cloud being for a second bone of the patient's bones and for a second tracker associated with the second bone. [Aspect 17] The system of aspect 16, wherein when calculating the initial or rough positioning, the system matches bone surface points of the third point cloud onto a computer model of the first bone and matches the bone surface points of the fourth point cloud onto a computer model of the second bone. [Aspect 18] The system of aspect 11, wherein the processing device executes the one or more instructions to calculate a final positioning of multiple bones using the initial or rough positioning and the separated 3D point cloud, which achieves a final positioning between the separated 3D point cloud and the patient's bones. [Aspect 19] The system of aspect 18, wherein in calculating the final multiple bone positioning in which the final positioning between the classified 3D bone surface point cloud and the patient's bones exists, the system iteratively refines the positioning of the separated 3D point cloud to a computer model of the patient's bones and iteratively refines the separation of the separated 3D point cloud. [Aspect 20] 1. A method of processing ultrasound images of bones of a patient, the ultrasound images including bone surfaces for each of the patient's bones, the method comprising: detecting the bone surface of each of the patient's bones in the ultrasound image; Isolating a first point cloud of ultrasound image pixels associated with the bone surface of each of the patient's bones; A method comprising: [Aspect 21] 21. The method of embodiment 20, wherein the detection of the bone surface occurs via an image processing algorithm. [Aspect 22] 22. The method of claim 21, wherein the image processing algorithm comprises a machine learning model. [Aspect 23] 22. The method of claim 21, wherein the separation of the first point cloud occurs via a pixel classification neural network. [Aspect 24] 22. The method of claim 21, wherein the separation of the first point cloud occurs via an image-based classification neural network. [Aspect 25] The method of claim 20, further comprising calculating a transformation of the first point cloud into a separated 3D point cloud, the separated 3D point cloud being separated such that the ultrasound image pixels of the separated 3D point cloud are each correlated to a corresponding bone surface of the patient's bone. [Aspect 26] The method of claim 25, wherein in calculating the transformation of the first point cloud to the separated 3D point cloud, the ultrasound image pixels are calibrated to an ultrasound probe tracker, and the ultrasound probe tracker is calibrated to a tracking camera. [Aspect 27] 27. The method of embodiment 26, wherein the propagation speed of ultrasound in a particular medium is taken into account when calibrating the ultrasound image pixels to the ultrasound probe tracker. [Aspect 28] The method of claim 25, wherein when calculating the transformation of the first point cloud to the separated 3D point cloud, the ultrasound image pixels are calibrated to an ultrasound probe tracker, the ultrasound probe tracker is calibrated to a tracking camera, and the coordinate system is relative to the bone surface via an anatomical structure tracker placed on the bone surface of the patient's bone. [Aspect 29] 26. The method of claim 25, wherein the separation of the first point cloud occurs via a geometric analysis of the first point cloud. [Aspect 30] 26. The method of embodiment 25, further comprising calculating an initial or rough positioning of a second point cloud obtained from the patient's bone to a bone model of the patient's bone. [Aspect 31] 31. The method of embodiment 30, wherein the second point cloud includes a plurality of point clouds for a plurality of trackers on a bone of the patient. [Aspect 32] The method of claim 31, wherein the multiple point clouds include one point cloud positioned on a bone model of the bone model of the patient's bone and another point cloud positioned on another bone model of the bone model of the patient's bone. [Aspect 33] 31. The method of embodiment 30, wherein the initial or rough positioning is landmark-based. [Aspect 34] 31. The method of embodiment 30, wherein the initial or coarse positioning is calculated from tracker positions and orientations of anatomical structures. [Aspect 35] 31. The method of claim 30, wherein when calculating the initial or rough positioning, a third point cloud and a fourth point cloud are generated, the third point cloud being for a first bone of the patient's bones and for a first tracker associated with the first bone, and the fourth point cloud being for a second bone of the patient's bones and for a second tracker associated with the second bone. [Aspect 36] 36. The method of claim 35, wherein when calculating the initial or rough positioning, bone surface points of the third point cloud are matched onto a computer model of the first bone and the bone surface points of the fourth point cloud are matched onto a computer model of the second bone. [Aspect 37] The method of claim 30, further comprising employing the initial or rough positioning and the separated 3D point cloud to calculate a final positioning of the multiple bones, wherein the final positioning of the multiple bones achieves a final positioning between the separated 3D point cloud and the patient's bones. [Aspect 38] The method of claim 37, wherein in calculating the final bone positioning in which the final positioning between the classified 3D bone surface point cloud and the patient's bones exists, the positioning of the separated 3D point cloud to a computer model of the patient's bones is iteratively refined and the separation of the separated 3D point cloud is iteratively refined.

Claims

1. 1. A surgical system configured to process ultrasound images of bones of a patient, the ultrasound images including bone surfaces for each of the patient's bones, the surgical system comprising: at least one surgical tool; a computing device including a processing device and a computer-readable medium having one or more executable instructions stored thereon, the processing device configured to execute the one or more executable instructions, the one or more executable instructions comprising: i) detecting the bone surfaces of each of the patient's bones in the ultrasound image as ultrasound image pixels; ii) converting the ultrasound image pixels into 3D points; iii) generating a classified 3D point cloud for each bone surface; iv) acquiring a point cloud using tracking of the three-dimensional positions of trackers placed on the patient's bones; v) finally registering the point cloud obtained using tracking of the three-dimensional position of a tracker placed on the patient's bone and registered with respect to the bone model of the patient's bone with the 3D point cloud classified for each bone surface, and for the bone model of the patient's bone, matching the point cloud obtained using tracking of the three-dimensional position of a tracker placed on the patient's bone and registered with respect to the bone model of the patient's bone with the 3D point cloud classified for each bone surface; The at least one surgical tool is in communication with the computing device, and the final bone positioning serves as an input for navigating the at least one surgical tool relative to each of the patient's bones.

2. The system of claim 1 , wherein the detection of the bone surfaces occurs via an image processing algorithm that forms at least a part of the one or more executable instructions.

3. The system of claim 2 , wherein the image processing algorithm comprises a machine learning model.

4. 1. A method of processing ultrasound images of bones of a patient, the ultrasound images including bone surfaces for each of the patient's bones, the method comprising: detecting the bone surfaces of each of the patient's bones in the ultrasound image as ultrasound image pixels; converting the ultrasound image pixels into 3D points; generating a 3D point cloud classified for each bone surface; acquiring a point cloud using tracking of three-dimensional positions of a tracker placed on the patient's bones; a bone model of the patient's bone and the point cloud obtained using tracking of the three-dimensional position of a tracker attached to the patient's bone and positioned relative to the bone model of the patient's bone are finally registered with the 3D point cloud classified for each bone surface, and for the bone model of the patient's bone, the point cloud obtained using tracking of the three-dimensional position of a tracker attached to the patient's bone and positioned relative to the bone model of the patient's bone coincides with the 3D point cloud classified for each bone surface; Including, Using the final bone positioning to navigate at least one surgical tool relative to each of the patient's bones.

5. The method of claim 4 , wherein the detection of the bone surfaces occurs via an image processing algorithm.

6. The method of claim 5 , wherein the image processing algorithm comprises a machine learning model.

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