JP4612196B2 - 靭帯移植片配置のため造影し、計画する装置 - Google Patents

靭帯移植片配置のため造影し、計画する装置 Download PDF

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JP4612196B2
JP4612196B2 JP2000604771A JP2000604771A JP4612196B2 JP 4612196 B2 JP4612196 B2 JP 4612196B2 JP 2000604771 A JP2000604771 A JP 2000604771A JP 2000604771 A JP2000604771 A JP 2000604771A JP 4612196 B2 JP4612196 B2 JP 4612196B2
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computer
pointer
ligament
ray
endoscope
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マルヴァン ザティ
ルッツ ペーター ノルテ
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Description

【０００１】
（技術分野）
本発明は、請求項１の前文に記載の靭帯移植片配置をリアルタイムでコンピューター処理により自然位（ｉｎ ｓｉｔｕ）でプランニングし、ガイダンスする装置に係るものであり、そして請求項８の前文に記載の靭帯移植片配置をリアルタイムでコンピューター処理により自然位（ｉｎ ｓｉｔｕ）でプランニングし、ガイダンスする方法に係るものである。
【０００２】
（背景技術）
前方十字形靭帯（ＡＧＬ）の断裂は極く普通にスポーツで生じる障害である。内視鏡を最小限侵入させて近接させ、自生の移植片で再構成するのがＡＧＬの修復の標準となっている。これの利点は手術の外傷が最も小さいということである。
【０００３】
適正なＡＧＬ配置について知られている現状では、ＡＣＬ靭帯の約４０％が不適当に配置されているということであり、これは不幸なことである。このことは処置の質に深刻な問題をもたらし、適正に行われなければ、結局は膝全体の修復を必要とすることになる膝構造の時期尚早な変質を招来する。
【０００４】
これらの不適正な配置は、限られた局部的な内視鏡観察に対して部分的に原因となり得て、普通の術後のＸ線写真で見れるように、外科医に靭帯位置の全体観察をさせない。内視鏡で視認される標識点がこういうことで限られてくるということから経験のある外科医は、手術中位置を確認できる量的手法として蛍光透視の利用を提唱している。
【０００５】
適正靭帯配置には次のような多くのファクターがある。
ａ）解剖学的標識点に対する適正なドリル孔位置；
ｂ）衝突の回避；
ｃ）靭帯伸張が１０％を越えないことの保証（１０％伸張を超えるときコラーゲン繊維が破断する）；
ｄ）膝の安定性の回復のための適正な移植片の張力と位置；そして
ｅ）良質な骨への移植片の適正な固定
【０００６】
ＡＣＬ修復の場合、移植片接着を大腿部のどの点にするかを決める方法はＥＰ ０ ６０３０８９ ＣＩＮＱＵＩＮに開示されている。この既知の方法は、脛骨の移植片取付け点に対して大腿部の移植片取付け点を決めることについて、膝の屈伸中それら２つの点の間の距離が変わらないように決めている。この既知の方法では、基準子とポインターとを使用し、両方ともエネルギーを発する指標を有し、自然位の３次元座標系内での指標の位置を３次元位置測定装置により、例えばオプティカル・カスタム・ポジション測定装置（ＯＰＴＯＴＲＡＫ、ノーサン・ディジタル、ウオータール、オン）により、求める。この位置測定装置は自然位の３次元座標系に対する指標の位置を測定する。それを使ってポインターの先端の位置もコンピューターにより求める。
【０００７】
この方法は次の段階を含んでいる。
１）脛骨に第一の基準子を取付ける。
２）事前に決定した点Ｔ1にポインターの先端を当て、そして第一の基準子に対するポインターの位置を測定する。
３）不変の点が期待される位置の近くで、大腿骨の滑車（ｔｒｏｃｈｌｅａ）において幾つかの点Ｐiにポインターの先端を配置する。
４）点Ｐiのそれぞれと点Ｔ1との距離を計算する。
５）脛骨に対して大腿骨を変位させ、点Ｐiのそれぞれと点Ｔ1との距離の変動を計算する。
６）最も不変の距離を示しているＰ1を点Ｐiの中から選択する。
【０００８】
この方法は膝の動きを測って、或る伸張基準を守って靭帯の「機能的な」配置を求める。
この既知の方法の欠点は、関節の全解剖学的構造に対して移植片の位置を全体的に見るといったような解剖学的配置状態を確認できないことである。
この点について本発明は救済手段を提供しようとするものである。
【０００９】
本発明の目的は、多様の移植片の態様、外科的思考そして外科技術に対して解剖構造的な、そして（構造的でない）機能的な、両方の基準を支持できる装置を提供することである。
【００１０】
（発明の開示）
この問題を解決する本発明の装置は請求項１に記載の特徴を有する靭帯移植片の配置をリアルタイムでコンピューター処理により自然位でプランニングし、ガイダンスする装置であり、本発明の方法は請求項８に記載の特徴を有する靭帯移植片の配置をリアルタイムでコンピューター処理により自然位でプランニングし、ガイダンスする方法である。
【００１１】
本発明の付随的な有利な実施例の特徴は従属請求項に記載されている。
本発明の装置の利点は、非常に異なる外科技術に対しても、前方十字形の靭帯挿入を許す融通性を持っているということである。
【００１２】
本発明の装置は、
Ａ）それぞれが少なくとも３つの指標を有する２つの剛性の基準子と、大腿骨と脛骨とに１つずつ基準子を取付けるネジもしくはピン；
Ｂ）少なくとも３つの指標を有するポインター；
Ｃ）内視鏡；
Ｄ）コンピューター；
Ｅ）指標の位置を求めるためコンピューターに接続された位置計測器；
Ｆ）手術前もしくは手術中使用されるＸ線源；
Ｇ）医療像データを集めるＸ線レシーバー（この医療データは数字フォーマットの形で直接コンピューターへ転送されるか、もしくはＸ線撮影フィルムを走査してコンピューターに入力する）；そして
Ｈ）コンピューターへ接続され、そして少なくとも３つの指標を有する超音波装置
を備えている。
【００１３】
使用される位置計測器によって異なるが、前記指標はエネルギーを放出し、エネルギーを受けもしくは反射する手段であって、例えばエネルギー放出手段としては、
−光源；
−発光デバイス（発光ダイオード）；
−赤外線放出ダイオード（ＩＲＥＤ）；
−音響トランスミッター；もしくは
−磁界を発生するためのコイル、
または、エネルギーを受ける手段としては、
−ホトダイオード；
−マイクロホーン：もしくは
−ホール効果素子
等を設置してもよい。
【００１４】
さらに、本発明の装置は少なくとも３つの指標を有するドリル装置を備えていてもよい。このドリル装置に取付けた指標により、ドリル装置の自然位での位置、特にドリル先端の位置を求めることができる。このようなドリル先端は、コンピューターであらかじめ計画した骨に位置決めされてもよい。ドリルがあけた孔の進路はコンピューターで制御されてもよく、コンピューターであらかじめ計画した孔に従ってドリル装置を案内する。これらの孔の位置の計画は医療像を使って行ってもよい。
【００１５】
本発明の装置の好ましい実施例では、ポインターと内視鏡とは１つになった、コンピューターに組み込まれた内視鏡装置として形成されている。
超音波装置は、リアルタイム信号処理を可能とするような、１つの軸に沿って超音波ビームを放射し、そして受けるＡモードの超音波装置である。
【００１６】
特定のソフトウエアにより、コンピューターはポインターによりあらかじめ求めた靭帯の取付け点と取付け点との間の接続を表している３次元表示を呈示する。さらに、この靭帯取付点を使用して、コンピューターは膝の屈伸中、靭帯を表示する。
【００１７】
本発明の方法は以下の段階から成る。
Ａ）医療像として１つの大腿骨と脛骨の膝部分の少なくともＸ線写真をつくり；
Ｂ）その医療像をコンピューターに転送し；
Ｃ）ポインターを使って、自然位での３次元座標系内の脛骨と大腿骨の表面の点をそれぞれ測定し；
Ｄ）超音波装置を使って、自然位での３次元座標系内の脛骨と大腿骨の表面の点をそれぞれ測定し；そして
Ｅ）前記Ａ、ＣそしてＤで得たデータにより靭帯移植片の配置を解剖構造的に、そして（構造的でない）機能的に決める。
【００１８】
脛骨と大腿骨の表面で手術中測定された点を使って患者の手術中の位置とＸ線写真のデータとの間の数学的関係を確立してもよい。
Ｘ線写真を手術前もしくは手術中につくり、そして靭帯をどこに置くかを決める助けとして使ってもよい。
【００１９】
さらに、本発明の方法はコンピューターにより、拡大像を求める段階を含んでもよい。
好ましくはＸ線写真はテンプレートとして準備される。そのテンプレートを操作することにより、コンピューターで表示された医療像上の解剖学的標識点に対して、所望の靭帯移植片の配置を直接計画できる。
本発明の方法は脛骨に、大腿骨にそれぞれ起点指標を植え込む段階を含んでもよい。
【００２０】
本発明を好ましい実施例を示す図面を参照して詳細に説明する。
図１は本発明の装置の好ましい実施例を示す。
図１に示す本発明の装置は、
−手術前もしくは手術中に使用してもよいＸ線源１；
−医療像データを集めるためのＸ線レシーバー２；
−コンピューター３（このコンピューター３へ数字フォーマットとして直接に、またはＸ線撮影フィルムを走査して取込むかのどちらかで医療像データを転送する）；
−それぞれが４つの指標を有する２つの剛性の基準子４，５と、大腿骨８と脛骨９とに基準子４，５を取付けるネジ７もしくはピン；
−１２の指標６を有するポインター１０；
−ディスプレイ１２を有する内視鏡１１；
−コンピューター３へ接続され、そして４つの指標６を有するＡモード超音波装置１３；
−指標６の位置を求めるためにコンピューター３に接続された位置計測器１４；そして
−４つの指標６を有するドリル装置１５
を備えている。
【００２１】
Ｘ線源１とＸ線レシーバー２を使って手術前もしくは手術中にＸ線写真をつくってもよい。手術前にＸ線写真を撮影すると、数字フォーマットもしくはＸ線撮影フィルムとして利用することができる。数字フォーマットで利用するなら、このＸ線写真はコンピューターに直接転送され、そうでなければ、Ｘ線フィルムは走査されてコンピューター３に取込まれる。もし手術中にＸ線写真を撮影するなら、Ｘ線源１とＸ線レシーバー２を使って蛍光透視を行う。Ｘ線写真は標準配向で、例えば前方−後方そして中央−側方から撮るべきであり、そしてＸ線を透過しない指標を有する定規を膝の側に配置して撮るべきである。定規の上のＸ線を透過しない指標は像に現れ、そしてコンピューター３内でディジタル化されて像の倍率を決定する。このＸ線写真はテンプレートとして用意される。解剖学的標識点、例えば中間と横の丸い隆起もしくは滑車に対して所望の靭帯配置を、テンプレートの操作によりコンピューター３に表示される医療像の上で直接計画できる。
【００２２】
機能的な配慮をするため大腿骨８、脛骨９そしてポインター１０の位置測定は、位置測定装置１４により行われる。本発明の装置の好ましい実施例では、位置測定装置１４はオプトエレクトロニクス・ナビゲーション・システム（オプトトラク３０２０、ノーザン・ディジタル、キャン．）である。指標６は赤外線放出ダイオード（ＩＲＥＤ）であり、位置測定装置１４で検出され、それにより基準子４，５、ポインターの先端１６、ドリルの先端１７そして超音波装置１３のヘッド１８の位置を計算できる。
【００２３】
内視鏡１１による直接視認制御によりポインター１０を使って脛骨９の構造と大腿骨８の構造をそれぞれディジタル化できる。本発明の装置の好ましい実施例において、ポインター１０に内視鏡１１が一体化したように、ポインター１０はコンピューターに統合された内視鏡的触接フックとなる。
【００２４】
後部大腿骨と脛骨の丸い隆起のような標識点は、ポインター１０による直接ディジタル化によっては得にくい。このため本発明の装置は指標６を付けたＡモード超音波装置１３を取込んでいる。この超音波装置１３とコンピューター３とにより骨表面と超音波ビームとの交差点と超音波装置１３のヘッド１８との間の距離を計算できる。自然位での３次元座標２０内での超音波ビームの方向と超音波ヘッド１８の位置とが位置測定装置１４により求められるので、交差点１９の位置は、コンピューター３による座標変換によって自然位で３次元座標系２０内で求めてもよい。
【００２５】
大腿骨８の表面上で、脛骨９の表面上でそれぞれ手術中に測定された点を使って患者の手術中の位置と医療像のデータとの間の関係を確立してもよい。医療像の上でのそのような座標変換はコンピューターで自然位で３次元座標系２０に取込んでもよく、それにより移植片の配置の解剖学的な、そして機能的な考察を可能とする。
【図面の簡単な説明】
【図１】 本発明の装置の好ましい実施例を示す図である。

Claims (5)

  1. Ａ）それぞれが少なくとも３つの指標（６）を有する２つの剛性の基準子（４，５）と、大腿骨（８）と脛骨（９）とに１つずつ基準子（４，５）を取付けるネジ（７）もしくはピン；
    Ｂ）少なくとも３つの指標（６）を有するポインター（１０）；
    Ｃ）内視鏡（１１）；
    Ｄ）コンピューター（３）；そして
    Ｅ）指標（６）の位置を求めるためコンピューター（３）に接続された位置計測器（１４）を備えた靭帯移植片の配置をリアルタイムでコンピューターで処理して自然位でプランニングし、ガイダンスする装置において、
    Ｆ）手術前もしくは手術中使用されるＸ線源（１）；
    Ｇ）数字フォーマットの形で直接コンピューター（３）へ転送されるか、もしくはＸ線撮影フィルムを走査してコンピューター（３）に入力する、医療像データを集めるＸ線レシーバー（２）；
    Ｈ）コンピューター（３）へ接続され、そして少なくとも３つの指標（６）を有する超音波装置（１３）
    をさらに備えており、また前記コンピュータ（３）は
    Ｉ）大腿骨（８）と脛骨（９）のそれぞれの上における前記ポインター（１０）の位置に基づいて、ならびに前記Ｘ線レシーバー（２）を使って集められた医療像データに基づいて、靱帯移植片配置のための位置を示すデータを取得し、そして
    Ｋ）膝の屈伸中、前記ポインター（１０）により求めた靭帯取付点を使用して靱帯の３次元表示を呈示するように設計されていることを特徴とする靭帯移植片の配置をリアルタイムでコンピューターで処理してプランニングし、ガイダンスする装置。
  2. 少なくとも３つの指標（６）を有するドリル装置（１５）を備えていることを特徴とする請求項１に記載の装置。
  3. ポインター（１０）と内視鏡（１１）とが一体化して、コンピューターに取込まれた内視鏡装置となっていることを特徴とする請求項１もしくは２に記載の装置。
  4. 超音波装置（１３）はＡモード超音波装置であることを特徴とする請求項１ないし３の何れか１項に記載の装置。
  5. Ｘ線源（１）とＸ線レシーバー（２）とが蛍光透視鏡として構成されていることを特徴とする請求項１ないし４の何れか１項に記載の装置。
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