Computer Aided Surgery

ISSN: 1092-9088 (Print) 1097-0150 (Online) Journal homepage: https://www.tandfonline.com/loi/icsu20

New orthopaedic implant management tool

for computer-assisted planning, navigation,
and simulation: From implant CAD files to a
standardized XML-based implant database

S. Sagbo, F. Blochaou, F. Langlotz, C. Vangenot, L.-P. Nolte & G. Zheng

To cite this article: S. Sagbo, F. Blochaou, F. Langlotz, C. Vangenot, L.-P. Nolte & G. Zheng
(2005) New orthopaedic implant management tool for computer-assisted planning, navigation,
and simulation: From implant CAD files to a standardized XML-based implant database, Computer
Aided Surgery, 10:5-6, 311-319, DOI: 10.3109/10929080500389803

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Computer Aided Surgery, September/November 2005; 10(5/6): 311 – 319

New orthopaedic implant management tool for computer-assisted

planning, navigation, and simulation: From implant CAD files to a
standardized XML-based implant database

S. SAGBO1,2, F. BLOCHAOU3, F. LANGLOTZ1, C. VANGENOT3, L.-P. NOLTE1, & G. ZHENG1

1
M.E. Müller Research Center for Orthopaedic Surgery, Institute for Surgical Technology and Biomechanics, University of
Bern, Bern, Switzerland, and 2Robotic Systems Laboratory and 3Database Laboratory, Ecole Polytechnique Fédérale de
Lausanne (EPFL), Lausanne, Switzerland

(Received 28 April, 2005; accepted 30 May, 2005)

Abstract
Computer-Assisted Orthopaedic Surgery (CAOS) has made much progress over the last 10 years. Navigation systems have
been recognized as important tools that help surgeons, and various such systems have been developed. A disadvantage of
these systems is that they use non-standard formalisms and techniques. As a result, there are no standard concepts for
implant and tool management or data formats to store information for use in 3D planning and navigation. We addressed
these limitations and developed a practical and generic solution that offers benefits for surgeons, implant manufacturers,
and CAS application developers. We developed a virtual implant database containing geometrical as well as calibration infor-
mation for orthopedic implants and instruments, with a focus on trauma. This database has been successfully tested for
various applications in the client/server mode.
The implant information is not static, however, because manufacturers periodically revise their implants, resulting in the
deletion of some implants and the introduction of new ones. Tracking these continuous changes and keeping CAS systems up
to date is a tedious task if done manually. This leads to additional costs for system development, and some errors are inevi-
tably generated due to the huge amount of information that has to be processed.
To ease management with respect to implant life cycle, we developed a tool to assist end-users (surgeons, hospitals, CAS
system providers, and implant manufacturers) in managing their implants. Our system can be used for pre-operative planning
and intra-operative navigation, and also for any surgical simulation involving orthopedic implants. Currently, this tool allows
addition of new implants, modification of existing ones, deletion of obsolete implants, export of a given implant, and also
creation of backups.
Our implant management system has been successfully tested in the laboratory with very promising results. It makes it
possible to fill the current gap that exists between the CAS system and implant manufacturers, hospitals, and surgeons.

Keywords: CAD files, orthopedic implant management system, XML implant file, XML database, virtual reality, planning,
navigation, simulation, unified interface, computer-aided surgery

Introduction that more realistic rendering and additional naviga-

A wide variety of different plates, screws, and nails are
used in trauma surgery [1]. However, scaled visuali-
zation and tracking of these devices and their corres-
ponding surgical instruments is currently only
possible using fluoroscopy [2 – 5], which requires
radiation exposure for the patient and the surgical
team. Current CAS systems often simplify the
shapes of implants or instruments, but it is likely
tion information will improve the functionality of
navigation systems [6].
A novel concept has been developed to provide
this functionality. The concept centers around a
virtual implant database [7] that contains both geo-
metric and calibration information for trauma
implants and instruments. This should enable realis-
tic navigation of various implants through a common

Correspondence: Serge Sagbo, MEM Research Center for Orthopaedic Surgery, Institute for Surgical Technology and Biomechanics,
University of Bern, Stauffacherstrasse 78, CH-3014 Bern, Switzerland. Tel: þ41 31 631 59 55. Fax: þ41 31 631 59 60. E-mail:
serge.sagbo@memcenter.unibe.ch
ISSN 1092-9088 print=ISSN 1097-0150 online #2005 Taylor & Francis
DOI: 10.1080=10929080500389803
312 S. Sagbo et al.
interface [8], and could be used with any navigation
application.
A database has been established containing various
virtual representations of osteosynthesis implants
and anchoring devices for fracture reduction and fix-
ation, as well as images of various prostheses for total
joint replacement (knee and hip). This database can
be browsed for details of any stored virtual implant.
In its current implementation, the provided interface
supports the planning and navigation parameters of
LISS and LC-DCP plates (Synthes, Westchester,
PA, USA), as well as searching functionalities (allow-
ing search by implant size, manufacturer, bone part,
or implant type). The system has been successfully
tested for several computer-assisted orthopedic
surgery applications [7,9]. The aim was to evaluate
integration issues, network access, speed, and usabil-
ity. The implant information is not static, however,
because manufacturers periodically revise their
implants, resulting in the deletion of some implants
and the introduction of new ones. Tracking these
continuous changes and keeping CAS systems up
to date is a tedious task if done manually. This
leads to additional costs for system development,
and some errors are inevitably generated due to the
huge amount of information that has to be processed.
To overcome these limitations and improve the
current implant management process in CAS, we
designed and developed, on top of our existing
Virtual Implant Database, a graphical administration
tool which aims to help surgeons, implant manufac-
turers, and CAS system providers easily administer
the implant database. With respect to confidentiality
and security issues required for medical data, the tool
has been designed with additional security mecha-
nisms and ergonomic considerations. Moreover, no
database or Structured Query Language (SQL)
knowledge is needed by the end-users. Our initial
laboratory tests yielded successful results, and
improvements are planned, along with more exhaus-
tive tests involving surgeons, manufacturers, and
CAS system providers.
Related work
To our knowledge, there has been no research on
providing a virtual implant database as a global and
generic rapid application development (RAD) frame-
work. Most of the existing CAS systems are based on
proprietary file-based solutions for implant manage-
ment [10]. Little work has been published dealing
with implant selection tools or proprietary implant
databases.
Jaramaz and DiGioia [11], in the context of total
hip replacement (THR), proposed techniques for
choosing the correct implant size. They also showed
that correct implant positioning and alignment
remains one of the main challenges in orthopedic
surgery. Taylor et al. [12] presented the
ROBODOC system (Integrated Surgical Systems,
Davis, CA, USA) for performing THR. With this
device, the surgeon plans the surgery from patient-
specific pre-operative data to determine which
implant design and size to use and the desired
placement of the implant relative to the patient’s
anatomy. Bächler et al. [13] have presented a system
for computer-aided biological fracture plate fixation
using minimally invasive surgical techniques. It was
proposed to extend this system using a fracture plate
database from different manufacturers and for differ-
ent surgical procedures. In addition, several groups
have proposed techniques for finding the best
implant based on virtual fluoroscopy. [2,6,14–18].
Wu et al. [19] concluded that a CAS procedure
usually involves different information from different
sources. Therefore, the integration of a CAS,
Computer Aided Design (CAD), and Computer
Aided Manufacture (CAM) interface enables optim-
ization of pre-operative planning, taking into
consideration not only medical but also technical
boundary conditions.
The major weaknesses of these systems are data
exchange problems, the lack of a standardized
implant storage format, security issues (file corrup-
tion, simultaneous access problems), and the lack
of real-time sharing of implant data. Our graphically
based administration tool for implant management
and the concept of using XML to standardize
orthopedic implants using a database is a novel
concept in CAS.
Materials and methods
The work presented here is part of the CARIM
(Computer Assisted Reduction and Imaging) project
[20]. The aim was to establish a virtual implant data-
base containing geometrical as well as calibration
information for orthopedic implants and instru-
ments. This should allow different surgical navigation
applications to navigate any number of different types
of implants from this database (Figure 1).
We constrained our method to respect data
exchange standard and development formalisms.
We then used the Unified Modeling Language
(UML) [21] to capture and describe our implant
domain specification. We used Qt (Trolltech, Oslo,
Norway) [22] for our graphical user interface (GUI)
development and Coin3D (Systems in Motion,
Oslo, Norway) [23] for the 3D object manipulation.
MySql (MySQL AB, Uppsala, Sweden) [24] and
Caché database (InterSystems, Cambridge, USA)
[25] were used for storage. Our customized Implant
XML engine was built on top of the Qt Document
Object Model (DOM) library [22]. To achieve the
 Orthopaedic implant management tool 313

Figure 1. Virtual implant database: system overview. Various implant types and CAS systems are supported. (color version available online)

goals mentioned above, we adopted the following
methodology (Figure 2).
1. Virtual implant database design. All implants are
stored in a database containing tables and their
relationships, which handle implant planning
and navigation parameters and also various
virtual representations of osteosynthesis
implants and anchoring devices.
2. Unified Implant Access Interface. An application
programming interface (API) is provided
between the database and the client appli-
cations and acts as a communication channel
[8]. This layer provides main functionalities to
connect to the database, search implants,
preview implant parameters (including 2D
images and 3D models), and insert – , update –,
delete and backup implants.
3. Implant XML file structure. A well-defined
CAS-compliant XML implant file is generated
from the implant CAD files. The first part of
the XML file describes the general parameters
common to all implants, whereas the second
part describes the specific parameters for that
implant type.
4. Customized implant XML engine. A custom
XML engine (XMLImplantReader and
XMLImplantWriter) has been developed and

Figure 2. Implant management tool overview. (color version available online)

314 S. Sagbo et al.
helps in loading XML files in the database or
exporting implants from the database to a
given XML file.
5. Graphical user interface. An advanced GUI allows
the end-users (CAS system providers, hospital,
and manufacturers) to manage implants. Our
system workflow is organized in three stages:
first, the user carries out actions while clicking
buttons in the interface. These actions are refor-
mulated in SQL requests in the interface layer.
The requests are then sent to the database
server, which treats them and returns the
results of the requests. Each step will be
described in more detail in the following sections.
Virtual implant database design
We used the entity –relationship principle [26] (the
core principle of relational database systems) to
design the tables and relationships that describe our
orthopedic implant domain. We first designed the
implant category table which handles the various
implant categories routinely used by surgeons
during orthopedic operations: plates, screws, and
nails for trauma surgery; hip and knee components
for prosthetic operations.
Figure 3. Entity–Relational (ER) schema for plate and screw.
Each implant table is organized in two parts: the
first part contains fields describing the generic par-
ameters common to all implants (e.g., the implant
name, description, manufacturer, etc.), whereas the
second part describes specific parameters with
respect to implant category (Figure 3). The novelty
of our concept is that we created generic objects to
handle various implant types. The information
required to add implants to our database depends
on the implant category and type (e.g., plate, screw,
nail, etc.).
The implant manufacturers provided us with the
following:
. Implant geometry (3D model, shape descrip-
tion, and principal dimensions);
. Reference points used for navigation:
W For implants where holes are important
(e.g., plates), we used information such as
the center, axis, and orientation of each hole;
W For spherical implants with a center (e.g., hip
cups), we used the geometrical center and
geometrical axis;
W For implants with an alignment plane (e.g.,
hip stems), we used points defining the align-
ment plane or alignment axis.

System interface design and implementation
Our implant database system is composed of three
main parts: the implant data storage component,
the core processing component, and the published
interface (Figure 4). The storage component
handles the structure, relationships, and rules
between implants (e.g., which plate can be used
with which screw). The implementation has been
done on top of a well-known database management
system (MySQL database system and Caché
system). The core processing component manages
network, data processing, and security issues. The
published interface will allow any CAS application
to access implants easily. It acts as a communication
channel between the implant database and the CAS
applications or end-users. Two actions are necessary
to access implants: connection with a valid login and
search for the best-fitting implant or insert/update/
delete if administration rights have been granted.
XML implant file design
Three-dimensional CAD files do not provide a struc-
tured, easy-to-process, and interchangeable standard
that can be handled by CAS developers (for implant
planning and navigation) without a tedious and
manual conversion process. To overcome this
problem, we chose to use Virtual Reality Modeling
Language (VRML) for 3D implant mesh represen-
tation and Autocad DXF format for 2D engineering
drawings. To ease inter-operability between CAS
systems and to allow exchange of data and expertise
among the medical research community, we designed
a structured XML implant file with reference to
several viewing modalities (2D image, 3D model,
etc.). This XML file is currently generated based
on information received from implant manufacturers
and is dependent on implant type (Figure 5).
Figure 4. VIDB layered architecture: Unified Implant Access Interface.
Orthopaedic implant management tool 315
We used specific tools such as VoloView (Auto-
desk, San Rafael, CA, USA) to extract the relevant
planning and navigation information and to provide
this as input to our developed tool. XML implant
files are then generated and inserted in our database.
Customized implant XML engine
To transfer implant data from XML files to a
database, we need to map the XML document
schema (DTD, XML Schemas, etc.) to the database
schema. The data transfer software is then built on
top of this mapping [27]. We first parse and check
the validity (syntax checking and well-formed
validity) of the given XML implants files using our
customized implant reader engine. XMLImplant-
Reader opens XML files and builds in memory the
corresponding document tree. The output of our
XML reader is a collection of implant objects with
their attributes that can be manipulated to insert
data in the database.
We also developed a writer component, XML
ImplantWriter, which reads data from the database,
builds in memory the corresponding implant object,
and generates an implant file according to the
implant category and type.
GUI for implant management
One of the main advantages of our system is that the
end-users do not need to know about the underlying
design and implementation techniques. SQL knowl-
edge is not required either: users can easily manage
their implants without typing SQL requests. The
user’s interaction with the system can be summarized
in three stages (Figure 6):
1. The user carries out actions through the graphi-
cal interface.
316 S. Sagbo et al.
Figure 5. Example of an implant XML file.
2. These actions are reformulated into corre-
sponding requests and sent to the core proces-
sing component via the communication
channel.
3. The requests are forwarded to the database
server, which treats them and returns the
results.
Figure 6. GUI event processing.
Results
We have successfully achieved the initial goals for the
implant management tool. We developed a GUI-
based application that, in a semi-automatic manner,
helps surgeons, implant manufacturers, and CAS
system developers to continuously keep their systems
up to date for clinical use. In doing this, we also devel-
oped a new XML implant standard that eases inter-
operability and data sharing and provides a close link
between manufacturers, CAS system providers, and
surgeons. The main functionalities provided are
. Add, Delete, Update implant;
. Preview implant parameters;
. Backup implants; and
. Advanced search.
This article describes the entire development
process to support XML file manipulation: load
implant files via XMLImplantFileReader and backup
implants from the database via XMLImplantFileWriter.
All the functionalities of the administration tool are
implemented in the GUI.
Load XML implant file and preview. Before per-
forming any of the administration tasks, the user
can obtain visual feedback such as a preview of the
implants that he/she wants to insert or modify. At
this stage, one can load an XML implant file and
browse each implant.
New implant insertion. Users can insert implants in
the database based on the XML file that they initially
prepared. If some of the implants already exist in the
database, their attributes will be modified by the new
values read from the XML implant file.
Update existing implant in the database. Users have
to find in the database the implant that they wish to
modify by applying a searching filter such as the
implant category, implant manufacturer, or implant
type. The user browses the implant list, selects one
item, then edits the appropriate parameters.
Implant backup. As describe above, users select
from the database the list of implants to be backed
up by applying searching filters. The user can then
select the implants to be saved and add them to a
control list. This step could be repeated several
times by changing the filtering criteria until the user
is satisfied. Finally, he just has to click on the
‘backup’ button, whereupon an implant XML file
containing the selected implant will be created and
saved in the specified location.
Advanced search. During the planning and naviga-
tion of an orthopedic surgical procedure, it is import-
ant to find not only the best implant but also the
fixation devices that are associated with the selected
plate (for trauma surgery). For prosthetic operations,
it is also necessary to suggest to surgeons the best

available components (hip cup, stem, head, etc.).
Our advanced search functionality is intended to
provide a filter combination based on existing
relationships, constraints, and clinical rules between
implants. For the case shown in Figure 7, the
search starts by selecting the anatomy part (e.g.,
tibia, femur, etc.). As a result, only implants designed
for those specific anatomy parts are displayed. We
can then apply a precise filter such as implant
manufacturer or implant category. Depending on
the implant type, we can iteratively continue the
filtering process using criteria such as desired
implant length, plate hole number, etc. While click-
ing on a plate in the result list, our system automati-
cally finds the fixation devices (e.g., screws) that can
be used with this plate. Two- and three-dimensional
views are also provided for visual feedback.
Delete obsolete implant from database. The function
delete allows users to remove obsolete implants from
the database. The workflow is similar to the backup
functionality described above, with the difference
that the selected implants will be deleted from the
database.
Discussion
We have presented a graphically based implant
management tool for use with a computer-assisted
orthopedic planning and navigation system. As this
Figure 7. Advanced search finds the best plates and the corresponding fixation devices.
Orthopaedic implant management tool 317
tool is built on top of a virtual implant database, we
first provided an overview of this new concept and pre-
sented our new implant management concept centered
around the presented administration tool. After evalu-
ation of existing database management systems, we
designed and deployed a multi-platform implant data-
base that addressed the current limitations of existing
CAS systems with regard to the way in which implants
are managed. Our implant interface provides CAS
applications with simultaneous communication and
search algorithms for implants. The delivered solution
is manufacturer- and CAS-system-independent. Our
tests show that our concept enables and facilitates the
rapid integration of orthopedic surgical devices into
planning and navigation systems [7–9], thanks to the
standard communication interface provided between
the CAS and the implant management systems. We
currently support osteosynthesis plates [9], screws,
nails and hip prostheses (stems, cups, and heads). Inte-
gration of knee prosthesis components is ongoing. The
delivered solution can be used on Linux, Windows,
and Solaris operating systems.
Validation tests have been successfully carried out
with long-bone fracture-reduction planning software
and digital template planning software (both deve-
loped at our Institute). The intention of the tests
was to evaluate integration issues, network access,
speed, and usability of our system within CAS
systems (Figure 8). Moreover, a virtual implant
318 S. Sagbo et al.

Figure 8. Integration tests with CAS: a 3D implant model (left) or a 2D implant contour image of a LISS plate (right) is selected from our
database. [Left: X. Dong and V. Vitanis, 2003; Right: C. Anderegg, 2003.] (color version available online)

browser system was developed for multi-purpose
demonstrations (Figure 9).
During this project, several lessons have been
learned from a clinical and software design point of
view. This project is still under development, and
the following additional features and research topics
will be addressed in the near future:
. Improving the GUI for routine use by adding
additional functionalities, such as ‘undo’, after
a delete action.
. Processing more implants using our tool and
making quantitative performance measurements.
. Investigating the fully automatic process by
linking our system with CAD tools and directly
processing implant data (e.g., by integrating a
DXF parser in our design) and storing the
implant files in a native XML database.
. Validation of surgical efficiency in collaboration
with surgeons, manufacturers, and CAS
developers.
. Improvement of search functionalities, addition
of intelligence by exploring rules-based database
systems, expert systems, knowledge-based
systems, and data mining techniques.
Conclusion
Our proposed solution is a new concept that
addresses the limitations of existing CAS systems
with regard to orthopedic implant management.
Compared with existing solutions, our approach has
many advantages: data reusability, security mechan-
isms, a robust database system, client/server archi-
tecture, ease of use, and a framework for RAD
which allows CAS application developers to focus
more on surgical procedures.
The implant management tool presented here is a
new application that addresses the current limitations
and fills the gaps between the hospital’s available
CAS system implants and the implants provided by
the manufacturers. Laboratory tests of the system’s
usability and efficiency have been successful. Some
improvements are planned to allow for fully auto-
mated implant XML file generation directly from
CAD files received from implant manufacturers.

Figure 9. Virtual implant browser. (color version available online)


However, it is necessary to conduct more exhaustive
tests and continue improving the XML implant
scheme.
Currently, our application can work locally and
with a remote database server via a local network.
Planned improvements will enable it to work via
secure Internet tunnels.
Thanks to the concept and the tool presented here,
we can, in the near future, integrate more clinical
rules and ontology into our system. The overall
system will be improved to take into account the
requirements of surgeons, manufacturers, and CAS
system providers.
The proposed implant XML concept and its link
with our virtual implant database will improve the
inter-operability and integration of implants
between CAS systems. New implants can be made
available to surgeons rapidly without the need for
manual processing.
Acknowledgments
This project is funded by the AO/ASIF Foundation
through CARIM (Computer Assisted Reduction
and Imaging) project 1. Implant data was provided
by Synthes-Stratec.
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