Penn Vet Goes Boldly Into Three Dimensions

Penn Vet Goes Boldly Into Three Dimensions

By: Sacha Adorno Published: Aug 29, 2016

Ever the pioneer, Penn Vet is venturing into new frontiers, exploring dimensions of medicine once only imagined. Led by its Neurology and Neurosurgery service, this foray into the future began a few years ago, when Dr. Evelyn Galban, Clinical Assistant Professor of Neurology and Neurosurgery, turned to 3D printing for help in a complex case.

An Innovative Effort

A 3D-printed model of a dog's skull used to plan a complicated surgery ahead of time.At the time, Galban and her team were assessing Millie, an eight-month-old canine patient with a large mass on her skull. “We were looking at Millie’s CT scans and trying to clearly understand what surgery would involve—what areas would be affected and how serious it would be,” said Galban. “These questions are hard to answer with two dimensional images. So we started thinking about solutions that would let us hold Millie’s skull and look at it from all angles. That’s when we came up with the idea of printing a 3D replica of the skull, mass and all.”

Neurology resident Dr. Jonathan Wood researched the availability of 3D printers across the University, finding one in PennDesign’s Fabrication Lab. Galban contacted the lab for what would be the beginning of a successful inter-University collaboration to help animal patients—and to transform veterinary neurology and neurosurgery.

Working with Millie’s CT scans, the Fabrication Lab printed a perfectly precise model of her skull, made from a gypsum powder that’s bound by acrylic and sealed with a cyanoacrylate, an industrial-grade adhesive. Having this clone enabled Galban, Wood, and the rest of Millie’s veterinary team to gain a deeper understanding of the mass’ placement and to practice their surgical approach before the pup’s operation.

Ultimately, Millie did not end up on Penn Vet’s operating table. But Galban and her team were hooked on 3D printing. In partnership with the Fabrication Lab, they have used the technology to replicate injuries and disease in other animals, including a cat and a goat. And, earlier this year, they successfully completed a complicated procedure on a dog that likely would not have been possible without a 3D model.

Eager to create a collaborative global forum where veterinarians and students can share 3D models of real cases, Galban teamed up with the National Institutes of Health’s 3D Print Exchange—a web-based portal of printable models related to biomedical science. Over time, she aims to build Penn Vet’s collection on the Print Exchange into the world’s largest library of 3D animal models for veterinary practitioners everywhere to print, study, discuss, and consult.

Smart Neuro

Dr. Jonathan Wood consults with radiologist Dr. Jonathan Nevins (foreground) about a 3D rendering of a CT image.Although Penn Vet’s bold journey into multi-dimensional medicine is in its earliest stages, Galban has big plans for applying 3D technologies to neurology and neurosurgery. She is calling the School’s 3D medicine program SMART Neuro—simulate, model, animate, reconstruct, transform. Currently, SMART Neuro offers the 3D Print Exchange library and 3D printing. Looking forward, Galban envisions it will one day include virtual reality and holography, both of which permit interactive simulations of individual surgeries with room for trial and error that’s not available on live patients.

Explained Galban, “I’m extremely interested in how virtual reality tools can give students deeper insight into real surgical cases and faculty dynamic methods of educating and engaging tactile learners.”

Pushing SMART Neuro’s boundaries even further is the ultimate in futuristic medicine: holography. At a recent conference, Galban had the opportunity to interact with a holographic heart.

“The hologram projected from a tablet in three dimensions,” she said. “Wearing special glasses and holding a special pen, I was able to rotate the heart in any direction, make it beat, add blood to it, and dissect it. I am excited to explore bringing holography to the School.”

Even though a fully realized SMART Neuro program still remains on the horizon for Penn Vet—more research is needed to identify what it would take to acquire the necessary equipment—Galban believes 3D medicine holds limitless possibilities for teaching, learning, and research.

“These innovations can really open up what we, as surgeons, educators, and researchers, are able to do,” she said. “They will not only make us more confident going into risky procedures, but will help everyone involved, from families to students to clinical staff, understand what’s going to happen before we even start working on the patient. The implications for education and advancing quality of care are truly boundary-breaking. And research applications for 3D medicine are limited only by the questions asked.”

In Clubber’s Case, A World of Difference

Clubber poses after surgery with the two models of his skullSeven-year-old Clubber came to Penn Vet in late 2015 for treatment of a fibro-osseous proliferation between his eyes that extended to his brain. Penn Vet advised surgery, and the dog’s owners opted in.

It was a risky and complicated procedure that would require removing a large portion of the skull. So Penn Vet called in a new partner to help in the case—PennDesign’s Fabrication Lab.

Using files provided by Penn Vet, the lab printed a 3D model of Clubber’s diseased skull. Ahead of Clubber’s surgery, resident Jonathan Wood carved into the bone-like replica, creating an operating road map. Wood also used the model to mold a titanium mesh panel to replace the excised portion of the dog’s skull and protect his brain.

On operating day in January, Clubber’s surgical team removed a piece of his cranium, frontal sinus, and the orbits, referencing the 3D model for intra-operative guidance. “Having the model made a world of difference for us,” said Wood. “If we didn’t have the option to practice on the skull, I probably would not have recommended such an extensive surgery.”

After a seamless recovery, today Clubber is his regular self—happy, healthy, and eager to play. He recently visited the Fabrication Lab staff. Said Stephen Smeltzer, PennDesign’s
Digital Fabrications Manager, “Working on Clubber’s case was unique for us. Our work isn’t usually applied in such immediate, life-saving situations. We are proud to have played a part in giving Clubber a new lease on life.”

Robot Revolution

Robot Revolution

By: Louisa Shepard Published: Aug 29, 2016

Taking the lead to revolutionize equine imaging, Penn Vet’s New Bolton Center recently acquired a robotics-controlled system for use with the standing and moving horse.

Penn Vet is the first veterinary teaching hospital in the world using the EQUIMAGINE™ system, which has clinical and research applications for both animal and human medicine. In collaboration with Four Dimensional Digital Imaging (4DDI), the company behind the system’s innovation, New Bolton Center veterinarians are developing application-related protocols for large animals.

“The robots,” as the system is called on campus, were installed in February—a year and a week after New Bolton Center leaders first viewed the technology. The team is developing protocols for the horse, and optimizing and refining image quality. They anticipate full development will take until the spring of 2017.

“We thought, if it works, it could change the face of equine imaging,” said Dr. Barbara Dallap Schaer, Medical Director of New Bolton Center.

The system is capable of capturing the equine anatomy in a way never before possible: while the horse is awake, moving, and load-bearing. Existing computed tomography (CT) systems usually require the horse to be anesthetized and are limited to parts of the animal that fit into the opening in the cylindrical machines.

“The robots can easily move all around the horse in any orientation while the horse is standing, so we can see many parts of the anatomy we’ve never seen before,” Dallap Schaer said.

The system delivers the “holy grail” of imaging: a clear, complex, high-resolution image that tolerates patient motion, she said.

We can see these things in more detail than ever before, and in ways not possible with traditional CT,” she continued.

This bold innovation in imaging is part of Penn Vet’s One Health mission to advance animal and human health, said Dean Joan Hendricks.

“There have been tremendous advances in health care throughout our long history, many of them at New Bolton Center. This new robotics system is a remarkable innovation,” Hendricks said at an April press conference to unveil the robots to the public.

“All of our hopes are moving along,” she continued. “We are excited about the potential for our large animal patients, especially horses. And, as we often see to be the case, these innovations may also help people.”

What Can the Robots Do?

The robotics-driven technology unites automation with powerful computer algorithms. ABB, a leading global manufacturer of industrial robots, supplies the robots and many of the control components used in the 4DDI systems. Pairs of robots move around the animal, programmed and directed by a technician in a control room. The approach will ultimately allow examination of the entire horse anatomy, with initial work focusing on areas with the greatest clinical need: the head, neck, and limbs.

A three-dimensional reconstruction of an equine carpus (knee) from CT scan data generated by the imaging system.The EQUIMAGINE™ system can collect typical, two-dimensional CT images; create three-dimensional images; produce 360-degree digital radiographic studies; and capture highspeed fluoroscopic images. It also can perform tomosynthesis, which produces extremely high-resolution images of a very small, focused area. Eventually, researchers, clinicians, and engineers hope to program the robots to capture images of a horse running on a treadmill.

The quality and resolution of the real-time images created with the EQUIMAGINE™ system far exceeds existing technology available for the standing horse. And the system also makes imaging much more efficient and effective. The three-dimensional scans take less than a minute, a fraction of the time it takes to produce multiple static images.

Most specialists at New Bolton Center will be able to take advantage of the robotics-driven technology, including those in surgery, sports medicine, neurology, cardiovascular medicine, and internal medicine. “The possibilities are almost unlimited in terms of the conditions that can be addressed with this system,” Dallap Schaer said.

Preventing catastrophic injuries is one of these possibilities, as the experts look at distal limbs of the standing horse, said Dr. Dean Richardson, Chief of Surgery at New Bolton Center. He is providing surgical expertise for further refinement of the system—especially with respect to orthopedics.

Richardson has vast experience using CT imaging during surgery to treat horses with serious fractures. The images from the new system are much more detailed, he said, and can help to identify not only a fracture, but also its specific characteristics: location, depth, and breadth. He expects the new technology will also help prevent injuries, especially in racehorses, by allowing early detection of fractures.

A CT scan of a foal neck with atlanto-axial joint sepsis and associated osteomyelitis of the axis (C2).“Three-dimensional imaging provides the opportunity to be more precise in our
treatments. That’s a big step forward,” Richardson explained. “The goal in veterinary and human medicine is to provide less invasive and more precise surgical procedures.”

“We feel very confident this technology has the potential to prevent catastrophic breakdowns at racetracks by identifying these pre-existing lesions much more easily,” he added.

New Bolton Center’s purchase of the system includes four robots: the two large units now installed in New Bolton Center’s treadmill building, and two smaller units to be installed near New Bolton Center’s orthopedic surgery suite later this year.

After months of installation, development, and testing, client-owned horses came for clinical trials in May. Specialists from 4DDI are working with New Bolton Center clinicians during the first year to further the application capabilities of the system. And Penn Vet has rounded out its staff in conjunction with the new robotic technology.

Radiologist Dr. Chris Ryan, a Penn Vet alumnus who has a background not only
in equine medicine but also in engineering, is a key member of the team, dedicated to interpreting the scans.

“My goal is to help bring this new robotic imaging modality from the research and development phase to everyday clinical use,” said Ryan, who joined the staff in 2015.

In addition, radiologist and Penn Vet alumna Dr. Kathryn Wulster joined New Bolton Center’s full-time faculty in August as an Assistant Professor of Diagnostic Imaging. While Wulster will provide expertise for many imaging modalities, her main clinical focus will be to advance MRI and robotic CT capabilities.

How Does It Work?

New Bolton Center’s new imaging system is located in a spacious, wood-paneled building constructed 25 years ago for the Jeffords high-speed treadmill, a revolutionary equine sports medicine technology at that time. Now, the robotic arms are bookends on either side of the treadmill, and the computer equipment and controls are in an adjacent enclosed, windowed room.

The horse is walked up a ramp and sedated. Communicating through a sophisticated human-machine interface (HMI), a technician directs the robots to the ready position near the horse, and then adjusts the two arms based on the anatomy of that particular patient. The robot arms are paired and move together, the emitter on one arm and detector on the other. The system requires only two people to operate, one to hold the horse and the other to manipulate the controls. The operator sets the pathway and the robotic arms move around the animal. The image acquisition takes about 30 seconds.

Dr. Dean Richardson, Chief of Surgery at New Bolton Center, works with the new robotics-controlled system for use with the standing and moving horse.Carole Johnson, Director of Client Services and Imaging, and a radiology technician with 35 years of experience acquiring images of the horse, provides guidance and technical support. Under Johnson’s direction, imaging technician Kathryn Minacci has taken the lead on operating the robots and reconstructing the images.

The EQUIMAGINE™ process is significantly less invasive, less risky, and less expensive than using general anesthesia. While general anesthesia is routinely used for imaging and medical procedures, there are always risks when a horse wakes and stands up, so it is avoided when possible.

“The process of awaking from general anesthesia is an athletic event for the horse,” Dallap Schaer said. “Eliminating the need for anesthesia is a significant advantage for us.”

Human-Animal Connection

The system will be important not only for clinical use in the hospital, but also for research, teaching, and translational opportunities.

“This technology enables us to push the ‘One Health’ research frontiers in imaging to better understand potential new pathologies that haven’t been detected before,” said Dr. Thomas Schaer, Director of Penn Vet’s Preclinical Service Core & Translation in Orthopedic Surgery, who is leading the translational research efforts.

The robotics-driven imaging will be used to support many initiatives to help the horse, including treatment of horses with neurologic disease, and racehorse and performance horse safety. As Schaer explained, “We will image the lower limb of the horse on the treadmill to look for clues in joints while in motion. These dynamic studies may help us better understand patterns that could explain why joint degeneration occurs.”

With many specialists engaged in research, Penn Vet experts are also working with colleagues at Penn Medicine—as well as the Rothman Institute and Nemours Children’s Health System—to identify and develop applications in human medicine.

“Whether you are a bipedal human or a quadruped, you are going to benefit from this,” said Schaer. “It is incredibly exciting.”

Dr. Dean Richardson, Chief of Surgery, and Dr. Barbara Dallap Schaer, Medical Director of New Bolton Center, position a horse within the robots.Penn Medicine’s Dr. Neil Malhotra is Vice Chairman for Operations and Associate Program Director of the Department of Neurological Surgery at the Hospital of the University of Pennsylvania. He is also Co-Director of the Translational Spine Research Lab, and has been collaborating with Schaer for the past 10 years.

In his work as a neurosurgeon, Malhotra treats and studies the brain, the spinal
column, and the spinal cord. The robotic technology, he said, “gets us one step closer to understanding pain” because clinicians can see joints and the spine in natural motion.

“There is the potential opportunity to understand both disease and treatments of disease,” Malhotra said. “We are already talking about projects we can do immediately involving

The ability to obtain high-quality images of a human joint in motion, or the spine, or the head, could open up vast possibilities of discovery in the areas of diagnosis, treatment, and medical product development. The technology could be used in many human medicine specialties, Schaer said. Excellent imaging capabilities such as MRI and CT exist, but they are static. Dynamic imaging can add an entire new dimension.

“The system is going to allow us to explore tissues in a dynamic setting, in motion. Being able to image a veterinary or human patient in motion can be a game changer,” Schaer said.

“For example, evaluating joints or the spine when they move will allow us to expand our knowledge to better understand certain clinical symptoms.”

In pediatric patients, having the ability to compensate for accidental motion in imaging could be a “game changer” for children and infants who are too compromised or too sick for sedation or general anesthesia. The robotics-controlled system would allow imaging of a child while awake and moving, talking with their parents, even playing a game on their phones while the images are taken in less than a minute.

Additionally, robotics-controlled imaging has the potential to improve intra-operative imaging and workflows, Schaer said. Operating suites equipped with imaging robots with no constraints to a gantry will allow for quick and precise imaging studies of virtually any part of the patient’s body on demand.

Clinical, Research, and Educational Innovation

As the experts at New Bolton Center work with the new system and better understand its full potential, these discoveries can then be translated to clinical use. “These are hypothesisdriven research applications that ultimately will funnel into improved clinical care,” Schaer said.

For research purposes, one goal is to first understand “normal” and then “abnormal” in imaging at a greater resolution. “We now have another tool that allows us to image our patients in areas we’ve never been able to image, or image well, and there is a lot to learn,” he said.

There are great possibilities for teaching, as well. “Three-dimensional imaging is an enormously valuable tool in teaching anatomy, and there is nothing more important in the education of a medical specialist than understanding anatomy,” Richardson noted.

The long-range plan is to incorporate the imaging system into a new surgical translational research center.

“New Bolton Center has a history of advancing equine surgery and medicine,”
Richardson said. “This system is just one more tool that will prove New Bolton Center is on the forefront of veterinary medicine.”

A Leap of Faith, A New Frontier

(From left) Nicholas Hunt and Yiorgos Papaioannou of Four Dimensional Digital Imaging (4DDI) with Penn Vet’s Dr. Barbara Dallap Schaer, Medical Director of New Bolton Center.Why did Four Dimensional Digital Imaging (4DDI) choose New Bolton Center as the beta site for the EQUIMAGINE™ system?

The veterinary experts at Penn Vet are willing to collaborate to develop the protocols for use with large animals, noted Nicholas Hunt, Chief Technology Officer for 4DDI, who has led the team doing the installation.

“The caliber of the individuals I’m working with here at New Bolton Center is truly humbling. It’s clear to me why they are viewed as industry leaders in the field of veterinary medicine,” Hunt said. “The attention to process quality and safety of the operators, as well as the animals, is remarkable.”

The horse is probably “the most sophisticated and difficult patient we will ever encounter,” because of the size and complexity of the animal, as well as the need to correct for motion, said Yiorgos Papaioannou, 4DDI Chief Executive Officer.

“If we are able to tackle and solve the challenges with the horse, the technology could be easily transferred to other domains of imaging, in humans, or small animals,” he said. “It’s a great opportunity for us to validate our work with renowned academics, surgeons, radiologists, and radiographic technicians.”

The collaboration with 4DDI also offered significant advantages for New Bolton Center. A large-bore CT had been tested in the fall of 2014, but it didn’t meet the many needs of the hospital and its specialists. The robotic technology offered so many more possibilities.

In addition, attracting a full-time, large animal radiologist—a rare commodity—was impossible without a critical mass of the latest equipment and technologies, said Dallap Schaer, who took the reins of the New Bolton Center hospital in 2014.

Forging into this unknown territory has been a leap of faith, she said. “At some point you have to just take that leap. We determined that, if it could work, we would be 20 years ahead. It might be a really big push, and it might be a big risk, but the gain would be tremendous.”

The New Bolton Center team did its due diligence, going through a series of steps before signing the purchase contract. Dallap Schaer and Richardson visited the robot plant in Michigan to learn how the technology worked, then scanned cadaver limbs, then scanned a live horse, and evaluated the results.

“We feel strongly that if someone is going to develop such a system it should be at a veterinary teaching hospital,” Dallap Schaer said. “It should be done rigorously and with the mindful input of many.”

Every day, working with the robots brings a new advance, a new discovery.

“We have a lot to learn about this technology,” Richardson said. “Three-dimensional imaging opens new doors to diagnosis and treatments. We are very excited to be on the forefront of those discoveries.”

As Dallap Schaer emphasized, “We are trying to bring together all of our strengths at Penn Vet to be truly transformational.”