Robotic reduction of complex fractures using 3D puzzle solving algorithm

Lead Research Organisation: University of the West of England
Department Name: Faculty of Environment and Technology


The joints of the body are frequently involved in bone breaks, typically classified as intra-articular fractures. If a joint is to function properly again, that is to provide pain-free stability and movement, the broken pieces of the joint must be subjected to an anatomic reduction e.g. put back together as perfectly as possible. This project's aim is to set a research basis for creating a robotics device for precise anatomic reduction of complex, joints' fractures using the state of the art of 3D imaging, pattern recognition and robotics. The cost of trauma in hospitals is massive and a saving that robotics could potentially bring is promising. We believe that Bristol Robotics Laboratory's vibrant cross-disciplinary environment and its close association with Bristol Royal Infirmary places the investigators in an excellent position to exploit the opportunity of combining their robotics and clinical expertise with commercial 3D imaging software solutions developed by Simpleware.Trauma accounts for the highest proportion of healthcare expenditure. The BRI Limb unit has been at the forefront of injury research for the past three decades. BRL has, on the robotics side, been a fast developing robotics laboratory with a wide expertise in many areas of service and swarm robots. In order to promote the research in the area of orthopaedic robotics, we have formed a collaboration between the department of orthopedic surgery at the University of Bristol (Professor Roger Atkins), the Bristol Robotics Laboratory (Dr S Dogramadzi), the Centre for Fine Print Research at the University of the West of England (Dr P Walters and Dr D Huson) and a software company (Simpleware Ltd). This proposal is a first attempt to initiate the realization of an ambitious idea that can potentially bring benefits to a broad community of stakeholders. It is a feasibility study that aims to develop a novel robotic device capable of reducing complex joint fractures at the appropriate level of autonomy. An automated 3D jigsaw solving algorithm needs to be developed at this stage that would allow calculation of the optimum paths in overall alignment of the broken joint's segments. When the fracture is successfully reduced in simulation, the next step is to develop a robotic device to manipulate the fractured joint's parts using a fine wire circular frame applied across the joint. This will allow less exposure to CT scan for patients and staff, considerable resource saving, more rapid recovery and less scarring of the limb.Robot assisted surgery is an emerging interdisciplinary field that aims at improving the outcome of surgical procedures, reducing intra-operative time and radiation exposure to patients and staff as well as minimizing the invasiveness of a variety of surgical procedures. It seems very likely that Medical Robotics and Computer Assisted Surgery (MRCAS) will be a pervasive element of future society; there are many indications e.g. MRCAS report ( that this will be a huge opportunity for life enhancement and commercial exploitation. The total worldwide market for MRCAS devices and equipment was around $1.3 billion in 2006 and is expected to reach $5.7 billion by 2011, an average annual grow rate of 34.7%. There is a natural synergy in this project; the PI has a track record in robotics and a strong background in mathematics and control, the Advisor is an experienced clinician with an academic portfolio of developments in orthopaedics surgery. The collaborating company Simpleware will provide their software licence for the duration of the project as well as the software support. BRL's rapid prototyping facilities will contribute to realisation of the project's hardware and the visualisation of the real fractures obtained from BRI's medical archives.

Planned Impact

We beleieve that the following groups and institutions will benefit from the results of this proposal: Orthopaedic surgeons - This work will bring about a significant advance in the way that orthopaedic surgeons visualise and understand complex fractures. Although CT scan allows visualisation of the fractures on daily basis, having the physical models in front of them will lead to new insights even for experienced orthopaedic clinicians. This project's results could be further developed into a useful tool for the trainee doctors and students. The 3D puzzle solving both in simulation and on the robotic device will provide the surgeons with new approaches to solve the complex fractures reductions. NHS and Overseas health organisations - We would like to create a first step to a more sustainable and resource saving solution for the frequent and expensive orthopaedic hospital procedures. The economic cost of trauma accounts for the highest proportion of healthcare expenditure. As explained in the 'Case for Support', trauma patients require long hospitalization periods pre and post operatively. Rehabilitation period is substantial and similarly is the off-sick leave. This research could result in a reduction of not only the patients' hospital stays but also a number of patients returning to hospitals due to recurring pains and misaligned fractures. Patients treated for the orthopaedic types of injuries who potentially face long term disability or osteoporosis if the reduction is not accurately managed. Another advantage of utilizing robots is the ability for a gentler interaction with the patient, due to direct and well-controlled trajectories without repetitive and uncontrolled movements, which usually occur during manual reductions. Utilizing robotic solutions could remove the experienced surgeon from the treatment loop and allow an accurate fracture treatment in district hospitals or remote areas where specialist doctors are not available (battlefields, etc.). This will consequently bring the cost of the patient or the consultant transportation down and allow faster treatment of a fracture. UK robotics industry and biomedical engineering - Knowledge transfer and commercialisation of the project results related to the proposed software developments will be agreed with Simpleware. This project has potentially a good commercial value as stated in Simpleware's letter of support. On the other side, Medical Robotics is one of the robotics areas that have already proved to have a clear commercial impact in UK - Acrobot Ltd, Prosurgics Ltd, Renishaw, etc. A majority of other robotics research results are still confined to research laboratories. The first prototype of robotic device developed for the anatomic reduction of complex joints fractures will be a good showpiece for new, engineering collaborations with UK companies interested in this area. This project being a feasability study will have a little impact on commerical exploitation by Medical robotics industry. All impact and dissemination activities will be carried out by the project members. Each project member will publicise the project in his/her discipline through a participation in national and international conferences, lectures, seminars and relevant meetings but also using media tools in their respective institutions, all of which will ensure an excellent coverage in medical, academic and commercial societies. We all have a considerable experience in producing and delivering scientific material which is also a projected requirement for a research assistant that will be employed on the project.


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Description This project has developed in two directions: 1) path recognition and 3D puzzle solving algorithm 2) designing and building a physical prototype of a robotic system that strictly follows the clinical procedure of a typical joint fracture reduction on the other. The physical system's operation has been demonstrated on the distal femur fracture with three distinctive fragments. It consists of three hexapod type robots, two for manipulation of the bone fragments ('internal robots') and the third ('external robot') for extending, aligning and fixing the joint fragments after the manipulation. The internal robots hold pins that are manually inserted into the two fragments and perform minute translations and rotations through pre-calculated trajectories. The internal robots reduce the fracture by putting the two fragments together, fixate and reduce them to the third one. The external robot in this system fixates the fragments when repositioned by the internal robots, creates a workspace for the internal robots and restores limb's length and alignment. Small parallel robots have the most appropriate technical characteristics for this application due to their high stiffness, force compensation and positional accuracy. This makes them ideal to operate safely with surgeons and to overcome high friction forces posed by the joint's soft tissue.
Investigation in automatic 3D puzzle solving and reduction is based on a combination of two different approaches. The algorithm developed is based on partial feature matching and volume equivalence of the whole and broken joint fragments. Results suggest that although volumetric equivalence is useful in directly solving two fragment problems when integrated into a dynamic program, this framework failed a "proof by induction" type test, whereas increasing the number of fragments led to an infinite number of candidate solutions. Reducing this solution space although possible is believed to be unfeasible as evaluation of the constraints required would increase the computational expense considerably. Therefore, volumetric parameters are implemented alongside more traditional surface descriptors to locate the true solution. These results, along with a detailed description of the algorithm and its components are to be documented and submitted to the IEEE for review and publication.
Exploitation Route The findings have been taken forward into a translational project now funded by NIHR, i4i stream. Results can be further used by robotic designers,patternr recognition researchers in archeology and other areas concerned with puzzle pattern solving.
Sectors Education,Healthcare,Culture, Heritage, Museums and Collections

Description The findings have been patented and taken to the next stage. The project is now funded by NIHR.
First Year Of Impact 2013
Sector Healthcare
Impact Types Societal,Economic

Description Membership at BSI
Geographic Reach National 
Policy Influence Type Participation in a guidance/advisory committee
Impact Development of medical robotics standards and feeding into the international work of ISO.
Description Membership at the IET
Geographic Reach National 
Policy Influence Type Participation in a guidance/advisory committee
Description First EPSRC Grant Scheme
Amount £98,000 (GBP)
Organisation Engineering and Physical Sciences Research Council (EPSRC) 
Sector Public
Country United Kingdom
Start 01/2010 
End 12/2011
Description i4i
Amount £642,000 (GBP)
Funding ID II-SB-0712-20002 
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 09/2013 
End 08/2016
Title UK Clinical Research Network Study Portfolio 
Description IRAS Project Code 141124 UKCRN ID 17626 Robotic Assisted Fracture Surgery Force measurements in fracture surgery. 
Type Of Material Database/Collection of data 
Provided To Others? No  
Impact The results will inform clinical and engineering community when studying biomechanics of fractures. For robot assisted surgery this is important to understand allowed forces in robotic fracture management. 
Description HTC 
Organisation University of Leeds
Country United Kingdom 
Sector Academic/University 
PI Contribution Creating a South West branch for the Health Technology Centre run by University of Leeds.
Collaborator Contribution Inclusion into United Kingdom scientific and technical network for Colorectal Surgery
Impact This is a multidisciplinary collaboration including engineering, biosensing and nano technology.
Start Year 2013
Description Simpleware 
Organisation Simpleware Ltd
Country United Kingdom 
Sector Private 
PI Contribution The project presented a case study for use of Simpleware software in Orthopaedics.
Collaborator Contribution Simpleware donated a software license to the project.
Impact NIHR project has been won based on the results achieved in this project.
Start Year 2009
Description University Hospitals Bristol 
Organisation Bristol Royal Infirmary
Country United Kingdom 
Sector Hospitals 
PI Contribution Research and development in the area of robotic fracture surgery.
Collaborator Contribution Providing clinical expertise in orthopaedic surgery.
Impact Successful EPSRC grant in 2010 and a successful NIHR i4i grant in 2013
Start Year 2013
Description Volmo 
Organisation FilmLight
Country United Kingdom 
Sector Private 
PI Contribution The research team at Bristol Robotics Laboratory tests the software and acknowledge its use in publications and presentations.
Collaborator Contribution Volmo supplies 3D modelling software for CT images.
Impact No outputs can be reported yet.
Start Year 2014
Title Device for anatomic reduction of fractures 
Description This is a robotic system that can reduce fractures that involve joints. 
IP Reference  
Protection Patent application published
Year Protection Granted 2011
Licensed No
Impact There are no direct impacts as yet.
Title Prototype of a robot-assisted fracture surgery system 
Description This is a first patented prototype of a robot-assisted fracture surgery system 
Type Of Technology Physical Model/Kit 
Year Produced 2011 
Impact It was used as a proof of concept for i4i NIHR project that started in 2013 
Description IEEE Robotics and Automation Conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact This was an international conference which sparked more interest in this research.
Year(s) Of Engagement Activity 2012
Description TEDx talk 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact TEDx talk is a world renowned talk event targeted to general public and distributed through TED and TEDx channels. 100 people attended this live event but many more are reached through internet.
Year(s) Of Engagement Activity 2016