Innervation zone location of the biceps brachii,a comparison between genders and correlation with anthropometric measurements

Avoiding the innervation zone (IZ) is important when collecting surface electromyographic data. The purposes of this study were threefold: (1) to examine the precision of two different techniques for expressing IZ location for the biceps brachii, (2) to compare these locations between men and women, and (3) to determine if IZ movement with changes in elbow joint angle is related to different anthropometric measures. Twenty-four subjects (mean ± SD ages = 21.8 ± 3.5 yr) performed isometric contractions of the right forearm flexors at each of three separate elbow joint angles (90°, 120°, and 150° between the arm and forearm). During each contraction, the location of the IZ for the biceps brachii was visually identified using a linear electrode array. These IZ locations were expressed in both absolute (i.e. as a distance (mm) from the acromion process) and relative (i.e. as a percentage of humerus length) terms. The results suggested that the estimations of IZ location were more precise when expressed in relative versus absolute terms, and were generally different for men and women. The shift in IZ location with changes in elbow joint angle was not, owever, related to height, weight, or humerus length.     

The effect of surface area digitizations on the prediction of spherical anatomical geometries for computer-assisted applications

Intraoperative digitization of osseous structures is an integral component of computer-assisted orthopaedic surgery. This study determined the repeatability and accuracy of predicting known radii and center locations of spherical objects for different proportions of digitized surface areas and various sphere sizes. Also, we investigated these accuracies for some relevant near-spherical osseous structures where results from full area digitizations were considered to be true. Digitizations were performed using an electromagnetic tracker with a stylus on the total and fractional surfaces of 10 hemispheres, ranging from 10 to 28 mm in radius. Repeatability was quantified by digitizing five trials of the entire surface and various fractional areas of selected hemisphere sizes. Similar trials were conducted on models of a humeral and femoral head, using the full head area as baseline and digitizing 15 and 30 mm diameter areas of the full head. Mean error for the predicted radii and center positions of the hemispheres ranged from 0.39±0.29 to 0.14±0.07 mm and 0.52±0.31 to 0.22±0.12 mm, respectively. Repeatability for the predicted radii and centers produced maximum standard deviations of 0.31 and 0.42 mm, respectively. All errors decreased as fractional area (40%, 60%, 80% and 100%) increased (p<0.05). Radius of curvature and center position errors for the humeral head model were 1.51±2.11 and 2.28±1.51 mm, respectively. These errors for the femoral head model were 3.37±4.14 and 4.25±4.14 mm, respectively. Errors resulting from the prediction of radius and center indicate that non-spherical anatomical structures are more sensitive to the digitized area, and hence digitization of the largest surface possible seems warranted.     

Effect of various upper limb multibody models on soft tissue artefact correction: A case study

Soft tissue artefacts (STA) introduce errors in joint kinematics when using cutaneous markers, especially on the scapula. Both segmental optimisation and multibody kinematics optimisation (MKO) algorithms have been developed to improve kinematics estimates. MKO based on a chain model with joint constraints avoids apparent joint dislocation but is sensitive to the biofidelity of chosen joint constraints. Since no recommendation exists for the scapula, our objective was to determine the best models to accurately estimate its kinematics. One participant was equipped with skin markers and with an intracortical pin screwed in the scapula. Segmental optimisation and MKO for 24-chain models (including four variations of the scapulothoracic joint) were compared against the pin-derived kinematics using root mean square error (RMSE) on Cardan angles. Segmental optimisation led to an accurate scapula kinematics (1.1° ≤ RMSE ≤ 3.3°) even for high arm elevation angles. When MKO was applied, no clinically significant difference was found between the different scapulothoracic models (0.9° ≤ RMSE ≤ 4.1°) except when a free scapulothoracic joint was modelled (1.9° ≤ RMSE ≤ 9.6°). To conclude, using MKO as a STA correction method was not more accurate than segmental optimisation for estimating scapula kinematics.     

The range of axial rotation of the glenohumeral joint

There is a paucity of data in the literature on the restraining effects of the glenohumeral (GH) ligaments; cadaveric testing is one of the best methods for determining the function of these types of tissues. The aim of this work was to commission a custom-made six degrees of freedom (dof) joint loading apparatus and to establish a protocol for laxity testing of cadaveric shoulder specimens. Nine cadaveric shoulder specimens were used in this study and each specimen had all muscle resected leaving the scapula, humerus (transected at mid-shaft) and GH capsule. Specimens were mounted on the testing apparatus with the joint in the neutral position and at 30°, 60° and 90° GH abduction in the coronal, scapula and 30° forward flexion planes. For each orientation, 0–1 N m in 0.1 N m increments was applied in internal/external rotation and the angular displacement recorded. The toe-region of the moment–displacement curves ended at approximately ±0.5 N m. The highest rotational range of motion for the joint was 140° for ±1.0 N m at 30° GH abduction in the scapula plane. The range of motion shifted towards external rotation with increasing levels of abduction. The results provide the optimum loading regime to pre-condition shoulder specimens and minimise viscoelastic effects in the ligaments prior to laxity testing (>0.5 N m at 30° GH abduction in any of the three planes). Knowledge of the mechanical properties of the GH capsuloligamentous complex has implications for modelling of the shoulder as well surgical planning and intervention.     

Identification of rupture locations in patient-specific abdominal aortic aneurysms using experimental and computational techniques

In the event of abdominal aortic aneurysm (AAA) rupture, the outcome is often death. This paper aims to experimentally identify the rupture locations of in vitro AAA models and validate these rupture sites using finite element analysis (FEA). Silicone rubber AAA models were manufactured using two different materials (Sylgard 160 and Sylgard 170, Dow Corning) and imaged using computed tomography (CT). Experimental models were inflated until rupture with high speed photography used to capture the site of rupture. 3D reconstructions from CT scans and subsequent FEA of these models enabled the wall stress and wall thickness to be determined for each of the geometries. Experimental models ruptured at regions of inflection, not at regions of maximum diameter. Rupture pressures (mean±SD) for the Sylgard 160 and Sylgard 170 models were 650.6±195.1 mmHg and 410.7±159.9 mmHg, respectively. Computational models accurately predicted the locations of rupture. Peak wall stress for the Sylgard 160 and Sylgard 170 models was 2.15±0.26 MPa at an internal pressure of 650 mmHg and 1.69±0.38 MPa at an internal pressure of 410 mmHg, respectively. Mean wall thickness of all models was 2.19±0.40 mm, with a mean wall thickness at the location of rupture of 1.85±0.33 and 1.71±0.29 mm for the Sylgard 160 and Sylgard 170 materials, respectively. Rupture occurred at the location of peak stress in 80% (16/20) of cases and at high stress regions but not peak stress in 10% (2/20) of cases. 10% (2/20) of models had defects in the AAA wall which moved the rupture location away from regions of elevated stress. The results presented may further contribute to the understanding of AAA biomechanics and ultimately AAA rupture prediction.     

Measuring humeral head translation using fluoroscopy: A validation study

Numerous techniques have been employed to monitor humeral head translation due to its involvement with several shoulder pathologies. However, most of the techniques were not validated. The objective of this study is to compare the accuracy of manual digitization and contour registration in measuring superior translation of the humeral head. Eight pairs of cadaver scapulae and humerii bones were harvested for this study. Each scapula and humerus was secured in a customized jig that allowed for control of humeral head translations and a vise that permitted rotations of the scapula about three axes. Fluoroscopy was used to take images of the shoulder bones. Scapular orientation was manipulated in different positions while the humerus was at 90° of humeral elevation in the scapular plane. Humeral head translation was measured using the two methods and was compared to the known translation. Additionally, accuracy of the contour registration method to measure 2-D scapular rotations was assessed. The range for the root mean square (RMS) error for manual digitization method was 0.27 mm - 0.43 mm and the contour registration method had a RMS error ranging from 0.18 mm - 0.40 mm. In addition, the RMS error for the scapular angle rotation using the contour registration method was 2.4°. Both methods showed acceptable errors. However, on average, the contour registration method showed lesser measurement error compared to the manual digitization method. In addition, the contour registration method was able to show good accuracy in measuring rotation that is useful in 2-D image analysis.     

Mechanical properties of the patellar tendon in adults and children

It is not currently known how the mechanical properties of human tendons change with maturation in the two sexes. To address this, the stiffness and Young's modulus of the patellar tendon were measured in men, women, boys and girls (each group, n=10). Patellar tendon force (F_pt) was calculated from the measured joint moment during a ramped voluntary isometric knee extension contraction, the antagonist knee extensor muscle co-activation quantified from its electromyographical activity, and the patellar tendon moment arm measured from magnetic resonance images. Tendon elongation was imaged using the sagittal-plane ultrasound scans throughout the contraction. Tendon cross-sectional area was measured at rest from ultrasound scans in the transverse plane. Maximal F_pt and tendon elongation were (mean±SE) 5453±307 N and 5±0.5 mm for men, 3877±307 N and 4.9±0.6 mm for women, 2017±170 N and 6.2±0.5 mm for boys and 2169±182 N and 5.9±0.7 mm for girls. In all groups, tendon stiffness and Young's modulus were examined at the level that corresponded to the maximal 30% of the weakest participant's F_pt and stress, respectively; these were 925–1321 N and 11.5–16.5 MPa, respectively. Stiffness was 94% greater in men than boys and 84% greater in women than girls (p<0.01), with no differences between men and women, or boys and girls (men 1076±87 N/mm; women 1030±139 N/mm; boys 555±71 N/mm and girls 561.5±57.4 N/mm). Young's modulus was 99% greater in men than boys (p<0.01), and 66% greater in women than girls (p<0.05). There were no differences in modulus between men and women, or boys and girls (men 597±49 MPa; women 549±70 MPa; boys 255±42 MPa and girls 302±33 MPa). These findings indicate that the mechanical stiffness of tendon increases with maturation due to an increased Young's modulus and, in females due to a greater increase in tendon cross-sectional area than tendon length.     

Estimations of relative effort during sit-to-stand increase when accounting for variations in maximum voluntary torque with joint angle and angular velocity

The main purpose of this study was to compare three methods of determining relative effort during sit-to-stand (STS). Fourteen young (mean 19.6 ± SD 1.2 years old) and 17 older (61.7 ± 5.5 years old) adults completed six STS trials at three speeds: slow, normal, and fast. Sagittal plane joint torques at the hip, knee, and ankle were calculated through inverse dynamics. Isometric and isokinetic maximum voluntary contractions (MVC) for the hip, knee, and ankle were collected and used for model parameters to predict the participant-specific maximum voluntary joint torque. Three different measures of relative effort were determined by normalizing STS joint torques to three different estimates of maximum voluntary torque. Relative effort at the hip, knee, and ankle were higher when accounting for variations in maximum voluntary torque with joint angle and angular velocity (hip = 26.3 ± 13.5%, knee = 78.4 ± 32.2%, ankle = 27.9 ± 14.1%) compared to methods which do not account for these variations (hip = 23.5 ± 11.7%, knee = 51.7 ± 15.0%, ankle = 20.7 ± 10.4%). At higher velocities, the difference in calculating relative effort with respect to isometric MVC or incorporating joint angle and angular velocity became more evident. Estimates of relative effort that account for the variations in maximum voluntary torque with joint angle and angular velocity may provide higher levels of accuracy compared to methods based on measurements of maximal isometric torques.     

Tibio-femoral joint contact in healthy and osteoarthritic knees during quasi-static squat: A bi-planar X-ray analysis

The aim of this study was to quantify the tibio-femoral contact point (CP) locations in healthy and osteoarthritic (OA) subjects during a weight-bearing squat using stand-alone biplanar X-ray images.Ten healthy and 9 severe OA subjects performed quasi-static squats. Bi-planar X-ray images were recorded at 0°, 15°, 30°, 45°, and 70° of knee flexion. A reconstruction/registration process was used to create 3D models of tibia, fibula, and femur from bi-planar X-rays and to measure their positions at each posture. A weighted centroid of proximity algorithm was used to calculate the tibio-femoral CP locations. The accuracy of the reconstruction/registration process in measuring the quasi-static kinematics and the contact parameters was evaluated in a validation study.The quasi-static kinematics data revealed that in OA knees, adduction angles were greater (p<0.01), and the femur was located more medially relative to the tibia (p<0.01). Similarly, the average CP locations on the medial and lateral tibial plateaus of the OA patients were shifted (6.5±0.7 mm; p<0.01) and (9.6±3.1 mm; p<0.01) medially compared to the healthy group. From 0° to 70° flexion, CPs moved 8.1±5.3 mm and 8.9±5.3 mm posteriorly on the medial and lateral plateaus of healthy knees; while in OA joints CPs moved 10.1±8.4 mm and 3.6±2.8 mm posteriorly. The average minimum tibio-femoral bone-to-bone distances of the OA joints were lower in both compartments (p<0.01).The CPs in the OA joints were located more medially and displayed a higher ratio of medial to lateral posterior translations compared to healthy joints.     

Changes in force and tendinous tissue elongation during the early phase of tetanic summation in in vivo human tibialis anterior muscle

The purpose of this study was to determine the changes that occur in tendinous tissue properties during the early phase of tetanic summation in the in vivo human tibialis anterior muscle (TA). The torque response and tendinous tissue elongation following single stimuli, two-pulse trains, and three-pulse trains were recorded in the TA during isometric contractions. The elongation, compliance, and lengthening velocity of tendinous tissue were determined by real-time ultrasonography. The contribution of the response to the second stimulation (C2) was obtained by subtracting the response to the single stimulation (C1) from the response of doublet. The third contribution (C3) was obtained by subtracting the response to the doublet from that of the triplet. C2 (7.8±0.5 Nm) and C3 (7.3±0.6 Nm) had torque responses significantly higher than C1 (3.6±0.7 Nm). In contrast, the elongations of tendinous tissue for C2 (2.8±0.4 mm) and C3 (1.7±0.2 mm) were significantly lower than for C1 (4.9±0.3 mm), indicating that the summation pattern of tendinous tissue elongation is different from the summation pattern of torque response. In addition, this showed considerable difference both between C1 (0.12±0.01 mm/N; 83±4.6 mm/s) and C2 (0.03±0.005 mm/N; 50±6.3 mm/s) and between C1 and C3 (0.02±0.002 mm/N; 39±6.4 mm/s) in the compliance and lengthening velocity of tendinous tissue. These results suggest that changes in tendinous tissue properties between first and second contraction are related to different summation patterns of force and tendinous tissue elongation during early phase of tetanic summation.     

Lower limb joint work and joint work contribution during downhill and uphill walking at different inclinations

Work performance and individual joint contribution to total work are important information for creating training protocols, but were not assessed so far for sloped walking. Therefore, the purpose of this study was to analyze lower limb joint work and joint contribution of the hip, knee and ankle to total lower limb work during sloped walking in a healthy population. Eighteen male participants (27.0 ± 4.7 yrs, 1.80 ± 0.05 m, 74.5 ± 8.2 kg) walked on an instrumented ramp at inclination angles of 0°, ±6°, ±12° and ±18° at 1.1 m/s. Kinematic and kinetic data were captured using a motion-capture system (Vicon) and two force plates (AMTI). Joint power curves, joint work (positive, negative, absolute) and each joint’s contribution to total lower limb work were analyzed throughout the stance phase using an ANOVA with repeated measures. With increasing inclination positive joint work increased for the ankle and hip joint and in total during uphill walking. Negative joint work increased for each joint and in total work during downhill walking. Absolute work was increased during both uphill (all joints) and downhill (ankle & knee) walking. Knee joint contribution to total negative and absolute work increased during downhill walking while hip and ankle contributions decreased. This study identified, that, when switching from level to a 6° and from 6° to a 12° inclination the gain of individual joint work is more pronounced compared to switching from 12° to an 18° inclination. The results might be used for training recommendations and specific training intervention with respect to sloped walking.     

Ultrasonographic imaging of the reproductive tract and surgical recovery of oocytes in Cebus apella (capuchin monkeys)

Two-dimensional real-time and Doppler ultrasonography are valuable non-invasive methods to assess reproductive anatomy and physiology. In adult, postpubertal female Cebus apella (capuchin monkeys), the objectives were to determine (1) uterine and ovarian dimensions, ovarian follicular dynamics, day of ovulation, and arterial blood flow of uterus and utero-ovarian ligament during the follicular phase of the menstrual cycle and (2) the number of oocytes aspirated from antral follicles at laparotomy. Based on two-dimensional, transabdominal B-mode ultrasonography, mean (± S.E.M.) length, height, width, and volume of the uterus were 17.9 ± 0.4, 12.4 ± 0.3, 13.6 ± 0.3 mm, and 1.55 ± 0.08 mL, respectively, and of the ovary were 13.4 ± 0.2, 8.2 ± 0.1, 7.7 ± 0.1 mm, and 4.5 ± 0.2 mL. Ovarian follicles were monitored for 6 days before ovulation, which occurred on day 9.3 ± 0.5 (range, days 7–11; day 1 = start of menses), with 10 of 12 ovulations in the right ovary. Diameter and volume of the preovulatory follicle were 10.1 ± 0.2 mm and 0.55 ± 0.03 mL (on the estimated day of ovulation) and of the CL were 8.1 ± 0.4 mm and 0.3 ± 0.05 mL. Resistivity and pulsatility indices were 0.86 ± 0.02 and 2.15 ± 0.11 for uterine arteries, and were 0.69 ± 0.04 and 1.63 ± 0.15 for the utero-ovarian ligament (UOL) artery; just prior to ovulation, both indices peaked (P < 0.05) in the uterine artery ipsilateral to the side of ovulation, but both reached a nadir (P < 0.05) in the UOL artery. In the absence of ovarian stimulation, 31 oocytes (diameter, 137 ± 10 μm) were aspirated (average of 2 oocytes/(female attempt)) on days 5, 7, and 9. In conclusion, transabdominal ultrasonography facilitated assessment of reproductive anatomy and physiology in C. apella adult females. Resistance and pulsatility indices of uterine and UOL arteries changed near the time of ovulation. Dominant follicles were easiest to aspirate at 8–9 mm in diameter (∼day 9), with intact cumulus-oocyte complexes recovered from ovarian follicles 2–9 mm in diameter.     

Glenohumeral joint kinematics measured by intracortical pins,reflective markers,and computed tomography: A novel technique to assess acromiohumeral distance

Combination of biplane fluoroscopy and CT-scan provides accurate 3D measurement of the acromiohumeral distance (AHD) during dynamic tasks. However, participants performed only two and six trials in previous experiments to respect the recommended radiation exposure per year. Our objective was to propose a technique to assess the AHD in 3D during dynamic tasks without this limitation. The AHD was computed from glenohumeral kinematics obtained using markers fitted to pins drilled into the scapula and the humerus combined with 3D bone geometry obtained using CT-scan. Four participants performed range-of-motion, daily-living, and sports activities. Sixty-six out of 158 trials performed by each participant were analyzed. Two participants were not considered due to experimental issues. AHD decreased with arm elevation. Overall, the smallest AHD occurred in abduction (1.1 mm (P1) and 1.2 mm (P2)). The smallest AHD were 2.4 mm (P1) and 3.1 mm (P2) during ADL. It was 2.8 mm (P1) and 1.1 mm (P2) during sports activities. The humeral head greater and lesser tuberosities came the nearest to the acromion. The proposed technique increases the number of trials acquired during one experiment compared to previous. The identification of movements maximizing AHD is possible, which may provide benefits for shoulder rehabilitation.     

Measurement of clavicular length and shortening after a midshaft clavicular fracture: Spatial digitization versus planar roentgen photogrammetry

Purpose: Clavicular shortening after fracture is deemed prognostic for clinical outcome and is therefore generally assessed on radiographs. It is used for clinical decision making regarding operative or non-operative treatment in the first 2 weeks after trauma, although the reliability and accuracy of the measurements are unclear. This study aimed to assess the reliability of roentgen photogrammetry (2D) of clavicular length and shortening, and to compare these with 3D-spatial digitization measurements, obtained with an electromagnetic recording system (Flock of Birds). Patients and methods: Thirty-two participants with a consolidated non-operatively treated two or multi-fragmented dislocated midshaft clavicular fracture were analysed. Two observers measured clavicular lengths and absolute and proportional clavicular shortening on radiographs taken before and after fracture consolidation. The clavicular lengths were also measured with spatial digitization. Inter-observer agreement on the radiographic measurements was assessed using the Intraclass Correlation Coefficient (ICC). Agreement between the radiographic and spatial digitization measurements was assessed using a Bland–Altman plot. Results: The inter-observer agreement on clavicular length, and absolute and proportional shortening on trauma radiographs was almost perfect (ICC > 0.90), but moderate for absolute shortening after consolidation (ICC = 0.45). The Bland–Altman plot compared measurements of length on AP panorama radiographs with spatial digitization and showed that planar roentgen photogrammetry resulted in up to 37 mm longer and 34 mm shorter measurements than spatial digitization. Conclusion: Measurements of clavicular length on radiographs are highly reliable between observers, but may not reflect the actual length and shortening of the clavicle when compared to length measurements with spatial digitization. We recommend to use proportional shortening when measuring clavicular length or shortening on radiographs for clinical decision making.     

Concordance of the location of the innervation zone of the tibialis anterior muscle using voluntary and imposed contractions by electrostimulation

Background: The innervation zone (IZ) corresponds to the location of the neuromuscular junctions. Its location can be determined by using arranged surface linear electrode arrays. Typically, voluntary muscle contractions (VC) are used in this method. However, it also may be necessary to locate the IZ under clinical conditions such as spasticity, in which this type of contraction is difficult to perform. Therefore, contractions imposed by electrostimulation (ES) can be an alternative. There is little background comparing the locations of IZ obtained by two different types of contractions. Objective: Evaluate the concordance between using voluntary and imposed contractions from electrostimulation in order to determine the location of the innervation zone of the tibialis anterior muscle in healthy volunteers. Methods: The tibialis anterior (TA) muscle of sixteen volunteers (men: 8; women: 8; age: 22.1 ± 1.4 years, weight: 61.6 ± 7.5 kg, height: 167.1 ± 7.5 cm) were evaluated using a linear electrode array. The IZ of the TA muscle was located using two types of muscle contractions, voluntary (10% MVC) and imposed contractions by ES. The concordance between both conditions was evaluated using the Bland–Altman method and the concordance correlation coefficient (CCC). The analyses were applied to the absolute and relative positions to the length of an anatomical landmark frame. Results: CCC for absolute position was 0.98 (p < 0.0001, 95% CI [0.98–1.00], and CCC for relative positions also was 0.98 (p < 0.0001, 95% CI [0.97–1.00]). The Bland–Altman analysis for absolute data showed an average difference of −0.63 mm (SD: 4.1). Whereas, for adjusted data, the average difference was −0.20% (SD: 1.2). The power of the results, based on absolute data, was 98%, whereas for relative data, 82%. Conclusion: In healthy volunteers, there was a substantially concordance between the location of the IZ of the TA muscle derived from using contractions imposed by ES and the location derived from using VC.     

Voluntary activation of the trapezius muscle in cases with neck/shoulder pain compared to healthy controls

Subjects reporting neck/shoulder pain have been shown to generate less force during maximal voluntary isometric contractions (MVC) of the shoulder muscles compared to healthy controls. This has been suggested to be caused by a pain-related decrease in voluntary activation (VA) rather than lack of muscle mass. The aim of the present study was to investigate VA of the trapezius muscle during MVCs in subjects with and without neck/shoulder pain by use of the twitch interpolation technique.Ten cases suffering from pain and ten age and gender matched, healthy controls were included in the study. Upper trapezius muscle thickness was measured using ultrasonography and pain intensity was measured on a 100 mm visual analog scale (VAS). VA was calculated from five maximal muscle activation attempts. Superimposed stimuli were delivered to the accessory nerve at peak force and during a 2% MVC following the maximal contraction.Presented as mean ± SD for cases and controls, respectively: VAS; 16.0 ± 14.4 mm and 2.1 ± 4.1 mm (P = 0.004), MVC; 545 ± 161 N and 664 ± 195 N (P = 0.016), upper trapezius muscle thickness; 10.9 ± 1.9 mm and 10.4 ± 1.5 mm (P = 0.20), VA; 93.6 ± 14.2% and 96.3 ± 6.0% (P = 0.29).In spite of significantly eight-fold higher pain intensity and ∼20% lower MVC for cases compared to controls, no difference was found in VA. Possible explanations for the reduction in MVC could be differences in co-activation of antagonists and synergists as well as muscle quality.     

Translational and rotational localization errors in cone-beam CT based image-guided lung stereotactic radiotherapy

PurposeAccurate localization is crucial in delivering safe and effective stereotactic body radiation therapy (SBRT). The aim of this study was to analyse the accuracy of image-guidance using the cone-beam computed tomography (CBCT) of the VERO system in 57 patients treated for lung SBRT and to calculate the treatment margins.Materials and methodsThe internal target volume (ITV) was obtained by contouring the tumor on maximum and mean intensity projection CT images reconstructed from a respiration correlated 4D-CT. Translational and rotational tumor localization errors were identified by comparing the manual registration of the ITV to the motion-blurred tumor on the CBCT and they were corrected by means of the robotic couch and the ring rotation. A verification CBCT was acquired after correction in order to evaluate residual errors.ResultsThe mean 3D vector at initial set-up was 6.6 ± 2.3 mm, which was significantly reduced to 1.6 ± 0.8 mm after 6D automatic correction. 94% of the rotational errors were within 3°. The PTV margins used to compensate for residual tumor localization errors were 3.1, 3.5 and 3.3 mm in the LR, SI and AP directions, respectively.ConclusionsOn-line image guidance with the ITV–CBCT matching technique and automatic 6D correction of the VERO system allowed a very accurate tumor localization in lung SBRT.