The image intensifier is an essential part of orthopaedic trauma surgery. The Image Intensifier can move in a number of planes and has to be positioned accurately. Frustration arises in the surgeon, the radiographer and the rest of the theatre staff when the image intensifier is moved in the wrong direction and there are also increased radiation hazards to all involved if unnecessary x-rays are taken due to incorrect positioning. Communication between the surgeon and the radiographer lies at the heart of safe practice. A questionnaire was designed and circulated to all the radiographers using the image intensifier and to orthopaedic surgeons including consultants, SpRs in London southwest deanery and SHOs of St George’s Hospital, London. They were then asked to write descriptors on a diagram illustrating the major movements of the image intensifier (Vertically up/down, to the patients left/right and head/feet). The questionnaires were completed by 32 radiographers and 48 surgeons (8 consultants, 33 registrars and 7 SHOs). There was very little consensus either within or between the groups as to what command should be used for which direction. A set of directions was agreed upon and put on image intensifier machine. When used these produced a significant reduction in misunderstood commands Confusion abounds when directing the Image Intensifier. When a set of directions can be agreed upon stress reduces and satisfaction improves although it is difficult to measure the reduction in radiation exposure

We describe a method of closed, unlocked nailing for femoral fractures using ultrasound instead of an image intensifier. Radiography was used only to confirm that the guide wire had been passed into the intramedullary canal of both fragments. The method succeeded in 26 of 30 cases. The failures all occurred in fractures which could not be reduced within 20 minutes. The operating time in those nailed successfully with ultrasound control was not different from the time for 30 control cases using conventional methods with an image intensifier

Introduction: Image Intensifier screening is commonly utilised in orthopaedic theatres. There has been concern regarding the cumulative radiation dose to surgeons and theatre personnel. The mini C-arm intensifier has been reported to scatter less radiation and have a reduced radiation dose to patient and theatre staff. Material and Methods: 2 month prospective survey of usage of radiographer-operated large intensifier and surgeon-operated mini C-arm image intensifier in a district general hospital orthopaedic theatre department. Results: 153 cases required image intensifier screening. 63% used the large intensifier and 37% the mini c-arm intensifier. The complication rate for the large intensifier was 16%. There were delays in 11% of cases using the large intensifier. The total radiographer attendance time was 123 hours. For the mini C-arm intensifier there were no complications or delays. The minimum radiographer time saved by using this machine was 21.9 hours. Conclusion: The mini C-arm intensifier has saved 15% of the radiographer workload with its current pattern of usage in our department. There have been no complications or delays as a result of its usage in theatres. Other departments are encouraged to consider acquisition of such a machine to facilitate theatre throughput and reduce demands on the radiology department

Background. Paediatric pelvic corrective surgery for developmentally dysplastic hips requires that the acetabular roof is angulated to improve stability and reduce morbidity. Accurate bony positioning is vital in a weight-bearing joint as is appropriate placement of metalwork without intrusion into the joint. This can often be difficult to visualise using conventional image intensifier equipment in a 2D plane. Methods. The ARCADIS Orbic 3D image intensifier produces CT-quality multi-axial images which can be manipulated intra-operatively to give immediate feedback of positioning of internal fixation. The reported radiation dose is 1/5 and 1/30 of a standard spiral CT in high and low quality modes, respectively. Results. We present 15 elective cases of paediatric pelvic osteotomy and fixation of SUFE, with use of the ARCADIS Orbic 3D image intensifier. Images were taken intra-operatively in order to confirm satisfactory fracture reduction and appropriate positioning of fixation devices avoiding joint spaces. This was achieved by 3D reconstruction and review of the surgical field in theatre. In all of the cases appropriate bony placement and position of fixation devices was demonstrated in the multi-axial images and 3D reconstruction. Conclusions. The use of 3D image intensification is a novelty in the UK. Our results suggest that the 3D image intensifier is a valuable aid in the field of paediatric surgery. Accurate positioning of internal fixation devices can be confidently confirmed ‘on-table’. The radiation dose is also significantly less than a standard spiral CT

Aim: To evaluate intraoperative use of the Mini C-Arm compared with standard X-ray image intensification. Method: Radiation exposure data was collected for patients undergoing orthopaedic operative procedures. Data was collected over a 3 month period using a standard Siemens Siremobil 2000 X-Ray image intensifier (175 procedures) and also from a new smaller surgeon– operated Vertec Fluoroscan X-Ray image intensifier (144 procedures). Skin entrance radiation dose was calculated for the procedures with each X-ray unit. Results: There were sufficient numbers of wrist procedures to permit comparison of the X-ray units. The skin entrance dose of radiation was calculated and found to be lower for all procedures with the surgeon-operated X-ray unit. Discussion: New, small surgeon-operated X-ray image intensifiers are now available and are safer for theatre staff due to reduced X-ray beam scatter. These X-ray units remove the need for a radiographer to be present in theatre. This is also of importance as staff shortages in radiography persist. Conclusion: Surgeon-operated X-ray image intensification is safe and convenient in the orthopaedic operating theatre without increasing radiation exposure

Introduction. The Patient Archiving and Communication System (PACS) has revolutionised the way that radiographs are stored and viewed in orthopaedic surgery. A recent advance has been the ability to upload images directly from the image intensifier to PACS. We postulated that this facility may reduce the need for post operative ‘check’ radiographs following many orthopaedic trauma procedures. Patients and Method. We performed an audit of post-operative radiographs requested in our University Hospital over three time periods: 31 days immediately before the direct upload facility was introduced, 31 days immediately after and a 31 day period two months later. Details from the operating lists were cross-referenced with image intensifier records to identify cases where it had been used. PACS records were then checked to determine if these images were available to view and if a formal ‘check’ radiograph was performed in the period prior to discharge. Results. A total of 624 orthopaedic trauma operations were reviewed. In the period before direct-upload of images began, 62% of all trauma procedures utilised the image intensifier and in 26% post-operative ‘check’ radiographs were taken. In the period immediately after uploading began, the image intensifier was used in 66% of cases with 84% of these images being uploaded. Fifteen percent of the patients had a check radiograph during this period. Two months later the image intensifier was used in 67% of cases. Although 96% of these images were uploaded, 14% still had a formal post-operative radiograph. Conclusion. The facility to upload images from the image intensifier in the operating theatre directly onto the PACS system has reduced the number of post-operative ‘check’ radiographs requested in our trauma department by 11%. This has reduced both the cost and radiation exposure involved in orthopaedic trauma surgery but has not eliminated the need for post-operative radiographs completely

Introduction: Radiation dose exposure to patients in a main X-ray department in a hospital is well documented and controlled. Few studies report the radiation exposure to patients undergoing spinal surgery received from an image intensifier. There are no recommended doses published when using the image intensifier. Methods: We reviewed the radiation doses and exposure times from computer and radiation log records of all the patients who underwent trauma & orthopaedic surgery which required an image intensifier between January and September 2005. The Dose-Area-Product (Gray/cm2) and screening time was recorded. Results: More than 600 patients underwent trauma & orthopaedic surgery that required an image intensifier at the time of surgery. The mean screening Dose Area Product of the patients undergoing spinal surgery and other common procedures are shown (Gray/cm2):- Lumbar fusion – 23. Disc replacement – 10. Discogram – 4.9. Foraminal injection – 4.4. DHS – 1.86. IMHS – 1.33. ORIF Ankle – 0.89. MUA k-wire wrist – 0.04. The four surgical procedures which required the most radiation were spinal procedures. The maximum radiation is given to patients undergoing lumbar spinal fusion. Conclusion: Patients undergoing spinal surgery can receive as much radiation exposure as those undergoing procedures such as barium swallow or standard lumbar spine films. Efforts should be made to reduce radiation exposure to orthopaedic patients, and operating surgeons especially those undergoing spinal surgery. By publishing our radiation exposure doses, we can begin to establish guidelines for recommended patient doses

We wish to draw attention to the potential dangers of using the C-arm radiolucent plate of an image intensifier as an operating table

The International Commission on Radiological Protection has established standards for radiation protection. This study aims to determine actual and perceived radiation dose and audit safe practice when using image-intensifiers in theatre.

Between September 2012 and March 2013, 50 surgeons were surveyed during 39 procedures. Information collected by radiographers included the number of images the surgeons thought they used, actual number used, dose, screening time, number of people scrubbed, wearing thyroid collars and standing within 1m of the image-intensifier when in use.

The primary surgeon was more likely to estimate the number of images used correctly compared to the assistant. Supervising consultants were most accurate, followed by registrars as primary surgeons, consultants as primary surgeons then assisting registrars, and lastly SHOs. Most surgeons underestimated the number of images used. 87.5% of scrubbed staff were standing within 1m of the image-intensifier during screening and 36.5% were wearing thyroid protection. Three surgeons stated they were not wearing collars as they were unavailable.

We conclude that surgeons have a reasonable estimation of the x-rays used but are not undertaking simple steps to protect themselves from radiation. We plan to initiate an education program within the department and have ordered new, lightweight thyroid collars.

Introduction: Preoperative use of tomodensitometry is a common practice when assessing fractures with intraarticular involvement, helping to determine the most appropriate surgical approach according to the lesions observed. To date, during the surgical procedure itself, radiographical or fluoroscopic controls still largely rely on two dimensions X rays. We assessed the possible benefits of intraoperative tridimensional reconstructions using mobile isocentric fluoroscopy (iso-C-3D) after one year of use.

Material and Methods: All the procedures where intra-operative tridimensional fluoroscopy was used were assessed prospectively for one year. The type of osteosynthesis as well as specific modalities of installation and therapeutic measures driven from analysis of the images were analyzed.

Results: During the first year of use, intraoperative tridimensional reconstruction had been carried out in 48 procedures in 47 patients. The region involved was calcaneus 13 times, thoracolumbar spine 12 times, acetabulum 11 times, tibial condyles 9 times, axis 2 times and pelvis one time. Installation was the same than usually performed in the cases of calcaneus and axis osteosynthesis. For the other localisations, obtention of good quality images was facilitated through the use of a carbon table for spine and osteosynthesis of the tibial condyles, and through the use of a carbon traction table for acetabular or pelvic fractures. Intraoperative tridimensional reconstruction allowed to check for freedom of the vertebral canal after reduction and osteosynthesis of the spine. in the cases of fracture of the calcaneus, reduction of one thalamic fragment was improved in one case and one intraarticular screw could be changed in another case. In the case of acetabular surgery, one screw stabilizing the posterior wall was found intraarticular on tridimensional reconstruction and could be changed before closure.

Discussion: Intraoperative tridimensional reconstruction, during its first year of use, allowed to avoid 3 early reinterventions (for 2 calcaneus and one acetabulum). Accurate interpretation of standard plain X ray in these two localizations is difficult because of the spherical shape of the hip joint and because good quality imaging, especially the retrotibial view, is hardly obtained intraoperatively in fractures of the cacaneus. When using tridemensional reconstructions, acquisition of good quality images has to be anticipated during the installation of the patient, limiting any interfereces with metallic supports to a minimum.

Conclusion: the results obtained over the first year of use of intraoperative tridimensional reconstructions with the ISO-C-3D encouraged the authors to generalize its use when performing osteosynthesis of the acetabulum or calcaneus as well as percutaneus osteosynthesis of articular fractures.

Aims

The use of fluoroscopy in orthopaedic surgery creates risk of radiation exposure to surgeons. Appropriate personal protective equipment (PPE) can help mitigate this. The primary aim of this study was to assess if current radiation protection in orthopaedic trauma is safe. The secondary aims were to describe normative data of radiation exposure during common orthopaedic procedures, evaluate ways to improve any deficits in protection, and validate the use of electronic personal dosimeters (EPDs) in assessing radiation dose in orthopaedic surgery.

Introduction. The vast majority of orthopaedic surgeons use C-arm fluoroscopy in the operating theatre when building a circular external fixator. In the absence of previous research in this area, we hypothesised that the surgeon who builds a circular external fixator is exposed to a greater amount of radiation purely as a result of the presence of the metallic fixator in the x-ray beam. The aim of our study therefore was to investigate how the presence of a circular external fixator affects the radiation dose to the surgeon and the surgical assistant. Materials & Methods. A simulated environment was created using a radiolucent operating table, an acrylic lower limb phantom (below knee segment), various configurations of metalic circular external fixation, and a standard size C-arm image intensifier. The variables investigated were 1. the amount of metal in the beam 2. the orientation of the beam (PA vertical vs lateral) 3. the horizonal distance of the person from the beam (surgeon vs assistant) and 4. the vertical distance of the various body parts from the beam (e.g. thyroid, groin). In terms of radiation dose, we recorded two things : 1. the dose produced by the image intensifier 2. the dose rate at standardised positions in the operating theatre. The latter was done using a solid-state survey sensor. These positions represented both where the surgeon and surgical assistant typically stand plus the heights of their various body regions relative to the operating table. Results. The effect of the presence of the circular external fixator : all frame constructs tested resulted in a statistically significant greater radiation dose both produced by the image intensifier and received by the surgical team. The effect of the beam orientation : the PA (vertical) orientation resulted in a statistically significant greater radiation dose for the surgeon than did the lateral orientation, but made no difference for the assistant. The effect of horizontal distance from the beam : unsurprisingly, the surgeon (who was closer to the beam) received a statistically significant greater radiation dose than the assistant. The effect of vertical distance from the beam : for the surgeon, the dose received was highest at the level of the phantom leg / frame, whilst for the assistant there was no statistically significant difference for any level. Conclusions. To our knowledge, this is the first study investigating the radiation dose rate to the orthopaedic surgeon when building a circular external fixator. We found that the surgeon does indeed receive a ‘double whammy’ because the image intensifier puts out a greater amount of radiation plus the metalic frame scatters more of the x-ray beam. Whilst the amounts are relatively small, we think that it's important to quantify doses that orthopaedic surgeons receive to ensure optimal radiation practices

Intra-articular punctures and injections are performed routinely on patients with injuries to and chronic diseases of joints, to release an effusion or haemarthrosis, or to inject drugs. The purpose of this study was to investigate the accuracy of placement of the needle during this procedure. A total of 76 cadaver acromioclavicular joints were injected with a solution containing methyl blue and subsequently dissected to distinguish intra- from peri-articular injection. In order to assess the importance of experience in achieving accurate placement, half of the injections were performed by an inexperienced resident and half by a skilled specialist. The specialist injected a further 20 cadaver acromioclavicular joints with the aid of an image intensifier. The overall frequency of peri-articular injection was much higher than expected at 43% (33 of 76) overall, with 42% (16 of 38) by the specialist and 45% (17 of 38) by the resident. The specialist entered the joint in all 20 cases when using the image intensifier. Correct positioning of the needle in the joint should be facilitated by fluoroscopy, thereby guaranteeing an intra-articular injection

Surgical treatment of pelvic injuries is one of the most challenging tasks in trauma surgery. Intra-operative two-dimensional imaging technology can often not cope with the complex requirements of the three-dimensional anatomy of the pelvis. A registration, which is difficult to achieve with minimal invasive techniques, is obligatory for the CT-based navigation. Changes in the reduction can only be visualized inadequately. The intra-operative imaging after completed osteosynthesis has significantly enhanced since the introduction of three-dimensional image amplifiers. The three-dimensional data can be used directly for the visualization of the osteosynthesis material by linking it to a navigation system. Since January 2001 the Trauma Center Ludwig-shafen has the ability to perform the registration-free three-dimensional navigation by linking the 3D image intensifier to a navigation system. From January 2002 to January 2005 30 patients with a pelvic injury, where the intra-operative navigation was carried out with the 3D image intensifier, were included in a prospective study. A complete neurological status, conventional fluoroscopic diagnosis, and CT-images were available pre-operatively for all patients. This information formed the basis for the classification and indication for surgery. Patients were positioned on a metal-free carbon table. Due to the registration-free navigation, and thus without the need for a manual registration of landmarks, a tissue-saving preparation could be performed. The postoperative assessment of the implant position was carried out by an independent radiologist. Screw placement on the pelvic ring was performed in 23 patients (IS lag screws), in 3 patients on both sides. Periacetabular screws were implanted in 7 patients with acetabular fractures. A prerequisite was that the closed repositioning and a temporary fixation could be carried out before the recording of the 3D dataset. 7 surgeons participated in this study. The 3D image intensifier and the navigation system were always operated by the same person. In total 66 screws were implanted (49 IS screws, 17 periacetabular screws). One misplacement of a IS screw with a penetration of the neuroforamen was found during post-operative check-ups. The screw position was corrected during revision surgery. The mean fluoroscopy time for the recording of the 3D scans and the 2D check-ups was 1.78 (+/− 0.4) min. The mean operating time was 105 (+/− 24) min. This prospective study demonstrated the clinical use of navigation in a three-dimensional dataset from the 3D image intensifier with automatic registration on the pelvis. A relatively high misplacement ratio during IS lag screw placement in the traditional, percutaneous technique according to Matta up to 30% is described in literature. The 3D image intensifier navigation facilitates a standardized working process in the operating room. This is reflected in the low range in fluoroscopy and operating time. The limiting factor in pelvic surgery is the relatively small image volume of the 3D image intensifier of 12 cm3 and the low image quality compared to a CT

Background. The use of a knotless TightRope for the stabilisation of a syndesmotic injury is a well-recognised mode of fixation. It has been described that the device can be inserted using a “closed” technique. This presents a risk of saphenous nerve entrapment and post-operative pain. Aim. We aimed to establish the actual risk of injury to the Saphenous Nerve using a “closed” technique for the insertion of a TightRope. Method. 20 TightRopes were inserted into Fresh Frozen Cadavers. This was done using the senior authors preferred technique of divergent tightropes with the distal implant directed slightly anterior to the fibula-tibia axis and the proximal implant slightly posterior in order to simulate the greatest risk to the nerve. This was done under image Intensifier guidance to simulate an intraoperative environment. The medial side of the distal tibia was then dissected to directly record and measure the relationship of the TightRope to the Saphenous Nerve. Measurements were taken using digital calipers from the centre of the button on the medial side of the TightRope to the centre of the nerve at the point of closest proximity. Results. 12 TightRopes were found to exit posterior to the nerve, 7 anterior and 1 penetrated through the centre of the nerve. The mean distance from the centre of the button to the nerve was 6.99mm (range 0.72–14.52mm, standard deviation 4.33mm). In 9 of the 20 TightRopes, the nerve was found to be less than 5mm away. Conclusion. Our findings demonstrated that the risks of damaging or indeed entrapping the Saphenous nerve were high, and therefore we would advocate an open incision on the medial side with judicious exploration to ensure there is no damage to the medial neurological structures