Aim. With the current wave of enthusiasm for internal fixation with volar locking plates in the treatment of distal radial fractures, radiology of the wrist needs review. With current standardised x-rays of the wrist there is often an appearance of intra-articular screws. This is on account of the objective of getting very distal subchondral fixation and fixation into the radial styloid. As a consequence, due to the volar tilt and radial inclination of the ‘anatomic’ wrist, fixation is often perceived and reported to be intra-articular. It is proposed in this study that ‘standard’ wrist x-rays post-internal fixation be taken with 20° elbow flexion on the lateral view to counteract radial inclination. The postero-anterior view should be angled 10° to view the joint without the effect of normal radial tilt. Method and Materials. 30 consecutive wrists treated by fixed angled volar fixation were analysed. In each case standard x-rays and the proposed ‘20, 10’ radiographs were obtained. The ‘20, 10’ x-rays were taken with a custom-made set of bolsters set at 20° and 10° for the Lateral and PA views. Each set of x-rays (a standard PA and lateral and the so called ‘20, 10’ proposed radiographs) were commented on by 2 Radiologists and 2 Orthopaedic Surgeons. Results. It would appear that in both the Radiologists' and Orthopaedic surgeons' reports there was a higher degree of confidence in reporting on the 20, 10 views than on the standard views. In just over 50% of cases standard views had the appearance of intra-articular fixation while this perception was disproven with the newly proposed 20, 10 views. The correlation between Radiologist and Orthopaedic Surgeon reports was almost 100%. Conclusion. With the current trend to volar wrist fixation we should adapt our radiology protocols. We propose 20, 10 angled x-rays as standard for post-operative wrist radiology

Neck of femur fractures are a common presentation and certain patients can be managed with a total hip replacement. To receive a total hip replacement the pelvic X-rays should be templated as per AO guidelines and a common way this is performed is by including a calibration marker on the X-ray. The aim of this study is to assess and improve upon the use of the calibration marker. Details of patients admitted with a neck of femur fracture from January 1st 2018 until December 31st 2018 were gathered and used to review each initial X-ray and determine if a calibration marker was included. 376 patients were admitted with a neck of femur fracture over the one year period. 36% of patients did not have a calibration marker on their initial pelvic X-ray and 11% did not have a chest X ray. 215 patients had an intracapsular fracture and 39 went on to have a total hip replacement. 12 patients were lacking a calibration marker on their original X ray and required a repeat X ray. After a poster was placed in the radiographer booth acting as a visual aid, the use of a calibration marker improved from 62% to 70%. Calibration markers are useful tools which can aid the pre-operative planning for hip replacement surgeries shortening operative time, increase precision and reduce prosthetic loosening, lowers the risk of peri-prosthetic fractures, reduce leg length discrepancy and ensure the required implants are available. If a marker is not included on the initial X-rays, and a patient has a neck of femur fracture which requires a joint replacement, they may have to have additional X-rays performed as was the case for 12 patients in this study. This process leads to possible delays in surgery, additional radiation and increased healthcare costs

Purpose: According to the Ottawa rules, x-rays are not needed after knee trauma unless one or more of the following clinical criteria are present: age over 55 years, pain at palpation of the head of the fibula, pain at palpation of the anterior aspect of the patella, impossible knee flexion beyond 90°, inability to walk four steps immediately after trauma and at the emergency consultation. We conducted a prospective study in a consecutive series of patients to check the validity of this rule in daily practice. Materials and methods: From December 2001 to January 2002, we included all patients consulting in an emergency situation for recent trauma involving only the knee joint. We excluded patients aged less than ten years, wounds without trauma, trauma more than two days before consultation, and patients with a history of trauma involving the same knee. An emergency physical exam was performed in all cases with identification of the study criteria. Standard x-rays (AP and lateral view in the supine position) were obtained for all patients. The patients and the x-rays were seen later by a senior orthopaedic surgeon and a senior radiologist who noted the presence of fracture requiring specific therapeutic management. The sensitivity, specificity and positive and negative predictive values of the Ottawa rule were determined for search for fracture. Results: One hundred thirty-eight patients met the inclusion criteria during the study period. The sensitivity and negative predictive value of the Ottawa rule were 100%; the specificity was 36%, and the positive predictive value was 25%. Nineteen fractures (14%) requiring specific therapeutic management were identified: all patients had at least one positive sign. Seventy-six patients (55%) without fracture had at least one positive sign. Forty-three patients (31%) without fracture did not have any positive sign. The x-rays were not contributive for these patients. Discussion and conclusion: This study demonstrated the validity of the Ottawa rule in the clinical setting of our practice. With widespread use of this rule, approximately one-third of the x-rays performed for recent trauma involving the knee alone could be avoided

THA continues to improve but complications still occur. Improper restoration of hip mechanics can lead to a number of clinical problems: increase in leg length, soft tissue laxity, weakness of the abductors, mechanical impingement, increase of wear and improper implant sizing can lead to thigh pain, subsidence and hip dislocation. Six-hundred-and-fifty-five primary cementless THA were performed over the past twenty-four years by the senior author at two hospitals. Three different stems were used, two being modular and one being monoblock. A variety of cups head sizes and bearing material were used. All cups were implanted cementless. All surgeries were performed with the posterior approach. Sixty percent of patients were female forty percent males. Majority of cases were for OA. Cup revisions have been the biggest problem to-date with excessive wear of the poly material. This is more than likely due to the first and second generation designs that had poor locking mechanics. Over the last four years since going to MOM technology cup revisions have not been seen. On the femoral side there have been no femoral lysis, five dislocations two treated closed and three open reductions treated with constrained sockets. Four stem revisions, all for late sepsis. There has been two recent aseptic loosening, and only one traumatic dislocation since going to large MOM heads. One was one post-op with an ASR MOM cup that had spun out of position of function and the second a week later that was only six weeks post-op and came in for her first post-operative visit. Routine use of intra-operative x-rays has resulted in +80% decision on fine-tuning of implant sizing by either increasing stem size and or femoral offset. Intra- operative x-rays provide valuable assistance and allow full advantage of the features and benefits of stem modularity reducing post-operative complications

Introduction. Digital x-rays on computer screens are difficult to template due to the lack of standardized magnification. This can be overcome by the use of markers placed onto or next to the patient but have certain shortcomings. Trochanteric marker placements are operator dependant and very difficult to use in the obese patient. Inter- thigh markers are also operator dependent and often embarrassing for radiographer and patient. Anterior combined with posterior markers are very accurate (King et al) but can only be used with a digital template system which is costly and time consuming. We would like to describe a new method of posterior bar markers that are easy to use with standard hip templates. Methods. Over a period of 30 months this method of templating was used on 296 primary total hip replacements. Fifty eight patients had a previous hip replacement with known head diameter which was used as a control to assess the accuracy of enlargement with this method. X-rays were taken of each patient as a standard supine AP of both hips with the patient lying on a marker ruler with 30mm metal bar markers. The X- rays are then loaded onto a PACS digital x-ray system for use in theatre. In theatre the X-rays are enlarged until the 30mm bar markers are enlarged to 31mm on a standard ruler which represents a 20% (as seen in patients with contralateral hip replacements) enlargement of the hip and standard 20% enlarged plastic templates can then be used to measure the neck resection level and assess implant size and offset. The patients with previous contralateral hip replacements were used as controls to evaluate the accuracy of this method by correlating the head size on the enlarged x-ray with the 20% enlarged ruler on the template. Results. This is an easy and reproducible method of taking marked x-rays in our radiology department and no time consuming software is necessary for this method. The level of neck resection differs for every hip with a range of 0–23 mm as measured from a point on the superior area of the femoral neck. In most cases (91%) the selected level of neck resection corresponded to correction of leg length and stability. The remaining cases needed an extra neck resection osteotomy of 1–4 mm. This method correlated well with the final implant size and offset in 97% of cases. Conclusion. The posterior bar marker method is a cheap and easy method to use when templating X-rays prior to hip replacement surgery and is as accurate as any other method without the problem of operator dependency. NO DISCLOSURES

Patients with osteoarthritis of the knee reviewed by the General practioners, are usually referred for further management to the orthopaedic surgeon. It was our observation that patients were usually referred with supine knee X-rays. This meant weight-bearing films were repeated at the clinic. Methods: We sent out questionnaires to GPs inquiring whether they asked for X-rays of the knee prior to patient referral and whether they asked for weight bearing films. We also reviewed the policy in one National Hospital Service trust and one teaching hospital with regards to GPs asking for weight bearing films. The time patients spent waiting at the X-rays department was noted. Finally we inquired about the cost of a knee X-ray. Results: A total number of 65 questionnaires were sent and the response was 44 i.e. 67%. 80% of the GPs asked for non weight bearing X-rays prior to referral. Only 5% asked for weight bearing films. The radiology departments of hospitals in one NHS trust and the teaching hospital did not accept weight bearing requests from GPs. The time taken for a patient to get an X ray in the department was at least 30 minutes and the cost of X rays of the knee was £51. With an average of two patients with osteoarthritis of the knee per clinic, the cumulative waiting time for repeated X-rays was 1 hr per clinic, 5 hrs per week and 240 hrs per year. With an average of two X rays per clinic the cumulative cost was £102 per clinic, £510 per week and £24480 per year. Discussion: Non weight bearing X-rays of the knee do not add any value in making or confirming a diagnosis of osteoarthritis yet they are costly both in terms of time and money. Weight bearing films were repeated for patients with these X-rays. The cumulative cost in terms of time can be better used to review other patients and therefore reduce the waiting time before surgeons can see referrals. The other issue is the cumulative cost which can be put to better use in the trust. The time wasted by the patients who have repeated X-rays was not considered, but is also of importance. Conclusion: Patients with osteoarthritis of the knee should have weight bearing films from the initial onset. This will save time for the patient and the surgeon and will save the hospital money

To assess if paediatric patients are getting adequate gonadal protection whilst undergoing pelvic X-rays. A retrospective study of 100 AP pelvic X-rays in 62 consecutive paediatric patients was performed. All children 16 years and under (mean = 8 years) who had an AP pelvic X-ray at our institution between 1. st. April 2004 and 1. st. July 2005 were included in the study. When reviewing the X-rays, the manufacturer’s guidelines for ideal shield size and position were strictly followed to assess whether adequate gonadal protection was being achieved (the lead shield must be completely covering the true pelvis in girls and the scrotum in boys). A subsequent questionnaire survey involving 20 radiographers was carried out. In 78 cases gonadal protection was inadequate. This was unrelated to the child’s age or sex. In 72 cases shield position and in 11 cases shield size was incorrect. The survey showed that 40% of radiographers believed that the gonadal shield was either difficult to use or had a poor design. Twenty percent felt they had received inadequate training. Gonadal shields reduce radiation exposure of the reproductive organs during pelvic X-rays. Many designs are available on the market but not all designs function adequately. Our study showed that a poor design of gonadal shield can cause unnecessary radiation exposure. We present this audit to make people aware of this poor design and recommend that a detailed market survey prior to buying such equipment and subsequent training of staff in its proper use must be carried out

Introduction. We investigated whether grey scale early ultrasonography could be used for the accurate initial diagnosis of non displaced occult scaphoid fractures. Methods. This is a prospective blind clinical study that includes 36 patients that came to the emergency room with suspected clinical symptoms for scaphoid fracture but negative initial X-ray's. After that, a high resolution ultrasonography (without Doppler) was performed. Both wrists of each patient were examined, for comparison. After 14 days, new X-rays were performed, which compared to the early sonographic results of the patients. Results. 25 out of the 36 patients that were included in the study found with subperiosteal hematoma, while 11 of them had also cortical discontinuity. Besides, follow-up X-rays were diagnostic of fracture in 22 patients. 7 patients were ultrasound-positive for fracture but their late X-ray's remained negative, while 4 patients were ultrasound-negative with positive X-ray's. We performed a CT scan on these 11 patients, where we found early ultrasound's sensitivity: 87.5%, specificity: 75%, positive prognostic value: 84% and negative prognostic value: 72%. On the other hand, late X-ray's had sensitivity: 87.5%, specificity: 91%, positive prognostic value: 95% and negative prognostic value: 78% in the detection of occult fractures. Conclusion. The use of early scaphoid ultrasound in the E.R. is valuable in the hands of the orthopaedic surgeon and decongests the radiology department and the national health system from further specific and expensive imaging studies. So, this examination offers the possibility to reduce the time of diagnosis of these occult fractures, so as to provide early and correct treatment. Level of Evidence. II

Introduction. The aim of this study was to assess whether routine X-Rays at six weeks altered the subsequent management of patients who underwent a Scarf osteotomy. Materials and Methods. Between 1997 and 2010, 218 consecutive primary scarf osteotomies of the first metatarsal were performed by two foot and ankle surgeons in a single unit. 71 were combined with an Akin closing wedge osteotomy of the proximal phalanx of the great toe and soft tissue release. Additional osteotomies were performed on the lesser toes in 30 cases. Intraoperative X-Rays were taken. We retrospectively looked at clinic letters for all patients who attended six weeks post operatively and recorded the outcomes following X-Rays. Results. 209 patients were assessed six weeks post operatively with radiographs of the foot. 9 patients were lost to follow up. Four patients (1.9%) were identified as having complications at the osteotomy: recurrence of deformity seen in two patients, delayed union with failure of fixation, and painless hypertrophic nonunion. Discussion. Only a very small proportion of patients developed complications at the osteotomy site following a Scarf osteotomy for hallux valgus. Both cases of recurrence were diagnosed clinically. Failure of fixation was due to poor patient compliance. No revision procedures were planned for any patients. Conclusion. The senior author no longer requests postoperative X-Rays routinely. We believe that the majority of patients may be safely and successfully assessed clinically following Scarf osteotomy without the need for routine X-Rays

The limiting factor in the growth of RSA as a wide spread clinical tool is the man-hours needed to run a study. Calibration takes more than half of the processing time. The aim of this study is to develop automatic calibration method applicable to the grid and line patterns common in all RSA systems. This method uses a Harris Corner detector to find candidate positions on an image one 16th the original area (16 times quicker). Canny edge detection in regions of interest around the candidate positions on the full size image produce circular edges for marker-balls. A conic section is fitted to this edge using the Bookstein method to produce an accurate estimation of position to a local accuracy of 0.01 mm. Scanner distortion was modeled using a stabilised B-spline mesh to produce global accuracy of 0.03mm. A model based pattern recognition method can be used to label the marker-balls correctly. For sets of 4 marker balls a Homography was calculated and used to predict the positions of the other points in the grid. If supporting marker-balls are found in the predicted positions, they are counted. The four-point set, which returns the greatest number of support marker-balls, is the best estimate of a grid. Reference markers in the grid are used to localise it. The method had a ninety- percent success rate on a set of 20 clinical X-rays. In two X-rays not enough marker-balls were visible due to a poor exposure. It finds marker-balls in a 15-MB image in 50 seconds on a 180 MHz silicon graphics O2. Labelling speed depends on the number of marker-balls and is 45 seconds per group of 50. This method is widely implementable, as it requires just the 3D positions of the markers in each plate of the calibration object for input

Introduction: While conventional acetate x-rays came at a fixed size and magnification, digital x-rays are freely scalable on the screen and thus must be individually calibrated for surgical measurements (templating). The standard technique is calibration by a reference object (ruler, ball, coin) to be placed into the x-ray. In clinical practice, x-rays are often taken without a calibration object, the object may be malpositioned or the bucky system’s objectfilm distance is unknown to scale with a fixed magnification. Thus calibration based on an anatomic dimension would be a useful alternative in clinical practice. In this study x-ray calibration using the femoral head diameter as derived by an anatomic formula is compared to the standard technique of using a calibration ball and acetate type fixed magnification. Methods: In a prospective study three calibration Methods: were applied to post-op AP digital x-rays of 42 patients (m/f=12/30, height: 151–185cm) following primary total hip arthroplasty (ABG-II, 28mm heads) using a common templating software (Endomap): M1) 30mm metal ball lateral to the affected side at the height of the trochanter, M2) a fixed magnification of 121% (average of bucky system as derived from a pilot study) and M3) anatomic calibration by assigning to the natural femoral head of the contralateral side its diameter derived by an anatomic formula. The gender specific linear relationship between height (h [cm]) and the bony femoral head diameter (d [mm]) was obtained from a CT study (n=120): Males: d=0.156h+23.941, Females: d=0.154h+20.040). For each method applied by two independent observers, the implant’s metal head was measured and the relative error [%] calculated. Results: The standard technique, calibration by a reference object produced a relative error (mean +/−SD) of 2.01+/−1.82% (max=7.9%). Fixed magnification had sign. less error at 1.41+/−1.3% (max=6.5%, p< 0.05). Anatomic calibration produced sign. higher errors at 2.77+/−1.96% (max=8.4%, p< 0.05). Inter-rater reliability was highest for the fixed magnification (r=0.93) and less for ball calibration (r=0.67) and anatomic calibration (r=0.52). Discussion: It was shown once more that in THR fixed magnification of digital x-rays is on average more accurate and reliable than using a calibration object such as a ball. The theoretical benefit of individual calibration is lost by the variability in landmark palpation, object placement and patient movement though last can be limited by taping the object (e.g. coin) to the skin. Anatomic calibration based on the current formula cannot replace the use of calibration objects. However its error is within clinically tolerable ranges and it can be used when no calibration object is available or the system’s magnification is unknown. The error may be reduced by more accurate height measurements

Introduction. In clinical routine surgeons depend largely on 2D x-ray radiographs and their experience to plan and evaluate surgical interventions around the knee joint. Numerous studies have shown that pure 2D x-ray radiography based measurements are not accurate due to the error in determining accurate radiography magnification and the projection characteristics of 2D radiographs. Using 2D x-ray radiographs to plan 3D knee joint surgery may lead to component misalignment in Total Knee Arthroplasty (TKA) or to over- or under-correction of the mechanical axis in Lower Extremity Osteotomy (LEO). Recently we developed a personalized X-ray reconstruction-based planning and post-operative treatment evaluation system called “iLeg” for TKA or LEO. Based on a patented X-ray image calibration cage and a unique 2D–3D reconstruction technique, iLeg can generate accurate patient-specific 3D models of a complete lower extremity from two standing X-rays for true 3D planning and evaluation of surgical interventions at the knee joint. The goal of this study is to validate the accuracy of this newly developed system using digitally reconstructed radiographs (DRRs) generated from CT data of cadavers. Methods. CT data of 12 cadavers (24 legs) were used in the study. For each leg, two DRRs, one from the antero-posterior (AP) direction and the other from the later-medial (LM) direction, were generated following clinical requirements and used as the input to the iLeg software. The 2D–3D reconstruction was then done by non-rigidly matching statistical shape models (SSMs) of both femur and tibia to the DRRs (seee Fig. 1). In order to evaluate the 2D–3D reconstruction accuracy, we conducted a semi-automatic segmentation of all CT data using the commercial software Amira (FEI Corporate, Oregon, USA). The reconstructed surface models of each leg were then compared with the surface models segmented from the associated CT data. Since the DRRs were generated from the associated CT data, the surface models were reconstructed in the local coordinate system of the CT data. Thus, we can directly compare the reconstructed surface models with the surface models segmented from the associated CT data, which we took as the ground truth. Again, we used the software Amira to compute distances from each vertex on the reconstructed surface models to the associated ground truth models. Results. When the reconstructed models were compared with the surface models segmented from the associated CT data, a mean reconstruction accuracy of 1.2±0.2mm, 1.3±0.2mm, 1.4±0.3mm and 1.3±0.2mm was found for left femur, right femur, left tibia and right tibia, respectively. When looking into the reconstruction of each subject, we found an average reconstruction accuracy in the range of 1.1mm to 1.5mm. Overall, the reconstruction accuracy was found to be 1.3±0.2mm. Discussions. We presented a cadaver study to validate the accuracy of reconstructing 3D patient-specific models of a complete lower extremity from 2D X-rays. Our experimental results demonstrate that the complete lower extremity can be reconstructed accurately from 2D X-rays. Please note that the errors we reported above include both pose and shape reconstruction errors whole most of previous studies only reported shape reconstruction errors

Purpose of the study: Labrum lesions can be an important source of hip pain. Besides the classical causes, certain morophological anomalies can be associated with labrum lesions. The purpose of this work was to study the contribution of plain x-rays to the search for morphological anomalies of the hip in patients with labrum lesions. Materials and methods: Twenty-six patients with labrum lesions were included in this study. The plain x-rays protocol included an anteroposterior view of the pelvis in the standing position, a Lequesne oblique view and a lateral view of the neck in the hip flexion position. Patients with severe hip dysplasia (VCA or VCI < 15° or THE > 15°) were excluded. Measurements were made after digitalization using a dedicated software. Measures were: neck-shaft angle, acetabular cover, lateral alpha (neck axis, center of the head, most lateral point of the head sphere), lateral offset, acetabular version. Femoral data in flexion were compared with 20 controls. Results: Acetabular cover was considered moderately insufficient in five patients (VCA and/or VCE 15–25°). These patients had the same alpha angle as the control population (56°), i.e. no anomaly of the neck-head junction. The 21 patients with non-dysplastic hips exhibited a significantly greater alpha angle (64±9° versus 54.6±8°, p< 0.01) than the controls. All controls presented an alpha angle ≤ 69°. Among the 21 non-dysplastic patients, five presented coxa vara (< 125°), five acetabular retroversion, nine an alpha angle > 69°. In all, 77% of patients presented morphological anomalies of the hip. Among the six «normal» hips using these measures, three presented a pistol-grip aspect which could not be quantified with these measures. Discussion: This analysis confirms the association between morphological anomalies detectable on plain x-rays and labrum lesions in patients who do no present severely insufficient acetabular coverage. We were unable to detect any difference in femoral offset compared with the control population. Conclusion: A standard x-ray protocol can, in the majority of cases, detect morphological anomalies of the hip, an important etiological diagnostic element for understanding pathogenic mechanisms

Introduction: Ankle inversion injuries are common, with an incidence of 1 per day per 10,000 of the population. Chronic instability is a frequent sequela, and has been estimated to occur after approximately 10 to 20% patients, regardless of the type of initial treatment. Magnetic Resonance Imaging (MRI) has become a routine diagnostic tool in investigating knee injuries, but little has been published concerning ankle injuries and ankle instability. Aim: To compare the efficacy of conventional magnetic resonance (MR) imaging and stress radiography in the detection of lateral collateral ligament abnormalities in patients with chronic ankle instability. Materials and Methods: All patients presenting to the senior author’s OPD with clinical impression of ankle instability were investigated prospectively using MRI and stress x-rays (Telos). These films were officially reported and then, these reports were subsequently reviewed post-anatomical reconstruction. Results: Over a two-year period, 18 patients underwent anatomical reconstruction using the modified Brostrom technique. MRI identified a tear of the anterior talofibular (AFT) ligament in 12 (66%) patients, and the calcaneofibular (CF) ligament was torn in 9 (50%) patients. Stress radiography identified instability of 14 of the 18 (77%) patients. Stress radiography identified instability of 14 of the 18 (77%) patients. Surgical exploration revealed either attenuation or rupture of either the AFT and/or CF ligaments in all 18 patients. MRI demonstrated concomitant injuries to the ankle and subtalar joints, including peroneal tenosynovitis (76%), anterolateral impingement syndrome (66%) and attenuated peroneal retinaculum (55%). Conclusion: Ankle instability may be more reliably demonstrated using stress x-rays than MRI: however, lowfield MRI is a very useful diagnostic tool in the study of concomitant ankle injuries and we would suggest that both modalities be considered, especially if surgical intervention is anticipated

Aim: To determine the accuracy of the posterior-to-anterior (PA) 15 degrees caudad view of the clavicle to assess amount of shortening of clavicular fractures. Method: The first stage of the study involved taking x-rays of an adult skeleton, centred on the clavicle. The projections included the standard anterior-to-posterior (AP) 15 degrees cephalad view, and the PA 15 degrees caudad view. Additional images were taken in the 15 degrees caudad view with a series of oblique rotational views, and oblique images in the vertical plane. Metal markers were placed on the clavicle at 10mm intervals. The clavicular length and the interval between markers were measured on the x rays.The second stage of the study involved obtaining the PA 15 degrees caudad x-ray on 50 patients with clavicular fractures. The non injured clavicle was also x-rayed. The lengths of the non injured clavicle and the lengths of the fragments of the fractured clavicle were recorded. Results: The length of the clavicle of the skeleton in the AP standard image was 149mm. The length in the PA 15 degrees caudad image was 130mm, with a maximum of 4mm variation on the oblique views up to 30 degrees. The true length was 124mm.Forty-five fractures were diaphyseal, and five were outer third fractures. There was less than 5mm measured difference in the length of injured and non injured clavicle in 38 out of 45 patients with diaphyseal fractures (84%). Conclusions: The PA 15 degrees caudad clavicular x-ray provided a more accurate assessment of clavicular shortening than the standard AP view, and was well tolerated by the patients

Purpose of study. A recent audit in our institution showed that 40% of Lumbar spine X-rays ordered by General Practitioners were outside the Royal College of Radiology guidelines. Little in 1998 had commented that GPs requested Lumber Spine X-rays for psychosocial reasons. Methods. An online survey was conducted on . www.surveymonkey.com. among the local GPs to determine their practice and preferences in investigating low back pain. The 5 questions in the survey were “rating scale questions” on a scale of 1 and 10, where 1 = DISAgree and 10 = Agree. A request to participate in the survey was sent to all the local General Practitioners by e-mail. Results. 36 General Practitioners participated in the survey. Participants agreed that if there were no red flags and no significant neurological deficit they were satisfied in not requesting further investigations (6.03/10). They did not feel the need to order investigation just to reassure an anxious patient (5.31). In day to day practice they however were forced to request X-rays (6.72) though they preferred to request MRI scans (7.55). They also felt frustrated that MRI scans could not be directly ordered by GPs (6.69). Conclusion. This limited study demonstrates that General Practitioners “Do not investigate back pain just to reassure the patient but are frustrated that they are not able to directly request MRI scans for their patients. Increased efforts to educate the public and health professionals that a negative X-ray result of the lumbar spine is not reassuring should be matched by easy access to MRI scans

This research sought a mathematical model to relate the postero-anterior (PA) and lateral (LAT) views of the spinal curve in scoliosis in an attempt to justify the acquisition of only One X-ray, thereby reducing patient exposure to harmful X-radiation while preserving complete 3D characterization of the spine. Using powerful developments in functional statistics and machine learning, no such relation could be found. Thus, this research sustained the clinical decision to acquire two biplanar X-rays and supported current research in 3D spinal curvature analysis. Scoliosis is monitored through full spinal X-rays, and this serial protocol causes an increased incidence of cancer development. This research sustains the clinical decision at Hôpital Sainte-Justine in Montréal and elsewhere to acquire postero-anterior (PA) and lateral (LAT) X-rays, despite the increased exposure to X-radiation. Indeed, geometrically, these two views are required to reconstruct the spine in 3D. However, under the assumption of strong physiological patterns between the PA and LAT views of the spinal curve, one of these X-rays may be redundant for some or all patients. The purpose of this study was to seek this a priori assumption. To this end, a database consisting of three hundred and sixty-nine spinal reconstructions from distinct patients was used. Two powerful geometric modeling approaches were exploited: functional data analysis and minimum noise fractions. These resulted in five comprehensive, uncorrelated and noise-insensitive features in each plane. Simple linear regression yielded no relation that was statistically significant (p< 0.05) and genereralizable to a set of previously unseen samples. Therefore, nonlinear relational modeling was attempted using support vector regression, a recent advance in machine learning theory. This tool was incapable of identifying a robust regression, suggesting that the PA and LAT views are mathematically independent. Thus, this study highlights the necessity of two biplanar X-rays to evaluate scoliotic deformities and fully characterize spinal shape. Further, this study supports the practical insufficiency observed by clinical staff with respect to current 2D scoliosis classifications that has resulted in current efforts to propose 3D classification schemes

Purpose of study. The Royal College of Radiology (RCR) provides guideline criteria to order lumbar spine X-rays for back pain. An audit was undertaken in our hospital to see compliance with this guideline. Methods. 200 lumbar spine radiology requests received in the hospital radiology department from General Practitioners over a 12 month period were identified. These 200 requests and their corresponding radiology reports were retrospectively analyzed. Results. Out of the 200 patients 80 were male and 120 were female. 1 patient was < 18 years, 75 patients were between 18 and 55 years, 52 patients were between 55 and 70 and 72 patients were > 70 years of age. Only 125 patients satisfied the RCR criteria for requiring a Lumbar Spine X-ray. 104 of these 125 patients met the criteria only because of age (> 55). The remaining 21 had other criteria like history of malignancy, osteoporosis or trauma that required imaging. Of the 200 X-rays the only significant pathology that was identified from the report was osteoporotic fractures in 35 patients. The most commonest diagnostic report was spondylosis which was seen in 92 patients. Among the 75 patients between the age of 18 and 55 only 2 fulfilled the criteria for requiring a lumbar spine X-ray. Hence 73 (36.5%) X-rays were outside the criteria. Among the 52 patients between the ages of 55 and 70 only 6 had a criteria other than age. Conclusion. This limited study demonstrates the following two possibilities. More stricter adherence to guidelines in patients aged 18 to 55. In this study 73 (36.5%) X-rays could have been avoided by this method. We believe that there is a case for the college to increase the age related criteria from 55 to 70 to be at par with American guidelines. If this method was used an additional 46 (23%) X-rays could have been avoided

To establish whether postoperative x-rays were of sufficient quality compared to those at the first outpatients’ appointment, uncomplicated primary total knee replacements performed by one surgeon were reviewed retrospectively. Measurements were made from these X-rays. Rotation was also assessed. Forty-eight knee replacements were reviewed. Postoperative films showed the tibial tray to be tilted an average of 5. 04 degrees and a femoral valgus angle of 1. 56 degrees. First outpatients’ X-rays showed the tibial tray to be tilted an average of 1. 16 degrees and the femoral valgus angle to be an average 5. 16 degrees. 15 of 25 postoperative films were found to be rotated compared to 1 of 25 in the outpatients’ group. Immediate postoperative films are of variable and often poor quality. Films at the first outpatients’ appointment were of superior quality

The gold standard for measuring knee alignment is the lower limb mechanical axis. This is traditionally assessed by weight-bearing full length lower limb X-rays (LLX). CT scanograms (CTS) are however, becoming increasingly popular in view of lower radiation exposure, speed and supine positioning. We assessed the correlation and reproducibility of knee joint coronal alignment using these two imaging modalities. LLX and CTS images were obtained in 24 knees with degenerate joint disease or failed TKR. Hip to ankle mechanical alignment were measured using the PACS software. Coronal knee alignment was assessed from the centre of the knee, measuring the valgus/varus angle relative to the mechanical axis. Measurements were made by two orthopaedic surgeons (Research Fellow and Consultant) on two separate occasions. The mean alignment angles measured by observers 1 and 2 on CTS were 180.29° (SD 6.04) and 180.71° (SD 6.13) respectively, while on LLX were 181.04° (SD7.58) and 181.04° (SD 7.72). The measurements between the two observers were highly correlated for both the CTS (r = 0.97, p < 0.001) and the LLX (r = 0.99, p < 0.001). The angles measured on CTS and LLX were highly correlated (r = 0.826, p < 0.001) with high degree of internal consistency (ICC = 0.804). Malalignment of greater than 5° was seen in 19% of the CTS and 35% of the LLX. There was good correlation between CT scanogram and weight-bearing X-ray measurements in normally-aligned knees. However, as expected, in the malaligned lower limb, the influence of weight-bearing is critical which demonstrates the significance of weight-bearing X-rays