VolumeRAD imaging in the evaluation of fractures of the foot

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Norma Cook
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1 VolumeRAD imaging in the evaluation of fractures of the foot Eildar Abyar, MD Ian Smithson, MD Carl Farah, MD* Nisha Rao, MD* Michael J. Shereff MD Division of Foot and Ankle Surgery Department of Orthopaedics and Sports Medicine, University of South Florida *Department of Radiology, University of South Florida

2 VolumeRAD imaging in the evaluation of fractures of the foot Eildar Abyar, MD My disclosure is in the Final AOFAS Program Book. I have no potential conflicts with this presentation.

3 Foot Fractures Stress or non-displaced fractures, can easily be missed on plain radiographs 80% of all foot and ankle injuries get an x-ray, fewer than 15% have a significant fracture Inadequate treatment Painful non union, mal union and arthritis exacerbated by: Weight bearing Ambulation Imaging techniques: Radiography:Basic imaging tool,less sensitivity and accuracy,stress or non-displaced fractures, are commonly missed in plain radiographs CT-scan: Efficient,more expensive than X-ray,may miss trabecular fractures, radiation exposure >>X-ray MRI: Most powerful technique,hard to differentiate occult fracture from simple bone bruising,less available and more expensive than X- ray,recommended for cases in which X-ray or CT are inconclusive. Bone Scan: Sensitive but not specific, false positive in tumors, infections and inflammations, less available and more expensive than x-ray

4 Volume-Rad Imaging This recently invented application provides multiple high resolution slice images using an X-ray system. Low-dose projection images are taken during a single sweep of the X-ray tube over a limited angle. A computer then assembles the information to provide up to 60 high-resolution slice images with a selectable thickness ranging from 1 to 10 mm. This technique has been used in mammography for several years. It has recently become available for musculoskeletal radiography. It has lower cost and less radiation than a CT-scan. Imaging Techniques: Images obtained with GE Definium 8000 M3 digital x-ray machine (GE healthcare, USA) with 0.1 mm pixel spacing Radiography: o Foot: AP, Lat, Oblique views Volume Rad: o Foot: Lateral/Frontal 24 low-dose projections, 4mm thickness the detector was stationary, whereas the x-ray tube performed a horizontal continuous movement from -26 to +26 X-ray Volume-Rad

5 Material and Methods 134 patients with foot injuries between July 2009 and June 2012 All patients had clinical symptoms of fracture: pain, swelling, Ecchymosis and impaired function Initial plain X-ray: Foot AP, oblique, lateral views Follow up Imaging by Volume-Rad in single plane (AP/ Lateral) Control by CT, MRI or Bone Scan 37 Patients (19 male,18 female) included in this study Mean age: 31 years (Range 15-78) Median age: 23 years Inclusion criteria: Acute foot trauma and pain Exclusion criteria: Old known fractures, severe arthritis, diabetic and charcot foot Radiographic studies reviewed on PACS by 4 reviewers : One senior Musculoskeletal Radiologist, one musculoskeletal radiology fellow, two orthopaedics surgeons. Each observer reviewed x-ray, volume-rad, x-ray plus volume-rad and finally CT, MRI or Bone scan as a control. Each study reviewed separately with the observers blinded to the other examinations. Images were analyzed for presence or absence of foot and ankle fractures

6 Results X-ray vs. Volume-Rad X-ray after Volume-Rad X-ray Volume-Rad X-ray X-ray+Volume-Rad Sensitivity Accuracy Specificity Precision Sensitivity Accuracy Specificity Precision Inter-observer Agreement X-ray Volume-Rad Overall Fixed Free

7 X-Ray Volume-Rad Navicular fracture Lifranc Fracture Talus Post. Process Fracture

8 Discussion Volume-Rad imaging proved to be more sensitive, specific and accurate for evaluation of fractures of the foot as compared to plain x-rays. Inter-observer agreement value analysis shows a high level unanimity between observers in Volume-Rad compared to X-ray In 62% of cases Volume-Rad Imaging reveals additional information compare to X-ray CT scan and MRI may help in the diagnosis of foot fractures but Volume-Rad imaging may provide some information with less radiation and lower cost.

9 Conclusion Volume Rad is associated with less cost, radiation, and time with more potential availability in outpatient clinics than CT and MRI. We have demonstrated the value of Volume-Rad imaging to identify fractures of the foot. Volume-Rad imaging allows creation of sectional images with less overlapping anatomy. This provides clinicians a higher degree of confidence in diagnosis compared to x-ray.

10 References Noël A, Ottenin MA, Germain C, Soler M, Villani N, Grosprêtre O, Blum A. Comparison of irradiation for tomosynthesis and CT of the wrist J Radiol Jan;92(1):32-9 Berkowitz MJ, Kim DH. Process and tubercle fractures of the hindfoot. J Am Acad Orthop Surg Dec;13(8): Dougall TW, Ashcroft GP. Flexor hallucis longus tendon interposition in a fracture of the medial tubercle of the posterior process of the talus. Injury Oct;28(8): Geijer M, Börjesson AM, Göthlin JH. Clinical utility of tomosynthesis in suspected scaphoid fracture. A pilot study. Skeletal Radiol Jul;40(7): Ebraheim NA, Patil V, Frisch NC, Liu X. Diagnosis of medial tubercle fractures of the talar posterior process using oblique views. Injury Nov;38(11): Hayashi D, Xu L, Roemer FW, Hunter DJ, Li L, Katur AM, Guermazi A. Detection of osteophytes and subchondral cysts in the knee with use of tomosynthesis. Radiology Apr;263(1): Canella C, Philippe P, Pansini V, Salleron J, Flipo RM, Cotten A. Use of tomosynthesis for erosion evaluation in rheumatoid arthritic hands and wrists. Radiology Jan;258(1): Kalinosky B, Sabol JM, Piacsek K, Heckel B, Gilat Schmidt T. Quantifying the tibiofemoral joint space using x-ray tomosynthesis. Med Phys Dec;38(12): usculoskeletal Imaging Tochigi Y, Suh JS, Amendola A, Pedersen DR, Saltzman CL. Ankle alignment on lateral radiographs. Part 1: sensitivity of measures to perturbations of ankle positioning. Foot Ankle Int Feb;27(2):82-7

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