for Image Scaling Enabling Digital Orthopaedics
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1 Calibration Devices, Use & Positioning for Image Scaling Enabling Digital Orthopaedics
2 DIGITAL IMAGE SCALING As Radiology becomes filmless. Current planning practices used by surgeons with acetate sheets become difficult or obsolete. When images are printed to film sometimes it is fit to film rather than at acquisition size and magnification is not known. Solution: A surgical planning software application that uses digital templates and a mechanism for scaling the image.
3 RADIOLOGY INPUT IS VITAL So Orthopaedic templating is accurate Calculating magnification is essential An object of known size is used Linearly measured in the Scaling stage of OrthoView It automatically calculates l the pixels/mm Now uses this for all measures Giving an improved result and patient outcomes
4 Scaling the X-ray Image Mandatory procedure in OrthoView. WHY? The magnification of any bony area is never known. Knowing the magnification factor is critical for matching the prosthesis to the bone it will be implanted into.
5 Magnification Magnification factor is a product of the distance of the bony anatomy from the x-ray cassette and the diverging nature of the x-ray beam. Magnification % = Source Image Distance (FFD) x 100 Source Object Distance (FOD) 25mm
6 Scaling To accurately scale the anatomy a radiopaque marker is placed against or attached to the patient, in the plane of the joint or area of interest when the image is acquired. In OrthoView either use Automatic (Quickscale ) or Manual measurement of the scaling device, alternatively
7 Scaling options Mimic i the current practice with acetate templates of estimating the Oversize %. Type this value in the field. If a scaling device which calculates magnification% is used then the value will need dto be added din this field.
8 Scaling Issues 1.. Radiology need to know which patients require scaling markers positioned on films. Solution: The Orthopaedics and Radiology departments need to discuss and determine how this will be achieved. For example added to patient requests for pre-defined imaging examinations pre-operatively. NOTE: A new working practice procedure should be defined d in accordance with departmental t guidelines
9 Scaling Issues 2 A Scaling Marker of choice needs to be obtained and distributed for use. Solution: The size in mm of the marker must be circulated to Orthopaedic surgeons. Markers are available from some Orthopaedic manufacturers, website based suppliers, an existing or x-ray designed device can be used. Scaling Marker details follow
10 Scaling Markers. Markers in the form of spheres or discs are easy to obtain. Around 25mm in size has become the default standard. d A method which does not use a radiopaque object has been developed using a ruler calibrated for an individual x-ray room Those incorporating any linear aspect as shown below are best avoided as positioning errors can cause foreshortening on the resultant image, and hence an inaccurate reading. If used, they should be carefully placed parallel to the imaging plane or cassette.
11 Radiographic Marker Selection OrthoView does not endorse any particular radiographic marker device. The following are all widely available. Suction Base Devices with a flexible arm holding a 25mm sphere. Suitable for horizontal or vertical stand use. Akucal Evo calibration stand see website for details of products order@j2medical.com tel: Wolverson X-Ray Ltd see website for details of products sales@wolversonx-ray.co.uk tel: +44 (0)
12 Alternatively Xemarc hollow spheres, Chatham Hill South Glastonbury, CT T: F: E: Uses 25mm spheres which can be attached using sticky pads to the patient. Or the 20 gooseneck stand made of radiolucent material for positioning across the patient.
13 Or another UK developed HipScaler calibration device This device uses a 25mm disc, set in a perspex at four set heights. Ideal for hip and pelvis imaging. Single discs also available.
14 Also Calibrated Ruler Device X-CalibR magnification ruler - A method to scale radiographs without a radiopaque scaling object for hips & other body areas Using a number of known measures and applying them in the magnification formula M=FFD/FOD it is possible to create a calibrated ruler for each x-ray room bucky where the resultant magnification percentage is read directly from the ruler. See website for further details & ordering. This percentage magnification is then annotated on the digital image and typed into the Oversize % field in the scaling stage of OrthoView.
15 Another Option A low cost option is to use an agreed coin or disc of known size
16 Scaling Issues 3 Positioning of markers is crucial for accuracy and staff training will be needed. Solution: Positioning guidance for a range of joints follows...
17 Positioning Guide for Markers All positioning of markers shown is a guide to use and specific surgeons may require a particular joint or bony area to be marked according to their own requirements. The devices shown can be replaced with alternative objects of known size. All objects used in a patient contact environment will need to be cleaned according to the local health and safety hygiene requirements with a suitable non- abrasive cleaning solution applied after each use. A selection of commonly examined body areas requiring marker placement follows
18 Positioning Guide for Markers PELVIS Position patient to include upper 1/3 of femoral shaft on the pelvis image There are 2 stages for marker positioning on the pelvis image. Step 1 1. Position at the level of the greater trochanter on the lateral side of the pelvis, equivalent to the hip joint level. Unless the patient is narrow at the hip Step 2 the marker will be projected beyond the margin of the image, therefore 2. Move the marker carefully to the same vertical height level between the thighs where it will be visible in the radiation field.
19 Positioning i Guide for Markers HIP AP Hip, same positioning as pelvis, at the vertical level/height of the greater trochanter on the lateral side of the hip. Include marker in the radiation field. Lateral Oblique Hip, designed to view the femoral stem width rather than the hip cup which can be measured in the AP. The marker is placed laterally mid-thigh to best establish the level l of the femoral shaft. For very large patients any adipose tissue will need to be taken into account. Lateral Inferior-Superior, NOF# view. Marker is positioned anteriorly mid-thigh to establish femoral canal width only near position of marker.
20 Positioning Guide for Markers LONG BONES, FEMUR etc. AP View, place the marker midway between anterior and posterior surfaces over the shaft on the lateral side of the bone Lateral View ML -place the marker on the anterior part of the limb in the mid-line. LM place on the anterior midline of the limb around the area of interest if known. As the surgeon will need to know how the lateral was taken annotate with horizontal beam or LM if possible. AP ML LM ML- taped sphere marker
21 Positioning Guide for Markers AP - Disc Lat - Disc AP - Sphere Lat - Sphere KNEE Position patient so an equal amount of femoral and tibial shaft are visible on the image. AP View, marker is placed over the lateral side of the knee in the joint line, roughly midway between anterior and posterior surfaces, however if a patient is well muscled this needs to be considered. Lateral (ML) View, marker is placed on the anterior side of the knee, either superior or inferior to patella in the midline Lateral (LM) View, see Femur
22 Positioning Guide for Markers SHOULDER AP Marker is placed on the lateral side of the humeral head at the mid-point between the palpable anterior and posterior bony prominences of the acromion to best define the humeral head. A disc applied with surgical tape and a fixed sphere and arm device with suction base are shown.
23 Positioning Guide for Markers HUMERUS AP & LATERAL AP View, marker is placed on the lateral part of the upper arm at the mid-point between the anterior and posterior side. Sphere and disc usage are shown. Lateral View, marker is placed on the posterior side of the upper arm midway between the lateral and medial surfaces of the limb.
24 Positioning Guide for Markers SPINE Cervical Spine, AP and Lateral AP View, place marker on the lateral side of the neck over the midpoint between the anterior and posterior aspects of the neck. Lateral View, place the marker over the cervical spinous processes on the posterior aspect of the neck. Thoracic and Lumbar Spine Lateral View, place marker over the spinous processes at the appropriate spinal level. Note: an AP coned view does not allow marker placement, however for full length spine scoliosis images a marker can be placed on the lateral abdomen at spinal level of interest or some centres will prefer to use a ruler device. T.Spine L.Spine C.Spine - AP C.Spine Lat C.Spine Lat
25 In Summary Thanks goes to the Radiology staff of Queen Alexander Hospital, Portsmouth, UK for assisting us so generously with their time and patience in producing the positioning images. In particular Alice Mitchell, Radiographic Assistant & Sarah Davies, Senior 1 Radiographer. For further information on any aspects of this presentation please contact us at info@orthoview.com This is also available on
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