CR in Orthopedics

Agfa's DX-SX-rays are a life blood of orthopedic medicine, and for years, plain-film x-ray has been the gold standard. However, more practices are installing computed radiography (CR) and experiencing the benefits: reduced imaging costs, improved workflow efficiencies, expedient information delivery, and simultaneous access to images and clinical information by multiple users. CR brings the advantages of compact design, a lower price point than its digital radiography cousin, and a variety of specialized views tailored just for orthopedics.

Rolling out CR office by office was a successful strategy for M&M Orthopedics in Downers Grove, Ill. The orthopedic practice includes five office sites, and its staff consists of 18 orthopedic surgeons, two podiatrists, one physical medicine and rehabilitation specialist, and six physician assistants.

Specializations include general orthopedics, fracture care for children and adults, sports medicine, joint reconstruction, hand, spine, foot and ankle, arthroscopic surgery, and pediatric orthopedics. Approximately 100 patients are imaged per day, per site, and 75 percent to 80 percent of these patients get x-rays, says COO Mary Jane Munley.

Once deciding it was time to go digital, M&M Orthopedics rolled out a Fujifilm Medical Systems’ XG5000 CR system, which is a high-capacity, multi-plate reader, at a site that was moving its office to a larger facility. Once up and running, CR has been implemented at M&M’s four remaining locations. Fuji’s XL OrthoCR system is used at locations that x-ray a smaller number of patients.

M&M favored CR over DR because of the cost. With CR, M&M could still use its current x-ray imaging equipment, as CR uses conventional x-ray equipment to perform imaging studies, replacing the film in the cassette with a reusable imaging plate that is read by a laser after exposure, yielding a digital image on the user’s computer.

The imaging technology quickly proved to be a valuable investment for the organization. A multi-site practice, patients generally choose which M&M facility to visit based on their schedule and convenience, says Munley. With digital images and PACS, internet-based image distribution eliminated the need to transport large amounts of plain-film to various sites.

“Another reason we wanted CR [and PACS] was the storage aspect of radiographic film,” says Munley. “It’s heavy, bulky, and you need a lot of space to store it. As medicine and healthcare progress, you want to be able to use your square footage to care for patients rather than store x-ray film.”

Munley also emphasizes the value of CR’s imaging and processing speed. “Technologists take the x-ray, put it in the reader, and [the image] comes up almost immediately,” says Munley.

CR from a tech’s point of view

Premier Orthopedics in Nashville, Tenn., has been using CR and PACS for nearly two years, and one distinct advantage to the technology is the electronic storage and retrieval of images, says Edie Manning, RT(R). Manning is the primary radiologic technologist at Premier Orthopedics. With one x-ray unit and a Fujifilm CR reader, Manning is able to image, on average, 65 to 70 patients daily. “Our facility is really busy,” she says. “A slow day for us might be 30 patients.”

When Manning needs to refer to prior films to get a better understanding of a patient’s orthopedic condition, she accesses the PACS. Prior to CR, Manning would have to travel down the hall to the file room, locate the patient’s chart, and then view the plain-films on a lightbox.

“Now I get the chart for the order, go to the computer, pull up the patient’s last image and I am looking at it in five seconds,” says Manning.

Another element Manning likes about CR is its speed. In a hard-copy environment, Manning could image four patients in 30 minutes. With CR, the same number of patients can be imaged in 15 minutes. But Manning admits it took her some time to accept the analog-to-digital transition. “I had a hard time with it at first,” she explains. “I did not want to go digital. We were so good with hard-copy x-ray. To me, we had a system that worked perfectly.”

However, after going live with CR, it took Manning only a few days to adjust to using filmless cassettes and looking at the images on a computer screen. “Within two days, I was excited about the change to digital.”

“The benefit of digital is not necessarily the image itself,” opines Manning. “It’s more the speed and accessibility it brings to orthopedics. We put patients through so much quicker with CR than we did with film.”

At Columbus Ortho in Columbus, Miss., Agfa Healthcare’s DX-S CR system is being used in combination with PACS. With four orthopedic surgeons and one nurse practitioner, the practice sees approximately 100 patients daily. The Agfa unit recently replaced Columbus’s first CR system that was installed five years ago. The system combines DirectriX needle-based detector technology and Scanhead line-to-line CR simulation and light collection technology to increase CR performance.

The benefit of CR compared with using plain-film in an orthopedic practice is speed. “From the time the patient is x-rayed and by the time the patient is getting off the table, the doctor is looking at the image down the hall,” says Debbie Swartz, RT(R), assistant manager. “The speed is incredible, and the quality is better.”

Swartz says the practice would never go back to a hard-copy environment. “Orthopedics is a fast-moving practice,” says Swartz. “We basically do not treat anybody without an x-ray taken of him or her. Volumewise for orthopedics, the speed of CR is wonderful. It’s ideal when you can get quality with the speed factor.”

CR + PACS: Anywhere-anytime access

Orthopedic physicians deal with very heavy case loads on a daily basis, and diagnostic-quality images must be ready and available for the doctors at the time patients are seen in their office. Since digital image capture and PACS facilitate the transmission of images, a growing number of orthopedic practices are using digital image capture devices along with PACS for anywhere, anytime access to images.

Physicians at Panorama Orthopedics & Spine Center, a busy orthopedic practice in Golden, Colo., that also hosts a Level 1 Trauma center, wanted to go digital and implemented Eastman Kodak Co.’s CR 900 and 950 systems in combination with a Kodak PACS and diagnostic workstations. The CR 950 is a high-capacity, multi-cassette reader that processes 16 cassettes [8 exposed/8 erased] cassettes at one time.

The Panorama Campus hosts a modern orthopedic clinic, a surgery/convalescent center, an imaging center, a physical therapy rehabilitation center, and an orthopedic research center. Orthopedic specialists include trauma surgeons, sports medicine doctors, total joint doctors, hand surgeons, and spine surgeons.

Panorama did consider both CR and DR. Choosing CR, Bharat Desai, MD, an orthopedic specialist at Panorama and head of orthopedic trauma at Panorama’s Level 1 Trauma Center, says DR was still in its infancy and could not be used for various special projections required by the orthopedic doctors. “Our spine doctors need to get standing films upright,” explains Desai. “That was a big issue at the time with DR.” Acquiring weight-bearing feet x-rays was not possible with DR, and the technology was not good at stitching images together, which is oftentimes needed for scoliosis series or long leg films.

One of the biggest hurdles with CR was that the doctors were not used to looking at electronic images. However, efficiency was an instantaneous advantage. “Financially, we are not paying for [hard-copy] storage and retrieval costs,” says Desai. “The technologists are able to perform the imaging exams at a faster pace. The doctors are able to see more patients or spend more time with the same amount of patients. Also, the doctors can retrieve relevant priors easier from a computer workstation because the images get stored electronically in the PACS.”

Christine Wilson, CIO, says that the utilization of plain-film created a “bottleneck” in the patient flow through the clinic. “Technologists would take the image, process the image, wait for the QA to be done, return the patient, print the films, and then deliver them back to the doctors,” she describes. “It could be 15 to 20 minutes from the time the doctor initially saw the patient to the time the doctor returned to the room to view the x-rays. That has been cut down drastically to a matter of a few minutes with CR. This has made us more efficient, and patient satisfaction has increased.

“We really have not been able to find a strong downside to CR,” adds Wilson.

An imaging strategy to meet your needs

Digital imaging, PACS, and sophisticated software viewing applications are expanding physicians’ diagnostic and treatment capabilities at Hospital for Special Surgery (HSS). A 135-bed hospital located in New York, the center’s Department of Radiology & Imaging excels in musculoskeletal, orthopedic, and rheumatologic imaging. HSS was ranked as second in the nation in orthopedics and third in rheumatology by U.S. News & World Report in their 2006 America’s Best Hospitals survey.

According to Helene Pavlov, MD, FACR, radiologist-in-chief, HSS, professor of radiology, professor of radiology in orthopedic surgery, Weill Medical College of Cornell University in New York City, approximately 185,000 musculoskeletal imaging exams are performed annually at HSS. Approximately 136,000 are conventional x-rays of which approximately 95 percent are acquired by CR or DR.

“One of the main reasons to undergo this transition [to digital imaging] is to be state of the art,” says Pavlov. HSS first installed Philips Medical Systems’ Computed Radiography (CR).

Radiologists were immediately on board with CR, but the orthopedic surgeons were more reluctant to eliminate film. “Image size was their main concern, especially for our arthoplasty, trauma, and sports medicine surgeons,” says Pavlov. “Measurements are a very critical issue for them because of templating and pre-surgical planning. [Orthopedic surgeons] have to select hardware carefully to fit to the specific bone or joint problem. They are very used to the system based on film, which is why we told them we would keep film until they are comfortable changing.”

Validation was essential. HSS’s orthopedic surgeons had to be certain that their measurement techniques used on film also could be used on digital images when planning their surgeries, especially when orthopedic hardware devices were involved.

CR did improve workflow, but challenges for technologists included having to revise the routine technique charts for plain-film. “The imaging plates [used with CR] have different sensitivities from cassette screens, so dosages had to be changed,” explains Pavlov. “It took a while to figure out what techniques were needed. Also, you can’t rely on phototiming with CR in the same way as analog. The technologists needed to change some protocols and use manual techniques for some positions because of the way the CR reader works.”

Looking for even faster patient turnaround time and throughput efficiency, HSS implemented DR. The hospital installed Philips’ DigitalDiagnost systems. DR further improved patient throughput and enhanced technologist workflow. Digital image capture became even more appealing to the orthopedic surgeons, since the technology allowed for the expedient delivery of patient image information.

CR is still needed at HSS, for special projections that cannot currently be performed with DR. Utilizing a combination of both technologies, HSS found a digital imaging strategy that worked best for them.

“You have to do the transition,” says Pavlov. “It is the world of the future. The transition is not as easy nor is it as difficult as it appears on the surface. You have to plan for it, you have to definitely validate all images, and if you are going to print images, you have to be very careful how they get printed so as to assure diagnostic-quality images and not to change the size of the image or lose data available on the soft-copy monitors. You have to control the entire transition process and set up a mechanism to establish and maintain competence and quality assurance standards. As long as the transition and the delivery of the images to the physicians is a controlled, planned event, it will be successful.”