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Operative fluoroscopy in hand and upper limb surgery
OPERATIVE
FLUOROSCOPY IN HAND LIMB SURGERY
AND
UPPER
One hundred cases G. I. BAIN, J. HUNT and J. A. MEHTA
From the Modbury Public Hospital, Modbury, South Australia, Australia We reviewed the use of a low radiation portable fluoroscopy unit in 100 patients. The most common indication was closed reduction of distal radial fractures. Fracture and joint stability were assessed on the real-time monitor and stored on videotape. Static images were stored on thermographic paper. Fluoroscopically guided joint injections and localization of implants, foreign bodies and bone tumours were performed. Fluoroscopy is a useful adjunct to arthroscopic assisted fracture reduction and other arthroscopic procedures such as distal ulnar resection. These new generation units produce superior resolution images, are easy to manoeuvre and do not require a radiographer.
Journal of Hand Surgery (British and European Volume, 1997) 22B." 5." 656-658 Intraoperative fluoroscopy was first used by Coltman (1948) and since then has been used extensively in many areas of surgery. Advances in fluoroscopic technology have enabled high resolution images to be obtained using significantly lower doses of radiation (Gehrke et al, 1993). The new generation fluoroscopy units are compact, portable and have a smaller C-arm. Their application has been reported in foot and ankle surgery (Gehrke et al, 1993). The purpose of this paper is to review our clinical experience with portable operative fluoroscopy in hand and upper limb surgery. METHOD AND MATERIALS
An analysis of the use of low radiation fluoroscopy in 100 patients with upper limb problems treated at the North Eastern Community Hospital, Adelaide, South Australia, was performed. All were treated by one surgeon (GIB) between May 1995 and February 1996 using the 3 inch Fluoroscan (Fluoroscan Imaging Systems Inc., Illinois) (Fig 1). This unit is smaller than conventional fuoroscopy machines. It has an adjustable boom with three degrees of freedom, allowing the mini C-arm to be placed in any position. Image production is initiated with a foot pedal. The onboard computer automatically adjusts the voltage and amperage to provide high quality images using minimal radiation. Static or realtime images were obtained and recorded on thermographic paper or video tape. In accordance with the South Australian Radiation Protection and Control Act 1982, the operating surgeon obtained a restricted radiation licence and all staff within the operating theatre were required to wear a 0.25 mm lead apron and a thermoluminescent dosimeter (TLD).
...............
Fig 1
Portable low dose fluoroscopy unit.
Other indications included open reduction of fractures (Fig 2). Dynamic assessment of fracture stability was performed in real-time including assessment of reduction in several planes. Images were immediately reproduced on thermographic paper. The fluoroscopy unit was used to aid in insertion of two Austofix humeral intramedullary nails and perform distal cross-locking. The proximal humerus was adequately visualized but the limited working distance within the mini C-arm made cross locking technically
RESULTS
Details of patients are presented in Table 1. The most common indication was closed reduction and percutaneous K-wire fixation of distal radial fractures. 656
OPERATIVE FLUOROSCOPY
Fig 2
657
Open reduction and internal fixation of fracture of the scaphoid.
Table 1--List of cases
Fig 3
Diagnostic block with insertion of hypodermic needle into thumb carpometacarpal joint under fluoroscopic control.
Trauma
Closed reduction of fractures Percutaneous reduction of fractures Arthroscopic assisted reduction of fractures Application of PIP joint Compass Hinge Humeral closed intra-medullary nailing Foreign bodies Total trauma cases
8 25 12 8 2 3 58
Elective
Limited and full wrist fusion CMC joint fusion Examination of joint stability Arthroscopic "-ectomy" procedures Diagnostic joint injection Localization of bone tumour Removal of implants Total elective cases
7 2 4 3 3 3 20 42
more difficult than when using a conventional image intensifier. Fluoroscopy was used for the assessment of joint stability. The superior ~esolution of the new generation fluoroscopy units was valuable for removal of small foreign bodies and percutaneous K-wires. It was also useful in localizing bony tumours (e.g. enchondromas) and confirming the adequacy of their resection. Diagnostic anaesthetic blocks of the carpometacarpal joint of the thumb and acromioclavicular joint were performed by advancing the needle into the joint under fluoroscopic control (Fig 3). In the management of intraarticular distal radial fractures, radial head fractures, scaphoid fractures and scapholunate dissociation, 'joysticks' were placed into the fracture/bony fragments under fluoroscopy. These
Table 2--Indications for fluoroscopy in hand and upper limb surgery
Assessment of fracture and joint stability Assessment of reduction of fractures and dislocations Assessment of position of internal fixation Localization of implants, foreign bodies and tumours Assessment of arthroscopic and open "-ectomy" procedures Therapeutic and diagnostic joint injection Dynamic and static arthrography
fragments were then manipulated under arthroscopic control with the 'joysticks' and an intraarticular probe to obtain an optimal reduction (Bain et al, 1996a; 1996b). The alignment and the position of the internal fixation was assessed with fluoroscopy. As the fluoroscopy unit was controlled by the surgeon, the manipulation of the C-arm was performed with precision, thus reducing surgical time. None of the patients in this group required formal open reduction. Fluoroscopy was used to determine the adequacy of arthroscopic resection of the radial head, radial styloid and the distal ulna (Bain and Roth, 1995). DISCUSSION
Portable fluoroscopy is a useful diagnostic and therapeutic tool in hand and upper limb surgery (Table 2). It offers a number of advantages over conventional image intensifiers, which are bulky, difficult to manoeuvre, produce larger amounts of radiation and have inferior
658
resolution. In contrast, the new generation portable fluoroscopy units are small, easy to manoeuvre, produce a fraction of the radiation and have superior resolution. They are controlled and operated by the surgeon and therefore do not require a radiographer. Images are printed immediately on to thermographic paper or stored on video tape. The thermographic images are cheaper, small enough to be kept in patient notes and eliminate storage problems associated with X-ray films. Reproductions can be made with a photocopier. The new generation portable fluoroscopy units have a radiation intensity measured in micro-amps compared with those of conventional units which are measured in milli-amps (Gehrke et al, 1993). The patient and surgical staff are exposed to significantly less radiation from the primary beam and radiation scatter. Gehrke et al (1993) calculated that with a very high work load, a surgeon 30 cm from the fluoroscopy unit would receive 0.56 mR/ year which is considerably less than the permissible exposure for the general public of 100 mR/year. Because of the low radiation levels, some American states have legislated that surgical staff are not required to wear lead aprons (Gehrke et al, 1993). As well as its other uses (Table 2), fluoroscopy could also be used for establishing portals for arthroscopy in small joints such as the carpometacarpal joint of the thumb and the distal radioulnar joint.
THE JOURNAL OF HAND SURGERY VOL. 22B No. 5 OCTOBER 1997
In time, these portable fluoroscopy units will become more affordable, encouraging widespread use, particularly in the emergency room and office. Fractures and dislocations could be quickly assessed, without the need for the patient to be transported to the X-ray department. We conclude that the new generation portable fluoroscopy units are well suited to hand and upper limb surgery, return control to the operating surgeon and extend surgical capabilities. References Bain GI, Richards RS, Roth JH. Arthroscopy of the wrist: introduction and indications. In: McGinty JB, Caspari RB, Jackson RW, Poehling GG (Eds.): Operative arthroscopy, 2nd edn. Philadelphia, Lippincott-Raven, 1996a: 897-904. Bain GI, Richards RS, Roth JH. Wrist arthroscopy: indications and technique. In: Peimer CA (Ed.): Surgery of the hand and the upper extremity. New York, McGraw-Hill, 1996b, Vol. 1: 867-882. Bain GI, Roth JH (1995). The role of arthroscopy in arthritis. "Ectorny" procedures. Hand Clinics, 11:51 58. Coltman JW (1948). Fluoroscopic image brightening by electronic means. Radiology, 15:359 366. Gehrke JC, Mellenberg DE, Donelly RE (1993). The fluoroscan imaging system in foot and ankle surgery. Foot and Ankle, 14: 545-549.
Received: 8 January 1997 Accepted alter revision:2 April 1997 Dr G. 1. Bain, Department of Orthopaedic Surgery,Modbury Public Hospital, Smart Road, South Australia 5092, Australia. © 1997The British Societyfor Surgeryof the Hand
FLUOROSCOPY IN HAND LIMB SURGERY
AND
UPPER
One hundred cases G. I. BAIN, J. HUNT and J. A. MEHTA
From the Modbury Public Hospital, Modbury, South Australia, Australia We reviewed the use of a low radiation portable fluoroscopy unit in 100 patients. The most common indication was closed reduction of distal radial fractures. Fracture and joint stability were assessed on the real-time monitor and stored on videotape. Static images were stored on thermographic paper. Fluoroscopically guided joint injections and localization of implants, foreign bodies and bone tumours were performed. Fluoroscopy is a useful adjunct to arthroscopic assisted fracture reduction and other arthroscopic procedures such as distal ulnar resection. These new generation units produce superior resolution images, are easy to manoeuvre and do not require a radiographer.
Journal of Hand Surgery (British and European Volume, 1997) 22B." 5." 656-658 Intraoperative fluoroscopy was first used by Coltman (1948) and since then has been used extensively in many areas of surgery. Advances in fluoroscopic technology have enabled high resolution images to be obtained using significantly lower doses of radiation (Gehrke et al, 1993). The new generation fluoroscopy units are compact, portable and have a smaller C-arm. Their application has been reported in foot and ankle surgery (Gehrke et al, 1993). The purpose of this paper is to review our clinical experience with portable operative fluoroscopy in hand and upper limb surgery. METHOD AND MATERIALS
An analysis of the use of low radiation fluoroscopy in 100 patients with upper limb problems treated at the North Eastern Community Hospital, Adelaide, South Australia, was performed. All were treated by one surgeon (GIB) between May 1995 and February 1996 using the 3 inch Fluoroscan (Fluoroscan Imaging Systems Inc., Illinois) (Fig 1). This unit is smaller than conventional fuoroscopy machines. It has an adjustable boom with three degrees of freedom, allowing the mini C-arm to be placed in any position. Image production is initiated with a foot pedal. The onboard computer automatically adjusts the voltage and amperage to provide high quality images using minimal radiation. Static or realtime images were obtained and recorded on thermographic paper or video tape. In accordance with the South Australian Radiation Protection and Control Act 1982, the operating surgeon obtained a restricted radiation licence and all staff within the operating theatre were required to wear a 0.25 mm lead apron and a thermoluminescent dosimeter (TLD).
...............
Fig 1
Portable low dose fluoroscopy unit.
Other indications included open reduction of fractures (Fig 2). Dynamic assessment of fracture stability was performed in real-time including assessment of reduction in several planes. Images were immediately reproduced on thermographic paper. The fluoroscopy unit was used to aid in insertion of two Austofix humeral intramedullary nails and perform distal cross-locking. The proximal humerus was adequately visualized but the limited working distance within the mini C-arm made cross locking technically
RESULTS
Details of patients are presented in Table 1. The most common indication was closed reduction and percutaneous K-wire fixation of distal radial fractures. 656
OPERATIVE FLUOROSCOPY
Fig 2
657
Open reduction and internal fixation of fracture of the scaphoid.
Table 1--List of cases
Fig 3
Diagnostic block with insertion of hypodermic needle into thumb carpometacarpal joint under fluoroscopic control.
Trauma
Closed reduction of fractures Percutaneous reduction of fractures Arthroscopic assisted reduction of fractures Application of PIP joint Compass Hinge Humeral closed intra-medullary nailing Foreign bodies Total trauma cases
8 25 12 8 2 3 58
Elective
Limited and full wrist fusion CMC joint fusion Examination of joint stability Arthroscopic "-ectomy" procedures Diagnostic joint injection Localization of bone tumour Removal of implants Total elective cases
7 2 4 3 3 3 20 42
more difficult than when using a conventional image intensifier. Fluoroscopy was used for the assessment of joint stability. The superior ~esolution of the new generation fluoroscopy units was valuable for removal of small foreign bodies and percutaneous K-wires. It was also useful in localizing bony tumours (e.g. enchondromas) and confirming the adequacy of their resection. Diagnostic anaesthetic blocks of the carpometacarpal joint of the thumb and acromioclavicular joint were performed by advancing the needle into the joint under fluoroscopic control (Fig 3). In the management of intraarticular distal radial fractures, radial head fractures, scaphoid fractures and scapholunate dissociation, 'joysticks' were placed into the fracture/bony fragments under fluoroscopy. These
Table 2--Indications for fluoroscopy in hand and upper limb surgery
Assessment of fracture and joint stability Assessment of reduction of fractures and dislocations Assessment of position of internal fixation Localization of implants, foreign bodies and tumours Assessment of arthroscopic and open "-ectomy" procedures Therapeutic and diagnostic joint injection Dynamic and static arthrography
fragments were then manipulated under arthroscopic control with the 'joysticks' and an intraarticular probe to obtain an optimal reduction (Bain et al, 1996a; 1996b). The alignment and the position of the internal fixation was assessed with fluoroscopy. As the fluoroscopy unit was controlled by the surgeon, the manipulation of the C-arm was performed with precision, thus reducing surgical time. None of the patients in this group required formal open reduction. Fluoroscopy was used to determine the adequacy of arthroscopic resection of the radial head, radial styloid and the distal ulna (Bain and Roth, 1995). DISCUSSION
Portable fluoroscopy is a useful diagnostic and therapeutic tool in hand and upper limb surgery (Table 2). It offers a number of advantages over conventional image intensifiers, which are bulky, difficult to manoeuvre, produce larger amounts of radiation and have inferior
658
resolution. In contrast, the new generation portable fluoroscopy units are small, easy to manoeuvre, produce a fraction of the radiation and have superior resolution. They are controlled and operated by the surgeon and therefore do not require a radiographer. Images are printed immediately on to thermographic paper or stored on video tape. The thermographic images are cheaper, small enough to be kept in patient notes and eliminate storage problems associated with X-ray films. Reproductions can be made with a photocopier. The new generation portable fluoroscopy units have a radiation intensity measured in micro-amps compared with those of conventional units which are measured in milli-amps (Gehrke et al, 1993). The patient and surgical staff are exposed to significantly less radiation from the primary beam and radiation scatter. Gehrke et al (1993) calculated that with a very high work load, a surgeon 30 cm from the fluoroscopy unit would receive 0.56 mR/ year which is considerably less than the permissible exposure for the general public of 100 mR/year. Because of the low radiation levels, some American states have legislated that surgical staff are not required to wear lead aprons (Gehrke et al, 1993). As well as its other uses (Table 2), fluoroscopy could also be used for establishing portals for arthroscopy in small joints such as the carpometacarpal joint of the thumb and the distal radioulnar joint.
THE JOURNAL OF HAND SURGERY VOL. 22B No. 5 OCTOBER 1997
In time, these portable fluoroscopy units will become more affordable, encouraging widespread use, particularly in the emergency room and office. Fractures and dislocations could be quickly assessed, without the need for the patient to be transported to the X-ray department. We conclude that the new generation portable fluoroscopy units are well suited to hand and upper limb surgery, return control to the operating surgeon and extend surgical capabilities. References Bain GI, Richards RS, Roth JH. Arthroscopy of the wrist: introduction and indications. In: McGinty JB, Caspari RB, Jackson RW, Poehling GG (Eds.): Operative arthroscopy, 2nd edn. Philadelphia, Lippincott-Raven, 1996a: 897-904. Bain GI, Richards RS, Roth JH. Wrist arthroscopy: indications and technique. In: Peimer CA (Ed.): Surgery of the hand and the upper extremity. New York, McGraw-Hill, 1996b, Vol. 1: 867-882. Bain GI, Roth JH (1995). The role of arthroscopy in arthritis. "Ectorny" procedures. Hand Clinics, 11:51 58. Coltman JW (1948). Fluoroscopic image brightening by electronic means. Radiology, 15:359 366. Gehrke JC, Mellenberg DE, Donelly RE (1993). The fluoroscan imaging system in foot and ankle surgery. Foot and Ankle, 14: 545-549.
Received: 8 January 1997 Accepted alter revision:2 April 1997 Dr G. 1. Bain, Department of Orthopaedic Surgery,Modbury Public Hospital, Smart Road, South Australia 5092, Australia. © 1997The British Societyfor Surgeryof the Hand