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Portable mini-fluoroscopy improves operative efficiency in hand surgery
Portable Mini-Fluoroscopy Improves Operative Efficiency in Hand Surgery Jennifer Moriatis Wolf, MD, Arnold-Peter C. Weiss, MD, Providence, RI A paired case cohort study was performed using retrospective review of operative times for defined hand surgical procedures in an attempt to quantify efficiency with and without the use of portable fluoroscopy. Patients included in the study underwent 1 of 4 defined surgical procedures controlled to ensure similar operative technique (total wrist fusion, in situ 4-corner fusion, closed reduction/internal fixation using K-wires of phalangeal shaft fractures, and metacarpophalangeal or interphalangeal joint fusions using K-wires). One group used intraoperative standard film radiographs and the other used portable mini-fluoroscopy to examine hardware placement. Both groups were paired by operative procedure to eliminate procedure bias on overall operating time. Analysis demonstrated a 38% reduction in total operative time in the group using portable mini-fluoroscopy compared with standard intraoperative radiographs. (J Hand Surg 1999;24A:182–184. Copyright © 1999 by the American Society for Surgery of the Hand.) Key words: Fluoroscopy, operative time, portable, efficiency, surgery.
The use of internal fixation either by open technique or percutaneous methods has required radiographic confirmation of hardware placement. Classic methods have centered on the use of intraoperative standard anteroposterior and lateral radiographs for examining hardware placement and length relationships. Due to the time of film development inherent in this technique and the potential to require alteration of the hardware placement, substantial inefficiencies during surgical procedures can occur. The use of fluoroscopy in place of standard radiographs has been limited due to the high radiation exposure associated with larger units. The recent introduction From the Division of Hand, Upper Extremity, and Microvascular Surgery, Department of Orthopaedics, Brown University School of Medicine, Rhode Island Hospital, Providence, RI. Received for publication February 25, 1998; accepted in revised form July 13, 1998. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Arnold-Peter C. Weiss, MD, University Orthopedics, Inc, 2 Dudley St, 2nd Floor, Providence, RI 02905. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A01-0027$3.00/0
182 The Journal of Hand Surgery
of portable mini-fluoroscopic units providing substantially lower levels of intraoperative radiation exposure and immediate feedback of hardware placement has provided the potential for improved efficiency. This paired case cohort study of 4 standard surgical procedures using internal hardware placement examines total operative time between groups examined by standard radiographic methods and portable mini-fluoroscopy.
Materials and Methods Thirty patients who had undergone 1 of 4 standard hand surgical procedures were included in the study via retrospective chart review of operative time parameters. All surgical procedures were performed by the senior surgeon. All patients underwent surgery during a 15-month period for the defined surgical procedures. This study time interval was chosen since a portable mini-fluoroscopic unit was purchased approximately halfway through the time period by our hospital and because it was long enough to allow enough patients with fairly standard procedures to be accumulated. In addition, because the
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 183
procedures came from the senior surgeon’s surgical log during this time interval, any significant experience bias was eliminated. Surgical procedures included in this study were those in which the authors felt extrinsic variables (ie, age, sex, obesity, degree of arthritis or fracture displacement, associated injuries, and time from injury) would not have a significant effect on operative time due to the nature of the procedure itself. The 4 surgical procedures examined included total wrist fusion, in situ 4-corner fusion, closed reduction/internal fixation using K-wires of phalangeal shaft fractures, and metacarpophalangeal (MCP) or interphalangeal (IP) joint fusions using K-wires. All patients undergoing total wrist fusion had posttraumatic degenerative disorders without significant segmental bone loss; the procedure was performed by standard dorsal plate fixation with local bone graft augmentation. All patients undergoing 4-corner fusion had a concomitant scaphoid excision; the surgery was performed to treat scapholunate advanced collapse of the wrist or radioscaphoid arthritis, with fixation being performed by identical staple technique and local distal radius bone grafting. All cases of phalangeal shaft fractures underwent surgery within 10 days of the date of injury and did not involve an articular component or comminution. All of the MCP or IP joint fusions were conducted to treat posttraumatic osteoarthritis; the MCP joint fusions involved the thumb in all patients and the IP joint fusions involved only the fingers (no thumb IP joint fusions were performed). These 4 surgical procedures were chosen by the senior author since little variation in surgical technique would be required to accomplish each of the procedures technically. Other potential surgical procedures, such as open reduction/internal fixation of proximal interphalangeal fracture/dislocations, were not felt to be appropriate since the technical difficulties of obtaining appropriate reduction and fixation vary widely depending on the fracture type and displacement. We examined 15 cases that had undergone these procedures using standard intraoperative anteroposterior and lateral radiographs and 15 cases that had undergone identical procedures using portable minifluoroscopy (FluoroScan Imaging Systems, Northbrook, IL). All the portable mini-fluoroscopies were performed by the surgeon; the standard intraoperative radiographs were performed by a radiologic technician who both took the radiographs and developed the films. Each group of 15 patients consisted
of 3 total wrist fusions using a dorsal wrist fusion plate and local bone graft, 3 cases of closed reduction/internal fixation using K-wires for unstable phalangeal shaft fractures, 2 cases of in situ 4-corner fusions for intercarpal ligament instability, and 7 cases of either MCP or IP joint fusions using a cup and cone technique and K-wire fixation. Operating room charts were reviewed to determine the total tourniquet and operative times for each of the procedures. Operating time was specifically calculated based on records indicating the time from incision to completion of the operative procedure. In our hospital, these 2 parameters are documented for each procedure performed. In no case was anesthesia time used in calculating the operative time. Dictated operative reports were reviewed to ensure that surgical technique for each of the paired groups was nearly identical to eliminate technical components affecting the overall operative time. In each procedure group, the average operative time for each method of radiographic evaluation was determined and normalized to a ratio. The subsequent ratios from each of the 4 procedures were averaged to determine operative efficiency based on the radiographic evaluation method. Statistical analysis of raw data was performed using InStat 2.0 Software (GraphPad Software, San Diego, CA) by ANOVA; significance was defined as p , .05.
Results In each of the 4 surgical procedure groups examined, the use of the portable mini-fluoroscopic unit improved overall operating time efficiency. Operative efficiency increased the most in the closed reduction/internal fixation of phalangeal fracture group, with a 55% decrease in total operating time. Operating time decreased 39% in the total wrist fusion group and 48% in the in situ 4-corner fusion group. In the MCP/IP fusion group, operating time decreased 19%. Overall, a statistically significant (p , .05) decrease of 38% in total operating time was noted for the groups using portable mini-fluoroscopic evaluation of hardware placement compared with the groups using intraoperative plain radiographs (Table 1). None of the cases using portable mini-fluoroscopy took longer to perform than any of the cases using intraoperative plain radiographic evaluation.
Discussion The safety and effectiveness of portable fluoroscopy has been demonstrated in a clinical study of its
184 Wolf and Weiss / Mini-Fluoroscopy Improves Operative Time
Table 1. Summary of Data Surgical Procedure
No. of Cases
Average Operating Room Time Ratio (Radiographs/Mini-Fluoroscopy)
Time Efficiency Improvement With Mini-Fluoroscopy
Total wrist fusion 4-corner fusion CRIF phalanx fracture MCP/IP joint fusion Overall efficiency improvement
6 4 6 14 30
96 min/59 min (1.6:1) 90 min/47 min (1.9:1) 40 min/18 min (2.2:1) 38 min/31 min (1.2:1) 1.6:1 (weighted to no. of cases)*
39% 48% 55% 19% 38%*
CRIF, closed reduction/internal fixation * p , .05.
use in emergency management of distal extremity fractures.1 This study demonstrated both a reduction in overall radiation exposure in patients treated with closed manipulation of multiple types of distal extremity fractures and an improved success rate overall of fracture manipulation by using portable fluoroscopic techniques compared with standard radiographic methods. In addition, technical tips in the use of portable mini-fluoroscopy have been reported to improve efficiency in patients undergoing foot and ankle surgery.2 Although intraoperative image quality from portable mini-fluoroscopy is not equal to that of standard radiography, the use of fluoroscopy enables multiple images to be obtained, providing greater viewing versatility. We believe that the quality versus versatility issue generally equates the 2 techniques relative to the ability of either of them to define hardware placement for fracture reduction. Improvement in operative time is obviously the one variable that provides significant advantage for the use of fluoroscopic methods. One of the most important issues for the hand surgeon, as well as hospital administrators and commercial insurers, is whether this type of unit actually improves overall outcome of hardware placement and/or improves efficiency of the surgical procedure based on immediate feedback of hardware placement. Improved efficiency is often balanced against the cost of obtaining a portable mini-fluoroscopic unit compared with maintaining the standard radiographic plate technique, which is invariably already available. Our study demonstrates an overall 38% reduction in operative time when examining 1 of 4 standard surgical procedures undertaken by the hand surgeon. Using reasonable assumptions
($1,000/hr operating room time, including anesthesia; average hand surgeon 5 300 cases/yr, of which 20% would use mini-fluoroscopy; average case operating room time before fluoroscopy for this subset of cases 5 50 minutes), the cost savings is estimated to be $19,000 per year and the average hand surgeon could perform an additional 40 to 80 operations per year. It appears that even with a high error assumption on this estimate, portable mini-fluoroscopy is extremely cost-effective to both institutions and surgeons, especially in situations of multiple surgeon utilization. This study may underestimate improvement in overall operating room time efficiency since the largest number of cases were in the group with the smallest efficiency improvement in operating room time. Although for control purposes this study only examined 4 particular surgical procedures, we have found portable mini-fluoroscopy useful for any operative procedure that involves osseous anatomy or hardware placement. We have found that the use of the portable mini-fluoroscope makes complex surgical procedures substantially easier due to immediate feedback and, based on the results of this study, more efficient and indirectly cost-effective.
References 1. Lee SMK, Orlinsky M, Chan LS. Safety and effectiveness of portable fluoroscopy in the emergency department for the management of distal extremity fractures. Ann Emerg Med 1994;24:725–730. 2. Gehrke JC, Mellenberg DE Jr, Donnelly PA-C, Johnson KA. The fluoroscan imaging system in foot and ankle surgery. Foot Ankle 1993;545–549.
The use of internal fixation either by open technique or percutaneous methods has required radiographic confirmation of hardware placement. Classic methods have centered on the use of intraoperative standard anteroposterior and lateral radiographs for examining hardware placement and length relationships. Due to the time of film development inherent in this technique and the potential to require alteration of the hardware placement, substantial inefficiencies during surgical procedures can occur. The use of fluoroscopy in place of standard radiographs has been limited due to the high radiation exposure associated with larger units. The recent introduction From the Division of Hand, Upper Extremity, and Microvascular Surgery, Department of Orthopaedics, Brown University School of Medicine, Rhode Island Hospital, Providence, RI. Received for publication February 25, 1998; accepted in revised form July 13, 1998. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Arnold-Peter C. Weiss, MD, University Orthopedics, Inc, 2 Dudley St, 2nd Floor, Providence, RI 02905. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A01-0027$3.00/0
182 The Journal of Hand Surgery
of portable mini-fluoroscopic units providing substantially lower levels of intraoperative radiation exposure and immediate feedback of hardware placement has provided the potential for improved efficiency. This paired case cohort study of 4 standard surgical procedures using internal hardware placement examines total operative time between groups examined by standard radiographic methods and portable mini-fluoroscopy.
Materials and Methods Thirty patients who had undergone 1 of 4 standard hand surgical procedures were included in the study via retrospective chart review of operative time parameters. All surgical procedures were performed by the senior surgeon. All patients underwent surgery during a 15-month period for the defined surgical procedures. This study time interval was chosen since a portable mini-fluoroscopic unit was purchased approximately halfway through the time period by our hospital and because it was long enough to allow enough patients with fairly standard procedures to be accumulated. In addition, because the
The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 183
procedures came from the senior surgeon’s surgical log during this time interval, any significant experience bias was eliminated. Surgical procedures included in this study were those in which the authors felt extrinsic variables (ie, age, sex, obesity, degree of arthritis or fracture displacement, associated injuries, and time from injury) would not have a significant effect on operative time due to the nature of the procedure itself. The 4 surgical procedures examined included total wrist fusion, in situ 4-corner fusion, closed reduction/internal fixation using K-wires of phalangeal shaft fractures, and metacarpophalangeal (MCP) or interphalangeal (IP) joint fusions using K-wires. All patients undergoing total wrist fusion had posttraumatic degenerative disorders without significant segmental bone loss; the procedure was performed by standard dorsal plate fixation with local bone graft augmentation. All patients undergoing 4-corner fusion had a concomitant scaphoid excision; the surgery was performed to treat scapholunate advanced collapse of the wrist or radioscaphoid arthritis, with fixation being performed by identical staple technique and local distal radius bone grafting. All cases of phalangeal shaft fractures underwent surgery within 10 days of the date of injury and did not involve an articular component or comminution. All of the MCP or IP joint fusions were conducted to treat posttraumatic osteoarthritis; the MCP joint fusions involved the thumb in all patients and the IP joint fusions involved only the fingers (no thumb IP joint fusions were performed). These 4 surgical procedures were chosen by the senior author since little variation in surgical technique would be required to accomplish each of the procedures technically. Other potential surgical procedures, such as open reduction/internal fixation of proximal interphalangeal fracture/dislocations, were not felt to be appropriate since the technical difficulties of obtaining appropriate reduction and fixation vary widely depending on the fracture type and displacement. We examined 15 cases that had undergone these procedures using standard intraoperative anteroposterior and lateral radiographs and 15 cases that had undergone identical procedures using portable minifluoroscopy (FluoroScan Imaging Systems, Northbrook, IL). All the portable mini-fluoroscopies were performed by the surgeon; the standard intraoperative radiographs were performed by a radiologic technician who both took the radiographs and developed the films. Each group of 15 patients consisted
of 3 total wrist fusions using a dorsal wrist fusion plate and local bone graft, 3 cases of closed reduction/internal fixation using K-wires for unstable phalangeal shaft fractures, 2 cases of in situ 4-corner fusions for intercarpal ligament instability, and 7 cases of either MCP or IP joint fusions using a cup and cone technique and K-wire fixation. Operating room charts were reviewed to determine the total tourniquet and operative times for each of the procedures. Operating time was specifically calculated based on records indicating the time from incision to completion of the operative procedure. In our hospital, these 2 parameters are documented for each procedure performed. In no case was anesthesia time used in calculating the operative time. Dictated operative reports were reviewed to ensure that surgical technique for each of the paired groups was nearly identical to eliminate technical components affecting the overall operative time. In each procedure group, the average operative time for each method of radiographic evaluation was determined and normalized to a ratio. The subsequent ratios from each of the 4 procedures were averaged to determine operative efficiency based on the radiographic evaluation method. Statistical analysis of raw data was performed using InStat 2.0 Software (GraphPad Software, San Diego, CA) by ANOVA; significance was defined as p , .05.
Results In each of the 4 surgical procedure groups examined, the use of the portable mini-fluoroscopic unit improved overall operating time efficiency. Operative efficiency increased the most in the closed reduction/internal fixation of phalangeal fracture group, with a 55% decrease in total operating time. Operating time decreased 39% in the total wrist fusion group and 48% in the in situ 4-corner fusion group. In the MCP/IP fusion group, operating time decreased 19%. Overall, a statistically significant (p , .05) decrease of 38% in total operating time was noted for the groups using portable mini-fluoroscopic evaluation of hardware placement compared with the groups using intraoperative plain radiographs (Table 1). None of the cases using portable mini-fluoroscopy took longer to perform than any of the cases using intraoperative plain radiographic evaluation.
Discussion The safety and effectiveness of portable fluoroscopy has been demonstrated in a clinical study of its
184 Wolf and Weiss / Mini-Fluoroscopy Improves Operative Time
Table 1. Summary of Data Surgical Procedure
No. of Cases
Average Operating Room Time Ratio (Radiographs/Mini-Fluoroscopy)
Time Efficiency Improvement With Mini-Fluoroscopy
Total wrist fusion 4-corner fusion CRIF phalanx fracture MCP/IP joint fusion Overall efficiency improvement
6 4 6 14 30
96 min/59 min (1.6:1) 90 min/47 min (1.9:1) 40 min/18 min (2.2:1) 38 min/31 min (1.2:1) 1.6:1 (weighted to no. of cases)*
39% 48% 55% 19% 38%*
CRIF, closed reduction/internal fixation * p , .05.
use in emergency management of distal extremity fractures.1 This study demonstrated both a reduction in overall radiation exposure in patients treated with closed manipulation of multiple types of distal extremity fractures and an improved success rate overall of fracture manipulation by using portable fluoroscopic techniques compared with standard radiographic methods. In addition, technical tips in the use of portable mini-fluoroscopy have been reported to improve efficiency in patients undergoing foot and ankle surgery.2 Although intraoperative image quality from portable mini-fluoroscopy is not equal to that of standard radiography, the use of fluoroscopy enables multiple images to be obtained, providing greater viewing versatility. We believe that the quality versus versatility issue generally equates the 2 techniques relative to the ability of either of them to define hardware placement for fracture reduction. Improvement in operative time is obviously the one variable that provides significant advantage for the use of fluoroscopic methods. One of the most important issues for the hand surgeon, as well as hospital administrators and commercial insurers, is whether this type of unit actually improves overall outcome of hardware placement and/or improves efficiency of the surgical procedure based on immediate feedback of hardware placement. Improved efficiency is often balanced against the cost of obtaining a portable mini-fluoroscopic unit compared with maintaining the standard radiographic plate technique, which is invariably already available. Our study demonstrates an overall 38% reduction in operative time when examining 1 of 4 standard surgical procedures undertaken by the hand surgeon. Using reasonable assumptions
($1,000/hr operating room time, including anesthesia; average hand surgeon 5 300 cases/yr, of which 20% would use mini-fluoroscopy; average case operating room time before fluoroscopy for this subset of cases 5 50 minutes), the cost savings is estimated to be $19,000 per year and the average hand surgeon could perform an additional 40 to 80 operations per year. It appears that even with a high error assumption on this estimate, portable mini-fluoroscopy is extremely cost-effective to both institutions and surgeons, especially in situations of multiple surgeon utilization. This study may underestimate improvement in overall operating room time efficiency since the largest number of cases were in the group with the smallest efficiency improvement in operating room time. Although for control purposes this study only examined 4 particular surgical procedures, we have found portable mini-fluoroscopy useful for any operative procedure that involves osseous anatomy or hardware placement. We have found that the use of the portable mini-fluoroscope makes complex surgical procedures substantially easier due to immediate feedback and, based on the results of this study, more efficient and indirectly cost-effective.
References 1. Lee SMK, Orlinsky M, Chan LS. Safety and effectiveness of portable fluoroscopy in the emergency department for the management of distal extremity fractures. Ann Emerg Med 1994;24:725–730. 2. Gehrke JC, Mellenberg DE Jr, Donnelly PA-C, Johnson KA. The fluoroscan imaging system in foot and ankle surgery. Foot Ankle 1993;545–549.