Download The Mini C-arm Adds Quality and Efficiency to the Pediatric

n Feature Article
The Mini C-arm Adds Quality and Efficiency
to the Pediatric Orthopedic Outpatient Clinic
Matthew G. Fanelli, MD; William L. Hennrikus, MD; Jennifer M. Slough Hill, MD;
Douglas G. Armstrong, MD; Steven H. King, CHP, CMHP
abstract
The mini C-arm has become increasingly popular in the practice of orthopedics. To the authors’ knowledge, its use in the pediatric orthopedic outpatient
clinic has not been reported. The purpose of this study was to evaluate the
practice efficiency and radiation exposure to the patient when the mini C-arm
was used in the pediatric orthopedic outpatient clinic. One hundred consecutive midshaft and distal forearm fractures were evaluated by one orthopedic
surgeon in follow-up using a mini C-arm. For each case, the radiation physicist
calculated the amount of skin exposure in milligray (mGy). The average skin
exposure to the patient from the mini C-arm was 0.58 mGy, compared with
0.2 mGy for anteroposterior view and lateral view radiographs. Use of the mini
C-arm, in place of plain radiographs obtained in the radiology department,
decreased time waiting during clinic visits by 23 minutes. This study reports 2
important findings. First, surprisingly, the mini C-arm used a slightly higher radiation dose than standard imaging with plain radiographs. Second, use of the
mini C-arm saved time and improved the efficiency of the clinic visit. Overall,
the mini C-arm improves quality and efficiency in the pediatric orthopedic
outpatient clinic. [Orthopedics. 2016; 39(6):e1097-e1099.]
T
he mini C-arm has become increasingly popular in the practice
of orthopedics. In the outpatient
clinic, it improves practice efficiency by
eliminating the need for formal radiographs in some cases.1 Without the need
to travel to the radiology department, the
time spent traveling to and waiting for imaging studies is reduced.2
The mini C-arm had previously been
primarily studied in the operating room
and the emergency department. In the
emergency department, Lee et al3 reported that the mini C-arm exposed patients
to less radiation than radiographs when
reducing pediatric forearm fractures. This
finding3 represents a trend in the literature
suggesting that the mini C-arm exposes
NOVEMBER/DECEMBER 2016 | Volume 39 • Number 6
patients to a lower radiation dose than
plain radiographs.2,4 Lee et al3 estimated
the radiation dose for each reduction from
the number of paper images that the resident printed and saved during the fracture
reduction. However, Sumko et al5 found
that Lee et al3 and other authors underestimated radiation exposure from the mini
C-arm. Sumko et al5 accurately measured
the radiation exposure by recording the
amount of kilovolts and milliamps and the
number of seconds of foot pedal use.
To the authors’ knowledge, use of the
mini C-arm in the pediatric orthopedic
outpatient clinic has not been reported.
The purpose of this study was to evaluate
the practice efficiency and radiation exposure to the patient when the mini C-arm is
used in this setting.
The authors are from the Department of Orthopaedic Surgery (MGF, WLH, JMSH, DGA) and
the Division of Health Physics (SHK), Penn State
College of Medicine, Hershey, Pennsylvania.
The authors have no relevant financial relationships to disclose.
Correspondence should be addressed to:
William L. Hennrikus, MD, Department of Orthopaedic Surgery, Penn State College of Medicine,
30 Hope Dr, Hershey, PA 17033 (whennrikus@
hmc.psu.edu).
Received: February 25, 2016; Accepted: July
28, 2016.
doi: 10.3928/01477447-20160808-01
e1097
n Feature Article
Figure: Lateral view of the follow-up evaluation
of a distal forearm fracture using the mini C-arm
(OrthoScan, Inc, Scottsdale, Arizona).
Materials and Methods
The Penn State College of Medicine
Institutional Review Board approved this
study. All data were de-identified once
collected from charts and reported in
aggregate form only. One hundred consecutive pediatric forearm fractures were
evaluated by one orthopedic surgeon
(W.L.H.) in follow-up in the outpatient
clinic using a mini C-arm (OrthoScan,
Inc, Scottsdale, Arizona). An examination room in the back corner of the clinic
was exclusively designated for the use
and storage of the mini C-arm. Per the
radiation physicist (S.H.K.), no lead lining or other modifications of the room
were necessary for safe operation of the
mini C-arm.
For each fracture evaluation, the radiation emitted in milligray (mGy) and the
time in seconds were recorded. The treating surgeon includes a paragraph in the
clinic note stating that the mini C-arm was
used, the interpretation of the images obtained, the radiation emitted, and the time
of radiation exposure. A log book is also
kept with the patient information and corresponding radiation emitted and time of
radiation exposure. The log book is examined by radiation physics on an annual basis. Using these data, a radiation physicist
(S.H.K.) calculated the amount of skin
exposure for each fracture evaluated. This
study examined fractures evaluated in the
pediatric orthopedic outpatient clinic that
were previously reduced in the emergency
department. The mini C-arm was used to
assess fractures for postreduction healing,
loss of reduction, and/or potential growth
arrest. Because approximately 5% of reduced fractures displace in the cast, imaging is an important component of fracture
follow-up care.6 The Figure shows an image obtained with the mini C-arm.
For comparison with the time needed
to obtain conventional plain radiographs
in the radiology department, time data for
20 consecutive forearm fractures imaged
in the radiology department were record-
Table
Radiation Exposure by Fracture Category
Total No.
Average
Age, y
No. Male
No. Female
Radiation
Exposure to
Skin, mGy
45
11.6
29
16
0.56
Ulna
2
10.0
1
1
0.74
Radius/ulna
38
10.3
25
13
0.61
0
0
0
0
0
Ulna
2
8.0
2
0
0.36
Radius/ulna
13
5.8
8
5
0.54
Fracture Category
Distal
Radius
Midshaft
Radius
e1098
ed. Descriptive statistics were generated.
The treating orthopedic surgeon wore his
hospital-issued radiation safety badge for
all mini C-arm evaluations.
Results
One hundred postreduction evaluations
were studied. The sex distribution was
65% male and 35% female. The average
age was 10.3 years (range, 1-17 years).
The fractures evaluated were divided into
6 categories based on their location (distal
or midshaft forearm) and the bones involved (radius, ulna, or both). The most
common fracture patterns were those of
the distal radius (45%), distal radius and
ulna (38%), and midshaft radius and ulna
(13%). The remaining fracture categories
encompassed a smaller proportion of the
fractures evaluated (Table). The average
external skin radiation exposure to the
patient was 0.58 mGy and the average
length of exposure was 1.22 seconds. The
surgeon did not experience changes in radiation safety badge exposure during the
study. Use of the mini C-arm, in place of
radiographs obtained in the radiology department, which is located 25 yards down
the hall, decreased imaging wait times by
23 minutes (range, 18-29 minutes) in the
authors’ clinic.
Discussion
At the authors’ institution, a forearm
radiograph exposes the patient to 0.10
mGy of radiation per view. This value is
comparable to those reported in the literature.3 The authors’ policy for followup fracture care dictates obtaining an
anteroposterior view and a lateral view
of the fracture. This exposes patients to
0.20 mGy of radiation with each set of
radiographs obtained. Based on the data
collected, use of the mini C-arm exposes
patients to more radiation than comparable radiographs.5,7 Sharieff et al8 reported
that the image quality from the mini Carm was highly reliable and that these
images could be used as an alternative to
postreduction radiographs. On the basis
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n Feature Article
of their experience with the patients in
this study, the current authors concur with
Sharieff et al.8
When obtaining imaging studies, the
diagnostic information provided must be
weighed against the theoretically damaging radiation to which the patient is exposed, particularly in the form of cancers
and genetic damage.9 Radiation exposure
to patients can be minimized by using dosereducing recommendations.10 The authors’
institution has a policy of minimizing radiation exposure when using the mini C-arm.
These recommendations include having
physicians stand away from the mini C-arm
(2 m if possible), using lead aprons (including by the patient), having physicians keep
their hands out of the beam, and minimizing unnecessary imaging.11-14
In the current study, use of the mini
C-arm decreased the overall length of
follow-up visits. Compared with radiographs obtained in the radiology department, use of the mini C-arm decreased
imaging wait times by 23 minutes. Decreased appointment times have an important impact on patient satisfaction
scores. In today’s practice environment,
patient satisfaction is used by health care
systems as a measure of quality. Segal et
al15 found that waiting time significantly
correlated with the rating of providers on
patient satisfaction surveys in pediatric
orthopedic practices. The more timeefficient workflow achieved by incorporating the mini C-arm into orthopedic
practice will potentially improve patient
satisfaction scores, increasing the quality
measured.
The decrease in time spent waiting for
imaging has increased the time available
for seeing patients. The authors estimate
that use of the mini C-arm has enabled
2 new patients to be seen per half day of
clinic or 4 new patients to be seen per full
day of clinic. With professional and facil-
ity fees, the authors estimate that this increase in new patients seen correlates with
an additional $500 in billing per half day
of clinic or $1000 in billing per full day of
clinic. Charges for a plain radiograph of
the distal or midshaft forearm total $300:
$150 for the radiograph technician fee and
$150 for the radiologist fee. Because the
authors do not charge a technical or reading fee when the mini C-arm is used in the
pediatric orthopedic outpatient clinic, the
patient saves $300. The primary expense
of operating the mini C-arm is the printer
paper ($360 per year). The increased billing from the efficiency created by the mini
C-arm offsets the operating expense of the
mini C-arm unit.
Shortcomings of the current study
included its retrospective design, small
sample, just one mini C-arm unit being
studied, and data being collected from
only one surgeon and center.
Conclusion
Use of the mini C-arm in the pediatric orthopedic outpatient clinic led to 2
important findings. First, surprisingly,
the mini C-arm used a slightly higher radiation dose than standard imaging with
plain radiographs. Second, use of the mini
C-arm saved time and improved the efficiency of the clinic visit. Use of personal
protective equipment and safe imaging
practices is recommended to enhance
safety. Overall, the mini C-arm improves
quality and efficiency in the pediatric orthopedic outpatient clinic.
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