Plain Films are Still the Answer : The Right Views Everytime - PowerPoint PPT Presentation

Plain Films are Still the Answer : The Right Views Everytime Benjamin G. Domb, M.D. Medical Director, American Hip Institute Director of Orthopedics, Adventist Hinsdale Hospital David Maldonado, M.D. Fellow, American Hip Institute Hinsdale Orthopaedics

Disclosures • American Hip Institute a , AANA Learning Center Committee a , Adventist Hinsdale Hospital c , Arthroscopy Journal a , Amplitude c , Arthrex b,c,d , DJO Global d , Medacta b,c , Orthomerica d , Stryker b,c a – boardmember; b – research support; c – consulting; d – royalty; e - stockholder • Hinsdale Orthopaedics

My Experience • Used CT w 3D recons for >500 cases • I realized I was no longer gaining any info from CT • Why? o My brain adapted to build a 3D model in my mind from the x-rays Hinsdale Orthopaedics

Our Protocol: What are we looking for? Osteoarthritis: • AP pelvis  Early signs od OA. • o Supine  T ӧ nnis grade, joint space o Standing Coverage: •  LCEA,T ӧ nnis angle, ACEA Bilateral Dunn view • Acetabular architecture: • False Profile •  Cross-over sign  Retroversion signs Neck-Head junction: •  Alpha angle  Off-set Hinsdale Orthopaedics

Early Signs of OA Hinsdale Orthopaedics

Joint space, not only in AP but False Profile View Hinsdale Orthopaedics

LCE angle of Wiberg with Ogata modification * Hinsdale *Ogata S et al, J Bone Joint Surg Br. 1990 Orthopaedics

T ӧ nnis angle Hinsdale Orthopaedics

Ischial, Cross-over, and Posterior Wall signs Hinsdale Orthopaedics

Alpha angle and Off-set Hinsdale Orthopaedics

ACE angle Hinsdale Orthopaedics

By the end, just with X-rays... AP pelvis False Profile Dunn view (S & U) Joint space Coverage Acetabular version Sphericity Coverage Joint space Early OA “Normal” Overcovered Cam Dysplasia Early OA Yes Dysplasia No Yes Yes No Yes No No True “Borderline” Space ≥ 2mm Dysplasia Dysplasia Anterior Retroversion Yes No overcoverage No Yes Yes Yes No Posterior deficiency No Hinsdale Orthopaedics

What are we missing? • Femoral version • Can we obtained it without CT? Hinsdale Orthopaedics

MRI for Femoral Version Botser IB, Ozoude GC, Martin DE, Siddiqi AJ, Kuppuswami S, Domb BG. Femoral Anteversion in the Hip: Comparison of Measurement by Computed Tomography, Magnetic Resonance Imaging, and Physical Examination Arthroscopy. 2012 May;28(5):619-27 Schneider B, Laubenberger J, Jemlich S, Groene K, Weber HM, Langer M. Measurement of femoral antetorsion and tibial torsion by magnetic resonance imaging. Br J Radiol. 1997;70(834):575–579. Hinsdale Orthopaedics

Still thinking in CT for everybody... Computed Tomography Scans in Patients With Young Adult Hip Pain Carry a Lifetime Risk of Malignancy. Wylie JD et al. Arthroscopy 2017 “Protocols with CT scans of the hip/pelvis pose (...) a large relative risk (5-17 times) of cancer compared with radiographs alone in the imaging evaluation for hip pain that decreases with increasing age”. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. Miglioretti DL et al. JAMA Pediatr 2013 “Nationally, 4 million pediatric CT scans of the head, abdomen/pelvis, chest, or spine performed each year are projected to cause 4870 future cancers”. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Smith-Bindman et al. Arch Intern Med 2009 Radiation doses from commonly performed diagnostic CT examinations were higher and more variable than generally quoted. Benefits of CT imaging must be balanced against the potential harm from its associated radiation. Hinsdale Orthopaedics

Low dose CT In fact is 50% less that standard CT, but safe enough ? Biswas D., Bible JE., Bohan M., Simpson AK., Whang PG., Grauer JN., Radiation exposure from musculoskeletal computerized tomographic scans, J Bone Joint Surg Am., August 2009, 91(8):1882-9 Hinsdale Orthopaedics

Radiation Facts • Background Radiation dose from natural sources is approximately 3 mSv per year. • Round-trip flight from New York to London is 0.1 mSv. • CT = 3½ years of background radiation or 108 round-trip flights from New York to London. • What about just 1 lower-dose CT scan preoperatively ??? • 1 to 2 years of background radiation and 35 to 57 round-trip flights from New York to London Computed Tomography Scans in Patients With Young Adult Hip Pain Carry a Lifetime Risk of Malignancy. Wylie JD et al. Arthroscopy 2017 Hinsdale Orthopaedics

Conclusion 1) Consider getting CT in your first 300 hip arthroscopies. After that, you likely won’t gain any information from it. 2) Remember: “Do no harm...” 3) Downsides is cancer 4) The experienced hip surgeon can get all the info we need from X-rays, complement with MRA and avoid the downsides of CT. Hinsdale Orthopaedics

Thank You www.AmericanHipInstitute.org Benjamin G. Domb, M.D. Medical Director, American Hip Institute Director of Orthopedics, Adventist Hinsdale Hospital Hinsdale Orthopaedics