EOS in MEDIC presented in Thailand, Dr NGUYEN VAN CONG, MEDIC MEDICAL CENTER

Giơi thiêu hê thông XQ EOS của Medic

T i BV Bangkok General Hospital & BV aChulalongkorn t i Bangkok Thai Lana

Bangkok

BV Chulalonkorn

Bangkok General Hospital

EOS : a new dimension to radiological outcome

NGUYEN VAN CONG MD, RADIOLOGISTMEDIC CENTER, HCMC, VIET NAM

ABOUT HOA HAO MEDIC CENTER, HCMC, VIET NAM

www.medic.com.vn

Activity of Medic Center

• Private clinic since 1990, with more than 700 employees in which there are about 250 doctors.

• Director : Dr Phan Thanh Hai• We work from 4 am to 7 pm (7 day a week) • Around 1000 – 1500 patients/day • Specialized in diagnostic purposes as Medical imaging:

– 3 CT scan machines (Toshiba Aquilion 1 with 320 detectors)– 3 MRI of 1.5 tesla (Siemens, GE…)– 10 rooms of conventional x ray using DR (Canon, Konica Minolta,

Samsung, Drtech…)– 50 US machine (Siemens, GE, Samsung, Philips, Aloka…)– Modern automated lab machines from Siemens, Roche, Abbott,

Horiba…– 1 EOS system since October 2014

How does it work?

Clinical Goals & Challenges for MSK Imaging

Dose Reduction

Diagnostic Confidence

Throughput

Less Dose = reduced cancer risk

Reduced exam time :-> more patients -> better economical model

No stitching High image quality No Magnification3D measurements

= reduced errors risk

CT scan of the spine

CT SCAN FOR FULL SPINE: SUPINE POSITION , HEAVY RADIATION

Dose Reduction

BEFORE EOS IMAGING

CT SCAN FOR FULL SPINE: SUPINE POSITION , HEAVY RADIATION

Dose Reduction

BEFORE EOS IMAGING

FULL SPINE WITH STITCHING USING DRDose

Reduction

BEFORE EOS IMAGING

• Conventional stiching:• Full spine= 2.5 mSv• CT scan of the spine =10 mSv Compared with EOS: Full spine AP & LAT= 0,358 mSv – 0,470 mSv ( 1 Sv = 1 Gy = 1 J/kg)

Radiation dose in conventional stitching = 5-7 fold of EOS system.

Radiation dose in CT scan = 21-28 fold of EOS system.

COMPARISON WITH OTHER MODALITIESDose

Reduction

BEFORE VS WITH EOS IMAGING

Average skin dose reduced from 6 to 9 times in the

thoraco-abdominal region when using the slot-scanner

instead of CR with equivalent or better image

quality(1)

Medical Imaging Radiation is a Public Health Concern

(1)Diagnostic imaging of spinal deformities: reducing patients radiation dose with a new slot-scanning X-ray imager. Deschenes S, Charron G, Beaudoin G, Labelle H, Dubois J, Miron MC, Parent S. Spine (Phila Pa 1976)2010 Apr 20;35(9):989-94(2)Comparison of radiation dose, workflow, patient comfort and financial break-even of standard digital radiography and a novel biplanar low-dose X-ray system for upright full-length lower limb and whole spine radiography. Dietrich TJ, Pfirrmann CW, Schwab A, Pankalla K, Buck FM. Skeletal Radiol. 2013.

EOS provides upright full-length lower limb and whole spine

at 2 times less dose than the best tuned DR (2)

CR EOS


Reduction

WITH EOS IMAGING

Medical Imaging Radiation is a Public Health Concern

Micro Dose average dose/examination is equivalent to 7 days of background radiation


Reduction

WITH EOS IMAGING

Micro Dose in MEDIC: •For pediatric patients with leg lenghth discrepancy under 10 y.o•In the future for pediatric patients which are coming for scoliosis follow up •For school screening program for scoliosis in HCMC?

The quality is good enough for measuring leg lenght or detect abnormal curve of the spine

Dose Reduction

WITH EOS IMAGING

FULL LEG LENGTH WITH MICRODOSEDose

Reduction

WITH EOS IMAGING


Dose Reduction


Throughput





THROUGHPUT

Patient in the examination room

Image processing

Transfer to PACS

Throughput


EOS DR (MEDIC)

Lower limbs

3 min 15 min

Spine

3min 15 min


Dose Reduction


Throughput





Diagnostic Confidence STITCHING OF IMAGES

To obtain full spine or full leg xray, at least 4 exposures are needed, for AP and lateral views

The patient much be stand still for at least 60”

BEFORE EOS IMAGING


BEFORE EOS IMAGING

STITCHING OF IMAGES

Using special software, our IT will stich x-ray pictures manually, very time consuming (15’ at least)

STITCHING OF IMAGESDiagnostic Confidence

BEFORE EOS IMAGING


BEFORE EOS IMAGING

CONVENTIONAL DR RADIOGRAPHY STICHING


BEFORE EOS IMAGING

The limitation of x-ray imaging is diagnostic error due to stitching

High rates of stitching errors (16%) have been reported and contribute to the dissatisfaction of

surgeons with respect to the spine radiographs produced by stitching(*)


BEFORE EOS IMAGING

(*) Diagnostic errors from digital stitching of scoliosis images – the importance of evaluating the source images prior to making a final diagnosis .Nucharin Supakul & Keith Newbrough & Mervyn D. Cohen & S. Gregory Jennings, Pediatr Radiol (2012)

Fully

Automated stitching

Xray MACHINE


BEFORE EOS IMAGING


BAD STITCHING

KEY POINTS

•We cannot do the whole body stitching.

•Difficulty with weak patient, motion artifact..can reduce quality or failure to stich.

BEFORE EOS IMAGING


EOS allows full body AP/LAT acquisition in one scan with no diagnostic error due

to stitching


WITH EOS IMAGING

EOS: LINEAR SCAN -> NO STITCHING OF IMAGES

Full leg length DR stiching, 2 contrast between zones is bad

Diagnostic Confidence IMAGE QUALITY

EOS

homogeneous image, high image quality due to automatic ajustement of the detector

Poor contrast between zone due to the same exposure parameters for different zones

homogeneous image, high image quality due to automatic ajustement of the detector


EOS

IMAGE QUALITY

Diagnostic Confidence IMAGE QUALITY

EOShomogeneous image, high image quality due to automatic ajustement of the detector

We use e-film sofware to measure:

1st we must define the ruler by measuring the width of a DR panel (35x43mm) and by that ruler we make the mensurations which doesn’t mean that we correct the beam magnification

Inaccuracy of mensuration


While EOS correct the magnification automatically with the software and from the linear scan technology

EOS provide a true size image

70

cm

80

cm

70

cm

70

cm

Conventional xray EOS

Linear detector

scan

MAGNIFICATION OF IMAGESDiagnostic Confidence


KEY POINTS

Manually done and also due to xray beam magnification, the measurement of length, angles of the spine, lower limb are not accurate.

BEFORE EOS IMAGING

With 2 orthogonal xrays, STEREOS can recontructs a 3D picture help us to measure 3D deformity in scoliosis, malformation of lower limbs etc…

3D MEASUREMENTSDiagnostic Confidence

WITH EOS IMAGING

SCOLIOSIS PATIENT WITH

EOS X RAY WITH 3D RECONSTRUCTION AND MEASUREMENT RESULTS

WITH EOS IMAGING

WITH EOS IMAGING

Diagnostic Confidence 3D MEASUREMENTS

2D can not evaluate torsions and rotation

phenomena

EOS 3D measurements allows for a more accurate evaluation of hip-knee-ankle

(HKA) angle(6)And femoral offset(7) compared

to 2D

(6)Evaluation of a new low-dose biplanar system to assess lower-limb alignment in 3D: a phantom study: P. Thelen & C. Delin & D.Folinais & C. Radier, skeletal radiology, 2012(7)Offset and anteversion reconstruction after cemented and uncemented total hip arthroplasty: an evaluation with the low dose EOS system comparing 2 and 3 dimensional imaging: J.Y. Lazennec, A. Brusson, D. Folinais, M.A. Rousseau, A.E. Pour, International orthopedics, 2014

The limitation of x-ray imaging is diagnostic error due to inaccurate 2D measurement


Diagnostic Confidence MEDIC patient Y: 2D measurements 1 view


Pelvic tilt: 2.1 cm

Right Leg: Valgus

Left Leg: Varus

Functional length discrepancy:

2.5 cm (left leg shorter)

Anatomical length discrepancy:


2D diagnostic

Diagnostic Confidence MEDIC patient Y:EOS + 3D

measurements


3D diagnostic

Pelvic tilt: 2.1 cm

Right Leg: Valgus 5°

Left Leg: Valgus 12°

Functional length

discrepancy: 2.4 cm (left leg

shorter)

Anatomical length

discrepancy: 0,7 cm

(right leg shorter)

Knee flexion on left side 43°

Diagnostic Confidence 2D measurement VS 3D measurements


3D diagnostic

Pelvic tilt: 2.1 cm

Right leg: Valgus 5°

Left leg: Valgus 12°

Functional length discrepancy:


Anatomical length discrepancy:

0,7 cm (right leg shorter)

Knee flexion on left side 43°

2D diagnostic

Pelvic tilt: 2.1 cm

Right leg: Valgus

Left Leg : Varus

Functional length


shorter)

Anatomical length


shorter)

Only 3D weight bearing measurement allows an exact assessment of patient

anatomy

SOME EXAMPLES OF IMAGES PERFORMED AT MEDIC CENTER

BENDING TEST

FOLLOW-UP

SCOLIOSIS

SAME PATIENT

POST SURGICALLY TREATED

FULL BODY X RAY

EOS FULL SPINE WITHOUT AND WITH BRACE

FULL BODY OF PATIENT WITH TOTAL HIP ARTHROPLASTY

Conclusion EOS xray system with it advantages:

– Low radiation dose – Fast workflow without stitching – Hight image quality with good accurate measurements 2D & 3D– Weight bearing positionning

EOS answers to the increasing demand of orthopedic surgeons for accurate measurements.

So, EOS will replace old conventional stitching Xrays

Orthopedic activities in HCMC Viet Nam

• In HCMC there are 4 hospitals specialized on Orthopedic surgery, 3 rehabilitation centers for treatment of spine deformation, leg length discrepancy, hip and knee arthroplasty… (more than 2000 cases per year)

• The need for orthopedic imaging with physiologic weight bearing, acurate measurement of angles, length…is increasing

PROMOTIONAL ACTIVITIES

How do we increase the number of patients?

Arthoplasty congress in Saigon-ITO


21st Annual Meeting of The Spine Society of Ho Chi Minh City in Nha Trang in December 2014


Our guests from Thailand

PROMOTIONAL ACTIVITIES21st Annual Meeting of The Spine Society of Ho Chi Minh City in Nha

Trang in December 2014

PROMOTIONAL ACTIVITIES21st Annual Meeting of The Spine Society of Ho Chi Minh City in Nha

Trang in December 2014

Dr Nguyen Van Cong

(Radiologist EOS user at MEDIC)

Dr Vo Van Thanh

(Spine surgeon EOS user at MEDIC)

Prof Jorg Franke – Germany

Sagittal balance and the EOS System experiences from a German spine center

21st Annual Meeting of The Spine Society of Ho Chi Minh City in Nha Trang in December 2014


Invitation of an international German speaker (EOS user)

Medic Center is private, we can afford best equipments to serve our customers.

Quality, acceptable cost, time saving are our advantages

For EOS xray system mainly orthopedic patients sent by surgeons, rehabilitation physicians, chiropractors...

PROMOTIONAL ACTIVITIESFrom where are the patients coming to have an EOS in MEDIC?

ACTIVITY ASSESSMENT AFTER 6 MONTHS

• Number of patients in 6 month: 835• Mean patient/day: 4 -> 8• Max patient/ day: 10 -> 20

– Full body: 49%– Full spine: 36%– Full leg length: 15%

Thank You for your attentionReference:1. Diagnostic errors from digital stitching of scoliosis images – the importance of evaluating the source

images prior to making a final diagnosis Nucharin Supakul & Keith Newbrough & Mervyn D. Cohen & S. Gregory Jennings, Pediatr Radiol (2012)

2, Ionizing radiation doses during lower limb torsion and anteversion measurements by EOS stereoradiography and computed tomography: Delin C, Silvera S, Bassinet C , Thelen P, Rehel JL, legmann P, Folinais D. Eur J Radiol. 2013.

(4) Ultra low dose imaging for the follow up of idiopathic scoliosis: How low is reasonably achievable with new slot-scan technology? Alison M, Ferrero E, Tanase A, Rega A, Ilharreborde B, Mazda K, Sebag G. Communication at RSNA 2013

5. Diagnostic imaging of spinal deformities: reducing patients radiation dose with a new slot-scanning X-ray imager. Deschenes S, Charron G, Beaudoin G, Labelle H, Dubois J, Miron MC, Parent S. Spine (Phila Pa 1976)2010 Apr 20;35(9):989-94

6. Comparison of radiation dose, workflow, patient comfort and financial break-even of standard digital radiography and a novel biplanar low-dose X-ray system for upright full-length lower limb and whole spine radiography. Dietrich TJ, Pfirrmann CW, Schwab A, Pankalla K, Buck FM. Skeletal Radiol. 2013.

EOS in MEDIC presented in Thailand, Dr NGUYEN VAN CONG, MEDIC MEDICAL CENTER

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Transcript of EOS in MEDIC presented in Thailand, Dr NGUYEN VAN CONG, MEDIC MEDICAL CENTER