Unveiling Real3D Imaging with Robotic Advanced X-Ray - All Extremities

The title of our study was our clinical experience with real 3D augmented radiographs of the upper and lower extremities. This is a new concept that we adopted in our emergency department setting. These are our disclosures and disclaimers again. So the objectives of our study was to evaluate diagnostic performance in detecting extremity fractures between real 3D multi planar reconstruction or MP Rs and conventional radiographs or CRS alone and to assess the diagnostic quality of real 3 DMPR. I'll start with showing you some of these images that we got. This is an elbow SASTRO NPR image. You notice how nice these images look. You can see very good delineation of osseous structures and soft tissues. Here's another example of a coronal NPR of the metal car pose and the wrist. And you'll notice that 5th metacarpal fracture as well as really nice delineation of the cortices and detailed evaluation of the trabajillae. This is another MPR image of the foot 9 in the axial plane and you'll notice some artifact. However again, and as Doctor Dunn said, in our experience, we haven't really had issues with these sorts of artifacts in interpreting our images. You'll notice again excellent cortical delineation, trabecular detail as well as if you put these images on soft tissues, you'll actually get quite good soft tissue contrast for interpretation purposes. Our methods included a single centre retrospective review. We acquired our data from January to April of 2023. Each exam had a conventional radio graph in multiple planes as well as MPR images that were reconstructed. Two radiologists sequentially interpreted the CR and MPR images and looked at the quality of the study based on a four point liquor scale to evaluate the image quality. Scoring in terms of methods are a diagnostic testing. Analysis was performed with reference standard or reference standard was if the patient had short term follow up imaging with cross-sectional imaging and the fracture was confirmed or excluded, or if the patient came back within two weeks with a healing fracture on radiographs or follow up cross-sectional imaging. If the patient did not come back with follow up imaging including healing fractures or confirmatory cross-sectional imaging, than that patient was deemed negative for a fracture. We did a binary classification as positive or negative for fractures both on CRS and MPRS and then we performed an inter class correlation coefficient for inter reader reliability. These are some of our results when it comes to diagnostic analysis. As you can see, we had 58 cases, sixteen of which were positive for fractures. Of those 16 cases, the conventional radiographs only detected about eight of those cases, and we also have three false positive cases with conventional radiographs. As you can see, NPR detected all sixteen of those fractures, which gives us really good sensitivity and specificity for this technology. Klopper Pearson 95% confidence interval for test accuracy for fracture detection was also performed, which shows a wider range for conventional radiographs between .69 and .9. However, for real 3D and PR, those values were much higher with a significant statistical P value. All of the cases of our undiagnosed fractures, unconventional radiographs were non displaced and PR was also able to identify 2 cases of soft tissue pathology that weren't really evident on unconventional radiographs. In terms of our image quality, 88% of those images were deemed adequate or higher than needed image quality. Per the image quality scoring criteria by one of the radiologists, 4% was qualified as poor primarily due to patient motion and 8% of limited quality due to high nose noise and those were really related to body habitus. Our ICC was 0.79, indicating good inter reader reliability. We also took the time to look at how long it took for our technologists to perform this exam and that time is from the time the patient entered our suite to when the patient exited the suite. And as you can see, as we looked at this time within the 1st 30 days of imaging, our technologies, we're not familiar with this technology. And so it took them quite a bit of time to position some of these patients and acquire the images. And so we had outliers to begin with. As we went on to the second and 3rd 30 days of our study, you can see that they were able to get better at imaging and positioning these patients faster. And so the outliers were fewer and fewer. And we were able to shave off about 10 minutes of our in and out time when it came to this technology. I also like to share some of our images and cases that we had so I can highlight the MPR usage in addition to conventional radiographs. This first case is a 22 year old man with right ankle pain after seizure. And as you can see on those lateral radiographs, so there is a non displaced evaluative type fracture at the dorsal aspect of the tailor head at the site of attachment of the dorsal tailor navicular capsule. You will also notice that there is a Halo calcaneal, uh, I'm sorry, an avicular calcaneal coalition as uh, denoted by the white circle. Uh, here is a blown up image showing you that a bolsive type fracture at the dorsal aspect of the tailor head. As we look at the Mr. images, you'll again notice that I've also type fracture of the dorsal tailor head. However, there were nondislaced fractures of the bone at the Taylor Calcaneum Coalition. Uh, uh, where you'll see that blue arrows and here's another image of the coalition where you can see the fiber osseous appearance of it. Here's our second case of a 46 year old man who was unable to bear weight after ice hockey injury. On frontal and lateral radiographs, you'll notice that there's not a big joint of fusion and no displaced fractures are identified. We can't really see fractures, although we did look at all of these on PAX imaging and I'm showing you images on a screen obviously of lower quality than our diagnostic monitors. As we looked at our MPR images, however, we see a depressed fracture of the posterior lateral tibial plateau and that was confirmed on MRI imaging. When we turned into our soft tissue windows, we see soft tissue prominence along that medial joint line where the MCL resides and this was confirmed on MRI imaging where there is soft tissue demand, redundancy of the MCL. This MCL was torn off of its tibial attachment. Our third case is a 19 year old man with wrist pain after snowboarding injury and on the lateral radiograph that this the radial fracture is no mystery. However, when we looked at the NPR images, we also noticed soft tissue findings of lipohemerthosis in an extensor tendon sheath. The NPR images were of such high quality that our orthopedic surgeons who usually like to get cross-sectional imaging for preoperative planning really did not need additional imaging after we acquired these set of images for them. Our 4th case is a 62 year old woman with fall out, fall on outstretched hand, prior fracture fixation 1 1/2 years earlier of the distal radius. And on the frontal and lateral radiographs, you'll notice the placing screw fixation of the distal radius which kind of get in the way of fracture detection. But at least on these radiographs, we were not able to see fractures. However, when we looked at the NPR images, as you'll see on those axial images there is St. Artifact but you'll see those non displaced fractures planes but the dorsal aspect of the radius on the SEO images as well as on the of sexual images where there is buckling of that posterior distal radial cortex. And so this patient had an acute fracture with prior fracture deformity and fixation of the distal radius. When we looked at the coronal images of the same case, we noticed scapalunate dissociation which was not evident on our radio graphic images. Our fifth case is a 73 year old woman with knee pain and difficulty weight bearing after slipping on stairs. As we look at the frontal and lateral grafts of the knee, the radiologist detected a joint of fusion and then they astutely saw this linear mineralization along the lateral tibial plateau and thought that might be a non displaced fracture. However, when we looked at the NPR images, you'll notice that focus of mineralization was related to an anterior osteophyte of the lateral tibial plateau. And so this was one of our false positive cases. The fusion in this case was likely related to osteoarthritic changes of the knee are 6 cases, a 49 year old man with their finger being hit by a sledgehammer. The mildly displaced transverse fracture of the ring finger metal failings is again no diagnostic mystery on the radiographs. You'll see them on both frontal and lateral radiographs. However, when we looked at the NPR images and I'm including the unremarkable index finger as comparison on axial and satch to images, you'll notice that on the soft tissue window, there is abrupt thinning of the flexor digitorum profundus at the site of attachment on the distal failings. And on the normal index, you'll see this kind of uniform thickness of the flexor digitorum profundus tendon as it attaches to the distal failings. And so we thought there was FDP pathology and we mentioned it. And when the orthopaedic surgeon went in to fix the fracture, they also noticed the laceration of the FDP and that got repaired as well as or if of the metal failings. Our 7th case is a 23 year old man with snowboarding elbow injury. This was a hyperextension injury on the lateral elbow radiograph and you'll notice that there is no joint effusion and that's one of the things that we typically look for in these trauma cases of the elbow. When there is an effusion, non displaced, a cold fracture is often suspected video graphically. However, lack of effusion kind of gives us a little bit more confidence in saying there's no fracture. But when in this case we looked at the NPR images, we actually saw a nondisplaced fracture of the coronary process, even though this patient had not accumulated a lot of effusion at this point. In terms of limitations, obviously, this is the retrospective study with a small sample size from a single institution and more and more data needs to be collected and possibly in a prospective fashion. In conclusion, our initial results indicate that real 3D is significantly more accurate than conventional radiographs for fracture detection and can be performed with high quality in the Ed setting. The study is ongoing to acquire more cases and perform an Roc analysis. In closing, I'd like to say that our augmented XR exam, which is our national radio graphs plus real 3D is a new protocol that can increase just confidence in detecting fractures in the Ed setting. These are my references. And with that, we're going to turn over to the panel discussion.

0.93 16 0.83 0.73 42 39 0.5 40 20 09 60 36346312 36346312. Revolutionizing Trauma Diagnosis Unveiling Real3D Imaging with Robotic Advanced X-Ray All Extremities Clinical Experience with Real3D Augmented XR Exam of Upper Maryam Soltanolkotabi and Lower Extremities A New Concept for Early Extremity Fracture Lee, Clara Detection in the Emergency Department Setting Maryam Soltanolkotabi, MD Frederic Noo HEALTH CUNIVERSITY OF UTAH HEALTH DELL P DUNN UNIVERSITY OF UTAH The productClinical Experience with Real3De not availability Augmented XR Exam of Upper commerciall available in Their future Dr. Noo, Dr. Soltanolland Lower Extremities mployed by an institution that receives financial support from Siemens Healthineers for collaborations. The statements by customers of Siemens Healthineers described herein are based on resultA New Concept for Early Extremity Fracture etting. exist (e.g ., hospital size, samples mix, case mix, level of IT and/or automation adoption) there can be no guarantee that other customers will achieve the same reMaryam Soltanolkotabi, MD Disclosures/disclaimers The product/feature and/or service offerings mentioned herein are not commercially available in all countries and/or for all modalities. Their future availability cannot be guaranteed. Dr. Noo, Dr. Soltanolkotabi, Dr. Dunn and Dr. Kelly are all employed by an based on results that were achieved in the customer's unique setting. Because there is no "typical" hospital or laboratory and many variables will achieve the same results. OBJECTIVES · To evaluate diagnostic performance in detecting extremity fractures of: Real3D Multiplanar Reconstructions (MPR) VS. Conventional Radiograph (CR) alone . To assess the diagnostic quality of Real3D MPR. Real3D imaging of an unremarkable elbow Bone windowow MPR Images a hand/wristawitle fx Real3D imaging of a foot/ankle METHODS · A single-center retrospective review · January-April 2023 · Each exam includes CR and MPR Two radiologists -Interpret CR and MPR - Scored image quality, IQSC METHODS (CONT.) Reference standard negative for fracture. reliability. · Diagnostic testing analysis with · Binary classification as positive or · The intraclass correlation coefficient (ICC) was calculated for inter-reader True Negative False Positive True Positive Total Cases Sensitivity Specificity PPV NPV (n=58) CR MPR RESULTS-FRACTURE DETECTION False Negative RESULTS (CONT.) accuracy for fracture detection: [0.69,0.9] for CR [0.94,1.0] for Real3D MPR p-value <. 03 · All cases of undiagnosed fractures on CR were nondisplaced. reliabilitYdentified two cases of soft tissue pathology not evident on CR RESULTS-Image Quality · 88%: adequate or higher than needed image quality per the IQSC criteria by one radiologist. · 4%: poor quality primarily due to patient motion. · 8%: limited quality due to high noise (body · ICC was 0.79, indicating good inter-reader habitus). reliability RESULTS- Exam Time Exam Time: Time to position the patient and complete an exam in minutes. Time (minute) First 30-Days Second 30-Days Third 30-Days CASE 1 22-year-old man with right ankle pain after seizure. 46-year-old man unable to bear weight after ice hockey injury. 19-year-old man with wrist pain after snowboarding injury. 62-year-old woman with FOOSH, prior fx fixation 1.5 years earlier. slipping on stairs. 73-year-old woman with knee pain and difficulty weightbearing after LJ 49-year-old man, finger hit by sledgehammer. Index Long Ring 23-year-old man with snowboarding elbow hyperextension injury. LIMITATIONS · Retrospective design · Small sample size from single institution CONCLUSION · Initial results indicate that Real3D is significantly more accurate than CR for fracture detection and can be performed with high quality in the ED setting. . The study is ongoing to acquire more cases and perform an ROC analysis. CLOSING REMARKS Our augmented XR exam (CR + Real3D) is a new protocol that can increase radiologist confidence in detecting fractures in the ED REFERENCES Free Cone-Beam CT in Acute Elbow Trauma. Radiology. 2023 Mar:306(3):e221200. doi: 10.1148/radiol.221200. Epub 2022 Nov 8. PMID: Grunz JP, Gietzen CH, Kunz AS, Weng AM, Veyhl-Wichmann M. Ergün S, Bley TA, Schmitt R, Gassenmaier T. Twin Robotic X-Ray System for 3D Cone-Beam CT of the Wrist: An Evaluation of Image Quality and Radiation Dose. AJR Am J Roentgenol. 2020 Feb:214(2):422-427. doi: 10.2214/AJR.19.21911. Epub 2019 Dec 4. PMID: 31799871. Twin robotic x-ray system in small bone and joint trauma: impact of cone-beam computed tomography on treatment decisions. Eur Radiol. 2021 Jun:31(6):3600-3609. doi: 10.1007/s00330-020-07563-5. Epub 2020 Dec 5. PMID: 33280057; PMCID: PMC8128787. Grunz JP, Weng AM, Gietzen CH, Veyhl-Wichmann M, Pennig L, Kunz A, Schmitt R, Ergün S, Bley TA, Gassenmaier T. Evaluation of Ultro- obotic Radiography potential in con igh-resolution cone-beam CT imaging with a twin roboti Sci Rep. Klintström E, Klintström B, Spångeus A, Sandborg M, Woisetschläger M. Trabecular bone microstructure analysis on data from a novel twin PMC10088033 3-D x-ray system: phantom-based comparison of 3-D tomography with conventional computed tomography. J Med Imaging (Bellingham). 2018 Jan;5(1):015502. doi: 10.1117/1.JMI.5.1.015502. Epub 2018 Mar 6. PMID: 29541651; PMCID: PMC5839419. beam CT with a twin robotic x-ray system in elbow imaging: comparison of image quality to high-resolution multidetector CT. Eur Radiol Exp. 2020 Sep 8;4(1):52. doi: 10.1186/s41747-020-00177-y. PMID: 32895778; PMCID: PMC7477066 High-Resolution Cone-Beam CT Prototype of Twin Robotic Radiography System for Cadaveric Wrist Imaging. Acad Radiol. 2021 Oct:28(10):e314-e322. doi: 10.1016/j.acra.2020.06.018. Epub 2020 Jul 10. PMID: 32654956 Luetkens KS, Ergün S, Huflage H, Kunz AS, Gietzen CH, Conrads N, Pennig L, Goertz L, Bley TA, Gassenmaier T, Grunz JP. Dose reduction potential in cone-beam CT imaging of upper extremity joints with a twin robotic x-ray system. Sci Rep. 2021 Oct 11;11(1):20176. doi: 10.1038/s41598-021-99748-1. PMID: 34635787; PMCID: PMC8505435. using a novel twin robotic X-ray system: Assessment of image quality and radiation dose. Eur J Radiol. 2019 Oct;119:108659. doi: 10.1016/j.ejrad.2019.108659. Epub 2019 Sep 7. PMID: 31520930. Kunz AS, Patzer TS, Grunz JP, Luetkens KS, Hartung V, Hendel R, Fieber T, Genest F, Ergün S, Bley TA, Huflage H. Metal artifact reduction in ultra-high-resolution cone-beam CT imaging with a twin robotic X-ray system. Sci Rep. 2022 Sep 16;12(1):15549. doi: 10.1038/s41598-022- 19978-9. PMID: 36114270; PMCID: PMC9481547. Webinar Outline · Learning objectives · Introduction to Real3D imaging technology · Clinical experience with knee imaging · Clinical experience over all extremities Stay tuned. An interdisci robotic advanced X-ray will follow An interdisciplinary panel discussion on the use of Real3D imaging with Siemens Healthineers AG, 2024 Multitom Rax is not commercially available in all countries. Due to regulatory reasons its future availability cannot be guaranteed. Please contact your local Siemens Healthineers organization for further details. True2scale Body Scan and Real3D are options. The statements by customers of Siemens Healthineers described herein are based on results that were achieved in the customer's unique setting. Because there is no "typical" hospital and many variables exist (e.g ., hospital size, case mix, level of IT and/or automation adoption) there can be no guarantee that other customers will achieve the same results. Speakers are employed by an institution that receives financial support from Siemens Healthineers for collaborations. SIEMENS Healthineers