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Marcel AJ, Alaia EF, Alaia MJ, Katz LD, Medvecky MJ, Porrino J. Perspectives and institutional policies on patient safety and image quality regarding the use of knee-spanning external fixators in MRI: A survey study of the Society of Skeletal Radiology. Skeletal Radiol 2024; 53:525-536. [PMID: 37695343 DOI: 10.1007/s00256-023-04445-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/18/2023] [Accepted: 08/26/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVE Concerns regarding patient safety and image quality have made the use of knee-spanning external fixators in MRI a challenging clinical scenario. The purpose of our study was to poll practicing musculoskeletal radiologists on their personal experiences regarding the use of knee-spanning external fixators in MRI in an effort to consolidate practice trends for the radiologists' benefit. METHODS A 27-item survey was created to address the institutional use, safety, adverse events, quality, and perspectives of the radiologist related to MRI of an externally fixated knee. The survey was distributed to 1739 members of the Society of Skeletal Radiology. RESULTS A total of 72 members of the Society of Skeletal Radiology completed the survey. Most notably, 40 of 72 (55.56%) respondents are permitted to place a knee-spanning external fixator inside the MR bore at their institution, while19 of 72 (26.39%) respondents are not permitted to do so. Fourteen of 32 (43.75%) respondents have institutional guidelines for safely performing an MRI of an externally fixated knee. Twenty-five of 32 (78.13%) respondents are comfortable permitting an MRI of an externally fixated knee. CONCLUSION We found a general lack of consensus regarding the decision to scan a patient with a knee-spanning external fixator in MRI. Many institutions lack safety guidelines, and providers rely upon a heterogeneous breadth of resources for safety information. A re-examination of the FDA device labeling nomenclature and expectations of the individual manufacturers may be needed to bridge this gap and help direct management decisions placed upon the provider.
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Affiliation(s)
- Aaron J Marcel
- Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, CT, USA.
| | - Erin F Alaia
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Michael J Alaia
- Division of Sports Medicine, Department of Orthopaedic Surgery, New York University Langone Orthopedic Center, New York, NY, USA
| | - Lee D Katz
- Department of Radiology, Musculoskeletal Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Michael J Medvecky
- Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Jack Porrino
- Department of Radiology, Musculoskeletal Imaging, Yale School of Medicine, New Haven, CT, USA
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Marcel AJ, Green JS, Alaia EF, Alaia MJ, Katz LD, Medvecky MJ. Patient Safety in MRI with the Use of a Joint-Spanning External Fixator for Knee Dislocation: A Critical Analysis Review. JBJS Rev 2023; 11:01874474-202308000-00002. [PMID: 37535762 DOI: 10.2106/jbjs.rvw.23.00070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
» Universal safety guidelines for the use of a knee-spanning external fixator in magnetic resonance imaging (MRI) are unlikely to be established considering the high variability in device construct configurations.» Per the US Food and Drug Administration, manufacturers are to provide parameters for safe MRI scanning for "MR Conditional" devices; however, such labeling may be limited in detail. Physicians should reference manufacturer labels as a starting point while making an educated clinical decision.» Scanning of a knee-spanning external fixator inside the MR bore has been safely demonstrated in previous studies, although with small sample sizes.» When considering MRI in a patient treated with a knee-spanning external fixator, physicians should use all available resources and coordinate with their medical team to make a clinically reasonable decision contrasting patient benefit vs. potential harm.
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Affiliation(s)
- Aaron J Marcel
- Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut
| | - Joshua S Green
- Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut
| | - Erin F Alaia
- Department of Radiology, NYU Grossman School of Medicine, New York, New York
| | - Michael J Alaia
- Division of Sports Medicine, Department of Orthopaedic Surgery, New York University Langone Orthopaedic Center, New York, New York
| | - Lee D Katz
- Department of Radiology, Musculoskeletal Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Michael J Medvecky
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
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Magnetic Resonance Imaging of the Knee in the Presence of Bridging External Fixation: A Comparative Experimental Evaluation of Four External Fixators, Including Dolphix ®. J Funct Morphol Kinesiol 2021; 7:jfmk7010004. [PMID: 35076530 PMCID: PMC8788467 DOI: 10.3390/jfmk7010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/22/2021] [Accepted: 12/28/2021] [Indexed: 11/17/2022] Open
Abstract
Performing MR investigation on patients instrumented with external fixators is still controversial. The aim of this study is to evaluate the quality of MR imaging of the knee structures in the presence of bridging external fixators. Different cadaveric lower limbs were instrumented with the MR-conditional external fixators Hofmann III (Stryker, Kalamazoo, MI, USA), Large external Fixator (DePuy Synthes, Raynham, MA, USA), XtraFix (Zymmer, Warsaw, IN, USA) and a newer implant of Ketron Peek CA30 and ERGAL 7075 pins, Dolphix®, (Citieffe, Bologna, Italy). The specimens were MR scanned before and after the instrumentation. The images were subjectively judged by a pool of blinded radiologists and then quantitatively evaluated calculating signal intensity, signal to noise and contrast to noise in the five regions of interest. The area of distortion due to the presence of metallic pins was calculated. All the images were considered equally useful for diagnosis with no differences between devices (p > 0.05). Only few differences in the quantification of images have been detected between groups while the presence of metallic components was the main limit of the procedure. The mean length of the radius of the area of distortion of the pins were 53.17 ± 8.19 mm, 45.07 ± 4.33 mm, 17 ± 5.4 mm and 37.12 ± 10.17 mm per pins provided by Zimmer, Synthes, Citieffe and Stryker, respectively (p = 0.041). The implant of Ketron Peek CA30 and ERGAL 7075 pins showed the smallest distortion area.
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Ryan S, Moon AS, Gordon M, Flacke S, Soni S, Salzler MJ, Stelma S, Marcantonio A. External Fixation Devices Within the Magnetic Resonance Imaging Bore: A Safety and Radiologic Analysis. J Orthop Trauma 2021; 35:e25-e30. [PMID: 32482974 DOI: 10.1097/bot.0000000000001848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To (1) report the thermal changes encountered at the pin/skin interface in a cadaver with a knee-spanning external fixator inside the magnetic resonance imaging (MRI) bore and (2) report on the quality of the MRI sequences collected. METHODS Three commonly used external fixation systems were placed on cadaveric lower extremities to simulate knee external fixation. Fiber optic thermal probes were placed at the pin/skin interface of a femoral and tibial pin. A control probe was embedded in the soft tissues of the thigh. Full knee MRI scans were performed using a 1.5-Tesla magnet. Real-time thermal data were collected. A clinically significant increase in temperature compared with the control was defined as 2°C. Two blinded radiologists evaluated the images for image quality and overall diagnostic utility using a standardized 5-point grading scale. RESULTS There were statistically significant differences in the temperature changes between the femoral/tibial pin sites and the control probe sites during each phase of the MRI scan. However, there was only one clinically significant difference in temperature change during a single sequence of one MRI scan of one of the external fixator devices. Overall image quality was graded as a 4 for each image set with 100% interobserver agreement (k = 1.0). CONCLUSIONS Despite significant differences in temperature changes between the pin sites and controls over multiple MRI sequences in commonly used external fixator devices, the differences in temperature change are likely not clinically relevant. Overall image quality and interpretability of the images were excellent.
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Affiliation(s)
- Scott Ryan
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA
| | - Andrew S Moon
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA
| | - Matthew Gordon
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA
| | - Sebastian Flacke
- Department of Radiology, Lahey Hospital & Medical Center, Burlington, MA; and
| | - Shalin Soni
- Department of Radiology, Lahey Hospital & Medical Center, Burlington, MA; and
| | | | - Sarah Stelma
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA
| | - Andrew Marcantonio
- Department of Orthopaedic Surgery, Lahey Hospital & Medical Center, Burlington, MA
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Hu Q, Yu VY, Yang Y, Hu P, Sheng K, Lee PP, Kishan AU, Raldow AC, O'Connell DP, Woods KE, Cao M. Practical Safety Considerations for Integration of Magnetic Resonance Imaging in Radiation Therapy. Pract Radiat Oncol 2020; 10:443-453. [PMID: 32781246 DOI: 10.1016/j.prro.2020.07.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/16/2020] [Accepted: 07/28/2020] [Indexed: 12/29/2022]
Abstract
Interest in integrating magnetic resonance imaging (MRI) in radiation therapy (RT) practice has increased dramatically in recent years owing to its unique advantages such as excellent soft tissue contrast and capability of measuring biological properties. Continuous real-time imaging for intrafractional motion tracking without ionizing radiation serves as a particularly attractive feature for applications in RT. Despite its many advantages, the integration of MRI in RT workflows is not straightforward, with many unmet needs. MR safety remains one of the key challenges and concerns in the clinical implementation of MR simulators and MR-guided radiation therapy systems in radiation oncology. Most RT staff are not accustomed to working in an environment with a strong magnetic field. There are specific requirements in RT that are different from diagnostic applications. A large variety of implants and devices used in routine RT practice do not have clear MR safety labels. RT-specific imaging pulse sequences focusing on fast acquisition, high spatial integrity, and continuous, real-time acquisition require additional MR safety testing and evaluation. This article provides an overview of MR safety tailored toward RT staff, followed by discussions on specific requirements and challenges associated with MR safety in the RT environment. Strategies and techniques for developing an MR safety program specific to RT are presented and discussed.
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Affiliation(s)
- Qiongge Hu
- Department of Radiation Oncology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Victoria Y Yu
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yingli Yang
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Peng Hu
- Department of Radiology, University of California, Los Angeles, California
| | - Ke Sheng
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Percy P Lee
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amar U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Ann C Raldow
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Dylan P O'Connell
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Kaley E Woods
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, California.
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