The Potential Value of Weight Bearing Images Acquired by Cone Beam CT

Carestream cone beam CT

Many orthopedic conditions are best evaluated by imaging studies acquired to simulate functional positions and weight bearing activity.  This is especially true of diseases that involve the articular surfaces of the joints, such as fractures, malalignment syndromes, and degenerative diseases.  For example, radiologists and orthopedists both prefer to evaluate patients with knee arthritis by acquiring weight bearing images, as they more accurately reflect simple functions like walking and using stairs.

UBMD Orthopedics and Sports Medicine is a large academic practice plan that provides comprehensive musculoskeletal care to more than 40,000 patients per year.  Our clinical sites offer digital X-ray and MRI imaging, but we do not operate a CT scanner.

We have partnered with Carestream Health to evaluate the ability of a new portable cone beam CT (CBCT) scanner to acquire 2D and 3D images of the extremities.  Of its many capabilities, the CT scanner can acquire images while the patient is weight bearing and with the extremities in various positions while they are under physiological load. A good illustration of the potential utility of this type of imaging is when it is applied to clinical cases of patellofemoral instability.

Two of the challenges of this condition are identifying the cause of patella subluxation or dislocation, and then calculating the amount of correction that would be necessary when tibial tubercle transfer surgery is planned.

In the past several years the tibial tubercle-trochlear groove offset (TT-TG) distance has been relied upon as an objective measure of the Q angle, and when excessive, results in the lateral vector that pulls the patella over the lateral femoral trochlea.  Even though the TT-TG offset is an objective measure, studies have shown that the absolute value can be affected by the method of image acquisition.

Practically all conventional CT scans of the knee are obtained with the patient lying supine on the table with the leg in full extension and the muscles relaxed.  Because of the natural screw home mechanism of the knee, the tibial tubercle rotates externally in relation to the femoral trochear groove during the final few degrees of knee extension.  The active quadriceps exerts a medial vector on the patella. These two factors are reported to falsely elevate the TT-TG offset distance as measured when the CT scan is acquired in the conventional way.

UBMD Orthopaedics and Sports Medicine and Carestream Health are conducting an institutional IRB-approved clinical study to compare measures of TT-TG offset obtained on a conventional CT scanner to those obtained on the prototype portable CBCT scanner – while the patient is standing, the quadriceps is active, and the knee is flexed to 30 degrees.  The hypothesis is that the average TT-TG offset distance measured by CBCT will be less than that measured on regular CT scan.  If the hypothesis is proven, this will have significant implications on defining abnormal TT-TG offset, and on calculating the amount of surgical correction when tibial tubercle transfer is the required procedure for patellar instability.

A second clinical study will evaluate the ability of weight bearing CT scan to more accurately image(2D and 3D) the ankle and tibiofibular syndesmosis.  This type of evaluation may be crucial to determining which ankle injuries are unstable, and allow clinicians to stabilize those that need surgery and avoid surgery on those that do not.

Other researchers at UB and Carestream are looking to validate computational measures of joint surface area of contact and joint surface pressure when obtained while subjects are weight bearing in the cone beam CT scanner.  This has the potential to become a non-invasive tool to evaluate a host of orthopedic conditions that affect the biomechanical behavior of the joints, such as arthritis, meniscus loss, instability, and malalignment syndromes.

Carestream OnSight 3D Extremity System received FDA 510(k) clearance in September 2016.

Dr. John Marzo, UBMDJohn M. Marzo, MD, is an associate professor of clinical orthopaedics at the State University of New York at Buffalo’s Jacobs School of Medicine & Biomedical Sciences. His research interests in the basic sciences relate to the biomechanics of the shoulder and the knee, with the most recent project sponsored by Carestream Health to investigate the advantages of a new prototype portable 3D cone beam CT scanner. He is also a member of Carestream’s Advisory Group, a collective of medical professionals that advises the company on healthcare IT trends.

Diagnostic Reading #45: Five Must-Read Articles From the Past Week

Carestream LogoThis week’s Diagnostic Reading focuses on duplicate imaging on emergency patients, medjacking, the cost doctors are paying for technology, tomosynthesis implementation, and the importance of setting up a data security plan.

1. Study: Emergency Patients Get Duplicate X-ray, CT Exams – AuntMinne

Researchers from Emory University examined the cases of more than 3,600 patients who underwent both x-ray and CT studies on the same body part as part of their workup after admission to the emergency department (ED). The team found that many of these exams were unnecessary, with both x-ray and CT sometimes ordered simultaneously, or CT ordered before results from an initial x-ray study were received.

2. Medjacking: The Newest Healthcare Risk? – Healthcare IT News

A recent article in WorldNow proclaimed, “It may sound like a science fiction novel, but medical devices could someday be the target of hackers.” But the fact is that these devices are already being hacked, a trend that is alarming hospitals and other healthcare organizations. In fact, this kind of hacking is already widespread enough to have a new name: medjacking.

3. Docs are Paying More for Technology Than Ever Before – Healthcare IT News

According to a new MGMA report, medical practices across the U.S. are now spending a lot more on technology this year, up nearly 34 percent from four years ago. The annual report published by Medical Group Management Association shows that just from last year alone, physician-owned multi-specialty groups reported nearly a 12 percent increase in technology-related operating costs.

4. Imaging Department Reaps Benefits of Tomo After Careful Implementation – Radiology Business

The Baylor College of Medicine department of radiology recently implemented DBT at their breast imaging department. They wrote about the experience for the  Journal of the American College of Radiology, stressing the importance of taking things one step at a time. Ebuoma and colleagues wrote that the first step was getting staff fully prepared for the transition. From the person answering questions from behind the front desk to the radiologists interpreting the images, each staff member had to adapt to this new technology and how it would impact their day-to-day operations.

5. Data Security: The Importance of Planning, Training, and Having a Risk-Management Strategy – Healthcare Informatics

According to a recent report from the Breach Level Index, the healthcare industry had the highest number of data breaches in the first half of 2015 and also led the way in number of records breached by industry, with 84.4 million records. These findings represent a dramatic shift from the past few years when healthcare had relatively small numbers of records involved in data breaches, according to the report. The report findings are just one more reminder of the ongoing threats to healthcare information security and highlight the importance of building a strong information security program.

What Does Clinical Collaboration Really Mean?

Carestream Clinical Collaboration PlatformWe’ve been talking about clinical collaboration and Carestream’s Clinical Collaboration Platform quite often since before RSNA 2014.

For us, clinical collaboration was born out the use of our vendor-neutral archive (VNA). The VNA served as a housing mechanism for medical images across a variety of –ologies, not just limited to DICOM images. With the VNA, the images remain safe and accessible when necessary, however, to enable intelligent, user-based sharing, more than just storage is needed.

To go beyond the VNA and expand the capabilities that truly lay within its technology, there remained a need to bring in other systems that could result in an enterprise-wide tool to unite departments. With our own Clinical Collaboration Platform, we break down the capabilities in four areas: capture, manage, archive, and collaborate.

Capture. The goal is to provide a unified, patient-centered clinical record that pulls together images and data from departmental systems across the enterprise, and even beyond it. The solution needs to be flexible enough to be where the data acquisition happens: bed-side, by specific modalities, even from mobile devices in a wound care/urgent care environment.

Manage. From a web-based portal the user can now manage clinical imaging data whether it’s at the point of care or as part of the administrative process. Having the right clinical context to each image or clinical data ensures that information can be properly stored, viewed, and share these clinical images and accompanying data. This capability involves advanced metadata tagging, quality control to ensure consistency, and leveraging latest industry standards to ensure interoperability.

Archive. This stage involves the storage and access of clinically meaningful data throughout the enterprise, with access across each patient’s clinical history. This consolidated repository for clinical data helps to support effect collaboration via intelligent lifecycle management, optimized storage and access anytime, anywhere, standards-based and vendor-neutral, and risk-free migration from legacy archives.

Collaborate. This is the ultimate stage that supports dynamic collaboration between providers, patients, payers, administrators and IT managers, with tools and views tailored to each user’s needs. The main goal is to put patients at the center of efficient, effective healthcare. This involves EMR/EHR integration, zero-footprint interface for administrators, user-specific functionality, patient engagement, and payer reporting.

With the evolution of the VNA going beyond the simplicity of storage and access, it is clear that these new capabilities will bring out the value of allowing clinicians to collaborate with each other and take part in valuable communication with their patients. This has been the direction healthcare has been heading in for sometime, and the time is now to embrace these advancements.

You can visit our website for more information about Carestream’s Clinical Collaboration Platform.

Cristine Kao, Healthcare IT, CarestreamCristine Kao is the global marketing director for Carestream’s Healthcare Information Solutions (HCIS) business.


Diagnostic Reading #44: Five Must-Read Articles From the Past Week

Carestream LogoIt’s time for a new edition of Diagnostic Imaging. This week we’re looking at medical imaging and pregnant women, digital tomosynthesis and CT lung nodules, how business intelligence affects security, doctors using EHRs, and imaging informatics and archiving in Scotland.

Diagnostic Imaging May Be Safe for Pregnant Women – Diagnostic Imaging

According to a review article published in the Journal of the American Academy of Orthopaedic Surgeons (JAAOS),  some radiologic imaging can be safe for pregnant women who have sustained traumatic injuries. Researchers from the Thomas Jefferson University in Philadelphia, PA, and the Garden State OB/GYN Associates in Voorhees, NJ reviewed the diagnostic dilemma that confronts emergency room physicians when pregnant women present with traumatic injuries that require diagnostic imaging.

Digital Tomo Falls Short of CT Lung Nodules – AuntMinnie

A new study published September 8 in the Journal of Digital Imaging indicates that tomo may have a tough time finding a role in the chest that’s not already well-served by the other two modalities. Researchers from the Mayo Clinic in Rochester, MN, compared digital tomosynthesis with chest x-ray in a population of 82 individuals, while also comparing both technologies to CT as the gold standard. They found that tomo was much better than standard radiography in several areas, such as for detecting nodules larger than 4 mm — considered the threshold for clinical significance.

Security Needs Business Intelligence – Healthcare IT News

A truly risk-based security framework needs more than mere protective measures. It requires awareness. This article features quotes from Ron Mehring, senior director and chief information security officer, Texas Health Resources, who oversees security architecture and operations at the sprawling 25-hospital system/ Mehring explains how large health systems need to escalate up from “baseline security requirements” to something much more robust.

More Than 80 Percent of Docs Use EHRs – Healthcare IT News

More than eight in 10 doctors across the country, or 83 percent, have adopted electronic healthcare record systems, according to a new report from the Office of the National Coordinator for Health IT. Counting only certified EHR adoption, however, that rate goes down to 74 percent. Also, 51 percent of doctors are using only basic EHR functionalities, according to ONC.

Imaging Informatics: Archiving Scotland – Radiology Today

Alan Fleming, program manager for National Health Services (NHS) Scotland, says the process of setting up Scotland’s archive required extensive input from both clinical and business stakeholders. One of the most important tasks was selecting a supplier for PACS, data center storage, and hosting [Disclosure: Carestream was selected to provide the PACS and national image archive]. NHS Scotland also had to specify the services that would be provided by the archive, and the final implementation plan required approval from senior government officials.

Video: Demo of Carestream’s New Fluoroscopy System

Back in July, we made our announcement that Carestream was officially entering the radiography/fluoroscopy (R/F) market with the introduction of the DRX-Excel Plus and the DRX-Excel.

Below is the first look of the DRX-Excel Plus in action. The demo video will take you through the various capabilities of this new fluoroscopy technology, including the various features and settings on its control panel and the different positions available on the system for a variety of exams.

Video: The Value of Imaging Sharing in Clinical Collaboration

With Carestream’s Clinical Collaboration Platform, you will see how more images can be shared across the enterprise from more modalities.

The ability to share more image formats across more devices is integral to making collaboration throughout the enterprise a reality.

In the animated video below, learn how image sharing on the Clinical Collaboration Platform is able to give clinicians real time, on-demand access to imaging results, as well as how it can empower patients to share their images between facilities, physicians, and specialists.

You can visit our Clinical Collaboration Platform page to learn more.

Diagnostic Reading #43: Five Must-Read Articles From the Past Week

Carestream LogoWe are back this week with a new issue of Diagnostic Reading. This week’s topics focus on structured radiology reporting, sonographer health, EMR data security, EHR usability standards, and radiologist performance tied to Physician Compare metrics.

1. Structured Reporting Improves Quality of MRI Reports – AuntMinnie

At Brigham and Women’s Hospital, a structured reporting template yielded a significant improvement in the quality of MRI reports for the crucial task of staging rectal cancer. A team led by Dr. V. Anik Sahni found that the percentage of reports deemed to be satisfactory or optimal nearly doubled after the voluntary adoption of structured reports, reaching more than 70%. Furthermore, more than 40% of reports were judged to be optimal after structured reporting was implemented, whereas none were prior to adoption.

2. Making a Difference as a Sonographer: Pain in the Neck – AuntMinnie

Doug Wuebben, registered echocardiographer and also a consultant, international presenter, and author of e-books in the areas of ergonomics, exercise and pain, and injury correction for sonographers, goes through a number of exercises and stretches sonographers can do in order to prevent injuries.

3. Even with Encryption, EMR Data at Risk – Healthcare IT News

A recent security report by Microsoft finds that, even when cloaked in encryption technology, “an alarming amount of sensitive information can be recovered” from electronic medical record databases. For the report, “Inference Attacks on Property-Preserving Encrypted Databases,” which included 200 hospitals, researchers from Microsoft, University of Illinois and Portland State University examined four types of cyberattacks targeted at EMRs.

4. Study: Large Number of EHRs Do Not Meet Usability Standards – Healthcare Informatics

A significant percentage of electronic health record (EHR) vendors failed to meet federally mandated user-centered design requirements and did not conform to usability testing standards for their EHRs, according to a new report. The report, from the National Center for Human Factors in Healthcare at the Washington, D.C.-based MedStar Health, found that this lack of adherence to usability testing standards by EHR vendors could result in poor usability of EHRs.

5. Are Physicians Compare Metrics Missing the Mark on Radiologist Performance – Radiology Business

According to a recent study published by the  Journal of the American College of Radiology , the CMS Physicians Compare Initiative should include more imaging-specific metrics so it can accurately reflect a radiologist’s overall performance. Andrew B. Rosenkrantz, MD, of the department of radiology at the New York University Langone Medical Center, and colleagues studied how radiologists scored in six different Physicians Compare metrics compared to nonradiologists. In two of the metrics, radiologists significantly outperformed the nonradiologists. Radiologists scored 60.5 percent in PQRS participation, while nonradiologists scored 39.4 percent. And in receipt of PQRS Maintenance of Certification incentives, radiologists scored a 4.7 percent while nonradiologists scored 0.3 percent.

What’s the Big Deal about GPUs in Ultrasound Imaging?

If you’ve wondered how a little video game box could produce and destroy high-resolution, 3D fantasy worlds in the blink of an eye, look no further than the console’s graphics processing unit or GPU.

GPUs are better equipped than CPUs – the central processing unit that processes data in most computers – to quickly compute functions and algorithms related to rendering images.

CPUs process blocks of data sequentially, which is great for work like spreadsheet analysis and database queries. However, CPUs are not optimal for forming images and the calculations needed to give the combination of fast frame rate and high resolution required in video games and ultrasound.

Digital imaging, especially 3D and 4D images, has to process a large amount of data very rapidly. The GPU has hundreds of cores that can process thousands of data sets in parallel. This gives the semiconductor chip the processing power that’s needed to render fine structures, grayscale, and color contrast in ultrasound images without compromising speed. GPUs can speed up software processes by up to 100x over a CPU alone.

CPU-GPU Ultrasound Illustrator

(source: GPU Programming in MATLAB,

Advanced ultrasound beamforming and post-processing technologies can greatly benefit from access to increased computing power now and in the future. As evident by the chart below, theoretical CPU performance has peaked over time as GPU performance continues to improve exponentially.


(source: CPU vs. GPU Performance,

Embracing this, the development of the CARESTREAM Touch Prime Ultrasound System presented an opportunity to shift away from conventional CPU-only approaches.

Our new system architecture offloads many functions from the CPU to integrated advanced GPU processing units. Compared to CPU-only architectures, the tradeoffs between frame rate and image resolution can be drastically reduced.

The GPU power in the Touch Prime Ultrasound System combines with our proprietary beamforming hardware. The inherent data parallelism and high throughput offered by this software and hardware combination is the basis for the beamforming architecture introduced by Carestream as SynTek architecture.

SynTek architecture is a significant departure from the serial line-by-line acquisition approaches. With Syntek, a given tissue region is insonified in multiple directions from independent transmit firings. The echoes received by the transducer are coherently summed together, taking into account the difference in round-trip travel time from the transducer to the tissue location and back for each of the firings. Thus, by combining the information independently obtained from many such transmit events throughout the imaging region of interest, the SynTek architecture in effect synthesizes a transmit beam that is narrow not only at a single point or region in the image (around the transmit focus in conventional imaging), but over the entire spatial extent, leading to improved image quality.

In color flow and Doppler imaging, SynTek architecture allows for more consistent visualization of subtle tissue contrast differences, while simultaneously improving the ability to see small structures. There is more information at depth as well as increased frame rates for improved visualization of moving structures.

In a conventional system, using such a transmit scheme with multiple transmit firings would have led to a reduction in frame rate. However, the parallel acquisition and real-time processing capabilities of the SynTek architecture leads to minimal compromise in frame rate at the cost of image quality.

Innovation Powered by Leading-Edge Technology
Medical ultrasound imaging continues to seamlessly leverage advances from the consumer space, and the use of GPUs in combination with highly-integrated front-end hardware in the CARESTREAM Touch Prime Ultrasound System is a prime example of this trend.

Download my technology brief: “Touch Prime: Advanced ultrasound imaging with an extraordinary user experience” to learn more about how Carestream is harnessing the power of GPUs and parallel computing to bring more technology-driven applications to ultrasound.

Ajay Anand, CarestreamAjay Anand is a member of the ultrasound R&D team at Carestream Health. He has more than 10 years’ experience leading the development of novel ultrasound technologies, and is a co-inventor of more than 20 patent filings in the field of medical ultrasound.


Video: Introducing the New DRX Plus Detectors

Last week brought about the announcement that we have entered into the third generation of DRX detectors: the DRX Plus 3543 and the DRX Plus 3543C detectors.

With this new generation of detectors, users can expect the following benefits:

  • 79% increase in battery life allows for improved productivity and allows increased imaging between battery changes
  • Higher DQE enables the potential for lower dose and improved image quality
  • Fast calibration time, boot time, preview time, and time to full resolution display

The video below includes more information about the capabilities of the DRX Plus detectors.