MORE AND LESS Newer C-arms provide better images while producing less radiation.

The newest C-arms provide a level of flexibility, precision, clarity and service previously unseen in outpatient orthopedics. There are plenty of options on the market. Bells and whistles are nice, but what you need is good imaging, reliability, and machines that are easy and safe to use. As the radiology systems administrator of a large orthopedic practice, I’m tapped into what you should look for in C-arms. Here are a few things at the top of my list.

1. Imaging capabilities
The digital revolution has reached the world of fluoroscopy. For those who can afford it, direct digital radiology can display high-definition “moving X-rays” on flat-panel detectors. That’s a great thing to have when you’re dealing with very small anatomical structures.

Fortunately, that level of detail isn’t crucial for most orthopedic procedures. For one thing, surgeons are typically looking at larger anatomy — bones and joints. For another, they’re already finding ways to push the surgical envelope, thanks to the sharp, higher-resolution images provided by the latest C-arm models.

Take foreign body removal, for example. If we have a patient who’s stepped on glass or a nail, instead of blindly digging around the anatomy and hoping to find the object or target area, we can use the C-arm to locate it and go straight to it.

VERSATILE SIZE Super C-arms can be used for spinal injection procedures and for radiofrequency ablation.

2. Usability
End-user operability isn’t something to take for granted. How easy is a C-arm to use and to manipulate around the patient? Is it technologist-friendly? Be sure you take models for test drives before investing a significant portion of your capital equipment budget in a purchase.

The advent of mini C-arms, which can be moved easily from room to room, has pushed imaging boundaries even further. In most cases, we can use the mini C-arms for anything involving the distal extremities — lower legs, feet, ankles, elbows, hands and wrists. They’re versatile enough to be used in foreign body removal, trigger point injections and arthrograms — when patients have dye injected into joints to check for any leakage or tear in the joint space.

Although we can use the mini C-arms for almost anything if a patient’s anatomy is small enough, we’ve also been able to incorporate our larger C-arms into guiding spinal injection procedures done for pain management and for radiofrequency ablation. But for thicker parts of the anatomy — the hips and pelvis, for example — typically we need to use the larger C-arms in lead-lined rooms. A lot depends on the body habitus. You sometimes need that extra power to be able to penetrate denser anatomy.

3. Reduced radiation exposure
We’re also seeing manufacturers make impressive strides in reducing the radiation doses their machines produce. Newer models are able to provide good pictures with less radiation. You want to be able to assure patients that their exposure levels will be “as low as reasonably achievable” (ALARA). That’s an increasing concern on the minds of outpatients and something we’ve been incorporating into our imaging protocols for years.

Along with easy mobility and a small footprint, the radiation dosage mini C-arms give off is so low, you typically don’t have to line procedure room walls with lead the way you do with larger C-arm units. The amount of radiation produced by super (larger) C-arms is as minimal as that of mini C-arms at the low end of the spectrum. Super C-arms also have a much higher range and greater potential for radiation scatter. Still, settings that enable pulsed images instead of continuous live imaging, the use of shutters to focus the beam on the area of the body being imaged and proper positioning of the unit’s image intensifier can help to reduce the dose of radiation delivered.

We consider it our responsibility and are required by law to make every effort to lower the dosage that our patients, providers, staff and especially our radiologic technicians, are exposed to. High-definition digital technology is promising in that regard, too, with improved sensitivity to X-rays allowing for a further reduction in radiation. That’s something we can look forward to.

FOCAL POINT You don’t need the most advanced digital technology in orthopedics, but image quality is still important.

4. Maintenance costs
When C-arms break, they can be extremely expensive to repair, so focus on a vendor’s quality, track record, service support and longevity. It’s always best to do business with a reputable company with a proven track record.

Also, be sure you know how quickly you can get replacement parts. One of the big differences between hospital and standalone outpatient facilities is that hospitals are likely to have multiple rooms with C-arms. If one goes down, it’s not as big a deal. But in our little outpatient corner of the world, we don’t have that option. When a C-arm goes down, we go from 100% capacity to 0%. Reliability is huge.

Above all, make sure you have a solid maintenance program. I’m the biggest proponent of working with maintenance contractors my vendors know. To me, that just makes sense. The key with any expensive piece of equipment is don’t just run it until it breaks. If it starts performing poorly or sounding weird, act quickly. You pay way too much for equipment and maintenance to not have it working at all times.

5. Refurbished options
Sometimes you can get lucky and find a refurbished machine that suits all your needs. In fact, we’re using refurbished machines in a couple of our centers right now, and they’ve worked out well. They have the same warranties, the same availability of parts, the same maintenance plans, and so on. All of these things are negotiable, and if you happen to find a good unit, you can expect considerable savings compared with a comparable new one. But the market is hit or miss. Few high-quality, used C-arms become available, and when they do, they move quickly and it’s first come, first served.