The useful life of a well-maintained C-arm may span more than a decade, but most facilities will be lucky to experience 7 to 10 years of normal use. One indicator that it's time for an upgrade is an overall decrease in the image quality your equipment delivers. A deteriorating image makes it more difficult to complete cases within their allotted time frames, and extending procedure times results in increased radiation doses to patients and staff, user dissatisfaction and lost revenue for the facility. There's good news, though: Your next C-arm may incorporate some impressive advances. Here's what to look for.

The flat factor
What a difference a decade makes. The latest generation of mobile fluoroscopic imaging units has come a long way from older, bulkier models. In 2009 the flat panel detector, an alternative to traditional image intensifier technology, was introduced in the United States. Not only are flat panel detectors more streamlined, they're also able to provide highly detailed imaging, even of small structures, for orthopedic clarity while exposing patients and staff to less radiation. Flat detectors also run cooler than image intensifiers, a technology that had not seen significant changes since its introduction.

Mobile C-arms feature image intensifiers and image receptors that are either 6 inches, 9 inches or 12 to 13 inches. A 6-inch field of view is usually found on mini C-arm systems, which are ideally suited for such orthopedic extremity applications as wrist, elbow, ankle and foot surgeries. Mini C-arms with flat panel detectors create the lowest radiation doses, making them a good choice for pediatric applications.

The compact design of flat panel detectors clears a lot of space in a surgical suite, allowing the physician more room at the field and demanding less of a storage footprint between cases. Touchscreen capabilities as well as the ability to swivel and lock the arm at almost any angle provide operational ease and efficiency.

Get the picture
Every C-arm system currently on the market includes digital storage for the images it captures. As with computers, the amount of storage capacity you'll need will depend on your facility's and your surgeons' workflow. External drives that work in conjunction with C-arms can be used to supplement their storage.

Most units also have the built-in capability to convert the images to the universal DICOM standard for data portability across viewing platforms. If you're considering buying a refurbished previous-generation C-arm, however, you may need to purchase a separate accessory for the conversion.

Major manufacturers also now offer the wireless transfer of images to a facility's PACS system, which eliminates the need to push and steer a heavy piece of equipment out of the procedure room and down the corridor to the nearest data jack (then back again), just to upload your surgical images. Wireless transfer avoids wear and tear on your technology — as well as on your tech.

Also keep in mind that with either type of C-arm, a flat panel detector or an image intensifier system, the availability of a removable grid is invaluable for orthopedic cases. Used during an exam, a grid reduces the effect of scatter radiation to enable outstanding clarity of images while reducing and stabilizing bone fractures, for example. Non-radiologists can think of it this way: If a gridless exam is comparable to looking at the moon with your naked eye, an exam with a grid is like looking with a telescope.

Imaging economics
You're likely to invest more than $150,000 into a new C-arm, so it's important to choose the right one. As with most other surgery-related technologies, an informed purchasing decision should be based on your case mix and case volume. Most manufacturers offer multiple models with different standard software packages included. Be aware that the cost of additional software is what really drives up the price of a unit.

While a longer usable life is among the many advantages of a flat panel detector system, they also tend to cost about twice as much as an image intensifier system. Parts and service will cost more, too, which is a significant consideration considering the potential lifespan of the system.

Many facilities opt to purchase a refurbished C-arm, which typically saves them anywhere from 10% to 30% off the price of a new system. Because C-arms that use image intensifier technology have been around for many years, there is a large market for refurbished units of that type. Less so for flat panel detector units, at least at present. Refurb buyers, beware: Purchasing from a reputable vendor is extremely important, as is the warranty you obtain on the deal. Whether purchasing a new or a refurbished C-arm, make sure that the purchase cost includes training, set up and shipping costs. And don't close the deal without finding out how long the warranty is effective for, and which of the technology's components are covered and excluded. OSM

GE Healthcare
OEC 9900 Elite Mobile C-Arm
gehealthcare.com
(866) 281-7545
Pricing: $167,00 to $345,000
FYI: When a C-arm can reliably capture a high-quality surgical image on the first attempt, eliminating the need for retakes and repeated exposures, it effectively reduces procedure times and moderates radiation doses. GE Healthcare's OEC 9900 Elite delivers this efficiency and safety through its increased image processing power, intuitive and easy-to-use interface, and fast, agile positioning. Imaging profiles compensate for bone and tissue, enhancing features of interest. High-definition, flat-panel monitors on an articulating arm offer ergonomic views. And remote service connectivity enables on-site system performance diagnostics.

Hologic
Fluoroscan InSight FD Mini C-Arm
fluoroscan.com
(781) 999-7300
Pricing: not disclosed
FYI: The Fluoroscan Insight FD system's rotating flat detector provides versatile positioning and quality imaging for extremity surgeons. The high-sensitivity CMOS detector and its image processing algorithms deliver distortion-free images, while the system's touchscreen controls offer convenient image adjustment for clear and accurate visualization. Its rotational ability, tailored for extremity anatomy, allows for optimal workspace access, patient positioning and dose efficiency. A 24-inch, high-definition, color widescreen monitor displays large, sharp images for enhanced visualization, even at distance viewing.

OrthoScan
FD Pulse
orthoscan.com
(480) 503-8010
Pricing: not disclosed
FYI: Pulsed fluoroscopy sets OrthoScan's FD Pulse mini C-arm apart. Offering a range of selectable pulse-per-second settings, the system is able to reduce its radiation dose without sacrificing image quality or detail. Its large, CMOS-driven flat detector not only delivers a wide field of view, it also enables efficient positioning without stressing patient anatomy and presents a more compact footprint in the OR. LED lights on the undersurface of the X-ray source reduce the shadows cast by the unit's C, and bilateral controls on each side of the tube head assembly allow easy access to imaging and documentation controls from each side of the sterile field.

Philips
Veradius Unity
philips.com/veradiusunity
(800) 229-6417
Pricing: not disclosed
FYI: A C-arm's ability to consistently deliver high-quality images depends on effective communication and interaction between the physician and the equipment's operator, says Philips. The user-friendly tablet interface on its Veradius Unity system ensures efficient teamwork in surgical imaging. The digital, flat-detector, mobile C-arm also offers ClearGuide, Color Coding and Positioning Memory settings to optimize image quality, while dose efficiency features such as BodySmart and a range of exposure modes keep radiation as low as possible.

Siemens Medical Solutions
Cios Alpha Mobile C-Arm
usa.healthcare.siemens.com
(888) 826-9702
Pricing: not disclosed
FYI: A compact 30-cm-by-30-cm flat-panel detector that provides a field of view up to 25% larger than conventional C-arms combined with a 25 kW generator for optimal penetration of dense anatomy delivers high-quality images at the lowest possible dose for patients of nearly any size. Siemens' Cios Alpha mobile system also features a tableside touchscreen interface, automatic brightness and contrast regulation, an active cooling system to minimize image degradation, intelligent power management to prevent overheating delays, and position storage settings that return the device to a saved position at the touch of a button.

Ziehm Imaging
Ziehm Vision RFD 3D
ziehm.com
(407) 615-8560
Pricing: not disclosed
FYI: Within the design of a conventional C-arm lies both two- and three-dimensional imaging functionality, for intraoperative CT-scan-style reconstruction of patient anatomy. The Ziehm Vision RFD 3D's 30-cm-by-30-cm flat panel optimizes imaging and its 16-cm edge length is able to capture up to 7 vertebrae in a single scan volume. A variable isocenter enables collision-free scanning around the OR table, and a memory function stores and recalls 3 positions. Object-detected dose control refines the image quality even in the case of moving or peripheral anatomy.