Like an old gas guzzler, your conventional C-arms sure do take up a lot of space and give off a lot of radiation, and the image quality has lost its luster. But your C-arms have served your doctors well. So why would you upgrade to flat-panel detectors that can cost around 2 to 3 times more than your trusted image intensifiers?

In a few words: superior image quality with minimal dose. Not only are flat-panel detectors more streamlined (think smaller and lighter), they also provide clearer, sharper images, even of small structures, while exposing patients and staff to less radiation. Flat-panel detectors, introduced in the United States in 2009, also run cooler than image intensifiers and have a longer usable life. Here are 6 points to keep in mind when choosing between a system with an analog image intensifier and a system with a flat-panel digital detector.

1. Image quality.

Flat-panel C-arms will give you optimum image quality, without degradation, for a very long time.

"A flat-panel detector can show much more minute detail — superfine details — than an image intensifier," says John Alexander, RT, (R), (CT), CPC, radiology systems administrator at OrthoCarolina in Charlotte, N.C.

Flat-panel technology achieves higher spatial resolution in comparison to conventional C-arms. Due to the high level of resolution, the flat panel emits less distortion that negatively effects the image quality. This is especially true when magnification mode is used during fluoroscopy.

"In the old systems, you took an X-ray and turned it into light so that it could be seen on the TV screen. Now, with digital, the photo sensors are taking the place of the TV systems and electronically turn them into images directly," says Rick Perez, director of radiology and imaging services at NYU Winthrop Hospital in Mineola, N.Y.

2. Radiation dose.

A flat-panel detector has a far better sensitivity to ionizing radiation that is used to create medical images. Typically, the flat-panel detector is made of amorphous silicon that is considerably more radio sensitive. The C-arm doesn't have to use as much power — or what is referred to as "technique" — to provide higher quality images.

"By not using as much power, it saves radiation exposure to the patient and the OR staff because there is less scatter," says Mr. Alexander.

Scatter is the radiation that comes off the patient and goes out at a 90-degree angle toward the physician and staff in the OR.

"So, with better collimation, we can reduce radiation not only to the patient but also to the staff in the OR," says Mr. Perez.

Most surgeons go through a radiation safety course before using the C-arm, says Mr. Perez. Surgeons study collimation — the process by which a beam of radiant electromagnetic energy is lined up to minimize divergence or convergence — so they can follow ALARA: As Low As Reasonably Achievable.

ALARA is the core concept of any radiation safety program. "It applies to all radiological situations that can give rise to personal doses, including both occupational and public exposures to direct and indirect radiation from either radioactive materials or radiation producing machines," according to Tufts University Radiation Safety Program.

The lower radiation doses were a key aspect for Greg DeConciliis, PA-C, CASC, administrator at Boston Out-Patient Surgical Suites in Waltham, Mass., when he was shopping for flat-panel C-arms.

"We're using these machines on repetitive cases like hand and foot cases. It's the surgeons and staff who benefit from as little radiation as possible," says Mr. DeConciliis.

3. Maneuverability.

Image intensifiers are fairly large in size, which makes them difficult to position during fluoroscopy procedures. The flat-panel detectors are less bulky and considerably lighter. Because it's smaller and lighter, it's easier to maneuver in those compact spaces around the OR table. Plus, you can swivel the flat-panel screens.

"With storage a major issue for us, we were looking for a unit that was smaller and much easier to maneuver," says Mr. DeConciliis , who purchased a new machine and a demo.

4. Digital file saving.

As with most computers, the amount of storage you'll need for your images depends on your facility's and your surgeons' workflow. Most units have the built-in capacity to convert images to the universal DICOM (Digital Imaging and Communications in Medicine) standard for data portability across viewing platforms. Some of the large manufacturers also offer a wireless transfer of images to a facility's PACS system, which avoids wear and tear on the technology.

"So, in a DICOM format, it will come across the machine into PACS. With digital, it's less radiation and it's direct, so it can go over easier but in a larger format size," says Mr. Perez. "When you look at your technology, it's always the size and the dose."

Mr. DeConciliis says paper printouts of pictures appear to be a thing of the past.

"The ability for a surgeon to put a thumb drive in at the beginning of the day, and then take it at the end of the day with all of his files, makes it easy to incorporate into the EMR system in their office. It also saves the step of scanning pictures," says Mr. DeConciliis.

5. Reliability.

Though flat-panel detectors have very few moving parts and are built to last a long time, routine maintenance is still sound practice. "I harp on this to my X-ray techs all the time: We paid way too much money to buy it and we're paying way too much money to maintain it," says Mr. Alexander. "So, if that thing starts to even look at you cross-eyed, you call maintenance."

That way, Mr. Alexander says, he decides when the maintenance on the C-arm is going to be done instead of running it until it breaks down.

"They only break down when they're in use and that will be in the middle of a surgical procedure. And that's not the time you want your C-arm to malfunction," says Mr. Alexander.

6. The manufacturer

The market for flat-panel detectors — from $50,000 up to $175,000 depending on the vendor, software package and other options — includes larger companies that are making C-arms, but also now smaller companies that are getting into the technology and it's becoming more readily available. Smaller companies may be able to beat the price of the larger companies, but they may not have the infrastructure to support it.

"The big companies have the field engineers in place and the depth in their experience and knowledge of the technology," says Mr. Alexander.

But when C-arms do break, they can be expensive to repair, so focus on a vendor's quality, track record, service support and longevity as well. Also, be sure to know how quickly you can get replacement parts.

Phasing to flat

The imaging industry is migrating toward phasing out image intensifiers in favor of the flat-panel detectors. If your budget doesn't allow for a digital upgrade at this time, analog technology with image intensifiers are still out there. Plus, you can get second-hand and refurbished conventional C-arms. But the digital technology has changed the playing field.

"We're going to have to migrate someday because we won't have a choice," says Mr. Alexander. "We're rapidly approaching the day where we won't be able to buy a new C-arm that uses the image intensifier. We're only going to have the option of a flat panel."

Mr. DeConciliis sees it the same way and believes there are valid reasons for transitioning to flat panel.

"The technology, ease of use and lower radiation are all pretty compelling reasons to make the switch," says Mr. DeConciliis. OSM