Kim Schultz, RN, BSN, MAOL, CNOR, the director of the Orthopaedic Surgery Center of Illinois in Springfield, Ill., recently bought 2 new C-arms: a vascular unit for her pain management doctors ($165,000) and a standard model for her orthopedic surgeons ($150,000). Despite the hefty price tags and a few too many needs for repair, Ms. Schultz says she and her physicians are thrilled with how far the field of fluoroscopy has advanced since they bought their first C-arm more than a decade ago.

"They're both state-of-the-art," she says. "Simple and very, very easy to operate. With the touch-screen, you don't have to worry about a mouse and keyboard. You just move and go. And the screen resolution is 10 times better than the old one. Physicians are happier that they have better images to view when they're performing a case."

Another perk: digital file-saving. The C-arms come with the built-in ability to upload images to the ASC's electronic medical records. Digital data-keeping means you don't have to buy printing cartridges and paper. While paper and film printing is still available and in use today, storing images and accessing in a digital format is most common. Be sure you coordinate your C-arm purchase with your IT department. "All I wanted to do is plug it in the wall and push go," says Ms. Schultz. "But everything has to be compatible over your network so that the C-arm saves images in the correct format."

Most newer C-arm models will have DICOM (Digital Imaging and Communications in Medicine) built into them, says Chris Sharrock, the C-arm product manager at Block Imaging, a C-arm refurbisher in Holt, Mich. DICOM lets you interface your unit with remote viewing stations. A C-arm with DICOM can send the pictures it takes to the facility network for viewing at multiple terminals and often through web access. Older C-arms can still convert their images to DICOM, but will require an accessory known as a DICOM box to convert them to the universal format that other workstations will recognize, says Mr. Sharrock.

Which C-arm is right for you?
Today's fluoroscopy devices are safer, nimbler and more powerful. The manufacturer of a new mobile C-arm touts its ability to deliver the lowest radiation dose possible without sacrificing image quality. The key? The C-arm asymmetrically crops images on all sides, thereby putting the area of immediate importance into primary focus and reducing exposure for staff and patient alike. Then there's a yet-to-be released 3D C-arm with a 30-cm-by-30-cm flat-panel, "the world's only 3D C-arm with flat-panel technology that provides a 16 cm edge length per scan volume." This C-arm will offer 180 ? image information of any anatomical structure. "With up to 7 vertebrae in one scan volume, it offers the largest 3D image volume in the market," says the company.

3D imaging offers unparalleled precision and accuracy, says Theresa Criscitelli, EdD, RN, CNOR, assistant director of professional nursing practice and education at Winthrop University Hospital in Mineola, N.Y. "The ability to generate three-dimensional reconstructions has revolutionized intraoperative imaging over the past few years," says Ms. Criscitelli. "In order to obtain the complete three-dimensional volume, the C-arm has to move on an elliptical path with a variable isocenter."

Digital vs. analog
Resolution, radiation safety and price might have been the key considerations on the last C-arm you purchased, but nowadays you'll want to look at image intensifier size and magnification, generator size and portability. "Space in the operating room is at a premium. A C-arm that is compact, yet transportable is ideal," says Ms. Criscitelli.

You want a C-arm that can expose any patient at every angle, a big "C" in order to accommodate large patients. "This is important, as the size of our patients varies and the type of procedures our pain management physicians do continues to change," says a hospital OR manager.

Lynn Lillie, RN, BSN, CNOR, director of surgical services at Fort Madison (Iowa) Community Hospital, recently added a new mobile C-arm that features digital imaging for use in the OR and ER to her hospital's 2 full-size C-arms. "We don't have to depend on radiology to use it," she says.

Penetration power is a key feature to consider in a C-arm, says Mr. Sharrock. "For the orthopedic or pain physician, it will come into play while taking lateral abdomen or spine shots on large or obese patients," he says. Without the proper power, the image will appear too dark, and for invasive vascular surgery, the ability to do lateral abdominal shots, angiograms and run offs is crucial, explains Mr. Sharrock. "This is where generator size comes into play. If your particular specialty is limited to extremities, it may not be necessary to spend more on a bigger generator. If you operate in a field like bariatrics, it will be worth your while to investigate the more powerful end of the spectrum."

Then there's digital vs. analog. When it comes to image quality, analog just can't compete with digital or flat-panel technology, says Mr. Sharrock. Only analog C-arms have image intensifiers (IIs), pretty expensive parts that eventually lose image gain. IIs are readily available on the second-hand market, both "certified used" and "refurbished." A digital detector ?system, on the other hand, has no II. Instead, says Mr. Sharrock, these units are equipped with flat-panel digital detectors that exhibit very limited degradation and over a much longer period of use.

Another drawback to having an II is the need to collimate down when viewing anatomy in a higher magnification. "While finer details become visible, the field of vision is reduced further and further with each subsequent magnification," says Mr. Sharrock, "whereas magnification on a digital system is possible without any reduction of scale." Flat-panel detectors are steadily replacing image intensifiers on mobile C-arms, says Ms. Criscitelli.

It's also important to consider saving time and dose. Real-time dose readouts allow for immediate information about the radiation dose received, says Ms. Criscitelli. "A barrier for users of C-arms is that the film badge provides information on a monthly basis of how much dose is received," she says. "But this means that reports are a month behind and employees would not know that they are in an unsafe zone of radiation exposure. This technology will help to modify their actions immediately. The goal is minimal amounts of contrast media and shorter fluoroscopy times."