Radiographic Film Research Articles

Clinical LINAC-Based Electron FLASH: Pathway for Practical Translation to Trials of FLASH Radiotherapy

<h3>Purpose/Objective(s)</h3> Studies show ultra-high dose rate (UHDR) radiotherapy (RT), at rates of ≥40 Gy per second, can produce the FLASH effect: reduced toxicity with equal tumor control when compared to conventional RT. Leveraging these benefits for clinical translation can profoundly impact RT. Early clinical trials exhibited safe delivery of UHDR-RT using specialized RT machines. Our prior study showed that a reversible configuration of a standard linear accelerator (LINAC) can be optimized for UHDR output. Here, we explored the components necessary for clinically practical delivery of LINAC-based electron FLASH RT. <h3>Materials/Methods</h3> Using a standard, clinically operational system for image-guided radiation, we configured the program board for a decommissioned electron beam energy for UHDR delivery. No LINAC hardware manipulation or exchange was performed. Key changes included adjustment of the dose per pulse and pulse delivery control using the gating interface. Of note, the scattering foil remained in place within the beam so that field sizes and depth doses could approximate those of standard clinical operations. A commercial electron arc applicator was installed at the face of the gantry using the standard applicator mount to allow for short SSD electron collimation. Copper electron blocks were fabricated with apertures ranging from 3.0 to 20.0 cm. Dose rates were measured at dmax for 100 to 59 cm source-to-surface distances (SSD) (level of machine head) and beam profile measurements were captured at 80 cm SSD using an IC profiler and radiographic film. <h3>Results</h3> UHDR rates ranging from 36.8 to 112.8 Gy/s were measured at 100 to 59 cm SSD, respectively. An 80 cm SSD was selected for treatment arrangement measurements to maintain UHDR and clinical utility, allowing for 13.5 cm of clearance. UHDR ≥60 Gy/s was observed at 80 cm SSD with all field sizes, using a standard, scattered electron beam, with an R80 depth of 6.1 cm, approximating to a 16-18 MeV energy. Average dose per pulse was measured at 0.33 Gy/pulse. Circular block apertures of 3, 10, and 20 cm exhibited beam flatness <5.0 % variability and symmetry of 2.2 to 6.2%. Penumbra width between the 80 and 20% isodose lines (IDL) measured at 0.7, 1.1, and 1.4 cm, respectively. <h3>Conclusion</h3> Optimizing a reversible setup for UHDR irradiation on a standard LINAC, electron delivery at dose rates expected to produce the FLASH effect was achieved. Flat, homogenous field sizes, ranging from 3 to 20 cm of coverage, were obtained at a clinically practical SSD of 80 cm with a treatment depth of 6.1 cm to the 80% IDL. This setup would enable UHDR irradiation at useful depths for a number of different clinical indications, bringing us a step closer to practical UHDR RT using a standard LINAC in future clinical trials.

Ultra-High Dose-Rate Carbon-Ion Scanning Irradiation with a Compact Type Medical Synchrotron toward FLASH Research

<h3>Purpose/Objective(s)</h3> To establish an irradiation system to enable the ultra-high dose-rate (uHDR; FLASH) scanned carbon-ion irradiation with a compact type medical synchrotron. <h3>Materials/Methods</h3> After technical adjustments of the accelerator operation parameters, the medical synchrotron extracted ≥1.0 × 10⁹ carbon-ions (2.0 nC/spill) at 208.3 MeV/u (86 mm in range) within a maximum 100 ms. The uHDR carbon-ion beam delivery system was designed to prevent damage to monitors in the nozzle due to the uHDR beam by avoiding passage through the nozzle. The dose amount was adjusted by the extraction time of the total spill with a function generator. The carbon-ion beam was scanned once to create a field within the extraction time. Advanced Markus chamber and radiographic film were used to measure the absolute dose and the field size respectively, at a plateau depth. Operation voltage of the chamber was set to 400 V at the uHDR. <h3>Results</h3> The FLASH irradiation utilizing beam scanning was confirmed with a dose of 5.4 Gy (homogeneity of ±2%) for the beam in a volume of at least 16 mm × 16 mm in a square field and a corresponding dose-rate of 95 Gy/s (± 1%). The dose was changed to about 0.7, 1.5, 2.9 Gy for the dose-rate and the field size. Details of the results are shown in Table1. <h3>Conclusion</h3> The FLASH dose-rates >40 Gy/s at different dose levels were achieved in a useful field size for research created by the scanned carbon-ion beams with the compact type medical synchrotron. This study reported promising beam characteristics of uHDR scanned carbon-ion beams, at different dose levels, and can be used for further investigation of carbon-ion FLASH research. The dose and dose-rate established with the uHDR irradiation system can be applied in biological experiments.

Robustness of Biology-Guided Radiotherapy Delivery to PET Biodistribution Changes within Target

<h3>Purpose/Objective(s)</h3> Biology-guided radiotherapy (BgRT) is a novel tracked dose delivery modality that uses positron emission tomography (PET) emissions to deliver hypofractionated planned fluence to the target. This study evaluated PET biodistribution changes within target during BgRT delivery. <h3>Materials/Methods</h3> Two phantom experiments were designed to evaluate the FDG signal variations and dosimetric effects under stationary target and moving target on a non-clinical investigational radiotherapy system. For the stationary case, a custom built cylindrical 4-D detector phantom insert with a spherical target of 22 mm in diameter containing 4 quadrants that can be filled independently was used to mimic homogenous and non-homogenous FDG uptake conditions. A C-shape insert was used as a PET avid OAR. For simulating PET signal loss within tumor: BgRT plan was created for the spherical target with all quadrants filled and the plan was delivered when ¾ volume of the target was PET-avid. For the PET signal gain within tumor scenario: BgRT plan was created for the same spherical CTV structure where ¾ volume of the target was filled with FDG, mimicking non-homogeneous uptake, and delivered to a full volume PET-avid target. The dosimetric accuracy of BgRT delivery was evaluated using 3%/3 mm Gamma criterion using 4-D detector measurements. Target biodistribution changes under motion was evaluated by creating a BgRT plan with an FDG filled 26 mm diameter spherical target as a CTV and C-shape OAR moving independently (target:3D respiratory, OAR: sinusoidal motions) within a large water filled phantom. During BgRT delivery the PET avid target insert was switched to a smaller 22 mm spherical insert, simulating 40% uniform PET distribution reduction within 26mm CTV. For the moving target experiment, BgRT delivered dose was evaluated using the radiographic film under the condition of CTV coverage ≥97% and maximum dose ≤130%. For all the experiments, the target and the C-shaped OAR were filled with FDG at a ratio of 8:1 with respect to the water background mimicking normal tissue uptake, and a 5 mm CTV to PTV expansion to be targeted with a prescription of 50Gy in 5 fractions. <h3>Results</h3> For the stationary scenarios, BgRT delivery at remissive and progressive conditions achieved gamma pass-rate of 93.2 and 97.7%, respectively. The CTV coverage goals for the motion experiment were met where the minimum CTV dose was 103.3% and the maximum dose was 123.8%. <h3>Conclusion</h3> This study evaluated the biodistribution changes within CTV from planning to delivery suggesting the BgRT delivery is robust with respect to daily variations of PET signal within the PTV under these experimental conditions. Clinical feasibility of BgRT needs further evaluation.

Preclinical Research Platform for Ocular FLASH Irradiation

<h3>Purpose/Objective(s)</h3> Normal tissue sparing effects from FLASH radiotherapy (RT) are potentially transformative for the treatment of ocular cancers. Reducing damage to the abundant at-risk structures within the eye can prospectively increase visual retention rates, relax treatment margins, and eliminate the need for motion tracking by surgically implanted fiducials. To date, no prior work has explored FLASH-RT effects in the context of the eye. In this work, we have conducted a pilot study of x-ray FLASH effects for ocular irradiation in a preclinical mouse model by measuring the functional and pathological changes in healthy eyes following FLASH or conventional (CONV) dose rate irradiation. <h3>Materials/Methods</h3> An immobilization device was designed to enable focal irradiation to a single mouse eye using a FLASH-capable rotating anode x-ray tube. A 5 mm diameter lead collimator was manufactured to encompass the 3 mm target of the entire eye. Dose and dose rate measurements were performed with calibrated radiographic EBT3 films. Cone-beam CTs were acquired of four C57BL6J mice in immobilization to confirm setup reproducibility, quantified by the mean Hausdorff distance between bone segmentations. Healthy 8-week-old C57BL6J mice were irradiated with 150 kVp x-rays to doses of 21 Gy or 34 Gy at FLASH (right eye) and CONV (left eye) dose rates, respectively. Both eyes were irradiated to limit the influence of varying baseline vision between animals in our analysis. Visual acuity was assessed in 3 mice per dose level using scotopic electroretinography (ERG) up to 2 months post irradiation. Histopathological changes were assessed through H&E staining of harvested eyes. <h3>Results</h3> Mouse setup in our immobilization device was highly reproducible, with a mean Hausdorff distance of 0.34 ± 0.10 mm. Measured dose rates within the field were 67.0 ± 1.9 Gy/s and 1.2 ± 0.1 Gy/s at FLASH and CONV settings, respectively. ERGs revealed that FLASH-irradiated eyes at 21 Gy retained visual function up to 2 months post irradiation, while 21 Gy CONV induced blindness at all sampled time points with more severe surrounding skin effects. At 34 Gy, all eyes were blinded within 1 week, with comparable skin toxicities in the irradiated areas regardless of dose rate. Pathological assessment showed a loss of the photoreceptor layer of the retina from CONV irradiation, which remained intact in FLASH-treated mice. <h3>Conclusion</h3> We have developed a novel platform to study x-ray FLASH effects from ocular irradiation in mice. Functional ERG assay revealed a preservation of visual function from 21 Gy at FLASH dose rates that was not present from 21 Gy CONV. Differential damages between FLASH and CONV irradiations were confirmed through histopathology. This first demonstration of FLASH normal tissue sparing effects in a mouse eye model presents a unique and promising translation opportunity for clinical FLASH treatment. Further studies are ongoing to explore the long-term effects of FLASH radiation on vision and its efficacy on intraocular tumors.

The Immune Response and Intestinal Injury after X-Ray FLASH Irradiation in Murine Breast Cancer Transplanted Models

<h3>Purpose/Objective(s)</h3> The present study investigated the anti-tumor effect, immune response, and intestinal injury in breast cancer-bearing mice after ultra-high dose rate radiotherapy (FLASH-RT) and conventional dose rate radiotherapy (CONV-RT). <h3>Materials/Methods</h3> Six-week-old female C57BL/6 mice were inoculated subcutaneously with Py8119 and Py230 breast tumor cells in the inguinal mammary gland, and received 10 Gy abdominal 6 MeV X-ray FLASH-RT (>100 Gy/s) or CONV-RT (0.2 Gy/s) 15 days after tumor inoculation. EBT3 radiographic films were used to confirm the dose. Tumor samples were obtained 2 weeks post-irradiation (PI) in Py8119 tumor-bearing mice, spleen tissues were collected 4 weeks PI in Py230 tumor-bearing mice. Flow cytometry (FC) was performed with tumor and spleen tissues and immunohistochemistry (IHC) staining was performed in tumor tissues to test CD3+, CD4+, and CD8+ T lymphocytes. The number and length of remaining crypts were measured to evaluate acute intestine damage 3 days PI. <h3>Results</h3> Both FLASH-RT and CONV-RT significantly reduced the tumor weights. FC showed increased CD8+/CD3+ and CD8+/CD4+ ratios in tumor tissues and IHC confirmed a similar CD8+ T cells percentage 2 weeks PI, but there is no significant difference between FLASH and CONV groups. Surprisingly, significantly smaller spleen weight and substantially higher CD8+/CD3+ and CD8+/CD4+ ratios in the spleen in FLASH compared with non-irradiated control and CONV groups 4 weeks PI, indicating FLASH might stimulate a systematic immune response. FLASH irradiated mice had more remaining crypts and significantly longer crypt length than CONV irradiated mice, indicating a normal tissue sparing effect of FLASH-RT. <h3>Conclusion</h3> FLASH-RT and CONV-RT effectively suppressed tumor growth and promoted CD8+ T cell influx into the tumor. FLASH-RT resulted in a smaller weight and a higher proliferative rate of CD8+ T cells in the spleen than CONV-RT, which might indicate a different systematic immune effect between FLASH-RT and CONV-RT. FLASH-RT significantly spared the intestine from early damage.

FLASH Effects Induced by kV X-Rays in a Murine Skin Model

<h3>Purpose/Objective(s)</h3> Current research on FLASH dose rate radiotherapy is predominantly performed with advanced proton or electron accelerators of limited access to the laboratory researcher. Stationary anode orthovoltage x-ray irradiators would be desirable but are currently incapable of supporting the power requirements to operate at FLASH dose rates. In this study, we investigate the use of rotating anode x-ray tubes to overcome these limitations. We present the dosimetric characterization of a rotating anode x-ray system for laboratory FLASH research and its implementation for a pilot study of radiation skin toxicities in mice. <h3>Materials/Methods</h3> A high-capacity rotating anode x-ray tube was installed in our laboratory with a 75-kW generator, operating at 150 kVp with 0.025 mm Cu added filtration. Calibrated radiographic film was irradiated at varying depths in kV solid water to measure output, beam profiles, and depth-dose parameters (PDD). A variety of wild-type mice (GR/GRT, CMV) were irradiated to the hind flank to 38 or 48 Gy at the highest achievable dose rate (FLASH-IR). Conventional dose rate irradiations (CONV-IR) to the same doses were performed at 3 Gy/min using a 220 kVp x-ray irradiator. Visible skin toxicities were assessed weekly and quantified using a skin scoring scale for endpoints of hair loss, erythema, and ulceration (n= 7 per dose at each dose rate). At 8-weeks post irradiation, skin samples were harvested and stained with H&E to assess pathological changes from FLASH-IR or CONV-IR x-rays. <h3>Results</h3> Dose rates peaked at 101 Gy/s in the cathode side of the radiation field from anode heel effects. The total field size at 46 mm SSD was 20 × 20mm². A useable region of 10 × 20 mm² for FLASH studies was defined as the cathode-half of the field, with an average dose rate of 96.1 ± 2.8 Gy/s. The PDD within this region falls to 67% at 5mm depth in solid water and 51% at 10 mm. At 4 weeks post irradiation, CONV-IR mice saw hair loss and erythema in the entire irradiated region, while all FLASH-IR mice retained hair in-field with no change in skin condition. By 8 weeks post irradiation, skin effects in all FLASH-IR mice did not progress beyond hair loss in field, while all CONV-IR mice had progressed to more severe skin toxicities. Pathological assessments are ongoing. Early analysis shows higher frequency of ulceration, dermis hyperplasia, and fibrosis from CONV-IR than FLASH-IR. <h3>Conclusion</h3> This study presents the first observation of FLASH effects induced by a single pulse of kV x-rays in an animal skin toxicity model. FLASH dose rates requisite for preclinical research are achievable with kV x-rays using rotating anode technology. X-ray FLASH effects in skin occur at comparable doses to those published for FLASH electrons and protons. The use of a single x-ray pulse suggests that average dose rate is the necessary condition, in contrast to fine pulse structure, for the induction of FLASH effects.

Using EBT3 Films and Monte Carlo Simulations to Determine the Percent Depth Dose of a New Y-90 Disc Source for Episcleral Brachytherapy

<h3>Purpose/Objective(s)</h3> A novel Y-90-disc beta source was recently developed for episcleral eye plaque brachytherapy. The purpose of this study was to determine the percent depth dose (PDD) of this new source using the EBT3 film measurements and Monte Carlo simulations. <h3>Materials/Methods</h3> Radiographic films of the same batch were calibrated using the 6MV beam of a linear accelerator, and used to measure the dose distribution of this Y-90-disc source in water. Monte Carlo simulations were performed to calculate the in-water dose distribution using the "GATE," a software based on a Monte Carlo simulation toolkit developed by the international OpenGATE collaboration. The simulation codes were first validated with the TG43, ICRU56, and ICRU72 results, and then used to simulate the radiation transport in the Y-90-disc source, its capsule and the surrounding water medium. The standard Y-90 beta spectrum from ICRU 72 was used, and the physics processes for beta and photon interactions with matters were all included. Three-dimensional dose distribution was simulated, from which the PDD curve along the central axis perpendicular to the disk surface was extracted and compared with that obtained from the film measurements. <h3>Results</h3> The measured PDD curve, normalized to the point at 1 mm above the source capsule, agreed well with the simulated PDD curve with an average difference of -0.27±1.5%. Since the eye plaque brachytherapy might be prescribed to a point with a low PDD (e.g., 5%-10%), we further analyzed the agreement in this area. The difference between the measured and simulated PDDs gradually increases for depths larger than 3.5 mm (measured 16.7% vs. simulated 16.6 %). At 5 millimeters (5.9% vs. 4.3%), the simulated PDD is 26.2% lower than the measured, which we believe is still a clinically acceptable agreement. For larger depths, the difference increased quickly to a level that we could not confidently conclude that the measured PDD is accurate. <h3>Conclusion</h3> PDD of this new Y-90 source was successfully measured with the EBT3 films and confirmed by Monte Carlo simulations for depth up to 5 mm from the surface of the plaque. Large discrepancies were observed for depths beyond 5 mm. More studies are needed to confirm the PDD if the treatment needs to be prescribed to a depth larger than 5 mm.

Does the Reduction Matter? Non-Emergent Ankle Fractures and the Effect of Near-Anatomic Reduction

Category: Ankle; Other Introduction/Purpose: Ankle fractures are a common orthopedic injury observed in a wide variety of patient populations. Prior to being seen by an orthopedic specialist, patients with ankle fractures may have already undergone several procedures in the field or in the emergency department to stabilize or reduce the injured bone. While a paradigm that near-anatomic reduction improves outcomes in non-urgent ankle fractures exists, no study to date has shown objective evidence of this in postoperative patient- reported outcomes. The present study aims to evaluate whether adequate reduction of non-emergent ankle fractures within 24 hours of inciting injury influenced postoperative outcomes. Methods: All non-emergent ankle fractures treated by a single foot and ankle, fellowship-trained surgeon were queried over a period of 5 years and retrospectively evaluated through the electronic medical record. 97 patients over the age of 18 years with traumatic ankle fracture etiologies were considered. Plain film radiographs from initial presentation to the emergency department or first visit to orthopedics clinic were evaluated by the attending physician for adequate reduction based on AP and lateral tibiotalar congruency. Patient demographics and surgical outcomes data were collected from electronic medical record review. In the cases deemed to be dislocated or subluxated on initial injury films, the days until adequate reduction were calculated along with patient-reported VAS and SF-36 scores. Non-continuous data were compared using chi-squared tests, while continuous, non- normally distributed data were compared utilizing a Mann-Whitney U test. Alpha and beta for this study were assumed to be 0.05 and 0.8, respectively. Results: The average age was 46, with 68.9% of the patient population that was female. 51 patients were found to be adequately reduced within 24 hours, while 39 were not. The average time to final PRO follow-up was 12.6 months +- 1.9. No differences in preoperative VAS, SF-36 physical nor mental scores were noted between adequately and inadequately reduced cohorts (p= 0.654, p=0.262, p=0.760 respectively). Similarly, no differences in final postoperative follow up VAS, SF-36 physical nor mental scores were observed (p=0.503, p=0.252, p=0.296 respectively). VAS pain scores in both cohorts also improved to a similar degree over the preoperative to final postoperative follow up time point (p=0.261). Conclusion: These data show no difference in patient-reported pain or physical and mental functioning scores over 1 year after surgical fixation of the ankle, regardless of whether the ankle joint was adequately reduced within 24 hours of injury. We assert that anatomic reduction of the ankle joint following traumatic, non-emergent ankle fracture does not play a significant role in overall patient outcomes over 1 year following surgical correction.

Are Both Preoperative Full-Spine 3Dimensional Computed Tomography Scans and X-Ray Films Necessary for Patients with Ankylosing Spondylitis Kyphosis?

ObjectiveThis study is aimed to investigate whether both pre‐operative full‐spine 3Dimensional computed tomography scan (3D CT) and X‐ray film were necessary for patients with severe ankylosing spondylitis (AS) kyphosis deformity.MethodsThe research objects were selected from the inpatients with AS in our hospital from 2017 to 2019. A total of 42 patients were included in the study. On both the synthesized 2Dimensional (2D) lateral radiograph and X‐ray film, the globe kyphosis (GK), the lumber lordosis (LL), the thoracolumbar kyphosis (TLK) and the thoracic kyphosis (TK) were measured. And the angle seventh thoracic vertebra (T7), the angle twelfth thoracic vertebra (T12) and the angle third lumber vertebra (L3) were also measured. Two researchers with professional medical education were randomly selected to perform the measurement method and record the measurement data. Two researchers independently completed, recorded, and evaluated the accuracy and consistency of the measurement data. This study used intraclass correlation coefficient (ICC) to analyze the synthesized 2D lateral radiograph and general X‐ray film of 42 subjects by two researchers, in order to evaluate the consistency of data measurement results between the examiners. Through the comparison of the above parameters that the GK, LL, TLK, TK, angle T7, angle T12 and angle L3, the evaluation was made both pre‐operative full‐spine 3D CT and X‐ray film were necessary for patients with severe AS kyphosis deformity.ResultsThere was no significant difference between the GK, LL, TLK, TK, angle T7, angle T12, angle L3 on the synthesized 2D lateral radiograph and that on X‐ray film (P = 0.240, 0.324, 0.199, 0.095, 0.421, 0.087, 0.478). Agreement two researchers was excellent with ICC of the GK, LL, TLK, TK, angle T7, angle T12, angle L3 (0.977, 0.969, 0.986, 0.945, 0.947, 0.915, 0.857) on the synthesized 2D lateral radiograph. The Bland–Altman plot results that the measurement results of examiners are reliable and stable.ConclusionBy estimating the degree of spinal sagittal imbalance and measuring the Cobb angle, we can see that full‐length spine radiographs of the patients are unnecessary for patients with severe AS kyphosis deformity who will or have undergone preoperative spine 3D CT.

Design and construction of a radiographic film dryer

Radiographs are vital in hospital diagnostic processes. After a radiograph is processed from the developer, it must be dried before it can be interpreted by the radiologist. Two methods are basically available for radiograph drying – open sun drying and oven drying. Despite variability in weather conditions which can hamper effective radiograph drying, most diagnostic centers still rely on the open sun drying method due to the unavailability of radiograph dryer. This project presents the design and construction of a radiographic film dryer that is cost effective, user friendly and serviceable using local technology. The dryer is composed of a heater, a blower, an extractor and a drying cabin that is capable of containing 25 detachable film hangers (49.5 cm) placed into two rails (37 cm) at both sides. Good quality of dried radiographs were obtained when chamber heating/air evacuation were done at 5 minutes time interval. 25 radiographs of two major sizes; 18 cm × 24 cm (smallest) and 35 cm × 43 cm (largest) were dried approximately 5 and 10 minutes respectively at maximum temperature of 55 0C. The drying process was both temperature and time controlled as moisture content was removed from the processed films in real time for quick diagnostic processes.

Design and construction of a radiographic film dryer

Design and construction of a radiographic film dryer

The case for intra-operative X-ray in cochlear implantation: Four illustrative cases and literature review

Objectives: To demonstrate the utility of routine intraoperative plain film imaging in optimizing outcomes in cochlear implantation. Introduction: Evolving surgical techniques, programming, and electrode arrays have all improved performance outcomes in cochlear implantation. Yet despite decreasing complication rates, electrode misplacement remains a common occurrence. Utilization of intraoperative confirmational tools (radiologic, electrophysiologic) remains unstandardized despite the acknowledged importance of proper electrode positioning. The purpose of this article is to illustrate the use and benefits of intraoperative X-ray (IOXR) in four cases, particularly in cases of normal electrophysiologic testing. Methods: Four cases performed by an experienced CI surgeon are discussed where electrode malposition was only detected through X-ray. Literature review was performed on the use of intraoperative imaging, focusing on plain film radiography. Results: Case 1–3 describe examples of resistance-free electrode insertion in patients with normal pre-operative imaging. Intraoperative impedances and neural response telemetry (NRT) were normal. However, IOXR ultimately revealed tip fold-over prompting array repositioning. Case 4 describes an elective replacement of a soft-failing device. Resistance was encountered during array insertion, with IOXR demonstrating incomplete insertion compared with prior imaging. Positioning was revised to achieve pre-revision insertion depth, demonstrating the utility of prior IOXR in revision cases. Literature review of IOXR is discussed. Conclusion: Appropriate placement of the electrode is paramount to successful CI outcomes. These cases illustrate IOXR as a safe, effective method to ensure optimal placement even in cases of normal electrophysiologic testing, supporting its routine use even by the most seasoned surgeons.

A novel way of quantifying bone defect in primary total knee replacements using plain radiographs.

Bone defect assessment in primary advanced knee arthritis can present a challenge for the surgeon and lead to unfavourable outcomes if not adequately determined during preoperative planning. The aim of this study was to introduce a new, simple and quick way to assess and quantify bone defect using short film radiographs and utilising it to choose the total knee prosthesis. This is a prospective case series of patients who underwent TKA (Total Knee Arthroplasty) using various types of prostheses. Three different angles - Tibiofemoral angle, MPTA (medial proximal tibial angle), and JLCA (joint line convergence angle) - were measured preoperatively to evaluate limb alignment, placement of the tibial, and femoral components of total knee prosthesis. Postoperatively roentgenographic index introduced by Lotke et al was used to assess our preoperative methodology. The American knee society score was used pre- and postoperatively up to one year. A total of eight knees of six patients were analysed (four males, two females). The mean age of the patients was 57.75±5.701 years. All the knees were in varying degrees of varus deformity preoperatively. The accuracy of the preoperatively used radiological angles was analysed by postoperative measurement of tibiofemoral angle (d), tibial anatomical axis (b) and femoral anatomical axis (a), and Roentgenographic index as suggested by Lotke et al. Postoperatively, all the knees were in valgus with tibiofemoral angle (d) 6.50±0.926, tibial component alignment (b) mean was 89±1.195, and femoral component alignment (a) mean was 5.13±0.991 valgus. Mean roentgenographic index was 89.38±3.292. American knee society score improved at one-year follow-up postoperatively and was statistically significant with p<0.001. In this study, a new classification for bone defects in primary arthritic knees by utilising simple plain radiograph short films and as a guide for implant selection is proposed.

Fetal Disseminated Malignant Rhabdoid Tumor.

Fetal Disseminated Malignant Rhabdoid Tumor.

A Physical Therapist's Experience as a Point-of-Contact Care Provider in a Wilderness Environment: A Case Series Report

Background Wilderness physical therapists (WPTs) are on-scene primary providers who combine physical therapy, emergency first aid, and wilderness survival skills to manage people with a wide array of injuries and illnesses in remote environments. Case Presentation Patient 1, a 51-year-old female, was unable to bear weight after sustaining a right knee injury from falling into a river while hiking. The WPT immobilized a suspected knee fracture using a SAM® Splint, moved the patient and her group to safer location, and constructed a shelter. Shortly after, patient 2, a 14-year-old male, fell and sustained a forehead laceration. Hemostasis was obtained and the patient was monitored for neurologic abnormalities. Safety was complicated by rainfall, darkness, and the absence of cell service to notify emergency medical services. Outcome and Follow-Up Emergency medical services arrived 4 hours after the initial injury and evacuated both individuals. Plain film radiographs of patient 1's knee were interpreted as normal; however, subsequent magnetic resonance imaging revealed a posterior tibial plateau fracture with ligamentous injury. Following a 20-hour observation period, patient 2 was returned to continue the hike with his group. Discussion This case illustrates the emergency medical, leadership, and situational awareness skills required of a WPT. This case also illustrates the in-field application of the Ottawa knee rules and the importance of careful neurologic assessment in individuals with head trauma. JOSPT Cases 2022;2(3):175–182. Epub: 21 June 2022. doi:10.2519/josptcases.2022.10944

Man With Right Shoulder Pain

A 61-year-old man fell from his scooter resulting in right shoulder pain. The patient required first aid in a local hospital where plain film radiography showed no apparent abnormalities. He then presented to our emergency department due to persistent pain and an inability to move his right shoulder, with his right arm in a supportive sling. Radiography revealed rounding of the humeral head (Figure 1), which was confirmed by point-of-care ultrasound (Figure 2A ).Figure 2Point-of-care ultrasound, using a curvilinear probe in the transverse orientation behind the scapular spine. A, Before the procedure, the humeral head was protruding from the glenoid toward the posterior aspect of the shoulder, indicating a posterior dislocation. B, After the procedure, the humeral head was immediately adjacent to the glenoid, confirming a successful reduction. Ant, anterior side; Post, posterior side; Med, medial side; Lat, lateral side; D, deltoid muscle; G, glenoid; H, humeral head; I, infraspinatus muscle; S, scapula spine.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Posterior dislocation of the right shoulder. Point-of-care ultrasound showed that the humeral head protruded from the glenoid toward the posterior side. A closed reduction of the right shoulder was performed, and point-of-care ultrasound confirmed a successful reduction (Figure 2B). The patient was discharged and was followed up in an outpatient clinic. Posterior shoulder dislocations are rare. Missed diagnoses are frequent because the humeral head appears aligned within the glenoid fossa on plain film radiograph.1Hatzis N. Kaar T.K. Wirth M.A. et al.The often overlooked posterior dislocation of the shoulder.Tex Med. 2001; 97: 62-67PubMed Google Scholar,2Magnussen A.P. Watura C. Torr N. et al.Missed posterior shoulder fracture dislocations: a new protocol from a London major trauma centre.BMJ Open Quality. 2020; 9e000550Crossref Scopus (1) Google Scholar Additionally, patients with shoulder trauma usually have the shoulder immobilized with a sling at the time of imaging, causing the anteroposterior radiographs obtained to be imprecise with the expected rounding of the humeral head. This makes the characteristic “light bulb” sign on a radiograph unreliable.2Magnussen A.P. Watura C. Torr N. et al.Missed posterior shoulder fracture dislocations: a new protocol from a London major trauma centre.BMJ Open Quality. 2020; 9e000550Crossref Scopus (1) Google Scholar Ultrasonography is highly sensitive and specific for the identification of shoulder dislocation.3Gottlieb M. Holladay D. Peksa G.D. Point-of-care ultrasound for the diagnosis of shoulder dislocation: A systematic review and meta-analysis.Am J Emerg Med. 2019; 37: 757-761Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Normally, the humeral head appears as a hyperechoic, semicircular line with an acoustic shadow immediately lateral to the glenoid. The humeral head will not be congruent to the glenoid in shoulder dislocations, appearing deeper with an anterior dislocation and more superficial with a posterior dislocation.

Prediction of difficulty in direct laryngoscopy

To establish easily measurable and reproducible preoperative parameters predicting difficult laryngeal exposure in direct laryngoscopy. A prospective study including 71 patients who underwent transoral microsurgery for benign or malignant lesions of the larynx was performed in our department from January 2021 to November 2021. Physical assessment included the Mallampati score, weight, height, body mass index and measurements of seven parameters in the cervical region. Eleven parameters were measured on the cervical radiography film. Among our patients, 19 were included in the difficult laryngeal exposure (DLE) group. High Mallampati and Cormack scores were significantly associated with DLE (p = 0.005 and p < 0.0001). Limited mouth opening, direct thyromental distance (DTMD) < 67 mm in neutral position, DTMD < 82 mm and sternomental distance < 157 mm at full head extension were statistically related to DLE. For radiological assessment, the effective length of the maxilla and the atlanto-occipital distance were related to DLE. Using stepwise logistic regression, only the effective length of the maxilla and atlanto-occipital distance were selected as independent predictors for DLE (p: 0.015 and 0.001). Preoperative prediction of DLE is useful for both surgeons and patients. The length of the maxilla and the atlanto-occipital distance were found to be independent risk factors for DLE. This highlights the effect of overgrowth of the maxilla, protrusion of the upper teeth and limited extension of the cervical spine as the major risk factors for difficult laryngeal exposure.

Kinematic and kinetic analysis of transfemoral prosthesis

&lt;p&gt;The feasibility of using transfemoral prosthesis Otto bock with 3R80 knee and articulated ankle1C30 “Trias” was analyzed from the perspective of dynamics and clinic. The kinematic and kinetic study of gait were performed on 5 amputated volunteers and 5 controls using videography techniques and force platform. Kinetic asymmetry gait is one of the main causes of hip joint degeneration. Combining kinematic and kinetic variables, we can draw important conclusions related to the dynamic imbalance of the main causes of hip degenerative diseases through the clinical trials of radiography film and density measurement, which has become an important tool to evaluate the feasibility of prosthetic design.&lt;/p&gt;

Cephalometric analysis of upper lip thickness as a critical aid in formulating a treatment plan in skeletal Class I malocclusion in adults

It is very crucial to understand that both soft tissue drape and the underlying skeletal malocclusion, are sometimes overlooked and this could be misleading for diagnosis and treatment planning .Therefore a sound knowledge of underlying malocclusion and CTP (cephalometric treatment planning) along with accurate clinical examination can aid in better diagnosis and treatment planning. The objective of this study is to understand that soft tissue drape and underlying skeletal malocclusion in Angle’s class I malocclusion could be misleading in treatment planning and therefore to perform necessary cephalometric hard and soft tissue analysis. Lateral cephalograms were obtained in NHP (Natural head position) position of size (20×25cm) FUJIFILM and lateral cephalograms were obtained on radiographic films. Evaluation of lateral cephalograms and the above mentioned parameters were traced and assessed by manual tracing of 150 lateral cephalogram was done using tracing papers with the help of tracing backlight box .Tracing was done with lead pencil point (0.3 mm HB). 150 patient of central Indian population with Angle’s class I malocclusion full permanent dentition between ages 18-45 years were included. Out of these 150 patients 75 males and 75 females patients are included in the study. Upper lip anterior and lip angle shows moderate positive correlation with W angle. The key ridge shows a strong positive correlation with W angle. The upper lip thickness can be used as a treatment plan predictor in Angle’s class I malocclusion as it is strong correlated with W angle. Soft tissue drape especially the upper lip thickness is an essential parameter along with identification of underlying skeletal malocclusion with cephalometric treatment planning measurement like W angle, for treatment planning of even a simple Angle’s class I malocclusion case.

Evaluation of dose distribution of an intraoperative radiotherapy device using thermoluminescent dosimeters and radiographic films.

BackgroundTo investigate dose distribution of the 5cm spherical applicator of the INTRABEAM™ intraoperative radiation therapy (IORT) device via thermoluminescence dosimeters (TLDs) and Radiographic films. Independent dose distribution assessment of IORT devices is considered important. Several methods are described for this purpose, including TLDs and films. However, Radiographic films are not routinely used.Materials and methodsTwenty TLDs were used for depth dose measuring and evaluating the isotropy in water. Additionally, the isotropy was assessed separately via Radiographic films in air by drawing isodose curves.ResultsTLD measurements showed a steep dose decline which the relative average dose of 0.94 at the applicator surface reduced to 0.32, 0.13, and 0.07 at 1, 2, and 3 cm depths in water, respectively. Some remarkable isodose curves prepared using Radiographic films showed forward anisotropy of the 5 cm applicator.ConclusionA very steep dose decline and approximately isotropic dose distribution of the 5 cm applicator were observed via TLD measurements. Radiographic films showed acceptable potential for drawing dose distribution maps. However, they should be applied in more various radiation setups to be implemented more confidently.