Postoperative Extremity Tomosynthesis-A Superimposition-Free Alternative to Standard Radiography?

Rationale and objectives: This study investigates the performance of tomosynthesis in the presence of osteosynthetic implants, aiming to overcome superimposition-induced limitations in conventional radiograms.

Materials and methods: After surgical fracture induction and subsequent osteosynthesis, 8 cadaveric fracture models (wrist, metacarpus, ankle, metatarsus) were scanned with the prototypical tomosynthesis mode of a multiuse x-ray system. Tomosynthesis protocols at 60, 80, and 116 kV (sweep angle 10°, 13 FPS) were compared with standard radiograms. Five radiologists independently rated diagnostic assessability based on an equidistant 7-point scale focusing on fracture delineation, intra-articular screw placement, and implant positioning. The intraclass correlation coefficient (ICC) was calculated to analyze interrater agreement.

Results: Radiation dose in radiography was 0.48 ± 0.26 dGy·cm 2 versus 0.12 ± 0.01, 0.36 ± 0.02, and 1.95 ± 0.11 dGy·cm 2 for tomosynthesis scans at 60, 80, and 116 kV. Delineation of fracture lines was superior for 80/116 kV tomosynthesis compared with radiograms ( P ≤ 0.003). Assessability of intra-articular screw placement was deemed favorable for all tomosynthesis protocols ( P ≤ 0.004), whereas superiority for evaluation of implant positioning could not be ascertained (all P 's ≥ 0.599). Diagnostic confidence was higher for 80/116 kV tomosynthesis versus radiograms and 60 kV tomosynthesis ( P ≤ 0.002). Interrater agreement was good for fracture delineation (ICC, 0.803; 95% confidence interval [CI], 0.598-0.904), intra-articular screw placement (ICC, 0.802; 95% CI, 0.599-0.903), implant positioning (ICC, 0.855; 95% CI, 0.729-0.926), and diagnostic confidence (ICC, 0.842; 95% CI, 0.556-0.934).

Conclusions: In the postoperative workup of extremity fractures, tomosynthesis allows for superior assessment of fracture lines and intra-articular screw positioning with greater diagnostic confidence at radiation doses comparable to conventional radiograms.