By: Dr. John R. Gleason

A Future Market Insights report estimates a 4.9 percent annual growth rate of orthopaedic imaging over the next 10 years.

Increased demand creates both challenges and opportunities for physicians and their patients.

Most orthopaedic exams are conducted with traditional CT and MR systems. Because these systems are very large and expensive, they are usually installed at hospitals or imaging centers.



A new entry in the CT market is cone beam CT (CBCT) systems, which offer affordable 3-D imaging at the point of care. This new paradigm equips patients to obtain an initial evaluation, imaging exam, diagnosis and treatment plan — all in a single visit. This is a tremendous advantage for patients, many of whom are in pain and have limited mobility. It also offers greater convenience for orthopaedic specialists.

We recently purchased a CBCT system for our practice and it has proven to be an invaluable tool. As an orthopaedic surgeon, I need extremely high-resolution images to develop an accurate diagnosis.

Our CBCT system delivers exceptional image quality and also captures weight-bearing exams — an important advantage not offered by traditional CT. Seeing the joint in a weight-bearing state helps me determine if a joint is subluxed or dislocated, and allows me to detect displacement of a fracture or a tear in ligaments or tendons. This CBCT system can also help with diagnosis and treatment of arthritis and cartilage lesions of the upper and lower extremities, and evaluation of bony and soft tissue masses.

Being able to deliver a diagnosis and treatment plan minutes after an exam not only saves time, it also reduces stress for patients because I am able to immediately tell them whether they need surgery, or if physical therapy or rest is the best treatment.

We evaluated cone beam CT systems for several years prior to making a purchase. First-generation systems only captured foot and ankle exams, but now systems are available that also image hands, elbows and wrists. Most orthopaedic practices want a system that images upper and lower extremities because that represents their patient base. It’s not practical to invest in a system that only images half of your patients.



Several factors are important when evaluating CBCT systems, including:

Image quality – Orthopaedic injuries can be subtle. CBCT systems can offer differences in image quality, so it’s important to view images from multiple suppliers before making your selection. A precise diagnosis requires that the quality of CBCT images be at least as good as a traditional CT exam, and some CBCT systems offer even more detailed images.

Large field of view – CBCT systems can differ in the amount of anatomy that is captured in a single scan. For example, you will want to make sure the system is capable of capturing the tripod of the foot to make an accurate diagnosis.



Ability to capture weight-bearing exams – This capability is critical to the diagnosis of many orthopaedic conditions, so the ability to view anatomy under load is an important advantage.

Radiation dose – Evaluating dose is always important. A CBCT extremity scan should deliver approximately 5 to 40 μSv, as compared to an extremity MDCT scan that delivers approximately 30 to 160 μSv.

Reduced image scatter – Advanced scatter and metal artifact correction algorithms enhance visualization. Specialized software allows surgeons to see metal implants in an area without degrading visualization of bone or soft tissue.

Accessibility – We selected a system with a door that opens to allow patients to easily walk into the system’s imaging area. Other systems require patients to step up and into an opening in the unit, which can be difficult for patients with an injury.

Speed – Our system has a large-area detector that can capture a 3-D image in a single rotation, which takes only 25 seconds. Image processing time is about four minutes. This allows us to achieve an efficient workflow with minimal patient wait times.

Deploying the system
Our CBCT system can be installed in a day. Its compact size allows it to fit nicely into an exam room. The system can be plugged into a standard electrical outlet and does not require special wiring. Our technologists report that the CBCT system is even easier to use than a digital radiography system. Ease of use is important because it simultaneously reduces training time and increases productivity and workflow. In a busy orthopaedic practice, this is an important asset.

Cone beam CT technology is a relatively new modality, but it’s easy for us to obtain prior authorization for the exam or a retrospective authorization after the exam. The process is the same as getting authorization for MR or CT scans.

When evaluating any new purchase, achieving a reasonable return on investment is important. While we implemented the system to enhance patient care, the CBCT system also generates revenue for the practice and allows us to bill for imaging exams that would otherwise be referred out to other facilities.

On-site imaging delivers benefits for both physicians and patients. Advances in CBCT technology make it possible for orthopaedic practices and other imaging services providers to capture and view exceptionally high-quality images at a reasonable cost. And patients gain greater convenience and the potential for faster diagnosis and treatment.

About the author: Dr. John R. Gleason is the co-president of Resurgens Orthopaedics in Atlanta.