Post operative radiographs protocols

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I wonder if there is a general consensus regarding the use of post op radiographs.

Back in the 1980's and 90's When I first became involved in podiatric surgery in the UK, the department I worked within, routinely undertook post op radiographs of osteotomies immediately after the procedure. A further film was taken at 6 weeks to look at healing. Following policy and procedure changes the immediate post op film was dropped and then after a while the routine 6 week film was dropped and only patients who seemed to be departing from the normal post op course were x rayed ( ie pain, swelling recurrence of deformity.

More recently departments I hacve worked have the policy that post op views are taken at 1-2 weeks, and then again only if there are any unusual symptoms.



What are your typical protocols?

 

Hi Simon

I think immediate post-op and confirmation of bone healing - ie day one and week 6, would be the ideal. Not possible or easy for all units. I do one x-ray at week 4 (week 6 for fusions) but I do think one SHOULD be taken at some point

best

Ian

 

In the USA, the lawyers would have a field day if we did not take x-rays.

Steven

 

Thanks guys.

The use of an immediate post op film perplexes me. I understand the premise, ie the case was in good shape when it left me. Looking specifically at forefoot procedures, where the quality of fixation can be reliably assessed on the table, should we be subjecting our patients to an intervention which carries a radiation dose to confirm what has already been identified on the table? All of the immediate post op films I have come across have shown good fixation and expected alignment.

It could be argued that a delayed post op film, say within 2 weeks of surgery might capture a more meaningful information and so justify the radiation dose better.

Certainly, fusion sites or procedures where fixation is less readily assessed are a different animal and progress of healing needs to be assessed, for example when moving to more weight bearing activity.

Heres the link to a paper: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1964739/

 

An immediate post-operative x-ray has one value and that is to provide an objective contemporaneous record of the osteotomy, the correction and the fixation.
Logically the clinical benefit to the patient of an immediate post-operative x-ray is nil. To be clinically beneficial the x-ray would have to show something that could not be visualised well otherwise and would have to be intraoperative i.e. taken at the point before closure so that if something of concern was noted on the x-ray it could be acted upon.
I would certainly say that there is a good indication for intraoperative x-rays to assess correction whenever more than one bone is being moved in relation to others. I'm sure that it might be possible to undertake osteotomy of say more than one adjacent metatarsal and get a reasonable result however it would surely be much more sensible to be able to see the correction where possible and get an optimum alignment.
What is also of very questionable benefit to the patient are x-rays taken during a trouble-free recovery purely to assess healing. Bone heals at a predictable rate and therefore a regular post-operative protocol should normally be sufficient to ensure a successful healing in a compliant patient. There is nothing to suggest that taking x-rays regularly can prevent a problem any more than giving the patient an appropriate post-op regime to follow and advising the patient what to look out for so that if there is a cause for concern this can be raised with the clinician and then certainly x-rays can be part of the investigative follow-up where clinically indicated.
Modern C-arm Fluoroscopes (such as the Fluoroscan) provide such low doses of radiation exposure in snapshot mode that they are a valuable tool and have an excellent risk vs benefit index to help avoid surprises.
Tom

 

Thanks Tom, That approach makes a lot of sense to me

 

By the sounds of things, we x-ray patients more frequently than others where we work.

For a typical 1st metatarsal osteotomy (Scarf for example) we x-ray at the first post op visit which will normally be between 3 and 6 days. I am not entirely sure that I agree with just arranging an x-ray if something appears to be amiss. I have seen numerous post op fractures at the first visit where the patient reports no pain and the foot does not look particularly swollen. Maybe we just don't trust our patients much but I certainly think that patients will invariably weightbear more than they should in the early post op phase, partially whilst their foot is still numb.

We will then x-ray at the 6-8 week mark to monitor how the healing process is coming along. I do appreciate Tom's points regarding the rate of bone healing and that x-rays at this point cannot prevent a problem but I do see merit in checking things at this stage. Occassionally, I will note at this point an excessive amount of bone callus in an asymptomatic patient and as a result, I would suggest they stay in their training shoes for a while longer rather than letting them venture into various other styles of footwear. Advise regarding appropriate activity levels can also be amended if necessary. Does it make a difference? I don't know because I've never done it differently but I'd rather be on the safe side.

Adverse signs are better picked up sooner rather than later and for this reason alone, I am happier x-raying more frequently. This afternoon, I had a patient referred to us for a 2nd opinion. She was troubled with "a very stiff big toe" following bunion correction St Elsewhere and at 12 months post operative, was experiencing discomfort within the joint. Clinically, the hallux was rectus but the 1st MTPJ range of montion was considerably less than the contralateral side and as a fitness instructor, this was proving to be an issue for the lady. The x-ray taken today had shown that the Scarf osteotomy had fractured at some point in the post operative stage and as a result, the metatarsal head had bowed dorsally, essentially inducing hallus limitus. This patient had not been x-rayed at all post op and the patient reported what she thought was an uneventful recovery. If the problem had been identified early, this lady would not have had to go through 12 months of recovery to then potentially need another operation and another recovery period.
I wondered how this case would pan out if it ended up in court?

For our midfoot and hindfoot fusions, we will check alignment and fixation intra-op then will not x-ray again untill the 8 week point where we would hope to change weightbearing status and again at the 12 week point for the same reason. An x-ray at 18 weeks is take to ensure there are no adverse signs form the patient fully weightbearing.

Apologies for rambling a bit there!

Ryan

 

Intra or immediately post op. Then after two weeks to assure correction is maintained and hardware is in place. Then at 6 weeks (forefoot bones should be healed by then) and every month thereafter for the more complex (rearfoot) procedures.

Depends on patient demographics as well. For smokers I take radiographs more often. If there is a bone density issue or bones that are not amenable to healing (Charcot for instance), I usually take radiographs every two weeks.