The use of a spirit-level to improve radiograph quality in ring fixators

The use of ring fixators in lower limb reconstruction and deformity correction both for trauma and elective procedures is now widespread. The long course of treatment requires regular outpatient review with frequent radiological imaging to assess the progression of treatment and plan correctional adjustment. Following publication of a technique using a frame mounted spirit-level to aid radiographers in accurately aligning the limb for optimal imaging we implemented a similar technique in our department and carried out a two part prospective comparative study to assess the impact on radiograph quality. Comparison was made of radiograph quality, X-rays taken, patient trips to the radiology department and X-ray exposure before and after implementation of the spirit-level guide technique in patients attending an out-patient clinic for routine follow up following ring fixator application. 26 patients were included in the control arm and 33 in the intervention group. On review, 42.3% of patients in the control group were deemed to have had suboptimal imaging compared with only 9.1% of those imaged using the spirit-level guide, a statistically significant improvement. When comparing total numbers of images taken for each group to achieve the requested number of adequate views there was less statistical significance, nor was there a statistically significant difference in radiation dose between the groups. A significant reduction in the number of inadequate images being taken, with a subsequent reduction in patients requiring return to the radiology department for re-imaging and then re-review in clinic, has clear implications for patients, clinicians and hospital efficiency. The patient journey time is reduced, less time and fewer resources are used in the radiology department and patients in clinic are seen more efficiently and with less wasted time. We conclude that the implementation of a simple frame mounted spirit-level as a guide for radiographers in the outpatient clinic significantly reduces the number of suboptimal and wasted images taken in the assessment of patients being treated by ring fixator.