Innovative Developments and New Methods

Initial Clinical Experiences with the

SIREMOBIL Iso-C 3D
E. Euler 1, S. Heining 1, T. Fischer 2, K. J. Pfeifer 2, W. Mutschler 1

1
Surgical Clinic and Polyclinic, Clinic of the University of Munich – City Center, Munich, Germany
2
Institute for Radiological Diagnostics, Clinic of the University of Munich – City Center, Munich, Germany

Keywords pedicle screws were developed [1]. These considerably

• isocentric 3D C-arm • 3D imaging
• computer-assisted surgery
Introduction
Intra-operative fluoroscopy in conjunction with a
C-arm is used for controlling the position of skeletal
sections or implants (e. g., osteosynthetic plates, screws,
or pins) or other technical auxiliary devices (e.g., guide-
wires). Unsatisfactory reconstruction results for dis-
located joint fractures or incorrectly positioned screws
are frequently discovered only after generating a CT
scan for control purposes. Based on preoperatively pre-
pared CT data sets, navigation systems for positioning
aid in decreasing the number of incorrectly positioned
screws [2]. However, with respect to the repair of joint
fractures during reconstructive surgery, these systems
do not allow for precise intraoperative control of reposi-
tioning since the type and number of bone fragments
that can be determined using this navigation system
are currently limited to a few large fragments. A new
method of intra-operative 3D imaging with a mobile
isocentric C-arm (SIREMOBIL Iso-C3D, Siemens AG,
Medical Solutions, Erlangen, Germany) promises rou-
tinely performed intra-operative C-arm scans combined
with the advantages of intra-operative 3D imaging at
considerably greater cost-savings than was the case with
the previous CT procedures.
We have performed several studies [3-5] that demon-
strate the diagnostic value of 3D image reconstruction
for the intra-operative display of high contrast skeletal
objects, e. g., the extremities. Sample images illustrate
how the SIREMOBIL Iso-C3D has proven itself as a new
imaging method in a clinical environment.

Materials and Methods

Fig. 1
SIREMOBIL Iso-C 3D:
The isocentric C-arm is auto-
matically rotated 190° for 3D
image acquisition.
64 electromedica 70 (2002) no. 1
The mobile SIREMOBIL Iso-C3D (Fig. 1) calculates
an image volume from 50 or 100 individual 2D images
processed during an automatic orbital movement in one
to two minutes, resulting in an image volume of 123 cm3.
A few seconds following the completion of the C-arm’s
motorized orbital movement, the surgeon receives
imaging of the scanned volume in any imaging plane of
his or her choosing. The results from preclinical studies
of image quality and diagnostic relevance have already
been reported [6].
Following approval of the system for clinical imaging
of the cervical spine and joints of the extremities, and the
delivery of the first series model, information obtained
from preclinical studies has since been applied to routine
clinical practice. Clinical application observations of the
system were used to determine, document and interpret
influences upon the work routine in trauma surgery.
 Results Examples of 3D images are presented in the following
The clinical, intra-operative application of the C-arm illustrations and described in the accompanying captions
for three-dimensional imaging of the cervical spine and (Fig. 2-5).
the upper and lower extremities presents no problem
in conjunction with the use of non-metallic pads. Discussion
This new method of imaging was very successful in Previous use on the cervical spine as well as on the
approximately 30 intra-operative applications (Table 1). upper and lower extremities already assure that this new
The workflow may be outlined as follows: Bone fragment technique for generating three-dimensional images with
repositioning and preliminary placement with Kirschner the SIREMOBIL Iso-C 3D will assume a significant role
wires using 2D fluoroscopy, control during 3D recon- in improving the quality of intra-operative healthcare.
struction (“preliminary scan”), definitive 2D-controlled The size and handling of the system differs little from
osteosynthesis, final 3D reconstruction (“definitive normal C-arm systems, which means that significant
scan”). Immediately thereafter, the operator processes
the images (windowing, selection of image planes).
Reconstructions in both the anatomical planes and the
planes of the implants have proven valuable. Therefore,
in the preliminary scan, for example, the intraosteal
position of the Kirschner wires may be controlled, and
the length of the screws to be inserted may be determined
with the ruler function of the syngo® common user
interface. Each scan is automatically saved in DICOM
format; it is advisable, however, to save important indi-
vidual images at the same time for hardcopy documen-
tation purposes. In the vast majority of cases, the final
3D image replaced a postoperative CT (Table 2).

syngo is a registered trademark of Siemens AG.

RX CT
Cervical spine 3
Elbow joint 5
Carpus, Metacarpal 2
Wrist joint 8
Knee joint 4
Distal tibia, Ankle joint 3
Tarsus 7
Total 32

Table 1
Clinical application of the
SIREMOBIL Iso-C3D.

Number of scans Number of Iso-C 3D replaces

during one surgery surgeries N postoperative CT
1 10 *
2 18 17
3 3 1
4 1 1 Iso-C3D
*A postoperative CT was Table 2 Fig. 2
necessary. The 3D scan Number of Iso-C3D scans Preoperative conventional
was used intraoperatively performed during a (RX) and CT images of a dense
for display of the recon- surgery (N) and the fracture; the intra-operative
structed joint surface. replacement of the Iso-C3D images (Iso-C3D) allow
postoperative CT with for evaluation of the correct
the new technology. positioning of both osteo-
synthetic screws.

electromedica 70 (2002) no. 1 65

 Innovative Developments and New Methods
RX Iso-C 3D
additional logistical expenditures are a non-issue. Three-
dimensional imaging lends diagnostic certainty to intra-
operative procedures such as the optimal reconstruction
of joint surfaces and the ideal positioning of implants.
This method will prove particularly important in recon-
structing joint surfaces and in the field of minimally
invasive instrumentation. This applies not only to the
implementation of the technique alone, but also in
combination with other technical and assessment pro-
cedures, particularly navigational procedures. This
would allow not only for the possibility of navigating in
66 electromedica 70 (2002) no. 1
Fig. 3
The intra-operative slice images
(Iso-C3D) display the reconstructed
trochlea and the intraosteal posi-
tion of the osteosynthetic screws
during correction of the previous
osteosynthesis with Kirschner
wires (RX, left); the postoperative
radiographs (RX, right) present
RX an overview of the successfully
performed corrective measures.
Fig. 4
Intra-operative images before
(top) and after (bottom)
implementation of osteosynthetic
screws; these images clearly
illustrate the pre- and post-
operative information obtained
instantly when applying the
Iso-C 3D three-dimensional C-arm tech-
nique.
a current (e. g., following a successful repositioning
maneuver) three-dimensional record, but also the option
of the considerably less difficult (non-invasive) regis-
tration of even smaller fragments undetectable to pre-
viously available navigation systems. This would provide
an elegant solution to one of the most pressing and as
yet unresolved problems facing navigation. 3D imaging
also offers direct visual verification of the position of
osteosynthetic implants and reconstructed joint surfaces,
something that was not possible with previous navigation
methods.
 Literature

[1] Nolte LP, Zamorano LJ, Jiang Z, Wang Q, Langlotz F, Arm E,

Visarius H. A Novel Approach to Computer Assisted Spine Surgery.
Proc 1st Int Symp on Medical Robotics and Computer Assisted Surgery
(MRCAS) 1994; 323-328.
[2] Laine T, Lund T, Ylikosk M, Lohikoski J, Schlenzka D. Accuracy
of pedicle screw insertion with and without computer assistance:
A randomised controlled clinical study in 100 consecutive patients.
Eur Spine J 9 2000; 235-40.
RX
[3] Euler E, Wirth S, Linsenmaier U, Mutschler W, Pfeifer KJ,
Hebecker A. Vergleichende Untersuchung zur Qualität C-Bogen-basier-
ter 3-D-Bildgebung am Talus. Unfallchirurg 2001; 104: 839-846.
[4] Kotsianos D, Rock C, Euler E, Wirth S, Linsenmaier U, Brandl R,
Mutschler W, Pfeifer KJ. 3D-Bildgebung an einem mobilen chirur-
gischen Bildverstärker (Iso-C 3D): Erste Bildbeispiele zur Fraktur-
diagnostik an peripheren Gelenken im Vergleich mit Spiral-CT und
konventioneller Radiologie. Unfallchirurg 2001; 104(9): 834-838.
CT
[5] Rock C, Linsenmaier U, Brandl R, Kotsianos D, Wirth S,
Kaltschmidt R, Euler E, Mutschler W, Pfeifer KJ. Vorstellung eines
neuen mobilen C-Bogen-/CT-Kombinationsgerät (Iso-C 3D): Erste
Ergebnisse der 3D-Schnittbildgebung. Unfallchirurg 2001; 104(9):
827-833.
[6] Euler E, Wirth S, Pfeifer KJ, Mutschler W, Hebecker A.
3D-Imaging with an Isocentric Mobile C-Arm. electromedica 68,
122-126, 2000.

Iso-C 3D
Fig. 5
Luxation fracture of the talus
in a conventional radiograph
(RX) and in a preoperative CT;

the intra-operative Iso-C3D

images (Iso-C3D) show the recon-
structed joint surface and the
correct position of the screws;
Abbreviations
please refer also to illustrations CT = Computed Tomography
in the “Talus Study” [6].

The navigation systems described in this article are not offered by

Siemens Medical Solutions, Inc., USA.

Author’s address
Dr. Ekkehard Euler
Chirurgische Klinik und Poliklinik
Klinikum der Universität München-Innenstadt
(Direktor: Prof. Dr. W. Mutschler)
Nussbaumstraße 20
D-80336 Munich
Germany
e-mail: euler@ch-i.med.uni-muenchen.de

electromedica 70 (2002) no. 1 67