Tomosynthesis of the Appendicular Skeleton on a Twin Robotic X-ray System: A Cadaveric Fracture Study

Rationale and Objectives Aiming to offset image quality limitations in radiographs due to superimposition, this study investigates the diagnostic potential of appendicular skeleton tomosynthesis. Materials and Methods Eight cadaveric extremities (four hands and feet) were examined employing the prototypical tomosynthesis mode of a twin robotic X-ray scanner. 12 protocols with varying sweep angles (10, 20 vs. 40°), frame rates (13 vs. 26 fps), and tube voltages (60 vs. 80 kV) were compared to radiographs. Four radiologists separately evaluated cortical and trabecular bone visualization and fracture patterns. Interreader reliability was assessed based on the intraclass correlation coefficient (ICC). Results Radiation dose in radiography was 0.59 ± 0.20 dGy * cm2 versus 0.11 ± 0.00 to 2.46 ± 0.17 dGy * cm2 for tomosynthesis. Cortical bone display was inferior for radiographs compared to 40° and 20° tomosynthesis. Best results were ascertained for the 80 kV/40°/26 fps protocol. Trabecular bone depiction was also superior in tomosynthesis (p ≤ 0.009) and best with the 80 kV/10°/26 fps setting. Interreader reliability was moderate for cortical bone display (ICC 0.521, 95% confidence interval 0.356–0.641) and good for trabecular bone (0.759, 0.697–0.810). Diagnostic accuracy for articular involvement and multifragment situations was higher in tomosynthesis (93.8–100%/92.2–100%) vs. radiography (85.9%/82.8%.). Diagnostic confidence was also better in tomosynthesis (p ≤ 0.003). Conclusion Compared to radiography, tomosynthesis allows for superior assessability of cortical and trabecular bone and fracture morphology, especially at high framerates. Operating on a multipurpose X-ray system, tomosynthesis of the appendicular skeleton can be performed without additional scanner hardware.