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Perspectives and institutional policies on patient safety and image quality regarding the use of knee-spanning external fixators in MRI: A survey study of the Society of Skeletal Radiology

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Abstract

Objective

Concerns regarding patient safety and image quality have made the use of knee-spanning external fixators in MRI a challenging clinical scenario. The purpose of our study was to poll practicing musculoskeletal radiologists on their personal experiences regarding the use of knee-spanning external fixators in MRI in an effort to consolidate practice trends for the radiologists’ benefit.

Methods

A 27-item survey was created to address the institutional use, safety, adverse events, quality, and perspectives of the radiologist related to MRI of an externally fixated knee. The survey was distributed to 1739 members of the Society of Skeletal Radiology.

Results

A total of 72 members of the Society of Skeletal Radiology completed the survey. Most notably, 40 of 72 (55.56%) respondents are permitted to place a knee-spanning external fixator inside the MR bore at their institution, while19 of 72 (26.39%) respondents are not permitted to do so. Fourteen of 32 (43.75%) respondents have institutional guidelines for safely performing an MRI of an externally fixated knee. Twenty-five of 32 (78.13%) respondents are comfortable permitting an MRI of an externally fixated knee.

Conclusion

We found a general lack of consensus regarding the decision to scan a patient with a knee-spanning external fixator in MRI. Many institutions lack safety guidelines, and providers rely upon a heterogeneous breadth of resources for safety information. A re-examination of the FDA device labeling nomenclature and expectations of the individual manufacturers may be needed to bridge this gap and help direct management decisions placed upon the provider.

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Author information

Authors and Affiliations

  1. Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, CT, USA

    Aaron J. Marcel

  2. Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA

    Erin F. Alaia

  3. Division of Sports Medicine, Department of Orthopaedic Surgery, New York University Langone Orthopedic Center, New York, NY, USA

    Michael J. Alaia

  4. Department of Radiology, Musculoskeletal Imaging, Yale School of Medicine, New Haven, CT, USA

    Lee D. Katz & Jack Porrino

  5. Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT, USA

    Michael J. Medvecky

Authors
  1. Aaron J. Marcel
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  2. Erin F. Alaia
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  3. Michael J. Alaia
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  4. Lee D. Katz
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  5. Michael J. Medvecky
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  6. Jack Porrino
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Corresponding author

Correspondence to Aaron J. Marcel.

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Investigation performed at Yale School of Medicine, New Haven, CT.

Appendices

Appendix 1: Knee-spanning external fixators in MRI: institutional policies and perspectives on patient safety and image quality

Post-reduction stabilization of knee dislocations with an external fixator is indicated after emergent vascular surgery. Subsequent need for magnetic resonance imaging (MRI) to evaluate ligamentous injury presents a clinical impasse, as there is persistent uncertainty regarding the safe use and clinical utility of MRI in the presence of a knee-spanning external fixator. Although studies have indicated MRIs with knee-spanning external fixators can be safe and provide images of diagnostic quality, no universal safety guidelines exist.

The purpose of this survey is to poll practicing musculoskeletal radiologists on their current institutional policies, personal experiences, and knowledge regarding the use of knee-spanning external fixators in MRI. All questions below are in regard to a patient who presents with a severe knee injury for which a knee-spanning external fixation device has been placed to maintain joint reduction and provide stability.

Please answer the following questions to the best of your knowledge with regard to your CURRENT practice.

  1. 1.

    At your institution, are knee-spanning external fixators permitted to be placed inside the MR bore for imaging of the knee? If "No" or “I don’t know” please explain why, answer Question 15, and refrain from taking the remainder of this survey.

    1. a.

      Yes

    2. b.

      No (Please explain why)

    3. c.

      I don’t know

  2. 2.

    How many years have you been an attending radiologist?

    1. a.

       < 5 years

    2. b.

      5 – 10 years

    3. c.

      11 – 20 years

    4. d.

       > 20 years

  3. 3.

    Are you a fellowship trained musculoskeletal radiologist?

    1. a.

      Yes

    2. b.

      No

  4. 4.

    Which of the following best describes your current practice setting?

    1. a.

      Academic

    2. b.

      Private practice

    3. c.

      Hybrid (partially academic/partially private practice)

    4. d.

      Other (Please explain)

  5. 5.

    What level hospital care is your institution designated?

    1. a.

      Level I trauma center

    2. b.

      Level II trauma center

    3. c.

      Level III trauma center

    4. d.

      Level IV trauma center

    5. e.

      Level V trauma center

    6. f.

      I do not work at a trauma center

    7. g.

      I don’t know

  6. 6.

    Does your institution have clearly written, easily accessible guidelines on how to safely perform an MRI of an externally fixated knee?

    1. a.

      Yes

    2. b.

      No

    3. c.

      I don’t know

  7. 7.

    How do you identify conditions/parameters for safe MRI scanning of an externally fixated knee? Select all the apply.

    1. a.

      Card or manual provided by the external fixator manufacturer

    2. b.

      Reviewing labels on the external fixation device

    3. c.

      Reviewing manufacturer website for safety guidelines

    4. d.

      Subscribing to guidelines provided by your institution

    5. e.

      Other (Please explain)

    6. f.

      I don’t know

  8. 8.

    Is a risk–benefit discussion with the ordering provider or orthopaedic surgeon required prior to an MRI of an externally fixated knee?

    1. a.

      Yes

    2. b.

      No

    3. c.

      I don’t know

  9. 9.

    Is it required to explain the risks of MRI of an externally fixated knee to the patient prior to imaging?

    1. a.

      Yes

    2. b.

      No

    3. c.

      I don’t know

  10. 10.

    Is it required to test each knee-spanning external fixator for ferromagnetism with a bar magnet before performing an MRI?

    1. a.

      Yes

    2. b.

      No

    3. c.

      I don’t know

  11. 11.

    Do you perform any other pre-MRI safety tests on knee-spanning external fixators before the scan is acquired? If “Yes,” please explain.

    1. a.

      Yes (Please explain)

    2. b.

      No

    3. c.

      I don’t know

  12. 12.

    How often are MRI scanners checked for proper function (e.g., phantom scans)?

    1. a.

      Daily

    2. b.

      Weekly

    3. c.

      Biweekly

    4. d.

      Monthly

    5. e.

      Other (Please explain)

    6. f.

      I don’t know

  13. 13.

    What personnel are required to be present for MRI of an externally fixated knee? Select all that apply.

    1. a.

      Radiology technologist

    2. b.

      Attending radiologist

    3. c.

      Attending ordering clinician

    4. d.

      Resident or Fellow Radiologist

    5. e.

      Resident or Fellow ordering clinician

    6. f.

      Other (Please explain)

    7. g.

      I don’t know

  14. 14.

    During MRI of an externally fixated knee, is the patient required to be alert and oriented?

    1. a.

      Yes

    2. b.

      No

    3. c.

      I don’t know

  15. 15.

    Is a patient who needs an MRI for a non-knee injury (e.g., head, shoulder, etc.) permitted to obtain an MRI if they are in a knee-spanning external fixator? Example: A polytrauma patient.

    1. a.

      Yes

    2. b.

      No

    3. c.

      Depends on the body part being scanned (Please explain)

    4. d.

      I don’t know

  16. 16.

    Are you comfortable permitting an MRI of an externally fixated knee? Select all that apply.

    1. a.

      Yes

    2. b.

      No, because of unclear safety guidelines

    3. c.

      No, because of potential heating

    4. d.

      No, because of potential movement

    5. e.

      No, because of potential damage to the MRI scanner

    6. f.

      No, because of another reason (Please explain)

  17. 17.

    Have you ever refused to perform an MRI of an externally fixated knee? Select all that apply.

    1. a.

      Yes, because of unclear institutional guidelines

    2. b.

      Yes, because of worry of heating

    3. c.

      Yes, because of worry of movement of the limb

    4. d.

      Yes, because of worry of damage to the MRI scanner

    5. e.

      Yes, because of presumed poor image quality

    6. f.

      Yes, because of another reason (Please explain)

    7. g.

      No

  18. 18.

    Are you familiar with the U.S Food and Drug Administration’s (FDA) designation of metal devices as MR Safe, MR Conditional, and MR Unsafe?

    1. a.

      Yes

    2. b.

      No

    3. c.

      Somewhat familiar

  19. 19.

    Are you familiar with the FDA’s change in terminology regarding metal devices and how it relates to knee-spanning external fixators (i.e., change of knee-spanning external fixators from “MR Safe” or “MR Compatible” to “MR Conditional,” and then subsequent elimination of the term “MR Compatible”)?

    1. a.

      Yes

    2. b.

      No

    3. c.

      Somewhat familiar

  20. 20.

    At your current institution, how many adverse safety events have occurred since 2014 (past 9 years) as a direct result of MRI of an externally fixated knee? This includes heating, displacement of the external fixator or movement of the patient’s limb, damage to the MRI scanner, or patient pain (this does not include patient anxiety).

    1. a.

      0

    2. b.

      1 – 2

    3. c.

      More than 2

    4. d.

      I don’t know

  21. 21.

    To the best of your knowledge, has any patient experienced heating during an MRI of an externally fixated knee?

    1. a.

      Yes

    2. b.

      No

    3. c.

      I don’t know

  22. 22.

    To the best of your knowledge, has any patient experienced displacement of the knee-spanning external fixator or movement of the imaged limb during an MRI of an externally fixated knee? This does not include normal mechanical vibration.

    1. a.

      Yes

    2. b.

      No

    3. c.

      I don’t know

  23. 23.

    To the best of your knowledge, has an MRI of an externally fixated knee resulted in damage to the MRI scanner?

    1. a.

      Yes

    2. b.

      No

    3. c.

      I don’t know

  24. 24.

    Does image artifact in an MRI of an externally fixated knee significantly obstruct your ability to identify abnormalities at the extensor apparatus, cruciate ligaments, collateral ligaments, menisci, and/or bone marrow?

    1. a.

      Yes, but rarely

    2. b.

      Yes, about half of the time

    3. c.

      Yes, most of the time

    4. d.

      No

  25. 25.

    In your opinion, are MRIs of an externally fixated knee useful for pre-operative surgical planning?

    1. a.

      Yes

    2. b.

      No

    3. c.

      Sometimes

    4. d.

      I don’t know

  26. 26.

    Have you had a patient return for a repeat MRI of an externally fixated knee as a result of poor image quality?

    1. a.

      Yes, but rarely

    2. b.

      Yes, about half of the time

    3. c.

      Yes, most of the time

    4. d.

      No

  27. 27.

    Please feel free to add any additional comments.

Appendix 2: Society of Skeletal Radiology Distribution E-mail

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Marcel, A.J., Alaia, E.F., Alaia, M.J. et al. Perspectives and institutional policies on patient safety and image quality regarding the use of knee-spanning external fixators in MRI: A survey study of the Society of Skeletal Radiology. Skeletal Radiol 53, 525–536 (2024). https://doi.org/10.1007/s00256-023-04445-x

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