Good afternoon everyone. My name is Charlotte and thank you for joining us for today's lunchtime webinar, Advanced Imaging Without CT presented by Podra Keagan. This webinar is currently sponsored by Adapttic, therefore, I'd like to now hand over to Konrad from Adaptix, who is the VP of product management.

He'll be starting today's session. Thank you, Conrad. Great, thank you.

Thank you very much, Charlotte. Yeah, we're absolutely delighted to be able to sponsor this webinar and particularly to hear from Podrick, about his experience of using the system. Almost all of this webinar really will be, Podrick just showing images, discussing cases, but I just wanted to spend a couple of minutes at the start to both introduce the company and to tell you a little bit about the technology in the system.

So Adapttic, is a UK company. We're based in Oxford. We've got lots of, clever scientists and PhDs here have manufacturing, up in Scotland, but we also manufacture, our systems in Germany.

The company started really developing new types of, technology for generating X-rays, and it's the same sort of technology transformation. That happened with lighting as we went from all star light bulbs to LEDs. So we're using that new technology with a human orthopaedic system, which is currently going through regulatory clearance.

We'll be using that exactly that same technology in the field of intraoral human dental imaging. A couple of years further down the track, we'll be using that, extending that to general radiology and chest imaging, but of course today what we're talking about is veterinary imaging and that system. And what's at the heart of everything that we do here at Adapttic is using our technology to bring low dose, low-cost 3D X-ray imaging to the patient.

Now we all know that 2D X-ray imaging, incredibly ubiquitous, by far still the most common imaging modality, and is really a shadowgram. So based on differential absorption according to the tissues. But the problem with a 2D X-ray is that what we're trying to image is complex 3D shapes.

So 3D animals, 3D people with different conditions. And so if you look at those three examples above, is there a fracture there? Is there a tumour, is that just faeces?

Is there bone loss so much harder to see where you have the underlying and overlying tissue. Now we know that we've got amazing CT MRI 3D scanners, they're available but they're not particularly suitable for initial imaging, both of them much due to the much higher cost, the dose, the waiting times, etc. And the way that a CT works, if I can just remind you of that, is that you're taking a high powered source of X-rays, rotating that around the subject with a ring of detectors, and then you're forming this very, this series of, of highly detailed slices through the body that you can re-slice in any direction.

But the problem with that is it takes a lot of energy to make that rotation. You often need a separate room, you need the 3 phase power, etc. Etc.

So the question is, is there is an alternative to that? And the answer I hope you'll find is, yes, that Thomas synthesis, so that's the technique at the heart of what we do, really is an alternative to that. It's cheaper than CT machine operates, occupies so much less space.

And when it comes to smaller species, the resolution of the detector that we use means that in plane get even higher resolution than with CT. And that's a great quote from Martin Whitehead, who was one of the first people to take a look at the system at Chipping Norton Vets. So a couple of pictures there of the system, so you see it actually occupies very little space, about the size of a desktop printer, quite open access, so positioning the subject from a number of different angles.

And at the heart of the technology, so explaining how it works at the top there is that we're generating a series of very low dose X-ray imaging images from a series of different positions. So that covers up a range of different angles. And what that allows you to do, just like our eyes, we have two eyes, and as we cover up each eye, we're getting a slightly different view, and that gives us depth information.

Thomas synthesis reconstruction works in the same way. Only instead of having two eyes, we actually have a grid of these different eyes, if you like, 45 eyes, which allows us to get detailed depth information and reconstruct then this stack of slices through the subject. So the way that that's presented and project will show you a bunch of these images is that you're able to scroll through from bottom to top.

So just some key features of the machine there, it weighs just 22 kg. You plug it into the mains. It takes just under a minute, a moment to acquire the data set, and that will come down all the time.

Reconstruction, you get your first 3D image in about 10 seconds after it's finished, and a full stack of 50 slices, after 20 seconds. The impro resolution is 100 microns, and what you're that can mean in terms of a dental acquisition is that you can do that whole mouth series in just one or two acquisitions. The system is integrated with a Dicom based web pack.

It means that you can be sending your images off to another Dicom system. You can view them from any computer, you can also just review the images from an app on your phone. And then finally, in addition to innovating on the technology side, we also offer the system in what we call a paper study model.

So rather than needing to make a big capital upfront investment to buy this, there's actually just . Initial installation fee, there's quite a small monthly fee for software and service, but then you just pay when you use it. So you pay a fee for an orthopaedic study, and a study is basically as many images of the animal as you want to take during a day for a single fee, and we discount that for dental studies.

So, that's all really I wanted to share with you. We hope after you've seen Podrick's presentation, you're really interested in getting hold of one of these things. Please do visit our website.

It's available right now in the UK, and we're rolling out to the US and the EU, starting, early in 2023. So that's all from me. I'll stop sharing now and I'll hand over.

Thank you, Conrad, for your introduction on Adaptics. So, our speaker today is Doctor Podrick Eagan, who graduated from the Royal Dick School of Veterinary Studies in Edinburgh in 2007. He began his career working in his hometown of Leeds at a charity clinic, followed by 3 years working as a mixed vet and a year working as an emergency and critical care vet.

After completing a surgical internship and surgical residency at Fitzpatrick Referrals in Surrey, Podrick achieved his ECBS surgical diploma in February 2019 and was recognised as a EBVS European specialist in small animal surgery and a RCVS specialist in small animal surgery. During his surgical training, Podrick is published widely on the management of osteochondral defects in the canine. While Podrick enjoys all aspects of small animal surgery, his particular areas of clinical interests are the management of canine elbow disease and management of the feline trauma patient.

Outside of work, Podrick exhausts many hours attempting to train his two unruly dachshunds. I wish to let you all know that today's session will be recorded and available on playback later today, and you'll all receive a certificate for today's attendance also. Please use the Q&A box for any questions you may have for Podrick or Conrad throughout the presentation at the end of end of today's session.

We will see if we can answer any of these questions that you may have. If we run out of time with the questions submitted, we will email out any responses to you in the next few days. So with no further ado, I'd like to now hand over to Podre.

Thank you. Hello everyone, thank you for sacrificing your lunch hour to come and listen to me to talk about the adaptics unit, . It's a lovely introdu from from from Charlotte and basically I spend my working life at East New Bretney Clinic and we're based right up here on the coast of Scotland and my case loads.

Mainly orthopaedic, I've drifted away from the soft tissue world, I haven't seen insides in a long time, so my working week tends to be somewhere between 12 to 15 primary orthopaedic cases, and with that, For full disclosure, I absolutely adore technology and toys. I'm afraid I'm one of those vets. If there is a new instrument, new technology, new arthroscope, new drill, I want it.

And as I was wandering through BSAVA when I saw the adapttic Digital Thomas synthesis unit. I wanted to get it into the clinic and play with it, and that's how this lecture's come about. I pestered adaptics to let me have a unit and.

One of our motivations was our, our CT that we have on site at the moment is becoming end of life, it's image quality is dropping off, it's reliability is dropping off, and we needed some sort of halfway house for us, and that's where digital Thomas synthesis came into play, and. In veterinary practise, this unit is kind of this compromise between digital radiography and CT. It it bridges the gap between these two modalities, especially what we found at least in orthopaedic practise.

As Conrad said, based on X-ray technology, it has a very high in plane resolution, . It's validated and used widely in human radiology, so I think this transference of this modality from from from human imaging to to veterinary imaging makes sense. In humans, orthopaedic pre and postoperative assessments, intraoperative imaging, dental imaging appears to be the mainstay when you review the literature of other digital Thomas synthesis units that exist, that's if you do a search on PubMed, you can find those studies.

Thoracic imaging, it seems to be in its infancy, but there seems to be a lot of potential there. Abdominal image imaging. Probably not gonna be it's mainstay of use when you review the human literature.

It's really good at finding calculi within the urinary tract in humans and digital synthesis, but maybe CT is better for that, for that multiplanar reconstruction and. Breast screening in the US is really moving across to digital Thomas synthesis, and the NHS at the moment, the Research Advisory Committee have an ongoing study to evaluate its use in, in, in humans, as opposed to CT, so lower radiation and plain radiography for, for breast screening. With that, I'm moving on to orthopaedics, there's studies going on in in humans doing bone density assessments at the same time of breast screening to try and pick up metabolic bone diseases.

In human orthopaedics, we see wrist and hand and foot being the mainstay of the use of this technology at the moment, and scaphoid fractures in the human wrist notoriously hard to identify. A and B imaging that we have here is a 21 year old male with a scaphoid injury. The X-rays taken in A and B don't show a fracture.

Then when we compare digital Thomas synthesis, which is image C, the, the lovely massive white arrow doesn't come with the digital homosynthesis, it's added afterwards, but we can see a clear partial fissure. Which is more evident on the digital the synthesis than the, computer topography of CT which is shown on image D. One of the other areas where digital homosynthesis seems to be playing an important role is the assessment of fracture healing.

Here we have a human that's got an intramedullary compressive screw place for a phalangeal fracture, the plane raiography on on the left of the screen. It appears that we have union of that fracture. But then with the digital synthesis, we can see that we have a persistent fracture line crossing through the end of that phalanx.

So this is not a heel fracture, we have a non-union at this point. Looking at non-unions in particular, digital homosynthesis, generates less artefact around metallic objects in comparison to CT and and and plane radiography. Here we have a periprosthetic fracture of the femur in a human.

It's been repaired, they've used cables, they tend to cause solage wire cables in in humans. And on the left we have a plain X-ray, which the arrow points to what we've got callous formation. It looks like we've got bridging callus.

We're actually then on the digital homosynthesis we can see that we have a area of failure of a fracture healing, and this moves from the callus through to the cable. So this is likely a persistent non-union that's caused by disruption of the periosteal blood supply by that cable at the fracture site. So.

It's used in humans, it's validated. We introduced it into our practise. We attempted to exchange some of our standard imaging for the adapt its unit and in doing so see could we get the same kind of diagnostic quality.

So the first area that we started. Using adaptics was in dental imaging. So our clinic as well as mainly orthopaedic, has a, a, a relatively busy first opinion side as well.

So you know we see dental patients almost every day of the week, and our historic standard approach would have been the well positioned. I'm not going to pretend I do dentistry on a, on a day to day basis, but I spent enough time in general practise to understand the frustration of getting well positioned dental radiographs. So this would be an example of our, standard routine, plane radiography, dental imaging, and for adaptics, our initial protocol was to image the patient in 3 planes, so we would image the patient.

A dorsoventra with the mandible parallel to the sensor, and then a right and left lateral. The complexity of this imaging protocol reflects a little bit on the learning curve that's associated with interpreting these images. It's, it's very different to looking at a plain radiograph and it takes time, I think, to gain confidence and er competency in being able to take this stack off, essentially you can think of it like a stack of plain X-rays and flick through them and get the information that you need.

When I'm assessing patient imaging on the digitalhoma synthesis, I find myself moving back and forth through the stack of images and maybe a lot, a lot more than I would on CT, but it's a skill, that you learn pretty quickly. And, you know, giving examples of what these imaging, what this imaging looks like, we have a canine in for dental radiography. You can see quite clearly from these single slices that have been taken from the stack of images.

That you can identify the structures that we want to be able to identify on on a dental radiography quite easily. The, tooth, the, alveolar canal, the root APCs, the mandibular canal, we can assess the pulp cavity. We are, we have got some images of patients with pathology later on, but you know relatively clean mouth here.

We found we needed the right and left lateral to gain the clearest imaging of the, the arcade. The dorsoventral, the ventral dorsal and when you when you move through this stack of images, it's, it's less intuitive really. We've found that we can start to exclude this image unless we see some pathology that doesn't quite make sense and we want that orthogonal view of a particular structure to see what's going on.

When we look at our feline patients, the imaging that's produced by the adaptics is, is pretty beautiful and with tooth absorption being the main reason or motivation to carry on with, with feline dentistry, we've found that the unit so far identifies that very readily. It allows us to gain some pretty beautiful images of tooth absorption. Notes, just as we're kind of going through this and and what we can see is that when you image the feline skull at least .

Views of the temporomandibular joints are are absolutely gorgeous, and if you're assessing, we haven't had any patients that have come in with fractures of the of the TMJ, but I think it would be a beautiful modality to take images of patients with that kind of pathology. So when we look at our feline tooth resorption. We've seen about 29% of, of, of cats that undergo assessment of their oral cavity with the mandibular, the premolars 30747 being our most common sites, .

So CT and plane radiography have obviously been evaluated extensively for assessing felines for tooth resorption. CT is interesting, I think that most people would presume that it's the modality of choice when assessing these patients. The studies that have been done show that sensitivity for for identifying tooth absorption in the cat is, is pretty low with CT somewhere between 42 to 57%.

The specificity, it's good to excellent, so it can rule out tooth absorption, but it can also miss it. The sensitivity sits somewhere between 92 96%. And the poor sensitivity in cats is likely related to the limitations about the spatial resolution of CT compared to radiography.

And the one thing adaptics can offer is a higher spatial resolution in comparison to to CT. So we've been. Adap adaptic thing.

We can't quite decide what, what should be the we use for it. Our cat dentals, are standard now. We found that, it has massively reduced the time associated with dental imaging, .

Our standard is that the patient is anaesthetized, although they wouldn't have to be anaesthetized if you were considering carrying out adaptics for maybe monitoring purposes for cats with early tooth resorption. We anaesthetize them, they're standard then get their right and left lateral imaging sequences obtained. We try and keep the dental arcade that we are imaging parallel to the sensor, so it's usually a small amount of padding to make sure that that happens.

We take the two acquisitions as standard, they're ready to review and ready to go within 2 minutes, and then the usually in that time between acquisition. To the to the radiography we can get on and do our scaling and policing and then we're ready to assess for removal. Example of some pathologies that we've seen recently, here we have a lateral .

Dental arcade here. We have a, we've moved through the stack so that we focus entirely on the maxillary canine. We can see this canine has a bulk cavity of an acceptable width.

We don't see any apical lesions. There's no evidence of any decay or injury to the tooth. When we look at the patient's contralateral maxillary canine, we can see that we've lost definition of the apical root structure.

We appear to have resorption. Of this route, and we have evidence of tooth resorption elsewhere in the cat's mouth. We needed or felt that in some cases we wanted to validate, what we were seeing on the adaptics just to make sure we're making good decisions for our patients.

So this cat also had a plain radiograph taken of that lesion, kind of confirms what we see on the adaptics that we look like we've got root, absorption. Had it extracted and confirmed on visual assessment of the tooth thereafter. So when we take our feline dental our canine dental imaging, we usually end up with this sequence of three stacks of imaging within the packs viewer that the adaptic sends its images to.

This lets us scroll through this, these 3 volts of information, independently and also use them together to confirm pathology. I think it highlights, the DV I've found less use in dogs, but actually it it's probably more useful than cats. I think highlight also on that DV view in the centre of the screen, that we have beautiful images of the nasal cavity of the turbinates within there, and also of the the middle and inner ear.

I've been desperate, and this is a terrible thing, er as being a surgeon, you always want to do surgery, but I've been desperate for a cat to come in with, with polyps. I regard that as an orthopaedic surgery because you have to go through bone to get to the, to the, to the middle ear. So, but we haven't had any come in.

I would, I, I think it would be really interesting doing a study on, on cats with polyp disease with this particular technology because the, the level of detail that you can get at the cat's middle ear is is absolutely beautiful. So we have our 3 stacks of images, we tend to keep those pretty close to the dental table, we can then do our charting of the mouth with our scaling and polishing, and then use the information that we've got from the adapters to go on and do do whatever extractions are required. Tooth resorption lesions seem to .

Show up pretty well on the imaging we're pleased so far with it. Here we have a it was a 6 year old feline presenting with two absorption lesions occurring at the same time. We've lost 3 or 7 with the crown gone and the root being resolved, and we have early signs of resorption and this maxillary premolar as well.

Both, these teeth ended up being so this is our second case tooth resorption, 307, 407 in this patient, . Post operative extraction radiographs taken, we haven't moved to doing postoperative, Extraction adaptics on our patients yet and that's really just a workflow issue on our behalf. Our adaptics unit is in our CT room.

So, moving the patients back for postoperative imaging doesn't really work for us. We we often flash pla x-rays to confirm, confirm that that all routes have been removed. Moving on to, you know, what we gain from, away from dentistry to some extent to looking at skull imaging, the images produced of the cat's skull are absolutely beautiful in comparison to our plane X-rays.

Obviously we've talked about visualising the two structures, but you can see the nasal cavities absolutely beautifully. You can see the ear canal and the internal ear and have really nice view of those dorsal lateral and ventromedial chambers of the bullet. So while we haven't encountered pathology within the middle ear and bulla, I think it would be a a good modality for for assessing those patients.

And even assessing completeness of your bular osteotomy. One of the areas that we've most enjoyed exploring the adaptics uses is in our caseload of developmental elbow disease. We lost our CTU for a couple of weeks and had to rely on the adaptics fully to assess our patients, and I'm sure everyone on the call at the moment, is, is, you know, well aware of what we're trying to assess in these patients.

We're looking for periaticulosteophytosis, we're looking for subtrochlear sclerosis, and assessment of that medial coronoid process. Subtrochlear sclerosis, usually readily visible on our, on our, on our plane lateral radiographs. This is x-rays from a patient between 4 and 6 months of age and we can see the subtrochlear sclerosis developing on this ulnar due to medial coronoid disease.

So, we started by plain lateral imaging of our developmental elbow dogs. We stopped at that in the first instance because we're not running a study on this machine, so we felt doing excessive on multiple planes, was not appropriate without without gaining ethical review, so we substituted our simple plain lateral radiograph for an adaptics to see what information we could gain and maybe prevent us from having to do other imaging, so. We have a a a radiograph on the left here which demonstrates a dog with subtrochlear sclerosis.

We have a video playing then on the right of the screen, this is gonna scroll through the stack, so this is the information you get as you evaluate your stack. Here we have the ulna coming into view, we can see that subtrochlear sclerosis very clearly and as we move out, the coronoid is gonna come into view there just below the radial head. This stat will repeat, and this is where I've I suppose found the biggest learning curve is is trying to assess these images.

It isn't like assessing CT that we see day in, day out, but once you kind of get the knack of it, it's, it's, it's really does produce some nice images. We have here we have the radial head coming into view, we're gonna slice through that radial head. At the same time we're gonna look at humour radial congruity, we're gonna follow the ulnar then we know that the coronoid is gonna start to come into view now and that's the coronoid just below the radial head then.

And we do this mainly in our practise, cos we're trying to figure out do dogs need this. We do our imaging to assess the intra-articular pathology of the elbow that we think warrants arthroscopy. We know that arthroscopy is the gold reference standard technique for evaluating for coronoid disease in the dog.

We know that radiography and CT are pretty sensitive, but radiography at least is a very low specificity, and CT not as high as people would think. We we're looking at our data at the moment and we expect digital automa synthesis to sit somewhere between radiography and CT. With fragmentation of the medial carnoid process, it's seems to have a pretty high sensitivity and specificity.

Fissuring, it's probably arthroscopy and CT that are gonna remain the gold standard for those patients, but we're also on this learning curve. This is a new technology, we've got to learn how to integrate it and interpret it, and that's gonna take time. And I think refinement and patient positioning and acquisition plan is going to improve the sensitivity and specificity for this technology as time goes by.

But if we look at some of the cases we've seen lately, this is a six year old Labrador coming with a relatively acute fall in lameness. I've just got single adaptix images here for us to look at, and in this case on our CT we can see that the dog has fragmented the tip of its medial coronine process. We have one single slice from the volume and we can see that it also demonstrates that the dog has taken the tip of its coronoid off.

This dog had arthroscopy removal of that fragmented coronoid to try and alleviate its discomfort. Small injuries to the coronoid are also able to be picked up, but I think that this is where the skill of reading them comes over time, so CT confirms it's very small tip fragment and there we can see a very small tip fragment on arthroscopy. So, on the, on the adapt its imaging, based on the strength of what we've learned, we move on to do arthroscopy and see that the arthroscopy images do indeed correlate with what we're seeing on the adaptics and CT.

Just more kind of obvious medial coronoid fragmentation, we see it on the CT on the right, we can see it pretty evidently on that single volume slice on the left. And the other thing which is important, you know, we have a normal coronoid here and assessing that coronoid on the adaptics as well, no pathology could be identified. We've also been exploring the use of this technology in some of our growth deformities that we see.

CT I think will probably remain the mainstay if, if you need 3D models or anything made of your growth deformities. In this particular case we have a clear radial procavatum, so this patient has short ulnar syndrome. We've got it stack of images that we get with the volume and again you've got to just think as each anatomical area of interest comes into view, you have to assess it, move on, so here we have radial head.

We're gonna move through on this in view, we're gonna then move on, we know the next thing we should see is the coronoid which is lowered in this dog. If we look at some Single slices from this dog's volume. We can see that it has a clear humeral ulnar incongruity and a clear radial ulnar step.

I thought was interesting is that when we take the slice through its coronoid, we also can see that it's coronoid has been distillized due to this short ulna syndrome. A dog like this, because of that short ulnar, we want to release it, we want to let that ulnar pop back up against the humerus, we can go on and do a distal ulnar rustectomy. Now something that seems quite regional when it comes to to orthopaedics is humeral intercondular fissure.

We see a lot of humeral intercondular fissure up here in Fife because everyone seems to own a spaniel. So we see a lot of lateralchondrial fractures because of human endochondrial fissure, we see an awful lot of dogs come in for workup of this condition, interestingly to today. So we've got some.

Imaging stacks of what we see for these patients, so you know we have a, a patient here with plain radiography demonstrating that this is a human interchondral fiss that we can see relatively clearly. And this patient, we want to Also look at its epicondylar ridge. It has clear remodelling in this region.

This is indicating that this dog's er lateral humeral condyle is doing everything it can to try and not fracture. So we pop our beautiful spaniel into the image in his . An idea of our setup, we image our patients on the, on the floor at the moment, mainly because I'm really terrified of knocking this beautiful machine off the table and breaking it and getting a bill for it.

So we've set up this, cushions around the machine that levels the machine up then for the patient so we can kind of lay them flat. We've found that, just from giving an insight into the, the things we found difficult and the things we've improved on. The, the, the sensor lifts, if you, if you don't level the patient with the sensor, we've found that inaccuracies in positioning generates artefacts.

Soaptics have got this black cushion that goes with it, and we've extended it with one of our table cushions, and then we just use phone pads as as we would in plain radiography to get the patient positioned as accurately as possible. That's the one thing we've learned, I think with introducing it into our orthopaedic cases is that. CT you can get away with sloppy positioning because you can .

Get over during the multiplanar reconstruction part of the image formatting. With the apy imaging, the positioning is as important as it is with plain radiography, so accurate positioning is vital. And here we have some adaptty images of these of this patient.

We're gonna concentrate on its right and hopefully this stack will go back to the beginning again. Yes it will. We're gonna see it's funeral interchondduar fissure come into view now, we can assess its completeness, then as it runs through again, we can see.

That the epicondylar ridge appears like it has a fracture through it, we can see a line, so stopping and looking at some of those individual frames, yet the HIF is really, really obvious, but we can see that there's been at least a partial fracture. Maybe even you know a fair way through that epicondylar ridge for it to have to lay down that much callous and it's, it's, it's really is holding on. So we had this patient back after surgery and surgery was a transcondular screw, to stabilise that humanchonddular fissure.

And interestingly, well, for me, because I lead a really sad life, I just love looking at bones all day, is that once that humanochonddular fissure was stabilised, we see. Complete remodelling and that that epicondylar ridge is going to go back to normal now, we can see that the, the evidence of the fracture that we could see on the other slides has gone. We can see that it is remodelling, it's smoothing out, and if you X-ray that in, I'd takes that in 3 or 4 months, it will probably look anatomically normal at that point.

I think one thing to highlight cos we're here is that the metal artefact that we get with adapttic imaging is is a lot lower than CT. And we can image these patients, a bit more successfully than than at least our current CT machine. I think one area that's interesting for, oh sorry, that's the other limb that we can see, but we get nice imaging off the, off the implant, so I think if this was a broken screw or something like that, it'd be very easy to pick up.

And I think one area I found interesting so far is, incomplete HIF. This is something we see quite often up here, and here's a, a lovely example of the dogs. Plain radiograph or single slice from its adaptics I should say, no evidence of anything going on with that elbow.

We move on and look at its stack of slices. That video for us. We can see As we move through We have a small partial humeral intercondylar fissure which will disappear again as we move through.

So this is one of these dogs that we see, which is in this case, it was an asymptomatic HIF and you know, we take two single slices from its volume, we can see on the left, we don't have a fissure and on the right we have a clear fissure transversing the humour will come down. This is a disease that if missed, you know, is the number one cause of of of other fractures, at least in our spaniels and and probably in our French bulldogs now, I see. A depressing number of French bulldogs being sent over from the west coast of Scotland with Y fractures and lateral conjuar fractures, and in recent months we've had 22 dogs with bilateral Y fractures in the French bulldogs, and that's secondary to humanchondulalfissure.

So these are being missed and and that I think a lot of them are missed because a dog comes in with lameness, you take some for limb x-rays, and they're just not visible if they're in their early stages, adaptics. What we've seen so far will definitely pick up these early fissures. And with the asymptomatic patients we know that you know, about 43% of them are gonna have contralateral HIF so if we if we identify it in one leg, it's probably gonna be in the other.

Study done when you're looking at 34 asymptomatic patients, they run with about a 1 in 5 fracture rate. About 5% require a transcontable screw and lameness that that's associated with that, . HIF and If they fracture within 2 years, they were likely to fracture.

If they go beyond 2 years and don't fracture, probably not, and having the information that there's a partial fissure there allows this kind of to make the the decision between conservative or surgical management for these patients. We see a lot of limpy dogs, and while we see a lot of for limb lameness, we also see a whole lot of hind limb lameness. And, and plain radiography is, is our mainstay for evaluating hips and cruciates.

Adaptics is quite interesting because what we found. That it can do is, is, is maybe in people that are on that learning curve for assessing stifles, especially for perioticulosteophytosis and intra-articular effusion, is that it can give a more images to help gain confidence of what's going on. So I've popped a few knees through to see what what's going on with them and actually the level of detail is is pretty impressive.

So here's a couple of slices from a, from a standard . A lateral image of a dog with a cruise ship, we can see that it has clear, Effusion So that's a fusion within the stifle joint, and then subsequently we get compression of the infra patella fat pad. And I think people fall into two camps.

You either assess with the effusion or you, you squash you assess for the triangle being squished, and it, it does give a beautiful set of images when you assess the effused, oh the diffused cycle. Move on to kind of look at a stack of those images. Remember when we're assessing these patients, we are moving through this stack.

So anatomy is gonna come in and out of focus. And that's the thing I find is most difficult when learning the skill set of assessing these images. So this typical stifle, we'll wait for the stack to go back to the beginning again.

The first thing that's gonna come into view is gonna be that tibial plateau. Next thing we're gonna move through is the lateral. Femoral condyle with the extensive groove.

We can see clear osteophyte at the distal pole of the patella. The proximal aspect of the trochlear groove. And clearer fusion in this stifle as well.

Then we're gonna go out the other side of the trochlear, we see more osteophyte. Looking at another knee, gain, clear effusion, I always look at compression of the infrapatella fat pad. These two images show though that we can see very articular osteophoic beautiful on and on this imaging and it allows you to assess your degenerative changes more accurately than plain radiography, it appears.

I think what this imaging is going to do is open up a lot of areas of potential study for the veterinary profession. We only can understand the sensitivity and specificity and valid validity of using these imaging protocols if we can understand where they're they're best used within within the profession. Another knee just to kind of hammer it home with this one interestingly though that we can see cranial subluxation of the tibia in comparison to the femur, we see clear.

Compression of this infrapatellarat pad and Osteophyte at the insertion of the cruciate ligament on the tibial plateau, which is often a hallmark for early cruciate disease. So these stifles that have very low grade effusion, you're not quite sure what's going on yet, you know, maybe it needs repeat imaging in 2 or 3 weeks to see as the progression of fusion. For me, if there's osteophyte at the insertion of the cruciate, there's a big red flag that we've got cruiseate disease going on.

But we also see clear periarticular osteophytosis in this patient with osteophytes around the the the popliteal cessaoids, the insertion of the joint capsule on the trochlear and the trochlear groove. We've investigated what this technology can do to help us in our fracture patients and our fracture and osteotomy assessment. It's got some interesting quirks to, to, to, to light about using the technology.

Now we all know the pain ofsessing a cat pelvic trauma, and it is a a scenario where the adaptics. Really does seem to potentially come into its own. The cat pelvis, it's a small volume, so it, it sits nicely on the sensor.

We can see this image stack here. We have a cat that has an ileal wing fracture one side. We can move through then and see that it's got an articular acetabular fracture, the other side with comminution.

With cat pelvises at least, it's really helped with decision making for us. RCT is is aged and it struggles a bit with cat pelvises due to the small volume, the spatial resolution of the images we get is pretty terrible when it comes to cats, whereas adaptics, the small sensor size, the way it images, the volumes and the the technology behind the the digital homosynthesis, it gives these beautiful images, . In comparison to our CT, we couldn't make the call whether that, you know, your wing was going to be articular or not if that patient presents to us just because the resolution is such that we, we, we couldn't make, make that call, but we can see on the adaptics that the fracture's closed, but it isn't articular.

This side, the acetagulum has been spared, and then we moved through to look at the other coccofemoral joint. We can see that we have a clear. Acetabular fracture this side with communut.

This is a a beautifully positioned pelvis. The pelvis has been placed 90 degrees perpendicular to the sensor, and that's why we get such beautiful images. We've learned that.

In things like elbow fractures. Unless the positioning is As accurate as you can achieve, and that sometimes may mean gaining reduction of the fracture prior to imaging, that the images are of of less use, and in these kind of scenarios, unless you've got a, a relatively minimally displaced fracture, I think you, you need something you can do multiplan a reconstruction on. So CT I think for an elbow like this where we have a bichodular fracture that's displaced.

It's very hard to interpret what's going on and the reasoning behind why some clinicians may decide to do CT on an injury like this, which is to understand the comminution, the fracture pattern where I can get implants in. We found at least that Unless you can get that really accurate orthogonal, so we would take two views of some main thing, most things like this to try and be able to take those two stacks of volumes, and understand what's going on in an orthogonal view. We've done a, we've dropped a few post-op TPLOs through it, and one thing and I like to do is the amount of periodicul osteophyte that these patients with long standing cruise ships have, we've found that assessing the osteotomy.

It's, it's useful, because you get less artefact behind the plate, . Plain radiography this at this stage would probably remain a mainstay. I'd be interested to do a study maybe with our cranial closing wedge osteotomies, which sometimes can be a little more challenging to understand on plane radiography whether whether they've healed or not.

I think adapt it's real use in those patients. We don't want to CT them. That doesn't justify that amount of radiation for seeing as an osteotomy, but I think .

Well, there's loads of areas that we can, you can look at this, this, this technology in. We've looked at a couple of our proximate ulnar osteotomies. These can be difficult to decide whether they fully healed or not.

We can see the image on the left. We can still see a clear, . Shadow of where the osteostomy took place, but when we look at the adapted, stack as we move through them on the left we can see that there's obvious periosteal callus, there's end osteo remodelling going on and that that osteotstomy is bridged.

It's, it's pretty much you know. Moving on to kind of the the usefulness when we've got implants in position, we do get some artefact, but less than we get on, on CT know with something like a mandibular fracture which does have a malunion up on the the left side that aware of. We do get some artefact, but it, it does, if you find the right slice as you move through the image, you can see that there's bridging callus behind, these implants and the patch has indeed heal.

So Veterinary digitalma synthesis. What have we learned at the practise? We've been using it now for about 12 weeks.

We've found that with Dentistry, it's completely, changed our workflow, and the guys adore it, and I need to start chatting to Conrad about trying to keep the machine, . We've, from an orthopaedic point of view, we've found some really useful scenarios for the, for the machine and I, I think one of the next steps for us is that we would, we would love to see. Is it something we could bring into theatre over time?

It's used in, in humans, intraoperative imaging. One thing I think that holds us back in in veterinary is the sheer cost of the CRM and then the radiation protection, that's required with that. Whereas I think that, you know, this, there is really an area that's unexplored in in veterinary for this and.

For assessment of osteostomy position or anything that we can get the the the animal's limb within the confines of the of the machine, I think it would be really interesting. So for me, you know, pros are. Reduction in radiation does.

We're kind of oblivious to this a little bit in veterinary medicine, but in human medicine, if you've had X number of CTs in a year, you ain't getting any more unless you, it's a life or death scenario. We, we shouldn't underestimate what the exposure to radiation does to our patients. Lower machine costs.

I am, I'm trying to buy a new CT at the moment. It's it's about the price of a house, so. We need it for the type of practise we do and adapt it definitely can play a role in our practise on a day to day basis, but.

For a practise that hasn't either got the space for the finances to obtain a CT, you know, it gives you that real kind of bridge between digital radiography and CT. The lower structural costs . No requirement for a three-phase power supply, no requirement for a specific room, it really, it's fine in a, in a well shielded, .

X-ray room obviously with RPA involvement about the safety of it. The detailed analysis of bone structure is the one thing that as an orthopaedic surgeon, I know I'm really sad, but it's amazing to see the trabecular pattern in the level of accuracy that we can in, in this imaging. Bone tells us an awful lot about what's going on with it.

If you look at it and you see the changes that are occurring, it comes right back to Wolf's law, the shape of bone, it responds to the forces that are applied to it. We can learn an awful lot about what's going on, from an orthopaedic point of view by looking for subtle changes within the medullary canal and, and, and this, the level of detail we get with digital Thomas and this allows us to do this. The high spatial resolution which we've kind of talked about is is way higher than the CT and akin to to plain radiography, and our improved imaging of highly attenuating structures.

So when there's metal in place, we can see a bit more than we will with plane radiography and, with CT unless your CT has some very fancy and quite expensive metal artefact reduction algorithms on it. The cons. I'm not here to Yeah, a salesman.

I'm here to tell you about our kind of honest experience of, of this technology from the point of view of a specialist that, that loves technology and, and thinks we should embrace it a bit more within the profession. Just because something works doesn't mean we can't make it better. At the minute we have limited validation in veterinary medicine, but we're hoping to change that.

We're hoping to change that with with the proper ethical reviews and we think that that there there's a real slice of at least veterinary dentistry, veterinary orthopaedics, and probably in the future some areas of soft tissue that we can really bring this technology into play. The learning curve for acquisition is there, but if you take decent radiographs, you probably can take decent volumes on digital tunnel synthesis. The learning curve of interpretation.

Maybe less so in dentistry, the guys found it really intuitive when using it in dentistry, but in orthopaedics, I think there is a bit of a learning curve and you have to look at lots and lots of volumes to get confident in what you're seeing, and probably at some point do parallel imaging to make sure that your interpretation is validated. We do see some motion artefacts with some of the acquisitions, but as Connor mentioned, the acquisition time is going down and down as the unit is, is improved. And at last con is that, you know, multiplayer reconstruction isn't like a CT.

You don't take that one set of images and then can MPR them if you want. A quasi multiplanar reconstruction, you're gonna have to image the patient in two planes, and that's what we've started to do with our elbows now in a small number of dogs instead of CT. We're gonna image them like you've you've seen we did for the humancono fishes.

We're also imaging the lateral plane as well, we're seeing where we can go with with with that. I usually desperately try and find some imaging that's been done on what I'm talking about in dinosaurs cause I really love dinosaurs, . But I've got the next best thing, cause digital homa synthesis hasn't been used to image many fossils at this point in time that I can find anyway.

And this is a, a, a little bearded dragon that's affected by metabolic bone disease. And just to kind of highlight the beautiful resolution of these images, this little fella has got a radial fracture and a tibial fracture, . And I'm gonna hands up.

I've, I've never seen a frog as a vet before, but I just love these images. Just such a podgy little thing. I have also tried this morning to find out lots about frog anatomy, but there's, there's a real, if anyone wants to write lots of papers on digital homosynthesis of frogs and the subsequent anatomy, I can tell you there's a real hole in the literature there.

I hope you've enjoyed the lecture. I hope I've given you kind of a an honest understanding of, of, of this technology and where we found it useful in our clinic. Every clinic's different, everyone has a different case load, but I think it, it, it, it is definitely a technology that can open up avenues of diagnostics and treatments that we're not exploring yet.

So lower costs in a time that, you know, costs are affecting all the practises, they're affecting clients. And maybe this halfway house between digital radiography and CT is an avenue that we're ignoring that could help patients and clients. So if anyone's got any questions, I'm more than happy to answer them.

If I can't answer them now, myself, Conrad, the guys at Daptics will be able to get back to you. Thank you very much. Thank you Padrick for presenting today's webinar.

Very cool images, with, the amazing technology of Adaptics. So we have had quite a few questions submitted, so, we'll crack on and get through what we can and like you've said, we will email responses if we can't get through them all. So let's have a look.

So the first one I've got is high, which is the maximum area of imaging with this 3D system and maximum depth? Can it be used for Great Dane thorax? No, it's not gonna be able to be used for Great Dane thorax.

So far for us we've found that. I think you've got to think carefully about what you're going to image and the validity of the images you're gonna gain. Orthopaedics, dentistry, it's perfect.

Feline pelvis is, we haven't put any canine pelvises through, but we need to kind of explore what the what the maximum depth, but. Thoracic movement artefact is going to catch you out here with the system as it stands at the moment, but I think in the future that will probably change. We're, we're on, we're, we're on the beginning of this journey, I think for digital homa synthesis in veterinary medicine, and I think if we focus on what it does really well, that will help us embrace the technology rather than trying to apply it to areas we're gonna get substandard diagnostics.

And that's, well that's my view on it anyway at the moment. Cheers, thank you. So the next one we've got is, is this technology basically the same as the tomography machines prior to CT but in a digital form, and only for small body regions field of view, which is sort of what you've answered, I think.

I think Conrad probably can answer that with regarding to sensor size, cos I would be, I think I know. Yeah, so 4. So the sensor size is 11 by 15 in the system that you've been evaluating, Podrick, coming, pretty soon, we have one which has the same in plain resolution but double the sensor size.

In terms of how does it compare with all old style tomography? I mean, it is a homosynthesis technique, but traditionally what you've got in general radiology. Today, or digital breast synthesis is the systems tend to sample in just one linear direction, so they take a source through one direction.

We are having our X-rays on a, on a grid shaped pattern. So that's, that helps in terms of the image quality and getting that good layer distinction between the different layers. So, so that's a little bit about how, how the system differs.

Cheers. The next one we've got is, do you think that this, new technology posing positioning becomes a little less important as it compares tradition to traditional X-rays? Our experience has been accurate positioning gets you the best images.

You know, we've had the, well, we were a bit lazy, we weren't completely, straight with our elbow positioning, and I think the diagnostic, quality starts to drop quite quickly, which is the same with plain radiography, and that's, I suppose, where it sits in between CT. You can get away with terrible positioning if you've got a half decent machine. And a and a good, good driver, so hopefully a good radiographer will get over bad positioning, with the, I think so far with the digital homo synthesis, with some things like dentals you can get away with a bit of, a bit of poor positioning because you can move through the volume, but with something like an elbow, you need to be incredibly accurate to get the specificity and sensitivity that that we want from it, so .

You can't be sloppy, unless you want to, and you don't want to be doing repeat acquisitions. The whole point of this is we're gonna expose our patients to less radiation, accurate positioning, single acquisition, done and dusted. That's what we've been at the beginning, we, we weren't, and we learned very quickly that we're not getting the images we need, so accurate positioning, just like you would with a plain radiograph is the way forward.

Perfect, thank you for that. Unfortunately, guys, we are out of time, so those questions that have come through, we will get, those responses to you guys. But thank you again, Podrick for such an informative session and thank you also Conrad from Adapt and Adaptic for sponsoring today's session.

We hope that everyone enjoyed today's webinar and we hope to see you all again. Thank you for joining. Take care everyone, bye bye.