Changing practice in intraoperative imaging through a performance improvement (PI) program

09. May 2018

Study shows positive outcomes from an international multicenter PI program

Daniel Rikli in the video 'Intraoperative imaging of the proximal femur'​

Daniel Rikli, Michael Blauth, Samir Mehta, Franz Seibert, and colleagues recently published the positive outcomes from an international multicenter performance improvement (PI) program. Their study shows an educational intervention (criteria, video, and poster) improved surgeons’ ability to obtain and assess lateral view intraoperative images of the proximal femur and can improve the quality of reduction and implant positioning (open access in Injury​).

We interviewed Rikli about the study that the committee and the investigators at the five participating hospitals conducted in collaboration with the AO Education Institute and AOCID with the support of an educational grant from Siemens. The site investigators were Andreas Platz (Triemli Hospital, Zurich, CH), Emanuel Benninger (Cantonal Hospital Winterthur, CH), Franz Seibert (University Hospital Graz, AT), Brett Crist (University of Missouri Hospital and Clinics, US), and Matevž Tomaževič (University Medical Centre Ljubljana, SI).​

Going back to the origins of the study, how did you define the problem? 

"During the morning conference at our clinic we realized that the quality of the intraoperative images from the procedures performed the day before was generally poor. The views were different for every operation and landmarks that I would rely on were not depicted. This was especially true for the axial view of the proximal femur during nailing for pertrochanteric fractures. Michael, Samir, and Franz shared similar experiences and we thought we should do something about this problem. A needs assessment showed a high level of variability in what surgeons and residents considered good or poor quality. It also showed that many surgeons have had no formal or structured education on intraoperative imaging."

What is the desired outcome of the PI program? 

"Early on in the discussions, we decided to concentrate on the proximal femur, because pertrochanteric fractures are frequent and the consequences of a poorly performed operation are serious. We felt that the lateral (axial) view is a crucial moment for the success of the procedure. We realized that correct imaging and reduction are closely interrelated: you can only obtain a correct lateral view if the reduction is optimal. We, therefore, hypothesized that the entire procedure can be improved if we teach how to correctly obtain the standard views intraoperatively. We then established and agreed criteria to obtain standard imaging and to assess reduction and implant positioning and created an educational video and poster to achieve a defined set of learning objectives. In our multicenter study over two years in four countries, we were able to prove that our hypothesis was correct. The data showed significant improvements, which is impressive when you consider that the participants were quite experienced practicing surgeons. We thank the site investigators and the surgeons in all five hospitals for their engagement and the time they dedicated to the program."

How can this research be taken further?

"I strongly believe that we need similar data for all anatomical regions where we perform surgeries on the skeleton. This will enable us to teach the procedures in a more systematic and structured manner. Together, this systematic approach and the criteria helps us to improve the quality of our daily clinical work."

This study of educational inventions on imaging builds on previous AO work: Michael Kraus, Florian Gebhard, and colleagues in Ulm, Germany published A Workplace-Based Educational Intervention on MRI in Spinal Trauma (Journal of Surgical Education, 2016) and Alessio Chiappini, Gregory Jost, and Luigi Mariani conducted a PI study on sagittal balance at the University Hospital Basel (CH) in 2016.

The educational video and poster showing the criteria and standard views are available at A protocol and template files for conducting this PI in other orthopedic trauma departments is available from

Optimizing intraoperative imaging during proximal femoral fracture fixation
 Download the image here: PosterIntraopImagingProximalFemurFractures.jpgPosterIntraoperativeImaging.jpg