English

Application Guide

Automatic Stitching
DigitalDiagnost
Introduction

Introduction Content

This application guide introduces the

03 Configuration
new functionality delivered within
Release 1.5 with regard to the auto- 04 Patient support

stitching application.
05 Room set-up

06 Anatomical database

08 Examination procedure

12 Image stitching at the DigitalDiagnost

console

13 Stitching methods and view

16 Calibration and measurements

18 Creation of the composite via the

viewer

19 Post processing and printing

DigitalDiagnost VM DigitalDiagnost TH

Note: For details and safe operation with the DigitalDiagnost system please refer to the
Instructions for Use of the DigitalDiagnost system.

2
Configuration

Within our portfolio, stitching consists of
four options for the components
vertical stands (VS,VM) and
tables (TH,TH-S),
which can be ordered individually to suit the
customer needs.
For the new fully automatic acquisition and
image stitching on the vertical stands or
tables option 1 and 2 are required and in
addition option 3 for vertical stand
applications.
Beside these automatic options there is still
the manual option 4 available.
1. Motorized tube (CS)
To allow the automatic acquisition
functionality of the system the tube must
be motorized.
For single detector systems VM and VS
the option motorized tube is required.
For table TH with/without VM/VS the
option Tomo option is required.
This allows to perform tomography on
the TH in addition.
2. Automatic stitching (License)
To support the automatic stitching of the
images on the DigitalDiagnost console this
license is required. A new ruler (which is
compatible to the new stitching algorithm)
is also part of this license.This new ruler
must be used when wanting to use the new
automatic software.
3. Patient support
A new and improved support stand is
available with accessories to immobilize
the patient for vertical stand applications
(see page 4).
A grid is also included to facilitate the
stitching acquisitions (see page 8).
4. Manual stitching acquisition kit
It allows the manual acquisition of
exposures for tubes without motors.
This application guide is not applicable to
this option, please see RADOrtho Package
guide (codenr. 04512 987 10661) for details.

Please note

An EasyVision RAD workstation is no longer required and also not available for
systems with the stitching license.The essential tools are now available on the
DigitalDiagnost and are described later in this guide.

Existing systems without the motorized tube can only be upgraded with the
motors by an entire replacement of the ceiling suspension. For full details
concerning further commercial questions please refer to the commercial
documentation.

3
Patient support
Along side the introduction of auto
stitching, a new patient support stand is
available.This support stand includes the
bars from the TH table (at both sides) and
therefore the TH accessories can be
reused.
Supported accessories are handgrips and
the back supports from the TH and
shoulder support from the EasyDiagnost.
It is forbidden to use the compression belt
due to risk of strangulation.
In addition straps and height adjustable
sidebars are new accessories now available
to help reduce any patient movement.
4
The new stand does not include the new
ruler as this is part of the stitching license.
If older/other rulers are used, the algorithm
may not work or give strange results and
therefore it is not recommended!
The new ruler and old ruler are interchange-
able and so old stands can also support the
new ruler and vice versa.
The new patient support stand
It is now possible to also perform stitching
with patients laying on the table TH or TH-S.
The ruler can be removed from the stand for
this use or can be ordered extra as a spare
part via the service channel.
Other than the stand (for vertical stand
applications) and the ruler, no other
accessories are needed for the automatic
system functionality.
The floor attachments of the new stand are
different to the old stand.The service
department must install these into the new
positions (instructions via service.)
Room set-up SID and patient coverage

The automatic system can support patient The following table lists minimum SIDs required to achieve
coverage up to 120 cm (47") long. certain patient coverage.
The required coverage influences the SID
that is needed in the room set-up.
Tube Patient coverage Minimum SID
An additional influence also comes from the
tube that is used. Tube type, standard
RO 1750 / SRO 33100 80 cm (31") 175 cm (69")
The tubes used in DigitalDiagnost are 120 cm (47") 260 cm (102")
RO 1750 (standard with 50 kW generator)
SRO 33100 (standard for 65 kW / 80 kW Tube type, option
generators) SRO 2550 / SRO 0951 80 cm (31") 160 cm (63")
SRO 2550 and SRO 0951 (optional tube 120 cm (47") 235 cm (93")
extensions).

Please note for use with table

The tube can be raised and the table For simplicitys sake, one can use the
lowered to maximize patient coverage. 120 cm (47") patient coverage required

For TH table applications, the maximum

SID for both legs and spines.
coverage is restricted to 90 cm (35.4"),
which is the movement of the detector
under the table base.

For all table applications the restriction of

coverage also comes from the maximum
SID that is possible and therefore the
ceiling height has an influence.

5
Anatomical database

There are new stitching examinations /
views within the system. As a change to
previous releases the user only now
selects the view (e.g. AP spine) and the
number of the images that are taken (two
or three) is calculated automatically from
the collimation on the patient.
Each view has 5 APRs (the first three are Examples
used for when three images are acquired and If the user changes from AEC technique to
the last two APRs are used when two images a non AEC for the first APR, all subsequent
are acquired). APRs will be non AEC technique.
These APRs can be configured individually as
normal with different kV, mAs etc. If the user increases the kV by 3 generator
but only one technique per view is possible: steps on the first APR, all subsequent APRs
AEC or non AEC. will be increased by 3 generator steps.
Within the examination phase of each
patient, it is not possible to individually adjust
every exposure. An override can be made to
the starting APR (in kV, mAs, technique etc.)
and this will be applied to all subsequent
APRs used in the view / series.

Please note
The stitching examinations/views are only
present in systems that have the stitching
licence.

In the default system, you will find in the anatomical database for spine:

Anatomical group Examination Acquisition APR without grid APR with grid

Spine Long Spine Long Spine ap AEC spine ap S spine ap S=

Spine Long Spine Long Spine lat AEC spine lat S spine lat S=

Spine Long Spine Long Spine ap Non AEC spine ap 1S spine ap 1S=
spine ap 2S spine ap 2S=
spine ap 2S spine ap 2S=
spine ap 1S spine ap 1S=
spine ap 2S spine ap 2S=

Spine Long Spine Long Spine lat Non AEC spine lat 1S spine lat 1S=
spine lat 2S spine lat 2S=
spine lat 2S spine lat 2S=
spine lat 1S spine lat 1S=
spine lat 2S spine lat 2S=

Spine Long Spine PCR Long Spine PCR 1 long spine ap

Long Spine PCR 2 long spine ap

Please check the APR values and program accordingly to what SID is programmed at the individual system.

Note: = means with grid

6
In the default system, you will find in the anatomical database for lower extremity:

Anatomical group Examination Acquisition APR without grid APR

Lower Extremities Long Leg Long Leg L pelvis/hip S pelvis/hip S=

femur/knee S femur/knee S=
low.l/ankle S low.l/ankle S=
pelvis/hip S pelvis/hip S=
low.l/ankle S low.l/ankle S=

Lower Extremities Long Leg Long Leg R pelvis/hip S pelvis/hip S=

femur/knee S femur/knee S=
low.l/ankle S low.l/ankle S=
pelvis/hip S pelvis/hip S=
low.l/ankle S low.l/ankle S=

Lower Extremities Long Leg Long Legs Both pelvis/hip S pelvis/hip S=

femur/knee S femur/knee S=
low.l/ankle S low.l/ankle S=
pelvis/hip S pelvis/hip S=
low.l/ankle S low.l/ankle S=

Lower Extremities Long Leg PCR Long Leg PCR1 long leg
Long Leg PCR2 long leg
Long Leg PCR3 long leg

Please check the APR values and program accordingly to what SID is programmed at the individual system.

Note: = means with grid.

Each stitching examination and view can be
renamed if required.To add additional
stitching views, duplicate a view and
rename / reconfigure (see the configuration
instructions).
Typical other studies that can use the
stitching software include femur and tibia
/ fibia examinations.These must be
programmed in the configuration.

7
Examination procedure
Select patient at the workstation and
start examination.
Select required stitching view and the
collimation will open to the view default.
Without having a stitching view selected
the collimation is limited to
43 cm x 43 cm (17" x 17").
The workstation is now ready.
Vertical stand acquisitions
Make sure the detector is at 90 degrees,
it can be positioned in any height.
Insert the correct grid or remove
depending on the application performed
and patient.
The stitching grid provided has ratio 8:1,
f0 = 180, 36 lp and has applicational range
from 126 cm to 315 cm.
Clip the feet of the stand into the metal
fasteners.This positions the stand in
front of the vertical stand so that the
detector can move up and down behind
the support.
Lock the front wheels.
Move the ceiling suspension to the
programmed SID for stitching (tube must
be at 90 degrees).
8
Patient positioning
Place patient on support stand (either
standing on the step for examining legs or
on the floor for spines or sitting patients on
a stool).
Adjust the patient handles and straps to the
patient and secure.
Adjust the tube height so that the light field
covers the entire region of interest (C1 to
sacrum for spine or ilium to ankle joint for
legs).
Collimate if necessary in x and y direction.
Adjust the ruler so that it will be beside the
spine or in between the legs within the
X-ray field.
Please note
The X-ray acquisitions are taken head
downwards.
Spine examinations have a default coverage
(y direction) of 80 cm / 31.5" as resulting in
two images and leg examination of 120 cm /
47" as resulting in three images.
Changes to this default collimation in
y direction may result in more or fewer
images taken.
Table acquisitions
Make sure the detector is at 0 degrees and
under the table for VM systems. For TH or
VM systems, the detector can be in any
longitudinal position.
Insert the correct grid or remove
depending on the application performed and
patient.
The stitching grid provided has ratio 8:1,
f0 = 180, 36 lp and has applicational range
from 126 cm to 315 cm.
Take the ruler either from the stand or
from storage and place on table top under
mattress if preferred.
Please note
The use of the mattress will increase the
magnification of the image and therefore the
image should then be re-calibrated later.
Take care when placing the ruler as
adjustment after the patient is lying on it
may be limited!
Patient positioning for table acquisitions
Patient positioning
Place patient on table.
Adjust the tube height to the required SID.
For TH table applications the tube must be
in a longitudinal and lateral lock but not
height.
For TH-S table applications only the lateral
lock must be active.
Tube must be at 0 degrees.
Care should be taken with the vertical
stand VM not to position the required X-ray
area close to the table base.The system will
not allow any movements that cause the
detector to collide with the table and a
user guidance will be given on the tube
head.
Use the floating tabletop to position the
entire region of interest in the light field.
Collimate if necessary in x and y direction.
Adjust the ruler so that it will be beside the
spine or in between the legs within the
X-ray field.
Please note
The algorythm can work more effectively if
these is a least 1 cm from the ruler to the
border of the exposed area.
The X-ray acquisitions are taken from left
to right on the table TH, and on the TH-S
the direction is from the defined head end
of the detector. If the patient is positioned
with head to the right side, the images must
be rotated before stitching together as they
will appear upside down.This can be
performed on the console.
Perform a test run Safety aspects
It is possible to perform a test run of the Patient support
movements without the exposure.
After setting up the system, pressing the Risk of tilting!
test button on the tube control handle
activates this function.The same button is It is not allowed to move the patient
also used for tomography tests. support with a patient on it.
Before stepping onto the patient support,
On completion, the system will return to lock the front wheels.
the start position again. Take care at stepping onto the patient
support.
Pressing any button on the tube during the Use patient support only at flat floor.
test run aborts the test and the user must
manually move the system back to the 0 or
90 degree position. Technical data
Patient support
Return to the workstation Max. patient weight 225 kg
Check and modify generator settings if Al equivalent 0.9 mm
necessary.
Technique, kV, mAs can be modified.
Please note
Changes to the first APR influence all
subsequent APRs (see page 6).
9
Examination procedure (contd.)
Exposure release
Once the patient and system are correctly
set up
Press the exposure button and KEEP
THIS PRESSED FOR THE WHOLE
DURATION OF THE VIEW
(2 or 3 exposures).
This controls the system movement and
the X-ray release.
Releasing the exposure button cancels
the whole acquisition and only images
taken up to then can be stitched
together.The view cannot be stopped
and resumed.
Automatic movement on the vertical stand
Focus
Tube Height
10
Please note
Length of time between exposures of
which the patient must remain still:
For 2 exposures up to 80 cm / 31.5"
coverage typically used
for spine = 7 seconds
For 3 exposures up to 120 cm / 47"
coverage typically used
for legs = 12 seconds.
The automatic movements of the system promote the single focus
approach (as with conventional and CR technique) thus given
equivalent geometric results. During acquisition the detector moves
and the tube tilts around the focal spot.
1st Image
overlap
Tube Tilt
2nd Image
overlap
3rd Image
SID
 After the last exposure beep is heard the All composites must be confirmed / Dose product
patient can move, release of the exposure rejected before the user is allowed to Each individual image will have the dose
button is possible and the system will return to the patient list (like with normal information with the DICOM header. The
return to the starting point once again. views.) Rejected composites will still be composite image will contain this
available with the individual images within information burnt in each individual image
During the sequence the images will appear the viewer and so can be created again. at the side, which is exported to print and
in the verification screen. At any point if the PACS.The composite image is exported
patient moves or the image are not as On pressing the stitching button, the user is via SC (Secondary Capture) and therefore
required, the sequence can be stopped by taken into the stitching frame. Here the the dose field is not present in the
releasing the exposure button. It is not composite will be displayed for checking. DICOM header of this image type.
possible to confirm each image as they
appear, confirmation should be performed Please note
after the exposure sequence. If the auto stitching failed, the user is given a
warning and the user must stitch the images
On confirmation of the last stitching image, together manually.
the composite will be made automatically
(in the background) taking approximately
40 s to 60 s for two and three images
respectively dependent on area of
exposure.
The maximum time for the full
120 cm x 43 cm (47"x 17") coverage is
80 seconds.
It is however possible to take further
stitching views or normal views during this
time.

As soon as there is a composite available

for verifying, the stitching button will alight
Stitching button within the verification screen
yellow.

Please note
Only one composite at a time within the
stitching frame can be viewed and
confirmed / rejected.

11
Image stitching at the DigitalDiagnost console

All image stitching is now performed at the console itself and no longer at the EasyVision RAD
workstation.
There are two ways to enter the stitching frame:
either directly during the normal workflow via the verification screen to allow for auto printing
and export of the composite or
after the examination is completed (to perhaps allow more time for measurements etc.)
via the viewer but print and export must then be performed manually.

In both cases the same functionality is available.

On entry to the stitching frame from the verification screen, the composite will be presented.

Stitching frame (accessed via the verification screen) with successful autostitched composite

Caution!
The user must always carefully check the results of the autostitching.
The overlap area of the ruler (shown by the lines) should be closely
inspected for correctness. If any errors are seen, the user should de-
stitch and re-stitch the images manually.

12
Stitching methods and view

User Interface buttons

Stitching methods
1 Automatically stitch images together
2 Apply cross marks to images (semi-
automatic)
3 Stitch images together as arranged (or
with use of cross marks)
1
4 Un-stitch composite
2/3
5 Rotate individual image anti-clockwise
6 Mirror individual image 4
7 Rotate individual image clockwise
8 Lock mouse in x direction (horizontal)
5
9 Move image up (1 pixel)
10 Lock mouse in y direction (vertical) 6/7
11 Move image left (1 pixel) 8
12 Move image down (1 pixel) 9 / 10
13 Move image right (1 pixel)
11
12 / 13

View
14 Move to top overlap area
14
15 Display composite
16 Display overlap region (the top is the 15 / 16
first to be presented) 17
17 Move to bottom overlap area 18 / 19
18 Show scale life-size
20
19 Show scale pixel to pixel (maximum
resolution) 21
20 Show / hide image overlap lines
21 Transparency mode on / off

13
Stitching methods and view (contd.)

Stitching Methods
This panel offers the tools to auto stitch,
apply the cross markers for semi-
automatic stitching and to stitch the
images as arranged or as positioned by the
cross marks.
The arrows allow for the manipulation of
the individual images either to rotate,
move by a pixel for more precise
positioning or to lock the movement in x
and y direction for mouse movement.
Rotation of the individual images may be
neccessary if the images appear incorrectly
rotated (wrongly configured or different
patient orientation).
Please note
The semi automatic tool (apply cross marks
to images) allows the user to place a cross
on the same place on the two images which
will then be used to align together. Once
the crosses are placed, the user must select
the stitch images button to activate the
stitching.
This is how the images will be presented
also when entry is from the viewer tool.
The user can either try to auto stitch the
images if entering from the viewer or
alternatively stitch them together manually
if autostitching has failed.
If required the user can unstitch the
composite, modify the individual images and
manually stitch back together.

All images can be selected and moved

with the mouse to reorder.
If the autostitching failed, the individual
images will be presented to the user on
entry to the stitching frame.

Stitching frame with unsuccessful autostitching showing the individual images

14
 Stitching frame showing transparency mode active

View
This panel offers the tools to modify what is
viewed within the image area. Users can
activate with one touch buttons whether the
whole composite is visible or the overlapping
areas. In addition the user can use the
up/down buttons to toggle between the
borders or use the life-size and pixel-to-pixel
zoom factors for more precise positioning.

The overview is always presented in the

bottom left corner.This can also be used to A
navigate through the image by dragging the
box.

There are several other tools which aid the

manual stitching process:
The transparency mode enables the user to
see through the images helping the
alignment of the ruler/or anatomical area.
The images are graduated together both at
50% each.The red line indicates which
image is activated to move.
This can be toggled on / off using the
transparency button [A]. Stitching frame showing the show lines active

Once checked, the user can remove the

overlapping lines on the image which
demonstrates where the overlap of the
images exists. Due to the advanced image
processing, this overlap area is often now
not distinguishable. Some clinicians may
require this for checking of accuracy
accross this area.

These lines are printed and exported [B] if

left on. B

15
Calibration and measurements

User Interface buttons

Calibration:
1 Make calibration (once calibrated: 1
show/hide on image)
2 Reset to default calibration 2

Measurements:
3 Draw ruler
4 Measure distance 3
5 Measure angle 4/5
6 Draw vertical alignment
6
7 Draw vertical alignment point
8 Draw femoral height difference 7/8
9 Draw 4 point cobb angle
9
10 Draw 6 point cobb angle
11 Add annotation 10
12 Delete graphic

11

12

Calibration
The images are calibrated to the known
pixel size.The user is however able to
recalibrate the image (either on the
stitching ruler or a known size of an
object placed in the anatomical plane.)
This can be performed to increase the
accuracy of the measurements.

To do this select calibrate,

click on two points on the ruler or any
known size object in the image and
enter the value.

Stitching frame showing

the calibration line

16
 Calibration and reset button showing the status active

Calibration (contd.)
After entering the value in mm or cm, the
new calibration is now applied and the button
will turn blue.
The default value is in cm.This is configurable
in the unstructured items (configuration
tool).To remove the calibration and return to
the default pixel size, press the reset
button.
Once the image is calibrated, the calibration
line can be shown or hidden on the image
(for export and print) by toggling the
calibration button. Each calibration only is
applied to one series (view) of images.

Measurements
Stitching frame showing the automatic print and export settings
The user can add annotations, measurements,
angles, cobb angles, femoral difference and
vertical alignment to the image.
The required graphic can be selected using
the mouse and activated by clicking on points
in the image. For more precise positioning,
the life-size or pixel-to-pixel scale can be
used. All graphics once placed on the image
can be modified by selecting with the mouse
or deleting using the delete button.
The size / font / style of the graphics can be
changed by using the right mouse whilst
pointing the mouse over the required
graphic.
On completion of the composite and any
desired measurements, the user can then
either confirm or reject the result.
Confirm will start the activation of auto
export and print (as configured) for the
composite image. Reject will cancel the
activation of auto export/print for the
composite image.
On the selection of confirm, the automatic
Please note print/export options for the composite are
All rejected individual images and activated.
composites are available in the viewer and The default settings can be modified for each
can be re-stitched or re-processed for composite (the same as with normal images).
printing or export later.

17
Creation of the composite via the viewer

Viewer showing selection of the individual images

Creation of the composite via the viewer

As stated earlier, it is possible to select the
individual images in the viewer and access the
stitching frame for making the composite.
Some users may prefer this as it can be done at
a later stage than the acquisition if more time is
required (to add measurements etc.) without
blocking the normal workflow in the room.

The system creates a composite everytime the

images are stitching together. If then additional
annotations, measurements or overlap lines are
placed on the image and confirmed, the system
creates another composite. Both will be seen in
the viewer.

Please note
Single images or composites cannot be
selected for entry into the stitching frame. For
entry into the stitching frame, two or more
individual images (from the same view/series)
needed to be selected.

To select the individual images, hold the shift

button down (on the keyboard) whilst clicking
on the images. The stitch button will then The stitching frame from entry via the viewer
become active.
On entry into the stitching frame, the
individual images are presented.

Please note
The defaults for automatic export and print
are not present, neither are the confirm or
reject buttons active.
These buttons only apply when entering from
the verification screen.
All composites made from the viewer must be
exported and printed manually.

The user can activate the autostitching button,

if this fails the user must manually stitch the
images together (described previously). Once
completed, the user can select the stamp view
to return to the viewer.The new composite will
be available here from printing / reprocessing /
export.

18
Post processing and printing

Result of autostitching Result of autostitching

Post processing and Printing

Each stitching view (e.g. AP Spine) can be
configured with a specific processing method.
The same method is also applied to the
composite.
The individual images can be reprocessed
using their specific post methods if required
(for cervical spine, thoracic spine etc.).
The composite can also be reprocessed using
different image processing. A composite can
also be created multiple times out of the
original individual ones.

Additional software provides the composite

with two new enhancements. Firstly there is
line removal performed (so the overlapping
region is blended together and is less
distracting) and then a grey level equalization
across the entire image produces the
appearance of a single image and not two
or three.
As noted earlier, it is possible to add lines on
the image to show where the overlapping
took place.

The composite can be printed in different ways depending

on the supported printer.
DigitalDiagnost release 1.5 supports the new Codonics XL
printer, which supports printing in life-size for these images
over several films, which are attached together. Printing in
life-size then supports the use of orthopedic templates used
previously with conventional film / CR cassette use.
Printing on standard printers is realized by fit to the film
mode, which scales the whole composite to fit onto a
35 cm x 43 cm (14" x 17") film.

19
Philips Medical Systems is part
of Royal Philips Electronics
Koninklijke Philips Electronics N.V. 2006
All rights are reserved. Reproduction or transmission
in whole or in part, in any form or by any means,
electronic, mechanical or otherwise, is prohibited
without the prior written consent of the copyright
owner.

www.medical.philips.com Printed in Germany.

4512 987 13271 AA/712 * NOV 2006
medical@philips.com

Manufacturing address
Philips Medical Systems DMC GmbH

Roentgenstrasse 24

22335 Hamburg

Germany