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Radiation Risk in Orthopedic Surgery: Ways to Protect Yourself and the Patient

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Abstract

Radiation exposure to the patient has become an increasing problem in health care and has received attention in the media. The exposure to health care personnel is an issue as well. This article reviews radiation exposure caused by various devices used in the practice of orthopaedic surgery and the relative exposure to involved health care workers. Ways to protect oneself from such exposure is also discussed.

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... 2,28-40 Recent studies revealed an increased risk of cancer, mainly attributable to radiation exposure, among orthopaedic surgeons. 38 In a small Italian hospital, orthopaedic surgeons exhibited a cumulative cancer incidence of 29% over a 24-year-period, in opposition to 11% for non-orthopaedics physicians and 4% for workers unexposed to radiation. 41 Another American study found that female orthopaedic surgeons have a 1.9-fold increased prevalence of cancer generally and 2.9-fold increased prevalence of breast cancer compared to general female population of similar age and race. ...
... Two acronyms sum up all of these measures; ALARA and DEBT. 17,30,[34][35][36][37][38][39]44 The principle of ALARA (as low as reasonably achievable) was originally introduced by ICRP with respect to patient exposure, but soon became apparent that it should also apply medical personnel. 38 DEBT (Distance, Exposure, Barriers and Techniques) reports all Table 1 Mean time and range of time for distal locking procedures. ...
... 17,30,[34][35][36][37][38][39]44 The principle of ALARA (as low as reasonably achievable) was originally introduced by ICRP with respect to patient exposure, but soon became apparent that it should also apply medical personnel. 38 DEBT (Distance, Exposure, Barriers and Techniques) reports all Table 1 Mean time and range of time for distal locking procedures. practical guidelines for radioprotection (increase distance from the radiation source, limitation of fluoroscopy time, use of barriers or even development of new techniques). ...
... Nurses can engage in a variety of medical ionizing radiation procedures. For example, when X-ray imaging involves exposing patients, it sometimes needs to be conducted in wards for patients who cannot walk to the X-ray room, exposing them to scattered radiation [7]. Deterministic effects are also referred to as tissue reactions, depending on the amounts of radiation exposure. ...
... Deterministic effects are also referred to as tissue reactions, depending on the amounts of radiation exposure. At higher doses, health effects such as skin injury and hair loss may be more severe [7][8][9]. is endangers the safety of nurses and patients when exceeding the radiation threshold [10]. Besides, tumors and leukemia are the stochastic effects of radiation, arising throughout extended periods caused by genetic material changes [8,9]. ...
... However, the competence of nurses in radiation remains a poorly studied term. e previous study shows that there has been a general lack of radiation education among nurses [7,20]. ...
Article
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Radiology is a vital diagnostic tool for multiple disorders that plays an essential role in the healthcare sector. Nurses are majorly involved in a healthcare setting by accompanying patients during the examination. Thus, nurses tend to be exposed during inward X-ray examination, requiring them to keep up with radiation use safety. However, nurses’ competence in radiation is still a concept that has not been well studied in Malaysia. The study aimed to define the level of usage understanding and radiation protection among Malaysian nurses. In this research, a cross-sectional survey was conducted among 395 nurses working in hospitals, clinics, and other healthcare sectors in Malaysia. The survey is based on the developed Healthcare Professional Knowledge of Radiation Protection (HPKRP) scale, distributed via the online Google Forms. SPSS version 25.0 (IBM Corporation) was used to analyze the data in this study. Malaysian nurses reported the highest knowledge level in radiation protection with a mean of 6.03 ± 2.59. The second highest is safe ionizing radiation guidelines with 5.83 ± 2.77, but low knowledge levels in radiation physics and radiation usage principle (4.69 ± 2.49). Therefore, healthcare facilities should strengthen the training standards for all nurses working with or exposed to radiation.
... Assuming an average fluoroscopy time of 15 seconds per case with a cumulative career caseload of 550 arthroscopic cases using standard protective equipment, surgeon radiation exposure using the inverted C-arm orientation was estimated to be 1.2 mGy, 40% of the patient's exposure during a single case (P < .05). 1,7 The calculation of the patient's carcinogenesis risk due to ionizing radiation determined a risk of 1.4 Â 10 -5 for the inverted orientation compared with 3.7 Â 10 -5 for the standard orientation. Using the patient's carcinogenesis risk calculation, there was an estimated 62% risk reduction in radiation exposure with the inverted orientation. ...
... Although a useful method of preventing deterministic and stochastic effects, the patient's positioning and operative site can preclude the ability of providing appropriate protection. 1,8 The reported data are consistent with findings in the previous literature of a significantly higher radiation exposure to patients compared with surgeons. This is of particular concern given the close proximity of the patient's gonads, one of the more radiation-sensitive organs in the body, to the surgical field and the inability to appropriately shield these organs. ...
... Lead aprons have shown to reduce exposure considerably depending on the fluoroscopic projections, with reductions of up to 16-fold. 1,20 Unfortunately, with the setup of hip arthroscopic surgery, there is no available method to appropriately shield the patient's gonads. As such, one could infer that with the patients receiving higher levels of radiation, their lifetime cancer risk would be increased as compared with the surgeon's overall risk during hip arthroscopic surgery. ...
Article
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Background Fluoroscopic guidance is routinely utilized during hip arthroscopic surgery. Previous studies have shown that the C-arm orientation can significantly affect radiation exposure for both the surgeon and the patient during orthopaedic procedures. However, this has not been previously assessed for hip arthroscopic surgery. Hypothesis Using an inverted C-arm during hip arthroscopic surgery will reduce radiation exposure to the patient and surgeon. Study Design Descriptive laboratory study. Methods A simulation study measured scatter radiation during hip arthroscopic surgery performed in the supine position under fluoroscopic guidance with an anthropomorphic pelvic phantom on a radiolucent operating table. Radiation exposure tested 2 different C-arm orientations: standard and inverted. Testing was performed at 6 locations corresponding to the patient, surgeon’s neck, surgeon’s waist, surgical technician, anesthesiologist, and radiology technician. Statistical analysis was performed using univariate and multivariate analyses assessing radiation exposure between the C-arm orientations. A risk calculation for carcinogenesis was performed based on reported radiation dosages. Results Radiation exposure (in mGy/min) was more than 100-fold higher for the patient compared with the surgeon in both C-arm orientations. The inverted C-arm orientation resulted in a 2.48-fold decrease in patient radiation exposure when compared with the standard orientation (10.8 mGy/min vs 26.8 mGy/min, respectively). There was a small but significant increase in surgeon radiation exposure in the inverted orientation compared with the standard orientation (0.072 vs 0.067 mGy/min, respectively). The patient’s carcinogenesis risk was decreased 2.64-fold with the inverted orientation compared with the standard orientation (1.4 × 10–5 vs 3.7 × 10–5, respectively). Conclusion The inverted C-arm orientation resulted in a 2.48-fold decrease in patient radiation exposure with a 2.64-fold decrease in the carcinogenesis risk compared with the standard orientation. Inadvertently, the inverted orientation provided a 9-cm increase in the surgeon’s working area. Our data supported the clinical utilization of the inverted C-arm orientation during hip arthroscopic surgery to minimize patient radiation exposure. Although there was a minimal but significant increase in surgeon radiation exposure with the inverted orientation, we believe that this is negligible when incorporated with standard leaded protective equipment as contrasted with the significant dose reduction for the patient as well as the decreased risk of carcinogenesis and hereditary disorders. Clinical Relevance Patients undergoing hip arthroscopic surgery routinely acquire radiation exposure during the use of the C-arm. Measures to minimize radiation via the inverted C-arm orientation will decrease the unnecessary risk to the patient while continuing to allow for optimal treatment.
... The most important of these is maintaining distance from the fluoroscopy tube, wearing lead aprons, wearing neck protectors for the thyroid, wearing protective glasses, having a surgical team that is experienced in the surgical technique (open and minimally invasive) and using a scopy technician. [1,10,18,23,24] Perhaps the most important is the provision of specific periodic training to the surgical team related to radiation risk and protection. In a study by Khan et al., [25] it was reported that new surgeons working in orthopedics and trauma were not aware of the negative effects of ionised radiation or protection methods. ...
... [19] By keeping the tube below the table, direct or disseminated radiation is contained within a limited area. [23] In the current study, imaging was completed with the tube remaining under the table. In some centers, it has been shown that the use of the PACS system (picture archiving communication system) has reduced the radiation dose. ...
Article
Objective: The aim of the study was to determine the amount of radiation exposure in the orthopedic operating theater, to show that the radiation dose was decreased with distance from the tube, and to inform personnel about protective measures. Methods: Ionised radiation was measured in the orthopedic operating theater where fluoroscopy was used between 18 February 2014 and 02 June 2014. Four dosimeters were placed at the head and foot of the operating table and at 200 cm from those areas at a height of 60 cm vertical to the floor. Results: At the end of 104 days, the total values were determined as 90.5 mrem at the foot of the table, 68.17 mrem at the head of the table, 7.5 mrem at 200 cm from the foot of the table, and 5.17 mrem at 200 cm from the head of the table. A significant decrease was observed in the values determined at a distance from the radiation source. Conclusion: The rate of radiation determined in the dosimeters decreased when distance from the radiation source increased. During the use of fluoroscopy in orthopedic surgery, the wearing of lead aprons, neck protectors, and glasses, in addition to maintaining a distance from the tube, will reduce the radiation exposure of individuals.
... The most important of these is maintaining distance from the fluoroscopy tube, wearing lead aprons, wearing neck protectors for the thyroid, wearing protective glasses, having a surgical team that is experienced in the surgical technique (open and minimally invasive) and using a scopy technician. [1,10,18,23,24] Perhaps the most important is the provision of specific periodic training to the surgical team related to radiation risk and protection. In a study by Khan et al., [25] it was reported that new surgeons working in orthopedics and trauma were not aware of the negative effects of ionised radiation or protection methods. ...
... [19] By keeping the tube below the table, direct or disseminated radiation is contained within a limited area. [23] In the current study, imaging was completed with the tube remaining under the table. In some centers, it has been shown that the use of the PACS system (picture archiving communication system) has reduced the radiation dose. ...
Article
Full-text available
The aim of the study was to determine the amount of radiation exposure in the orthopedic operating theater, to show that the radiation dose was decreased with distance from the tube, and to inform personnel about protective measures. Ionised radiation was measured in the orthopedic operating theater where fluoroscopy was used between 18 February 2014 and 02 June 2014. Four dosimeters were placed at the head and foot of the operating table and at 200 cm from those areas at a height of 60 cm vertical to the floor. At the end of 104 days, the total values were determined as 90.5 mrem at the foot of the table, 68.17 mrem at the head of the table, 7.5 mrem at 200 cm from the foot of the table, and 5.17 mrem at 200 cm from the head of the table. A significant decrease was observed in the values determined at a distance from the radiation source. The rate of radiation determined in the dosimeters decreased when distance from the radiation source increased. During the use of fluoroscopy in orthopedic surgery, the wearing of lead aprons, neck protectors, and glasses, in addition to maintaining a distance from the tube, will reduce the radiation exposure of individuals.
... Occupational radiation exposure to orthopaedic surgeons has been shown to increase the likelihood to develop a cancer during their lifetime compared to other healthcare workers by fivefold [7]. Methods employed to reduce the risk from ionizing radiation include: minimizing radiation use, personal protective apparel, routine radiation dose monitoring, and intra-operative positioning reducing scatter radiation [8,9] (Table 3). ...
... Fluoroscopy scatter radiation follows the inverse square law, which suggests that moving from 1 m to 2 m from the C-arm reduces radiation exposure by a factor of four [9]. The X-ray [1,8,9] Institutions Provide and maintain personal protective equipment including lead gowns, thyroid shields, and eye goggles Regular audit of radiation exposure of radiographers and high-risk individuals Limit staff in operating room using fluoroscopy to those only essential personnel Regular maintenance of fluoroscopic equipment [1] source produces the greatest radiation exposure in a linear direction and so standing directly behind the X-ray generator or detector/intensifier also reduces exposure [9]. Nordeen et al. demonstrated a statistically significant difference in radiation exposure (measured in screening time) when the surgeon had control of when a fluoroscopy image was taken rather than the radiographer [11]. ...
Article
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IntroductionRadiation exposure from intra-operative fluoroscopy in orthopaedic trauma surgery is a common occupational hazard. References for fluoroscopy use in the operating room for commonly performed operations have not been reported adequately. This study aimed to report appropriate intra-operative fluoroscopy use in orthopaedic trauma and compare the effect of surgery type and surgeon grade on radiation exposure. Methods Data on 849 cases over an 18-month period were analysed retrospectively. Median and 75th centile values for dose area product (DAP), screening time (ST), and number of fluoroscopy images were calculated for procedures where n > 9 (n = 808). ResultsMedian DAP for dynamic hip screws for extracapsular femoral neck fractures was 668 mGy/cm2 (ST 36 s), 1040 mGy/cm2 (ST 49 s) for short proximal femoral nail, 1720 mGy/cm2 (ST 2 m 36 s) for long femoral nail for diaphyseal fractures, 25 mGy/cm2 (ST 25 s) for manipulation and Kirschner wire fixation in distal radius fractures, and 27 mGy/cm2 (ST 23 s) for volar locking plate fixation in distal radius fractures. These represented the five commonest procedures performed in the trauma operating room in our hospital. Experienced surgeons utilized less radiation in the operating room than junior surgeons (DAP 90.55 vs. 366.5 mGy/cm2, p = 0.001) and took fewer fluoroscopic images (49 vs. 66, p = 0.008) overall. Conclusions This study reports reference values for common trauma operations. These can be utilized by surgeons in the operating room to raise awareness and perform clinical audits of appropriate fluoroscopy use for orthopaedic trauma, using this study as guidance for standards. We demonstrated a significant reduction in fluoroscopy usage with increasing surgeon experience.
... The European Union banned Pb usage in the healthcare sector, thereby creating the urgent necessity of a Pb substitute candidate [8]. Alternatively, various composite materials were proposed as effective absorbers and attenuators for the X-ray and Gamma-ray irradiation [9,10]. These shielding materials must have the capacity to attenuate the ionizing radiations passing through them thoroughly, thereby minimizing the risk of exposure to workers and people around. ...
Article
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The fabrication of Nano-based shielding materials is an advancing research area in material sciences and nanotechnology. Although bulky lead-based products remain the primary choice for radiation protection, environmental disadvantages and high toxicity limit their potentials, necessitating less costly, compatible, eco-friendly, and light-weight alternatives. The theme of the presented investigation is to compare the ionization radiation shielding potentialities of the lead acetate (LA), lead nitrate (LN), and bismuth nitrate (BN)-doped zinc oxide nanorods-based thin films (ZONRs-TFs) produced via the chemical bath deposition (CBD) technique. The impact of the selected materials’ doping content on morphological and structural properties of ZONRs-TF was investigated. The X-ray diffractometer (XRD) analyses of both undoped and doped TFs revealed the existence of hexagonal quartzite crystal structures. The composition analysis by energy dispersive (EDX) detected the corrected elemental compositions of the deposited films. Field emission scanning electronic microscope (FESEM) images of the TFs showed highly porous and irregular surface morphologies of the randomly aligned NRs with cracks and voids. The undoped and 2 wt.% BN-doped TFs showed the smallest and largest grain size of 10.44 nm and 38.98 nm, respectively. The linear attenuation coefficient (µ) values of all the optimally doped ZONRs-TFs measured against the X-ray photon irradiation disclosed their excrement shielding potency. The measured µ values of the ZONRs-TFs displayed the trend of 1 wt.% LA-doped TF > 1 wt.% LN-doped TF > 3 wt.% BN-doped TF > undoped TFs). The values of μ of the ZONRs-TFs can be customized by adjusting the doping contents, which in turn controls the thickness and morphology of the TFs. In short, the proposed new types of the LA-, LN- and BN-doped ZONRs-TFs may contribute towards the development of the prospective ionization radiation shielding materials.
... 18 With this background, interest has grown in achieving radiation exposure that is as low as reasonably achievable (ALARA). 19 The options available for decreasing radiation exposure have been described with the acronym DEBT --Distance, Exposure, Barriers and Techniques/Technologies. 20 The first three of these options have largely been optimized, leaving new technologies as the primary source of gains in radiation safety. A recent study by Kirousis and colleagues used dosimetry during tibial IMN procedures to quantify the radiation doses to the patients, surgeons and operators of fluoroscopy equipment. ...
Article
To compare the time required for proximal locking screw placement between a standard freehand technique and the navigated technique as well as to quantify the reduction in ionizing radiation exposure. A fresh-frozen cadaver model was used for 48 proximal interlocking screw procedures. Each procedure consisted of insertion of two anteroposterior locking screws. Standard fluoroscopic technique was used for 24 procedures and an electromagnetic navigation system was used for the remaining 24. Procedure duration was recorded using an electronic timer and radiation doses were documented. Mean total insertion time for both proximal interlocking screws was 405 ± 165.7 seconds with the freehand technique and 311 ± 78.3 seconds in the navigation group (p = 0.002). All procedures resulted in successful locking screw placement. Mean ionizing radiation exposure time for proximal locking was 29.5 ± 12.8 s. Proximal locking screw insertion using the navigation technique evaluated in this work was significantly faster than the standard fluoroscopic method. The navigated technique is effective and has the potential to prevent ionizing radiation exposure.
... There the acronym DEBT (distance, exposure, barriers, technique) was described, referring to ways to decrease radiation exposure. In accordance with QSVI guidelines and ALARA, the resident should take extra precautions to decrease radiation such as: standing away from the mini C-arm when possible-ideally farther than 1 M, wearing radiation badges to track cumulative exposure, decreasing magnification (mini C-arm boosts radiation to maintain image brightness), inverting C-arm by positioning the mini C-arm with the receiver down, keeping the surgeon's hands out of the beam, and the surgeon and the patient should wear a lead apron [1,6,8,9,16,17] (Table 2). ...
Article
Background: Fluoroscopy during fracture reduction allows a physician to assess fractures and immediately treat a pediatric patient. However, concern regarding the effects of radiation exposure has led us to find ways to keep radiation exposures as low as reasonably achievable. One potentially simple way, which to our knowledge has not been explored, to decrease radiation exposure is through formal education before mini C-arm use. Questions/purposes: We questioned whether a radiation safety educational program decreases radiation (1) time and (2) exposure among residents and patients. Patients and methods: This is a retrospective study in which second-year residents underwent a 3-hour educational program regarding mini C-arm use and radiation safety taught by our institution's health physics department. We evaluated the records of all patients who underwent a pediatric both-bone forearm or distal radius fracture reduction in the emergency department 3 months before the educational program or after the program. To be included in the study, records included simple both-bone forearm fractures, simple distal radius fractures, and patient age younger than 18 years, and could not include patients with multiple fractures in the same limb. This resulted in study groups of 53 and 45 patients' records in the groups before and after the educational session, respectively. Radiation emission from the mini C-arm between both groups were compared. Results: Exposure time with the mini C-arm was longer in patients treated before the educational intervention than in those treated after the intervention (patients with both-bone forearm fractures: mean = 41.2, SD = 24.7, 95% CI, 23.14-59.26 vs mean = 28.9, SD = 14.4, 95% CI, 15.91-41.89, p = 0.066; patients with distal radius fractures: mean = 38.1, SD = 26.1, 95% CI, 25.1-51.1 vs mean = 26.7, SD = 15.8, 95% CI, 16.44-36.96, p = 0.042). Calculated radiation exposure with the mini C-arm was larger in patients treated before the educational intervention than in those treated after the intervention (patients with both-bone forearm fractures: mean = 90.9, SD = 60.9, 95% CI, 51.06-130.74 vs mean = 30.4, SD = 18.5, 95% CI, 16.73-44.07, p < 0.001; patients with distal radius fractures: mean = 83.1, SD = 58.9, 95% CI, 54.75-111.45 vs mean = 32.6, SD = 26.4, 95% CI, 20.07-45.13, p < 0.001). Conclusions: A radiation-safety program resulted in decreased radiation exposure to residents and patients, and in decreased mini C-arm exposure time during pediatric fracture reductions. Level of evidence: Level III, therapeutic study.
... Although long-term lowdose radiation exposure effects are largely unknown, hospital radiation safety protocols rely on the principle of using ionizing radiation doses that are "as low as reasonably achievable" to create image quality that is adequate. 1,5,9,[15][16][17] In a survey of 517 orthopaedic residents conducted by Bowman et al., it was shown that 98% thought that personal protective equipment should be provided to them and that overall, however, only 54.2% reported being provided with Individual resident monthly dosimeter measurements (mrem) before and after personalized lead protocol (PLP). ...
Article
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Radiation exposure of orthopaedic residents should be accurately monitored to monitor and mitigate risk. The purpose of this study was to determine whether a personalized lead protocol (PLP) with a radiation monitoring officer would improve radiation exposure monitoring of orthopaedic surgery residents. Materials and methods: This was a retrospective case-control study of 15 orthopaedic surgery residents monitored for radiation exposure during a 2-year period (March 2017 until February 2019). During the first 12-month period (phase 1), residents were given monthly radiation dosimeter badges and instructed to attach them daily to the communal lead aprons hanging outside the operating rooms. During the second 12-month period (phase 2), a PLP (PLP group) was instituted in which residents were given lead aprons embroidered with their individual names. A radiation safety officer was appointed who placed the badges monthly on all lead aprons and collected them at the end of the month, whereas faculty ensured residents wore their personalized lead apron. Data collected included fluoroscopy use time and radiation dosimeter readings during all orthopaedic surgeries in the study period. Results: There were 1,252 orthopaedic surgeries using fluoroscopy during phase 1 in the control group and 1,269 during phase 2 in the PLP group. The total monthly fluoroscopy exposure time for all cases averaged 190 minutes during phase 1 and 169 minutes during phase 2, with no significant difference between the groups (p < 0.45). During phase 1, 73.1% of the dosimeters reported radiation exposure, whereas during phase 2, 88.7% of the dosimeters reported radiation exposure (p < 0.001). During phase 1, the average monthly resident dosimeter exposure reading was 7.26 millirems (mrem) ± 37.07, vs. 19.00 mrem ± 51.16 during phase 2, which was significantly higher (p < 0.036). Conclusions: Institution of a PLP increased the compliance and exposure readings of radiation dosimeter badges for orthopaedic surgery residents, whereas the actual monthly fluoroscopy time did not change. Teaching hospitals should consider implementing a PLP to more accurately monitor exposure. Level of evidence: 3.
... [10] Methods to decrease radiation exposure were discussed and collected under the title of Distance, Exposure, Barriers and Techniques/Technologies (DEBT). [11] The purpose of this study was to develop a new technique to decrease radiation exposure. Since type-A3 fractures may be accompanied by several complications during surgery, this type of fracture has not been included in the present study in order to be able to evaluate the effectiveness of doublefluoroscopy used with an oblique position. ...
Article
BACKGROUND: The purpose of this study was to determine the comparative effectiveness of the use of single fluoroscopy versus double fluoroscopy during intramedullary nailing in the oblique position for intertrochanteric femur fractures in terms of surgery and radiation time. METHODS: Fifty-two patients (20 men, 32 women; average age: 78.2 years; range: 69-88 years) were included in the study. While double fluoroscopy was used for 25 patients, single fluoroscopy was used for the remaining 27 patients. Data of the preparation time between anesthesia and surgery, surgery time, radiation time, bleeding volume, postoperative collodiaphyseal angle between the fractures and intact parts, and the tip-apex distance (TAD) were compared. RESULTS: The surgery time in the double and single fluoroscopy groups averaged 34.48±8.92 minutes and 50.37±16.63 minutes, respectively (p<0.01). The radiation time was 42.72±16.00 seconds for the double-fluoroscopy group and 68.22±21.53 seconds for the single-fluoroscopy group (p<0.01). The surgical preparation time, bleeding volume, collodiaphyseal angle and TAD distance did not vary significantly between groups (p>0.05). CONCLUSION: The use of double fluoroscopy in the oblique position in the surgical treatment of intertrochanteric femur fractures reduced the surgical time and the anesthesia time for patients, as well as the exposure to radiation, thereby also reducing the risk of complications.
... Many studies have investigated the radiation doses surgeons are exposed to during different fluoroscopically guided orthopaedic procedures [3][4][5]. The highest radiation exposures are observed in spinal surgery and intramedullary nailing of long bones [3,4,6]. Especially, the radiation doses to the hands are critical as surgeons often put their hands into the direct beam to position the extremity during fluoroscopy [7]. ...
Article
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Objective: Although orthopaedic surgeons frequently utilize intraoperative imaging, there is a lack of knowledge about their patterns of radiation protection. The goal of this study was thus to fill this gap by evaluating the use of protection against radiation in relation to concerns, safety guidelines and instructions. Methods: A survey addressing the issue was performed in 531 orthopaedic and trauma surgeons. The questionnaire comprised 26 questions concerning the use of intraoperative radiation in clinical practice, concerns about it and protection against. Results: Over 31% of the surgeons are very concerned about their radiation exposure in their job and about 48% are slightly to moderately concerned. Surgeons from Asia-Pacific, Latin America, and Middle East are significantly more concerned about radiation in their job compared to European surgeons (p<0.002). However, only one fifth of the surgeons wear a dosimeter and half of them never use it. Nearly 65% of the surgeons always wear a lead apron, but only 30.8% wear a thyroid protection. Lead gloves and lead glasses were always worn by only 2.5 % (13/531) and 3.1% (16/531) respectively. Half of the respondents are aware of the radiation protection officer in their clinic, but 38.8% stated the issue has never been the subject of training at their institution. Internal training significantly affects the usage of dosimeters (odds ratio=2.97, 95% confidence interval: 2.00 – 4.39; p<0.001).Conclusion: Although most operating surgeons worry about their exposure, the knowledge and the practical implementation of radiological protection measures in clinical practice is still insufficient. Education is key for better radiation protection in orthopaedic practice.
... 8,9,11 When a patient is exposed to ionising radiation in the procedures guided with fluoroscopy, staff members are exposed to the scattered radiation. 12 Tissue reactions, previously referred to as 'deterministic effects', depend on the amount of radiation exposure, and health effects such as skin damage and blood changes, among others, will be more severe at higher doses. 12e14 Tissue reactions have appeared following both interventional radiology and cardiology procedures. ...
Article
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Introduction: Healthcare professionals must sufficiently understand ionising radiation and the associated protection measures to avoid unnecessarily exposing patients and staff to ionising radiation. Hence, a proper safety culture is important to lowering health risks. The development and establishment of an instrument that can indicate healthcare professionals' understanding/knowledge of radiation protection concepts can greatly contribute to a good safety culture. The purpose of the present study was to develop and psychometrically test the Healthcare Professional Knowledge of Radiation Protection (HPKRP) self-evaluation scale, which was designed to measure the knowledge level of radiation protection by healthcare professionals working with ionising radiation in a clinical environment. Methods: The presented research employed a cross-sectional study design. Data were collected from eight Finnish hospitals in 2017. A total of 252 eligible nurses responded to the newly developed HPKRP scale. The face and content validity were tested with the Content Validity Index (CVI). Explorative factor analysis was used to test construct validity, whereas reliability was tested with Cronbach's alpha. Results: Overall S-CVI for the HPKRP scale was 0.83. Exploratory factor analysis revealed a three-factor model for the HcPCRP scale containing 33 items. The first factor was defined by Radiation physics and principles of radiation usage, the second factor by Radiation protection, and the third factor by Guidelines of safe ionising radiation usage. These three factors explained 72% of the total variance. Cronbach's alpha coefficient for the scale ranged from 0.93 to 0.96. Conclusion: The results provide strong evidence for the validity and reliability of the HPKRP scale. Additionally, educators can use the scale to evaluate healthcare students' understanding in radiation safety before and after education.
... Therefore, the main source of radiation is scattered X-ray medical personnel. [10,11] As some of the effects of ionizing radiation appear in the distant future, the use of these beams should be observed in accordance with ALAR's law to prevent unnecessary radiation reaching personnel. [5] Medical personnel plays an important role in radiation protection because they perform radiology tests directly. ...
Article
Introduction: The use of ionizing radiation in various sciences, especially in medical science, has played an important role in human health. As the use of radiology tests in medical centers, including the operating room ward, is increasing, increasing the level of awareness of the operating room staff can improve their performance in this area as well as reduce the risk of exposure to radiation. The aim of this study was to determine the knowledge and performance of surgical technologists about radiation protection in Zahedan educational hospitals. Materials and methods: The present study is a descriptive-analytical study that was performed on 80 surgical technologists of Zahedan teaching hospitals from January 2019 to December 2019. The Knowledge Questionnaire was used in this study, which was a researcher-made questionnaire. After filling out questionnaires and checklists, the data were analyzed by SPSS software using descriptive statistics and analytical, statistical tests, including independent t-test and Pearson correlation coefficient. Results: The results showed that the mean age of participants was 31 ± 7.03 years . 27% were men, and 53% were women. The mean of work experience was 7 ± 7.56. The mean score of knowledge was 6 ± 3.02 and the performance score was 12 ± 7.38. There was a correlation between age, awareness and performance of the participants (P < 0.001), and there was a correlation between participants' radiation protection training and awareness and performance (P = 0.000). There is a direct relationship between staff knowledge and performance. No significant relationship was found between the other variables (P = 0.029). Conclusion: The results of the study showed that there is a relationship between radiation protection training courses so that the personnel who passed these courses are more aware and functioning. Given that action is needed to raise awareness through workshops.
... It is well known that exposure time, distance from the radiation source, and barriers against radiation exposure are important factors for reducing the radiation exposure dose 22 . In order to reduce radiation exposure during fluoroscopy, we have focused on techniques such as positioning of the C-arm, pulsed fluoroscopy, and collimation 1,[23][24][25][26] . Although some studies have examined the effects of reducing the radiation exposure dose by using pulsed fluoroscopy and collimation 27,28 , we are not aware of any comprehensive studies that have accurately replicated clinical situations to evaluate the reduction in the radiation exposure dose associated with different fluoroscopic procedures. ...
Article
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Background Awareness of the harmful effects of long-term low-dose radiation is rising. Many studies have assessed both patient and physician exposure to radiation in association with the use of fluoroscopy in the operating room. However, to our knowledge, previous studies have not assessed, in a detailed fashion, the reduction in radiation exposure that pulsation and collimation provide. Methods Seven fresh cadavers were irradiated for 5 minutes with C-arm fluoroscopy with use of standard x-ray and pulsed and collimated x-ray beams. The x-ray sources were placed under the table, over the table, and lateral to the table. Radiation exposure doses were measured at different points, such as the center of the radiation field on the cadaver as well as at the locations of the surgeon’s hand and thyroid gland. In addition, Monte Carlo simulation (a physics equation to predict exposure) was performed to estimate the dose reduction and to confirm the experimental results. Results The radiation exposure doses associated with the use of pulsed fluoroscopy (8 times per second) were reduced by approximately 30% for the patient and by approximately 70% for the surgeon’s hand and thyroid gland as compared with those associated with the use of continuous fluoroscopy. The radiation exposure doses associated with the use of collimated beams were reduced to approximately 65% for the surgeon’s hand and thyroid gland as compared with those associated with the use of non-collimated fluoroscopy. These results were consistent with the simulation, and the phenomena could be appropriately explained by physics. Conclusions The present study revealed the effectiveness of pulsed and collimated x-ray beams in reducing radiation exposure doses resulting from C-arm fluoroscopy. Surgeons should consider using the techniques of pulsed fluoroscopy and collimation to protect patients and themselves from radiation. Clinical Relevance This study presents data regarding the reduction of radiation exposure provided by pulsed fluoroscopy and collimation.
Article
The resident curriculum of the American Board of Orthopaedic Surgery emphasizes radiation safety. Gendelberg showed that, immediately after a program on fluoroscopic safety, residents used less radiation when using the mini C-arm to reduce pediatric fractures. The current study evaluated whether this effect lasted. Residents underwent a new annual 3-hour session on mini C-arm use and radiation. Group A included 53 reductions performed before training. Group B included 45 reductions performed immediately after training. Group C included 46 reductions performed 11 months later. For distal radius fractures, exposure time and amount were 38.1 seconds and 83.1 mR, respectively, for group A; 26.7 seconds and 32.6 mR, respectively, for group B; and 24.1 seconds and 40.0 mR, respectively, for group C. When radiation time and amount were compared between group B and group C, P values were .525 and .293, respectively. When group C and group A were compared, P values were <.05 and <.01, respectively. For both bone forearm fractures, exposure time and amount were 41.2 seconds and 90.9 mR, respectively, for group A; 28.9 seconds and 30.4 mR, respectively, for group B; and 31.2 seconds and 43.6 mR, respectively, for group C. When radiation time and amount were compared between group B and group C, P values were .704 and .117, respectively. When group C and group A were compared, P values were .183 and .004, respectively. No significant difference in radiation exposure was noted immediately after training vs 11 months later. A sustained decrease in radiation exposure occurred after an educational program on safe mini C-arm use. [Orthopedics. 201x; xx(x):xx-xx.].
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Purpose The current techniques used to lock distal screws for the nailing of long bone fractures exposes the surgeons, radiologists and patients to a hearty dose of ionizing radiation. The SureshotTM Distal Targeting System is a new technique that, with the same results, allows for shorter surgery times and, consequently, less exposure to radiation. Materials and Methods The study was performed on 59 patients (34 males and 25 females) with a simple humerus fracture diagnosis, type 1.2.A according to the AO classification, who were divided into 2 groups. Group 1 was treated with ante-grade intramedullary nailing with distal locking screws inserted with a free hand technique. Group 2 was treated with the intramedullary nail using the Sureshot TM Distal Targeting System. Two intra-operative time parameters were evaluated in both groups: the time needed for the positioning of the distal locking screws and the time of exposure to ionizing radiations during this procedure. Results Group 2 showed a lower average distal locking time compared to group 1 (645.48'' vs 1023.57''), and also a lower average time of exposure to ionizing radiation than in group 1 (4.35'' vs. 28,96''). Conclusions The Sureshot TM Distal Targeting System has proven to be equally effective when compared to the traditional techniques, with the added benefits of a significant reduction of both surgical time and risk factors related to the exposure to ionizing radiation for all the operating room staff and the patient.
Article
Background Chronic exposure to occupational ionising radiation is seen as one reason for elevated cancer prevalence. Objective: The aim of this retrospective study was to evaluate radiation exposure of anaesthetists by real-time dosimetry. Methods Data of 296 patients were analyzed. Ten types of trauma operation procedures including osteosynthesis of upper and lower extremity fractures and minimally invasive stabilisation of traumatic and osteoporotic vertebral fractures were accomplished. Evaluation was performed by an occupational dosimetry system, which visualises anaesthetists radiation exposure feedback compared to surgeons in real-time. Results A significantly lower radiation exposure to anaesthetists compared to surgeons was observed in four types of operative procedures: Plate fixation of proximal humerus fractures, osteosynthesis of proximal femoral fractures, stabilisation of traumatic and osteoporotic vertebral fractures. In four types of operations (plate osteosynthesis of proximal humeral, distal radial and tibial fractures and intramedullary nailing of the clavicle), anaesthetists` amount of radiation exceeded one-third of the surgeons' exposure, especially if the C-arm tube was positioned close to the anaesthetists work station at the patients' head. Conclusion By using the occupational radiation dose monitoring system, radiation exposure to anaesthetists was visualised in real-time during trauma operations. Radiation exposure of anaesthetists depends on the type of operation and the position of the C-arm. The system may help to increase anaesthetists` awareness concerning radiation exposure and to enhance compliance in using radiation protection techniques.
Article
Background: Computer-assisted surgery (CAS) techniques have been shown to improve implant placement and reduce the radiation time during cephalomedullary nailing in cadaveric and pilot clinical studies of intertrochanteric hip fractures. However, clinical comparisons of CAS and conventional techniques are lacking. It is unclear whether CAS offers clear advantages in terms of radiation time, operative time, and accuracy of lag-screw placement in patients undergoing surgery for intertrochanteric hip fractures and whether any potential difference in accuracy is associated with a change in the risk of lag-screw cut-out postoperatively. Questions/purposes: In patients undergoing cephalomedullary nailing for intertrochanteric hip fractures compared with the conventional technique, we asked: (1) Is the CAS technique associated with a decrease in tip-apex distance (TAD), with less variation and fewer outliers at the standard (25 mm) and lower (15 mm) TAD thresholds? (2) Is the CAS technique associated with a decrease in radiation and operative time? (3) If the CAS technique results in a decrease in TAD, is this decrease associated with a decrease in lag screw cut-out postoperatively? Methods: Between Oct 2007 and June 2015, 964 stable and unstable intertrochanteric hip fractures were treated surgically at our institution. Of these, 23% (225 of 964) were isolated, acute intertrochanteric hip fractures managed by a single surgeon. Ninety-five percent (213 of 225) of hip fractures were surgically treated with the same cephalomedullary nail based on the general indications of displaced fractures, poor bone quality, and medical complexity. This same surgeon used a sliding hip screw device in the remaining 5% (12 of 225) of hip fractures for the treatment of nondisplaced and minimally displaced fractures in younger patients with fewer medical comorbidities and good bone quality. Between October 2007 and August 2011, all procedures were performed with conventional lag screw placement (n = 110), and between September 2011 and June 2015, all procedures were performed with CAS (n = 103) for lag screw placement. Postoperative radiographs were missing or unavailable for TAD analysis for 3% (3 of 110) of the conventional technique group and 6% (6 of 103) of the CAS group, so these patients were excluded. The remaining 97% (107 of 110) of conventional procedures and 94% (97 of 103) of CAS procedures were included in the TAD, radiation time, and operative time analysis. For the evaluation of cut-out postoperatively, 24% (26 of 107) of conventional patients and 25% (24 of 97) of CAS patients were excluded due to mortality and/or loss to follow-up at a minimum of 1 year. The remaining 76% (81 of 107) of conventional patients and 75% (73 of 97) of CAS patients were included in the cut-out analysis. A retrospective chart review was performed to obtain the data and then compare TAD, radiation time, operative time, and cut-out between the two cohorts. Results: The median TAD for the CAS procedures was lower than the median TAD for the conventional procedures (median 13 mm versus median 16 mm, median difference 3 mm; p < 0.001 power for difference = 85%). In addition, the TAD variation was also less for the CAS procedures compared with the conventional procedures (interquartile range [IQR] 4 mm versus IQR 9 mm, IQR difference 5 mm; p < 0.001, power for difference = 98%). A TAD greater than 25 mm was found in 1% (1 of 97) of the CAS procedures and 12% (13 of 107) of the conventional procedures. A difference between the proportions could be detected indicating a lesser chance of a TAD > 25 mm in the CAS cohort (odds ratio = 0.075 [95% confidence interval 0.010 to 0.587]; p = 0.002, power for difference 90%). A TAD > 15 mm was found in 23% (22 of 97) of the CAS procedures and 56% (60 of 107) of the conventional procedures, also indicating a lesser chance of a TAD > 15 mm in the CAS cohort (OR = 0.230 [95% CI 0.125 to 0.423], relative risk for TAD > 15 mm = 0.404 [95% CI 0.270 to 0.606]; p < 0.001, power for difference > 99%). The median radiation time for the CAS cohort was lower than the median radiation time for the conventional cohort (median 1.4 minutes versus median 1.7 minutes, median difference 0.3 minutes; p = 0.002, power for difference = 81%). No difference in median total operating time was found for the CAS procedures compared with the conventional procedures (median 36 minutes versus median 38 minutes, median difference 2 minutes; p = 0.227, power for difference = 18%, power for equivalency = 93%). There was no difference in cut-out noted with the use of the CAS compared with the conventional technique with the numbers available. Based on the current results, the upper 95% probability for a cutout complication ranges from 0% to 5% in the CAS cohort versus 0% to 9% in the conventional cohort (difference of upper 95% CI = 4%). Conclusion: CAS use is associated with a decrease in median TAD with less variation and fewer outliers during cephalomedullary nailing. Compared with the conventional technique, fewer outliers were noted with the CAS at the standard TAD threshold of 25 mm and a lower TAD threshold of 15 mm. Additional research is needed to determine the association of TAD variation and outliers on cut-out and to determine if there is any clinical value to the decrease in TAD variation and outliers noted here. The patient and surgical team are exposed to less radiation with the CAS compared with the conventional technique, but this difference is small and it is unclear if this benefit justifies CAS use. Incorporating CAS into the cephalomedullary nailing procedure is not associated with a change in operative time, so there are no costs or risks associated with increased operative time. More procedures would be needed to provide adequate power to better analyze the risk of lag screw cut-out, allowing a more complete understanding of the value of this technology compared with its cost. Level of evidence: Level III, therapeutic study.
Article
Objective: To compare the radiation exposure of the primary surgeon while using the conventional c-arm and mini c-arm fluoroscopy at the shoulder Material and method: Twelve shoulders of six fresh cadavers were used to simulate this experimental study. Radiation exposure of the primary surgeon was measured at the head and neck region. The average radiation dose was measured using both the conventional c-arm and mini c-arm, then the findings were compared. Results: Mean radiation energy of the conventional c-arm was significantly lower than the mini c-arm at 59.39 ± 1.43 kV and 70.58 ± 4.01 kV respectively (p < 0.001). Dose rates to which the primary surgeon was exposed from the conventional c-arm and the mini c-arm were 81.46 ± 30.37 μSv/hour and 87.54 ± 43.69 μSv/hour, respectively. However, the difference was not statistically significant (p = 0.875). Conclusion: There is no difference in the level of radiation safety for the primary surgeon when using the conventional c-arm vs. the mini c-arm for a fluoroscopic-assisted shoulder procedure. Therefore, selection of the methodology should be based on equipment availability and clinical considerations.
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Use of computed tomography (CT) for diagnostic evaluation has increased dramatically over the past 2 decades. Even though CT is associated with substantially higher radiation exposure than conventional radiography, typical doses are not known. We sought to estimate the radiation dose associated with common CT studies in clinical practice and quantify the potential cancer risk associated with these examinations. We conducted a retrospective cross-sectional study describing radiation dose associated with the 11 most common types of diagnostic CT studies performed on 1119 consecutive adult patients at 4 San Francisco Bay Area institutions in California between January 1 and May 30, 2008. We estimated lifetime attributable risks of cancer by study type from these measured doses. Radiation doses varied significantly between the different types of CT studies. The overall median effective doses ranged from 2 millisieverts (mSv) for a routine head CT scan to 31 mSv for a multiphase abdomen and pelvis CT scan. Within each type of CT study, effective dose varied significantly within and across institutions, with a mean 13-fold variation between the highest and lowest dose for each study type. The estimated number of CT scans that will lead to the development of a cancer varied widely depending on the specific type of CT examination and the patient's age and sex. An estimated 1 in 270 women who underwent CT coronary angiography at age 40 years will develop cancer from that CT scan (1 in 600 men), compared with an estimated 1 in 8100 women who had a routine head CT scan at the same age (1 in 11 080 men). For 20-year-old patients, the risks were approximately doubled, and for 60-year-old patients, they were approximately 50% lower. Radiation doses from commonly performed diagnostic CT examinations are higher and more variable than generally quoted, highlighting the need for greater standardization across institutions.
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Intramedullary nailing under fluoroscopic guidance is a common operation. We studied the intraoperative radiation dose received by both the patient and the personnel. 25 intramedullary nailing procedures of the tibia were studied. All patients suffered from tibial fractures and were treated using the Grosse-Kempf intramedullary nail, with free-hand technique for fixation of the distal screws, under fluoroscopic guidance. The exposure, at selected positions, was recorded using an ion chamber, while the dose area product (DAP) was measured with a DAP meter, attached to the tube head. Thermoluminescent dosimeters (TLDs) were used to derive the occupational dose to the personnel, and also to monitor the surface dose on the gonads of some of the patients. The mean operation time was 101 (48-240) min, with a mean fluoroscopic time of 72 seconds and a mean DAP value of 75 cGy x cm(2). The surface dose to the gonads of the patients was less than 8.8 mGy during any procedure, and thus cannot be considered to be a contraindication for the use of this technique. Occupational dose differed substantially between members of the operating personnel, the maximum dose recorded being to the operator of the fluoroscopic equipment (0.11 mSv). Our findings underscore the care required by the primary operator not to exceed the dose constraint of 10 mSv per year. The rest of the operating personnel, although they do not receive very high doses, should focus on the dose optimization of the technique.
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The growing use of imaging procedures in the United States has raised concerns about exposure to low-dose ionizing radiation in the general population. We identified 952,420 nonelderly adults (between 18 and 64 years of age) in five health care markets across the United States between January 1, 2005, and December 31, 2007. Utilization data were used to estimate cumulative effective doses of radiation from imaging procedures and to calculate population-based rates of exposure, with annual effective doses defined as low (< or = 3 mSv), moderate (> 3 to 20 mSv), high (> 20 to 50 mSv), or very high (> 50 mSv). During the study period, 655,613 enrollees (68.8%) underwent at least one imaging procedure associated with radiation exposure. The mean (+/-SD) cumulative effective dose from imaging procedures was 2.4+/-6.0 mSv per enrollee per year; however, a wide distribution was noted, with a median effective dose of 0.1 mSv per enrollee per year (interquartile range, 0.0 to 1.7). Overall, moderate effective doses of radiation were incurred in 193.8 enrollees per 1000 per year, whereas high and very high doses were incurred in 18.6 and 1.9 enrollees per 1000 per year, respectively. In general, cumulative effective doses of radiation from imaging procedures increased with advancing age and were higher in women than in men. Computed tomographic and nuclear imaging accounted for 75.4% of the cumulative effective dose, with 81.8% of the total administered in outpatient settings. Imaging procedures are an important source of exposure to ionizing radiation in the United States and can result in high cumulative effective doses of radiation.
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The objective of this study was to directly measure the radiation exposure to the orthopaedic surgeon and to measure dose points to the surgeon's fingers, thyroid gland, and forehead during intraoperative fluoroscopy in periacetabular osteotomy (PAO). In a series of 23 consecutive periacetabular osteotomy procedures, exposure monitoring was carried out using thermo luminescent dosimeters. The effective dose received by the operating surgeon was 0.008 mSv per operation which adds up to a yearly dose of 0.64 mSv from PAO. The median point equivalent dose (mSv) exposure under PAO was 0.009 for the forehead and thyroid gland, 0.045 for the right index finger, and 0.039 for the left index finger. The effective estimated yearly dose received by the operating surgeon was very low. Wearing a lead collar reduces radiation exposure to the thyroid gland while the lead gloves did not protect the surgeon's fingers.
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In this study, radiation exposure to the surgeon and supporting staff from a mini C-arm unit during fluoroscopically guided orthopaedic surgeries was studied. A Diadose dosemeter and Gamma-Scout meter were used for air-kerma measurements for primary and scattered radiations. The entrance dose of hands, eyes and thyroid of the surgeon was measured during direct observation. Scattered air-kerma rate was measured to quantify the received entrance dose of the supporting staff. During direct observation, the skin-entrance exposure rates of the surgeon's hand, eye and thyroid gland were 8036, 0.85 and 0.9 microGy min(-1), respectively. The scattered exposure rate was precipitously dropped beyond the path of the primary radiation beam, and reached 0.51 microGy min(-1) at a distance of 40 cm from the beam's central axis. This study showed that the surgeon's hand was the most dose-limiting organ for fluoroscopically guided orthopaedic surgery procedures when it was exposed to primary radiation. The exposure of supporting staff at a working distance of >20 cm from the beam was minimal during fluoroscopy by mini C-arm unit.
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Modern orthopaedic trauma practice involves increased exposure of the surgeon to ionising radiation. However, there have been no studies to investigate whether the doses received are within limits for non-classified workers. In this study, whole body, eye and extremity, namely hand, doses were measured in six orthopaedic surgeons during trauma cases requiring the use of X-rays in theatre. None of the subjects approached the recommended maximum dose levels for either the whole body, eyes or hands. This finding is reassuring. In orthopaedics, the limiting dose is that to the hands. This differs from previously studied groups, such as radiologists and cardiologists, in whom the limiting factor is the dose to the lens of the eye. Although current precautions appear to be adequate, safe practice in the future will depend on continuing vigilance and repetition of studies similar to this one as techniques and workloads change.
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Five cancer cases over 7 years were reported in a small orthopaedic hospital where radiation protection practice was poor. To investigate whether workers subject to routine radiation dosimetric assessment in that hospital had an increased cancer risk. One hundred and fifty-eight workers subject to routine dose assessment and 158 age-sex-matched unexposed workers were questioned about cancer occurrence. All tumours were analysed as a single diagnostic category. Cumulative 1976-2000 cancer incidence was 29 (9/31), 6 (8/125) and 4% (7/158) in orthopaedics, exposed other than orthopaedics, and unexposed workers, respectively. At logistic regression analysis, working as orthopaedic surgeon significantly (P<0.002) increased the risk of tumours. These findings caution against surgeons' underestimation of the potential radiation risk and insufficient promotion of safe work practices by their health care institutions.
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We monitored image intensifier use by orthopaedic trainees to assess their exposure to ionising radiation and to investigate the influence of sub-specialty training. Five different orthopaedic registrars recorded their monthly image intensifier screening times and exposure doses for all cases (trauma and elective), for a combined total of 12 non-consecutive months. Radiation exposure was monitored using shoulder and waist film badges worn both by surgeons and radiographers screening their cases. Registrars in spinal sub-specialties were exposed to significantly higher doses per case and cumulative doses per month than non-spinal trainees (P < 0.05), but significantly lower screening times per case (P < 0.05). There were no significant differences in cumulative screening times per month (P > 0.05). Regression analysis for all surgeons showed a significant relationship between shoulder film badge reading and cumulative dose exposed per month (P < 0.05), but not for cumulative screening time. Shoulder film badge recordings were significantly higher for spinal compared with non-spinal registrars (P < 0.05), although all badges were below the level for radiation reporting. Only one radiographer badge recorded a dose above threshold. Whilst the long-term effects of sub-reporting doses of radiation are not fully understood, we consider that this study demonstrates that trainees should not be complacent in accepting inadequate radiation protection. The higher doses encountered with spinal imaging means that sub-specialty trainees should be alerted to the risk of their increased exposure. The principle of minimising radiation exposure must be maintained by all trainees at all times.
We measured the scattered radiation received by theatre staff, using high-sensitivity electronic personal dosimeters, during fixation of extracapsular fractures of the neck of the femur by dynamic hip screw. The dose received was correlated with that received by the patient, and the distance from the source of radiation. A scintillation detector and a water-filled model were used to define a map of the dose rate of scattered radiation in a standard operating theatre during surgery. Beyond two metres from the source of radiation, the scattered dose received was consistently low, while within the operating distance that received by staff was significant for both lateral and posteroanterior (PA) projections. The routine use of lead aprons outside the 2 m zone may be unnecessary. Within that zone it is recommended that lead aprons be worn and that thyroid shields are available for the surgeon and nursing assistants.
Article
Damage to the microcirculation caused by high-dose ionizing radiation is well known but data concerning low-dose exposure are scant and contrasting. We employed capillary microscopy to study dermal microcirculation damage resulting from occupational exposure to ionizing radiation doses lower than 5 rem/year (maximum permissible dose in Italy). We studied 145 physicians (60.7% radiologists, 33.8% orthopedic specialists, 5.5% cardiologists) occupationally exposed to ionizing radiation and a control group of 106 subjects in comparable but different occupations not exposed to ionizing radiation or to other skin hazards. All subjects were administered a clinical protocol and underwent capillary microscopy of the fingernail-fold. Capillary microscopy alterations were classified as absent, mild, moderate, marked and severe. Our data confirm that occupational exposure to low-dose ionizing radiation can lead to morphological and functional alterations of the dermal microcirculation, which can be identified early by capillary microscopy. © 1996 Wiley-Liss, Inc.
Article
Computer-assisted orthopaedic surgery (CAOS) is performed by digitizing the patient's anatomy, combining the images in a computerized system, and integrating the surgical instruments into the digitized image background. This allows the surgeon to navigate the surgical instruments and the bone in an improved, virtual visual environment. CAOS in traumatology is performed with images obtained by fluoroscopy, CT, or three-dimensional fluoroscopy. CAOS is used in basic trauma procedures for preoperative planning, fracture reduction, intramedullary nailing, percutaneous screw or plate fixation, and hardware or shrapnel removal. Potential benefits of CAOS include minimal invasiveness, increased accuracy, and decreased radiation exposure. Limitations include a significant learning curve, increased surgical time, requirements for special setup and equipment handling in the operating room, specialized technical support, and cost. Current evidence shows no advantage with CAOS in trauma cases compared with conventional methods. Prospective randomized trials and clinical outcomes are lacking.
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The risk of cancer in female orthopaedic surgeons is unknown. The present study was motivated by anecdotal reports of cancer occurring in female orthopaedic surgeons. In one residency program, three of twelve women were diagnosed with cancer during residency or shortly after graduation. We conducted a cross-sectional survey to determine whether the prevalence of cancer overall, and breast cancer specifically, was higher in practicing female orthopaedic surgeons compared with the general U.S. population. ### Survey Methods In 2007, inquiries into professional orthopaedic surgeon organizations yielded no comprehensive public listing of practicing female surgeons. Therefore, the 2006 membership directory of the American Academy of Orthopaedic Surgeons (AAOS) was used to obtain the names and mailing addresses of all female orthopaedic surgeons who were AAOS fellows. In ambiguous cases, we determined the sex of the surgeon by searching the Internet or making a telephone call to the physician’s office number. We identified 657 potentially eligible AAOS fellows and mailed each one a cover letter explaining the purpose of the study, a survey, and a stamped, return-addressed envelope in July 2007. A follow-up letter and identical survey were mailed in October 2007. Duplicate surveys were deleted. These duplicates were identified because the survey respondent wrote on the survey that it was a duplicate or informed the investigator by e-mail that a duplicate was returned by mail. Other duplicates were identified because the information on the first and second survey was identical. Survey responses were collected between July 2007 and August 2008. Responses from forty-two individuals indicated that they were male (thirteen), not orthopaedic surgeons (fourteen), or retired (fifteen), and therefore ineligible for the study. Of the remaining 615 surveyed individuals, 499 (81.1%) responded and were eligible for the study. The survey included questions about the participant’s age, years in practice, type of practice, and current in-office …
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Over the years, there has been a tremendous increase in the use of fluoroscopy in orthopaedics. The risk of contracting cancer is significantly higher for an orthopedic surgeon. Hip and spine surgeries account for 99% of the total radiation dose. The amount of radiation to patients and operating surgeon depends on the position of the patient and the type of protection used during the surgery. A retrospective study to assess the influence of the radiation exposure of the operating surgeon during fluoroscopically assisted fixation of fractures of neck of femur (dynamic hip screw) and ankle (Weber B) was performed at a district general hospital in the United Kingdom. Sixty patients with undisplaced intertrochanteric fracture were included in the hip group, and 60 patients with isolated fracture of lateral malleolus without communition were included in the ankle group. The hip and ankle groups were further divided into subgroups of 20 patients each depending on the operative experience of the operating surgeon. All patients had fluoroscopically assisted fixation of fracture by the same approach and technique. The radiation dose and screening time of each group were recorded and analyzed. The radiation dose and screening time during fluoroscopically assisted fixation of fracture neck of femur were significantly high with surgeons and trainees with less than 3 years of surgical experience in comparison with surgeons with more than 10 years of experience. The radiation dose and screening time during fluoroscopically assisted fixation of Weber B fracture of ankle were relatively independent of operating surgeon's surgical experience. The experience of operating surgeon is one of the important factors affecting screening time and radiation dose during fluoroscopically assisted fixation of fracture neck of femur. The use of snapshot pulsed fluoroscopy and involvement of senior surgeons could significantly reduce the radiation dose and screening time.
Article
Computerized tomographic scans are routinely obtained to evaluate a number of musculoskeletal conditions. However, since computerized tomographic scans expose patients to the greatest amounts of radiation of all imaging modalities, the physician must be cognizant of the effective doses of radiation that are administered. This investigation was performed to quantify the effective doses of computerized tomographic scans that are performed for various musculoskeletal applications. The digital imaging archive of a single institution was retrospectively reviewed to identify helical computerized tomographic scans that were completed to visualize the extremities or spine. Imaging parameters were recorded for each examination, and dosimetry calculator software was used to calculate the effective dose values according to a modified protocol derived from publication SR250 of the National Radiological Protection Board of the United Kingdom. Computerized tomographic scans of the chest, abdomen, and pelvis were also collected, and the effective doses were compared with those reported by prior groups in order to validate the results of the current study. The mean effective doses for computerized tomographic scans of the chest, abdomen, and pelvis (5.27, 4.95, and 4.85 mSv, respectively) were consistent with those of previous investigations. The highest mean effective doses were recorded for studies evaluating the spine (4.36, 17.99, and 19.15 mSv for the cervical, thoracic, and lumbar spines, respectively). In the upper extremity, the effective dose of a computerized tomographic scan of the shoulder (2.06 mSv) was higher than those of the elbow (0.14 mSv) and wrist (0.03 mSv). Similarly, the effective dose of a hip scan (3.09 mSv) was significantly higher than those observed with knee (0.16 mSv) and ankle (0.07 mSv) scans. Computerized tomographic scans of the axial and appendicular skeleton are associated with substantially elevated radiation exposures, but the effective dose declines substantially for anatomic structures that are further away from the torso.
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The first computer-assisted orthopaedic trauma procedures were limited to navigated drill-guide applications, in which the computer was used to predict the trajectory of the drill guide relative to stored radiographic images. By 2003, software for fracture reduction was commercially available. The ability to perform a minimally invasive fracture reduction with the aid of stored images, combined with navigated insertion of internal fixation, has long been considered the highest achievement in image-guided fracture surgery. It is now possible to apply computer-assisted techniques to all fractures that have traditionally been treated with the aid of intraoperative fluoroscopic control. Less-invasive fixation of long-bone fractures is often complicated by malrotation or shortening of the injured extremity, sometimes requiring reoperation. Recent developments in computer-assisted surgery now allow the orthopaedic surgeon to precisely match the anatomy of the injured extremity to that of the uninjured limb with respect to length and rotational alignment. This is particularly important in comminuted fractures, for which there are no anatomic clues to guide accurate reduction, and in the correction of malreduced fractures. Although computer-assisted technology is now readily available, it has not yet found widespread acceptance in the orthopaedic trauma community. New software workflows (i.e., the step-by-step progression through various screens in the software program during a computer-guided procedure) specific to individual procedures and implants may hasten adoption of these techniques.
Article
Use of c-arm fluoroscopy is common in the operating room, outpatient clinic, and emergency department. Consequently, there is a concern regarding radiation exposure. Mini-c-arm fluoroscopes have gained popularity; however, few studies have quantified exposure during mini-c-arm imaging of a body part larger than a hand or wrist. The purpose of this study was to measure radiation exposure sustained by the patient and surgeon during the use of large and mini-c-arm fluoroscopy of an ankle specimen. Standard and mini-c-arm fluoroscopes were used to image a cadaver ankle specimen, which was suspended on an adjustable platform. Dosimeters were mounted at specific positions and angulations to detect direct and scatter radiation. Testing was conducted under various scenarios that altered the proximity of the specimen and the radiation source. We attempted to capture a range of exposure data under conditions ranging from a best to a worst-case scenario, as one may encounter in a procedural setting. With all configurations tested, measurable exposure during use of the large-c-arm fluoroscope was considerably higher than that during use of the mini-c-arm fluoroscope. Patient and surgeon exposure was notably amplified when the specimen was positioned closer to the x-ray source. The exposure values that we measured during ankle fluoroscopy were consistently higher than the exposure values that have been recorded previously during hand or wrist imaging. Exposure of the patient and surgeon to radiation depends on the tissue density and the shape of the imaged extremity. Elevated exposure levels can be expected when larger body parts are imaged or when the extremity is positioned closer to the x-ray source. When it is possible to satisfactorily image an extremity with use of the mini c-arm, it should be chosen over its larger counterpart.
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Digital radiography devices, rapidly replacing analog screen-film detectors, are now common in diagnostic radiological imaging, where implementation has been accelerated by the commodity status of electronic imaging and display systems. The shift from narrow latitude, fixed-speed screen-film detectors to wide latitude, variable-speed digital detectors has created a flexible imaging system that can easily result in overexposures to the patient without the knowledge of the operator, thus potentially increasing the radiation burden of the patient population from radiographic examinations. In addition, image processing can be inappropriately applied causing inconsistent or artifactual appearance of anatomy, which can lead to misdiagnosis. On the other hand, many advantages can be obtained from the variable-speed digital detector, such as an ability to lower dose in many examinations, image post-processing for disease-specific conditions, display flexibility to change the appearance of the image and aid the physician in making a differential diagnosis, and easy access to digital images. An understanding of digital radiography is necessary to minimize the possibility of overexposures and inconsistent results, and to achieve the principle of as low as reasonably achievable (ALARA) for the safe and effective care of all patients. Thus many issues must be considered for optimal implementation of digital radiography, as reviewed in this article.
Article
In many standard situations in radiation protection the effective dose is underestimated if it is based on the depth personal dose equivalent Hp(10) measured with a single dosimeter in the anterior thoracic region (chest) underneath the protective apron (Hp,c,u). The estimate can be significantly improved by inclusion of a second dosimeter worn on the front area of the neck over of the protective garment (Hp,n,o) representing organs and areas that are usually not completely covered by the protective garment. The recent recommendations of the International Commission on Radiological Protection (ICRP) emphasize the contribution of the head and neck region to the effective dose. This accentuates the need for a valid representation of this body region in the effective dose algorithm. In this paper we derived coefficients for the two-dosimeter situation using phantom measurements for selected radiological procedures with different geometries between patient and investigator. According to ICRP 60, the algorithm with {without} thyroid protection is E = 0.64{0.64} Hp,c,u + 0.016{0.073} Hp,n,o. According to ICRP 103, the algorithm becomes E = 0.60{0.60} Hp,c,u + 0.047{0.094} Hp,n,o. The ICRP 103 model reveals that the underestimation of the effective dose based on Hp(10) using a single dosimeter worn under the protective garment is even higher than previously assumed based on ICRP 60. Future personal dosimetry should be qualified by a two-dosimeter concept. The head and neck region which is not covered by a conventional protective garment needs to be protected by mounted shielding or other constructive measures.
Article
During interlocking intramedullary nailing of twenty-five femoral and five tibial fractures, the primary surgeon wore both a universal film badge on the collar of the lead apron and a thermoluminescent dosimeter ring on the dominant hand to quantify the radiation that he or she received. When distal interlocking was performed, the first ring was removed and a second ring was used so that a separate recording could be made for this portion of the procedure. At the conclusion of the study, all of the recorded doses of radiation were averaged. The average amount of radiation to the head and neck during the entire procedure was 7.0 millirems of deep exposure and 8.0 millirems of shallow exposure. The average dose of radiation to the dominant hand during insertion of the intramedullary nail and the proximal interlocking screw was 13.0 millirems, while the average amount during insertion of the distal interlocking nail was 12.0 millirems. Both of these averages are well within the government guidelines for allowable exposure to radiation during one-quarter (three months) of a year. Precautions that are to be observed during this procedure are recommended.
Article
Because of the increased use of fluoroscopic guidance techniques in certain orthopaedic surgical procedures, surgeons and other operating-room personnel who are involved in these procedures are voicing growing concern over possible associated radiation health hazards. Using thin-layer lithium fluoride chips for thermoluminescence dosimetry, we directly measured the radiation exposure encountered by the primary surgeon during seven operative procedures that were done utilizing fluoroscopic guidance techniques. Dosimetry studies were also carried out using a tissue-equivalent phantom model to determine the directions of maximum scatter radiation. These studies indicated that the standard protective apron that is commonly worn during the use of fluoroscopy provides adequate protection to most of the body; however, the surgeon is exposed to significant levels of scatter radiation to the head, neck, and hands, Dosimetry studies showed that positioning the fluoroscopic beam vertically to the fracture site of the supine patient, with the x-ray source posterior to the patient, provided the lowest levels of scatter radiation to the surgeon in the normal working position.
Article
Although ionizing radiation has been well known as a carcinogen for more than 70 years, only a small part of the total cancer mortality burden in the United States can be attributed to radiation effects—less than 3%. Little can be done about much of the exposure to radiation that exists—about half of the total results from natural background radiation. More than 40% derives from medical and dental practice—mostly as diagnostic X-rays. Something less than 5% comes from nuclear weapons fallout from atmospheric tests and well under 1% from the use of nuclear energy for generating electric power. Substantial reduction of the total radiation burden on the population can be achieved only by reduction of X-rays used in medicine and dentistry. This will, however, involve careful consideration of the balance between radiation benefits and risks, as well as requiring that such X-ray exposures be reduced to the minimum required to achieve the necessary medical purpose.
Article
A prospective study of sixty-five orthopaedic procedures performed with fluoroscopic assistance was undertaken to determine the risk to the primary orthopaedic surgeon with regard to radiation. Radiation was monitored with the use of a universal film badge placed outside the collar of a lead apron, and a gas-sterilized thermoluminescent dosimeter ring worn on each hand. The rings were changed with every operation, but the same film badge was transferred from surgeon to surgeon. The hand dominance of the surgeon, the duration of the operative procedure, the type of operation, and the total time that fluoroscopy had been used were noted. The study was conducted during twenty-one intramedullary nailing procedures (thirteen involving distal locking), forty open reductions with internal fixation (plates and screws), and four external-fixation procedures. All of the badges and rings were submitted for a report regarding radiation exposure. No relationship was found between a ring with a positive reading for exposure to radiation and the duration of the operation. Similarly, there was no correlation between a positive reading and the surgeon's hand dominance. The mean duration of the fluoroscopy was 2.3 minutes for the group for which the rings did not show a positive reading and 4.7 minutes for the group for which the rings did show a positive reading. This was a significant difference (p < 0.0001). There was no positive reading for exposure to radiation from any ring that had been worn during a procedure in which the fluoroscope had been used for less than 1.7 minutes.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
The hazards of exposure to ionising radiation are well documented. Fears have been raised that occupational exposure to ionising radiation by orthopaedic surgeons may have detrimental effects on the future health of their unborn offspring. The current members of the British Orthopaedic Trainees' Association and orthopaedic consultants appointed during the last 5 years in the United Kingdom were contacted using a postal questionnaire. Obstetricians and gynaecologists of a similar age group were also contacted to act as the control group. The collected data were compared with the latest national data as published by the Office of Population Censuses and Surveys for England and Wales (OPCS, 1991). In all, 504 questionnaires were posted to orthopaedic surgeons and 1597 to obstetricians and gynaecologists. Reply rates were 334 (66%) and 986 (62%), respectively. Our data reveal a higher rate of congenital abnormalities as compared with the normal population in both groups (P < 0.001). However, there were no statistically significant differences in the rate of congenital abnormalities between the offspring of orthopaedic surgeons and obstetricians and gynaecologists (P = 0.78). These findings suggest that the increased rate of congenital abnormalities observed in both groups is more likely to be associated with factors other than exposure to X-rays. In this study, male surgeons had a higher incidence of female children compared with the normal population (P = 0.01). The incidence of childhood malignancies does not appear to be raised in either group. These findings suggest that the current levels of occupational exposure to X-rays by orthopaedic surgeons is unlikely to be associated with an increased risk of congenital abnormalities or childhood malignancies in their children.
Article
To correlate the amount of radiation exposure to members of the orthopaedic surgical team based on their relative positions during a simulated fluoroscopically assisted orthopaedic procedure. Experimental study using commercially available fluoroscopic units and dosimetry badges designed to measure "eye" (ocular lens), "shallow" (hands/skin), and "deep" (whole-body) radiation exposure. Standard hospital operating room at a level one trauma center. Dosimetry badge clusters at specified distances from a fluoroscopic x-ray beam. Represented positions were direct beam contact, surgeon (12 in/30.5 cm), first assistant (24 in/70 cm), scrub nurse (36 in/91.4 cm), and anesthesiologist (60 in/152.4 cm). Dosimetry badges were systematically exposed by a protocol intended to maximize radiation scatter. A maximum time for continuous fluoroscope use was set at ten minutes. Radiation exposure readings from dosimetry badges processed by a commercially available dosimetry service. Maximum readings are reported. Direct beam contact resulted in approximately 4000 mrem/minute (40 mSv/min) of radiation exposure. Deep exposure for the surgeon and first assistant was 20 mrem/min (0.2 mSv/min) and 6 mrem/min (0.06 mSv/min), respectively. Superficial exposure was 29 mrem/min (0.29 mSv/min) for the surgeon and 10 mrem/min (0.1 mSv/min) for the first assistant. Eye exposure was 10 mrem/min (0.1 mSv/min) for the surgeon and 6 mrem/min (0.06 mSv/min) for the first assistant. At the scrub nurse position, no deep or eye exposure was detected. One positive badge for shallow exposure was noted at the scrub nurse position, reflecting a 2 mrem/min (0.02 mSv/min) exposure rate. After ten minutes of continuous exposure, badges assigned to the anesthesiologist position never registered any positive readings. These results indicate that unprotected individuals working twenty-four inches (70 cm) or less from a fluoroscopic beam receive significant amounts of radiation, whereas those working thirty-six inches (91.4 cm) or greater from the beam receive an extremely low amount of radiation.
Article
This study analyses the relationship between the level of experience of both surgeon and radiographer and the radiation dose administered in theatre, during fixation of extracapsular proximal femoral fractures. From the 63 dynamic hip screw procedures performed, 10 were done by Senior House Officers (SHOs), 10 by Consultants and 43 by Registrars, whereas Basic Radiographers were involved in all cases. Fractures were classified as two part, three part or four part. A four part fracture required higher levels of radiation dose and screening time as compared with a two part fracture. All two part fractures were screened by radiographers of similar experience; however, the radiation dose and screening time were different amongst different levels of surgeon. The highest radiation dose and screening times were recorded when an SHO was the operating surgeon and the lowest when a registrar was the surgeon. The two part and three part fractures performed by registrars were subdivided according to the experience of the radiographer. In both cases a statistically significant difference was found between the dose of radiation administered in theatre and the years of experience of the radiographers (p < 0.05).
Article
During 41 procedures of intramedullary nailing of femoral and tibial fractures, the primary surgeon and the first assistant wore ring dosimeters on their dominant index fingers. While the average fluoroscopy time per procedure was 4.6 min, the average dose of radiation to the dominant hand of the primary surgeon was 1.27 mSv and 1.19 mSv to the first assistant. The dose limit for the extremities is 500 mSv per year, as recommended by the International Commission on Radiological Protection. Extrapolation of the mean dose of the primary surgeon and first assistant per procedure of 1.23 mSv leads to the result that the recommended dose limit of 500 mSv would only be exceeded if more than 407 intramedullary nailing procedures are carried out per year. The duration of fluoroscopy time correlated with the radiation dose to the hands of the surgeons, though it was determined by phantom measurements that the majority of radiation exposure occurred during brief exposures of the hands in the direct X-ray beam on the X-ray tube near side of the patient. In order to assess the surface doses of the thyroid gland to the primary surgeon with and without a lead shield, we performed in vitro measurements during operative procedures of the lower leg simulating different intraoperative situations under fluoroscopic control. The average registered ionizing dosage without a thyroid shield was approximately 70 times higher than with thyroid lead protection. In a previous study we found average fluoroscopy times during intramedullary nailing of the tibia and femur of 4.6 min per procedure. Extrapolation of this value leads to the result, that even when 1000 intramedullary nailings were carried out without wearing lead protection, only 13 per cent of the dose limit recommended by the International Commission on Radiological Protection for the thyroid of 300 mSv per year would be reached; by wearing the lead protection only 0.2 per cent of the recommended dose would be reached.
Article
Radiation is used during orthopaedic surgery in more than 15 million studies performed yearly. The biologic effects of radiation have been shown to inhibit mitosis by producing irrepairable deoxyribonucleic acid double strand breaks or create structural changes by damaging the nucleus, thereby producing potential genetic transmissions. Although human cells are thought to be resistant to malignant change and no studies have shown toxic effects resulting from long-term exposure to low-dose radiation, risks still are assumed. To decrease all risks, radiographic units should undergo periodic calibration, surgeons should wear protective devices, increase their working distance from the x-ray beam, and limit their duration of radiation exposure by making certain that they follow the guidelines set forth by the National Council for Radiation Protection and Measurement.
Article
Intraoperative fluoroscopy is commonly used in surgical procedures on upper extremities. We compared radiation exposure from two possible positions of the mobile digital fluoroscopy unit (c-arm): (1) the standard technique, with the x-ray tube down (near the floor) and the image intensifier at the top of the c-arm, and (2) the inverted position, in which the image intensifier is used as a table and the x-ray tube is up. A commercially available c-arm was used to irradiate a phantom hand in one of three configurations. In the first, the phantom hand was placed on an armboard equidistant from the x-ray tube and the image intensifier with the beam directed upward. In the second, the c-arm was inverted with the beam directed downward and the image intensifier used as a table. The third configuration was identical to the second except that a magnified image was used. Radiation exposure was measured at four locations corresponding to the approximate position of the surgeon's head, chest, and groin and the patient's hand. The amount of radiation exposure to both the surgeon and the patient was significantly less when the c-arm was used in the inverted position (p < 0.0001). The dose rate to the patient's hand was reduced by 59%. The radiation exposure to the surgeon's head, body, and groin with the inverted-c-arm technique was 67%, 45%, and 15% of the measured doses with the x-ray-tube-down configuration. When we used the magnification mode of the image intensifier, with its correspondingly smaller field size, the doses were further reduced to 46%, 32%, and 11% of the standard-configuration values. Use of the inverted-c-arm technique with the image intensifier as an operating table can significantly reduce radiation exposure to the surgeon and the patient during surgical procedures on upper extremities.
Article
We measured the scattered radiation received by theatre staff, using high-sensitivity electronic personal dosimeters, during fixation of extracapsular fractures of the neck of the femur by dynamic hip screw. The dose received was correlated with that received by the patient, and the distance from the source of radiation. A scintillation detector and a water-filled model were used to define a map of the dose rate of scattered radiation in a standard operating theatre during surgery. Beyond two metres from the source of radiation, the scattered dose received was consistently low, while within the operating distance that received by staff was significant for both lateral and posteroanterior (PA) projections. The routine use of lead aprons outside the 2 m zone may be unnecessary. Within that zone it is recommended that lead aprons be worn and that thyroid shields are available for the surgeon and nursing assistants.
Article
Intramedullary nailing is probably the best method of treating long bone fractures in the lower limb. The operation is guided by fluoroscopy, for guide-wire insertion, fracture reduction and distal locking. No study so far has measured the scatter radiation to the patient's gonads during intramedullary, particularly femoral, nailing. The purpose here was to estimate the radiation hazard to the patients' gonads and surgeons' hands during intramedullary nailing for lower limb fractures. From April 1994 to June 1998, 184 consecutive patients had 224 nailings for lower limb fractures. Twenty-eight patients had Marchetti-Vincenzi nails and the rest had Russell-Taylor nails. There were 45 males and 40 females who had femoral nailing and 71 males and 28 females who had tibial nailing. The mean (range) age for femoral nailing was 56 (17-95.5) years and the mean age for tibia nailing was 44 (16.5-87.5) years. The average time of radiation when done by consultants was half that of middle-grade surgeons. The mean tibial nailing radiation time for the consultant was 0.56 min and for the middle-grade 1.28 min. The mean femoral nailing radiation time for the consultant was 0.52 min and for the middle-grade 1.61 min (P<0.05). The mean tibial and femoral nailing time were less for Marchetti nailing (P<0.05). Regular protection of the gonads of these patients is mandatory. This study shows that the radiation exposure for Marchetti-Vincenzi nailing is significantly less than for Russell-Taylor nailing. The overall radiation to patient gonads and surgeon hands was within acceptable limits.
Article
A distal locking device for the solid intramedullary tibial nails has been tried on bone models. This device allows simple and accurate insertion of distal locking screws with minimum radiation exposure to the patient and the surgeons. It also reduces the operation time. The aim of this experiment was to test the accuracy of the new aiming device and to measure the radiation exposure time during the procedure.
Article
Orthopaedic surgeons use intraoperative portable fluoroscopy and roentgenography. The present study was an attempt to find out if there is a difference between the occupational radiation exposure to the orthopaedic surgeon and assistant surgeon in the operating room while using intraoperative fluoroscopy or radiographic control and to measure it. During a 3-month period, 107 consecutive operations were monitored for radiation exposure. At monthly intervals, the radiation doses were measured in millirem and recorded. The distance of the orthopaedic surgeon and the assistant surgeon from the X-ray source were noted in every fluoroscopic check. The orthopaedic surgeon was always at a safe distance (more than 90 cm), but the assistant surgeon always stood nearby (10 cm) the X-ray source for positioning of the patient. The radiation exposure according to the badge on the shoulder was consecutively 3, 4, 3 mrem for the orthopaedic surgeon and 20, 19, 22 mrem for the assistant surgeon. The radiation exposure according to the badges on the anaesthetic machine, in the room and under the apron of the orthopaedic surgeon were all zero, whereas the readings of the badge under the apron of the assistant surgeon were 7, 6, 5 mrem consecutively. Our findings show that although the radiation exposure during orthopaedic operations is below the recommendations of the European Committee on Radiation Protection, there is a higher risk of exposure for the assistant surgeon. It has to be kept in mind that there could be morphological and functional damage in cells exposed to radiation. Therefore, we should continue to use appropriate shielding precautions in view of the unknown long-term risks.
Article
Personnel assisting in or performing fluoroscopically guided procedures may be exposed to high doses of radiation. Accurate occupational dosimetric data for the orthopaedic theater staff are of paramount importance for practicing radiation safety. Fluoroscopic screening was performed on an anthropomorphic phantom with use of four projections common in image-guided orthopaedic surgery. The simulated projections were categorized, according to the imaged anatomic area and the beam orientation, as (1) hip joint posterior-anterior, (2) hip joint lateral cross-table 45 degrees, (3) lumbar spine anterior-posterior, and (4) lumbar spine lateral 90 degrees. The scattered air kerma rate was measured on a grid surrounding the operating table. For each grid point, the effective dose, eye lens dose, and face skin dose values, normalized over the tube dose area product, were derived. For the effective dose calculations, three radiation protection conditions were considered: (1) with the exposed personnel using no protection measures, (2) with the exposed personnel wearing a 0.5-mm lead-equivalent protective apron, and (3) with the exposed personnel wearing both an apron and a thyroid collar. Maximum permissible workloads for typical hip, spine, and kyphoplasty procedures were derived on the basis of compliance with effective dose, eye lens dose, and skin dose limits. We found that the effective dose, eye lens dose, and face skin dose to an orthopaedic surgeon wearing a 0.5-mm lead-equivalent apron will not exceed the corresponding limits if the dose area product of the fluoroscopically guided procedure is <0.38 Gy m (2). When protective eye goggles are also worn, the maximum permissible dose area product increases to 0.70 Gy m (2), while the additional use of a thyroid shield allows a workload of 1.20 Gy m (2). The effective dose to the orthopaedic surgeon working tableside during a typical hip, spine, kyphoplasty procedure was 5.1, 21, and 250 micro Sv, respectively, when a 0.5-mm lead-equivalent apron alone was used. The additional use of a thyroid shield reduced the effective dose to 2.4, 8.4, and 96 micro Sv per typical hip, spine, and kyphoplasty procedure, respectively. The levels of occupational exposure vary considerably with the type of fluoroscopically assisted procedure, staff positioning, and the radiation protection measures used. The data presented in the current study will allow for accurate estimation of the occupational dose to orthopaedic theater personnel.
Article
Intraoperative fluoroscopy is the tool for intraoperative control of long bone fracture reduction and osteosynthesis. Limitations of this technology include: High radiation exposure to the patient and the surgical team, limited field of view, image distortion, limitation to 2-D representations, and cumbersome updating of verification images. Fluoroscopy based navigation systems partially address these limitations by allowing fluoroscopic images to be used for real-time surgical localization and instrument tracking. In a clinical study on computer guidance by virtual fluoroscopy for distal locking, the capability to provide online guidance with significantly reduced fluoroscopy times is demonstrated. Virtual fluoroscopy applied for guidewire placement in a laboratory setup demonstrated the potential of the method to reduce procedure times, and the potential to increase precision of implant placement with decreased fluoroscopy times. By using virtual reality enhancement, starting from multiple registered fluoroscopy images, a virtual 3-D cylinder model for each principal bone fragment is reconstructed. This spatial cylinder model is not only used to supply a 3-D image of the fracture, but also allows effective fragment projection extraction from the fluoroscopic images and further achieves radiation-free updates of in-situ surgical fluoroscopic images through a non-linear interpolation and warping algorithm. After primary image acquisition, the image intensifier was replaced by the virtual reality system. It was shown that all the steps of the procedure, including fracture reduction and LISS osteosynthesis can be performed completely in virtual reality.
Article
The use of mobile fluoroscopic devices during orthopaedic procedures is associated with substantial concern with regard to the radiation exposure to surgeons and support staff. The perceived increased risks associated with large c-arm devices have been well documented. However, no study to date has documented the relative radiation risk associated with the use of a mini-c-arm device. The purpose of the current study was to determine the amount of radiation received by the surgeon during the use of a mini-c-arm device and to compare this amount with documented measurements associated with the large c-arm device. With use of a radiation dosimeter, measurements were carried out with tissue-equivalent anthropomorphic phantoms to quantitatively determine exposure rates at various locations and distances from the mini-c-arm for two common upper and lower extremity procedures. Regardless of position, distance, or relative duration of exposure, exposure rates resulting from the use of the mini-c-arm device were one to two orders of magnitude lower than those reported in the literature in association with the use of the large c-arm device. The mini-c-arm device should be utilized whenever feasible in order to eliminate many of the concerns associated with use of the large c-arm device, specifically those related to cumulative radiation hazards, positioning considerations, relative distance from the beam, and the need for protective shielding.
Article
Increased use of intraoperative fluoroscopy exposes the surgeon to significant amounts of radiation. The average yearly exposure of the public to ionizing radiation is 360 millirems (mrem), of which 300 mrem is from background radiation and 60 mrem from diagnostic radiographs. A chest radiograph exposes the patient to approximately 25 mrem and a hip radiograph to 500 mrem. A regular C-arm exposes the patient to approximately 1,200 to 4,000 mrem/min. The surgeon may receive exposure to the hands from the primary beam and to the rest of the body from scatter. Recommended yearly limits of radiation are 5,000 mrem to the torso and 50,000 mrem to the hands. Exposure to the hands may be higher than previously estimated, even from the mini C-arm. Potential decreases in radiation exposure can be accomplished by reduced exposure time; increased distance from the beam; increased shielding with gown, thyroid gland cover, gloves, and glasses; beam collimation; using the low-dose option; inverting the C-arm; and surgeon control of the C-arm.
Article
A prospective clinical trial was performed to assess the suitability of a new type of sterilisable, user-friendly radiation protection glove. In a preliminary trial, we showed that the dominant hand of the primary operating orthopaedic surgeon receives the highest dose of radiation. During a 4-month period, 98 procedures were done requiring the use of an image intensifier. The doses of radiation to the dominant hand of the operating surgeon were reduced to less than the doses of radiation to the non-dominant hand. The glove was sterilisable, user-friendly and accepted by the majority of surgeons. It offers greater than 90% attenuation of X-rays and is superior to all other scatter gloves on the market.
Article
This prospective study was conducted to determine the level of radiation exposure of trainee anaesthetists working in urology, orthopaedics and radiology environments. Anaesthetists wore lithium fluoride thermoluminescent dosimeter (TLD) badges over a 6-month period. The position of badges was standardised at the collar site (TLD1) and at waist level (TLD2). Area specific dosimeters were used and exchanged between anaesthetists. Of a total of 723 procedures, anaesthetists were exposed to radiation in 33% of procedures in orthopaedics, 30% in urology and 39% in radiology. The mean (SD) exposure time to radiation per case was significantly greater in orthopaedics than in urology (9.2 (4) min vs. 4.2 (2) min). The radiation exposure per case was highest in radiology (19.2 (22) min). The net combined exposure over a 6-month period was 0.2177 mSv in urology, 0.4265 mSv in orthopaedics and 3.8457 mSv in radiology. The combined exposure was less than the 20 mSv recommended as the maximum exposure per year. Our data does not support the need for routine dosimetric monitoring of anaesthetists working in the above settings.
Article
Mini-c-arm fluoroscopy has become an important resource to the orthopaedic surgeon. Exposure of the orthopaedic surgical team to radiation during standard large-c-arm fluoroscopy has been well studied; however, little is known about the amount of exposure to which a surgical team is subjected with the use of mini-c-arm fluoroscopy. Moreover, there is controversy regarding the use of protective measures with mini-c-arm fluoroscopy. We evaluated the use of mini-c-arm fluoroscopy during a simulated surgical procedure to quantify the relative radiation doses at various locations in the operative field. A standard calibrated mini-c-arm fluoroscope was used to image a phantom upper extremity with thirteen radiation dosimeters placed at various distances and angulations to detect radiation exposure. After 155 sequential fluoroscopy exposures, totaling 300.2 seconds of imaging time, only the sensor placed in a direct line with the imaging beam recorded a substantial amount of measurable radiation exposure. The surgical team is exposed to minimal radiation during routine use of mini-c-arm fluoroscopy, except when they are in the direct path of the radiation beam.
Article
We carried out a prospective study over a period of 12 months to measure the exposure to radiation of the hands of a dedicated foot and ankle surgeon. A thermoluminescent dosimeter ring (TLD) was used to measure the cumulative dose of radiation. Fluoroscopy was used in operations on the foot and ankle. The total screening time was 3028 s, with a mean time per procedure of 37.4 s (0.6 to 197). This correlated positively with the number of procedures performed (r = 0.92, p < 0.001), and with the dose of radiation in both the left (r = 0.85, p = 0.0005) and right TLDs (r = 0.59, p = 0.419). There was no significant difference in the dose of radiation between the two hands (t-test, p = 0.62). The total dose to the right TLD over the 12 months was 2.4 millisieverts. This is a simple and convenient method for evaluating the exposure of a single surgeon to radiation. The radiation detected was well below the annual dose limit set by the International Commission on Radiological Protection.
Article
The number of computed tomographic (CT) studies performed is increasing rapidly. Because CT scans involve much higher doses of radiation than plain films, we are seeing a marked increase in radiation exposure in the general population. Epidemiologic studies indicate that the radiation dose from even two or three CT scans results in a detectable increase in the risk of cancer, especially in children. This article summarizes the facts about this form of radiation exposure and the implications for public health.
Article
In recent years, there has been a rapid increase in the number of CT scans performed, both in the US and the UK, which has fuelled concern about the long-term consequences of these exposures, particularly in terms of cancer induction. Statistics from the US and the UK indicate a 20-fold and 12-fold increase, respectively, in CT usage over the past two decades, with per caput CT usage in the US being about five times that in the UK. In both countries, most of the collective dose from diagnostic radiology comes from high-dose (in the radiological context) procedures such as CT, interventional radiology and barium enemas; for these procedures, the relevant organ doses are in the range for which there is now direct credible epidemiological evidence of an excess risk of cancer, without the need to extrapolate risks from higher doses. Even for high-dose radiological procedures, the risk to the individual patient is small, so that the benefit/risk balance is generally in the patients' favour. Concerns arise when CT examinations are used without a proven clinical rationale, when alternative modalities could be used with equal efficacy, or when CT scans are repeated unnecessarily. It has been estimated, at least in the US, that these scenarios account for up to one-third of all CT scans. A further issue is the increasing use of CT scans as a screening procedure in asymptomatic patients; at this time, the benefit/risk balance for any of the commonly suggested CT screening techniques has yet to be established.
Article
This paper provides a review of the 2007 recommendations of the International Commission on Radiological Protection (ICRP). These new recommendations take account of the latest biological and physical information and consolidate the additional guidance provided by ICRP since 1990. The changes to the scientific data are not substantial. ICRP has retained its fundamental hypothesis for the induction of stochastic effects of linearity of dose and effect without threshold and a dose and dose-rate effectiveness factor (DDREF) of 2 to derive nominal risk coefficients for low doses and low dose rates. While the overall detriment from low radiation doses has remained unchanged, ICRP has made adjustments to the values of the radiation and tissue weighting factors. In particular, the tissue weighting factor for breast has increased while that for gonads has decreased. There are some presentational changes to the system of protection. While ICRP has maintained the three fundamental principles--justification, optimisation of protection, and dose limitation-it has attempted to develop a more holistic approach to radiological protection covering all exposure situations--planned, existing and emergency--and all radiation sources, whether of natural or artificial origin. This approach should ensure that attention is focused on those exposures that can reasonably be controlled. It has also strengthened the principle of optimisation of protection with a particular emphasis on the use of constraints for planned exposure situations and reference levels for existing and emergency exposure situations. Dose constraints and reference levels are categorised into three bands which should assist in rationalising the many values of dose restrictions given in earlier ICRP publications. There are no changes to the dose limits. ICRP also indicates its intentions with respect to the development of further guidance on the protection of the environment. The fact that these new recommendations are more a matter of consolidation of previous ICRP recommendations and guidance should provide confidence that the system of protection established by and large in its present form several decades ago has reached a certain level of maturity. As such, no major changes to radiological protection regulations based on the 1990 recommendations should be necessary.
Radiation exposure to the or-thopaedic surgeon during periacetabular osteotomy Radiation protection for your hands Seibert JA: Digital radiography: Image quality and radiation dose
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  • H Daugaard
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  • Hilton Dl Ai Back
  • Briggs Tw
Mechlenburg I, Daugaard H, Søballe K: Radiation exposure to the or-thopaedic surgeon during periacetabular osteotomy. Int Orthop 33: 1747-1751, 2009 36. Back DL, Hilton AI, Briggs TW, et al: Radiation protection for your hands. Injury 36:1416-1420, 2005 37. Seibert JA: Digital radiography: Image quality and radiation dose. Health Phys 95:586-598, 2008
Experimental model for a new distal locking aiming device for solid intramedullary tibia nails Distal locking using an electromag-netic field guided computer based real time system
  • Abdlslam Km
  • Bonnaire
  • Patel P P Tornetta
  • Tseng S
Abdlslam KM, Bonnaire F: Experimental model for a new distal locking aiming device for solid intramedullary tibia nails. Injury 34:363-366, 39. Tornetta P, Patel P, tseng S, et al: Distal locking using an electromag-netic field guided computer based real time system. Proceedings of the 25th Annual OTA Annual Meeting; San Diego, CA, October, 2009, p. 343-344