Article

Tracking Cumulative Radiation Exposure in Orthopaedic Surgeons and Residents: What Dose Are We Getting?

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Abstract

BACKGROUND: The purpose of this study was to determine the amount of cumulative radiation exposure received by orthopaedic surgeons and residents in various subspecialties. We obtained dosimeter measures over 12 months on 24 residents and 16 attending surgeons. METHODS: Monthly radiation exposure was measured over a 12-month period for 24 orthopaedic residents and 16 orthopaedic attending surgeons. The participants wore a Landauer Luxel dosimeter on the breast pocket of their lead apron. The dosimeters were exchanged every rotation (5 to 7 weeks) for the resident participants and every month for the attending surgeon participants. Radiation exposure was compared by orthopaedic subspecialty, level of training, and type of fluoroscopy used (regular C-arm compared with mini C-arm). RESULTS: Orthopaedic residents participating in this study received monthly mean radiation exposures of 0.2 to 79 mrem/month, lower than the dose limits of 5,000 mrem/year recommended by the United States Nuclear Regulatory Commission (U.S. NRC). Senior residents rotating on trauma were exposed to the highest monthly radiation (79 mrem/month [range, 15 to 243 mrem/month]) compared with all other specialty rotations (p < 0.001). Similarly, attending orthopaedic surgeons who specialize in trauma or deformity surgery received the highest radiation exposure of their peers, and the mean exposure was 53 mrem/month (range, 0 to 355 mrem/month). CONCLUSIONS: Residents and attending surgeons performing trauma or deformity surgical procedures are exposed to significantly higher doses of radiation compared with all other subspecialties within orthopaedic surgery, but the doses are still within the recommended limits. CLINICAL RELEVANCE: The use of ionizing radiation in the operating room has become an indispensable part of orthopaedic surgery. Although all surgeons in our study received lower than the yearly recommended dose limit, it is important to be aware of how much radiation we are exposed to as surgeons and to take measures to further limit that exposure.

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... Certain subspecialties within orthopaedic surgery are exposed to higher amounts of radiation due to the nature of procedures performed. Gausden, et al., showed that attending orthopaedic surgeons specializing in trauma or deformity surgery received the highest radiation exposure [8]. For example, fluoroscopically intensive procedures such as those that utilize locked intramedullary nailing systems are responsible for the highest radiation doses amongst orthopaedic surgeons [1,2,7]. ...
... Many patient factors also increase a surgeon's radiation exposure, including increased patient Body Mass Index (BMI) and fracture complexity [10]. In addition, the surgeon's radiation exposure per case is dependent on the years of operating room experience [8,10]. Early career surgeons within their first three years of independent practice were exposed to significantly higher radiation than their senior colleagues with greater than ten years of experience [8,10]. ...
... In addition, the surgeon's radiation exposure per case is dependent on the years of operating room experience [8,10]. Early career surgeons within their first three years of independent practice were exposed to significantly higher radiation than their senior colleagues with greater than ten years of experience [8,10]. ...
Article
Objective: There is ample literature demonstrating significant health risks associated with radiation exposure, yet there is no standardized radiation safety training for Canadian orthopaedic surgery residents. This is the first national survey investigating the prevalence of radiation safety training and radiation safety practices in Canadian orthopaedic residency programs. Methods: A nationaln online survey was distributed to orthopaedic residents currently enrolled in a Canadian program from all post-graduate (PGY) levels who were fluent in English or French with a medical doctorate or equivalent training. Fellows, international elective or observer ship students were excluded. Results: Overall response rate across Canada was 41% (n=116). Most respondents (94%, n=102) were concerned about the negative effects of radiation, yet only 11% (n=12) felt confident with their radiation safety knowledge. Of the residents who felt confident in their knowledge, only 42% (n=5) answered all three radiation safety screening questions correctly. Overall, 58% (n=66) of respondents had undergone some form of radiation safety training. Compliance with protective lead was high (92%, n=93) when available, but 82% (n=92) of respondents cited issues accessing properly fitting lead. Only 18% (n=20) of orthopaedic residents reported routinely wearing dosimeters. Conclusion: Limited access to properly fitting protective lead, poor radiation safety knowledge, and lack of routine radiation monitoring could be placing residents at risk for poor health outcomes in the future. These results provide impetus for orthopaedic residency programs across Canada to implement higher safety standards in the form of standardized radiation safety training, routine dosimeter use, improved lead availability, and continued abidance to radiation safety protocols.
... 18 In man, surgeons who specialize in trauma and or deformity surgery are exposed to relatively high doses of radiation from intraoperative fluoroscopy, and junior surgeons received higher doses of radiation than senior surgeons. 19,20 Because the use of intraoperative imaging is becoming more commonplace in small animal orthopedics, it is important to understand the relative risks associated with fluoroscopically assisted procedures for operating room personnel. Hersh-Boyle and colleagues 21 documented radiation exposure to dogs and cats undergoing orthopedic and interventional procedures, but, to the best of the authors' knowledge, no published report has documented direct exposure levels for veterinary surgical personnel during MIO. ...
... For comparison, orthopedic surgery residents in one study in man received mean radiation exposures of 0.2 to 79 mrem/month, and those who specialize in trauma or deformity surgery were exposed to 53 mrem/month. 19 On the basis of a linear regression model from the exposure levels to the assistant, 0.2 mrem was reached after 10.8 cases, and 79 mrem would not be reached until after 2984 cases. Linear regression analysis could not be performed for the exposure to the underthe-vest measurements from the surgeon or the assistant or from the dominant wrist of the surgeon because no detectable readings were present after a total of 17 cases. ...
... It has been previously documented that, in human medicine, senior orthopedic surgeons used less fluoroscopic screening time and, as a result, were exposed to lower radiation levels compared with junior surgeons. 19,20 All procedures in this study were performed by a novice surgeon, and inexperience may have contributed to increased fluoroscopic shot acquisition. Additional veterinary studies in which novice and experienced surgeons are compared are required to validate the difference in exposure noted in human medicine. ...
Article
Objective: To determine radiation exposure to surgical personnel and to evaluate the accuracy of a modified percutaneous lag screw fixation technique for sacroiliac luxation (SIL) under fluoroscopic guidance in dogs. Study design: Cadaveric experimental study. Sample population: Seventeen beagle cadavers with iatrogenic SIL. Methods: Seventeen beagles with iatrogenic SIL underwent reduction and stabilization with 3.5-mm screws. Hypodermic needles (14 gauge) and fluo-roscopy were used to orient two Kirschner wires for temporary stabilization and to guide drilling of glide and pilot holes using cannulated drill bits. Duration of surgery and radiation exposure were recorded. Postoperative computed tomographic evaluation of screw position and angulation was performed. Results: Average time for fixation was 15.85 minutes (range, 6.37-33.5). Cumulative radiation doses of 0.4 mrem for the dominant arm of the assistant and 0 mrem for the primary surgeon were recorded. The mean dorso-ventral and craniocaudal screw angles were 0.68 ± 3.4 (range − 5.4 to 9.5) and 1.9 ± 3.2 (range − 4.3 to 9.1), respectively. Sixteen of the 17 dogs had 100% sacral screw purchase, with the remaining case achieving 93.4% purchase. Conclusion: Fluoroscopy-assisted percutaneous placement of 3.5-mm corti-cal screws in lag fashion performed with 14-gauge needles in conjunction with Kirschner wires and cannulated drill bits yielded repeatable accurate
... 18 In man, surgeons who specialize in trauma and or deformity surgery are exposed to relatively high doses of radiation from intraoperative fluoroscopy, and junior surgeons received higher doses of radiation than senior surgeons. 19,20 Because the use of intraoperative imaging is becoming more commonplace in small animal orthopedics, it is important to understand the relative risks associated with fluoroscopically assisted procedures for operating room personnel. Hersh-Boyle and colleagues 21 documented radiation exposure to dogs and cats undergoing orthopedic and interventional procedures, but, to the best of the authors' knowledge, no published report has documented direct exposure levels for veterinary surgical personnel during MIO. ...
... For comparison, orthopedic surgery residents in one study in man received mean radiation exposures of 0.2 to 79 mrem/month, and those who specialize in trauma or deformity surgery were exposed to 53 mrem/month. 19 On the basis of a linear regression model from the exposure levels to the assistant, 0.2 mrem was reached after 10.8 cases, and 79 mrem would not be reached until after 2984 cases. Linear regression analysis could not be performed for the exposure to the underthe-vest measurements from the surgeon or the assistant or from the dominant wrist of the surgeon because no detectable readings were present after a total of 17 cases. ...
... It has been previously documented that, in human medicine, senior orthopedic surgeons used less fluoroscopic screening time and, as a result, were exposed to lower radiation levels compared with junior surgeons. 19,20 All procedures in this study were performed by a novice surgeon, and inexperience may have contributed to increased fluoroscopic shot acquisition. Additional veterinary studies in which novice and experienced surgeons are compared are required to validate the difference in exposure noted in human medicine. ...
Full-text available
Article
Objective: To determine radiation exposure to surgical personnel and to evaluate the accuracy of a modified percutaneous lag screw fixation technique for sacroiliac luxation (SIL) under fluoroscopic guidance in dogs. Study design: Cadaveric experimental study. Sample population: Seventeen beagle cadavers with iatrogenic SIL. Methods: Seventeen beagles with iatrogenic SIL underwent reduction and stabilization with 3.5-mm screws. Hypodermic needles (14 gauge) and fluoroscopy were used to orient two Kirschner wires for temporary stabilization and to guide drilling of glide and pilot holes using cannulated drill bits. Duration of surgery and radiation exposure were recorded. Postoperative computed tomographic evaluation of screw position and angulation was performed. Results: Average time for fixation was 15.85 minutes (range, 6.37-33.5). Cumulative radiation doses of 0.4 mrem for the dominant arm of the assistant and 0 mrem for the primary surgeon were recorded. The mean dorsoventral and craniocaudal screw angles were 0.68° ± 3.4° (range - 5.4° to 9.5°) and 1.9° ± 3.2° (range - 4.3° to 9.1°), respectively. Sixteen of the 17 dogs had 100% sacral screw purchase, with the remaining case achieving 93.4% purchase. Conclusion: Fluoroscopy-assisted percutaneous placement of 3.5-mm cortical screws in lag fashion performed with 14-gauge needles in conjunction with Kirschner wires and cannulated drill bits yielded repeatable accurate screw placement with low levels of ionizing radiation exposure to the surgical team. Clinical significance: The described technique may be a viable method for minimally invasive osteosynthesis fixation of SIL with low levels of radiation exposure to the surgical team. These results provide evidence to support further evaluation of radiation exposure in clinical cases and can aid in study design and sample size determination.
... al. tracked cumulative radiation dose in one year among various orthopaedic subspecialties and across several training levels at a single institution, demonstrating that trauma surgeons were exposed to the highest amounts of radiation and arthroplasty surgeons the least. 12 The relationship between operating room (OR) data such as total fluoroscopy time, number of procedures performed per day by a surgeon, and radiation exposure, was explored in one previous study but focused on hand radiation exposure and was limited to one institution. 13 Given the increased prevalence of breast cancer in female orthopaedic surgeons relative to the general US population and even other surgical specialties, radiation exposure in the context of operating room characteristics has significant implications for limiting occupational risk in this population. ...
... The finding that trauma surgeons have significantly higher radiation exposure levels according to the dosimeter outside the lead apron aligns with our hypothesis, and previous findings describing higher radiation exposure levels among trauma surgeons. 12 Given the large effect size and population coverage of our sample (6% and 16% of female trauma surgeons and arthroplasty surgeons, respectively), this result helps confirm on a national level that the differences in radiation exposure between these two specialties are reproducible. Radiation exposure increases cancer risk, and doses accumulated over the course in career could be a concern for contributing to the increased prevalence of breast cancer among female orthopaedic surgeons. ...
... Nevertheless, the dose levels grouped by specialty are still in a similar range, with one study reporting an average of 52.7 mrem/month among trauma surgeons and 4.0 mrem/month among arthroplasty surgeons. 12 According to the dose readings from the dosimeters placed under the lead apron on the chest, almost no radiation penetrated through the lead aprons. Considering every surgeon in this study reported wearing a lead apron when fluoroscopy was used, the overall risk of radiation penetrance to the surgeon's chest in the area detected by the dosimeter is reassuring. ...
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Article
Background: The risks of radiation exposure in orthopaedic surgery have become a topic of increasing interest in the setting of widespread fluoroscopy use and concern for an increased prevalence of breast cancer among female orthopaedic surgeons. The aim of this national study of 31 female orthopaedic surgeons was to achieve a deeper understanding of fluoroscopic use in the OR and its associated exposure to radiation, by comparing female orthopaedic trauma and arthroplasty surgeons. Methods: A total of 31 surgeons wore dosimeters for 10 operating days each to track cumulative radiation exposure. Surgeons were not asked to modify their practice in any way, with no requirement that the operating days had to be chosen with the knowledge that fluoroscopy would be used. Participants were also asked to fill out a form at the end of each day, detailing the number of cases that day, the number of hours spent in the OR, and the total amount of time using fluoroscopy. Results: Trauma surgeons received significantly higher radiation doses in the OR (p=0.01) and reported longer use of fluoroscopy (p<0.001). Trauma surgeons also spent more time per day in the OR and had more cases per day compared to arthroplasty surgeons, but this difference was not significant. Radiation dose penetrating through protective equipment remained minimal. Conclusion: Although the female trauma surgeons in the study operated longer and performed more procedures per day, the higher radiation exposure was best explained by the amount of time fluoroscopy is used in the OR. The fluoroscopic times in this study therefore may be a useful self-assessment tool for attending trauma and arthroplasty surgeons. Awareness of these differences will hopefully increase an individual surgeon's mindfulness toward the length of fluoroscopy use in each case, regardless of orthopaedic subspecialty.Level of Evidence: IV.
... The literature shows increasing concern for radiation risk in theatre, and orthopedics is now among the most severely exposed specialties [6][7][8][9][10][11]. Many studies reported increased risk of radiation-induced cataract in exposed populations [4,5,11]. ...
... Gausden et al. reported much higher overall exposure levels in residents and senior surgeons specializing in traumatology, although still well below the regulatory threshold [11]. This discrepancy is probably due to how our department is organized, with no dedicated traumatologists but each surgeon alternating between orthopedics and traumatology in their schedule; moreover, we do not manage spinal trauma, which constitutes a major source of radiation [7,11]. ...
... Although orthopedic surgeons remain well below the theoretic pathogenic exposure level, the "precautionary principle" should still be applied. Protective goggles are recommended, but are rarely used, as they are expensive and impractical [1,5,7,15]. They should be used not systematically but only in case of high-prolonged radiation. ...
... 2,3,6-12 Several factors that influence exposure risk have been identified including type of surgery, distance from radiation source, subspecialty practiced, and experience level of the surgeon. 1,5,8,10,11 Several precautions can be taken to limit radiation exposure including the principles of maximizing distance from the radiation source, limiting time of exposure, avoiding direct exposure of body parts, and the use of protective equipment including lead aprons, thyroid shields, and glasses (Table 1). 8 What is less well known is how much orthopedic surgeons know about the risks of radiation exposure and whether/how often they apply the principles of exposure prevention. ...
... While exposure totals do not seem to approach yearly limits set by the NRC, understanding of dose limitations, risks of exposure, and personal prophylactic practices is suboptimal. 10,[14][15][16][17] For instance, a recent study by Bowman and colleagues surveyed orthopaedic residents on radiation safety training, provision of personal protective equipment, and general radiation knowledge. Results indicated low baseline radiation knowledge scores: 39% of residents knew the recommended distance to stand from a radiation source, 10.8% knew yearly allowable radiation dose limitations, and only 32.4% were aware of the American Academy of Orthopaedic Surgery (AAOS) guidelines regarding the use of personal protective equipment. ...
... Previous studies demonstrated that radiation experienced by orthopedic surgeons falls below yearly limits established by the NRC. 2,3,6,7,[9][10][11][12][13] However, no dose of radiation exposure is without the risk of potential adverse effects. It remains unknown what combination of education and access to personal protective equipment will further Article Table 1. ...
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Article
Fluoroscopy poses an occupational hazard to orthopedic surgeons. The purpose of this study was to examine resident and faculty understanding of radiation safety and to determine whether or not a radiation safety intervention would improve radiation safety knowledge. An anonymous survey was developed to assess attitudes and knowledge regarding radiation safety and exposure. It was distributed to faculty and residents at an academic orthopedic program before and after a radiation safety lecture. Pre- and post-lecture survey results were compared. 19 residents and 22 faculty members completed the pre-lecture survey while 11 residents and 17 faculty members completed the post-lecture survey. Pre-lecture survey scores were 48.3% for residents and 49.5% for faculty; post-lecture survey scores were 52.7% and 46.1% respectively. Differences between pre and post-survey scores were not significant. This study revealed low baseline radiation safety knowledge scores for both orthopedic residents and faculty. As evidence by our results, a single radiation safety information lecture did not significantly impact radiation knowledge. Radiation safety training should have a formal role in orthopedic surgery academic curricula.
... The literature shows increasing concern for radiation risk in theatre, and orthopedics is now among the most severely exposed specialties [6][7][8][9][10][11]. Many studies reported increased risk of radiation-induced cataract in exposed populations [4,5,11]. ...
... Gausden et al. reported much higher overall exposure levels in residents and senior surgeons specializing in traumatology, although still well below the regulatory threshold [11]. This discrepancy is probably due to how our department is organized, with no dedicated traumatologists but each surgeon alternating between orthopedics and traumatology in their schedule; moreover, we do not manage spinal trauma, which constitutes a major source of radiation [7,11]. ...
... Although orthopedic surgeons remain well below the theoretic pathogenic exposure level, the "precautionary principle" should still be applied. Protective goggles are recommended, but are rarely used, as they are expensive and impractical [1,5,7,15]. They should be used not systematically but only in case of high-prolonged radiation. ...
Article
Introduction: Numerous studies in recent years highlighted an increased risk of pathologies related to ionizing radiation in caregivers. A new French decree was adopted on June 4, 2018, dividing by 7.5 the radiation dose authorized in the lens for exposed workers. Hypothesis: The hypothesis of the present study was that ocular irradiation in orthopedic surgeons was below the new legal threshold. Method: The equivalent dose (mSv) received by the lens was prospectively assessed in 10 orthopedic surgeons (5 senior, 5 residents), using 3 passive dosimeters placed at the forehead and either temple. Each intervention of each operator was recorded, with dose per area in the operating room at each use of the fluoroscope. Results: All equivalent doses to the lens at the end of the 4 month study period were well below threshold. Doses were not significantly different between forehead and either temple (p=0.7, p=0.6 for the 2 temples). There was no difference according to side of the head (p=0.3). The dose received in the lens correlated with the dose delivered in the room (p=0.004). There were no significant differences in irradiation according to the surgeon's experience (p=0.2) or trauma activity rate (p=0.4). Discussion: No studies have reported equivalent doses to the lens exceeding the authorized limit. But none previously measured equivalent dose to the lens according to the axis of irradiation in the eyes. The present study showed that orthopedic surgeons received as much eye radiation laterally as frontally. Ocular radiation protection needs therefore to be as effective laterally as frontally. The surgeon's experience did not emerge as a protective factor against ocular irradiation.
... The increased use of imaging techniques in orthopedic surgical operations leads to increased exposure to radiation among orthopedic surgeons, and hence orthopedic surgeons may be classified as a high-risk group for occupational radiation exposure [3,[5][6][7]. Despite being exposed to such radiation on a regular basis, the overall knowledge and awareness about radiation and safety protocols among orthopedic surgeons are lacking [2,7,8]. ...
... With the advancement in medical technology, the use of imaging modalities that utilize ionizing radiation has increased significantly; this could be attributed to the benefits they offer in terms of rapid and accurate diagnosing methods [2,3,[5][6][7][8][9][10]. However, it is not without its adverse effects on the human body. ...
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Article
Background and objective The use of radiation imaging techniques in operation theaters is essential for numerous surgical procedures and patients’ overall well-being. Radiation imaging techniques enable the surgeon to have a real-time visualization of the anatomy and to perform operations with a greater chance of success, decrease rates of patient morbidity, and enable surgeons to obtain imaging records before the patient leaves the theater room. However, with the increased use of imaging techniques in orthopedic surgical operations, orthopedic surgeons are being exposed to higher levels of radiation, and hence they can be classified as a high-risk group for occupational radiation exposure. This study aimed to assess orthopedic surgeons' awareness and knowledge regarding radiation exposure safety. Materials and methods A questionnaire-based descriptive cross-sectional study was conducted from January to March 2022 to assess the knowledge regarding ionizing radiation exposure safety among orthopedic surgeons, including consultants, specialists, and residents, at both private and governmental hospitals in Al-Madinah city, Saudi Arabia. Ethical approval was obtained from the Ministry of Health (MOH) of Al-Madinah (approval number: H-03-l.l-084). The applied statistical tests were frequency and MCT tests for univariate variables while Chi-square was applied for bivariate variables. With a 95% confidence interval (CI), a p-value of more than 0.05 was used as the cut-off value for the significance level. Results A total of 57 surgeons participated in the study, of which 57.9% were exposed to radiation two to three times per week. Additionally, more than half of the physicians (66.7%) were not trained to use fluoroscopy (C-arm machine). Of note, 78.9% of orthopedic surgeons reported that they used the protective apron as protective equipment, while 17.5% of them used both a protective apron and thyroid shield. However, only less than half of the orthopedic surgeons (43.9%) in our study practiced radiation safety in the operating room. Conclusion Our study revealed a lack of knowledge and awareness related to ionizing radiation exposure safety among orthopedic surgeons in Al-Madinah city, Saudi Arabia.
... Thus, there have been concerns on the compounded radiation exposure of surgeons [1][2][3][4]. Although several clinical studies have reported that doses of exposure are within the recommended limits, the current radiation exposure limits are extrapolated from the values reported in studies of individuals who survived the atomic bombings in Hiroshima and Nagasaki [5][6][7]. Thus, the limited evidence on the long-term health-related effects of low-dose radiation raises concerns on the development of cataract, thyroid diseases, and cancer [8][9][10][11][12]. ...
... Because of the increasing medical radiation exposure over time [1], the younger generation is more likely to be exposed to radiation. Moreover, younger and less experienced physicians tend to have higher radiation exposure [5]. ...
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Article
Background Exposure to occupational radiation can lower the male sex ratio. However, specific radiation exposure to the testes has not been evaluated. Objective This study aimed to examine the association between testicular radiation exposure and lower male sex ratio in children. Methods A comprehensive questionnaire survey was administered to 62 full-time male doctors with children aged < 10 years at 5 hospitals. Based on the possibility of testicular radiation exposure 1 year before the child’s birth, participants were assigned to 3 groups as follows: RT (orthopedic surgery), RNT (cardiology/neurosurgery), and N (others). Intergroup differences in the proportion of female children were ascertained, and the female sex ratio (number of female/total number) of each group was compared against the standard value of 0.486. Multivariate logistic regression analysis with a generalized estimating equation was used to model the effects on the probability of female birth while controlling for the correlation among the same fathers. Results The study population included 62 fathers and 109 children, 49 were female: 19/27, 11/30, and 19/52 in the RT, RNT, and N group, respectively; the RT group had the highest proportion of females ( p = 0.009). The p values for comparisons with the standard sex ratio (0.486) were 0.02, 0.19, and 0.08 for the RT, RNT, and N groups, respectively. Based on the N group, the adjusted odds ratios for the child to be female were 4.40 (95% confidence interval 1.60–2.48) and 1.03 (0.40–2.61) for the RT and RNT groups, respectively. Conclusions Our results imply an association between testicular radiation exposure and low male sex ratio of offspring. Confirmatory evidence is needed from larger studies which measure the pre-conceptional doses accumulated in various temporal periods, separating out spermatogonial and spermatid effects.
... Surgeons are frequently exposed to a host of occupational hazards that all pose an established risk to their health and safety. In the operating room (OR), the ubiquity of these hazards guarantees inevitable exposure to blood-borne pathogens for approximately 5.6 million healthcare workers, an average of 5-50mrem/case, 10-350mrem/month, or 2000-3000mrem/year of radiation depending on the surgical specialty, and biological by-products from surgical smoke [1][2][3][4]. Accordingly, the collaborative nature of the surgical field places surgeons at risk of exposure to hazards not always specific to their own specialty. Vascular surgeons, Orthopedic surgeons, and Plastic surgeons working together on a complex operation may use intraoperative technologies that emit radiation or produce vibratory sound above recommended levels that may not be typical within their own respective specialties [3,5]. ...
... Accordingly, the collaborative nature of the surgical field places surgeons at risk of exposure to hazards not always specific to their own specialty. Vascular surgeons, Orthopedic surgeons, and Plastic surgeons working together on a complex operation may use intraoperative technologies that emit radiation or produce vibratory sound above recommended levels that may not be typical within their own respective specialties [3,5]. While efforts have been made to improve OR safety through mandated occupational safety trainings, no policies or trainings exist on non-traditional hazards that address the chemical or biological materials emitted from laser or surgical smoke, anesthetic gases, or ergonomics, to name a few [1,2]. ...
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Article
Background: Occupational health hazards are ubiquitously found in the operating room, guaranteeing an inevitable risk of exposure to the surgeon. Although provisions on occupational health and safety in healthcare exist, they do not address non-traditional hazards found in the operating room. In order to determine whether surgeons or trainees receive any form of occupational health training, we examine the associations between occupational health training and exposure rate. Study design: A cross-sectional survey was distributed. Respondent characteristics included academic level, race/ethnicity, and gender. The survey evaluated seven surgical disciplines and 13 occupational hazards. Multivariable logistic regression was used to examine the association between academic level, surgical specialty, and exposure rate. Results: Our cohort of 183 respondents (33.1% response rate) consisted of attendings (n = 72, 39.3%) and trainees (n = 111, 60.7%). Surgical trainees were less likely to have been trained in cytotoxic drugs (OR 0.22, p<0.001), methylmethacrylate (OR 0.15, p<0.001), patient lifting (OR 0.43, p = 0.009), radiation (OR 0.40, p = 0.007), and surgical smoke (OR 0.41, p = 0.041) than attending surgeons. Additionally, trainees were more likely to experience frequent exposure to bloodborne pathogens (OR 5.26, p<0.001), methylmethacrylate (OR 2.86, p<0.001), cytotoxic drugs (OR 3.03, p<0.001), and formaldehyde (2.08, p = 0.011), to name a few. Conclusion: Although surgeon safety is not a domain in residency training, standardized efforts to educate and change the culture of safety in residency programs is warranted. Our study demonstrates a disparity between trainees and attendings with a recommendation to provide formal training to trainees independent of their anticipated risk of exposure.
... However, during the fluoroscopic procedures, the surgeons may be exposed to the primary beam and scattered radiation [2,5]. As the use of fluoroscopy is continuously increasing in orthopedic surgery and orthopedic surgeons are often closely exposed to the radiation source during operations, they are considered a high-risk group of occupational radiation exposure [6][7][8][9][10]. ...
... Study participants were classified by job specialty as spine or trauma specialists (ST), other orthopedic specialists (Others), and residents, based on previous studies in which spine or trauma surgeons were reported to be exposed to radiation more than the other orthopedic surgeons [3,6]. Descriptive statistics for the demographics and work-related characteristics are presented. ...
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Article
Background: The use of fluoroscopically-guided interventional (FGI) procedures by orthopedic surgeons has been increasing. This study aimed to investigate the occupational radiation exposure among orthopedic surgeons in South Korea. Methods: A nationwide survey of orthopedic surgeons was conducted in South Korea in October 2017. The dosimetry data of the participants were obtained from the National Dosimetry Registry. The orthopedic surgeons were categorized by job specialty [spine or trauma specialists, other orthopedic specialists, and residents], and descriptive statistics for the demographics and work-related characteristics were presented. Multivariable logistic regression analysis was used to evaluate the risk factors for the orthopedic surgeons who were not linked with the dosimetry data. Results: Among the total participants (n = 513), 40.5% of the orthopedic surgeons spent more than 50% of their time working with the FGI procedures when compared with their overall work. The average frequency of the FGI procedures among the orthopedic surgeons was 12.3 days per month. Less than 30% of the participants were regularly provided with radiation monitoring badges. The proportion of subjects who always wore lead aprons and thyroid shields were 52 and 29%, respectively. The residents group experienced more unfavorable working conditions of radiation exposure than the other specialists. The dosimetry data were not significantly linked among the residents (odds ratio [OR] 2.10, 95% confidence interval [CI] 1.11-3.95) and orthopedic surgeons working at small hospitals (OR 4.76, 95% CI 1.05-21.51). Conclusions: Although orthopedic surgeons often performed FGI procedures, they wore protective gear less frequently, and a large proportion of orthopedic surgeons were not monitored by the national radiation dosimetry system. As the number of radiation procedures performed by the orthopedic surgeons increases, more intensive approaches are needed to reduce radiation exposure, especially for spine and trauma surgeons.
... Within the orthopedic specialty their exposure levels are second only to that of trauma/limb deformity surgeons. 8 The hybrid operating room (OR) is a modern concept of surgical theater integrating a motorized C-am with intraoperative 3D imaging capability, well suited for spine surgery. [9][10][11] The purpose of this study was to quantify the radiation exposure to surgical staff and patients in a hybrid OR when using Augmented Reality Surgical Navigation (ARSN) for pedicle screw placement. ...
... The median amount of spinal levels treated was 8 [2][3][4][5][6][7][8][9][10][11][12]. An average of 43 AE 5 seconds of 2D x-ray imaging (fluoroscopy) was used for the identification of spinal level and isocentering to locate the region of interest. ...
Article
Study design: Prospective observational study. Objective: To assess staff and patient radiation exposure during augmented reality surgical navigation (ARSN) in spine surgery. Summary of background data: Surgical navigation in combination with intraoperative 3D imaging has been shown to significantly increase the clinical accuracy of pedicle screw placement. Although this technique may increase the total radiation exposure compared to fluoroscopy, the occupational exposure can be minimized, as navigation is radiation free and staff can be positioned behind protective shielding during 3D imaging. The patient radiation exposure during treatment and verification of pedicle screw positions can also be reduced. Methods: Twenty patients undergoing spine surgery with pedicle screw placement were included in the study. The staff radiation exposure was measured using real-time active personnel dosimeters (APD) and was further compared with measurements using a reference dosimeter attached to the C-arm (i.e., a worst-case staff exposure situation). The patient radiation exposures were recorded, and effective doses (ED) were determined. Results: The average staff exposure per procedure was 0.21 ± 0.06 μSv. The average staff-to-reference dose ratio per procedure was 0.05% and decreased to less than 0.01% after a few procedures had been performed. The average patient ED was 15.8 ± 1.8 mSv which mainly correlated with the number of vertebrae treated and the number of CBCT acquisitions performed. A low dose protocol used for the final 10 procedures yielded a 32% ED reduction per spinal level treated. Conclusion: This study demonstrated significantly lower occupational doses compared to values reported in literature. Real-time APD contributed to a fast optimization and adoption of protective measures throughout the study. Even though our data include both CBCT for navigation planning and intraoperative screw placement verification, we find low patient radiation exposure levels compared to published data. Level of evidence: 3.
... Previous studies have demonstrated that those specializing in trauma are exposed to higher rates of radiation. 33,34 In this study, increased fluoroscopy use was not associated with an increased breast cancer prevalence. We also did not detect an increased breast cancer risk by radiation exposure group or specialty type; however, the sample size may have been too low to detect differences. ...
Article
Introduction: Cancer is the second leading cause of death among women in the United States. Previous studies demonstrate a higher prevalence of cancer among female orthopaedic surgeons. This study aimed to provide an updated prevalence of breast and all-cause cancer among female orthopaedic surgeons using a larger and more current study population. Methods: We distributed surveys to female orthopaedic surgeons in national orthopaedic specialty societies. Six hundred seventy-two survey responses were collected. We calculated standardized prevalence ratios (SPRs) and 95% confidence intervals (CIs) based on gender-specific, race-specific, and age-specific cancer prevalence statistics in the US population. We compared the distribution of breast cancer risk factors with that of women in the 2018 and 2009 California Health Interview Survey. Results: Fifty-one of the 672 surveyed surgeons reported a diagnosis of invasive cancer. Twenty reported breast cancer with a prevalence higher among female orthopaedic surgeons compared with the US female population (SPR: 2.89, 95% CI: 2.16 to 3.81, P < 0.001). The breast cancer prevalence was also higher among orthopaedic surgeons compared with the US female population (SPR: 3.97, 95% CI: 2.43 to 6.14, P = 0.003). Discussion: The increased prevalence of breast and all-cause cancer among a larger and more diverse cohort of female orthopaedic surgeons confirms previous studies and provides an update regarding a concerning public health issue within this specialty.
... After our PLP was implemented, our monthly resident dosimeter readings went from 7.26 to 19.00 mrem. Our post PLP average dosimeter reading of 19.00 mrem is more similar to a previous report where average resident dosimeter readings were 26.9 mrem 10 . This provides evidence that with traditional radiation monitoring, the dosimeter readings may have been underreported, and after PLP, readings were more accurate. ...
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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.
... While the trend in orthopaedics and other surgical disciplines has been a move from open to minimally invasive procedures, has trended in orthopedic and other surgical disciplines, this approach often increases radiation exposure for both the patient and the whole medical team as surgeons need to take repetitive X-ray images to control the procedure and validate the placement of tools and implants [53][54][55][56][57][58][59][60][61][62]. AR technologies can allow surgeons to track the movement of their tools and implants in relation to patient anatomy in real time obviating the need for repetitive X-ray exposure. ...
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Purpose of Review Imaging technologies (X-ray, CT, MRI, and ultrasound) have revolutionized orthopedic surgery, allowing for the more efficient diagnosis, monitoring, and treatment of musculoskeletal aliments. The current review investigates recent literature surrounding the impact of augmented reality (AR) imaging technologies on orthopedic surgery. In particular, it investigates the impact that AR technologies may have on provider cognitive burden, operative times, occupational radiation exposure, and surgical precision and outcomes. Recent Findings Many AR technologies have been shown to lower provider cognitive burden and reduce operative time and radiation exposure while improving surgical precision in pre-clinical cadaveric and sawbones models. So far, only a few platforms focusing on pedicle screw placement have been approved by the FDA. These technologies have been implemented clinically with mixed results when compared to traditional free-hand approaches. Summary It remains to be seen if current AR technologies can deliver upon their multitude of promises, and the ability to do so seems contingent upon continued technological progress. Additionally, the impact of these platforms will likely be highly conditional on clinical indication and provider type. It remains unclear if AR will be broadly accepted and utilized or if it will be reserved for niche indications where it adds significant value. One thing is clear, orthopedics’ high utilization of pre- and intra-operative imaging, combined with the relative ease of tracking rigid structures like bone as compared to soft tissues, has made it the clear beachhead market for AR technologies in medicine.
... Particularly, in the field of spine surgery, the recent widespread use of lateral lumbar interbody fusion [1,2] and percutaneous pedicle screw insertion [3] has amplified the occupational radiation exposure among surgeons and other health care professionals. Although studies have shown that radiation dose during orthopaedic surgery is within the permissible limits [4], it is not clear whether this value really applies to low-dose long-term exposure, as those dose limits were established on the basis of data from survivors of the atomic bombings of Hiroshima and Nagasaki (i.e. high-dose, short-term exposure) [5]. ...
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PurposeTo investigate the association between occupational direct radiation exposure to the hands and longitudinal melanonychia (LM) and hand eczema in spine surgeons. MethodsA web-based questionnaire survey of the Society for Minimally Invasive Spinal Treatment (MIST) in Japan was conducted. The proportion of LM and hand eczema in hands with high and low-radiation exposure was compared using Fisher’s exact test. The odds ratios (ORs) and their 95% confidence intervals (CIs) for the prevalence of LM and hand eczema in the high-radiation exposure hands were calculated using generalized estimating equations for logistic regression as control for the correlation of observations among the same individuals and possible confounders.ResultsAmong 324 members of the society, responses were received from 229 members (70.7%). A total of 454 hands from 227 participants were analysed. The prevalence of LM and hand eczema was 43% and 29%, respectively. In a hand-by-hand comparison, more hands had LM in the high-radiation exposure group than the low-radiation exposure group (90 [40%] vs. 39 [17%], respectively, p < 0.001). A similar trend was observed for hand eczema (63 [28%] vs. 33 [15%], respectively, p = 0.001). The adjusted OR for high-radiation exposure hands was 3.18 (95% CI: 2.24–4.52). Consistent results were obtained for hand eczema, with an adjusted OR of 2.26 (95% CI: 1.67–3.06).Conclusion The present study suggests that direct radiation exposure to physician’s hands is associated with LM and hand eczema. Those with LM and radially biased hand eczema may have had high direct radiation exposure.
... Regardless of their professional rank, orthopedic deformity and trauma surgeons are exposed to a remarkable risk of ionizing radiation, as opposed to other specialties. [3] Even with the expansion of mini fluoroscopy (mini C-arm), significant radiation exposure to the surgeon can occur. Therefore, this will require reiteration of radiation safety awareness among orthopedic surgeons. ...
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Objectives: Orthopedic surgeons are heavy fluoroscopy users, which is one of the primary sources of ionizing radiation. Therefore, risks from exposure to these radiations need to be appraised. This study aimed to estimate orthopedic surgeons’ knowledge and awareness in Saudi Arabia regarding radiation safety and fluoroscopy use. Methods: This cross-sectional study was conducted from May to August 2020. A total of 150 replies were received from various cities in Saudi Arabia to an 18‑item questionnaire. It covered frequency of radiation exposure, safety measures used, and training for radiation safety and fluoroscopy use. Results: The study showed a broad unfortunate negative-associated trend in surgeons’ knowledge, with the training of radiation safety and fluoroscopy use, especially for eye and hand‑related safety precautions. However, 61% of male surgeons and 48.6% of female surgeons were significantly worried about diseases caused by radiation exposure. Conclusion: This study revealed that most orthopedic surgeons in Saudi Arabia have a limited background on ionizing radiation risks and safe fluoroscopy use. Awareness of radiation safety is required for the well‑being of orthopedic surgeons.
... surgeon's lifetime when compared to healthcare workers unexposed to radiation [4]. Several aspects such as the type of surgery, type of C-arm, the position of the C-arm and distance of the surgeon from it, the radiation dose, mode of use (pulse or fluoro) and the operating surgeon's experience, all influence the amount of radiation received [1,5,6]. Organizations such as the International Commission on Radiological Protection (ICRP) and Atomic Energy Regulatory Board (AERB) of India have given guidelines on radiation safety and established standards for the same [7,8]. ...
Article
Background: In spite of frequent exposure to radiation, orthopaedic surgeons lack knowledge about radiation safety and do not comply with safety practices. We surveyed orthopaedic trainees and consultants in India to determine their knowledge and practices regarding radiation safety. Methods: A questionnaire with 16 multiple choice questions was sent out using Google forms. We included practicing orthopaedic surgeons (consultants), fellows and trainees pursuing DNB, MS and D. Ortho courses across India. Results: We received 439/700 responses (62.7% response rate) from 233 (53.1%) consultants and 206 (46.9%) trainees. Only 71 (16.2%) were aware of the ALARA (As Low As Reasonably Achievable) principle. While lead aprons were always used by 379 (86.3%), thyroid shields were never used by 302 (68.8%) respondents. Knowledge about the ALARA principle was significantly associated with radiation safety practices. A significantly greater proportion of participants who were aware about the ALARA principle always used lead aprons (OR 1.15; 95% CI 1.0 to 1.2, p = 0.001) and thyroid shields (OR 2.00; 95% CI 1.0 to 3.7, p = 0.029) and had their dosimeters checked within the last 1 year (OR 1.69; 95% CI 1.0 to 2.8, p = 0.039) when compared to those who were not aware of the ALARA principle. Almost 99% respondents expressed interest in participating in a radiation safety training program. Conclusion: A majority of the respondents were keen to obtain training in radiation safety. We believe that professional organizations and hospitals could initiate training programs for the orthopaedic community in India to improve their radiation safety knowledge and practices.
... Although direct evidence linking adverse health effects to orthopaedic occupational radiation exposure is limited, there are indirect evidence from historical and proceduralist literature indicating that orthopaedic surgeons should continue to follow the principle of "as low as reasonably achievable" to minimize occupational radiation exposure. Gausden EB et al. [21] performed a prospective study to assess the amount of cumulative radiation exposure received by 16 orthopaedic surgeons and 24 residents in various subspecialties. They reported that residents and attending surgeons performing trauma or deformity surgical procedures were exposed to significantly higher doses of radiation compared to those with other subspecialties within orthopaedic surgery, although their doses did not exceed the recommended tolerance. ...
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Article
Introduction When locking intramedullary nails, inserting the distal interlocking screw accurately and quickly with less radiation exposure is very important. The purpose of this randomized control study was to compare radiation exposure and accuracy of distal locking screws between free-hand fluoroscopic guidance and the use of a distal targeting system (DTS). Materials and methods Inclusion criteria of this study were patients older than 60 years who need an intramedullary nailing due to unstable intertrochanteric and subtrochanteric fracture. The primary outcome was the attempt numbers of image intensifier during the insertion of distal locking screws. Secondary outcomes were operative time and angles between distal locking screws and nail. Results A total of 36 patients participated in the study. Eighteen patients using free-hand fluoroscopic guidance were assigned to Group I while 18 patients using DTS were assigned to Group II. The number of attempts of image intensifier during distal screw insertion (57.3 ± 31.42 vs. 11.5 ± 7.41, p < 0.001), ratio of attempt number for distal screws to the total attempts (0.33 ± 0.21 vs. 0.12 ± 0.08, p = 0.001), the number of hand exposure to image intensifier directly (75.0 ± 29.55 vs. 13.5 ± 19.07, p < 0.001), and the time of radiation exposure during distal screws insertion (42.57 ± 2.42 s vs. 12.72 ± 8.10 s, p < 0.001) were significantly lower in Group II compared to those in Group I. And, operation time (96.3 min ± 18.94 vs. 76.1 min ± 14.10, p < 0.001) was also statistically significantly lower in Group II. Both distal locking screws were significantly closer to perpendicular direction to the nail in Group II. Conclusion The attempt number of image intensifier during the insertion of two distal locking screws was significantly reduced with DTS compared with that with free hand fluoroscopic guidance. Angle between distal locking screws and nail was also more accurate using DTS.
... Ionizing radiation is a concern for patients and, especially, for surgeons and operating room staff who are exposed to it continuously over time. [27][28][29][30][31] Many of the recently introduced technologies for distal interlocking aim to reduce radiation exposure by decreasing the number of radiographic images required to perform the procedure. 7,[32][33][34][35] In the current study, we found that both the mean and the variance of the number of fluoroscopic images acquired were lower when using VAF for distal interlocking. ...
Article
Background We aimed to assess the feasibility of a video‐augmented fluoroscopy (VAF) technique using a camera‐augmented mobile C‐arm (CamC) for distal interlocking of intramedullary nails. Methods Three surgeons performed distal interlocking on seven pairs of cadaveric bovine carpal bones using the VAF system and conventional fluoroscopy. We compared radiation exposure, procedure time and drilling quality between the VAF system and conventional fluoroscopic guidance. Results Distal interlocking using VAF significantly reduced the number of fluoroscopic images compared to conventional fluoroscopy (P<0.05). No significant difference in overall procedure time (P=0.96) or drilling quality (P=0.12) was detected. VAF demonstrated improvement in radiation exposure when used by a less experienced surgeon (P<0.05). Conclusion VAF is a feasible technique for distal interlocking. Overlaid visualization of the osseous anatomy in relation to the surgical field of view appears to improve surgeons’ perception of relevant structures and their spatial orientation for the use of surgical instruments.
... However, the medical staff suffered cumulative radiation exposure during every surgery, especially for the spine surgeons. When comparing radiation exposure experienced by a spine surgeon to other orthopedic subspecialties, a spine surgeon sees 50 times the lifetime radiation dose compared to that of a hip surgeon [24]. The authors in [25] have demonstrated that, in the case of the Oarm system, there exists little to no scatter at distances beyond approximately 4 m. ...
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Article
Objective There is a steep learning curve with traditional percutaneous endoscopic lumbar discectomy (PELD). The aim of this study is to assess the safety and efficacy of PELD assisted by O-arm-based navigation for treating lumbar disc herniation (LDH). Methods From September of 2017 to January of 2018, 118 patients with symptomatic LDH were enrolled in the prospective cohort study. The patients undergoing PELD with O-arm-based navigation technique were defined as group A (58 cases), and those undergoing traditional X-ray fluoroscopy method were defined as group B (60 cases). We recorded the operation time, cannula placement time, radiation exposure time, visual analog scale (VAS), Oswestry Disability Index (ODI), and Macnab criteria score of the 2 groups. Results The average operation time (95.21 ± 19.05 mins) and the cannula placement time (36.38 ± 14.67 mins) in group A were significantly reduced compared with group B (operation time, 113.83 ± 22.01 mins, P<0.001; cannula placement time, 52.63 ± 17.94 mins, P<0.001). The learning curve of PELD in group A was steeper than that in group B and was lower in the relatively flat region of the end. There were significant differences of the clinical parameters at different time points (VAS of low back, P < 0.001; VAS of leg, P < 0.001; and ODI, P < 0.001). The VAS scores for low back pain and leg pain improved significantly in both groups after surgery and gradually improved as time went by. No serious complication was observed in any patients in either group. Conclusion The study indicated that PELD assisted by O-arm navigation is safe, accurate, and efficient for the treatment of lumbar intervertebral disc herniation. It reshaped the learning curve of PELD, reduced the difficulty of surgery, and minimized radiation exposure to surgeons. This study was registered at Chinese Clinical Trail Registry (Registration Number: ChiCTR1800019586).
Article
Due to its many benefits, fluoroscopy-guided intraoperative orthopedic surgery treatments are proliferating. However, during the fluoroscopic guided interventional (FGI) procedures, orthopedists were exposed to substantial radiation doses from primary and dispersed radiation. This study aims to quantify the annual ionizing radiation exposure to personnel during orthopedic surgery operations. Twenty-eight employees in all the orthopedic departments were under observation, including 11 (39.5%) nurses and 17 (60.7%) orthopedic surgeons (one female and 16 males). The yearly effective dosages were observed for two years in a row (2019 and 2020). Thermoluminecnt dosimeters(TLD-100: LiF: Mg, Ti) were utilized to assess the exposure levels of the staff. High-frequency generators and the ability to retain the last radiograph are features of C-arm machines. Owing to the rise need for fluoroscopic guided intraoperative orthopedic surgery, nurses and medical doctors, including orthopedic surgeons, received yearly effective doses (Hp(10)) with averages, standard deviations, and ranges of 0.960 (0.4–1.48) and 0.810 (0.44–1.3), respectively. According to the current orthopedic surgery department practice, the study's findings indicated that the personnel is adequately safeguarded.
Article
Background Standardized education on the short and long-term health hazards of radiation and thus the awareness regarding current radiation exposure limits is restricted in the field of orthopaedics. There is a lack of awareness regarding the risks related to radiation exposure amongst orthopaedic surgeons and therefore the recommended safety precautions to assess and mitigate these potential risks should be emphasized. Orthopaedic surgeons should adopt the ALARA (as low as reasonably achievable) principle. All precautions should be taken to keep all members of the operation room safe from radiation exposure and safeguard patients too. Methods The survey questionnaire developed in consult with senior orthopaedic surgeons and radiation protection officer consisting of 27 questions was conducted among the orthopaedic surgeons and resident doctors. Results 15% responders were unaware about risks of radiation exposure in routine orthopaedic surgery and 82% unaware of the recommended yearly allowance per individual. 30% responders were unaware of correct positioning of the C-arm and 44% were unaware regarding the same distance to be maintained from the C-arm to reduce radiation exposure. 27% responders were unaware regarding pulsed fluoroscopy and its benefits. 45% responders were unsure regarding the thickness of the lead apron. 83% never use a thyroid gland shield and none of the responders use leaded eye glasses. Only 11% responders use lead badges for documentation of radiation exposure. Conclusion Orthopaedic surgeons should understand the basics and basis of radiation exposure limits, be familiar with this literature on the incidence of tumors, dermatitis, cancer risk and cataracts and understand the current intraoperative fluoroscopy safety recommendations. The damaging effects to human tissue caused by radiation exposure are documented since the first reports regarding use of radiographs, hence emphasis on radiation safety and protection should be universally incorporated into graduate medical education.
Chapter
Modern surgery still relies greatly on the knowledge and manual skills of the individual surgeon. Years of training are needed to hone the skills necessary for safe and effective patient management. In the evaluation of a patient, the clinical information is supplemented by radiological imaging such as CT and MRI. The experienced surgeon plans the surgery aided by the aggregated preoperative information. Despite all preparations, surgery still involves the manipulation of complex and dynamic 3D structures, and human errors cannot be eliminated. Surgical navigation systems can improve surgical precision through the alignment of 3D radiological information to the patient in the operating room (OR). Although navigation systems display imaging data in standardized views such as axial, sagittal, and coronal, none of them truly represents the perspective of the surgeon. Navigation systems adopting augmented reality (AR) differ from other systems by providing the surgeon with visual information matching the surgeon’s perspective. The possibility to superimpose virtual data on the surgeon’s view of the surgical field offers a new dimension to surgical navigation, and great technological strides have brought AR into the OR. In this chapter, a summary of the state-of-the-art AR navigation solutions for spine surgery will be presented.
Article
Objectives To perform a dose assessment of radiation received to the surgeon’s gonads when performing upper limb fluoroscopy-guided procedures when the C-arm may be positioned in between the surgeon’s legs. Methods A calibrated MDH-Radcal 2025 electrometer was used to read the radiation dose for a single exposure and a 5-s screening radiograph with the C-arm firing up and down. These were performed with and without a lead gown positioned over the ionisation chamber where it would ordinarily lie over gonads during surgery. Results With the tube firing down and lead apron in place the single exposure (SE) recorded<0.01 uSv and screening exposure (SC) recorded 0.01 uSv. With the tube firing up, with lead the SE recorded 0.09 uSv and the SC 0.54 uSv. In the same situation without lead, the recordings were 0.13 uSv SE and 0. 65 uSv SC. Conclusions With the X-ray tube firing up, there is a measurable radiation dose to the area where the surgeons’ gonads lie. The standard lead apron does not provide shielding of the gonads for a surgeon sitting down performing the operation with the tube firing up since the principal source of the radiation is below the edge of the apron and thus scatters up into the unprotected groin. Advances in knowledge Fluoroscopy with conventional C-arm in upper limb procedures can cause scatter irradiation to gonads. The X-ray beam should always be fired from top to bottom otherwise large doses can be emitted and the lead gown is less protective.
Article
Introduction. The literature review deals with the effects of ionizing radiation and radiation on the body of medical personnel. Materials and methods. 50 actual sources were analyzed. The relevance of the study of the constant, long-term influence of low doses of radiation is shown, in view of the increasing use of sources of ionizing radiation in various fields of scientific and practical human activity, including medicine. Results. Thanks to the analysis of numerous literature data, it was revealed that operating doctors, who are faced in their work with sources of ionizing radiation, often do not have a sufficient level of protection of the thyroid tissue from radiation. It was revealed that the overwhelming majority of studies highlighting thyroid pathology in medical personnel working with X-rays are aimed at identifying the risks of thyroid cancer and does not take into account the pathology of non-tumor genesis. Analyzed the data of scientific publications, allowing to draw a conclusion about the effects of chronic exposure to ionizing radiation, namely X-rays, in low doses on the thyroid tissue from a morphological and functional point of view. Discussion. It was established on the basis of the analysis of experimental data that under the influence of low-dose X-ray radiation, the intercellular contacts of thyrocytes are disconnected, which can lead to a decrease in the synthesis of thyroid hormones and, as a consequence, to the development of hypothyroidism. Conclusion. Based on the analysis of the experimental data, it has been established that under the influence of low-dose X-rays there is a disconnection of intercellular contacts of thyrocytes, which may lead to a decrease in the synthesis of thyroid hormones and, consequently, to the development of hypothyroidism.
Article
Objectives Using proximal femoral nailing (PFN) in the lateral decubitus (lateral) position may be an option when no traction table is available. We hypothesized that applying PFN would be effective and reliable in the lateral position without a traction table. To test our hypothesis, we compared the two techniques in a prospective, randomized controlled study. Patients and methods Eighty patients (> 60 years of age) with unstable intertrochanteric fractures were randomly operated on prospectively in the lateral position without a traction table (Group 1) or in the supine position with a traction table (Group 2) between April 2018 and April 2019. We compared the surgery preparation time, total anesthesia time, duration of surgery, fluoroscopy exposure time, and amount of bleeding between the two procedures. The type-apex distance (TAD), collodiaphyseal angle (CDA), reduction quality, and lag quadrant were measured radiologically. The Harris Hip Score (HHS) was also calculated. Results The mean follow-up time was 18.5 (14–27) months in Group 1 and 19.9 (14–27) months in Group 2. The mean follow-up time, mean age, sex distribution, and fracture pattern were similar between the groups. The preparation time and total anesthesia time of Group 2 were longer than those of Group 1, and the fluoroscopy time of Group 2 was shorter than that of Group 1 (p < 0.05). No significant differences in surgical time, bleeding amount, TAD, CDA, target lag quadrant, reduction quality, or the HHS were observed between the two groups. Conclusions We concluded that PFN is a safe and effective alternative for the treatment of unstable intertrochanteric femoral fractures when a traction table is not available in the operating room.
Article
Résumé Introduction Quotidiennement, le chirurgien du pied et de la cheville utilise un mini-amplificateur de brillance. Nous avons souhaité quantifier son exposition aux radiations ionisantes. Hypothèse L’exposition aux rayons X pour un chirurgien du pied et de la cheville utilisant un mini-amplificateur de brillance était inférieure aux doses limites autorisées par l’autorité de sureté nucléaire (20 mSv/an pour le corps et le cristallin, 150 mSv/an pour la thyroïde et 500 mSv/an pour la peau et les extrémités). Matériel et méthodes Il s’agissait d’une série prospective, monocentrique, mono-opérateur, réalisée entre février 2014 et décembre 2017. Sur cette période, les doses émises par le mini-amplificateur, d’un champ de 15 centimètres, étaient répertoriées pendant les 1064 interventions. Les doses reçues par le chirurgien ont été recueillies par trois dosimètres passifs (thorax, oculaire et main) et un actif. Une valeur de p inférieure à 5 % a été considérée comme statistiquement significative. Résultats 64,4 % des interventions concernaient l’avant-pied, 35,3 % l’arrière-pied et la cheville et 0,3 % étaient exclusivement percutanées. Le produit dose-surface moyen par intervention était de 3,9 cGy/cm² ± 7. Pour la chirurgie de l’avant-pied il était de 1,1 cGy/cm² ± 0,9, pour la chirurgie de la cheville et de l’arrière-pied de 8,7 cGy/cm² ± 9,7 (p < 0,05), avec une durée moyenne de rayonnement de respectivement 7,6 secondes ± 5,3 et 36,7 secondes ± 35,5 pour un nombre de clichés de respectivement 4,1 ± 2,7 et 18,7 ± 20,5. Les reprises de prothèse totale de cheville étaient les chirurgies les plus irradiantes : 20,1 cGy/cm² ± 14,7. La dosimétrie active quotidienne moyenne était de 2,2 microSv ± 1,4. L’irradiation annuelle moyenne pour la main, le cristallin et le corps entier profond Hp(10) et superficiel Hp(0,07) était respectivement de 1,28 mSv, 0,6 mSv, 0,31 mSv et 0,19 mSv. L’exposition annuelle la plus importante a été retrouvée pour les mains : 2,68 mSv en 2015. Nous avons retrouvé, entre la dosimétrie active quotidienne et la dose quotidienne émise par le mini-amplificateur de brillance une relation linéaire significative : dosimétrie active quotidienne = (dose quotidienne émise par l’amplificateur × 0,11) + 0,54. Leur coefficient de corrélation était de 0,77. Discussion/conclusion L’exposition du chirurgien du pied et de la cheville, utilisant un mini-amplificateur de brillance, était très inférieure aux seuils limites mais également aux résultats de la littérature. Niveau de preuve IV.
Article
Introduction: Foot and ankle surgeons make daily use of mini-C-arm fluoroscopes. The present study aimed to quantify associated radiation doses. Hypothesis: X-ray exposure for foot and ankle surgeons using a mini-C-arm fluoroscope is below the nuclear safety authority authorized doses of 20 mSv/year for the whole body and crystalline lens, 150 mSv/year for the thyroid and 500 mSv/year for the skin and limbs. Material and methods: A single-center, single-surgeon prospective series was treated between February 2014 and December 2017. Doses emitted by the mini-C-arm (15cm field) were recorded during 1,064 operations. Doses received by the surgeon were recorded by 3 passive dosimeters (thorax, eyes and hands) and 1 active dosimeter. The significance threshold was set at p<0.05. Results: 64.4% of procedures concerned the forefoot, 35.3% the hindfoot and ankle, and 0.3% were strictly percutaneous. Mean dose-area product (DAP) per procedure was 3.9 cGy/cm2 ± 7: in forefoot surgery, 1.1 cGy/cm2 ± 0.9, and in hindfoot and ankle surgery 8.7 cGy/cm2 ± 9.7 (p < 0.05), for mean irradiation times of 7.6sec ± 5.3 and 36.7sec ± 35.5 respectively and image numbers 4.1 ± 2.7 and 18.7 ± 20.5. Total ankle replacement was associated with the highest doses: 20.1 cGy/cm2 ± 14.7. Mean daily active dosimetry was 2.2μSv ± 1.4. Mean annual dose to the hand, crystalline lens and deep (Hp(10)) and shallow (Hp(0.07)) whole body was respectively 1.28 mSv, 0.6 mSv, 0.31 mSv and 0.19 mSv. The highest annual exposure was recorded for the hands: 2.68 mSv in 2015. There was a significant linear relationship between daily active dosimetry and daily emission: daily active dosimetry = (DAP x 0.11) + 0.54, for a correlation coefficient of 0.77. Discussion/conclusion: The exposure of foot and ankle surgeons using mini-C-arms was well below threshold, and also lower than in the literature. Level of evidence: IV.
Article
The sustained use of intraoperative fluoroscopy has led to increased use of minimally invasive surgical techniques, enhanced surgeon proficiency, improved anatomic corrections, reduced patient morbidity, earlier functional recovery, and decreased length of hospital stay. As a result, orthopedic attending surgeons and residents are exposed to more radiation, increasing the risk of cancer and radiation-induced cataracts compared with the general population and those who work in other surgical specialties. The magnitude of radiation exposure depends on the susceptibility of the tissues affected, medical specialty, the position of the C-arm, distance from the radiation beam, level of difficulty of the surgical procedure, surgeon experience, level of resident training, and level of supervision by the attending surgeon. However, little information is available on the effect of supervision level on radiation exposure for orthopedic senior residents. The goal of this study was to investigate whether level of supervision by the attending surgeon affects the radiation exposure of orthopedic senior residents during surgical treatment of proximal femur fracture with cephalomedullary nail fixation. This retrospective cohort study was performed from January 2019 to March 2019. No significant relationship between supervision level and radiation exposure of senior residents was observed. Supervision level does not significantly affect radiation exposure for senior residents; therefore, the implementation of standardized training in radiation safety may be a more essential measure to decrease radiation exposure. [Orthopedics. 2021;44(3):e402-e406.].
Article
Background This study aimed to assess orthopedic surgeons’ attitudes and behaviors toward occupational radiation exposure and investigate the prevalence of occupational radiation-induced skin injury among orthopedic surgeons. Similarly, risk factors for the presence of radiation-induced skin injury were investigated. Methods Overall, 108 orthopedic surgeons were administered self-reported questionnaires about occupational radiation exposure, and their hands were then photographed. Their fields of expertise were classified into spine, arthroplasty, sports medicine, hand, oncology, rheumatoid arthritis, pediatric orthopedic, and resident. Dermatologists evaluated the surgeons’ skin conditions and classified into 3 grades of injury: grade 0, no clinical symptoms; grade 1, careful observation required; and grade 2, detailed examination required. Logistic regression analysis was performed to investigate the factors related to the presence of radiation-induced skin injury. Crude and adjusted logistic regression analysis using the backward stepwise selection method was similarly conducted. Receiver operating characteristic curve (ROC) analysis was performed to estimate the predictive power of exposure time, occupational period, and accumulated annual exposure time for radiation-induced skin injury. Results In total, 93.5% of the surgeons were careful about occupational radiation exposure, of which 76.8% used a dosimeter. Skin changes in the hands were self-reported by 42.5% of the surgeons, and radiation-induced skin injury was diagnosed in 31.4%. The accuracy of the self-reported skin changes was 100% for grade 2 and 61.5% for grade 1. Adjusted regression analysis showed that dermatologists’ diagnosis-related factors were self-reported skin changes (odds ratio [OR] 3.1) and spine surgeons (OR 3.2). ROC analysis demonstrated that an occupational period >21 years and an accumulated exposure time >6696 min were considered risk factors, with ORs of 4.07 and 5.99, respectively. Conclusions Orthopedic surgeons, particularly spine surgeons, should be regularly examined by dermatologists early in their careers for early detection of radiation-induced skin injury on the hands.
Article
Surgeons are exposed to occupational hazards daily. Risks include chemical, biological, and physical hazards that place providers in serious harm. Departmental policies or written guides to help pregnant surgeons navigate the hospital is lacking. In response to the scarcity in the literature, we have summarized current guidelines and recommendations to aid surgeons in making an informed decision. In addition, we present a brief narrative of the impact of these exposures during pregnancy, methods of transmission, and where relevant, include specialties that are at risk of these exposures.
Article
Objectives: To quantify the amount of radiation exposure from a commercially available computed tomography surgical imaging system that occurs in areas of the operating room that are generally believed to be safe and to correlate these amounts with established safety recommendations. Design: Experimental in vitro study. Setting: Standard hospital operating room at a level one trauma center. Participants: Radiation survey instruments at specified distances from an intraoperative computed tomography scanner. Represented positions were the location of the anesthesiologist (80cm), the radiation technologist (180cm), the substerile room (500cm), the operating room door (600cm), the next-room nursing station (960cm), and the hallway (1000cm). Intervention: Radiation survey instruments were systematically exposed by a protocol intended to imitate expected radiation scatter during operative room use. Main outcome measurements: Radiation exposure readings from radiation survey instruments RESULTS:: Mean radiation exposure rates are reported. Mean exposure rate was highest at the anesthesiologist (2200 mrem/hr), followed by the door (25.33 mrem/hr), the technologist (21.0 mrem/hr), the substerile room (8.2 mrem/hr), the hallway (2.633 mrem/hr), and then the next-room nursing station (1.557 mrem/hr). The mean integrated doses per scan were 15.03 mrem for the anesthesiologist, 0.170 mrem for the technologist, 0.136 mrem at the door, 0.033 mrem in the substerile room, 0.014 mrem in the hallway, and 0.005 mrem at the next-door nursing station. The exposure was related both to distance from the machine as well as to orientation from the machine. Conclusions: These results indicate that although there is measurable radiation exposure outside of the operating room, the magnitude is low enough to be clinically insignificant. This study provides data that reinforces the need to wear protective gear or leave the room during the use of intraoperative CT, but unsuspecting surrounding staff need not worry about uninformed exposure.
Article
Objective: To compare surgical duration and clinical outcomes with associated complications in surgeons using gamification techniques for resident education versus those surgeons who do not. Design: Retrospective, cohort study. Level III evidence. Surgical interventions included long cephalomedullary nailing with gamification techniques compared to long cephalomedullary nailing alone. Main outcome measurements were total fluoroscopy time, operative time, hospital length of stay, discharge status, and complications. Setting: Urban Level 1 Trauma Center. Participants: One fourty-eight adult patients with operative intertrochanteric femur fractures from January 2010 to January 2019. Results: There were lower total operative times (45.6 vs. 57.1 minutes, p =< 0.01) and fluoroscopy times (1.6 vs. 2.1 minutes, p = 0.01) in the gamification group. There were no significant differences between groups in patient demographics, fracture pattern, postoperative complications, length of hospital stay, total follow-up, total ICU stay time, or discharge to extended care facility versus home. Conclusions: Gamification techniques with use of long cephalomedullary nails are a valid approach to the treatment of intertrochanteric femur fractures. This approach demonstrates equivalent outcomes postoperatively to nongamification treatment of intertrochanteric femur fractures, with the potential advantage of decreased operative and fluoroscopic times.
Article
Objective: To identify if residents are at greater risk for radiation exposure from intraoperative fluoroscopy while earlier in their training and during more complex procedures. Methods: We analyzed 852 extra-capsular proximal femur fracture fixation cases. We compared fluoroscopy times by various levels of resident training, fracture type, and implant used. Attending only cases were used as a control group. Results: Fluoroscopy times during subtrochanteric fracture fixation (176.1 ± 11.27 seconds) were longer than intertrochanteric (111.4 ± 2.44 secs) and basicervical fractures (91.49 ± 5.77 secs). Long nail (150.2 ± 3.75 secs) times were longer than short (92.3 ± 3.15 secs) and intermediate (76.45 ± 3.01 secs) nails. Significantly more fluoroscopy was utilized in junior (115.9 ± 4.24 secs), senior (123.0 ± 6.08 secs), junior combo (130.6 ± 7.74 secs) and senior combo cases (131.8 ± 6.11 secs) compared to the control (94.91 ± 3.91). Conclusion: Orthopaedic surgery residents and attendings must remain aware of radiation exposure secondary to intra-operative fluoroscopy. Appropriate personal protective equipment should be worn, and more experienced surgeons should take a more active role in the complex cases to decrease exposure risk. Level of evidence: Prognostic, Level III.
Article
Purpose: To describe an algorithm for arthroscopic reduction and minimally invasive surgery (ARMIS) and compare the surgical outcomes with standard open reduction-internal fixation (ORIF) for the treatment of supination-external rotation (SER) ankle fractures. Methods: The inclusion criteria for this study were patients aged 16 years or older, the presence of a unilateral SER fracture, and injuries less than 2 weeks old. We retrospectively identified patients with SER fractures who underwent ORIF from January 2008 to December 2011 or ARMIS from January 2012 to December 2015. Data collected in December 2013 for the ORIF group and in December 2017 for the ARMIS group were compared. The algorithm for ARMIS was minimally invasive plating for lateral malleolar fractures first, followed by ankle arthroscopy for detection of syndesmotic injuries and then arthroscopic reduction of medial malleolar fractures or mini-open repair of the deltoid ligament. The talocrural angle, fibular length, tibiomedial malleolar angle, medial clear space, and tibiofibular clear space were measured radiographically. Functional evaluations included the visual analog scale pain score, American Orthopaedic Foot & Ankle Society ankle-hindfoot scales, and range of motion of bilateral ankles. Complications and reoperations were recorded for comparison. Results: A total of 105 patients with SER fractures, 65 in the ARMIS group and 40 in the ORIF group, were included. Significantly lower incidences of complications (7.7% vs 27.5%, P = .006) and reoperations (1.5% vs 12.5%, P = .029) were found in the ARMIS group than in the ORIF group. More syndesmotic injuries were detected in the ARMIS group than in the ORIS group (80% vs 57.5%, P = .021). The visual analog scale pain score was significantly lower on day 3 postoperatively in the ARMIS group than in the ORIS group (1.96 ± 1.18 vs 2.83 ± 1.07, P = .027). The postoperative stay was shorter in the ARMIS group than in the ORIF group (3.66 ± 1.39 days vs 4.46 ± 2.23 days, P = .024). The operative time was longer in the ARMIS group than in the ORIS group (105.22 ± 27.13 minutes vs 93.59 ± 22.79 minutes, P = .038). A longer fluoroscopic time (0.43 ± 0.25 minutes vs 0.17 ± 0.07 minutes, P < .001) and a higher dose of irradiation (1,216.46 ± 603.99 μGy vs 389.38 ± 217.89 μGy, P < .001) were observed in the ARMIS group. No significant differences in radiographic measurements were found between the operative and nonoperative ankles in both groups. Conclusions: Our algorithm and the ARMIS techniques may be a safe, reliable, and effective option in the treatment of SER fractures. ARMIS achieves promising surgical outcomes with less early postoperative pain, a shorter postoperative stay, and lower incidences of complications and reoperations compared with ORIF. However, the operative time is longer and the irradiation dose is higher with the ARMIS techniques. Level of evidence: Level III, retrospective comparative study.
Article
Introduction: Percutaneously-placed sacroiliac (SI) screws are currently the gold-standard fixation technique for fixation of the posterior pelvic ring. The relatively high prevalence of sacral dysmorphism in the general population introduces a high risk of cortical breach with resultant neurovascular damage. This study was performed to compare the accuracy of SI screw placement with and without the use of intraoperative navigation, as well as to externally validate the sacral dysmorphism score in a trauma patient cohort. Patients and methods: All trauma patients who underwent sacroiliac screw fixation for pelvic fractures at a level 1 trauma centre over a 6 year period were identified. True axial and coronal sacral reconstructions were obtained from their pre-operative CT scans and assessed qualitatively and quantitatively for sacral dysmorphism - a sacral dysmorphism score was calculated by two independent assessors. Post-operative CT scans were then analysed for breaches and correlated with the hospital medical records to check for any clinical sequelae. Results: 68 screws were inserted in 36 patients, most sustaining injuries from road traffic accidents (50%) or falls from height (36.1%). There was a male preponderance (83.3%) with the majority of the screws inserted percutaneously (86.1%). Intraoperative navigation was used in 47.2% of the patient cohort. 30.6% of the cohort were found to have dysmorphic sacra. The mean sacral dysmorphism scores were not significantly different between navigated and non-navigated groups. Three cortical breaches occurred, two in patients with sacral dysmorphism scores >70 and occurring despite the use of intraoperative navigation. There was no significant difference in the rates of breach between navigated and non-navigated groups. None of the breaches resulted in any clinically observable neurovascular deficit. Conclusion: The sacral dysmorphism score can be clinically applied to a cohort of trauma patients with pelvic fractures. In patients with highly dysmorphic sacra, reflected by high sacral dysmorphism scores, intraoperative navigation is not in itself sufficient to prevent cortical breaches. In such patients it would be prudent to consider instrumentation of the lower sacral corridors instead.
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Background There is much uncertainty about the risks of leukaemia and lymphoma after repeated or protracted low-dose radiation exposure typical of occupational, environmental, and diagnostic medical settings. We quantified associations between protracted low-dose radiation exposures and leukaemia, lymphoma, and multiple myeloma mortality among radiation-monitored adults employed in France, the UK, and the USA. Methods We assembled a cohort of 308 297 radiation-monitored workers employed for at least 1 year by the Atomic Energy Commission, AREVA Nuclear Cycle, or the National Electricity Company in France, the Departments of Energy and Defence in the USA, and nuclear industry employers included in the National Registry for Radiation Workers in the UK. The cohort was followed up for a total of 8·22 million person-years. We ascertained deaths caused by leukaemia, lymphoma, and multiple myeloma. We used Poisson regression to quantify associations between estimated red bone marrow absorbed dose and leukaemia and lymphoma mortality. Findings Doses were accrued at very low rates (mean 1·1 mGy per year, SD 2·6). The excess relative risk of leukaemia mortality (excluding chronic lymphocytic leukaemia) was 2·96 per Gy (90% CI 1·17–5·21; lagged 2 years), most notably because of an association between radiation dose and mortality from chronic myeloid leukaemia (excess relative risk per Gy 10·45, 90% CI 4·48–19·65). Interpretation This study provides strong evidence of positive associations between protracted low-dose radiation exposure and leukaemia.
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Article
Orthopedic trainees are assessed during training regarding their use of radiological screening during operative procedures. The authors investigated whether orthopedic trainees' use of fluoroscopic screening during ankle fixation operations varied with the 2 variables of consultant supervision and trainee experience. Data from operative fixation of isolated Weber B ankle fractures were reviewed. The intraoperative radiation dose was retrieved from radiographers' data. Operations performed by consultants were used as a control group (n=25 patients). Trainee supervision was assessed as "trainer in operating room (OR)" and "trainer out of OR." Regarding experience, the patients were divided into those operated on primarily by trainees in their first (n=36 patients) and in their last (n=34 patients) 3 years of formal specialist training. All trainee groups used more radiation than consultants. Supervision did not affect the radiation use of senior trainees (P<.05). Senior trainees used less radiation than their junior peers (P<.02). Junior trainees supervised by a trainer in the OR used less radiation than junior trainees supervised by a trainer outside of the OR (P<.05). During open reduction and internal fixation of ankle fractures, junior orthopedic trainees use less intraoperative radiation when they are supervised by a trainer in the OR. The more experience a surgeon has, the less fluoroscopic screening is used during operative ankle fixation.
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Article
Background Various procedures, especially minimal invasive techniques using fluoroscopy, pose a risk of radiation exposure to orthopaedic staff. Anatomical sites such as the eyes, thyroid glands and hands are more vulnerable to radiation considering the limited use of personal protective devices in the workplace. The objective of the study is to assess the annual mean cumulative and per procedure radiation dose received at anatomical locations like eyes, thyroid glands and hands in orthopaedic staff using systematic review. Methods The review of literature was conducted using systematic search of the database sources like PUBMED and EMBASE using appropriate keywords. The eligibility criteria and the data extraction of literature were based on study design (cohort or cross-sectional study), study population (orthopaedic surgeons or their assistants), exposure (doses of workplace radiation exposure at hands/fingers, eye/forehead, neck/thyroid), language (German and English). The literature search was conducted using a PRISMA checklist and flow chart. Results Forty-two articles were found eligible and included for the review. The results show that radiation doses for the anatomical locations of eye, thyroid gland and hands were lower than the dose levels recommended. But there is a considerable variation of radiation dose received at all three anatomical locations mainly due to different situations including procedures (open and minimally invasive), work experience (junior and senior surgeons),distance from the primary and secondary radiation, and use of personal protective equipments (PPEs). The surgeons receive higher radiation dose during minimally invasive procedures compared to open procedures. Junior surgeons are at higher risk of radiation exposure compared to seniors. PPEs play a significant role in reduction of radiation dose. Conclusions Although the current radiation precautions appear to be adequate based on the low dose radiation, more in-depth studies are required on the variations of radiation dose in orthopaedic staff, at different anatomical locations and situations.
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Article
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.
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.
Article
Objectives: The use of fluoroscopy for indirect guidance in orthopaedic trauma surgery has increased. The purpose of this investigation is to assess how real-time visualization of radiation exposure impacts dose levels during orthopaedic trauma operations. Design: Observational comparative study SETTING:: Level 1 trauma center orthopaedic trauma surgery operating room PATIENTS/PARTICIPANTS:: The participants in this study were 83 patients with fractures of the ankle, tibia, femur or acetabulum receiving definitive surgical fixation of their fracture; children under 18 years of age were excluded from the study. Fellowship trained orthopaedic trauma surgeons, resident orthopaedic surgeons, radiology technicians, and scrub nurses involved in the operations on included fracture patients were also participants. Intervention: Real-time radiation exposure feedback from the Philips DoseAware device. Main outcome measurements: Radiation exposure from fluoroscopy compared between Phase 1, during which participants were blinded to exposure levels, and Phase 2, during which participants were able to see exposure levels in real time. Results: Overall mean radiation exposure was decreased by 60% in phase 2 as compared with phase 1 (p=0.023). Mean surgeon (MS; average of primary and assistant surgeon) and mean non-surgeon personnel (MNSP; average of xray technician, scrub nurse, and patient) radiation exposure were decreased from phase 1 to phase 2, by 58% and 80% respectively (MS p=0.034; MNSP p=0.043). From phase 1 to phase 2, MS radiation for femoral shaft fractures decreased by 80% or 162.0 μSv (p=0.02) and by 81% or 128.9 μSv (p=0.014) for acetabular fractures. Discussion: Our data demonstrate that real-time visualization of radiation exposure during orthopaedic trauma operations can decrease radiation exposure in the highest exposure cases. Further research is necessary to determine if the reduction in radiation exposure is sustained over time and to understand how real-time radiation exposure data mitigates exposure. Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Article
Radiation protection is becoming more important with an ongoing increase in radiation exposure due to the use of X-rays in minimally invasive procedures in orthopaedic and trauma surgeries. However, sufficient education in medical physics and radiation protection can often be improved. A questionnaire consisting of four questions about personal data and ten questions about radiation protection was distributed to lead consultants, consultants, residents, medical students, and medical technical assistants at two institutions, a level 1 trauma center and a children's hospital. This study consisted of 83 participants. The compliance with radiation protection, i.e., usage of a dosimetry, an apron, and a thyroid shield on a regular basis was only seen in 54 %. Participants from the trauma center wore a dosimeter and thyroid shield significantly more often. The regular use of a thyroid shield differed significantly between job positions. It was observed in 80 % of students, but only 15 % of technical assistants. Only 65 % of all knowledge questions were answered correctly. There was a discrepancy between incorrectly answered knowledge questions (35 %) and those marked as uncertain (20 %). Different job positions did not have an impact on the answers to the questions in most instances. The compliance with and the knowledge about radiation protection seems to be unnecessarily low in trauma physicians and technical assistants. The discrepancy in falsely answered questions and those marked as uncertain may suggest that participants may overestimate their knowledge about radiation protection, which is potentially harmful due to the increased radiation exposure. Therefore, we advocate a quick and valuable training of trauma surgeons and medical staff addressing the important preventive measures, some of which are illustrated in the present study. These consist of wearing dosimetry and protection devices, reduction in X-ray duration, preferably antero-posterior C-arm positioning with the image intensifier close to the patient and the surgeon, maximal distance, collimation, and increased voltage. Furthermore, the use of visual feedback on complex and potentially hazardous radiation facts may be useful for training purposes. Cross-sectional study with a questionnaire.
Article
Background: Closed reduction and percutaneous pinning of a pediatric supracondylar fracture of the humerus requires operating directly next to the C-arm to hold reduction and perform fixation under direct imaging. This study was designed to compare radiation exposure from two C-arm configurations: with the image intensifier serving as the operating surface, and with a radiolucent hand table serving as the operating surface and the image intensifier positioned above the table. Methods: We used a cadaveric specimen in this study to determine radiation exposure to the operative elbow and to the surgeon at the waist and neck levels during simulated closed reduction and percutaneous pinning of a pediatric supracondylar fracture of the humerus. Radiation exposure measurements were made (1) with the C-arm image intensifier serving as the operating surface, with the emitter positioned above the operative elbow; and (2) with the image intensifier positioned above a hand table, with the emitter below the table. Results: When the image intensifier was used as the operating surface, we noted 16% less scatter radiation at the waist level of the surgeon but 53% more neck-level scatter radiation compared with when the hand table was used as the operating surface and the image intensifier was positioned above the table. In terms of direct radiation exposure to the operative elbow, use of the image intensifier as the operating surface resulted in 21% more radiation exposure than from use of the other configuration. The direct radiation exposure was also more than two orders of magnitude greater than the neck and waist-level scatter radiation exposure. Conclusions: Traditionally, there has been concern over increased radiation exposure when the C-arm image intensifier is used as an operating surface, with the emitter above, compared with when the image intensifier is positioned above the operating surface, with the emitter below. We determined that, although there was a statistically significant difference in radiation exposure between the two configurations, neither was safer than the other at all tested levels. Clinical relevance: In contrast to traditional teaching regarding radiation exposure, neither C-arm configuration-with the image intensifier serving as the operating surface or with the image intensifier positioned above a radiolucent hand table-was shown to be clearly safer for pediatric supracondylar humeral fracture fixation.
Article
Purpose: To determine and compare the radiation exposure to surgeons' hands with large and mini C-arm fluoroscopy in a practical, clinically based model. Methods: Two hand surgeons monitored radiation exposure to their hands with a ring dosimeter over a 14-month period using large and mini C-arm fluoroscopic units. One surgeon performed all cases with a large C-arm unit in a hospital setting, and the other performed all cases with mini C-arms in surgical centers. For each case, fluoroscopic time, the output displayed by the unit, radiation by time, and ring dosimeter absorption were recorded and analyzed. Results: A total of 160 consecutive cases were reviewed with 71 cases and 89 cases in the large and mini C-arm groups, respectively. The median output displayed by the large C-arm was 0.7 mGy/case, and the median output displayed by the mini C-arm was 10.0 mGy/case. With output as a product of time, the median calculated values were 0.02 mGy/s for the large C-arm group and 0.28 mGy/s for the mini C-arm group. Cumulative ring dosimeter absorption to the surgeons' hands was found to be 380 mrem for 71 cases in the large C-arm group versus 1,000 mrem for 89 cases in the mini C-arm group. Conclusions: In our model, the use of the mini C-arm resulted in more than a 10-fold increase in the rate of output and approximately double the dosimeter absorption to the surgeon's hand compared with the large C-arm. Although it has been shown that the mini C-arm produces less radiation scatter, in a practical model, it may not be a safer alternative with respect to the surgeon's hands. Based on these findings, we recommend that surgeons be more aware of radiation exposure risk, know their C-arm unit's specifications, and try to minimize radiation exposure. Type of study/level of evidence: Prognostic II.
Article
Direct beam radiation exposure to the surgeon, especially to their hands, is extremely common during supracondylar humerus fracture pinnings and results in exposure to significantly greater doses of ionizing radiation when compared with scatter radiation. The purpose of this study was to determine how often surgeons are exposed to direct beam radiation during this surgery and whether the C-arm position and the surgeon's experience influence radiation exposure. In this double blind study, we collected 3842 fluoroscopic still images from 78 closed reduction and percutaneous pinning surgeries for supracondylar humerus fractures performed or supervised by 6 attending surgeons. The percentage of images containing a surgeon's body was calculated as an indicator of direct beam radiation exposure. Total fluoroscopy time, C-arm position (standard or inverted), and whether the primary surgeon was an attending, resident, or both were recorded. Nonparametric statistical analyses were performed. Fluoroscopy lasted for a median of 34 seconds, and the surgeon was exposed to direct beam radiation in a median of 13% of fluoroscopy films, with exposure ranging from 0% to 97% per surgery. Fluoroscopy was significantly longer when the C-arm position was inverted when compared with the standard position (43 vs. 26 s, P=0.034). Surgeons' exposure to direct beam radiation was also slightly greater when the C-arm position was inverted (16% vs. 10%, P=0.087). The duration of fluoroscopy exposure and the percentage of films with the body exposed to radiation did not differ based on whether the surgery was performed by an attending, a resident, or both (P=0.53 and 0.28, respectively). However, the percentage of films with bodily radiation exposure did significantly differ between the attending physicians (P=0.029). Direct beam radiation exposure varied widely between surgeries and surgeons, ranging from none to nearly constant exposure. Surgical time also significantly increased with the C-arm in the inverted position compared with the standard position. Given the significant variation in exposure between attending physicians, it is likely that exposure to direct beam radiation can be avoided with improved awareness about the risk of direct beam radiation exposure and cautious surgical technique. Not applicable.
Article
Study design:: Prospective in vivo investigation of fluoroscopic radiation exposure during spinal surgery. Objective:: To quantify the total amount of radiation dosage and identify techniques to maintain safe levels of fluoroscopic exposure in the operating room. Summary of background data:: No previous study has performed an in vivo examination of fluoroscopic radiation exposure to the spinal surgeon and operating room personnel. Previous similar studies were in vitro, employed older versions of fluoroscopy, and increased fluoro times associated with pedicle screw placement. Methods:: Thirty-five surgeries were evaluated in 18 males and 17 females (mean age 52.4 y, range 26.0-79.4). Surgeries included 37 lumbar levels fused, 45 lumbar decompressions, 8 anterior cervical fusions, and 19 TLIF procedures. Spinal instrumentation was implemented in all fusion procedures (104 lumbar pedicle screws, 14 iliac, 22 anterior cervical). Radiation dosimetry was obtained through unprotected badges placed on surgeon's chest, first assistant chest, cranial and caudal end of operating table. Results:: Total fluoroscopic time was 37.01 minutes. Mean fluoroscopic time with lumbar spine instrumentation was greater than decompression alone (1.74 min vs 0.22 min). Total fluoroscopic radiation exposure was obtained for surgeon (1225 mrem), first assistant (369 mrem), cranial table (92 mrem) and caudal table (150 mrem). Mean dose/minutes (mrem/min) was calculated for surgeon (33.1), first assistant (9.97), cranial table (2.48), and caudal table (4.05). To remain below the maximum yearly permissible level of radiation, the estimated total number of minutes for the surgeon would be 453. Conclusion:: The results of this in vivo study indicate fluoroscopic dosage to the spine surgeon remains below the annual maximum limit of radiation exposure. Increasing distance from radiation source led to a significantly diminished in vivo dosimetry reading. Monitoring fluoroscopic time and maintaining a distance from the beam source, radiation exposure to the spine surgeon may be kept within current safety standards.
Article
To determine whole body and hand radiation exposure to the hand surgeon wearing a lead apron during routine intraoperative use of the mini C-arm fluoroscope. Four surgeons (3 hand attending surgeons and 1 hand fellow) monitored their radiation exposure for a total of 200 consecutive cases (50 cases per surgeon) requiring mini C-arm fluoroscopy. Each surgeon measured radiation exposure with a badge dosimeter placed on the outside breast pocket of the lead apron (external whole body exposure), a second badge dosimeter under the lead apron (shielded whole body exposure), and a ring dosimeter (hand exposure). Completed records were noted in 198 cases, with an average fluoroscopy time of 133.52 seconds and average cumulative dose of 19,260 rem-cm(2) per case. The total measured radiation exposures for the (1) external whole body exposure dosimeters were 16 mrem (for shallow depth), 7 mrem (for eye depth), and less than 1 mrem (for deep depth); (2) shielded whole body badge dosimeters recorded less than 1 mrem; and (3) ring dosimeters totaled 170 mrem. The total radial exposure for 4 ring dosimeters that had registered a threshold of 30 mrem or more of radiation exposure was 170 mrem at the skin level, for an average of 42.5 mrem per dosimeter ring or 6.3 mrem per case. This study of whole body and hand radiation exposure from the mini C-arm includes the largest number of surgical cases in the published literature. The measured whole body and hand radiation exposure received by the hand surgeon from the mini C-arm represents a minimal risk of radiation, based on the current National Council on Radiation Protection and Management standards of annual dose limits (5,000 mrem per year for whole body and 50,000 mrem per year to the extremities).
Article
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
Occupational radiation exposure was measured using three film badges and one ring thermoluminescent dosimeter. The radiation dose in the hospital but outside the operating room was measured as zero for the 12-month period. The measured trunk dose in the operating room was 5 mrem, and the measured dose to the head and neck region was 227 mrem. For selected orthopedic procedures a ring thermoluminescent dosimeter was worn on the left ring finger (under a lead glove when appropriate) and measured 0 mrem. The measured occupational radiation exposure to the author was well below the recommendations of the U.S. National Committee on Radiation Protection for maximal permissible dose. However, caution is advised since the long-term biologic effects of exposure to low doses of radiation are not well known. Since many factors influence the amount of radiation to individual surgeons, the data obtained are not necessarily representative.
Article
We prospectively evaluated the radiation exposure during 50 consecutive fluoroscopically assisted anterior cruciate ligament reconstructions. Three different methods of anterior cruciate ligament reconstruction were performed using either rolled fascia lata allograft or bone-tendon-bone autograft. For the 50 procedures, total time using the fluoroscope was 119.61 minutes, or 2.38 minutes per procedure. The 16 primary fascia lata allograft reconstructions averaged 1.38 minutes of fluoroscope use per procedure compared with 4.69 minutes for the two revision allograft fascia lata surgeries, 3.14 minutes per procedure for the 30 primary bone-tendon-bone reconstructions, and 4.18 minutes per procedure for the two surgeries performed with an allograft meniscal transplant. The difference in exposure time between the 16 primary allograft fascia lata surgeries and the 30 primary allograft or autograft bone-tendon-bone surgeries was statistically significant. The average radiation exposure to the surgeon was 0.67 mrem per minute of fluoroscope use. It would take 7463.08 minutes of fluoroscope time, or 11,139 primary fascia lata allograft reconstructions, to exceed the recommended occupational exposure limit of 5000 mrem per year. It appears that the orthopaedic surgeon receives minimal radiation when using the fluoroscope to assist in anterior cruciate ligament reconstruction, especially when doing a primary fascia lata allograft procedure.
Article
The hands of the surgeon are most likely to be directly exposed to ionizing radiation during fluoroscopic screening in the orthopaedic theatre. There is however little information available on the level of exposure to radiation during the normal working pattern of individual surgeons. The purpose of this study was to directly measure the radiation exposure to the hands during fluoroscopic screening in a series of consecutive cases over a month in order to establish whether these staff need to be designated classified persons, and if not, whether they need to be routinely monitored. Extremity monitoring was carried out using thermoluminescent dosimeters. The dosimeter was secured to the operating surgeon's dominant index finger. 44 procedures were carried out by nine different surgeons. The total radiation dose received per surgeon ranged from 48-2329 microSv. In 80% of procedures the dose of radiation to the surgeon's hand was less than 100 microSv. The extrapolated annual dose, even for the surgeon with the highest radiation exposure, was well below the annual dose limit for extremities of 500 mSv per year recommended by the International Commission on Radiological Protection, and embodied in the Ionizing Radiations Regulations 1985. Despite the relatively low doses of radiation received by surgeons in this study, occupational exposure to all personnel should be kept to the lowest practicable levels, and a review of procedures, including dose measurements, from time to time is advised.
Article
A study aimed to establish the level of radiation exposure to orthopaedic surgeons involved in the care of injured patients; parts of the body most at risk, and to establishing whether surgeon control of X-ray image intensification reduced the risk. This was conducted on five orthopaedic surgeons regularly involved in musculoskeletal care. Radiation dosage (in millisieverts (mSv) to the body, neck, eyes and hands, was measured by means of dosimeters applied to these areas, before and after surgeon-controlled use of X-ray image intensification. Although all doses measured were within current safety guidelines (1.25 mSv total body dose/month, 3.75 mSv eye dose/month and 12.5 mSv extremity dose/month), the hands were most at risk (maximum recorded dosage 3.95 mSv/month). Control by the surgeons of X-ray image intensification significantly reduced exposure of the hands (P < 0.05).
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
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
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
This paper reviews the current knowledge of cosmic radiation and its applicability to commercial aviation. Galactic cosmic radiation emanates from outside the solar system, while occasionally a disturbance in the suns' atmosphere leads to a surge in radiation particles. Protection is provided by the suns' magnetic field, the earths' magnetic field, and the earths' atmosphere. Dose rates are dependent on the altitude, the geomagnetic latitude and the solar cycle. For occupational exposure to ionising radiation, which includes aircrew, the International Commission on Radiological Protection recommends maximum mean body effective dose limits of 20mSv/yr (averaged over 5 years, with a maximum in any 1 year of 50mSv). Radiation doses can be measured during flight or may be calculated using a computer-modelling program such as CARI, EPCARD, SIEVERT or PCAIRE. Mean ambient equivalent dose rates are consistently reported in the region of 4-5microSv/h for long-haul pilots and 1-3microSv/h for short-haul, giving an annual mean effective exposure of the order 2-3mSv for long-haul and 1-2mSv for short-haul pilots. Epidemiological studies of flight crew have not shown conclusive evidence for any increase in cancer mortality or cancer incidence directly attributable to ionising radiation exposure. Whilst there is no level of radiation exposure below which effects do not occur, current evidence indicates that the probability of airline crew or passengers suffering adverse health effects as a result of exposure to cosmic radiation is very low.
Radiation exposure of Filipino orthopedic residents in tertiary level hospitals
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Rosario MS, Garduce VP, Geronilla MB, Sison JKT, Pasion ELC. Radiation exposure of Filipino orthopedic residents in tertiary level hospitals. J Bone Rep Rec. 2015.
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Hsu RY, Lareau CR, Kim JS, Koruprolu S, Born CT, Schiller JR. The effect of C-arm position on radiation exposure during fixation of pediatric supracondylar fractures of the humerus. J Bone Joint Surg Am. 2014 Aug 6;96(15):e129. 27. Goldstone KE, Wright IH, Cohen B. Radiation exposure to the hands of orthopaedic surgeons during procedures under fluoroscopic X-ray control. Br J Radiol. 1993 Oct;66(790):899-901.
Radiation exposure of Filipino orthopedic residents in tertiary level hospitals
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Occupational radiation protection in interventional radiology: a joint guideline of the Cardiovascular and Interventional Radiology Society of Europe and the Society of Interventional Radiology
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