Orthopaedic surgeons' use and knowledge of ionizing radiation during surgical treatment for femoroacetabular impingement

Radiation exposure doses to the surgical team during hip surgery is significantly higher during lateral imaging than posteroanterior imaging: a cadaveric simulation study

BACKGROUND

Fluoroscopy is indispensable when determining appropriate and effective interventions in orthopedic surgery. On the other hand, there is growing concern about the health hazards of occupational radiation exposure. The aim of this cadaveric simulation study was to measure radiation exposure doses to the surgical team during hip surgery.

METHODS

We reproduced the intraoperative setting of hip surgery using 7 fresh frozen cadavers (5 male, 2 female) to simulate patients and mannequins to simulate the surgeon, scrub nurse, and anesthesiologist. Six real-time dosimeters were mounted at sites corresponding to the optic lens, thyroid gland, chest, gonads, foot, and hand on each mannequin. The radiation exposure dose to each team member was measured during posteroanterior and lateral fluoroscopic imaging.

RESULTS

Radiation exposure doses to the surgeon were significantly higher during 3 min of lateral imaging than during 3 min of posteroanterior imaging at the optic lens (8.1 times higher), thyroid gland (10.3 times), chest (10.8 times), and hand (19.8 times) (p = 0.018, p = 0.018, p = 0.018, and p = 0.018, respectively). During lateral imaging, the radiation doses to the nurse were 0.16, 0.12, 0.09, 0.72, and 0.38 times those to the surgeon at the optic lens, thyroid, chest, gonads, and foot, respectively. The radiation dose to the anesthesiologist was zero at all anatomic sites during posteroanterior imaging and very small during lateral imaging.

CONCLUSIONS

Radiation exposure dose was significantly higher during lateral imaging up to 19.8 times comparing to the posteroanterior imaging. It is effective to reduce the lateral imaging time for reducing the intraoperative radiation exposure. In addition, appropriate distance from fluoroscopy resulted in very low exposure for nurses and anesthesiologists. Surgeon should pay attention that surgical staff do not get closer than necessary to the irradiation field.

Therapeutic Efficacy and Safety of Percutaneous Curved Vertebroplasty in Osteoporotic Vertebral Compression Fractures: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis is aimed to provide higher quality evidence regarding the efficacy and safety between PCVP and PVP/KP in OVCFs. We searched the Cochrane Library, PubMed, Web of Science, and Embase databases for all randomized controlled trials (RCTs) and observational studies (cohort or case-control studies) that compare PCVP to PVP/KP for OVCFs. The Cochrane Collaboration's Risk of Bias Tool and Newcastle-Ottawa Scale (NOS) were used to evaluate the quality of the RCTs and non-RCTs, respectively. Meta-analysis was performed using RevMan 5.4 software. A total of seven articles consisting of 562 patients with 593 diseased vertebral bodies were included. Statistically significant differences were found in the postoperative visual analog scale (VAS) at 1 day (MD = -0.11; 95% CI: [-0.21 to -0.01], p = 0.03), but not at 3 months (MD = -0.21; 95% CI: [-0.41-0.00], p = 0.05) or 6 months (MD = 0.03; 95% CI: [-0.13-0.20], p = 0.70). There was no statistically significant difference in postoperative Oswestry disability index (ODI) at 1 day (MD = -0.28; 95% CI: [-0.62-0.05], p = 0.10), 3 months (MD = -1.52; 95% CI: [-3.11-0.07], p = 0.06), or 6 months (MD = 0.18; 95% CI: [-0.13-0.48], p = 0.25). Additionally, there were no statistically significant differences in Cobb angle (MD = 0.30; 95% CI: [-1.69-2.30], p = 0.77) or anterior vertebral body height (SMD = -0.01; 95% CI: [-0.26-0.23], p = 0.92) after surgery. Statistically significant differences were found in surgical time (MD = -8.60; 95% CI: [-13.75 to -3.45], p = 0.001), cement infusion volume (MD = -0.82; 95% CI: [-1.50 to -0.14], P = 0.02), and dose of fluoroscopy (SMD = -1.22; 95% CI: [-1.84 to -0.60], p = 0.0001) between curved and noncurved techniques, especially compared to bilateral PVP. Moreover, cement leakage showed statistically significant difference (OR = 0.40; 95% CI: [0.27-0.60], p < 0.0001). Compared with PVP/KP, PCVP is superior for pain relief at short-term follow-up. Additionally, PCVP has the advantages of significantly lower surgical time, radiation exposure, bone cement infusion volume, and cement leakage incidence compared to bilateral PVP, while no statistically significant difference is found when compared with unilateral PVP or PKP. In terms of quality of life and radiologic outcomes, the effects of PCVP and PVP/KP are not significantly different. Overall, this meta-analysis reveals that PCVP was an effective and safe therapy for patients with OVCFs.

Enhancing Radiation Safety Culture: Investigating the Mediating Role of Awareness Among Orthopedic Doctors and Operation Theatre Assistants

INTRODUCTION

The increasing use of minimally invasive orthopedic procedures has led to a greater reliance on fluoroscopy, resulting in elevated radiation exposure for surgeons. This study aimed to evaluate the knowledge, awareness, and daily practices of orthopedic surgeons regarding radiation safety in an academic hospital. Understanding radiation safety is crucial to minimize patient exposure and prevent adverse effects on surgeons.

METHODS

This cross-sectional study was conducted at the Department of Orthopedics of different tertiary care hospitals in Rawalpindi, Pakistan. Data were collected prospectively for two years, and a total of 505 participants, including residents, consultants, and operation theatre assistants, completed a questionnaire. The questionnaire was validated by experts and covered information on fluoroscopy usage, frequency of surgeries, awareness of radiation safety, and protective measures. Ethical approval was obtained, and data were analyzed using SPSS version 26.0.

RESULTS

The majority of participants were male (74.1%), and the sample included various ranks of orthopedic surgeons. Only 56.2% of participants were aware of the usage of fluoroscopy, and 40.2% had read some research on the topic. While 44.6% used lead aprons for radiation protection, the usage of other protective measures and dosimeters was limited. The mediation analysis showed an insignificant indirect association between the rank of orthopedic surgeons, number of surgeries performed, and fluoroscopy usage as a mediator. Awareness and reading research on fluoroscopy were significantly associated with radiation protection.

CONCLUSION

The knowledge, awareness, and daily practices of orthopedic surgeons regarding radiation safety in fluoroscopy use need improvement. The findings emphasize the importance of implementing training programs, providing radiation protection devices, and ensuring compliance with safety guidelines.

[Intraoperative imaging of children and adolescents, for selected fractures and in follow-up after conservative and operative treatment : Part 2 of the results of a nationwide online survey of the Pediatric Traumatology Section of the German Trauma Society]

The indication for radiographic examinations in pediatric and adolescent trauma patients should follow ALARA (as low as reasonably achievable). Because of the effect of radiation on the growing sensitive tissues of these young patients, a strict indication should always be given for radiation use and during controls after fracture repair.

METHODS

An online survey by the Pediatric Traumatology Section (SKT) of the German Trauma Society (DGU) from Nov. 15, 2019, to Feb. 29, 2020, targeting trauma, pediatric, and general surgeons and orthopedic surgeons.

RESULTS

Participants: 788. Intraoperative applications: Collimation 50% always, postprocessing for magnification 40%, pulsed x-ray 47%, and 89% no continuous fluoroscopy; 63% osteosynthesis never directly on image intensifier. Radiographic controls after implant removal never used by 24%. After operated supracondylar humerus fracture, controls are performed up to 6 times. After distal radius greenstick fracture, 40% refrain from further X-ray controls, after conservatively treated clavicular shaft fracture, 55% refrain from further controls, others X-ray several times. After nondisplaced conservatively treated tibial shaft fracture, 63% recommend radiographic control after 1 week in two planes, 24% after 2 weeks, 37% after 4 weeks, and 32% after 6 weeks.

DISCUSSION

The analysis shows that there is no uniform radiological management of children and adolescents with fractures among the respondents. For some indications for the use of radiography, the benefit does not seem evident. The ALARA principle does not seem to be consistently followed.

CONCLUSION

Comparing the documented results of the survey with the consensus results of the SKT, differences are apparent.

Are Indian orthopaedic surgeons aware of the health hazards of radiation exposure? A survey and review on awareness and ways to mitigate them

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.

Occupational Hazards to the Joint Replacement Surgeon: Radiation Exposure

BACKGROUND

Intraoperative fluoroscopy is an essential tool to assist orthopedic surgeons in accurately and safely implanting hardware. In arthroplasty cases, its use is on the rise with the increasing popularity of the direct anterior (DA) approach for THA. However, exposure of ionizing radiation poses a potential health risk to surgeons. While the benefits of intraoperative fluoroscopy in DA THA is becoming clearer, and are well-described in the literature, the potential health dangers associated with career-long cumulative radiation exposure are rarely discussed.

METHODS

In this article, we review the available literature to discuss radiation safety in orthopedics with a focus on total joint arthroplasty. We present the basic science of radiation, discuss the amount of radiation exposure in orthopedic surgery, and review the potential health risks associated with long-term exposure.

CONCLUSION

Overall, the radiation dose exposure to arthroplasty surgeons is low and within recommendations for occupation exposure limits. However, due to the stochastic health impacts of ionizing radiation, there is no threshold dose below which radiation exposure is truly safe. Therefore, it is imperative that surgeons practice proper fluoroscopy safety habits, such as wearing proper protective equipment, minimizing fluoroscopy time and magnification, and maximizing distance from the radiation source to minimize the life-long cumulative radiation exposure and associated health risks.

What is the adult experience of Perthes' disease? : initial findings from an international web-based survey

AIMS

Perthes' disease is an uncommon hip disorder with limited data on the long-term outcomes in adulthood. We partnered with community-based foundations and utilized web-based survey methodology to develop the Adult Perthes Survey, which includes demographics, childhood and adult Perthes' disease history, the University of California Los Angeles (UCLA) Activity Scale item, Short Form-36, the Hip disability and Osteoarthritis Outcome Score, and a body pain diagram. Here we investigate the following questions: 1) what is the feasibility of obtaining > 1,000 survey responses from adults who had Perthes' disease using a web-based platform?; and 2) what are the baseline characteristics and demographic composition of our sample?

METHODS

The survey link was available publicly for 15 months and advertised among support groups. Of 1,505 participants who attempted the Adult Perthes survey, 1,182 completed it with a median timeframe of 11 minutes (IQR 8.633 to 14.72). Participants who dropped out were similar to those who completed the survey on several fixed variables. Participants represented 45 countries including the USA (n = 570; 48%), UK (n = 295; 25%), Australia (n = 133; 11%), and Canada (n = 46; 4%). Of the 1,182 respondents, 58% were female and the mean age was 39 years (SD 12.6).

RESULTS

Ages at onset of Perthes' disease were < six years (n = 512; 43%), six to seven years (n = 321; 27%), eight to 11 years (n = 261; 22%), and > 11 years (n = 76; 6%), similar to the known age distribution of Perthes' disease. During childhood, 40% (n = 476) of respondents had at least one surgery. Bracing, weightbearing restriction, and absence of any treatment varied significantly between USA and non-USA respondents (p < 0.001, p = 0.002, and p < 0.001, respectively). As adults, 22% (n = 261) had at least one total hip arthroplasty, and 30% (n = 347) had any type of surgery; both more commonly reported among women (p = 0.002).

CONCLUSION

While there are limitations due to self-sampling, our study shows the feasibility of obtaining a large set of patient-reported data from adults who had childhood Perthes' from multiple countries. Cite this article: Bone Jt Open 2022;3(5):404-414.

Assessment of Health Professionals' Attitudes on Radiation Protection Measures

(1) Background: Health professionals' knowledge, beliefs and perceptions concerning radiation protection may affect their behaviour during surgery and consequently influence the quality of health services. This study highlights the health professionals' average knowledge level and captures the beliefs, perceptions, and behaviours in a large public Greek hospital. (2) Materials and Methods: A cross-sectional study was carried out, including health professionals working in operating rooms. One hundred thirty-two staff members participated by responding to an original questionnaire. The sample consisted of nurses, radiographers and medical doctors of various specialties involved daily in surgical procedures where ionizing radiation is required. The survey was conducted from March to June 2021, and the response rate was 97%. (3) Results: The level of overall knowledge of health professionals regarding radiation protection safety was not satisfactory. Females and employees with a lower level of education had more misconceptions about radiation and radiation protection. Employees of younger ages and with less previous experience were more likely to have negative emotions towards radiation exposure. Finally, employees with fewer children tended to express physical complaints caused by their negative emotions due to radiation exposure. (4) Conclusions: Health professionals' lack of basic and specialized knowledge concerning radiation protection safety had a negative impact on the provision of health services. The continuing training of the staff seemed to be the only solution to reverse this trend. The training should highlight how radiation exposure can be minimized, safeguarding health professionals' trust and sense of security by significantly improving their working environment.

What we know about intra-operative radiation exposure and hazards to operating theatre staff: A systematic review

BACKGROUND

The widespread adoption of minimally invasive surgery and increased use of intra-operative fluoroscopy places surgeons and trainees at risk of cumulative occupational radiation exposure. Unfortunately, there is limited published data specific to surgeons on the potential health implications. This study aims to review current literature regarding the hazards of cumulative radiation exposure among operating theatre staff.

METHODS

A systematic review was conducted of four databases for studies reporting on cumulative intra-operative radiation exposure for operating theatre staff and the hazards associated with prolonged and frequent use. References from relevant studies were screened for additional texts. English language studies, controlled trials and cross-sectional studies were included. Abstracts and full-text studies were assessed for relevance and eligibility independently by two authors using Covidence.

RESULTS

Six studies were included, with cancer being the most commonly reported long-term health hazard possibly associated with cumulative radiation exposure. A 1.85 fold greater prevalence of all cancers and 2.9 fold greater prevalence of breast cancer was reported amongst female orthopaedic surgeons compared to a sex- and age-adjusted population, but the results were not replicated amongst other surgical specialties. Multiple limitations of quantifying health risks of intra-operative radiation exposure were identified, including identifying a dose-effect relationship and confounders such as nulliparity and maternal age.

CONCLUSION

This article highlights the lack of robust evidence regarding the potential hazards of cumulative occupational intra-operative radiation exposure. This study demonstrates the importance of developing standardised national radiation safety protocols for surgical colleges and subspecialties to minimise risks to operating theatre staff.

Radiation exposure in fluoroscopy-guided anterior total hip arthroplasty: a systematic review

PURPOSE

To investigate the average fluoroscopy time, as well as the patient and surgical staff average radiation exposure in the context of intraoperative fluoroscopy use during anterior total hip arthroplasty (THA).

METHODS

PubMed, Cochrane, Embase, Web of Science and Scopus were systematically searched for studies pertaining to intraoperative anterior THA fluoroscopy (PROSPERO ID 258049). The comprehensive literary search was conducted using "THA," "fluoroscopy" and "radiation exposure" as the search criteria, which resulted in 187 total papers. Of these 187 papers, 11 studies were included in this systematic review as they involved anterior THA and specifically contained data regarding radiation exposure dose and/or time.

RESULTS

Eleven studies were included, enrolling 1839 patients. The average fluoroscopy time was 21.4 (95% confidence interval [CI] 16.6-26.1) seconds, whereas the average patient radiation dose was 1.8 × 10^-3 (95% CI 7.4 × 10^-4-2.9 × 10^-3) Gy.

CONCLUSIONS

Although several studies fail to report fluoroscopy time and radiation dose in THA patients, fluoroscopy-guided THA has emerged as a safe procedure. Additional studies may analyze if radiation exposure during the surgeon's THA learning curve is significantly higher, as well as what protocols may potentially reduce radiation exposure even further.

Beliefs and behaviours of radiographers and other health professionals concerning radiation protection safety in a high-volume Greek public hospital. Development of a new measuring instrument

INTRODUCTION

The use of fluoroscopy-assisted surgical procedures has been increasing recently. The extensive use of fluoroscopy, combined with the lack of knowledge about radiation risks among operating room (OR) personnel (surgeons, anaesthetists, nurses, and radiographers), may lead to misconceptions. The perceptions and beliefs of any health professional concerning radiation protection safety (RPS) may affect their behaviour during surgery, leading to negative outcomes. The aim of this study was to construct a new, original, reliable, and valid instrument to record the beliefs, perceptions, and behaviours of health professionals during surgery, which reflects the established culture of RPS.

METHODS

A questionnaire was designed, consisting of 95 questions grouped into six coherent sections. The study was performed at a Greek public hospital with a high workload in terms of fluoroscopically guided surgical operations.

RESULTS

It was distributed among 136 people, and 132 completed questionnaires were collected (response rate 97%). Exploratory factor analysis was performed separately for each scale studied and Cronbach's Alpha reliability analysis was also performed. The reliability of the greater part of the new measurement tool ranged from very good to acceptable.

CONCLUSION

The questionnaire developed in this study is a valid and reliable option for recording health professionals' perceptions, beliefs, and behaviours concerning the RPS culture.

IMPLICATIONS FOR PRACTICE

This study helps clinical radiographers to understand a possible knowledge gap about RPS and locates the specific fields that the OR personnel misunderstand. It also can support and establish local learning organisations with regular targeted staff training for health professionals, thereby leading to a generally improved RPS culture.

The Impact of Unguided Trauma Simulation Practice on Novice Performance: A Randomized Controlled Trial

INTRODUCTION

The purpose of this investigation was to determine the impact of simulator practice on task completion time, radiation use, success rate, and overall quality in a simulation of placing a distal locking screw.

METHODS

This was a prospective, randomized control trial with one-to-one randomization and parallel group design. Twenty-eight volunteer novice trainees (medical and premedical students) participated. Using the TraumaVision Virtual Reality Simulator (Swemac, Sweden), subjects performed locking screw placement using the "perfect circle" technique. All subjects underwent a pretest and posttest on the simulator. The simulator group completed three additional simulator training sessions. The primary outcome variables were simulator-collected task completion time, success rate, radiation exposure time, and overall score.

RESULTS

No notable difference existed between groups for pretest completion time, radiation use, success rate, or overall score. No notable difference in posttest radiation use or overall procedure score was found between groups. A significant difference existed in posttest total completion time (trained = 251.2 ± 103.4; control = 497.3 ± 223.1; P = 0.001) and success rate (64.3% versus 100%; P = 0.041) between groups. In addition, a significant difference existed in variance between groups for completion time (P = 0.029).

CONCLUSIONS

These findings suggest that independent simulator practice leads to improved speed and success rates; however, radiation use and overall score do not improve in the same manner. The design of simulator-based curriculum must be tailored to specific educational objectives and ultimately validated in the clinical setting.

Is It Safe to Use a Lead Screen During Hip Arthroscopy?

Purpose

To assess the radiation attenuation of lead screens in comparison to lead gowns in a simulated hip arthroscopy setting.

Methods

In this quantitative laboratory study, a phantom pelvis was used to simulate the scatter produced by patients during hip arthroscopy. Radiation measurements were taken using a handheld radiation detector positioned perpendicular to the phantom pelvis at 1.5 m and 2 m. Measurements were taken without shielding as a control, behind a lead gown (0.4-mm lead equivalent), and behind a lead screen (0.5-mm lead equivalent).

Results

With the detector at 1.5 m perpendicular to the hip, equivalent radiation was attenuated by the lead screen (94%) and the lead gown (94%). With the detector at 2 m perpendicular to the hip, the lead screen at 1.7 m attenuated 95% of radiation.

Conclusions

In hip arthroscopy, using lead screens is a safe and more comfortable alternative to wearing lead gowns. The lead screen should be at least 1.2 m from the radiation source, with the surgeon standing closely behind the screen, fully covered.

Clinical Relevance

Lead screens can be safely used in hip arthroscopy.

Tips, quips and pearls: Ultrasound-guided distal metatarsal minimal invasive osteotomy (US-DMMO)

Metatarsalgia is a frequent cause of forefoot pain. Surgical treatment is based on the performance of osteotomies at the level of the minor radii to restore a normal distribution of pressure within the forefoot and improve the biomechanics during gait. In recent years, percutaneous surgery of the foot, and specifically distal metatarsal minimal invasive osteotomy, have proven to be a valid technique, providing satisfactory clinical results, similar to open osteotomy with less soft tissue aggression, but it requires intraoperative fluoroscopy to be performed. This article will present a modification to guide the procedure by ultrasound providing a new option that eliminates radiation and provides greater portability and accessibility.

What can we learn from surveys? A systematic review of survey studies addressing femoroacetabular impingement syndrome

The purpose of this study was to systematically review the methodology, response rate and quality of survey studies related to femoroacetabular impingement (FAI) syndrome. A search was conducted on three databases (PubMed, EMBASE, MEDLINE) for relevant studies from database inception to 27 January 2020. Data extracted included study and survey characteristics, as well as response rates. The quality of the included studies was also assessed using a previously published quality assessment tool. Data were analysed with means, ranges, standard deviations, 95% confidence intervals and bivariate analysis. Eleven studies (13 surveys) were included in this review out of a total of 1608 initial titles found. Surveys were most often administered via the Internet (72%) to orthopaedic surgeons (54%). The mean response rate was 70.4%. The mean quality score was moderate 13.3/24 (SD ±4.3). The criterion that most often scored high was ‘clearly defined purpose and objectives’ (11/11). The most common survey topic investigated surgeons’ knowledge regarding FAI diagnosis and management (n = 7). In addition, bivariate analysis between quality score and response rate showed no significant correlation (Spearman’s rho = −0.090, P = 0.85). Overall, survey studies related to FAI syndrome most often use Internet-based methods to administer surveys. The most common target audience is orthopaedic surgeons. The topics of the surveys most often revolve around orthopaedic surgeons’ knowledge and opinions relating to the diagnosis and management of FAI syndrome. The response rate is high in patient surveys and lower in larger surgeon surveys. Overall, the studies are of moderate quality.

Radiation Safety Knowledge and Practices: Is the Indian Orthopaedic Community Well-informed?

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.

Intraoperative radiation exposure in hip arthroscopy: a systematic review

Fluoroscopy is used in hip arthroscopy (HA) for portal placement, instrument localisation, and guidance in bony resection. The recent increase in arthroscopic hip procedures may place patients and surgeons at risk for increased radiation exposure and radiation-induced complications. The purpose of the current systematic review was to assess intraoperative radiation exposure in HA. The systematic review was conducted according to PRISMA guidelines; inclusion criteria were studies assessing radiation exposure in HA. 9 studies including 994 patients were included. Mean age was 38.6 years and 48% (436 of 906) were female. Mean time of fluoroscopy exposure was 0.58 minutes. Dose area product was 129.5 cGycm². Mean intraoperative absorbed radiation dose studies was 12.6 mGy. Mean intraoperative effective dose was 0.48 mSv. The mean occupational exposure to the surgeon per case was 0.0031 mSv. Higher patient body mass index (BMI) correlated to greater patient effective and cumulative dose (p < 0.05, r = 0.404), and greater occupational exposure (p < 0.001, r = 0.460). Increasing surgeon experience decreased fluoroscopy time (p = 0.039) and radiation dose (p = 0.002). Radiation dose and effective dose were well under the thresholds for deterministic effects (2 Gy) and annual radiation exposure for occupational workers (20 mSv). Intraoperative radiation exposure to patients and surgeons is within acceptable annual radiation limits. Ensuring careful selection of perioperative imaging modalities, proper protective shielding, specifically the use of leaded eyeglasses, and optimal C-arm positioning are key strategies to reduce radiation exposure to patients and surgeons alike.

The knowledge, awareness and practices of radiation safety amongst orthopaedic surgeons

Background

Fluoroscopic imaging in orthopaedic theatres is increasing, with added risk to the orthopaedic surgeon who is increasingly being exposed to ionising radiation. It is thus crucial for orthopaedic surgeons to have a working knowledge of radiation safety. In spite of these concerns, however, many orthopaedic surgeons do not receive standard training in radiation safety.

Objectives

The evaluation of orthopaedic surgeons' knowledge, awareness and everyday practices regarding radiation safety in an academic hospital.

Methods

A questionnaire with multiple-choice-type questions was developed by a panel of experts and used to conduct a descriptive study. The questionnaire had multiple dimensions, each evaluating orthopaedic knowledge, awareness and practices, respectively. The study population included orthopaedic surgeons rotating within the orthopaedic circuit of the University of Pretoria.

Results

Orthopaedic surgeons regularly make use of fluoroscopic imaging in theatre, with 34 (77%) participants indicating that they use fluoroscopy in more than half of all their procedures performed. Most participants have insufficient knowledge of radiation safety, with the majority failing to correctly answer basic questions on radiation safety. Forty (91%) participants do not wear personal dosimeters, in spite of 39 participants (89%) believing that they are vulnerable to adverse effects. Basic radiation protection devices are underutilised, with 32 (73%) participants indicating that they have not received adequate training in radiation safety.

Conclusion

The majority of orthopaedic surgeons regularly use fluoroscopic imaging in theatre yet lack in-depth knowledge and awareness regarding radiation safety associated with this imaging modality. Implementation of a radiation safety training programme is thus recommended.

Radiation Exposure and Health Risks for Orthopaedic Surgeons

Orthopaedic surgeons are routinely exposed to intraoperative radiation and, therefore, follow the principle of "as low as reasonably achievable" with regard to occupational safety. However, standardized education on the long-term health effects of radiation and the basis for current radiation exposure limits is limited in the field of orthopaedics. Much of orthopaedic surgeons' understanding of radiation exposure limits is extrapolated from studies of survivors of the atomic bombings in Hiroshima and Nagasaki, Japan. Epidemiologic studies on cancer risk in surgeons and interventional proceduralists and dosimetry studies on true radiation exposure during trauma and spine surgery recently have been conducted. Orthopaedic surgeons should understand the basics and basis of radiation exposure limits, be familiar with the current literature on the incidence of solid tumors and cataracts in orthopaedic surgeons, and understand the evidence behind current intraoperative fluoroscopy safety recommendations.

Computed Tomography Scans in Patients With Young Adult Hip Pain Carry a Lifetime Risk of Malignancy

PURPOSE

To calculate the lifetime risk of malignancy in young adult patients with hip pain using 5 different imaging and radiation dose protocols with or without pre- and postoperative computed tomography (CT).

METHODS

Radiographic and CT patient radiation doses were retrospectively reviewed. Imaging protocols for hip pain composed of radiographs with or without pre- and postoperative CT scans were modeled and radiation doses were estimated using the PCXMC computer code. Based on these radiation doses, lifetime attributable risks of cancer and mortality for a 10- through 60-year-old male and female were calculated as published by the committee on the Biological Effects of Ionizing Radiation (BEIR) in the BEIR VII report. Relative risks and number needed to harm (NNH) were calculated for each protocol.

RESULTS

Based on a review of our institutional database, 2 CT scan doses were used for this study: a high 5.06 mSv and a low 2.86 mSv. Effective doses of radiation ranged from 0.59 to 0.66 mSv for radiographs alone to 10.71 to 10.78 mSv for radiographs and CT both pre- and postoperatively at the higher dose. Lifetime attributable risk of cancer for radiographs alone was 0.006% and 0.011% for a 20-year-old male and female, respectively. Lifetime attributable risk of cancer for radiographs along with pre- and postoperative CT scans at higher dose was 0.105% and 0.177% for a 20-year-old male and female, respectively. Radiographs alone lead to an NNH of 16,667 for males and 9,090 for females, whereas the protocol with pre- and postoperative CT scans at the higher dose led to an NNH of 952 for males and 564 for females. The relative risk of this protocol compared to radiographs alone was 17.5 for males and 16.1 for females.

CONCLUSION

Protocols with CT scans of the hip/pelvis pose a small lifetime attributable risk (0.034%-0.177% for a 20-year-old) but a large relative risk (5-17 times) of cancer compared with radiographs alone in the imaging evaluation for hip pain that decreases with increasing age.

CLINICAL RELEVANCE

This study illustrates the need for clinicians to understand the imaging protocols used at their institution to understand the risks and benefits of using those protocols in their practice.

Intraoperative Radiation Exposure During Hip Arthroscopy

BACKGROUND

The frequency of hip arthroscopy for the treatment of acute and chronic chondrolabral pathology and femoroacetabular impingement (FAI) has increased exponentially over the past decade. While surgeon and patient radiation exposure has been well documented in other areas of the orthopaedic literature, little is known about the procedure-specific and cumulative doses affecting the hip arthroscopist.

PURPOSE

To determine the mean annual radiation exposure to the hip arthroscopist and the mean surgeon exposure per case.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 210 consecutive hip arthroscopies performed in 209 patients by a single surgeon at a single ambulatory surgical center in a cohort consisting of approximately 50% bony (cam and pincer) pathology were prospectively reviewed, documenting the specific procedures performed in each case and the readings from a radiation dosimeter worn by the surgeon during positioning and while performing the procedures. Radiation readings for deep dose-equivalent (DDE), lens dose-equivalent (LDE), and shallow dose-equivalent (SDE) were measured. These readings were compared with the annual radiation dose limit recommendations established by the International Commission on Radiological Protection (ICRP).

RESULTS

The total radiation doses for the operative surgeon during all 210 cases were 183 mrem (1.83 mSv) DDE, 183 mrem (1.83 mSv) LDE, and 176 mrem (1.76 mSv) SDE. The mean exposure per case was 0.871 mrem (0.00871 mSv) DDE, 0.871 mrem (0.00871 mSv) LDE, and 0.838 mrem (0.00838 mSv) SDE. The operative surgeon's mean annual exposure, performing 70 hip arthroscopies per year with 55% involving bony work, was 61.0 mrem (0.610 mSv) DDE, 61.0 mrem (0.610 mSv) LDE, and 58.7 mrem (0.587 mSv) SDE. These results are well below the ICRP annual limits of 50,000 mrem (500 mSv) DDE, 2000 mrem (20 mSv) LDE, and 50,000 mrem (500 mSv) SDE.

CONCLUSION

For an experienced hip arthroscopist utilizing fluoroscopy during setup and bony resection, the annual and per-patient exposure to radiation remains well below the recommended ICRP limits.

CLINICAL RELEVANCE

Considering the increasing annual frequency of hip arthroscopies being performed, information regarding procedure-specific and cumulative doses of radiation exposure affecting the hip arthroscopist may provide valuable safety information for the orthopaedic community.

Dynamic Hip Examination for Assessment of Impingement During Hip Arthroscopy

Arthroscopic procedures for treatment of hip pathology are growing exponentially as a result of continued improvements in the understanding of intra- and extra-articular hip anatomy and technological advancements in instrumentation. Nevertheless, it has been reported that the main cause of revision hip arthroscopy is related to a suboptimal intrasurgical management of the abnormal morphology in femoroacetabular impingement (FAI). Under-resection, over-resection, and in some cases combined under-resection and over-resection at different locations of the cam lesion at the femoral head-neck junction may lead to poor outcomes as a result of residual impingement or the iatrogenic creation of structural instability. Thus, an intraoperative assessment technique capable of revealing in real time the effect of the resection is vital for a successful procedure. Therefore, we present a technical note describing our preferred method to dynamically assess overall hip range of motion, motion at risk, and evaluation of the osteoplasty after surgical correction of FAI.