Radiation safety knowledge and practices among Irish orthopaedic trainees

Worker's exposure to radiation in fluoroscopy, assessing and instruments: A systematic literature review

This review aims to identify and analyze the instruments employed for assessing the overall performance of workers exposed to fluoroscopy during surgical procedures and/or interventional procedures, using the PRISMA methodology. The studies were located through searches conducted on PubMed, Web of Science, Lilacs, ScienceDirect, B-ON, EBSCOhost, and EBSCO Discovery Service on March 27, 2023. Additional studies were identified using backward and forward citation techniques. The PEO strategic model was followed. The search spanned studies published between 2012 and 2022. The quality of the studies underwent assessment using the Joanna Briggs Institute checklist for analytical cross-sectional studies. Out of the 23 studies identified, encompassing 3604 individuals, 12 (52%) addressed the reliability and/or validity of the instruments, while 3 (13%) focused on the development and psychometric testing of the instruments. Only 5 instruments (23%), validated and reliable, exclusively evaluated occupational radiological protection. The predominant dimension covered was knowledge (82%, n = 19). The population was assessed in 18 studies, pre- and post-intervention in 2 studies, and 21 studies provided recommendations or tools for improvement. Individuals in the studies utilized passive dosimeters (ranging from 5% to 98%), thyroid shields (15% to 98%), and aprons or lead skirts/coats (28% to 99%). The evidence quality was moderate (6/8). This study underscores the imperative to enhance compliance with protective and monitoring equipment. Furthermore, additional information is warranted concerning the validity and reliability of the instruments used, as well as the development of instruments that are both valid and reliable.

Knowledge, Attitude, and Practices Regarding Radiation and its Hazards Among Orthopaedic Surgeons in India: A Questionnaire-Based Study

Introduction

Orthopaedic surgeons are among the most frequent users of radiation and are often exposed to X-Ray radiation regularly. There is an overall unsatisfactory level of knowledge, attitude, and practices regarding the same among surgeons. This study aimed to assess the practices among orthopaedic surgeons regarding radiation and its hazards in India.

Methodology

This questionnaire-based survey was conducted between March and September 2022. The questionnaire broadly assessed the knowledge, awareness, and practices among orthopaedic surgeons regularly exposed to X-ray radiation. The questionnaire consisted of objective and Likert scale questions which were distributed to the respondents electronically using publicly available contact information. A qualitative review of interpretations obtained from the responses and available evidence in the literature was then performed.

Results

The response rate for the survey was 36.4%. 65.9% reported using trunk protection all the time during procedures. 57.1% of respondents reported not using thyroid protection during procedures. 92.3% reported not using protective goggles and 100% did not use appropriate gloves. 76.9% were not issued dosimeters, and only 5.5% of those who had been issued one wore it during radiation procedures. 58.2% reported having a dedicated employee to operate the machine. 86.8% of respondents did not have formal training and 81.3% were not aware of institutes offering formal training.

Conclusion

There is very high compliance with the use of protection aprons among the respondents however, the use of other apparel like thyroid shields, protection goggles and gloves was poor. The awareness regarding radiation exposure was also poor as most respondents were not issued dosimeters, however, those issued with one were well aware of their exposure. It is imperative to prioritize both surgeons' and patients' safety where radiation exposure is concerned.

A standardised communication tool reduces radiation exposure associated with intraoperative fluoroscopy

BACKGROUND

The widespread use of intraoperative fluoroscopy in orthopaedic procedures has revolutionised surgical practice. However, there are risks associated with using ionising radiation. Efforts to reduce radiation exposure include low-dose imaging protocols and lead protective equipment. Current communication during fluoroscopic procedures can be inefficient and lead to excessive radiation exposure for patients and staff.

AIMS

This study aims to implement a communication tool with standardised commands to reduce radiation exposure in an Irish orthopaedic department.

METHODS

Radiation exposure was evaluated using dose-area product (DAP) measured in uGy/m2. A control group was recorded before implementing the communication tool. Training sessions were conducted and posters of the standardised commands were displayed. Feedback was collected from surgeons and radiographers via surveys. Statistical analysis was performed to compare pre- and post-intervention groups.

RESULTS

A total of 673 surgical cases were included over 6 months. The post-intervention group showed a mean reduction in radiation exposure from 59.8 to 36.4 uGy/m2 (p < 0.011). Subset analyses revealed reduced radiation exposure for ORIF of the distal radius, ankle, humerus, and phalanges. Surgeons and radiographers recognised the need for improved communication and expressed willingness to learn the new tool.

CONCLUSIONS

Implementation of a standardised communication tool effectively reduced patient and staff radiation exposure. It was also believed to have a positive effect on theatre staff morale. Incorporating a universal language tool into training programmes could be beneficial. Surgeons and radiographers provided several suggestions to improve the effectiveness and implementation of this tool into other units.

Decreasing exposure to thyroid radiation in an orthopaedic theatre setting: an educational intervention

The use of personal protective equipment (PPE) can significantly reduce staff exposure to harmful radiation and infection. Fluoroscopic procedures in orthopaedic theatre can generate high levels of radiation and good adherence to PPE use is essential to reduce long term cancer risk, including thyroid cancer. To assess baseline compliance with PPE, availability of PPE in theatre and carry out an intervention to promote greater use of PPE. This was a closed-loop interventional study set in a level 1 trauma centre and an elective/rehabilitation unit. Data were collected in 40 cases pre and post-intervention from 26th May-7th July 2017. All health care practitioners present at fluoroscopic screening were observed. PPE availability was audited daily. A questionnaire was used to assess surgical and nursing knowledge/practices regarding radiation/infection safety. An educational presentation was delivered to the groups at highest risk of exposure. 39/41 questionnaires were completed (29 surgeons, 10 nurses). 41% of respondents had taken a radiation training course or felt they had adequate training. There was a significant increase in the use of thyroid guards by surgeons 13/115 (11.3%) pre-intervention to 54/117 (46.2%) post-intervention (p<0.001) and radiographers (p=0.019) post-intervention. Logistic regression showed an 89.7% increased likelihood of thyroid guard use post-intervention and a 12.7% increased chance of thyroid guard use for each extra guard available. A short educational, easily replicated session, significantly improved compliance with thyroid guards by orthopaedic surgeons.

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.

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.

Underestimation of Radiation Doses by Compliance of Wearing Dosimeters among Fluoroscopically-Guided Interventional Medical Workers in Korea

This study aimed to estimate the level of underestimation of National Dose Registry (NDR) doses based on the workers’ dosimeter wearing compliance. In 2021, a nationwide survey of Korean medical radiation workers was conducted. A total of 989 medical workers who performed fluoroscopically-guided interventional procedures participated, and their NDR was compared with the adjusted doses by multiplying the correction factors based on the individual level of dosimeter compliance from the questionnaire. Ordinal logistic regression analysis was performed to identify the factors for low dosimeter wearing. Based on the data from the NDR, the average annual effective radiation dose was 0.95 mSv, while the compliance-adjusted dose was 1.79 mSv, yielding an 89% increase. The risks for low compliance with wearing a badge were significantly higher among doctors, professionals other than radiologists or cardiologists, workers not frequently involved in performing fluoroscopically-guided interventional procedures, and workers who did not frequently wear protective devices. This study provided quantitative information demonstrating that the NDR data may have underestimated the actual occupational radiation exposure. The underestimation of NDR doses may lead to biased risk estimates in epidemiological studies for radiation workers, and considerable attention on dosimetry wearing compliance is required to interpret and utilize NDR data.

Radiation safety awareness and practices amongst orthopaedic surgeons in Scotland

As orthopaedic surgeons we use x-rays every day; not only when diagnosing pathology but often to assist in operative management of said pathology or ensure satisfactory outcomes for our patients in clinic. An awareness of the correct use of ionising radiation in the form of fluoroscopic imaging is therefore of great importance to reduce intraoperative exposure and has led to the development of the As Little As Reasonably Achievable (ALARA) principle. The primary aim of this study is to determine the knowledge and practises of radiation safety amongst orthopaedic surgeons in Scotland. Secondary aim is to assess the prevalence of back pain and relation to lead gowns. A google forms survey containing 20 questions about both an individual's radiation practises, and knowledge and departmental practises were distributed to all 4 deaneries in Scotland. In total 72 responses were received from 20 hospitals across all 4 Scottish deaneries. This included 28 Consultants, 23 Senior trainees and 21 Junior trainees. We found that the level of radiation training and knowledge varied considerably across seniority and the nation. Of those surveyed 100% reported always wear lead aprons/gowns however only 46.2% (n = 34) frequently or always wear thyroid protection when using X-rays. Only 55% (n = 40) of those surveyed had completed a radiation safety course with this being far less likely amongst junior trainees (29%, n = 6) than amongst Consultants (82%, n = 23) and senior trainees (48%, n = 11) (p < 0.0001). To our knowledge this is the most extensive survey into the radiation practises of Orthopaedic Surgeons in the literature and shows the need for increased education and awareness of radiation safety practises, particularly amongst junior trainees.

Gonad irradiation from fluoroscopy during upper limb orthopaedic procedures in a UK District General Hospital

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.

Clinical outcomes of the use of 3D printing models in fracture management: a meta-analysis of randomized studies

PURPOSE

The use of three-dimensional printing models in medical practice has been booming recently and its application to orthopedic surgery is gaining popularity. When treating fractures by open reduction and internal fixation, potential benefits have been associated with the use of 3D printing models. This review aims to quantitatively analyze the effectiveness of using 3D printing models in fracture management.

MATERIALS AND METHODS

A structured systematic review was conducted, and multiple databases were searched using a combination of terms related to 3D printing in fracture management. The literature search was limited from inception to Nov 2020. Only comparative randomized studies were accepted for inclusion. Any software or material using 3D printing versus no technological assistance was included. All types of fracture treated by open reduction and internal fixation were included. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was applied with the Joanna Briggs Institute's critical appraisal tool used to assess the quality of the included studies. Quantitative analysis was performed.

RESULTS

Based on 13 RCTs including 673 patients (325 and 348 in the 3D and control groups, respectively), the weighted effect size outcomes were as follows: (a) operative duration - 1.47 (95% CI = - 1.759 to - 1.182), (b) intraoperative blood loss - 1.41 (95% CI = - 1.792 to - 1.029), (c) fluoroscopy use - 1.25 (95% CI = - 1.637 to - 0.867), in favor of the 3D group. The weighted Odds ratio outcomes were: (a) overall good or excellent result 2.05 (95% CI = 1.119 to 3.845) and (b) anatomic fracture reduction 2.64 (95% CI = 1.150 to 6.051) in favor of the 3D group. The mean residual displacement and time to union showed no significant difference. The mean JBI appraisal tool score for the randomized studies was of 9, out of a maximum of 13.

CONCLUSIONS

When compared to the non-use of 3D technology for open reduction and internal fixation of fractures, the review demonstrated evidence that 3D printing yielded significantly better perioperative results. Further studies are needed to evaluate the effect of 3D printing on union and long-term function.

LEVEL OF EVIDENCE

I.

An assessment of radiation use, knowledge and concerns in trainee cardiologists in Ireland

OBJECTIVE

To evaluate knowledge, routine use and concerns of trainee cardiologists in the Republic of Ireland regarding radiation use in the cardiac catheterization laboratory.

METHODS

We handed out a Radiation Questionnaire to cardiology trainees in February 2020 at the Irish Cardiac Society "Spring Meeting". The questionnaire assessed radiation protection use amongst trainees and tested knowledge of X-ray basics.

RESULTS

Many trainees report inadequate access to properly sized lead protection, and infrequent dosimeter usage. Over one-third of trainees report musculoskeletal issues from wearing leads, the majority of whom use correct size lead <60% of the time.33.3% report radiation concerns will affect their decision making regarding subspeciality training, but notably 83.3% of females and only 19% of males surveyed report this, showing this is a bigger issue for females in cardiology. Less than half of trainees feel adequately educated about radiation.

CONCLUSION

Our assessment show deficiencies in the provision and use of personal protective equipment to trainees, highlights extra radiation concerns of female cardiology trainees, and notes gaps in knowledge in radiation use.

ADVANCES IN KNOWLEDGE

Our assessment highlights deficiencies in the education of cardiology trainees regarding ionizing radiation, and suggests this area needs to be improved upon.

Radiation in orthopaedics (RIO) study: a national survey of UK orthopaedic surgeons

OBJECTIVES

Orthopaedic surgeons have a responsibility to minimise risks of ionising radiation to patients, themselves and staff. This study aims to establish the understanding of radiation practice, legislation and risk by orthopaedic surgeons.

METHODS

A nationwide online survey of UK-based orthopaedic surgeons was conducted. Participants answered 18 multiple-choice questions assessing level of radiation safety training, basic principles/knowledge of ionising radiation, relevant legislation and operating practice.

RESULTS

A total of 406 surgeons completed the survey. 92% reported using intraoperative ionising radiation at least once per week. 38% received no formal training on radiation safety. Knowledge of basic principles of radiation and legislation was limited. There was variable knowledge when labelling an image intensifier machine and choosing its safest orientation. Poor uptake of radiation protection equipment was noted. Only 19% agreed they had adequate training in ionising radiation safety and 27% reported receiving adequate training in equipment emitting ionising radiation in the operating theatre.

CONCLUSION

Many orthopaedic surgeons in the UK do not believe they are adequately trained in radiation safety. There is a deficiency amongst practicing surgeons in basic knowledge, relevant legislation and practicalities of the use of ionising radiation in the operating room. This could potentially put patients and health-care professionals at additional risk. We recommend that a standardised national training programme on the basic principles and safety of ionising radiation is implemented for all practicing orthopaedic surgeons.

ADVANCES IN KNOWLEDGE

This paper is the first UK national survey amongst orthopaedic surgeons and is one of the largest reported internationally.

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.

Radiation safety and knowledge: an international survey of 708 interventional pain physicians

INTRODUCTION

Interventional pain procedures have increased in complexity, often requiring longer radiation exposure times and subsequently higher doses. The practicing physician requires an in-depth knowledge and evidence-based knowledge of radiation safety to limit the health risks to themselves, patients and healthcare staff. The objective of this study was to examine current radiation safety practices and knowledge among interventional pain physicians and compare them to evidence-based recommendations.

MATERIALS AND METHODS

A 49-question survey was developed based on an extensive review of national and international guidelines on radiation safety. The survey was web-based and distributed through the following professional organizations: Association of Pain Program Directors, American Academy of Pain Medicine, American Society of Regional Anesthesia and Pain Medicine, European Society of Regional Anesthesia and Pain Therapy, International Neuromodulation Society, and North American Neuromodulation Society. Responses to radiation safety practices and knowledge questions were evaluated and compared with evidence-based recommendations. An exploratory data analysis examined associations with radiation safety training/education, geographical location, practice type, self-perceived understanding, and fellowship experience.

RESULTS

Of 708 responding physicians, 93% reported concern over the health effects of radiation, while only 63% had ever received radiation safety training/education. Overall, ≥80% physician compliance with evidence-based radiation safety practice recommendations was demonstrated for only 2/15 survey questions. Physician knowledge of radiation safety principles was low, with 0/10 survey questions having correct response rates ≥80%.

CONCLUSION

We have identified deficiencies in the implementation of evidence-based practices and knowledge gaps in radiation safety. Further education and training are warranted for both fellowship training and postgraduate medical practice. The substantial gaps identified should be addressed to better protect physicians, staff and patients from unnecessary exposure to ionizing radiation during interventional pain procedures.

Establishing local diagnostic reference levels for common orthopaedic procedures using the mini C-arm fluoroscope

OBJECTIVE

Mini C-arm fluoroscopes are widely used by orthopaedic surgeons for intraoperative image guidance without the need for radiographers. This puts the responsibility for radiation exposure firmly with the operating surgeon. In order to maintain safe and best practice under U.K. Ionising Radiation (Medical Exposure) Regulations, one must limit radiation exposure and audit performance using national diagnostic reference levels (DRLs). In the case of the mini C-arm, there are no national DRLs. IR(ME)R, therefore, require the establishment of local DRLs by each hospital to act as an alternative guideline for safe radiation use. The aim of our audit was to establish local DRLs based on our experience operating with the use of the mini C-arm over the last 7 years.

METHODS

This retrospective audit evaluates the end dose-area product (DAP) recorded for common trauma and orthopaedic procedures using the mini C-arm in a busy district general hospital.We present the quartile data and have set the cut-off point as the third quartile for formulating the local DRLs, consistent with the methodology for the conventional fluoroscope.

RESULTS

For our data set (n = 1664), the third quartile DAP values were lowest for surgeries to the forearm (5.38 cGycm²), hand (7.62 cGycm²), and foot/ankle (8.56 cGycm²), and highest for wrist (10.64 cGycm²) and elbow (14.61 cGycm²) procedures.

ADVANCES IN KNOWLEDGE

To our knowledge, this is the largest data set used to establish local DRLs. Other centres may find our guidelines useful whilst they establish their own local DRLs.

Intraoperative risks of radiation exposure for the surgeon and patient

Intraoperative radiological imaging serves an essential role in many spine surgery procedures. It is critical that patients, staff and physicians have an adequate understanding of the risks and benefits associated with radiation exposure for all involved. In this review, we briefly introduce the current trends associated with intraoperative radiological imaging. With the increased utilization of minimally invasive spine surgery (MIS) techniques, the benefits of intraoperative imaging have become even more important. Less surgical exposure, however, often equates to an increased requirement for intraoperative imaging. Understanding the conventions for radiation measurement, radiological fundamental concepts, along with deterministic or stochastic effects gives a framework for conceptualizing how radiation exposure relates to the risk of various sequela. Additionally, we describe the various options surgeons have for intraoperative imaging modalities including those based on conventional fluoroscopy, computer tomography, and magnetic resonance imaging. We also describe different ways to prevent unnecessary radiation exposure including dose reduction, better education, and use of personal protective equipment (PPE). Finally, we conclude with a reflection on the progress that has been made to limit intraoperative radiation exposure and the promise of future technology and policy.

Radiation exposure and fluoroscopically-guided interventional procedures among orthopedic surgeons in South Korea

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.

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.

Comparing the Efficiency, Radiation Exposure, and Accuracy Using C-Arm versus O-Arm With 3D Navigation in Placement of Transiliac-Transsacral and Iliosacral Screws: A Cadaveric Study Evaluating an Early Career Surgeon

OBJECTIVES

To compare the efficiency, radiation exposure to surgeon and patient, and accuracy of C-arm versus O-arm with navigation in the placement of transiliac-transsacral and iliosacral screws by an orthopaedic trauma fellow, for a surgeon early in practice.

METHODS

Twelve fresh frozen cadavers were obtained. Preoperative computed tomography scans were reviewed to assess for safe corridors in the S1 and S2 segments. Iliosacral screws were assigned to the S1 segment in dysmorphic pelvises. Screws were randomized to modality and laterality. An orthopaedic trauma fellow placed all screws. Time of procedure and radiation exposure to the cadaver and surgeon were recorded. Three fellowship-trained orthopaedic trauma surgeons rated the safety of each screw on postoperative computed tomography scan.

RESULTS

Six normal and 6 dysmorphic pelvises were identified. Eighteen transiliac-transsacral screws and 6 iliosacral screws were distributed evenly between C-arm and O-arm. Average operative duration per screw was significantly shorter using C-arm compared with O-arm (15.7 minutes ± 6.1 vs. 23.7 ± 8.5, P = 0.014). Screw placement with C-arm exposed the surgeon to a significantly greater amount of radiation (3.87 × 10 rads vs. 0.32 × 10, P < 0.001) while O-arm exposed the cadaver to a significantly greater amount of radiation (0.03 vs. 2.76 rads, P < 0.001). Two S2 transiliac-transsacral screws (1 C-arm and 1 O-arm) were categorized as unsafe based on scoring. There was no difference in screw accuracy between modalities.

CONCLUSIONS

A difference in accuracy between modalities could not be elucidated, whereas efficiency was improved with utilization of C-arm, with statistical significance. A statistically significant increase in radiation exposure to the surgeon using C-arm was found, which may be clinically significant over a career. The results of this study can be extrapolated to a fellow or surgeon early in practice. The decision between use of these modalities will vary depending on surgeon preference and hospital resources.

Impact of Resident Training Level on Radiation Exposure During Fixation of Proximal Femur Fractures

OBJECTIVE

To identify whether residents are at greater risk of radiation exposure from intraoperative fluoroscopy while earlier in their training and during more complex procedures.

METHODS

We analyzed 852 extracapsular 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 seconds) and basicervical fractures (91.49 ± 5.77 seconds). Long nail (150.2 ± 3.75 seconds) times were longer than short (92.3 ± 3.15 seconds) and intermediate (76.45 ± 3.01 seconds) nails. Significantly, more fluoroscopy was used in junior (115.9 ± 4.24 seconds), senior (123.0 ± 6.08 seconds), junior combo (130.6 ± 7.74 seconds), and senior combo cases (131.8 ± 6.11 seconds) compared with the control (94.91 ± 3.91).

CONCLUSION

Orthopaedic surgery residents and attendings must remain aware of radiation exposure secondary to intraoperative 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. See Instructions for Authors for a complete description of levels of evidence.

Underestimation of fluoroscopic exposure among orthopedic residents

OBJECTIVES

Concerns about radiation exposure for health care workers have increased in the last decade, along with the increased use of fluoroscopic imaging for surgical procedures. Recent literature suggests that surgeons with the least experience have higher exposure during surgery, and their perception of exposure may be lower. The purpose of this study was to examine the accuracy of orthopedic resident trainees' estimates of their exposure during fluoroscopy cases.

MATERIALS AND METHODS

Orthopedic resident trainees were surveyed after participation in various fluoroscopic orthopedic surgeries and asked to estimate the number of fluoroscopy exposures used. Their answers were compared against the actual number of exposures retrieved from the fluoroscopy machine. The perceived number of exposures was then compared to the actual number taken for junior residents in training year 1, 2, or 3 versus senior residents in training year 4 or 5.

RESULTS

Nineteen residents were surveyed, 13 of which were junior residents and six of which were senior residents. Of the 13 junior-level residents, total estimation was 441 exposures, versus 1411 actual exposures, an underestimation of over 69%. The six senior residents totaled 457 estimated exposures, compared to 645 actual exposures, for an underestimation of just under 30%.

CONCLUSIONS

In this survey study at a single institution, junior-level residents greatly underestimated radiation exposure compared to senior-level residents. Trainees should be aware that they grossly underestimate their exposure levels during procedures, and residency programs should emphasize fluoroscopic training early.

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 in Orthopaedics

» The damaging effects to human tissue caused by radiation exposure have been documented since the first reports regarding use of radiographs in the late nineteenth century. » Orthopaedic surgeons and residents often are undereducated about the risks associated with radiation exposure and the recommended safety precautions to help mitigate these potential risks. » Orthopaedic surgeons need to adopt the ALARA (as low as reasonably achievable) principle: whenever possible, all available precautions should be taken to keep all members of the operating room safe from radiation exposure while emphasizing the best appropriate care for patients. » An emphasis on radiation safety and protection should be universally incorporated into graduate medical education.

Does surgeon experience influence the amount of radiation exposure during orthopedic procedures? A systematic review

With an increasing use of intraoperative fluoroscopy in operating rooms worldwide, the topic of radiation exposure has become a major concern among hospital staff, doctors and patients alike. Since fluoroscopy has become an integral part in orthopedic intraoperative management, we sought to identify whether surgeon grade or experience plays a role in the amount of radiation used and consequently exposed. We performed a systematic review examining the association between surgeon experience and radiation exposure using primary outcome measures (radiation dose and total screening time/fluoroscopy time). To be included in the review, the study population had to compare varying surgeon experience levels and their effect on the primary outcomes. A total of eighteen studies were included in the review. The studies were a mix of prospective and retrospective studies with low to moderate quality as evaluated by the MINORs criteria. Studies were variable in defining surgeon experience levels and in the type of operations being performed. Majority of the studies showed that inexperienced surgeons/trainees had a higher total fluoroscopy time and a higher mean radiation exposure as compared to experienced surgeons. We conclude that higher surgeon experience significantly reduces usage of fluoroscopy and the consequent radiation exposure in orthopedic procedures. Introduction of strict radiation guidelines involving limited usage of fluoroscopy and supervision of trainees may be beneficial in controlling radiation exposure in the future.

Radiation exposure and the orthopedic surgeon's hand: Measurement of the equivalent dose over 13 months

Exposure to ionizing radiation in the operating room is governed by practical prevention and protection measures on the international, national and local levels. We evaluated the equivalent dose to the hand of an orthopedic surgeon over 13 months. An orthopedic surgeon wore a ring dosimeter on the ring finger of his right hand for all surgical procedures requiring intraoperative fluoroscopy between March 2014 and April 2015. Monthly doses were evaluated by the IRSN over the study period. The number and type of procedures were compiled as well as the type of fluoroscopy unit used. Four hundred procedures were performed during this period, including 182 with fluoroscopy. The equivalent cumulative dose at the hand was 4,75 mSv. No correlation was found with the type of procedure or type of fluoroscopy unit (conventional or mini C-arm). Equivalent doses were below the annual regulatory limit in France of 500 mSv. These results are consistent with those reported in the literature. However, recent studies have noted that both younger surgeons in training and more experienced surgeons must remember to use radiation protection measures.

Intraoperative radiation safety in orthopaedics: a review of the ALARA (As low as reasonably achievable) principle

The use of fluoroscopy has become commonplace in many orthopaedic surgery procedures. The benefits of fluoroscopy are not without risk of radiation to patient, surgeon, and operating room staff. There is a paucity of knowledge by the average orthopaedic resident in terms proper usage and safety. Personal protective equipment, proper positioning, effective communication with the radiology technician are just of few of the ways outlined in this article to decrease the amount of radiation exposure in the operating room. This knowledge ensures that the amount of radiation exposure is as low as reasonably achievable. Currently, in the United States, guidelines for teaching radiation safety in orthopaedic surgery residency training is non-existent. In Europe, studies have also exhibited a lack of standardized teaching on the basics of radiation safety in the operating room. This review article will outline the basics of fluoroscopy and educate the reader on how to safe fluoroscopic image utilization.