Hazard of ionizing radiation to trauma surgeons: reducing the risk

The Effect of an Intraoperative Real-Time Counter on Radiation Exposure Events During Operative Treatment of Distal Radius Fractures

PURPOSE

Occupational radiation exposure can have adverse health consequences for surgeons. The purpose of this study was to determine if utilization of an intraoperative, real-time radiograph counter results in decreased radiation exposure events (REEs) during open reduction and internal fixation (ORIF) of distal radius fractures (DRFs).

METHODS

We reviewed all cases of isolated ORIF DRFs performed at a single center from January 2021 to February 2023. All cases performed on or after January 1, 2022 used an intraoperative radiograph counter, referred to as a "shot-clock" (SC) group. Cases prior to this date were performed without a SC and served as a control group (NoSC group). Baseline demographics, fracture, and surgical characteristics were recorded. Final intraoperative radiographs were reviewed to record reduction parameters (radial inclination, volar tilt, and ulnar variance). REEs, fluoroscopy exposure times, and total radiation doses milligray (mGy) were compared between groups.

RESULTS

A total of 160 ORIF DRF cases were included in the NoSC group, and 135 were included in the SC group. The NoSC group had significantly more extra-articular fractures compared with the SC group. Reduction parameters after ORIF were similar between groups. The mean number of REEs decreased by 48% in the SC group. Cases performed with the SC group had significantly lower total radiation doses (0.8 vs 0.5 mGy) and radiation exposure times (41.9 vs 24.2 seconds). Mean operative times also decreased for the SC group (70 minutes) compared with that for the NoSC group (81 minutes).

CONCLUSIONS

A real-time intraoperative radiograph counter was associated with decreased REEs, exposure times, and total radiation doses during ORIF DRFs. Cases performed with a SC had significantly shorter operative times without compromising reduction quality. Using an intraoperative SC counter during cases requiring fluoroscopy may aid in decreasing radiation exposure, which serves as an occupational hazard for hand and upper-extremity surgeons.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

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.

Cellular Bi2O3/natural rubber composites for light-weight and lead-free gamma-shielding materials and their properties under gamma irradiation

This work investigated the effects of a radiation-protective filler, namely bismuth oxide (Bi2O3), and blowing agents, namely azodicarbonamide (ADC) and oxy-bis (benzene sulfonyl) hydrazide (OBSH), on gamma attenuation and the mechanical, physical, and morphological properties of cellular natural rubber (NR) composites for potential use as light-weight and lead-free gamma-shielding materials. The contents of Bi2O3 were varied from 100 to 300 and 500 parts per hundred of rubber by weight (phr) and the contents of ADC or OBSH were varied from 0 to 8 and 16 phr. The results indicated that the addition of Bi2O3 enhanced the overall gamma-shielding ability, density, tensile modulus, and hardness (Shore OO), but lowered the tensile strength and elongation at break. On the other hand, the addition of ADC or OBSH resulted in decreases in the density, linear attenuation coefficient ( μ), and overall tensile properties but an increase in the mass attenuation coefficient ( μm), with ADC producing better mechanical properties than samples with OBSH. In addition, investigations on the properties of the cellular Bi2O3/NR composites under additional 35 kGy and 70 kGy gamma irradiation revealed that the irradiated samples had increased density, tensile modulus, and hardness (Shore OO), but decreased tensile strength, elongation at break, and μm after such ageing. In conclusion, the overall results suggested that the developed cellular Bi2O3/NR composites not only had efficient and promising gamma-shielding and mechanical properties but also offered comfort and light-weight to users, which could potentially reduce discomforts caused by wearing heavier conventional radiation-protective equipment.

Are we putting ourselves in danger? Occupational hazards and job safety for orthopaedic surgeons

As physicians, we strive to meet the needs of our patients. In doing so, we are often exposed to hazards that have the potential to not only compromise our health, but also our ability to deliver the best possible healthcare. Occupational hazards specific to the field of orthopaedics include infectious organisms, radiation, surgical smoke, chemicals, hazardous noise, musculoskeletal injury, and psychosocial stressors. Even though orthopaedic surgeons acknowledge the risk, most lack in-depth knowledge of the associated long-term harm associated with these hazards and ways of reducing risk of exposure. Orthopaedic surgeons should increase awareness, follow established guidelines, and integrate preventative measures to create the safest possible work environment. It is our hope that by improving our own health, we will be better equipped to address the health concerns of those we serve-our patients.

Radiation exposure during direct versus indirect image acquisition during fluoroscopy-controlled internal fixation of a hip fracture: Results of a randomized controlled trial

BACKGROUND

Intra-operative image acquisition can be obtained indirectly (via verbal request to a technician) or directly (executed at the tableside, by a surgeon stepping on a foot pedal). Direct image acquisition could reduce the exposure time and thus the risk of radiation damage. The aim of this randomized controlled trial was to compare direct surgeon-controlled fluoroscopy with indirect technician-operated fluoroscopy during internal fixation of a hip fracture.

METHODS

From March 5, 2014 to August 19, 2015, 100 patients who had sustained a hip fracture that required internal fixation were enrolled. Patients were randomized between direct surgeon-controlled image acquisition using a foot pedal (n = 52) and indirect image acquisition by a radiology technician (n = 48). The primary outcome measure was the radiation exposure time; secondary outcome measures were the associated effective radiation dose and the dose area product.

(DAP) RESULTS

A total of 96 patients (with a median age of 84 years) were enrolled in this study. Eighty-nine (93%) patients had a pertrochanteric fracture. No statistically significant differences between direct image acquisition and indirect image acquisition were found for overall radiation time, total radiation dose or DAP for the total population. When adjusted for potential confounders, a difference in overall radiation time of 18.50 s (95% CI 2.19; 34.81, p = 0.027) was found in favour of indirect image acquisition.

CONCLUSION

This study showed statistically significantly lower radiation duration using indirect fluoroscopy for the total population and the pertrochanteric fracture subgroup when adjusted for several confounders. No significant effect on radiation dose and DAP was found.

Does nonexistent of your hands on the screen guarantee no radiation exposure to your body? - Study on exposure of the practitioner's hands to radiation during C-arm fluoroscopy-guided injections and effectiveness of a new shielding device

Observational phantom study.This study aimed to evaluate the radiation exposure dose of practitioner's hands when performing C-arm guided procedures and to determine the usefulness of our newly designed radiation shielding device.C-arm guided procedures including lumbar transforaminal epidural steroid injections (TFESIs) are commonly used for pain control induced by lumbar radiculopathy. The practitioner's hands are vulnerable to radiation exposure because of the long exposure time and short distance from the radiation resource. No studies to date have reported the cumulative exposure of the physician's hands according to location and exposure time.Using a chest phantom irradiated with X-rays under lumbar TFESI conditions, cumulative scatter radiation dose was measured at 36 points using a dosimeter. The measurements were checked at 1, 3, 5, 10 minutes of radiation exposure. The experiment was repeated using our newly designed shielding device.Significant radiation accumulation was observed in the field where the practitioner's hands might be placed during C-arm guided procedures. The further the distance from the radiation resource and the shorter the exposure time, the smaller was the cumulative radiation expose dose. The new shielding device showed an excellent shielding rate (66.0%-99.9%) when the dosimeter was within the shielding range. However, at some points, increased accumulated radiation exposure dose was observed, although the dosimeter was within the range of the shielding device.To reduce radiation exposure of the practitioner's hands when performing C-arm-guided procedures, the radiation exposure time should be decreased and a greater distance from the radiation resource should be maintained. When using our shielding device, placing the hand close to the device surface and minimizing the time using fluoroscopy minimized the radiation exposure of the hand.

Radiation protection and standardization

X - Rays has become integral and indispensable part of health care diagnosis and intervention. Intervention procedures in Orthopedics surgery now mostly performed under image intensifiers (C-Arm) which involve the risks of occupational overexposure of radiation to the patients and health care personnel. The principles of radiation protection are helpful in keeping radiation exposure just adequate for diagnostic and intervention procedures. Regular surveillance of protective apparel is necessary for longevity of safety. It is responsibility of all OT personnel to know and implement radiation safety. Each situation involving X-ray radiation should include justification of the procedure, minimum radiation exposure just adequate for diagnostic and interventional procedures.

What Leads to Lead: Results of a Nationwide Survey Exploring Attitudes and Practices of Orthopaedic Surgery Residents Regarding Radiation Safety

BACKGROUND

Excessive radiation to health-care providers has been linked to risks of cancer and cataracts, but its negative effects can be substantially reduced by lead aprons, thyroid shields, and leaded glasses. Hospitals are required to provide education and proper personal protective equipment, yet discrepancies exist between recommendations and compliance. This article presents the results of a survey of U.S. orthopaedic surgery residents concerning attitudes toward radiation exposure and personal protective equipment behavior.

METHODS

An invitation to participate in a web-based, anonymous survey was distributed to 46 U.S. allopathic orthopaedic surgery residency programs (1,207 potential resident respondents). The survey was conceptually divided into the following areas: demographic characteristics, training and attitudes concerning occupational hazards, personal protective equipment provision and use, and general safety knowledge. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated for the association between these characteristics and compliance with thyroid shield or lead gown wear.

RESULTS

In this study, 518 surveys were received, with 1 survey excluded because of insufficient response, leaving 517 surveys for analysis (42.8% response rate). Ninety-eight percent of residents believed that personal protective equipment should be provided by the hospital or residency program. However, provision of personal protective equipment was not universal, with 33.8% reporting none and 54.2% reporting provision of a gown and thyroid shield. The prevalence of leaded glasses usage was 21%. Poor lead gown compliance and thyroid shield wear were associated with difficulty finding the corresponding equipment: PR, 2.51 (95% CI, 1.75 to 3.62; p < 0.001) for poor lead gown compliance and PR, 2.14 (95% CI, 1.46 to 3.16; p < 0.0001) for poor thyroid shield wear. Not being provided with personal protective equipment was also significantly associated with low compliance with both lead gowns (PR, 1.47 [95% CI, 1.04 to 2.08]; p = 0.03) and thyroid shields (PR, 1.69 [95% CI, 1.18 to 2.41]; p = 0.004). Respondents from the Southeast, West, or Midwest had lower compliance with lead gown usage. Forgetting was the number 1 reason to not wear a lead apron (42%).

CONCLUSIONS

Radiation exposure is associated with increased risk of serious health problems. Our findings identified that the availability of lead personal protective equipment leads to increased compliance among residents surveyed. In addition to yearly occupational hazard training specific to orthopaedic surgery, greater efforts by residency programs and hospitals are needed to improve access to lead personal protective equipment and compliance for orthopaedic residents.

Pulsation and Collimation During Fluoroscopy to Decrease Radiation: A Cadaver Study

Background

Awareness of the harmful effects of long-term low-dose radiation is rising. Many studies have assessed both patient and physician exposure to radiation in association with the use of fluoroscopy in the operating room. However, to our knowledge, previous studies have not assessed, in a detailed fashion, the reduction in radiation exposure that pulsation and collimation provide.

Methods

Seven fresh cadavers were irradiated for 5 minutes with C-arm fluoroscopy with use of standard x-ray and pulsed and collimated x-ray beams. The x-ray sources were placed under the table, over the table, and lateral to the table. Radiation exposure doses were measured at different points, such as the center of the radiation field on the cadaver as well as at the locations of the surgeon's hand and thyroid gland. In addition, Monte Carlo simulation (a physics equation to predict exposure) was performed to estimate the dose reduction and to confirm the experimental results.

Results

The radiation exposure doses associated with the use of pulsed fluoroscopy (8 times per second) were reduced by approximately 30% for the patient and by approximately 70% for the surgeon's hand and thyroid gland as compared with those associated with the use of continuous fluoroscopy. The radiation exposure doses associated with the use of collimated beams were reduced to approximately 65% for the surgeon's hand and thyroid gland as compared with those associated with the use of non-collimated fluoroscopy. These results were consistent with the simulation, and the phenomena could be appropriately explained by physics.

Conclusions

The present study revealed the effectiveness of pulsed and collimated x-ray beams in reducing radiation exposure doses resulting from C-arm fluoroscopy. Surgeons should consider using the techniques of pulsed fluoroscopy and collimation to protect patients and themselves from radiation.

Clinical Relevance

This study presents data regarding the reduction of radiation exposure provided by pulsed fluoroscopy and collimation.

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

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.

Quantification of radiation exposure in the operating theatre during management of common fractures of the upper extremity in children

Introduction Surgical procedures to manage trauma to the wrist, forearm and elbow in children are very common. Image intensifiers are used routinely, yet studies/guidelines that quantify expected radiation exposure in such procedures are lacking. Methods Information on demographics, injury type, surgeon grade and dose area product (DAP) of radiation exposure per procedure was collected prospectively for 248 patients undergoing manipulation/fixation of injuries to the elbow, forearm or wrist at a paediatric hospital over 1 year. Results DAP exposure (in cGycm(2)) differed significantly across different procedures (p<0.001): wrist manipulation under anaesthesia (MUA; median, 0.39), wrist k-wiring (1.01), forearm MUA (0.50), flexible nailing of the forearm (2.67), supracondylar fracture MUA and k-wiring (2.23) and open reduction and internal fixation of the lateral humeral condyle (0.96). Fixation of a Gartland grade-3 supracondylar fracture (2.94cGycm(2)) was associated with higher exposure than grade-2 fixation (1.95cGycm(2)) (p=0.048). Fractures of the wrist or forearm necessitating metalwork fixation resulted in higher exposure than those requiring manipulation only (both p<0.001). For procedures undertaken by trainees, trainee seniority (between year-5 and year-8 and clinical fellow, p≥0.24) did not affect the DAP significantly. Conclusions The spectrum of radiation exposures for common procedures utilised in the management of paediatric upper limb trauma were quantified. These findings will be useful to surgeons auditing their practice and quantifying radiation-associated risks to patients. Our data may serve as a basis for implementing protocols designed to improve patient safety.

Intraoperative Radiation Exposure During Revision Total Ankle Replacement

Intraoperative C-arm image intensification is required for primary total ankle replacement implantation. Significant radiation exposure has been linked to these procedures; however, the radiation exposure during revision total ankle replacement remains unknown. Therefore, we sought to evaluate the radiation exposure encountered during revision total ankle replacement. The data from 41 patients were retrospectively analyzed from a prospective database: 19 Agility(™) to Agility(™); 4 Agility(™) to Custom Agility(™); 9 Agility(™) to INBONE(®) II; 5 Agility(™) to Salto Talaris(®) XT; 2 Scandinavian Total Ankle Replacement Prosthesis to Salto Talaris(®) XT; and 2 INBONE(®) I to INBONE(®) II revision total ankle replacements were performed. Two broad categories were identified: partial revision (Agility(™) to Agility(™), Agility(™) to Custom Agility(™), INBONE(®) I to INBONE(®) II) and complete conversion (Agility(™) to INBONE(®) II, Agility(™) to Salto Talaris(®) XT, Scandinavian Total Ankle Replacement Prosthesis to Salto Talaris(®) XT). The mean radiation exposure per case was significant at 3.49 ± 2.21 mGy. Complete conversions, specifically Agility(™) to INBONE(®) II, exhibited the greatest radiation exposure and C-arm time. Revision implant selection and revision type (complete or partial) directly contributed to radiation exposure. Accordingly, revision systems requiring less radiation exposure are preferable. Surgeons should strive to minimize intraoperative complications and limit additional procedures to those necessary, because both lead to additional radiation exposure.

Radiation Exposure during Fluoroscopic Guided Direct Anterior Approach for Total Hip Arthroplasty

Fluoroscopic guidance is commonly utilized during direct anterior total hip arthroplasty (DA THA). The purpose of this study was to measure patient and surgeon exposure utilizing this technique. Fifty-one consecutive patients who underwent primary DA THA by a single surgeon were prospectively studied. Fluoroscopic guidance was utilized according to an established protocol. Dose-area product (DAP) (Gy-cm(2)) and fluoroscopy time were recorded for each case. Surgeon exposure was recorded by a dosimeter. The median DAP was 0.716 Gy-cm(2) (range 0.251-1.81). Mean fluoroscopy time was 0.59 minutes. Dosimeter results were 10 mrem for all procedures combined. DAP and fluoroscopy times were comparable to published values for other fluoroscopically guided hip procedures. This information may aid in setting reference dose levels for this procedure.

The compliance with and knowledge about radiation protection in operating room personnel: a cross-sectional study with a questionnaire

INTRODUCTION

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

STUDY DESIGN

Cross-sectional study with a questionnaire.

Safer mobile fluoroscopy in the trauma theatre: a survey of orthopaedic registrars and theatre staff

The Ionising Radiation (Protection of Persons Undergoing Medical Examination or Treatment) Regulations 1988 (POPUMET) made it compulsory from June 1990 for all staff directing medical exposures to ionising radiation to receive formal tuition at a core knowledge course. This course described the hazards of ionising radiation and the safe use of x-ray equipment. It instructed on the nature of ionising radiation and its interaction with tissues, principles and means of dose reduction to patient and operator, the importance of using the patient’s existing radiological information and statutory responsibilities. The POPUMET course was discontinued following the Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R). IR(ME)R training for healthcare professionals is available as a half-day theoretical course suitable for those designated as ‘referrer’ by their employers. Other locally run ionising radiation protection courses are tailored to the varied requirements of a spectrum of healthcare professionals.

Radiation exposure of eyes, thyroid gland and hands in orthopaedic staff: a systematic review

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.

ICRP Publication 117. Radiological protection in fluoroscopically guided procedures performed outside the imaging department

An increasing number of medical specialists are using fluoroscopy outside imaging departments, but there has been general neglect of radiological protection coverage of fluoroscopy machines used outside imaging departments. Lack of radiological protection training of those working with fluoroscopy outside imaging departments can increase the radiation risk to workers and patients. Procedures such as endovascular aneurysm repair, renal angioplasty, iliac angioplasty, ureteric stent placement, therapeutic endoscopic retrograde cholangio-pancreatography,and bile duct stenting and drainage have the potential to impart skin doses exceeding Gy. Although tissue reactions among patients and workers from fluoroscopy procedures have, to date, only been reported in interventional radiology and cardiology,the level of fluoroscopy use outside imaging departments creates potential for such injuries.A brief account of the health effects of ionising radiation and protection principles is presented in Section 2. Section 3 deals with general aspects of the protection of workers and patients that are common to all, whereas specific aspects are covered in Section 4 for vascular surgery, urology, orthopaedic surgery, obstetrics and gynaecology,gastroenterology and hepatobiliary system, and anaesthetics and pain management.Although sentinel lymph node biopsy involves the use of radio-isotopic methods rather than fluoroscopy, performance of this procedure in operating theatres is covered in this report as it is unlikely that this topic will be addressed in another ICRP publication in coming years. Information on radiation dose levels to patients and workers, and dose management is presented for each speciality.

Accuracy of intraoperative fluoroscopy with and without laser guidance in foot and ankle surgery

BACKGROUND

The use of intraoperative fluoroscopy in orthopedic surgery involves frequent exposure to ionizing radiation in the operating room. Although a number of studies have found radiation exposure to orthopedic surgeons to be well below recommended doses, the long-term effects of low-dose radiation are not well known. Thus, all effective practical methods should be undertaken to reduce the exposure to radiation. Our purpose was to determine whether the use of a laser-aiming device improves the accuracy of intraoperative fluoroscopy to reduce, by implication, radiation exposure in the operating room.

METHODS

From March to October 2004, there were 92 consecutive cases requiring use of fluoroscopy in the orthopedic foot and ankle service of the authors' institution. The number of accurate and inaccurate images with or without the presence of a radiology technician and a laser-aiming device were compared.

RESULTS

The accuracy of imaging with the laser-aiming device was higher than the imaging without the device (p < 0.001). The accuracy of the images obtained by the surgeon was higher than the technicians' images when laser guidance was used (p= 0.027). There was no significant difference between the images obtained by the surgeon or the technicians when the aiming device was not used (p = 0.09).

CONCLUSION

The use of a laser-aiming device to help position during fluoroscopy is recommended in an effort to reduce radiation exposure in foot and ankle surgery.

A comparative study of radiation dose and screening time between mini C-arm and standard fluoroscopy in elective foot and ankle surgery

BACKGROUND

Mini C-arm devices have gained popularity in extremity surgery. There is little evidence of the benefits of this technique in the clinical setting of foot and ankle surgery. We used dose area product (DAP) to compare radiation usage between mini C-arm and standard fluoroscopy.

METHODS

We prospectively reviewed 127 cases requiring intra-operative screening during elective foot and ankle surgery.

RESULTS

Mini C-arm was used in 55 patients and standard fluoroscopy in 72 patients. There was a statistically significant reduction in mean DAP using the mini C-arm, 3.46 Gy cm² vs 7.43 Gy cm² (P=0.0013). There was no difference in screening time. The annual saving from using the mini C-arm could be £9391, saving the total cost of the device over 5 years.

CONCLUSION

The mini C-arm reduces radiation risk and costs when compared to standard fluoroscopy. We recommend its regular use in foot and ankle surgery.

Effect of introduction of mini C-arm image intensifier in orthopaedic theatre

INTRODUCTION

Image intensifier screening is commonly used in orthopaedic theatres. There has been concern regarding the cumulative radiation dose to surgeons and theatre personnel. The mini C-arm intensifier has been reported to scatter less radiation and have a reduced radiation dose to patients and theatre staff.

MATERIALS AND METHODS

A 2-month prospective survey of usage of radiographer-operated large intensifier and surgeon-operated mini C-arm image intensifier in a district general hospital orthopaedic theatre department.

RESULTS

A total of 153 cases required image intensifier screening - 63% used the large intensifier and 37% the mini C-arm intensifier. There were difficulties with equipment with the large intensifier in 16% of cases. There were delays in 11% of cases using the large intensifier. The total radiographer attendance time was 123 h. For the mini C-arm intensifier, there were no equipment difficulties or delays. The minimum radiographer time saved by using this machine was 21.9 hours.

CONCLUSIONS

The mini C-arm intensifier has saved 15% of the radiographer workload with its current pattern of usage in our department. There have been no problems or delays as a result of its usage in theatre. Usage of the large image intensifier resulted in a 16% problem rate and 11% delay rate. Other departments are encouraged to consider acquisition of a mini C-arm intensifier to facilitate theatre throughput, reduce risk to the patient and theatre personnel, and reduce demands on the radiology department.

[Precision of guidewire placement--can it be improved by applying the new, isocentric aiming principle?]

BACKGROUND

Exact placement of a guidewire is difficult for the less experienced surgeon as this complex 3D task usually is controlled by means of 2D fluoroscopic projections. The new isocentric aiming principle presented here splits up the 3D task into two planar, 2D steps. Movements of the guidewire to achieve correct placement are limited to one plane per step and can therefore be exactly controlled by fluoroscopy. The fluoroscopic projection needs to be changed only once in between the two steps.

METHODS

The isocentric aiming principle became applicable to the proximal femur region by means of a mechanical aiming device. We have done an experimental study in order to compare the new isocentric aiming principle to the freehand aiming technique which is routinely applied. We documented the precision of guidewire placement achieved (angular deviation of the guidewire in two projections, linear deviation of the actual from the intended entry point), number of fluoroscopic controls, and procedure time when guidewire placement is done by an experienced and by an inexperienced surgeon.

RESULTS

When applying the isocentric aiming principle the inexperienced surgeon succeeded in fixing the entry angle of the guidewire more precisely both in the AP [1.3 degrees (0.0-2.0 degrees ) versus 2.3 degrees (0.0-9.0 degrees ), p=0.034] as well as in the axial view [1.0 degrees (0.0-2.5 degrees ) versus 6.5 degrees (0.0-12.0 degrees ), p=0.036]. Linear displacement was not significantly different between the two methods: 4.4 (0.7-9.6) mm deviation with the isocentric aiming principle versus 3.9 (1.6-5.7) mm, p=0.406, when the freehand technique is applied. When applying the isocentric aiming principle for guidewire placement the experienced surgeon achieved less precise angulation in the AP view [2.5 degrees (0.0-4.0 degrees ) versus 1.8 degrees (0.0-3.5 degrees ), p=0.061], improved precision in the axial view [2.0 degrees (1.0-3.0 degrees ) versus 3.0 degrees (0.0-5.0 degrees ), p=0.074], and a slightly worsened linear displacement [2.5 (1.0-4.2) mm versus 2.0 (1.0-2.6) mm, p=0.131]. Both surgeons needed less fluoroscopic controls when using the isocentric aiming principle instead of the freehand aiming method: inexperienced surgeon: 8.0 controls (7.0-16.0) instead of 13.0 controls (7.0-16.0), p=0.043; experienced surgeon: 14.5 controls (8.0-26.0) instead of 16.5 controls (12.0-33.0), p=0.282. However due to the additional time needed to fix and align the aiming device to the bone both surgeons required increased procedure time when using the isocentric aiming principle: 4.3 (3.0-6.9) min instead of 2.6 (2.2-4.0) min, p=0.005, for the inexperienced surgeon and 3.3 (2.3-4.3) min instead of 1.9 (1.4-2.8) min, p=0.001, for the experienced surgeon.

CONCLUSIONS

Based on the experimental results we would suggest clinical application of the isocentric aiming principle especially for the less experienced surgeon. Increased precision would outweigh the drawback of a slightly prolonged procedure time. X-ray exposure may also be reduced when using the isocentric aiming principle for guidewire placement. However our results have to be verified by a clinical study beforehand. The isocentric aiming principle can also be applied in other situations that allow for two orthogonal projections for guidewire placement.

Ionising radiation exposure to orthopaedic trainees: the effect of sub-specialty training

INTRODUCTION

We monitored image intensifier use by orthopaedic trainees to assess their exposure to ionising radiation and to investigate the influence of sub-specialty training.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Radiation protection for your hands

A prospective clinical trial was performed to assess the suitability of a new type of sterilisable, user-friendly radiation protection glove. In a preliminary trial, we showed that the dominant hand of the primary operating orthopaedic surgeon receives the highest dose of radiation. During a 4-month period, 98 procedures were done requiring the use of an image intensifier. The doses of radiation to the dominant hand of the operating surgeon were reduced to less than the doses of radiation to the non-dominant hand. The glove was sterilisable, user-friendly and accepted by the majority of surgeons. It offers greater than 90% attenuation of X-rays and is superior to all other scatter gloves on the market.

Radiation exposure to the hands of orthopaedic surgeons: are we underestimating the risk?

INTRODUCTION

Previous studies reported that the radiation exposure to the hands of orthopaedic surgeons was far below the acceptable limit. However, the risk could have been underestimated as some factors were overlooked, namely monitoring trainees during average workload, placing dosimeters over the most susceptible locations, measuring the cumulative dosage of radiation and considering the dose limit for non-classified workers.

MATERIALS AND METHODS

We performed a prospective study in two centres to estimate the radiation dose to the hands of two consultant trauma surgeons and two trainees (one assisting and one operating) while performing 47 fluoroscopy-assisted procedures. We used validated thermoluminescent dosimeters (TLDs) rings and fingerstalls for monitoring the cumulative dosage.

RESULTS

Trainees were at higher risk while performing intramedullary nailing and during assistance. Higher radiation doses were recorded from dominant index fingers and particularly fingertips.

CONCLUSION

The risk of radiation exposure appears to be higher than previously reported. Fingertips are more susceptible to radiation exposure and should therefore be monitored in forthcoming studies.

STAFF EXPOSURE TO IONIZING RADIATION IN A MAJOR TRAUMA CENTRE

BACKGROUND

The purpose of the present paper was to determine the safety of staff members with regard to ionizing radiation in a major trauma centre in a 19-month period.

METHODS AND RESULTS

A group of five doctors, five nurses and a trauma orderly wore personal radiation monitors under lead aprons while at work. The highest individual cumulative result after 586 days was 0.18 mSv for a nurse. If the exposure rate to ionizing radiation was constant, this would be equivalent to 0.114 mSv per year. Therefore the results are well below the recommended occupational dose limit of 20 mSv per year.

CONCLUSION

Wearing of lead aprons during trauma resuscitation appears to be safe and provides adequate protection.

Occupational radiation exposure to the surgeon

Increased use of intraoperative fluoroscopy exposes the surgeon to significant amounts of radiation. The average yearly exposure of the public to ionizing radiation is 360 millirems (mrem), of which 300 mrem is from background radiation and 60 mrem from diagnostic radiographs. A chest radiograph exposes the patient to approximately 25 mrem and a hip radiograph to 500 mrem. A regular C-arm exposes the patient to approximately 1,200 to 4,000 mrem/min. The surgeon may receive exposure to the hands from the primary beam and to the rest of the body from scatter. Recommended yearly limits of radiation are 5,000 mrem to the torso and 50,000 mrem to the hands. Exposure to the hands may be higher than previously estimated, even from the mini C-arm. Potential decreases in radiation exposure can be accomplished by reduced exposure time; increased distance from the beam; increased shielding with gown, thyroid gland cover, gloves, and glasses; beam collimation; using the low-dose option; inverting the C-arm; and surgeon control of the C-arm.

Occupational gonadal and embryo/fetal doses from fluoroscopically assisted surgical treatments of spinal disorders

STUDY DESIGN

Simulation of lumbar spine fluoroscopy used during surgical treatments of spinal disorders on a humanoid phantom and monitoring of the scattered radiation levels.

OBJECTIVES

To assess the potential of adverse effects to progeny due to the preconceptual and embryo/fetal exposure to ionizing radiation resulting from the parental occupational exposure to scattered radiation from lumbar fluoroscopy.

SUMMARY OF BACKGROUND DATA

There are no available data on embryo/fetal doses resulting from maternal occupational exposure in the orthopedic theater. Besides, studies on staff gonadal doses from fluoroscopically assisted spine surgery are scarce and their results are not generally applicable.

METHODS

Lumbar spine anterior-posterior and lateral fluoroscopy were performed on an anthropomorphic phantom. Scattered radiation within the orthopedic theater was recorded at the staff genitals and waist level. Gonadal, abdominal surface, and embryo/fetal doses normalized to the dose-area-product specific to each projection were calculated.

RESULTS

If the annual dose limits of occupational exposure are continuously exhausted for 10 years, the resulting radiogenic risk of congenital malformation in infants born to the orthopedic theater staff will be at least two orders of magnitude lower than the corresponding spontaneous probability. The occupational exposure of the pregnant mother bears a negligible contribution to the risk of hereditary effect on the newborn's progeny compared with the natural incidence rate.

CONCLUSIONS

Radiogenic genetic and embryo/fetal risks resulting from occupational exposure due to fluoroscopically assisted surgical treatments of spinal disorders are well within tolerance levels provided that rigorous confinement to all pertinent occupational dose constraints is established.

Occupational exposure from common fluoroscopic projections used in orthopaedic surgery

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Assessment of the efficacy of Proguard RR-2 radio-protective gloves during forearm manipulation

The hazards of ionising radiation are well known and precautions, such as lead aprons and thyroid shields are routinely used. Orthopaedic surgeon's hands are at particular risk from direct and scatter radiation, when manipulating forearm fractures, due to the proximity of the image intensifier. The use of lead gloves has been recommended in the literature but are seldom employed. Proguard RR-2 gloves provide similar tactile sensitivity to double gloves and are claimed by the manufacturer to provide up to 55% protection in vitro at a direct beam energy level of 60 kV. This claim was tested in a clinical setting. The gloves were worn during forearm manipulations and the radiation dose measured using thermoluminescent dosimeters (TLDs). The results demonstrated a radiation attenuation of 60-64%. These gloves appear to achieve a good compromise between protection and sensitivity and should be included in routine protection against ionising radiation during MUA.

Novel computer-assisted fluoroscopy system for intraoperative guidance: feasibility study for distal locking of femoral nails

OBJECTIVES

Orthopaedic procedures that use fluoroscopy require intraoperative mental navigation of the surgical tools in a three-dimensional space. Moreover, because of their reliance on real-time monitoring, such procedures are frequently associated with increased x-ray exposure. The goal of this study was to develop a computer-guided surgical navigation system based on fluoroscopic images that not only facilitates direction of surgical tools within anatomy, but also provides constant feedback without the need for radiologic updates. To evaluate the feasibility of the new technology, the authors used it on cases requiring distal locking of femoral nails.

METHODS

The hardware components of the system include an instrumented C-arm, optoelectronic position sensor, stereotactic tools, and custom-made software. Computer integration of these devices permitted C-arm alignment assistance and real-time navigation control without constant x-ray exposure. The nails were locked in a variety of media, including plastic femurs, dry human femoral specimens, human cadavers, and one clinical case. Unreamed femoral nail sizes ranged from 9/340 to 12/400. Radiographs were taken to confirm that screws were positioned correctly, and fluoroscopic time associated with the locking procedure was recorded.

RESULTS

All distal holes were locked successfully. In eight (11 percent) of seventy-six holes, the drill bit touched the canal of the locking hole, albeit with no damage to the nail and no clinical consequences. The fluoroscopy time per pair of screws was 1.67 seconds.

CONCLUSIONS

The developed system enables the physician to precisely navigate surgical instruments throughout the anatomy using just a few computer-calibrated radiographic images. The total radiation time per procedure can be significantly reduced because additional x-ray exposure is not required for tool navigation.

Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion

STUDY DESIGN

In vitro study to determine occupational radiation exposure during lumbar fluoroscopy.

OBJECTIVES

To assess radiation exposure to the spine surgeon during fluoroscopically assisted thoracolumbar pedicle screw placement.

SUMMARY OF BACKGROUND DATA

Occupational radiation exposure during a variety of fluoroscopically assisted musculoskeletal procedures has been previously evaluated. No prior study has assessed fluoroscopy-related radiation exposure to the spine surgeon.

METHODS

Bilateral pedicle screw placement (T11-S1) was performed in six cadavers using lateral fluoroscopic imaging. Radiation dose rates to the surgeon's neck, torso, and dominant hand were measured with dosimeter badges and thermolucent dosimeter (TLD) rings. Radiation levels were also quantified at various distances from the dorsal lumbar surface using an ion chamber radiation survey meter.

RESULTS

The mean dose rate to the neck was 8.3 mrem/min. The dose rate to the torso was greatest when the surgeon was positioned ipsilateral to the beam source (53.3 mrem/min, compared with 2.2 mrem/min on the contralateral side). The average hand dose rate was 58.2 mrem/min. A significant increase in hand dose rate was associated with placement of screws ipsilateral to the beam source (P = 0.0005) and larger specimens (P = 0.0007). Radiation levels significantly decreased as distance from the beam source and dorsal body surface increased. The greatest levels of radiation were noted on the side where the primary radiograph beam entered the cadaver.

CONCLUSION

Fluoroscopically assisted thoracolumbar pedicle screw placement exposes the spine surgeon to significantly greater radiation levels than other, nonspinal musculoskeletal procedures that involve the use of a fluoroscope. In fact, dose rates are up to 10-12 times greater. Spine surgeons performing fluoroscopically assisted thoracolumbar procedures should monitor their annual radiation exposure. Measures to reduce radiation exposure and surgeon awareness of high-exposure body and hand positions are certainly called for.

A simple laser guide to reduce the screening time during the insertion of dynamic hip screws

A simple laser pointer can be used to guide the radiographer to position the image intensifier during the insertion of a dynamic hip screw in the treatment of fractures of the trochanteric area of the proximal femur. This significantly reduces the screening time and, by implication, the amount of radiation for the theatre staff and patient.

Ionising radiation during internal fixation of extracapsular neck of femur fractures

This study analyses the relationship between the level of experience of both surgeon and radiographer and the radiation dose administered in theatre, during fixation of extracapsular proximal femoral fractures. From the 63 dynamic hip screw procedures performed, 10 were done by Senior House Officers (SHOs), 10 by Consultants and 43 by Registrars, whereas Basic Radiographers were involved in all cases. Fractures were classified as two part, three part or four part. A four part fracture required higher levels of radiation dose and screening time as compared with a two part fracture. All two part fractures were screened by radiographers of similar experience; however, the radiation dose and screening time were different amongst different levels of surgeon. The highest radiation dose and screening times were recorded when an SHO was the operating surgeon and the lowest when a registrar was the surgeon. The two part and three part fractures performed by registrars were subdivided according to the experience of the radiographer. In both cases a statistically significant difference was found between the dose of radiation administered in theatre and the years of experience of the radiographers (p < 0.05).

Radiation exposure to the orthopaedic surgical team during fluoroscopy: "how far away is far enough?"

OBJECTIVES

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.

DESIGN

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.

SETTING

Standard hospital operating room at a level one trauma center.

PARTICIPANTS

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).

INTERVENTION

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.

MAIN OUTCOME MEASUREMENTS

Radiation exposure readings from dosimetry badges processed by a commercially available dosimetry service.

RESULTS

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.

CONCLUSIONS

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.