The Impact of Lead Aprons on Posture of Orthopaedic Surgeons

Safety and Optimizing Ergonomics for Cardiothoracic Surgeons

Cardiothoracic surgery, demanding in nature, often results in surgeons suffering from musculoskeletal injuries, causing chronic pain and leading to premature retirement. A significant majority report experiencing pain, exacerbated by minimally invasive techniques such as video-assisted thoracoscopic surgery. Despite this, many surgeons delay seeking medical assistance. To mitigate these risks, preventative strategies such as strength exercises, stretching during operations, and taking brief breaks are crucial. However, the surgical community faces a shortage of institutional support and comprehensive ergonomic education. Advancements in technology, including artificial intelligence and virtual reality, could offer future solutions.

High Prevalence of Work-related Musculoskeletal Disorders and Limited Evidence-based Ergonomics in Orthopaedic Surgery: A Systematic Review

BACKGROUND

The Centers for Disease Control defines work-related musculoskeletal disorders as disorders of the nerves, muscles, tendons, joints, spinal discs, and cartilage that are caused or exacerbated by the environment or nature of work. Previous meta-analyses have characterized work-related musculoskeletal disorders among interventionists, general surgeons, and other surgical subspecialties, but prevalence estimates, prognosis, and ergonomic considerations vary by study and surgical specialty.

QUESTIONS/PURPOSES

(1) What is the career prevalence of work-related musculoskeletal disorders in orthopaedic surgeons? (2) What is the treatment prevalence associated with work-related musculoskeletal disorders in orthopaedic surgeons? (3) What is the disability burden of work-related musculoskeletal disorders in orthopaedic surgeons? (4) What is the scope of orthopaedic surgical ergonomic assessments and interventions?

METHODS

A systematic review of English-language studies from PubMed, MEDLINE, Embase, and Scopus was performed in December 2022 and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies that presented prevalence estimates of work-related musculoskeletal disorders or assessed surgical ergonomics in orthopaedic surgery were included. Reviews, case reports, gray literature (conference abstracts and preprints), and studies with mixed-surgeon (nonorthopaedic) populations were excluded. The search yielded 5603 abstracts; 24 survey-based studies with 4876 orthopaedic surgeons (mean age 48 years; 79% of surgeons were men) were included for an analysis of work-related musculoskeletal disorders, and 18 articles were included for a descriptive synthesis of ergonomic assessment. Quality assessment using the Joanna Briggs Institute Tool revealed that studies had a low to moderate risk of bias, largely because of self-reporting survey-based methodology. Because of considerable heterogeneity and risk of bias, prevalence outcomes were not pooled and instead are presented as ranges (mean I 2 = 91.3%).

RESULTS

The career prevalence of work-related musculoskeletal disorders in orthopaedic surgeons ranged from 37% to 97%. By anatomic location, the prevalence of work-related musculoskeletal disorders in the head and neck ranged from 4% to 74%; back ranged from 9% to 77%; forearm, wrist, and hand ranged from 12% to 54%; elbow ranged from 3% to 28%; shoulder ranged from 3% to 34%; hip and thigh ranged from 1% to 10%; knee and lower leg ranged from 1% to 31%; and foot and ankle ranged from 4% to 25%. Of orthopaedic surgeons reporting work-related musculoskeletal disorders, 9% to 33% had a leave of absence, practice restriction or modification, or early retirement, and 27% to 83% received some form of treatment. Orthopaedic surgeons experienced biomechanical, cardiovascular, neuromuscular, and metabolic stress during procedures. Interventions to improve orthopaedic surgical ergonomics have been limited, but have included robotic assistance, proper visualization aids, appropriate use of power tools, and safely minimizing lead apron use. In hip and knee arthroplasty, robotic assistance was the most effective in improving posture and reducing caloric expenditure. In spine surgery, proper use of surgical loupes was the most effective in improving posture.

CONCLUSION

Although the reported ranges of our main findings were wide, even on the low end of the reported ranges, work-related musculoskeletal disability among orthopaedic surgeons appears to be a substantial concern. We recommend that orthopaedic residency training programs incorporate surgical ergonomics or work injury lectures, workshops, and film review (alongside existing film review of surgical skills) into their curricula. We suggest hospitals engage in shared decision-making with surgeons through anonymous needs assessment surveys to implement wellness programs specific to surgeons' musculoskeletal needs. We urge institutions to assess surgeon ergonomics during routine quality assessment of novel surgical instruments and workflows.

LEVEL OF EVIDENCE

Level III, prognostic study.

The Biomechanical Burden of Orthopaedic Procedures and Musculoskeletal Injuries Sustained by Orthopaedic Surgeons: A Systematic Review

BACKGROUND

Orthopaedic surgeons are at high risk for experiencing work-related musculoskeletal (MSK) injuries and chronic pain due to repetitive large magnitude forces, altered posture from lead vests, and prolonged irregular body positions. We sought to synthesize available evidence regarding (1) the biomechanics of orthopaedic surgery and (2) MSK injuries sustained by orthopaedic surgeons with subsequent treatment and consequences.

METHODS

To conduct this systematic review, we queried 4 databases (PubMed, Embase, MEDLINE, and Web of Science) for original research studies presenting on the biomechanics of orthopaedic surgery or MSK injuries sustained by orthopaedic surgeons. Studies were excluded if they were not original research (i.e., reviews) or reported on non-MSK injuries and injuries in patients or nonorthopaedic specialists. The literature search yielded 3,202 publications, 34 of which were included in the final analysis.

RESULTS

Eight studies reported on the biomechanics of orthopaedic surgery. Surgeons spent an average 41.6% of operating time slouched. Head and whole spine angles were closest to natural standing position when using a microscope for visualization and with higher surgical field heights. Use of lead aprons resulted in a shifted weight distribution on the forefoot, gain in thoracic kyphosis, and increase in lateral deviation from postural loading. Twenty-six studies reported on MSK symptoms and injuries experienced by orthopaedic surgeons, with an overall prevalence from 44% to 97%. The most common body regions involved were lower back (15.2%-89.5%), hip/thigh (5.0%-86.6%), neck (2.4%-74%), hand/wrist (10.5%-54%), shoulder (7.1%-48.5%), elbow (3.1%-28.3%), knee/lower leg (7.9%-27.4%), and foot/ankle (7%-25.7%). Of surgeons with any reported MSK symptom or injury, 27% to 65.7% required nonoperative treatment, 3.2% to 34.3% surgery, and 4.5% to 31% time off work. Up to 59.3% of surgeons reported that their injuries would negatively influence their ability to perform surgical procedures in the future.

CONCLUSIONS

The orthopaedic surgeon population experiences a high prevalence of MSK symptoms and injuries, likely secondary to the biomechanical burdens of tasks required of them during strenuous operations.

LEVEL OF EVIDENCE

Level III. See Instructions for Authors for a complete description of levels of evidence.

Ergonomics and Work-Related Musculoskeletal Disorders: Characteristics Among Female Interventionists

Interventional radiology is a procedural specialty that performs minimally invasive operations under image guidance. Currently, there are inadequate ergonomic protocols for work-related musculoskeletal disorder (WMSD) prevention in interventional radiology (IR), and there is a paucity of information discerning gender differences in WMSDs. This article reviews current literature that addresses WMSDs in female physicians practicing interventional and fluoroscopic procedures, including interventional radiology, interventional cardiology, electrophysiology, vascular surgery, orthopedic surgery, neurosurgery, and gastroenterology. We searched PubMed and EBSCOhost databases for ergonomic studies that reported female physician WMSDs in the specialties listed above. After a thorough evaluation for inclusion based on eligibility criteria, 11 studies were included. From this search, there was poor female representation, averaging 25.7% of respondents. Several characteristics identified across the studies were that women were generally shorter, wore smaller glove sizes, and were younger than their male colleagues. Seventy-two percent of female proceduralists reported WMSDs versus 46.6% of their male colleagues. Additionally, women may experience more upper extremity pain than lumbar pain, which men commonly reported. Potential contributing factors to WMSDs are the size and design of procedural tools and the possible predisposition of female physicians to experience upper extremity WMSDs while performing the same operations as men. As more women enter medicine and pursue careers in procedural fields like interventional radiology, it is essential to address these discrepancies and develop ergonomically sound solutions for women.