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

Intraoperative Radiation Exposure During Midfoot Charcot Reconstruction

While radiation exposure in foot and ankle surgery varies by procedure, attempts to minimize this hazard remain imperative to protect patients and surgeons. Hindfoot deformity correction employs significant radiation through intraoperative fluoroscopy, however, a paucity of data exists concerning Charcot reconstruction. This investigation describes and compares radiation exposure across varying Charcot pathology and fixation constructs. A retrospective chart review of patients undergoing midfoot Charcot reconstruction under large C-arm assistance from 2016-2022 was conducted. Demographics, pathology-specific, and intervention-specific variables were recorded and compared among midfoot reconstructions. The threshold for statistical significance was set at p ≤ .05. Among 40 patients, the average midfoot radiation exposure and fluoroscopy times were 9.5 ± 5.39 mGy and 256.64 ± 130.67 seconds, respectively. There existed no statistically significant difference in radiation exposure (p = .32) or fluoroscopy times (p = .71) among the different midfoot constructs. There existed a statistically significant relationship between radiation exposure with weight (p = .01) body mass index (p = .03) and number of stages (p = .04). Similarly, a relationship existed between fluoroscopy time with weight (p = .02), body mass index (p = .03), and number of beams/screws (p = .003). Due to the complexity of Charcot reconstruction coupled with multiple robust types of fixation, surgeons must remain cognizant of fluoroscopy usage. Moreover, providers who routinely perform Charcot reconstruction should wear personal protective equipment to protect against radiation.

Factors associated with increased radiation exposure in the fixation of proximal femoral fractures

INTRODUCTION

When using radiation intraoperatively, a surgeon should aim to keep the radiation dose as low as is reasonably achievable to obtain the therapeutic goal. We aimed to investigate factors associated with increased radiation exposure in fixation of proximal femur fractures.

METHODS

We assessed 369 neck of femur fractures over a 1-year period in a district general hospital. All hip fracture subtypes that had undergone surgical fixation were included. We assessed the relationship between type of fracture, implants used and surgeon level of experience with the dose-area product (DAP; cGy/cm2) and screening time (dS). We also looked at the quality of reduction and fixation and its effect on the radiation exposure.

RESULTS

A total of 184 patients were included in our analysis; 185 patients who were treated with hip arthroplasty were excluded. There was a significant association between higher DAP and fracture subtype (p = 0.001), fracture complexity (p < 0.001), if an additional implant was used (p = 0.001), if fixation was satisfactory (p = 0.002) and operative time (p < 0.001). DAP was higher with a proximal femoral nail than with a dynamic hip screw, especially when a long nail was used. There was some evidence of an association between the surgeon's level of experience and DAP exposure, although this was not statistically significant (p = 0.069).

CONCLUSIONS

Increased radiation in proximal femur fractures is seen in the fixation of complex fractures, some subtypes, with certain types of implants used and if an additional implant was required. Surgeon seniority did not result in less radiation exposure, which is in contrast to other published studies.

Role of Laser Pointer in Budgeting Fluoroscopy-Time and Radiation Exposure

BACKGROUND

Literature on radiation exposure with use of the mini C-arm and value of having built-in laser guidance is limited. The purpose of this study was to determine whether laser guidance use on a mini C-arm fluoroscopy unit can reduce radiation exposure.

METHODS

Surgeons (N = 25) performed the same simulated surgical task, which involved obtaining "perfect circle" views of 2 cannulated screws placed into a cadaveric wrist, done with and without C-arm laser guidance. The testing order was randomized. Main outcomes were time to complete the task, number of shots required to complete the task, number of blank shots taken, radiation exposure, total dose area product (DAP), and total exposure time.

RESULTS

Laser guidance significantly reduced the percentage of surgeons who took blank shots, from 88% of the group without the laser to 12% of the group with the laser, and decreased the total average blank shots in the group from 3.5 to 0.1. While we found laser guidance led to shorter time to complete the task, decreased shots taken, and decreased exposure time and DAP, these findings only approached significance.

CONCLUSION

While debate continues regarding whether mini or standard C-arm is safest, it is clear that decreasing the overall number of exposures limits potential adverse effects. Our study demonstrated that when using a mini C-arm, laser guidance decreases the number of exposures required to capture an image. These findings warrant a larger study to define the specific exposure savings and indicate potential benefit of mini C-arm use with laser guidance.

Reducing frame rate and pulse rate for routine diagnostic cerebral angiography: ALARA principles in practice

OBJECTIVE

Diagnostic cerebral angiograms (DCAs) are widely used in neurosurgery due to their high sensitivity and specificity to diagnose and characterize pathology using ionizing radiation. Eliminating unnecessary radiation is critical to reduce risk to patients, providers, and health care staff. We investigated if reducing pulse and frame rates during routine DCAs would decrease radiation burden without compromising image quality.

METHODS

We performed a retrospective review of prospectively acquired data after implementing a quality improvement protocol in which pulse rate and frame rate were reduced from 15 p/s to 7.5 p/s and 7.5 f/s to 4.0 f/s respectively. Radiation doses and exposures were calculated. Two endovascular neurosurgeons reviewed randomly selected angiograms of both doses and blindly assessed their quality.

RESULTS

A total of 40 consecutive angiograms were retrospectively analyzed, 20 prior to the protocol change and 20 after. After the intervention, radiation dose, radiation per run, total exposure, and exposure per run were all significantly decreased even after adjustment for BMI (all p<0.05). On multivariable analysis, we identified a 46% decrease in total radiation dose and 39% decrease in exposure without compromising image quality or procedure time.

CONCLUSIONS

We demonstrated that for routine DCAs, pulse rate of 7.5 with a frame rate of 4.0 is sufficient to obtain diagnostic information without compromising image quality or elongating procedure time. In the interest of patient, provider, and health care staff safety, we strongly encourage all interventionalists to be cognizant of radiation usage to avoid unnecessary radiation exposure and consequential health risks.

Orthopaedic surgeons' knowledge and practice of radiation safety when using fluoroscopy during procedures: A narrative review

OBJECTIVES

The fluoroscopy environment poses a potential occupational radiation exposure risk to theatre personnel. Risks can be mitigated with effective application of radiation protection knowledge and methods. This review aimed to determine the link between orthopaedic surgeon's knowledge and the use of appropriate safety methods when using fluoroscopy.

KEY FINDINGS

A keyword search of three databases discovered six articles, totalling 2209 orthopaedic surgeons, who completed surveys to assess knowledge on various aspects of radiation safety and training. Participants had varying levels of experience. Moreover 1981 participants always wore a lead gown (89 %), while only 1052 participants wore thyroid protection (47 %). 449 participants (20 %) received some form of training.

CONCLUSION

Although surveys asked a range of questions it appeared that there was low knowledge of the ALARP principles. Usage of protective equipment is a legal requirement and thus was observed throughout, however, there were a number of incidences of disregarding some protective measures. Although there appeared to be limited knowledge surrounding radiation protection measures and lack of training provided, no clear link was demonstrated between compliance with protective methods and knowledge of the risks.

IMPLICATIONS FOR PRACTICE

Formal and continuous training should be provided for the enhancement of knowledge to ensure the safety of all staff and help prevent the long-term effects of ionising radiation when using fluoroscopy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Radiation dose to staff from medical X-ray scatter in the orthopaedic theatre

PURPOSE

Given the growing demand for intraoperative imaging, there is increased concern for radiation dose for orthopaedic surgical staff. This study sought to determine the distribution of scatter radiation from fluoroscopic imaging in the orthopaedic surgical environment, with particular emphasis on the positions of personnel and the type of orthopaedic surgery performed.

METHODS

A radiation survey detector was deployed at various angles and distances around an anthropomorphic phantom. The scatter dose rate in microsieverts per hour (µSv/h) was recorded using consistent exposure parameters for five common surgical procedures. A C-arm unit produced radiation for the hip arthroscopy, hip replacement and knee simulations, whilst a mini C-arm unit produced fluoroscopy for the foot and hand simulations.

RESULTS

Readings were tabulated, and coloured heatmaps were generated from scatter measurements for each of the five procedures. Positions corresponding to the typical location of the surgical staff (surgeon, surgical assistant, anaesthetist, instrument (scrub) nurse, circulation (scout) nurse and anaesthetic nurse) were superimposed on heatmaps. The surgeon's proximity to the radiation source meant this position experienced the greatest amount of radiation in all five surgical procedures. Mini C-arm doses were considered low in all procedures for positions, with and without lead protection.

CONCLUSION

This investigation demonstrated the distribution of scattered radiation dose experienced at different positions within the orthopaedic surgical theatre. It reinforces the importance of staff increasing their distance from the primary beam where possible, reducing exposure time and increasing shielding with lead protection.

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

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

THE USE OF ADHESIVE RADIOPAQUE GRIDS IN GENICULAR NERVE BLOCK BY RADIOSCOPY

The performance of genicular nerve block requires an imaging method to guide the procedure. Radioscopy has the disadvantage of being radiation dependent.

Objective

To assess whether the use of adhesive radiopaque grids reduce radiation exposure in these cases.

Methods

This is a cross-sectional study conducted with 23 orthopedists in which needles were positioned in a model with and without the use of adhesive radiopaque grids. The number of fluoroscopy shots necessary for proper positioning in three points (superior lateral, superior medial, and inferior medial) were registered.

Results

A statistical difference was observed in the three blocking points studied. The number of radioscopies required for these three points were 12.1 ± 2.5 in the group without grid and 5.0 ± 1.8 in the group with grid. The superior medial point presented the greatest numerical difference and the inferior medial point the smallest.

Conclusion

The use of adhesive radiopaque grids led to a statistically significant reduction in the number of radioscopies/fluoroscopies required to perform the genicular block. The use of this device increases the safety of the physician and patient by reducing radiation exposure in this procedure. Level of Evidence III, Level of Evidence II, Random Clinical Trial.

Multi-Layered Composites of Natural Rubber (NR) and Bismuth Oxide (Bi2O3) with Enhanced X-ray Shielding and Mechanical Properties

Due to rapid increases in the utilization of radiation and nuclear technologies, effective and suitable radiation-shielding materials have become one of the most sought-after options to protect users and the public from excessive exposure to the radiation. However, most radiation-shielding materials have greatly reduced mechanical properties after the addition of fillers, resulting in their limited useability and shortened lifetime. Therefore, this work aimed to alleviate such drawbacks/limitations by exploring a possible method to simultaneously enhance both the X-ray shielding and mechanical properties of bismuth oxide (Bi₂O₃)/natural rubber (NR) composites through multi-layered structures, with varying (1-5) layers and a total combined thickness of 10 mm. To correctly determine the effects of the multi-layered structures on the properties of NR composites, the formulation and layer configuration for all multi-layered samples were tailored such that their theoretical X-ray shielding properties were equal to those of a single-layered sample that contained 200 phr Bi₂O₃. The results indicated that the multi-layered Bi₂O₃/NR composites with neat NR sheets on both outer layers (sample-D, sample-F, sample-H, and sample-I) had noticeably higher tensile strength and elongation at break than those of the other designs. Furthermore, all multi-layered samples (sample-B to sample-I), regardless of the layer structure, had enhanced X-ray shielding properties compared to those with a single layer (sample-A), as shown by their higher values of the linear attenuation coefficient (µ) and lead equivalence (Pb_eq) and the lower value of the half-value layer (HVL) in the former. This work also determined the effects of thermal aging on relevant properties for all samples, with the results revealing that all the thermal-aged composites had higher values for the tensile modulus but lower values for the swelling percentage, tensile strength, and elongation at break, compared with the non-aged composites. Hence, based on the overall outcomes from this work, it could be concluded that the worrisome decreases in mechanical properties of the common single-layered NR composites after the addition of Bi₂O₃ could be prevented/reduced by introducing appropriate multi-layered structures, which would not only widen potential applications but also prolong the lifetime of the composites.

Analysis of Spanish vocational radiographers' education through clinical training and perceptions of core subject teachers: A survey

INTRODUCTION

This work presents a prospective analysis of the key aspects involved in the Spanish radiographer's perception of the weaknesses of the current educational curriculum in terms of teaching staff's qualifications and composition in the clinical training and core subjects. The goal is to show clinical training and professional's perception of the teaching quality and to characterise the weakness detected within the context of the European radiographer's academic system.

METHODS

The perception of the quality of the training received by the professionals was collected through an anonymous survey. A total of 758 valid responses were received, and were analysed to three hypotheses: the variability of the teachers' qualifications in the core subjects, the variability in terms of internships time carried out by the students, and assessment about teaching quality of the teachers.

RESULTS

The results prove there is a huge variability and little academic affinity of the teachers' degrees with the core subjects. On the other hand, the results shows there is a scarcity of clinical training hours in Spain, especially compared to European standards. It was demonstrated that teachers with a specific radiographer degree obtained the best scores.

CONCLUSION

It is mandatory to adjust the criteria for selecting clinical imaging teachers to improve the teaching quality in Spain and increase the clinical training period of the Spanish radiographers to match their European counterparts.

IMPLICATION FOR PRACTICE

Improving the training of Spanish radiographers will contribute to standardising the training quality of the whole European profession.

Intraoperative fluoroscopic radiation in orthopedic trauma: correlation with surgery type and surgeon experience

Background

While fluoroscopy is widely used in orthopedic trauma surgeries, it is associated with harmful effects and should, therefore, be minimized. However, reference values for these surgeries have not been defined, and it is not known how surgeon experience affects these factors. The aims of this study were to analyze the radiation emitted and exposure time for common orthopedic trauma surgeries and to assess whether they are affected by surgeon experience.

Methods

Data from 1842 trauma orthopedic procedures were retrospectively analyzed. A total of 1421 procedures were included in the analysis. Radiation dose and time were collected to identify reference values for each surgery and compared for when the lead surgeon was a young resident, a senior resident, or a specialist.

Results

The most performed surgeries requiring fluoroscopy were proximal femur short intramedullary nailing (n = 401), ankle open reduction and internal fixation (ORIF) (n = 141), distal radius ORIF (n = 125), and proximal femur dynamic hip screw (DHS) (n = 114). Surgeries using higher radiation dose were proximal femur long intramedullary nailing (mean dose area [DAP]): 1361.35 mGycm²), proximal femur DHS (1094.81 mGycm²), and proximal femur short intramedullary nailing (891.41 mGycm²). Surgeries requiring longer radiation time were proximal humerus and/or humeral shaft intramedullary nailing (02 mm:20 ss), proximal femur long intramedullary nailing (02 mm:04 ss), and tibial shaft/distal tibia intramedullary nailing (01 mm:49 ss). Senior residents required shorter radiation time when performing short intramedullary nailing of the proximal femur than young residents. Specialists required more radiation dose than residents when performing tibial nailing and tibial plateau ORIF and required longer radiation time than young residents when performing tibial nailing.

Conclusions

This study presents mean values of radiation dose and time for common orthopedic trauma surgeries. Orthopedic surgeon experience influences radiation dose and time values. Contrary to expected, less experience is associated with lower values in some of the cases analyzed.

Minimizing Surgeon Radiation Exposure During Operative Treatment of Pediatric Supracondylar Humerus Fractures

BACKGROUND

Orthopaedic surgeons are exposed to high levels of radiation, which may lead to higher rates of cancer among orthopaedic surgeons. There are a series of techniques currently practiced to pin supracondylar humerus fractures including pinning the arm on the C-arm itself, using a plexiglass rectangle or a graphite floating arm board; however, the variation in radiation exposure to the surgeon is unknown. We aimed to determine how the position of the C-arm affects radiation exposure to the surgeon during the treatment of a pediatric supracondylar humerus fracture.

MATERIAL AND METHODS

A simulated operating room was created to simulate a closed reduction and percutaneous pinning of a supracondylar humerus fracture. A phantom model was used to simulate the patient's arm. We assessed performing the procedure with the arm on plexiglass, graphite, or on top of the C-arm image receptor. The C-arm was positioned either with the source down and image receptor up (standard position) or with the source up and image receptor down (inverted position). Radiation exposure was recorded from levels corresponding to the surgeon's head, midline, and groin. The estimated effective dose equivalent was calculated to account for the varying radiation sensitivity of different organs.

RESULTS

We found the effective dose equivalent, or the overall body damage from radiation, was 5.4 to 7.8% higher than the surgeon when the C-arm was in the inverted position (source up, image receptor down). We did not find any differences in radiation exposure to the surgeon when the arm was supported on plexiglass versus graphite.

CONCLUSION

The C-arm positioned in the standard fashion exposes the surgeon to less damaging radiation. Therefore, when the surgeon is standing, we recommend using the C-arm in the standard position.

CLINICAL RELEVANCE

Orthopaedic surgeons who stand should use the C-arm in the standard position to pin supracondylar humerus fractures to lower the risk of ionizing radiation exposure.

Observational prospective unblinded case-control study to evaluate the effect of the Gamma3® distal targeting system for long nails on radiation exposure and time for distal screw placement

PURPOSE

To determine if the DTS decreases radiation exposure (primary outcome measure), fluoroscopy time (secondary outcome measure), and time to distal screw placement (secondary outcome measure) compared to the freehand "perfect circles" method when used for locking of cephalomedullary nails in the treatment of femur fractures METHODS: Fifty-eight patients with hip or femoral shaft fractures that were treated with a long cephalomedullary nail were enrolled in this study. Cohorts were determined based on the method of distal interlocking screw placement into either the "Perfect Circles" or "Distal Targeting" cohort. Time from cephalad screw placement to placement of final distal interlocking screw (seconds), radiation exposure (mGy), and fluoroscopy time (seconds) were compared between groups. Hospital quality measures were compared between cohorts.

RESULTS

Use of the DTS resulted in 77% (4.3x) lower radiation exposure (p < 0.001), 64% (2.7x) lower fluoroscopy time (p < 0.001), and 60% (1.7x) lower intraoperative time from end of cephalad screw placement to end of distal interlocking screw placement (p < 0.001) compared to the freehand "perfect circles" method. There was no difference in 30-day or 90-day complication rates between cohorts.

CONCLUSION

The Stryker Gamma3® Distal Targeting System is a safe, effective and efficient alternative to the freehand "perfect circles" method.

Radiation educational program significantly reduces intraoperative fluoroscopy time during locking plate fixation for distal radius fractures

BACKGROUND

The use of C-arm fluoroscopy poses a risk of radiation exposure to the surgeons. This study aimed to examine the intraoperative fluoroscopy time of the distal radius plating before and after radiation educational program.

METHODS

A total of 68 cases (48 women and 20 men; average age, 61.8 years) were reviewed between July 2017 and October 2019. All patients were treated with volar locking plate fixation for distal radius fractures. On October 2018, we had a 1-h radiation educational program for orthopedic surgeons. Intraoperative fluoroscopy time was compared between 34 cases in the preintervention group (group A) and 34 cases in the postintervention group (group B). Radiographic correction loss of the fracture was assessed by ulnar variance (UV), radial inclination (RI), and volar tilt (VT) between immediately after surgery and at the time of bone union.

RESULTS

A significant difference was found in intraoperative fluoroscopy time between 329 s in group A and 123 s in group B. ΔUV between immediately after surgery and at the time of bone union was 0.6 mm in group A and 0.3 mm in group B; ΔRI was -0.3° in group A, -0.1° in group B, ΔVT is -0.4° in group A, and -0.1° in group B. No significant difference was found among them.

CONCLUSIONS

After an educational program on radiation exposure, the intraoperative fluoroscopy time was significantly saved in the plating surgery for the distal radius fractures. The shortening of the intraoperative fluoroscopy time did not affect the loss of radiographic correction of the fractures.

[Imaging after trauma in clinics and practice for children and adolescents : Part 1 of the results of a nationwide online survey of the Pediatric Traumatology Section of the German Trauma Society]

BACKGROUND

The indication for radiography should strictly follow the ALARA (as low as reasonably achievable) principle in pediatric and adolescent trauma patients. The effect of radiation on the growing sensitive tissue of these patients should not be disregarded.

QUESTION

The Pediatric Traumatology Section (SKT) of the German Trauma Society (DGU) wanted to clarify how the principle is followed in trauma care.

METHODS

An online survey was open for 10 weeks. Target groups were trauma surgeons, pediatric surgeons, general surgeons, and orthopedic surgeons.

RESULTS

From Nov. 15, 2019, to Feb. 29, 2020, 788 physicians participated: branch office 20.56%, MVZ 4.31%, hospital 75.13%; resident 16.62%, senior 38.07%, chief 22.59%. By specialist qualification, the distribution was: 38.34% surgery, 33.16% trauma surgery, 36.66% special trauma surgery, 70.34% orthopedics and trauma surgery, 18.78% pediatric surgery. Frequency of contact with fractures in the above age group was reported as 37% < 10/month, 27% < 20/M, 36% > 20/M. About 52% always request radiographs in 2 planes after acute trauma. X-ray of the opposite side for unclear findings was rejected by 70%. 23% use sonography regularly in fracture diagnosis. In polytrauma children and adolescents, whole-body CT is never used in 18%, rarely in 50%, and standard in 14%.

DISCUSSION

The analysis shows that there is no uniform radiological management of children and adolescents with fractures among the respondents.

CONCLUSION

Comparing the results of the survey with the consensus findings of the SKT recently published in this journal, persuasion is still needed to change the use of radiography in primary diagnosis.

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

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

METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

Knowledge and practice of radiation protection in the operating theater among orthopedic surgeons

Purpose

Many orthopedic procedures, particularly minimally invasive surgeries that require fluoroscopic imaging, present a radiation exposure risk to the orthopedic surgeon. Surgeons may have a higher risk of developing cancer if they receive significant amounts of radiation. Using personal protective equipment (PPE) and appropriate imaging device positioning, plays an important role in reducing the surgeon's radiation exposure. However, there is a lack of knowledge about the surgeon's radiation safety awareness and practices. Therefore, the aim of this study is to investigate the practices and radiation protection knowledge of orthopedic surgeons in the operating theater.

Approach

A nationwide survey was conducted from October 2021 to January 2022 to evaluate the radiation protection practices and awareness of orthopedic surgeons in Jordan. Normalized practice and knowledge scores were evaluated through the survey and compared between different groups. Descriptive statistics were used to present the surgeon's practices and radiation protection knowledge. Student's t -test was used to compare the outcomes between surgeons that received radiation protection training and surgeons who did not. Using ANOVA analysis, we compared the score outcomes for all the other variables.

Results

The surgeons that received radiation protection training had significantly higher practice score 39.6% compared with 31% for the group that did not have training ( p = 0.01 ). No statistically significant difference in the knowledge scores was found between the two groups. Although 91% of the surgeons reported using some kind of PPE, only 5.5% used a dosimeter badge during surgeries.

Conclusion

There is an obvious deficit in radiation safety training of orthopedic surgeons.

Knowledge Regarding Ionizing Radiation Exposure Safety Among Orthopedic Surgeons at Hospitals in Al-Madinah

Background and objective The use of radiation imaging techniques in operation theaters is essential for numerous surgical procedures and patients' overall well-being. Radiation imaging techniques enable the surgeon to have a real-time visualization of the anatomy and to perform operations with a greater chance of success, decrease rates of patient morbidity, and enable surgeons to obtain imaging records before the patient leaves the theater room. However, with the increased use of imaging techniques in orthopedic surgical operations, orthopedic surgeons are being exposed to higher levels of radiation, and hence they can be classified as a high-risk group for occupational radiation exposure. This study aimed to assess orthopedic surgeons' awareness and knowledge regarding radiation exposure safety. Materials and methods A questionnaire-based descriptive cross-sectional study was conducted from January to March 2022 to assess the knowledge regarding ionizing radiation exposure safety among orthopedic surgeons, including consultants, specialists, and residents, at both private and governmental hospitals in Al-Madinah city, Saudi Arabia. Ethical approval was obtained from the Ministry of Health (MOH) of Al-Madinah (approval number: H-03-l.l-084). The applied statistical tests were frequency and MCT tests for univariate variables while Chi-square was applied for bivariate variables. With a 95% confidence interval (CI), a p-value of more than 0.05 was used as the cut-off value for the significance level. Results A total of 57 surgeons participated in the study, of which 57.9% were exposed to radiation two to three times per week. Additionally, more than half of the physicians (66.7%) were not trained to use fluoroscopy (C-arm machine). Of note, 78.9% of orthopedic surgeons reported that they used the protective apron as protective equipment, while 17.5% of them used both a protective apron and thyroid shield. However, only less than half of the orthopedic surgeons (43.9%) in our study practiced radiation safety in the operating room. Conclusion Our study revealed a lack of knowledge and awareness related to ionizing radiation exposure safety among orthopedic surgeons in Al-Madinah city, Saudi Arabia.

[Postoperative imaging of the musculoskeletal system : Clinical aspects]

BACKGROUND

Postoperative imaging in trauma surgery is an essential part of documenting optimal osteosynthetic care. A precise and goal-oriented analysis with a justifiable indication is essential. The clinical information has a great impact on the quality of imaging. An objective evaluation and structured reporting complete the postoperative imaging procedure.

MATERIALS AND METHODS

Conventional x‑rays in two planes is the standard of postoperative imaging in musculoskeletal surgery. In specific anatomic structures, additional images may be necessary. The postoperative x‑ray is the simplest way to visualize a successful osteosynthesis and combines the most important points of postoperative management. Computed tomography (CT) is mostly used in emergencies, but also in the postoperative management of some elective procedures, including patients with surgery of the spine, hip or to the proximal long bones of the extremities. Furthermore, CT is useful in postoperative imaging of complicated ankle fractures. Magnetic resonance imaging (MRI) plays a modest role in postoperative imaging and is mostly used in musculoskeletal cancer surgery. Ultrasound rather plays a subordinated role in postoperative management, but it is increasingly becoming established as a tool for postoperative quality control. The great advantage is dynamic visualization in real time.

CONCLUSION

Postoperative imaging remains challenging, but can detect most issues regarding osteosynthesis, which can be then be treated or monitored. Various imaging modalities are available to make reliable statements on osteosynthetic material, bone and soft tissue.

Ultrasound in the Diagnosis of Pediatric Distal Radius Fractures: Does it Really Change the Treatment Policy? An Orthopedic View

BACKGROUND

Distal radius fractures are the most common pediatric fractures, increasing in number in recent decades. Although simple bi-planar radiographs are sufficient for diagnosis, wrist ultrasonography has been popularized in recent years for fracture detection, mostly because of the concern about children's radiation exposure. Despite its availability and diagnostic accuracy, ultrasound has not gained widespread acceptance and popularity among orthopedic surgeons. We asked about the reasons for its lack of acceptance as a diagnostic tool by orthopedic surgeons, and its failure to be incorporated into diagnostic algorithms.

MATERIAL AND METHODS

We reviewed the latest articles concerning the use of ultrasound in the diagnosis of pediatric distal radius fracture. Data extraction was performed from each study with a focus on the following items: the specialty field of the authors, number of patients, number of fractures, mean age of the patients, and the gold standard method of diagnosis.

RESULTS

Nine studies concerning the diagnostic accuracy of ultrasound in detecting distal radius fractures in children were included in the review. The most common field of practice of the authors was emergency medicine. Only two studies had an orthopedic surgeon among their authors. All studies employed X-ray imaging as the gold standard method. All studies were designed as prospective trials without randomization of patients. Generally, there was no independent blinded reviewer for the interpretation of ultrasound and X-ray images.

CONCLUSIONS

Most studies were completed by emergency medicine physicians, without involving an orthopedic surgeon. Ultrasound evaluation was undertaken primarily by emergency medicine physicians with little experience. These studies were not randomized controlled trials, and knowledge of the history and clinical presentation of the subjects could have led to information bias. The relatively low number of included patients and lack of follow-up examinations were other limitations. As a result, we believe that ultrasound has not proven to be a suitable substitute for conventional X-ray imaging in the detection of pediatric distal radius fractures. We propose X-ray evaluation as the clinical gold standard method for pediatric wrist fractures.

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.

Comparison of radiation exposure to physicians between anteroposterior and lateral real-time fluoroscopy when performing lumbar transforaminal epidural steroid injections: A randomized controlled trial

BACKGROUND

Lumbar transforaminal epidural steroid injections are used widely to alleviate low back radicular pain, but it requires real-time fluoroscopy, which can increase the risk of radiation exposure. Anteroposterior or lateral real-time fluoroscopy can be used during lumbar transforaminal epidural steroid injections, but there have been no comparative studies on the exposure of physicians to radiation from anteroposterior or lateral real-time fluoroscopy. The aim of this study was to compare the cumulative radiation exposure to each body part of the physician according to the method of real-time fluoroscopy when performing lumbar transforaminal epidural steroid injections.

METHODS

A single physician performed lumbar transforaminal epidural steroid injections, and 2 groups of patients were formed based on the method used: group A (anteroposterior real-time fluoroscopy) and group L (lateral real-time fluoroscopy). Dosimeters were placed outside the chest, inside the chest, outside the thyroid collar, inside the thyroid collar, outside the groin, inside the groin, outside the lead gloves, and left rim of the glasses.

RESULTS

A total of 200 lumbar transforaminal epidural steroid injections were analyzed, and the radiation exposure was measured by cumulative dose equivalents in mSv. The dose equivalents were lower at every level in group A compared with group L except for outside the groin.

CONCLUSIONS

The cumulative radiation exposure at all the measurement sites was lower for anteroposterior real-time fluoroscopy compared with lateral real-time fluoroscopy when performing lumbar transforaminal epidural steroid injections, except for outside the groin.

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.

Dose reduction for minimizing radiation in displaced paediatric supracondylar humerus fractures: single vs. automated pulse mode

Conventional C-arm image intensifiers (CCA) are an essential and indispensable aid in modern orthopaedic surgery. CCAs are defaulted to auto-pulse mode which emit multiple pulses (or bursts) of radiation to obtain optimum image quality. The number of pulses per shot can be configured manually. The purpose of this study is to investigate the efficacy of the single pulse mode of CCA in reducing and fixing paediatric supracondylar humeral fractures (SCHF). A retrospective chart review of 99 paediatric patients who underwent closed reduction and percutaneous pinning of displaced SCHF was performed. Fifty-one consecutive cases operated with auto-pulse mode (group A). Another 48 consecutive cases were operated with the single-pulse mode (group B). Baumann's angle, operative duration and average radiation dose rate were recorded for comparison between both groups. Twenty postpinning images were randomly selected (10 from each group) to study intra- and interobserver reliability. Twelve doctors were recruited and tasked to identify if each X-ray was taken with the auto-pulse or single-pulse mode. This was repeated after 2 weeks. The patients in the auto-pulse mode group had a significantly higher mean radiation dose of 40.4 ± 32.51 cGycm2/min compared to that of 14.8 ± 3.24 cGycm2/min for the single-pulse group (P ≤ 0.001). All patients in both groups had Baumann's angle within normal range of 64-81°. No significant difference was noted in average intraoperative timings between both groups (P = 0.869). In the majority of cases, the doctors were unable to visually differentiate between the modes of CCA used. The single-pulse mode is an excellent alternative to the auto-pulse mode in fixing SCHF. It gives significantly lower radiation without compromising the surgical outcome. Level of evidence: Level III retrospective comparative study.

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.

Learning-based occupational x-ray scatter estimation

Objective. During x-ray-guided interventional procedures, the medical staff is exposed to scattered ionizing radiation caused by the patient. To increase the staff’s awareness of the invisible radiation and monitor dose online, computational scatter estimation methods are convenient. However, such methods are usually based on Monte Carlo (MC) simulations, which are inherently computationally expensive. Yet, in the interventional environment, immediate feedback to the personnel is desirable. Approach. In this work, we propose deep neural networks to mitigate the computational effort of MC simulations. Our learning-based models consider detailed models of the (outer) patient shape and (inner) anatomy, additional objects in the room, and the x-ray tube spectrum to cover imaging settings encountered in real interventional settings. We investigate two cases of scatter prediction. First, we employ network architectures to estimate the full three-dimensional (3D) scatter distribution. Second, we investigate the prediction of two-dimensional (2D) intensity projections that facilitate the intra-procedural visualization. Main results. Depending on the dimensionality of the estimated scatter distribution and the network architecture, the mean relative error of each network is in the range of 12% and 14% compared to MC simulations. However, 3D scatter distributions can be estimated within 60 ms and 2D distributions within 15 ms. Significance. Overall, our method is suitable to support the online assessment of scattered ionizing radiation in the interventional environment and can help to lower the occupational radiation risk.

An Online Learning Tool to Obtain, Optimize, and Interpret Radiographs During Total Hip Arthroplasty

Total hip arthroplasty (THA) is a common orthopedic procedure which has been growing in popularity with the elderly population. With more surgeons completing anterior THAs, intraoperative radiographs have become commonplace. Unfortunately, there is a lack of education in regard to obtaining, optimizing, and interpreting these radiographs. The purpose of this study was to develop and test the efficacy of an online learning tool that medical students, residents, and C-arm technicians could use to improve their understanding of THA radiography. The learning tool taught users how to obtain an optimal AP pelvis radiograph and how to interpret radiographs so THA components could be placed in their optimal position. This learning tool was sent to medical students, orthopedic surgery residents, and C-arm technicians along with a pre-test, post-test, and feedback survey. Twenty users (eleven medical students and nine orthopedic surgery residents) completed the learning tool. Post-test scores (M=96.4%, SD=2.9%) were significantly greater than pre-test scores (M=68.3%, SD=23.9%) for all users (t=5.5069, P<.0001). The user's level of training was positively correlated with pre-test scores. Surveys from the users revealed that the learning tool provided significant learning opportunities, was relatively easy to understand, but was slightly too long. Users felt that this learning tool would be best suited for senior medical students, junior orthopedic surgery residents, and C-arm technicians. With the positive results of this study, the authors hope to further develop this learning tool for widespread adoption and to develop similar learning tools in the future.

Automated light-induced synthesis of 89Zr-radiolabeled antibodies for immuno-positron emission tomography

Clinical production of 89Zr-radiolabeled antibodies (89Zr-mAbs) for positron emission tomography imaging relies on the pre-conjugation of desferrioxamine B (DFO) to the purified protein, followed by isolation and characterization of the functionalized intermediate, and then manual radiosynthesis. Although highly successful, this route exposes radiochemists to a potentially large radiation dose and entails several technological and economic hurdles that limit access of 89Zr-mAbs to just a specialist few Nuclear Medicine facilities worldwide. Here, we introduce a fully automated synthesis box that can produce individual doses of 89Zr-mAbs formulated in sterile solution in < 25 min starting from [89Zr(C2O4)4]4- (89Zr-oxalate), our good laboratory practice-compliant photoactivatable desferrioxamine-based chelate (DFO-PEG3-ArN3), and clinical-grade antibodies without the need for pre-purification of protein. The automated steps include neutralization of the 89Zr-oxalate stock, chelate radiolabeling, and light-induced protein conjugation, followed by 89Zr-mAb purification, formulation, and sterile filtration. As proof-of-principle, 89ZrDFO-PEG3-azepin-trastuzumab was synthesized directly from Herceptin in < 25 min with an overall decay-corrected radiochemical yield of 20.1 ± 2.4% (n = 3), a radiochemical purity > 99%, and chemical purity > 99%. The synthesis unit can also produce 89Zr-mAbs via the conventional radiolabeling routes from pre-functionalized DFO-mAbs that are currently used in the clinic. This automated method will improve access to state-of-the-art 89Zr-mAbs at the many Nuclear Medicine and research institutions that require automated devices for radiotracer production.

Percutaneous iliosacral screw and trans-iliac trans-sacral screw with single C-arm fluoroscope intensifier is a safe treatment for pelvic ring injuries

To elucidate the accuracy, efficacy, and safety of percutaneous iliosacral screw (ISS) and trans-iliac trans-sacral screw (TITS) insertion using a single C-arm fluoroscopy intensifier. Additionally, the potential risk factors that might cause mal-positioned screws were identified. Patients with pelvic ring injuries who underwent percutaneous screw fixation in a single medical institute were divided into an ISS group (n = 59) and a TITS group (n = 62) and assessed. The angles deviated from ideal orientation (ADIO) of the implanted screw were measured, and potential risk factors for mal-positioned screws were analyzed. Overall, the reduction quality of the pelvic ring was good or excellent in 70 patients (82.4%) by Matta’s criteria and in 48 patients (56.5%) by Lefaivre’s criteria. ADIO measurements of the ISS and TITS groups via multi-planar computed tomography were 9.16° ± 6.97° and 3.09° ± 2.8° in the axial view, respectively, and 5.92° ± 3.65° and 2.10° ± 2.01° in the coronal view, respectively. Univariate statistical analysis revealed body mass index as the single potential risk factor of mal-positioned screws. With careful preoperative planning and intraoperative preparations, placing ISS and TITS under the guidance of single C-arm fluoroscopy intensifier is a reliable and safe technique. Caution should be exercised when performing this procedure in patients with a high body mass index.

Efficacy of low dose and ultra-low dose on the visibility of peri-implant fenestration and dehiscences: a computed tomography study

PURPOSE

This study aimed to evaluate the visibility of peri-implant fenestration and dehiscences on computed tomography (CT) images taken with 2 different doses.

MATERIAL AND METHODS

The defects were created on the apical of 6 implants randomly selected from 20 titanium implants placed in the ribs, and dehiscences were created on the cervical of 8 implants. No defects were created around 6 implants. Macroscopic analysis of the implanted ribs was accepted as the gold standard. From the samples, images were taken by using both ultra-low dose (80 kVp, 50 mA, 1.25 mm slice thickness) and low dose (100 kVp, 50 mA, 1.25 mm slice thickness) protocols in CT. The images obtained were evaluated using a 5-point scale.

RESULTS

No significant difference was found between the area under the receiver operating characteristic of ultra-low dose protocol and low dose protocol in both defects based on the Wilcoxon test (p > 0.05).

CONCLUSIONS

The ultra-low dose protocol could be applied by adhering to the "as low as reasonably achievable" principle in the diagnosis of peri-implant defects.

A survey on knowledge, attitude, and practices of workplace radiation safety amongst anaesthesiology personnel in northern Indian tertiary care institutes

Background and Aims:

Exposure to ionising radiation to Anaesthesiology consultants, residents, technicians and nurses (Anaesthesiology personnel) is steadily increasing as a consequence of growing usage of imaging technology for diagnostic and therapeutic purposes. We conducted a questionnaire-based survey of Anaesthesiology professionals (consultants, residents, technicians and nursing staff) working in three major tertiary care medical institutes in northern India regarding the existing knowledge, attitudes and practices of radiation safety at their workplaces.

Methods:

A printed and validated 30-point questionnaire was distributed. Questions were graded into the domains of demographics (6 questions), knowledge (9 questions), attitude (4 questions) and practice (11 questions). Data obtained from the responses was collated and analysed statistically

Results:

Out of the 403 questionnaires distributed, 222 were returned completed (55%). Majority of the respondents were residents (53.60%) and males (57.20%). Many were unaware of the principle of As Low As Reasonably Achievable (ALARA), (70.7%) regarding collimators (65.85%) and their usage (41.9%). Maximum respondents stressed on the necessity of knowing the exposure dosage of radiations (89.2%) and were concerned regarding the same (87.8%). Lead apron was the commonest protection equipment and 97.3% of them were not using dosimeters. Highest levels of knowledge, attitude, and practices were demonstrated by the consultants. In terms of practices, the technicians fared better than the residents.

Conclusion:

Knowledge, attitude and practices regarding radiation protection issues and doses of radiological procedures is limited. Although all the cadres scored high on their attitude scores, the practice sector requires improvement.

Use of intraoperative C-arm fluoroscopy in open reduction and internal fixation of mandibular condyle fracture - A case report

The Rationale:

Condyle fractures are a common type of mandibular fracture that can result in malocclusion. Open reduction and internal fixation (ORIF) in condylar fracture is considered as the most acceptable treatment modality.

Patient Concerns:

The patient complained of pain and difficulty in the jaw while chewing.

Diagnosis:

An orthopantomogram and reverse Towne’s view can lead to diagnosis of the condylar fracture.

Treatment:

Open reduction and internal fixation using intraoperative real-time visualisation of subcondylar fracture reduction utilising the C-arm fluoroscopic approach were used to allow for adequate anatomical repositioning and fast restoration of function to meet the patient’s concerns.

Outcomes:

We were able to achieve correct reduction of the fracture fragments with restoration of function and occlusion.

Take-away Lessons:

When this procedure is used to treat condylar fractures, surgeons can get a better view of the fracture segments while eliminating the need for postoperative intermaxillary fixation and also reduces the complications from inappropriate reduction and fixation.

3D printing in orthopaedic surgery: a scoping review of randomized controlled trials

Aims

The use of 3D printing has become increasingly popular and has been widely used in orthopaedic surgery. There has been a trend towards an increasing number of publications in this field, but existing literature incorporates limited high-quality studies, and there is a lack of reports on outcomes. The aim of this study was to perform a scoping review with Level I evidence on the application and effectiveness of 3D printing.

Methods

A literature search was performed in PubMed, Embase, and Web of Science databases. The keywords used for the search criteria were ((3d print*) OR (rapid prototyp*) OR (additive manufactur*)) AND (orthopaedic). The inclusion criteria were: 1) use of 3D printing in orthopaedics, 2) randomized controlled trials, and 3) studies with participants/patients. Risk of bias was assessed with Cochrane Collaboration Tool and PEDro Score. Pooled analysis was performed.

Results

Overall, 21 studies were included in our study with a pooled total of 932 participants. Pooled analysis showed that operating time (p < 0.001), blood loss (p < 0.001), fluoroscopy times (p < 0.001), bone union time (p < 0.001), pain (p = 0.040), accuracy (p < 0.001), and functional scores (p < 0.001) were significantly improved with 3D printing compared to the control group. There were no significant differences in complications.

Conclusion

3D printing is a rapidly developing field in orthopaedics. Our findings show that 3D printing is advantageous in terms of operating time, blood loss, fluoroscopy times, bone union time, pain, accuracy, and function. The use of 3D printing did not increase the risk of complications.

Cite this article: Bone Joint Res 2021;10(12):807–819.

Reconstruction of Orthographic Mosaics From Perspective X-Ray Images

Image stitching is a prominent challenge in medical imaging, where the limited field-of-view captured by single images prohibits holistic analysis of patient anatomy. The barrier that prevents straight-forward mosaicing of 2D images is depth mismatch due to parallax. In this work, we leverage the Fourier slice theorem to aggregate information from multiple transmission images in parallax-free domains using fundamental principles of X-ray image formation. The details of the stitched image are subsequently restored using a novel deep learning strategy that exploits similarity measures designed around frequency, as well as dense and sparse spatial image content. Our work provides evidence that reconstruction of orthographic mosaics is possible with realistic motions of the C-arm involving both translation and rotation. We also show that these orthographic mosaics enable metric measurements of clinically relevant quantities directly on the 2D image plane.

Minimising radiation exposure to the surgeon in minimally invasive spine surgeries: A systematic review of 15 studies

BACKGROUND

Intraoperative imaging in minimally invasive spinal surgeries is associated with significant radiation exposure to surgeons, which overtime can lead to serious health hazards including malignancy. In this study, the authors conducted a systematic review to evaluate the efficacy of navigation assisted fluoroscopy methods on radiation exposure to the surgeon in minimally invasive spine surgeries, percutaneous endoscopic lumbar discectomy/percutaneous endoscopic transforaminal discectomy versus minimally invasive spine transforaminal lumbar interbody fusion (PELD/PETD versus MIS-TLIF).

METHODS

A systematic literature search was conducted using PUBMED/MEDLINE on 20th July, 2020. Inclusion criteria were applied according to study design, surgical technique, spinal region, and language. Data extracted included lumbar segment, average operation time (min), fluoroscopic time (s), and radiation dose (μSV), efficacy of modified navigation versus conventional techniques; on reducing operation, fluoroscopy times and effective radiation dose.

RESULTS

Fifteen studies (ten prospectives, and five retrospectives) were included for quantitative analysis. PELD recorded a shorter operation time (by 126.3min, p<0.001) and fluoroscopic time (by 22.9s, p=0.3) than MIS-TLIF. The highest radiation dose/case (μSV) for both techniques were recorded at the surgeon's: finger, chest, neck and eye. The effective dose for MIS-TLIF was 30μSV higher than PELD. Modified navigation techniques recorded a shorter operation time (by 15.9min, p=0.3); fluoroscopy time (by 289.8s, p=0.3); effective radiation dose (by 169.5μSV, p=0.3) than conventional fluoroscopy methods.

DISCUSSION

This systematic literature review showed that although navigation assisted fluoroscopy techniques are superior to conventional methods in minimising radiation exposure, lack of statistical significance warrants future randomised controlled trials, to solidify their efficacy in reducing radiation related hazards.

Comparison of fluoroscopy time in short and long cephalomedullary nailing for 31A2 intertrochanteric hip fractures

There is no study that has compared the radiation exposure during short (Short PFN) and long proximal femoral nailing (Long PFN) for 31A2 intertrochanteric hip fractures. The objective of the present study was to compare the radiation exposure time in short and long proximal femoral nail during the treatment of 31A2 intertrochanteric hip fractures. This prospective cohort study was carried out in a University teaching hospital. Sixty one consecutive patients with 31A2 intertrochanteric femur fracture treated with pro- ximal femoral nail were included in the study. The distal locking in the short PFN was performed using the locking zig and distal locking in the long PFN was performed using the free hand perfect circle technique. The same mobile image intensifier (Multimobil 5E, Siemens, Erlangen, Germany) was used in the entire study. The outcome measure was the fluoroscopy exposure time (seconds) which was measured directly from the image intensifier. Thirty patients underwent fixation with short PFN and 31 patients underwent fixation using long PFN. The mean fluoroscopy exposure time in short PFN cohort was 189.5 seconds ± 26 (range : 150-250 seconds) and the mean fluoroscopy exposure time in long PFN cohort was 283.4 seconds ± 43.8 (range : 200-400 seconds). The mean fluoroscopy exposure time was 93.9 seconds shorter in the short PFN cohort and this difference was statistically significant (p < 0.0001 ; 95% CI : 75.4 to 112.3). The radiation exposure to the operating team is significantly less during treatment with short PFN in 31A2 intertrochanteric fractures.

Fluorescence Guided Surgery

Fluorescence guided surgery (FGS) is an imaging technique that allows the surgeon to visualise different structures and types of tissue during a surgical procedure that may not be as visible under white light conditions. Due to the many potential advantages of fluorescence guided surgery compared to more traditional clinical imaging techniques such as its higher contrast and sensitivity, less subjective use, and ease of instrument operation, the research interest in fluorescence guided surgery continues to grow over various key aspects such as fluorescent probe development and surgical system development as well as its potential clinical applications. This review looks to summarise some of the emerging opportunities and developments that have already been made in fluorescence guided surgery in recent years while highlighting its advantages as well as limitations that need to be overcome in order to utilise the full potential of fluorescence within the surgical environment.

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.

Level of Supervision and Radiation Exposure of Senior Orthopedic Residents During Surgical Treatment of Proximal Femur Fracture

The sustained use of intraoperative fluoroscopy has led to increased use of minimally invasive surgical techniques, enhanced surgeon proficiency, improved anatomic corrections, reduced patient morbidity, earlier functional recovery, and decreased length of hospital stay. As a result, orthopedic attending surgeons and residents are exposed to more radiation, increasing the risk of cancer and radiation-induced cataracts compared with the general population and those who work in other surgical specialties. The magnitude of radiation exposure depends on the susceptibility of the tissues affected, medical specialty, the position of the C-arm, distance from the radiation beam, level of difficulty of the surgical procedure, surgeon experience, level of resident training, and level of supervision by the attending surgeon. However, little information is available on the effect of supervision level on radiation exposure for orthopedic senior residents. The goal of this study was to investigate whether level of supervision by the attending surgeon affects the radiation exposure of orthopedic senior residents during surgical treatment of proximal femur fracture with cephalomedullary nail fixation. This retrospective cohort study was performed from January 2019 to March 2019. No significant relationship between supervision level and radiation exposure of senior residents was observed. Supervision level does not significantly affect radiation exposure for senior residents; therefore, the implementation of standardized training in radiation safety may be a more essential measure to decrease radiation exposure. [Orthopedics. 2021;44(3):e402-e406.].

A pilot study to evaluate the face & construct validity of an orthopaedic virtual reality simulator

AIMS

This study aimed to identify the face and construct validity of the Precision OS trauma module proximal femoral nail procedure. Secondary outcomes included perceived use of simulation in surgical training, with structured feedback from participants.

METHODS

A comparative interventional study was carried out in a regional orthopaedics trauma unit hospital. Volunteers were stratified into novice, intermediate and expert groups based on self-reported levels of experience. Each participant carried out a simulated proximal femoral nail on an immersive virtual platform following instruction on its use, with objective metrics such as time and x-rays, and novel metrics calculated by the simulation module recorded. Face validity was also assessed.

RESULTS

The proximal femoral nail module demonstrated construct validity. Kruskal Wallis test demonstrated a statistically significant difference across all group's novel performance (p=.018). Intermediate surgeons performed significantly better than novices (P=.022), with shorter procedural times (P=.018) Three of the intermediate group achieved the proficiency level set by the expert group, with no significant difference noted between these two groups (=.06). Time taken to completion for expert surgeons was less than intermediate group, although this did not reach significance (P=.19).

CONCLUSION

The proximal femoral nail module on the Precision OS platform demonstrated good face, and construct validity. Further research evaluating use of virtual platform simulation in surgical trauma training is needed.

Interventional pain training using phantom model during COVID-19 pandemic

Background

Fluoroscopic‐guided lumbar procedures have increased in daily pain practice because the lumbar spine is one of the most common sources of pain. Interventional pain fellows must develop a minimum number of skills during their training in order to achieve the competences without neglecting radiological safety. However, medical training in fluoroscopic‐guided interventions is being affected by the current coronavirus disease 2019 (COVID‐19) situation.

Methods

The objective of this study was to evaluate the use of a phantom model for lumbar injection as a training strategy during the COVID‐19 pandemic in fellows of interventional pain. The study was divided into theoretical and practical modules. The hands‐on practice was performed in a lumbar model phantom where fellows were evaluated in four fluoroscopically guided approaches: intra‐articular facet block (IAFB), medial branch block (MBB), transforaminal block (TFB), and interlaminar block (ILB) divided in 5 sessions. The aim was to make as many punctures as possible in every session. We measured total procedural performance (TPP), total needle hand time (TNH), and total radiation dose generated by the fluoroscopic machine (TRD) during each procedure. Additionally, a survey was applied to evaluate confidence and satisfaction before and after training.

Results

A total of 320 lumbar punctures were completed. The results were statistically significant in all approaches attempted (p < 0.01). The fellow’s survey for satisfaction and confidence demonstrated a significant difference between pre and post‐test (p < 0.01).

Conclusions

The results of this study highlight the importance of adaptations and adoption of new educational models. The use of the phantom model for simulation could be a strategy for other emerging situations, like the COVID‐19 pandemic. Including this practice in the interventional pain programs could lead to better results for the patient and operator radiology safety.

Assessing Risks Awareness in Operating Rooms among Post-Graduate Students: A Pilot Study

Background: In this study, we promote a global approach to occupational risk perception in order to improve occupational health and safety training programs. The study investigates the occupational risk perception of operating room healthcare workers using an Analytic Hierarchy Process approach. Methods: A pilot study was carried out through a cross-sectional survey in a university hospital in Southern Italy. An ad hoc questionnaire was administered to enrolled medical post-graduate students working in the operating room. Results: Fifty medical specialists from seven fields (anaesthetists, digestive system surgeons, general surgeons, maxillofacial surgeons, thoracic surgeons, urologists, and gynaecologists) were questioned about perceived occupational risk by themselves. Biological, ionizing radiation, and chemical risks were the most commonly perceived in order of priority (w = 0.300, 0.219, 0.210). Concerning the biological risk, gynaecologists unexpected perceived this risk as less critical (w = 0.2820) than anaesthesiologists (w = 0.3354), which have the lowest perception of the risk of ionizing radiation (w = 0.1657). Conclusions: Prioritization methods could improve risk perception in healthcare settings and help detect training needs and perform sustainable training programs.

[X-ray diagnostics of fractures in childhood and adolescence-Consensus report of the scientific working group of the pediatric traumatology section of the German Society for Trauma Surgery (DGU)]

Seit Jahrzehnten ist die Projektionsradiographie Standard in der Diagnostik von Frakturen und Verletzungen auch bei Patienten im Kindes- und Jugendalter. Bei jeder Untersuchung mit Röntgenstrahlen sollen aber auch individuell Nutzen und Risiko gegeneinander abgewogen werden. Die Sektion Kindertraumatologie der DGU hat zu verschiedenen Aspekten der Bildgebung zu Diagnostik und Verlaufsbeurteilung, zu Einstellungsmöglichkeiten der intraoperativen Bildgebung, zum Röntgen der Gegenseite, zu Polytrauma und CT, zu postoperativen radiologischen Kontrollen und dem Einsatz der Sonographie ein Konsenspapier erarbeitet.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

A Review of Orthopaedic Surgical Set-Up and Introduction of the TULIPS Mnemonic - Six Simple Steps for Optimising Set-Up in Orthopaedic Surgery

Conducting a thorough check to ensure that all equipment and personnel are positioned correctly at the start of any operation is essential for both the safety of the surgical team and the patient outcome. Orthopaedic surgery in particular carries a high risk of occupational injury and this group could benefit greatly from ergonomic improvements. This review highlights multiple factors that can influence safety of surgeons, surgical efficiency and patient outcomes. "TULIPS" is a mnemonic that lists six key steps in optimising the surgical procedure through effective positioning of equipment and personnel pre-operatively. This was trialled by distribution amongst orthopaedic registrars regionally and it received excellent feedback, with the majority changing their current practice. Here we report that using this simple and memorable checklist can assist orthopaedic surgeons in setting up the operating theatre, facilitating ergonomic improvements that can reduce the risk of musculoskeletal injury and radiation exposure.