Intraoperative radiation use by trainees during ankle fracture fixation

Differences in Intraoperative Fluoroscopic Radiation Exposure During Ankle Fracture Open Reduction and Internal Fixation Between Orthopaedic Surgery and Podiatry

Surgical ankle fractures pose a unique situation because both podiatrists and orthopaedic surgeons manage these injuries. Intraoperative fluoroscopy is routinely used; however, excessive radiation can be harmful to both the patient and the surgical team. The primary goal of this study was to determine whether there is a difference in the amount of intraoperative radiation exposure during ankle fracture open reduction and internal fixation (ORIF) when performed by orthopaedic surgeons versus podiatrists. This is a retrospective review of patients who underwent ankle fracture ORIF at an urban level I trauma center between January 1st, 2018, and April 1st, 2023. The electronic health record was queried using International Classification of Diseases nine and 10 codes associated with ankle fractures. Patients aged older than 18 years with an ankle fracture managed surgically were included. Subjects were then stratified by procedure. The mean total radiation dose (mRad) and mean total fluoroscopic time (seconds) were then compared between those performed by orthopaedic surgeons and podiatrists. Of the 333 included procedures, 186 were done by orthopaedic surgeons and 147 were done by podiatrists. Using multiple linear regression analysis to control for age, sex, race, ethnicity, and body mass index, patients undergoing isolated malleolus ORIF with syndesmosis repair performed by orthopaedic surgery were found to have a significantly lower mean fluoroscopic time compared with those performed by podiatry (68.4 s versus 104.8 s; P = 0.028). In addition, trimalleolar ORIF with syndesmotic repair performed by orthopaedic surgery had a significantly lower mean total radiation dose compared with those performed by podiatry (244.6 mRad v 565.6 mRad; P = 0.009). Patients and surgical teams are exposed to markedly less radiation in isolated malleolar and trimalleolar fracture ORIF with syndesmosis repair when performed by an orthopaedic surgeon as compared with those performed by a podiatrist.

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.

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.

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.].

Does Surgical Experience Decrease Radiation Exposure in the Operating Room?

BACKGROUND

Intraoperative fluoroscopy facilitates minimally invasive surgery, and although it is irreplaceable in terms of intraoperative guidance, it results in substantial radiation exposure to the patient and surgical team. Although the risk of radiation exposure because of equipment factors has been described, there is little known about the impact of surgeon experience on radiation exposure. The aim of this study was to determine whether there is a relationship between years of surgical experience and total dose of radiation used for an archetypal pediatric orthopaedic surgical procedure that requires intraoperative fluoroscopy.

METHODS

This was a retrospective cohort study of children undergoing closed reduction and percutaneous pinning for supracondylar humerus fractures at a level I pediatric trauma center. Information pertaining to radiation dosage was gathered including fluoroscopic time, total images acquired, magnification use, and dose area product (DAP). Regression analysis was used to evaluate the effect of surgeon experience on the outcome variables.

RESULTS

A total of 759 pediatric patients treated by 17 attending surgeons were included. The median surgeon experience was 8.94 years (interquartile range, 5.9 to 19.8). Increased number of pins was associated with increased DAP (P<0.001) and lower years of experience (P=0.025). There was significantly higher fluoroscopy time in seconds (56.9 vs. 42.1 s, P=0.001), DAP (179.9 vs. 110.3 mGy-cm2, P=0.001), use of magnification (39.5 vs. 31.9 s, P=0.043), and total number of images obtained (74.5 vs. 57.6, P=0.008) in attending surgeons with <1 year of experience compared with those with greater experience. An operator extremity was visible in at least 1 saved image in 263 of 759 (35%) cases.

CONCLUSION

Increased surgical experience was significantly associated with decreased fluoroscopy usage, including time, number of images, and dose. Surgeon inexperience increases radiation exposure for patients and staff by over 60% when treating supracondylar humerus fractures. This study clearly identifies methods to reduce radiation exposure, including use of pulsed fluoroscopy instead of continuous fluoroscopy, decreasing use of magnification, removing the operator's extremity from the field, and judicious use and placement of each additional pin.

LEVEL OF EVIDENCE

Level III.

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

OBJECTIVE

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

METHODS

We analyzed 852 extracapsular proximal femur fracture fixation cases. We compared fluoroscopy times by various levels of resident training, fracture type, and implant used. Attending-only cases were used as a control group.

RESULTS

Fluoroscopy times during subtrochanteric fracture fixation (176.1 ± 11.27 seconds) were longer than intertrochanteric (111.4 ± 2.44 seconds) and basicervical fractures (91.49 ± 5.77 seconds). Long nail (150.2 ± 3.75 seconds) times were longer than short (92.3 ± 3.15 seconds) and intermediate (76.45 ± 3.01 seconds) nails. Significantly, more fluoroscopy was used in junior (115.9 ± 4.24 seconds), senior (123.0 ± 6.08 seconds), junior combo (130.6 ± 7.74 seconds), and senior combo cases (131.8 ± 6.11 seconds) compared with the control (94.91 ± 3.91).

CONCLUSION

Orthopaedic surgery residents and attendings must remain aware of radiation exposure secondary to intraoperative fluoroscopy. Appropriate personal protective equipment should be worn, and more experienced surgeons should take a more active role in the complex cases to decrease exposure risk.

LEVEL OF EVIDENCE

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

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

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

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

BACKGROUND

The purpose of this study was to determine the amount of cumulative radiation exposure received by orthopaedic surgeons and residents in various subspecialties. We obtained dosimeter measures over 12 months on 24 residents and 16 attending surgeons.

METHODS

Monthly radiation exposure was measured over a 12-month period for 24 orthopaedic residents and 16 orthopaedic attending surgeons. The participants wore a Landauer Luxel dosimeter on the breast pocket of their lead apron. The dosimeters were exchanged every rotation (5 to 7 weeks) for the resident participants and every month for the attending surgeon participants. Radiation exposure was compared by orthopaedic subspecialty, level of training, and type of fluoroscopy used (regular C-arm compared with mini C-arm).

RESULTS

Orthopaedic residents participating in this study received monthly mean radiation exposures of 0.2 to 79 mrem/month, lower than the dose limits of 5,000 mrem/year recommended by the United States Nuclear Regulatory Commission (U.S. NRC). Senior residents rotating on trauma were exposed to the highest monthly radiation (79 mrem/month [range, 15 to 243 mrem/month]) compared with all other specialty rotations (p < 0.001). Similarly, attending orthopaedic surgeons who specialize in trauma or deformity surgery received the highest radiation exposure of their peers, and the mean exposure was 53 mrem/month (range, 0 to 355 mrem/month).

CONCLUSIONS

Residents and attending surgeons performing trauma or deformity surgical procedures are exposed to significantly higher doses of radiation compared with all other subspecialties within orthopaedic surgery, but the doses are still within the recommended limits.

CLINICAL RELEVANCE

The use of ionizing radiation in the operating room has become an indispensable part of orthopaedic surgery. Although all surgeons in our study received lower than the yearly recommended dose limit, it is important to be aware of how much radiation we are exposed to as surgeons and to take measures to further limit that exposure.

Factors influencing radiation exposure during internal fixation of hip fractures

The use of fluoroscopy is of great importance for operative fixation of fractures. Previous studies have shown an increased fluoroscopy time for intramedullary nails and with junior surgeons in comparison with more experienced surgeons. We examined the impact of operation length on fluoroscopy dose, cumulative fluoroscopy time between consultant and registrar surgeons and cumulative fluoroscopy time between dynamic hip screw and intramedullary nailing. We performed a retrospective cohort study of all patients admitted to our centre over the period of 1 year. Patients who underwent dynamic hip screw (DHS) or intramedullary (IM) nailing were identified from our in-hospital hip fracture database. Intraoperative fluoroscopy images were then accessed through our hospital's medical imaging software. A total of 137 patients were identified. Fluoroscopy reports were not available for 49 patients, resulting in a final total of 88 patients. Patients whose operation lasted longer than 1 h received a statistically significant higher dose of radiation (183.83 cGYM2 vs. 368.22 cGYM2; p value 0.0002). Operations performed by a consultant resulted in less cumulative fluoroscopy time in comparison with those performed by a registrar or specialist registrar although this was not statistically significant (00:00:53 vs. 00:00:45; p vaue 0.38). Cumulative fluoroscopy time was less in dynamic hip screw compared to long intramedullary nails (00:00:39 vs. 00:01:29; p value <0.001) and short intramedullary nails (00:00:39 vs. 00:01:52; p value 0.387). Studies, which had a cumulative fluoroscopy time exceeding 50 secs, delivered a higher radiation dose (434.34cGYM2 vs. 150.51cGYM2; p value <0.001). We concluded that there is no significant impact in cumulative fluoroscopy time in operations performed by either a registrar or consultant. Dynamic hip screws have a lower fluoroscopy time in comparison with long intramedullary nails.

Variability in Fluoroscopic Image Acquisition During Operative Fixation of Ankle Fractures

The goal of this study was to determine whether injury, level of surgeon training, and patient factors are associated with increased use of fluoroscopy during open reduction and internal fixation of ankle fractures. These relationships are not well defined. The study was a retrospective chart review of patients treated at an academic institution with primary open reduction and internal fixation of an ankle. Patient demographics, including sex, age, and body mass index, were collected, as was surgeon year of training (residency and fellowship). Image acquisition data included total number of images, total imaging time, and cumulative dose. Ankle fractures were classified according to the Weber and Lauge-Hansen classifications and the number of fixation points. Bivariate analysis and multiple regression models were used to predict increasing fluoroscopic image acquisition. Alpha was set at 0.05. Of 158 patients identified, 58 were excluded. After bivariate analysis, fracture complexity and year of training showed a significant correlation with increasing image acquisition. After multiple regression analysis, fracture complexity and year of training remained clinically significant and were independent predictors of increased image acquisition. Increasing fracture complexity resulted in 20 additional images, 16 additional seconds, and an increase in radiation of 0.7 mGy. Increasing year of training resulted in an additional 6 images and an increase of 0.35 mGy in cumulative dose. The findings suggest that protocols to educate trainee surgeons in minimizing the use of fluoroscopy would be beneficial at all levels of training and should target multiple fracture patterns.

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

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