Radiation Exposure Safety Patterns with the Use of Intraoperative Fluoroscopy.
Though major agencies such as the National Council on Radiation Protection and Measurements (NCRP) and the International Commission on Radiological Protection (ICRP) have outlined general standards for reducing occupational radiation exposure, guidelines specific to upper extremity surgery do not exist, and it is unclear whether surgeons and their staff are practicing safe measures. The purpose of this study was to assess current practice patterns in regard to radiation safety by members of the American Society for Surgery of the Hand (ASSH). We also aimed to determine how these trends vary by experience and demographics.
Materials and Methods
An 18-question online survey (TypeForm, Barcelona. Spain) was created to assess current practice patterns of the queried hand and upper extremity surgeons. Questions on demographic information, including gender, years in practice (after the final year of training), surgical sub-specialty, surgical volume, and geographic region of practice (either West. South, Northeast, and Midwest) were also included (Table 1). After approval by the institutional review board and the ASSH, the survey was sent to active and candidate ASSH members in the USA (N = 3,352). As the survey focuses on surgical exposure to radiation, hand therapists were excluded from participation. International members were excluded from participation as well in order to better reflect practice patterns in the USA alone. An initial e-mail followed by one reminder e-mail was sent, and members were given 3 months in total to respond to the survey. Results of the survey were recorded in a spreadsheet, and results were made anonymous throughout the process of data collection and analysis. The recommended position of the mini C-arm was indicated as the vertical position, and the recommended position of the standard C-arm was indicated as the inverted position (Fig. 1) based on previous recommendations. (7,13,14)
Descriptive statistics were generated for data on practice patterns and demographic information. Multivariate logistic and multinomial regressions were then used to determine predictors for fluoroscopy practices while adjusting for demographic factors. Specifically, variables tested included gender, specialty of training, geographic location, years in practice, and cases performed per month. Comparisons were made to see if these variables predicted the use of protective devices and use of the fluoroscope in the recommended position. For the regressions analysis, comparisons were made to the references of orthopedics specialty, male gender, northeast geographic region, less than 10 years in practice, and less than 20 surgeries per month. Results were expressed in odds ratios with 95% confidence intervals.
Of the 3,352 members, 46 were excluded for non-functional e-mail addresses (N = 40) or for requests not to participate in survey research (N = 6), leaving 3,306 eligible members. Of these, 904 (27.3%) responded to the survey.
Respondents were predominantly male (86%) and were nearly equally represented by geographic region within the USA. The majority was trained in orthopedic surgery (85%) and had completed an upper extremity fellowship (98%). The largest representation of surgeons were within the first 10 years of practice (38%) and performed 31 to 50 procedures per month (44%), (Table 2). Most surgeons did not use a dosimeter to monitor radiation exposure (70%), preferred the mini C-arm for both elbow surgery (70%) and hand surgery (91%) cases, and had not changed practice patterns over the past 5 years (71%). The majority (96%) also did not attribute their radiation exposure to contributing to any pathologic process (Table 3).
Practice patterns for surgeons using specific fluoroscopic devices were assessed separately (Table 4). One percent of members reported not using the mini C-arm and 13% reported not using the standard C-arm. For the remaining members, 42% of respondents did not use protective devices when using the mini C-arm compared to 5% who did not with the standard C-arm. The lead apron and thyroid shields were used often with both the mini C-arm (55%, 42%) and the standard C-arm (81%, 63%), respectively. The majority of surgeons utilized both devices in the recommended positions, recommended their staff to wear lead, and minimized the use of live fluoroscopy regardless of device. Approximately 89% and 96% of respondents reported that their use of protective devices has not changed in the last 5 years using mini C-arm and standard C-arm, respectively. The remaining respondents noted an increase use in protective devices with the mini C-arm (88%) and the standard C-arm (95%).
There were several significant results from our regression analyses (Table 5). Adjusting for all other factors, women were more likely to use a personal dosimeter, use protection with the mini C-arm, and have positively changed their practice patterns over the past 5 years when compared to men. Those practicing over 30 years were less likely to use protective devices with both the standard and mini C-arms and were less likely to use the mini C-arm in the recommended position when compared to respondents with less than 10 years of experience. Orthopedic surgeons were more likely to use protection with the standard C-arm and use the mini C-arm in the recommended position when compared to plastic surgeons. Surgeons in the South were less likely to use protective devices with both the standard and mini C-arms, and those in the West were most likely to use both the standard and mini C-arms in the recommended positions. All other comparisons not listed were insignificant.
With the increasing use of fluoroscopy, the upper extremity surgeon should aim to minimize radiation exposure for the surgical team and the patient. Several studies have evaluated the most effective ways to accomplish this, including the use of protective devices, proper fluoroscope positioning, minimizing x-ray time, and increased awareness of occupational radiation exposure. (6-12) Despite these findings, it is unclear whether surgeons and their staff are practicing safe measures routinely.
The results of our study suggest that there is variability in the national practice of occupational radiation safety with upper extremity surgery. The majority of ASSH members prefer the mini C-arm, use both the mini and standard C-arms in the recommended positions, and used leaded aprons and thyroid shields while using the standard C-arm. However, 70% did not routinely monitor radiation exposure with a dosimeter, and only 42% used thyroid shields with the mini C-arm. Based on our analysis, women were more likely to practice radiation safety measures, which may be attributed to both more awareness and concerns with exposure during pregnancy and childbearing years. (15) Respondents from the Western United States overwhelmingly practiced the most radiation safety nationally. Of these members, the majority (52%) was from California, which is the only state that requires a fluoroscopy permit exam for practitioners and has state-mandated radiation dose logs to be completed by facilities.
Respondents with less than 10 years of experience were more likely to use protective devices and use the mini C-arm in the recommended position when compared to those with over 30 years of experience. In addition, orthopedic surgeons were more likely to use protective devices with the standard C-arm and properly position the mini C-arm when compared to plastic surgeons. These findings are possibly attributed to greater utilization of fluoroscopy during surgery for orthopedic trainees. (16)
The overwhelming majority of members (96%) did not attribute any personal pathologic process to radiation exposure, but a small subset did make a distinction. Most notably, cataract disease (2%) and thyroid-related issues (2%) were reported at the highest rate. In one report, interventional cardiologists and their nursing staff were over five times as likely to have posterior lens opacities when compared to age-matched and sex-matched unexposed controls. (17) Thyroid cancer is the malignancy most closely associated with radiation exposure. Specifically, papillary thyroid cancer has been shown to most commonly arise in those who have had lifetime doses of ionizing radiation greater than 5,000 rem. (18) Although a direct connection cannot be made, the results do highlight the importance of potential health-related complications that can occur from excessive radiation exposure.
The NCRP has recommended that the annual occupational radiation exposure to the whole body should not exceed 5 rem, and the ICRP has furthered reduced this to 2 rem. (19) Annual limits for specific organs have also been recommended, including the eye (15 rem), thyroid gland (30 rem), skin (50 rem), and the embryo (0.5 rem over 9 months). (20) For perspective, predictable levels of emitted radiation have been estimated for a single chest radiograph (25 mrem), a hip radiograph series (500 mrem), computed tomography of the wrist (700 mrem), and cardiac catheterization (150,000 mrem per study). (2) An average mini C-arm emits 120 to 400 mrem per minute of use, the standard C-arm emits 1,200 to 4,000 mrem per minute of use, (13) and exposure to the hands in particular is up to 20 mrem per case. (8) Although it has been suggested that the estimated annual radiation exposure during hand surgery is below the maximum recommended limit, it is difficult to fully account for scatter and direct exposure that a surgeon may receive to unmonitored areas. (2)
There are several ways to reduce radiation exposure to both the surgeon and surgical staff. A reliable and proven method is with the utilization of leaded devices. Radiation attenuation has been reported for leaded glasses (30% to 70%), thyroid shields (90%), leaded aprons (90%), and radiation-protective gloves (50% to 70%). (2,21) Maximizing one's distance from the x-ray source is another method that can be accomplished in multiple ways. By maintaining 1 foot of distance between the source, the surgeon receives approximately 29 mrem/min to the body. By doubling the distance to 2 feet, the exposure reduces to 6 mrem/min. Beyond 3 feet, there is virtually no radiation detected. (22) Another method of maximizing distance from the x-ray source is through proper positioning of the fluoroscope. By positioning the smaller x-ray source above the patient and the larger image intensifier below, there is a larger field for easier positioning of the extremity and reduced need for repeat images. In addition, the distance from the x-ray source to the operative extremity and surgeon is also increased. (7) The choice of fluoroscope (either mini or standard) is another factor that may reduce exposure. Athwal et al. (11) noted in a cadaveric study that the mini C-arm universally emitted less radiation than the standard C-arm in several different clinical configurations. Other studies have supported this claim. (10,13) However, use of fluoroscopy with the mini C-arm should still be judicious. Vosbikian et al. (23) demonstrated that exposure to the hands is nearly double with the use of the mini C-arm when compared to the standard C-arm due to a smaller distance from the x-ray source to the surgeon's hands. In addition, surgeons utilize more than double the fluoroscopy time with a mini C-arm compared to a standard C-arm, thereby contributing to more radiation emitted per case. (23)
Our results suggest that majority of members have not changed their practices in regard to radiation safety over the past 5 years; however, the remaining respondents have strongly shifted toward an increase in the use of protective devices. This can be attributed in part to changes in hospital and state regulations that may have contributed to this shift. In 2010, the United States Food and Drug Administration's (FDA) Center for Devices and Radiological Health launched an initiative to reduce radiation exposure with medical imaging in response to reports of increasing occupational exposure from a NCRP investigation. Since then, the FDA has applied new mandates to imaging manufacturers, professional organizations, other governmental agencies, and health care systems. (24-26) In addition, there has been a stronger emphasis in radiation safety specifically in the practice of upper extremity surgery in the past 5 years. Recent studies have focused on organ-specific radiation exposure (including the eyes and the hands) the effectiveness and utility of current protective measures, and larger and more robust study designs for assessing true exposure rates. (21,27,28) Similarly, there has been a stronger emphasis in occupational radiation exposure safety in orthopedic trauma surgery, spine surgery, interventional radiology, cardiology, and urology. (5,29-32) Despite the interest, however, clear guidelines for formally teaching radiation safety to medical students and residents are lacking in the United States. (33) Organized education in radiation protection may instill positive safety habits for resident surgeons during and after their training. Our results highlight this potential trend, as those with less years of experience were most likely use protective devices and use the fluoroscopes in the recommended positions.
There are several limitations to this study. As this study was based on responses from a survey, definitive conclusions cannot be drawn from the results. Survey studies cannot control for potential sources of biases, and therefore results should be interpreted while understanding these inherent limitations. Of the eligible participants, only 27.3% responded, which is within range of the 20% to 50% reported from previous published studies. (34-41) It is unclear whether all members received the survey due to e-mail filters or blocking software. The software excludes members who filled out an incomplete survey and does not account for members who filled out the survey multiple times. The survey was only 18 questions long and in a multiple choice format, which helped to expedite data collection but also limited the potential information that could be gained. As such, the survey may have not captured all important data that is often necessary to make more definitive conclusions. There is likely variability in the availability of certain protective devices, personal dosimeters, or fluoroscopic machines among practices. Lastly, though the survey was only distributed to active members of the ASSH, we believe the survey captures a large population that strongly reflects practice patterns and attitudes of hand and upper extremity surgeons in the United States.
It is unclear how much occupational radiation an upper extremity surgeon can safely tolerate over a lifetime. There are several simple safety measures that can be undertaken to assure that exposure is reduced for the surgeon and surgical staff. Increased awareness should be made for trainees and practicing surgeons to follow current radiation safety recommendations and suggestions.
None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.
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Amar A. Patel, MD, Arpan A. Patel, MD, and F.Thomas D. Kaplan, MD
Amar A. Patel, MD, Orthopaedic Associates of Riverside, Chicago, Illinois. Arpan A. Patel, MD, University of California, Los Angeles, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Los Angeles, California. F. Thomas D. Kaplan, MD, The Indiana Hand to Shoulder Center, Indianapolis, Indiana.
Correspondence: Amar A. Patel, MD, Orthopaedic Associates of Riverside, 353 East Burlington Street, Suite 100, Riverside, Illinois 60546, USA; email@example.com.
Caption: Figure 1 C-arm positions. Mini C-arm. (A) Horizontal position with the x-ray source and image intensifier positioned above the table and in-line with the patient. (B) Vertical position with the x-ray source and the image intensifier positioned above and below the patient and the table. Standard C-arm. (C) Standard position with the x-ray source positioned below the patient and the beam directed toward the image intensifier above the patient. (D) Inverted position with the x-ray source positioned above the patient and the beam directed toward the image intensifier below the patient
Table 1 Survey to Assess Radiation Exposure Sent to US Members of the American Society for Surgery of the Hand 1. What is your specialty? a. Orthopaedic Surgery b. Plastic Surgery c. General Surgery d. Neurosurgery e. Other 2. How many years have you been in practice? a. 0 to 5 years b. 6 to 10 years c. 11 to 15 years d. 16 to 20 years e. 20 to 25 years f. 25 to 30 years g. More than 30 years 3. What is your primary practice type? a. Solo Private b. Solo Private with Academic Affiliation c. Group Private d. Group Private with Academic Affiliation e. Purely Academic f. Government-based (i.e., Veterans Affairs) g. Currently in Fellowship 4. How would you describe your work status? a. Full-time b. Part-time c. Retired 5. What is your gender? a. Male b. Female 6. What state do you practice in? (Please list the two-letter state postal code, i.e., CA for California) 7. Have you completed a fellowship in hand and upper extremity surgery? a. Yes b. No 8. What percent of your practice involves hand and elbow surgery? a. 0-25% b. 26-50% c. 51-75% d. 76 - 100% 9. How many surgeries do you perform per month? a. Less than 10 b. 11-20 c. 21-30 d. 31-40 e. 41-50 f 51-60 g. More than 60 10. What percent of your surgeries require the use of fluoroscopy? a. 0-25% b. 26-50% c. 51-75% d. 76 - 100% 11. Do you record your radiation exposure with a personal dosimeter? a. No b. Yes, but I have not been over the recommended limit of exposure c. Yes, and I have been over the recommended limit of exposure d. Yes, but I am unaware of my results 12. What most influences your decision for your current practices in regards to radiation safety? a. Attending preferences in training b. Hospital regulations c. Post-training education (journal articles, lectures, etc.) d. Personal preferences not directly influenced from any of the above 13. Have you developed a pathologic process that you directly attribute to radiation exposure during surgery? Examples of these include but are not limited to cancers, cataract disease, and thyroid dysfunction, reproductive disorders? a. No b. Cataract disease c. Reproductive disorders d. Non-cancerous thyroid dysfunction e. Thyroid cancer f Leukemia/lymphoma g. Skin cancer h. Other (please list) 14. What type of fluoroscopy do you prefer to use for elbow surgery cases? a. Standard C-arm b. Mini C-arm c. I do not perform elbow surgery 15. What type of fluoroscopy do you prefer to use for hand surgery (distal to the elbow) cases? d. Standard C-arm e. Mini C-arm 16. Have you changed your preference since starting your practice? a. No b. Yes, I use Standard C-arm more now c. Yes, I use Mini C-arm more now 17. Mini C-Arm (for Hand and Elbow Cases Only) 1. Do you use any special protective devices while using fluoroscopy? (select all that apply) a. Thyroid shield b. Lead apron c. Leaded glasses/loupes d. Radiation protection gloves e. None 2. Has your use of protective devices changed in the last 5 years a. Yes b. No c. I do not use the mini C-arm If Yes - Please describe _____________ 3. When using the mini C-arm, do you prefer the machine horizontal or vertical? a. Horizontal b. Vertical c. No preference d. I do not use the mini C-arm 4. Does your staff wear lead during cases using fluoroscopy? a. Yes b. No c. I do not use the mini C-arm 5. Do you use live fluoroscopy for your cases? a. Yes, frequently b. Yes, but rarely c. No d. I do not use the mini C-arm 18. Standard C-Arm (for Hand and Elbow Cases) 1. Do you use any special protective devices while using fluoroscopy? (select all that apply) a. Thyroid shield b. Lead apron c. Leaded glasses/loupes d. Radiation protection gloves e. None 2. Has your use of protective devices changed in the last 5 years a. Yes b. No c. I do not use the standard C-arm If Yes - Please describe __________ 3. Does your staff wear lead during cases using fluoroscopy? a. Yes b.No c. I do not use the standard C-arm 4. Do you use live fluoroscopy for your cases? a. Yes, frequently b. Yes, but rarely c.No d. I do not use the standard C-arm 5. When using the standard C-arm, do you prefer to use it in position in standard or inverted position (Fig. 1)? Table 2 Demographics (%) Gender Male 86 Female 14 Location West 22 Northeast 27 South 24 Midwest 27 Specialty Orthopedic Surgery 85 Plastic Surgery 12 General Surgery 3 Completed Upper Extremity Fellowship Yes 98% No 2% Practice Type Group Private 45 Group Private with Academics 22 Purely Academic 15 Solo Private 7 Solo Private with Academic 5 Government 1 In Training 4 Years in Practice 0 to 10 38 11 to 20 21 21 to 30 27 Over 30 13 Surgeries per month <10 3 11 to 30 26 31 to 50 44 >50 28 Table 3 General Practice Patterns for Radiation Exposure (%) Surgeries requiring fluoroscopy 0 to 25% 52 26 to 50% 40 51 to 75% 6 76 to 100% 1 Personal Dosimeter? No 70 Yes, but unaware of results 14 Yes, but under limit 16 Yes, but over limit < 1 (N = 3) Pathologic Process from Exposure No 96 Cataract 2 Thyroid Cancer 1 Thyroid Dysfunction 1 Skin Cancer 1 Reproductive Disorders 1 Leukemia/Lymphoma < 1 (N = 4) Dermatitis < 1 (N = 3) Renal Cancer <1(N= 1) Breast Cancer <1(N= 1) Spinal Cancer <1(N= 1) Fluoroscopic Device Preference Hand Mini C-arm 91 Standard C-arm 9 Elbow Mini C-arm 70 Standard C-arm 30 Changes in Patterns No 71 More Mini C-arm 26 More Standard C-arm 3 Influence Post-training Education 46 Personal Preference 35 Hospital Regulations 15 Preferences from Training 14 Table 4 Practice Patterns Using the Mini and Standard C-Arms (%) Mini C-arm Protective Devices None 42 Lead apron 55 Thyroid shield 42 Radiation protection gloves 3 Leaded loupes 2 Leaded glasses 2 Staff wears lead Yes 74 No 26 Use of Live Fluoroscopy Rarely 64 Frequently 23 No 12 Fluoroscopy Position Vertical 62 Horizontal 31 No preference 7 Changes Last Five Years None 89 More use of protective measures 9 Less use of protective measures 1 Standard C-arm Protective Devices None 5 Lead apron 81 Thyroid shield 63 Radiation protection gloves 3 Leaded loupes 2 Leaded glasses 4 Staff wears lead Yes 86 No 14 Use of Live Fluoroscopy Rarely 60 Frequently 12 No 28 Fluoroscopy position X-ray source on the bottom 32 Intensifier on the bottom 54 No preference 14 Changes Last Five Years None 96 More use of protective measures 3 Less use of protective measures 1 Table 5 Significant Comparisons from Statistical Analysis Variable Odd's Ratio Use of Personal Dosimeter 11 to 20 Years in Practice 1.98 21 to 30 Years in Practice 2.76 > 30 Years in Practice 2.29 Female 1.75 21 to 40 Surgeries per Month 1.93 41 to 60 Surgeries per Month 2.07 Protection with Mni C-arm 11 to 20 Years in Practice 0.42 21 to 30 Years in Practice 0.25 > 30 Years in Practice 0.46 Female Gender 2.45 South Region 0.48 Protection with Standard C-arm Plastic Surgery 0.28 > 30 Years in Practice 0.32 South Region 0.33 Practice Changes for Mni C-arm Midwest Region 0.43 > 60 Cases per Month 0.24 Practice Changes for Standard C-arm Female Gender 2.86 Preferred Position for Mini C-arm Plastic Surgery 0.62 > 30 Years in Practice 0.60 West Region 2.02 Preferred Position for Standard C-arm 21 to 30 Years in Practice 3.07 > 30 Years in Practice 2.14 West Region 1.72 Variable 95% Confidence Interval P-Value Use of Personal Dosimeter 11 to 20 Years in Practice 1.32-2.98 0.001 21 to 30 Years in Practice 1.89-4.04 < 0.001 > 30 Years in Practice 1.39-3.76 0.001 Female 1.15-2.67 0.009 21 to 40 Surgeries per Month 1.12-3.33 0.018 41 to 60 Surgeries per Month 1.16-3.68 0.013 Protection with Mni C-arm 11 to 20 Years in Practice 0.29-0.62 < 0.001 21 to 30 Years in Practice 0.17-0.36 < 0.001 > 30 Years in Practice 0.29-0.74 0.001 Female Gender 1.52-3.94 < 0.001 South Region 0.32-0.72 < 0.001 Protection with Standard C-arm Plastic Surgery 0.12-0.68 0.005 > 30 Years in Practice 0.10-0.95 0.041 South Region 0.13-0.87 0.024 Practice Changes for Mni C-arm Midwest Region 0.21-0.87 0.02 > 60 Cases per Month 0.07-0.82 0.02 Practice Changes for Standard C-arm Female Gender 1.02-8.00 0.05 Preferred Position for Mini C-arm Plastic Surgery 0.41-0.94 0.02 > 30 Years in Practice 0.38-0.95 0.03 West Region 1.36-2.99 < 0.001 Preferred Position for Standard C-arm 21 to 30 Years in Practice 2.08-4.54 < 0.001 > 30 Years in Practice 1.28-3.56 0.003 West Region 1.12-2.64 0.013
Please Note: Illustration(s) are not available due to copyright restrictions.
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|Author:||Patel, Amar A.; Patel, Arpan A.; Kaplan, F.Thomas D.|
|Publication:||Bulletin of the NYU Hospital for Joint Diseases|
|Date:||Jul 1, 2018|
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