Printer Friendly

Radiation Exposure Safety Patterns with the Use of Intraoperative Fluoroscopy.

Fluoroscopic imaging is a valuable tool for the upper extremity surgeon that has dramatically increased in popularity over the last two decades. (1,2) Increased use of fluoroscopy predisposes the surgeon and surgical staff to higher levels of radiation, thereby raising the concern for possible long-term harmful effects. Several federal and state agencies have established general standards for limiting occupation radiation exposure in controlled settings. (3-5) Other recommendations include the use of personal dosimeters, proper positioning of the x-ray source beam, protective devices, and reducing scatter by ensuring that the operative site is as close as possible to the image intensifier. (6-12)

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.

Results

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.

Discussion

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.

Disclosure Statement

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.

References

(1.) Norris TG. Radiation safety in fluoroscopy. Radiol Technol. 2002 Jul-Aug;73(6):511-33; quiz 534-6, 566.

(2.) Singer G. Occupational radiation exposure to the surgeon. J Am Acad Orthop Surg. 2005 Jan-Feb;13(1):69-76.

(3.) Federal Guidance report No. 14. Radiation Protection Guidance for Diagnostic and Interventional X-ray Procedures. United States Environmental Protection Agency. Washington, DC, November 2014.

(4.) JonesCG. Areview of the history of U.S. radiation protection regulations, recommendations, and standards. Health Phys. 2005 Jun;88(6):697-716.

(5.) Miller DL, Vano E, Bartal G, et al. Occupational radiation protection in interventional radiology: a joint guideline of the Cardiovascular and Interventional Radiology Society of Europe and the Society of Interventional Radiology. J Vasc Interv Radiol. 2010 May;21(5):607-15.

(6.) Wagner LK, Mulhern OR. Radiation-attenuating surgical gloves: effects of scatter and secondary electron production. Radiology. 1996 Jul;200(1):45-8.

(7.) Tremains MR, Georgiadis GM, Dennis MJ. Radiation exposure with use of the inverted-c-arm technique in upper-extremity surgery. J Bone Joint Surg Am. 2001 May;83-A(5):674-8.

(8.) Singer G. Radiation exposure to the hands from mini C-arm fluoroscopy. J Hand Surg Am. 2005 Jul;30(4):795-7.

(9.) Muller LP, Suffner J, Wenda K, et al. Radiation exposure to the hands and the thyroid of the surgeon during intramedullary nailing. Injury. 1998 Jul;29(6):461-8.

(10.) Giordano BD, Ryder S, Baumhauer JF, et al. Exposure to direct and scatter radiation with use of mini-c-arm fluoroscopy. J Bone Joint Surg Am. 2007 May;89(5):948-52.

(11.) Athwal GS, Bueno RA Jr, Wolfe SW. Radiation exposure in hand surgery: mini versus standard C-arm. J Hand Surg Am. 2005 Nov;30(6):1310-6.

(12.) Arnstein PM, Richards AM, Putney R. The risk from radiation exposure during operative X-ray screening in hand surgery. J Hand Surg Br. 1994 Jun;19(3):393-6.

(13.) Badman BL, Rill L, Butkovich B, et al. Radiation exposure with use of the mini-C-arm for routine orthopaedic imaging procedures. JBone Joint Surg Am. 2005 Jan;87(l):13-7.

(14.) Bush WH, Jones D, Brannen GE. Radiation dose to personnel during percutaneous renal calculus removal. AJR Am J Roentgenol. 1985 Dec;145(6):1261-4.

(15.) McCollough CH, Schueler BA, Atwell TD, et al. Radiation exposure and pregnancy: when should we be concerned? Radiographics. 2007 Jul-Aug;27(4):909-17; discussion 917-8.

(16.) Giordano BD, Grauer JN, Miller CP, et al. Radiation exposure issues in orthopaedics. J Bone Joint Surg Am. 2011 Jun 15;93(12):e69(1-10).

(17.) Ciraj-Bjelac O, Rehani MM, Sim KH, et al. Risk for radiation-induced cataract for staff in interventional cardiology: is there reason for concern? Catheter Cardiovasc Interv. 2010 Nov 15;76(6):826-34.

(18.) Hamatani K, Eguchi H, Ito R, et al. RET/PTC rearrangements preferentially occurred in papillary thyroid cancer among atomic bomb survivors exposed to high radiation dose. Cancer Res. 2008 Sep l;68(17):7176-82.

(19.) Baiter S. An overview of radiation safety regulatory recommendations and requirements. Catheter Cardiovasc Interv. 1999 Aug;47(4):469-74.

(20.) Wrixon AD. New recommendations from the International Commission on Radiological Protection--a review. Phys Med Biol. 2008 Apr 21;53(8):R41-60.

(21.) Hoffler CE, Ilyas AM. Fluoroscopic radiation exposure: are we protecting ourselves adequately? J Bone Joint Surg Am. 2015 May 6;97(9):721-5.

(22.) Mehlman CT, DiPasquale TG. Radiation exposure to the orthopaedic surgical team during fluoroscopy: "how far away is far enough?" J Orthop Trauma. 1997 Aug;ll(6):392-8.

(23.) Vosbikian MM, Ilyas AM, Watson DD, et al. Radiation exposure to hand surgeons' hands: a practical comparison of large and mini C-arm fluoroscopy. J Hand Surg Am. 2014 Sep;39(9):1805-9.

(24.) Amis ES Jr, Butler PF, Applegate KE, et al. American College of Radiology white paper on radiation dose in medicine. J Am Coll Radiol. 2007 May;4(5):272-84.

(25.) Brenner DJ, Hricak H. Radiation exposure from medical imaging: time to regulate? JAMA. 2010 Jul 14;304(2):208-9.

(26.) Brink JA, Miller DL. U.S. National Diagnostic Reference Levels: Closing the Gap. Radiology. 2015 Oct;277(1):3-6.

(27.) Tuohy CJ, Weikert DR, Watson JT, et al. Hand and body radiation exposure with the use of mini C-arm fluoroscopy. J Hand Surg Am. 2011 Apr;36(4): 632-8.

(28.) Wang ML, Hoffler CE, Ilyas AM, et al. Hand Surgery and Fluoroscopic Eye Radiation Dosage A Prospective Pilot Comparison of Large Versus Mini C-Arm Fluoroscopy Use. Hand (NY). 2017 Jan;12(l):21-5.

(29.) Roux A, Bronsard N, Blanchet N, et al. Can fluoroscopy radiation exposure be measured in minimally invasive trauma surgery? Orthop Traumatol Surg Res. 2011 Oct;97(6): 662-7.

(30.) Bartal G, Vano E, Paulo G, et al. Management of patient and staff radiation dose in interventional radiology: current concepts. Cardiovasc Intervent Radiol. 2014 Apr;37(2):289-98.

(31.) Lee K, Lee KM, Park MS, et al. Measurements of surgeons' exposure to ionizing radiation dose during intraoperative use of C-arm fluoroscopy. Spine (Phila Pa 1976). 2012 Jun 15;37(14):1240-4.

(32.) Dudley AG, Dwyer ME, Fox JA, et al. Prospective Assessment of Radiation in Pediatric Urology: The Pediatric Urology Radiation Safety Evaluation Study. J Urol. 2016 Jul;196(l):202-6.

(33.) Kaplan DJ, Patel JN, Liporace FA, et al. Intraoperative radiation safety in orthopaedics: a review of the ALARA (As low as reasonably achievable) principle. Patient Saf Surg. 2016 Dec;10:27.

(34.) Desai MJ, Mithani SK, Lodha SJ, et al. Major Peripheral Nerve Injuries After Elbow Arthroscopy. Arthroscopy. 2016 Jul;32(6):999-1002.e8.

(35.) Kegel G, Marshall A, Barron OA, et al. Steroid injections in the upper extremity: experienced clinical opinion versus evidence-based practices. Orthopedics. 2013 Sep;36(9):e1141-8.

(36.) Leinberry CF, Rivlin M, Maltenfort M, et al. Treatment of carpal tunnel syndrome by members of the American Society for Surgery of the Hand: a 25-year perspective. J Hand Surg Am. 2012 Oct;37(10):1997-2003.e3.

(37.) Mathes DW, Schlenker R, Ploplys E, Vedder N. A survey of north american hand surgeons on their current attitudes toward hand transplantation. J Hand Surg Am. 2009 May-Jun;34(5):808-14.

(38.) Munns JJ, Awan HM. Trends in carpal tunnel surgery: an online survey of members of the American Society for Surgery of the Hand. J Hand Surg Am. 2015 Apr;40(4):767-71.e2. "

(39.) Payatakes AH, Zagoreos NP, Fedorcik GG, et al. Current practice of microsurgery by members of the American Society for Surgery of the Hand. J Hand Surg Am. 2007 Apr;32(4):541-7.

(40.) Shubinets V, Gerety PA, Pannucci CJ, et al. Attitude of hand surgeons toward Affordable Care Act: A survey of members of American Society for Surgery of the Hand. J Orthop. 2017 Oct25;14(1):38-44.

(41.) Wolf JM, Delaronde S. Current trends in nonoperative and operative treatment of trapeziometacarpal osteoarthritis: a survey of US hand surgeons. J Hand Surg Am. 2012 Jan;37(1):77-82.

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; amarpan@gmail.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.
COPYRIGHT 2018 J. Michael Ryan Publishing Co.
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2018 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Author:Patel, Amar A.; Patel, Arpan A.; Kaplan, F.Thomas D.
Publication:Bulletin of the NYU Hospital for Joint Diseases
Article Type:Report
Geographic Code:1USA
Date:Jul 1, 2018
Words:5351
Previous Article:Biomechanics of the Injured Fibula Following Plate Fixation of a Concomitant Tibia Fracture To Fix or Not to Fix?
Next Article:Musculoskeletal Injuries in Yoga.
Topics:

Terms of use | Privacy policy | Copyright © 2021 Farlex, Inc. | Feedback | For webmasters |