Response to Hafez et al.’s “Radiation exposure to the hands of orthopaedic surgeons: are we underestimating the risk?”

Abstract

Dear Sir, I have read the article by Hafez et al. [2]. regarding radiation exposure to the hands of the orthopaedic surgeons. The study was well planned and performed. I want to draw attention to another area regarding the adverse effects of radiation that we are exposed to during the operations, i.e. the exposure of the eyes to radiation, which can cause cataracts. As technology evolves, more complex operations can be done on human bodies with the aid of its results. C-arm fluoroscopy is one of these, which has enabled many complex procedures to be performed with minimal invasive methods on our patients in the last decades. The increased use of fluoroscopy in the last decades by both orthopaedists and other specialists has expanded the risk for healthcare providers of these areas [2–4]. Radiation protection for radiologists and radiology personnel is an accepted standard of practice in all medical institutions, and occupational radiation dose has declined for these job types during the last three or four decades [3]. Many of the surgeons performing fluoroscopic operations are unaware of both the potential of injury from these operations and the simple measures to prevent them [5]. Acute effects of radiation are not commonly a problem but stochastic effects like carcinogenesis (which does not have a threshold) and non-stochastic effects of radiation like radiation-induced cataracts or dermatitis still remain a concern [1, 3]. Personnel in C-arm fluoroscopic procedures receive radiation exposures that can reach or even exceed the dose limits. When the procedures are complex, the doses may even be 50% greater than typically reported and can even reach levels experienced in some cancer radiotherapy fractions [3, 5]. The thyroid gland and the body have long been protected by lead aprons and more recently lead gloves, glasses and shields [3, 4] are in use but the risk is still high. Many procedures performed by inexperienced surgeons with the aid of fluoroscopy are done like ‘‘live TV shows’’ and this is one of the cases of overexposure [4]. In addition, some procedures like kypho-vertebroplasty require near continuous fluoroscopy throughout the procedure [4]. In some operations, the C-arm is used upside down to be able to place the thinner radiation source under the operating table when there is not enough space to accommodate the bulky receiver part. This directly exposes and also puts the eyes and the thyroid gland in a greater risk. There is still need for studies to calculate the radiation exposures of various parts of the body and head during different surgical procedures regarding ‘‘orthopaedic surgeons’’. From this perspective, Hafez et al. [2] have made quite a valuable contribution to the relevant literature. The estimates about other professions (like interventional radiology or cardiology) are far from giving a clear idea of orthopaedist’s exposures, because in most instances, orthopaedic operations require extremity repositioning while under fluoroscopy and this can prevent the application of appropriate surface shielding against scattering radiation, which is another important source of radiation exposure [4]. Training about the radiological protection of the orthopaedic surgeons and the physicians should be one of the main parts of education because for those using interventional techniques, prevention is much easier than treatment of these injuries. New surgical techniques and new materials of shielding should be developed to minimize the X-ray exposure during the operation. Arch Orthop Trauma Surg (2005) 125: 575–576 DOI 10.1007/s00402-005-0039-8