Radiation exposure to the orthopedic surgeon—a dosimetric comparison of two mini C-arm fluoroscopy models: a pilot study

Timothy H. Vernier Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA

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Whitney D. Hinson Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA

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Valentine D. Verpaalen Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA

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Abstract

OBJECTIVE

Perform a cadaveric experimental pilot study to measure and compare potential radiation exposure to an orthopedic surgeon from 2 different-generation mini C-arm models during a simulated orthopedic surgery.

SAMPLE

16 radiation dosimeters.

METHODS

Mock surgery setups were constructed with a canine cadaver thoracic limb and 2 different-generation mini C-arm models. Four radiation dosimeters were placed near the mini C-arm to mimic common locations of radiation exposure during image acquisition. One mini C-arm was placed in auto technique mode, and 100 static images were acquired. The dosimeters were replaced, and a 5-minute-long dynamic image was acquired. The same protocols were repeated for the second mini C-arm. The dosimetry badges were then submitted for radiation exposure quantification.

RESULTS

All but 1 dosimeter had radiation exposure levels below the detectable limits of the dosimeter. The dosimeter closest to the primary x-ray beam of 1 mini C-arm during dynamic image acquisition had a reading of 1 mrem.

CLINICAL RELEVANCE

Intraoperative radiation exposure from the mini C-arm is low, specifically to areas not protected by lead and in close proximity to the primary x-ray beam. That being said, surgeons should always practice the principles of ALARA (ie, as low as reasonably achievable) to minimize radiation exposure in the workplace.

Abstract

OBJECTIVE

Perform a cadaveric experimental pilot study to measure and compare potential radiation exposure to an orthopedic surgeon from 2 different-generation mini C-arm models during a simulated orthopedic surgery.

SAMPLE

16 radiation dosimeters.

METHODS

Mock surgery setups were constructed with a canine cadaver thoracic limb and 2 different-generation mini C-arm models. Four radiation dosimeters were placed near the mini C-arm to mimic common locations of radiation exposure during image acquisition. One mini C-arm was placed in auto technique mode, and 100 static images were acquired. The dosimeters were replaced, and a 5-minute-long dynamic image was acquired. The same protocols were repeated for the second mini C-arm. The dosimetry badges were then submitted for radiation exposure quantification.

RESULTS

All but 1 dosimeter had radiation exposure levels below the detectable limits of the dosimeter. The dosimeter closest to the primary x-ray beam of 1 mini C-arm during dynamic image acquisition had a reading of 1 mrem.

CLINICAL RELEVANCE

Intraoperative radiation exposure from the mini C-arm is low, specifically to areas not protected by lead and in close proximity to the primary x-ray beam. That being said, surgeons should always practice the principles of ALARA (ie, as low as reasonably achievable) to minimize radiation exposure in the workplace.

Introduction

In veterinary medicine, fluoroscopy has become a frequently used tool to aid in a wide range of minimally invasive procedures, including fracture fixation.1 In particular, the C-arm and mini C-arm are 2 commonly used units for intraoperative fluoroscopy. With the increased use of fluoroscopy in veterinary medicine, surgeons should be aware of the increase in radiation exposure to them and the rest of the surgical team. The 3 main sources of radiation exposure during fluoroscopy include the primary beam, scatter radiation, and leakage radiation.2 Radiation from the primary beam comes from the x-rays used to produce an image. Scatter radiation is produced when an x-ray from the primary beam interacts with the target being imaged and is deflected instead of being absorbed. Leakage radiation comes from x-rays that escape the housing of the x-ray generator and do not travel in the path of the primary beam toward the target. Radiation exposure from scatter radiation is several times lower than radiation levels from the primary beam, and leakage radiation doses are several orders of magnitude lower than scatter radiation doses.3 For orthopedic surgeons, most of their radiation exposure comes from scatter radiation, as surgeons are rarely in the primary x-ray beam.4 More specifically, studies510 in human medicine show that an orthopedic surgeon’s hands are exposed to the most amount of radiation compared to any other body part. This is likely due to the proximity of the surgeon’s hands to the primary x-ray beam and scatter radiation.

The 2 organizations responsible for setting radiation safety standards are the International Commission on Radiological Protection and the National Council on Radiation Protection and Measurements. The International Commission on Radiological Protection sets a total effective dose equivalent limit of 20 mSv/y (2,000 mrem/y) averaged over 5 years for the whole body and lens of the eye, with no more than 50 mSv in 1 year.11,12 The most recent National Council on Radiation Protection and Measurements recommendations for occupational limits is a total effective dose equivalent of 50 mSv/y (5,000 mrem/y) for the body and an absorbed dose of 50 mGy/y (50 mSv/y or 5,000 mrem/y) for the lens.13,14 However, both organizations set a limit of 500 mSv/y (50,000 mrem/y) for the hands.13 The effects of radiation exposure can be divided into 2 categories: deterministic and stochastic. Deterministic effects have a dose-dependent relationship, meaning effects occur after a threshold of radiation is met and absorbed by tissues. These effects occur due to tissue damage and include skin erythema, hair loss, and infertility.15 Stochastic effects do not have a relationship between the dose absorbed and severity of injury. These effects occur at the DNA level, and while an increase in dose does not necessarily increase the severity of injury, it does increase the likelihood of an oncogenic mutation arising.2

In a 2005 study, Mastrangelo et al16 found a greater incidence of cancer among human orthopedic surgeons when poor radiation safety measures were practiced. Additionally, Chou et al17,18 found an increased prevalence of breast cancer among human orthopedic surgeons when compared to plastic and urologic surgeons, even after controlling for lifestyle and socioeconomic factors. It is also known that prolonged radiation exposure can also lead to the formation of cataracts.2,4,15,19 There have not been any studies that have investigated the occupational radiation-related cancer risk in veterinary surgeons. Most veterinary personnel wear a lead gown and thyroid shield when exposed to x-rays.20 With 0.25-mm- and 0.50-mm-thick lead gowns, 90% and 99% of radiation is attenuated, respectively.4,9,20,21 Other forms of personal protective equipment, such as lead glasses and gloves, are used much less commonly. In a survey of 240 veterinarians that had a history of operating an x-ray unit in a small animal fluoroscopic procedure, approximately 60% of respondents never wore hand or eye protection.20 Standard glasses attenuate approximately 20% of radiation, whereas leaded glasses reduce x-ray exposure by 90%.22 As for hand protection, radiation-attenuating gloves reduce x-ray exposure by 25% to 70%, and radiation-attenuating cream decreases exposure by 40%.5,23 Reasons for not wearing hand or eye protection included lack of awareness of available products, discomfort, lack of requirements, interference with procedures, inconvenience, and belief that hand shielding is unnecessary due to the high occupational dose limits for the hands.5,20

Given the number of veterinarians using fluoroscopy without hand or eye protection and the fact that a surgeon’s hands receive the most radiation exposure during surgery, it is important to quantify how much radiation the hands and body of a surgeon, or any other assisting personnel, may be exposed to during surgery. The primary objective of this pilot study was to measure the potential radiation exposure to a surgeon and surgical assistant in a standardized environment. Quantifying radiation exposure to the lens of the eye was beyond the scope of this study. Current literature510 suggests that the hands receive the highest amount of radiation compared to any other body part. Therefore, we hypothesized that the location immediately above the center of a primary beam directed parallel to the operating room table, where the surgeon’s hand is typically located when holding the limb up for image acquisition, would receive the most radiation exposure compared to locations farther away from the primary beam. The secondary objective of this pilot study was to compare the radiation exposure between an older and newer mini C-arm model. At this time, there is no evidence to show that different generations of C-arms produce differing amounts of radiation. We hypothesized that there would be no difference in the amount of scatter radiation produced by the 2 different mini C-arm models.

Methods

Dosimeter placement and positioning

The amount of x-ray exposure at 4 different locations in the operating room from 2 different models of mini C-arms during static and dynamic image acquisition was investigated. A mock surgery was set up in a procedure room using a canine cadaver forelimb resting against the center of the flat panel detector of either the 6600 (OEC Mini 6600; General Electric Healthcare) or the Elite (OEC Elite MiniView; General Electric Healthcare) mini C-arm. Surgical drapes or metallic instruments were not placed around the limb for consistency and to prevent the production of scatter radiation from other objects. Four optically stimulated luminescence dosimetry badges (Luxel +; Landauer) that had a minimum sensitivity of 1 mrem24 were placed on or near the mini C-arm to mimic locations a surgeon and an assistant might stand during surgery while holding the limb being imaged. Dosimeter No. 1 was placed next to the exposure button of the x-ray generator (Figure 1) to simulate where a surgeon’s hand would be during acquisition of a static or dynamic image. Dosimeter No. 2 was placed on the opposite end, behind the center of the flat panel detector, to represent radiation exposure to an assistant’s body. Dosimeter No. 3 was placed on the manus of the cadaver limb, 14 cm above the center of the primary beam, to simulate where the surgeon or assistant might hold the limb for imaging. Lastly, dosimeter No. 4 was placed 122 cm away from the center of the primary beam to simulate radiation exposure at the farthest distance a person could stand if using a wired foot pedal to acquire fluoroscopic images.

Figure 1
Figure 1

Mini C-arm with positions of the 4 dosimeters. Dosimeter No. 1 was placed next to the exposure button of the x-ray generator. Dosimeter No. 2 was placed on the opposite end, behind the center of the flat panel detector. Dosimeter No. 3 was placed on the manus of the cadaver limb, 14 cm above the center of the primary beam. Dosimeter No. 4 was placed 122 cm away from the center of the primary beam.

Citation: Journal of the American Veterinary Medical Association 262, 3; 10.2460/javma.23.05.0297

Fluoroscopy settings

The mini C-arms were placed in a horizontal position, so the primary x-ray beam was directed above and parallel to the operating room table. This orientation was chosen because it is a common way images are obtained during surgery at our institution. They were placed in auto technique mode, which allowed the mini C-arms to automatically adjust the kilovolt peak and milliamperes to produce an optimized image. Images for the Elite mini C-arm were acquired in low-dose mode, which is the most commonly used mode at our institution, as it reduces the amount of radiation produced while still generating diagnostic images. This mode was not available for the 6600 mini C-arm. Once all 4 dosimeters were in place, 100 static images of the cadaver limb were obtained with the 6600 mini C-arm. Static image acquisition is defined as obtaining a single radiographic image, whereas dynamic image acquisition is defined as obtaining a series of continuous images. The full field of view during each image was obtained, as no collimation was performed. No personnel were in the room, as all images were acquired remotely from outside the room. Next, the dosimeters were replaced, and a 5-minute-long dynamic image was obtained of the limb, again, without any personnel in the room. The time frame for dynamic image acquisition was based on the results of a survey by Freitas et al30 that reported a median time of 1.6 minutes of fluoroscopy use during orthopedic surgery. Hersch-Boyle et al1 also reported a median of 1.71 minutes of fluoroscopy use during orthopedic surgeries. The same procedures were repeated for the Elite mini C-arm. The authors visually confirmed adequate image acquisition throughout the study. The dosimetry badges were then collected and submitted for radiation exposure quantification.

Results

Both mini C-arms had constant x-ray technique for both image acquisition modes, except for the Elite mini C-arm during static image acquisition mode, where the exposure changed by 0.0003 mA on average with each image obtained (Table 1).

Table 1

Average x-ray technique for both C-arm models in static and dynamic image acquisition mode.

OEC Mini 6600 OEC Elite MiniView
Static image acquisition 0.022 mA, 42 kVp 0.0827 mA, 53 kVp
Dynamic image acquisition 0.022 mA, 42 kVp 0.083 mA, 53 kVp

The 6600 mini C-arm did not provide the absorbed dose of radiation of the cadaver limb. However, the Elite mini C-arm calculated the cadaver limb had an absorbed dose of 1.27 mGy after taking 100 static images and 5.59 mGy after taking a 5-minute-long dynamic image.

Of the 16 dosimeters exposed to radiation from the mini C-arms, 15 had a reading below the minimum reporting capability of the dosimeter. The only dosimeter that obtained a reportable radiation dose was dosimeter No. 3 from the Elite mini C-arm during dynamic image acquisition, which reported a dose of 1 mrem (Table 2).

Table 2

Radiation exposure of dosimeters in each position during static and dynamic image acquisition mode.

C-arm model and dosimeter No. Static image acquisition radiation exposure (mrem) Dynamic image acquisition radiation exposure (mrem)
6600-1 M M
6600-2 M M
6600-3 M M
6600-4 M M
Elite-1 M M
Elite-2 M M
Elite-3 M 1
Elite-4 M M

M = Minimal (ie, after the control subtraction, the resulting occupational dose was below the minimal reporting capabilities of the dosimeter).

Discussion

The overarching goal of this pilot study was to quantify potential radiation exposure to a surgeon and surgical assistant during a simulated orthopedic surgery using 2 different-generation mini C-arm models. One hundred static images and 5 minutes of dynamic images were acquired to simulate 1 operation with heavy fluoroscopic use and to compare radiation exposure between the 2 image acquisition modes. The results of this study indicate that even with 5 minutes of continuous fluoroscopy use, the dosimeter representing the surgeon’s hand for positioning of the limb during fluoroscopy only received 1 mrem of radiation using the newer-generation model. Similar results were seen in a study by Naiman et al,25 where a surgical assistant obtained a dose of 0.4 mrem on their wrist after 639 fluoroscopic images were obtained over 17 surgical cases. While we do not recommend approaching the occupational radiation exposure limit of 50,000 mrem/y, the results of this study indicate that if using the newer-generation mini C-arm model, a surgeon’s hand would need to be exposed to an average of 80 h of continuous fluoroscopy use/wk to reach the exposure limit.

All other dosimeters, including all the dosimeters for the older-generation mini C-arm model, did not reach the minimum detectable limit of radiation. Although it is possible that use of the newer-generation model results in greater levels of radiation exposure than the older-generation model, the lack of quantifiable radiation exposure provided insufficient data for statistical comparison. In addition, it is possible that the automated x-ray technique settings used by the Elite mini C-arm to obtain images during dynamic image acquisition were responsible for producing a reading above the minimum detectable limit for dosimeter No. 3. With higher milliamperes and kilovolt peak compared to the 6600 model, more scatter radiation is expected due to more high-energy x-rays being produced. Although the technique for the Elite mini C-arm was similar during static image acquisition, the total exposure time for static image acquisition was 67 seconds, whereas dynamic image acquisition took 300 seconds. This accounts for the absence of detectable radiation during static image acquisition. Regardless, due to the lack of quantifiable radiation exposure, we were unable to accept or reject our hypotheses.

There are multiple possible explanations for the remaining 15 dosimeters that did not reach the minimum detectable limit of radiation, all likely involving the 3 basic principles of ALARA (ie, as low as reasonably achievable): time, distance, and shielding. First, it is possible that the number of static images and duration of dynamic image acquisition were inadequate to produce a significant amount of scatter radiation. The cadaver limb was in the primary x-ray beam and received an absorbed dose of 5.59 mGy after 5 minutes of dynamic image acquisition from the Elite mini C-arm. This corresponds to an equivalent dose of 5.59 mSv or 559 mrem, but this may not have caused enough scatter radiation to be produced and absorbed by the surrounding dosimeters. Second, dosimeter No. 4 may have been at a distance far enough away that it did not receive a significant amount of radiation. Lastly, dosimeters Nos. 1 and 2 were on the mini C-arm itself, which may have shielded them from radiation. It is important to note that while these dosimeters did not reach their minimum reporting capability, it is unlikely that the dose of radiation received is zero. The lower limit of detection of the dosimeters was 1 mrem, so we can only conclude that they received < 1 mrem during static and dynamic image acquisition.26 These dosimeters were chosen for this study because they are used at our institution for radiation exposure monitoring. We acknowledge the limitations of these dosimeters, including their minimum reporting capability as well as light-induced fading and activation.26 Prior to use, the dosimeters were kept in a dark environment under room temperature to minimize any environmental effects that would alter dosimeter readings. Ring dosimeters were not used in this study, as they had a minimum detectable limit of 10 mrem.

Although it is reassuring to know that orthopedic surgeons are unlikely to meet the annual limits for radiation exposure, especially to parts of the body not covered by lead during routine use, it remains critical for the orthopedic surgeon to follow the principles of ALARA while using intraoperative fluoroscopy. By minimizing the time working with radiation, maximizing the distance from the x-ray source, and using appropriate personal protective equipment, a person’s occupational radiation exposure can be reduced. In addition to wearing personal protective equipment, shielding can also be achieved from the position of the C-arm itself. It is generally accepted that the surgeon should work behind the image intensifier or flat panel detector of the C-arm, as this location receives the least scatter radiation.27,28 To maximize the distance between a surgeon’s hand and any scatter radiation, surgeons should consider using a long surgical instrument to hold the limb during acquisition of a fluoroscopic image. It is important to consider using a nonmetal instrument, as the presence of metal in the radiographic field of view increases the amount of scatter radiation produced.29 The inverse square law states that the intensity of radiation is inversely proportional to the square of the distance from the primary source. Therefore, by doubling the distance from the primary source, the amount of radiation absorbed decreases by a factor of 4.

Keeping the ALARA principles in mind, it is important to emphasize that the low-dose exposure setting was used on the Elite mini C-arm, which reduces the milliamperes of the exposure by approximately 50%. The reader should therefore be wary of translating the results of this study to a scenario in which the Elite mini C-arm is used with a standard-dose exposure setting.

There are several limitations to this study. First of all, the cadaver, mini C-arm, and dosimeters were fixed in a specific location, whereas in reality, a surgeon is constantly moving the limb being operated on, the mini C-arm, and their own hands and body. With these changes in positions, the amount of radiation that operating room personnel are exposed to would be different from what is reported in this study. Furthermore, the position of the mini C-arm in relation to the operating room table can also lead to different amounts of scatter radiation being produced.30 The kilovolt peak and milliamperes of the mini C-arm stayed constant during fluoroscopic use in our study, but in surgery, radiographic exposure is constantly changing when the C-arm is placed in the auto technique setting. This is because adequate radiographic exposure is affected by the thickness of the tissue being penetrated by x-rays as well as the presence of surgical instruments in the x-ray field, which may change as the surgeon manipulates the position of the limb. These results are specific for imaging an extremity during orthopedic surgery and likely do not apply for other surgical settings such as pelvic or spinal imaging, abdominal imaging for placement of a subcutaneous ureteral bypass system, or interventional radiology procedures. Investigation into the amount of scatter radiation produced during these procedures with surgical instruments in the x-ray field could be investigated in a future study. The Elite mini C-arm had annual preventative maintenance performed at the time of this study, but the 6600 model was only serviced on an as-needed basis, which may have skewed radiation exposure data due to x-ray tube wear.

A myriad of different heights, distances, and angles relative to the primary x-ray beam of the mini C-arm could have been chosen for placement of the dosimeters. Placement of more dosimeters in different locations may have yielded different results, showing higher amounts of radiation in specific locations. However, as this was a pilot study, only 4 dosimeters/simulated surgery were used. Lastly, it is possible that the dosimeter that had a reading of 1 mrem was defective or damaged or had exposure to radiation that did not come from the mini C-arm. The authors do not believe this is likely; however, to disprove this, additional sets of dosimeters for each mini C-arm and image acquisition mode would need to be tested. If this investigative approach used to approximate radiation exposure to an orthopedic surgeon were used on a larger scale, additional sets of dosimeters, variable mini C-arm positions, and the addition of surgical instruments in the x-ray field would be considered in the design of the study. Furthermore, a larger number of static images and a longer duration of dynamic image acquisition could be considered to ensure the dosimeters reach their minimum detection limit.

In conclusion, the results of this study indicate that hand and body radiation exposure from intraoperative fluoroscopy using either the 6600 or Elite mini C-arm models is likely to remain well below the occupational radiation exposure limits. Regardless, because of the possibility of stochastic effects and natural background radiation unaccounted for in occupational radiation dose limits, operating personnel should adhere to ALARA principles to minimize long-term radiation exposure and the risk of subsequent negative health effects.

Acknowledgments

The authors thank Brandon Jordan for his technical support.

Presented at the 2023 Veterinary Orthopedic Society Meeting, Big Sky, Montana, March 2023.

Disclosures

The authors have nothing to disclose. No AI-assisted technologies were used in the generation of this manuscript.

Funding

The authors have nothing to disclose.

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