Radiation protection of patients in orthopedic surgery

Frequently asked questions by the health professionals

» Can patients undergoing fluoroscopic procedures experience significant radiation effects? 
» Which factors can affect patient dose in spine or orthopedic imaging procedures? 
» How can I manage patient dose? 
» What adverse effects could happen as a result of dose reduction actions?

» Can patients undergoing fluoroscopic procedures experience significant radiation effects?

No.

The radiation doses delivered to patients in most orthopaedic procedures under normal conditions will not cause effects such as skin injury, infertility and cataract. The typical skin dose in most uro-radiological procedures is less than 1 Gy whereas the threshold for erythema is 2 Gy. However, carcinogenic and genetic effects cannot be ruled out, although the probability of such effects can be minimized and is usually small. The typical radiation dose values in terms of dose area product (DAP) are mostly in the range of 0.02 to 20 Gy.cm2. At this level of radiation exposure, probability of radiation effects is much smaller than the benefits that usually occur.

» Which factors can affect patient dose in spine or orthopedic imaging procedures?

There are patient dependent, equipment dependent and procedure dependent factors.

Patient dependent factors include: body mass or body thickness in the beam, complexity of the lesion and anatomic target structure, previous radiation exposure, radiosensitivity of some patients.

Equipment dependent factors include: setting of dose rates in pulsed fluoro- and continuous fluoro mode, appropriate quality control, last image hold, acquisition, and virtual collimation.

The main procedure related factors are: number of radiographic frames per run, collimation, fluoroscopic and radiographic acquisition modes, fluoroscopy time, wedge filter, magnification, distance of patient to image receptor (image intensifier or flat panel detector), distance between X-ray tube and patient, and tube angulations.

Further reading:

• Radiation Protection in Diagnostic and Interventional Radiology

» How can I manage patient dose?

By keeping the X-ray tube as far away from the patient as feasible, keeping the image receptor as close to the patient as possible, keeping the foot on the pedal only when essential, reducing the number of images acquired (runs), using the navigation system, collimating the X-ray beam, using last image hold, using pulsed fluoroscopy, minimal use of magnification reducing exposure to radiosensitive organs such as the breast and reducing oblique views.

» What adverse effects could happen as a result of dose reduction actions?

Optimization of protection requires that exposure of patients be the minimum necessary to achieve the required diagnostic and therapeutic objective of the interventional procedure. By no means should dose reduction compromise clinical information and outcome. In diagnosis, if the dose is reduced below the minimum necessary, the adverse effects may result in reduced quality and extent of information.

Read more:

• BOR, D., T. SANCAK, T. OLGAR et al. Comparison of effective doses obtained from dose-area product and air kerma measurements in interventional radiology. Br. J. Radiol. 77916 (2004) 315-322. 
• CIRAJ-BJELAC, O., REHANI, M.M., SIM, K.H., LIEW, H.B., VANO, E., KLEIMAN, N.J., Risk for radiation induced cataract for staff in interventional cardiology: Is there reason for concern? Catheter. Cardiovasc. Interv. (Jun. 2010). 
• CRAWLEY, M.T., ROGERS, A.T., Dose-area product measurements in a range of common orthopaedic procedures and their possible use in establishing local diagnostic levels. Br. J. Radiol. 73 (2000) 740-744. 
• HART, A., WALL, B.F., Radiation exposure of the UK population from medical and dental x-ray examinations. NRPB-W4 (2002) 
• METTLER FA, HUDA W, YOSHIZUMI TT, AND MAHESH M. Effective Doses in Radiology and Diagnostic Nuclear Medicine: A Catalog. Radiology 248 1 (2008) 254-263. 
• THEOCHAROPOULOS, N., PERISINAKIS, K., DAMILAKIS, J., PAPADOKOSTAKIS, G., HADJIPAVLOU, A., GOURTSOYIANNIS, N., Occupational Exposure from Common Fluoroscopic Projections Used in Orthopaedic Surgery. The Journal of Bone and Joint Surgery, 85 (2003) 1698-1703. 
• VANO, E., GONZALEZ, L., BENEYTEZ, F., MORENO, F., Lens injuries induced by occupational exposure in non-optimised interventional radiology laboratories, Br. J. Radiol. 71 (1998) 728-733. 
• VANO, E., KLEIMAN, N.J., DURAN, A., REHANI, M.M., ECHEVERRI, D., CABRERA, M., Radiation cataract risk in interventional cardiology personnel. Radiat Res. 174 4 (2010) 490-495.