Occupational Hazards of Orthopedic Surgery Exposures: Infection, Smoke, and Noise

Ergonomics in the Operating Room: Recommendations for Orthopaedic Surgeons

Orthopaedic surgeons face notable occupational hazards, including suboptimal ergonomics in the operating room (OR). This results in high rates of musculoskeletal injuries that affect at least four in 10 orthopaedic surgeons. Sex disparities exacerbate these issues, with female surgeons reporting markedly higher rates of occupational injuries and discomfort with surgical instrument use compared with male surgeons. Factors such as sustained nonergonomic positions, poor instrument design, improper OR setups, and forceful and repetitive movements contribute to these injuries. With upward of one in three injured orthopaedic surgeons taking leaves, modifying their practices, or retiring prematurely, there is a need to safeguard the health and longevity of the orthopaedic workforce. Surgeons can mitigate the risk of musculoskeletal injuries by maintaining neutral body positions, adjusting their OR environment (e.g., table height), and incorporating brief interventions (e.g., position changes and regular microbreaks). Educating surgeons on these interventions is important for reducing harm. Institutions can consider adapting policies and conducting research focused on enhancing ergonomics to further contribute to creating safer surgical environments. Improving OR ergonomics not only influences orthopaedic surgeon well-being and practice longevity but also enhances patient care and reduces the economic toll of occupational injuries.

Automatic Impactors in Total Hip Arthroplasty: A State-of-the-Art Review

BACKGROUND

Total hip arthroplasty (THA) is an increasingly common procedure that places considerable physical strain on orthopaedic surgeons over time. The procedure requires precise impaction for optimal implant fixation and long-term stability. Automated impactors have emerged as innovative tools to address the limitations of manual mallets, with efforts to improve surgeons' physical health, surgical efficiency, and patient outcomes. This review evaluates the specifications, clinical applications, ergonomic benefits, and occupational hazards such as noise of commercially available automated impactors, including KINCISE, Woodpecker, HAMMR, and orthodrive. This is compared to existing literature on the devices and supplemented with independent noise measurements. It aimed to provide actionable insights to guide device selection based on clinical scenarios and operating room needs.

METHODS

A systematic PubMed search (2013 to 2024) identified 147 relevant articles after excluding studies on impaction grafting and trauma. Product specifications and noise data were supplemented with patent information and manufacturer details. Noise mitigation strategies and ergonomic considerations were also explored. Sound levels of three of the discussed impactors were measured to supplement this review.

RESULTS

Automated impactors demonstrated significant reductions in femoral broaching time, improved consistency, and reduced surgeon fatigue compared to manual methods. Periprosthetic fracture risk was equal to or less than that of manual broaching. Each impactor exhibited unique strengths: KINCISE offered versatility, Woodpecker precision, HAMMR adjustability, and orthodrive the lowest noise production of the devices measured. However, trade-offs compared to the traditional mallet included cost, learning curves, and limited versatility in some devices. Time-weighted average (TWA) noise levels ranged from 57.37 to 67.47 dBA across devices, with maximum levels ranging from 101.2 to 107.3 dBA, remaining below the Occupational Safety and Health Administration TWA 85 dBA threshold and the World Health Organization (WHO) maximum threshold of 110 dBA.

CONCLUSIONS

Automated impactors enhance procedural efficiency and ergonomics in THA, but device selection should be tailored to specific surgical and institutional needs. Noise levels were similar across devices, though close to the WHO maximum threshold. Future research should focus on long-term patient outcomes and standardizing testing protocols for these devices.

Sound levels in the operating theatre resulting from hammering during cementless total hip arthroplasty

BACKGROUND

Although hearing loss in orthopaedic surgeons from exposure to hammering sounds have been previously reported, there are no reports on the noise environment during total hip arthroplasty (THA) in Japan. The aim of this study was to investigate the sound level generated by cementless THA in Japan, and to discuss the broader sound environment within this space.

METHODS

94 cementless THAs (94 patients with informed consent) performed by four surgeons were included. The equivalent continuous A-weighted sound levels (LAeq) in a series of 1086 continuous hammering maneuvers without pause and the maximum C-weighted sound levels (LCpeak) in 17,210 hammering sounds were investigated.

RESULTS

Among the hammering sounds analysed in terms of LAeq, the sound pressure level associated with some procedures did result in non-scrubbed personnel being exposed to the 8-h sound levels exceeding the LAeq threshold (85 dB), while most procedures exceeded this threshold for scrubbed personnel. For scrubbed personnel, the maximum number of operations that could be safely attended per day were 16.1 and 1.6 operations under average and worst-case scenario conditions, respectively. For LCpeak, no sound was found to be above the threshold (135 dB) for either non-scrubbed or scrubbed personnel.

CONCLUSIONS

Although average sound levels in a standard operating theatre during cementless THA did not exceed recommended thresholds among non-scrubbed medical practitioners, our data are not sufficient to conclude that the sound environment is safe for scrubbed personnel close to the sound source. Further investigation is needed regarding sound exposure and the occurrence of hearing impairment in surgeons who perform total hip arthroplasties.

Noise-Induced Hearing Loss: Should Surgeons Be Wearing Ear Protection During Primary Total Joint Arthroplasty?

Background

The risk of noise-induced hearing loss (NIHL) to orthopedic surgeons due to occupational exposures is unknown. A level of 85 decibels (dB) over an 8-hour time-weighted average (TWA) is considered hazardous.

Question/Purpose

We sought to identify whether manual and/or robotic arthroplasty procedures increase surgeons' risk of developing NIHL.

Methods

At our institution, we prospectively collected intraoperative recordings with a microphone attached to the surgeon during manual total knee arthroplasty (TKA), manual total hip arthroplasty (THA), and robotic-assisted total knee arthroplasty (RTKA). Recordings taken in the operating room without operating room staff present served as baseline controls. The 172 recordings consisted of 46 baseline, 42 THA, 40 TKA, and 44 RTKA recordings. Decibel levels were reported as "maximum dB level" (the highest sound pressure level using an A-weighted dB scale), "LAeq" (the equivalent continuous sound level), "LCpeak" (the peak sound pressure level using a C-weighted dB scale), and "TWA" (the average dB level projected over an 8-hour period). The percentage of allowable daily noise dose was reported as "dose" and the measured dose projected over 8 hours as "projected dose."

Results

The recordings of surgeries had average maximum dB levels ranging from 106.0 to 108.0 dB, all significantly greater than controls. Robotic-assisted total knee arthroplasties had the highest average dose (18.7%) and average projected dose (252.0%).

Conclusions

Our review of recordings at a single institution found that noise levels of RTKAs surpassed projected doses of 100%. Orthopedic surgeons performing more than 2 RTKAs per day may be at increased risk of NIHL. Further research is needed to assess the effectiveness of measures such as ear protection to minimize surgeons' exposure.

Study on impact of robotic-assisted orthopaedic industrial noise (SIREN)

INTRODUCTION

The aim of this study was to evaluate noise exposure to the operating room staff consisting of the surgeon, assistant, anaesthetist and Mako Product Specialist (MPS) during Mako robotic-arm assisted total knee arthroplasty (TKA) and total hip arthroplasty (THA). We aimed to determine whether employees were exposed to noise at or above a lower exposure action value (LEAV) set out by the Noise at Work Regulations 2005, Health and Safety Executive (HSE), UK.

MATERIALS AND METHODS

We prospectively recorded intra-operative noise levels in Mako robotic-arm assisted TKA and THA over a period of two months using the MicW i436 connected to an iOS device (Apple), using the Sound Level Meter App (iOS) by the National Institute for Occupation Safety and Health (NIOSH). Data obtained was then used to calculate "worst case" daily exposure value to assess if sound levels were compliant with UK guidelines. Comparison between operating room staff groups was performed with ANOVA testing.

RESULTS

A total of 19 TKA and 11 THA operations were recorded. During TKA, for the primary surgeon and the assistant, the equivalent continuous sound pressure level (LAeq) was over 80 dB, exceeding the LEAV set out by the Noise at Work Regulations by HSE. During THA, the average LAeq and peak sound pressure levels did not exceed the LEAV. The calculated daily exposure for the primary surgeon in TKA was 82 dB. A Tukey post hoc test revealed that LAeq was statistically significantly lower in the anaesthetist and MPS (p < .001) compared to the primary surgeon and assistant in both TKA and THA.

CONCLUSIONS

Operating room staff, particularly the primary surgeon and assistant are exposed to significant levels of noise during Mako robotic-arm assisted TKA and THA. Formal assessments should be performed to further assess the risk of noise induced hearing loss in robotic-arm assisted arthroplasty.

Risk of noise-induced hearing loss in the spine surgeon

Background

Occupation-related noise-induced hearing loss (NIHL) has both negative economic and quality of life implications. The risk spine surgeons undertake in regards to NIHL during operative intervention is unknown. Governing bodies, including the National Institute for Occupational Safety and Health, have recommended exposure limits not to exceed 85 decibels (dB) over 8 hours. The purpose of this study is to characterize noise exposure to spine surgeons in the operating room (OR).

Methods

Prospective collection of intraoperative recordings of spinal surgeries (cervical and thoracic/lumbar) was undertaken. Data gathered included procedure, operative duration, presence of background music, and noise information. Noise information included maximum decibel level (MDL), Peak level (LCPeak), Equivalent continuous sound pressure level, time weighted average (TWA), dose, and projected dose. Noise measurements were compared with baseline controls with and without music (empty ORs).

Results

Two hundred seven noise recordings were analyzed. One hundred eighteen of those being spinal surgeries, 49 baseline recordings without music, and 40 with music. Maximum decibel level reached a maximum value of 111.5 dBA, with an average amongst surgical recordings of 103 dBA. Maximum decibel level exceeded 85 dBA in 100% of cases and was greater than 100 dBA in 78%. The maximum LCPeak recorded was 132.9 dBC with an average of 120 dBC. Furthermore, the average dose was 7.8% with an average projected dose of 26.5%. The highest dose occurred during a laminectomy at 72.9% of daily allowable noise. Maximum projected dose yielded 156% during a 3-level anterior cervical discectomy and fusion.

Conclusions

Spine surgeons are routinely exposed to damaging noise levels (>85 dBA) during operative intervention. With spine surgeons often performing multiple surgeries a day, the cumulative risk of noise exposure cannot be ignored. The synergistic effects of continuous and impact noise places spine surgeons at risk for the development of occupation-related NIHL.

Impact of Excessive Noise Generation in Orthopaedic Operating Theatres: A Comprehensive Review

Excessive noise in the orthopaedic operating theatre (OT) is an underrecognized and often neglected health hazard noticed amongst surgeons, patients and theatre and scrub practitioners. A comprehensive search strategy was conducted using databases, such as PubMed, Scopus and Web of Science, with the search words 'noise', 'NIHL' and 'orthopaedics' to retrieve the significant data and generate this narrative review. We evaluated the typical causes, potential hazards and negative effects of noise-induced impacts on OT personnel and patients. Strategies to mitigate the effects of unnecessary, disproportionate noises in the OT environment were explored. Excessive noise generated in orthopaedic OTs can produce several negative effects on patients, surgeons and staff. Noise-induced hearing loss (NIHL) is a rare and under-noticed disorder. The orthopaedic OT environment, with the ever-increasing use of power tools and surgical instruments, contributes to detrimental noise generation. NIHL is an occupational hazard. Raising awareness, appropriate training and clinical governance in collaboration with the hospital risk management team amongst all the medical and paramedical fraternities working in orthopaedic theatres can mitigate challenges faced due to the deleterious effects of excessive noise. We propose recommendations and standard operating protocols that can be incorporated into hospital policies to prevent NIHL among the orthopaedic fraternity and patients alike.

Surgical smoke and the orthopedic surgeon: a non-systematic review of the hazards and strategies for mitigating risk

INTRODUCTION

Surgical smoke generated through the use of electrical surgical devices poses a risk to the surgeon, medical personnel in the operating room, and the patient by exposing them to environmentally hazardous particulate matter. Previous investigation has shown that surgical smoke leads to an increased risk of pulmonary conditions, circulatory disorders, and irritation of the eyes, nose, and throat. Transmission of infectious disease can occur through inhalation of viral particles, and the presence of carcinogens are also of major concern. The deleterious effects of surgical smoke are well documented in several subspecialties, namely dermatology and general surgery, but there has been little discussion on the topic amongst orthopedic surgeons.

METHODS

A non-systematic review of the literature was completed with the aim of identifying the major categories of adverse health effects associated with surgical smoke inhalation and offering recommendations to reduce these hazards in the orthopedic surgical community.

RESULTS

Three primary categories of risk associated with surgical smoke inhalation were identified: inflammation, viral/bacterial transmission, and carcinogenicity. In addition, strategies for mitigating risk and best practice recommendations were explored.

CONCLUSION

Surgical smoke is an under-recognized occupational hazard within the orthopedic surgery literature. There are several strategies which can be employed to reduce risk. Further investigation is needed to understand the long-term impact of these risks, as well as what can be done to improve the practicality and compliance with protective measures.