Mini C-Arm Fluoroscopy: Does Its Configuration Matter for Radiation Exposure to the Surgeon?

Safe usage of Mini 'C'-arm in operating room environment: Implications for clinical practice

BACKGROUND

Mini 'C'-arm machine is an advanced medical imaging device used primarily for intraoperative imaging during surgical, orthopaedic and emergency care procedures. Since the technology is based on ionising radiation, safe usage of Mini 'C'-arm machine is mandatory to protect patients and operating personnel.

OBJECTIVE

The main objective is to describe the various components related to patients, operator and equipment to ensure safe usage of Mini 'C'-arm machine. A comprehensive search strategy using the PEO (Population, Exposure, Outcome) framework was conducted using Embase, PubMed, Google Scholar and ResearchGate databases to identify suitable literature. The keywords used for the search included 'Fluoroscopy', 'Ionising Radiation' and 'surgical safety'.

KEY FINDINGS

Safe usage of Mini 'C'-arm equipment involves components of operator training, operator safety, patient safety, radiation dose, operating room logistics, handling of images and auditing of Mini 'C'-arm use.

CONCLUSION

Mini 'C'-arm provides an invaluable, portable imaging tool in a spectrum of general surgical and orthopaedic interventional procedures. However, safe usage of Mini 'C'-arm machine requires a multifaceted approach including operator responsibility and safety, patient protection, equipment maintenance, radiation dose awareness, documentation and sound reporting mechanisms.

[Intraoperative imaging of children and adolescents, for selected fractures and in follow-up after conservative and operative treatment : Part 2 of the results of a nationwide online survey of the Pediatric Traumatology Section of the German Trauma Society]

The indication for radiographic examinations in pediatric and adolescent trauma patients should follow ALARA (as low as reasonably achievable). Because of the effect of radiation on the growing sensitive tissues of these young patients, a strict indication should always be given for radiation use and during controls after fracture repair.

METHODS

An online survey by the Pediatric Traumatology Section (SKT) of the German Trauma Society (DGU) from Nov. 15, 2019, to Feb. 29, 2020, targeting trauma, pediatric, and general surgeons and orthopedic surgeons.

RESULTS

Participants: 788. Intraoperative applications: Collimation 50% always, postprocessing for magnification 40%, pulsed x-ray 47%, and 89% no continuous fluoroscopy; 63% osteosynthesis never directly on image intensifier. Radiographic controls after implant removal never used by 24%. After operated supracondylar humerus fracture, controls are performed up to 6 times. After distal radius greenstick fracture, 40% refrain from further X-ray controls, after conservatively treated clavicular shaft fracture, 55% refrain from further controls, others X-ray several times. After nondisplaced conservatively treated tibial shaft fracture, 63% recommend radiographic control after 1 week in two planes, 24% after 2 weeks, 37% after 4 weeks, and 32% after 6 weeks.

DISCUSSION

The analysis shows that there is no uniform radiological management of children and adolescents with fractures among the respondents. For some indications for the use of radiography, the benefit does not seem evident. The ALARA principle does not seem to be consistently followed.

CONCLUSION

Comparing the documented results of the survey with the consensus results of the SKT, differences are apparent.

Investigating Patient-Level Radiation Exposure in Hand and Wrist Fracture Surgery

BACKGROUND

Although occupational exposure to radiation has been previously studied in the hand surgery literature, there is a paucity of studies looking at radiation exposure to the patient during fluoroscopy-guided hand surgery. We aimed to describe the level of radiation experienced by patients undergoing common hand and wrist fracture fixation and to identify risk factors for increased radiation exposure.

METHODS

We performed a retrospective review of patients at a single institution who underwent fracture fixation of the hand, wrist, or forearm requiring mini c-arm fluoroscopic guidance from 2016 to 2020. Data points collected included patient demographics, procedural details, and indicators of radiation exposure including dose-area product (DAP), total intraoperative images, and total fluoroscopy time. Effective dose (ED) was calculated using DAP, field size, and a previously established conversion factor.

RESULTS

The final sample included 361 patients with an average age of 46 years. Procedures included fixation of forearm fractures (3.3%), distal radius fractures (35.7%), metacarpal fractures (30.8%), and phalangeal fractures (30.2%). The median number of intraoperative images acquired was 36, median total fluoroscopy time was 43 seconds, median DAP was 4.8 cGycm2, and median ED was 0.13 μSv. Distal (metacarpal and phalangeal) fractures required more intraoperative images and longer total fluoroscopy time (49 images, 61 seconds) compared with proximal (forearm and distal radius) fractures (39 images, 47 seconds) (images, P = 0.004; exposure time, P = 0.004). However, distal fractures had a lower average ED compared with proximal fractures (0.15 vs 0.19 μSv, P = 0.020). When compared with open procedures, percutaneous procedures had higher DAPs (8.8 vs 4.9 cGycm2, P < 0.001), higher ED (0.22 vs 0.15 μSv, P < 0.001), more intraoperative images (65 vs 36 images, P < 0.001), and longer total fluoroscopy time (81.9 vs 44.4 seconds, P < 0.001).

CONCLUSIONS

Patient-level radiation exposure during fluoroscopy-guided hand and wrist procedures is low relative to other common imaging modalities, such as dental radiographs, chest x-rays, and computed tomography scans, and is comparable with less than a few hours of natural background radiation exposure, highlighting the overall safety of this important technology. Further study should be performed to establish reference ranges, which could lead to improved patient counseling and evidence-based guidelines on patient shielding.