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AAOS Now / Issue: Oct 2025 / clinical03

AAOS Now

Published 10/19/2025
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Julia Perugini, BS; Jad Lawand, MS; Pooya Hosseinzadeh, MD, FAAOS
Clinical

Radiation exposure is a hidden burden in orthopaedic surgery

Imaging is an important part of orthopaedic surgery, from preoperative radiographs and CT scans to intraoperative fluoroscopy. These tools assist with diagnosis, reductions, operative planning, and intraoperative decision-making. Although imaging targets the patient, orthopaedic surgeons and OR staff accumulate lifetime radiation exposure. This article highlights the known risks associated with radiation exposure and outlines strategies for protection and education.

The reality of radiation in orthopaedics
To understand why these strategies are critical, it is important to appreciate the current realities of radiation exposure faced by orthopaedic surgeons. Radiation exposure is becoming more of a risk in orthopaedics, as surgeons are operating at higher volumes, and new techniques and procedures that utilize radiographic imaging are continuously being developed. Although tools that emit radiation are being utilized more often, it can be difficult to quantify the amount of radiation individuals are being exposed to. Radiation exposure can vary depending on the individual choices of the surgical team and the type of surgery. As a subspecialty, orthopaedic trauma has been associated with the highest radiation exposure.

These risks can be particularly significant for certain groups, such as female orthopaedic surgeons, who face unique health considerations. Female orthopaedic surgeons have been found to have 3.97 times higher prevalence of breast cancer compared with the average woman in the United States, according to data from 2024. Garcia et al. found various complications related to women’s health arising from hazards in the OR, including higher rates of infertility and pregnancy complications, which are at least partially related to radiation exposure.

Risk mitigation
Given these risks, it is essential to understand current guidelines aimed at limiting occupational radiation exposure. The current recommendation of the International Atomic Energy Agency is not to exceed 100 millisieverts (mSv) in five years, which equates a maximum of 20 mSv/year. The U.S. Nuclear Regulatory Commission has a recommended limit of 5,000 millirem (mrem) per year. Many U.S. states require dosimeters to be worn to measure radiation exposure during cases, but they may not provide accurate estimates of exposure, with potential to underestimate the true amount.

Beyond guidelines, multiple risk-mitigation strategies can further reduce exposure and protect surgical teams. Requiring personal protective equipment is important to mitigate the risks of chronic radiation exposure, such as cancer and cataracts. In terms of protective technology, lead aprons tend to have the highest compliance, with thyroid guards, lead eyewear, lead gloves, and dosimetry being used less frequently, according to Duggan et al. The estimated radiation exposure of an orthopaedic surgeon using protective equipment is well under the recommended exposure amount, at <2 msv per year. however, improper fit can reduce the amount of protection surgeons receive.>

Newer imaging techniques, such as isocentric 3D C-arms, O-arms, and intraoperative MRI, provide high resolution, but surgeons should take care to note the relative radiation doses of each kind of technology. For example, O-arms can be associated with higher radiation doses per use, compared to fluoroscopy, according to Costa et al. There are also different ways to utilize these instruments. Marco et al. found that pulsed fluoroscopy may decrease exposure as compared to O-arms and standard fluoroscopy.

Positioning of the imaging devices, as well as positioning of oneself, can decrease radiation exposure. In terms of the inverse square principle, radiation exposure decreases as one gets further from the source. The intensifier should be close to what is being imaged on the patient, and the surgeon should back away or stand on the other side when possible to reduce radiation exposure from scatter. Studies suggest that new technology may also decrease radiation exposure, such as navigation-assisted fluoroscopy, robotically assisted procedures, augmented reality-based feedback for C-arm repositioning, and beam collimation.

Training gaps
Protective measures are effective only if surgeons and staff receive proper training. However, there are currently no guidelines regarding such training in the United States.

Various studies have shown a lack of training regarding radiation protection in orthopaedics. Sharma et al. reported that approximately 70% of participating orthopaedic surgeons never received formal radiation safety training. A study from Ahmad Abanomy, PhD, found that only 3.9% of surgeons had formal radiation training, and 7.8% were aware of the “as low as reasonably achievable,” or ALARA, principle. Many studies have shown that orthopaedic surgeons underestimate their radiation exposure, with trainees greatly underestimating it. Furthermore, Walsh et al. reported that a single lecture did not lead to significant increases in assessed knowledge on radiation safety. Not only do orthopaedic surgeons need radiation safety as part of the curriculum, but they also need to revisit it multiple times.

The existence of clear guidelines and education could have direct effects on the adoption of safe behaviors. Being aware of the problem of radiation exposure and reading studies related to the issue have been associated with protective behaviors during radiation exposure, according to Khan et al.

Increased use of imaging tools in orthopaedic surgery inevitably leads to occupational radiation exposure, posing potential health risks for surgeons and staff. Although international guidelines provide dose limits, exposure varies widely depending on individual behavior and institutional policies. Effective risk mitigation requires a combination of proper protective equipment and adherence to radiation safety principles. Education and standardized institutional policies remain key to improving awareness and compliance. Formal, repeated radiation safety training should be implemented across all levels of orthopaedic education and practice to safeguard surgeons throughout their careers.

Julia Perugini, BS, is a medical student at Washington University School of Medicine in St. Louis, Missouri.

Jay Lawand, MS, is a medical student at the University of Texas Medical Branch in Galveston, Texas.

Pooya Hosseinzadeh, MD, FAAOS, is an associate professor in the Department of Orthopaedic Surgery at Washington University School of Medicine. Dr. Hosseinzadeh is also a member of the AAOS Now Editorial Board.

References 

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