Editor’s note: This article is the second in a three-part series examining key occupational hazards in orthopaedics, with the goal of increasing awareness and promoting safer clinical environments.

Modern orthopaedic surgery relies on technologies that improve operative efficiency and precision. However, electrocautery devices, polymethyl methacrylate (PMMA) bone cement, powered instrumentation, and sterilants/ disinfectants can expose surgeons and operating room personnel to volatile organic compounds (VOCs), particulates, vapors, aerosols, biological debris, and chemical by-products that may carry occupational risks.

Occupational concerns in surgery have evolved from bloodborne pathogens and sharps injuries to surgical smoke and other airborne contaminants. Notwithstanding guidance from the National Institute for Occupational Safety and Health (NIOSH) and the Occupational Safety and Health Administration (OSHA), surveys suggest many healthcare workers receive limited training on surgical smoke hazards and mitigation strategies.

Although publications have highlighted concerns about cumulative occupational exposure, conflicting data regarding long-term health effects and mitigation strategies have hindered consensus. This article reviews common chemical exposures in orthopaedic practice, associated health concerns, and practical approaches to reducing risk.

Concerns
Surgical smoke generated by electrocautery devices, ultrasonic scalpels, and power tools contains particulate matter, polycyclic aromatic hydrocarbons (PAH), VOCs, and carbon monoxide (CO), several of which have demonstrated mutagenic and carcinogenic properties.

Biological and viral materials including human papillomavirus (HPV), hepatitis B (HepB), and human immunodeficiency virus (HIV) were also identified in surgical smoke, although documented transmission has been limited to HPV. A key finding in the literature is that aerosol concentration was found to be higher nearest the surgical site, and highest when the surgical site was opened.

PMMA bone cement is frequently used in arthroplasty procedures, during which methyl methacrylate (MMA) vapor may be released during cement mixing, curing, and implantation, according to Compton et al.

In a field test during primary total knee arthroplasty, ambient MMA levels first reached approximately 400 parts per million (ppm) around three minutes, followed by a second peak near 450 ppm at 11 minutes. Exposure to MMA vapor at approximately 125 ppm, slightly exceeding the OSHA threshold of 100 ppm, may result in watery eyes and throat irritation.

Additional studies reported hypersensitivity, neurological indications, and irritation associated with MMA exposure. Also, prolonged exposure above 400 ppm could lead to damage to tracheal tissue. Similar investigations evaluating acute PMMA-related clinical symptoms reported chest tightness, throat irritation, episodic cough, and dyspnea. Confounding variables and limited data resulted in insufficient evidence directly implicating MMA in the onset of asthma.

Orthopaedic procedures often involve drilling, sawing, and reaming, leaving operating room staff at increased risk of being exposed to aerosolized metallic particles. Although literature characterizing aerosolized metallic particles is limited, prior investigations demonstrated iron, chromium, and aluminum microparticle liberation by arthroscopic shavers and drills during simulated procedures. As powered instrumentation and implant manipulation remain routine components of orthopaedic surgery, increasing literature has evaluated the potential inflammatory and toxic implications associated with repeated particulate exposure.

Particles identical in composition to surgical instruments were also identified, with characterized particles inducing inflammatory chemokines, cytokines, and matrix-degrading enzymes in bovine and human synoviocytes. In a comparison of implant alloy particles, CoCrMo-alloy (cobalt, chromium, and molybdenum) particles were significantly more toxic and proinflammatory to human osteoblasts, fibroblasts, and macrophages than larger Ti-alloy (titanium) particles or smaller Zr-based (zirconium) particles. Beyond metallic particulate vulnerability, repeated exposure to sterilants and disinfectants such as glutaraldehyde, hydrogen peroxide, and peracetic acid commonly caused irritating and sensitizing effects involving the respiratory tract and skin, occupational asthma, irritant dermatitis, and chronic bronchitis with respect to glutaraldehyde.

Researchers associated acute exposure to surgical smoke, PMMA vapors, and airborne chemical irritants with neurological, dermatological, pulmonary, respiratory, sensory, and genetic symptoms. A study from Soysal and colleagues involving general surgery operating room personnel reported burning and tearing in the eyes, nausea, cough, and respiratory symptoms during or shortly after data collection (P ≤ 0.05). When measuring concentrations of particulate matter, one study recorded how distance, instrumentation, and exposure time influenced the symptomatic response to chemical contact.

Following electrocautery utilization, particulate matter (PM) ≤ 2.5 μm in diameter was found in concentrations of surgical smoke adjacent to the operative field. Data increased to 2,258 μg/m3 before rapidly decreasing after the device stopped. Additionally, a dust meter placed 2 m from the surgeon recorded minimal increases, suggesting concentrations were greatest nearest active plume generation. Factors affecting exposure symptoms included procedural duration, operative proximity, and surgical instrumentation.

Literature evaluating personal protective equipment (PPE) has emphasized the limitations of standard surgical masks for filtering ultrafine particles. N95 respirators provide greater filtration efficiency and may offer greater protection against electrocautery smoke and aerosolized particles.

Long-term health concerns remain less certain. Some studies have found long-term pulmonary and epidemiological effects. In their 2024 review, Benaim and Jaspers noted that a study by Navarro et al. found hyperplasia or squamous metaplasia in 16 of 23 surgical residents after four years of training compared with one of 20 nonsurgical residents. They also cited findings from the U.S. Nurses’ Health Study suggesting an association between operating room employment and increased risk of asthma and chronic obstructive pulmonary disease after 10-20 years.

Occupational epidemiology findings also suggest surgeons and operating room staff may experience cumulative exposure, though a direct correlation between exposure and disease is lacking. Furthermore, the same study from Landford and colleagues involving 183 surgeons across seven specialties identified surgical trainees reporting daily exposure to surgical smoke at rates 19.7 times higher than attending surgeons, while only 19.8% of trainees reported receiving formal training to combat surgical smoke.

Collectively, these findings suggest that operating room staff may experience overlapping exposure to surgical smoke, PMMA vapor, metallic particulates, and aerosolized debris.

Mitigation systems
Current literature suggests that local exhaust ventilation systems positioned near active plume generation may be effective at significantly reducing inhalation of hazardous aerosols. NIOSH and OSHA guidelines recommend the use of smoke-evacuation systems in combination with N95 respirators and proper PPE as the primary protection against accumulation of airborne particles. In addition, the American Society of Heating, Refrigerating and Air-Conditioning Engineers published ventilation standards recommending a minimum of 20 air changes per hour, undirected laminar fl ow, and HEPA (high-efficiency particulate air) or ULPA (ultra-low penetration air) filters with frequent replacement. One study analyzing the implementation of simple ventilation improvement methods resorted to redirecting supply diff users, closing select exhaust grilles, and sealing the doorway as engineering controls, reducing surgeon zone PM1.0 from 65.4 to 9.5 μg/m3 (P < 0.01). These findings demonstrated that low-cost ventilation improvements may serve as effective mitigation strategies without compromising changes in PPE or compliance behavior.

While conflicting data on long-term health effects lack consensus, literature supports continued investigation of practical mitigation strategies to improve occupational safety and operative workflow.

This article was submitted on behalf of the AAOS Committee on Healthcare Safety. The authors would like to thank Shivam Srivastava for help with searching the literature and preparing the preliminary manuscript.

Holden Telehowski, BS, is a student at the University of Michigan, Ann Arbor. Britanny Hamama, MD, is an orthopaedic surgery resident at the Michigan State University-McLaren Health Care program in Flint, Michigan.

Abdullah Arif, MD, is an orthopaedic surgery resident at the Michigan State University- McLaren Health Care program in Flint, Michigan.

Ajay Srivastava, MD, FAAOS, is an adult reconstruction surgeon and director of the McLaren Flint orthopaedic surgery residency program at McLaren Flint Medical Center and Hurley Medical Center in Flint, Michigan.

Common Chemical exposures in orthopaedic practice

• Surgical smoke from electrocautery and ultrasonic devices
• Methyl methacrylate vapor from bone cement
• Aerosolized metallic particles from drills and saws
• Sterilants and disinfectants, including glutaraldehyde