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Perioperative and intraoperative C-arm fluoroscopy is an important tool in orthopedic surgery. It enhances surgical decision-making and decreases the duration of surgery, but it poses a risk of ionizing radiation exposure to the patient and the surgeon. Thorough knowledge of fluoroscopy techniques allows for shaper imaging to reduce radiation exposure to the surgeon and the patient. This activity provides a comprehensive review of the fundamentals of fluoroscopy, application of fluoroscopy in orthopedics, interpretation, techniques, application in special situations, and safety protocols used by the interprofessional team to minimize radiation exposure with emphasis on the need for training in radiation safety and recent advances. Objectives: Describe the common indications of fluoroscopy in orthopedics. Outline risk factors of imaging and psychosocial considerations for patients undergoing fluoroscopy. Identify management considerations for patients with special considerations like pregnancy and pediatric patients. Explain the common use by the interprofessional team of fluoroscopy equipment. Access free multiple choice questions on this topic.

Wilhelm Röentgen, in 1895 used the mathematical "X" to describe unknown rays, which he discovered, and two weeks after his discovery, he produced the first X-ray image of his wife’s hand, the first medical imaging photo published in December 1895.[1] The New York Times then predicted the “transformation of modern surgery by enabling the surgeon to detect the presence of foreign bodies.” Since his discovery, X-rays have advanced from fuzzy images of bones and foreign bodies to 3D cone beam imaging within a century since his discovery. X-rays are the most common evaluation tool utilized in orthopedics to diagnose and evaluate various musculoskeletal diseases. Mobile X-ray units developed by Madam Marie Curie were the first to run to help military surgeons on the field. While radiography provides static images, fluoroscopy uses X-rays to obtain real-time images and videos of the internal structure and function of the patient. The first fluoroscope consisted of an X-ray tube and a fluorescent screen, but the major problem was producing images with sufficient brightness for visualization. Image intensifiers using optical lenses and mirrors for magnification were developed, and later a video camera and monitor were attached to allow better viewing. The C-arm, an X-ray machine with a half-moon frame, was developed, making the X-ray machine mobile in all directions.[2] The image intensifier with a monitor connected to the C-arm, a work-station unit, enhanced picture quality, and ease of viewing. The application of digital imaging and processing techniques improved image quality and digital recording of the images. The fluoroscopy imaging unit is one of the most valuable tools in the armamentarium of an orthopedic surgeon. Although utilized daily, there is a paucity of knowledge regarding proper usage and safety. This article outlines basic fluoroscopy protocols to enable young surgeons to effectively and safely use radiation to their advantage.

A diagnostic or therapeutic intervention involving fluoroscopy involves a team of professionals ranging from the surgeon to the anesthetist, the radiographer, and the theatre staff. Interprofessional communication is essential to improve the efficient use of fluoroscopy with decreased exposure to all team members. Proper coordination with physicians, nurses, and X-ray technicians will lead to less radiation and shorter surgeries. Evidence shows a common language between surgeon and operator, and knowledge of terms during C-arm usage can go a long way in decreasing radiation exposure and surgery time. Diagnostic and intraoperative fluoroscopy in special situations such as in pregnancy and young children should utilize an interdisciplinary team to ensure safety from ionizing radiation to the mother and the fetus. Fluoroscopy in acute polytrauma patients can be challenging as it is difficult to maintain adequate positioning. Pre-planning with the intensivists and the radiology team helps better interpret images, decreases surgical time, and minimizes radiation exposure.

Team Safety Protocol Natural radiation exposure up to a dose of 2 to 200 mSv per year is presently based on the geographical area.[32] The average dose due to radiation exposure from medical devices is about 2 mSv. The maximum permissible dose (MPD) is the upper limit of the radiation dose that one can receive without the risk of significant side effects. The annual whole-body dose limit for physicians is 50 mSv. C-arms pose a potential threat to the patient as well as to the staff in the operating room. As low as reasonably achievable (ALARA) suggests that even a small dose of diagnostic radiation must be avoided if it has no direct benefit in the procedure.[33] This is achieved by using three basic protective measures in radiation safety: time, distance, and shielding. The surgeons have to weigh the hazard to benefit ratio due to the radiation and monitor the individual dose.[34] The use of a personal dosimeter within the radiation control zone of 4 meters is compulsory in many countries. Lead gowns with thyroid protection must be worn by all staff in the operating room. The lead gowns with thyroid protection need to be checked regularly to ensure intact material. The patient must be protected with lead mats as long as they do not hinder the surgical field. The surgeon's knowledge of the settings of the device and its application decreases the dosage of exposed radiation. Pulsed fluoroscopy and single images are commonly used instead of continuous fluoroscopy as it decreases the radiation. Dynamic fluoroscopy should be used only if necessary and for a very short duration.[34] The surgeon needs to keep his hands out of the beam effectively. By making the field of view smaller and using a split diaphragm, scattered radiation can be reduced, thereby decreasing the exposure to the surgeon's hand. Distance is the most effective method to reduce exposure as exposure is decreased exponentially with distance. For all personnel with the risk of regular exposure to ionizing radiation, the use of dosimeters must be made mandatory. Real-time dosimeters allow for direct visualization of the radiation dose, which will help increase awareness regarding radiation hazards in personnel.