Medical radiation exposure increased 6-fold since 1980 in the United States population, and estimates suggest that up to 3% of all future malignant neoplasia could be caused by previous ionizing radiation exposure . Therefore, several studies have been and are being done to gather all the information possible to create plans in which we can utilize the best evidence and technology available to help patients without causing undesired harm to them and to medical teams.
Currently, there are very conflicting evidence in the literature regarding some effects of ionizing radiation. One topic that is very interesting is the possibility of radiation exposure during daily practice increase the frequency of females offsprings in male doctors. One of the first studies that mentioned this topic was published in 1997 by Zadeh and Briggs, in the United Kingdom, and they have reported that both male orthopedic surgeons and male obstetricians and gynecologists had a higher incidence of female children . In addition, there was an increased risk for congenital abnormalities and there was statistical difference comparing to population in all those findings . Since the obstetricians and gynecologists had no radiation exposure, Zadeh and Briggs proposed that occupational exposure to X-ray was not associated to those findings and, possibly the exposure to operating theatre environment was the cause . However, Hama et al. from Japan broke down the participants of his study into two groups, “lightly irradiated” and “highly irradiated” (one or more incidents of annual radiation exposure > 10 mSv), and they have found a significant statistical increase in the risk of lower male proportion in the offspring of radiologists from the “highly irradiated” group . Finally, the most recent study on this topic, published by Choi et al., used a sample of male invasive cardiologists. The authors found no significant difference in the proportion of male and female offspring, even when analyzing a sub-group with higher radiation exposure . In the present study, we have found similar results to Choi et al. and Zadeh and Briggs. No difference in male proportions in offspring of male Brazilian orthopedic surgeons was identified and, the proportions were similar to the Brazilian population (Table 4) . We also compared a group of lower radiation exposure to a group of higher exposure, which was determined by the number of surgeries requiring fluoroscopy per week per surgeons, and again no difference was found in the offspring sex proportion (Table 4).
Another controversial topic is the relationship between the use of lead apron and back pain in orthopedic surgeons or other professionals that deal with x-ray on their practice. The first study to our knowledge which looked into this relationship was published by Moore et al. and did not prove the use of lead apron as a risk factor for back pain . Later, a research on the prevalence of spinal disc disease among interventional cardiologists claims the existence of the “interventionalist’s disc disease”, when they report the significant differences between the incidence of skeletal complaints in interventional cardiologists and other two specialties compared (orthopedists and rheumatologists) . In their study, it was shown a greater incidence of cervical problems instead of lumbar. It was also observed that interventional cardiologists use aprons for longer periods, which increase the effects of lead apron use in the axial skeleton . However, in our study we have found similar results to Moore’s study. There was no significant relationship between back pain frequency and apron use among Brazilian orthopedic surgeons, but we could see in descriptive analysis that most of our participants complained of back pain during prolonged surgeries. Therefore, we think it might be necessary much more hours of apron use to cause harmful effects and back pain related to it, which is in accordance to the study about interventional cardiologists. However, prolonged procedures even without apron use might be a cause of back pain, which we have not seen a study comparing both situations. Furthermore, another study suggests that interventionists wearing single-sided aprons and working more than 10 hours/day complained more of shoulder and back pain, while most professionals that wear correct fit and light-weight aprons with appropriate lead equivalence did not complain of any physical problems .
Our study also assessed how the Brazilian orthopedic surgeons are protecting themselves from occupational ionizing radiation and if they know the theory behind the prevention from harmful effects of x-ray. Unfortunately, the results showed a lack of radiation protection equipment use and lack of knowledge about basic topics on radiation prevention. In our sample, 65.9% use only apron as protection equipment while it is very well known that radiation is the main risk factor for thyroid cancer . Only 32.1% of the participants use at least apron and thyroid shield and, 5.8% use all the protection equipment, including apron, thyroid shield and radiation protection glasses. Dosimeter is not used by the majority, 52.7%, and, from the ones that use it, only 22.1% use it always. A recent study about fluoroscopic radiation exposure highlighted that eyes and hands of the surgeons receive more radiation than other body parts and, therefore surgeons should routinely use eye and hand protection in addition to the basic apron and thyroid shield . It´s noteworthy that a study published by Muir et al. showed that some aprons were identified with labelling showing higher protection than in fact they presented when tested .
In regard to the questions about knowledge on radiation prevention, most of the Brazilian orthopedic surgeons did not present an appropriate performance. Only 2.7% hit the acceptable annual maximum radiation dose. 10.5% knew the pregnancy period of greater risk to the fetus when exposed to x-ray, and 5.8% hit the acceptable maximum radiation dose during pregnancy. 25.2% knew that the distance of 3 meters or more from radiation-emitting tube is considered safe and 44.2%, the safest positioning of the radiation-emitting tube. 25.2% got right that smaller tubes generally emit grater entrance dose to magnify the image and, therefore, emit more radiation. 55.4% knew that the surgery team receives more scattered radiation in surgical procedures performed in obese patients. And finally, the question with the best performance only had 58.5% of right answers saying that the hand, the eyes, and the thyroid are the most exposed and at greater risk of radiation related lesions. No significant differences were found when comparing the knowledge across all orthopedic surgery specialties, in any topic. All specialties had the same performance. It seems that probably the poor performance in the questionnaire is not a particularity of the Brazilian reality. In 2013, an original study showed that orthopedic surgeons from Canada lacked knowledge about the risk of eye cataracts when exposed to radiation and 75% reported no awareness of radiation dose limits existence . A survey analysis from Turkey, obviously with different set of questions, demonstrated an inadequate knowledge about the uses and risks of fluoroscopy and radiation prevention . Another article from Latin America showed that 75.7% of their sample never or rarely used a dosimeter badge, only 20.2% use lead glasses on their practice and, also highlighted significant differences between countries and many other knowledge deficiencies .
An interventional study was performed in order to analyze the impact of a surgeon education plan about radiation protection (15). The educational intervention was applied to surgeons performing complex endovascular procedures and, a strong relationship (p < 0.001) between the intervention and decrease in radiation dose was found, excluding fenestrated endovascular aneurysm repair which remained a procedure with high radiation exposure . In addition, some articles summarize in a didactic manner the main important aspects of how to decrease unnecessary radiation exposure, educating about radiation harmful effects, dose, and protection equipment. In those articles, they highlight that minimally invasive surgery increases radiation exposure, especially when applied to spine surgery [16, 17]. It is also highlighted the concept of ALARA (As Low As Reasonably Achievable) and the mnemonic DEBT (distance, exposure, barriers, and time) as pillars of the practical guidelines [16, 18–20].
As main limitation, our study design and sample characteristics do not allow to conclude that orthopaedic surgeons from all countries present the same knowledge regarding radiation exposure and safety procedures to prevent harmful effects. Another limitation is the lack of uniformity between subspecialties. We had 134 trauma surgeons versus 6 pediatric surgeons, 15 foot and ankle surgeons, and 17 hand surgeons, which potentially limits comparison between specialists in terms of knowledge and other variables analyzed in this study. Nevertheless, focusing on the basic education for medical residents before any specialization, we feel our data demonstrates quite clearly that orthopedic practitioners present low level of knowledge on the harmful effects of radiation exposure.