The International Commission on Radiological Protection has established standards for radiation protection. This study aims to determine actual and perceived radiation dose and audit safe practice when using image-intensifiers in theatre.

Between September 2012 and March 2013, 50 surgeons were surveyed during 39 procedures. Information collected by radiographers included the number of images the surgeons thought they used, actual number used, dose, screening time, number of people scrubbed, wearing thyroid collars and standing within 1m of the image-intensifier when in use.

The primary surgeon was more likely to estimate the number of images used correctly compared to the assistant. Supervising consultants were most accurate, followed by registrars as primary surgeons, consultants as primary surgeons then assisting registrars, and lastly SHOs. Most surgeons underestimated the number of images used. 87.5% of scrubbed staff were standing within 1m of the image-intensifier during screening and 36.5% were wearing thyroid protection. Three surgeons stated they were not wearing collars as they were unavailable.

We conclude that surgeons have a reasonable estimation of the x-rays used but are not undertaking simple steps to protect themselves from radiation. We plan to initiate an education program within the department and have ordered new, lightweight thyroid collars.

Recent reports observe that orthopaedic surgeons lack essential knowledge about ionising radiation. We aim to demonstrate perceived use of image-intensifiers by surgeons and awareness of radiation doses used during fractured neck of femur surgery.

Surgeons at a regional trauma centre were sent an online questionnaire. They were shown two neck of femur fracture radiographs and asked the total number of images they would use to reduce and fix the fracture with a dynamic-hip-screw / inter-medullary nail respectively. They were asked the maximum safe radiation dose, and that of ‘hip pining’ compared to CXR as outlined by the Ionising Radiation Regulations 1999.

For a DHS, consultants and registrars estimate their image use similarly. For IM nailing, consultants estimated higher image use than registrars, and double the number of X-rays taken for IM nailing compared to DHS. Knowledge levels regarding radiation doses during orthopaedic hip procedures are very low.

There is an expectation that more images will be used in IM nailing procedures. We plan to educate orthopaedic surgeons about radiation dose and safety. Correlating our findings with actual use of image in theatre when performing hip fracture surgery would extend the use of this study.

Background

During cephalomedullary nail stabilisation of subtrochanteric femoral fractures, damage to the distal anterior femoral cortex by the nail is a recognised cause of periprosthetic fracture. Currently available cephalomedullary devices vary widely in anteroposterior curvature, though all are less curved than the mean anatomic human femur. This study tests the hypothesis that a cephalomedullary device with greater anteroposterior curvature will achieve a more favourable position in the distal femur, with greater distance of the nail tip from the anterior cortex, and therefore lower risk of cortical damage.

We present the clinical and radiological outcome of a prospective series of 22 Buechel-Pappas Total Ankle Replacements (TAR) implanted in 19 patients with a mean follow-up of 9 years (range 6 to 13). The only published long term results of this prosthesis in the literature are from the originators' unit.

Patients have been prospectively reviewed yearly since 1991. None was lost to follow-up. The primary diagnosis was rheumatoid arthritis in 11 and osteoarthritis in 8 patients. 12 patients were female. Mean patient age was 64 (range 39 to 81). At the time of review 4 patients (6 ankles) had died between 12 and 69 months post-operatively of unrelated causes with their prostheses in situ. One patient had a below knee amputation for chronic venous ulceration 11 years after a TAR which until that point had continued to function well. One patient with severe rheumatoid arthritis had the implant removed at 8 weeks for deep infection. Another patient with rheumatoid arthritis had the TAR revised to a tibio-talar-calcaneal fusion 59 months post-operatively for talar avascular necrosis. One patient has pain from impingement and another patient with rheumatoid arthritis has intermittent pain at 8 years following her TAR. Every other implant continues to function well. The New Jersey LCS ankle assessment scores increased from a mean of 35 pre-operatively to 82 post-operatively. The increases were largely due to pain relief and improved function with the pre-operative range of motion being preserved. These scores have been maintained in the long term. No surviving implant is radiologically loose.

Our results suggest that the Buechel-Pappas TAR offers good clinical and radiological long-term results to patients with often disabling ankle arthritis