Occupational Hazards for the Practicing Orthopaedic Surgeon: A Standard Review

Abstract

Orthopaedic surgeons are exposed to various occupational hazards in a busy daily practice which can cause potential physical injury and additional mental stress. By better understanding the hazards that are faced in the operating theater and the preventive measures that can be taken to avoid injury, orthopaedic surgeons can remain effective in their patient care duties. Infectious exposures, radiation exposure, noise pollution, chemical hazards, and physical demands are frequently encountered at the time of surgery and should be attenuated or avoided when possible. Simple preventive measures can prolong careers and protect the operating surgeon from musculoskeletal injuries and even solid organ damage and malignancy. Important consideration should be taken to recognize potential occupational hazards and act prophylactically before injury has occurred, and constant vigilance is required to avoid additive injury over time from physical and chemical insults.

Level of Evidence: 

Level V

Orthopaedic surgeons face many occupational hazards daily, and it is of paramount importance to be aware of and understand how to mitigate potential injuries. Total costs from all occupational injuries can exceed $190 billion annually in the United States inclusive of necessary health care and lost productivity.¹ Although not specific to orthopaedic surgeons, recent statistics highlight the dangers that surgeons face, indicating that work in a hospital setting may contribute to more nonfatal occupational injuries than even employment in construction or manufacturing. Indeed, of 313 total industries surveyed, the hospital industry ranks as the third most expensive when considering economic losses from occupational injuries.²

General awareness and prevention of occupational safety among orthopaedic surgeons have increased in recent years, but there are many subtle occupational dangers that often go unnoticed and can be difficult to modify. Infectious exposure from sharp instruments or needles, physical insults such as radiation or noise pollution, and chemical exposure from inhalants or topical substances are some of the inherent hazards of participating in surgery. The purpose of this review article was to not only inform surgeons of these hazards but also potentially provide information that can be helpful in preventing and mitigating adverse effects from common workplace exposures.

Infectious Exposures for Orthopaedic Surgeons

Needlestick or Sharp Injuries

Most orthopaedic surgeons report having sustained a needlestick or sharp injury by the end of residency training, with a recent study demonstrating that 77.1% (172/223) of trainees completing 1 year of residency had sustained a needlestick or sharp injury, with this prevalence increasing to 90.5% (57/63) by the fourth year of training.³ Needle penetration during wound closure was the most common mode of injury, followed by pin or wire penetration during fixation. Alarmingly, over 55% of the respondents had failed to report this exposure to the appropriate institutional department.³ Another survey showed similar noncompliance with reporting, with only 38% of the surgeons reporting an accidental blood or bodily fluid exposure, 33% never reporting the incident, and the remaining 29% not reporting the incident every time.⁴ It seems that many infectious exposures are underreported and even selectively ignored by surgeons.

Percutaneous needlestick transmission rates are reported to be at 0.3% for HIV, 1.8% for hepatitis C virus (HCV), and as high as 6% to 30% for hepatitis B virus (HBV).⁵ There remains a likely small but unquantified risk of HBV or HCV infection from direct exposure to mucous membranes (such as the eye, nose, or mouth), and there have been no documented transmissions through intact skin.^4,5 Conversely, risk of transmission from mucocutaneous exposure to HIV-infected blood is roughly 0.1% (1 in 1,000).⁵ Similarly, no documented transmission has been reported when a small amount of HIV-infected blood contacts the intact skin of the surgeon.⁵ Extreme care should be taken to avoid any contact with nonintact skin or mucous membranes when patients are known carriers of these viruses. Surgeons should also consider the use of thick knit gloves over standard surgical gloves during high-risk surgical procedures.

Needlestick exposure and blood or bodily fluid exposure to the mucocutaneous membranes require copious irrigation as well with sterile fluid, water, or saline.^4,5 It is critical to immediately report and address the incident, which may entail the immediate cessation of surgical participation. As can be inferred from the available data, many surgeons are resistant to reporting all exposures, and the fear of abandoning duties may create a barrier to addressing exposures in a timely manner.

Treating HBV, HCV, and HIV exposure necessitates timely intervention and close surveillance after potential contact. Surgeons should receive the entire hepatitis B vaccine series with testing to confirm conferred immunity 1 to 2 months later.⁵ Treatment of actual HBV exposure includes administration of the hepatitis B vaccine if not previously vaccinated.⁵ Hepatitis B immune globulin may be used alone or in combination with the vaccination for postexposure prophylaxis, and this should begin within 24 hours and no later than 7 days after contact.⁵ Current guidelines recommend a 4-week course of 2 antiretroviral medications for HIV exposures, with 3 medications being used when exposures to a larger volume of blood indicate a greater risk for transmitting HIV.⁵ No available therapeutics can prevent HCV infection after exposure, but HCV antibody and liver enzyme levels, including alanine and aspartate aminotransferase, should be gathered at the time of exposure and again at 4 to 6 months after the exposure.⁶ Hepatitis C cure rates of up to 95% to 99% can be achieved with currently available antiviral medications should seroconversion occur.⁶

Skin and Ocular Exposure to Pathogens

Standard precautions should always be used when surgeons could be exposed to bodily fluids, nonintact skin, and/or mucous membranes. This includes proper hand hygiene and the use of adequate preoperative skin preparation, correct use of personal protective equipment, proper handling of sharp objects, cleaning and disinfecting of surgical supplies, and disposal of used equipment or tools during surgery.

The type of surgical gloves worn and the way in which they are used can be useful in preventing bodily fluid or blood exposure. A prospective study with a glove perforation rate of 3.58% (1,452 gloves in 130 separate operations) showed that most perforations occurred at the nondominant index finger or thumb because of shearing injuries, largely being unnoticed by the surgeon.⁷ Most of these perforations occurred in a primary surgeon during nailing procedures and internal fixation without the use of wires. Another study demonstrated a much higher perforation rate of 18.5% (1,769 gloves from 349 operations); the risk of blood contamination was approximately 13 times higher with single gloves than double gloves.⁸ In this same study, wearing two indicator gloves seemed to protect the inner glove from perforation when compared with the use of two regular gloves (4.9% vs 24% risk of perforation).⁸ Using double gloves is recommended for all orthopaedic procedures, and surgeons should routinely check their gloves for evidence of shearing injury, especially when the hand is physically introduced into the surgical or fracture site.

Various forms of eye protection have been debated, and there are many surgeons who use personal prescription eyeglasses both for convenience and comfort. However, Mansour et al⁹ found that using modern prescription glasses was comparable with the absence of any eye protection at all, with both groups demonstrating high conjunctival contamination rates of 83%. They examined other forms of protection, demonstrating eye contamination rates of 50% for loupes, 30% for facemasks and eye shields, 17% for hard plastic glasses, and 3% for disposable plastic glasses.⁹ Surprisingly, it would seem that disposable plastic glasses (Figure 1) provide the most effective protection from conjunctival contamination during surgery.

Figure 1: Image showing disposable plastic eye shields for surgical personnel use.

Respiratory Exposure to Pathogens

Numerous pathogens are known to be transmitted through respiratory droplet spread. Surgical procedures may increase the risk of certain exposures, particularly during airway intubation and management, which may increase aerosols, thereby increasing the risk of inoculation. Most recently, a new infectious hazard introducing itself into the orthopaedic workplace is the potential and likely inevitable exposure to severe acute respiratory syndrome–related coronavirus 2, the respiratory virus causing coronavirus disease-2019 (COVID-19). At the beginning of the pandemic, preoperative testing was limited to symptomatic patients only. However, since that time, it has become more and more evident that screening patients based on symptoms alone is insufficient. Many infections in surgical patients or operating room personnel are asymptomatic, and as a result, the risk for potential surgeon exposure to this virus is probably much higher than initially thought.

Public health agencies have recently recommended that orthopaedic surgeons working in an environment that may expose them to COVID-19 should wear face shields, level 4 surgical gowns, gloves, and N95 respirator masks (Figure 2).¹⁰ Surgeons may also choose to use a powered air-purifying respirator for facial protection, especially if their N-95 mask fit is poor or the procedure to be done is quite lengthy.¹⁰ It was previously opined that surgical hoods (ie, “spacesuits”) that are commonly used during arthroplasty may confer a protective effect, but these hoods do not filter enough particles in the 0.02- to 1-μm diameter range to meet the standard for protective respirators.¹¹ Thus, an N95 respirator should always be used intraoperatively underneath the surgical hood. Elective cases should always be postponed when patients test positive for COVID-19, and strict personal protective equipment precautions should be used when emergent surgery becomes necessary. In addition, surgeries should be limited to essential personnel only so as to limit aerosolization exposure to the surgical team during intubation.¹²

Figure 2: Image showing ideal PPE to be used for potential COVID-19 exposure. CDC = Centers for Disease Control and Prevention. COVID-19 = coronavirus disease-2019, PPE = personal protective equipment.

Moreover, outside of the operating room, there is some evidence supporting N95 respirator use at all times when in the hospital setting.^10,12 Even in the clinical setting, it is common to encounter this virus, and CDC recommendations currently support the use of N95 respirators by healthcare personnel working in close contact with COVID-19–positive patients.¹³ Surgeons with pre-existing medical conditions or comorbidities should be extremely cautious to use proper personal protective equipment when in contact with patients with COVID-19, but all surgeons are at risk for decompensation.

Radiation Exposure in Orthopaedic Surgery

Background and Epidemiology

Radiation imaging has revolutionized the level of care that orthopaedic surgeons can provide, allowing for improved intraoperative reduction, alignment, and fixation while also preserving efficiency during surgical procedures. However, as a result, orthopaedic surgeons and operating room staff are in constant contact with ionizing radiation, with predicted effects occurring in an increasing dose-dependent manner over time. These risks are minimized but not eliminated entirely by the usage of appropriate lead protective devices.¹⁴

One sievert (Sv) is the human dose resulting from exposure to one gray of radiation, both newer measurement units replacing the more dated roentgen. The International Commission on Radiological Protection (ICRP) and the US National Council on Radiation Protection & Measurements recommend occupational radiation thresholds of 20 millisievert (mSv) and 50 mSv per year, respectively.¹⁵ At the ICRP recommended rate of exposure, it would take roughly 50 years to accrue enough radiation to increase the absolute mortality risk from cancer by 5% and an individual's risk of developing solid cancer at any age by 60%.^15,16

It is estimated that an unshielded surgeon can do roughly 250 procedures per year before exceeding the recommended annual radiation dose.¹⁷ Because lead aprons and collars reduce overall exposure to 10% of emitted radiation, up to 2,500 procedures could theoretically be done before exceeding annual dosing guidelines. Tsalafoutas et al¹⁷ reported surgeon radiation doses (in millisieverts) of 0.10 (hands), 0.02 (chest), 0.01 (thyroid), 0.01 (eyes), 0.07 (gonads), and 0.05 (legs) during routine intramedullary nailing of peritrochanteric fractures. Surgeons must be aware that the hands, gonads, and legs may absorb up to 5 to 10x times more radiation than other body parts because of being partially or completely unshielded.

Ocular Radiation Exposure

Studies calling into question the relationship between higher radiation exposure and ocular pathology have been done. In 2004, a survey found cataracts in 5 of 59 (8%) interventional radiologists and an additional 22 specialists (37%) had small paracentral opacities, a possible marker for developing cataracts.¹⁸ Vano et al¹⁹ later reported similar findings, with posterior lens opacities developing in 38% of cardiologists working in an interventional radiology suite as compared with 12% of healthy control subjects (relative risk = 3.2). After these studies, the ICRP changed their ocular dosing guidelines in recent years, decreasing recommended annual eye and lens exposure from 150 to 20 mSv per year.

Thyroid Radiation Exposure

Younger age at the time of radiation exposure has been associated with a higher propensity to develop thyroid malignancy when compared with older controls.²⁰ In addition, the risk of developing any thyroid malignancy seems to decrease exponentially as age increases. Younger surgeons should take utmost care to wear a lead collar at all times when using fluoroscopy and minimize thyroid radiation exposure, even when involved in procedures outside the operating room such as emergency department reductions or in-office procedures.

C-Arm Management and Positioning

Orthopaedic surgeons must be aware of fluoroscopy practices that can dramatically decrease radiation dose over time. For example, when vertically oriented, the optimum position would be for the radiation tube to be placed under the patient, and the image intensifier to be placed above the patient. In this way, a decreased amount of scatter radiation would be delivered to the surgeon's upper body and eyes (Figure 3, A and B). Additional contributions to radiation exposure include patient size because of increased scatter and the need for a higher dose to obtain a quality image. Increasing the distance between the surgeon and machine intraoperatively can decrease radiation exposure inversely.^14,16 Hands can absorb as much as 10 times the amount of radiation as the remainder of the body, with a study by Hsu et al²¹ showing that standing 1 foot from the radiograph beam gives 0.3% of scatter radiation of that of the direct beam. Cautious use of the magnification mode should also be employed, given that this dramatically increases focused radiation to the operating surgeon. In addition, the surgeon who is standing on the emitter side a horizontally oriented C-arm machine during a spine or hip surgery will absorb much more radiation than the surgeon who stands on the intensifier side, calculated to be as much as a four to eightfold increase in the concentrated dose.²²

Figure 3: A, Image showing a representative radiation scatter for a C-arm fluoroscopy with the radiograph tube positioned under the table. Reprinted from ERCP (third edition), Eugene Lin, Beth Schueler, Radiologic Issues and Radiation Safety During ERCP chapter 3 pages 14-29. 2019, with permission from Elsevier. B, Image showing a representative radiation scatter for a C-arm fluoroscopy with the radiograph tube positioned over the patient. Reprinted from ERCP (third edition), Eugene Lin, Beth Schueler, Radiologic Issues and Radiation Safety During ERCP chapter 3 pages 14-29. 2019, with permission from Elsevier.

Fluoroscopy machines should also be designed to use collimation, which serves to narrow the beam of radiation and control scatter. Judicious use of radiographs and limiting proximity to radiation sources during surgery can markedly lessen exposure over time, along with the usage of low-dose radiation modes. Remaining continuously conscious of the distance from fluoroscopy has actually been shown to alter surgeon practices, resulting in a lower total dose of radiation in a study by Baumgartner et al.²³ Surgeons with real-time dosimetry visualization during surgery used practices that resulted in an overall 60% less radiation exposure, including standing further from the machine and conserving total fluoroscopy time (1.38 versus 1.95 minutes during procedure).

Although studies suggest a decrease in radiation exposure with the use of the “mini C-arm,”²⁴ compared with a standard C-arm, whenever possible the surgeon should use personal protection equipment including radiation shielding. Lead aprons and collars should always be worn by surgeons when using fluoroscopy, and the effectiveness of this simple measure has been demonstrated by multiple studies. According to Hayda et al,¹⁶ radiation exposure to the chest is decreased by 90% and 99%, respectively, when using a 0.25 and 0.5 mm lead apron during intramedullary nailing. It is recommended that surgeons use a personal high-quality lead apron and collar when possible. These materials can become less effective over time, especially when surgeons or residents use outfits that have been shared between multiple surgical personnel.

Noise Exposure for Orthopaedic Surgeons

Surgeons are constantly exposed to higher noise intensities, whether it be using power tools and surgical equipment or even exposure to intraoperative music and personnel chatter. According to the National Institute of Occupation Safety and Health, recommendations are to limit noise exposure to 85 decibels (dBa) over an 8-hour period, with a maximal threshold of 140 dBa proposed at any one time.²⁵ Exceeding this limitation regularly may carry as much as a 35% risk of hearing loss in later years of life.²⁵

Many orthopaedic surgeons are likely not even aware that they are exposed to sound levels which exceed standard recommendations regularly. Noise levels in pediatric and adult orthopaedic cast clinics can be measured in the range of 76.5 to 77.8 dBa, but peak noises occasionally reach 140.7 dBa, levels which are known to be hazardous.²⁶ According to Love,²⁷ noise intensity during total joint arthroplasty averaged 74.8 and 82.1 dBa with intermittent intensities of more than 100 dBa, and noise levels occasionally exceeded 140 dBa during femoral cutting, femoral shaft reaming, and pneumatic hose release. Commonly recorded noise intensities for orthopaedic tools are presented in Table 1.^27,28

Table 1 - Average Noise Exposure Levels for Common Insults in the Operating Room

	Reciprocating/Sagittal Saw	AO Drill	3M Mini Driver	Mallet	Disconnecting Pneumatic Hose	3M Maxi Driver	Universal Air Tool	Plaster Saw
Noise level range (dB)	81–110	78–86	78–105	65	102–127	86–92	98	83–110
Time to exceed daily noise threshold (min)	1.9	270	15	—	0.075	98	21	4.5

Willett²⁸ demonstrated that increasing distance between surgeon and oscillating saw from 45 cm to 3 m decreases noise intensity from 95-100 to 88 dBa. Although this measure may provide a protective benefit to surgeons, this is difficult to use in real-life practice where tactile and visual feedback is thus limited by increasing distance from surgical instruments.

There are other safeguards that can be used to limit noise exposure and generate a quieter environment during a surgical procedure. It is prudent to avoid loud music or other forms of distraction such as operating personnel chatter and traffic during elective and emergent orthopaedic procedures. Surgical hoods used during total joint arthroplasty may also limit peak noise intensity to an extent. Power tools or pneumatic devices should be updated regularly because older tools may generate increased noise exposure and lack technology which has been introduced to mitigate noise levels. Future tactics to limit noise exposure that could be studied and used more widely involve the use of protective ear devices or even noise canceling earphones (Figure 4, A and B) during key portions of the procedure.

Figure 4: A and B, Images showing protective ear devices to avoid peak noise exposures during surgery.

Chemical Hazards of Orthopaedic Surgery

Surgical Smoke Exposure

The long-term effects of constant exposure to surgical smoke generated by electrocautery are still unknown. Surgical smoke is largely composed of steam but can include particulate debris from surgical chemicals, blood and tissue, and viruses and bacteria. Formaldehyde, acrylonitrile, hydrogen cyanide, and benzene are some of the toxic substances that can be liberated and absorbed through the skin and respiratory tract; benzene has been linked to cases of leukemia in adult subjects.²⁹ The smoke generated by fulgurating 1 g of tissue with electrocautery may be equivalent to the mutagenic potential of 6 unfiltered cigarettes, and particles may linger in the air for even 20 minutes after the usage of electrocautery.³⁰

General prevention of exposures to large quantities of surgical smoke and accompanying chemicals is strongly advised. Unfortunately, surgical masks typically only filter particles greater than 5 μm, and it has been shown that surgical smoke particulate commonly measures less than 1.1 μm, with some viral particles smaller than 0.1 μm.³¹ Operating room ventilation should entail, at a minimum, 15 air exchanges hourly, and it is a common practice to use positive pressure ventilation in all operating rooms.³² Surgical masks and even N95 respirators should be worn with an excellent fit when appropriate, and surgeons should consider alternative means of cutting, débridement, and hemostasis so as to avoid excessive electrocautery usage. Smoke evacuators are being used more frequently at the recommendation of occupational health agencies, immediately adjacent to the surgical incision or attached to the electrocautery device (Figure 5). Indeed, a paraincisional evacuator and a smoke evacuation outlet on the electrocautery pen were both quite effective during spine surgery, decreasing average surgical smoke exposure by 59.7% and 44.1% when compared with the usage of standard suction equipment, respectively.³³

Figure 5: Image showing electrocautery with an integrated suction device.

Polymethylmethacrylate Exposure

The hazards of polymethylmethacrylate (PMMA) and its vapor have been discussed in the scientific community and the orthopaedic literature. It is a potentially teratogenic substance, and exposure to high vapor levels may be associated with acute skin, eye, and mucous membrane toxicity. However, at maximal mixing concentrations during arthroplasty, PMMA vapor concentrations were measured at only 17 ppm (hand mixing) and 4 ppm (vacuum mixing), levels generally agreed to be quite safe for the general population.³⁴ It is unlikely that concentrations during arthroplasty cement mixing could ever reach thresholds at which acute toxicity may occur, but caution should be taken to avoid direct inoculation into the eyes or mucous membranes.

Although it is assumed to be relatively safe for nonpregnant individuals at low concentrations which are present in the air during total joint arthroplasty, it is still not entirely understood what implications even a minor exposure may have for pregnant orthopaedic surgeons. A recent survey was extended to the Ruth Jackson Orthopaedic Society to better define PMMA usage among female orthopaedic surgeons.³⁵ After education on the adverse effects of PMMA, the survey found that 41.7% of respondents would leave the operating theater when pregnant, and 24.7% of respondents would leave when breastfeeding. In addition, 8.4% of respondents agreed that this potential exposure had factored into their subspecialty choice. From these data, it seems that many surgeons who may become pregnant or begin breastfeeding would choose to avoid PMMA exposure when possible.

Musculoskeletal Demands of Orthopaedic Surgery

Common Injuries

Occupational injury among orthopaedic surgeons is quite common because of the physical demands placed on the body, which can be cumulative. Surgeons tend to operate in positions that can not only cause novel injuries but potentially exacerbate pre-existing conditions. These biomechanical stresses create pain and slowly give way to soft-tissue and bony injuries. In a recent survey, nearly 80% of British surgeons described experiencing musculoskeletal pain on a regular basis while operating. Experiencing any amount of pain was strongly associated with suboptimal table height, microscope use, and prolonged standing or sitting in kyphotic positions.³⁶

A recent survey among American Academy of Orthopaedic Surgeons members demonstrated that 44% of surgeons had sustained one or more injuries during their career, with the hand being most commonly injured (25%), followed closely by lower back injuries (19%). The prevalence of injury increased with greater number of years doing surgery and was highest among those surgeons who had worked for more than 21 years.³⁷ When differentiating between orthopaedic subspecialties, adult reconstructive surgeons seem to be at high risk, with nearly 61% of these specialists reporting at least one work-related injury during their career.³⁸ Common pathology reported included low back pain (28%), lateral epicondylitis of the elbow (14%), shoulder tendinitis (14%), lumbar disk herniation (13%), and wrist arthritis (12%).³⁹ High volume (>100 arthroplasties per year) and aging (>55 years) reconstructive surgeons were found to be at higher risk of having taken time away from work because of these injuries.³⁸

Surgical Ergonomics

It is recommended that operating table height be adjusted properly to remain at approximately 70% to 80% of resting elbow level height of the operating surgeon, but table height can be adjusted accordingly throughout a procedure. Precision activities such as screw insertion or tissue handling should be done roughly 5 to 10 cm below elbow height, but heavy tasks such as drilling or impacting may require that the table be lowered to as much as 20 to 40 cm below the elbow height.⁴⁰ The surgeon should stand close to the operating table and avoid rotating the torso more than 45 degrees from neutral. Frequent position changes are advised, with short stretching breaks if necessary.³⁹ Proper body mechanics and positioning for orthopaedic surgeons is demonstrated in Figure 6, A and incorrect position is demonstrated in Figure 6, B.

Figure 6: A, Image demonstrating proper body mechanics and positioning for orthopaedic surgeons. B, Image demonstrating incorrect body position for orthopaedic surgeons.

Proper lifting and holding mechanics should be used during arthroscopic surgery when stresses are placed on the operative joint, and footstools should be used to adjust ergonomics properly. Footwear should provide moderate arch support and a slightly raised heel height; the use of antifatigue floor mats can also provide notable comfort and cushioning to the surgeon's stance.³⁹ Fatigue has clearly been shown to negatively affect procedural performance and quality not only in the orthopaedic theater but also in many other occupations. Proper ergonomics and avoidance of overexertion are critical so that orthopaedic surgeons can continue to perform effectively both daily and throughout their career.

Additional topics not discussed in this article but which may pose notable hazards to the orthopaedic surgeon include violence in the workplace, physician burnout, and mental health problems. Additional reviews on these topics are warranted but remain beyond the scope of the present document.

Summary

As orthopaedic surgeons continue to face evolving occupational challenges, it is important to take steps to reduce unnecessary hazards. Providing quality care in this profession is centered at an individual level, and attention to occupational safety is an often overlooked but necessary step in the training of each new generation of orthopaedic surgeons. Prolonging wellness and protecting physical functioning will allow surgeons to continue to work longer careers while maintaining their effectiveness.