Radiation exposure in orthopaedic trauma surgery: A systematic review and meta-analysis

Fluoroscopic imaging is a cornerstone of modern orthopaedic trauma surgery, providing real-time guidance for fracture reduction and implant positioning. However, repeated intraoperative exposure poses significant radiation risks to patients and operating room personnel. Despite its routine use, there is limited consolidated evidence quantifying radiation exposure in common orthopaedic trauma procedures, and standardized diagnostic reference levels (DRLs) have yet to be established.

This systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. Comprehensive searches of PubMed, EMBASE, Cochrane CENTRAL, Web of Science, Scopus, and Ovid were performed up to May 2023. Studies reporting intraoperative radiation exposure using dose-area product (DAP, mGy·cm²) and/or fluoroscopy screening time (minutes:seconds) were included. Data were pooled using a random-effects model (DerSimonian-Laird). Study quality and risk of bias were assessed using the Joanna Briggs Institute (JBI) and ROBINS-I tools. The review could not be registered with PROSPERO, as retrospective registration is not permitted; however, the methodology fully adhered to PRISMA standards.

Seven studies comprising 4159 patients met inclusion criteria. Proximal femoral nailing (PFN) showed the highest mean DAP (3168.8 ± 382.5 mGy cm²), followed by dynamic hip screw fixation (1606.5 ± 79 mGy cm²) and femoral intramedullary nailing (1251.6 ± 76.5 mGy cm²). The longest fluoroscopy times occurred during femoral and tibial nailing. Substantial heterogeneity (I² > 99 %) reflected procedural and operator variability, with surgeon experience identified as a major determinant of exposure.

Femoral fixation procedures pose the highest radiation risk in orthopaedic trauma surgery. Structured radiation-safety education, adherence to ALARA principles, and establishment of standardized DRLs are essential. Future studies should report variance data and evaluate navigation-assisted and robotic techniques to minimize exposure.