Is it safe for pregnant podiatrists to use fluoroscopy in the operating room? This was the question posed by last week’s edition of Practice Perfect. We discussed some radiation safety fundamentals and introduced statistics about the amount of radiation we may receive under various circumstances. Significantly, based on prior research, we learned that with the use of a lead apron of 0.5mm thickness, the radiation exposure to a surgeon during an ankle fracture ORIF is 9 x 10^-5 rem, a very small amount. This impressively small number may help us breath a sigh of relief, but what does the research literature tell us about the exposure risk of pregnant surgeons?

Unfortunately, no research study to date exists to determine the actual exposure of pregnant podiatric surgeons or their fetuses to X-ray radiation (I wouldn’t hold my breath on this), and the literature about any pregnant surgeon exposure is minimal, so we’ll have to extrapolate from the literature that does exist.

According to United States federal law, the Department of Energy limits the exposure of a declared pregnant woman to 0.5 rem¹, which is 1/10^th the allowed exposure of the current U.S. National Council on Radiologic Protection and Measurements’ (NCRP) amount of 5 rem/year.

Damilakis and colleagues, in an attempt to determine actual safe radiation doses for the fetus of medical personnel working in areas of potentially high fluoroscopic exposure, utilized a radiographic phantom in a supine position which was then exposed to three directions of thoracic fluoroscopic views (anteroposterior and two different oblique exposures). The amount of radiation released was measured at 25cm intervals from the table in multiple planes. These results were compared to five patients with similar dimensions to the phantom. They then performed a mathematical analysis leading to an anticipated fetal dose². This study found that the biological risk of childhood cancer to the fetus of a caregiver in this environment was 500 x 10^-6. This is similar to the natural prevalence of childhood cancer, which is 769 x 10^{-6 3}. This study shows the risk in this potentially higher exposure occupational area is no more than what we would expect for the average child. It’s important to keep in mind that the calculations used by the investigators utilized the highest doses recommended and additionally used thoracic radiography, which greatly increases the scatter radiation in comparison to the lower limb surgery podiatrists typically perform. Hence, the study may actually overcall the amount of radiation exposure.

So far, we have a physician exposure of 9 x 10^-5 rem during an ankle fracture ORIF with the surgeon wearing a 0.5mm lead apron and a lifetime cancer risk of 500 x 10^-6 for the child of a pregnant person utilizing high doses of fluoroscopically-induced radiation.

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We receive approximately 100 times more radiation from several common external sources in the environment than a well-protected surgeon does doing an ankle fracture repair!

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To keep this in perspective, consider the amount of background radiation the average person is exposed to per year shown in Table 1. We receive approximately 100 times more radiation from several common external sources in the environment than a well-protected surgeon does doing an ankle fracture repair!

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Given the incredibly low radiation exposures and apparent lack of increased risk of disease to the fetus, it appears our pregnant colleagues and their unborn children are safe.

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Given the incredibly low radiation exposures and apparent lack of increased risk of disease to the fetus, it appears our pregnant colleagues and their unborn children are safe. Despite this, we should remain vigilant about preventing inadvertent radiation exposure through the following:

Responsible use of fluoroscopic instruments and maintaining proper protocols will protect those unborn fetuses as well as the surgeon and staff in the operating room. For those not convinced by these numbers, it’s always safe to temporarily stay away from intraoperative fluoroscopy, at least during the first trimester of pregnancy, if not longer as dictated by one’s own concerns. I would never force a pregnant surgeon to do anything she feels could jeopardize her progeny, but I’ll rest well knowing our current technology well protects us in the operating room.

Best wishes.