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Radiation Exposure With Use Of the Inverted-C-Arm Technique in Upper-Extremity Surgery
Michael R. Tremains, MD; Gregory M. Georgiadis, MD; Michael J. Dennis, PhD
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Investigation performed at the Departments of Orthopaedic Surgery and Radiology, Medical College of Ohio, Toledo, Ohio
Michael R. Tremains, MD Gregory M. Georgiadis, MD Michael J. Dennis, PhD Departments of Orthopaedic Surgery (M.R.T. and G.M.G.) and Radiology (M.J.D.), Medical College of Ohio, 3065 Arlington Avenue, Toledo, OH 43614. E-mail address for M.R. Tremains: mtremains@netscape.net. E-mail address for G.M. Georgiadis: ggeorgiadis@mco.edu
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our CD-ROM (call 781-449-9780, ext. 140, to order).

J Bone Joint Surg Am, 2001 May 01;83(5):674-678
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Background: Intraoperative fluoroscopy is commonly used in surgical procedures on upper extremities. We compared radiation exposure from two possible positions of the mobile digital fluoroscopy unit (c-arm): (1) the standard technique, with the x-ray tube down (near the floor) and the image intensifier at the top of the c-arm, and (2) the inverted position, in which the image intensifier is used as a table and the x-ray tube is up.

Methods: A commercially available c-arm was used to irradiate a phantom hand in one of three configurations. In the first, the phantom hand was placed on an armboard equidistant from the x-ray tube and the image intensifier with the beam directed upward. In the second, the c-arm was inverted with the beam directed downward and the image intensifier used as a table. The third configuration was identical to the second except that a magnified image was used. Radiation exposure was measured at four locations corresponding to the approximate position of the surgeon’s head, chest, and groin and the patient’s hand.

Results: The amount of radiation exposure to both the surgeon and the patient was significantly less when the c-arm was used in the inverted position (p < 0.0001). The dose rate to the patient’s hand was reduced by 59%. The radiation exposure to the surgeon’s head, body, and groin with the inverted-c-arm technique was 67%, 45%, and 15% of the measured doses with the x-ray-tube-down configuration. When we used the magnification mode of the image intensifier, with its correspondingly smaller field size, the doses were further reduced to 46%, 32%, and 11% of the standard-configuration values.

Conclusions: Use of the inverted-c-arm technique with the image intensifier as an operating table can significantly reduce radiation exposure to the surgeon and the patient during surgical procedures on upper extremities.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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