In this simulation study, we measured the radiation exposure dose to the surgeon, nurse, and anesthesiologist in the setting of fluoroscopic hip surgery using cadaveric specimens. The surgeon was exposed to the most of radiation (up to 11.4 times more than to the nurse). For all surgical team members, the exposure dose was up to 19.8-fold higher during lateral imaging than during PA imaging.

According to the recommendations of the International Commission on Radiological Protection, the annual occupational radiation exposure thresholds are 20 mSv (100 mSv/5 years, maximum 50 mSv/year) for the optic lens, 500 mSv for the thyroid gland, and 500 mSv for the hand. Surgeons should be aware of the stochastic effects of radiation, that is, the long-term risk of cancer and genetic defects associated with repeated exposure to ionizing radiation [11]. The probability of stochastic effects of radiation exposure increases with radiation dose. Therefore, the exposure dose received during fluoroscopy should be minimized in accordance with the ALARA (as low as reasonably achievable) principle [12, 13].

It is well known that distance from the radiation source is an important factor in radiation exposure dose [8]. The simplest way of minimizing radiation exposure is to stay as far away from the radiation source as possible. Alonso et al. reported that outside a 2-m radius from the radiation source, there is little or no risk of radiation exposure [14]. Mehlman et al. reported that unprotected individuals working 70 cm (24 inches) or less from a fluoroscopic beam received significant amounts of radiation [15]. Moreover, they found that personnel working 90 cm away from the beam were exposed to a low radiation dose and that those working 150 cm away received almost no radiation. In the present study, a surgeon working 50 cm from the X-ray source received the highest radiation dose; specifically, the dose to the surgeon was up to 11.4 times higher than that to a nurse working 130 cm away. Although a scrub nurse working 130 cm from the source was exposed to a small amount of radiation, an anesthesiologist working 185 cm from the source received almost none. This finding is consistent with previous reports and suggests that the nurse and anesthesiologist can limit their risk of stochastic effects of radiation to maintain an appropriate distance from radiation source during surgery.

Surgeons should make every effort to reduce their radiation exposure, given their need to work close to the radiation source. In our study, the highest radiation doses were recorded at the surgeon’s hand. Although the dose of scatter radiation to the hand in our study was small comparing to annual occupational radiation exposure thresholds according to the recommendations of the International Commission on Radiological Protection (500 mSv), we only evaluated the scatter radiation not included the direct radiation. It is common for surgeon to be expose to direct radiation, such as in the process of repairing fracture site. Thus, we should consider intraoperative radiation exposure including the effects of direct radiation. When the surgeon’s hand strays into the irradiation field, the direct radiation dose is 20–100 times greater than the scatter dose [16,17,18,19]. Therefore, surgeons should keep their hands as far away from the irradiation field as possible during surgery.

Another important finding in this study was that the radiation dose was significantly higher during lateral imaging than during PA imaging, which can be explained by the greater distance across which the X-ray beam needs to travel in the lateral direction. The mean PA diameter of the hip was 14.7 cm and the mean mediolateral diameter was 22.9 cm in the present study. Furthermore, the voltage and amplitude values for the C-arm were higher during lateral imaging than during PA imaging. Therefore, greater caution regarding radiation exposure is needed during lateral imaging.

This study has several limitations. First, the cadavers used were relatively small (mean height, 162.9 cm; mean weight, 58.7 kg). The irradiation dose increases with increasing body size. Therefore, physique should be considered when interpreting the results of this study. Second, the shielding effect of radiation equipment, such as gloves and goggles, was not considered. There are reports showing that personal protective equipment reduces an individual’s exposure to radiation [20, 21]. Therefore, occupational radiation exposure dose should be considered in light of whether protective equipment is worn.

In conclusion, this study has quantified the scatter radiation exposure doses to the surgical team at several anatomic sites during hip surgery. Because surgeons are exposed to a larger amount of radiation than other members of the surgical team, they should implement measures to reduce their exposure and the risk of stochastic effects of radiation. Based on our results, reducing the duration of the lateral imaging may be one of the effective methods for reducing intraoperative radiation exposure dose. In addition, the nurse and anesthesiologist can avoid health hazards from occupational radiation exposure by maintaining an appropriate distance from the radiation source.