Radiation safety in orthopaedic surgery: educational guidelines for surgeons using X-rays and C-arm fluoroscopy

Orthopaedic surgeries frequently rely on intraoperative imaging, particularly X-rays and C-arm fluoroscopy, to enhance procedural accuracy. However, these modalities expose surgeons and operating theatre personnel to ionizing radiation, leading to both immediate and long-term health risks. Despite the availability of protective measures and the ALARA (As low as reasonably achievable) principle, adherence to radiation safety in orthopaedics remains suboptimal. This review highlights radiation hazards in orthopaedic practice and presents practical, evidence-based strategies for minimizing occupational risk. A comprehensive literature review was performed, focusing on intraoperative radiation exposure in orthopaedics, its biological effects, and preventive measures. International radiological safety guidelines, surgical protocols, and recent orthopaedic studies were analyzed, with emphasis on practical recommendations for operative settings. Ionizing radiation can cause deterministic effects (cataracts, skin injury) and stochastic effects (malignancy, infertility, genetic mutation). Key strategies to reduce exposure include minimizing fluoroscopy time, increasing distance from the source, using shielding devices, adopting pulsed fluoroscopy, and optimizing C-arm positioning. Pregnant staff require additional precautions such as double dosimetry and modified work schedules. Despite the availability of personal protective equipment (PPE), lack of structured education and poor compliance remain major challenges. Radiation exposure during orthopaedic procedures is a preventable occupational hazard. Strict enforcement of safety protocols, adequate PPE, routine training, and institutional monitoring are essential to protect surgeons and operating teams.