Title : Factors influencing intraoperative radiation exposure during ankle fracture orif: A six-year retrospective analysis
Abstract:
Background: Intraoperative fluoroscopy is integral to ankle fracture Open Reduction and Internal Fixation (ORIF), but repeated image acquisition exposes patients and theatre staff to ionising radiation. Published reference values for orthopaedic trauma fluoroscopy are limited, and the operative factors associated with radiation use during ankle ORIF remain incompletely defined.
Methods: We performed a six-year retrospective observational analysis of 419 patients who underwent ankle ORIF at a single institution. Data were extracted from electronic patient records, operative notes and the radiology archiving system. Outcomes were fluoroscopy time and fluoroscopy-derived radiation dose metrics, reported as dose-area product (Gy cm2) and cumulative dose (mGy), as recorded by the fluoroscopy system. Candidate predictors included patient age and sex, Weber fracture type, injury/fixation pattern, surgical approach, plate type, syndesmotic fixation, posterior malleolar fixation, surgeon grade and screw variables. Multivariable ordinary least-squares regression was used to assess independent associations, with Tukey post-hoc testing for pairwise categorical comparisons.
Results: The radiation duration model explained 23.9% of variance and was statistically significant overall. Increased total screw number was associated with longer fluoroscopy time, whereas higher lag-screw number was associated with shorter fluoroscopy time. Pairwise analyses showed greater radiation duration in trimalleolar injuries and trimalleolar fixation, posterior malleolar fixation, syndesmotic fixation, posterolateral approaches and LCDCP plate constructs. Dose-area product and cumulative dose models showed broadly similar patterns, with higher exposure associated with syndesmotic fixation, posterior malleolar fixation, trimalleolar patterns and greater screw number. Surgeon grade, age and sex were not consistently associated with exposure across post-hoc comparisons.
Conclusion: Intraoperative radiation exposure during ankle ORIF was driven mainly by fracture complexity, fixation strategy and surgical approach rather than surgeon seniority. Complex injuries requiring posterior malleolar or syndesmotic fixation should be regarded as higher-exposure cases. Standardised fluoroscopy protocols, structured surgeon-radiographer communication, real-time feedback and ALARA-based practice may reduce exposure without compromising fixation quality.
