title: Reducing intraoperative duration and ionising radiation exposure during the insertion of distal locking screws of intramedullary nails: a small-scale study comparing the current fluoroscopic method against radiation-free, electromagnetic navigation.
abstract: BACKGROUND
  Intramedullary nailing is the standard surgical treatment for mid-diaphyseal fractures of long bones; however, it is also a high radiation dose procedure. Distal locking is regularly cited as a demanding element of the procedure, and there remains a reliance on X-ray fluoroscopy to locate the distal holes. A recently developed electromagnetic navigation (EMN) system allows radiation-free distal locking, with a virtual on-screen image.
  
  
  OBJECTIVE
  To compare operative duration, fluoroscopy time and radiation dose when using EMN over fluoroscopy, for the distal locking of intramedullary nails.
  
  
  METHODS
  Consecutive patients with mid-diaphyseal fractures of the tibia and femur, treatable with intramedullary nails, were prospectively enrolled during a 9-month period. The sample consisted of 29 individuals, 19 under fluoroscopic guidance and 10 utilising EMN. Participants were allocated depending on the type of intramedullary nail used and surgeon's preference. These were further divided into tibial and femoral subcategories, relative to the fracture site.
  
  
  RESULTS
  EMN reduced fluoroscopy time by 49 (p = 0.038) and 28 s during tibial and femoral nailings, respectively. Radiation dose was reduced by 18 cGy/cm2(p = 0.046) during tibial and 181 cGy/cm2during femoral nailings when utilising EMN. Operative duration was 11 min slower during tibial nailings using EMN, but 38 min faster in respect of femoral nailings.
  
  
  CONCLUSIONS
  This study has evidenced statistically significant reductions in both fluoroscopy time and radiation dose when using EMN for the distal locking of intramedullary nails. It is expected that overall operative duration would also decrease in line with similar studies, with increased usage and a larger sample.
authors: West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, UK. darren.grimwood@wsh.nhs.uk.
authors: Darren
authors: http://orcid.org/0000-0003-0498-6834
authors: D
authors: Grimwood
authors: University Campus Suffolk, Ipswich, UK.
authors: Jane
authors: J
authors: Harvey-Lloyd
mesh_terms: D000328:Adult; D057186:Comparative Effectiveness Research; D060733:Electromagnetic Radiation; D005260:Female; D005264:Femoral Fractures / Q000175:diagnosis / Q000601:surgery; D005471:Fluoroscopy / Q000009:adverse effects / Q000379:methods; D005594:Fracture Fixation, Intramedullary / Q000009:adverse effects / Q000379:methods; D006801:Humans; D007430:Intraoperative Care / Q000295:instrumentation / Q000379:methods; D008297:Male; D061646:Operative Time; D010043:Outcome and Process Assessment, Health Care; D011829:Radiation Dosage; D025321:Surgery, Computer-Assisted / Q000295:instrumentation / Q000379:methods; D013978:Tibial Fractures / Q000175:diagnosis / Q000601:surgery
keywords: Intramedullary nailing; Orthopaedic trauma; Radiation exposure; Theatre radiography