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C OPYRIGHT 2011
BY

T HE J OURNAL

OF

B ONE

AND J OINT

S URGERY, I NCORPORATED

the

Orthopaedic
forum
Occupational Hazards to the Pregnant Orthopaedic Surgeon
Roxanne R. Keene, MD, Diane C. Hillard-Sembell, MD, Brooke S. Robinson, MPH, Wendy M. Novicoff, PhD, and Khaled J. Saleh, BSc, MD, MSc, FRCS(C), MHCM Abstract: The number of female orthopaedic residents and orthopaedic surgeons has increased substantially. Concerns have been raised regarding the effect of the work environment on the health of the female orthopaedic surgeon and her fetus or neonate. Occupational risks, and specically risks to the pregnant orthopaedic surgeon, are becoming an important issue in medicine. Such risks include exposure to methylmethacrylate (MMA), anesthetic gases, bloodborne pathogens, radiation, emotional stress, and physical stress. Awareness of and knowledge about such exposures are needed for the pregnant orthopaedic surgeon to make informed decisions about her occupational exposures and to be proactive about her own and her childs health. The percentage of women in medical schools in the U.S. increased from 11.1% in 1970 to 48.3% in 20071, and the percentage of women in orthopaedic residency training programs increased from 0.60% in 1970 to 12.0% in 20092. According to Katz et al., the rates of preterm labor, preterm delivery, low birth weight, and abruptio placentae are higher in female physicians compared with the general female population3. Although pregnancy complications can also result from other factors, such as having children later in life, complications during early pregnancy can be attributed to exposure to chemicals, gases, radiation, and infectious diseases4. This paper will review the occupational hazards associated with orthopaedic surgery. The hazards associated with methylmethacrylate (MMA), anesthetic gases, blood-borne pathogens, radiation, emotional stress, and physical stress are of specic concern for the pregnant orthopaedic surgeon. Because female orthopaedic surgeons are consistently exposed to these risks5, a review and discussion of the available literature will be presented to allow the practicing female surgeon to make informed decisions about her prenatal and postnatal exposures. Potential Occupational Hazards Methylmethacrylate (MMA) Methylmethacrylate (MMA) is commonly used as the cement for xation of orthopaedic prosthetic devices. The U.S. Environmental Protection Agency recommends exposure to a timeweighted average of no more than 100 parts per million (ppm) of MMA over an eight-hour work day6. Developmental effects following MMA exposure have been documented in animal studies. Singh et al. calculated the acute toxicity and lethal dose of MMA in rats to be approximately

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a nancial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to inuence or have the potential to inuence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to inuence or have the potential to inuence what is written in this work. The complete Disclosures of Potential Conicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am. 2011;93:e141(1-5)

http://dx.doi.org/10.2106/JBJS.K.00061

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1.33 mL/kg7. On the basis of these calculations, pregnant rats received an intraperitoneal injection of MMA at one-tenth, one-fth, or one-third of the acute lethal dose. Dose-related increases in gross and skeletal abnormalities of the fetus and a reduction in fetal weight at birth were observed7. A similar study by McLaughlin et al. evaluated the effect of MMA vapor on pregnant mice8. The MMA exposure was markedly greater than the recommended occupational exposure (1330 ppm compared with 100 ppm averaged over an eight-hour day). However, the proportion of normal compared with abnormal fetuses and the number of fetal deaths did not differ signicantly compared with unexposed mice8. McLaughlin et al. also studied the MMA concentration that resulted from MMA mixing. MMA exposure was greatest in the operating room during the beginning of the mixing process, going from 280 ppm to <10 ppm eleven minutes after the start of mixing8. Although these two studies are over thirty years old, to our knowledge no current studies have examined the lethal dose or toxicity of MMA in pregnant animals. Schlegel et al. compared various vacuum mixing devices to classic hand mixing of MMA in an open bowl9; gas chromatography was used to measure the concentration of MMA at the level of the nurses breathing zone during the mixing procedure. Use of the vacuum mixing devices resulted in a substantial reduction of 50% to 75% in the concentration of MMA vapor in the breathing zone. However, the characteristic smell of MMA, which can be detected at a concentration as low as 0.2 ppm, was still evident9. Darre et al. measured an MMA concentration of 50 to 100 ppm in the breathing zone of a surgeon performing hip arthroplasty; however, use of a surgical helmet or local surgical eld suction reduced this to an undetectable level10. In a similar study, Cloft et al. measured the concentration of MMA vapor during percutaneous vertebroplasty11. The cement was mixed without the use of a fume hood or vapor control device. The room air ow was 22 air changes per hour. The concentration of MMA vapor in air samples taken from the location of the surgeons was less than the studys detection limit of approximately 5 ppm. Thus, Cloft et al. concluded that a fume hood was not necessary for MMA use during vertebroplasty11. Finally, a study conducted by Linehan and Gioe investigated the effect of MMA exposure on breast milk12. The authors measured the MMA concentration in the serum and breast milk of orthopaedic surgeons after they had performed hybrid total hip and total knee arthroplasty12. No evidence of MMA was found at the 0.50 ppm level, and no surgeons samples tested higher than the control specimens did. Even though the study by Linehan and Gioe included only surgeons who used vacuum mixing and a vertical laminar ow hood, other modalities such as surgical helmets, local surgical eld suction, vapor control devices, or room air exchange could presumably also reduce the MMA concentration in the serum and breast milk of orthopaedic surgeons to an undetectable level12. Anesthetic Gases Exposure to anesthetic gases also poses a risk for the pregnant orthopaedic surgeon because such agents potentially have an

inhibitory effect on dividing cells. Exposure to these agents can increase the rate of formation of abnormal cells and the rate of chromosomal aberrations; however, this has not been demonstrated at doses used for general anesthesia13. Moreover, subanesthetic levels have not exhibited fetotoxic effects13. The Occupational Safety and Health Administration of the U.S. Department of Labor provides guidelines to advise and assist employers in providing and maintaining a healthy work environment14. Regulations for hospitals limit the permissible level of anesthetic gases in the air of the operating room, with the limit for nitrous oxide being a time-weighted average of 25 ppm over the period of anesthetic administration and the limit for halogenated agents being 2 ppm averaged over a onehour period14. However, leaks do occur, with the potential sources being tank valves, tubing defects, and reservoir bags14. Improper anesthesia techniques and improper practices (such as leaving valves open, spilling anesthetic agents, or inadequately tting face masks) can also contribute to exposure. Although efforts to control anesthetic gas pollution have led to substantial improvements over the years, occupational exposure still occurs14. Blood-Borne Pathogens Exposure to blood-borne pathogens is another potentially serious occupational risk to pregnant female orthopaedic surgeons, who frequently handle sharp instruments, metal objects, and bone fragments during surgery15. The blood-borne pathogens that are most commonly involved in occupational transmission are hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeciency virus (HIV)15,16. Although hepatitis B and C also have serious health consequences to the exposed surgeon, HIV is of the greatest concern to the pregnant orthopaedic surgeon because of its potentially fatal health consequences to the fetus if the mother goes untreated. Azidothymidine (AZT) is commonly used in post-exposure prophylaxis, as it is the only drug that has been shown to reduce the risk of HIV infection17. Connor et al. conducted a multicenter trial in which AZT administration to HIV-infected pregnant women was associated with a 67% reduction in the transmission of HIV to the fetus18. Limited information on the side effects of antiretroviral drugs on the developing fetus or neonate is available17. However, in vitro screening tests have suggested that AZT and all other nucleoside reverse transcriptase inhibitors (NRTIs) licensed by the Food and Drug Administration (FDA) may be carcinogenic and/or mutagenic17,19. Moreover, there is a risk of transmitting HIV, nucleoside reverse transcriptase inhibitors, and the protease inhibitor nelnavir to the infant via breast milk, and it is not known whether other approved antiretroviral drugs also pass through breast milk17. Thus, women who experience a high-risk exposure should consider discontinuing breast feeding. According to the World Health Organization (WHO), breastfeeding is recommended except if the mother either has HIV or has been exposed to HIV and is unsure whether she has become infected. In this instance, even if the mother is being treated with antiretroviral drugs, the WHO

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recommends that she avoid breastfeeding and nd a replacement feeding that is sustainable and safe20. Radiation Orthopaedic surgeons rely heavily on the use of radiography, including intraoperative uoroscopic imaging. This use of radiography has the potential to expose the pregnant female surgeon and her fetus to dangerously high levels of radiation. Most of the available data on the effects of radiation on the human body, including on the fetus, were obtained by studying the 1945 atomic bomb survivors from Hiroshima and Nagasaki. This group included approximately 2800 pregnant women, 500 of whom received a radiation dose of >500 to 1000 milliGray (mGy)21. According to the National Council on Radiation Protection and Measurements (NCRP), the maximum radiation exposure to the fetus before harm occurs is 0.05 Gy22. Potential side effects of radiation exposure of >0.05 Gy to the fetus include prenatal death, growth restriction, small head size, severe mental retardation, organ malformation, and childhood cancer23. These side effects depend on the radiation dose and on the developmental stage of the conceptus at the time of exposure23. Because the embryo or fetus is more sensitive to radiation at certain stages of development, radiation risks decrease as the pregnancy progresses23. Prior to two weeks of gestation, the embryo is very sensitive to radiation, and a dose of >0.1 Gy (equivalent to approximately 75 uoroscopy uses or extremity radiographs) may cause death of the embryo23. However, if the embryo survives, radiation-induced non-cancer health effects are uncommon. As long as the fetal dose remains <0.05 Gy (equivalent to approximately 38 uoroscopy uses or extremity radiographs) throughout the duration of the gestation, radiation-induced non-cancer health effects are usually not detectable23. The International Commission on Radiological Protection (ICRP) has estimated the risk of cancer during childhood and the lifetime cancer risk associated with prenatal radiation exposure24. According to the ICRP, a prenatal exposure of <0.05 Gy is associated with an estimated 0.30% to 1.00% rate of childhood cancer and an estimated 38% to 40% lifetime cancer rate, rates which are similar to those associated with no prenatal radiation exposure24. An exposure of >0.50 Gy is associated with a >6% childhood cancer rate and a >55% lifetime cancer rate25. Thus, diagnostic radiation doses are associated with a small risk of cancer, but no evidence for an increase in mental retardation, congenital malformations, or microcephaly has been shown to be associated with the occupational exposure that a pregnant orthopaedic surgeons child would typically receive over the course of the pregnancy. Most radiology exposures without protection to the pregnant orthopaedic surgeons child result in fetal absorption of <0.05 Gy per exposure26. In order to reduce their exposure during radiography, the NCRP recommends that personnel should work at least 2 m away from the radiation source27. A recent study by Shaw et al. noted that a pregnant physician can reduce the radiation exposure of the fetus by a factor of four by doubling her distance from the radiation source28. Furthermore, the NCRP reported that a standard 0.5-mm-thick lead apron attenuates 99% of radiation27. Other

reports have recommended that radiation monitors be worn at collar level outside the lead apron and at the fetal level inside the apron29. Maternal tissues will attenuate 70% of the remaining radiation that is not absorbed by the apron, so only 30% will reach the fetus. A fetal lead apron, which has 0.5 mm of lead only at the fetal level, is also available29. According to Marx et al., the use of a fetal lead apron, in conjunction with the standard lead apron, reduces radiation exposure to the fetus by an additional 66%30. Thus, it is recommended that a pregnant orthopaedic surgeon wear two lead aprons, standard and fetal, in order to reduce radiation exposure to both herself and her fetus27-30. Stress Both emotional stress and physical stress pose an occupational hazard to the female orthopaedic surgeon.
Emotional Stress

Potential emotional stressors for any female surgeon include discrimination, lack of role models, role strain, and overload. These stressors can lead to depression, suicide, and divorce, with the rates of suicide and divorce being greater among female surgeons than among the general female public31. There are conicting views on the effects of stressors involving family life on female physicians31,32. On the one hand, women physicians often lack mentors to provide guidance on issues such as the most appropriate time to have a child and the way to handle conicts between professional, personal, and family lives31. Conversely, another study has shown that family life can actually decrease a surgeons emotional stress level. The Physician Worklife Study, which examined career satisfaction and various aspects of work life among physicians, showed that work-family conicts may not be a source of burnout in female physicians32. Also, although female surgeons were more likely to be childless, those with at least three children were happier and more emotionally stable than those with one or no children32. According to a 1992 study by Phelan, 31% of 1197 female residents experienced pregnancy during residency33. The residents cited fatigue from being on call and working extended hours, limited time with a spouse or partner, and increased physical activity and emotional strain as causes of stress33. This psychological stress can have a negative effect on the fetus, such as preterm birth and lower birth weight34. A more recent survey of forty-two surgical residency graduates by Mayer et al. in 2001 found that fourteen of the twentytwo men and three of the twenty women had children born during residency35. Mayer et al. found that 80% of these seventeen residents would have considered practicing surgery part time in exchange for more time with their children35. Moreover, the 1999 report of the American College of Surgeons Advisory Council for General Surgery brought to light the fact that surgery training programs fail to confront social and professional issues regarding pregnant residents35. Thus, even with the stricter work hour restrictions that are now in place for residents, there is still an emotional struggle, and additional stress, for orthopaedic residents who want to have a family.

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Although emotional stress poses a substantial health hazard for many pregnant women and their fetuses, the abovementioned stressors in the orthopaedic work environment create an increased occupational risk for pregnant orthopaedic surgeons. A study by Walsh et al. found that residents could deal with these emotional stressors better if they had more exibility in their rotations and if they had necessary allowances, such as regular breaks and privacy, while breastfeeding36.
Physical Stress

The specialty of orthopaedic surgery inherently involves a level of physical exertion greater than that seen in many other medical or surgical subspecialties. Furthermore, the demands of on-call trauma treatment can be associated with long hours of standing, lifting, and bending. These occupational factors may be of special concern for the pregnant orthopaedic surgeon because of the potential for work-related musculoskeletal symptoms and adverse pregnancy outcomes37-45. The physiological responses of pregnant women and their fetuses have been shown to be related37-40. DiPietro found a bidirectional relationship between fetal behaviors and maternal physiological responses and noted that fetuses had a higher level of motor activity if the pregnant women had greater anxiety or stress37. Likewise, when the fetus moved, there was a rise in the maternal skin conductance37. Physiological changes in pregnant women include increases in the body core temperature, metabolic rate, and heart rate and stroke volume, as well as musculoskeletal changes37,38. The interactions between pregnancy and exercise have been well studied but not well understood37-40. Gavard and Artal found that exercise had a positive effect on pregnancy outcomes by increasing cardiovascular tness; in addition, exercise reduced maternal weight and the occurrence of gestational diabetes and preeclampsia38. Similarly, DeMaio and Magann recommended that pregnant women participate in submaximal aerobic exercises, resistance training exercises, and/or aquatic exercises for thirty minutes on most days of the week39. They found that brief submaximal exercise at 70% of maximum aerobic capacity did not affect the fetal o heart rate39. In comparison, Lereim and R found that various orthopaedic procedures resulted in an aerobic workload of 20% to 30% of the maximum aerobic capacity40. Thus, submaximal aerobic exercise is benecial for pregnant orthopaedic surgeons in order to maintain the aerobic capacity necessary to continue working. Several studies have examined the effect of work activity during pregnancy41,42. Croteau et al. conducted a case-control study to evaluate whether occupational conditions were associated with preterm delivery, dened as birth of the infant before thirty-seven weeks of gestation41. Of the occupational conditions present from the onset of pregnancy, two physical factors were signicantly associated with preterm delivery: a demanding posture (bending, squatting, or raising the arms above shoulder level) for three hours or more per day and whole-body vibrations41. However, no statistical difference in

the rate of preterm delivery was found in women who worked long hours or who engaged in prolonged standing41. Hatch et al. found that long hours of work (>40 hours per week) were associated with reduced fetal growth, with infants of women who had worked long hours late in pregnancy having a lower gestation-adjusted birth weight42. Musculoskeletal changes occur during pregnancy, and the effect of these changes on work-related musculoskeletal complaints may be magnied in the orthopaedic surgeon43. The musculoskeletal changes during pregnancy are predominantly related to alteration of the center of gravity, weight gain, the effect of circulating hormones on ligaments, and uid retention. Low back pain occurs in as many as one-half of all pregnant women44. As a pregnant woman assumes a position of hyperlordosis, this shift in load distribution theoretically generates increased stress on the intervertebral discs, facet joints, and ligaments44. Adjusting occupational conditions for working pregnant women to result in shorter work hours, more frequent sitting, and improved body posture when sitting has been advocated to ameliorate low back pain45. In order to better incorporate these recommendations into her daily life, a pregnant full-time orthopaedic surgeon should be educated regarding these modications and should be proactive in implementing these preventive measures, starting in the rst trimester40,41,45. Summary Although male and female surgeons face similar occupational risks in the work environment, the effects of these risks on a pregnant orthopaedic surgeons fetus or neonate make her situation unique. Whether it is exposure to MMA, anesthetic gases, blood-borne pathogens, radiation, or stress, the female orthopaedic surgeon should know about how her occupational risks prior to, during, and following pregnancy might affect not only her health but her childs health. The number of female orthopaedic residents has increased 33% from 2001 to 20081. As the number of female surgeons continues to increase, improved awareness of the unique occupational risks to pregnant orthopaedic surgeonsand a proactive approach to prevent or minimize such risksare imperative for the well-being of the mother and her child.

Roxanne R. Keene, MD Diane C. Hillard-Sembell, MD Brooke S. Robinson, MPH Khaled J. Saleh, BSc, MD, MSc, FRCS(C), MHCM Division of Orthopaedics, Department of Surgery, Southern Illinois University School of Medicine, 701 North 1st Street, Springeld, IL 62702. E-mail address for K.J. Saleh: ksaleh@siumed.edu Wendy M. Novicoff, PhD University of Virginia School of Medicine, P.O. Box 800159 HSC, Charlottesville, VA 22908

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