Intraoperative Surgical Smoke During Arthroplasty: Early Unhealthy-Level Exposure and Approach-Dependent Risk.

BACKGROUND: Surgical smoke is a gaseous intraoperative byproduct that contains numerous toxic compounds, including fine particles with a diameter of ≤2.5 µm (PM2.5). However, intraoperative exposure during joint arthroplasty has not been well characterized. In this study, we aimed to quantify PM2.5 exposure during arthroplasty and to determine, by procedure and approach, how often it reached potentially harmful levels.

METHODS: We conducted a single-center prospective study of 83 primary arthroplasties (20 bipolar hemiarthroplasties [BHAs] via a direct lateral approach, 35 total hip arthroplasties [THAs] via a direct anterior approach, and 28 total knee arthroplasties [TKAs]). Intraoperative PM2.5 concentrations were measured using a portable monitor and were mapped to Air Quality Index (AQI) categories. Summary metrics, including maximum and cumulative PM2.5 exposure, were calculated by procedure. Logistic regression was used to estimate odds ratios (ORs) for exceeding AQI thresholds.

RESULTS: In BHA and TKA, PM2.5 concentrations increased sharply during field development, whereas they remained low throughout THA. The median maximum PM2.5 concentrations were 129.50 µg/m3 (interquartile range [IQR], 85.44 to 275.28 µg/m3) for BHA, 6.14 µg/m3 (IQR, 2.54 to 23.94 µg/m3) for THA, and 118.80 µg/m3 (IQR, 56.23 to 208.04 µg/m3) for TKA. The concentrations were significantly higher in BHA and TKA (both adjusted p < 0.001) than in THA. At 25% of the normalized surgical time, 80% of BHA cases and 71% of TKA cases reached an AQI of Unhealthy or worse, whereas most THA cases remained within the Good or Moderate categories. The adjusted ORs for reaching an AQI of Unhealthy or worse were 34.280 (95% confidence interval [CI], 7.479 to 215.044; p < 0.001) for BHA and 21.971 (95% CI, 6.011 to 101.814; p < 0.001) for TKA compared with THA.

CONCLUSIONS: BHA via a direct lateral approach and TKA generated substantially higher intraoperative PM2.5 concentrations than THA via a direct anterior approach, and many cases reached an AQI of Unhealthy or worse. Procedure and approach are not readily modifiable determinants of surgical smoke exposure, underscoring the need for comprehensive control strategies, including smoke evacuation and high-efficiency masks, in arthroplasty practice.

CLINICAL RELEVANCE: Operating room teams may be exposed to potentially harmful levels of surgical smoke during arthroplasty. Understanding the characteristics of this exposure may help to guide strategies to optimize the operating room environment.