Radiation Exposure in Percutaneous Zadek Osteotomy vs Open Haglund Resection: A Retrospective Comparative Study

Abstract

Background:

Fluoroscopy is a vital imaging technique in orthopaedic surgery, particularly with the growing adoption of minimally invasive surgery (MIS). Because of their increased reliance on intraoperative imaging, MIS techniques may necessitate greater use of fluoroscopy and radiation compared with open procedures; therefore, the use of modern mini C-arm systems is recommended to mitigate radiation exposure. Although MIS offers significant benefits, its use also raises concerns regarding radiation exposure for both patients and surgical staff. This study evaluated radiation dose and fluoroscopy time comparing 2 common procedures used to treat insertional Achilles tendinitis: the percutaneous Zadek osteotomy (ZO) and the open midline Achilles tendon splitting Haglund resection (HR). We hypothesized that the percutaneous ZO would be associated with increased radiation dose and fluoroscopy time in comparison to the open HR but would be below the recommended occupational exposure limits.

Methods:

A retrospective review was conducted of all patients who underwent a percutaneous ZO or an open HR between January 2021 and July 2025. All procedures were performed by one of 2 fellowship-trained foot and ankle surgeons at a single academic institution. Radiation exposure was assessed using total radiation dose (mGy) and total fluoroscopy time (minutes).

Results:

A total of 139 patients met inclusion criteria. Sixty patients underwent a percutaneous ZO, whereas 79 underwent an open HR. The percutaneous ZO cohort demonstrated a mean fluoroscopy time of 2.83 ± 1.64 (range, 0.70-7.17) minutes and an average radiation dose of 3.25 ± 2.06 (range, 0.55-8.07) mGy. Meanwhile an average fluoroscopy time of 0.42 ± 0.19 (range, 0.03-0.90) minutes was observed in the open HR cohort, which had a mean radiation dose of 0.38 ± 0.20 (range, 0.02-1.17) mGy. The percutaneous ZO cohort demonstrated a significantly higher radiation dose (P < .001) and fluoroscopy time (P < .001).

Conclusion:

The percutaneous ZO was associated with a significantly higher radiation dose than the open HR; however, despite being statistically significant, this may not be clinically relevant. As surgeons receive only 0.50% of the dose, approximately 1225 percutaneous ZO procedures would be required to exceed annual safety limits. These findings suggest that radiation exposure during the percutaneous ZO technique remains well below the International Commission on Radiological Protection’s annual occupational limit of 20.00 mSv. Consistent with the ALARA principle, low-dose mini C-arm settings and protective equipment help minimize radiation exposure to patients and surgical staff.

Level of Evidence:

Level III, retrospective comparative study.

Introduction

Fluoroscopy has become a widely used imaging technique, gaining particular importance in the field of orthopaedic trauma. It has proven especially valuable in procedures such as intramedullary nailing, external fixation, percutaneous screw placement, and the management of complex fractures.^{1 -3} Currently, C-arm fluoroscopy is used across nearly all orthopaedic subspecialties to address a wide range of clinical needs, including fracture reduction, joint injections, deformity correction, and implant placement. Despite its integral role in everyday practice, studies have presented concerns regarding radiation exposure.^4,5 Although patient safety remains a priority, concerns about fluoroscopy often focus on occupational radiation exposure among health care providers. Unlike patients, who may undergo fluoroscopic imaging only a few times in their lives, orthopaedic surgeons and operating room staff are exposed as part of their routine practice. A 2024 study from the Calgary Orthopaedic Resident Research Group reported that, even with protective equipment, orthopaedic residents received an average annual radiation dose of 3.30 ± 0.64 millisieverts (mSv)—roughly equivalent to 165 chest radiographs.^6,7 For context, natural background radiation exposes the average person to roughly 3.00 mSv annually. ⁸

Occupational radiation exposure primarily results from scatter, which occurs when the X-ray beam interacts with objects along its path. This interaction deflects X-ray photons from their original course, generating secondary radiation that spreads in multiple directions and inadvertently exposes surrounding personnel and environments. The amount of scattered radiation decreases as distance from the radiation source increases. ⁹ Of the photons emitted, only about 2% reach the image intensifier, whereas 10% to 20% are scattered and the remainder are absorbed within the operative field. Surgeons experience markedly higher radiation exposure when standing in the path of the primary beam; this is known as primary radiation exposure.^10,11 Furthermore, occupational radiation exposure tends to be higher during procedures on patients with obesity, because increased radiation doses are often necessary to achieve tissue penetration.^12,13 Nevertheless, newer fluoroscopy units can result in lower radiation exposure compared with older systems. ¹⁴ Radiation dose, expressed as cumulative air kerma, represents the total kinetic energy released when ionizing radiation interacts with air; it is measured in milligray (mGy) at a reference point located 15.00 cm from the X-ray tube’s center.

Recently, minimally invasive surgery (MIS) has gained popularity across orthopaedic subspecialties. These procedures depend on fluoroscopy for real-time visualization of anatomical structures, aiding in tasks such as implant placement and instrumentation. As MIS is highly reliant on intraoperative imaging, it often requires more frequent or extended fluoroscopic use than conventional open approaches. ⁸ Although MIS is increasingly being utilized in orthopaedics, there remains a notable gap in the literature regarding radiation doses and risks associated with MIS foot and ankle procedures. In particular, further investigation is needed to better characterize radiation exposure during hindfoot procedures.

The purpose of the current study was to quantify the radiation dose and fluoroscopy time associated with 2 common procedures to treat insertional Achilles tendinitis: the percutaneous Zadek osteotomy (ZO) and the open midline Achilles tendon splitting Haglund resection (HR). It was hypothesized that the percutaneous ZO would be associated with increased radiation dose and fluoroscopy time in comparison to the open HR.

Methods

Following institutional review board approval, patients who underwent a percutaneous ZO or an open HR between January 2021 and July 2025 were included in the current retrospective review. All included patients were >18 years of age at the time of their procedure. Inclusion criteria consisted of patients undergoing either a percutaneous ZO or an open HR. Patients were excluded if radiographic imaging data was unavailable, a revision procedure occurred, or if they underwent concomitant procedures that could confound radiation measurements. The surgical technique for the percutaneous ZO procedure was as previously described by Kaplan et al, ¹⁵ whereas the surgical technique for the open HR was as previously described by Ahn et al ¹⁶ (Figures 1 and 2).

Figure 1.

(A) Sagittal and (B) axial schematic drawings of quadrant cut guide for percutaneous Zadek osteotomy as provided by Kaplan et al. ¹⁵

Figure 2.

(A) The Achilles tendon was centrally split through a midline skin incision to expose the exostosis, (B) the exostosis was completely excised in an oblique fashion, and (C) following bony excision, the tendon was repaired using a running suture as provided by Ahn et al. ¹⁶

Our secondary outcomes were to (1) assess radiation dose (mGy) in common orthopaedic surgeries requiring fluoroscopy, (2) compare these metrics of common orthopaedic surgeries to those observed in the percutaneous ZO and open HR procedures, and (3) assess radiation exposure to the surgeon’s body under lead protection and to the hands while using radiation-reduction gloves.

Data Collection and Analysis

A total of 139 patients met the inclusion criteria for the current study. Although 60 patients underwent a percutaneous ZO, 79 patients underwent an open HR. All procedures were performed by one of 2 fellowship-trained orthopaedic foot and ankle surgeons at a single institution. A mini C-arm fluoroscopy unit (FD Mini-Carm 1000-0004 by OrthoScan Inc. or Elite MiniView by GE Healthcare) was used intraoperatively for all cases. The patients were not randomized, and their surgical procedure was determined per their surgeon’s preference. The procedure type and associated patient demographics were recorded for each case. The primary outcomes for this study were radiation dose (mGy), as reported by the mini C-arm fluoroscopy unit and total fluoroscopy time (minutes) using the standard mode, not low dose, mode for all procedures. Because X-rays have a radiation weighting factor of 1, their biological effectiveness (expressed in mSv) is considered equivalent to their dose (expressed in mGy). ¹⁷

Separate from data collection for the primary study outcomes, using low-dose mode on a mini C-arm, radiation exposure was measured using a dosimeter secured in the surgeon’s scrub pocket beneath a 0.50-mm lead apron (Instadose Plus, Mirion Technologies Dosimetry Services). This monitor transmitted dosimetry data to Mirion Dosimetry every 2 weeks; then, these data were analyzed, and the wearer was assigned an exposure as specified by the data. In addition, a ring dosimeter was worn on the surgeon’s operative hand on the ring finger beneath a Sensicare PI Shield glove to measure radiation exposure during fluoroscopic use (Thermo-luminescent Dosimeter Ring Monitor MeasuRing Type 19, Mirion Technologies Dosimetry Services).

Descriptive statistics are reported as a mean ± SD. Given the lack of significant precedence in the literature, a power analysis was not performed; rather, the effect size and CI were reported for each comparison. All continuous data were compared between patients who underwent an open or MIS approach on independent sample t test. All statistical analysis was performed on SPSS 29 (IBM Corp, New York); P < .05 was considered to be significant.

Results

A total of 139 patients met the inclusion criteria for the current study and were retrospectively reviewed. For treatment of insertional Achilles tendinitis, 60 patients underwent a percutaneous ZO whereas 79 patients underwent an open HR (Table 1). Patients who underwent a percutaneous ZO procedure had a mean body mass index (BMI) of 36.09 ± 8.72 (range, 18.56-58.96), whereas patients who underwent an open HR had an average BMI of 37.35 ± 8.35 (range, 18.52-61.08) (P = .389) (Table 1).

Table 1.

Patients, BMI, Radiation Dose, and Fluoroscopy Time for Percutaneous ZO vs Open HR. ^a

Procedure	n	BMI	Mean Radiation Dose (mGy)	Mean Fluoroscopy Time (min)
Percutaneous ZO, mean ± SD (range)	60	36.09 ± 8.72 (18.56-58.96)	3.25 ± 2.06 (0.55-8.07)	2.83 ± 1.64 (0.70-7.17)
Open HR, mean ± SD (range)	79	37.35 ± 8.35 (18.52-61.08)	0.38 ± 0.20 (0.02-1.17)	0.42 ± 0.19 (0.03-0.90)
P	–	.389	<.001*	<.001*
Effect size	–	−0.148	2.116	2.225
CI	–	−0.484, 0.188	1.694, 2.532	1.796, 2.649

Abbreviations: BMI, body mass index; HR, Haglund resection; ZO, Zadek osteotomy.

^aAll data are represented as a mean ± SD.

^*All P <.05 were considered to be significant.

A mean fluoroscopy time of 2.83 ± 1.64 (range, 0.70-7.17) minutes and a radiation dose of 3.25 ± 2.06 (range, 0.55-8.07) mGy were observed in the percutaneous ZO cohort. An average fluoroscopy time of 0.42 ± 0.19 (range, 0.03-0.90) minutes and a radiation dose of 0.38 ± 0.20 (range, 0.02-1.17) mGy were observed in the open HR cohort. When compared, the percutaneous ZO cohort demonstrated a significantly higher radiation dose (P < .001) and fluoroscopy time (P < .001) (Table 1).

Occupational radiation exposure beneath lead demonstrated 100% attenuation, with a 0% transmission to protected regions of the thyroid, chest, abdomen, and genitalia. The mean radiation exposure to the hands was 5.07 millirem (mrem) per 3.25 mGy (mean percutaneous ZO radiation dose).

Discussion

In this retrospective comparative study, we found that the percutaneous ZO was associated with a significantly higher radiation dose and fluoroscopy time compared with the open HR. However, the percutaneous ZO results in low overall occupational radiation exposure with minimal risk to providers.

We performed a retrospective comparison of minimally invasive and open surgery techniques. To provide an assessment of occupational radiation exposure for treating insertional Achilles tendinitis, we will contrast 2 highly prevalent and internationally established procedures.^{18 -22} Although both techniques rely on fluoroscopy for execution, the increasing adoption of MIS has heightened concerns regarding elevated radiation exposure. By evaluating these 2 established procedures, we aim to quantify and address the radiologic risk.

For context, the International Commission on Radiological Protection (ICRP) advises limiting occupational radiation exposure to less than 20.00 mSv per year. ²³ The Calgary Orthopaedic Resident Research Group reported in 2024 that orthopaedic surgeons receive a mean occupational radiation exposure of 3.30 ± 0.64 mSv, based on an average of 107.00 ± 38.00 operating days. ⁶ Dorman et al ⁹ demonstrated that when using a mini C-arm, a 0.25-mm lead apron exposed to a 50-kilovoltage peak (kVp) beam reduces radiation exposure for surgical staff to approximately 0.50% of the original dose. Based on our findings, if a surgeon performs 50 percutaneous ZO procedures per year, with an average exposure of 0.0163 mSv per case (3.25 × 0.50%), the cumulative annual occupational exposure would be approximately 0.813 mSv (0.0163 × 50). When compared with the ICRP’s recommended occupational exposure limit of less than 20.00 mSv per year, the percutaneous ZO remains well below the guideline. To exceed this safety threshold, a surgeon would need to perform more than 1225 percutaneous ZO procedures (20 ÷ 0.0163) within a single year. ²³ It is important to note that these low cumulative exposure estimates are based on the use of lead aprons with a minimum thickness of 0.25-mm lead equivalence.

The primary concern with radiation exposure is due to its associated health risks, including cataract formation and, most notably, cancer. ²⁴ Over a 30-year career, performing 50 percutaneous ZO procedures annually would result in a cumulative radiation exposure of 24.39 mSv (0.813 × 30). Based on current literature, every 1.00 mSv of radiation exposure corresponds to an estimated 0.005% increase in lifetime cancer risk.^23,25 Accordingly, the cumulative exposure from percutaneous ZO procedures is estimated to correspond to a 0.12% increase in lifetime cancer risk. Furthermore, the mean occupational exposure associated with performing 50 percutaneous ZO procedures (0.813 mSv) remains several orders of magnitude below the thresholds for deterministic effects, such as erythema (2.0 Gy), cataract formation (2.0 Gy), permanent epilation (7.0 Gy), and delayed skin necrosis (12.0 Gy). ²⁴

Concerns about radiation exposure are often cited by surgeons who are hesitant to adopt MIS techniques for foot and ankle procedures. In our study, the percutaneous ZO procedure demonstrated higher radiation doses than the open HR; however, although this difference reached statistical significance, its clinical significance appears limited.

To better contextualize these findings, it is helpful to compare the observed fluoroscopy time and radiation dose with those reported for other orthopaedic procedures, as well as for specialties that rely heavily on fluoroscopy, such as interventional cardiology. ²⁶ Orthopaedic trauma surgeons are generally reported to experience the highest levels of occupational radiation exposure. ²⁷ Tsalafoutas et al ²⁸ found that intramedullary nailing (IMN) of diaphyseal femoral fractures averaged 6.30 ± 2.70 (range, 3.00-11.60) minutes of fluoroscopy and a mean radiation dose of 331.00 ± 21.00 (range, 70.00-807.00) mGy (Table 2). This radiation dose is 871 times larger than the open HR and 101 times larger than the percutaneous ZO.

Table 2.

Radiation Doses of Common Orthopaedic Procedures and Percutaneous ZO.

Procedure	Mean Radiation Dose (mGy), Mean ± SD (Range)	Mean Fluoroscopy Time (min), Mean ± SD (Range)
Percutaneous ZO	3.25 ± 2.06 (0.55-8.07)	2.83 ± 1.64 (0.70-7.17)
IMN of peritrochanteric fractures	183.00 ± 138.00 (15.00-772.00)	3.20 ± 1.70 (1.10-10.20)
IMN of diaphyseal femoral fractures	331.00 ± 21.00 (70.00-807.00)	6.30 ± 2.70 (3.00-11.60)
IMN of tibia	137.00 ± 111.00 (41.00-378.00)	5.70 ± 3.50 (2.00-12.20)
Distal radius fracture fixed with a plate	17.00 ± 10.00 (3.30-26.00)	1.80 ± 0.90 (0.30-3.00)

Abbreviations: IMN, intramedullary nailing; ZO, Zadek osteotomy.

In comparison to other common orthopaedic procedures, the percutaneous ZO cohort demonstrated a lower radiation dose than both distal radius plating and IMN of the tibia. Tsalafoutas et al ²⁸ reported that for distal radius plating, the mean radiation dose was 17.00 ± 10.00 (range, 3.30-26.00) mGy, which was higher than that observed in the percutaneous ZO group; the mean fluoroscopy time for distal radius plating was 1.80 ± 0.90 (range, 0.30-3.00) minutes. Furthermore, IMN of the tibia required a mean fluoroscopy time of 5.70 ± 3.50 (range, 2.00-12.20) minutes and an average radiation dose of 137.00 ± 111.00 (range, 41.00-378.00) mGy, which was greater than the percutaneous ZO cohort (Table 2). ²⁸

Furthermore, Tsalafoutas et al ²⁸ depicted that IMN of peritrochanteric fractures had a mean fluoroscopy time of 3.20 ± 1.70 (range, 1.10-10.20) minutes with a mean radiation dose of 183.00 ± 138.00 (range, 15.00-772.00) mGy (Table 2). Performing IMN for peritrochanteric fractures only 10 times per year—each delivering an approximate radiation dose of 183.00 mGy—would result in an annual total dose of 1830 mGy (183.00 × 10). ²⁸ According to Dorman et al, ⁹ surgeons receive about 1.25% of the radiation emitted by a standard large C-arm when using a 70-kVp beam and a 0.375-mm-thick lead apron. Based on this, the annual surgeon exposure would be approximately 22.88 mSv (1830 × 1.25%), leading to a cumulative exposure of 686.25 mSv over a 30-year career (22.875 × 30). This corresponds to an estimated 3.43% increase in lifetime cancer risk—28 times higher than that associated with the percutaneous ZO, despite involving only one-fifth as many procedures.

Compared with interventional cardiology, fluoroscopy use in both cohorts appears relatively limited. For instance, Wang et al ²⁹ reported peak skin doses associated with common interventional cardiology procedures, highlighting that percutaneous transluminal coronary angioplasty required a mean radiation dose of 1155.00 ± 708.00 (range, 236.00-4302.00) mGy and an average fluoroscopy time of 16.20 ± 9.00 (range, 3.10-47.00) minutes. Similarly, coronary angiography required a mean radiation dose of 290.00 ± 199.00 (range, 30.00-993.00) mGy with an average fluoroscopy time of 5.20 ± 4.10 (range, 0.70-16.00) minutes.

It is important to note that our procedures were performed using a mini C-arm instead of a standard large C-arm, which likely contributed to the radiation doses observed (Figures 3-5). Nevertheless, this does not detract from the importance of our findings, as the recorded exposure remained well below the thresholds recommended by the ICRP. In this study, radiation dose was measured as cumulative air kerma (mGy), reflecting the output of the mini C-arm, whereas staff exposure (mSv) was estimated using attenuation rates reported by Dorman et al. ⁹ To our knowledge, there is currently no literature directly assessing fluoroscopy for percutaneous ZO and open HR procedures.

Figure 3.

Standard large C-arm fluoroscopy unit for intraoperative imaging.

Figure 4.

Mini C-arm fluoroscopy unit (Elite MiniView by GE Healthcare) for intraoperative imaging.

Figure 5.

Mini C-arm fluoroscopy unit (FD Mini-Carm 1000-0004 by OrthoScan Inc) for intraoperative imaging.

Regardless of these results, surgeons should strive to prioritize radiation safety and follow the “as low as reasonably achievable” (ALARA) principle when using fluoroscopy. Importantly, there are strategies to reduce radiation exposure beyond limiting fluoroscopy time; for instance, the use of a mini C-arm can markedly decrease radiation levels. ³⁰ In foot and ankle surgery, studies have shown that using a mini C-arm significantly reduces the dose area product without a corresponding increase in screening time. ³¹ The observed reduction in radiation dose may be attributed to factors such as the smaller detector area, reduced tube power, tighter beam collimation, and the surgeon’s direct control over screening. ³² Radiation exposure can be further minimized by using low-dose settings on a mini C-arm. For instance, the OEC MiniView MAX C-arm by GE Healthcare operates at a maximum output of 0.16 mA at 80 kVp, whereas its low-dose mode reduces output to 0.08 mA at 80 kVp—resulting in up to a 50% decrease in radiation exposure. ³³ At our institution, this approach has been implemented to reduce radiation exposure. Notably, the difference in image quality between low- and high-dose fluoroscopy is minimal, allowing for significant reductions in cumulative radiation without compromising diagnostic accuracy (Figures 6-9). In practices with a high volume of MIS procedures and frequent on-call responsibilities, cumulative radiation exposure may be increased. When safe and available, the use of a well-maintained mini C-arm may minimize radiation exposure. Further, newer fluoroscopy units, particularly those with flat-panel detectors, can result in lower radiation exposure compared to older image-intensifier systems. ¹⁴

Figure 6.

Lateral view fluoroscopic image using high dose during percutaneous Zadek osteotomy (ZO) procedure.

Figure 7.

Lateral view fluoroscopic image using low dose during percutaneous Zadek osteotomy (ZO) procedure.

Figure 8.

Harris heel view fluoroscopic image using high dose during percutaneous Zadek osteotomy (ZO) procedure.

Figure 9.

Harris heel view fluoroscopic image using low dose during percutaneous Zadek osteotomy (ZO) procedure.

To limit scatter exposure during imaging, surgeons should stand on the side of the image receiver. Scatter can be further minimized by positioning the patient as close to the receiver and as far from the X-ray tube as possible. Maintaining greater distance between the surgeon and the patient also substantially reduces occupational radiation exposure. Although the hands are typically subjected to the highest doses during procedures, this risk can be mitigated with radiation reduction gloves; for example, tungsten gloves attenuate roughly 90% of an 80-kVp beam.^{34 -36} In our practice, surgeons wear Sensicare PI Shield gloves made of synthetic polyisoprene, which attenuate 51.6% of a 79.8-kVp beam. We found that the mean hand radiation exposure during a percutaneous ZO procedure conducted under low-dose mini C-arm fluoroscopy (40-80 kVp) was 5.07 mrem. Assuming 50 procedures are performed annually, the cumulative radiation exposure would be approximately 253.50 mrem (5.07 × 50), representing only 0.507% of the ICRP’s annual extremity dose limit of 50 000 mrem. ¹⁷ Furthermore, the mini C-arm’s automatic mode should be disabled, as it may increase radiation output in an attempt to optimize image quality through protective gloves, potentially resulting in higher exposure to surgical staff.

Protective equipment such as lead aprons, thyroid shields, and leaded glasses offer additional protection against radiation exposure. ³⁷ In our practice, occupational radiation exposure beneath lead protection showed complete attenuation, with no detectable transmission to shielded regions of the thyroid, chest, abdomen, or genitalia when using 0.50 mm lead for a 40- to 80-kVp beam mini C-arm on low dose mode. Furthermore, as surgeons gain experience, fluoroscopy times typically decline, resulting in additional reductions in radiation exposure.^38,39 These strategies are effective in reducing cumulative radiation exposure among surgical staff (Table 3).

Table 3.

Recommendations to Minimize Radiation Exposure.

Utilize mini C-arm when possible

Utilize low-dose mode when possible

Wear radiation reduction gloves

Wear a lead apron and a thyroid shield

Wear leaded glasses

Have surgical staff positioned on the side of the image receiver

Have the patient positioned as close as possible to the image receiver and as far as possible from the X-ray tube

Increase the distance between the surgeon and the patient

This study was retrospective in nature and therefore subject to inherent limitations. Patients were not matched for homogeneity among age, sex, laterality, or comorbidities across cohorts. In addition, all procedures were performed by fellowship-trained orthopaedic foot and ankle surgeons with substantial MIS experience, which may limit the generalizability of the results. Finally, complications, including revision procedures, were not assessed. Although Hall et al ⁴⁰ have reported the percutaneous ZO to be associated with low complication and revision rates, this remains an important factor when evaluating any orthopaedic intervention. Further, advancements in fluoroscopy equipment, including improved detector efficiency, dose-reduction algorithms, and automated exposure controls, have led to lower radiation exposure in newer systems. ¹⁴ For example, the radiation dose estimates for common orthopaedic procedures were derived from literature in 2007; subsequent advances in imaging technology may have reduced radiation exposure in current practice. Consequently, radiation dose measurements from the study period may not be fully representative of future fluoroscopy platforms, which should be considered when interpreting these findings.

Despite these limitations, this study offers novel data on radiation dose and fluoroscopy time associated with the percutaneous ZO and open HR. It should be noted, however, that the quantitative data were collected over a limited time frame and must be interpreted cautiously. These preliminary findings are intended to provide early insight into exposure patterns and potential strategies for mitigating radiation risk. Our results suggest that, when performed with appropriate technique and imaging protocols, the percutaneous ZO generates minimal radiation exposure, remaining well below the ICRP’s recommended annual limit.

Conclusion

Although the percutaneous ZO procedure was associated with a significantly greater radiation dose than the open HR, total exposure remains well below the ICRP-recommended occupational exposure limit of 20.00 mSv per year. These findings suggest that, although the percutaneous ZO requires greater use of intraoperative imaging, it remains safe for providers when imaging protocols are carefully followed. Consistent with the ALARA principle, techniques such as using low-dose mini C-arm settings and using protective equipment are effective strategies to minimize unnecessary radiation exposure for both patients and surgical staff.