Are we putting ourselves in danger? Occupational hazards and job safety for orthopaedic surgeons

Abstract

As physicians, we strive to meet the needs of our patients. In doing so, we are often exposed to hazards that have the potential to not only compromise our health, but also our ability to deliver the best possible healthcare. Occupational hazards specific to the field of orthopaedics include infectious organisms, radiation, surgical smoke, chemicals, hazardous noise, musculoskeletal injury, and psychosocial stressors. Even though orthopaedic surgeons acknowledge the risk, most lack in-depth knowledge of the associated long-term harm associated with these hazards and ways of reducing risk of exposure. Orthopaedic surgeons should increase awareness, follow established guidelines, and integrate preventative measures to create the safest possible work environment. It is our hope that by improving our own health, we will be better equipped to address the health concerns of those we serve—our patients.

1. Introduction

Every day, millions of physicians go to work with the goal of improving patients' lives. In doing so, physicians take on considerable risk of harm to themselves. This is particularly true of orthopaedic surgery—a field that exposes surgeons to an array of harmful agents while placing them under enormous physical, emotional strain.¹ It's important for orthopaedists to be aware of not only the potential hazards they face in the operating room (OR), but also the precautions that should be taken to avoid them. In this current review, we discuss common occupational hazards encountered by surgeons in daily practice and current safety recommendations to reduce the risk of experiencing harm.

1.1. Exposure to infection

In the OR, surgeons may be exposed to infectious pathogens through percutaneous, airborne, and mucocutaneous contact. Orthopaedists face an elevated risk relative to other specialties due to increased contact with sharp objects such as saws, drills, and sharp bone fragments that can cause percutaneous injury. Mucocutaneous exposure to pathogens is also increased due to splattering from power tools and pulsatile irrigation. In a review of 1828 patients, 74% of exposures were potentially preventable by using recommended personal protective equipment (PPE).² Risk factors for exposure include orthopaedic trauma surgeries, procedures lasting over 3 h, and those with a blood loss greater than 300 mL.² Not surprisingly, the majority of percutaneous injuries are caused by suture needles, largely due to inattentiveness and unsafe practices such as recapping needles.³ Approximately one third of physicians do not report needlestick injuries due to a perceived low risk of transmission and lack of time.⁴

The most frequently encountered and dangerous pathogens include human immunodeficiency virus (HIV), Hepatitis B (HBV), and Hepatitis C (HCV) (Table 1). The risk of infection with these pathogens is dependent on a variety of factors including the type of pathogen, the infectivity of the pathogen in the patient at the time of exposure, the type and severity of the injury, and the use of pre- and post-exposure treatments.

Table 1.

Exposure to bloodborne pathogens.

Bloodborne Pathogens	HIV	Hepatitis B	Hepatitis C
Rate of percutaneous injury	0.3%	6–30%	1.8%
Rate of mucocutaneous injury	0.09%	Not quantified	Rare
Pre-exposure considerations	Prevention	Vaccination	Prevention
Post-exposure considerations	Zidovudine	HepB Immunoglobulin	Sofosbuvir/ledipasvir

The risk of HIV infection via percutaneous injury is 0.3%, while the risk via mucocutaneous exposure is 0.09%.⁵ The risk of HIV seroconversion decreases about 81% with the use of post-exposure prophylactic Zidovudine. Although minimizing the risk of infection is critical, it is important to realize that the risk of infection even without prophylaxis is quite low, and HIV antiviral medications have numerous side effects.⁵

The risk of HBV infection via percutaneous injury is estimated between 6% and 30%, and while risk via mucocutaneous exposure has not been quantified, it is thought to be higher than other bloodborne pathogens. HBV immunization provides a protective antibody response in over 90% of healthy recipients. Post-exposure prophylaxis with HBV immunoglobulin may have an added benefit for those who aren't vaccinated.⁵

The risk of HCV infection via percutaneous injury is 1.8%, while risk via mucocutaneous exposure is extremely rare. Although there currently is no effective post-exposure prophylactic regimen for HCV, multiple drug treatments for HCV are now available, including sofosbuvir, ledipasvir, and daclatasvir. HCV cure rates can be as high as 97% depending on HCV genotype and therapeutic regimen.⁶

The best way to prevent occupational infection is to follow the standard precautions established by the Hospital Infection Control Practices Advisory Committee (HICPAC). The basis of these guidelines is to treat all patients as if they are potentially infectious and take all necessary precautions such as frequent hand washing and proper use of PPE.

Hand washing has been shown to not only reduce the incidence of nosocomial infections but also reduce infection in hospital personnel themselves. Prior studies indicate wearing a double layer of gloves significantly decreases the risk of contamination as compared to wearing a single layer of gloves. The risk is further mitigated with the use of a cut-resistant inner glove and changing outer gloves at predetermined intervals.⁷ However, there is a significant difference in sensation between single and double layering of gloves.⁸ Ultimately, the surgeon must determine if the loss of sensitivity is significant enough to affect the outcome of the surgery.

Face masks and eyewear are particularly important in preventing mucocutaneous exposure and eye trauma due to the spray of blood and bone fragments caused by the use of power tools. One study assessed different forms of eyewear and found that modern prescription glasses did not provide sufficient protection against exposure. Increasing levels of protection were provided by surgical loupes, combined facemask-shield, hard plastic glasses, and disposable plastic glasses, respectively.⁹

Surgical gowns provide a barrier to contamination. Gowns with higher water and oil repellency and smaller pore size provide the greatest protection. Gowns are rated by level of protection according to the Association for Advancement of Medical Instrumentation (AAMI) standard, from least protective AAMI level 1 to the highest level 4. Level 2 gowns, such as those worn when interacting with a patient with contact-precaution, are rated to resist liquid penetration applied with hydrostatic pressure. Most sterile surgical gowns are rated level 3 or level 4. The distinguishing feature of a level 4 gown is its resistance to viral penetration.¹⁰ Body exhaust suits can provide additional protection from droplet transmission, although additional respiratory protection is only necessary if there is a risk of airborne transmission.

Respiratory infections are of special interest since the outbreak of coronavirus disease (COVID-19) in Wuhan, Hubei Province, People's Republic of China in December 2019. An early report from the region described the experience of 26 orthopaedic surgeons from eight different hospitals who were infected with COVID-19.¹¹ The suspected sites of exposure were general wards (79%), hospital public spaces (20.8%), OR's (12.5%), intensive care units (4.2%), and clinics (4.2%). Transmission from these doctors to others occurred in 25% of cases, most commonly to family members. Risk factors for infection included severe fatigue and not wearing an N95 respirator. Protective factors included wearing an N95 respirator at all times and participation in real-time training. Recommended safety measures include maintaining a high level of clinical suspicion for infection, minimizing nonessential procedures, adhering to social distancing measures, and following PPE guidelines as recommended by the U.S. Center for Disease Control (CDC).

1.2. Exposure to radiation

Orthopaedic surgeons are far more reliant on intraoperative imaging compared to other specialists, and thus experience much greater radiation exposure. Often, orthopaedists must remain close to the fluoroscopy beam and cannot increase distance to reduce exposure. A recent study of Italian orthopaedic surgeons showed that orthopaedists experienced five times as much radiation exposure compared to other hospital employees. Additionally, 29% of orthopaedists developed malignancies compared to 4% in controls.¹² Another cross-sectional study at a large urban academic enter found the prevalence of cancer was 85% higher in female orthopaedists than in the general U.S. population, including a three-fold increase in breast cancer.¹³ In addition, there was a significantly higher risk of complications during pregnancy (31.2%) compared to the general U.S. population (14.5%).¹⁴

Since there is no truly safe dose of radiation, one should always aim for a radiation dose as low as reasonably achievable—a concept known as ALARA. Nevertheless, the US National Council on Radiation Protection and Measurements (NCRP) recommends a maximum annual total body dose of 5 rem, while the International Commission on Radiological Protection (ICRP) recommends 2 rem.¹⁵ For reference, a chest radiograph exposes a patient to approximately 25 mrem. Standard C-arm fluoroscopy exposes a patient to 1,200 to 4,000 mrem/min. The surgeon may receive exposure to the hands from the primary beam and to the torso from scatter. Recommended yearly limits of radiation are 5,000 mrem to the torso and 50,000 mrem to the hands.¹⁶ There are additional guidelines for the maximum allowable doses specific to pregnant women and specific organs (Table 2).

Table 2.

Maximum allowable radiation doses for various body parts and special patient populations.

Max Allowable Radiation Dose (in rem)
Annual total body (NRCP)	5
Annual total body (ICRP)	2
Embryo/fetus (>9mo)	0.5
Eye	15
Thyroid gland	30
All other organs (including gonads)	50
Pediatric	10% of adult dose

A majority of the radiation to which the orthopaedic surgeon is exposed comes from scattered radiation, which is significantly less than primary radiation from the x-ray beam. The exposure rate from primary radiation from a standard C-arm is between 1200 and 4000 mrem/min, while the exposure rate for scatter is about 5 mrem/min at 2 feet and 1 mrem/min at 4 feet from the beam. Given this significant difference, surgeons must make every effort to keep their hands out of the beam.¹⁶

Level of radiation exposure varies with surgical subspecialty, procedure, and positioning of personnel and equipment. During orthopaedic trauma procedures, a surgeon's hands receive the most radiation exposure.¹⁷ Muller et al. found that during intramedullary nail placement, the thyroid gland was exposed to the most radiation when the C-arm was placed in the lateral position (3.32 mrem/min), but use of a lead thyroid shield reduced exposure by a factor of 70.¹⁸ Radiation exposure in spine procedures can be ten-fold higher as compared to other musculoskeletal procedures. During pedicle screw insertion, radiation exposure to the hand averages 58.2 mrem/min.¹⁹ Also, radiation levels are highest on the side where the primary beam enters the surgical site.¹⁹

Navigation systems are emerging as a useful adjunct in orthopaedic trauma and spine surgery. These systems utilize intraoperative computed tomography-based (CT) navigation resulting in markedly reduced radiation exposure to staff. Wang et al. compared radiation exposure from CT-based navigation versus conventional C-arm fluoroscopy for several different orthopaedic surgical procedures, finding that CT-based navigation led to a 91% reduction of overall radiation exposure.²⁰

Hand and foot specialists tend to utilize the mini-C arm for their procedures, which have 1/10th the radiation scatter of a standard C-arm. However, the ultimate radiation absorption may be higher for the mini-C arm due to increased fluoroscopy time and decreased distance between the surgeon and the emitter. A single institution study found median output displayed by the large C-arm was 0.7 mGy/case, and the median output displayed by the mini C-arm was 10.0 mGy/case.²¹ Cumulative ring dosimeter absorption to the surgeons' hands was found to be 380 mrem in the large C-arm group versus 1,000 mrem in the mini C-arm group. Thus, the use of the mini C-arm resulted in more than a 10-fold increase in the rate of output and approximately double the dosimeter absorption to the surgeon's hand compared with the large C-arm.²¹ Although it has been shown that the mini C-arm produces less radiation scatter, in a practical model, it may not be a safer alternative with respect to the surgeon's hands.

There are four recommended methods to reduce radiation exposure from scatter include 1) decreasing time, 2) increasing distance, 3) shielding, and 4) contamination control. Increasing distancing by just two meters drastically reduces the beam intensity to 0.025% of the original strength. With shielding, 0.25 mm lead gowns will attenuate 90% of the radiation while 0.5 mm lead gowns attenuate 99% of the radiation at the cost of added weight. Leaded glasses provide 30%–70% attenuation compared to 20% for ordinary glasses. Thyroid shields of 0.5 mm thickness achieve 90% exposure reduction.²² Specially designed radiation attenuating surgical gloves only provide an exposure reduction of 7%–50% and were even less effective at high energy levels, giving the surgeon a false sense of security.²³ Other exposure reduction techniques include using the low-dose option on C-arms when maximum resolution is not needed, using a laser guide to center the beam to avoid unnecessary off-center images, and maintaining surgeon control of the C-arm with a foot pedal.

1.3. Exposure to surgical smoke

Surgical electrocautery, also known as Bovie, is routinely used in surgical procedures. This device passes an electrical current through tissue, producing heat that causes cells to explode and tissues to divide; or it causes cells to dry and tissues to coagulate. Consequently, electrocautery produces a plume, which consists of roughly 85% water vapor and 5% chemicals and cellular debris, the latter of which may have carcinogenic, mutagenic and inflammatory effects. Up to 80 different chemicals have been identified in surgical smoke including formaldehyde (an irritant and potential carcinogen), acetaldehyde (carcinogen), benzene (carcinogen), and toluene (irritant and neurotoxin).²⁴ Surgical smoke can create lung parenchyma changes similar to those that created by cigarette smoke, such as alveolar congestion, blood vessel hypertrophy, and focal emphysematous changes.²⁵ The smoke from one gram of tissue destroyed by electrocautery has the mutagenic potential of smoking six unfiltered cigarettes.²⁶ The average plume created in one day in the operating room was found to be equivalent to as many as smoking 30 unfiltered cigarettes.²⁷

Both viruses and bacteria have been isolated from surgical smoke, raising concern of potential infectious disease transmission. Bacteria such as Bacillus subtilus, Staphylococcus aureus, and Mycobacterium tuberculosis have been isolated from electrocautery smoke.²⁸ Additionally, viruses including HIV and Human Papilloma Virus (HPV) have been identified in vapor created from electrocautery.²⁹ However, no studies have conclusively demonstrated the transmission of viruses or cancer cells to operating room personnel. Safety concerns persists as studies have demonstrated an association between surgical smoke and headaches; ocular, nasopharyngeal and laryngeal irritations; dermatitis; and multiple respiratory conditions.²⁹ One orthopaedic surgeon underwent a double-lung transplant for pulmonary fibrosis, which was attributed to years of exposure to Bovie smoke.³⁰

Suctioning smoke near its source is the most effective way to minimize exposure. Most surgeons use wall-mounted suction devices to extract smoke, however this may be inadequate.³¹ The National Institute of Occupational Safety and Health (NIOSH) recommends using a smoke evacuator system that can pull 50 cubic feet per minute with a capture velocity of 100–150 feet per minute, approximately two inches from the surgical site.³² While standard surgical masks do not protect against ultrafine particles, masks should always be worn to prevent exposure to large particles, including viruses.²⁸

1.4. Exposure to chemicals

Bone cement has been in widespread use in orthopaedic surgery since the 1950's. The basic ingredient in bone cement is methylmethacrylate (MMA). Rare but serious complications are associated with the use of MMA in patients. Cardiovascular complications include hypotension, thromboembolic events, and cardiac shock.³³ Although, there are no known cases of cardiovascular complications occurring directly in personnel handling bone cement, MMA poses a multitude of other hazards.

Orthopaedic surgeons are most affected by MMA's toxic effects on the dermatological, pulmonary and neurological systems. Individuals who come in direct skin contact with MMA, may experience skin sensitization.³³ While the evidence for respiratory sensitization is equivocal, MMA is a known respiratory irritant. Case series have cited new diagnoses of asthma, laryngitis, and pneumonitis in MMA-exposed workers.³⁴ Although the cytotoxic and carcinogenic effects of MMA are unclear, MMA has been found to be toxic to human neurons in vitro.³⁵ Multiple cases of peripheral neuropathy in the hands of dental technicians who routinely handle MMA have also been reported.³⁶

Additionally, there is widespread concern that MMA may pose risks to pregnant female orthopaedic surgeons and be toxic to developing fetuses. The United States Environmental Protection Agency (EPA) has set the limit for exposure to <100 parts per million (ppm) over an eight-hour period, and animal models demonstrate fetotoxicity at levels >1,000 ppm. This level of exposure occurs during a single total joint replacement with greatest exposure during the MMA mixing process.³⁷ Despite the notional concerns of toxicity based on animal models, serum and breast milk levels of MMA in two breastfeeding surgeons following exposure to MMA during total joint arthroplasty surgery were found to be no different than in controls.³⁸

Nevertheless, the World Health Organization (WHO) has proposed measures to mitigate occupational exposure to MMA.³⁹ The WHO recommends programs to increase awareness of MMA's hazards by providing staff with appropriate training. Individuals should avoid direct skin contact with MMA and wear appropriate PPE personal protective equipment consistent with infection control guidelines. MMA should be used in a well-ventilated area, equipped with recirculating air filters with gas absorbents of acid carbon.

1.5. Exposure to hazardous noise

Orthopaedic surgeons are routinely exposed to hazardous noise and are therefore at increased risk of experiencing noise-induced hearing loss (NIHL). In the OR, spectral recordings of twenty major surgical instruments used in five surgical specialties found that noise levels reached as high as 131 dB.⁴⁰ Approximately half of orthopaedic surgeons with long-term use of these tools have early signs of NIHL.⁴¹

The National Institute on Deafness and Other Communicable Disorders reports that prolonged exposure to noise above 90 dB (dB) leads to hearing loss, while regular exposure above 110 dB at one-minute duration risks permanent hearing loss. Therefore, the Occupational Safety and Health Administration (OSHA) set a threshold for hazardous noise to a time-weighted-average of 85 dB in an eight-hour work shift. If that threshold is exceeded, the allowable duration of exposure must be halved for every 5 dB increase over 85 dB.

Studies have quantified the level of noise in orthopaedics. During cast removal, noise levels average 76 dB over an eight-hour day, with a peak noise level averaging 140 dB.⁴² During total knee or total hip arthroplasty, noise levels reach 105.6 dB with use of a mallet and 97.9 dB while using an oscillating saw.⁴¹ High-speed gas turbine drills create noise up to 118 dB. Suction tips with tissue trapped inside can create a whistling noise of up to 96 dB.⁴³

The noise level in an orthopaedic operating room consistently exceeds the threshold level set by OSHA, whose guidelines suggest that orthopaedists should be managed in a hearing conservation program, undergoing regular audiometric testing and wear hearing protection. Additionally, all orthopaedic personnel are advised to distance themselves from the source as the hazardous noise exposure is inversely related to distance. Finally, surgeons are encouraged to use power tools that produce lower noise levels.⁴⁴

1.6. Exposure to musculoskeletal injury

Suffice is to say, orthopaedic surgery is physically demanding. The brute force requirement of musculoskeletal manipulation, prolonged standing in the OR, and lack of ergonomic insight can lead to physical injuries to surgeons. Static stress caused by non-neutral postures can lead to fatigue and disability as much as dynamic stress does. Much of the back and neck pain, resulting in lumbar and cervical spondylosis, is likely due to prolonged static head-bent and back-bent postures. The average adult reconstruction orthopaedic surgeon swings a 3- to 5-lb mallet about 300 swings in a single day— the likely etiology of high rates of lateral epicondylitis and rotator cuff pathology experienced by orthopaedists.⁴⁵ Nearly two-thirds of adult reconstruction orthopaedic surgeons have experienced a work-related injury at some point in their career, and 31% of these surgeons required surgery themselves to treat the injury.⁴⁵

In another survey of all orthopaedic subspecialties, 25% of respondents reported sustaining an injury to the hand; 19%, to the lower back; 10%, to the neck; 7%, to the shoulder (Table 3). Common injuries to the hand include carpal tunnel syndrome and carpometacarpal thumb arthritis, which are related to the constant forceful grip and pinch of nonergonomic instruments. Approximately 39% of orthopaedists required medical care as a result of their injury, but only 25% of injured surgeons reported the injury to their institution. Ten percent of surgeons reported missing work as a result of a workplace injury, with 4% missing at least three weeks.⁴⁶ The introduction of arthroscopic procedures, while better for the recovery of the patient, places further stress on the bodies of surgeons. Compared with surgeons performing open surgery, surgeons performing minimally invasive procedures were significantly more likely to experience pain in the neck, arm or shoulder, hands, and legs.⁴⁷ Arthroscopy requires fixation on a screen in order to move instruments; there is minimal neck and back movement leading to stiffness. Similarly, arthroscopy has fewer degrees of freedom leading to more frequent awkward movements of the upper extremities.

Table 3.

(A) Common locations of pain among orthopaedic surgeons; (B) Common injuries sustained by orthopaedic surgeons.

A: Common Locations of Pain in Orthopaedic Surgeons (% surveyed)		B: Common Injuries Sustained by Orthopaedic Surgeons (% surveyed)
Neck	66%	Cervical disc herniation	24%
Neck with radiculopathy	29%	Rotator cuff pathology	24%
Shoulder	49%	Lateral epicondylitis	17%
Elbow	28%	Carpal tunnel syndrome	11%
Wrist	26%	CMC/MCP joint arthritis	12%
Hand/finger	31%	Lumbar disc herniation	20%
Low back	66%	Spinal stenosis	8%
Low back with radiculopathy	29%	Varicose veins	20%

In order to minimize these injuries, orthopaedic surgeons must pay special attention to the ergonomics of operating. This can be achieved by using more ergonomic instruments and postures that keep the body in the most neutral position possible. Currently, despite well-understood differences in hand size, surgical instruments are still only produced in a single size. These should be improved for ergonomic ease. Surgical instrument design companies should be encouraged by orthopaedic surgeons to create more ergonomic instruments.

There are specific actions that surgeons can take to maintain an ideal posture, many of which simply involve patient positioning. Operating at an incorrect height can put extra stress on surgeons' backs and elbows. The optimal operating height is 0.7–0.8 times the elbow height of the surgeon.⁴⁸ Also, the patient should be positioned as close to the surgeon as possible. During arthroscopic procedures, the monitor should be positioned to allow the surgeon to maintain a neutral posture. Viewing monitors and the operative field should be positioned to maintain the surgeon's gaze angle between 15 and 40° below horizontal. Other actions the surgeon can take include keeping the operative field angled 45° to the surgeon's torso, frequent position changes especially during arthroscopic procedures, short breaks for stretching, and the use of a stool or a foot rest when possible.⁴⁸

1.7. Exposure to burnout, stress, and physician suicide

Burnout, stress, and suicide are major occupational hazards for physicians. Sleep deprivation, long work hours, excessive workload, financial hardship, legal issues exacerbate these issues. This may lead to a higher risk of depression, suicide, drug abuse, alcoholism, marital disruption, and burnout.

Burnout is defined as a work-related syndrome involving emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment. Burnout negatively affects patient care, professionalism, and even the physicians’ own well-being. Sargent et al. were the first to assess burnout in orthopaedic trainees.⁴⁹ They found 32% percent of the residents and 28.4% of the faculty scored in the high range of emotional exhaustion, 56% percent of the residents and 24.8% of the faculty scored in the high range of depersonalization (Table 4). Eighteen percent of the residents and 10% of the faculty scored in the low range of personal accomplishment. A recent review estimates overall burnout rates among orthopaedic surgeons to be in the range of 50–60%, compared to 30–40% of general surgeons. The highest rates of burnout were observed in orthopaedic residents, followed by department chairs, followed by faculty members.⁵⁰

Table 4.

Rates of burnout among orthopaedic surgeons.

Burnout Among Orthopaedic Surgeons	High Range of Emotional Exhaustion	High Range of Depersonalization	Low Range of Personal Accomplishment
Residents	32%	56%	18%
Faculty	28.4%	24.8	10%
Chairmen and Program Directors	36%–52%	24%–33%	0%–4%

The suicide rate among male physicians is 40% higher relative to males in the general population, whereas the suicide rate among female physicians is 130% higher relative to females in the general population.⁵¹ In a survey of 7905 surgeons, 501 (6.3%) reported suicidal ideation (SI) during the previous 12 months.⁵² SI is up to three times more common among surgeons than the general population. Only 26.0% of surgeons sought psychiatric help, and of those who didn't, 60.1% stated they were reluctant to seek help due to concern that it could compromise their careers. The higher rate of SI among surgeons is even more striking considering that surgeons are highly educated, nearly universally employed, and mostly married—all factors known to reduce risk of suicide in the general population. Although individuals aged 45 to 54 in the general population have a lower risk of SI than younger individuals do, the reverse appears to be true for surgeons.⁵²

Identification of protective factors and risk factors for emotional disturbance may provide guidance on how to address these issues. A survey of orthopaedic faculty and trainees found that emotional exhaustion correlated with anxiety regarding clinical competence, stressful relationships with colleagues, and increased conflict between life and work at home. Other risk factors for burnout include increased work hours, increased alcohol use, and diminished quality of life at home including marriage and parenthood. Protective factors include increased perception of a supportive work environment, presence of a mentor, making time for exercise or hobbies, and maintaining strong personal relationships with family.⁵³

While medical societies and institutions have increasingly advocated for ways of reducing burnout, much of their efforts have focused on the individual, rather than the system itself. Despite living in a technologically advanced world, physicians often experience burnout as a result of burdensome administrative work. If the healthcare system does not undergo a fundamental change in the way it is run, anti-burnout measures may only serve as a temporary band-aid.

2. Conclusion

As orthopaedic surgeons, we strive to meet the needs of our patients. In doing so, we are constantly exposed to health hazards that compromise our personal health and safety. These risks include exposure to infectious diseases, radiation, toxic chemicals, physical injury, and psychosocial stressors. We believe that this article should be considered essential reading for all orthopaedists as increased understanding of these occupational hazards will lead to implementation of strategies that foster a safer work environment. It is our hope that by improving our own health and well-being, we will ultimately be better equipped to meet the needs of those we serve—our patients.

Declaration of competing interest

No relevant conflicts