ORIGINAL ARTICLE
Laser Targeting With C-Arm Fluoroscopy: Effect on Image
Acquisition and Radiation Exposure
Franklin D. Shuler, MD, PhD,* Justin L. Daigre, MD,† Danh Pham, MSIV,‡
and Vincent L. Kish, ASEE†
Objectives: Reducing unnecessary radiation exposure from med-
ical imaging is paramount. This study assessed whether a laser
aiming guide for C-arm fluoroscopy reduced the number of
exposures needed to obtain an acceptable image, thereby reducing
total fluoroscopy time for hip, knee, and ankle fluoroscopy.
Methods: An obese cadaver was placed supine on a radiolucent
surgical table. Images were obtained by licensed radiologic technol-
ogists using a calibrated OEC 9900 Elite C-arm with laser targeting
(LT) and without LT (NLT). Dosimeters were placed 1, 3, and 6 ft
(30.5, 91.5, and 183 cm) away from the center of the C-arm at
90-degree angles at 2 levels, simulating thyroid and gonadal
exposure. Posterior–anterior (PA) images of the bilateral lower
extremities were obtained with each technician acquiring 24 centered
images (hip, knee, and ankle) using both LT and NLT C-arm
fluoroscopy.
Results: Total fluoroscopy time was reduced by 19% when using
LT with a 39% reduction for the knee and a 29% reduction for the
ankle. The addition of LT improved the likelihood of obtaining
a centered image for knees and ankles but not for hips. The gonadal
dosimetry data were significantly higher than the thyroid dosimetry
badges at 1 ft. At the 3-ft zone, only trace amounts of radiation were
detected; the 6-ft zone reported no radiation exposure in either group.
Conclusions: LT helped with imaging knees and ankles with
statistically significant reductions in fluoroscopy time and a statisti-
cally significant improvement of image quality defined as obtaining
a centered PA image faster. The dosimetry badges detected minimal
exposure at 3 ft and no detectable exposure at 6 ft at both levels.
Key Words: fluoroscopy, C-arm, laser, radiation exposure, fluoros-
copy time
(J Orthop Trauma 2013;27:e97–e102)
Accepted for publication June 22, 2012.
From the *Department of Orthopaedic Surgery, Marshall University,
Huntington, WV; †Department of Orthopaedics, West Virginia University,
Morgantown, WV; and ‡West Virginia University School of Medicine,
West Virginia University, Morgantown, WV.
The authors declare no external funding for this study.
F. D. Shuler is a consultant for Medtronic and is on their speaker bureau. The
remaining authors have no conflicts of interest to declare.
Reprints: Justin L. Daigre, MD, Department of Orthopaedics, West Virginia
University, PO Box 9196, Morgantown, WV 26506-9196 (e-mail:
jdaigre@hsc.wvu.edu).
Copyright © 2013 by Lippincott Williams & Wilkins
J Orthop Trauma  Volume 27, Number 5, May 2013
INTRODUCTION
In 2010, the US Food and Drug Administration issued
a white paper and initiative to reduce unnecessary radiation
exposure from medical imaging.1 Of the imaging modalities
addressed in this initiative, only one is in direct control of the
orthopaedic surgeon—intraoperative fluoroscopy. Increased
use of C-arm fluoroscopy has been realized because of its utility
in fracture reduction, facilitation of internal fixation, and in the
development of minimally invasive surgical techniques.1–7
Radiation exposure from intraoperative fluoroscopy is
derived from either primary radiation exposure (direct beam
contact) or from scatter or stray radiation. Direct beam contact
using a regular C-arm can result in exposure rates ranging
from 1200 to 4000 millirem per minute depending on the
body part imaged.8 Scatter radiation is produced when the
direct beam interacts with objects in its path (ie, operating
room table, instruments, and patient) (Fig. 1). As the volume
of tissue increases during C-arm fluoroscopy, the scattered or
stray radiation increases and provides the main source of
radiation dose to personnel in the operating room. Increasing
the distance from the radiation source reduces radiation
exposure via the inverse square rule: increasing the distance
from the radiation source decreases radiation exposure
proportional to 1 by distance.2 Decreases in radiation expo-
sure to the patient, surgeon, and ancillary staff are desirable.
A decrease in radiation exposure during intraoperative fluo-
roscopy can be realized by decreasing fluoroscopy time and
number of digital spot images acquired, increasing the dis-
tance from the radiation source, using collimation, avoiding
magnification, using a mini C-arm, increasing patient and
surgeon shielding, and allowing surgeon control of the
C-arm.9–11 An additional tool that could potentially decrease
exposure time with fluoroscopy is laser targeting (LT).12,13
LT used in conjunction with C-arm fluoroscopy could
prove a useful tool in complying with mandates to reduce
unnecessary radiation exposure. However, previous studies
have demonstrated equivocal findings. Conn and Hallett12
showed that a simple laser guide used in hip-fracture fixation
reduced screening time up to 40% thus limiting exposure
time. In a prospective, randomized, controlled trial, Harris
et al13 showed that a laser aiming guide did not reduce the
number of exposures or total exposure time in fluoroscopy of
several body regions in a non–case-controlled study. Our
study was designed to assess whether a laser aiming guide
for C-arm fluoroscopy would reduce the number of exposures
needed to obtain an acceptable image, thereby reducing the
total exposure time for hip, knee, and ankle fluoroscopy.
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Shuler et al J Orthop Trauma  Volume 27, Number 5, May 2013

FIGURE 1. C-arm scatter radiation:

surgeon radiation exposure during
C-arm fluoroscopy comes from 2
sources: primary (direct beam expo-
sure) and scatter radiation. Surgeon
exposure to scatter radiation increa-
ses as patients’ BMI increases (com-
pare A to B). This project used an
obese cadaver (BMI 43.6) to increase
the production of scatter radiation.
Source: An Investigation of Operator
Exposure in Interventional Radiology
permission from RadioGraphics.14

MATERIALS AND METHODS
The study protocol was approved by our Institutional
Biosafety Committee as a biosafety level BSL2. C-arm
technologists registered with the American Registry of
Radiologic Technologists at various levels of experience
(n = 16 with C-arm experience ranging from 1 year 8 months
to 28 years with average experience of 5 years 8 months)
were brought to the operating room for live C-arm fluoros-
copy image acquisition. A fresh obese cadaver (body mass
index or BMI 43.6; 122.5 kg) obtained from our Human Gift
Registry was used in all experiments. This project specifically
used an obese cadaver to increase the production of scatter or
stray radiation with PA projections used with the image
intensifier above the cadaver. The cadaver was placed supine
on a Jackson radiolucent operating room table (Mizuhosi,
Union City, CA) at a fixed table height of 36 inches
(91.5 cm) from the floor. The cadaver was covered in a cool-
ing blanket from the head to several centimeters above the
umbilicus to protect cadaver identity with an impervious body
bag used for biocontainment. The pelvis and lower extremi-
ties were exposed during the testing protocol. Towel bumps
were placed under the lateral aspect of the lower legs to
facilitate image acquisition at the ankles.
A calibrated OEC 9900 Elite C-arm (GE Healthcare,
Salt Lake City, UT) was used for image acquisition. A
removable OEC laser aimer for the 9900 Elite C-arm (GE
Healthcare) was used as the laser aiming guide with sterile
drapes not interfering with its intensity. The attachment site
for the laser was on the image intensifier. Optically stimulated
luminescence (OSL) badge dosimeters (Landauer Inc,
Glenwood, IL) were used to collect ionizing radiation doses
from the fluoroscopy. The OSL dosimeters detect x-rays
and gamma rays from 1 mrem to 1000 rem). The deep dose
(Hp10) is +/2 15% at the 95% confidence interval for
photons above 20 keV, and the shallow dose (Hp0.07) is
+/2 15% at the 95% confidence interval for photons above
20 keV. An apparatus was designed to hold the dosimeters at
fixed distances from the center of the C-arm (Fig. 2). The
apparatus fit on the C-arm image intensifier [vertically fixed
at 56 inches (142.3 cm) from the floor] and projected 4 arms
at 90-degrees from each other (45, 135, 225, and 315
degrees). The arms were radiolucent and more than 6 ft in

FIGURE 2. Detection of scatter radi-

ation during fluoroscopy with and
without LT. A, Three-dimensional
radiation detection was performed
both above and below the radiolu-
cent operating room table. Radiation
detection above the table simulated
surgeon thyroid exposure and
detection below the table simulated
surgeon gonadal exposure. B, Dos-
imeters were placed above and
below the operating room table
on radiolucent guidelines rigidly
attached to the C-arm intensifier at 1,
3, and 6 ft (30.5, 91.5, and 183 cm)
at four 90-degrees intervals. Images
used with permission from Markus
Wagner, Peter L. Reichertz Institute
for Medical Informatics, Hanover
Medical School, Germany.

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J Orthop Trauma  Volume 27, Number 5, May 2013
length. The length of these arms prevented us from obtaining
lateral images in this protocol. By rigidly attaching guidelines
to the C-arm image intensifier, distance from the center of the
radiation beam was kept constant during the horizontal C-arm
motion required to complete the testing protocol. There were
2 planes to the apparatus, one at the level of the thyroid and
one at the level of the gonads. OSL dosimeters were placed at
1, 3, and 6 ft (30.5, 91.5, and 183 cm) away from the center of
the C-arm on all 4 arms and on both planes totaling 24 dos-
imeters on the apparatus at one time. The dosimeters were
staggered on the apparatus so as not to block radiation to the
other badges. Separate sets of badges were used in the LT and
non-LT groups. A total of 56 dosimeters were used during the
testing protocol: 24 for the LT group and 24 for the non-LT
group. Eight background radiation badges were kept outside
of the operating room as controls.
Before entering the operating room, each American
Registry of Radiologic Technologist–registered radiologic
technologist was randomized to laser or non-laser use. The
technologist’s name and years of intraoperative C-arm expe-
rience were recorded. The technologist was escorted into the
operative theater with the C-arm positioned above the umbi-
licus with fixed operating room table and C-arm height used
throughout the image protocol. If randomized to laser use, the
technologist would obtain 6 PA images of the lower extrem-
ities using the laser attachment. The following 6 PA images
were obtained: (1) PA of the right hip centered at the femoral
head, (2) PA of the left knee with the knee in the center of the
film, (3) PA of the right ankle with the ankle centered, (4) PA
of the left hip centered at the femoral head, (5) PA of the right
knee with the knee in the center of the film, and (6) PA of the
left ankle with the ankle centered. The technologist used fluo-
roscopy (short taps of continuous mode with last-image hold)
to obtain the images with no manual techniques. The technol-
ogist was required to move the C-arm to each location to
obtain centered images. After the sixth image was obtained,
the technologist would then repeat the 6 images in order again
with the use of the laser. After the acquisition of 12 centered
images, the technologist would repeat acquisition of the 12
centered PA images without use of the laser. The same
sequence was followed for those who started with non-laser
use. The technologist would then leave the room and the laser
attachment would either be applied to the C-arm image
intensifier or removed depending on the technologist’s ran-
domization. The OSL badges were changed as well to reflect
the laser or non-laser group and the protocol repeated. Only
PA images were obtained during this protocol because the
size of the apparatus precluded the technologists from swing-
ing the C-arm to obtain a lateral image.
Eight technologists started the protocol in the LT group
and 8 started the protocol in the NLT group. Because the
protocol repeated image acquisition after completion of the
first set of 6 centered radiographs, there was the potential for
bias with improved image acquisition for subsequent trials.
Data collected during protocol initiation did not show
a statistically significant difference in number of images
obtained during repeat image acquisition with this assertion
confirmed following final data analysis (see discussion).
Ó 2013 Lippincott Williams & Wilkins
Laser Targeting with C-Arm Fluoroscopy
An image was considered centered and acceptable if the
joint was at the center of the monitor screen within a 4-cm
diameter (Fig. 3). Two-dimensional (x and y axis) deviations
from the center in centimeters were recorded for all images
using a template directly applied to the C-arm monitor.
Repeat image acquisition was required for noncentered
images and the number of attempts for appropriately centered
image acquisition was recorded. C-arm technologists were
not able to see measurements after image acquisition to avoid
potential bias on centered images. For noncentered images,
the technologist was asked to take another image centered
at the joint of interest. Once an acceptable image was
obtained, the technologist moved to the next body region.
Each technologist ultimately acquired 24 centered images
both with and without LT. All data were collected in a spread-
sheet for statistical analysis.
There were 4 outcomes measures assessed, (1) Does LT
decrease C-arm fluoroscopy exposure time for acceptable
centered image acquisition for a PA image series (hip, knee,
and ankle)? (2) Does LT result in a decrease in the number of
attempts for acceptable image acquisition? (3) Does C-arm
experience decrease radiation exposure and improve image
positioning accuracy either with or without LT? (4) Is there a
learning curve associated with this protocol that can
produce bias?
All data collected and analyzed were expressed as
means with statistical analysis performed using a Student t
test. A P value of ,0.05 was considered significant.
RESULTS
The number of image acquisition attempts, fluoroscopy
time, and average image distance from center for hip, knee, and
ankle fluoroscopy with and without LT is shown (Tables 1–3).
Use of LT resulted in statistically significant decreases
in the number of image attempts to obtain centered images at
the knee and ankle but not at the hip. The average distance
from center per attempt is shown (Table 3). Each image
acquired had the average distance (in centimeters) from center
calculated using the Pythagorean theorem. Statistically signif-
icant decreases were noted for the knee (4.95 vs. 3.24 cm;
NLT vs. LT) and ankle (5.75 vs. 3.57 cm; NLT vs. LT) but
not for the hip (6.56 vs. 6.03 cm; NLT vs. LT).
With use of LT, statistically significant improvements
were noted for obtaining centered images of the knee and
ankle but not of the hip (total reduction in distance from
center: hip, 8%; knee, 35%; and ankle, 38%). Although
randomization was used in trials with or without LT, we
assessed for a possible learning curve between acquisition of
centered images 1–6 (trial 1) and images 7–12 (trial 2). No
statistically significant differences were noted between the
first 6 and second 6 centered images obtained with and with-
out LT (trial 1 vs. trial 2: 423 vs. 399 images; P = 0.2651).
LT reduced the total fluoroscopy time by 19% for all 3
body regions imaged with an 81-seconds decrease in total
in-beam exposure using LT during the protocol. With the use
of LT, statistically significant decreases in fluoroscopy time
were noted for image acquisition at the knee (39% reduction)
and ankle (29% reduction) but not at the hip.
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Shuler et al J Orthop Trauma  Volume 27, Number 5, May 2013

FIGURE 3. Determination of centered fluoroscopic images. Two-dimensional determination (x and y axis) of centered fluoro-
scopic images was performed for all images captured during the protocol. In (A) and (B), a PA radiograph of the femoral head was
obtained. In (A), the hip was considered off center (27 cm x axis, +8 cm y axis). In (B), the hip was considered centered (+1 cm x
axis, 22 cm y axis). The scatter plot in (C) demonstrates that the addition of LT provided little benefit in obtaining centered hip
radiographs. In (D), the ankle was off center and in (E), the ankle was considered centered. The scatter plot in (F) demonstrates
that the addition of LT provided significant benefit in obtaining a centered ankle image.

A total of 56 OSL dosimeters were analyzed (24 from
LT, 24 from non-LT, and 8 controls). The average radiation
dose in millirem is reported for simulated thyroid and gonadal
exposure at the 1, 3, and 6 ft zones (Fig. 4). At 1 ft from center
of the radiation beam, scatter radiation was 12-fold greater in
the simulated gonadal dose (mean mrem: 66.9 NLT/68.3 LT)
than the simulated thyroid dose (mean mrem: 5.4 NLT/5.6 LT).
At 3 ft, there was a significant reduction in radiation dose and
no radiation dose was detected at 6 ft. No difference in milli-
rem dosimetry data was noted between laser and non-LT
groups. The gonadal level dosimetry badges at the 1-ft zone
had the highest radiation exposure with a total of 273 mrem
with LT and 267 mrem without LT. The thyroid level dosim-
etry badges at the 1-ft zone reported significantly less radiation
with a total of 22 mrem both with and without LT. At the 3-ft
zone, only trace amounts of radiation were detected at the
gonadal level, whereas the 6-ft zone reported zero radiation
exposure for both laser and non-laser groups. There were no
statistically significant differences in radiation doses either with
or without LT.
Technician experience (range of operating room C-arm
experience from 1 year 8 months to 28 years) did not produce
statistically significant differences in fluoroscopy time, num-
ber of image attempts, or average distance from the center.
DISCUSSION
Because the US Food and Drug Administration issued
an initiative for reducing radiation exposure, many actions
have been taken to reduce this risk to patients, surgeons, and
ancillary staff. Our study was designed to assess whether
laser-guided C-arm fluoroscopy would help reduce radiation
exposure in the operating room because previous studies have
yielded conflicting data on whether laser guidance is helpful

TABLE 1. Number of Image Attempts TABLE 2. Fluoroscopy Time in Seconds

Region No LT With LT P Region No LT With LT P
Hip 164 173 0.5129 Hip 151 161 0.4433
Knee 143 83 ,0.0001 Knee 126 77 ,0.0001
Ankle 158 100 ,0.0001 Ankle 143 101 ,0.0001
Total 465 357 ,0.0001 Total 420 339 ,0.0001

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J Orthop Trauma  Volume 27, Number 5, May 2013
TABLE 3. Average Centimeters From Center Per Attempt
Region No LT With LT P Although total fluoroscopy time was decreased by 19% using
Hip 6.56 6.03 0.1199
Knee 4.95 3.24 ,0.0001
Ankle 5.75 3.57 ,0.0001
Total 17.27 12.83 ,0.0001
with C-arm fluoroscopy.12,13 The primary method of decreas-
ing intraoperative radiation exposure is to minimize fluoros-
copy time. These data show that for common lower extremity
fluoroscopy procedures, the addition of C-arm LT helps
reduce fluoroscopy time and obtain a more centered image
with fewer attempts for knees and ankles but not for hips.
Statistically significant reductions in fluoroscopy time
were obtained following the addition of LT for the knee and
ankle (39% and 29% reduction, respectively). We observed
that the addition of LT in joints with bony landmarks (ie,
patella, medial and lateral malleoli) aided in obtaining
a centered image with deviations from center reduced 34%
for knees and 38% for ankles using LT (both statistically
significant). Without the presence of defined bony landmarks
in our protocol using an obese cadaver (BMI 43.6), it was not
surprising to note that LT did not help with image acquisition
at the hip with no statistically significant reduction in
fluoroscopy time, no reduction in number of attempts to
obtain a centered image, and no reduction in distance from
center per attempt. Support for this assertion was noted from
the statistically significant increase in the average distance
from center per attempt comparing the hip to the knee and
ankle with LT (Table 3).
It is important to highlight that fluoroscopy time
actually increased using LT for the PA of the hip (151 vs.
161 seconds). This increase in fluoroscopy time at the thickest
part of the patient would be expected to yield the highest
contribution to OSL dosimetry data because of scatter
radiation (Fig. 1). Because the hip would generate greater
FIGURE 4. Radiation OSL dosimeter data (n = 4 per location).
Scatter radiation is 0.1% of beam energy at 3 ft and 0.025% of
beam energy at 6 ft. At 1 ft, simulated gonadal dose was
12-fold greater than simulated thyroid dose. At 3 ft, there was
a significant reduction in radiation dose and no radiation dose
was detected at 6 ft.
Ó 2013 Lippincott Williams & Wilkins
Laser Targeting with C-Arm Fluoroscopy
scatter radiation than the knee or ankle, the hip is the primary
contributor to the radiation exposure in this protocol.
LT (Table 2), no difference in dosimetry data was noted
between laser and non-LT groups (Fig. 4). The increase in
fluoroscopy time at the hip using LT would be expected to
offset any decrease in radiation exposure obtained by decreas-
ing fluoroscopy time at the knee or ankle. If different OSL
dosimeters were used for each body region studied in this
protocol (hip, knee, and ankle), a decrease in fluoroscopy time
would be expected to produce a decrease in radiation expo-
sure. To reemphasize, in clinical practice, the best way to
decrease radiation exposure with C-arm fluoroscopy is to
decrease fluoroscopy time.
Our protocol simulated gonadal and thyroid radiation
exposure. A statistically significant increase in exposure was
noted for the gonadal region versus thyroid at the 1- and 3-ft
zones. These results were expected because of the effect of
scatter radiation and were shown in a previous report
(Fig. 1).8,14 As x-rays travel through matter, scatter radiation
is produced. Increasing the amount of matter through which
x-rays travel increases the scatter radiation. In addition,
increased scatter radiation was generated in the protocol
because of the length of fluoroscopy time.
Crawford et al15 showed that the average fluoroscopy
time for various orthopaedic trauma cases (ie, intramedullary
nailing of femurs and tibias) ranged from 1.5 to 2.23 minutes
depending on the case. Our total fluoroscopy time
(12.65 minutes; 7 minutes NLT, 5.65 minutes LT) is about
6 times higher than an average orthopaedic trauma case. In
a 1997 report by Mehlman and DiPasquale,8 a 10-minute
C-arm exposure was used to establish the “3-ft rule,” where
there was no detection of radiation at neck and waist level. It
should be emphasized that the previous 1997 report had a limit
of detection of 10 mrem with this report using a limit of 1
mrem. Our data demonstrated that, at 3 ft, there was only 1
mrem of radiation detected at the thyroid level and a total of
10 mrem detected at the gonadal level for 12.65 minutes of
total fluoroscopy time. The previous report reinforced the use
of personal radiation protection for “individuals working 24
inches (70 cm) or less from a fluoroscopic x-ray beam.”8 With
improved sensitivity in this study, personal radiation protec-
tion should be worn even if greater than 3-ft away from the
C-arm radiation source.
LT helped with imaging knees and ankles with
statistically significant reductions in fluoroscopy time and
a statistically significant improvement of image quality
defined as obtaining a centered PA image faster. The
dosimetry badges detected minimal exposure at 3 ft and no
detectable exposure at 6 ft at both levels.
ACKNOWLEDGMENTS
The authors would like to thank Nina Clovis and
Suzanne Smith for their help with cadaveric acquisition and
manuscript review. They would like to thank Jackie Sions,
Myra Jo Beach, and Brian Grose for granting them access to
the operating room to complete this research project. The
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Shuler et al
Radiation Safety Office and Nasser Razmianfar provided the
dosimeters and a project specific radiation dosimetry report.
Dr Gerald Hobbs performed statistical analysis. The authors
thank Dee Headley for allowing them access to a C-arm unit
and providing the licensed technicians to complete this
project. Specifically, they would like to thank Lauren Beiter,
Donna Bindernage, Amanda Brenneman Shelby Chasko,
Ashley Clutter, Kevin Doorley, David Fries, Melissa
May, Valerie Moyer, Luvinia Rice, Kirk Rogozinksi,
Geoffrey Rozak, Gina Short, Stephanie Sinsel, Abbey Swiger,
and Melinda Wright for participation in this experiment. They
thank Markus Wagner for permission to use Figure 2 and
RadioGraphics and Beth Schueler for permission to use the
diagram in Figures 1 and 4.
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