Noise-Induced Hearing Loss: Should Surgeons Be Wearing Ear Protection During Primary Total Joint Arthroplasty?

Abstract

Background:

The risk of noise-induced hearing loss (NIHL) to orthopedic surgeons due to occupational exposures is unknown. A level of 85 decibels (dB) over an 8-hour time-weighted average (TWA) is considered hazardous.

Question/Purpose:

We sought to identify whether manual and/or robotic arthroplasty procedures increase surgeons’ risk of developing NIHL.

Methods:

At our institution, we prospectively collected intraoperative recordings with a microphone attached to the surgeon during manual total knee arthroplasty (TKA), manual total hip arthroplasty (THA), and robotic-assisted total knee arthroplasty (RTKA). Recordings taken in the operating room without operating room staff present served as baseline controls. The 172 recordings consisted of 46 baseline, 42 THA, 40 TKA, and 44 RTKA recordings. Decibel levels were reported as “maximum dB level” (the highest sound pressure level using an A-weighted dB scale), “LA_eq” (the equivalent continuous sound level), “LC_peak” (the peak sound pressure level using a C-weighted dB scale), and “TWA” (the average dB level projected over an 8-hour period). The percentage of allowable daily noise dose was reported as “dose” and the measured dose projected over 8 hours as “projected dose.”

Results:

The recordings of surgeries had average maximum dB levels ranging from 106.0 to 108.0 dB, all significantly greater than controls. Robotic-assisted total knee arthroplasties had the highest average dose (18.7%) and average projected dose (252.0%).

Conclusions:

Our review of recordings at a single institution found that noise levels of RTKAs surpassed projected doses of 100%. Orthopedic surgeons performing more than 2 RTKAs per day may be at increased risk of NIHL. Further research is needed to assess the effectiveness of measures such as ear protection to minimize surgeons’ exposure.

Keywords

noise-induced hearing loss decibel orthopedics adult reconstruction

Introduction

Exposure to elevated levels or prolonged durations of noise can cause a temporary decrease in hearing sensitivity that typically returns to normal. However, repeated insults to the cochlea can cause permanent damage and irreversible noise-induced hearing loss (NIHL) [20]. The National Institute for Occupational Safety and Health (NIOSH) has a recommended exposure limit (REL) for occupational noise of 85 decibels (dB) averaged over an 8-hour period. Exposures at or above this REL are considered hazardous [20]. Furthermore, sound pressure levels generated by impulsive (impact) noises (such as 2 metal objects striking each other) are considered more harmful than continuous noises and should be limited, according to the Occupational Safety and Health Administration (OSHA) [21]. Previous studies investigating the hazard of noise exposure in orthopedic surgery have shown conflicting results on risk to surgeons [3,12,16,18,25,30].

Orthopedic surgery makes use of instruments that routinely create high dB levels [14,16,18], some shown to generate levels greater than 85 dB [13,14,16,18,19,28,29]. During total joint arthroplasty (TJA), surgeons frequently use mallets and saws, which can produce 113 and 109.8 dB, respectively [30]. In manual TJA, the intraoperative noise exposure for adult reconstruction procedures has been shown to have an average maximum dB level (MDL) of 102.0, although measures to protect surgeons’ hearing have not been widely adopted [13], and there are limited data collected on the magnitude of noise during robotic TJA procedures [10]. Some recordings have reported elevated noise levels during robotic surgery but were not performed within the surgeons’ hearing zone (a 2-foot-wide sphere around the head) [21]. As the use of robotics in TJA rises, further investigation is needed into the risk of NIHL for surgeons [2,11,24].

Protective measures should be pursued if intraoperative noise levels exceed REL, as NIHL impedes communication and carries an associated risk of cognitive dysfunction [7,22,27]. The purpose of this study was to (1) determine whether primary TJA generates noise levels placing orthopedic surgeons at risk for developing NIHL and (2) establish whether robotic TJA places surgeons at an elevated risk for NIHL.

Methods

Following institutional review board approval, we prospectively collected intraoperative audio recordings for manual total knee arthroplasty (TKA), manual total hip arthroplasty (THA), and robotic-assisted total knee arthroplasty (RTKA) at a single institution. Three adult reconstruction surgeons were included, 1 who performed both manual and robotic TJA (surgeon A) and 2 who performed only manual TKA and THA (surgeons B and C). A total of 172 recordings were made according to an a priori power analysis, assuming an effect size of 0.25, 3 groups, a power of 80%, and an alpha of 0.05.

Recordings were collected using an iMM-6 calibrated external microphone attached to an Apple iOS device with the Sound Level Meter (SLM) application developed by NIOSH. Baseline noise levels were recorded using 30-second sound recordings (based on SLM recommendations for constant noise), with the microphone at the center of an empty operating room prior to surgical start time, with only ventilations systems and monitors audible in the background. Based on the a priori power analysis, we collected 40 baseline recordings prior to each case; these were used as control measurements. Intraoperatively, noise levels were recorded with the microphone attached to the surgeon’s collar (within the hearing zone). These recordings began prior to scrubbing and ended with removal of the surgical gown.

Metrics including duration of surgery, MDL, LA_eq (the equivalent continuous sound level), LC_peak (the peak sound pressure level using a C-weighted dB scale), time-weighted average (TWA), dose, and projected dose were recorded using the SLM application. These were reported in an A-weighted dB scale (dBA), which are frequencies detectable to the human ear, with the exception of LC_peak, reported using a C-weighted dB scale (dBC) that includes frequencies the human ear may not perceive but contribute to overall noise. For example, dBC is ideal for short duration sounds of low or high frequency, such as a mallet striking a broach.

The MDL was defined as the highest sound pressure level during a recording in dBA. In contrast, LC_peak was defined as the peak sound pressure level during a given recording in dBC. LA_eq was the average continuous sound level reported in dBA during the recording. The TWA used the average sound level during the recording to predict what the average sound level would be for an 8-hour period, reported in dBA. Dose was reported as a percentage of the maximum allowed daily noise, similar to a medication dose where exposures above 100% are considered hazardous. Projected dose uses the recorded dose to project the dose if an individual was exposed to that level of noise for an 8-hour period (Table 1).

Table 1.

Definitions for noise measurement metrics.

Metric	Definition
Maximum decibel level (MDL)	Highest sound pressure level during the recording period in A-weighted dB
LC_peak	Highest sound pressure level during the recording period in C-weighted dB
LAeq	Average sound pressure level during the recording period in A-weighted dB
Time-weighted average (TWA)	Average sound pressure level during the recording period calculated for an 8-hour time period
Dose	Percentage of allowable daily noise where exposures above 100% are considered hazardous
Projected dose	Dose for a recording period calculated for an 8-hour time period

MDL maximum decibel level, TWA time-weighted average.

Independent t-test for parametric data and the Mann-Whitney test for nonparametric data were used to compare baseline and TJA recordings. The Bonferroni method was used to correct the bias due to multiple testing for pairwise comparisons that was checked with the use of the Fligner-Killeen test. Unadjusted and adjusted multivariable generalized linear model regressions were run utilizing TWA as the dependent outcome. A threshold of P < .05 and a variance inflation factor of < 5 were used to advance factors to the adjusted multivariable generalized linear model. These factors included MDL, LC_peak, LA_eq, TWA, dose, and projected dose. The results are presented as point estimates with 95% confidence intervals (CIs). All statistical analyses were performed with use of R (version 3.6.3).

Results

Of the 172 recordings collected and analyzed, 46 were baseline recordings (26.7%) and 126 were surgical recordings (74.3%). Surgical recordings included 42 THA (24.4%), 40 TKA (23.2%), and 44 RTKA (25.6%). Surgical recordings were significantly louder than the control, baseline recordings for MDL, LC_peak, LA_eq, TWA, dose, and projected dose (Table 2). All cases had an MDL >95 dBA (Table 3). Surgeon A had a significantly greater MDL, LC_peak, LA_eq, TWA, dose, and projected dose than both surgeon B and surgeon C, with the exception of LC_peak when compared to surgeon C (Table 4).

Table 2.

Maximum decibel level, LC_peak, LA_eq, TWA, dose, and projected dose for baseline and total joint arthroplasty.

	Baseline	Recordings
	N = 46	N = 126	P-value
Maximum dB level	84.8 (10.4)	106 (5.1)	<.001
LC_peak (dBC)	110 (14.9)	123 (4.7)	<.001
LA_eq (dB)	65.5 (4.6)	84.0 (4.5)	<.001
TWA (dB)	33.4 (5.5)	73.5 (4.0)	<.001
Dose (%)	0.00 (0.0)	10.5 (12.2)	<.001
Projected Dose (%)	0.47 (0.4)	128 (178)	<.001

TWA time-weighted average.

Table 3.

Maximum decibel level, LC_peak, LA_eq, time-weighted average, dose, and projected dose for manual THA, manual TKA, and robotic TKA.

	THA		TKA		TKA (ROBOT)
	N = 42		N = 40		N = 44
	Mean +/- SD	95% CI	Mean +/- SD	95% CI	Mean +/- SD	95% CI
Maximum dB level (dB)	106 (3.6)	[105,107]	103 (3.4)	[102,104]	108 (6.1)	[107,110]
LC_peak	125 (2.2)	[124,125]	123 (2.9)	[122,124]	122 (6.9)	[119,124]
LA_eq	82.8 (3.9)	[81.6,84.0]	80.6 (3.0)	[79.6,81.5]	88.2 (2.4)	[87.5,88.9]
TWA (dB)	72.5 (3.6)	[71.4,73.6]	70.(3.2)	[69.7,71.8]	76.9 (2.4)	[76.1,77.6]
Dose (%)	7.36 (5.9)	[5.5,9.2]	4.89 (3.9)	[3.64,6.1]	18.7 (16.8)	[13.6,23.8]
Projected dose (%)	81.2 (76.2)	[57.5,105]	39.6 (39.9)	[26.852.4]	252 (244)	[178,326]

CI confidence interval, THA total hip arthroplasty, TKA total knee arthroplasty, SD standard deviation, TWA time-weighted average.

Table 4.

Comparison of maximum decibel level, LC_peak, LA_eq, time-weighted average, dose, and projected dose between surgeons; levels are presented as mean and standard deviation (SD).

				P-Value
Surgeon	A (N = 70)	B (N = 28)	C (N = 28)	A vs B	A vs C	B vs C
Mean (SD)
Maximum dB level (dB)	108 (5.27)	105 (4.21)	103 (2.86)	.005	<.001	.331
LC_peak	122 (5.67)	125 (2.68)	123 (2.74)	.014	.957	.085
LA_eq	87.4 (2.39)	79.9 (2.84)	79.4 (1.63)	<.001	<.001	.714
TWA (dB)	76.0 (2.49)	70.5 (3.61)	70.0 (2.62)	<.001	<.001	.740
Dose (%)	0.16 (0.14)	0.05 (0.04)	0.04 (0.02)	<.001	<.001	.908
Projected dose (%)	2.08 (2.05)	0.33 (0.26)	0.21 (0.11)	<.001	<.001	.953

SD standard deviation, TWA time-weighted average.

The RTKA had the highest average MDL, followed by THA. The TKA had the lowest MDL; in fact, it was 5.0 dBA lower than the average MDL for TKA. The average LC_peak was the highest for THA; it was 2.0 and 3.0 dBC greater than the average LC_peak for TKA and RTKA, respectively. The average LA_eq was the highest for RTKA; it was 5.4 dBA greater than the average LA_eq for THA and 7.6 dBA greater than the average LA_eq for TKA. The average TWA was the highest for RTKA, then THA, and the lowest for TKA (Table 3).

The average dose was the highest for RTKA, then THA, and the lowest for TKA with an average of 18.7% (95% CI = 13.6% to 23.8%), 7.4% (95% CI = 5.5% to 9.2%), and 4.9% (95% CI = 3.5% to 6.1%), respectively. Finally, the average projected dose exceeded 100% for RTKA, but not for THA or TKA. Averaged projected dose was 252.0% (95% CI = 178.0% to 326.0%) for RTKA, 81.2% (95% CI = 57.5% to 105.0%) for THA, and 39.6% (95% CI = 26.8% to 52.4%) for TKA.

The overall highest MDL was 130.1 dBA for an RTKA. The highest overall LC_peak was 129.6 dBC for a TKA. One RTKA had the highest LA_eq (96.0 dBA), TWA of (84.5 dBA), dose (89.0%), and projected dose (1265.3%). Thirteen THA cases exceeded a projected dose of 100%. Three TKA cases exceeded a projected dose of 100.0%. All RTKAs except for one exceeded a projected dose of 100.0%.

The TWA remained significantly greater for TKA, THA, and RTKA recordings compared to the baseline recordings when adjusted for MDL, LA_eq, dose, and projected dose (P = < .001; Table 5). Three variables were found to be a significant predictor of TWA for THA, TKA, and RTKA, which consisted of LA_eq, dose, and projected dose (P < .001; Table 6). A 1 dBA increase in LA_eq was found to increase TWA by 0.9, 1.1, and 0.9 for THA, TKA, and RTKA, respectively. A 1% increase in dose correlated with a 0.5, 0.5, and 0.2 dBA increase in TWA for THA, TKA, and RTKA, respectively. A 1% decrease in projected dose was found to decrease TWA by 0.04, 0.05, and 0.01 for THA, TKA, and RTKA, respectively.

Table 5.

Unadjusted and adjusted multivariable generalized linear regressions for TWA.

	TWA			TWA
Predictors	Estimates	CI	P	Estimates	CI	P
Baseline	40.1	38.6 to 41.6	<.001	30.7	28.0 to 33.4	<.001
Maximum dB level (dB)				0.02	–0.1 to 0.1	.734
LC_peak				–0.1	–0.1 to 0.02	.126
LAeq				0.4	0.3 to 0.6	<.001
Dose (%)				0.4	0.2 to 0.7	.001
Projected dose (%)				–0.02	–0.04 to 00.0	.022

CI confidence interval, TWA time-weighted average.

Table 6.

Factors associated with TWA for each subspecialty.

	THA			TKA			TKA Robot
Predictors	Estimates	CI	P	Estimates	CI	P	Estimates	CI	P
Maximum dB level (dB)	–0.01	–0.1 to 0.1	.868	–0.06	–0.2 to 0.03	.200	0.01	–0.02 to 0.04	.394
LC_peak	0.02	–0.1 to 0.1	.768	0.07	–0.02 to 0.17	.112	0.02	–0.02 to 0.1	.293
LAeq	0.93	0.8 to 1.0	<.001	1.1	0.81 to 1.40	<.001	0.9	0.7 to 1.1	<.001
Dose (%)	0.52	0.41 to 0.63	<.001	0.5	0.34 to 0.59	<.001	0.2	0.1 to 0.2	<.001
Projected dose (%)	–0.04	–0.05 to –0.03	<.001	–0.1	–0.1 to –0.03	<.001	–0.01	–0.01 to –0.01	<.001

CI confidence interval, THA total hip arthroplasty, TKA total knee arthroplasty.

Discussion

Noise-induced hearing loss can impact a surgeon’s work performance as it can impair ability to appreciate communication cues such as equipment sounds [4]. We found that for 3 surgeons at a single institution, TJA noise levels were routinely at, or above, NIOSH recommendations. Furthermore, we found increased occupational noise exposure associated with RTKA compared with TKA.

This study is not without limitations. First, although we attempted to control for standard background noise, additional confounding noise may have altered the microphone readings. Nonetheless, our study provides a realistic sound level in an operating theater. Second, we tested the exposure levels only of the operative surgeon and not those of the other operating room staff or the patient. However, the surgeon was closest to the instrumentation and therefore represented the person most at-risk of excessive noise exposure. Third, we do not perform robotic THA at our institution and our study only reported manual THA metrics, but we presume that robotic THA would create noise exposures similar to those of RTKA.

Instruments in the operating room have demonstrated reaching dB levels ranging from 85 to 142 dB, including those regularly employed during orthopedic surgery [19,25,28]. Total joint arthroplasty procedures frequently require the use of powered instruments that have been found to generate greater than 84 to 88 dB, but the type of noise can vary widely during TJA and requires different measurements to assess the risk to orthopedic surgeons [19]. LA_eq measured using an A-weighted filter has been shown to be a more appropriate measure for steady state noise, such as suction [23,26]. Comparatively, LC_peak measured using a C-weighted filter is more appropriate for measuring the peak sound pressure level for impulsive sounds, such as a mallet striking an impactor [23,26]. A study by Mäntysalo and Vuori [17] demonstrated that impulse noise negatively affected participants’ hearing after a shorter exposure compared with those exposed to a continuous noise.

Hönecke et al [10] used a microphone placed 1.5 m from the surgical site and found that RTKA exceeded NIOSH recommendations after adjusting for the distance of the microphone from the field. Our study confirmed that RTKA routinely exceeded NIOSH sound recommendations when using a microphone placed within the surgeon’s hearing zone. All RTKAs were performed by 1 surgeon using 1 RTKA system. The main surgical difference between the TKA and RTKA procedures was the use of the robotic arm to perform cuts, which was likely the greatest contributor to the significant difference in noise between the 2 procedures. Furthermore, compared with the 2 surgeons who performed manual TJA, the surgeon who routinely performed RTKA had significantly greater measurements for all variables except LC_peak. Love [16] found similar MDL for THA and TKA, but they did not measure RTKA. We found that compared with THA or TKA, RTKA was greater for all variables with the exception of LC_peak, which was the highest for THA. Levey et al [15] noted that an instantaneous noise greater than 120 dB is damaging to the ear, and previous studies have demonstrated the threshold for LC_peak to be 140 dB and LA_eq to be 85 dB [10]. Mäntysalo et al demonstrated that brief noise impulses such as those measured on LC_peak can cause significantly more damage than steady-state noise, which was confirmed by subsequent studies [17,26].

On average, RTKA exceeded an LA_eq of 85 dB compared with manual THA and TKA, contradicting previous findings by Hönecke et al [10] that RTKA did not present a greater risk than manual TKA. Furthermore, the average dose for RTKA was 18.67%, meaning a surgeon would exceed their daily noise dose in 5 to 6 RTKAs, but the highest dose for 1 case was 89.00% meaning that a surgeon could only perform 2 RTKAs before exceeding their allowable dose. Interestingly, THA has the highest LC_peak compared with RTKA which had the lowest LC_peak. Each measurement was a continuous sound recording, and we were unable to isolate the specific instruments or steps that generated the greatest dB levels. We suspect that manual impact of instruments leads to a high LC_peak seen in TKA and THA compared with RTKA. For TKA, this is likely from saws hitting the metal cutting guides during the cuts for the femur, tibia, and patella or mallets striking impactors for trialing and final implantation. During THA, these findings may rise from the saw during the femoral neck cut or the mallet striking the impactor during placement of the acetabulum shell or during broaching of the femur. Comparatively, LA_eq was found to be highest in RTKA, which may represent the continuous noise emitted from the robotic arm and saw blade while engaged as the RTKA does not use a cutting guide.

Hearing loss is a leading cause of disability; for surgeons, NIHL can have significant implications [4,5,6,31]. Hearing impairment directly affects communication, and communication failures are one of the greatest contributors to medical error in the operating room [8,9]. During TJA, communication is paramount as any misunderstanding could have serious consequences for the patient. Furthermore, Adams et al [1] demonstrated that speech intelligibility is impacted by the use of surgical helmets. We found that manual TJA created impulse noise from instruments striking each other and RTKA created continuous noise likely attributable to the robotic arm and saw.

However, there is no simple solution to minimize intraoperative noise exposure for surgeons. Ideally, hearing protection would be worn throughout the duration of the case, but this would provide a significant barrier to effective communication and place the staff and patient at risk for other injury. Flat attenuating hearing protection could be worn temporarily when impulse/continuous noise was being generated, but that could potentially prolong case duration to insert/remove hearing protection and risk breaking sterility. Furthermore, it would not protect against all noise exposure during a case. Headsets with a microphone would avoid negatively affecting communication but could interfere with surgical helmets. Technologic advancements to produce instruments that generate less overall sound pressure require time to develop and produce but would likely provide surgeons with the most benefit as they would serve to reduce overall sound during TJA.

In conclusion, our findings suggest that performing multiple TJAs, especially RTKAs, per day may expose orthopedic surgeons to noise above the maximum recommended levels, possibly increasing their risk of NIHL. The best strategies for minimizing noise exposures to arthroplasty surgeons requires further study.

Supplemental Material

sj-docx-1-hss-10.1177_15563316241254352 – Supplemental material for Noise-Induced Hearing Loss: Should Surgeons Be Wearing Ear Protection During Primary Total Joint Arthroplasty?

Supplemental material, sj-docx-1-hss-10.1177_15563316241254352 for Noise-Induced Hearing Loss: Should Surgeons Be Wearing Ear Protection During Primary Total Joint Arthroplasty? by Stephanie A. Kwan, Alvin C. Ong, Rex W. Lutz, Vincent W. Lau, Adam J. Santoro and Gregory K. Deirmengian in HSS Journal®

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Supplemental material, sj-docx-2-hss-10.1177_15563316241254352 for Noise-Induced Hearing Loss: Should Surgeons Be Wearing Ear Protection During Primary Total Joint Arthroplasty? by Stephanie A. Kwan, Alvin C. Ong, Rex W. Lutz, Vincent W. Lau, Adam J. Santoro and Gregory K. Deirmengian in HSS Journal®

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sj-docx-3-hss-10.1177_15563316241254352 – Supplemental material for Noise-Induced Hearing Loss: Should Surgeons Be Wearing Ear Protection During Primary Total Joint Arthroplasty?

Supplemental material, sj-docx-3-hss-10.1177_15563316241254352 for Noise-Induced Hearing Loss: Should Surgeons Be Wearing Ear Protection During Primary Total Joint Arthroplasty? by Stephanie A. Kwan, Alvin C. Ong, Rex W. Lutz, Vincent W. Lau, Adam J. Santoro and Gregory K. Deirmengian in HSS Journal®

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Supplemental material, sj-docx-4-hss-10.1177_15563316241254352 for Noise-Induced Hearing Loss: Should Surgeons Be Wearing Ear Protection During Primary Total Joint Arthroplasty? by Stephanie A. Kwan, Alvin C. Ong, Rex W. Lutz, Vincent W. Lau, Adam J. Santoro and Gregory K. Deirmengian in HSS Journal®

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Supplemental material, sj-docx-5-hss-10.1177_15563316241254352 for Noise-Induced Hearing Loss: Should Surgeons Be Wearing Ear Protection During Primary Total Joint Arthroplasty? by Stephanie A. Kwan, Alvin C. Ong, Rex W. Lutz, Vincent W. Lau, Adam J. Santoro and Gregory K. Deirmengian in HSS Journal®

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Supplemental material, sj-docx-6-hss-10.1177_15563316241254352 for Noise-Induced Hearing Loss: Should Surgeons Be Wearing Ear Protection During Primary Total Joint Arthroplasty? by Stephanie A. Kwan, Alvin C. Ong, Rex W. Lutz, Vincent W. Lau, Adam J. Santoro and Gregory K. Deirmengian in HSS Journal®

Footnotes

Acknowledgements

The authors thank Kerri-Anne Ciesielka, MPH, for her assistance in data analysis and interpretation.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: SAK DO, RWL DO, AJS DO, and VWL DO declare no potential conflicts of interest. ACO, MD, reports relationships with Stryker and Smith and Nephew. GKD, MD, reports relationships with Zimmer Biomet, Synthes, CD Diagnostics, Biostar Ventures, Trice, JBJS, and JOA.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.

Informed Consent

Informed consent was obtained from the subjects included in this study.

Level of Evidence

Level III, prospective review.

Required Author Forms

Disclosure forms provided by the authors are available with the online version of this article as supplemental material.

ORCID iDs

Stephanie A. Kwan

Rex W. Lutz

Adam J. Santoro

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