ReviewCortical bone drilling and thermal osteonecrosis
Introduction
Most articles concerning drilling are published in engineering journals, but the question is if those are applicable in medical practice. Most of research, focused on bone drilling, is done in dentistry. Nevertheless, there is significant number of orthopedic/traumatologic articles concerning drilling but some contradictions are still present. In this review the literature is summarized with intention to define parameters affecting the quality of cortical bone drilling, primarily heat transfer and heat induced damage to the bone.
With the development of modern surgery, bone drilling became a common step of an everyday procedure in orthopedics/traumatology and dentistry. Frictional heat from these operations may result in thermal necrosis of bone. In respect to current fracture fixation principles or reconstructive surgery, every loosening of implants in bone is adverse side effect. The implant failure rate for lower leg osteosynthesis is 2–7% (Augustin et al., 2007) and is higher compared to upper extremity due to physiologic stress during locomotion.
Many parameters influence loosening of bone–implant interface. One of them is thermal osteonecrosis explained in the section Thermal osteonecrosis. Bone temperature must be below the temperature of 47 °C during drilling to avoid thermal osteonecrosis (Eriksson and Adell, 1986, Eriksson and Albrektsson, 1984). Various parameters have been studied to reduce heat generation during bone drilling, including variations in drill design, drilling parameters and coolant delivery. Many factors contribute to heat generation during drilling but many articles focused only on a single or only several parameters of this rather complicated issue. However, there is lack of unity regarding the optimal combination of drill design, drilling process and coolant delivery. The ideal method for determining the bone temperature during drilling is difficult to define because bone is a complex anisotropic biological tissue, with organic and inorganic components. The interaction of the different components accounts for its complex mechanical and thermological properties which are difficult to study due to sensitivity to testing conditions and specimen preparation (Zelenov, 1985).
Section snippets
Historical remarks
Bone drilling is not a novelty in medicine. Human skeletons from ancient civilizations show surgically perforated holes in their skulls. Bone drilling was described in ancient Egyptian, Greek and Roman medicine. Accelerated development of medicine in late 19th and 20th century, due to asepsis, anesthesia/analgesia and antibiotics, led to blooming of dentistry and traumatology/orthopedics, two fields which demanded research on bone drilling. Initial studies of thermal changes during teeth
Bone drilling parameters
These parameters do not influence temperature rise and drilling efficiency independently — drilling parameters are interrelated. Therefore, absolute values of temperature rise in different articles should be considered carefully, taking in account the experimental setup — i.e. experiments were conducted 1) at room temperature, 2) at body temperature in a tank of solution and 3) with or without substitute for cooling effect of circulating blood. Regarding this, the principles of influence of the
Temperature measurement
Heat is thermal energy transferred between a system and its surroundings. The heat transfer can take place by three different mechanisms:
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Conduction — Thermal energy is transferred through the substance of the system.
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Convection — Thermal energy is transferred by relative motion of components of the system.
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Radiation — Thermal energy is transferred directly between separated parts of the system by electromagnetic radiation.
The heat generated during drilling of bone comes from the drilling process.
Historical remarks
Thermal
Future directions
This review analyzes the most influential factors on heat generation during bone drilling, and summarizes general standpoints of medical research. There are still some controversies, which will be a material for future experiments. Also there are some factors which are still unknown, or insufficiently examined.
Drill guide. A conclusion of study by Misir et al. (2009) is that preparation of an implant site using surgical drill guide generates more heat than preparation without drill guide
Conflict of interest
None.
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- 1
Department of Surgery, University Hospital Center Zagreb, Kišpatićeva 12, 10000 Zagreb, Croatia.
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Department of Surgery, University Hospital Center Zagreb and School of Medicine University of Zagreb, Kišpatićeva 12, 10000 Zagreb, Croatia.
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Department of Technology, Chair of Machine Tools, Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Ivana Lučića 5, 10000 Zagreb, Croatia.
- 4
Department of Robotics and Production System Automation, Chair of Engineering Automation, Faculty of Mechanical Engineering and Naval Architecture, University of Zagreb, Ivana Lučića 5, 10000 Zagreb, Croatia.
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Department of Traumatology, Clinical Hospital Center Sestre Milosrdnice (Traumatology Clinic), Draškovićeva 19, 10000 Zagreb, Croatia.