Review
Cortical bone drilling and thermal osteonecrosis

https://doi.org/10.1016/j.clinbiomech.2011.10.010Get rights and content

Abstract

Background

Bone drilling is a common step in operative fracture treatment and reconstructive surgery. During drilling elevated bone temperature is generated. Temperatures above 47 °C cause thermal osteonecrosis which contributes to screw loosening and subsequently implant failures and refractures.

Methods

The current literature on bone drilling and thermal osteonecrosis is reviewed. The methodologies involved in the experimental and clinical studies are described and compared.

Findings

Areas which require further investigation are highlighted and the potential use of more precise experimental setup and future technologies are addressed.

Interpretation

Important drill and drilling parameters that could cause increase in bone temperature and hence thermal osteonecrosis are reviewed and discussed: drilling speed, drill feed rate, cooling, drill diameter, drill point angle, drill material and wearing, drilling depth, pre-drilling, drill geometry and bone cortical thickness. Experimental methods of temperature measurement during bone drilling are defined and thermal osteonecrosis is discussed with its pathophysiology, significance in bone surgery and methods for its minimization.

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:

  • Conduction — Thermal energy is transferred through the substance of the system.

  • Convection — Thermal energy is transferred by relative motion of components of the system.

  • 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.

References (104)

  • M.G. Conzemius et al.

    A new animal model of femoral head osteonecrosis: one that progresses to human-like mechanical failure

    J. Orthop. Res.

    (2002)
  • S.R.H. Davidson et al.

    Measurement of thermal conductivity of bovine cortical bone

    Medical Engineering & Physics

    (2000)
  • J. Dörr et al.

    ‘In-situ’ temperature measurement to determine the machining potential of different tool coatings

    Surf. Coat.Technol.

    (2003)
  • R.A. Eriksson et al.

    Temperatures during drilling for the placement of implants using the Osseo integration technique

    J. Oral Maxillofac. Surg.

    (1986)
  • R.A. Eriksson et al.

    The effect of heat on bone regeneration: an experimental study in the rabbit using the bone growth chamber

    J. Oral Maxillofac. Surg.

    (1984)
  • J.R. Field et al.

    Bone blood flow response to surgical trauma

    Injury

    (2002)
  • J.P.M. Frölke et al.

    The assessment of cortical heat during intramedullary reaming of long bones

    Injury

    (2001)
  • J.E. Goetz et al.

    The apparent critical isotherm for cryoinsult-induced osteonecrotic lesions in emu femoral heads

    J. Biomech.

    (2008)
  • F. Karaca et al.

    Influence of orthopaedic drilling parameters on temperature and histopathology of bovine tibia: an in vitro study

    Medical Engineering & Physics

    (2011)
  • S. Karmani

    The thermal properties of bone and the effects of surgical intervention

    Current Orthopaedics

    (2006)
  • S. Karmani et al.

    The design and function of surgical drills and K-wires

    Current Orthopedics

    (2004)
  • W.R. Krause et al.

    Temperature elevations in orthopaedic cutting operations

    J. Biomech.

    (1982)
  • A.F. Misir et al.

    Effect of surgical drill guide on heat generated from implant drilling

    Journal of Oral and Maxillofacial Surgery

    (2009)
  • R.W. Moss

    Histopathologic reaction of bone to surgical cutting

    Oral Surg. Oral Med. Oral Pathol.

    (1964)
  • P. Müller-Hummel et al.

    Infrared temperature measurement on diamond-coated tools during machining

    Diamond Relat. Mater.

    (1994)
  • B.Z. Roitberg et al.

    UltraPower surgical drill system evaluation

    Surg. Neurol.

    (1997)
  • M. Sharawy et al.

    Heat generation during implant drilling: the significance of motor speed

    J. Oral Maxillofac. Surg.

    (2002)
  • S. Spatz

    Early reaction in bone following the use of burs rotating at conventional and ultra speeds

    Oral Surg. Oral Med. Oral Pathol.

    (1965)
  • M.B. Abouzgia et al.

    Temperature rise during drilling through bone

    Int. J. Oral Maxillofac. Implants

    (1997)
  • J. Aerssens et al.

    Interspecies differences in bone composition, density and quality: potential implications for in vivo bone

    Endocrinology

    (1998)
  • K. Alam et al.

    Measurements of surface roughness in conventional and ultrasonically assisted bone drilling

    Am. J. Biomed. Sci.

    (2009)
  • R. Anderson et al.

    Sequele of transfixation of bone

    Surgery

    (1943)
  • D. Anderson et al.

    Preliminary investigation of the temperature produced in Burring

    Br. Dent. J.

    (1942)
  • G. Augustin et al.

    Thermal osteonecrosis and bone drilling parameters revisited

    Arch. Orthop. Trauma Surg.

    (2007)
  • G. Augustin et al.

    Determination of spatial distribution of increase in bone temperature during drilling by infrared thermography: preliminary report

    Arch. Orthop. Trauma Surg.

    (2009)
  • R. Baron et al.

    Bone resorption

  • C.O. Bechtol

    A modified hand drill

    J. Bone Joint Surg. Am.

    (1956)
  • C.O. Bechtol et al.

    Metals and engineering in bone and joint surgery

    (1959)
  • A.T. Berman et al.

    Thermally induced bone necrosis in rabbits: relation to implant failure in humans

    Clin. Orthop.

    (1984)
  • S. Biyikli et al.

    Measurements of thermal properties for human femora

    J. Biomed. Mater. Res.

    (1986)
  • M.J. Bolland et al.

    Bilateral femoral head osteonecrosis after septic shock and multiorgan failure

    J. Bone Miner. Res.

    (2004)
  • P.J. Boyne

    Histologic response of bone to sectioning by high-speed rotary instruments

    J. Dent. Res.

    (1966)
  • D.L. Brisman

    The effect of speed, pressure, and time on bone temperature during the drilling of implant sites

    Int. J. Oral Maxillofac. Implants

    (1996)
  • A. Burstein et al.

    Bone strength, the effect of screw holes

    J. Bone Joint Surg. Am.

    (1972)
  • J.L. Canteroa et al.

    Dry drilling of alloy Ti–6Al–4V

    Int. J. Mach. Tool Manuf.

    (2005)
  • G. Cordioli et al.

    Heat generation during implant site preparation: an in vitro study

    Journal of Oral and Maxillofacial Implants

    (1997)
  • U. Cucuel et al.

    Des Vis Metalliques Enfoncees dans le Tissue des Os, pour le Traitment de Certaines Fractures

    Revue de Medecine et Chirurgie Paris

    (1850)
  • Z.H. Dailiana et al.

    Femoral head osteonecrosis with the use of cryosurgery — a new canine model

  • S.R.H. Davidson

    Heat transfer in bone during drilling. A thesis submitted in conformity with the requirements for the degree of Master of Applied Science

  • C. Ercoli et al.

    The influence of drill wear on cutting efficiency and heat production during osteotomy preparation for dental implants: a study of drill durability

    Int. J. Oral Maxillofac. Implants

    (2004)
  • Cited by (314)

    View all citing articles on Scopus
    1

    Department of Surgery, University Hospital Center Zagreb, Kišpatićeva 12, 10000 Zagreb, Croatia.

    2

    Department of Surgery, University Hospital Center Zagreb and School of Medicine University of Zagreb, Kišpatićeva 12, 10000 Zagreb, Croatia.

    3

    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.

    5

    Department of Traumatology, Clinical Hospital Center Sestre Milosrdnice (Traumatology Clinic), Draškovićeva 19, 10000 Zagreb, Croatia.

    View full text