BONEZONE Article: Surgical Drilling: Surgeon Perspective on Improving Care Standards

A textbook practice in orthopedic care, surgical drilling has been performed for decades with very few technical or technological advancements. In the previously-published article, The Unknowns of Surgical Drilling, the shortcomings of traditional orthopedic drilling were evaluated and discussed. The findings of the study focused on the importance of curvature, sharpness and material of drill bit tips, and how small adjustments to those can make a big difference when drilling through bone.

One major hazard of drilling not discussed was the issue of plunging. Plunging occurs when the drill bit penetrates beyond the far cortex of the bone. This presents a risk of “plunging” into critical structures such as nerves or vessels. In standard orthopedic drilling, surgeons depend on tactile and auditory feedback to know when to halt progression of the drill. Between doctors, patients and environmental factors, tactile and auditory feedback can be subjective; therefore, surgeons may not always sense they have penetrated the far cortex.

Every bone is different, and in patients with soft, comminuted or poor-quality bone, it becomes increasingly difficult to gauge the location of the second cortex to know when to stop drilling. A recently published study contrasted the differences in clavicle plunging with a standard orthopedic drill and one with innovative, sensing technology. Always keeping the patient’s safety at the forefront, Plunging Dangerously: A Quantitative Assessment of Drilling the Clavicle, illustrates the prevalence of drill plunging, the value and importance of enhanced technology in orthopedic drilling, and how the patient will benefit when cutting-edge technology is adopted in the practice of surgical drilling.

Study Purpose and Setup

With plunging being a common and potentially dangerous byproduct of orthopedic drilling, this study aimed to quantify the plunge depth during clavicle drilling utilizing both traditional drilling technique and drill sensing technology.

IntelliSense Drill Technology® (McGinley Orthopedics, Casper, WY) was the drill used for this study. The IntelliSense® Drill, designed with patient safety in mind, is equipped with sensing technology that measures the drill bit depth in real time and automatically stops the drill bit rotation as it penetrates the second cortex. This mode is ”bicortical mode.” Bicortical mode was used for the sensor drilling portion of the study. Freehand mode also measures the bit depth in real time, but disables the auto-stop technology. This mode was used for the traditional drilling portion of the study.

For the study, two orthopedic surgeons each drilled ten bicortical holes in the clavicle of the cadaveric specimen with the IntelliSense Drill in bicortical mode and and additional ten holes in freehand mode. The surgeons were blinded to the depth measurements as they drilled, and those IntelliSense Drill-measured depths were compared with computed tomography (CT)-measured depths to confirm accuracy. Following this, the cadaver was dissected and the mean distances from the clavicle to local neurovascular structures (the subclavian vein, subclavian artery and brachial plexus) were measured.

Findings

When looking at combined plunge results in freehand mode (i.e., standard drilling), the average plunge distance for the surgeons was 8.8mm. Following dissection, the mean distances to neurovascular structures were 15.5mm to the subclavian vein, 18.0 mm to the subclavian artery and 8.0 mm to the brachial plexus. In bicortical mode, the drill motor stopped when the second cortex was penetrated. The mean difference between the IntelliSense drill depth measurements and the CT-measured depths was 0.8mm.

Conclusions

Anatomically, it is clear that critical neurovascular structures are at risk for injury while drilling the clavicle. Perforating one or more of these structures can lead to surgical complications, injury or even death. When applied to anatomical regions without adjacent neurovascular structures, the findings of this study remain relevant as plunging can injure other soft tissue structures.

Standard drilling technique in orthopedics has not changed significantly over the years. Tactile feedback is subjective, and often dependent on the condition of each patient’s varying bone health, density and configuration. The results of this study illustrate the potential for inadvertent injury from standard orthopedic drilling technique.

Encouragingly, this study shows that the future is bright, thanks to technological advances in the orthopedic drilling realm. Medical and technological innovations, such as the IntelliSense Drill Technology, are constantly being developed to improve patient safety and outcomes. In this case, the IntelliSense Drill was able to encapsulate a standard process (orthopedic drilling) and focus on identifying and providing a solution for the problems and dangers drilling poses for patients. When improving patient safety and outcomes is the goal, the results of implementing innovative technology are a triumph for both patients and surgeons alike.

Alejandro Badia, MD, FACS, FRCSI is a hand and upper extremity surgeon at Badia Hand to Shoulder Center in Doral, Florida. He is past president of the International Society for Sport Traumatology of the Hand (ISSPORTH) and is a member of several orthopedic societies (AAOS, ASSH, AAHS, EWAS). He is currently focused on improving healthcare delivery in the orthopedics and sports medicine realm, including providing safe access to orthopedic care via their specialized telemedicine program at www.orthonowlive.com. 

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