Use of domestic drilling machines in orthopedic surgeries

Vania Regina Goveia Silma Maria Cunha Pinheiro Ribeiro Kazuko Uchikawa Graziano About the authors

Abstracts

As furadeiras elétricas domésticas tem sido empregadas em cirurgias ortopédicas nos Hospitais Brasileiros, para a perfuração óssea. Entretanto, trata-se de um equipamento elétrico, termossensível, não específico para uso cirúrgico, não avaliado quanto à eficácia da esterilização e não investigada a ocorrência de infecções cirúrgicas relacionadas ao seu uso. O objetivo dessa revisão foi descrever o estado da arte do uso das furadeiras domésticas em cirurgias ortopédicas, tendo em vista as dificuldades de limpeza e esterilização do equipamento. As bases de dados LILACS e MEDLINE foram consultadas usando vocabulários controlados, livres e a combinação deles, sem restrição de tempo. Foram localizados dois artigos que abordavam o uso de furadeiras elétricas domésticas em cirurgias ortopédicas. No primeiro, o autor sugere o descarte do equipamento quando percebida a contaminação interna por sangue, considerando as dificuldades da limpeza e esterilização. O segundo artigo descreve a adaptação de uma furadeira para o uso em cirurgias, cujo método de esterilização é pastilha de formalina em condições ambientais. Estudos são necessários para avaliar a prática atual e recomendar condições seguras de uso ou o seu abandono.

Esterilização; Cirurgia ortopédica; Equipamento ortopédico


Domestic ordinary drilling machines have been used in orthopedic surgeries in Brazilian hospitals, for bone drilling. However, it is an electric thermo-sensitive appliance, non-specific for surgical use, not assessed in terms of sterilization efficiency, as well as on potential surgical infections associated to its use. The objective of this review was to describe the state-of-the-art use of domestic drills in orthopaedic surgeries, considering the difficulties of cleaning and sterilization. The LILACS and MEDLINE databases were consulted using MeSH and free medical terms, without time restraints. Two specific articles were found about the use of domestic electric drills in orthopaedic surgeries. In the first article, the author suggests the disposal of the equipment in cases of any noticeable blood contamination that could result in difficulties to clean it. The second article describes how to adapt a domestic drilling machine for orthopaedic surgery, but the sterilization process is performed by using formalin tablets at room conditions. Further studies are required for evaluating the current practice and to recommend safe conditions for its use or towards giving it up.

Sterilization; Orthopaedics; Orthopaedic equipment


REVIEW ARTICLE

Use of domestic drilling machines in orthopedic surgeries

Vania Regina GoveiaI; Silma Maria Cunha Pinheiro RibeiroII; Kazuko Uchikawa GrazianoIII

IPost-graduation student in Adult Health Nursing, Nursing School, University of São Paulo – EE/USP

IIChair of the Department of Nursing, Pontifícia Universidade Católica of Minas Gerais, Coordinator of the Nursing Course, Pitágoras College, Belo Horizonte

IIIFull professor, Department of Medical-Surgical Nursing, EE/USP

Corresponding author

SUMMARY

Domestic ordinary drilling machines have been used in orthopedic surgeries in Brazilian hospitals, for bone drilling. However, it is an electric thermo-sensitive appliance, non-specific for surgical use, not assessed in terms of sterilization efficiency, as well as on potential surgical infections associated to its use. The objective of this review was to describe the state-of-the-art use of domestic drills in orthopaedic surgeries, considering the difficulties of cleaning and sterilization. The LILACS and MEDLINE databases were consulted using MeSH and free medical terms, without time restraints. Two specific articles were found about the use of domestic electric drills in orthopaedic surgeries. In the first article, the author suggests the disposal of the equipment in cases of any noticeable blood contamination that could result in difficulties to clean it. The second article describes how to adapt a domestic drilling machine for orthopaedic surgery, but the sterilization process is performed by using formalin tablets at room conditions. Further studies are required for evaluating the current practice and to recommend safe conditions for its use or towards giving it up.

Keywords: Sterilization; Orthopaedics; Orthopaedic equipment.

INTRODUCTION

The tools, materials and equipment used in a surgical procedure, i.e., those that make contact with a sterile body tissue, must be microorganisms-free, and therefore submitted to sterilization process. This is an important measure against postoperative infection occurrences(1,2).

A cleaning procedure removes debris and reduces the microbial load, and it’s the first step to assure a quality sterilization process(3,4). Two studies addressed microbial load on materials used in sterile body sites, with and without lumen, and found a small microbial load. Yet the authors highlight the importance of cleaning procedures for reducing microbial load, residual protein and salts that might interfere on materials’ sterilization process(5,6). Alfa et al. verified that interference in several low-temperature sterilization methods(7).

The selection of a sterilization method depends on physical features of the article to be submitted to the process, which can be heat-resistant or heat-sensitive. Ethylene oxide is the oldest low-temperature sterilization method and has been employed since the 1950’s for heat-sensitive medical/ hospital materials(8,9).

Surgical Site Infection

Surgical site infection is the third most common hospital infection in the United States, accounting for 14-16% of the total number of hospital infections. Several factors contribute to a patient’s risk of evolving to infection postoperatively, including surgical instruments’ sterilization(10). Infections in orthopaedic surgeries may be serious, and osteomyelitis is regarded as the most serious complication in surgical orthopaedics and traumatology(11). The incidence of infection following knee total arthroplasty is a Brazilian university hospital remains around 3%(12).

Orthopaedic surgeries and use of domestic drilling machines

Electric or pneumatic drillers are necessary in orthopaedic surgeries requiring bone drilling, such as for screws, steel wires, and internal or external fixators insertion. Special medical/ surgical-use drills are fully dismountable and autoclavable, allowing for an appropriate internal and external parts cleaning after use and sterilization assurance.

For over 50 years, domestic drilling machines have been used in orthopaedic surgeries in Brazilian hospitals for performing bone drilling, raising concerns among professionals acting in hospital-related infection control or, more specifically, in the area of materials sterilization, because those are electric thermo-sensitive equipment, not intended for surgical use, and not checked for potential damages to bone tissues or for sterilization effectiveness. This practice is certainly justified by financial reasons.

The objective of this review was to describe the state-of-the-art research on the use of domestic drilling machines in orthopaedic surgeries, considering the issues related to cleaning and sterilization of this kind of equipment.

METHODS

The search on electronic databases MEDLINE and LILACS was performed by imposing no time limitations, on BIREME and U.S. National Library of medicine portals, using controlled keywords (Medical Subject Headings - MeSH) and free keywords in Portuguese and English, and the AND Boolean operator for specificity, the controlled ones being as follows: esterilização/sterilization; cirurgia ortopédica/orthopedics; orthopedic procedures; equipamento ortopédico/orthopedic equipment; infecção da ferida operatória/surgical wound infection; osteomielite/osteomyelitis, and the free terms: drilling machine; drill; drilling; orthopedic drilling.

RESULTS

The results of the search on BIREME portal totaled 29 publications on MEDLINE database; 9 of these referent to 1993-2004 period, and 20 to 1966-1992 period. We found no results on LILACS database. The search on MEDLINE database of the U.S. National Library of Medicine using controlled keywords combined with free terms resulted into 12 articles for Orthopedic Equipment [MeSH] AND drilling machine; 10 articles for Orthopedic Procedures [MeSH] AND drilling machine; 5 articles for Sterilization [MeSH] and drilling and 86 articles for orthopedic drilling. When combined, the free and controlled keywords: Orthopedic Equipment [MeSH] AND Sterilization [MeSH] AND drilling machine, resulted in no article being found.

All summaries of the publications found were read and analyzed; nevertheless, only 2 articles were regarded as relevant to the objectives of this study, because they addressed the use of domestic drilling machines in orthopaedic surgeries. The other articles, which were excluded, did not address cleaning and sterilization of drilling machines used in orthopaedic procedures. Of the two articles relevant to this study, one original article published on an English journal in the late 1980’s(13), was found by searching for (1) Orthopedic Equipment [MeSH] AND drilling machine and (2) orthopedic drilling. The other article – a letter to the editor, published on an African journal in the beginning of 2002(14) – was found when searching for Orthopedic Equipment [MeSH] AND Sterilization [MeSH]. The first article addresses the use of a Makita® in orthopaedic surgeries and the second one describes how to adapt a domestic drilling machine to be used in orthopaedic procedures(13,14).

DISCUSSION

The article discussing the use of a Makita® electric drill for orthopaedic surgeries was published in 1988, 18 years ago (13). The authors recognize that cleaning may be an issue if the engine is contaminated with organic matter, and if it indeed occurs, they suggest discarding the equipment. It’s clear that by manipulating this kind of equipment, the external surface of the drilling machine is contaminated with blood, while its inner parts can get contaminated through the engine vents, and will not be detected by visual inspection, thus making the suggestion of discarding the equipment unfeasible. Another limitation of the study is related to the method for sterilization efficacy assessment by collecting material for swab microbiological studies; despite the negative result, this method considerably reduces the potential of microorganisms recovery.

The adaptation of a domestic drilling machine for use in orthopaedic surgeries, as presented in a letter to the editor by Musa in 2002, describes the method employed in a university hospital in Sokoto, Nigeria(14). We can notice this author’s concerns with equipment sterilization; however, he describes the adopted sterilization method employing formalin tablets, in non-validated conditions, placed next to the drilling machine in a closed container for 48 hours. This method, according to our references, constitute only a high-level disinfection method, but not a sterilization method(15).

We understand that cleaning domestic drilling machines used in orthopaedic surgeries constitutes a major challenge for professionals, because they cannot be sunk into detergent solutions due to their engine vents, which would warrant damages as a result of water entering into the engine. Usually, the external cleaning is performed by using a wet clothe, but the potential presence of blood in inner parts could interfere on sterilization. Thus, when an electric drill is turned in at the OR, there will be a potential risk of generating contaminated aerosols and the potential for surgical filed contamination.

The use of domestic drilling machines in orthopaedic surgeries in Brazilian hospitals is clearly inappropriate, in view of the existence of specially-designed equipment to that purpose. This practice in hospitals probably occurs due to the high cost of specific equipment and to the lack of studies assessing the risks of using them.

CONSIDERATIONS

Although the use of electric drills in orthopaedic surgical practice in Brazilian hospitals is common, there are no studies assessing the risks of using them in orthopaedic procedures, nor proven sterilization of these machines, once internal contamination by blood may occur.

Further investigations are warranted to confirm that external cleaning alone is not enough for a drilling machine, that no organic debris are left in the inner part of the equipment incurring in the risk of spreading contaminated aerosols when the engine is turned in at the surgical field, as well as the effectiveness of the low-temperature sterilization process. Further investigations must be conducted in order to support an old practice or to recommend for its dropout.

REFERENCES

  • Corresponding author:
    Vania Regina Goveia
    Rua Cláudio, 213, ap. 153
    CEP 05043-000. São Paulo – SP
    Telephones: (11) 3673-6389 or (11) 9988-5450
  • Received in: 07/28/06, approved in: 09/26/06

    Study developed by the department of Post-graduation in Adult Health Nursing, Nursing School, University of São Paulo.

    • 1. Spaulding EH. Chemical disinfection of medical and surgical materials. In: Laurence CA, Block SS. Disinfection, sterilization, and preservation. Philadelphia: Lea & Febiger; 1968. p. 517-31.
    • 2. Favero MS, Bond WW. Chemical disinfection of medical and surgical materials. In: Block SS. Disinfection, sterilization, and preservation. 4th ed. Philadelphia: Lea & Febiger; 1991. p. 617-41.
    • 3. Rutala WA. Disinfection, sterilization and waste disposal. In: Wenzel RP. Prevention and control of nosocomial infections. 2nd ed. Baltimore: Williams & Wilkins; 1993. p. 460-95.
    • 4. Graziano KU, Castro MES, Moura MLPA. A importância do procedimento de limpeza nos processos de desinfecção e esterilização de artigos. SOBECC 2002; 7:19-23.
    • 5. Chan-Myers H, McAlister D, Antonoplos P. Natural bioburden levels detected on rigid lumened medical devices before and after cleaning. Am J Infect Control. 1997; 25:471-6.
    • 6. Rutala WA, Gergen MF, Jones JF, Weber DJ. Levels of microbial contamination on surgical instruments. Am J Infect Control. 1998; 26:143-5.
    • 7. Alfa MJ, DeGagne P, Olson N, Puchalski T. Comparison of ion plasma, vaporized hydrogen peroxide, and 100% ethylene oxide sterilizers to the 12/88 ethilene oxide gas sterilizer. Infect Control Hosp Epidemiol. 1996; 17:92-100.
    • 8. Rutala WA, Weber DJ. Low-temperature sterilization technologies: do we need to redefine "sterilization"? Infect Control Hosp Epidemiol. 1996; 17:87-91.
    • 9. Rutala WA, Weber DJ. Clinical Effectiveness of low-temperature sterilization technologies. Infect Control Hosp Epidemiol. 1998; 19:798-804.
    • 10. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999; 27:97-132.
    • 11. Kutscha-Lissberg F, Hebler U, Kälicke T, Arens S. Principles of surgical therapy concepts for postoperative and chronic osteomyelitis. Orthopade. 2004; 33:439-54.
    • 12. Lima ALLM, Pécora JR, Albuquerque RM, Paula AP, DElia CO, Santos ALG, et al. Infecção pós-artroplastia total de joelho Considerações e protocolo de tratamento. Acta Ortop Bras. 2004; 12: 236-41.
    • 13. Railton R, Pringle RM, Shaw A. Evaluation of Makita electric drills for orthopaedic surgery. J Med Eng Technol. 1988; 12:20-3.
    • 14. Musa AA. How to adapt an ordinary drilling machine for orthopaedic surgery. West Afr J Med. 2002; 21:59.
    • 15. Graziano KU. O uso das pastilhas de paraformaldeído pelas instituições de saúde do Brasil. Parte II. Rev Esc Enfermagem USP. 2001; 36:253-61.

    Corresponding author: Vania Regina Goveia Rua Cláudio, 213, ap. 153 CEP 05043-000. São Paulo – SP Telephones: (11) 3673-6389 or (11) 9988-5450 vaniagoveia@uol.com.br

    Publication Dates

    • Publication in this collection
      04 Sept 2007
    • Date of issue
      2007

    History

    • Received
      28 Aug 2006
    • Accepted
      26 Sept 2006
    ATHA EDITORA Rua: Machado Bittencourt, 190, 4º andar - Vila Mariana - São Paulo Capital - CEP 04044-000, Telefone: 55-11-5087-9502 - São Paulo - SP - Brazil
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