The Tools of the Orthopedic Trade

Orthopedic surgeons are like star athletes, engaging in a highly physical profession that takes a significant toll on their bodies. David Ruch, MD, an orthopedic surgeon at Duke Health in Durham, N.C., began operating in 1988. "Neck arthritis or pinched nerves are a few common injuries among orthopods," he says. "We stand and lean forward at the neck to operate."

While that's true across many specialties, ergonomic issues with power tools can be problematic in orthopedics. The tools are loud. They vibrate. They kick back.

"The things that cause the most difficulties for us are reamers, which have a fair amount of torque in order to be able to core out hard bone to place implants during joint replacement procedures," says Dr. Ruch. "If the reamer hits a hard piece of bone, it'll spin the drill back and twist your wrist."

Dr. Ruch says orthopods pick up injury mitigation lessons throughout their careers. "You learn what not to do," he says. "You learn to start out slow with the reamer to give the bone a chance to widen without generating as much torque."

Then there are the power saws. "They have a lot of vibration," says Dr. Ruch, who also acknowledges that the decibel levels of power tools could have an impact on hearing over time, an issue he says requires study.

Orthopedic surgeons are powerless without power tools, and as their understanding of and demand for proper ergonomics evolves, new products in the category are striving to accommodate those needs. The latest drills and saws are designed to address surgeon comfort, usability and safety.

Ergonomic grips allow surgeons to maintain a neutral wrist position, which reduces the risk of them developing carpal tunnel injuries. Power tools are also available in lighter weights, which can reduce hand and wrist fatigue while enhancing the surgeon's maneuverability in the operating space. Textured areas on handles provide firmer grips for surgeons during intense drilling, sawing and cutting.

The latest generation of drills and saws come with wider ranges of torque and speed, providing surgeons with more precise control to make accurate cuts with less physical exertion in a variety of bone densities. Oscillating saw tips reduce noise and vibration, the cumulative effects of which can negatively impact the surgeon's health.

Some design features — such as reduced sparking to prevent surgical fire hazards and accidental burns — are meant to avoid more significant harm. Others are intended to lessen the mental strain of surgeons: Enhanced power supplies enable more consistent and reliable use with longer run times, and keyless drill chucks prevent loosening through secondary locking mechanisms, giving surgeons more confidence when drilling into dense bone.

Dr. Ruch's experience points to a quandary. Ergonomic issues in orthopedics have nothing to do with the failings of the tools themselves. The issue is that using them can be hard on various parts of the body. Surgeons must learn to use them properly while taking care of their bodies as much as they can. That plays into the overall ergonomics of the environments in which these surgeons work.

Researchers are working to find out how orthopedic surgeons can avoid or mitigate injury in order to prolong their careers and maintain their health. A comprehensive study published in Annals of Medicine and Surgery last year ( osmag.net/3wUPIpe) examined guidelines from governmental organizations like the Occupational Safety and Health Administration (OSHA) to see which might be transferable to operating rooms in hopes of improving surgical ergonomics and reducing musculoskeletal injuries orthopedic surgeons suffer.

Kade McQuivey, MD, a resident orthopedic surgeon in the department of orthopedic surgery at Mayo Clinic Arizona in Phoenix, published a multicenter survey earlier this year in the Journal of the American Academy of Orthopaedic Surgeons (osmag.net/3zsZJLY) that analyzed feedback on surgical ergonomics and musculoskeletal pain among orthopedic surgery residents. The survey hits close to home for Dr. McQuivey, who's in his fourth year in residency. He's already one of the injured.

"Midway through my second year, I acutely began to experience pain in my lower back," he says. "I attributed the majority of this pain to experiences I had in the operating room, where I was confident my poor surgical ergonomics had a significant impact on my condition. It was a culmination of several things I didn't know at that time I was doing incorrectly."

Dr. McQuivey ticks off the list of ergonomic issues: leaning over; lifting with his back and not his legs when transferring patients; not keeping the table at the appropriate height; not keeping a centered pelvis. "You spend enough hours doing these things and your muscle balance is going to get thrown off," he explains. "Those imbalances potentially led to some of the muscle and disc issues I had."

Dr. McQuivey ultimately underwent surgery for a ruptured disc in his lumbar spine. He was aware that ample research existed regarding the pain and injury of orthopods with many years of experience, and wondered as he recovered how many other orthopedic residents were already dealing with procedure-related injuries and pain, and how much.

"My hope was that we could identify not only the prevalence, but also attempt to find some ergonomic strategies that could be helpful to other residents," he says. "We are so one-track minded on learning surgery and anatomy, but we're not necessarily paying attention to ergonomics." He says formal training on ergonomics is picking up at medical schools, but it's still not part of the curriculum at many institutions.

His research identified ergonomic approaches that surgeons can use to keep themselves healthy. Among those modifications: keeping the table at the level of your elbows, or just below; focusing on evenly distributing weight throughout both legs; and not engaging solely the back muscles while transferring patients from beds to gurneys.

"Since we presented our study to our department, there's definitely been more of a focus on operating with correct posture," says Dr. McQuivey. "Every once in a while, you'll get a nudge from one of your attendings saying, 'Keep your back straight' or 'Let's raise the table.'"

Dr. McQuivey says some studies have demonstrated that noise pollution in the operating room from power tools, such as saws, wire drivers and mallets can lead to noise-induced hearing loss.

"The National Institute on Deafness reported that prolonged, repetitive exposure to greater than 90 dB will cause gradual hearing loss," he says. "Orthopedic saws and drills produce 90 dB to 100 dB at operator ear level in the operating room. Another study demonstrated that 50% of orthopedic personnel with long-term exposure to power instruments showed early signs of noise-induced hearing loss."