Tools With Big Power for Small Bones

The latest devices allow surgeons to operate in comfort and with confidence.

Like their large-bone-specialist counterparts, surgeons who work on hands, feet, ankles and elbows have a wide array of power tools to use for drilling, sawing, inserting K-wires, reaming and other tasks.

Here’s what orthopedic surgeons look for in these important devices, as well as other issues for leadership to consider when making purchases that will keep their physicians satisfied.

Cutting the cord

When Hui Zhang, MD, an orthopedic surgeon who specializes in foot and ankle procedures at Aurora Medical Center in Mt. Pleasant, Wis., was in residency from 2016 to 2021, he saw the shift from corded to cordless devices take place about halfway through his training. “This was a really nice development,” says Dr. Zhang. “Small power tools with cord attachments, in my view, are just one more thing to worry about. They make draping longer, extend the setup time and you have to make sure the cord is sterile. We already need to hook up a Bovie cord and suction tubing, so one less cord to contend with makes a difference.”

In addition to the increased control Dr. Zhang enjoys while using cordless drills with traditional handles, he uses pen drives that have multiple applications, including K-wire insertions by pushing or squeezing a trigger-like mechanism or, in some models, pressing a button.

The most important features in these tools are surgeon comfort with the ergonomically designed handles. “Some people love them because of increased freedom and precision, but some don’t, saying the tactile feedback they need when inserting a K-wire is reduced,” says Dr. Zhang. “I’m kind of in the middle. It’s a very different feel than you get from the traditional way of putting in K-wires. I just think it takes some getting used to, in addition to a short learning curve.”

While new fleets of tools might be more expensive, Dr. Zhang thinks the capital expenses are worth it because of the increased control and the ability for surgeons to better position themselves while making small cuts without needing to worry about working around or tangling cumbersome cords. Also, time is saved by more efficient draping and other prep work, and the risk of potentially expensive tripping accidents are reduced. Dr. Zhang says innovations such as smaller percutaneous instrumentation have led to more minimally invasive small- bone surgery in the last decade.

While still behind abdominal surgeries, where the laparoscopic approach is the standard and open procedures are rare, foot and ankle operations haven’t reached that point yet. “For example, I still perform bunion procedures as open surgeries,” says Dr. Zhang. “But the minimally invasive option is picking up steam, grabbing more of the market share and becoming more of a selling point for patients.”

Companies are offering minimally invasive burrs used in fusion procedures that come with special targeting guides from the manufacturers to help surgeons with aim and placement.

Comfort and power

GROUP CONSCIENCE Saws powered by gas provide the speed needed to make clean cuts using blades and burrs during elbow surgery.  |  J. Gabriel Horneff III

J. Gabriel Horneff III, MD, FAAOS, an assistant professor of clinical orthopedic surgery in the shoulder and elbow division at University of Pennsylvania in Philadelphia, agrees that comfort is king but uses tools connected to a gas line because of the power it produces. “Having something that fits into your hands comfortably, where you have a good, dexterous control over it, is really the most important thing,” says Dr. Horneff. “You like the power tools to fit into your hands as well as finer instruments such as surgical pens do.”

The gas-powered micro sagittal saw Dr. Horneff uses has a universal handle and single-use high-speed or wire-tip burrs he uses for ligament or bone reconstruction cases. “I think they provide more power than tools that run on battery packs,” he says. “When using those smaller instruments, you want the oscillating saw and burr going really fast to make for a cleaner cut. ‘Fast’ in this case is the opposite of reckless — a slower-moving device would be the equivalent of using a dull scalpel or a dull pair of scissors.”

After the tips are disposed of, the rest of the device gets reprocessed. Surgeons who opt for battery-powered devices should make sure that they have battery packs durable enough to withstand the rigors of daily high-level disinfection and sterilization.

Dr. Horneff says there should always be one backup tool on hand in case there’s an issue with the main one. He notes that it’s also important staff is trained on how the devices work. “If I need something like a retractor with no moving parts, I can just grab it myself,” he explains. “With these instruments, the OR staff must be familiar with how to attach them to the gas line in a sterile fashion. When you’re in the middle of a case, you want someone you can trust who is able to assemble these things on the back table and hand it to you in working order.”

Safety first

The Raleigh (N.C.) Orthopaedic Clinic has an eight-year-old surgery center that continues to grow. Nearly two dozen surgeons perform about 7,000 cases annually, and total joints cases and spine procedures have increased substantially in the past year. The growth in large part is attributed to the ASC’s reputation of being the safest surgical environment for select patients.

CEO Brian Bizub says that’s why the clinic buys high-quality power tools even if there are less expensive options available. “The moment a tool begins to overheat, we’re done with it, because we don’t want to take the chance of a malfunction,” says Mr. Bizub. “Safety is paramount and not having a safe fleet of tools would obviously jeopardize patient care, which is not something we’re interested in doing. A fire in the OR is not something anybody wants.”

Some of the tools purchased at the clinic’s inception are still working fine eight years later, while others had issues earlier in their lives. When the time comes to replace part of the fleet — be it a large tool for a knee replacement or a small one for hand procedures — its administrators check the market thoroughly for the best available options.

They look at specifications such as torque, durability and comfortable hand grips. “We’ve bought a lot of tools recently, because our clinic is eight years old, about the life of a power tool,” says Mr. Bizub. “So many of them needed replacing at the same time. We essentially look for all the same features that a homeowner would when buying power tools for their house repairs. They just cost about $30,000 more.”

While leadership at Raleigh Orthopaedic looks at new technology coming online from other manufacturers, the clinic tries to buy from the same vendor to keep operations standardized and repair and service agreements streamlined.

One company that supplies the clinic with power tools offers a change-out program, which Mr. Bizub said is a key feature. The manufacturer replaces a malfunctioning product if it experiences performance issues early in its life.

When it’s time to buy a new power tool, it’s majority rule. For a small drill, all the hand surgeons will meet with the representatives from three companies and try two or three models from each manufacturer. After the trial, they take a vote and the most popular drill is selected.

Then the administrators look at the pricing. “The expense is less of an issue than surgeon satisfaction, because a good power tool is going to last from three to eight years, so the return on investment is there,” says Mr. Bizub. OSM