A Data-Driven Methodology to Comprehensively Assess Bone Drilling Using Radar Plots.

Background: The study aims to develop a data-driven methodology to assess bone drilling in preparation for future clinical trials in residency training. The existing assessment methods are either subjective or do not consider the interdependence among individual skill factors, such as time and accuracy. This study uses quantitative data and radar plots to visualize the balance of the selected skill factors. Methods: In the experiment, straight vertical drilling was assessed across 3 skill levels: expert surgeons (N = 10), intermediate residents (postgraduate year-2-5, N = 5), and novice residents (postgraduate year-1, N = 10). Motion and force were measured for each drilling trial, and data from multiple trials were then converted into 5 performance indicators, including overshoot, drilling time, overshoot consistency, time consistency, and force fluctuation. Each indicator was then scored between 0 and 10, with 10 being the best, and plotted into a radar plot. Results: Statistical difference (p < 0.05) was confirmed among 3 skill levels in force, time, and overshoot data. The radar plots revealed that the novice group exhibited the most distorted pentagons compared with the well-formed pentagons observed in the case of expert participants. The intermediate group showed slight distortion that was between the expert and novice groups. Conclusion/Clinical Relevance: This research shows the utility of radar plots in drilling assessment in a comprehensive manner and lays the groundwork for a data-driven training scheme to prepare novice residents for clinical practice.

A neural network framework for immediate temperature prediction of surgical hand-held drilling.

BACKGROUND AND OBJECTIVE: Heat generation and associated temperature rise in surgical drilling can cause irreversible tissue damage. It is nearly impossible to provide immediate temperature prediction for a hand-held drilling process since both feed rate and motion vary with time. The objective of this study is to present and test a framework for immediate bone drilling temperature visualization based on a neural network (NN) model and a linear time-invariant (LTI) model. METHODS: In this study, the finite element analysis (FEA) model is used as the ground truth. The NN model is used to predict the location-dependent thermal responses of FEA, while LTI is used to superimpose these responses based on the location history of the heat source. The use of LTI can eliminate the uncertainty of the unlimited possibility in the time domain. To test the framework, two three-dimensional drilling cases are studied, one with a constant drilling feed and straight path and the other with a varying feed and a varying path. RESULTS: The NN model using U-net architecture can achieve the predicted correlation of over 97% with only 1% of the total number of data points. Using the framework with U-net and LTI, both case studies show good agreement in temporal and spatial temperature distributions with the ground truth. The average error near the drilling path is less than 10%. Discrepancies are mainly found near the heat source and the regions near the removed material. CONCLUSIONS: An FEA surrogate model for rapid and accurate prediction of 3D temperature during arbitrary bone drilling is successfully made. The overall error is less than 5% on average in the two case studies. Future improvements include strategies for training data selection and data formating.

An objective assessment for bone drilling: A pilot study on vertical drilling.

The purpose of this study is to propose a quantitative assessment scheme to help with surgical bone drilling training. This pilot study gathered and compared motion and force data from expert surgeons (n = 3) and novice residents (n = 6). The experiment used three-dimensional printed bone simulants of young bone (YB) and osteoporotic bone (OB), and drilling overshoot, time, and force were measured. There was no statistically significant difference in overshoot between the two groups (p = 0.217 for YB and 0.215 for OB). The results, however, show that the experts took less time (mean = 4.01 s) than the novices (mean = 9.98 s), with a statistical difference (p = 0.003 for YB and 0.0001 for OB). In addition, the expert group performed more consistently than the novices. The force analysis further revealed that experts used a higher force to drill the first cortical section and a noticeably lower force in the second cortex to control the overshoot (approximate reduction of 5.5 N). Finally, when drilling time and overshoot distance were combined, the motion data distinguished the skill gap between expert and novice drilling; the force data provided insight into the drilling mechanism and performance outcomes. This study lays the groundwork for a data-driven training scheme to prepare novice residents for clinical practice.

Amphiphilic, thixotropic additives for extrusion-based 3D printing of silica-reinforced silicone.

The ability to utilize extrusion-based, direct ink write (DIW) 3D printing to create silica-reinforced silicones with complex structures could expand their utility in industrial and biomedical applications. Sylgard 184, a common Pt-cure silicone, lacks the thixotropic behavior necessary for effective printing and its hydrophobicity renders cured structures susceptible to biofouling. Herein, we evaluated the efficacy of various PEO-silane amphiphiles (PEO-SAs) as thixotropic and surface modifying additives in Sylgard 184. Eight amphiphilic PEO-SAs of varying architecture (e.g. linear, star, and graft), crosslinkability, and PEO content were evaluated. Modified formulations were also prepared with additional amounts of silica filler, both hexamethyldisilazane (HMDS)-treated and dimethyldichlorosilane (DiMeDi)-treated types. Numerous PEO-SA modified silicone formulations demonstrated effective water-driven surface hydrophilicity that was generally diminished with the addition of HMDS-treated silica filler. While increased yield stress was observed for PEO-SA modified silicones with added HMDS-treated filler, none achieved the initial target for 3D printing (>1000 Pa). Only the formulations containing the DiMeDi-treated filler (17.3 wt%) were able to surpass this value. These formulations were then tested for their thixotropic properties and all surpassed the targets for recovered storage modulus (G') (>1000 Pa) and loss factor (<0.8). In particular, the triblock linear PEO-SA produced exceptionally high recovered G', low loss factor, and substantial water-driven restructuring to form a hydrophilic surface. Combined, these results demonstrate the potential of silicones modified with PEO-SA surface-modifying additives (SMAs) for extrusion-based, DIW 3D printing applications.

3D Printed composite for simulating thermal and mechanical responses of the cortical bone in orthopaedic surgery.

Synthetic bones made of polyurethane (PU) foams or glass-fiber reinforced epoxy are often used in surgical training, planning, and tool analysis, but these materials cannot be 3D printed for a patient-specific design. This paper introduces a new type of bone-mimicking material made by the binder jetting technology and a post-strengthening process with epoxy, namely 3D polymer-infiltrated composite (3DPIC). 3DPIC has been previously evaluated by surgeons as a proper alternative to commercial synthetic bones, but no quantitative testing data is available. Therefore, a series of experiments are conducted in this study to verify the use of 3DPIC. The first part of experiments includes the measurement of mechanical properties using the four-point bending and the measurement of thermal properties. The second part of experiments is to test drilling haptic and thermal responses of 3DPIC as compared to the cortical bone. The results show that 3DPIC has a comparable elastic modulus but a lower strength than the cortical bone. 3DPIC can produce realistic drilling force and torque as well as representative temperature change in drilling operations, but the bone debris tends to be more ductile and continuous than that of the cortical bone. Applications and limitations of 3DPIC are discussed based on these results.

A mechanistic force model for simulating haptics of hand-held bone burring operations.

This paper presents a mechanistic model to predict the forces experienced during bone burring with application to haptic feedback for virtual reality surgical simulations. Bone burring is a hand-held operation where the force perceived by the surgeon depends on the cutting tool orientation and motion. The model of this study adapted the concept of specific cutting energy and material removal rate based on machining theory to calculate force distribution on the spherical tool surface in a three-dimensional setting. A design of experiments with three tool cutting angles and three feed motions was performed to calibrate and validate the model. Despite some variance in the results, model predictions showed similar trends to experimental force patterns. While the actual force profile also exhibits significant oscillation, the dominant frequencies of this oscillating force component were found to be independent of cutting and non-cutting instances, and hence could be imposed as a uniform background signal. Though the presented model is primarily applicable to abrasive burrs, it has far-reaching applications within other types of surgical simulations as well.

A review of cutting mechanics and modeling techniques for biological materials.

This paper presents a comprehensive survey on the modeling of tissue cutting, including both soft tissue and bone cutting processes. In order to achieve higher accuracy in tissue cutting, as a critical process in surgical operations, the meticulous modeling of such processes is important in particular for surgical tool development and analysis. This review paper is focused on the mechanical concepts and modeling techniques utilized to simulate tissue cutting such as cutting forces and chip morphology. These models are presented in two major categories, namely soft tissue cutting and bone cutting. Fracture toughness is commonly used to describe tissue cutting while Johnson-Cook material model is often adopted for bone cutting in conjunction with finite element analysis (FEA). In each section, the most recent mathematical and computational models are summarized. The differences and similarities among these models, challenges, novel techniques, and recommendations for future work are discussed along with each section. This review is aimed to provide a broad and in-depth vision of the methods suitable for tissue and bone cutting simulations.

Simulator and 2 tools: Validation of performance measures from a novel neurosurgery simulation model using the current Standards framework.

BACKGROUND: Ventriculostomy is a common neurosurgical procedure with a relatively steep learning curve. A low-cost, high-fidelity simulator paired with procedure-specific performance measures would provide a safe environment to teach ventriculostomy procedural skills. The same validated simulation model could also allow for assessment of trainees' proficiencies with measures that align with Accreditation Council for Graduate Medical Education milestones. This study extends previous work to evaluate validity evidence from the simulator, its newly developed performance assessment, the Ventricolostomy Procedural Assessment Tool, and the Objective Structured Assessment for Technical Skills. METHODS: After Institutional Review Board exemption, performance data were collected from 11 novice and 3 expert neurosurgeons (n = 14). Participants self-reported their ability to perform tasks on the simulator using the Ventricolostomy Procedural Assessment Tool, an 11-item, step-wise instrument with 5-point rating scales ranging from 1 (unable to perform) to 5 (performs easily and smoothly). De-identified operative performances were videotaped and independently rated by 3 neurosurgeons, using the Ventricolostomy Procedural Assessment Tool and Objective Structured Assessment for Technical Skills. We evaluated multiple sources of validity evidence (2014 Standards) to examine psychometric quality of the measures and to test our assumption that the tools could discriminate between novice and expert performances adequately. We used a multifacet Rasch model and traditional indices, such as Cronbach alpha, intraclass correlation, and Wilcoxon signed-rank test estimates. RESULTS: Validity evidence relevant to test content and response processes was supported adequately. Evidence of internal structure was supported by high interitem consistency (n = 0.95) and inter-rater agreement for most Ventricolostomy Procedural Assessment Tool items (Intraclass correlation coefficient = [0.00, 0.91]) and all Objective Structured Assessment for Technical Skills items (Intraclass correlation coefficient = [0.80, 0.93]). Overall, novices performed at a lower level than experts on both scales (P < .05), supporting evidence relevant to relationships to other variables. Deeper analysis of novice/expert ratings indicated novices attained lower performances ratings for all Ventricolostomy Procedural Assessment Tool and Objective Structured Assessment for Technical Skills items, but statistical significance was only achieved for the Objective Structured Assessment for Technical Skills items (P < .01). Rater bias estimates were favorable, supporting evidence relevant to consequences of testing. CONCLUSION: Despite a small sample, favorable evidence using current Standards supports the use of the novel simulator and both tools combined for skills training and performance assessment, but challenges (potential threats to validity) should be considered prior to implementation.

A physical simulator for endoscopic endonasal drilling techniques: technical note.

In this paper, the authors present a physical model developed to teach surgeons the requisite drilling techniques when using an endoscopic endonasal approach (EEA) to the skull base. EEA is increasingly used for treating pathologies of the ventral and ventrolateral cranial base. Endonasal drilling is a unique skill in terms of the instruments used, the long reach required, and the restricted angulation, and gaining competency requires much practice. Based on the successful experience in creating custom simulators, the authors used 3D printing to build an EEA training model from post-processed thin-cut head CT scans, formulating the materials to provide realistic haptic feedback and endoscope handling. They performed a preliminary assessment at 2 institutions to evaluate content validity of the simulator as the first step of the validation process. Overall results were positive, particularly in terms of bony landmarks and haptic response, though minor refinements were suggested prior to use as a training device.

Heat accumulation during sequential cortical bone drilling.

Significant research exists regarding heat production during single-hole bone drilling. No published data exist regarding repetitive sequential drilling. This study elucidates the phenomenon of heat accumulation for sequential drilling with both Kirschner wires (K wires) and standard two-flute twist drills. It was hypothesized that cumulative heat would result in a higher temperature with each subsequent drill pass. Nine holes in a 3 × 3 array were drilled sequentially on moistened cadaveric tibia bone kept at body temperature (about 37 °C). Four thermocouples were placed at the center of four adjacent holes and 2 mm below the surface. A battery-driven hand drill guided by a servo-controlled motion system was used. Six samples were drilled with each tool (2.0 mm K wire and 2.0 and 2.5 mm standard drills). K wire drilling increased temperature from 5 °C at the first hole to 20 °C at holes 6 through 9. A similar trend was found in standard drills with less significant increments. The maximum temperatures of both tools increased from <0.5 °C to nearly 13 °C. The difference between drill sizes was found to be insignificant (P > 0.05). In conclusion, heat accumulated during sequential drilling, with size difference being insignificant. K wire produced more heat than its twist-drill counterparts. This study has demonstrated the heat accumulation phenomenon and its significant effect on temperature. Maximizing the drilling field and reducing the number of drill passes may decrease bone injury.

Two-Finger Tightness: What Is It? Measuring Torque and Reproducibility in a Simulated Model.

OBJECTIVES: Residents in training are often directed to insert screws using "two-finger tightness" to impart adequate torque but minimize the chance of a screw stripping in bone. This study seeks to quantify and describe two-finger tightness and to assess the variability of its application by residents in training. METHODS: Cortical bone was simulated using a polyurethane foam block (30-pcf density) that was prepared with predrilled holes for tightening 3.5 × 14-mm long cortical screws and mounted to a custom-built apparatus on a load cell to capture torque data. Thirty-three residents in training, ranging from the first through fifth years of residency, along with 8 staff members, were directed to tighten 6 screws to two-finger tightness in the test block, and peak torque values were recorded. The participants were blinded to their torque values. RESULTS: Stripping torque (2.73 ± 0.56 N·m) was determined from 36 trials and served as a threshold for failed screw placement. The average torques varied substantially with regard to absolute torque values, thus poorly defining two-finger tightness. Junior residents less consistently reproduced torque compared with other groups (0.29 and 0.32, respectively). CONCLUSIONS: These data quantify absolute values of two-finger tightness but demonstrate considerable variability in absolute torque values, percentage of stripping torque, and ability to consistently reproduce given torque levels. Increased years in training are weakly correlated with reproducibility, but experience does not seem to affect absolute torque levels. These results question the usefulness of two-finger tightness as a teaching tool and highlight the need for improvement in resident motor skill training and development within a teaching curriculum. Torque measuring devices may be a useful simulation tools for this purpose.

Numerical evaluation of sequential bone drilling strategies based on thermal damage.

Sequentially drilling multiple holes in bone is used clinically for surface preparation to aid in fusion of a joint, typically under non-irrigated conditions. Drilling induces a significant amount of heat and accumulates after multiple passes, which can result in thermal osteonecrosis and various complications. To understand the heat propagation over time, a 3D finite element model was developed to simulate sequential bone drilling. By incorporating proper material properties and a modified bone necrosis criteria, this model can visualize the propagation of damaged areas. For this study, comparisons between a 2.0 mm Kirschner wire and 2.0 mm twist drill were conducted with their heat sources determined using an inverse method and experimentally measured bone temperatures. Three clinically viable solutions to reduce thermally-induced bone damage were evaluated using finite element analysis, including tool selection, time interval between passes, and different drilling sequences. Results show that the ideal solution would be using twist drills rather than Kirschner wires if the situation allows. A shorter time interval between passes was also found to be beneficial as it reduces the total heat exposure time. Lastly, optimizing the drilling sequence reduced the thermal damage of bone, but the effect may be limited. This study demonstrates the feasibility of using the proposed model to study clinical issues and find potential solutions prior to clinical trials.

Development of a 3D-printed external ventricular drain placement simulator: technical note.

In this paper, the authors present a physical model developed to simulate accurate external ventricular drain (EVD) placement with realistic haptic and visual feedbacks to serve as a platform for complete procedural training. Insertion of an EVD via ventriculostomy is a common neurosurgical procedure used to monitor intracranial pressures and/or drain CSF. Currently, realistic training tools are scarce and mainly limited to virtual reality simulation systems. The use of 3D printing technology enables the development of realistic anatomical structures and customized design for physical simulators. In this study, the authors used the advantages of 3D printing to directly build the model geometry from stealth head CT scans and build a phantom brain mold based on 3D scans of a plastinated human brain. The resultant simulator provides realistic haptic feedback during a procedure, with visualization of catheter trajectory and fluid drainage. A multiinstitutional survey was also used to prove content validity of the simulator. With minor refinement, this simulator is expected to be a cost-effective tool for training neurosurgical residents in EVD placement.

Bone geometry on the contact stress in the shoulder for evaluation of pressure ulcers: finite element modeling and experimental validation.

This research presents the finite element modeling (FEM) of human-specific computed tomography (CT) data to study the effect of bone prominences on contact stress in the shoulder for prevention of pressure ulcers. The 3D geometry of scapula, skin, and surrounding soft tissues in the shoulder was reconstructed based on the anonymous CT data of a human subject in a prone posture (without loading on the shoulder) for FEM analysis of the contact stress. FEM analysis results show that the maximum stress is located at the prominence of the scapula with sharp bone geometry. This demonstrates that stress concentration at the bone prominence is a significant factor to cause the high contact stress, which is a source for pressure ulcers. For experimental validation, a physical shoulder model manufactured by 3D printing of the bone geometry and the mold for molding of tissue-mimicking silicone was developed. Compression tests of the mattress foam and silicone were conducted to find the nonlinear stress-strain relations as inputs for FEM. Experiments of compressing the shoulder model against the foam were carried out. Three flexible force sensors were embedded inside the model to measure the contact forces and compared to the FEM predictions. Results show that the FEM predicted forces match well with the experimental measurements and demonstrate that FEM can accurately predict the stress distributions in the shoulder to study the effect of bone geometry on the inception of pressure ulcers.

Comparison of cortical bone drilling induced heat production among common drilling tools.

OBJECTIVES: Significant data exist regarding heat production of twist drills; however, there are little data regarding cannulated drills or Kirschner (K) wires. This study compared the heat produced during bone drilling with twist drills, K wires, and a cannulated drill. It was hypothesized that drilling temperature would increase with tool sizes used in orthopaedic surgery; with twist drills producing the least amount of heat followed by cannulated drills and K wires. METHODS: Twist drills (2.0, 2.5, and 3.5 mm), K wires (1.25, 1.6, and 2.0 mm), and a cannulated drill (2.7 mm) were driven into warmed human cadaveric tibia by a battery-powered hand drill. The drill was secured on a servo-controlled linear actuator to provide a constant advancing speed (1 mm/s) during drilling. Two thermocouples were embedded 2 mm from the surface at 0.5 and 1.5 mm from the drill hole margin. Eight tests were performed for each tool. RESULTS: Twist drills exhibited a positive trend between size and heat production. The size effect was less significant with K wires. K wires resulted in significantly (P = 0.008 at 0.5 mm) higher peak temperatures than twist drills of the same size. A 2.7-mm cannulated drill produced more than double the temperature rise of a 2.5-mm twist drill. CONCLUSIONS: Twist drills produced the smallest temperature rise among all bit types. Thermal effects should not be a reason for choosing K-wire size. The cannulated drill showed significantly higher temperatures when compared with standard drills, reaching maximal temperatures comparable with K wires.

Study of insertion force and deformation for suturing with precurved NiTi guidewire.

This research presents an experimental study evaluating stomach suturing using a precurved nickel-titanium (NiTi) guidewire for an endoscopic minimally invasive obesity treatment. Precise path planning is critical for accurate and effective suturing. A position measurement system utilizing a hand-held magnetic sensor was used to measure the shape of a precurved guidewire and to determine the radius of curvature before and after suturing. Ex vivo stomach suturing experiments using four different guidewire tip designs varying the radius of curvature and bevel angles were conducted. The changes in radius of curvature and suturing force during suturing were measured. A model was developed to predict the guidewire radius of curvature based on the measured suturing force. Results show that a small bevel angle and a large radius of curvature reduce the suturing force and the combination of small bevel angle and small radius of curvature can maintain the shape of guidewire for accurate suturing.

Cool Mist Irrigation Improves Heat Dissipation during Surgical Bone Drilling.

Objective High-speed drilling generates heat in small cavities and may pose a risk for neurovascular tissues. We hypothesize that a continuous pressurized cold mist could be an alternative approach for better cooling during drilling of bone to access cranial lesions. This study aims to examine this idea experimentally. Design Ex-vivo drilling tests with controlled speed, feed, and depth were performed on cortical bone samples. Thermocouples were embedded underneath the drilling path to compare the temperature rises under mist cooling (at 3°C, < 300 mL/h) and flood irrigation (at 22°C, > 800 mL/h). Results A significant difference exists between these two systems (p value < 0.05). The measured temperature was ∼ 4°C lower for mist cooling than for flood irrigation, even with less than a third of the flow rate. Conclusion Experimental data indicate the capability of mist cooling to reduce heat generation while simultaneously enabling flow reduction and targeted cooling. An improved field of view in an extremely narrow access corridor may be achieved with this technology.

Optimal needle design for minimal insertion force and bevel length.

This research presents a methodology for optimal design of the needle geometry to minimize the insertion force and bevel length based on mathematical models of cutting edge inclination and rake angles and the insertion force. In brachytherapy, the needle with lower insertion force typically is easier for guidance and has less deflection. In this study, the needle with lancet point (denoted as lancet needle) is applied to demonstrate the model-based optimization for needle design. Mathematical models to calculate the bevel length and inclination and rake angles for lancet needle are presented. A needle insertion force model is developed to predict the insertion force for lancet needle. The genetic algorithm is utilized to optimize the needle geometry for two cases. One is to minimize the needle insertion force. Using the geometry of a commercial lancet needle as the baseline, the optimized needle has 11% lower insertion force with the same bevel length. The other case is to minimize the bevel length under the same needle insertion force. The optimized design can reduce the bevel length by 46%. Both optimized needle designs were validated experimentally in ex vivo porcine liver needle insertion tests and demonstrated the methodology of the model-based optimal needle design.

Temperature prediction in high speed bone grinding using motor PWM signal.

This research explores the feasibility of using motor electrical feedback to estimate temperature rise during a surgical bone grinding procedure. High-speed bone grinding is often used during skull base neurosurgery to remove cranial bone and approach skull base tumors through the nasal corridor. Grinding-induced heat could propagate and potentially injure surrounding nerves and arteries, and therefore, predicting the temperature in the grinding region would benefit neurosurgeons during the operation. High-speed electric motors are controlled by pulse-width-modulation (PWM) to alter the current input and thus maintain the rotational speed. Assuming full mechanical to thermal power conversion in the grinding process, PWM can be used as feedback for heat generation and temperature prediction. In this study, the conversion model was established from experiments under a variety of grinding conditions and an inverse heat transfer method to determine heat flux. Given a constant rotational speed, the heat conversion was represented by a linear function, and could predict temperature from the experimental data with less than 20% errors. Such results support the advance of this technology for practical application.

Thermal model to investigate the temperature in bone grinding for skull base neurosurgery.

This study develops a thermal model utilizing the inverse heat transfer method (IHTM) to investigate the bone grinding temperature created by a spherical diamond tool used for skull base neurosurgery. Bone grinding is a critical procedure in the expanded endonasal approach to remove the cranial bone and access to the skull base tumor via nasal corridor. The heat is generated during grinding and could damage the nerve or coagulate the blood in the carotid artery adjacent to the bone. The finite element analysis is adopted to investigate the grinding-induced bone temperature rise. The heat source distribution is defined by the thermal model, and the temperature distribution is solved using the IHTM with experimental inputs. Grinding experiments were conducted on a bovine cortical bone with embedded thermocouples. Results show significant temperature rise in bone grinding. Using 50°C as the threshold, the thermal injury can propagate about 3mm in the traverse direction, and 3mm below the ground surface under the dry grinding condition. The presented methodology demonstrated the capability of being a thermal analysis tool for bone grinding study.