Advances in (Un)conventional engineering of biomaterials and nursing care.
Hloch, S. ; Foldyna, J. ; Monka, P. 等
1. Introduction
In the course of the last decades orthopaedic surgery has been
developing rapidly. A significant qualitative change is being noted at
present when the development of technical and biological sciences is
moving the field of orthopaedic surgery forward (Ritter & Campbell,
1989), (Salgado et al., 2004). New knowledge in the sphere of basic
research and in the modern field in question have formed preconditions
and substantial possibilities of technique in case of conventional
orthopaedic surgical operations such as correction of uneven length and
deformations of limbs, osteosynthesis, but particularly in possibilities
of replacements of worn-out degenerative joints either on the
developing, inflammatory, traumatogenic, metabolic grounds or in the
postoperative states (Kl'oc, 2009). Number of patients suffering
from degenerative joint diseases (osteoarthritis) has been continually
increasing and due to its seriousness, therapeutic complications and
frequent patient/client (p/c) individualization the disease represents
inherent and significant medical, economic and social issue. The
successful replacement of the destroyed joint means improvement of
mobility, pain relief and returning back to accomplishing every day
activities for a p/c.
Many patients at working age re-enter into an employment
relationship after successful surgery related to the total
endoprosthesis. Achievement of implantation and reimplantation of the
total hip joint replacement and long-term longevity of endoprosthesis
depend on number of factors involving, for instance, correct surgery
indication, patient preparation, properly performed surgical operation.
A surgical operation rests chiefly in selection and effective technique
of the bone cutting which influence both quality and biological
potential of the generated surface. Utilization of up-to-date techniques
may cause frequent revision surgical operations. An aseptic loosening of
endoprosthesis represents the most common reason of subsequent
implantation failure. A long-term success of the implanted
endoprosthesis does not lie only in the used surgical techniques but
also in the method of cutting and machining of the bones, their
properties and technological procedures (Hreha et al., 2010). Measuring
micro and macro characteristics of the bone is insufficient for the
assessment of cutting conditions in terms of inhomogenity of the bone
for the cortical and spongy bone parts (Kato et al., 1998), (Jackson et
al., 2005).
2. State of The Art Analysis in Biomaterials (Un)Conventional
Cutting
The design of osteotomes as we know them today dates back to the
17th or 18th century. These tools, chisels, toothed saws and knives,
were copied from those used in the wood industry (Giraud et al., 1991).
Surgeons' tools only included a few technical improvements compared
with those commonly used for cutting other materials. The bone cutting
(Hreha et al., 2010), (Giraud et al., 1991), (Sugita et al., 2009),
(Haider et al., 2007) issue is currently an existing problem of more
surgeons even in regard to the fact that the bone tissue is compact and
living material (Kato et al., 1998), (Giraud et al., 1991).
A significant part of the clinical and non-clinical studies has
been conducted to assess performance of machining techniques with
utilization of diverse technological conditions. The following table 1
presents conventional (Udiljak et al., 2007), (Lee et al., 2011),
(Sugita et al., 2009), (Nelson & Weber, 1981), (Ark et al., 1998),
(Toksvig-Larsen et al., 1992) and non-conventional methods (Lustman et
al., 1991), (Nelson et al., 1988), (Biyikli & Modest, 1987),
(Siebert, 1993), (Jahn et al., 1992), (Wallace et al., 2004), (Armengol
et al., 1999), (Yoshikazu, 2011), (Papadaki et al., 2007), of the bone
tissue cutting or (Dunnen et al., 2013) drilling with water jet. Typical
measuring of the cutting and machining performance relates to the
surface texture, surface integrity, cutting force, temperature, and bone
healing after cutting, efficiency, mechanical tension, and cutting
accuracy (Giraud et al., 1991), (Udiljak et al., 2007). To select a
correct procedure of the bone machining, it is important to be aware of
the fact that the bone is a complex biomaterial and in terms of
mechanical properties it shows certain particularities in dependence on
the structure, location, stress direction, stress history (Kl'oc,
2009), (Jackson et al., 2005). It is typical due to structural
inhomogeneity and anisomery. The bone consists of a thick and compact
external tissue, i.e. cortical bone. The bone core is composed of porous
and spongy tissue referred to as the spongy bone. The cortical bone is
anisotropic and characterized by three different Young's modules
(Kato et al., 1998).
Mechanical properties of the bone vary in dependence on sex, age,
anatomy, nutrition. Nowadays in the field of the bone tissue cutting
there are mechanical tools being used which frequently represent
invasive intervention into the organism of the individual. While in the
first part of the last century chisels (Nelson & Weber, 1981) and
manual saws (Giraud et al., 1991) were preferred, at present an
air-powered saw with special indications and high-speed milling (Sugita
et al., 2009) cutters and drills (Udiljak et al., 2007), (Lee et al.,
2011) are used. Utilization of the aforementioned conventional
instruments in (re)implantation of total endoprostheses brings along
several drawbacks, e.g. increase of risk of disintegration, cracking and
various other complications (Ritter & Campbell, 1989), (Eriksson
& Albrektsson, 1994), (Krause et al., 1982), (Toksvig-Larsen, et
al., 1991), (Biyikli, et al., 1986), (Wachte & Stoll, 1991),
(Johansson et al.l, 1981). The existing technological advances referred
to decrease of the required effort of a surgeon in cutting and to
increase osteotomy speed in time with respect to operating parameters.
In many publications particular attention is continually devoted to the
issue of enhancement of the bone tissue cutting by conventional method
(Johansson et al.l, 1981), (Canestri, 1992), (Sugita et al., 2005),
(Mitsuishi et al., 2003), (Taylor & Stoianovici, 2003), (Kwon et
al., 2002), (Mitsuishi et al., 2002). Professor Udiljak (Udiljak et al.,
2007) and Tomislav Staroveski (Goran et al., 2012) studied the problem
of avoiding the occurrence of irreversible death of bone cells exposed
to high temperature during drilling. Jackson et al (Jackson et al.,
2005) in their investigation used diamond-coated cutting tool to prepare
bone for biomedical implants. He found that bending of the cutting tool
contributes significantly to the primary chip prior to significant
frictional interactions on the rake face of the cutting tool.
Haider et al. (Haider et al., 2007) reported a concept to eliminate
alignment jigs and facilitate smaller arthroplasty incisions. His paper
(Haider et al., 2007) has been awarded by HAP Paul Award. A new cutting
method for bone on its crack propagation characteristics has been
introduced by Sugita et al (2009). This method realizes high efficiency,
low mechanical stress and high precision in the bone machining. In study
of (Sugita & Mitsuishi, 2009) micro cutting of the bovine cortical
bone was performed and structure observed under a microscope. Two
research trends have referred to improvements focused primarily on
motorization of the cutting movements and tools (Canestri, 1992),
(Sugita et al., 2005), (Mitsuishi et al., 2003), (Taylor &
Stoianovici, 2003), (Kwon et al., 2002), (Mitsuishi et al., 2002).
Implementation of the automatized cutting represents the most
significant technical upgrade for a surgeon. Several diverse types of
mechanical drives for cutting are used with each drive connected to
various tools and control of their action of force. The concept of the
dynamically controlled milling was designed by a research team headed by
Sugita (Sugita et al., 2009). In the regime of force control the
software monitors cutting forces through which temperature reduction is
allowed. The authors assessed the influence of cutting time shortening,
overload of a tool, protection against temperature increase, and safety
check enhancement of action of force of a tool on the basis of real-time
monitoring. The use of a coolant as a prevention of the tissue necrosis
and utilization of tools sharpened in advance have been described by the
same characteristics in the so far published theses (Toksvig-Larsen, et
al., 1991).
Yet the question whether the given recommendations are accepted by
surgeons arises. In the course of the bone cutting a blade of a saw is
being cooled as the heat generated in contact between a tool and the
bone tissue has a negative influence upon biological potential of the
bone. The drilling equipment is effective, especially in combination
with robotic systems (Udiljak et al., 2007), (Lee et al., 2011), (Kwon
et al., 2002). Their accuracy is better in comparison with oscillating
saws (Giraud et al., 1991), (Ark et al., 1998), (Toksvig-Larsen et al.,
1992) yet alike in the aforementioned instance the heat generated as a
result of friction during drilling represents a drawback for the bone
quality. A substantial positive feature of chisels (Nelson & Weber,
1981) contrary to sawing and drilling stems in the unchanged bone tissue
vitality. Using a chisel frequently causes damaging of the soft tissue
by a sharp blade. The method is utilized in osteotomy techniques to
prolong the bone since not a maximal accuracy is required but a
biological potential of the purposefully destroyed bone surface.
oscillating saws may represent a necrosis source in the moment of a slip
occurrence causing penetration into other living tissues. Efficiency of
a surgery is decreased because oscillating instruments reach a zero
speed even in two positions. Problematic is also a cutting width which
is relatively wide in dependence on spacing of the blade teeth as well
as cutting line deflection (Giraud et al., 1991), (Ark et al., 1998),
(Toksvig-Larsen et al., 1992), (Krause et al., 1982). In these types of
the tissue cutting many fragments occur acting as foreign particles to
which the organism reacts by aseptic inflammation in the point of the
presence of chips through which the healing period is extended and
consequently costs and post-operative care length increase. Any of the
used mechanical methods are characterized by the same attribute
represented by attendance of a surgeon, i.e. a man, by which accuracy
level significantly decreases and causes negative actions of force upon
the bone tissue.
Not with standing heavy effort made by scientists and despite the
increased requirements the current applicable techniques of osteotomy in
orthopaedic surgery have changed minimally in the course of the last
decades. one of the options of making surgical operations more effective
is to use techniques working on the principle of photon erosion, water
erosion, and ultrasound. An excimer laser was considered to be a
suitable instrument to, for instance, remove the bone cement without the
bone damaging (Zimmer et al., 1992). With regard to its low ablation
rate clinical utilization in overall hip joint revision proved
impossible as per.
Ritter and Campbell (Ritter & Campbell, 1989) pointed out the
fact that conditions of the femoral channel were crucial for successful
revision alloplasty. It means that the bone cement must be completely
eliminated with minimal damaging of the cortical or cancellous bone.
Several methods have been described yet the best solution still remains
unknown.
Zimmer (Zimmer et al., 1992) mentioned that with the only excimer
laser approved for medical use in Germany the ablation rate could not be
sufficiently accelerated for all the bone cement in a hip revision
operation to be removed in adequate time. Due to high photon energy
excimer lasers induce radiation which may be used for electronic control
of a laser ray through spectral difference between the bone and bone
cement. Lasers used in the bone cutting up to now are still on the
experimental level Lustman et al., 1991), (Nelson et al., 1988),
(Biyikli & Modest, 1987), (Siebert, 1993), (Jahn et al., 1992),
(Wallace et al., 2004), (Armengol et al., 1999), (Yoshikazu, 2011),
(Papadaki et al., 2007). As to geometry lasers are capable of an
accurate cutting, yet reaching just shallow depths. Many scientists
study the technique, for instance, Papadaki et al (Papadaki et al.,
2007). An essential principle of interaction between a laser and
biomaterial makes the technique unsuitable. osteotomy requires the deep
cutting possible to be carried out only by high-powered CO2 lasers
(Biyikli & Modest, 1987) causing instant unacceptable thermal damage
of the tissue on the cutting surface (Giraud et al., 1991).
Use of ultrasound (Steiger et al., 1996), (Caillouette et al.,
1991), (Klapper et al., 1992) devices is not common in surgical practice
and still those are in the experimental development stage. The
specialized ultrasound devices possess a distinctive function which
excludes them out of the standard utilization in consequence of
temperature increase unless a coolant is used. In spite of maximal
effort the upgrades proposed by Volkov and Weis (Giraud et al., 1991)
are not trouble free. The reason lies both in the amount of work within
the restricted surgical field and thermal tissue damage.
Water jet is capable to cut any material in several directions
without thermal and mechanical deformation of the cutting material
(Hreha et al., 2010), (Kovacevic, 1991), (Sharma et al., 2011). The
cutting principle rests in forcing the abrasive water jet or pure water
jet to the point of the cutting at high speed. The permeate being the
kinetic energy carrier of the abrasive washes the removal products off
the point of the cutting and provides its cooling. As table 3 shows a
high potential stems in the technology of the abrasive water jet
cutting. The first medical applications of the technology were published
in the 80s when the water jet was used to cut the soft tissues. In a
large extent the water jet (WJ) is applied in all types of industry. In
medicine practice the water is possible to be utilized, for instance, in
cutting the organs; wound cleaning; liposuction; necrotic epidermis
removal; extraction of metastasis and glioma; cutting the tissues,
bones, tooth substance. options of use of the water jet application and
its advantages are described in (Hreha et al., 2010), (Kovacevic, 1991),
(Honl et al., 2000), (Kuhlmann et al., 2005), (Richter et al., 2009),
(Penchev et al., 1999), (Dunnen et al., 2013).
Nowadays the studies researching the use of the water jet even in
orthopaedics, for instance, in implantations and reimplantations of
total replacement of the hip and knee joints are available (Honl et al.,
2000), (Honl et al., 2001), (Kuhlmann et al., 2005), (Honl et al.,
2003). The objective is to draw attention to the fact that the AWJ may
in the future replace so far exerted technological procedures to cut
down on financial demands related to the surgical performance as well as
to reduce the period of hospitalization and early return of a patient
into the active life.
3. Related Problems
Latest knowledge of fundamental research (Johansson et al.l, 1981),
(Canestri, 1992), (Sugita et al., 2005) and up-to-date technology have
established conditions (Mitsuishi et al., 2003), (Taylor &
Stoianovici, 2003) and high potentials in the area of conventional
orthopaedic surgical operations as for instance corrections of uneven
length and deformations of limbs, osteosynthesis, but particularly in
possibilities of replacements of worn-out degenerative joints either on
the developing, inflammatory, traumatogenic, metabolic grounds or in the
postoperative states (Biyikli & Modest, 1987). Replacement of
worn-out joints (alloplasty) offers new treatment possibilities. Number
of patients suffering from degenerative joint diseases (osteoarthritis)
has been continually increasing and due to seriousness, therapeutic
complications and frequent patient/client individualization the disease
represents significant medical, economic and social issue (Kl'oc,
2009). Progress being achieved in orthopaedics, specifically in the
sphere of reconstructive surgery, allows partial even full return of a
p/c to normal life. Damaged joint replacement by the total
endoprosthesis represents the most remarkable advance in the history of
bone surgery (Hreha et al., 2010). For the patient the successful
replacement of destroyed joint means improvement of mobility, pain
relief and returning back to accomplish every day activities.
Many patients at working age come back to work after successful
surgery of the hip joint (total endoprosthesis implantation).
Implantation achievement of the total hip joint replacement and
long-term longevity of endoprosthesis depend on a lot of factors
involving correct indication, patient preparation, properly performed
surgical operation, surgeon's skills, technical device, operating
theatre conditions and postoperative care in which rehabilitation plays
an important role. Number of the hip joint total endoprostheses in the
world and Slovak Republic increases yearly (fig. 1, fig. 2) (Necas et
al., 1993). The presented development chart of number of alloplastic
surgical operations of the hip and knee joints in the territory of the
Slovak Republic draws on two sources: until 2003 it was statistics of
the chief expert in orthopaedics of Ministry of Health of the Slovak
Republic and since 2003 it has been the Slovak Arthroplasty Register
(SAR) (Necas et al., 1993). Gradually, application of the uncemented
total hip joint replacements increases (Jackson et al., 2005) (Fig. 1).
[FIGURE 1 OMITTED]
4. Analysis of Surgical Procedure
Technical innovations in the sphere of total replacement
development include multifactor impact on diverse joint aspects
(Kl'oc, 2009), (Hloch et al., 2013), (Kwon et al., 2002). New
contemporary techniques of osteotomy procedures allow precise cut final
grinding and thus optimal prosthesis placing in the bearing axis. The
result of this highly exact procedure is more precise endoprosthesis
fitting, fixation improvement and longevity (Jackson et al., 2005).
Prior to each surgery related to the total endoprosthesis of the hip
joint a preoperative planning is to be carried out allowing determining
size of the endoprosthesis components, their position following the
anchoring in order to retain the centre of rotation of the total
replacement (Fig. 2).
[FIGURE 2 OMITTED]
The preoperative planning requires X-ray of the pelvis in the AP
projection and the images of both hip joints in the axial projection.
The planning of the size and position of the components is carried out
using the templates. The surgery is possible to be performed using
different operative approaches, according to the surgery type, and
surgeon's usages. As per operative approach the operative technique
and surgery procedure are different. In standard anterolateral approach
following the preparation of the soft structure the hip joint is being
opened up. Foremost the head with the neck is resected and then the
joint cup of the acetabulum is proceeded to in order to be machined. The
acetabulum is being machined by use of special milling cutters in
accordance with the cup being implanted. Into the prepared socket of the
acetabulum either the cemented cup is anchored using bone cement or the
uncemented cup in case of which the polyethylene, metal or ceramic
articulation liner is inserted into the anchoring part. Consequently,
the femoral channel is prepared in case of which under the osteotomy
line the metaphyseal area is being extended by means of fenestrated
chisel. The chisel orientation has to retain the planned anteversion of
the femmoral component. Using special milling cutters the marrow cavity
is then milled with the milling cutters' size increasing in stages.
Thereafter the cavity is prepared by rasps according to the implanted
endoprosthesis type. A plastic head is inserted onto the last rasp size,
displacement is performed, endoprosthesis stability is tested and the
length of the limb is checked. In cemented endoprosthesis the cap made
of polyethylene or spongious bone is inserted into the cavity below the
tip of the femoral component and so is the drainage which drains
haematoma out of distal pole of the marrow cavity allowing thus bone
cement to be pressed into the marrow cavity. The centralizer of an
adequate size is inserted into the opening of lower part of the stem.
Following the drainage removal the stem is inserted into the femoral
channel filled with bone cement in desired anteversion. When cement has
grown mature the testing head, later changed into the definite one, is
reinserted. Should the cementless stem be used it is placed into the
prepared socket to provide fixed anchoring (Kloc, 2009).
5. Pro-futuro Approach to Problems Being Solved
Effective surgical process depends on technology. Due to many
benefits of water jet it is possible to use kinetic energy of waterjet
for destruction of bone cement --interface between femoral stem and
trabecular bone in case of reimplantation of femoral stems (Fig. 5).
There is an advantage of using water jets coming from the fact that the
jet is able to remove selectively the material with lower modulus of
elasticity (titanium endoprosthesis exhibits modulus of elasticity ETi =
200 GPa, bone cement (PMMA) Ebc = 4,5 / 4,8 GPa (Fig. 3), and trabecular
bone tissue Ebone = 14,8 GPa (Rho et al., 1993)). Considering low values
of mechanical characteristics of bone cement the water jet flow shall
cold-create a crack between a trabecular part of bone structure and the
stem of the femoral component without mechanical damage or deformation
to surrounding tissue during process of releasing of the stem of the
component. This hypothesis was partially experimentally verified in
following study (Hloch et al., 2013). Results from performed experiments
show that the pulsating water jet is a suitable technology for bone
cement removal due to the lowest pressures necessary for disintegration
of bone cement. Further research will be aimed at the evaluation of
disintegration of different kinds of bone cements commercially used in
orthopedic practice.
[FIGURE 3 OMITTED]
[FIGURE 4 OMITTED]
Other advantages represent small losses, quick and considerate
technological process of cutting of even heavy porous bones. Considering
its broad utilization the technology appears to be used especially in
case of reimplantations. Diameter of the water jet up to 0.5 mm means
remarkable advantage while working in very small areas at interface of
the prosthesis and bone tissue. The cutting process is basically cold,
thus thermal effect is avoided, and forces and reactions are relatively
low. Accurate manipulation with an applicator is possible both in manual
or robotic way. Given facts show possibility to remove prosthesis by the
technique of cutting in quicker and more considerate manner. The
following figures 4,5 shows the part of proposed workplace with
application of automated on-line control of surgical resection of the
hip joint using technology of abrasive water jet being solved within the
thesis by Blichova.
[FIGURE 5 OMITTED]
6. Conclusion, Remarks and Future direction of Research
New technologies are still introduced even in orthopaedic practice
with a promise of better care of patients, though often with limited
pieces of information. Therefore hospitals, medical establishments, and
surgeons face a need to evaluate relative advantages of new technologies
to be able to consider possible benefits for patients. The aim is to
decrease costs and potential undesirable clinical impacts connected with
their use. This scientific research work is based upon possibility to
apply the abrasive water jet cutting technology. It comprises outcomes
of exploration and possibilities of utilization of the abrasive water
jet cutting technology for purpose of responsible and profitable
introduction of the technology in orthopaedic practice. Innovation of
the exerted surgical procedures with utilization of the water jet in
medicine is a vision to the near future with solid foundation in fierce
competitive market environment. A joint effort in the future shall be
aimed at:
--carrying out quite a number of experiments and research studies
in the field of basic research with consequent implementation of the
applied research in the field of medicine and nursing practice,
--realizing and monitoring the results of the applied research in
the field of impact of surgical orthopaedic performances related to
total endoprosthesis and reimplantation with utilization of the water
jet.
Partial objectives specified within the field of technical
disciplines, medicine, and nursing:
--in the field of technical disciplines the objectives shall be
aimed at:
--prediction of the quality of the surfaces generated by the water
jet cutting,
--examination of the alternative biocompatible material and its
influence upon the quality and efficiency of the process to arrange
strict aseptic environment in terms of surgical operation,
--study of relation between the surface quality and change of
technological conditions of assessment of eligibility of the bone tissue
cutting process,
--development of sterile pumps and the cutting depth check,
--optimizing regime factors of the water jet for the future robotic
utilization,
--elaborating a proposal of the on-line control of a surgical
process,
--controlling the penetration process of the water jet,
--integration of general theoretical prognosis of the reached limit
depths,
--unification of interpretations and results to achieve a high
level of generalization for other workplaces.
In the field of surgical medicine to:
--point out the possibilities of quality enhancement of the
surgical operation using the water jet related to technological
procedure of the hip join replacement,
--monitor the cutting quality,
--monitor comfort of the surgical field, length of a surgical
operation, p/c's remaining under anaesthesia, etc.
At the field of nursing:
--to describe contribution for the nursing practice,
--to monitor impact of a new surgical technology upon a
patient/client (p/c),
--to point out particularities of nursing care,
--to compare a current rehabilitation program with a program using
the technology in question,
--to monitor p/c's hospitalization length,
--impact upon management of the rendered nursing care and
p/c's life quality after the total hip joint replacement,
--to elaborate standards and audit for a complex nursing care of a
p/c after the total endoprosthesis surgical operation using the latest
surgical technology,
--to monitor quality of postoperative process as well as of
elimination of postoperative complications in consequence of early
mobilization,
--to monitor a p/c's life quality and related overall social
and economical impact.
Surgical operations using the water jet represent a potential
instrument to enhance both surgical operations in favour of
patient's life quality improvement and eventually general social
and economical impact. Innovation of the exerted surgical procedures
with utilization of the water jet in medicine is a vision to the near
future with good foundation in a fierce competitive environment. In
spite of considerable advance in the application of the water jet
technology we are aware of the problems related to its application in
clinical practice and thus we do believe that by the contribution a
possible discussion focused on the field in question shall be initiated.
The purpose was not to draw attention to a detailed description of
a p/c nursing care management after TEP yet to centre on feasible
innovative therapeutic techniques using the water jet in orthopaedics
and orthopaedic nursing. At the same time the desire was aimed at
outlining the option of multidisciplinary connection in the field of
medicine, nursing, and technical disciplines. The fundamental idea was
requirement to provide a p/c with nursing care based on knowledge of
latest outcomes of a scientific research. A surgery related to TEP,
utilizing water jet, represents a viable instrument for surgery
enhancement. In perspective, it would be suitable, for instance, to work
out standards and audit for complex nursing care of a p/c after TEP
surgery with application of a new surgical technology, monitoring of
comfort of a surgical field, length of the surgery, keeping a p/c under
anaesthesia, quality of after-surgical development with a p/c as well as
elimination of surgical complications due to earlier mobilisation. last
but not least the focus was directed towards benefits in the sense of
increasing quality of life of a p/c and thus related overall social and
economic impact. However, quite a number of studies as well as
activities should be performed aimed at support and development of
theoretical basis of medical and nursing research with further
implementation in clinical practice. To acquire knowledge for more
detailed description of the process it is inevitable to define
indications and eventual contraindications in application of the water
jet in medicine.
7. Acknowledgments
experiments were carried out under the support of projects science
and research VEGA 1/0972/11, VEGA 2/0075/13, Institute of clean
technologies for mining and utilization of raw materials for energy use,
reg. no. CZ.1.05/2.1.00/03.0082 supported by the Research and
Development for Innovations Operational Programme financed by the
Structural Funds of the European Union and the state budget of the Czech
Republic, and with support for the long term conceptual development of
the research institution RVO:68145535.
8. References
Andratschke M.; Loerken J.; Eggers R.; et al. (2011)
Histomorphologic findings in the facial nerve after waterjet dissection
of the parotid gland. Animal studies in dogs HNO 59: 1055-1061
Ark TW, Neal JG, Thacker JG, Edlich RF (1998) Influence of
irrigation solutions on oscillating bone saw blade performance. J Biomed
Mater Res 1998; 43: 108-112. Armengol V. et al (1999) Scanning electron
microscopic analysis of diseased and healthy dental hard tissues after
ErYAG laser irradiation: in vitro study, J. Endodont. 25
(8)(1999)543-546
Baer HU, Stain SC, Guastella T, Maddern GJ, Blumgart LH. (1993)
Hepatic resection using a water jet dissector. HPB Surg 1993;6(3):189-96
Berry MG, Davies D. (2011) Liposuction: A review of principles and
techniques. Journal of Plastic, Reconstructive & Aesthetic Surgery,
2011, 64 (8), p.985-992 Vol. 57, 1(2012), p. 30-35
Berry MG, Davies D. (2011) Liposuction: A review of principles and
techniques. Journal of Plastic, Reconstructive & Aesthetic Surgery,
2011, 64 (8), p.985-992
Birth M; Kleemann M; Hildebrand P; et al. (2004) Intraoperative
online navigation of dissection of the hepatical tissue--a new dimension
in liver surgery? DOI: 10.1016/j.ics.2004.03.335
Biyikli S, Modest MF. (1987) Energy requirements for osteotomy of
femora and tibiae with a moving CW CO2 laser. Lasers Surg Med 1987; 7:
512-519.
Caillouette JT, Gorab RS, Klapper RC, Anzel SH. (1991) Revision
arthroplasty facilitated by ultrasonic tool cement removal. Part I: In
vitro evaluation. Orthop Rev 1991;20: 353-357
Canestri F. (1992) Proposal of a computerized algorithm for
continuous wave CO2 laser on-line control during orthopaedic surgery.
Phase I: theoretical introduction and first in vitro trials. Int J Clin
Monit Comput 1992;9: 31-44
Cuschieri A. (1994) Experimental evaluation of water-jet dissection
in endoscopic surgery. Endosc Surg Allied Technol 1994;2(3-4):202-4
Dunnen, D. et al. (2013) Pure water jet drilling of articular bone:
An in vitro feasibility study. Strojniski Vestnik/Journal of Mechanical
Engineering 59 (7-8), pp. 425-432
Eriksson, R. A.; Albrektsson, T. (1984) The effect of heat on bone
regeneration: an experimental study in the rabbit using the bone growth
chamber. J. oral Maxillofac. Surg. 42: 705-711; 1984
Foldyna J. et al. (2004) Utilization of ultrasound to enhance
high-speed water jet effects // Ultrasonic sonochemistry. vol.11,
3-4(2004), p. 131-137
Giraud JY, et al. (1991) Bone cutting. Clin. Physics and
Physiological Measurement.doi:10.1088/0143-0815/12/1/001
Goran A, et al (2012) Cortical bone drilling and thermal
osteonecrosis. Clinical Biomechanics, vol. 27, 4, pp. 313-325
Granick MS, et al. (2006) Clinical and economic impact of
hydrosurgical debridement on chronic wounds. Wounds 2006, 18:35-39
Gurunluoglu, R. (2007) Experiences with waterjet hydrosurgery
system in wound debridement. World Journal of Emergency Surgery. 2007,
doi:10.1186/1749-7922-2-10
Haider, H. et al. (2007) Minimally Invasive Total Knee Arthroplasty
Surgery Through Navigated Freehand Bone Cutting. The Journal of
Arthroplasty Vol. 22, 4(2007), p. 535-542
Hata Y, et al. (1994) Liver resection in children, using a
water-jet. J Pediatr Surg 1994; 29: 648-650
Hloch S et al. (2013) Dissintegration of bone cement by continual
and pulsating water jet. Vol.20 No.4, pp. 593-598
Honl M, et al. (2001) Water jet discotomy with microinvasive
approach-in vitro testing and initial clinical aspects of a new
procedure. Z Orthop Ihre Grenzgeb 2001; 139: 45-51
Honl M, et al. (2000) The use of water-jetting technology in
prostheses revision surgery--first results of parameter studies on bone
and bone cement. J Biomed Mater Res 2000; 53: 781-790
Honl M, et al. (2000) Water jet cutting for bones and bone
cement--parameter study of possibilities and limits of a new method.
Biomed Tech Berlin 2000; 45: 222-227
Honl M; Uebeyli H; Dierk O; et al. (2003) Use of a waterjet for
synovectomy: In vitro study of feasibility. Zeitschrift fur Orthopadie
und ihre Grenzgebiete 141:322-327
Hreha, P., Hloch, S., Magurova, D., et al. (2010) Water jet
technology used in medicine. // Tehnicki vjesnik. vol. 17, no. 2 (2010),
p. 237-240
Jackson MJ et al. (2005) Machining Cancellous Bone prior to
prosthetic implantation. Journal of Materials Engineering and
Performance International. (2005) 14:293-300
Jahn R, Dressel M, Neu W, Jungbluth KH. Ablation of hard biological
tissue with the excimer laser. Unfallchir 1992; 18: 261-265
Johansson JE, et al. (1981) Fracture of the ipsilateral femur in
patients with total hip replacement. J Bone Joint Surg Am 1981;63:
1435-1442
Kato N, Koshino T, Saito T, Takeuchi R. (1998) Estimation of
Young's modulus in swine cortical bone using quantitative computed
tomography. Bull Hosp Jt Dis. 1998;57(4):183-6
Klapper RC, Caillouette JT, Callaghan JJ, Hozack WJ. (1992)
Ultrasonic technology in revision joint arthroplasty. Clin orthop 1992;
147-154
Klein MB, et al. (2005) The Versajet water dissector: a new tool
for tangential excision. J Burn Care Rehabil 2005, 26:483-487
Kl'oc, J. (2009) Solutions disorders hip replacements, leading
to reoperation. PhD Thesis, Technical University of Kosice, 2009, p. 117
Kovacevic R. (1991) Surface texture in abrasive waterjet cutting. J
Manufact Syst 1991; 10: 32-40.
Krause, W. R.; Bradbury, D. W.; Kelly, J. E.; Lunceford, E. M.
(1982) Temperature elevations in orthopedic cutting operations. J.
Biomech. 15: 267-275; 1982
Kuhlmann C; Pude F; Bishup C; et al. (2005) Evaluation of potential
risks of abrasive water jet osteotomy in-vivo. Biomedizinische Technik
50:337-342
Kusnerova, M. et al. (2008) Derivation and measurement of the
velocity parameters of hydrodynamics oscillating system.//Strojarstvo:
Journal for theory and application in mechanical engineering. vol. 50,
no. 6 (2008), p. 375-379
Kwon D.S., et al. (2002) The Mechanism and the Registration Method
of a Surgical Robot for Hip Arthroplasty", IEEE International
Conference of Robotics and Automation, pp. 1889-1894, 2002
Lee J et al. (2011) A new thermal model for bone drilling with
applications to orthopaedic surgery. Medical Engineering & Physics
33 (2011), p. 1234- 1244
Lustmann J, et al. 193 nm excimer laser ablation of bone. Lasers
Surg Med 1991; 11: 51-57
Man D, Meyer H. Water jet-assisted lipoplasty. Aesthetic Surg J
2007;27:342-6. Mitsuishi M., et al., Development of a 9 Axes Machine
Tool for Bone Cutting, Annals of the CIRP, 52/1 (2003) 323
Mitsuishi, M. et al. (2002) A Study of Bone Micro-Cutting
Characteristics Using a Newly Developed Advanced Bone Cutting Machine
Tool for Total Knee Arthroplasty. CIRP-Annals of Manufacturing
Technology. Vol. 54, 1(2005), p. 41-46 Necas, L et al. (1993) Slovak
arthroplastic register--analysis. 2003 / 2008, 2009, pp. 325
Nelson CL, Weber MJ. (1981) Technique of windowing the femoral
shaft for removal of bone cement. Clin Orthop 1981; 336-337
Nelson JS, et al. (1988) Ablation of bone and methacrylate by a
prototype mid-infrared erbium: YAG laser. Lasers Surg Med 1988; 8:
494-500
O'Daly, B. et al. (2008) High-power low-frequency ultrasound:
A review of tissue dissection and ablation in medicine and surgery.
Journal of Materials Processing Technology. Volume 200, Issues 1-3,
Pages 38-58. 8 May 2008. (O'Daly et al., 2008)
Oertel J, Gaab MR, Piek J. (2003) Waterjet resection of brain
metastases--first clinical results with 10 patients. Eur J Surg Oncol
2003;29(4):407-14
Oertel J; Gaab MR; Schiller T; et al. (2004) Towards waterjet
dissection in neurosurgery: experimental in-vivo results with two
different nozzle types. Acta Neurochirurgica. 146:713-720
Oertel J; Gaab MR; Warzok R; et al. (2003) Waterjet dissection in
the brain: review of the experimental and clinical data with special
reference to meningioma surgery. Neurosurgical Review 26:168-174
Ogan K, Cadeddu JA. (2002) Minimally invasive management of the
small renal tumor: review of laparoscopic partial nephrectomy and
ablative techniques. J Endourol 2002;16(9):635-43
Papachristou DN, Barters R. (1982) Resection of the liver with a
water jet. Br J Surg 1982; 69(2):93-4
Papadaki, M. et al. (2007) Vertical ramus osteotomy with Er: YAG
laser: a feasibility study. Int. J. Oral Maxillofac. Surg. 36(2007), p.
1193-1197
Penchev RD; Losanoff JE; Kjossev KT (1999) Reconstructive renal
surgery using a water jet. Journal of Urology. 162:772-774
Persson BG, Jeppsson B, Tranberg KG, Roslund K, Bengmark S. (1989)
Transection of the liver with a water jet. Surg Gynecol Obstet
1989;168(3):267-8
Rho, J. Y.; Ashman, R. B.; Turner, C. H. (1993) Young's
modulus of trabecular and cortical bone material: ultrasonic and
microtensile measurements.//J Biomech. 26, 2(1993), pp. 111-119
Richter S. Kollmar O. Schuld J. et al. (2009) Randomized clinical
trial of efficacy and costs of three dissection devices in liver
resection. British Journal Of Surgery 96: 593-601
Ritter MA, Campbell ED (1989) The survival of the cemented femoral
component of a total hip replacement. Clin Orthop 243 : 143-147
S.Biyikli, M.F.Modest and R.Tarr (1986) Measurements of thermal
properties for human femora, J.Biomedical Materials Res., 20/9 (1986)
1335
Salgado AJ, Coutinho OP, Reis LR. (2004) Bone tissue Engineering:
State of teh Art and Future Trends. Macromol. Biosci. 2004, 4, 743-765
Sharma V., Chattopadhyaya S., Hloch S. (2011) Multi response
optimization of process parameters based on Taguchi-Fuzzy model for coal
cutting by water jet technology // International Journal of Advanced
Manufacturing Technology. Vol. 56, 9-12(2011), p. 1019-1025
Siebert W. (1993) Osteotomy with the experimental laser system.
Fortschr Kiefer Gesichtschir 1993; 38: 149-151
Smith JA. (1993) Possible venous air embolism with a new water jet
dissector. Br J Anaesth 1993;70(4):466-7
Steiger RN, Pandey R, McLardy-Smith P. (1996) Ultrasonically driven
tools. J Arthroplasty 1996;11: 120-121
Stutz JJ, Krahl D. (2009) Water jet-assisted liposuction for
patients with lipoedema: histologic and immunohistologic analysis of the
aspirates of 30 lipoedema patients. Aesthetic Plast Surg 2009;33:153-62.
Araco A, Gravante G, Araco F, et al. (2007) Comparison of power
water-assisted and traditional liposuction: a prospective randomized
trial of postoperative pain. Aesthetic Plast Surg 2007;31:259-65
Sugita N et al. (2009) Cutting tool protects for soft tissues in
bone milling machining. Int. J. of Automation Technology Vol.3No.2,
2009, pp. 185-186
Sugita N et al. (2009) Dynamic controlled milling process for bone
machining Journal of Materials Processing Technology 209(2009), p.
5777-5784
Sugita N, Mitsuishi M (2009) Specifications for machining the
bovine cortical bone in relation to its microstructure Journal of
Biomechanics 42(2009), p. 2826-2829
Sugita, N. et al (2009) A new cutting method for bone based on its
crack propagation characteristics. Cirp Annals--Manufacturing Technology
58(2009), p. 113-118
Sugita, N., Warisawa, S. and Mitsuishi, M., (2005) "A cutting
temperature study of
bone machining for orthopaedic robotic surgery". Proceedings
of the 20th Annual
Meeting of the ASPE, pp. pp. 142-145
Taylor RH., Stoianovici D (2003) "Medical Robotics in
Computer-Integrated Surgery", IEEE Trans. On Robotics and
Automation, Vol. 19, No. 5, pp. 765-781, 2003
Toksvig-Larsen, S et al. (1992) Temperature influence in different
orthopaedic saw blades, The J. Arthroplasty 7 (1) (1992) 21-24
Toksvig-Larsen, S.; Ryd, L.; Lindstrand, A. (1991) On the problem
of heat generation in bone cutting: studies on the effects of liquid
cooling. J. Bone Joint Surg. 73B: 13-15; 1991
Tschan C. A.; Tschan K.; Krauss J. K.; et al. (2009) First
experimental results with a new waterjet dissector: Erbejet 2 Acta
Neurochirurgica 151:1473-1482
Tschan Christoph A.; et al. (2010) Waterjet Dissection of
Peripheral Nerves: An Experimental Study of the Sciatic Nerve of Rats.
67: ons368
Tschan Christoph; Gaab Michael Robert; Krauss Joachim Kurt; et al.
(2009) Waterjet dissection of the vestibulocochlear nerve: an
experimental study Laboratory investigation. 110:656-661
Udiljak, T., Ciglar D., Skoric, S. (2007) Investigation into bone
drilling and thermal bone necrosis. Advances in Production Engineering
and Management, vol. 2, 3(2007), p. 103-112
Une Y, Uchino J, Horie T, Sato Y, Ogasawara K, Kakita A, et al.
(1989) Liver resection using a water jet. Cancer Chemother Pharmacol
1989;23 Suppl: S74-77.
Wachter, R.; Stoll, P. (1991) Increase of temperature during
osteotomy. J. Oral Maxillofac. Surg. 20: 245-249; 1991
Wallace RJ, et al. (2004) Experimental evaluation of laser cutting
of bone. Journal of Materials Processing Technology 149 (2004) 557-560
Yoshikazu O. (2011) Pulsed laser-induced liquid jet for skull base
tumor removal with vascular preservation through the transsphenoidal
approach: a clinical investigation Acta Neurochirurgica 153: 823-830
Zimmer M. et al. (1992) Bone-cement removal with the excimer laser
in revision arthroplasty. Arch Orthop Trauma Surg (1992) 112 : 15-17
Authors' data: Hloch, S[ergej] *; Foldyna, J[osef] *; Monka,
P[eter] **; Kozak, D[razan] ***; Magurova, D[agmar] ****; * Institute of
Geonics Academy of Science of Czech Republic, v.v.i., Ostrava Poruba,
Czech Republic; ** Faculty of Manufacturing Technologies, Technical
University of Kosice with a seat in Presov, Presov, Slovakia; *** Josip
Juraj Strossmayer University of Osijek, Mechanical Engineering Faculty
in Slavonski Brod, Croatia; **** Faculty of Health Care, University of
Presov, Slovakia; sergej.hloch@tuke.sk, peter.monka@tuke.sk
DOI: 10.2507/daaam.scibook.2013.13
Tab. 1. Bone cutting techniques
Osteotomy techniques Purpose description
Drilling High speed drilling Biocompatibility,
perforation Thermal bone
necrosis research,
decreasing axial force,
drill geometry
Milling High speed milling Minimally invasive
orthopaedic surgery,
cortical bone
reconstruction, surface
preparation
Sawing Thermal effects, study
Coated cutting tools Diamond-coated cutting tool
Microcutting Bone precision cutting
Rotational Acetabular
Osteotomy (RAO), to
understand changes
Laser beam induced in bone in terms
of temperature rise and
thermal damage,
feasibility of performing
complete oesteotomy,
examine bone healing
under functional loading,
vertical ramus osteotomy
To correct conditions of
the jaw and face , to
achieve a correct bite,
an aesthetic face and an
Ultrasonic machining enlarged airway, sinus
lift, alveolar ridge
expansion, exposure of
impacted canines,
lateralization of the
inferior alveolar nerve
removal of osseous tissue
close to the IAN,
orthognathic surgery,
autologous bone graft,
harvesting, periodontal
surgery, IAN
transposition, alveolar
distraction osteogenesis,
and the removal of
osseointegrated implants
Water jet Selection, cold cutting
of soft tissues,
destruction of bone
cement, small forces
Abrasive water jet Endoprothesis revision
surgery, bone cutting,
femoral component cutting
Pulsating water jet Bone cement removal
Osteotomy techniques Reference
Drilling High speed drilling (Giraud et al., 1991)
(Udiljak et al., 2007)
(Lee et al., 2011)
Milling High speed milling (Haider et al., 2007)
(Sugita et al., 2009)
Sawing (Ark et al., 1998),
(Toksvig-Larsen et al., 1992)
Coated cutting tools (Jackson et al., 2005)
Microcutting (Mitsuishi et al., 2002)
Lustman et al., 1991),
(Nelson et al., 1988),
(Biyikli & Modest, 1987),
(Siebert, 1993),
Laser beam (Jahn et al., 1992),
(Wallace et al., 2004),
(Armengol et al., 1999),
(Yoshikazu, 2011),
(Papadaki et al., 2007)
(Giraud et al., 1991),
Ultrasonic machining (Steiger et al., 1996),
(Caillouette et al., 1991),
(Klapper et al., 1992),
(O'Daly et al., 2008)
Water jet (Richter et al., 2009)
(Oertel et al., 2003)
Abrasive water jet (Honl et al., 2000)
(Honl et al., 2001)
(Honl et al., 2003)
Pulsating water jet (Hloch et al., 2013)
Tab. 2. Comparison of cutting techniques
Osc. saw Drilling Chisel Ultras-ound
Selectivity No No No No
Heat effect Yes Yes No Yes
Mechanical effects Yes Yes Yes Yes
Pollution of the Yes Yes Yes Yes
operating field
Damage to surrounding Yes Yes Yes Yes
tissue
Fragments Yes Yes Yes No
Easy handle Yes Yes Yes No
Robotic use No Yes No Yes
Cut gap wide wide wide wide
Laser Water Jet
Selectivity No Yes
Heat effect Yes No
Mechanical effects Yes No
Pollution of the Yes No
operating field
Damage to surrounding Yes N/A
tissue
Fragments No No
Easy handle No N/A
Robotic use Yes Yes
Cut gap narrow narrow
Tab. 3. Using Water Jet in medical fields
Field Using
Cutting the cemented and
Orthopaedics uncemented
endoprostheses, bone
cement and bones
Dentistry Tooth substance cutting
and abrading
Surgery Resection of soft
tissues: liver, gall
bladder, brain, kidneys,
prostate gland, wound
cleaning
Plastic surgery Dermal graft cleaning,
tattoo removal,
liposuction
Dermatolog Necrotic epidermis removal
hydrosurgery
Field Advantages
does not reach critical
Orthopaedics temperature in cutting
Dentistry Decreases risk of tooth
chipping, decreases
necessity of anaesthetics
blood vessels and nerve
Surgery tissues remain intact at
defined pressure,
minimized bleeding,
accurate and intact
cutting edges, absence of
necrotic edge, shortening
of ischaemia period
Plastic surgery Separation of the tissue
layers, higher accuracy
of results exclusive of
swellings and contour
changes
Dermatolog possibility of direct
hydrosurgery medicament dosing into
the water jet,
elimination of burns,
treatment of bedsore
Field Ref.
(Honl et al., 2000)
(Honl et al., 2001)
Orthopaedics (Kuhlmann et al., 2005)
(Honl et al., 2003)
(Honl et al., 2003)
(Dunnen et al., 2013)
Dentistry (Berry et al., 2011)
(Richter et al., 2009)
(Penchev et al., 1999)
(Hata et al., 1994)
(Cuschieri, 1994)
(Ogan & Cadeddu, 2002)
(Persson et al., 1989)
Surgery (Une et al., 1989)
(Birth et al., 2004)
(Smith, 1993)
(Papachristou, 1982)
(Baer et al., 1993)
(Andratschke et al., 2011)
(Tschan et al., 2010)
(Tschan et al., 2009)
(Oertel et al., 2004)
(Oertel et al., 2003)
Plastic surgery (Berry et al., 2011)
(Man & Mezer, 2007)
(Stutz & Krahl, 2009)
(Araco et al., 2007)
Dermatolog (Gurunluoglu, 2007)
hydrosurgery (Granick et al., 2006)
(Klein et al., 2005)
