Chapter 21: Orthopedic Surgery; Short Answer: Lower Leg Surgery

What additional instrumentation must be available for an AKA or BKA amputation?

A liston amputation knife, satterlee amputation saw and a gigli saw with handles or a power saw must be available. Other instruments include a putti rasp and bone file and sweet or Percy amputation retractor.

What is the purpose of a lateral post during the knee arthroscopy?

A padded lateral post is attached to the side of the OR table approximately at the level of the mid-thigh of the operative leg to facilitate placing counter-traction on the knee joint to open the medial side.

Why is a sandbag taped into position on the OR table as part of the setup?

A sandbag is taped in position on the OR table so that the surgeon can flex the leg and place the heel on the bag to keep the leg in position during the procedure.

What is the common goal of the procedures used to treat a bunion?

Removing the exostosis and realigning the great toe. The goals of surgery are to correct the deformity by removing the exostosis, restore the normal range of motion, and remove the abnormal bony portions to prevent reoccurrence.

Why is irrigation used at the end of the arthroscopy procedure?

Small pieces of tissue that are not irrigated out can get wedged in the joint, causing the knee to lock up in place.

Identify the types of intramedullary nails used for the femur.

1) Flexible nails: Rush and Ender 2) Interlocking nails: Trigen 3) Retrograde interlocking intramedullary nails 4) Standard nails: AO titanium femoral nail system

Place the following steps in order for the insertion of an IM (intramedullary) rod. (1-10)

1) Incision is made over greater trochanter 2) Guide pin is placed in medullary canal with drill 3) Drill using a cannulated drill bit and broach if necessary to enlarge opening 4) IM nail is inserted using insertion device and mallet, over guide pin if cannulated; guide pin is removed 5) Stab wound is made over proximal bolt site and triple trocar assembly is placed 6) Hole is drilled and the first proximal locking bolt is placed. Process is repeated for second bolt 7) Using fluoroscopy, the distal holes are located 8) Stab wound is made; placement of distal locking screw is completed 9) Using wrench, bolts are tightened 10) Incisions are closed and dressing is applied

What can be used to repair the ligament?

ACL repair involves replacement of ligament with autograft synthetic ligament or allograft. Autogrrafts are most often used and includes patellar-tendon grafts, quadriceps tendon, illiotibial band, or semitendinous tendon.

Name the procedures commonly used to treat bunions.

Aken, Chevron, Mckeever, Keller, and McBride techniques.

What is used to perform the fusion?

Bone tissue is saved from the articular surface removal process. If enough is obtained, an autograft from the iliac bone may not be needed. Bone grafts, screw, steinman pins, and cannulated screws are used.

Once the graft is in place, how will the grafts be secured in the tunnels?

Both ends of the graft are fixed with staples, bone screws with spiked washers interference screws or bioabsorbable screws according to the surgeon's preference.

What is the most common cause of a bunion?

Bunions are common in females due to the common shoe styles worn by women, including pointed toes and high heels. Other dispositions to developing a bunion include flat feet, imbalance due to muscle difficulties, and foot pronation.

Describe the types of femoral shaft fractures.

Commuted, transverse, oblique and spiral

What are the most common reasons for a total knee arthroplasty?

Damage due to degenerative joint disease or years of wear and tear causing pain, limping, and joint dysfunction that affects daily living.

Why is it important to save all bone chips and pieces of tissue from the remaining process?

During the procedure the ST should have collected as many bone chips as possible that were created during the reaming of the femoral and tibial tunnels. The surgeon may place the chips in the defect caused by harvesting of the patellar tendon as an aid in healing. A bone clamp may be used to keep the chips in place.

At the end of the procedure, describe the postoperative dressing.

Includes 4x4 sponges or fluffs and a posterior splint or short-leg cast is applied to the affected leg while the ankle is placed in slight plantar flexion (gravity equines).

Why is a triple arthrodesis performed? What bones are fused?

Performed for individuals suffering from a forefoot or hind foot deformity, which causes clubfoot; rheumatoid arthritis, and poliomyelitis. The bones of fusion include the subtler, calcaneocuboid, and talonavicular joints.

What is a perceived postoperative complication of amputations?

Phantom limb syndrome, causing a perceived severe pain.

What is used to retrieve the Achilles tendon for repair? What position is the patient in, and how is the foot positioned for the repair? Describe the suture used for the repair.

Retrieval with the tendon-pulling forceps or other atraumatic clamp. The patient is in the prone position and the foot is maintained in plantar flexion up to 5 degrees with the leg flexed at 15 degrees. The suture used to repair the rupture is surgeon's preference; it can range from 2-0 nonabsorbable to #5 braided polyester such as ticron or ethibond, but always on a non-cutting needle.

What additional complications can occur from the use of an allograft?

Risk of acquiring hepatitis or HIV and graft rejection.

Which ligament of the knee is commonly injured? How does that injury usually occur?

The ACL is commonly injured ligament; The injury usually occurs when the foot is placed and a quick pivot move in the opposite direction is made; this is called a valgus twisting injury.

Once all cuts have been made, a trial reduction will be completed. What should the ST be doing during this process?

The ST should be preparing the irrigation/evacuation system for irrigation and ensuring that the bone cement is ready for mixing. When the surgeon finishes the trail reduction, he or she will communicate the size of the prothesis; the ST should be prepared to confirm the sizes and receive the components from the circulator.

When retracting the capsule, it is essential to remember that "just enough is enough". What are some of the structures that must be preserved during the procedure?

The attachment of the capsule to the metatarsal neck, the neurovascular bundle, and the flexor hallucis longus tendon must be preserved.

While the surgeon is irrigating the cut, he instructs the ST to prepare the cement. What precautions are necessary for this process?

The cement is not prepared until the surgeon states he is ready. The ST is responsible for mixing and creating the cement. The majority of OR's have incorporated the use of a closed mixing systems that is attached to suction to exhaust the fumes made by the mixing cement. The fumes are irritating to the mucous membranes and possibly toxic to the liver. All laps are removed and replaced with clean laps. The ST should keep a small piece of cement on the back table and let the surgeon know when it has hardened.

Where is the graft placed? What type of suture will be used in the preparation of the graft?

The graft is placed in the intercondylar notch with attachments secured in the tibia and femur. The surgeon will place heavy nonabsorbable synthetic sutures through the drill holes for the tibial and femoral tunnels.

What is the most common injury that may be found during arthroscopy? What will be used to repair it?

The most common injury is a torn meniscus and a bucket handle tear may be found. It is repaired using a beaver blade or arthroscopic scissors and then a pituitary rongeur or arthoscopic shaver is used to smooth the edges. If necessary a meniscus repair kit is used to place sutures to bring torn edges back together.

Why is the femur kept in extension during the suturing of the quadriceps muscle?

While the surgeon is suturing the quadriceps in place, the ST will keep the femur in extension position to avoid hip flexion contracture.

The total knee arthroplasty requires preparation for the femoral component, tibial component, and patellar component. The most important cuts are made using the saw. What precautions does the surgical technologist make to ensure the cuts are completed efficiently?

The day prior, the ST will verify the batteries are charging in the units. During setup, the ST will confirm that the components are there. The saw blade and drill bits are the correct size, the blade fits the cutting slot or drill holes of the cutting guides, and extra saw blade is available. The ST will load the saw appropriate size saw blade in anticipation of its use and test the saw prior to handling it to the surgeon. The team members should be told that the saw is being tested. The safety locking should be kept in place until surgeon is ready to use the saw.

Why are x-rays placed on the view box prior to surgery?

The surgeon will create plastic overlay templates using the standard x-ray, marking measurements that show the size of implants that will be needed.

What are the most common reasons for performing an AKA or BKA?

Trauma or disease that inhibits a good vascular supply to the extremity, such as with diabetic patients with non healing ulcers or poor vascularity, tumors of bone marrow, infections , or congenital defect.