II Lecture Chapter 21 Short Answer: Lower Leg Surgery pp 470

Describe the types of femoral shaft fractures.

1. Comminuted 2. Transverse 3. Oblique 4. Spiral

Identify the types of intramedullary nails used for the femur.

1. Flexible Nails: Rush, Ender 2. Interlocking Nails: Trigen 3. Retrograde Interlocking Intramedullary Nails 4. Standard Nails: AO titanium femoral nail system

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?

A neuromuscular bundle is located right underneath the transverse intermetatarsal ligament that must be preserved. To protect the bundle a Freer elevator is inserted underneath the ligament and then the incision is made.

What is the purpose of a lateral post during 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 counteraction on the knee joint to open the medial side. An arthroscopic leg holder might also be utilized to "lock" the leg in a stable position.

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

All of these procedures have the same outcome or removing the exostosis and realigning the great toe. The goals of surgery are to correct the deformity by removing the exostosis, restore the normal ROM, and remove the abnormal bony portions to prevent reoccurance.

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

All radiographic studies including x-rays templates should be in the OR. Surgeon will create plastic overlay templates using the standard x-ray marking measurements that show the size of implants that will be needed.

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

An allograft is tissue taken from another person (cadaver). If allograft is used complications include risk of acquiring hepatitis or HIV or graft rejection.

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

Anterior Cruciate Ligament (ACL). The most often used is the is the patella tendon graft but can be used on the iliotibial band or semitendinosus tendon.

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

Basic orthopedic instrument set Power saw Oscillating saw blade Nitrogen tank Batteries Liston amputating knife Gigli saw Satterlee bone saw Large bone hook Culture tubes Closed wound drainage unit (HemoVac)

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.

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

Injury to the menisci is one of the most common knee injuries.

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

Irrigation and removal of any loose bodies.

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

TKA is indicated for patients who demonstrate radiographic intra-articular disease and severe knee pain or other symptoms that cannot be controlled by nonsurgical methods. 1. disease 2. degenerative joint disease 3. years of wear and tear (athletes)

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

Under arthroscopic visualization, a Schint clamp is passed up the tibial tunnel to grab the stay sutures to pull them out of the tibial tunnel and help in passing the graft. The surgeon also confirms that the bone plugs are in place by viewing the blue marks that were made on the edge of each bone plug.

Name the procedures commonly used to treat bunions.

Various types of surgical procedures are used to treat the condition, such as the Aken, Chevron, McKeever, Keller, and McBride techniques.

Place the following steps in order for the insertion of an IM (intramedullary) rod. A: Stab wound is made; placement of distal locking screw is completed B: Guide pin is placed in medullary canal with drill C: Using fluoroscopy, the distal holes are located D: IM nail is inserted using insertion device and mallet, over guide pin if cannulated; guide pin is removed E: Hole is drilled and the first proximal locking bolt is placed. Process is repeated for second bolt. F. Incision is made over greater trochanter G. Stab wound is made over proximal bolt site and triple trocar assembly is placed H: Drill using a cannulated drill bit and broach if necessary to enlarge opening I: Incisions are closed and dressing is applied J: Using wench, bolts are tightened

1. incision is made over greater trochanter 2. guide pins is placed in medullary canal with drill 3. drill using a cannulated drill bit and breach if necessary to enlarge opening 4. IM (intramedullary) 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

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

4 x 4 dressing sponges or Fluffs are placed. A posterior splint or short leg cast is applied with the foot maintained in gravity equinus position.

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

Arthroscopy is usually performed on the shoulder, elbow, wrist, knee, and ankle joints. 1. Synovitis (inflamed joint lining) of the knee, shoulder, elbow, wrist, or ankle 2. Injuries to the shoulder, such as rotator cuff tendon tears, impingement syndrome, and dislocations 3. Injuries to the knee, such as meniscal (cartilage) tears, wearing down of or injury to the cartilage cushion, and anterior cruciate ligament tears with instability 4. Injuries to the wrist, such as carpal tunnel syndrome 5. Loose bodies of bone and/or cartilage in the knee, shoulder, elbow, ankle, or wrist 6. Joint damage caused by rheumatoid arthritis or osteoarthritis

What can be used to repair the ligaments?

Arthroscopy: A meniscal repair set. They contain two Keith needles attached by suture. Usually 0 or 2-0 Vicryl, PDS, or Prolene. Generally, knee ligament repair surgery follows this process: You will be asked to remove clothing and will be given a gown to wear. An intravenous (IV) line may be started in your arm or hand. You will be positioned on the operating table. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. The skin over the surgical site will be cleansed with an antiseptic solution. The healthcare provider will make several small incisions in the knee area. The healthcare provider will perform the surgery using an arthroscope (a small tube-shaped instrument that is inserted into a joint). The healthcare provider may reattach the torn ligament or reconstruct the torn ligament by using a portion (graft) of the patellar tendon (that connects the kneecap to the tibia), the hamstring tendon (from the back of the thigh), or other autografts. The tendon graft may come from the person (autograft) or from an organ donor (allograft). The healthcare provider will drill small holes in the tibia and femur where the torn ligament was attached. The healthcare provider will thread the graft through the holes and attach it with surgical staples, screws, or other means. Bone eventually grows around the graft. The incision will be closed with stitches or surgical staples. A sterile bandage or dressing will be applied.

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

As part of positioning, the patient is placed supine with a sandbag bump placed under the hip on the operative site. (Possibly for hyperextension.)

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

During the procedure the surgical technologist 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 the harvesting of the patella tendon as an aid in healing. A bone tamp may be used to keep the chips in place. Demineralized bone-putty may also be placed in the harvest site.

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

New saw blades and drill bits be used for each TKA procedure. Confirm that the saw blade and drill bits are of the correct size, and fit in the cutting slot or drill holes of the cutting guides. Load the appropriate-size saw blade in anticipating of its use by the surgeon. Test the saw prior to handing it to the surgeon; the team members should be told that the saw is being tested so as not to startle them with the noise. The safety-locking device should then be kept in place until the surgeon is ready to use the saw. Irrigate the bone with eh Asepto syringe to prevent the bone from being overheated by the cutting action of the saw, thus causing charring and thermal necrosis of the bone. Be aware that the saw could become dull. An extra sterile saw should be available. An appropriate size saw blade is used for the tibial section.

What is a perceived postoperative complication of amputations?

Postoperative SSI Phantom limb syndrome causing a perceived severe pain Chronic effusion Necrosis of tissue

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.

The Achilles tendon requires retrieval with the tendon-pulling forceps or other atraumatic clamp. The patient is in the prone position. and the foot is maintained in the equinus (upward bending) position during surgery. Several suture techniques can be utilized by the surgeon. One popular type is called the Krachow whipstitch, in which suture is place 2.5 cm from the edge of the rupture to accomplish the approximation. The suture can range from 2-0 nonabsorbable to #5 Ticron or Ethibond, but always on a noncutting needle.

What is used to perform the fusion?

The correction of the hind foot valgus is achieved by fixation of the subtalar joint. The surgeon places a screw, the usual length being 65 mm, anterior to posterior or posterior or anterior. The forefoot rotation is corrected with fixation of the talonavicular joint. A smooth Steinman pin in inserted toward the center of the head of teh talus. Third fixation involves the calcaneocuboid joint, which corrects the forefoot abduction and adduction. Two 4.5 mm cannulated screws will be crossed placed from the anterior process of the calcaneus to the cuboid. After fixation is achieved, the bone graft is placed. A rongeur is used to cut the bone into small pieces. The bone is placed around the talonavicular joint, in the gap at the calcaneocuboid joint, and in the sinus tarsi. Bone tamps with a mallet may be used to tap the bone graft into place.

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

The surgical technologist should ask the surgeon when the bone cement should be mixed; timing is very important as the cement can dry quickly. When the surgeon has finished irrigating the cut bone surfaces with the pulse lavage and is ready for the cement, the surgical technologist should replace the laparotomy sponges on the field with clean ones.

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

The surgical technologist should confirm the correct sizes with the surgeon. The surgical technologist will receive the prostheses from the circulator.

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

The surgical technologist will keep the femur in extension to avoid hip flexion contracture.

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

Trauma or disease that inhibits the vascular supply to the extremity. Diabetic patients who are prone to nonhealing ulcers and poor vascularity Non-ischemic limbs due to bone or bone marrow tumor, infection, or congenital defect

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

Triple arthrodesis is most effective for individuals suffering from a forefoot or hind foot deformity. The procedure is contraindicated in children younger than 10 to 12 years of age because the procedure limits foot growth and has a high failure rate. Postoperatively the procedure only allows plantar flexion and dorsiflexion. The result of triple arthrodesis is the fusion of the subtalar, calcaneocuboid, and talonavicular joints.