Orthopedic Surgery RPN ppt Student Copy. 2023.pdf

Orthopedic Surgery Learning Outcomes Describe basic anatomy for orthopedic surgery. Understand types of equipment used in orthopedic surgery and their safety precautions. Compare cancellous and cortical bone grafts. Describe the interventions for fixating a fracture. Describe basic proce...

Orthopedic Surgery Learning Outcomes Describe basic anatomy for orthopedic surgery. Understand types of equipment used in orthopedic surgery and their safety precautions. Compare cancellous and cortical bone grafts. Describe the interventions for fixating a fracture. Describe basic procedural considerations for knee, hip, and spine surgeries. Anatomy – Bone The skeletal system is composed of 206 bones Supports soft tissues Provides a frame for the connection of ligaments and tendons Enables locomotion Anatomy Muscles - are tissues that cover bones and provide movement to the skeletal system. Ligaments - are bands of connective tissue that hold bone to bone and provide joint stability. Tendons - form at the end of muscles and transmit forces to bone or cartilage. Cartilage - is an elastic tissue layer at the end of bones that provide support and stability. Joints - are articulations of bones that connect one to another. Anatomy Anatomy – Long Bones Diaphysis – shaft - center of long bone Epiphysis – end of long bone and consist of cancellous bone Mataphysis – end of long bone that contains the Epiphyseal plate (growth plate) A line of cartilage that separates the Epiphysis and Diaphysis Present until skeletal maturity Anatomy- Long Bones Periosteum “Peri” – around “Osteum” - bone A layer of connective tissue that covers all (around) bone Synovial Membrane Covers all articulating surfaces of joints If a bone is being repaired for a fracture, the periosteal layer must be stripped away using instruments called ___________________. Periosteal Elevators Remove periosteum from bone Periosteum will regenerate over the bone again Blood Supply Cortical Bone (Cortex): Hard, dense bone that forms the outer shell and supports tissue and force Cancellous Bone: Soft and spongy tissue that contains bone marrow Located in the iliac crest, tibia, sternum, and ends of long bones Anatomy – Shoulder Ball and socket joint Consists of 4 muscles that make up the rotator cuff Humerus - the longest bone of the upper extremity and has two ends 1. Proximal end connects to capsule of the shoulder joint 2. Distal end connects to the ulna and radius Anatomy – Wrist and Hand 1. Carpals (x8) – wrist bones 2. Metacarpals (x14) – bones of the palm 3. Phalanges – bones of the digits The median nerve is in the palm of the hand and extends under the wrist. Anatomy – Hip Ball and socket joint Connection for muscles and ligaments to provide stability Three bones that form the acetabulum (socket) that connects to the femoral head: Ilium Pubis Ischium Greater Trochanter Outer upper portion of femur shaft Connection for _______________ Lesser Trochanter Posterior inferior base of neck of femur Connection for _______________ Anatomy - Knee Hinge joint that consists of two: Collateral ligaments a) Medial collateral ligament (MCL) b) Lateral collateral ligament (LCL) Menisci a) Medial b) Lateral Cruciate ligaments a) Anterior b) Posterior Anterior View of the Knee Articulations are the lateral and medial condyles Anatomy - Foot Hinge joint Formed by the end of the tibia and fibula Three types of bones: Tarsal bones (x7) Metatarsal bones (x5) Phalanges (x14) Anatomy - Spine Vertebrae form the longitudinal axis of the skeleton Connected by cartilage joints 7 Cervical 12 Thoracic 5 Lumbar Sacrum and Coccyx are fused Ortho Equipment Operating Room Table Power Surgical Instruments Radiography Pneumatic Tourniquets Air Flow Bone Cement (PMMA) Handling Prothesis  Tables A- Jackson Spinal Top Spinal surgery B- Fracture Table Femoral neck, shaft or tibial fractures  Power Surgical Instruments A- Power drill, Battery, and Drill bit B- Power drill, Battery and Oscillating attachment saw blade Pneumatic Ortho Drill Safety Saw and drills are usually air driven instruments Always test them before handing them up to the surgeon to use Ensure safety lock is on when not in use Ensure correct cord is attached to equipment and distal end is handed to circulating nurse Radiography The C-Arm (image intensifier) provides fluoroscopy throughout the procedure Staff must wear protective lead Tourniquet Used for extremity surgery Creates a bloodless surgical field Promote visualizations of the structures Other Bone Cement (PMMA) Powder (Barium) mixed with liquid (methyl monomer) by scrub nurse Used to fixate an implant system Highly flammable Medications Bone Wax – topical hemostasis Bacitracin – irrigation for contaminated bone/tissue Prosthesic Implants Visually inspection for defects Handled as little as possible Rinsed with appropriate solution (i.e. Bacitracin) if applicable Implant Information will be documented Sterilization process – biological indicator must be present for an implant! Perioperative Nursing Considerations PPE - Face shield, double-triple glove, x-ray gowns Traffic control Positioning Surgical count – Minor Draping – limb sequence Forced air warming blanket Sequence of bone fixation Surgical Interventions 1. Bone Graft 2. Fracture Surgery (Open vs Closed) 3. Bone Fixation 4. Arthroscopy 5. Total Knee Surgery 6. Total Hip Surgery 7. Spinal Surgery Bone Graft Used to fill defects and promote union of fractures Commonly from the Iliac Crest Allograft – bone obtained from a tissue bank Autografts – harvested from patient’s own bone Cancellous bone is spongy and vascular and will grow into the host bones Cortical bone grafts are hard dense bone that do not fuse on their own and need to be stabilized with ortho hardware (wire/screws) Bone Grafts Instruments Cortical: - Osteotome and Mallet - Power saw Cancellous: - Bone curette Fracture Surgery Fracture: a break in the continuity of the bone as a result of trauma, infection, or bone disease (i.e. osteoporosis) 1. Closed Reduction 2. External Fixation 3. Open Reduction Internal Fixation (ORIF) Purpose Reduce fracture anatomically Restore anatomical function Fix fractures in a stable fashion so healing can occur Preserve the blood supply Mobilize patients early so full rehabilitation can take place Closed Reduction Manipulation of the fragments without incising the skin X-ray guided A splint or cast will immobilize the fractured part until healing takes place Benefits: 1. Reduced risk of infection 2. Improved bone union 3. Reduce recovery time Closed Reduction External Fixation Fixation device provides rigid fixation and reduction without opening fracture site Less chance of infection Better management of soft tissue injuries around fracture site No cast Earlier mobilization External Fixation ORIF Exposure to fracture site and fixate fracture with internal fixation devices Used when fracture cannot be fixed with closed method Treatment of choice of long bones or hip Advantage = direct visualization of fracture ORIF- Types of Fixation Pins Wire Screw – i.e. Nancy, Gamma, Russel-Taylor a) Cannulated (threaded) b) Non-Cannulated (smooth) Plate and Screw Rod or Nails Prostheses: hips, knees shoulders, elbows ASIF/AO Plating System Association for the Study of Internal Fixation Includes: Basic Instrument Set Plate Set Screw Set Used to repair long bone fractures (often in trauma surgery) Foundation to ortho surgery LC-DCP – Locking Compression DCP – Dynamic Compression Plate Sequence to Fixate a Bone 1. Hold the bone with the bone holder to stabilize the fracture 2. Drill the bone with the drill (to make a hole for the screw) 3. Tap the hole (create a stable canal for the screw) – if necessary 4. Measure the depth with depth gauge (determines screw length) *Some surgeons will drill, measure, then tap if a non-tapping screw is used. Select the screw and/or plate for the fracture 5. Screw with screwdriver (to insert screw in bone) Remove the bone holder Intramedullary Rods, Nails, Pins Preferred method to fix long bone fractures Femur, humerus, tibia Sub Trochanteric Fractures Inserted in intramedullary canal of a fractured bone X-ray guided “Closed” but small incisions made to insert the pins, nails or rods This system increases the load sharing of the bone = less likely implant will break Less scarring, blood loss, and infection IM Rods/Nails Names: RUSSELL-TAYLOR and NANCY NAIL Russell-Taylor IM Nails Lower Leg Fractures with Fixation  Gamma Nail Varies in Length Use: Intertrochanteric fracture  Arthroscopy Used for diagnostic and operative purposes Knees and shoulders Normal Saline irrigation Similar to MIS: Camera, light source, suction, cautery Advantages: shorter recovery, less pain and scaring, quicker mobility Meniscal Tear Menisci provide capsular stability The most common type of injury GOAL: Preserve the knee structures Debrides and resects any chronic tears in the meniscus Sutures tear with a synthetic absorbable suture (i.e. PDS or Ethibond) ACL Repair Anterior Cruciate Ligament Repair Knee stabilizer structure Common torn ligament Cause: anterior and rotational stress (Athletes) Can require a graft to replace the ligament Most common is a _______________________ Arthroscopic repair is the preferred surgical approach Total Knee Arthroplasty (TKA) Replace the worn surfaces of the knee Cause: Arthritis Goal: preserve normal ligaments and maintain normal ROM of the knee Three ways TKA can be done and is based on patient’s condition Tricompartmental Knee Implant– Most Common type Fixation of knee implants: Total Uncemented, Total Cemented, Hybrid Hip Surgery Three types of Hip Fractures 1. Femoral Neck 2. Intertrochanteric 3. Subtrochanteric (less common only 5-10%) Classified based on anatomical location Types of Fractures Fracture Table Fixation Femoral Neck (Sub capital) Fracture a) Internal fixation with screws b) Total Hip Replacement Intertrochanteric Fracture Dynamic Hip Screw Subtrochanteric Fracture IM Nail Intertrochanteric Fracture Trochanteric = fracture of the femur between the greater and the lesser trochanters. They are extracapsular fractures that is, outside the hip joint’s fibrous capsule Internal fixation prevents malunion of the fracture Allows for earlier mobility Patients are usually put in traction and wait for OR Repair: Compression plate and lag screw Fixation Names: AMBI, FREELOCK, DHS DHS = Dynamic Hip Screw Procedure Considerations Patient induced on stretcher Traction is removed Patient transferred to fracture table Fracture reduced by closed reduction and checked by the surgeon via X- ray DHS Pinning of Trochanteric Fracture A - Guide pin inserted in femoral head Drill B - Measure with depth gauge for size of lag screw C - Reamers are inserted over the guide pin to ream out the channel for the lag screw and barrel of the DHS Tap lag screw channel D - Apply plate and lag screw inserted into hip Femoral Neck Fractures Most common in elderly women with osteoporosis Reduction required before internal fixation of the femoral neck Risk of nonunion and avascular necrosis of the femoral head Blood supply is compromised Internal Fixation with cannulated screws (AO technique) – Stable Total Hip Arthroplasty (Replacement) – Unstable Procedure Considerations Similar to Trochanteric Fractures Total Hip Arthroplasty (Replacement) Femoral Neck/Head Fracture Blood supply is compromised Prosthetics can be unipolar or bipolar THR – surgeon can build up the hip and acetabulum so both legs are the same length = improved alignment for walking Unipolar vs Bipolar Unipolar sub trochanteric fractures – only the femoral component is replaced and cemented in the femoral shaft Bipolar Modular prosthetic with metal (head) and plastic (cup) that reduces the friction between the prosthesis and acetabulum Bone Cement Femoral and Acetabular Component 1. Cemented acetabulum 2. Totally non-cemented 3. Hybrid with one component cemented and one non-cemented Bone cement can secure the prosthesis or screws/ridges, etc. Used based on surgeon’s preferences or patient’s age and condition Young/active patients = may hold the prosthesis in place without cement Remember – bone cement is toxic and should be mixed using a closed system Procedure Considerations- Hip Femoral head excised with oscillating saw The acetabulum is prepared and then the femur Ream acetabulum to remove arthritic debris Trial cups are used to size the socket Acetabular implant opened Procedure Considerations - Femur The femur prepared using a punch and the canal is reamed to accommodate the prosthesis The femoral component is trialed with metal trials and the patient’s leg is put through a full range of motion with the trial femur Femur implant selected, opened and inserted Secured with or without cement Femur and Hip prothesis connected Hip Reduced Routine closure and Hemovac drain The patient has a compression dressing and an abduction pillow put between their legs to prevent dislocation Spine Back surgery commonly performed on the lumbar and cervical Most mobile regions of spine More susceptible to injury or degeneration Neuro or Orthopedic cases Reasons for surgery: Degenerative or arthritic changes Spinal fusion for post-surgical or congenital defects (scoliosis) Laminectomy Done to relieve pressure on the spinal cord Usually “Lumbar” disc (L4-5, L5-S1) Most commonly used to treat spinal stenosis or a ruptured disc Lamina from the bony parts of the vertebrae must be removed to access the disc tissue _____________ used to “nibble” away the lamina bone ______________are used to remove the intervertebral disc Kerrison Rongeur Pituitary Rongeur Procedure Considerations Prone position Blood replacement Patient warming Neuro patties (with green strings for identification) are used for hemostasis Other Instrumentation: Cobb periosteal elevator Howarth periosteal elevator Bayonet forceps (improve view) Procedure Considerations The surgeon exposes the disc area Lamina bone is removed with Kerrison rongeur Once disc is exposed, nerve root is identified and retracted (blunt retractors) **nerve root protrudes from spinal cord! Surgeon then removes the disc with pituitary rongeur (forcep) Disc tissue is sent to pathology Spinal Fusion Surgery for the treatment of scoliosis or post traumatic cases (fractures) Goal: improve spinal alignment Instrumentation: Scoliosis: Harrington Rods Fractures: IM nail, compression plate/screw Same fixation repair sequence: Hold> Drill> Tap> Measure> Screw Wires may also need to be used if the fracture is unstable Spinal Fusion References Rothrock, J. (2022). Alexander’s Care for the Patient in Surgery (17th ed.) Elsevier. Tighe, S. (2015). Instrumentation for the Operating Room (9th ed.) Elsevier. ORNAC Standards 2023