Tuesday, October 10, 2017

SMITH AND NEPHEW TOTAL KNEE REPLACEMENT

Another Knee Replacement from another surgeon. Again these is how I observed and experienced on scrubbing with this surgeon. She might be changing it a little bit, but mostly this is how she does it.

It’s been what 3 years now that I’m working for the Neuro people but hey I still remember t o play with the ortho instruments. =)

PROCEDURE
TOTAL KNEE REPLACEMENT
POSITION
Supine with 2 TKR leg holder
EQUIPMENTS/ACCESSORIES
Torniquet Machine
Suction Machine X 2 (1 for cementing)
Diathermy Machine
Kendall SCD Machine
Leh Holder
SKIN PREPARATION / PHARMACEUTICALS
Povidone Iodine with alcohol
Hexodane (use for prepping after cutting of stockinette)
10% Povidone with 10% Alcohol
3L Normal Saline for washing using surgilav
INFILTRATION
Refer To Doctors Cocktail Dilution
DRAPES
Disposable Extremity Drape
ABD Pack – placed under the knee during suturing and washing
Extra-Extra ABD sheet (use to cover all the trolleys before pushing inside OT)
STEPS IN DRAPING
Loose ABD Sheet
U-Drape from the set
Dressing Towel to hold the leg
Stockinette (loose)
6 inches Elastic bandage
Extremity Drape (with hole in the center)
Green Sticky Tape from Extremity Drape
Utility Scissors (orange handle) to cut stockinette
Ioban
INSTRUMENTS SETS / SUPPLEMENTARY SETS / LOOSE INSTRUMENTS
SETS:
Ortho Basic Set
General Basin Set
Ortho Large Lambotte Osteotome Set
·       Osteotome Straight 13mm, 20mm, 30mm
·       Osteotome Curved 20mm
Ortho TKR Supplementary Set
SS Tray
LOOSE INSTRUMENTS:
Light Handle Medium
Quiver x 2
Big Straight Rongeur
Tibial Wedge Clamp (loose inst. Placed on Dr. Ho totebox)
Cobbs Elevator (small) s/b
Narrower Tip Nibbler (small) s/b
SUPPLIES / CONSUMMABLES
Diathermy Hand Control
Diathermy Scrapper
Suction Tubing
Yankuer Suction x 2
Tegaderm X 2 (to seal the hole from disposable suction tip)
Raytex Gauze, Penny Towel, Plain Gauze
Syringe 50 mls
Blade 10 x 5
Pulsavac Zimmer
Ioban 6650
Needle G23 (green) x 3, Needle G19 (pink blunt needle for tranexamic)
Orthoban X 2
6 inches Crepe Bandage X 2
Black Spinal Needle x 2 – S/B
Zimmer Mixi-Gun with short nozzle
Tranexamic Acid 500mg – 1.5gm needed
Gel Knee Wrap on op site after surgery
Surgical Marker x 2 (one will pass out after using to mark the skin)
SUTURES
Vicryl 1-0 (cutting) x 1 - muscle
Vicryl 2-0 (cutting) x 1 – fascia
Monocryl 3-0 (cutting) x 1 - skin
Stratafix round body x 2 (ref#:SXPPIA404) – skin
Dermabond Prineo – to open when skin closure is finishing (to prevent hardened of the glue)
DRESSING
Opsite L x2
Plain Gauze
6 inches Orthoban

6 inches Crepe Bandage x 2
REMARKS
1.     Hexodane and Hand Towel to clean the leg first before prepping the patient.
2.     Prepare 250mls of Normal Saline + 9mls of Plain Povidone to be use after implanting (washing)
3.     Use basin during washing of the knee
4.     Bone Cement: J&J Smart Set x 2
5.     During application of implants, wet osteotome straight 20mm for tibia and osteotome curved 20mm for femur.
6.     Intra-op Kendall Cuff on non-op leg.
7.     Once implanting remove all the power tool to mayo table and replace with the necessary intruments use for implanting.
8.     Fresh chlorhexidine in clean gollipot
9.     Post-op: kendall cuff to be place first before applying gel knee wrap
10.   Mayo Table to be on surgeon sides.

   
TKR COCKTAIL DILUTION
(total of 5 syringe 20mls each syringe)

DRUGS/CONCENTRATION
DOSE
REMARKS
1. ADRENALINE 1:1000
0.5ml

2. Morphine 10mg/ml

0.2ml
- to omit if patient had renal impairment .
- confirm with surgeon
- get from the AU staff and return the remaining balance to them (AU).
3. Ropivacaine 1% (200mg/20ml)
15mls (150mg)
Check with anesthetist the dosage/amount, if patient having block
4. Vancomycin 500mg x 2
1 gram (1000mg)
- check if patient has an allergy
- to dilute 5mls of normal saline each vial (you may use 5mls NS from the one you take out from the 100mls 0.9% NS)
5. Normal Saline 0.9%
75mls

6. Ketorolac 1ml/30mg
1ml/30mg
- give 1 ampule
- for non-asthmatic patient
7. Shincort (triamcinolone acetomide)
50mg/5ml
- for non-diabetic patient
- 20mls each from the diluted cocktail add 2.5mls shincort each syringe
- to give first

REMARKS:
1.     Inform the anesthetist first before making cocktail
2.     Check for patients allergies
3.     Use green needle (spinal needle black standby)
4.     Make sure to handover the balance of CD Morphine to AU Nurse for proper disposal and documentation.

INSTRUCTIONS:
1.     Mixed all the medications into 75mls normal saline
2.     Sites to be injected:
a.     Patella fat pad
b.     Femur – anterior periosteum
c.      Femur – posterior periosteum
d.     Medial collateral ligaments
e.     Quadriceps muscles
3.     The above procedure to be done before cementing .
4.     Will not use or do not prepare for revision cases.
5.     Use other alternative antibiotics if patient is allergic to penicillin, confirm this with the anesthetist.
6.     +/- nerve block
7.     On PCA (patient controlled analgesia) x 1 day.
8.     Do not use spike in preparing the cocktail.

commonly instrument use for Smith and Nephew TKR






















TOTAL KNEE REPLACEMENT
Procedure: (again this may vary from the surgeons mood=) and patient bone structures or severity of bone deform)

11. First knife to cut the skin.
22. Second knife or inside knife.
33. Retractors (langenback) 3rd assist surgeon will help to suction the op-site while the surgeon is cutting)
44. Surgeon might use diathermy and lanes forceps for hemostasis or use for cutting of tissues.
56. Inside knife to remove fat tissues until femoral bone totally expose.
67. Long threaded pins/drill









78. Femoral Jig + 2 short threaded pins

89. Checker to give separately (the battery) + screw driver



















910. Second femoral jig + 2 long pins on power (2nd femoral jig seen in number 8)













111. Pin remover (drill)
112. Remove the first jig (remaining top jig)
113. Angel Wing

114. Saw
115. Pin puller after sawing
116. Ochsner x 2 to secure the pins for cutting the jig
117. Saw
118. Standby water to irrigate the sawing bone
119. After cutting the bone out remove the the cutting jig (pin puller to pull the pins out)
120. Bone rongeur to remove the ostophytes
221. Marker Pen + Broad big osteotome (use as a ruler to mark the point where she will put the sizer)
222. Sizer + long pins followed by Stylus. (listen to what size the femoral implant is) 

223. Drill Pins (to remove the pins and the sizer)
224. Femoral cutting jig (take the size in which taken when sizing the bone)
handle (attached to femoral cutting jig)
femoral cutting jig (example size 4)


















223. Angel wing
224. X 3 long pins + saw
(Prepare the femoral trial to connect it to femoral handle or impactor while the surgeons are busy cutting the femoral bone)
femoral trial should be same size of the femoral cutting jig

225. Pin puller
226. Extractor to remove the cutting jig

227. 25mm Osteotome
328. Ochsner or rongeur to remove or pull the bones while diathermizing it.

(femoral prep done)

329. Double prong to lift the femoral bone while prepping the tibial bone

330. Tibial jig + Mallet
tibial jig

331. Short threaded pins x 2
332. Rubber to secure the tibial jig from patient leg


533. Monitor or the checker 
334. Out the top part of the jig + give the man in a boat
335. 2 long threaded pins x 2 (standby 2 retractor)
336. Angel wing
337. Out the checker
438. Ochsner to attached to pins before sawing
439. Saw
440. Pin puller (remove the tibial jig)
441. Tibial wedge to place on the cutted tibial bone (use in pulling the cutted tibial bone while diathermising it. If no use she might ask for rongeur or ochsner in pulling the bone). – once the tibial bone is out you might check the size of it using the the tibial plate usually for male patient size 4-5 and female is 2-4 seldom of having 1.5
442. Small homman (narrow) + Lagenback
443. Laminar Spreader (to spread or separate the femoral bone to tibia)
445. Blade, osteotome, curette, rongeur (to remove the excess bone or osteophytes from the femur and tibia.
446. Pin puller
447. She might ask for the retractor (double prong, homman, lagenback)
448. Spacer block (to check thickness of the insert)
9mm spacer block (black) if needed to add thickness give the grey one.
549. Prepare the tibial plate and insert (according to the patient tibial bone size)
550. Femoral Trial + mallet













551. Bristol to standby (for removal of tibia trial)
After Trial preparation of Patella
552. Patella cutting jig
553. Sizer + saw
554. Rongeur to remove the excess bone or for filling of bone
555. Patella clipper




556. Patella drill











. 57.  Patella trial which come in sizes too.

Once the patella is done she will remove the the femoral and tibial trial
5
558. Femoral Punch
659.  Extractor to remove the femoral trial
660.  Remove the tibial trial
661.  Double prong
662. Tibial plate (size of the patient)
663. 2 long pins + mallet
664. Fat drill
665. Brooch / mallet
666. Extractor to remove the brooch






667. Pin puller to remove the tibial plate

Prepation for tibial bone was done. surgeon may wash the knee with 3 liters normal saline using pulsivac. The scrub nurse then will the implant and mixing of the cement.
Cement use: (depends on surgeon preferred use)
1.     Smart set cement x2

Tools in mixing of cement (depends also on surgeons preference or if the scrub nurse knowledgibility in using mixing cement)

1.     Zimmer mixigun

After washing the knee the surgeon then will infiltrate mix cocktail on patient knee
(refer to cocktail mix)

Once all ready in placing the the final implant to patient prepare the following and place near the surgeon
1.     femoral implant + femoral punch (surgeon will place cement surrounding the implant)
2.     tibial implant + Tibial punch (surgeon will place cement surrounding the implant)
3.     patella implant (scrub nurse will place cement surrounding the implant make sure not covering the 3 dotted thingy on the implant (aha)
4.     insert + inserter
5.     Forceps and Mcdonalds in removing the excess cement
6.     Small osteotome standby

668.  Retractors (lagenback or homman once inserting all the implant).
769.  Closing start to count all your sharps and sponge
Use for closing
             1. Stratafix 1-0 round body x 2
             2. Vicryl 1-0
 3. Vicryl 2-0
 4. Stratafix 3-0 x 1
 5. Dermabond

770.  final counting

771.  Dressing Opsite L x2