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.
111. Pin remover (drill)
112. Remove the first jig (remaining top jig)
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)
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
227. 25mm Osteotome
328. Ochsner or rongeur to remove or pull the bones while diathermizing
it.
(femoral prep
done)
330. Tibial jig + Mallet
tibial jig |
331. Short threaded pins x 2
533. Monitor or the checker
335. 2 long threaded pins x 2 (standby 2 retractor)
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
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. |
551. Bristol to standby (for removal of tibia trial)
After Trial
preparation of Patella
554. Rongeur to remove the excess bone or for filling of bone
Once the patella
is done she will remove the the femoral and tibial trial
660. Remove the tibial trial
663. 2 long pins + mallet
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
1. Stratafix 1-0 round body x 2
2. Vicryl 1-0
3. Vicryl 2-0
4. Stratafix 3-0 x 1
4. Stratafix 3-0 x 1
5. Dermabond
770. final counting
771. Dressing Opsite L x2