1. Dene key terms useful to discuss total knee arthroplasty.
2. Review instruments used to prepare the site for total knee arthroplasy. 3. Identify instruments used to implant components for total knee arthroplasty. 4. Discuss cleaning and handling procedures for total knee arthroplasty instrumentation. 5. Explain protocols for inspecting instruments used for total knee arthroplasty. 6. State two special concerns to be addressed when processing arthroplasty instrumentation. Knowledge of several key terms is helpful when discussing TKA instrumentation including: Arthroplasty The surgical reconstruction or replacement of a joint Distal The farthest point from the point of origin Femur The thigh bone Osteoarthritis A type of arthritis in which the joint typically undergoes degeneration and inammation. Patella A large, at bone in the front of the knee joint; also called the kneecap Proximal Nearer to a point of reference or attachment Resection The surgical removal of body tissue Tibia The shin bone Prosthetic (articial) knees generally are comprised of femoral, tibial, and patellar components. To implant them, the surgeon makes an incision over the front of the knee and resects (removes) the distal end of the femur and the proximal end of the tibia to accommodate the prosthesis. The patella is exposed using retractors such as Chandler bone elevators, Hohmann bone levers, or Bennett bone levers. A mallet is used to tap a femoral locating device into place after guide pins have been inserted into the femur with a power drill. Note: saws and reamers are other power surgical instruments used in TKA procedures to increase speed and accuracy when placing instruments and resectioning bones. Additional tissue and bone can be removed with rongeurs, curettes, osteomes, or scissors. A distal femoral cutting block is then assembled onto the locating device to help the surgeon make accurate cuts into the patella with an oscillating saw. Additional cuts can be made with anterior and posterior cutting blocks. The tibia is properly located with a tibial alignment device, and a stylus is used to determine the exact level of resection. An oscillating saw is used to begin the resection which may be completed with an osteotome. Calipers and patellar cutting guides are used to accurately resurface the patella. Instruments for Total Knee Arthroplasty Sponsored by: CIS SELF-STUDY LESSON PLAN (Instrument Continuing Education-ICE) Instrument Continuing Education (ICE) lessons provide members with ongoing education in the complex and ever-changing area of surgical instru- ment care and handling. These lessons are designed for CIS technicians, but can be of value to any CRCST technician who works with surgical instrumentation. You can use these lessons as an in-service with your staff, or visit www.iahcsmm.org for online grading at a nominal fee: $5 per lesson, or bundled packages of 6 lessons for $25 (save $5) or 12 lessons for $50 (save $10). Each lesson plan graded online with a passing score of 70% or higher is worth one point (contact hour). You can use these points toward either your re- certication of CRCST (12 points) or CIS (6 points). Mailed submissions to IAHCSMM will not be graded and will not be granted a point value (paper/pencil grading of the ICE Lesson Plans is not available through IAHCSMM or Purdue University; IAHCSMM accepts only online subscriptions).
CHL CIS CRCST CHL CIS CRCST IAHCSMM LESSON PLANS Approximately 400,000 Total Knee Arthroplasties (TKAs; commonly called Total Knee Replacements) are performed annually by orthopedic surgeons, and the number of these surgeries is increasing at ve percent each year. They help to relieve pain and improve function from knee joint failure most commonly caused by osteoarthritis. Specialized instrumentation is required for these procedures, and it must be processed by Central Service personnel who have received applicable training to do so. Vendors provide different instruments for different facilities for several reasons including physician preference, the type of procedure performed, and group purchasing organization (GPO) contracts. However, there are sets that include basic instruments used for TKA surgeries, and these will be addressed in this lesson. Lesson Authors Paula Vandiver, CRCST, CIS Orthopedic Specialist CS Technician Anderson Hospital Maryville, IL Lisa Huber, CRCST, ACE, FCS Sterile Processing Director Anderson Hospital Maryville, IL IAHCSMM CIS Self-Study Lesson Plan
After the site is prepared, tibial and femoral trials are used before implanting the components to ensure adequate resection and to conrm that the implants are properly sized. The tibial tray is assembled to the tibial impactor and inserted into the prepared proximal end of the tibia using a mallet. The femoral component is inserted into the prepared distal end of the femur with a femoral impactor and mallet. If it will be cemented, the patella component is held in place by a patella clamp. The nal step before closure is to insert the tibial insert. The new joint comprised of the femoral, tibial, and patellar components functions the same as cartilage in a healthy knee to prevent the bones from rubbing together at the joint. Instruments used for TKA procedures present signicant processing challenges for Central Service personnel, and it is critical that they always follow the manufacturers instructions when processing them. Many instruments require manual cleaning because bone, tissue and, in some cases, cement can become so embedded in the instruments they must be cleaned with brushes before automatic washing. Drill bits and guides, cutting blocks, and the tibial keel punch and drill are among the instruments that may retain bone and tissue. Some instruments have knurled (crosshatch-designed) handles to help surgeons grip them. However, this feature retains bone, blood, and cement and presents a cleaning challenge. Central Service staff must also be aware of the detergents used in mechanical washers because they may not be compatible with the metals used to manufacture the TKA instruments and sterilization containers. Central Service technicians should consult the manufacturers instructions to learn about detergents that are compatible with the instruments and instrument trays. Also, many TKA instrument trays are designed with multiple layers. Central Service technicians must ensure that tray lids are removed, that instruments are disassembled, and that layers are separated to provide full contact between the spray action of the washer and instruments during cleaning. TKA instrumentation also poses special inspection challenges. Since instruments are placed directly upon bone and may be exposed to cement, meticulous inspection of all surfaces of each instrument for residual bioburden is imperative. All trials must also be carefully inspected because surgeons may try several sizes to determine that which is best. Femoral and tibial trials, femoral impactors, and large drill bit ends are examples of instruments that are difcult to visually inspect. Central Service employees should use a lighted magnifying glass to view these items, and they may request that a co-worker provide a double-check for the most challenging instruments. All instruments with cutting edges must be checked to ensure sharpness. Curettes and osteotomes are tested with a plastic dowel rod, rongeurs are tested with an index card, and scissors should be tested with the appropriate testing material. A successful system for reprocessing TKA i nstruments i ncl udes written departmental procedures that address several important issues: The need for on-going open communication between Central Service, operating room, and vendor personnel Packaging requirements Manufacturers written instructions for cleaning and sterilization Instrumentation inspection Tray assembly Continuing education TKA instrumentation provides special sterilization challenges because of the size, weight, and number of required trays, and the multiple layers of instruments within the trays. Many vendors require extended sterilization cycle times for TKA instruments. Since there are no standardized instructions, it is necessary to obtain detailed and specic processing information from each vendor providing loaner instrumentation. Careful inspection, cleaning, and sterilization of TKA i nstrumentati on according to the manufacturers requirements and written Central Service Department procedures can help prevent surgery delays, and they are essential elements to a quality patient outcome. References Primary Cruciate-Retaining & Cruciate- Substituting Procedures. DePuy Orthopedics. 2000. Inspecting Surgical Instruments: An Illustrated Guide. Spectrum Surgical Instruments. 2006. Instrumentation Resource Course: Identication, Handling and Processing of Surgical Instruments. International Association of Healthcare Central Service Materiel Management. 2006. Knee Joint Replacement. MedlinePlus. 2005. M. Swank. Orthopedic Personnel Roles in the OR for Computer-Assisted Total Knee Arthroplasty. AORN Journal. 2005. Central Service Technical Manual. Seventh Edition. International Association of Healthcare Central Service Materiel Management. 2007. Special thanks to Tom Andresen. DePuy Orthopedics Lesson Authors Paula Vandiver, CRCST, CIS Orthopedic Specialist CS Technician Anderson Hospital Maryville, IL Lisa Huber, CRCST, ACE, FCS Sterile Processing Director Anderson Hospital Maryville, IL Technical Editor Carla McDermott, RN, ACE Education Specialist Morton Plant Mease Healthcare Dunedin, FL. Series Writer/Editor Jack D. Ninemeier, Ph.D. Michigan State University East Lansing, MI. CIS SELF-STUDY LESSON PLANS
1. A rongeur may be used to a) ensure accurate placement of trials b) remove bone and tissue c) resect the femur d) accommodate the prosthesis 2. Three examples of retractors are a) Chandler, Osteotome, and Bennett b) Hohmann, Chandler, and Curette c) Chandler, Bennett, and Hohmann d) Chandler, Hohmann, and Keel 3. The cutting edge of curettes and osteotomes should be tested for sharpness with a (an) a) plastic dowel rod b) tongue depressor c) index card d) huck towel 4. The patella is also called the a) thigh bone b) kneecap c) shin bone d) hip bone 5. Prosthetic knees are generally comprised of a) Chandler, Hohmann, and Bennett components b) Distal, proximal, and resection components c) Femoral, tibial, and patellar components d) Anterior, posterior, and medial components 6. Knurled is a term that refers to a) deformity of the knee b) cuts made by a saw c) a type of resection d) the crosshatched design of instrument handles 7. Proximal refers to a) nearer to a point of reference or attachment b) the farthest point from the point of origin c) an alignment technique d) removal of tissue 8. The femur is the a) thigh bone b) kneecap c) shin bone d) hip bone 9. The tibia is the a) thigh bone b) kneecap c) shin bone d) hip bone 10. Cutting edges of rongeurs should be tested for sharpness with a (an) a) plastic dowel rod b) tongue depressor c) index card d) huck towel 11. Prior to the implantation of components, the surgeon will determine the proper size with which of the following? a) guides b) alignment devices c) stylus d) trials 12. The function of a stylus is to a) aid in the speed and accuracy of bone resection b) retain bone and tissue c) determine the exact level of resection d) accurately resurface the patella 13. The term, resection, refers to a) the surgical removal of body tissue b) surgical reconstruction or replacement of a joint c) cartilage preventing bones from rubbing together at the joint d) assurance of accurate cuts made by the surgeon 14. Which instruments are used for the accurate resurfacing of the patella? a) patella clamp and patella cutting guide b) patella cutting guide and caliper c) patella clamp and caliper d) patella cutting guide and stylus 15. The femoral component is inserted using a a) femoral impactor and mallet b) femoral locating device and mallet c) femoral cutting block and mallet d) femoral trial and mallet CIS Self-Study Lesson Plan Quiz (Instrument Continuing Education-ICE) Instruments for Total Knee Arthroplasty Questions (circle correct answer): Sponsored by: CHL CIS CRCST CHL CIS CRCST IAHCSMM LESSON PLANS REQUEST FOR PAPER/PENCIL SCORING (please print or type information below) REQUEST FOR ONLINE SCORING (payment and scoring made directly online at www.iahcsmm.org using either online check or credit card) q I have enclosed the scoring fee of $15. (Please make checks payable to Purdue University. We regret that no refunds can be given.) q Check here if you have a change of address q Check here if you wish to have your results emailed to you Detach quiz, fold, and return to: Purdue University PEC Business Ofce Stewart Center, Room 110 128 Memorial Mall West Lafayette, IN 47907-2034 (800) 830-0269
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