LEARNING OBJECTIVES:
1. Define 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 inflammation.
• Patella – A large, flat 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 (artificial) 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
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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-
certification 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
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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 five 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 confirm 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 final 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
significant 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 difficult 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
specific 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: Identification,
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
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