Sponsored by:
Instruments for Total Knee Arthroplasty
CIS
CIS Self-Study
Lesson Plan
(Instrument Continuing Education-ICE)
CRCST
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
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).
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.
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.
Knowledge of several key terms is helpful when over the front of the knee and resects (removes)
discussing TKA instrumentation including: the distal end of the femur and the proximal end
of the tibia to accommodate the prosthesis. The
• Arthroplasty – The surgical reconstruction or patella is exposed using retractors such as
replacement of a joint Chandler bone elevators, Hohmann bone levers,
or Bennett bone levers. A mallet is used to tap a
• Distal – The farthest point from the point
femoral locating device into place after guide
of origin
pins have been inserted into the femur with a
• Femur – The thigh bone power drill. Note: saws and reamers are other
power surgical instruments used in TKA
• Osteoarthritis – A type of arthritis in which procedures to increase speed and accuracy when
the joint typically undergoes degeneration placing instruments and resectioning bones.
and inflammation. Additional tissue and bone can be removed with
rongeurs, curettes, osteomes, or scissors. A distal
• Patella – A large, flat bone in the front of femoral cutting block is then assembled onto the
the knee joint; also called the kneecap locating device to help the surgeon make accurate
cuts into the patella with an oscillating saw.
• Proximal – Nearer to a point of reference
Additional cuts can be made with anterior and
or attachment
posterior cutting blocks.
• Resection – The surgical removal of The tibia is properly located with a tibial alignment
body tissue device, and a stylus is used to determine the exact
level of resection. An oscillating saw is used to
• Tibia – The shin bone
begin the resection which may be completed with
Prosthetic (artificial) knees generally are comprised an osteotome. Calipers and patellar cutting guides
of femoral, tibial, and patellar components. To are used to accurately resurface the patella.
implant them, the surgeon makes an incision

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
IAHCSMM
CIS Self-Study Lesson Plan
to cement, meticulous inspection of all surfaces References
of each instrument for residual bioburden is Primary Cruciate-Retaining & Cruciate-
imperative. All trials must also be carefully Substituting Procedures. DePuy Orthopedics.
inspected because surgeons may try several 2000.
sizes to determine that which is best. Femoral
Inspecting Surgical Instruments: An Illustrated
and tibial trials, femoral impactors, and large
Guide. Spectrum Surgical Instruments. 2006.
drill bit ends are examples of instruments that
are difficult to visually inspect. Central Service Instrumentation Resource Course: Identification,
employees should use a lighted magnifying Handling and Processing of Surgical Instruments.
glass to view these items, and they may request International Association of Healthcare Central
that a co-worker provide a “double-check” for Service Materiel Management. 2006.
the most challenging instruments. All Knee Joint Replacement. MedlinePlus. 2005.
instruments with cutting edges must be checked M. Swank. Orthopedic Personnel Roles in
to ensure sharpness. Curettes and osteotomes the OR for Computer-Assisted Total Knee
are tested with a plastic dowel rod, rongeurs are Arthroplasty. AORN Journal. 2005.
tested with an index card, and scissors should
Central Service Technical Manual. Seventh
be tested with the appropriate testing material.
Edition. International Association of Healthcare
A successful system for reprocessing T K A Central Service Materiel Management. 2007.
instruments includes written departmental Special thanks to Tom Andresen. DePuy
procedures that address several important issues: Orthopedics
• The need for on-going open communication
between Central Service, operating room,
and vendor personnel
CIS Self-Study Lesson Plans
• Packaging requirements
• Manufacturers’ written instructions for
cleaning and sterilization Lesson Authors
Paula Vandiver, CRCST, CIS
• Instrumentation inspection
Orthopedic Specialist CS Technician
• Tray assembly Anderson Hospital
Maryville, IL
• Continuing education
Lisa Huber, CRCST, ACE, FCS
TKA instrumentation provides special sterilization Sterile Processing Director
challenges because of the size, weight, and Anderson Hospital
number of required trays, and the multiple layers Maryville, IL
of instruments within the trays. Many vendors
require extended sterilization cycle times for TKA Technical Editor
instruments. Since there are no standardized Carla McDermott, RN, ACE
instructions, it is necessary to obtain detailed and Education Specialist
specific processing information from each vendor Morton Plant Mease Healthcare
providing loaner instrumentation. Dunedin, FL.
Careful inspection, cleaning, and sterilization of
Series Writer/Editor
TKA instrumentation according to the
Jack D. Ninemeier, Ph.D.
manufacturers’ requirements and written
Michigan State University
Central Service Department procedures can help
East Lansing, MI.
prevent surgery delays, and they are essential
elements to a quality patient outcome.
 CIS Self-Study Lesson Plan Quiz
(Instrument Continuing Education-ICE)
CIS
Instruments for Total Knee Arthroplasty
Questions (circle correct answer):

1. A rongeur may be used to 7. Proximal refers to 13. The term, “resection,” refers to
a) ensure accurate placement of trials a) nearer to a point of reference a) the surgical removal of body tissue
b) remove bone and tissue or attachment b) surgical reconstruction or replacement
c) resect the femur b) the farthest point from the point of a joint
CRCST of origin
d) accommodate the prosthesis c) cartilage preventing bones from
c) an alignment technique rubbing together at the joint
d) removal of tissue d) assurance of accurate cuts made by
2. Three examples of retractors are the surgeon
a) Chandler, Osteotome, and Bennett
b) Hohmann, Chandler, and Curette 8. The femur is the
c) Chandler, Bennett, and Hohmann a) thigh bone 14. Which instruments are used for the
b) kneecap accurate resurfacing of the patella?
d) Chandler, Hohmann, and Keel
c) shin bone a) patella clamp and patella cutting guide
d) hip bone b) patella cutting guide and caliper
c) patella clamp and caliper
3. The cutting edge of curettes and
d) patella cutting guide and stylus
osteotomes should be tested for
sharpness with a (an) 9. The tibia is the
a) plastic dowel rod a) thigh bone
b) tongue depressor b) kneecap 15. The femoral component is
c) index card c) shin bone inserted using a
d) huck towel d) hip bone a) femoral impactor and mallet
b) femoral locating device and mallet
c) femoral cutting block and mallet
10. Cutting edges of rongeurs should be d) femoral trial and mallet
4. The patella is also called the
a) thigh bone tested for sharpness with a (an)
b) kneecap a) plastic dowel rod
c) shin bone b) tongue depressor
d) hip bone c) index card
d) huck towel

5. Prosthetic knees are generally

comprised of 11. Prior to the implantation of
a) Chandler, Hohmann, and components, the surgeon will
Bennett components determine the proper size with
b) Distal, proximal, and which of the following?
resection components a) guides
c) Femoral, tibial, and patellar components b) alignment devices
d) Anterior, posterior, and c) stylus
medial components d) trials
Sponsored by:

6. “Knurled” is a term that refers to 12. The function of a stylus is to

a) deformity of the knee a) aid in the speed and accuracy of
b) cuts made by a saw bone resection
c) a type of resection b) retain bone and tissue
d) the crosshatched design of c) determine the exact level of resection
instrument handles d) accurately resurface the patella

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