9.1 Orthopedic Trauma, Joint Arthroplasty, and Arthroscopy
Key Takeaways
- Pneumatic tourniquet application requires careful padding with wrinkle-free Webril, limb exsanguination using an Esmarch bandage from distal to proximal (contraindicated in active infection, malignancy, or deep vein thrombosis), and strict adherence to pressure and inflation time limits (upper extremity: 200–250 mmHg for maximum 60–90 minutes; lower extremity: 250–350 mmHg for maximum 90–120 minutes) with mandatory 10–15 minute reperfusion intervals.
- Fracture fixation relies on precise instrumentation sequences: Open Reduction Internal Fixation (ORIF) utilizes bone-reduction clamps, drill sleeves, calibrated depth gauges, taps, and screws (cortical vs. cancellous), with lag screw technique achieving interfragmentary compression by overdrilling the near cortex and underdrilling the far cortex.
- Polymethyl methacrylate (PMMA) bone cement handling demands closed vacuum mixing to reduce porosity and toxic monomer vapor inhalation, awareness of exothermic curing reaching 80°C–100°C, and vigilant intraoperative monitoring for Bone Cement Implantation Syndrome (BCIS) characterized by sudden hypotension, hypoxemia, and cardiac arrhythmias during femoral pressurization.
- Orthopedic asepsis mandates ultra-clean air management (laminar flow with 20–60 air exchanges/hr, HEPA filtration), personal exhaust space suits, double gloving, and complete change of gloves and instruments before handling permanent prosthetic implants (total knee and hip arthroplasty).
Last updated: August 2026
9.1 Orthopedic Trauma, Joint Arthroplasty, and Arthroscopy
Orthopedic surgery encompasses the diagnosis, operative treatment, and reconstruction of injuries and disorders of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles, and neurovascular structures. For the Tech in Surgery - Certified (NCCT TS-C) examination, orthopedic surgery is tested through the Intraoperative Care and Preparation category (Surgeon Support) and the Essential Knowledge Base surgical-procedures concept.
The certified surgical technologist (CST) must maintain absolute mastery over orthopedic instrumentation sequences, pneumatic tourniquet protocols, power equipment operation, fracture biomechanics, implant handling, bone cement kinetics, and strict aseptic principles.
1. Skeletal Anatomy, Bone Histology, and Repair Physiology
The human skeleton consists of 206 bones divided into the axial skeleton (80 bones: skull, vertebral column, thoracic cage) and the appendicular skeleton (126 bones: upper and lower extremities, shoulder and pelvic girdles).
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| OSSEOUS TISSUE ARCHITECTURE |
| |
| +-- EPIPHYSIS --------+ (Articular Cartilage / Spongy Cancellous Bone) |
| | | - Red bone marrow (hematopoiesis) |
| +-- METAPHYSIS -------+ (Epiphyseal Growth Plate / Vascular transition) |
| | | |
| | | (Dense, compact Haversian bone) |
| | DIAPHYSIS | - Outer Fibrous Periosteum (blood supply) |
| | (Shaft) | - Inner Osteogenic Cambium Layer |
| | | - Medullary Cavity (Endosteum & Yellow Marrow) |
| | | |
| +-- METAPHYSIS -------+ |
| | | |
| +-- EPIPHYSIS --------+ (Distal Articulation) |
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Osseous Tissue Types
- Cortical (Compact) Bone: Dense, hard outer shell providing structural integrity and load-bearing strength. Organized into microscopic cylindrical units called osteons (Haversian systems) containing central vascular canals, concentric lamellae, and osteocytes.
- Cancellous (Spongy/Trabecular) Bone: Porous, lattice-like internal network of trabeculae located in the epiphyses and metaphyses of long bones and within flat bones. Contains red bone marrow responsible for hematopoiesis (erythrocyte and leukocyte production).
Periosteum and Endosteum
- Periosteum: A tough, vascular fibrous membrane covering all external bone surfaces except articular cartilage. It consists of an outer fibrous protective layer and an inner cambium layer rich in osteoprogenitor cells and osteoblasts essential for bone growth and repair. Preserving the periosteum during surgical dissection is vital for fracture union.
- Endosteum: A thin vascular membrane lining the inner medullary canal and trabeculae containing osteoprogenitor cells.
Cellular Elements of Bone
- Osteoblasts: Bone-forming cells that synthesize and secrete organic bone matrix (osteoid) and facilitate mineralization.
- Osteocytes: Mature bone cells embedded within lacunae that maintain cellular mineral homeostasis.
- Osteoclasts: Multinucleated giant cells derived from monocyte-macrophage lineage that resorb and remodel bone tissue via acid and enzymatic secretion.
Stages of Secondary Bone Fracture Healing
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| STAGES OF BONE FRACTURE HEALING |
| |
| [STAGE 1: Hematoma & Inflammatory Phase] (Hours to Day 5) |
| - Rupture of periosteal/endosteal vessels forms fracture hematoma. |
| - Inflammatory cytokines recruit neutrophils, macrophages, fibroblasts. |
| |
| [STAGE 2: Soft Fibrocartilaginous Callus] (Days 5 to 21) |
| - Granulation tissue, capillary ingrowth, and chondrogenesis. |
| - Collagen and cartilage bridge the fracture gap (soft union). |
| |
| [STAGE 3: Hard Bony Callus Formation] (Weeks 3 to 12) |
| - Osteoblasts convert fibrocartilage into woven cancellous bone. |
| - Clinical union achieved (fracture no longer moves). |
| |
| [STAGE 4: Bone Remodeling / Wolff's Law] (Months to Years) |
| - Osteoclasts resorb excess woven bone; osteons reconstruct compact bone. |
| - Bone adapts structurally along lines of mechanical stress (Wolff's Law).|
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2. Fracture Classification and Emergency Trauma Management
Fractures are categorized based on soft tissue integrity, mechanical vector, displacement, and anatomical configuration.
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| FRACTURE PATTERN SPECTRUM |
| |
| TRANSVERSE OBLIQUE SPIRAL COMMINUTED GREENSTICK |
| |---| | /| | //| | * * | | /| |
| |---| | / | |// | |* * *| | ( | |
| |---| |/ | |/ | | * * | |___| |
| (90-deg angle) (Angular) (Torsional) (>2 fragments) (Incomplete) |
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Clinical Fracture Patterns
- Closed (Simple) Fracture: The overlying cutaneous envelope and skin remain completely intact without external communication.
- Open (Compound) Fracture: Bone fragments puncture or lacerate through the skin and soft tissues, exposing the fracture site to external bacterial contamination. Requires emergency surgical debridement and irrigation within hours.
- Transverse Fracture: Horizontal fracture line perpendicular to the long axis of the bone, typically caused by direct tensile or bending trauma.
- Oblique Fracture: Angled fracture line (>30 degrees) resulting from combined axial compression and bending forces.
- Spiral Fracture: Helical fracture line winding around the shaft, produced by high-energy rotational/torsional forces.
- Comminuted Fracture: Bone splintered into three or more distinct fragments; inherently mechanically unstable.
- Segmental Fracture: Two distinct fracture lines isolating a free-floating central segment of bone shaft.
- Impacted / Compaction Fracture: One bone fragment is forcefully driven and wedged into the cancellous matrix of the adjacent fragment.
- Greenstick Fracture: Incomplete fracture occurring in pediatric patients where one cortex fractures while the opposing cortex bends without breaking.
- Avulsion Fracture: A bony prominence is torn away by violent tensile traction from an attached tendon or ligament (e.g., tibial tuberosity, malleolus).
- Pathological Fracture: Fracture occurring in bone weakened by pre-existing disease (osteoporosis, metastatic malignancy, osteomyelitis, bone cysts) under normal physiological loading.
Gustilo-Anderson Open Fracture Classification
| Classification | Wound Size | Soft Tissue Damage & Contamination | Periosteal Stripping & Bone Coverage | Infection Risk & Recommended Management |
|---|---|---|---|---|
| Grade I | Clean skin wound < 1 cm | Minimal muscle crush, clean inside-out puncture | Intact periosteum, simple transverse or short oblique pattern | Low infection risk (0–2%); 1st-generation cephalosporin (Cefazolin), emergency debridement, standard ORIF or casting. |
| Grade II | Laceration > 1 cm and < 10 cm | Moderate soft tissue damage, localized crush, minimal contamination | Minimal stripping, moderate comminution | Moderate infection risk (2–5%); Cefazolin, copious pulse lavage (6–9 L), internal fixation or stabilization. |
| Grade IIIA | Wound > 10 cm | Extensive soft tissue destruction, high-energy trauma (MVA, gunshot) | Adequate periosteal coverage of bone despite extensive laceration | High risk (5–10%); Cefazolin + Aminoglycoside (Gentamicin), emergent serial debridements, internal or external fixation. |
| Grade IIIB | Extensive wound > 10 cm | Severe soft tissue crush, heavy contamination, farm injuries | Extensive periosteal stripping; exposed bone requires soft tissue flap coverage | Very high risk (10–25%); Cefazolin + Gentamicin (+ Penicillin for soil/anaerobes), external fixation, microvascular flap coverage. |
| Grade IIIC | Any wound size | Open fracture associated with major arterial vascular injury requiring repair | Devitalized extremity requiring vascular reconstruction | Severe amputation/infection risk (25–50%); Immediate vascular shunting/repair, fasciotomy, rigid external fixation. |
Acute Compartment Syndrome: Surgical Emergency
[!CAUTION] Acute Compartment Syndrome (ACS): An orthopedic emergency resulting from elevated interstitial tissue fluid pressure within an inelastic osteofascial compartment. Elevated pressure (>30 mmHg or a delta pressure [Diastolic BP − Compartment Pressure] < 30 mmHg) compromises capillary microcirculation, leading to irreversible muscle and nerve ischemia within 4 to 6 hours and complete necrosis within 8 hours.
The 6 "P"s of Compartment Syndrome:
- Pain: Disproportionate to injury, refractory to analgesics, dramatically exacerbated by passive stretching of compartment muscles (the earliest and most sensitive clinical sign).
- Paresthesia: Numbness, tingling, or sensory deficit in cutaneous nerve distributions traversing the compartment.
- Pallor: Pale, shiny, cool extremity with sluggish capillary refill.
- Poikilothermia: Limb temperature equilibrates with ambient room temperature.
- Paralysis: Late sign indicating motor nerve and muscle necrosis.
- Pulselessness: Late, ominous sign; peripheral pulses may remain intact even in advanced compartment syndrome because systolic pressure exceeds compartment pressure.
Definitive Treatment: Emergency decompressive dermatofasciotomy (e.g., dual-incision 4-compartment fasciotomy in the lower leg: anterolateral and posteromedial incisions releasing anterior, lateral, superficial posterior, and deep posterior compartments). Wounds are left open and dressed with negative pressure wound therapy (NPWT/VAC).
3. Pneumatic Tourniquet Protocols and Safety Standards
Pneumatic tourniquets are precision surgical devices designed to occlude arterial inflow and provide a bloodless surgical field during extremity procedures, enhancing visualization and reducing blood loss.
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| PNEUMATIC TOURNIQUET SAFETY PROTOCOL |
| |
| 1. SKIN PREPARATION & WEBRIL PADDING |
| - Apply 2-3 smooth layers of cast padding (Webril) without wrinkles. |
| - Place cuff over point of maximum muscular circumference. |
| - Overlap cuff ends by 3 to 6 inches (too much causes roll/pinching). |
| |
| 2. SKIN DRAPING & FLUID ISOLATION |
| - Apply sterile drape or plastic barrier seal distal to cuff. |
| - Prevent prep solutions (ChloraPrep/Betadine) from pooling under cuff |
| (prevents chemical contact burns and skin necrosis). |
| |
| 3. LIMB EXSANGUINATION |
| - Elevate limb 45-90 degrees for 2 to 3 minutes. |
| - Wrap Esmarch latex/rubber bandage tightly from DISTAL digits to |
| immediately below distal edge of tourniquet cuff. |
| - CONTRAINDICATIONS to Esmarch: Infection/Abscess, Malignancy, DVT. |
| |
| 4. CUFF INFLATION & PRESSURE MONITORING |
| - Inflate rapidly to prevent venous engorgement. |
| - Upper Extremity: 200–250 mmHg (or 50–100 mmHg above baseline SBP). |
| - Lower Extremity: 250–350 mmHg (or 100–150 mmHg above baseline SBP). |
| |
| 5. TIME MONITORING & REPERFUSION MANDATES |
| - Upper Extremity Limit: 60 minutes (absolute max 90 minutes). |
| - Lower Extremity Limit: 90 minutes (absolute max 120 minutes). |
| - Circulator notifies surgical team at 60 min, then every 15 min. |
| - Deflation reperfusion interval: 10 to 15 minutes before re-inflating.|
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Tourniquet Complications & Pathophysiology
- Chemical Burns: Occur when flammable alcohol or iodophor skin prep solutions pool beneath the cuff and are subjected to prolonged pressure.
- Nerve Paralysis (Tourniquet Palsy): Mechanical compression and localized microvascular ischemia of major nerve trunks (e.g., radial nerve in arm, peroneal nerve in leg), resulting in motor weakness and sensory loss.
- Post-Tourniquet Syndrome: Transient extremity edema, stiffness, pallor, and subjective weakness following cuff deflation due to reactive hyperemia and microvascular permeability.
- Systemic Metabolic Shifts on Deflation: Releasing the tourniquet washes accumulated anaerobic metabolites (lactic acid, potassium, carbon dioxide, thrombi) into systemic circulation, causing a transient drop in mean arterial pressure (MAP), rise in end-tidal CO2 (EtCO2), and risk of micro-embolism.
4. Internal and External Fixation Instrumentation & Mechanics
Fracture management requires anatomical reduction and stable mechanical fixation to allow primary or secondary bone healing.
1. Open Reduction Internal Fixation (ORIF)
ORIF involves surgically exposing the fracture site, anatomically aligning bone fragments under direct vision, and securing them with mechanical implants (plates, screws, wires, pins).
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| ORIF DRILL & SCREW SEQUENCE |
| |
| 1. REDUCTION & CLAMPING |
| - Anatomic alignment using bone holding clamps (Kern, Lowman, Lewin). |
| |
| 2. DRILL SLEEVE / GUIDE PLACEMENT |
| - Protects surrounding soft tissues; centers drill bit in plate hole. |
| |
| 3. DRILLING |
| - Pneumatic/battery drill with calibrated drill bit. |
| - CST provides continuous sterile saline irrigation (prevents thermal |
| osteonecrosis at temperatures > 47 deg C). |
| |
| 4. DEPTH GAUGE MEASUREMENT |
| - Hook engages far cortex; slide barrel to plate; read exact screw mm. |
| |
| 5. TAPPING (THREAD CUTTING) |
| - Cuts female threads in cortical bone (skipped if self-tapping screw).|
| |
| 6. SCREW INSERTION & SEATING |
| - Screwdriver drives selected screw size until secure purchase made. |
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Surgical Screw Taxonomy and Characteristics
- Cortical Screws: Feature fine, shallow threads with a narrow pitch (distance between threads) and a high thread count per inch. Designed for dense, compact cortical diaphysis. Fully threaded along the entire shaft.
- Cancellous Screws: Feature deep, wide, coarse threads with a large pitch designed to gain purchase in soft, porous cancellous bone of the epiphysis/metaphysis. Available fully threaded or partially threaded (partially threaded screws act as lag screws to compress fragments).
- Cannulated Screws: Hollow central shaft designed to pass over a pre-placed guide pin / Kirschner wire (K-wire) under fluoroscopic guidance, guaranteeing precise trajectory.
- Locking Screws: Feature threaded screw heads that lock directly into threaded plate holes, creating a fixed-angle construct that does not rely on bone-plate friction. Ideal for osteoporotic bone.
- Lag Screw Technique: A mechanical principle where a screw exerts compression across a fracture line. The near cortex is overdrilled to the outer diameter of the screw threads (gliding hole), while the far cortex is drilled to the core root diameter (pilot hole). As the screw is tightened, the head engages the near cortex while the threads purchase only the far cortex, pulling the fragments tightly together.
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| LAG SCREW PRINCIPLE DYNAMICS |
| |
| Screw Head Near Cortex (Gliding Hole) Far Cortex (Threaded)|
| [===]===========( O V E R D R I L L )===(X X X X X X X X) |
| | (Threads do not bite) (Threads bite deep)|
| +--------------------> COMPRESSION FORCE <-----------------------+|
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Specialized Orthopedic Instrumentation Matrix
| Instrument Category | Specific Instrument Names | Primary Function & Mechanism | Handling & Safety Precautions |
|---|---|---|---|
| Periosteal Elevators | Cobb, Key, Langenbeck, Freer, Crego | Strips periosteum and soft tissue from bone cortex to expose fracture lines. | Keep working edge sharp; inspect for burs; pass with blade facing away from CST palm. |
| Bone Reduction Clamps | Kern, Lane, Lowman, Verbrugge, Lewin | Grasps, reduces, and maintains anatomical alignment of bone fragments. | Ensure ratchet engages securely; check for tissue pinching in hinge mechanisms. |
| Bone Cutting & Shaping | Liston bone cutting forceps, Stille-Luer rongeur, Osteotomes, Chisels | Resects bone fragments, trims sharp edges, harvests bone graft. | Pair osteotomes with orthopedic mallet; wipe rongeur jaws clean of bone debris with moist sponge between bites. |
| Bone Curettes | Brun, Volkmann, Cobb curettes | Scrapes diseased bone, evacuates cysts, harvests cancellous graft. | Maintain cutting cup sharpness; deliver bone graft to sterile bowl immediately. |
| Measuring & Drilling | Calibrated depth gauge, drill guides, soft tissue protectors | Measures drill hole depth in millimeters; shields muscle/nerves from rotating bit. | Ensure depth gauge hook is fully extended; verify millimeter markings against screw gauge. |
| Pins & Wires | Kirschner wires (K-wires), Steinman pins | Temporary or definitive fixation; skeletal traction; cannulated screw guides. | Handled with wire driver; sharp trocar/diamond tips; measure diameter accurately. |
2. Intramedullary (IM) Nailing
IM nailing is the standard of care for diaphyseal fractures of the femur, tibia, and humerus. A titanium or stainless steel rod is inserted into the medullary canal across the fracture site.
- Sequence: Entry portal created with awl at greater trochanter/piriformis fossa (femur) or tibial tubercle (tibia) -> Guide wire passed across fracture under C-arm fluoroscopy -> Flexible reamers driven over guide wire sequentially (increasing by 0.5 mm increments) to ream medullary canal -> Selected IM nail mounted on insertion jig and driven into canal -> Proximal and distal interlocking screws inserted using targeting guides and radiolucent drill.
3. External Fixation
External fixation stabilizes complex, highly comminuted, open (Gustilo IIIB/IIIC), or infected fractures where internal hardware is contraindicated.
- Components: Transfixion pins (Schanz pins, Steinman pins) drilled percutaneously into bone proximal and distal to fracture -> Clamps attached to pins -> Rigid carbon fiber connecting rods bridge the fracture zone outside the skin envelope.
5. Total Joint Arthroplasty (TJA) and Bone Cement Kinetics
Total joint arthroplasty replaces damaged articular cartilage and subchondral bone with prosthetic components to relieve pain and restore joint biomechanics.
1. Total Knee Arthroplasty (TKA)
- Components: Femoral component (cobalt-chromium alloy), Tibial baseplate (titanium alloy) with Ultra-High-Molecular-Weight Polyethylene (UHMWPE) articular insert, and Patellar resurfacing button (polyethylene).
- Procedural Flow: Anterior midline incision -> Medial parapatellar arthrotomy -> Eversion of patella -> Distal femoral resection using oscillating saw and intramedullary alignment guide -> Proximal tibial resection using extramedullary guide -> Anterior, posterior, and chamfer femoral cuts using 4-in-1 cutting block -> Patellar resection and drilling -> Trial reduction (sizing, ligament balancing, range of motion check) -> Pulse lavage irrigation -> Component implantation (cemented with PMMA or press-fit porous ingrowth) -> Polishing and closure.
2. Total Hip Arthroplasty (THA)
- Approaches:
- Posterior (Moore) Approach: Patient in lateral decubitus position; incises fascia lata and gluteus maximus, detaches short external rotators (piriformis, obturator internus). Post-op Dislocation Precautions: Avoid hip flexion > 90°, avoid adduction past midline, avoid internal rotation.
- Direct Anterior Approach (DAA): Patient in supine position on specialized orthopedic table (e.g., Hana table); intermuscular/internervous plane between tensor fasciae latae and rectus femoris without detaching muscles. Post-op Precautions: Avoid extreme hip extension and external rotation.
- Surgical Sequence: Joint exposure -> Dislocation of femoral head -> Femoral neck osteotomy with oscillating/reciprocating saw -> Acetabular exposure using specialized retractors (Charnley, Hohmann, Meyerding) -> Hemispherical acetabular reaming (increasing in 1 mm increments) -> Acetabular shell insertion (press-fit with porous titanium/hydroxyapatite coating ± dome fixation screws) -> Acetabular liner placement (UHMWPE or ceramic) -> Femoral canal broaching/rasping (sequential sizes) -> Calcar planar milling -> Trial reduction with trial neck and head -> Definitive femoral stem and modular head impaction -> Final joint reduction and stability testing.
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| TOTAL HIP ARTHROPLASTY COMPONENTS |
| |
| [ACETABULAR CUP ASSEMBLY] |
| (Titanium Outer Shell + UHMWPE / Ceramic Articular Liner) |
| \_____/ |
| ( O ) <--- Modular Femoral Head (Cobalt-Chrome / Ceramic) |
| | |
| [=====] <--- Modular Neck Trunnion |
| | | |
| | | <--- Femoral Stem (Titanium / Cobalt-Chrome) |
| | | (Press-Fit Hydroxyapatite or PMMA Cemented) |
| \ / |
| \ / |
| \_/ |
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3. Polymethyl Methacrylate (PMMA) Bone Cement
PMMA is a biocompatible polymer used to fixate prosthetic implants to host bone. It does not act as a true adhesive; rather, it acts as a mechanical grout that interlocks within the cancellous trabecular spaces.
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| PMMA BONE CEMENT PHASES |
| |
| 1. MIXING PHASE (1-2 min) |
| - Liquid methyl methacrylate monomer + Powder polymer (with BaSO4). |
| - Mixed in closed vacuum system (evacuates toxic fumes and bubbles). |
| |
| 2. WAITING / SANDY-STRINGY PHASE (2-3 min) |
| - Mixture transitions from wet sand to sticky strands. |
| |
| 3. DOUGHY / WORKING PHASE (4-6 min) |
| - Mixture no longer sticks to gloved fingers. |
| - Cement loaded into delivery gun; injected retrograde into canal. |
| |
| 4. CURING / POLYMERIZATION PHASE (8-12 min) |
| - Exothermic chemical reaction (temperatures reach 80°C to 100°C). |
| - Implant must be held completely motionless until rock-hard. |
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[!WARNING] Bone Cement Implantation Syndrome (BCIS): A life-threatening perioperative complication occurring during the pressurization of PMMA cement and prosthesis insertion into the femoral medullary canal. High intramedullary pressure forces micro-emboli of marrow fat, air, and methyl methacrylate monomer into systemic venous circulation, causing pulmonary micro-embolization, acute pulmonary hypertension, profound systemic hypotension, hypoxemia, cardiac arrhythmias, and potential cardiac arrest. The CST must ensure pulse lavage bone bed preparation is complete and announce to anesthesia "Cement going in" prior to canal pressurization.
6. Diagnostic and Operative Arthroscopy Protocols
Arthroscopy is the minimally invasive endoscopic visualization, diagnosis, and operative treatment of intra-articular structures.
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| ARTHROSCOPY SYSTEM OVERVIEW |
| |
| [LIGHT SOURCE & CAMERA] ===> [30° / 70° ARTHROSCOPE] ===> [TROCAR/CANNULA]|
| | |
| [IRRIGATION PUMP] ========> [INFLOW PORTAL] ===================> | JOINT |
| (Normal Saline / LR) (Maintains 30-60 mmHg distension) | CAVITY |
| | |
| [MOTORIZED SHAVER / RF] ==> [OPERATIVE PORTAL] =================>| |
| (Debridement & Ablation) | |
| | |
| [GRAVITY / SUCTION] <====== [OUTFLOW PORTAL] <==================/ |
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Arthroscopic Equipment & Parameters
- Arthroscope Optics: Rigid optical scopes with 30-degree (standard general visualization) or 70-degree (wide-angle visualization around anatomical corners, posterior knee compartments, subacromial space) angled lenses.
- Distension Media: Isotonic fluids (0.9% Normal Saline or Lactated Ringer's) are infused via an automated pressure-controlled pump. Fluid pressure is maintained between 30 and 50 mmHg in the shoulder and 40 and 60 mmHg in the knee to achieve joint distension and tamponade microvascular capillary bleeding.
- Fluid Extravasation Hazard: Excessive pump pressure or prolonged operative duration can cause massive fluid extravasation into surrounding interstitial musculature, resulting in severe soft tissue edema and secondary compartment syndrome.
- Arthroscopic Hand Instruments: Blunt nerve/joint probes (tactile exploration of cartilage and menisci), basket punches / forceps (resection of torn tissue), motorized shaver handpiece with aggressive resection burrs and blades, and radiofrequency (RF) bipolar electrosurgical ablator wands.
Common Arthroscopic Procedures
- Knee Arthroscopy: Partial meniscectomy, meniscal repair (inside-out, outside-in, all-inside techniques), and Anterior Cruciate Ligament (ACL) reconstruction using Bone-Tendon-Bone (BTB) autograft, quadrupled semitendinosus/gracilis tendon autograft, or allograft.
- Shoulder Arthroscopy: Subacromial decompression (acromioplasty), rotator cuff tendon repair (supraspinatus/infraspinatus anchor fixation), Bankart labral repair for anterior shoulder instability, and SLAP (Superior Labrum Anterior to Posterior) repair.
7. Orthopedic Aseptic Mandates and Infection Control
Postoperative orthopedic infections (periprosthetic joint infections - PJI) are devastating, frequently necessitating hardware removal, long-term IV antibiotics, and revision arthroplasty.
Perioperative Infection Control Standards
- Laminar Airflow Ventilation: Operating rooms utilize unidirectional ultraclean laminar airflow (vertical or horizontal) providing 20 to 60 air exchanges per hour through High-Efficiency Particulate Air (HEPA) filters that capture particles down to 0.3 microns.
- Personal Protection Systems (Space Suits): Sterile surgical exhaust hoods and gowns equipped with internal cooling fans and exhaust vacuum filtration are worn by sterile team members during joint arthroplasty to eliminate skin squames, respiratory droplets, and hair shed.
- Glove Protocol: All team members double-glove. Outer gloves are routinely changed every 60–90 minutes, immediately following draping, and prior to handling permanent prosthetic implants and bone cement.
- Implant Handling Rules: Implants must remain sealed in sterile manufacturer packaging until the surgeon determines exact trial size. Implants must never touch drapes, skin, or unsterile surfaces, and should be handled exclusively with dedicated smooth-jawed instruments or clean, freshly gloved hands.
- Antibiotic Prophylaxis: Weight-based prophylactic IV antibiotics (Cefazolin or Vancomycin for penicillin/MRSA risk) must be fully infused within 60 minutes prior to surgical incision (or before pneumatic tourniquet inflation).
Test Your Knowledge
What is the primary mechanical rationale for utilizing the lag screw technique during open reduction internal fixation (ORIF) of an oblique bone fracture?
A
B
C
D
Test Your Knowledge
During a total knee arthroplasty, the surgical technologist prepares polymethyl methacrylate (PMMA) bone cement in a closed vacuum mixing system. What life-threatening intraoperative complication must the surgical team anticipate during femoral canal pressurization?
A
B
C
D
Test Your Knowledge
Which of the following represents an absolute contraindication to the use of an Esmarch bandage for limb exsanguination prior to pneumatic tourniquet inflation?
A
B
C
D