Orthopedic Surgery
MADE EASY
DR WYNAND WESSELS
ORTHOPEDIC SURGEON
GRANDE PRAIRIE
Principles of Orthopedic Surgery

1. Fracture management

2. Elective surgery- “So many pieces”

3. Tourniquets

4. Arthroscopy principles

5. Set Design
Fracture management



1. Accurate reduction, Stable fixation

Biomechanical integrity/ Stability

Maintain joint congruency

Early mobilization- improves healing and reduces stiffness
2. Minimal soft tissue damage

Need to treat soft tissue with respect

All tissue as precious as skin on the face

Orthopedics doesn’t need to be aggressive
3. Preserve blood supply to bone as much as possible.

New implant designs

Minimal stripping of bone
Open Reduction Internal Fixation

1.Compound fractures

2. Nerve/ Vascular injury

3. Pathological fracture- metastases

4. Specific #’s- radius/ulna in adults

5. #’s involving joints
Fracture
Reduction
Hold
Cast
Wire
Children
Percutaneo
us
Simple
fractures
Cast
technique
Minimal
stripping
Image
guided
+/- Cast
Intramedullary
Plate screw
Biomechanic
al stability
Invasive
Stripping
Awl
Size and bend plate
Guidewire
Drill hole
Ream
Measure
Nail
Screw
Locking
Repeat
Drill
Measure
screw
External fixation
Complex fractures
Limb correction
Bone transport
Staged procedure
in mangled extremity
Elective surgery- joint replacement

Most complex of all cases

Nothing to be afraid of

Principles are the same in each system

READ the surgical technique!

Know the correct names of the instruments.

Take time to play with instruments- during the case is not the time
Total knee replacement

Example of complex equipment- (Zimmer Nexgen)

Every system has similar items- they just look different

Many items not used for every case
Steps

Open joint

Clean menisci, soft tissue

Measure Tibia and cut using guide

Measure and cut Femur

Balance soft tissue

Finish cuts on femur and tibia

Cement components in

Close joint
Tourniquets


Pneumatic tourniquets

Blood less field

Increases visualization

Decrease blood loss

Reduces operative time
Upper and lower limb

Above elbow

Above knee

Above Ankle
Selection

Sizing

Wider is better- reduced local pressure effect

Lower mmHg/cm2 is better

Long enough to go around limb


Single or double bladder


1.5 x circumference. ( 20” thigh- 30” tourniquet)
Double bladder for peripheral nerve block. Inflate proximal first. Inject. As anesthetic
takes effect inflate distal and deflate proximal. Reduces sensation of the cuff
Single use vs Reusable.

Cost
Inflation Pressure/ Time

Effective occlusion of all blood flow to and from the limb

Anaerobic metabolism


Lactate , pO2

Toxic substances

Release tourniquet causes reperfusion injury state.

Renal toxicity
,
pH , Myoglobin release
Less time is better

Maximum 2 hrs then release for 5 minutes every 30 minutes

Severe tissue necrosis if > 2hrs
.

Pressure

250mmHg for arm, 300mmHg for lower limbs often used.

Might be too high

New method is Limb Occlusion Pressure


Doppler to determine when arterial occlusion occurs.

Select pressure 60-100mmHg higher

Usually for arm <200 and legs 200-220

Very seldom used
Too high pressure causes irreversible damage to nerve fibres.

Wide cuff and low pressure inflation = less surface pressure
Arthroscopy Principles.

Why Arthroscopic surgery

Less invasive cosmetically

Improved visualization

Reduced pain and stiffness

Use water pressure to distend the joint capsule- Pump or gravity

Camera portal- often more than one

1 or more working portals

Outflow portal
Tips for setup

Setup most important items first

Camera

Light cord

Irrigation fluid

Shaver and suction.

Surgeon can start once camera is attached.

Position yourself to be able to see the monitor. Have to follow the procedure.
Shoulder case- table between yourself and surgeon

Anticipate next step
Knee Arthroscopy

1. Introduce cannula
Cannula + trochar

2. Camera + Fluid

3. Joint examination

4. Identify pathology

Eg. Meniscus tear – Repair or excise

“Working portal”

Suction joint

Closure- Suture or steri strip

Dressing
Handling instruments

Make sure you hand instrument the correct orientation

Surgeon is watching the monitor most of the time

Cannot reposition instrument in his hand

Do not drop instruments- delicate jaws, bend easily

Camera lens!!!!!

Do not bend

Do not put anything on top of it

Do not drop it

Cost $1800-5000 each

Match to sheath
During the case

Monitor the fluid level

If it runs dry …. Blood, sweat, tears!!
Monitor where the fluid runs too- OR floors are not level!

Huge puddle on floor not uncommon

Fall risk

Sometimes inevitable

Case progress quickly through steps

Plan 2 steps ahead
Orthopedics Instrument design

Most set are designed to use out of the tray

Old method was to unpack items on table.

Risk of dropping instrument

Misplaced instrument wastes time

Work out of the tray!
Femur Nail set- Gamma
5 Bolt for
guide
2
Guide
wire
3 Nail
guide
1 -Awl
4 Screwdriver for guide
Alternative setup