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Surgical techniques
1. SURGICAL TECHNIQUES AND APPROACHES
Dr. Mohammad Mahdi Shater
Orthopedic Surgery Resident
Baqiyatallah University of Medical Sciences
الرحیم الرحمن اهلل بسم
CAMPBELL’S OPERATIVE ORTHOPAEDICS, THIRTEENTH EDITION
2. use of tourniquets
use of radiographs and
image intensifiers in the operating room
positioning of the patient
local preparation of the patient
draping of the
operative techniques
SURGICAL TECHNIQUES
4. Operations on the extremities are made easier by the use of a tourniquet
The tourniquet is a potentially dangerous instrument
A pneumatic tourniquet is safer than an Esmarch tourniquet or the Martin sheet rubber
bandage.
Check of tourniquets
Padding
applying a tourniquet on an obese patient(tissue and padding)
Use of tourniquet
Pressure (age, size, blood pressure)
Tourniquet pressures of 135 to 255 mm Hg for the upper extremity and 175 to 305 mm Hg for
the lower extremity were satisfactory for maintaining hemostasis
TOURNIQUETS
5. wide tourniquet cuffs are more effective at lower inflation pressures than are narrow ones.
curved tourniquets vs straight tourniquets
chemical burn and prevention
Tourniquet paralysis can result from (1) excessive pressure; (2) insufficient pressure, resulting in
passive congestion of the part, with hemorrhagic infiltration of the nerve; (3) keeping the
tourniquet on too long; or (4) application without consideration of the local anatomy
Time
Posttourniquet syndrome
complications
TOURNIQUETS
7. The Esmarch tourniquet is still in use in some areas and is the safest and most practical of the
elastic tourniquets
A Martin rubber sheet bandage can be safely used as a tourniquet for short procedures on the
foot.
Special attention should be given when using tourniquets on fingers and toes
rubber ring tourniquet or a tourniquet made from a glove finger vs A glove finger or Penrose
drain or a modified glove finger with a volar flap
Sterile disposable rubber ring tourniquets are now available
Rubber ring tourniquets are not indicated in the presence of malignancy, infections, significant
skin lesions, unstable fractures or dislocations, poor peripheral blood flow, edema, or deep
venous thrombosis.
Antibiotic and tourniquets
TOURNIQUETS
8. Often it is necessary
Radiography technicians who work in the operating room must wear the same clothing and
masks as the circulating personnel
aseptic surgical technique in radiography
backup plain radiographs are necessary.
avoid exposure to radiographs
RADIOGRAPHS IN THE OPERATING ROOM
9. Mark surgical site
maximal safety
Airway
pressure on the chest or abdomen should be avoided
Prone
Supine
Latral
Padding should be placed over the area where a nerve may be pressed against the bone (i.e.,
the radial nerve in the arm, the ulnar nerve at the elbow, and the peroneal nerve at the neck of
the fibula).
POSITIONING OF THE PATIENT
10. Superficial oil and skin debris are removed with a thorough 10-minute soap-and-water scrub
We prefer a skin cleanser containing 7.5% povidone-iodine solution that is diluted
approximately 50% with sterile saline solution
Hexachlorophene containing skin cleanser is substituted when allergy to shellfish or iodine is
present or suspected
After scrubbing, the skin is blotted dry with sterile towels.
After a tourniquet has been placed, if one is required, the sterile sheets applied during the
earlier preparation should be removed
with a separate sterile sponge stick, beginning in the central area of the site of the incision and
proceeding peripherally
Tincture of iodine containing 85%, povidone-iodine solution
Sponges should not be saturated because the solution would extend beyond the operative field
LOCAL PREPARATION OF THE PATIENT
11. Excessive iodine, even in the operative field, should be removed with alcohol to prevent
chemical dermatitis.
Replace drapes
If a patient is allergic to iodine, plain alcohol can be used as a skin preparation
Colored proprietary antiseptics
When traumatic wounds are present, tincture of iodine and other alcohol-containing solutions
should not be used
operations around the upper third of the thigh, the pelvis, or the lower lumbar spine
Gluteal cleft and anus
instrument packs not be opened until skin preparation and draping are completed.
a nurse or anesthetist should be appointed to watch this stage of preparation.
LOCAL PREPARATION OF THE PATIENT
12. moist with sterile isotonic saline or lactated Ringer solution
triple antibiotic solution of bacitracin, neomycin, and polymyxin
Antibiotic solutions should remain in the wound for at least 1 minute
Pulsatile lavage systems is better
WOUND IRRIGATING SOLUTIONS
13. Draping is an important step in any surgical procedure and should not be assigned to an
inexperienced assistant.
towel clips or skin staples
overlap the prepared area of skin at least 3 inches (7.5 cm).
Gloves
DRAPING
14. The gloved hand should not come in contact with the skin before the incision is made
Stockinette
adhesive-coated material
plastic adhesive drape
Visibility is especially important
DRAPING THE EDGES OF THE INCISION
15. We strongly agree with the following AAOS recommendations regarding HIV, HBV, and HCV
precautions in the operating room
PREVENTION OF HUMAN IMMUNODEFICIENCY
VIRUS AND HEPATITIS VIRUS TRANSMISSION
16. The operative site should be marked before entering the operating room
Once the patient is under anesthesia, a designated member of the team should state the name
of the patient, the procedure, and the correct site.
PREVENTING MISTAKES
23. SPECIAL OPERATIVE TECHNIQUES
BONE GRAFTING
Fill cavities or defects resulting from cysts, tumors, or other causes
Bridge joints and provide arthrodesis
Bridge major defects or establish the continuity of a long bone
Provide bone blocks to limit joint motion (arthroereisis
Establish union in a pseudarthrosis
Promote union or fill defects in delayed union, malunion, fresh fractures, or osteotomies
24. SPECIAL OPERATIVE TECHNIQUES
BONE GRAFTING
STRUCTURE OF BONE GRAFTS
Cortical bone grafts are used primarily for structural support
cancellous bone grafts are used for osteogenesis.
25. SPECIAL OPERATIVE TECHNIQUES
BONE GRAFTING
SOURCES OF BONE GRAFTS
AUTOGENOUS GRAFTS
When the bone grafts come from the patient, the grafts usually are removed from the tibia,
fibula, or ilium
The subcutaneous anteromedial aspect of the tibia is an excellent source for structural
autografts
Disadvantages to the use of the tibia as a donor area include (1) a normal limb is jeopardized;
(2) the duration and magnitude of the procedure are increased; (3) ambulation must be delayed
until the defect in the tibia has partially healed; and (4) the tibia must be protected for 6 to 12
months to prevent fractures. For these reasons, structural autografts from the tibia are now
rarely used
proximal two thirds of the fibula
26. SPECIAL OPERATIVE TECHNIQUES
BONE GRAFTING
SOURCES OF BONE GRAFTS
ALLOGENIC GRAFTS
obtained from an individual other than the patien
Children
Osteochondral allografts
HETEROGENEOUS GRAFTS
27. SPECIAL OPERATIVE TECHNIQUES
BONE GRAFTING
SOURCES OF BONE GRAFTS
BONE BANK
To provide safe and useful allograft material
Safety
Differentiate
30. SPECIAL OPERATIVE TECHNIQUES
BONE GRAFTING
INDICATIONS FOR VARIOUS BONE GRAFT TECHNIQUES
ONLAY CORTICAL GRAFT
INLAY GRAFT
MULTIPLE CANCELLOUS CHIP GRAFTS
HEMICYLINDRICAL GRAFTS
WHOLE-BONE TRANSPLANT
CONDITIONS FAVORABLE FOR BONE GRAFTING