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

3. PREOPERATIVE PREPARATION
INSTRUMENTS
Soft or bone
Drill and oscillating saw
Lighting
high-intensity headlight
loupes
Camera
PROPHYLACTIC ANTICOAGULATION

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

6. 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

17. SPECIAL OPERATIVE TECHNIQUES
METHODS OF TENDON-TO-BONE FIXATION
FIXATION OF TENDON TO BONE
TECHNIQUE 1-1
TECHNIQUE 1-2

18. SPECIAL OPERATIVE TECHNIQUES
METHODS OF TENDON-TO-BONE FIXATION
TENDON TO BONE FIXATION USING LOCKING LOOP SUTURE
TECHNIQUE 1-3

19. SPECIAL OPERATIVE TECHNIQUES
METHODS OF TENDON-TO-BONE FIXATION
TENDON TO BONE FIXATION USING WIRE SUTURE
TECHNIQUE 1-4(cole)

20. SPECIAL OPERATIVE TECHNIQUES
METHODS OF TENDON-TO-BONE FIXATION
SUTURE ANCHORS

21. SPECIAL OPERATIVE TECHNIQUES
METHODS OF TENDON-TO-BONE FIXATION
FIXATION OF OSSEOUS ATTACHMENT OF TENDON TO BONE

22. SPECIAL OPERATIVE TECHNIQUES
METHODS OF TENDON-TO-BONE FIXATION
SUTURE BUTTONS

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

28. SPECIAL OPERATIVE TECHNIQUES
BONE GRAFTING
SOURCES OF BONE GRAFTS
CANCELLOUS BONE GRAFT SUBSTITUTES

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

31. SPECIAL OPERATIVE TECHNIQUES
BONE GRAFTING
PREPARATION OF BONE GRAFTS
REMOVAL OF A TIBIAL GRAFT

32. SPECIAL OPERATIVE TECHNIQUES
BONE GRAFTING
PREPARATION OF BONE GRAFTS
REMOVAL OF FIBULAR GRAFTS

33. SPECIAL OPERATIVE TECHNIQUES
BONE GRAFTING
PREPARATION OF BONE GRAFTS
REMOVAL OF FIBULAR GRAFTS

34. SPECIAL OPERATIVE TECHNIQUES
BONE GRAFTING
PREPARATION OF BONE GRAFTS
CANCELLOUS ILIAC CREST BONE GRAFTS
REMOVAL OF AN ILIAC BONE GRAFT

35. SPECIAL OPERATIVE TECHNIQUES
BONE GRAFTING
PREPARATION OF BONE GRAFTS
CANCELLOUS ILIAC CREST BONE GRAFTS
REMOVAL OF AN ILIAC BONE GRAFT