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Arthroscopically Assisted Anterior Cruciate Ligament Reconstruction
AORN JOURNAL
JANUARY 1989, VOL. 49, NO 1
Arthroscopically Assisted Anterior Cruciate Ligament Reconstruction Anna L. Hales, RN
A
11 ligaments stabilizejoints and guidejoint motion, and the anterior cruciate ligament (ACL) is no exception. Even though its biomechanical and physiological properties are complex, its role is simply to stabilize the knee joint by preventing forward movement and rotation of the tibia on the femur. The anatomy of the ACL and its location within the knee joint are directly related to its role. The ligament extends up from a point in front of and just lateral to the tibia1 spine and spirals back to join the femur on the posterior aspect of the medial surface of the lateral femoral condyle (Fig 1). It ranges in length from 30 to 40 mm and in width from 7 to 15 mm.
Historical Background
G
alen, a Greek anatomist, first described the ACL in 170 AD. He recognized that ligaments are joint stabilizers and supporters.' During the next 1,600 years, this structure was largely ignored, and the first recorded treatment of a ruptured ACL was in 1850. Two patients were managed with braces, and although they recovered, they experienced some ongoing disability.2 The first surgical repair of a torn ACL was performed in 1885 in Leeds,England. The patient was a 41-year-old miner who was injured at work. His surgery was performed 36 weeks after the injury, and in spite of the delay, it was considered a success. Eight years later, the miner described his leg as perfectly strong. He was able to work a full day, and he was able to run. His physician 234
determined that his knee was capable of full extension, normal mobility, and only slightly less than normal flexion? Between 1917 and 1950, the ACL received much attention from orthopedists. Many reviews and discussions were published and presented. They described various techniques that borrowed and rerouted almost every structure surrounding the knee in an attempt to create a suitable substitute for the injured ACL.4 By 1950, most methods of reconstruction had been attempted. More importantly, basic principles that today govern the management of the tom ACL had been identified and established. These include early diagnosis, early treatment, and the value of examination under anesthesia in obtaining an accurate diagnosis. In 1950, D. H. O'Donoghue, MD, an orthopedic surgeon from Oklahoma City, studied a large series of ACL tears in college athletes.5 Some believe that his work, which outlined the methods of diagnosis, operative procedure, and rehabilitation of the injured athlete, provided the
Anna L. Hales, RN,is a nursing coordinator, orthopedics, University Hospital, London, Ontario. She has a diploma in nursing from St Joseph's Hospital School of Nursing, North Bay, Ontario. The author acknowledges Peter Fowler, MD, Janet Purcell PI: and Betty Rutledgefor their assistance, and George Moogk, Department of Audiovisual Services, University Hospital,London, Ontario,for the illustrations.
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patella anterior cruciate
posterior cruciate ligament
lateral meniscus
medial meniscus
tibia
Fig 1. The anatomy of the knee joint,
momentum for today’s extensive interest in ACL deficiency.6 Professional athletes have always been prey to knee injuries, but with the increasing number of amateur and weekend athletes, the incidence of torn ACLs has increased. In fact, studies show that the ACL is the most frequently torn ligament.7 An increased awareness of sports-related trauma has accompanied the “fitness boom,” and modern research has enhanced knowledge of the physiology and biomechanics of the ACL. These factors have improved the competence of orthopedic surgeons, general practioners, coaches, and trainers in recognizing a torn ACL and the events that may cause an ACL tear. The objective of any treatment of a torn ACL is to restore the knee to optimum stability and function. Scientific and clinical research have provided the orthopedic surgeon with a selection
of options. Treatment can be conservative or surgical. Surgical treatment can be intraarticular or extraarticular. A number of autogenous structures borrowed from the knee can be used alone or augmented, and prosthetic devices can be used. At University Hospital, London, Ontario, the torn ACL is reconstructed using autogenous tissue that routinely is augmented with a Kennedy LAD’”, a polypropylene braid ligament augmentation device. This method is based on 15 years of research in both animals and humans that has established the following principles. An active person who receives no treatment for an ACL deficiency may experience serious complications. Repeated “giving way” of the knee leads to meniscal tears and instability that hampers the integrity of support structures such as the lateral and
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medial collateral ligaments. The eventual result is degenerative joint disease. Rehabilitation alone generally results in these problems more frequently than surgical treatment does. Substituting a tom ACL with autogenous tissue alone has considerable shortcomings? Autografts require six months to one year for revascularizationand strengthening.This establishes the desirability of an augmentation device to enhance the autograft and protect it from stretching or rupturing during the regenerative period. Prosthetic ligaments are mechanically attached to bone at both ends. They are subject to frequent failure and therefore are not considered successful.
Mechanism of Injury
M
ost knee ligament injuries are sports related, and soccer, football, and basketball are the major offenders. The most common cause of ACL tear is a decelerating and twisting motion when an athlete attempts to abruptly stop his or her forward movement. With sudden deceleration, the quadriceps muscles contract and pull the tibia forward on the femur. The athlete may turn his or her leg at the same time. Such simultaneous anterior and rotational stresses can result in a torn ACL. Although complete disruptions can occur at any point along the length of the ligament, they most often occur in the middle. Also, the ACL can avulse from either its femoral or tibial attachment.
Diagnosis
A
s the ligament tears, the individual feels his or her knee giving way. Pain and swelling occur almost immediately. Any effusion within 24 hours of injury is considered to be a hemarthrosis, and 75% of knees with an acute hemarthrosis will have a ruptured ACL.9 The patient’s history is the most important factor in making a correct diagnosis. Careful notation of the events leading up to the injury will provide the most relevant information for an accurate 238
diagnosis. A clinical examination of the knee is mandatory. This is most effective when done immediately after the injury wherever the incident occurred. If too much time elapses between the injury and examination, pain and spasm may affect the quality of the examination. A routine examination always includes the anterior drawer test, the Lachman’s test, and the pivot-shift test. If the patient cannot tolerate these, an examination under anesthesia is arranged to confirm anterior cruciate tear. These tests help the physician assess the anterior displacement of the tibia on the femur. Each of these can be positive or negative to various degrees. Complete and incomplete ligament disruptions will allow abnormal movement of the knee joint. The opposite leg is routinely examined for comparison. Anterior drawer test. This is done with the patient’s knee flexed to 90 degrees. His or her hamstrings are relaxed. The physician pulls the tibial condyles forward and away from the femur. Any excessive movement is a positive indication of ACL damage. Lachmn’s test. This is done in a similar fashion to the anterior drawer test but with the knee minimally flexed. It evaluates anterior subluxation of the tibia on the femur, and a positive result suggests an ACL disruption. Pivot-shift test. This maneuver begins with the knee extended (Fig 2). If the anterior cruciate ligament is torn, the tibia will be dislocated anteriorly. As the physician bends the patient’s knee, the tibia will jerk back into alignment with the femur at 20 to 30 degrees of flexion. Arthroscopy plays a major role in the diagnosis of ACL lesions. It rules out or confirmsa suspected ACL disruption and exposes other injuries within the knee joint, such as meniscal tears or osteochondral fractures. Arthroscopy also allows the surgeon to see the extent and location of the tear. Any meniscal surgery, either partial meniscectomy or meniscal suturing, can be performed during arthroscopy. Much reconstructive surgery can be performed arthroscopically as well. When an ACL ruptures, its fibers are stretched beyond the limits of their elasticity. The term “mop-ended” best describes the appearance of the
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Fig 2. Position and movement of the knee during the pivotshift test. torn ligament. This makes primary repair of the ACL impossible; however, in many cases if the diagnosis is made close to the time of injury, sutures can be placed in a stump of the ligament. These sutures bring the torn ends of the ligament together. In theory, the approximation of these ends will preserve the proprioceptive properties of the ACL. If a diagnosis is not made within two weeks of injury, the stump of ligament which may have been suitable for sutures will shrink, retract, and virtually disappear. This is why early diagnosis and treatment are ideal.
Preoperative Preparation
A
s a result of preoperative teaching, the patient comes to understand the nature of his or her injury in terms of ACL function. He or she must understand the surgical procedure and its objectives, as well as the use of a ligament augmentation device. Perhaps most importantly, the patient must be committed to
an extensive year-long rehabilitation program. He or she needs to know that a great deal of time for 10 months after surgery will be spent with the physiotherapist and that he or she must be an active participant in the rehabilitative process. Failure to comply with this program will jeopardize recovery. The primary responsibility for preoperative teaching lies with the surgeon and the surgical team. When thisgroup is satisfiedthat the patient understan& the nature of the surgery and the extent of the involvement required, the procedure is scheduled The patient is admitted to the hospital on the afternoon before surgery. Routine laboratory work includes a complete blood cell count, blood biochemistry, and chest x-ray. X-rays of the knee include a “tunnel view,” which demonstrates the size of the intercondylar notch and any osteophytes that may have formed. A nursing history provides information on which nursing decisions will be based. This includes data related to the admitting diagnosis
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Nursing duties are divided so the needs of the patient, anesthetist, scrub nurse, and surgeon can be met simultaneously. as well as to other relevant health problems. Previous surgery, medication history, and a physical and emotional assessment are all documented. The nurse can determine if the patient’s knowledge of the surgery and postoperative routine is adequate, and he or she can answer any questions the patient may have. Additional preoperative teaching is done by the nurse at this time. It is basically the same as for any patient having limb surgery. The nurse informs the patient of the entire perioperative routine and explains that compliance with the routine immediately postoperatively is essential. The nurse teaches deep breathing and coughing exercises and their role in preventing pneumonia. He or she also demonstrates isometric pedal exercises to minimize venous stasis. The nurse explains that during surgery, a suction drain will be inserted in the knee to minimize the chance of hematoma. He or she also explains that after surgery the patient’s leg will be wrapped in a large bulky bandage and immobilized by a hinged brace. The nurse tells the patient to expect some pain postoperatively and assures him or her that analgesics will be administered as a routine part of the care plan. On the morning of surgery, an intravenous (IV) line is started, and 1 g cefazolin is added. The patient is transported to the operating room and admitted to the receiving area of the operating room suite.
Preoperative Care
F
or this procedure, operating rooms generally are staffed with three nurses. Duties are divided so that the needs of the patient, anesthetist, scrub nurse, and surgeon can be met simultaneously. One circulating nurse is responsible for direct patient care, and another circulating nurse and a scrub nurse attend to the setup and instrumentation. 242
The circulating nurse greets the patient in the receiving area of the operating room suite. This initial contact is valuable to both nurse and patient. It gives the nurse the opportunity to complete the preoperative checklist and establish a rapport with the patient. The patient is given further opportunity to ask questions and communicate any fears. The nurse identifies the patient, marks the correct leg, notes any allergies, and determines that the patient has been NPO for the prescribed length of time. The nurse reviews the chart and ensures that the operative consent is accurate and that routine preoperative laboratory work is within normal limits. Once the patient is positioned on the OR bed, a safety strap is placed across his or her thighs. Basic standards of nursing care that apply to all patients are practiced at all times. The circulating nurse introduces the patient to the staff and states what procedure is to be performed, notes the correct leg, and explains any other facts that may affect the patient’s care. This nurse then assists with the induction of anesthesia. The circulating nurse’s responsibilities then focus on patient positioning. The patient remains supine during the procedure with his or her knees flexed 90 degrees over the end of the OR bed. The thigh is supported on both medial and lateral sides with a padded leg-holding system. This gives the leg necessary stability as it is manipulated throughout the surgery. After making sure that good body alignment and patient safety are maintained, the nurse secures the patient’s arms and pads pressure points. He or she protects neurological structures, such as the ulnar nerve, with eggcrate foam. An electrosurgical dispersive pad is secured to an appropriate area. The nurse places a tourniquet cuff high on the thigh. Tourniquet use follows a strict protocol which states that: tourniquet cuffs must be placed on the
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vastus medialis muscle
femur patella semitendinosus
fibula tibia
I Fig 3. Anatomy of the knee, showing the components of the pes anserinus.
fleshiest part of the limb to prevent possible damage to neurovascular structures, the ends of the tourniquet cuff must overlap 3 inches, all tourniquet gauges are checked prior to each use, and maximum inflation time for all tourniquets is two hours. For surgery on the leg, the tourniquet is routinely inflated to 300 mmHg. During surgery, the circulating nurse informs the surgeon when the tourniquet has been in place for 1 hour and then at 15-minute intervals after the first hour. If surgery exceeds 2 hours, the tourniquet is deflated and the procedure is finished without it. The circulating nurse shaves a small area on the lateral side of the distal thigh and a small anteromedial area just below the knee. The nurse scrubs the foot and leg for 2 minutes with a 7.5% povidone-iodine solution and preps the area with 2.5% iodine. He or she then drapes the leg with
two large drape sheets under the leg, a 6-inch stockinette over the leg to the tourniquet cuff, and an extremity drape.
Instrumentation
I
n addition to a basic orthopedic setup, this procedure requires a tibia1 drill guide, a power driver, a ligament wire passer, 2-0 wire, and a staple set. The surgeon also will need an angled curette (size 3 with a narrow shaft), 4- and 6mm rasps, a tendon leader, an open-ended tendon stripper, a basic arthroscopy setup, and an arthroscopy shaver system, which includes a soft tissue resector and an arthroplasty burr.
Surgical Procedure
T
he operative technique produces an augmented autograft that will function as an ACL. This autograft, constructed from
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/
bulldog clamps
semitendinosus lead suture
/
the semitendinosustendon, is biologically attached to the tibia, and mechanically fixed to the femur with a noncrushing staple. The semitendinosus tendon is part of the pes anserinus,which inserts on the anteromedial aspect of the proximal tibia. The pes anserinus is the conjoined tendon of the semitendinosus, gracilis, and sartorius muscles (Fig 3). This muscle-tendon unit contributes to internal rotation of the tibia and flexion of the knee. The semitendinosustendon is used because its use has produced no ill effects on the knee and when augmented, its strength is comparable to that of the ACL. Augmentation for the tendon is provided by the LAD'". This device, which is available in various lengths and two widths, was researched and developed by the late J. C. Kennedy, MD, of London, Ontario.*oThe reconstructed ligament will pass through a tibial tunnel, across the knee joint, and over the top of the lateral femoral condyle, and it will attach to the distal femur. This path closely resembles the anatomical placement of the original ACL. There are some variations in the surgical procedure depending on whether the injury is acute or chronic. If the injury is acute and the patient has not had a diagnostic arthroscopy, one is performed at this time. Any meniscal pathology is managed with meniscal suturing or partial meniscectomy . 246
Fig 4. Bulldog clamps hold the LAD'" in place. If the patient has had a previous arthroscopy and an ACL lesion was confirmed, the semitendinosus tendon is harvested before the arthroscope is introduced. At University Hospital, the setups are organized so that variations in the procedure can be accommodated with minimum difficulty or confusion for the nurses. An objective measure of knee joint laxity is obtained using a knee arthrometer before anesthesia is induced and again after induction but prior to surgery. These results are compared with those obtained immediately after surgery. The surgeon makes a small antero-medial incision just below the knee. He or she identifies the semitendinosus tendon at its tibial insertion and isolates it with a blunt hook. An open-ended tendon stripper is used to free the tendon from the surrounding soft tissue and transect it from the muscle. The semitendinosus autograft is measured and the appropriate length LAD'" is selected according to the patient's height. The LAD'" is sutured to the autograft. Three small plastic bulldog clamps are placed along the length of the tendon to hold the LAD'" in place during suturing (Fig 4). Absorbable 2-0 sutures are used at the beginning with a small taper needle. Suturing is completed with a nonabsorbable suture of the same weight at the tibial end of the graft. A tendon leader is attached to the graft. This
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Fig 5. The tendon leader takes the reconstructed ligament across the joint.
\
Fig 6. An arthroplasty burr widens the lateral wall of the femoral intercondylar notch.
device is made of stiff plastic with mesh casing at one end. It protects the new ligament and assists in passing it through the joint. The new ligament is secured in the mesh end of the leader, and the plastic end leads the reconstructed ligament across the joint (Fig 5). These steps produce an augmented semitendinosus graft. The remainder of the surgery will bring this structure across the knee joint, over the top of the lateral femoral condyle, and to the lateral side of the distal femur in a path similar to the anatomical placement of the original ACL. The surgeon inserts the arthroscope. He or she 248
uses a large-diameter full-radius synovial resector to debride synovium and scar tissue from the knee joint. Next, he or she uses a 4.5-mm arthroplasty burr to widen the lateral wall of the femoral intercondylar notch. This step also clears the notch of any osteophytes that may have formed and reduces the likelihood of impingement of the graft. A 6-mm rasp and straight and curved #3 curettes with narrow shafts are used to complete this step (Fig 6). An arthroscopic drill guide is essential for the satisfactory placement of the drill hole. It should emerge on the tibia1 plateau just anterior and
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Fig 7. After a guide pin is positioned, a cannulated drill bit is used to create the tibial tunnel.
Fig 8. The tendon leader, with attached composite graft, is pulled through the tibial tunnel, across the joint, and over the top of the lateral femoral condyle.
tendon [QadQr
Fig 9. The reconstructed anterior cruciate ligament is stapled to the distal femur. 249
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medial to the anatomic insertion of the ACL. Using such a device, the surgeon drills a guide pin into the knee from a point just medial to the tibial tubercle. Once the position of the guide pin is satisfactory, the surgeon creates the tibial tunnel with a 6-mm cannulated drill bit (Fig 7). The edges of the tunnel are smoothed with a 4-mm rasp to protect the composite graft from abrasion. The surgeon makes a short incision distally on the lateral thigh. A large round hook with an eye on the end is brought around the lateral femoral condyle anteriorly to posteriorly. This hook emerges from the incision on the distal thigh and is used to bring a folded 2-0 wire into the joint. A hemostat is placed on the oper, end of the wire, and the surgeon must take care to ensure that this end remains outside the incision. The surgeon uses an arthroscopy grasper through the tibial tunnel to grasp the looped end of the wire and pull it to the front of the knee. He or she then attaches the leader to the wire, which is then used to pull the composite graft through the tibial tunnel, across the joint, and over the top of the lateral femoral condyle (Fig 8). The nurse flexes the knee 30 degrees and the surgeon fixes the composite graft to the lateral femur with a small noncrushing staple (Fig 9). The knee is put through a full range of motion and pivot-shift and Lachman's tests. At the end of the surgical procedure, the wounds are copiously irrigated with a 0.5% solution of Tisusol'" and 10% povidone-iodine and a %-inch suction drain is put in place. The surgeon places the leg in a bulky dressing and a hinged splint brace set at 30 degrees of flexion (Fig lo).
Postoperative Routine
T
he patient is transferred to the postanesthesia care unit (PACU) where his or her leg remains elevated on pillows. The nurse checks vital signs every 15 minutes and monitors the neurovascular status of the limb. He or she also notes and assesses pedal pulses, skin color, motor power, and temperature of the toes and provides analgesics as required. He or she also checks the drain, which is attached to a selfregulating suction device, to ensure that it remains
patent. The patient usually returns to his or her room after approximately 1 to 1% hours in the PACU. In the room, the nurse observes the neurovascular condition of the leg once an hour for six hours and then every four hours for 24 hours. The nurse will assess this condition more frequently if he or she believes the patient's condition warrants it. As instructed preoperatively, the patient is encouraged to deep breathe, cough, and perform foot and calf exercises hourly. Postoperative care generally includes the administration of 10 mg morphine every four hours for up to two doses. Thereafter, oral analgesics such as acetaminophen with codeine are prescribed and given as required. The IV is discontinued when the patient is taking adequate amounts of fluid by mouth and has voided. Keeping the leg elevated on several pillows reduces swelling. The suction drain is removed when there are less than 50 mL of discharge in a 12-hour period. The physiotherapist sees the patient on the first postoperative day, fits him or her with crutches, and gives instructions on their use. The patient may begin to walk without bearing weight with crutches and standby assistance. The patient also begins to stretch the Achilles tendon and strengthen the quadriceps muscles and hamstrings. Discharge is planned for the third postoperative day. A nurse removes the bulky dressing, covers the incisions with dressing strips, and covers the leg with an elastic stockinette. The range of motion on the brace is increased to 90 degrees. Arrangements are made for the patient to begin the physiotherapy program during the first week postoperatively. He or she is given specific and detailed instructions so that stretching and strengthening exercises can be performed on a routine basis at home.
Physiotherapy
T
he physiotherapy routine is divided into 10 stages that last a total of approximately nine months. The goals of the initial stages are to minimize swelling and regain range of motion. This is accomplished by packing the knee 25 1
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Fig 10. The leg is placed in a bulky dressing and a hinged brace. with ice and stretching and gently cycling on a stationary bicycle. As swelling decreases and range of motion improves, the patient begins a gentle strengthening routine. The main muscle groups involved are the quadriceps and hamstrings. At approximately six to nine weeks postoperatively, a cane is used for support instead of crutches. At 12 to 16 weeks, full range of motion and full weight bearing should be achieved. The physiotherapist monitors the patient throughout the program to ensure that the expected progress is being made. At approximately 16 weeks postoperatively, a computerized strength test is performed on the knee. Depending on the results of this test, the patient is set up on an individualized strengthening routine. The patient is retested every four weeks, and his or her program is upgraded according to progress. Reevaluation and upgrading continue until discharge from the physiotherapist’s care approximately 10 months after surgery. These patients are systematically evaluated after surgery at three-, six-, nine-, and 12-month intervals so that their knee function can be assessed
and documented. Three parameters are used to determine the effectiveness of the surgical technique. These are categorized according to subjective and objective purposes, and all aspects of knee function are appraised. The first parameter is subjective-subjective. The patient describes his or her knee to the examiner and comments on his or her confidence in its stability and function. The second is a subjectiveobjective analysis in which established diagnostic tests such as Lachman’s and the pivot-shift are used to rate the stability of the knee. The third is an objective-objective exam in which an arthrometer is used to measure the anterior displacement of the tibia on the femur. To date, these evaluations have indicated that this procedure has met with good results.
Advantages of Arthroscopic Techniques
T
he great majority of patients with tom ACLs are healthy, active people who are anxious to return to their activities. Although the ACL can be reconstructed without 253
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A benefit of this arthroscopically assisted procedure is that the extensor mechanism of the knee is left intact. the use of the arthroscope, traditional approaches involve larger incisions and arthrotomies. Significant advantages of using the arthroscope include less pain, earlier rehabilitation, earlier active muscle control, and shorter hospitalization. As experience with these techniques increases, operative time will further decrease and patients will be suitable candidates for same-day surgery. A further benefit is that the extensor mechanism of the knee is left intact. In addition, the arthroscope makes it easier for the surgeon to see the intraarticular anatomy of the knee. This increases the surgeon’s accuracy in placing the reconstructed ligament into the joint. Arthroscopically assisted anterior cruciate ligament surgery is the method of the future, and allografts to replace the ACL will become increasingly popular. As methods for preserving and sterilizing allograftsare perfected and concerns about immunogenicity are resolved, using tissues from the knee will become unnecessary and arthroscopic techniques will become even less invasive.
Nursing Implications
A
rthroscopically assisted ACL reconstruction provided nurses at University Hospital with a challenge. At the beginning of our experience, we understood the goals of the surgery and its advantages and had a basic knowledge of the procedure, but our level of frustration was considerable. We were concerned about the sterility of the surgical field. With large quantities of imgant flowing through the knee, possible contamination seemed a serious problem even with impermeabledrapes. Doubling the layers of draping and changing gowns as soon as they became wet remedied this problem. In addition, arthroscopic instruments such as the camera, telescope, and shaver must be gas sterilized or soaked. Gassing between cases is not 254
possible, and although gluteraldehyde immersion
is not a problem with instruments in arthroscopic procedures, we believed that with this more extensive surgery we would be happier with instruments that had been terminally sterilized. Increasing our inventory of these has kept soaking at an absolute minimum. The many cables and tubings which connect to machinery off the field, including the camera, inflow and outflow tubing, light cord, shaver cable, electrosurgid cable, and operative suction, are potential sources of breaks in sterile technique. Securing all lines with self-adhesive fabric tape ensures that they will not be dragged back and forth off and on the sterile field. Adding extra length to tubings where possible keeps this equipment a good distance from the operative site. Another problem that required much thought was the placement of the video cart, arthroscopy pump, suction units, drainage bottles, and electrosurgical unit. It took a number of cases to sort out the details and come up with a plan that would make the progression of these cases efficient and reasonably uncomplicated for all operating room personnel. Through trial and error, we learned that the video equipment was best placed on the nonoperative side, all other machinery on the operative side, and that the scrub nurse was best on the operative side working off a draped Mayo stand placed over the patient’s chest. One other issue to deal with was instrumentation. Our basic orthopedic trays were not appropriate for this type of surgery. For example, curettes must have narrow shafts so that they can fit through arthroscopy punctures. Putting together ACL trays that contain only the specific required equipment has simplified the cases and has also made the upkeep of instruments easier. At the present time we have a systematic protocol that handles straightforward cases well. It is flexible enough to manage any additional procedures that may be necessary in whatever
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sequence they need to be performed. These may include meniscal suturing, repair or reconstruction of the posterior cruciate ligament, or repair of the lateral collateral or medial collateral ligaments. Our responsibility as OR nurses lies in adherence to established routine and in paying close attention to the details of each step. Effective communication with the surgeon is essential so that the operative plan may be related to all members of the team. In this way, patients will 0 consistently receive optimum care. Notes 1. G A Snook, “A short history of the anterior cruciate ligament and the treatment of tears,” Clinical Orthopedics and Related Research 172 (JanuaryFebruary 1983) 11-13. 2. Ibli?! 3. Ibli?! 4. Q M Burnett 11, P J Fowler, “Reconstruction of the anterior cruciate ligament: Historical overview,” Orthopedic Clinics ofNorth America 16 (January 1985) 147. 5. Snook, “A short history of the anterior cruciate ligament and the treatment of tears,” 11. 6. Ibli?! 7. R J Johnson, “The anterior cruciate ligament problem,” Clinical Orthopaedics and Related Research 172 (January-February 1983) 14. 8. J H Roth et al, “Polypropylene braid augmented and nonaugmented intraarticular anterior cruciate ligament reconstruction,” The American Journal of Sports Medicine 13 (September-October 1985) 321. 9. P J Fowler, “The classification and early diagnosis of knee joint instability,” Clinical Orthopaedics 147 (March-April 1980) 14. 10. Roth, “Polypropylene braid augmented and nonaugmented intraarticular anterior cruciate ligament reconstruction,” 336.
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Arthroscopically Assisted Anterior Cruciate Ligament Reconstruction Anna L. Hales, RN
A
11 ligaments stabilizejoints and guidejoint motion, and the anterior cruciate ligament (ACL) is no exception. Even though its biomechanical and physiological properties are complex, its role is simply to stabilize the knee joint by preventing forward movement and rotation of the tibia on the femur. The anatomy of the ACL and its location within the knee joint are directly related to its role. The ligament extends up from a point in front of and just lateral to the tibia1 spine and spirals back to join the femur on the posterior aspect of the medial surface of the lateral femoral condyle (Fig 1). It ranges in length from 30 to 40 mm and in width from 7 to 15 mm.
Historical Background
G
alen, a Greek anatomist, first described the ACL in 170 AD. He recognized that ligaments are joint stabilizers and supporters.' During the next 1,600 years, this structure was largely ignored, and the first recorded treatment of a ruptured ACL was in 1850. Two patients were managed with braces, and although they recovered, they experienced some ongoing disability.2 The first surgical repair of a torn ACL was performed in 1885 in Leeds,England. The patient was a 41-year-old miner who was injured at work. His surgery was performed 36 weeks after the injury, and in spite of the delay, it was considered a success. Eight years later, the miner described his leg as perfectly strong. He was able to work a full day, and he was able to run. His physician 234
determined that his knee was capable of full extension, normal mobility, and only slightly less than normal flexion? Between 1917 and 1950, the ACL received much attention from orthopedists. Many reviews and discussions were published and presented. They described various techniques that borrowed and rerouted almost every structure surrounding the knee in an attempt to create a suitable substitute for the injured ACL.4 By 1950, most methods of reconstruction had been attempted. More importantly, basic principles that today govern the management of the tom ACL had been identified and established. These include early diagnosis, early treatment, and the value of examination under anesthesia in obtaining an accurate diagnosis. In 1950, D. H. O'Donoghue, MD, an orthopedic surgeon from Oklahoma City, studied a large series of ACL tears in college athletes.5 Some believe that his work, which outlined the methods of diagnosis, operative procedure, and rehabilitation of the injured athlete, provided the
Anna L. Hales, RN,is a nursing coordinator, orthopedics, University Hospital, London, Ontario. She has a diploma in nursing from St Joseph's Hospital School of Nursing, North Bay, Ontario. The author acknowledges Peter Fowler, MD, Janet Purcell PI: and Betty Rutledgefor their assistance, and George Moogk, Department of Audiovisual Services, University Hospital,London, Ontario,for the illustrations.
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patella anterior cruciate
posterior cruciate ligament
lateral meniscus
medial meniscus
tibia
Fig 1. The anatomy of the knee joint,
momentum for today’s extensive interest in ACL deficiency.6 Professional athletes have always been prey to knee injuries, but with the increasing number of amateur and weekend athletes, the incidence of torn ACLs has increased. In fact, studies show that the ACL is the most frequently torn ligament.7 An increased awareness of sports-related trauma has accompanied the “fitness boom,” and modern research has enhanced knowledge of the physiology and biomechanics of the ACL. These factors have improved the competence of orthopedic surgeons, general practioners, coaches, and trainers in recognizing a torn ACL and the events that may cause an ACL tear. The objective of any treatment of a torn ACL is to restore the knee to optimum stability and function. Scientific and clinical research have provided the orthopedic surgeon with a selection
of options. Treatment can be conservative or surgical. Surgical treatment can be intraarticular or extraarticular. A number of autogenous structures borrowed from the knee can be used alone or augmented, and prosthetic devices can be used. At University Hospital, London, Ontario, the torn ACL is reconstructed using autogenous tissue that routinely is augmented with a Kennedy LAD’”, a polypropylene braid ligament augmentation device. This method is based on 15 years of research in both animals and humans that has established the following principles. An active person who receives no treatment for an ACL deficiency may experience serious complications. Repeated “giving way” of the knee leads to meniscal tears and instability that hampers the integrity of support structures such as the lateral and
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medial collateral ligaments. The eventual result is degenerative joint disease. Rehabilitation alone generally results in these problems more frequently than surgical treatment does. Substituting a tom ACL with autogenous tissue alone has considerable shortcomings? Autografts require six months to one year for revascularizationand strengthening.This establishes the desirability of an augmentation device to enhance the autograft and protect it from stretching or rupturing during the regenerative period. Prosthetic ligaments are mechanically attached to bone at both ends. They are subject to frequent failure and therefore are not considered successful.
Mechanism of Injury
M
ost knee ligament injuries are sports related, and soccer, football, and basketball are the major offenders. The most common cause of ACL tear is a decelerating and twisting motion when an athlete attempts to abruptly stop his or her forward movement. With sudden deceleration, the quadriceps muscles contract and pull the tibia forward on the femur. The athlete may turn his or her leg at the same time. Such simultaneous anterior and rotational stresses can result in a torn ACL. Although complete disruptions can occur at any point along the length of the ligament, they most often occur in the middle. Also, the ACL can avulse from either its femoral or tibial attachment.
Diagnosis
A
s the ligament tears, the individual feels his or her knee giving way. Pain and swelling occur almost immediately. Any effusion within 24 hours of injury is considered to be a hemarthrosis, and 75% of knees with an acute hemarthrosis will have a ruptured ACL.9 The patient’s history is the most important factor in making a correct diagnosis. Careful notation of the events leading up to the injury will provide the most relevant information for an accurate 238
diagnosis. A clinical examination of the knee is mandatory. This is most effective when done immediately after the injury wherever the incident occurred. If too much time elapses between the injury and examination, pain and spasm may affect the quality of the examination. A routine examination always includes the anterior drawer test, the Lachman’s test, and the pivot-shift test. If the patient cannot tolerate these, an examination under anesthesia is arranged to confirm anterior cruciate tear. These tests help the physician assess the anterior displacement of the tibia on the femur. Each of these can be positive or negative to various degrees. Complete and incomplete ligament disruptions will allow abnormal movement of the knee joint. The opposite leg is routinely examined for comparison. Anterior drawer test. This is done with the patient’s knee flexed to 90 degrees. His or her hamstrings are relaxed. The physician pulls the tibial condyles forward and away from the femur. Any excessive movement is a positive indication of ACL damage. Lachmn’s test. This is done in a similar fashion to the anterior drawer test but with the knee minimally flexed. It evaluates anterior subluxation of the tibia on the femur, and a positive result suggests an ACL disruption. Pivot-shift test. This maneuver begins with the knee extended (Fig 2). If the anterior cruciate ligament is torn, the tibia will be dislocated anteriorly. As the physician bends the patient’s knee, the tibia will jerk back into alignment with the femur at 20 to 30 degrees of flexion. Arthroscopy plays a major role in the diagnosis of ACL lesions. It rules out or confirmsa suspected ACL disruption and exposes other injuries within the knee joint, such as meniscal tears or osteochondral fractures. Arthroscopy also allows the surgeon to see the extent and location of the tear. Any meniscal surgery, either partial meniscectomy or meniscal suturing, can be performed during arthroscopy. Much reconstructive surgery can be performed arthroscopically as well. When an ACL ruptures, its fibers are stretched beyond the limits of their elasticity. The term “mop-ended” best describes the appearance of the
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Fig 2. Position and movement of the knee during the pivotshift test. torn ligament. This makes primary repair of the ACL impossible; however, in many cases if the diagnosis is made close to the time of injury, sutures can be placed in a stump of the ligament. These sutures bring the torn ends of the ligament together. In theory, the approximation of these ends will preserve the proprioceptive properties of the ACL. If a diagnosis is not made within two weeks of injury, the stump of ligament which may have been suitable for sutures will shrink, retract, and virtually disappear. This is why early diagnosis and treatment are ideal.
Preoperative Preparation
A
s a result of preoperative teaching, the patient comes to understand the nature of his or her injury in terms of ACL function. He or she must understand the surgical procedure and its objectives, as well as the use of a ligament augmentation device. Perhaps most importantly, the patient must be committed to
an extensive year-long rehabilitation program. He or she needs to know that a great deal of time for 10 months after surgery will be spent with the physiotherapist and that he or she must be an active participant in the rehabilitative process. Failure to comply with this program will jeopardize recovery. The primary responsibility for preoperative teaching lies with the surgeon and the surgical team. When thisgroup is satisfiedthat the patient understan& the nature of the surgery and the extent of the involvement required, the procedure is scheduled The patient is admitted to the hospital on the afternoon before surgery. Routine laboratory work includes a complete blood cell count, blood biochemistry, and chest x-ray. X-rays of the knee include a “tunnel view,” which demonstrates the size of the intercondylar notch and any osteophytes that may have formed. A nursing history provides information on which nursing decisions will be based. This includes data related to the admitting diagnosis
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Nursing duties are divided so the needs of the patient, anesthetist, scrub nurse, and surgeon can be met simultaneously. as well as to other relevant health problems. Previous surgery, medication history, and a physical and emotional assessment are all documented. The nurse can determine if the patient’s knowledge of the surgery and postoperative routine is adequate, and he or she can answer any questions the patient may have. Additional preoperative teaching is done by the nurse at this time. It is basically the same as for any patient having limb surgery. The nurse informs the patient of the entire perioperative routine and explains that compliance with the routine immediately postoperatively is essential. The nurse teaches deep breathing and coughing exercises and their role in preventing pneumonia. He or she also demonstrates isometric pedal exercises to minimize venous stasis. The nurse explains that during surgery, a suction drain will be inserted in the knee to minimize the chance of hematoma. He or she also explains that after surgery the patient’s leg will be wrapped in a large bulky bandage and immobilized by a hinged brace. The nurse tells the patient to expect some pain postoperatively and assures him or her that analgesics will be administered as a routine part of the care plan. On the morning of surgery, an intravenous (IV) line is started, and 1 g cefazolin is added. The patient is transported to the operating room and admitted to the receiving area of the operating room suite.
Preoperative Care
F
or this procedure, operating rooms generally are staffed with three nurses. Duties are divided so that the needs of the patient, anesthetist, scrub nurse, and surgeon can be met simultaneously. One circulating nurse is responsible for direct patient care, and another circulating nurse and a scrub nurse attend to the setup and instrumentation. 242
The circulating nurse greets the patient in the receiving area of the operating room suite. This initial contact is valuable to both nurse and patient. It gives the nurse the opportunity to complete the preoperative checklist and establish a rapport with the patient. The patient is given further opportunity to ask questions and communicate any fears. The nurse identifies the patient, marks the correct leg, notes any allergies, and determines that the patient has been NPO for the prescribed length of time. The nurse reviews the chart and ensures that the operative consent is accurate and that routine preoperative laboratory work is within normal limits. Once the patient is positioned on the OR bed, a safety strap is placed across his or her thighs. Basic standards of nursing care that apply to all patients are practiced at all times. The circulating nurse introduces the patient to the staff and states what procedure is to be performed, notes the correct leg, and explains any other facts that may affect the patient’s care. This nurse then assists with the induction of anesthesia. The circulating nurse’s responsibilities then focus on patient positioning. The patient remains supine during the procedure with his or her knees flexed 90 degrees over the end of the OR bed. The thigh is supported on both medial and lateral sides with a padded leg-holding system. This gives the leg necessary stability as it is manipulated throughout the surgery. After making sure that good body alignment and patient safety are maintained, the nurse secures the patient’s arms and pads pressure points. He or she protects neurological structures, such as the ulnar nerve, with eggcrate foam. An electrosurgical dispersive pad is secured to an appropriate area. The nurse places a tourniquet cuff high on the thigh. Tourniquet use follows a strict protocol which states that: tourniquet cuffs must be placed on the
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vastus medialis muscle
femur patella semitendinosus
fibula tibia
I Fig 3. Anatomy of the knee, showing the components of the pes anserinus.
fleshiest part of the limb to prevent possible damage to neurovascular structures, the ends of the tourniquet cuff must overlap 3 inches, all tourniquet gauges are checked prior to each use, and maximum inflation time for all tourniquets is two hours. For surgery on the leg, the tourniquet is routinely inflated to 300 mmHg. During surgery, the circulating nurse informs the surgeon when the tourniquet has been in place for 1 hour and then at 15-minute intervals after the first hour. If surgery exceeds 2 hours, the tourniquet is deflated and the procedure is finished without it. The circulating nurse shaves a small area on the lateral side of the distal thigh and a small anteromedial area just below the knee. The nurse scrubs the foot and leg for 2 minutes with a 7.5% povidone-iodine solution and preps the area with 2.5% iodine. He or she then drapes the leg with
two large drape sheets under the leg, a 6-inch stockinette over the leg to the tourniquet cuff, and an extremity drape.
Instrumentation
I
n addition to a basic orthopedic setup, this procedure requires a tibia1 drill guide, a power driver, a ligament wire passer, 2-0 wire, and a staple set. The surgeon also will need an angled curette (size 3 with a narrow shaft), 4- and 6mm rasps, a tendon leader, an open-ended tendon stripper, a basic arthroscopy setup, and an arthroscopy shaver system, which includes a soft tissue resector and an arthroplasty burr.
Surgical Procedure
T
he operative technique produces an augmented autograft that will function as an ACL. This autograft, constructed from
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/
bulldog clamps
semitendinosus lead suture
/
the semitendinosustendon, is biologically attached to the tibia, and mechanically fixed to the femur with a noncrushing staple. The semitendinosus tendon is part of the pes anserinus,which inserts on the anteromedial aspect of the proximal tibia. The pes anserinus is the conjoined tendon of the semitendinosus, gracilis, and sartorius muscles (Fig 3). This muscle-tendon unit contributes to internal rotation of the tibia and flexion of the knee. The semitendinosustendon is used because its use has produced no ill effects on the knee and when augmented, its strength is comparable to that of the ACL. Augmentation for the tendon is provided by the LAD'". This device, which is available in various lengths and two widths, was researched and developed by the late J. C. Kennedy, MD, of London, Ontario.*oThe reconstructed ligament will pass through a tibial tunnel, across the knee joint, and over the top of the lateral femoral condyle, and it will attach to the distal femur. This path closely resembles the anatomical placement of the original ACL. There are some variations in the surgical procedure depending on whether the injury is acute or chronic. If the injury is acute and the patient has not had a diagnostic arthroscopy, one is performed at this time. Any meniscal pathology is managed with meniscal suturing or partial meniscectomy . 246
Fig 4. Bulldog clamps hold the LAD'" in place. If the patient has had a previous arthroscopy and an ACL lesion was confirmed, the semitendinosus tendon is harvested before the arthroscope is introduced. At University Hospital, the setups are organized so that variations in the procedure can be accommodated with minimum difficulty or confusion for the nurses. An objective measure of knee joint laxity is obtained using a knee arthrometer before anesthesia is induced and again after induction but prior to surgery. These results are compared with those obtained immediately after surgery. The surgeon makes a small antero-medial incision just below the knee. He or she identifies the semitendinosus tendon at its tibial insertion and isolates it with a blunt hook. An open-ended tendon stripper is used to free the tendon from the surrounding soft tissue and transect it from the muscle. The semitendinosus autograft is measured and the appropriate length LAD'" is selected according to the patient's height. The LAD'" is sutured to the autograft. Three small plastic bulldog clamps are placed along the length of the tendon to hold the LAD'" in place during suturing (Fig 4). Absorbable 2-0 sutures are used at the beginning with a small taper needle. Suturing is completed with a nonabsorbable suture of the same weight at the tibial end of the graft. A tendon leader is attached to the graft. This
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Fig 5. The tendon leader takes the reconstructed ligament across the joint.
\
Fig 6. An arthroplasty burr widens the lateral wall of the femoral intercondylar notch.
device is made of stiff plastic with mesh casing at one end. It protects the new ligament and assists in passing it through the joint. The new ligament is secured in the mesh end of the leader, and the plastic end leads the reconstructed ligament across the joint (Fig 5). These steps produce an augmented semitendinosus graft. The remainder of the surgery will bring this structure across the knee joint, over the top of the lateral femoral condyle, and to the lateral side of the distal femur in a path similar to the anatomical placement of the original ACL. The surgeon inserts the arthroscope. He or she 248
uses a large-diameter full-radius synovial resector to debride synovium and scar tissue from the knee joint. Next, he or she uses a 4.5-mm arthroplasty burr to widen the lateral wall of the femoral intercondylar notch. This step also clears the notch of any osteophytes that may have formed and reduces the likelihood of impingement of the graft. A 6-mm rasp and straight and curved #3 curettes with narrow shafts are used to complete this step (Fig 6). An arthroscopic drill guide is essential for the satisfactory placement of the drill hole. It should emerge on the tibia1 plateau just anterior and
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Fig 7. After a guide pin is positioned, a cannulated drill bit is used to create the tibial tunnel.
Fig 8. The tendon leader, with attached composite graft, is pulled through the tibial tunnel, across the joint, and over the top of the lateral femoral condyle.
tendon [QadQr
Fig 9. The reconstructed anterior cruciate ligament is stapled to the distal femur. 249
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medial to the anatomic insertion of the ACL. Using such a device, the surgeon drills a guide pin into the knee from a point just medial to the tibial tubercle. Once the position of the guide pin is satisfactory, the surgeon creates the tibial tunnel with a 6-mm cannulated drill bit (Fig 7). The edges of the tunnel are smoothed with a 4-mm rasp to protect the composite graft from abrasion. The surgeon makes a short incision distally on the lateral thigh. A large round hook with an eye on the end is brought around the lateral femoral condyle anteriorly to posteriorly. This hook emerges from the incision on the distal thigh and is used to bring a folded 2-0 wire into the joint. A hemostat is placed on the oper, end of the wire, and the surgeon must take care to ensure that this end remains outside the incision. The surgeon uses an arthroscopy grasper through the tibial tunnel to grasp the looped end of the wire and pull it to the front of the knee. He or she then attaches the leader to the wire, which is then used to pull the composite graft through the tibial tunnel, across the joint, and over the top of the lateral femoral condyle (Fig 8). The nurse flexes the knee 30 degrees and the surgeon fixes the composite graft to the lateral femur with a small noncrushing staple (Fig 9). The knee is put through a full range of motion and pivot-shift and Lachman's tests. At the end of the surgical procedure, the wounds are copiously irrigated with a 0.5% solution of Tisusol'" and 10% povidone-iodine and a %-inch suction drain is put in place. The surgeon places the leg in a bulky dressing and a hinged splint brace set at 30 degrees of flexion (Fig lo).
Postoperative Routine
T
he patient is transferred to the postanesthesia care unit (PACU) where his or her leg remains elevated on pillows. The nurse checks vital signs every 15 minutes and monitors the neurovascular status of the limb. He or she also notes and assesses pedal pulses, skin color, motor power, and temperature of the toes and provides analgesics as required. He or she also checks the drain, which is attached to a selfregulating suction device, to ensure that it remains
patent. The patient usually returns to his or her room after approximately 1 to 1% hours in the PACU. In the room, the nurse observes the neurovascular condition of the leg once an hour for six hours and then every four hours for 24 hours. The nurse will assess this condition more frequently if he or she believes the patient's condition warrants it. As instructed preoperatively, the patient is encouraged to deep breathe, cough, and perform foot and calf exercises hourly. Postoperative care generally includes the administration of 10 mg morphine every four hours for up to two doses. Thereafter, oral analgesics such as acetaminophen with codeine are prescribed and given as required. The IV is discontinued when the patient is taking adequate amounts of fluid by mouth and has voided. Keeping the leg elevated on several pillows reduces swelling. The suction drain is removed when there are less than 50 mL of discharge in a 12-hour period. The physiotherapist sees the patient on the first postoperative day, fits him or her with crutches, and gives instructions on their use. The patient may begin to walk without bearing weight with crutches and standby assistance. The patient also begins to stretch the Achilles tendon and strengthen the quadriceps muscles and hamstrings. Discharge is planned for the third postoperative day. A nurse removes the bulky dressing, covers the incisions with dressing strips, and covers the leg with an elastic stockinette. The range of motion on the brace is increased to 90 degrees. Arrangements are made for the patient to begin the physiotherapy program during the first week postoperatively. He or she is given specific and detailed instructions so that stretching and strengthening exercises can be performed on a routine basis at home.
Physiotherapy
T
he physiotherapy routine is divided into 10 stages that last a total of approximately nine months. The goals of the initial stages are to minimize swelling and regain range of motion. This is accomplished by packing the knee 25 1
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Fig 10. The leg is placed in a bulky dressing and a hinged brace. with ice and stretching and gently cycling on a stationary bicycle. As swelling decreases and range of motion improves, the patient begins a gentle strengthening routine. The main muscle groups involved are the quadriceps and hamstrings. At approximately six to nine weeks postoperatively, a cane is used for support instead of crutches. At 12 to 16 weeks, full range of motion and full weight bearing should be achieved. The physiotherapist monitors the patient throughout the program to ensure that the expected progress is being made. At approximately 16 weeks postoperatively, a computerized strength test is performed on the knee. Depending on the results of this test, the patient is set up on an individualized strengthening routine. The patient is retested every four weeks, and his or her program is upgraded according to progress. Reevaluation and upgrading continue until discharge from the physiotherapist’s care approximately 10 months after surgery. These patients are systematically evaluated after surgery at three-, six-, nine-, and 12-month intervals so that their knee function can be assessed
and documented. Three parameters are used to determine the effectiveness of the surgical technique. These are categorized according to subjective and objective purposes, and all aspects of knee function are appraised. The first parameter is subjective-subjective. The patient describes his or her knee to the examiner and comments on his or her confidence in its stability and function. The second is a subjectiveobjective analysis in which established diagnostic tests such as Lachman’s and the pivot-shift are used to rate the stability of the knee. The third is an objective-objective exam in which an arthrometer is used to measure the anterior displacement of the tibia on the femur. To date, these evaluations have indicated that this procedure has met with good results.
Advantages of Arthroscopic Techniques
T
he great majority of patients with tom ACLs are healthy, active people who are anxious to return to their activities. Although the ACL can be reconstructed without 253
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A benefit of this arthroscopically assisted procedure is that the extensor mechanism of the knee is left intact. the use of the arthroscope, traditional approaches involve larger incisions and arthrotomies. Significant advantages of using the arthroscope include less pain, earlier rehabilitation, earlier active muscle control, and shorter hospitalization. As experience with these techniques increases, operative time will further decrease and patients will be suitable candidates for same-day surgery. A further benefit is that the extensor mechanism of the knee is left intact. In addition, the arthroscope makes it easier for the surgeon to see the intraarticular anatomy of the knee. This increases the surgeon’s accuracy in placing the reconstructed ligament into the joint. Arthroscopically assisted anterior cruciate ligament surgery is the method of the future, and allografts to replace the ACL will become increasingly popular. As methods for preserving and sterilizing allograftsare perfected and concerns about immunogenicity are resolved, using tissues from the knee will become unnecessary and arthroscopic techniques will become even less invasive.
Nursing Implications
A
rthroscopically assisted ACL reconstruction provided nurses at University Hospital with a challenge. At the beginning of our experience, we understood the goals of the surgery and its advantages and had a basic knowledge of the procedure, but our level of frustration was considerable. We were concerned about the sterility of the surgical field. With large quantities of imgant flowing through the knee, possible contamination seemed a serious problem even with impermeabledrapes. Doubling the layers of draping and changing gowns as soon as they became wet remedied this problem. In addition, arthroscopic instruments such as the camera, telescope, and shaver must be gas sterilized or soaked. Gassing between cases is not 254
possible, and although gluteraldehyde immersion
is not a problem with instruments in arthroscopic procedures, we believed that with this more extensive surgery we would be happier with instruments that had been terminally sterilized. Increasing our inventory of these has kept soaking at an absolute minimum. The many cables and tubings which connect to machinery off the field, including the camera, inflow and outflow tubing, light cord, shaver cable, electrosurgid cable, and operative suction, are potential sources of breaks in sterile technique. Securing all lines with self-adhesive fabric tape ensures that they will not be dragged back and forth off and on the sterile field. Adding extra length to tubings where possible keeps this equipment a good distance from the operative site. Another problem that required much thought was the placement of the video cart, arthroscopy pump, suction units, drainage bottles, and electrosurgical unit. It took a number of cases to sort out the details and come up with a plan that would make the progression of these cases efficient and reasonably uncomplicated for all operating room personnel. Through trial and error, we learned that the video equipment was best placed on the nonoperative side, all other machinery on the operative side, and that the scrub nurse was best on the operative side working off a draped Mayo stand placed over the patient’s chest. One other issue to deal with was instrumentation. Our basic orthopedic trays were not appropriate for this type of surgery. For example, curettes must have narrow shafts so that they can fit through arthroscopy punctures. Putting together ACL trays that contain only the specific required equipment has simplified the cases and has also made the upkeep of instruments easier. At the present time we have a systematic protocol that handles straightforward cases well. It is flexible enough to manage any additional procedures that may be necessary in whatever
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sequence they need to be performed. These may include meniscal suturing, repair or reconstruction of the posterior cruciate ligament, or repair of the lateral collateral or medial collateral ligaments. Our responsibility as OR nurses lies in adherence to established routine and in paying close attention to the details of each step. Effective communication with the surgeon is essential so that the operative plan may be related to all members of the team. In this way, patients will 0 consistently receive optimum care. Notes 1. G A Snook, “A short history of the anterior cruciate ligament and the treatment of tears,” Clinical Orthopedics and Related Research 172 (JanuaryFebruary 1983) 11-13. 2. Ibli?! 3. Ibli?! 4. Q M Burnett 11, P J Fowler, “Reconstruction of the anterior cruciate ligament: Historical overview,” Orthopedic Clinics ofNorth America 16 (January 1985) 147. 5. Snook, “A short history of the anterior cruciate ligament and the treatment of tears,” 11. 6. Ibli?! 7. R J Johnson, “The anterior cruciate ligament problem,” Clinical Orthopaedics and Related Research 172 (January-February 1983) 14. 8. J H Roth et al, “Polypropylene braid augmented and nonaugmented intraarticular anterior cruciate ligament reconstruction,” The American Journal of Sports Medicine 13 (September-October 1985) 321. 9. P J Fowler, “The classification and early diagnosis of knee joint instability,” Clinical Orthopaedics 147 (March-April 1980) 14. 10. Roth, “Polypropylene braid augmented and nonaugmented intraarticular anterior cruciate ligament reconstruction,” 336.
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