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University of Baguio

School of Nursing

General Luna Road

Baguio City

SY 2011-2012

Operating Room Write-up

TOTAL KNEE REPLACEMENT

A Clinical Report Presented to the Faculty of the School of Nursing

University of Baguio

In Partial Fulfillment of the Requirements of

NCENL07-RLE

Submitted by:

Group NPF-1

Concepcion, Patrick Jason S.


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I. Patients Profile

Patients name: Mr. X

Address: Bontoc, Mt. Province

Date of Birth: September 4, 1955

Age: 55 y/o

Sex: Male

Religion: Assembly of God

Nationality: Filipino

Date Admitted: June 14, 2011

Chief complaint: Pain localized on right knee

Admitting Diagnosis: Osteoarthritis

Final Diagnosis: Osteoarthritis


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II. Anatomy, Physiology, and PathophysiologyANATOMY and PHYSIOLOGY

The knee is the largest joint in the body. Normal knee function is required to perform most

everyday activities. The knee is made up of the lower end of the thighbone (femur), whichrotates on the upper end of the shin bone (tibia), and the kneecap (patella), which slides in

a groove on the end of the femur. Large ligaments attach to the femur and tibia to provide

stability. The long thigh muscles give the knee strength.

The joint surfaces where these three bones touch are covered with articular cartilage, a

smooth substance that cushions the bones and enables them to move easily.

All remaining surfaces of the knee are covered by a thin, smooth tissue liner called the

synovial membrane. This membrane releases a special fluid that lubricates the knee,

reducing friction to nearly zero in a healthy knee.

Normally, all of these components work in harmony. But disease or injury can disruptthis harmony, resulting in pain, muscle weakness, and reduced function.


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Figure 1: Right Knee

Although the knee joint may look like a simple joint, it is one of the most complex.

Moreover, the knee is more likely to be injured than is any other joint in the body. We

tend to ignore our knees until something happens to them that causes pain. As the

saying goes, however, "an ounce of prevention is worth a pound of cure."

If we take good care of our knees now, before there is a problem, we can really help

ourselves. In addition, if some problems with the knees develop, an exercise program

can be extremely beneficial.


The knee is essentially made up of four bones. The femur, which is the large bone in

your thigh, attaches by ligaments and a capsule to your tibia. Just below and next to thetibia is the fibula, which runs parallel to the tibia. The patella, or what we call the knee

cap, rides on the knee joint as the knee bends.

When the knee moves, it does not just bend and straighten, or, as it is medically termed,

flex and extend. There is also a slight rotational component in this motion. This

component was recognized only within the last 50 years, which may be part of the

reason people have so many unknown injuries. The knee muscles which go across the

knee joint are the quadriceps and the hamstrings. The quadriceps muscles are on the

front of the knee, and the hamstrings are on the back of the knee. The ligaments are

equally important in the knee joint because they hold the joint together. You may have

heard of people who have had ligament tears. Problems with ligaments are common. In

review, the bones support the knee and provide the rigid structure of the joint, the

muscles move the joint, and the ligaments stabilize the joint.


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Figure 3: Cross Sectional View of Right Knee

The knee joint also has a structure made of cartilage, which is called the meniscus or

meniscal cartilage. The meniscus is a C-shaped piece of tissue which fits into the joint

between the tibia and the femur. It helps to protect the joint and allows the bones to

slide freely on each other. There is also a bursa around the knee joint. A bursa is a little

fluid sac that helps the muscles and tendons slide freely as the knee moves.

To function well, a person needs to have strong and flexible muscles. In addition, the

meniscal cartilage, articular cartilage and ligaments must be smooth and strong.

Problems occur when any of these parts of the knee joint are damaged or irritated.

CRUCIATE LIGAMENTS



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There are two cruciate ligaments located in the center of the knee joint. The anterior

ruciate ligament (ACL) and the posterior cruciate ligament (PCL) are the major stabilizing

ligaments of the knee. In figure 4, on the lateral view, the posterior cruciate ligament

prevents the femur from sliding forward on the tibia (or the tibia from sliding backwards

on the femur). In the medial view, the anterior cruciate liagement prevents the femurfrom sliding backwards on the tibia (or the tibia sliding forwards on the femur). Most

importantly, both of these ligaments stabilize the knee in a rotational fashion. Thus, if

one of these ligaments is significantly damaged, the knee will be unstable when planting

the foot of the injured extremity and pivoting, causing the knee to buckle and give way.

The abnormal motion causes damage to the surface on the underside of the patella.


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PATHOPHYSIOLOGY

Common Causes of Knee Pain and Loss of Knee Function

Knee with Arthritis.

The most common cause of chronic knee pain and disability is arthritis. Osteoarthritis,

rheumatoid arthritis, and traumatic arthritis are the most common forms.

y Osteoarthritis usually occurs in people 50 years of age and older and often in individualswith a family history of arthritis. The cartilage that cushions the bones of the knee

softens and wears away. The bones then rub against one another, causing knee pain and

stiffness.

y Rheumatoid arthritis is a disease in which the synovial membrane becomes thickenedand inflamed, producing too much synovial fluid that overfills the joint space. This

chronic inflammation can damage the cartilage and eventually cause cartilage loss, pain,

and stiffness.

y Traumatic arthritis can follow a serious knee injury. A knee fracture or severe tears ofthe knee ligaments may damage the articular cartilage over time, causing knee pain and

limiting knee function.

O steoarthritis is primarily a disease of cartilage

y Cartilage is a unique tissue with viscoelastic and compressive properties which areimparted by its extracellular matrix, composed predominantly of type II collagen and

proteoglycans. Under normal conditions, this matrix is subjected to a dynamicremodeling process in which low levels of degradative and synthetic enzyme activities

are balanced, such that the volume of cartilage is maintained. In OA cartilage, however,

matrix degrading enzymes are overexpressed, shifting this balance in favor of net

degradation, with resultant loss of collagen and proteoglycans from the matrix.

Presumably in response to this loss, chondrocytes initially proliferate and synthesize

enhanced amounts of proteoglycan and collagen molecules. As the disease progresses,

however, reparative attempts are outmatched by progressive cartilage degradation.

Fibrillation, erosion and cracking initially appear in the superficial layer of cartilage and

progress over time to deeper layers, resulting eventually in large clinically observable

erosions. OA, in simplistic terms, therefore, can be thought of as a process ofprogressive cartilage matrix degradation to which an ineffectual attempt at repair is

made.


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III. PREPARATION OF THE PATIENTINFORMED CONSENT:I explained to the patient that he has a very serious injury of thecartilage of his knee because of his osteoarthritis. The bones then rub against one another,

causing knee pain and stiffness. I explained to him that these have a high incidence of

problems and complications including :

y Severe knee pain that limits his everyday activities, including walking, climbing stairs,and getting in and out of chairs.

y Moderate or severe knee pain while resting, either day or nighty Chronic knee inflammation and swelling that does not improve with rest or medicationsy Knee deformity: a bowing in or out of his kneey Knee stiffness: inability to bend and straighten his kneey Failure to obtain pain relief from nonsteroidal anti-inflammatory drugs. These

medications, including aspirin and ibuprofen, often are most effective in the early stages

of arthritis. Their effectiveness in controlling knee pain varies greatly from person toperson. These drugs may become less effective for patients with severe arthritis.

y Inability to tolerate or complications from pain medicationsy Failure to substantially improve with other treatments such as cortisone injections,

physical therapy, or other surgeries

He understands fully and wishes to proceed knowing that there are no guarantees as to

the result of the surgery.

POSITION: The patient was in supine position with his knees over the lower break in thetable; his arms were extended on arm-boards. Mr. X was secured with safety strap over the

thigh of his unaffected extremity. Sheet wadding and a tourniquet were applied to the top

of his thigh of the operative extremity.

SKIN PREPARATION: Foot holder was used. We began at the knee extending from

immediately below the tourniquet, on the thigh to the toes.

DRAPING: The leg of the Mr. X was held up, abducted; his foot was grasped in a tube

stockinette. A large sheet was draped over the end of the table. A drape sheet was draped

under the thigh. A folded towel was wrapped around the top of the thigh and clipped; the

tube stockinette was brought up over the towel. A drape sheet was draped over the top of

the thigh and clipped underneath. An individual drape sheet completed the draping.

ANESTHESIA: General anesthesia was administered by the anesthesiologist through

intravenous injection.


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IV. DISCUSSIONTOTAL KNEE REPLACEMENT

Knee replacement, or knee arthroplasty, is a surgical procedure to replace the weight-

bearing surfaces of the knee joint to relieve the pain and disability of osteoarthritis. It may

be performed for other knee diseases such as rheumatoid arthritis and psoriatic arthritis. In

patients with severe deformity from advanced rheumatoid arthritis, trauma, or long

standing osteoarthritis, the surgery may be more complicated and carry higher risk.

Replacement of the articular surfaces of the knee joint by prostheses. The procedure is

performed for pain, deformity, and instability secondary to rheumatoid arthritis,

osteoarthritis, and posttraumatic conditions. The articular surfaces of the femoral condyles,

tibial plateau, anterior trochlear surface of the femur, and articular surface of the patella

are trimmed to accept the prostheses. The prostheses are bonded to the bone with

methylmethacrylate.

On occasion a single component of the knees articular surface (e.g., medial femoral and

tibial condyles) needs to be replaced (unicompartmental). More commonly the entire or

total surface requires replacement (tricompartmental).

There are four categories of total knee systems:

1. Constrained (hinged): A hinge joint; infrequently used. Examples are Walldius, Guepar,Shiers, and St. George prostheses.

2. Nonhinged constrained: Spherocentric; allows motion that nearly duplicates that of thenormal knee. Examples are Attenborough and Sheehan prostheses.

3. Non-onstrained: Provides full coverage of the articular surfaces but adds little stability.Examples are Marmor, Savastano, Oxford, Porous Coated Anatomic (PCA), Bias, Mod II

Unicompartmental, TRICON-M, and TRICON-C prostheses.

4. Partially constrained: Provides stability as well as full coverage of the articular surface.Examples include Richards Maximum Contact (RMC), Insall-Buurstein, Kinematic II, and

Freeman-Swanson prostheses.

In general, the surgery consists of replacing the diseased or damaged joint surfaces of theknee with metal and plastic components shaped to allow continued motion of the knee.

The operation involves substantial postoperative pain, and includes vigorous physical

rehabilitation. The recovery period may be 6 weeks or longer and may involve the use of

mobility aids (e.g. walking frames, canes, crutches) to enable the patient's return to

preoperative mobility.

Knee replacement surgery is most commonly performed in people with

advanced osteoarthritis. It should be considered when conservative treatments have been

exhausted. Total knee replacement is also an option to correct significant knee joint or bone

trauma in young patients. Similarly, total knee replacement can be performed to correct

serious valgus or varus deformity. Physical therapy has been shown to improve function and

may delay or prevent the need for knee replacement. You will notice extreme pain.


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V. Instrumentation

Osteotomes Trial prosthesis

Total knee prosthesis Power drill

Power oscillating saw with jigs Electro surgical pencil


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Suction tubing Stockinette

Esmarch bandage Needle magnet

methylmethacrylate kit Bulb syringes


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Hemovac

Methylene blue dye Insufflator

Equiptment: Instrumentation:

Laminar airflow (if available) Basic orthopedic procedure trays

Foot holder Knee arthromy tray

Suction Osteotomes, gouges

Electrosurgical unit Trial prosthesis, Total knee

Tourniquet and insufflators prosthesis

Power sources for drill and saw Power drill and cord

Power oscillating saw with jigs

Supplies:Basin set, Electrosurgical pencil, Suction tubing

Blades (3) #10, (1) #15

Graduate, Bulb syringes (2), Tube (or impervious) stockinette, 6

Esmarch bandage, Needle magnet, Methylmethacrylate kit

Antibiotic irrigation, Closed drainage system (e.g., Hemovac)

Methylene blue dye (optional)

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