Orthopedic Surgery: Fracture Fixation, Joint Replacement, and Arthroscopy

Orthopedic Surgery: Fracture Fixation, Joint Replacement, and Arthroscopy

Orthopedic surgery addresses the bones, joints, muscles, tendons, and ligaments of the musculoskeletal system. As a surgical technologist in the scrub role, you are responsible for maintaining a sterile field, anticipating the surgeon's needs, and handling specialized implants and power equipment correctly. This lesson focuses on three major orthopedic categories: fracture fixation, joint replacement (arthroplasty), and arthroscopy.

Fracture Fixation

Fracture fixation stabilizes broken bone to allow healing and restore function. Internal fixation uses hardware placed inside the body, such as intramedullary nails, plates, and screws. External fixation uses a frame outside the body attached to pins that pass through the skin into bone. The scrub must understand the fixation system being used and have the correct implants organized and ready before the procedure begins. Always follow the manufacturer's surgical technique guide — this document specifies implant sequencing, instrument pairing, and the order of steps. No two systems are identical, and using the wrong guide can cause a patient safety error.

Total Knee Arthroplasty (TKA)

Total knee arthroplasty replaces the damaged surfaces of the femur, tibia, and often the patella with prosthetic components. The procedure follows a consistent sequence:

1. Exposure — The surgeon opens the joint, typically through a medial parapatellar approach, and displaces the patella to expose the distal femur and proximal tibia.

2. Bone cuts — Cutting guides are pinned to the bone. The sagittal saw and oscillating saw are used to resect bone surfaces precisely so the prosthetic components will seat correctly.

3. Trialing — Trial (temporary) components are placed to verify fit, alignment, and range of motion before the permanent implants are committed.

4. Cementing and final implant placement — Bone cement (polymethylmethacrylate, PMMA) is mixed and applied; permanent components are seated and held until the cement cures.

5. Closure — The joint capsule and soft tissues are closed in layers.

As the scrub, you must keep the back table and mayo stand organized throughout each phase, anticipate the next instrument needed, and communicate clearly. Cement mixing is time-sensitive — once mixed, you and the circulator must work efficiently.

Back-Table and Mayo Stand Setup

Begin setup by inventorying the instrument tray against the count sheet and the manufacturer's technique guide. Organize instruments in the order they will be used: exposure instruments first (retractors, electrosurgical pencil, knife handles), then cutting guides and alignment rods, then power tools and implant instruments, then closure instruments. The mayo stand holds only what is immediately needed for the current phase. Never place sharps randomly — designate a neutral zone (a basin or pad) for passing sharps between scrub and surgeon.

Power Equipment: Sagittal Saw and Drill

Power tools in orthopedics include the sagittal saw (blade moves side-to-side), the reciprocating saw (blade moves back-and-forth), and the drill/reamer. All are driven by battery, electric, or pneumatic (nitrogen) power.

Safe handling rules:

• Inspect power tools and cords or hoses before use; report defects to the circulator.
• Keep the safety engaged until the surgeon is ready to use the tool.
• Announce "power on" when handing a tool to the surgeon and "power off" when receiving it back. This verbal confirmation prevents accidental activation.
• When passing, grip the body of the tool — never the trigger — and present the handle toward the surgeon's palm.
• Always point the blade or bit away from personnel during transfer.
• Blades and bits are sharps; handle with instruments, not bare hands when possible.
• After use, confirm the safety is re-engaged before setting the tool down.

Arthroscopic Knee Procedures

Arthroscopy uses a small camera (arthroscope) and instruments inserted through small portals rather than a large incision. Common knee arthroscopy procedures include meniscectomy (removal of torn meniscus tissue), meniscus repair, anterior cruciate ligament (ACL) reconstruction, and chondroplasty. The scrub must set up the arthroscopic tower (camera, light source, fluid pump), the arthroscope, cannulas (sheaths that maintain the portals), and the hand instruments (probes, biters, shavers). The joint is distended with irrigation fluid — typically normal saline — to improve visualization.

Key scrub tasks in arthroscopy include connecting and white-balancing the camera, ensuring the light cable is secure, and managing fluid tubing so it does not contaminate the field. Keep shaver blades and biter instruments organized by size and type.

Surgical Counts in Orthopedics

Orthopedic procedures involve numerous small items — screws, drill bits, trial components, sponges, and instruments — making accurate counts critical. Counts are performed at the beginning of the case, before closure of a body cavity, and at wound closure. The scrub and circulator count together aloud. Any discrepancy must be reported to the surgeon immediately and resolved before the wound is closed. Document each count on the count sheet with the time and your initials.

Patient Safety Reminders

• Confirm implant size and lot number with the surgeon and circulator before opening.
• Never use an implant from a damaged or compromised package.
• Maintain strict sterile technique; orthopedic implants carry a high infection risk.
• Bone cement vapors are irritating; ensure adequate ventilation per facility policy.
• Tourniquet time is tracked by the circulator; be aware of elapsed time as it affects tissue viability.