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[The following produced for...]
[Professional Medical Audiences]
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[Music]
[AHS TV, Academy of Health Sciences]
[Music fades out]
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[A United States Army Medical Department Continuing Education Program]
[Music]
[Music]
[Quality Of Life]
[Music]
[Narrator:] Reconstructive surgery as manifest by joint replacement.
has dramatically extended the capability of the orthopedic surgeon
to help those crippled by arthritis and the effects of trauma.
It is the absolute nature of the success or failure of joint replacement surgery
that has brought a new and unique dimension to orthopedics.
Quality of life is the essence of joint replacement surgery.
It is our hope that we can share with you
some of the surgical and nursing techniques essential
to success in this type of surgery.
These are: Select and prepare the patient.
Clean air surgery.
Biomechanical principles.
Post operative care.
[Select and prepare patient]
[Doctor:] If you awoke tomorrow morning
with signs and symptoms of acute appendicitis,
the treatment would be rather obvious: appendectomy.
But the selection of a patient for total joint replacement is not always as clear-cut.
A series of clinic visits is usually necessary
to establish an ever-growing rapport between surgeon and patient.
It is necessary to understand
the patient in terms of three main factors:
the amount of pain he is experiencing,
his functional level of activity,
and his personality.
It is extremely important to fully appreciate
that each of these factors is interdependent on the others.
Pain limits activity. Activities cause pain,
and the type of personality in large part determines the patient's response to pain.
There is a rather consistent pattern of progression of pain
and decrease in activity.
The symptoms slowly increase in severity over a number of months or years,
a definite rate of progression.
Then, with an ever-increasing rate of acceleration,
measured in terms of months or weeks,
the symptoms rapidly become intolerable to the patient.
Prior to this time,
the symptoms were at best an annoyance, at worst a minor disability.
Now they become disabling,
and the patient's quality of life deteriorates.
[...]
We use an evaluation form developed by Professor John Charnley.
Basically, it assigns separate numerical values for pain,
activity, and range of motion.
We term this the par number.
[...]
The pain and activity data provides us with the information needed
to select patients suitable for total joint replacement.
The range of motion data, together with appropriate X-rays,
provides us with the data needed to plan the technical aspects of the surgery.
In summary,
the functional level of the patient,
and the amount of pain, and what kind of patient
are the basic questions to be answered
in order to properly select patients for total joint replacement.
The decision for surgical intervention is based on what is happening
to the quality of the patient's life.
[Nurse 1:] [?] I thought...
[Narrator:] Patients are counseled
by the nursing and physical therapy staff
concerning the details of the total joint,
the operation, and the postoperative course. [Nurse continues counseling]
Great emphasis is placed on ensuring that the patient is fully informed
about the entire course of his hospitalization. [Nurse continues]
The patient knows not only what to expect
but what is expected of him, especially in the postoperative period.
[Nurse 1:] …before surgery.
[Book opens]
In this book here as you can see,
this is an example of what the total hip looks like.
And, as you can see also by our model here, this is also a good example.
Here's your cup, and it is cemented in there with cement.
Then you can also see this part.
This is…
this is this is your leg here,
and they take this metal,
and they put it down into the shaft and also use the same cement in here
to maintain a good hold on this part.
So that after surgery,
your hip socket will be like this with your femur going in.
So that you have good range of motion with it.
Now, as you can see from the book here,
ehave some pictures of what you can expect.
[Book pages flipping]
This is the type of bed that you will be in immediately after surgery.
And we will show you how to use that,
after we get done with the demonstration here of the X-rays in our book and all.
Uh, immediately after surgery,
you'll be kept in recovery room for 24 hours.
And you will be brought back up to the floor.
On the floor, you'll come back with intravenous feedings in your arm,
and that's until you can take liquids by mouth.
Which will probably be the next day.
Also, you’ll come back with
some drains in your leg that will be hooked up to a suction machine.
And this is to make sure that you don't have an accumulation
of blood into your hip.
[Narrator:] Professor John Charnley of England
made joint replacement a reality.
He introduced high-density polyethylene for the socket.
A clean air system which has dramatically decreased the infection rate.
And methyl methacrylate,
the cement used to secure the replacement parts to the bone.
Implant surgery has become
an accepted tool of modern orthopedics.
It has provided pain relief and
return of function to thousands of patients who otherwise
would have been severely disabled because of their arthritis.
Though implant surgery offers a dramatic solution to these problems,
there are attendant risks.
The most devastating of these is infection.
In view of the absolute failure
following a major surgical infection in an implant procedure,
no rate of infection can ever become acceptable.
[Clean Air Surgery]
The operating room environment
has long been suspect as the major cause of surgical infection.
We intend to present certain principles
and techniques which have resulted in a marked decrease in airborne
and contact contamination.
The predominant source of contamination of the operating room is the surgical team.
Team discipline becomes paramount.
The number of personnel involved in the surgical procedure should be limited.
The number of times personnel enter and leave the room
should be strictly controlled.
The immediate members of the surgical team
should themselves be draped to exclude body shed.
The prepping and draping of the surgical patient,
which has been performed in a stylized fashion
in accordance with instructions passed down through the years,
reminds one of an ancient rite
rich in symbolism but lacking any significant rationale
in terms of our present knowledge.
Our associates in dermatology tell us
scrubbing encourages the migration of bacteria from the deeper pores.
Rather, they suggest an application technique of an antiseptic solution,
followed by a skin sealer.
Regretfully, some still use surgical drapes, which are porous,
permeable, and wettable.
These are totally ineffective as barriers against contamination.
In addition, they shed minute particles of lint.
Monitoring of the operating room
shows a marked increase in airborne contamination
during the time the patient is prepped and draped.
Teamwork is essential to decrease surgical time
and to decrease body movements.
The result is less airborne contamination.
We prefer to group surgical instruments in small trays
and expose only when needed,
therefore decreasing the time each instrument
is exposed to airborne contamination.
It is estimated that each member of the surgical team
may shed 10,000 particles per minute.
And these particles are carriers of viable bacteria.
In addition, each member expends approximately
500 BTUs of heat energy per hour,
further contributing to convection currents
which impel the airborne particles into the wound.
The body exhaust system for the surgical team
effectively separates the team from the operating room environment
and therefore from the surgical wound.
We have found the jet lavage irrigation system
particularly helpful,
and systematically irrigate the wound with an antibiotic solution
to remove tissue debris and implanted airborne particles.
In addition, we use suction drains
to the depth of the wound,
metallic skin clips,
then pressure retention sutures
for the closure of subcutaneous tissues.
All have contributed to a dramatic improvement
in the healing of the postoperative wound.
It is not wise to disregard the work of Lister and Charnley,
particularly when sepsis is concerned.
The principles of clean air surgery are here to stay.
[...]
[Doctor:] Biomechanical Principles of total hip reconstruction
require that Shenton’s line be restored,
equality of leg lengths be attained,
and that a one-to-one ratio be re-established
between the center of gravity of the body,
the center rotation of the femoral head,
and the abductor lever arm.
There should also be adequate separation of the femur
from the side wall of the pelvis in the neutral position.
One may then analyze the position of the components in more detail.
This may be analyzed in an orderly fashion
starting from the socket and proceeding distally.
A low AP pelvis X-ray is used
with the beam centered at the symphysis pubis.
First, the socket should be well-contained within bone
so that the cement is not subject to tensile stresses.
There should be a wedge of cement above the cup,
and cement should extrude into prepared cement holes
but not into the pelvis.
Version of the cup may be determined
by evaluating the distance
from the prosthesis to the outer ring.
This distance should be equal all the way around.
Inequality is evidence of version of 20 degrees or greater.
The socket should be at 45 degrees to the level.
The horizontal access line is measured through the bottom
of the obturator foramina.
The osteophytes should have been cleared so they do not abut the ephemeral neck.
Promoting subluxation.
Attention is then directed to the abductor mechanism
and the separation of the femur
from the side wall of the pelvis.
The abductor lever arm should be restored.
The greater trochantor, when removed,
should be replaced or transplanted, whichever is appropriate.
The top of the greater trochantor should not be above
the center of rotation of the femoral head.
On the femoral side,
the ball should be enclosed within the wire defining the cup.
to ensure that the prosthesis is seated
and that there is no intervening soft tissue or cement.
Ephemeral neck should be seen in full profile,
and the prosthesis should be in relative valgus with respect to the femoral shaft.
There should be a cement buttress immediately at the calcar
and laterally at the tip
to provide the required support when weight-bearing.
There should be cement throughout the femoral shaft
down to or extending slightly past
the tip of the femoral prosthesis.
If the above criteria have been met,
a technically successful Charnley total hip replacement
has been accomplished.
[Narrator:] Meticulous attention to detail,
as exemplified in the surgical procedure, [Post Operative Care]
is the key to success during the postoperative course.
The patient is kept in the recovery room overnight,
where close watch is maintained of all the biological systems.
Vital signs, urinary output,
and the electrocardiogram are closely monitored.
A high fluid intake is maintained,
and whole blood or pack cells administered as indicated.
Intermittent positive-pressure breathing treatments
are administered using the respirator as well as blow bottles.
The Hemovac is connected to constant suction.
Hematocrits are obtained the evening of surgery
and the first three postoperative mornings.
The head and neck should be elevated
to adjust for the preoperative [?].
A pillow is used to maintain the hips and abduction
and pillows are placed beneath each leg
to allow some flexation at the knees and hips.
Elastic stockings, Trendelenburg tilting each hour
and ankle, calf, and thigh exercises are used
to decrease the risk of thromboembolic disease.
Ice bags are used on the anterior thigh for 72 hours
to decrease blood loss and minimize postoperative discomfort.
The CircOlectric bed is tilted into a prone position every four hours...
for half-hours or as tolerated.
[Surgeon speaks to nurse in hospital]
[Narrator:] Dextran and pre-operative antibiotics
are continued for three days.
[Surgeon:] Does that include the antibiotics and the Dextran?
[Nurse 2:] Right.
Right here is the Dextran and the Keflin.
[Surgeon:] Thank you.
[Loud bed motor]
[Narrator:] The patient has walked on the first postoperative day.
[Physical therapist making adjustments]
It requires teamwork and expertise to assist the patient to ambulate.
[Physical therapist:] Okay, we’ll keep using a belt until you get a good stable gait.
[Physical therapist making adjustments to the belt]
Okay, just put your hands on the walker.
[Narrator:] A rolling walker is helpful.
[...]
The first step is the longest.
[Footsteps and walker clanking]
[Physical therapist:] Okay, you have your balance?
[Narrator:] The physical therapist’s role is to teach the patient
efficient and safe patterns
of activities of daily living.
[Physical therapist:] Let’s walk off this way.
[Narrator:] Although, the Circolectric bed is used the first three days,
the patient may soon be transferred to a Nelson bed
which allows greater independent control by the patient.
[Nurse 1:] [?] just at nighttime.
[Patient:] Yeah, yeah.
[Narrator:] By the time of discharge, about the third week following surgery,
the patient is able to independently perform
the routine activities of daily living.
[Nurse 1:] [Unintelligible conversation]
[Narrator:] The preparation for discharge is accomplished
with the same attention to detail,
as are all previous phases of the patient's hospital course.
[Patient:] [?] [Nurse 1:] Well, you’ll probably get some pain pills now
and your doctor will prescribe them.
You’ll have them just in case you need them.
[Nurse 3:] And you won't be taking home all the vitamins
and things that you've been on.
But you will have something for the pain.
[Patient:] You'll have these medications up there at the desk when I check out?
[Nurse 3:] Mm-hm. [Nurse 1:] Right.
[Administrator:] In the foregoing, we have covered the selection and preparation
of a patient for surgery,
the surgical procedure,
and the details of postoperative care,
which we feel have been important in well over 100 cases
of joint replacement at Letterman Army Medical Center.
It is our hope that you will consider the importance
of these details as you undertake
the responsibility for joint replacement surgery.
The ability of this surgery to restore the quality of life
is a new and exciting frontier in orthopedic surgery.
[Music]
[Presented by the Joint Replacement Section of the Orthopaedic Service]
[Film segments provided by Richard B. Welch, MD., St. Mary's Hospital, San Francisco, CA]
[Ralph Soto-Hall, MD, St. Joseph's Hospital, San Francisco, CA]
[With Col. John A. Feagin, MC; LTC Donald B. Seymour, MC]
[Maj. James L. Strait, MC; Letterman Army Med. Cen., Presidio, San Francisco]
[Produced by, Health Sciences Media Division, Television Branch, AHS, USA]
[Fort Sam Houston, Texas]
[Music]
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