WEBVTT

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[...]

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[The following produced for...]

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[Professional Medical Audiences]

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[...]

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[Music]

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[AHS TV, Academy of Health Sciences]

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[Music fades out]

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[...]

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[A United States Army Medical Department Continuing Education Program]

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[Music]

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[Music]

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[Quality Of Life]

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[Music]

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[Narrator:] Reconstructive surgery as
manifest by joint replacement.

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has dramatically extended the capability of
the orthopedic surgeon

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to help those crippled by arthritis and the
effects of trauma.

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It is the absolute nature of the success or
failure of joint replacement surgery

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that has brought a new and unique
dimension to orthopedics.

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Quality of life is the essence of joint
replacement surgery.

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It is our hope that we can share with you

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some of the surgical and nursing
techniques essential

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to success in this type of surgery.

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These are: Select and prepare the patient.

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Clean air surgery.

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Biomechanical principles.

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Post operative care.

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[Select and prepare patient]

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[Doctor:] If you awoke tomorrow morning

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with signs and symptoms of acute appendicitis,

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the treatment would be rather obvious:
appendectomy.

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But the selection of a patient for total joint
replacement is not always as clear-cut.

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A series of clinic visits is usually necessary

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to establish an ever-growing rapport
between surgeon and patient.

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It is necessary to understand

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the patient in terms of three main factors:

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the amount of pain he is experiencing,

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his functional level of activity,

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and his personality.

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It is extremely important to fully appreciate

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that each of these factors is interdependent on the others.

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Pain limits activity.  Activities cause pain,

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and the type of personality in large part
determines the patient's response to pain.

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There is a rather consistent pattern of
progression of pain

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and decrease in activity.

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The symptoms slowly increase in severity over a number of months or years,

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a definite rate of progression.

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Then, with an ever-increasing rate of
acceleration,

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measured in terms of months or weeks,

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the symptoms rapidly become intolerable
to the patient.

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Prior to this time,

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the symptoms were at best an annoyance,
at worst a minor disability.

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Now they become disabling,

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and the patient's quality of life
deteriorates.

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[...]

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We use an evaluation form developed by
Professor John Charnley.

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Basically, it assigns separate numerical
values for pain,

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activity, and range of motion.

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We term this the par number.

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[...]

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The pain and activity data provides us with
the information needed

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to select patients suitable for total joint
replacement.

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The range of motion data, together with
appropriate X-rays,

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provides us with the data needed to plan
the technical aspects of the surgery.

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In summary,

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the functional level of the patient,

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and the amount of pain, and what kind of
patient

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are the basic questions to be answered

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in order to properly select patients for
total joint replacement.

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The decision for surgical intervention is
based on what is happening

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to the quality of the patient's life.

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[Nurse 1:] [?] I thought...

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[Narrator:] Patients are counseled

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by the nursing and physical therapy staff

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concerning the details of the total joint,

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the operation, and the postoperative course. [Nurse continues counseling]

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Great emphasis is placed on ensuring that
the patient is fully informed

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about the entire course of his
hospitalization. [Nurse continues]

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The patient knows not only what to expect

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but what is expected of him, especially in
the postoperative period.

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[Nurse 1:] …before surgery.

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[Book opens]

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In this book here as you can see,

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this is an example of what the total hip
looks like.

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And, as you can see also by our model
here, this is also a good example.

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Here's your cup, and it is cemented in
there with cement.

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Then you can also see this part.

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This is…

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this is this is your leg here,

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and they take this metal,

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and they put it down into the shaft and
also use the same cement in here

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to maintain a good hold on this part.

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So that after surgery,

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your hip socket will be like this with your femur going in.

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So that you have good range of motion with it.

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Now, as you can see from the book here,

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ehave some pictures of what you can expect.

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[Book pages flipping]

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This is the type of bed that you will be in
immediately after surgery.

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And we will show you how to use that,

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after we get done with the demonstration
here of the X-rays in our book and all.

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Uh, immediately after surgery,

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you'll be kept in recovery room for 24
hours.

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And you will be brought back up to the
floor.

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On the floor, you'll come back with
intravenous feedings in your arm,

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and that's until you can take liquids by
mouth.

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Which will probably be the next day.

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Also, you’ll come back with

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some drains in your leg that will be
hooked up to a suction machine.

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And this is to make sure that you don't
have an accumulation

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of blood into your hip.

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[Narrator:] Professor John Charnley of
England

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made joint replacement a reality.

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He introduced high-density polyethylene
for the socket.

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A clean air system which has dramatically
decreased the infection rate.

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And methyl methacrylate,

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the cement used to secure the
replacement parts to the bone.

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Implant surgery has become

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an accepted tool of modern orthopedics.

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It has provided pain relief and

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return of function to thousands of patients
who otherwise

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would have been severely disabled
because of their arthritis.

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Though implant surgery offers a dramatic
solution to these problems,

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there are attendant risks.

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The most devastating of these is infection.

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In view of the absolute failure

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following a major surgical infection in an
implant procedure,

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no rate of infection can ever become
acceptable.

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[Clean Air Surgery]

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The operating room environment

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has long been suspect as the major cause
of surgical infection.

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We intend to present certain principles

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and techniques which have resulted in a
marked decrease in airborne

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and contact contamination.

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The predominant source of contamination
of the operating room is the surgical team.

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Team discipline becomes paramount.

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The number of personnel involved in the
surgical procedure should be limited.

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The number of times personnel enter and
leave the room

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should be strictly controlled.

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The immediate members of the surgical
team

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should themselves be draped to exclude
body shed.

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The prepping and draping of the surgical
patient,

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which has been performed in a stylized
fashion

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in accordance with instructions passed
down through the years,

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reminds one of an ancient rite

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rich in symbolism but lacking any significant rationale

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in terms of our present knowledge.

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Our associates in dermatology tell us

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scrubbing encourages the migration of
bacteria from the deeper pores.

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Rather, they suggest an application
technique of an antiseptic solution,

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followed by a skin sealer.

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Regretfully, some still use surgical drapes,
which are porous,

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permeable, and wettable.

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These are totally ineffective as barriers
against contamination.

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In addition, they shed minute particles of
lint.

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Monitoring of the operating room

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shows a marked increase in airborne
contamination

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during the time the patient is prepped and
draped.

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Teamwork is essential to decrease surgical
time

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and to decrease body movements.

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The result is less airborne contamination.

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We prefer to group surgical instruments in
small trays

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and expose only when needed,

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therefore decreasing the time each
instrument

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is exposed to airborne contamination.

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It is estimated that each member of the
surgical team

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may shed 10,000 particles per minute.

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And these particles are carriers of viable
bacteria.

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In addition, each member expends
approximately

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500 BTUs of heat energy per hour,

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further contributing to convection currents

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which impel the airborne particles into the
wound.

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The body exhaust system for the surgical
team

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effectively separates the team from the
operating room environment

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and therefore from the surgical wound.

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We have found the jet lavage irrigation
system

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particularly helpful,

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and systematically irrigate the wound with
an antibiotic solution

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to remove tissue debris and implanted
airborne particles.

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In addition, we use suction drains

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to the depth of the wound,

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metallic skin clips,

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then pressure retention sutures

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for the closure of subcutaneous tissues.

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All have contributed to a dramatic
improvement

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in the healing of the postoperative wound.

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It is not wise to disregard the work of
Lister and Charnley,

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particularly when sepsis is concerned.

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The principles of clean air surgery are here
to stay.

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[...]

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[Doctor:] Biomechanical Principles of total
hip reconstruction

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require that Shenton’s line be restored,

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equality of leg lengths be attained,

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and that a one-to-one ratio be re-established

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between the center of gravity of the body,

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the center rotation of the femoral head,

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and the abductor lever arm.

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There should also be adequate separation
of the femur

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from the side wall of the pelvis in the
neutral position.

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One may then analyze the position of the
components in more detail.

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This may be analyzed in an orderly fashion

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starting from the socket and proceeding
distally.

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A low AP pelvis X-ray is used

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with the beam centered at the symphysis
pubis.

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First, the socket should be well-contained
within bone

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so that the cement is not subject to tensile
stresses.

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There should be a wedge of cement above
the cup,

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and cement should extrude into prepared
cement holes

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but not into the pelvis.

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Version of the cup may be determined

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by evaluating the distance

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from the prosthesis to the outer ring.

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This distance should be equal all the way
around.

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Inequality is evidence of version of 20
degrees or greater.

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The socket should be at 45 degrees to the
level.

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The horizontal access line is measured
through the bottom

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of the obturator foramina.

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The osteophytes should have been cleared  so they do not abut the ephemeral neck.

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Promoting subluxation.

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Attention is then directed to the abductor
mechanism

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and the separation of the femur

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from the side wall of the pelvis.

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The abductor lever arm should be
restored.

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The greater trochantor, when removed,

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should be replaced or transplanted, whichever is appropriate.

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The top of the greater trochantor should
not be above

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the center of rotation of the femoral head.

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On the femoral side,

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the ball should be enclosed within the wire
defining the cup.

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to ensure that the prosthesis is seated

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and that there is no intervening soft tissue
or cement.

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Ephemeral neck should be seen in full
profile,

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and the prosthesis should be in relative
valgus with respect to the femoral shaft.

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There should be a cement buttress
immediately at the calcar

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and laterally at the tip

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to provide the required support when
weight-bearing.

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There should be cement throughout the
femoral shaft

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down to or extending slightly past

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the tip of the femoral prosthesis.

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If the above criteria have been met,

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a technically successful Charnley total hip
replacement

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has been accomplished.

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[Narrator:] Meticulous attention to detail,

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as exemplified in the surgical procedure,
[Post Operative Care]

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is the key to success during the
postoperative course.

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The patient is kept in the recovery room
overnight,

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where close watch is maintained of all the
biological systems.

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Vital signs, urinary output,

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and the electrocardiogram are closely
monitored.

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A high fluid intake is maintained,

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and whole blood or pack cells administered
as indicated.

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Intermittent positive-pressure breathing
treatments

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are administered using the respirator as
well as blow bottles.

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The Hemovac is connected to constant
suction.

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Hematocrits are obtained the evening of
surgery

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and the first three postoperative mornings.

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The head and neck should be elevated

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to adjust for the preoperative [?].

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A pillow is used to maintain the hips and
abduction

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and pillows are placed beneath each leg

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to allow some flexation at the knees and
hips.

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Elastic stockings, Trendelenburg tilting
each hour

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and ankle, calf, and thigh exercises are
used

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to decrease the risk of thromboembolic
disease.

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Ice bags are used on the anterior thigh for
72 hours

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to decrease blood loss and minimize
postoperative discomfort.

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The CircOlectric bed is tilted into a prone
position every four hours...

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for half-hours or as tolerated.

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[Surgeon speaks to nurse in hospital]

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[Narrator:] Dextran and pre-operative
antibiotics

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are continued for three days.

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[Surgeon:] Does that include the
antibiotics and the Dextran?

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[Nurse 2:] Right.

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Right here is the Dextran and the Keflin.

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[Surgeon:] Thank you.

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[Loud bed motor]

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[Narrator:] The patient has walked on the first postoperative day.

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[Physical therapist making adjustments]

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It requires teamwork and expertise to
assist the patient to ambulate.

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[Physical therapist:] Okay, we’ll keep using
a belt until you get a good stable gait.

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[Physical therapist making adjustments to
the belt]

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Okay, just put your hands on the walker.

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[Narrator:] A rolling walker is helpful.

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[...]

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The first step is the longest.

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[Footsteps and walker clanking]

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[Physical therapist:] Okay, you have your
balance?

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[Narrator:] The physical therapist’s role is to teach the patient

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efficient and safe patterns

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of activities of daily living.

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[Physical therapist:] Let’s walk off this way.

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[Narrator:] Although, the Circolectric bed
is used the first three days,

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the patient may soon be transferred to a
Nelson bed

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which allows greater independent control
by the patient.

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[Nurse 1:] [?] just at nighttime.

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[Patient:] Yeah, yeah.

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[Narrator:] By the time of discharge, about
the third week following surgery,

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the patient is able to independently
perform

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the routine activities of daily living.

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[Nurse 1:] [Unintelligible conversation]

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[Narrator:] The preparation for discharge is
accomplished

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with the same attention to detail,

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as are all previous phases of the patient's
hospital course.

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[Patient:] [?]  [Nurse 1:] Well, you’ll probably get some pain pills now

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and your doctor will prescribe them.

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You’ll have them just in case you need
them.

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[Nurse 3:] And you won't be taking home
all the vitamins

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and things that you've been on.

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But you will have something for the pain.

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[Patient:] You'll have these medications up
there at the desk when I check out?

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[Nurse 3:] Mm-hm.  [Nurse 1:] Right.

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[Administrator:] In the foregoing, we have
covered the selection and preparation

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of a patient for surgery,

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the surgical procedure,

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and the details of postoperative care,

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which we feel have been important in well
over 100 cases

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of joint replacement at Letterman Army
Medical Center.

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It is our hope that you will consider the
importance

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of these details as you undertake

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the responsibility for joint replacement
surgery.

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The ability of this surgery to restore the
quality of life

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is a new and exciting frontier in orthopedic
surgery.

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[Music]

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[Presented by the Joint Replacement
Section of the Orthopaedic Service]

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[Film segments provided by Richard B. Welch, MD., St. Mary's Hospital, San Francisco, CA]

17:21.900 --> 17:25.233
[Ralph Soto-Hall, MD, St. Joseph's Hospital,
San Francisco, CA]

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[With Col. John A. Feagin, MC; LTC Donald
B. Seymour, MC]

17:27.566 --> 17:31.799
[Maj. James L. Strait, MC; Letterman Army
Med. Cen., Presidio, San Francisco]

17:31.800 --> 17:34.933
[Produced by, Health Sciences Media
Division, Television Branch, AHS, USA]

17:34.933 --> 17:36.866
[Fort Sam Houston, Texas]

17:36.866 --> 17:39.766
[Music]

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[...]