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Hamstring tendon graft for anterior cruciate ligament reconstruction - Home Study Program
Deborah M. BoniThe incidence of sports injuries is on the rise as more teenagers and adults become involved with sports activities. Anterior cruciate ligament (ACL) tears are becoming more common among adults and female teenagers because of their increased participation in contact sports, especially with the increase in female soccer players. Although the medial collateral ligament (MCL) is the most commonly injured ligament of the knee, the ACL is the most commonly injured ligament that causes abnormal knee joint laxity. (1) Injury to the ACL without injury to other ligaments occurs in approximately 60% of ACL injuries. The classic history of an ACL tear is a sudden twisting of the knee at which time the patient hears a pop or snap. The patient also may complain of a feeling that the knee is giving away. During the initial injury, the ACL may not be the only stability structure torn. For example, a common triad of injuries includes the torn ACL, a medial meniscus tear, and a partial or complete MCL tear.
NORMAL ANATOMY
The knee joint is one of the largest and most complex joints in the body. It consists of
* the femur, which meets the tibia to form the main knee joint;
* the patella, a triangular-shaped bone embedded in the tendon of the quadriceps muscle, which is anterior to the knee joint in the intercondylar groove of the distal femur; and
* the patellofemoral joint, which is where the femur joins the patella.
The main knee joint has a medial and lateral compartment surrounded by a joint capsule that is attached proximally to the femoral condyles and distally to the tibial condyles and upper end of the fibula.
Ligaments are bundles of collagen fibers that provide stability and strength to the knee joint. The collateral ligaments (ie, medial, lateral) strap the outside of the joint and cruciate ligaments (ie, anterior, posterior) cross within the joint. The term cruciate comes from the word crux or cross and the word crucial. The cruciate ligaments consist of two fibrous bands that extend from the intercondylar fossa of the femur to attachments anteriorly and posteriorly in the intercondylar eminence of the tibia. They crisscross over one another to form an "X" inside the knee. The ACL connects the anterior surface of the tibia to the posterior surface of the femur and is crucial for preventing the knee from sliding forward. The posterior cruciate ligament (PCL) provides opposing support by passing anteriorly and medially (Figure 1). The capsule also is reinforced in front by the patellar and quadriceps tendons and posteriorly by the popliteus and gastrocnemius muscles.
[FIGURE 1 OMITTED]
The menisci (ie, thickened cartilage pads) are inserted between the femoral and tibial condyles and attached to the joint capsule. Menisci are almost totally avascular; therefore, degenerative changes usually are permanent. The suprapatellar bursa is situated between the tendon of the quadriceps femoris muscle and the anterior surface of the lower segment of the femoral portion of the knee joint. Synovial membrane (ie, a sheet of flattened connective tissue cells) lines the capsule of the joint and covers the infrapatellar fat pad, parts of the cruciate ligaments, and portions of the femur and tibia. (2)
Functional Anatomy
Normally, the knee flexes to a maximum of 135 degrees and extends to zero degrees. The two joints formed by the femur and tibia have a meniscus between them that acts as a smooth surface on which the joint can move. Bursa (ie, fluid-filled sacs) surround the knee joint to provide a gliding surface to reduce friction of the tendons, such as friction of the patellar tendon that attaches to the front of the tibia below the kneecap. Large blood vessels pass through the popliteal space behind the knee. The quadriceps muscle extends the knee joint, and the hamstring muscle flexes the knee joint.
The average adult ACL is approximately 3.5 cm long. It has a semicircular attachment at the posterior portion of the medial aspect of the lateral femoral condyle. The ACL lies in an anteromedial and distal direction, making an outward spiral and inserting near the anterior spine of the tibial plateau. The tibial attachment usually is 1.5 cm posterior to the anterior articular surface of the tibial plateau. The ACL, like the PCL, is an extrasynovial structure, and yet it is located intra-articularly.
The ACL provides a primary restraint to anterior tibial translation on the femur and acts as the major secondary restraint to medial tibial displacement. It provides stabilization to valgus and varus opening, as well as to internal and external rotation.
MECHANISM OF INJURY
The most common method of injuring the ACL happens without the knee coming in contact with another object. This kind of noncontact injury usually happens when the person changes direction rapidly so that, with the knee in full extension, the femur is rotated externally on a fixed tibia. Landing on a straight leg or attempting to make an abrupt stop also can torque the knee in this manner, causing an ACL injury. These kinds of injuries are common in basketball, football, volleyball, and soccer. Skiers and snow boarders also can experience this kind of injury because the foot and ankle is locked into a boot preventing the person from relieving the sudden torque on the knee. Also, the ACL often is injured by a direct blow of excessive lateral force to the knee. This valgus stress forces the knee into an abnormal position, tearing the ACL and other knee structures.
INITIAL PATIENT ASSESSMENT
When the patient presents for evaluation, he or she usually complains of knee instability. The patient most often describes having heard a pop or having felt a tearing sensation inside the knee. Moderate to severe pain was felt at the time of injury, and the patient was unable to continue the causative activity because of the pain. The knee joint became swollen within 24 hours of injury, but many patients state that the swelling occurred within three hours. Some patients report that the knee seemed to recover but became unstable and now feels as though it is giving out, especially during activities that require lateral movement of the knee, such as cutting or pivoting. Many patients, however, deny knee pain with straight ahead activities, such as running or jogging. Symptoms may be vague in nature and often require more definitive testing. Clinical evaluation includes the Lachman test, anterior drawer test, and pivot-shift maneuver. The ACL may be imaged, if necessary, by obtaining a magnetic resonance imaging (MRI) scan.
In the Lachman test, the patient lies supine on the table with the involved leg beside the health care provider performing the examination. The examiner holds the patient's knee at 30 degrees of flexion (Figure 2). The examiner stabilizes the patient's femur with one hand while anteriorly translating the proximal aspect of the tibia with the other hand. "A positive sign is indicated by a mushy, soft, end-feel when the tibia is moved forward." (3) A positive sign also may indicate that other structures, including the anterior capsule, are injured. (4) The Lachman test is the most sensitive test for detecting ACL deficiency.
[FIGURE 2 OMITTED]
For the anterior drawer test, the patient lies supine on the examination table with his or her knees flexed 90 degrees and both feet flat on the table (Figure 3). The health care provider examining the patient cups his or her hands around the patient's knee, placing his or her fingers on the medial and lateral hamstring insertion points and thumbs on the medial and lateral joint lines. The examiner then draws the tibia forward. The ACL may be torn if the tibia slides forward from under the femur (ie, positive anterior draw sign). (5)
[FIGURE 3 OMITTED]
The last definitive test for an ACL tear is the pivot-shift maneuver. The patient lies supine with his or her hip flexed 20 degrees and relaxed in slight medial rotation. The examiner holds the patient's foot with one hand, using the other hand to flex the patient's knee slightly. The examiner flexes the patient's knee by placing the heel of the hand behind the patient's fibula, over the lateral head of the gastrocnemius muscle, and medially rotating the patient's tibia, which causes the tibia to sublux anteriorly.
An MRI usually is obtained if two out of three of the previously mentioned tests are positive for an ACL tear. An MRI also may be performed to evaluate for additional or associated injuries. Reconstructive surgery is considered depending on how active the patient currently is and plans to be in the future, whether there are associated injuries, and the amount of abnormal knee laxity demonstrated.
PREOPERATIVE PATIENT CARE.
The day before surgery, the patient is instructed to see the preoperative nurse. This visit is vital to the patient's surgical experience. The preoperative nurse makes any additional appointments for the patient, such as laboratory tests if the patient is older than 40 years of age or if the patient has any ongoing, chronic illnesses. These laboratory tests should be reviewed by an internal medicine physician. The preoperative nurse provides the patient with written and oral instructions to ensure that he or she clearly understands preoperative and postoperative instructions. If the patient is going home the day of surgery, the nurse ensures that someone is available to drive the patient home and care for him or her postoperatively. The preoperative nurse assesses the patient's home status by asking questions regarding the patient's home situation. The following questions should be asked.
* Is the patient a single parent?
* If the patient is a parent, is there adequate childcare for the first three postoperative days?
*Is there anything that would hinder the patient's recovery (eg, need for help with pet care during the postoperative recovery period)?
The patient may be concerned about returning to his or her previous lifestyle and how long it will take to do so. The physician should have discussed this issue during the first diagnostic appointment. If the question should arise during the preoperative appointment, the nurse should reassure the patient that chances are very good that he or she can return to his or her previous lifestyle but that the patient should check with his or her physician. The patient should understand that rehabilitation is a long process, and he or she may need to wear a brace for six months or more when participating in sport activities. The nurse also should emphasize that the patient must use crutches for approximately two weeks. The nurse suggests that the patient wear loose clothing to fit over the brace. The nurse makes a physical therapy appointment for the patient during which a therapist will ensure that the patient can maneuver with crutches skillfully and safely. Toward the end of the preoperative visit, the patient may be asked to sign and date the informed consent form. The surgeon may have the patient sign the informed consent upon arrival in the preoperative area of the hospital. The form should specify the surgical leg, type of procedure to be performed, and grafting technique to be used (ie, hamstring, patella tendon, or both). The nurse witnesses the patient signing the form, but this does not indicate the nurse witnessed the surgeon educating the patient about the risks of the procedure or other options available.
Day of surgery. When the patient is brought to the OR holding area, the circulating nurse follows the facility policy for correct site surgery by verifying the surgical site with the patient and ensuring that the patient places his or her initials or an "X" on the correct surgical leg. The nurse also checks the consent form for completeness (eg, site is specified, all signatures have been obtained) and has the patient state what procedure is being performed. The circulating nurse then checks the chart for laboratory results and any other tests that were ordered preoperatively. The nurse shows any abnormal laboratory or test results to both the anesthesia care provider and surgeon. The OR holding nurse or anesthesia care provider inserts an IV catheter, starts an IV of lactated Ringer's solution, and infuses prophylactic antibiotics, if ordered by the surgeon. The circulating nurse develops and initiates a care plan specific for the patient (Table 1). The patient now is ready to enter the OR.
OPERATING ROOM PREPARATION
Nursing staff members work cooperatively with the surgeon and anesthesia care provider to ensure efficient and complete OR setup so the patient has a positive surgical outcome. The nurse also interfaces with sales representatives to ensure availability of specialty supplies, if needed. The scrub person verifies that all supplies and instruments have been obtained and function correctly. The circulating nurse verifies that all videotaping equipment, including the printer for arthroscopic images, is in working order before the patient enters the room. The OR suite also should have a pneumatic tourniquet preset at 300 mm Hg or 10 mm Hg higher than the patient's systolic pressure. A well-padded leg holder for the nonsurgical leg, such as a low lithotomy stirrup, is needed to prevent unnecessary pressure on muscles and bony prominences.
A fluid infusion pump is used to provide distention of the surgical knee during the procedure. Two 3-L bags of normal saline solution are hung from the fluid pump. A large back table is used for basic orthopedic and arthroscopic instruments (Table 2). The grafting instruments, such as the graft preparation board, endoscopic ligament button holder, and vein strippers are placed on a separate, small back table that the surgeon or assistant uses to prepare the hamstring tendon graft.
INTRAOPERATIVE PATIENT CARE
After the circulating nurse checks the patient into the OR suite, OR team members cooperatively double check the informed consent form and ensure that the patient has identified the surgical knee by initialing it. When all team members are in agreement, the anesthesia care provider administers the anesthetic agent. The anesthesia care provider either anesthetizes the patient using an endotracheal tube and general anesthesia or places an epidural catheter and administers a regional anesthetic. The circulating nurse, anesthesia care provider, and surgeon reposition the patient so that the popliteal space is approximately 2 inches beyond the break in the OR bed. The foot of the bed then is lowered. The surgeon applies a tourniquet cuff to the upper thigh of the patient's surgical leg and places the surgical leg in an arthroscopic leg holder. The circulating nurse places the nonsurgical leg in a well padded low lithotomy stirrup, ensuring that there is no undue pressure on the calf and peroneal nerve. After the circulating nurse pads and secures the patient's nonsurgical leg, he or she assesses the patient's pedal pulses.
While the circulating nurse, surgeon, and assistant are positioning the patient, the scrub person prepares the larger back table for the arthroscopic and reconstruction portions of the procedure and the hamstring tendon harvest and a smaller back table for assembly and preparation of the hamstring tendon. The circulating nurse shaves the patient's surgical leg from 3 inches to 4 inches above the knee to 4 inches below the patella, laterally and medially. The circulating nurse cleanses the patient's leg with povidoneiodine scrub and paint solutions circumferentially from the thigh to the toes. After the surgeon scrubs, gowns, and gloves, he or she and the scrub person drape the patient for a standard knee arthroscopy. The drapes include a plastic U-shaped drape that is placed around the patient's surgical leg and a lower extremity drape. A smaller drape, such as a half sheet, may be placed over the nonsurgical leg.
Placement of incisions. To achieve cleaner synovial penetration in the knee, the surgeon distends the patient's knee with saline before making the initial stab incision. The surgeon places his or her thumb in the angle between the patellar tendon and the joint line of the flexed knee and makes the incision above his or her thumb. The next stab incision is anteromedial. The point of entry should be slightly higher than that of the lateral incision to facilitate access to the region of the posterior horn of the meniscus.
Repair of associated injuries. Before the surgeon makes an incision to harvest the tendon graft, he or she assesses the knee arthroscopically for signs of meniscal tears and other associated injuries or to confirm the ACL rupture. If a meniscal tear is present, the surgeon either repairs it with 2-0 meniscal sutures or performs a partial meniscectomy using an aggressive arthroscopic blade and suction/shaver. After the surgeon assesses the knee and verifies an ACL rupture, he or she makes the incision to harvest the graft. Depending on surgeon preference, the tourniquet may be inflated to 300 mm Hg or 10 mm Hg higher than the patient's systolic pressure to provide a bloodless field. If the surgeon believes that the procedure may last longer than two hours, he or she may opt not to inflate the tourniquet.
Obtaining the tendon graft. An oblique or longitudinal incision approximately 4 cm to 7 cm long is made 2 cm to 3 cm medial to the tibial tubercle, and blunt dissection is carried through the subcutaneous fat to expose the sartorius muscle (Figure 4). The surgeon identifies by finger palpation the pes anserine tendons, which are the final common tendinous insertion of the sartorius, gracilis, and semitendinosus tendons along the proximal-medial aspect of the tibia (Figure 5). These muscles serve as flexors and internal rotators and help protect the knee from rotary as well as valgus stress. (6) The surgeon incises the skin and bluntly dissects through the subcutaneous fat to expose the sartorius. The gracilis and semitendinosus tendons can be seen and palpated as two small bumps lying under sartorial fascia. (7) After the surgeon separates the gracilis and semitendinosus tendons, he or she harvests them with a closed or slotted tendon stripper (Figure 6). The surgeon places a whip stitch on the tendon end with a #2 polyester braided nonabsorbable suture so that traction can be applied to each tendon. The surgeon pushes the tendon stripper in an upward direction along the course of the gracilis tendon until it is separated from its muscle belly. (8) The scrub person wraps the tendon graft in a moist laparotomy sponge and places it on the small back table. The surgeon harvests the semitendinosus tendon in the same manner. The tendons should measure approximately 100 mm to 150 mm in length when folded in half.
[FIGURE 4-6 OMITTED]
Preparing the graft. The assistant prepares the tendons using the graft preparation board. The graft preparation board is flat with a ruler along its edge to measure the length of the graft. A post at each end with removable clamps is used to hold the tendon securely. The assistant extracts muscle fibers from the tendon using a knife blade or periosteal elevator. After the tendon is free from muscle fibers, the assistant places a whip stitch on the proximal end of the tendon using a #2 polyester braided nonabsorbable suture. He or she folds the graft to half its original length and sizes the diameter using the tubular sizers ranging from 7 mm to 12 mm. The average graft size is between 8 mm and 9 mm in diameter (Figure 7). After sizing the graft, the assistant unfolds the graft to its original length and slips a button with a loop on the tendon. He or she again folds the graft in half and places it back on the graft master using the button holder attachment. The graft now is ready for later placement. The surgeon must create the tibial and femoral tunnels before the graft can be placed.
[FIGURE 7 OMITTED]
Creating the tibial tunnel. The surgeon creates the first of the two tunnels (ie, the tibial tunnel) approximately 30 mm in length, which enables proper placement of the graft. The size of the cannulated drill bit must match the size of the graft. The surgeon starts the tunnel halfway between the tibial tubercle and the posteromedial edge of the tibia. He or she uses landmarks (eg, the inner edge of the anterior horn of the lateral meniscus, the medial-tibial spine, the PCL, the ACL stump) to ensure correct placement of the tibial tunnel and proper placement of the graft. The purpose of these landmarks is to recreate the normal anatomical position of the original ACL tendon and prevent impingement of the graft.
Preparing the intercondylar notch. The surgeon shapes the top of the intercondylar notch to prevent impingement of the ACL graft when the patient's leg is in full extension. The graft eventually will erode if it is impinged upon. Using a suction/shaver with a round or an oval-shaped burr, the surgeon resects bone along the inner aspect of the lateral femoral condyle.
Creating the femoral tunnel. The assistant holds the patient's knee at a 90-degree angle to facilitate best placement of the guide pin. The surgeon places a femoral drill guide in the notch at the 11 o'clock position when working on the right knee and at the one o'clock position when working on the left knee. After the drill guide is positioned properly, the surgeon uses a 2.7-mm guide pin to drill through the lateral femoral cortex of the lateral thigh. He or she uses a cannulated drill bit to create the femoral tunnel using the pin as a guide. Using a biodegradable screw or a metal interference screw, the surgeon secures the graft in the femoral tunnel (Figure 8). The surgeon may choose to stretch the graft by holding the distal end of the graft under tension while cycling the knee through flexion and extension (Figure 9). With the graft under tension, the surgeon then anchors it to the tibia with a staple, 4.5-mm cortical screw and spiked washer, or both.
[FIGURE 8-9 OMITTED]
Closing. The surgeon and assistant close the incisions with absorbable, interrupted, subcutaneous sutures and self-adhesive wound approximating strips. They cover the incisions with 4-inch by 8-inch gauze dressings and elastic bandage wrap. The surgeon applies a range of motion brace and locks it in zero-degree flexion. The surgical team transfers the patient to a stretcher, and the circulating nurse elevates the patient's surgical extremity on a pillow placed under the patient's leg from the calf to the heel. The circulating nurse checks the patient's pedal pulses bilaterally before leaving the OR suite. The circulating nurse and anesthesia care provider then transport the patient to the postanesthesia care unit (PACU) with supplementary oxygen, if needed.
POSTOPERATIVE PATIENT CARE
The PACU nurse provides the patient with oxygen by face mask and continues cardiac and pulse oximetry monitoring. The PACU nurse ensures that a pillow is supporting the patient's surgical lower leg and places an ice bag on the patient's knee to minimize swelling and reduce pain. Some surgeons prefer using an ice water-filled soft compression brace for the first 24 to 48 hours. The circulating nurse gives a brief report to the PACU nurse, including the patient's history, allergies, antibiotics and local anesthesia administered intraoperatively, and any special needs the patient may have. The PACU nurse checks the patient's vital signs every five minutes along with bilateral checks of the patient's pedal pulses, circulation, and sensation. If the patient complains of pain, the PACU nurse uses the one to 10 pain scale, with 10 being the worst possible pain, and administers pain medications according to the patient's response. The patient usually is in the recovery room for approximately 45 minutes before being transferred to the postoperative medical-surgical unit.
Many patients who undergo ACL reconstruction are excellent candidates for patient controlled analgesia for 24 to 48 hours postoperatively. Oral pain medication usually is effective after this time.
Upon arrival in the medical-surgical unit, the assigned nurse measures the patient's vital signs and peripheral circulation every 15 minutes for one hour. The nurse continues to monitor the patient every hour until discharged.
Discharge instructions. The nurse explains possible adverse reactions that may occur, including swelling, burning, tingling, loss of sensation, and excessive bleeding. He or she also tells the patient who, when, and what numbers to call during both normal and after office hours in the event that the patient has questions or concerns. The nurse also instructs the patient to
* elevate the surgical leg and use ice for 48 hours to minimize swelling and pain;
* use crutches to avoid weight bearing on the surgical leg for approximately two weeks;
* not stand for long periods of time;
* bathe by placing a dry towel around the surgical limb covered by a clean garbage bag taped just above the dressing; and
* not drive for 72 hours.
Physical therapy. Before the patient is discharged, a physical therapist fits the patient with crutches and gives instructions regarding their correct use. If the patient must use stairs, the physical therapist instructs him or her on a safe method of climbing and descending stairs using crutches. The therapist instructs the patient regarding early quadriceps muscle strengthening exercises to be performed for the first two postoperative weeks. These exercises include
* straight leg raises,
* quadriceps sets in which the patient locks the quadriceps muscle until the back of his or her knee touches the bed, and
* heel slides in which the knee is flexed to 90 degrees.
The physical therapist also instructs the patient to maintain the brace at zero degrees flexion while ambulating during the first two weeks.
Follow-up physician visit. The patient returns to the surgeon's office two weeks after surgery for a wound check. The surgeon then instructs the patient to continue wearing the brace while beginning to bear full weight on the surgical leg.
CONCLUSION
This article discusses the use of hamstring tendon graft for ACL reconstruction. Several research studies have been performed comparing the use of a hamstring tendon graft verses a patella tendon graft. These studies demonstrate that even though both techniques result in a stable, functional knee, patients on whom hamstring grafts were used had less postoperative pain and a quicker return of quadriceps muscle function. One such study demonstrates that the advantages of using the hamstring tendon graft include
* the graft is larger and stronger than a patellar tendon graft,
* morbidity of the harvest technique donor site is less than that of patellar tendon grafts,
* there is little quadriceps inhibition after quadriceps harvest, and
* there is quicker return to sports activities after aggressive rehabilitation. (9)
Table 1
NURSING CARE PLAN FOR PATIENTS UNDERGOING
ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
Nursing diagnosis Intervention
Risk of infection * Assesses preoperatively for susceptibility to
related to length infection.
and type of
procedure and * Implements, monitors, and maintains aseptic
tissue technique.
manipulation
during procedure * Administers prescribed antibiotic therapy at
appropriate times.
* Initiates traffic control.
* Performs skin preparations.
* Helps minimize length of the intraoperative
phase of surgery by planning and anticipating
care.
* Prevents cross infection.
* Administers wound site care and applies sterile,
dry surgical dressing after wound closure.
Risk for acute * Provides pain management instruction and
and chronic describes pain management options.
pain
* Identifies desired level of pain control
preoperatively.
* Identifies cultural and value components related
to pain and pain control.
* Implements pain guidelines.
* Collaborates in initiating patient-controlled
analgesia.
* Evaluates response to pain management
interventions.
Risk of anxiety * Determines knowledge level and assesses coping
related to mechanisms and readiness to learn.
knowledge
deficit and * Explains expected sequence of events, including
stress of surgery family members in perioperative teaching when
appropriate.
* Evaluates response to instruction.
Risk for injury * Identifies baseline tissue perfusion and
due to preoperative neurovascular status of lower
positioning and extremities.
intraoperative
manipulation of * Assesses factors related to risk for ineffective
the surgical leg tissue perfusion (eg, chronic diseases,
immunosuppression).
* Positions the patient neutrally and anatomically
correct and pads pressure points.
* Evaluates for signs and symptoms of positioning
injury by comparing the patient's bilateral
lower extremities' neurovascular status with
preoperative status and checks for signs and
symptoms of injury as a result of positioning.
Interim Outcome
Nursing diagnosis outcome criteria statement
Risk of infection The patient's skin The patient is free
related to length remains intact from the signs
and type of and nonreddened, and symptoms
procedure and wound is dry, and of infection.
tissue temperature
manipulation remains
during procedure normothermic
throughout the
perioperative
period.
Risk for acute The patient The patient's vital
and chronic demonstrates and signs and other
pain reports adequate nonverbal symptoms
pain management remain
throughout the stable post-
perioperative operatively
period. indicating
adequate
pain control.
Risk of anxiety The patient The patient
related to demonstrates participates in
knowledge decreased anxiety decisions affecting
deficit and and increased the plan of care.
stress of surgery ability to cope
before induction. The patient
demonstrates
The patient knowledge of
verbalizes psychological
understanding of response to
the procedure and the procedure
expected outcomes and potential side
before induction. effects.
Risk for injury The patient's The patient is
due to function and free from signs
positioning and sensation is and symptoms of
intraoperative maintained or improved injury related to
manipulation of from baseline levels positioning.
the surgical leg throughout the
perioperative period.
The patient's pedal
pulses are present
and equal
bilaterally throughout
the perioperative
period.
Table 2
INSTRUMENTS FOR ANTERIOR
CRUCIATE LIGAMENT RECONSTRUCTION
Arthroscopic suction/shaver
Arthroscopic instruments
Cannulated drill bits, sizes 7 mm to 12 mm
Cannulated screw driver
Depth gauge
Drill guide
Graft preparation block
Graft preparation board
Guide wires
Large drill
Probe
Rasps, various sizes
Reamer
Tibial guide, right and left
Tunnel notcher
Vein stripper
NOTES
(1.) R L Larson, W A Grana, eds, The Knee Form, Function, Pathology, and Treatment (Philadelphia: WB Saunders Co, 1993).
(2.) M H Meeker, J C Rothrock, Alexander's Care of the Patient in Surgery, 11th ed (St Louis: Mosby, Inc, 1999).
(3.) R C Evans, Illustrated Essentials in Orthopedic Physical Assessment, second ed (St Louis: Mosby-Year Book, 1994) 802.
(4.) Ibid, 783.
(5.) S Hoppenfeld, R Hutton, Physical Examination of the Spine and Extremities (Philadelphia: Appleton and Lange, 1976).
(6.) "Anterior cruciate ligament," Wheeless' Textbook of Orthopaedics, http://www.orthou.net/o12/30.htm (accessed 12 Aug 2002).
(7.) C H Brown, J H Sklar, "Endoscopic anterior cruciate ligament reconstruction using quadrupled hamstring tendons and endobutton femoral fixation," Techniques in Orthopaedics 13 (1993) 281-298.
(8.) C H Brown, Jr, M E Steiner, E W Carson, "The use of hamstring tendons for anterior cruciate ligament reconstruction: Technique and results," Clinical Sports Medicine 12 (October 1993) 723-756.
(9.) C H Chen, W J Chen, C H Shih, "Arthroscopic anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft," Journal of Trauma 46 (April 1999) 678-682.
Examination
HAMSTRING TENDON GRAFT FOR
ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
1. A common triad of injuries experienced during
severe knee trauma includes all of the following
except
a. medial meniscus tear.
b. partial or complete medial collateral ligament
tear.
c. torn anterior cruciate ligament (ACL).
d. dislocated patella.
2. The classic description by the patient of an ACL
injury include all of the following except
a. feeling the knee give way with an audible popping
sound.
b. moderate to severe pain and inability to continue
the causative activity.
c. swelling occurs rapidly during the 30 to 60
minutes after injury.
d. pain subsides but continues with lateral movement
while denying pain with straight-ahead
activities.
3. The most sensitive test for determining whether
the ACL has been torn is the
a. anterior drawer test.
b. Lachman test.
c. pivot lift maneuver.
d. pivot shift maneuver.
4. When the patient enters the OR holding area, the
nurse confirms the surgical site by doing all of
the following except
a. trusting the surgical schedule.
b. asking the patient to identify the surgical leg.
c. having the patient place an "X" or initials on
the surgical leg.
d. checking the surgical consent.
5. The surgeon distends the patient's knee with
saline before making the initial stab incision to
a. achieve cleaner synovial penetration.
b. forcefully open the anterior compartment.
c. expand the skin.
d. loosen any adhesions.
6. The length of the hamstring graft should measure
in length.
a. 50 mm to 100 mm
b. 75 mm to 150 mm
c. 100 mm to 150 mm
d. 150 mm to 200 mm
7. After the procedure is complete, the range of
motion brace is locked at
a. zero-degree extension.
b. 60-degree extension.
c. zero-degree flexion.
d. 180-degree flexion.
8. The patient will remain on crutches for
a. one week.
b. two weeks.
c. three weeks.
d. four weeks.
9. The patient is instructed on early exercises to
strengthen the quadriceps muscle, including all
of the following except
a. bent leg raises.
b. heel slides.
c. quadricep sets.
d. straight leg raises.
10. One advantage of using the hamstring tendon
graft instead of other graft sites is
a. less need for extensive postoperative
rehabilitation.
b. the graft is smaller and stronger than the
patellar tendon.
c. quicker return to sports activities without the
need for aggressive rehabilitation.
d. less postoperative pain and a quicker return of
quadriceps muscle function.
Deborah M. Boni, RN, BSN, MAJ, US Air Force, was an RN first assistant and the operations officer for surgical services at MacDill Air Force Base, Fla, at the time this article was written.
George E. Herriott, MD, MAJ, US Air Force, is an orthopedic surgeon at MacDill Air Force Base, Fla.
COPYRIGHT 2002 Association of Operating Room Nurses, Inc.
COPYRIGHT 2002 Gale Group