Robin V. West and Keerat Singh

Identification

Proper identification of the patient and surgical site should be established before any operation. To prevent wrong-site surgery—an issue on which the American Academy of Orthopaedic Surgeons has been working since 1997—the Joint Commission on Accreditation of Healthcare Organization (JCAHO) adopted a protocol in 2004. Implementation varies from hospital to hospital, but in general, the surgeon or a “credentialed provider” on the surgical team places his or her initials on the operative site in indelible ink before administration of anesthesia. No other marking, such as an X, is recommended because it may be misinterpreted. The initials should be located in a region that remains visible after preparation and draping. Finally, during a “time-out” with the surgical team and operating room nurse, the site is confirmed again with the surgeon and the consent before an incision in made.

Anesthesia

Several factors contribute to the decision of which type of anesthesia is most appropriate for a given patient. The decision to use local, regional, or general anesthesia depends on the planned procedure, the general health of the patient, and the preference of the patient, anesthesiologist, and surgeon.

Patient Positioning

The patient is positioned supine on a standard operating table. If a tourniquet is used, a layer of padding is placed on the thigh before its application. The decision to use a tourniquet should be based on surgeon preference. In our institution we rarely use a tourniquet, relying instead on the pump pressure to ensure adequate visualization during the procedure.

On the basis of the surgeon’s preference, one of two setups is used at our hospital. In the first, the patient lies supine on the table with the feet just short of the end of the table. The nonoperative leg is protected with foam padding. The operative leg is flexed to 90 degrees. A sandbag is taped to the table for the foot to rest on when the knee is flexed. A lateral post is attached the table at the level of the midthigh. The post helps stabilize the leg when a valgus force is applied to visualize the medial compartment. This method allows easy access to all aspects of the knee. However, an assistant may be required to manipulate the leg during the procedure (Fig. 51-1).

The other option entails placement of the thigh in a leg holder and flexion of the foot of the table (Fig. 51-2). On the table, the patient’s operative knee must be just distal to the level of the break in the bed. The operative leg is placed into a leg holder that encompasses the proximal thigh. The opposite leg is placed into a well-leg holder and protected with foam under the knee. The operative leg is manipulated by placing it on the surgeon’s pelvis or thigh and applying a varus or valgus stress at the knee. If the leg holder is too tight, it can act as a venous tourniquet and cause bleeding during surgery. Whereas this method eliminates the need for an assistant, there is no support for the leg when it is in extension. Also, larger thighs may not fit well in the leg holder.

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