On the 4th of February, 2019,
I got to watch a total knee replacement.this elective surgery was done on a
patient who had severe osteoarthritis and had affectively no Articular
cartilage left on the left side of her right knee. I met Dr Atrah in the
theatre after changing into scrubs and boots and donning surgical mask and
gloves. I helped the performing team gown up and get ready for their surgery.
The patient, the lady of about mid 70s, was wheeled to the operating room,
anaesthetised from the lumbar spine down. We made brief Eye contact, the drapes
were put up to shroud her line of sight (as she was sedated yet conscious), The
chlorhexidine was applied to sterilise her right leg, and the first incision
was made to open the up and down to the bone.
Throughout the procedure, the
would would be drained of blood, and bleeding venules were cauterised. Atrah
prefers not to tourniquet the leg, as it causes a huge surge of blood post
surgery and could potentially lead to emboli. A few holes were drilled, part of
the bone were kept for sizing of the new tibiofemoral joint, Some angled cards
were made and rounded off, and after the trial joints were put in place, the
plastic patella and shiny steel femoral condyles and tibial head were cemented
in place. The doctors gave me some of the excess cement from the joint to hold
in my hand, and I felt it both create an exothermic reaction (helps bone
regrowth and vascularity) and harden to a rock.
After the procedure, the
patient was stitched up, and I was told that she would be able to walk on it
tomorrow.the whole procedure was like watching an artisan work in his workshop,
a carpenter building the new queen's throne. I was invited to see surgery
performed again the following day, and gladly opted to do so. I was treating hip
and knee patients as an Occupational Therapy student, and now, I was getting to
see the procedures I was treating in real time with real physician and patient
interactions.
For the hip surgery on 5/2, i
had a quick lunch and straight down to theatre to meet Mr Atrah once more. Per
the day prior, there was an airflow machine that cleaned the air of any
pathogens, sterile surfaces, debridement and cauterising tools, a liquid drainer,
and lots of sterile tools. The lady, previously having her opposite hip done,
chose to not have sedation. The leg was draped in an iodine wrap to isolate and
prevent infection, and the first incision was made. After severing the
gracilis, tensor fascia latae, vastus lateralus, gluteus minimus, and glutus
medius, the adipose tissue was separated and the femoral head was found. A bone
saw cut the capsule from the trochanteric notch, and the acetabulum was reamed
and bored out. The metal insert, after a trial run, was hammered into the
acetabulum, followed by the polyethylene socket that emulates articular
cartilage.
After this bit, a bit of
debridement was done, and the surgeon malleted a wedge into the patient’s intertrochanteric
neck to form an opening for the new head of femur (typically steel, chromium,
or cobalt) to be inserted with a few more sledgings. I was called over to the
surgical table to see the patient’s new, artificial hip flexing, extending, and
rotating. Under spinal anaesthesia, the patient could feel these movements, but
the sensations were dulled and painless. The severed muscles were stitched back
together (they would recover in a few weeks, just as muscles recover
post-workout), and the adipose tissue, dermis, and epidermis were sutured back
together. Finally, the epidermis was stapled, a bandaged was placed over the area,
and I followed the patient back to the recovery room, where she was desperate
for a cup of tea (as is the English way, I suppose).
Comparing these two surgeries
to another is like comparing oranges to tomatoes – one is a fruit, and one is
sort of like a fruit. In both cases, old arthritically affected joints were
sawed away, and shiny new metallic/plasticine parts were implanted. In both
cases, the patients were anesthetised from the lumbar spine down. Surgical
precautions were followed, and I saw a lot of similar tools (save the ones that
aligned the knee or hip and allowed for measurement, angling, and/or the actual
replacement). The surgeon was happily working his task, the team lead would
suture and staple the patient’s affected parts back together, and the surgical
assistant was deafeningly busy.
The major differences however
lied in the surgical process itself. With the knee, three separate bones - the
condylar surfaces, posterior patella, and tibial head - were sawed in places
and eventually replaced with metal (save the patella, which was plastic). With
the hip, there were only two; the head of the femur and the acetabulum (with it
all being metal sans the articular cartilage, which was polyetheline). The hip
was much deeper than the femur, and more muscles had to be severed and then
stitched together for the surgery to be successful. The knee had to be properly
aligned, and the trial process was much more intense. Just as well, knee
surgeries typically use cementing, whereas hips do not. I also noticed that a
lot more blood and marrow came from the knee operation than the hip, in spite
of all of the muscles and fat that were severed.
Comparing surgical theatre
between the USA (my homeland) and the UK, theatres in the US were more compact,
had more equipment, and had a bigger team of clinicians present. However, in
the UK, the infection control process was seemingly stricter. These differences
may also very well be a product of the actual operation itself as well: I saw
elective surgery in the UK, but the one in the states was done to save a
patient’s life (bypassing the Left Anterior Descending artery of the heart
using the Left Internal Mammary Artery).
The whole experience was exhilarating,
to say the least. Most of my friends consider themselves squeamish; I am quite
the opposite, save for a few bodily fluids. The bone cement sort of freaked me
out with the exothermic reaction, and I had a few ‘oh my god’ moments under my
breath during the procedures – namely when the bone bits started flying. Being informed of different parts of the
surgical process was also very exciting. I wish I had more time to develop and
ask more questions; albeit, most were answered during the surgical process.
All in all, I'm very thankful the procedures I've been able to observe. Next up in this process is to learn more about redesigning the home and broadening my clinical knowledge. Catch you all soon!
