18 Lower extremities 18

18 Lower extremities

18.1 Hips – 236

18.1.1 Supine position – 236 18.1.2 Lateral position – 238

18.2 Thigh – 240

18.2.1 Supine position – 240

18.2.2 Modified supine position – 242 18.2.3 Lateral position – 244

18.3 Knee – 246

18.3.1 Supine position – 246 18.3.2 Prone position – 248

18.4 Lower leg – 250 18.4.1 Supine position – 250

18.5 Foot – 252

18.5.1 Supine position – 252

18.5.2 Lateral position – 254

18.5.3 Prone position – 256

18.1 Hips

18.1.1 Supine position

. Figs. 18.1–18.5.

Indications

Ventral, anterolateral and lateral access to the hip joint for coxarthrosis, fracture of the neck of the femur, loosening of a hip replacement, necrosis of the head of the hip and tumours.

Preparations

4

Arm positioning devices

4

Shaving in the area of the incision and preoperative skin cleansing Positioning

4

Standard operating table position 1, position 2 or universal operating table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Normal positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Position both arms on the arm positioning device in abduction position

Apply the neutral electrode and connect to the HF surgery device

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

Position the operating lights

Patient warming system Risks

4

Secondary dislocation

. Fig. 18.1. Supine position on universal operating table with CRP back plate 1150.45 and supported extension plate

. Fig. 18.2. Supine position on CRP operat- ing table 1150.16 for 360° use of the image intensifier

. Fig. 18.4. Masking the extremity for preoperative skin disinfection and additional moisture protection also during the operation (7 see Fig. 18.15 on p. 243)

. Fig. 18.5. Good covering techniques allow for movement of the extremity (7 see Fig. 18.17 on p. 243)

. Fig. 18.3. Supine position on operating extension table (1150.20) with special leg plates for optimum fluoroscopy of the hips 18.1 · Hips

18.1.2 Lateral position

. Figs. 18.6–18.8.

Indications

Anterolateral and lateral access to the hip joint for coxarthrosis, fracture of the neck of the femur, coxitis, loosening of a hip replacement, resection arthro- plasty and tumours.

Preparations

4

Arm positioning devices

4

Shaving in the area of the incision and preoperative skin cleansing

Gel ring, gel cushion, Goepel leg holder, side supports, radial adjusting

clamps, padded cushions (normal and flat) and wedge cushions or tunnel cushions, body belts

Positioning

4

Standard operating table position 1, position 2 or universal operating table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Normal positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Fit the radial adjusting clamp to the side rail of the head plate, position the Goepel leg holder and place a gel padded mat on the operating table

Spread out the arm on the side not being operated

4

Move the patient over onto the healthy side

4

Move the lower arm forwards so that the weight of the upper body does not lie directly on the shoulder

4

Fit the body supports to the rails and brace on the level of the sacrum and symphysis

4 1st possibility:

position the legs with the padded cushions (normal and flat) and possibly wedge cushions

4

Fix the lower leg and the positioning aids with the body belts

position the legs with the tunnel cushion

Apply the neutral electrode and connect to the HF surgery device

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

Position the operating lights

Patient warming system Risks

4

. Fig. 18.6. Lateral position on CRP operating table 1150.16 with 2 CRP accessory adapters and lateral positioning cushion for anatomic positioning of the lower arm

. Fig. 18.8. Lateral position on universal operating table with lateral positioning cushion and operating table in flex position for neutral position of the spinal cord 18.1 · Hips

. Fig. 18.7. Lateral position on universal operating table with vacuum mat

18.2 Thigh

18.2.1 Supine position

. Figs. 18.9–18.13.

Indications

Ventral, lateral and medial access to the femur for fractures, posttraumatic misalignment, osteitis and tumours.

Preparations

4

Arm positioning devices

4

Shaving in the area of the incision and preoperative skin cleansing Positioning

4

Standard operating table position 1, position 2 or universal operating table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Normal positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Position both arms on the arm positioning device in abduction position

Apply the neutral electrode and connect to the HF surgery device

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

Position the operating lights

Patient warming system Risks

4

Secondary dislocation

. Fig. 18.9. Supine position on universal operating table with CRP back plate 1150.45 and supported extension plate

. Fig. 18.10. Supine position on CRP oper- ating table 1150.16 for 360° use of the image intensifier

18.2 · Thigh

. Fig. 18.12. Masking the extremity for preoperative skin disinfection and additional moisture protection also during the operati- on (7 see Fig. 18.15 on p. 243)

. Fig. 18.13. Good covering techniques allow for movement of the extremity

(7 see Fig. 18.17 on p. 243)

. Fig. 18.11. Supine position on operating extension table (1150.20) with special leg pla- tes for optimum fluoroscopy

18.2.2 Modified supine position

. Figs. 18.14–18.17.

Indications

Closed and open osteosynthesis procedures to the femur requiring intraope- rative fluoroscopy with a lateral ray path.

Preparations

4

Arm positioning devices

4

Shaving in the area of the incision and preoperative skin cleansing

Anaesthesia screen, Goepel leg holders, radial adjusting clamps, gel

cushion, side rail connection piece

Positioning

4

Standard operating table position 1, position 2 or universal operating table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Normal positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Fit the radial adjusting clamp to the side rail of the head plate on the side not being operated and fix the anaesthesia screen

4

Position the arm on the healthy side on the arm positioning device in the abduction position and fix the other arm with Velcro straps to the anaes- thesia screen over the thorax

4

Fit the side rail connection piece to the short side rail of the seat plate on the side not being operated (operating table 1120)

4

Fit the radial adjusting clamp and Goepel leg holder

Position the healthy leg on the Goepel leg holder

4

Apply the neutral electrode and connect to the HF surgery device

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

Position the operating lights

Patient warming system Risks

4

Secondary dislocation

4

Nerve injuries (pudendal nerve)

. Fig. 18.14. Supine position with leg in abduction on Goepel leg holder and left arm positioned at the anaesthesia screen (use of the image intensifier swivelled through)

. Fig. 18.17. Good covering techniques allow for movement of the extremity

. Fig. 18.16. Positioning the fractured leg on a leg plate with use of the image intensifier

. Fig. 18.15. Masking the extremity for preoperative skin disinfection and additional moisture protection also during the operation 18.2 · Thigh

18.2.3 Lateral position

. Figs. 18.18–18.20.

Indications

Lateral access to the femur for fractures, posttraumatic misalignment, osteitis and tumours.

Preparations

4

Arm positioning devices

4

Shaving in the area of the incision and preoperative skin cleansing

Gel ring, gel cushion, Goepel leg holder, side supports, radial adjusting

clamps, padded cushions (normal and flat) and wedge cushions or tunnel cushions, body belts

Positioning

4

Standard operating table position 1, position 2 or universal operating table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Normal positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Fit the radial adjusting clamp to the rail of the head plate, position the Goepel leg holder

4

Spread out the arm on the side not being operated

Move the patient onto the healthy side

4

Move the lower arm forwards so that the weight of the upper body does not lie directly on the shoulder

4

Fit the body supports to the side rails and brace on the level of the sacrum and symphysis

4 1st possibility:

position the legs with the padded cushions (normal and flat) and possibly wedge cushions

4

Fix the lower leg and the positioning aids with the body belts

position the legs with the tunnel cushion

Apply the neutral electrode and connect to the HF surgery device

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

Position the operating lights

Patient warming system Risks

4

Injury to the peroneal nerve

. Fig. 18.18. Lateral position on CRP oper- ating table 1150.16 with 2 CRP accessory adapters and lateral positioning cushion for anatomic positioning of the lower arm

. Fig. 18.19. Lateral position on universal operating table with vacuum mat

. Fig. 18.20. Lateral position on universal operating table with lateral positioning cushion and operating table in flex position for neutral position of the spinal cord 18.2 · Thigh

18.3 Knee

18.3.1 Supine position

. Figs. 18.21–18.25.

Indications

Lateral, medial, posteromedial, para- and transpatellar access to the knee joint for gonarthrosis, fractures, posttraumatic misalignment, infection, loosening of knee replacements, synovitis, tumours, ligament injuries and arthrofibrosis.

Preparations

4

Arm positioning devices

4

Shaving in the area of the incision and preoperative skin cleansing

Apply a tourniquet in position

Positioning

4

Standard operating table position 1, position 2 or universal operating table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Normal positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Position both arms on the arm positioning devices in the abduction position

4

Apply the neutral electrode and connect to the HF surgery device

Connect the compressed air supply to the tourniquet

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

Position the operating lights

Patient warming system

. Fig. 18.21. Legs positioned on divided leg plates with individual adjustment

. Fig. 18.22. Scanning possible through 360°

. Fig. 18.25. Foot holder for total replacement of the knee joint . Fig. 18.24. Legs positioned on CRP operating table 1150.16

. Fig. 18.23. Legs positioned on single-section CRP module 1150.45 18.3 · Knee

18.3.2 Prone position

. Figs. 18.26, 18.27.

Indications

Rear access to the knee joint for ligament injuries, tumours, vessel and nerve lesions.

Preparations

4

Arm positioning devices

4

Shaving in the area of the incision and preoperative skin cleansing

Apply a tourniquet in position

Positioning

4

Standard operating table position 1, position 2 or universal operating table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Transfer to the prepared operating table in the induction room

Position both tables next to each other, with the prepared table lowered

Place the patient in prone position on the padded cushion of the prepared

operating table and take him into the theatre

4

Normal positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Position the head on the special head positioning cushion

Position both arms on the arm positioning devices

4

Apply the neutral electrode and connect to the HF surgery device

Connect the compressed air supply to the tourniquet

4

Arrange self-adhesive covers for preoperative skin disinfection

Position the operating lights

4

Patient warming system

. Fig. 18.26. Prone position on CRP operat- ing table 1150.16 with CRP head plate for 360°C use of the image intensifier at the knee

. Fig. 18.27. Prone position on universal operating table 1150.30 with arms positioned in maximum 90° abduction

18.3 · Knee

18.4 Lower leg

18.4.1 Supine position

. Figs. 18.28–18.33.

Indications

Access to the shaft of the tibia, lateral access to the fibula, lateral and medial access to the head of the tibia for fractures, misalignment, pseudarthrosis, osteitis, tumour and fibula removal.

Preparations

4

Arm positioning devices

4

Shaving in the area of the incision and preoperative skin cleansing

Apply a tourniquet in position

Positioning

4

Standard operating table position 1, position 2 or universal operating table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Normal positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Position both arms on the arm positioning devices in abduction position

Apply the neutral electrode and connect to the HF surgery device

Connect the compressed air supply to the tourniquet

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

Position the operating lights

Patient warming system

. Fig. 18.28. Legs positioned on divided CRP leg plates with individu- al adjustment

. Fig. 18.29. Fluoroscopy possible through 360°

. Fig. 18.30. Legs positioned on single-section CRP module 1150.45 . Fig. 18.31. Legs positioned on CRP operating table 1150.16

. Fig. 18.32. Minimally invasive operation to the tibia with image intensifier in anteroposterior position

. Fig. 18.33. Lateral fluoroscopy of the tibia with left leg lowered 18.4 · Lower leg

18.5 Foot

18.5.1 Supine position

. Figs. 18.34–18.39.

Indications

Ventral, anterolateral, medial and posteromedial access to the ankle joint, access to the inner malleolus and outer malleolus, lateral and medial access to the talocalcaneonavicular, front, medial and plantar access to the middle foot and to the toes for fractures, posttraumatic, congenital and acquired misalignment, arthrosis, synovitis, osteochondral lesions, soft tissue lesions and tumours.

Preparations

4

Arm positioning devices

Wedge cushion, body support

4

Shaving in the area of the incision and preoperative skin cleansing

Apply a tourniquet in position

Positioning

4

Standard operating table position 1, position 2 or universal operating table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Normal positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Position both arms on the arm positioning device in abduction position

Apply the neutral electrode and connect to the HF surgery device

Connect the compressed air supply to the tourniquet

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

Position the operating lights

Patient warming system

. Fig. 18.34. Legs positioned on divided CRP leg plates with individual adjustment

. Fig. 18.36. Divided leg plates with individual adjustment . Fig. 18.35. Legs positioned on divided leg plates with use of the

image intensifier

. Fig. 18.37. Optimum scanning possibility with lateral ray path due to lowered leg plate

. Fig. 18.38. Body support with wedge cushion padding under the pelvis on the other side

. Fig. 18.39. Preoperative skin disinfection and additional moisture protection during the operation

18.5 · Foot

18.5.2 Lateral position

. Figs. 18.40–18.43.

Indications

Access to the fibula and Achilles tendon, lateral access to the calcaneus and talocalcaneonavicular, medial and posteromedial access to the calcaneus and talocalcaneonavicular for fractures, posttraumatic, congenital and acquired misalignment, arthrosis, synovitis, osteochondral lesions, tumours and soft tissue lesions.

Preparations

4

Arm positioning devices

4

Gel ring, gel cushion, Goepel leg holder, lateral supports, radial adjusting clamps, padded cushions (normal and flat) and wedge cushions or tunnel cushions, body belts

4

Shaving in the area of the incision and preoperative skin cleansing

Apply a tourniquet in position

Positioning

4

Standard operating table position 1, position 2 or universal operating table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Normal positioning of the operating table in the theatre

4

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Fit the radial adjusting clamp to the side rail of the head plate, position the Goepel leg holder and place a gel mat on the operating table

4

Spread out the arm on the side not being operated

Move the patient onto the healthy side

4

Move the lower arm forwards so that the weight of the upper body does not lie directly on the shoulder

4

Fit the radial adjusting clamps to the side rails of the back plate and posi- tion the body supports on the level of the coccyx and symphysis

4 1st possibility:

position the legs with the padded cushions (normal and flat) and possibly wedge cushions

4

Fix the lower leg and the positioning aids with the body belts

position the legs with the tunnel cushion

Apply the neutral electrode and connect to the HF surgery device

Connect the compressed air supply to the tourniquet

4

Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4

. Fig. 18.40. Legs positioned on single- section CRP module 1150.45 with padded cushion

. Fig. 18.43. Stable positioning of the foot and optimum access for the surgeon with use of the image intensifier from the opposite side in both levels

. Fig. 18.42. Lateral positioning on CRP operating table 1150.16 with CRP accessory adapter and lateral positioning cushion for anatomic positioning of the lower arm

. Fig. 18.41. Legs positioned on divided CRP leg plates with tunnel cushion

18.5 · Foot

18.5.3 Prone position

. Figs. 18.44, 18.45.

Indications

Posterolateral access to the talocalcaneonavicular and concealed osteosyn- thesis in the calcaneal part of the foot.

Preparations

4

Arm positioning devices

4

Shaving in the area of the incision and preoperative skin cleansing

Apply a tourniquet in position

Positioning

table

4

Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4

Transfer to the prepared operating table in the induction room

Position both tables next to each other, with the prepared table lowered

Place the patient in prone position on the padded cushion of the prepared

operating table and take him into the theatre

44

When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4

Position the head on the special head positioning cushion

Position both arms on the arm positioning devices

Connect the compressed air supply to the tourniquet

4

Arrange self-adhesive covers for preoperative skin disinfection

Position the operating lights

4

Patient warming system

Standard operating table position 1, position 2 or universal operating

Normal positioning of the operating table in the theatre

Apply the neutral electrode and connect to the HF surgery device

. Fig. 18.44. Prone position on universal operating table 1150.30 with arms positioned in maximum 90° abduction

. Fig. 18.45. Use of the image intensifier in anteroposterior position. C-arm with colour- ed handles for better communication bet- ween surgeon and operator

18.5 · Foot