Equipment Preparation

Immediately prior to an orthopedic surgery, the operating room is established with the appropriate equipment and instrumentation depending on the type of orthopedic procedure (Box 37.1, Figure 37.1). Creating a list of commonly used instruments and each surgeon’s preferences for a variety of procedures may help with efficiency when setting up an operating room (Figure 37.2). Heating systems are turned on. Intravenous fluids are spiked and primed. Anesthetic machines are checked for leaks (Figure 37.3), and an induction area is prepared with the necessary materials.

At this point, the appropriate diagnostic tests, including blood work, have been performed on the patient, and an intravenous catheter has been placed. When placing an intravenous catheter, consideration of the affected limb undergoing surgical intervention should be taken. For example, if performing surgery on the right radius/ulna, the IV catheter should be placed on the opposite forelimb or hindlimb. Depending on the patient’s signalment and history, a preoperative ECG should be performed to assess for an arrhythmia.

After the patient has been placed under general anesthesia, they can generally be positioned in lateral recumbency for preparation of the skin (side will depend on the laterality of the affected limb). Monitoring equipment can then be attached, including but not limited to electrocardiogram, pulse oximetry, non‐invasive blood pressure, and a capnometer. If a patient’s position needs to be adjusted at any point, it is ideal to disconnect the breathing circuit from the patient’s endotracheal tube to prevent extubation or tracheal damage.

Skin Preparation

If performing an elective surgery (e.g., medial patella luxation repair), it is advised to check the skin over the proposed surgical area, preferably before the patient is under general anesthesia. This can help determine if surgery needs to be delayed until the possible infection is cleared to minimize the risk of post‐surgical site infection. Since the duration of anesthesia correlates with infection rates, preoperative preparation should be thorough but efficient. Clipping should be performed outside of the operating room to minimize contamination. The technician should wear exam gloves while clipping. With a #40 clipper blade, shave the entire circumference of the affected limb in the region that includes the proximal and distal bone or joint relative to the affected bone or joint (Table 37.1). In some cases, the distal portion of the limb may remain unclipped (Figure 37.4). If a wound is present around the surgical area, sterile lube can be applied to the wound prior to clipping to prevent hair from entering the wound site. If a bone autograft is needed, confirm with the surgeon which additional sites need to be clipped. Be sure to watch the temperature of the clipper blade. If the blade becomes palpably hot, either replace the blade or spray with a cooling lubricant. In areas with friable, thin skin, it is advised to have steady movements to reduce the risk of unwanted abrasions. After clipping is completed, a vacuum can be used to pick up loose hair.

If there is an unclipped portion of the limb remaining, it can now be covered. Wrap the limb using an exam glove, covering all hair. Next, cover and secure the glove with tape until the glove is no longer visible. Be careful not to over‐stress the tape, cutting off blood circulation. Covering the foot this way will later allow the surgical limb to be scrubbed and included into the sterile field (Figure 37.5).

The technician should replace their exam gloves for the “dirty” scrub. Have two stacks of non‐woven gauze set aside. Keep one stack dry and the other one mildly dampened with water (Figure 37.4). Lightly pour chlorhexidine scrub onto the dampened gauze. Begin scrubbing from the center of the expected incision site and continue moving outward in a spiral course until the shaved region has been covered. Avoid an aggressive scrubbing motion to reduce the risk of skin irritation and inflammation. Follow it with the dry gauze to clear excess lather. This combination is repeated a minimum of three times or until the gauze no longer contains visible debris. If the foot was clipped, debris can be better removed by soaking it in a diluted chlorhexidine solution. For long‐haired patients, water or ultrasonic gel can be used to push the hair down to keep it away from the surgical field.

Preoperative Considerations

Local incisional anesthesia, an epidural, and a regional nerve block are all acceptable pain management strategies (Figure 37.6). If the doctor or technician plans on administering the epidural or nerve block, it can be done after the “dirty” scrub. Adding an intravenous constant rate infusion of an analgesic is another good strategy that can be applied if none of the above‐mentioned is possible.

If the anus is in close proximity to the proposed surgical area, a purse‐string suture technique can be applied to protect the surgical site from potential fecal contamination. Manual deobstipation and expression of the anal glands should be done prior to the purse string placement.