OCTOBER 1999, VOL 70, NO 4

Home Study Program HARWSllNG AND IMPLANTlNG ALLOGRAFe BONE

he article “Harvesting and implanting allograft bone” is the basis for this AORN Journal independent study. The behavioral objec- tives and examination for this program were prepared by Jeanne F. Hately, RN, MSN, CNOR, clinical editor, with consultation from Eileen Ullmann, RN, MHS, CNOR, professional education

specialist, Center for Perioperative Education. A minimum score of 70% on the multiple-choice examination is

necessary to earn two contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of comple- tion. The deadline for submitting this study is Nov 30, 2000.

Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to

AORN Customer Service c/o Home Study Program

2170 S Parker Rd, Suite 300 Denver, CO 8023 1-57 1 1

Or fax the information with a credit card number to (303) 750-3212

BEllAVlORlll OBJECTIVES After reading and studying the article on harvesting and implanting

allograft bone, the nurse will be able to (1) describe the uses of allograft bone, ( 2 ) identify sources of allograft bone, and (3) discuss the role of the perioperative nurse during the procurement

of allograft bone.

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Harvesting and Implanting Allograft Bone

llograft bone (ie, bone that is obtained from a donor) implantation is used for reconstructing serious bone defects. It is used for reconstruc- tion of bone loss during total joint revision surgery and bone replacement after large

bones that form the coxal bone (ie, the ilium, ischi- um, and pubis). The hip joint’s actions are flexion, extension, adduction, abduction, circumduction, and rotation: The depth of the hip joint is increased by a rim of fibrocartilage known as the acetabular labrum.5 The joint is completely enclosed by a strong, dense, ligamentous joint capsule extending from the margin of the acetabulum above to the femoral neck below. The joint capsule is lined by an extensive synovial membrane that commences at the margin of the cartilaginous surface of the femoral head and covers the portion of the femoral neck con- tained within the joint. From there, it is reflected back to cover the internal surface of the capsule and the fat mass contained at the base of the acetabulum and forms a tubular sheath around the ligamentum teres (Figure 1). Blood flow to the hip joint is sup- plied by the obturator, femoral circumflex, and gluteal arteries. The articular branches from the sacral plexus, great sciatic, obturator, and accessory obturator nerve and a filament from the branch of the anterior crural nerve provide the nerve upp ply.^

The hip joint is reinforced by strong ligaments: the anterior iliofemoral ligament, the inferior pub- ofemoral, and the spiraling posterior ischiofemoral

ligament (Figure 2). The way in which the ligaments are arranged secures the femoral head into the acetabulum when standing, giving stability to the joint (Figure 3). The ligamentum teres (ie, the ligament of the femoral head) is a flat intra- capsular ligament running from the femoral head to the lower lip of the acetabulum. The mechanical functions of the ligamentum teres are unclear because it is slack dur- ing most hip movements. It does

excisions of bone tumors.

HISTORY OF ALLOGRAFT BONE USE The scientific basis for bone transplantation

originated in the mid-nineteenth century with studies on the osteogenic properties of bone and periosteum and the beneficial influence of freezing in preserving these characteristics. In 1881, a Glasgow surgeon described the use of bone grafts to reconstruct a child’s humerus when part of the bone was lost from surgical intervention. In 1907, an entire knee joint was transplanted.’ The first reported use of preserved bone in orthopedic surgery was in 1942.2 Since then, the use of allograft bone has become common.s

ANATOMY AND PllysloLOGY OF THE HIP JOINT The hip joint is an enarthrodial (ie, ball and

socket) joint formed by the articulation of the femoral head and the acetabulum. It is a hemispher- ical socket located at the point of fusion of the three

A

A B S T R A C T Allograft bone (ie, bone that is obtained from a donor) implan-

tation is used for bone replacement and for reconstructing serious bone defects during total joint revision surgery. It is also used for bone replacement after large excisions of bone tumors. An extensive variety of laboratory tests must be completed, appropriate storage facilities for allograft bone have to be available, and protocols must be developed before a facility can set up a bone bank. Many ethical issues and nursing responsibilities need to be considered before the decision is made to use allograft bone. AORN J 7 0 (Oct 1999) 660-670.

G O R D O N C A R T E R , R N

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not appear to be important in stabilizing the hip joint, but it is important because it carries part of the blood supply to the femoral head.'

PURPOSE OF BONR BANKING The main purpose of a bone bank is to provide

allograft bone that is free of known transmissible diseases for surgical reconstruction and replace- ment. Obtaining allograft bone is an expensive pro- cedure, but it can be done cost-effectively. Certain criteria must be followed before a piece of allograft bone can be used. The criteria require the potential donor be screened and tested for known transmissi- ble diseases.

Sources of allograft bone. Bone stored for future use is obtained from two sources. One of the most fre- quently used sources are femoral heads taken from patients during primary total hip replacement surgery.

Cadavers are another source of allograft bone supply. Multiple long bones and sections of pelvis can be obtained from one cadaveric donor when procuring other transplantable tissue.

Exclusion criteria. At Waikato Hospital, Hamilton, New Zealand, potential donors scheduled for hip replacement surgery are screened using a ques- tionnaire that asks if they have or have had rheumatoid disease, neoplasms (other than basal cell carcinomas, which are usually noninvasive), an autoimmune dis- ease, or a communicable disease, or whether they have a lifestyle that places them at risk for a commu- nicable disease. After the questionnaire is answered and the donor meets the eligibility criteria, he or she signs a bone donor consent form that allows blood testing to be done and the bone to be harvested. This is necessary because the donor has to give informed consent for blood tests. At Waikato Hospital, we test for hepatitis B surface antigen, hepatitis B total core IgM antibody, hepatitis C antibody, HIV antibody, and syphilis serology. Negative serology is required on all tests to meet the eligibility criteria.

Blood test results are sent to the charge nurse of the orthopedic OR, who is also the bone bank coordi- nator, The bone bank coordinator collects all results and creates files, which are kept in the bone bank office, for each donor.

In an attempt to reduce the risk of exposure to potential recipients to hepatitis B, C, and HIV, donor bone is quarantined for six months. After six months, live donors are recalled for another blood screen. If the blood screen is negative, the bone is cleared for patient use. For cadaver donors, a six-month recall

Figure 1 . Cross-sectlon view of right hip joint. (ll1ustration by Mark Katnik, Denver)

for a repeat blood screen to satisfy the criteria is impossible; therefore, confidential inquiries are made about the health status of soft tissue viscera recipi- ents.* Confidentiality in these cases is paramount. The information is entered in a computer database and a security code is used. Hard copies of each file are kept in the bone bank office in the orthopedic OR to comply with the bone banking guidelines of the Australasian College of Surgeons.

Procurement of aUograj2 bone. Procurement of bone is performed under strict aseptic conditions. Allograft bone is usually obtained during routine total hip replacement when the femoral head is excised. The surgeon removes excess soft tissue, and some of the tissue is used as a sample for microbiology to test for unknown infectious organisms. The femoral head is swabbed with a microbiological culture swab to check for possible contamination that might have occurred during handling. The scrub person places the femoral head in a sterile screw-top plastic container, which is then placed in a larger screw-top plastic con- tainer and passed off the sterile field to the circulating nurse, who numbers, labels, and places it in ice in a polystyrene foam container. It is then transported to the blood donor center, where it is held in quarantine for six months in an -85" C (-185" F) freezer.

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Figure 2 Posterior view of right hip joint. (///ustfarion by Mark Katnik, Denver)

Cadaveric bone is procured at the end of a mul- tiorgan retrieval after the removal of soft tissue vis- cera. As described in the Australian Orthopaedic Association's National Guidelines for Bone and Tissue Banking in Australia, bone retrieval after vis- ceral retrieval can give the donor's body a macabre appearance; therefore, a calm, dignified environ- ment must be created to preserve the dignity of the deceased donor. It is important to reconstruct the cadaver with appropriately sized rigid structures to prevent disfigurement.'

Cadaveric bone may be retrieved from the mor- tuary in some centers; however, the OR is preferable because an aseptic environment can be maintained, and freshly harvested and frozen bone is structurally stronger than bone harvested in the mortuary. Bone harvested in a mortuary requires irradiation to steril- ize it because the mortuary is not considered a sterile environment.

Cadaveric bones are often long bones (eg, femurs) or sections of pelvis and cannot be placed in small sealed plastic containers. The larger bones, regardless of where they are harvested, must be wrapped in sterile wraps and sealed in two sterile plastic bags. The bone segment is swabbed with a microbiological culture swab before it is placed in the

sterile wrap. The purpose of swabbing is to make sure contamination in handling has not occurred during retrieval. After the bone sections are packaged, they are labeled and numbered with an identifying number and sent to the freezer to be quarantined.

USES FOR ALLOGRAFT BONE Allograft bone is most often used to reconstruct

acetabular and femoral defects in total hip revision surgery as either impacted morselated (ie, minced) bone or structural allografts. At Waikato Hospital, we use allograft bone as proximal femoral structural allo- grafts during total hip revision surgery, distal femoral and proximal tibia1 replacement during total knee revision surgery, and femoral diaphyseal bone as strut grafts to femurs. Strut grafts are sections of mid-shaft femoral diaphysis bones that are split lengthwise and used as a reinforcement for fractured bone or bone that has weakened as a result of osteolysis (ie, degenera- tion of bone caused by disease, infection, or ischemia). Distal femoral bones are sometimes used for replacement after excisions of femur bone tumors.

Allograft bone is most frequently used during total hip revision surgery and is indicated for use when previously implanted prostheses have failed (eg, aseptic loosening, periprosthetic fractures). Osteolysis occurs around the femoral stem and behind the acetabular cup components when the bony substance is lysed away, which causes the pre- viously implanted prostheses to loosen and move, causing pain. Severe osteolysis places the patient at risk for periprosthetic fractures. In these situations, impacted allograft bone is indicated for use. Aseptic loosening and the accumulation of polyethylene debris occurs from wear of the components at the articulation of the previously implanted femoral head and acetabulum and is thought to be the pri- mary reason for prosthetic failure. Other reasons for failure are less developed prosthetic designs and poor surgical and cementing techniques."

Allografts are used in several ways to repair bony defects. Donor femoral heads are morselated in a bone mill for impaction in the surgical site. Cortical bone defects are replaced with impacted morselated allograft bone followed by prosthetic cementing.

PREOPERATIVE CARE FOR PAnEMS RECEIVING ALLOGRAFTS

In the Waikato Hospital preadmission clinic, one week before their surgery, patients are assessed, and x-rays and routine laboratory blood samples are taken.

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A complete blood count, hemoglobin, hematocrit, international normalized ratio (INR) to determine clotting status, and a baseline of the same blood tests required from bone donors are taken. The blood tests screen the bone recipients to see if they have had, or are in, a carrier state preoperatively for any of the con- ditions for which bone donors are screened. This can provide documentation against future accusations from bone recipients, who may imply that they have contracted a condition from the implanted donor bone. A bone bank recipient consent form is used to obtain consent to receive bone from the bone bank if it is needed during surgery.

Preoperative nursing assessments, patient educa- tion and instruction, routine blood clot prophylaxis, and low molecular weight heparin is begun in the ward. Patients who have not been on anticoagulant therapy are admitted to the ward the day before sur- gery. Patients who have known clotting problems are admitted three to five days preoperatively to stabilize them on heparin and to keep their partial thrombo-

Figure 3 Anterior view of right hip joint. (//lustration by Mark Katnik, Denver)

plastin time (PTT) between 60 and 100 seconds. Five thousand units of heparin are given IV, then an infu- sion of 10,000 units in 100 mL of normal saline is infused per IV pump. The rate of infusion is individ- ualized for each patient. The patient's ITT is meas- ured six hours after the initial infusion and then daily at 8 AM or every six hours if the control is poor. The heparin is discontinued when the patient's INR is 2.0 for 24 hours, or the patient is kept on heparin for three to four days, at which time he or she is started on oral anticoagulants. International normalized ratio meas- ures the patient's prothrombin time (PT) in seconds. The patient's PT in seconds is divided by the normal clotting control value in seconds. Normal INR value is 0.9 to 1.2, and the therapeutic range is 2.0 to 4.0."

Patients are instructed by the ward nurse that they will have wound drains and that a urinary catheter will be in place for approximately 24 to 48 hours postoperatively. Patients are also instructed about bed rest, hip abduction, passive range of motion exercises, and nutrition. The patient's surgical site is prepared on the ward by shaving the hip area around the upper outer aspect of the thigh. Some sur- geons prefer to shave the surgical site themselves, in the OR, immediately before the surgical prep. Patients are fitted with antiembolic stockings that they wear for six weeks after they are discharged from the hospital.

On the day of surgery, the patient is transported to the preoperative holding area, where he or she is interviewed by the circulating nurse, who verifies NPO status, allergies, confirmation of the surgical site, presence of anesthesia and surgery consent forms, and bone bank recipient consent form. The nurse checks that patient x-rays (ie, recent anterior and posterior films of the pelvis and femur, lateral films of the hip) have been ordered and are in the OR. The circulating nurse looks at the surgical site to verify that the surgeon has marked the area with an arrow drawn to verify the surgical side. When the assessment is complete, the circulating nurse signs the check-in form.

The patient is bought into a room adjacent to the OR, where the anesthesia care provider inserts the IV lines. An epidural or spinal anesthetic often is used in combination with a general anesthetic. It is common practice in Waikato Hospital for anes- thesia care providers to combine spinal or epidural anesthetic with general anesthesia. Spinal and epidural anesthetics have a twofold purpose. One is to decrease intraoperative blood loss by reducing

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circulating blood volume through sympathetic blockade, and the other purpose when using epidurals is to provide postoperative pain relief.

Operating room preparation. The circulating nurse verifies the surgical hip side with the scrub per- son and assists him or her in opening the sterile instrument sets. Equipment is checked for readiness before the patient is brought into the OR. The circu- lating nurse checks the implants (ie, acetabular cups, femoral stems, femoral heads), cerclage cables, and acetabular and stainless steel mesh for readiness. Cerclage cables and mesh are on hand because total hip revision procedures that require allograft bone impaction often have large bone defects in the acetab- ulum or femoral shaft that require repair before the bone can be impacted. Approximately three allograft femoral heads are on hand for filling both acetabular and femoral defects. Allograft diaphyseal bone struts may be needed to reinforce femoral shaft fractures that may result from osteolysis, which leaves the femoral cortex extremely thin and fragile.

The equipment necessary for the total hip replace- ment includes the electrosurgical unit, power equip- ment, pulse lavage system, suction unit, Mayo stand, two kick buckets, four back tables, and patient position- ing equipment. A curved back support (ie, for lateral support during lateral positioning) and a tubular upright pelvic support made with nonconductive antistatic rub- ber are used for positioning. A beanbag positioning aid, used for lateral positioning of the patient, is placed on the OR bed so that it is under the patient when he or she is transferred to the OR bed. The Circulating nurse also takes great care to ensure that adequate padding and pil- lows are available in the OR for positioning.

The cost of joint replacement components is considerable, and it is important that the OR staff members are careful when selecting and opening the size requested by the surgeon. In New Zealand, patients who have surgery in the public hospital sys- tem do not pay for their prostheses; however, staff members have to be mindful of the cost to taxpayers. Waikato Hospital has an annual expenditure of approximately $1 million NZ (ie, approximately $555,555 US) for total joint components. The cost of joint components and accessories in a total hip revi- sion with allograft impaction is approximately $5,000 NZ (ie, approximately $2,720 US).

Surgical instruments. The instruments used for a total hip revision procedure are a basic orthopedic set, total hip revision set, drill and reamer, oscillating saw, bone mill, osteotomes, curettes, and specific total hip

The circulating nurse takes

care to ensure that adequate

padding is available in the

OR for positioning.

replacement set to implant the new prosthesis. Zntraoperative patient care. To reduce the risks

of infection, we have followed AORN’s “Re- commended practices for traffic patterns in the peri- operative practice setting” to reduce traffic flow in our two orthopedic ORs. The patient is transferred from his or her ward bed to the OR bed in the anesthesia preparation room to reduce the amount of dust and other particles that can be brought into the OR.

The patient is brought into the OR on the OR bed, After the patient is anesthetized, an indwelling urinary catheter, if requested by the surgeon, is inserted by the circulating nurse. He or she assists the surgeon in posi- tioning the patient laterally, taking care to pad any bony prominences and ensuring the patient is not unnecessarily exposed. The circulating nurse then applies the electrosurgical unit dispersive pad to an appropriate area away from the surgical site and is careful not to position the pad over an area where there are any previous metal implants or bony promi- nences. Electrosurgical unit dispersive pad manufac- turers recommend avoiding placement of a dispersive pad over implanted metal devices as they may over- heat the metal and bum the patient’s tissue.” The cir- culating nurse elevates the patient’s leg for skin prepa- ration and draping. The surgeon preps the entire leg from above the waist to the patient’s foot. Solutions used are either 1% iodine in 70% alcohol or 0.5% chlorhexidine in 70% alcohol.

Draping. At Waikato Hospital, total hip and knee procedures are draped with large barrier fabric U drapes. The scrub nurse and surgeon place a large drape over the patient’s lower leg to provide a sterile surface to cover the patient’s nonsurgical leg and the OR bed. An adherent impervious split sheet with an adhesive edge is placed in position to seal off the per- ineum and is secured over the top of the iliac crest. A

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large barrier fabric U drape is placed over the adherent impervious split sheet to provide an absorbent surface. Another large barrier fabric U drape is secured at the head of the OR bed over a large wooden bar that func- tions as a face screen, and the tails of the U drape are secured with towel clips to seal off the perineum. The patient’s leg is lowered by the circulating nurse onto a smaller drape, whch is wrapped around the leg to maintain sterility and secured in place by a long stock- inette and elastic bandage. A surgical incise drape seals the stockinette in place. To allow free movement of the limb intraoperatively, a large drape is opened length- wise and shaped into a pocket to lower the leg over the side of the bed during the procedure.

After the patient is draped for the surgical proce- dure, the circulating nurse helps the scrub person move the Mayo stand and sterile tables into position and connects the suction, electrosurgical unit, and pneumatic instrument hoses to the nonsterile nitrogen hose from the wall outlet valve. The circulating nurse verifies that the pressure for the pneumatic instru- ment hose is 100 mm Hg in accordance with the man- ufacturer’s specifications stated on the instrument. He or she writes the surgical count from the surgical record form on the count board.

Surgical technique. The incision, preferably long postero-lateral, is made, with the excision of old scar tissue. The surgeon incises the fascia lata and divides the tendinous part of the gluteus maximus at its insertion point into the femur.

The surgeon locates and identifies the sciatic nerve. Other major landmarks are identified, such as the ischium, sciatic notch, anterior ischium, the glu- teus medius tendon, lower border of the gluteus min- imus, and the ilium superior to and posterior to the margin of the hip socket.

The surgeon exposes and incises the joint cap- sule. A culture swab is obtained and sent for an urgent gram stain. The surgeon is notified if organisms or excessive neutrophils are present as this is an indica- tion to possibly abort the procedure and wait for cul- tures of the swab. If the culture is positive, a decision is made to remove the old prosthesis and cement and replace them with an antibiotic spacer. The procedure can be completed at a later date when the organisms are no longer present in an aspirate.

If the cultures are negative, the surgeon proceeds with the procedure. He or she dislocates the failed prosthesis and removes the old implant. Care is taken in cases of severe osteolysis because fractures can occur during dislocation. The femoral component is

carefully removed so that the femur is not fractured while the proximal cement is obstructing the femoral opening. The acetabular component is removed, and when all the failed components have been extracted, traces of old cement are rem0~ed. l~

Preparation of the graft. Two or more donor femoral heads are opened onto the sterile table. They are culture swabbed and then placed into warmed povidone-iodine solution to thaw. They are divided into small pieces and morselated in a bone mill to the desired particle size. Blood compatibility is not nec- essary between the allograft bone and the recipient, except in the case of rhesus (Rh) negative women of childbearing age.I4

Acetabular preparation. It is important to pre- serve as much of the patient’s acetabular bone as pos- sible. The existing bone bed is roughened to provide a base for the acetabular cup replacement. When there is a large defect present, the bone bed is rough- ened in preparation for cortico-cancellous bone graft that is impacted into the defect. Wire mesh helps con- tain the impacted bone graft for larger defects.15 Depending on the degree of the defect, a replacement acetabular cup is cemented in place with polymethyl methacrylate bone cement, or a press fit uncemented acetabular shell is impacted into the acetabulum.

Femoral preparahon. The old bone cement and granulomatous and fibrous membrane are completely removed so that the medullary canal is totally free from debris. The surgeon irrigates the canal with the pulsatile lavage.

Prophylactic cerclage wiring is necessary when osteolytic portions of the femoral cortex are extremely thin, making them easy to fracture when bone is vigorously impacted. Allograft diaphyseal femoral sections may be needed as strut grafts to reinforce the femoral shaft.

The distal femur is occluded with either a plug of bone cement that is left in situ or a polyethylene bone plug of appropriate diameter that is inserted to approximately 2 cm beyond the most distal lytic area. A guide rod is screwed into this plug, which has a threaded hole to accommodate the threaded tip of the guide. The plug acts as a centralizer in the femoral shaft for the impactors to keep them in line. It is important that the alignment is neutral to avoid the impactor’s being in varus (ie, an abnormal position). Prepared morselated bone chips from the donor femoral heads are spooned into the femoral canal and positioned into place with the impactors.

After the correct femoral head and neck length

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Table 1 are determined, the femoral stem is cemented into position. The UNDERGOING TOTAL HIP REPLACEMENT SURGERY

POSTOPERATIVE INSTRUCTIONS FOR PATIENTS

femoral head is impacted onto the femoral stem, the hip joint is reduced, and the wound is closed.'6

Do the following: Use crutches or walker until seen in the clinic.

cPostoperative ure* The Continue normal walking activities at home. patient is transported to the postanesthesia care unit (PACU), Continue to wear antiembolic stockings until the first clinic visit. where Oxygen is administered Use a pillow between legs when lying on the side or getting in and mask and the patient's oxygena- of bed, tion status is monitored. A report of the surgery is given to the Use equipment supplied to keep from flexing more than 90". PACU nurses and includes the Take pain relief medications as needed.

Keep appointments so that progress can be followed.

Let family physician or dentist know you have had a total hip joint

overall condition of the patient, number of drains in place, type of anesthetic used, mehcations used, and blood administration. replacement before any other surgery or dentistry performed, as

antibiotics may be necessary to prevent infection. The PACU nurse assesses the patient's signs and checks the wound for dressing patency and drainage. Patients

Resume normal sexual activities with care to prevent dislocation.

Plan activities with frequent rest periods. undergoing total hip revision sur- gery often are transferred to the postoperative high dependency unit (HDU), especially if there has been significant blood loss Sit on beds, intraoperatively. The HDU nurses are certified in administration of epidural medication for patients

Do not do me following: Bend at the hip more than 90".

Sit in a low or overstuffed sofa or chair.

Sit in bucket Seats in cars UnkSS there iS a cushion to raise the height.

Sit in bathtubs, use shower instead, with an indwelling epidural catheter so that postoperative Drive a car for six weeks, or until the surgeon permits.

analgesia can be -administered. The catheter is in place for no longer than two days.

Patients with an impacted allograft are confiied to strict bed rest for three to four weeks postop- eratively to allow the impacted bone time to consoli- date. During this time, it is important to avoid pres- sure area complications; therefore, the patient is turned every two to four hours to relieve pressure on

Turn leg internally or externally to an extreme.

Participate in running sports. Return t0 work Until Surgeon approves.

care plans accordingly. The nursing diagnoses are activity intolerance, anxiety, fear, risk of fluid vol- ume deficit, hypothermia, risk of infection, risk of injury, knowledge deficit, risk of latex allergy

the back and buttocks. Two nurses are required for turning the patient, and two pillows are placed between the patient's legs to prevent dislocation. This is important for patients with an epidural catheter as there is no muscle tone and therefore they are at risk of dislocation. When the bed rest period is over, patients are mobilized with crutches or a walker.

Nurses caring for patients undergoing total joint

response, impaired physical mobility, pain, risk of perioperative positioning injury, and risk of impaired skin integrity.

Discharge planning is begun preoperatively and includes arranging for plastic raised toilet seats, shower stools, handrails, and chair raises or a f i upright chair with armrests if the patient does not own one. The occupational therapist makes the

replacement procedures must be mindful of nursing diagnoses and interventions and develop the nursing

arrangements for these aids as the equipment is essential to prevent the patient from bending more

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Obtaining consent for

harvesting cadaver bone is a

delicate subject and not

always accepted by relatives.

than 90" to minimize the risk of dislocating the new hip. The physiotherapist teaches the patient how to manage crutches when going up and down stairs and deep breathing and coughing exercises to move spu- tum after surgery.

When discharged from the hospital, patients are supplied with a booklet with information about total hip replacement and what patients can and cannot do after a total hip replacement (Table 1).

Allograft banking responsibilities. The nursing responsibilities in bone banking are varied. It is the OR orthopedic staff members who are responsible for maintaining the bone bank because the OR is the place where the bone is retrieved and used, The role of the bone bank coordinator is a delegated position. At Waikato Hospital, the orthopedic OR charge nurse holds this title.

The range of available freezers, storage, and accessibility to bone storage is important. Close access to the OR is the ideal location. Monitoring of the freezer to maintain constant temperature is recom- mended in the Australian Orthopedic Association's guidelines for bone banking. The coordinator must ensure that the freezer selected is capable of having a monitor fitted into it. Freezers that are capable of tem- peratures of -85" C (-185" F) are a capital expenditure of approximately $1 8,000 NZ (ie, approximately

The bone bank coordinator's nursing responsibil- ities are checking the donor's laboratory reports, filing them, issuing bone for use in private and public hospi- tals, and discarding bone that fails to meet the criteria. The bone bank coordinator's responsibilities also involve supervising the bone harvesting, packaging, and documentation of all bone harvested. The coordi- nator, as a member of the bone bank committee, is responsible for formulating policy and procedures and

$10,000 US).

having them approved by the ethics committee for the effective working of the bone bank.

Ethical issues in bone banking. Bone donors are tested for HIV, hepatitis B and C, and other tests previously discussed. Live donors are given the option to be advised of positive results. If a positive result is confirmed, the orthopedic OR team members are advised that the patient is HIV or hepatitis B or C positive and that they are not to save the bone for storage. They rely on their knowledge and practice of universal precautions when handling body tissues and fluids to protect themselves. To maintain patient con- fidentiality, if his or her positive serology status is revealed to people who do not need to know, the staff members who reveal the information may face disci- plinary action.

Obtaining consent for harvesting cadaver bone is a delicate subject and not always well accepted by relatives of the deceased. Family members must be reassured that no obvious disfigurement will occur when the bone is removed. Harvesting of kidneys and other soft tissue viscera is a well-established practice, but harvesting bone is relatively new and is frequently refused by family members. There are eth- ical issues raised when obtaining bone and viscera from cadavers. Added stress can be placed on the donor's survivors when a request is made to donate organs. They may agree to donate soft tissues (eg, heart, lungs, liver, kidneys, eyes) but are sometimes reluctant to donate bones because they fear that their removal will cause gross disfigurement of their loved one. The survivors are reassured that the body will not be disfigured and that the orthopedic surgical team members will replace the bone with appropri- ately sized rigid structures to retain the body's shape. It is important that the organ retrieval team members permit harvesting of only the tissues for which the family has consented.

When using cadaver bone, the donor cannot be retested six months after donation, and the question is raised about whether the bone is safe to use. It is our practice to write to the National Transplant Donor Coordinator, based at Green Lane Hospital, Auckland, at the end of the quarantine period to request the infor- mation about health status of patients who have received internal viscera of the deceased. If the health status of these individuals is unchanged, the bone is considered safe to use. Maintaining confidentiality in this matter is of utmost importance.

If donor bone is used and postoperatively it is discovered that the cultures taken from the bone have

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shown bacteria growth, the surgeon must be notified. This means the recipient could be developing an infection in the reconstructed joint. An infection in an allograft bone recipient’s joint can be catastrophic; therefore, failure to advise the surgeon and patient in this respect is not only unethical but also negligent.

There are other issues surrounding donor tissue use. Bone banking is an expensive endeavor, and in many instances, there are not any provisions in place for private health care institutions to pay for the pro- cessing costs of the bane they use. Bone currently costs $500 NZ (ie, approximately $272 US) for laboratory processing of each femoral head. Unfortunately, tax- payers subsidize bone costs for private hospitals.

CASE STUDY Mrs B, a 73-year-old retired female, presented at

Waikato Hospital with a history of bilateral total hip joint replacements. Her left hip was replaced in 1985, and Mrs B’s chart did not state the date of her right hip replacement procedure. She began to experience pain in her left hip in 1991, which became progres- sively worse, and by 1995, she described her pain as “tremendous.”

X-rays were taken, and there was evidence of marked loosening of the old prosthesis with very poor bone quality proximally in the left hip. When Mrs B was examined, her left leg was shorter than her right leg and slightly externally rotated.

In November 1995, Mrs B had a left total hip joint revision with allograft impaction. The cement around the cup and stem from the previous surgery was fragmented. A large amount of black granulation tissue had eroded almost all of her greater trochanter. There was a distal femoral stem defect that was rein- forced with stainless steel mesh and stainless steel cerclage cables. A 20-mm bone plug was inserted, and as her greater trochanter was almost nonexistent, the adductors were sutured to the upper outer femoral shaft. Due to the fragility of the bone, Mrs B was con- fined to bed rest for four weeks.

At her three-month postoperative checkup, x- rays showed continuing consolidation of the allograft

N O T E S

and arthroplasty,” Surgery, Gynecology and Obstetrics (1925)

1 . E Lexer, “Joint transplantation

782-809. 2. A Inclan, “The use of pre-

served bone graft in orthopaedic sur- gery,” Journal of Bone und Joint

bone. In March 1998, two and one-half years after her left hip revision, the graft had consolidated, but x- rays of her right hip confirmed mechanical loosening. In July 1998, Mrs B underwent a total hip joint revi- sion with allograft impaction on her right hip.

Although the original acetabular cup was firmly in place, it was removed with little difficulty, and the stem was loose and easily removed. The cement was fragmented, and when removing the anterior portion of the cement mantle, the femoral shaft split anterior- ly. The distal plug of the original bone cement was left in place, and the anterior split was repaired with stainless steel mesh secured in place with three stain- less steel cerclage cables.

Postoperatively, Mrs B was on bed rest for two weeks. At her three-month postoperative checkup in October 1998, x-rays showed no evidence of compli- cations, and both components appeared to be in prop- er anatomical position.

CONCLUSION Bone banking is a procedure that can be of

immense benefit to patients with a large bony defect due to osteolytic changes, which is the result of failed joint replacements, or from bone tumors. There is a degree of risk when using tissue that is transplanted from one individual to another, but the effective results often outweigh the risks. There are many spe- cific nursing responsibilities, although at Waikato Hospital, these responsibilities fall on the shoulders of the bone bank coordinator. The use of allograft bone has made the reconstruction of failed total hip joint replacements possible. Patient outcomes can be very favorable with a reconstructed pain-free joint

with an osteo-integrated implant- ed allograft bone. A

Surgery 24 (1942) 81-96. 3. G Russell, R Hu, J Raso

“Bone banking in Canada: A review,” Canadian Journal of Surgeiy 32 (July 1989) 231-236.

and Surgical, 15th ed, T Pick, R Howden, eds (New York: Bounty

4. H Gray, Anatomy, Descriptive

Gordon Carter, RN, BN, is a spe- cialty nurse leader in the orthopaedic operating theatres at Vfaikato Hospital, Hamilton, New Zealand.

Books, 1977). 5. E Marieb, Human Anatomy

and Physiology, fourth ed (California: Benjamin/Cummings Science Publishing Co, 1998).

6. Gray, Anatomy, Descriptive and Surgical.

7. Marieb, Human Anatomy and

669 AORN JOURNAL

OeroBER 1999, VOL 70, NO 4 Carter

Phys

Committee, Bone Banking Protocol (Hamilton, New Zealand: Waikato Hospital, 1995).

9. D Morgan et al, National Guidelines for Bone and Tissue Banking Sub-committee of the Australian Orthopaedic Association

10. Y Kadoya, A Kobayashi, H Ohashi, “Wear and osteolysis in total joint replacements,” Acta Ortbpaedica Scandinavica Supplemenfum (February 1998) 1- 16; H Rubash et al “Pathogenesis of bone after total hip arthroplasty,” Orthopaedic Clinics of North America (April 1998) 173-186; S Smith, D Estok, W Harris, “Total hip arthroplasty with use of second gen-

8. Bone Bank Protocol

(1994) 5-31.

eration cementing techniques: An eighteen year average follow-up study,” Jouml of Bone and Joint Surgery (American) 80 (November 1998) 1632-1640.

1 1. J Clark, persod communica- tion with the author, Waikato Hospital, New Zealand, 15 August 1999.

12. S Fairchild, Perioperative Nursing Principles and Practice, second ed (Boston: Little, Brown and Co, 19%) 343.

13. G Gie, R Ling, T Sloof, X- change Revision Instruments System, Operative Technique (London: Howmedica International Ltd, 1994) 2-17.

14. Ibid. 15. Ibid. 16. Ibid.

SUGGESTED READING

ing: The Iiving donor.” Orthopaedic Nursing 10 (MarcWApril 1991) 47- 53.

graft bone in revision of total hip arthroplasty.” Clinical

Buckham, K. “Surgical bone bank-

Gross, A, et al. “The use of allo-

oRTHOPADEICS ANDRelated Research

Hart, M, Campbell, Jr, E: Kartub, M. “Bone banking: A cost-effective method for establishing a comu- nity hospital bone bank.” Clinical Orthopaedics and Related Resesrch 206 (May 1986) 295-300.

Sloof, T. Acetabular Augmentation in Cemented Arthroplasty: Pre- operative Assessment and Swgical Techniqlw, ed J Older. h d o n : Springer-Verlag, 1994.

197 (jULY/AUGUSE1985) 115-122.

AORN, Association of periOperative Registemd N u w , is accredit- ed as a pmvider of wntinuing educalion in nursing by #e American Nurses Gredmthling CenWs ( A “ s ) commjsson on Accreditalion. AORN recognizes #is activity as contiwing educa- tion for rqisfered nu=. This mognition d w not imply #af AORN or the ANCCs Commission on Accredtaifon approves or endorses any product included in tfw activik. AORN maintains the following provider numbers: Alabama ABNP0075, California BRNOG667, Flon’da 27H) 1 77, Kansas L To 1 14-03 16. Check wih

your stote board of nursing for accepkbil@ of educofon acffviiy for relicensure.

Professinal nurses are invited to submit manuscripts f b r the Home sfudv Prqmm. Manuscripfs or queries should be sent to Editor, AORN Journal, 2 1 70 S Parker Rd Suite 300, Mw, CO 8023 1 - 571 1. As with all mwuscr ip ts sent to ftw Journal, papers submit-

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American Academy of Nursing Announces New Director Terri Gaffney, RN, MPA, has been named director of the American Academy of Nursing (AAN). Gaffney has served as A A ” s interim director since January 1999 and officially assurn

making, was established in of the American Nurses As

ship and influencing the development health care policies and practices.

four years as director of the association’s state gov- ernment relations department. Her other previous

Gaffney has worked at ANA since 1991, serving

positions include associate legislative director at the Paralyzed Veterans of America, Washington, DC, and intensive care nurse at the National Cancer Instih~te at the National Institutes of Health, hckville, Md. Gaffney holds a master’s degree in public administra-

member of the American Society of Public Administrators and Women in Government Relations.

Director Appointed to the American Academy of Nursing (press release, Washhgion, DG: American N u m Association, Aug 13, 1999) 1-2.

670 AORN JOURNAL

Tem GaEney, RN, MPA, has been named director of the American Academy of Nursing (AAN). Gaffney has served as A A ” s interim director since January 1999 and officially assumed her new post on Sept 1, 1999. The AAN, comprising nursing leaders in prac- tice, education, research, management, and poky making, was established in 1973 under the guidance of the American Nurses Association (ANA). Its mis- sion includes providing nurses with visionary leader- ship and influencing the development of effective health care policies and practices.

four years as director of the association’s state gov- ernment relations department. Her other previous

Gaffney has worked at ANA since 1991, serving

positions include associate legislative director at the Paralyzed Veterans of America, Washington, DC, and intensive care nurse at the National Cancer Institute at the National Institutes of Health, kackville, Md. Gafhey holds a master’s degree in public administra- tion from Virginia Polytechnic Institute and State University, Blacksburg, and a baccalaureate from the Medical College of Viginia, Richmond. She is a member of the American Society of Public Administrators and Women in Government Relations.

Director Appointed to the American Academy of Nursing (press relimo, Washit@on, Dc: Amevrwn Nurses Amciation, Aug 13, 19%) 1-2.