AUGUST 2001, VOL 74, NO 2

Examination ANTERIOR CRUClATE LIGAMENT RECONSTRUCTION

1 .The normal anterior cruciate ligament (ACL) a. reinforces the knee capsule inferiorly and

b. provides anterior and posterior stability for the

c. reinforces the knee capsule medially and lat-

d. provides support for the knee capsule and sur-

superiorly.

knee and controls movement.

erally.

rounding soft tissue.

2.What is the most common cause of ACL injuries? a. contact injuries (eg, sports injuries) b. traumatic injuries (eg, automobile accidents) c. noncontact injuries related to deceleration or

d. pathophysiologic injuries related to diseases change of direction mechanisms

(eg, osteoarthritis)

3.Patients with ACL injuries state they hear a pop- ping sound or feel a tearing sensation at the time of injury. a. true b. false

4. Anterior cruciate ligament injuries may cause such pain that patients a. fall and often incur additional upper extremity

injuries. b. cannot return to athletic participation that day

unless the knee is wrapped with an elastic bandage.

c. fall or the knee collapses with rapid onset of swelling.

d. can return to athletic participation that day only after receiving pain medication.

5. Meniscal tears associated with ACL injury are frequent, occurring from a. 50% to 75% in the acute setting. b. 30% to 50% in the chronic setting. c. 25% to 50% in the chronic setting. d. 30% to 50% in the acute setting.

6. In addition to bone contusions, which ligaments

may be injured during ACL injuries? a. posterior cruciate ligament, acromioclavicular

ligament, or medial collateral ligament b. medial or lateral collateral ligaments, posterior

cruciate ligament, or posterolateral complex c. iliofemoral ligament, posterolateral complex,

or posterior cruciate ligament d. popliteal ligament, medial collateral ligament,

or posterolateral complex

7.Complete ACL injuries generally do not heal, and patients with ACL injuries are at risk for a. articular and menisci injury and inevitable

development of severe osteoarthritis. b. the knee giving way and the eventual need for

total knee replacement. c. multiple surgical procedures and continued

episodes of instability. d. the knee giving way with future deceleration

activities and subsequent articular surface and menisci injury.

8.Many patients may have a delay in diagnosis and treatment of an ACL injury because a. pain resolves and range of motion returns to

normal limits within 10 days so they do not seek medical care.

b. clinicians are hesitant to treat an initial ACL injury aggressively.

c. many insurance plans do not cover surgical repair of nonjob-related ACL injuries.

d. they fear the unavoidable pain of surgery and rehabilitation so they do not seek medical care.

9.Which of the following tests are used to diagnose an ACL injury? a. Loerhman’s test, posterior compartment test,

b. translation test, subluxation test, and anterior

c. anterior drawer test, Lachman’s test, and pivot

d. Lachman test, subluxation test, and pivot shift

and swing shift test

drawer test

shift test

test

166 AORN JOURNAL

AUGUST 2001. VOL 74, NO 2

10.The Lachman test is used in diagnosing an ACL injury by a. demonstrating increased translation of the tibia

b. applying posterior translation of the tibia. c. allowing quantification of anterior translation

d. demonstrating decreased valgus shift.

relative to the femur.

of the femur.

11 .A markedly abnormal anterior drawer test in an ACL injury suggests a. lateral femoral condyle contusion. b. tibia1 condyle microfracture. c. increased translation of the tibia relative to the

d. associated loss of secondary restraints. femur.

12.The pivot shift test a. ensures accurate diagnosis of an ACL injury

because the patient does not guard against pain. b. demonstrates subluxation reduction of the tibia

relative to the femur in an ACL injury. c. demonstrates the patient’s ability to pivot on

his or her leg. d. ensures that the patient is able to shift his or her

weight or pivot on the injured leg.

13.The is used to provide objective quantification of anterior translation of the patient’s knee analogous to the Lachman test. a. instrumented laxity-testing device b. goniometer c. traction bow tension device d. oscilloscope

1AWhich treatment is not appropriate for an ACL injury? a. nonsurgical treatment using a custom or gener-

ic ACL brace to reduce the severity and fre- quency of the patient’s knee giving way

b. surgically repairing associated injuries, such as meniscal tears, but not reconstructing the injured ACL

c. nonsurgical treatment using cortisone injections d. ACL reconstructive surgery in conjunction

with meniscal repair

15. Patients who are willing to slightly modify their athletic activities, use a brace during painful episodes, and commit themselves to short-term rehabilitation may not require ACL

reconstructive surgery. a. true b. false

16.The goal of ACL reconstructive surgery is to a. prevent future injury to associated ancillary

b. support adjoining soft tissue. c. provide at least minimal return to preinjury

d. eliminate the pivot shift phenomenon.

support ligaments.

mobility.

17.General indications for ACL reconstructive sur- gery include patients who a. are young, require knee mobility in their

employment, or experience at least five insta- bility episodes per year.

b. are young, involved in five or more hours of sports per week, have an arthrometer differ- ence greater than 5 mm, or experience three or more instability episodes per year.

c. are middle-aged, demonstrate the beginning onset of osteoarthritis, or experience five or more instability episodes per year.

d. are older adults, have immobility resultant from an ACL injury that will markedly increase their chance for morbidity, or experi- ence at least five instability episodes per year.

18.What is the most commonly used graft for ACL reconstructive surgery? a. patient’s patellar tendon b. Achilles tendon allograft c. synthetic graft d. patient’s hamstring tendon

19.Which procedure generally is not used as a surgi- cal approach for ACL reconstructive surgery? a. two-incision arthroscopy-assisted b. open arthrotomy c. single-incision arthroscopy-assisted d. open arthroplasty

20.Outpatient nursing staff members contact the patient the day before surgery to review a. general medical health issues and results of

laboratory tests and to explain the steps in the surgical procedure.

b. discharge planning needs, results of laboratory tests, and the importance of remaining NPO after midnight.

167 AORN JOURNAL

AUGUST 2001, VOL 74, NO 2

c. general medical health issues, information about the ACL surgery, and the importance of remaining NPO after midnight.

d. information about the ACL surgery, discharge planning needs, physical therapy, and required life style changes.

2l.Many ACL reconstructive surgeries can be per- formed on an outpatient basis. a. true b. false

=.Some of the risks related to knee arthroscopic surgery and ACL reconstruction include a. infection, thrombophlebitis, and intraoperative

myocardial infarction. b. pulmonary embolus, post-traumatic patellar

tendon rupture or patellar fracture, and electro- surgical unit bums.

c. thrombophlebitis, infection, and peripheral tis- sue ischemia.

d. recurrent laxity, reoperation for scar tissue, and infection.

=.The preoperative nursing assessment should include which of the following? a. confirm the patient’s identification and NPO

status, evaluate range of motion limits, note any allergies, and verify consent with patient

b. verify consent with patient, identify and mark pedal pulses for postoperative comparison, and establish preoperative understanding of required rehabilitation

c. confirm the patient’s identification and NPO status, note any allergies and laboratory test results, and verify consent and correct limb with patient

d. verify consents and NPO status, evaluate range of motion limits, and mark pedal pulses for postoperative comparison

24.To prevent wrong site surgery, the nurse a. contacts the physician for verbal confirmation

and has another nurse acknowledge the verbal confirmation with the surgical consent.

b. has the patient identify the surgical extremity and places one of the patient’s socks on the nonsurgical foot.

c. obtains the patient’s office records, double checks with the physician’s office personnel, and verifies the surgical consents.

d. verifies the consents, has the patient identify the surgical extremity, and writes the word “wrong” on the patient’s nonsurgical knee.

25.Postoperative discharge planning begins before the patient goes into surgery as the nurse a. verifies that the patient has transportation

home and that needed postoperative devices (eg, crutches, cryotherapy, brace) have been obtained.

b. makes the patient’s postoperative physical therapy appointment and has the patient demonstrate postoperative rehabilitation exer- cises.

c. obtains needed postoperative devices (eg, crutches, cryotherapy, brace) and makes the patient’s postoperative physical therapy appointment.

d. makes sure the patient has supplies for dress- ing changes and needed postoperative devices (eg, crutches, cryotherapy, brace).

26. If antibiotics are ordered for preoperative admin- istration, they should be administered minutes before the planned incision time. a. 15 b. 30 c. 45 d. 60

27.Epinephrine is used in the imgation solution to a. enhance tissue perfusion and healing. b. minimize postoperative pain. c. reduce or eliminate the need for a tourniquet. d. minimize tourniquet pain in patients with

regional anesthesia.

28. What is the correct dilution of epinephrine in the imgating saline for an ACL procedure? a. 3 mL of epinephrine (1:10,000) per 3,000 mL

b. 1 mL of epinephrine (1 : l0,OOO) per 3,000 mL

c. 3 mL of epinephrine (1:1,OOO) per 3,000 mL

d. 1 mL of epinephrine (1:1,000) per 3,000 mL

saline

saline

saline

saline

29.The circulating nurse assists in transferring the patient to the OR and prepares the patient for induction by

168 AORN JOURNAL

AUGUST 2001, VOL 74. NO 2

a. participating in a four-man lift to move the

b. securing the safety straps and removing the

c. securing the safety straps and providing arm

d. providing arm boards and removing the

patient to the OR bed.

infused antibiotic bag.

boards and warm cover sheets.

infused antibiotic bag.

=.The nurse does not place the patient’s surgical leg in the surgical leg holder until the patient is under anesthesia and the surgeon examines the knee because a. this may reduce or eliminate the need for a

b. this would increase the risk of soft tissue dam-

c. the tourniquet must be inflated first. d. the epidural catheter must be inserted before

pivot shift evaluation.

age during evaluation.

positioning.

31.The nurse places the patient’s nonsurgical leg in a padded gynecological stirrup leg holder with his or her knee and hip flexed to a. decrease resistance during intraoperative

b. prevent stretching of the popliteal and dorsal

c. avoid compression of the brachial plexus (eg,

d. reduce traction on the femoral nerve and to

manipulation of the surgical leg.

pedis nerves.

femoral artery, nerve bundle).

protect the common peroneal nerve.

=The circulating nurse documents care provided intraoperatively, including the a. types and amounts of sutures, location of the

arthroscopic tower, electrosurgery unit (ESU) dispersive pad placement, and preoperative assessment of skin condition.

b. total amount of saline infused arthroscopically, ESU dispersive pad placement, types and amounts of sutures, and location of the arthro- scopic tower.

c. total amount of saline infused arthroscopically, ESU dispersive pad placement, preoperative assessment of skin condition, and implants used.

d. types and amounts of sutures, ESU dispersive pad placement, preoperative assessment of skin condition, and location of arthroscopic tower.

33.A #I5 knife blade is used for placement of arthro-

scopic portals because a. it makes a cleaner stab incision than a #11

b. it is less likely to break if bone is contacted

c. it makes a deeper incision than a #I0 blade. d. it is less likely to damage the scope if contact-

blade.

inadvertently.

ed inadvertently.

=The surgeon uses an oscillating saw to make the bone plug cuts because it a. makes the cuts rapidly and decreases surgical

b. nearly eliminates the risk of peripheral soft tis-

c. is lighter and easier to manipulate than the

d. nearly eliminates the risk of intraoperative

time.

sue damage.

Gigli saw.

patellar fracture.

=The bone plug is prepared by a. removing irregular edges, measuring the bone

plug and soft tissue length, drilling two K-wire holes, and placing a suture through each hole.

b. trimming the cartilage, measuring the bone plug and soft tissue length, drilling three Steinman pin holes, and suturing the soft tissue circumferentially.

c. removing irregular edges, suturing the soft tis- sue circumferentially, and placing two Steinman pins at the junctions of bone and soft tissue.

d. trimming the cartilage, suturing the soft tissue lengths in half longitudinally, drilling two K- wire holes, and placing a suture through each hole.

=The graft is wrapped in a moist sponge and set aside but is not immersed in saline to a. prevent absorption of epinephrine added to the

b. block anabolic metabolism. c. avoid graft hypertrophy. d. inhibit proteolysis.

irrigation.

=.The purpose of notchplasty is to a. render a secure platform for in-growth of cor-

tical bone matrix. b. expand the lateral wall of the notch, which pro-

tects the graft from abrasion during early healing. c. prepare a surface for articulation and musculo-

tendinous attachment.

169 AORN JOURNAL

AUGUST 200 1, VOL 74, NO 2

d. provide a cushion and protection during weight bearing and movement.

38.Producing a tibial tunnel a. prepares an epiphyseal plate to which the bone

plug can be attached securely. b. furnishes a path for nutrients to feed the

injured area, which promotes healing. c. provides an intra-articular entrance that mim-

ics the former mid-third ACL insertion region. d. is expedient but increases the risk of postoper-

ative infection.

=If the patient’s knee has to be markedly extended during femoral tunnel placement, a. the tibial tunnel may have been improperly

b. the bone plug needs to lengthened. c. longer rehabilitation time can be expected. d. the surgeon should ensure the foot is extended

placed.

simultaneously.

-The surgeon orients the bone plug so the cortex is placed in the coronal plane and posteriorly ori- ented to a. improve the potential for return to full range of

b. reduce the likelihood of soft tissue injury dur-

c. facilitate in-growth of cortical bone matrix. d. reduce postoperative pain and increase compli-

motion postoperatively.

ing interference screw placement.

ance with rehabilitation.

41 .After the graft has been secured, the surgeon assesses the patient’s knee for stability by a. imitating the motion of the swing shift test and

posterior compartment test while applying coronal pressure.

b. manipulating the patient’s knee through a range of motion and imitating the motion of the swing shift test.

c. manipulating the patient’s knee through a range of motion and performing the Lachman, anterior drawer, and pivot shift tests.

d. performing the Lachman, anterior drawer, and pivot shift tests and applying coronal pressure during the posterior compartment test.

=The surgeon dresses the wound with the follow- ing items: a. self-adhesive wound approximating strips and

benzoin, 4 x 4 radiopaque sponges, nonelastic rolled gauze, cryotherapy, a stockinet, and a brace.

b. an abdominal pad, bulky cotton padding, ster- ile Kerlix, cryotherapy, an elastic bandage wrap, and a brace.

c. bulky cotton padding, finely woven gauze, sterile fluffs, nonelastic rolled gauze, stockinet, an elastic bandage wrap, and a brace.

d. self-adhesive wound approximating strips, fine- ly woven gauze, sterile fluffs, Kerlix, cryother- apy, an elastic bandage wrap, and a brace.

=After transfemng the patient from the postanes- thesia care unit to the postoperative holding area, the PACU nurse a. assesses the patient’s vital signs, pain levels,

neurovascular status, and the dressing for bleeding and connects and monitors the cryotherapy device.

b. assesses the patient’s vital signs and the dress- ing for bleeding, requests discharge x-rays, and notifies the physical therapy department of dis- charge plans.

c. requests discharge x-rays, notifies the physical therapy department of discharge plans, con- tacts the orthopedic clinic for cast placement, and monitors the cryotherapy device.

d. assesses the patient’s neurovascular status, con- tacts the orthopedic clinic for cast placement, and connects and monitors the cryotherapy device.

=Before discharge, the nurse a. ensures the patient has had a bowel move-

ment, reviews discharge planning, and answers questions.

b. reviews postoperative teaching, discharge planning, and follow-up office visits and answers questions.

c. reviews postoperative teaching, discusses when to return to work, and answers questions.

d. ensures the patient can use crutches correctly, reviews discharge planning, and answers questions.

&The patient attends physical therapy for instruc- tions regarding a. crutch walking and use of the postoperative

b. range of motion and leg exercises and use of brace and cryotherapy device.

170 AORN JOURNAL

AUGUST 2001, VOL 74, NO 2

the transcutaneous electrical nerve stimulator b. ensure absolute compliance with the self- (TENS). directed exercise regimen.

c. achieve partial extension and flexion of 45 and cryotherapy device.

d. ensure full range of motion and weight bearing range of motion, and leg exercises.

c. leg exercises and use of the TENS unit

d. crutch walking, use of the postoperative brace, degrees seven to 10 days postoperatively.

seven to 10 days postoperatively.

=To extend the duration between postoperative narcotic medication doses, patients are asked to a. apply ice and heat to the surgical knee alter-

nately for 10 minutes every hour. b. elevate the surgical leg and stay hydrated by

drinking eight 12-ounce glasses of fluids per day. c. take 650 mg of aspirin three times per day with

eight 12-ounce glasses of fluid. d. take plain acetaminophen approximately three

hours after taking the narcotic.

47.Approximately - of patients may require aspiration of a postoperative hemarthrosis. a. 5% b. 10% c. 15% d. 20%

48.The patient's motion goal is to a. achieve complete extension and flexion of 90

degrees seven to 10 days postoperatively.

AORN, Association of perioperative Registered Nurses, is accredit- ed as a provider of continuing education in nursing by the American Nurses Credentialing Centefs (ANCC's) Commission on Accreditation. AORN recognizes this activiv as continuing educa- tion for registered nurses. This recognition does not imply that AORN ar the ANCC's Commission on Accreditation approves or endorses any product included in the activity. AORN maintains the following state board of nursing provider numbers: Alabama ABNP0075, California C € f 730 19, and Florida FBN 2296. Check

=Which of these are not the goal of an accelerated rehabilitation protocol after ACL reconstructive surgery? a. use a stationary bicycle by seven to 10 days b. return to sports activities within six months c. use a stair stepper at four to six weeks d. run within three months

-Closed-chain strengthening exercises are advo- cated, which emphasize a. that the patient place his or her foot against a

surface so that the quadriceps, hamstring, and buttock muscles are used concurrently.

b. weight bearing with the postoperative brace in full extension.

c. keeping the toes of the surgical leg pronated during straight leg exercises to prevent addi- tional strain on the repaired ACL.

d. avoiding bent-leg and high-profile weight bearing exercises that overstrain the supporting soft tissues.

with your state board of nursing for acceptability of education activ- ify for relicensure.

Professional nurses are invited to submit manuscripts for the Home Study Program. Manuscripts or queries should be sent to €ditor, AORN Journal, 2 170 S Parker Rd, Suite 300, Denver, CO 8023 1 - 571 1. As with all manuscripts sent to the Journal, papers submit- ted for Home Study Programs should not have been previouslypub- lished or submitted simultaneously to any other publication.

171 AORN JOURNAL

AUGUST 2001, VOL 74, NO 2

Answer Sheet ANTERIOR CRUClAIE

LIGAMENT RECONSTRUCTION

lease fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail to:

AORN Customer Service c/o Home Study Program

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

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

A score of 70% correct is required for credit.

Event #I02011 Session #6423 Contact hours: 4 Fee: Members $20; Nonmembers $40

Program offered August 200 1. The deadline for this program is Aug 31, 2001.

1. Record your identification number in the appropri- ate section below. 2. Completely darken the space that indicates your answer to the examination starting with question one. 3. Record the time required to complete the program

4. Enclose fee if information is mailed.

AORN (ID) # Name Address City State Zip RN license # State Phone number ( If nonmember, please provide Social Security number

Fee enclosed or bill the credit card indicated 0 MC 0 Visa 0 Am Express 0 Discover Card ## Expiration date Signature

(for credit card authorization)

IDNumber

173 AORN JOURNAL

AUGUST 2001. VOL 74, NO 2

Learner Evaluation ANTERIOR CRUClATE LIGAMENT RECONSTRUCTION

The following evaluation is used to determine the extent to which this Home Study Program met your leam- inp needs. Rate the following items on a scale of 1 to 5.

Session Number 0000000000g 0000000000 0000000000 0000000000

(Low) (High) (Low) (High)

OBJECTIVES To what extent were the following objectives of this Home Study Program achieved?

(1) Discuss anterior cruciate ligament (ACL) injuries.

(2) Describe the diagnostic and treatment options for ACL injuries.

(3) Discuss ACL reconstruction. (4) Describe perioperative nursing care of the

patient undergoing ACL reconstruction.

PUR POSWGOAL To educate the perioperative nurse about ACL reconstruction.

CONTENT (5) Did this article increase your knowledge of

(6) Was the content clear and organized? (7) Did this article facilitate learning? (8) Were your individual objectives met? (9) How well did the objectives relate to the

the subject matter?

overall purpose/goal?

TEST WESnONSlANSWERS (10) Were they reflective of the content? (1 1) Were they easy to understand? (1 2 ) Did they address important points?

What other topics would you like to see addressed in a future Home Study Program? Would you be interest- ed or do you know someone who would be interested in writing an article on this topic?

Topic( s):

Author names and addresses:

174 AORN JOURNAL