Orthopedic instruments, while unique and comprehensive in their design, are simply instruments. Are they simple instruments? Absolutely not. They often have a complex anatomy, come equipped with more elaborate IFUs, and there is never just one set used in a surgical procedure. Seriously, a total knee revision case setup makes the operating room look like a barricade of instruments surrounding the patient and the operating team. However, they are surgical instruments that adhere to the foundational training we received in our sterile processing (SP) program and the skills we learn on the job.

We select appropriate detergent, make sure they go through the sonics, get a good to-and-fro brushing, and are inspected under quality lighting like the rest of the thousands of instruments we inspect daily. These foundational  principles and concepts are taught to us immediately. They typically make up our department’s standard works and process flow used to achieve the outcome required. The complexity of orthopedic instruments lends itself to a more in-depth application of these basic skills that will develop our subject matter expertise (SME).

 Body and mind

Mastering critical thinking requires us to veer away from subconscious confines. Performing the same daily tasks, in the same manner, has served the sterile processing industry for quite some time. “This is how we’ve always done it” echoes throughout departments for a reason, but requesting additional information is necessary to critical thinking. It aids understanding, comprehension, and challenges how we approach situations. This allows us to engage in reflective thinking regarding the analysis and evaluation of a situation or issue.

One piece of additional information not readily available in a sterile processing department (SPD) is the explanation of where and how these instruments are being used. Orthopedic instruments are essentially customized surgical tools used for a specific procedure on a body part. Unlike a Gelpi retractor, a patella button cannot be used just anywhere. Our in-house sets are often used in support of the surgeon alongside the orthopedic system sets.

The buildup

At first glance, an orthopedic set can be overwhelming, yet interesting at the same time. These instruments do not look like anything in our basic in-house sets. The different materials, deep grooves, and aggressive pin points can be quite stunning. These instruments are created for the specific joint or bone our patient needs help with. Understanding where in the patient’s body certain instruments will be used helps with their inspection, as with all instruments. An understanding of orthopedic instruments will also suggest where to look for bioburden and what type of debris may be present.

Bioburden is devastating in any surgical case and there is certainly more than one reason why we call it “gross debris.” Some of the most common forms of debris found on orthopedic instruments include bone, cement, and grease. Take a look at some of the key takeaways and identifiers listed below.

  1. Bone:
    1. In decontamination: hard, usually hidden by fat and blood, and very sticky.
    2. On assembly: white, still sticky, very thin, and often pressed against the inner wedges of an instrument.
    3. Post-sterilization: white, fibrous, fragile, and easily falls apart if manipulated.
    4. Can be on anything; highest likelihood on instruments used to prep the existing bone for new implants or repair.
  2. Cement:
    1. Typically white upon drying.
    2. Hard, flaky, and not always in blobs. Can be thin scrape lines.
    3. Difficult to see in decontamination when wet.
    4. Be aware of instruments that are used during the cementing process (like impactors) while inspecting.
  3. Grease:
    1. Caused by bone composition, fats, and possible joint fluid.
    2. Shiny presentation, water will usually bead up on it; hard to detect in decontamination because of gloved hands.
    3. Can be removed with good physical to-and-fro motions before mechanical washing.
    4. Be aware of the templating instruments used to determine implant sizes.
The follow through

While it is true that we are inspecting the entire instrument every time, the above insight highlights areas in need of closer inspection. If the SP technicians do not know what instruments are used to prep the bone, template implants, or for impacting, the information doesn’t help. The best way to provide this understanding is to make sure technicians see how the instruments are used. 

Orthopedic instruments are like puzzle pieces, typically pushing, pulling, twisting, and turning to lock and hold in place. Sterile processing professionals don’t magically know how all the instruments in their department are used just because they viewed one total hip arthroplasty. This may be difficult to achieve for a number of reasons: 

  1. There may not be enough room in the OR to accommodate this learning.
  2. SP management may not be able to afford technicians missing from the department.
  3. The SPD and perioperative team rapport may be weak. 

These are very real limitations we face that stifle the development of our professionals’ subject expertise. A workaround for this is to provide robust and informative in-services. Cue the glazed-overlook in SP professionals’ faces. The in-services provided must be of high quality. Some ways to assure that there are informative and maybe even entertaining in-services include: 

  1. Get them approved for CE credits. Extrinsic motivation is powerful. Even a half hour, 0.5 CE, can make a difference.
  2. Keep them brief; engagement is important for retainment. Attention spans are growing shorter and shorter. In-services of more than 30 minutes are less likely to be remembered.
  3. Plan speaking points with your vendor partners. This can include a primary topic to speak about, key points to be made, and a time limit. 

If scheduling an in-service with your vendor partners is difficult or impossible, pull hospital upper management into the equation. They are called our partners for a reason and their contracts may include providing education and training to the departments that use their instruments. In the meantime, we can encourage critical thinking and subject matter expertise development by providing videos of procedures. The internet can be a helpful tool in this regard. Ranging from graphic to simulated, these instructional videos can serve to increase interest and engagement. 


When it comes to complex and specialized orthopedic instruments, the processes aren’t necessarily what need to be changed or customized; it’s the SP professional’s skills that must be refined and given the opportunity to develop past foundational training. Through the introduction of additional information and comprehension, our critical thinking skills develop as we become orthopedic subject matter experts. This serves to not only improve the cleanliness and quality of the instrumentation, but also our SPD’s perception of and satisfaction with our work. The power of learning and comprehension permits us to truly hone our craft and focus on what this career can offer us and our patients.

 Note: The views and opinions expressed are of Sarah B. Cruz only and do not represent the businesses she works for or companies she collaborates with.