1 Introduction

The practice of orthopaedic surgery dates back hundreds of years. The first published use of the term “orthopaedia” was in 1741 by Nicholas Andry¹ – but the profession undoubtedly has an earlier unwritten history. In more recent times, the specialty has grown dramatically, with the advent of arthroplasty and continued advancement with internal fixation techniques.² Naturally, with more techniques comes more instrumentation - each with their own guide to use and specific nomenclature.

In the 1970s it was noted that the increasing introduction of novel surgical instruments lead to a lack of clarity and “on examining the terminology of this group of instruments we can note the absence of clear cut boundaries”.³ The same is only more true today. In fact, confusion now exists over the correct definition of many devices. Certain instruments exist as adaptations of another with a new name, while others exist on a spectrum where the preferred name depends on a changing size or diameter of the instrument. This uncertainty regarding nomenclature can lead to confusion in the operating theatre between surgeon and assistant, as well as the scrub and scout team.^4–6 Up to 36 % of communication errors in the operating theatre are equipment related^6,7 – such communication issues can lead to theatre delays and inefficiencies, and at their extreme can compromise patient safety.^5–12

A standardised approach to orthopaedic surgical instrument nomenclature is worthwhile and currently lacking in the literature. Clarity must be brought to the picture, and this is the aim of the following article. We present an evidence based approach to standardising nomenclature surrounding common orthopaedic instrumentation.

2 Methods

An online assessment tool depicting 14 commonly used orthopaedic surgical instruments was created and administered to study participants (Fig. 1). Each question was multiple choice, and showed an image of a surgical instrument with a selection of potentially appropriate responses chosen by the authors. The respondent was asked to select the single most appropriate response for the image shown. The respondent was also able to provide an alternate name they thought was more appropriate, if applicable. No feedback on responses was provided to respondents.

Close

Fig. 1 – The image set provided with the online assessment tool. Images categorised preliminarily by authors as follows: a) “mallet” b) “osteotome” c) “nail” d) “wire” e) “rasp” f) “pin” g) “nibbler” h) “prosthesis” i) “orthosis” j) “trochar” k) “obturator” l) “clamp” m) “Trethowan” n) “Keon-Cohen”.

Export to PPT

The online assessment tool was distributed to several orthopaedic units in both metropolitan and regional Victoria, Australia. This comprised orthopaedic consultants, registrars, scrub staff and allied health staff. Further responses from non-orthopaedic healthcare staff and non-healthcare trained individuals were sought via word of mouth and social media. Informed consent was obtained from each participant prior to enrolment in the study. No personal or identifiable data was collected during the study process.

Submitted responses were compiled and analysed for means analysis and trends amongst subgroups of respondents. As this study deals with subjective definitions rather than objective data, a consensus opinion was deemed the gold standard for achieving a successful definition. This was defined as 70 % of orthopaedic consultant, orthopaedic registrar and orthopaedic scrub or scout staff respondents – a numerical threshold used in prior consensus studies.^13,14 Non-orthopaedic respondents were categorised based on specialty of training, and provided various comparative cohorts against the orthopaedic opinion. A cohort from non-healthcare professional backgrounds was included to represent the general public and provide a “common sense” perspective on orthopaedic surgical nomenclature.

3 Results

Responses from a total of 136 participants were collated. This included 15 orthopaedic consultants, 16 orthopaedic registrars and three nursing scrub staff members (Table 1).

Orthopaedic consultants, registrars and scrub staff members all reached consensus opinion with agreement of 70 % or higher on the following instruments: mallet, osteotome, nail, wire, rasp, nibbler, prosthesis, and orthosis (Table 2). However, contention still exists over the definition of an arthroscopic obturator, bone clamp/forcep, and a bone lever/spike/jimmy/trethowan. In addition, an eponymously named retractor, the Keon-Cohen (or Jackson-Burrows), did not reach a consensus definition. While an arthroscopic trochar did reach an orthopaedic consensus definition, this was somewhat contentious.

4 Discussion

This study aimed to seek consensus definition for a variety of orthopaedic surgical instruments in an attempt to standardise nomenclature used in the operating theatre. Following a total of 136 responses, including 34 from orthopaedically trained respondents, we can successfully report standardised definitions for a mallet, osteotome, nail, wire, rasp, nibbler, prosthesis and orthosis (Table 2).

A mallet (now preferred to hammer) may be recognised by its long handle attached to a two-sided head and is typically used to strike another instrument with varying force. An osteotome is a pointed instrument with a double-bevelled flat blade typically used to cut bone, and is distinguished from a chisel which has only a single-sided bevel. A nail is a fixation device inserted into the medullary canal of a bone and is typically of a diameter wider than 6.5 mm – it's distinguishing feature. This is compared to a wire, which is also a fixation device but is typically inserted into cortical bone, and has a diameter 2 mm or less. While the authors propose that a pin is a fixation device with a diameter between 2 and 6.5 mm, bridging the gap between wire and nail, this definition did not reach a consensus response.

A rasp is an instrument with a roughened face used to smooth bone, and can be distinguished by its distinct individual teeth compared to a file which has a more simple abrasive surface. A nibbler is a hinged device with a sharpened spoon-shaped mouth used to remove bone, and this colloquialism has overtaken the term rongeur (French word meaning “gnawing”) as the preferred definition. A prosthesis is a medical device that replaces a part of the body, while an orthosis is an externally applied device that supports part of the body. Based on this study's results, we propose these standardised definitions.

Interestingly, these orthopaedic consensus definitions were frequently at odds with other specialties or other respondent groups. The only instruments that reached a consensus agreement across all groups were mallet, nibbler, prothesis and orthosis. This is a demonstration of how orthopaedic nomenclature may differ from other healthcare staff, and in particular from other surgical specialties. This is an important point, particularly for theatre nursing staff and junior doctors, whose prior surgical experience in other specialties may in fact hinder, rather than help, communication. This illustrates the importance of instrument nomenclature standardisation – both on an international scale, as well as locally within individual orthopaedic units, to ensure each theatre staff member has the same understanding of instrumentation terminology before an operation commences.

One instrument, frequently referred to as an obturator (from the Latin word obturare meaning to obstruct - due to its nature of obstructing or blocking the cannula of an arthroscopic trochar), did reach a surprising consensus definition. Rather than the expected etymology-based result of obturator, this device instead reached an orthopaedic consensus definition of trochar (74 % of orthopaedic responses). This is a controversial result and as such has not been proposed as the accepted definition in this paper. The reasons for this change in definition are not clear. However, this result may reflect the natural evolution of terminology within orthopaedic practice. This result should be verified in further research before it is proposed as an accepted definition.

One challenge commonly encountered with surgical instrument nomenclature is the use of eponymous names. One such eponymously named retractor, the Keon-Cohen (or Jackson-Burrows), was added part-way through the study to explore its definition (Fig. 1). Interestingly, the results showed a strong bias based on geographical location of orthopaedic training. Those that had trained in the United Kingdom referred to such a device as a Jackson-Burrows retractor, while those trained in Australia referred to it as a Keon-Cohen retractor. As such, this device did not reach a consensus definition. This result reflects a further complexity with reaching consensus opinion on this topic – geographical bias. However, in this modern age of increasing international collaboration, such bias adds further weight to the already strong argument for reaching international consensus guidelines on the names of surgical instruments.³ The consensus definitions proposed by the results of this study are from a cohort of the Australian orthopaedic community. These views should be verified by an international cohort of orthopaedic staff, while taking the opportunity to assess additional instruments, with the overall aim of creating a standardised definition set for orthopaedic surgical instrumentation worldwide.

5 Conclusion

This study proposes consensus definitions on several commonly used orthopaedic surgical instruments. However, consensus definitions do not exist for several surgical instruments. Orthopaedic nomenclature frequently differs from that used in other specialties, and clarification of terminology within local theatre teams is required to ensure optimal theatre outcomes are achieved. Widespread standardisation of instrument terminology will prove challenging, but has potential benefits such as improving efficiency in theatre, enhancing patient safety through improved communication and allowing greater clarity when sharing surgical techniques with colleagues. Ongoing efforts are required to bring further clarity to the orthopaedic surgical instrument nomenclature.

CRediT authorship contribution statement

Daniel Joel Epstein: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft. Andrew Philpott: Conceptualization, Investigation, Methodology, Writing – review & editing. Michael Bullen: Conceptualization, Investigation, Methodology, Writing – review & editing. Keith McCullough: Conceptualization, Data curation, Investigation, Methodology, Writing – review & editing, All authors read and approved the final manuscript.

Consent to publish

Informed consent was obtained from all study participants prior to their enrolment. This included express consent to both present and publish any data obtained during the research process. No identifiable data was obtained during the study process.

Consent to participate

Informed consent was obtained from all study participants prior to their enrolment. This included express consent to both present and publish any data obtained during the research process. No identifiable data was obtained during the study process.

Availability of data and materials

All study data and materials are available upon request. The researchers do not have access to a study data repository, but are happy to deposit data in to a repository if one became available.

Ethics approval

This study utilised an online opinion poll and did not collect any personal or identifiable data from participants. As such formal ethics committee approval was not sought as the risk to participants was minimal. The principles of ethical conduct of research were adhered to at all times.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.