SELF/Perioperative Nursing/Handling Implants and Devices

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▼This page is a part of the Perioperative Nursing Curriculum by ECSACONM and SELFPlease see the Intuitive Foundation Terms of Use and do not edit without permission.

By the end of this module, the perioperative nurse will reliably plan, set up, handle, document, and hand off surgical implants and devices—maintaining sterility, compatibility, and traceability—to support safe, efficient implantation and postoperative care.

• Describe how implants are verified for indication, compatibility, sterility, and integrity before surgery.
• Explain the rationale for separating trial implants from definitive implants and maintaining accurate counts and traceability.
• Identify the required elements of implant documentation, including UDI/lot numbers and intra-operative findings.
• Explain the use of traceability tools, such as implant cards and reprocessing protocols, to ensure patient safety and recall readiness.
• Describe the structured information that must be communicated during PACU handoff to support safe recovery.
• Recognize early signs of post-operative implant complications, including cement embolism and graft rejection.

Every implant procedure begins with precise mapping of the planned implant. Before instruments are opened, the nurse must confirm the procedure type, laterality, and level with both the surgical plan and the surgeon’s preference card. Implants from different systems are never mixed unless the manufacturer’s instructions for use (IFU) allow for it. A matrix of implant sizes should be cross-checked against the patient’s expected anatomy and radiographs. Backup implants—both larger and smaller sizes—must be present on the sterile field to account for intraoperative variation, such as unexpected bone density or anatomic anomalies.

Inventory integrity is verified in detail. Each implant’s outer packaging must be inspected for denting, wetness, compromised seals, or illegible labeling. Expiry dates must be checked, and the unique device identifier (UDI) and lot number logged before use. Counterfeit cues such as unusual fonts, faded holograms, or inconsistent color schemes must trigger immediate quarantine of the suspect implant and escalation to the charge nurse. If the sterile barrier is breached, that implant is not placed on the sterile field.

Sterility assurance requires careful monitoring during setup. Implants are opened onto the sterile field only when needed, to minimize exposure. Small packages should be presented one by one, not stacked, to avoid contamination from contact with wrapper edges. Trial implants must remain physically separated from definitive implants on the back table to prevent confusion, corrosion, or contamination. Moisture must be avoided, as wet packaging can permit microbial wicking into sterile contents.

The scrub nurse should arrange implants on the table in the same order the surgeon will need them during the operation. For example, in a spinal fusion procedure, start by placing the smallest screws at the front of the tray for the surgeon to use during pilot hole testing. Next, line up the definitive screws in increasing sizes, so the surgeon can quickly choose the correct diameter and length. Torque limiters should be positioned directly beside the screw trays for immediate access when tightening. Plates or rods should be laid out in ascending size order, with the smallest closest to the surgeon’s working area. Organizing the table in this sequence ensures smooth workflow, prevents confusion, and minimizes extra handling of implants that could compromise sterility.

The implant back table must be organized into zones: one for trial implants and one for definitive implants. Trial implants are temporary pieces the surgeon uses to test the fit, alignment, or size before placing the final device (for example, a plastic hip cup used only to check angles). Definitive implants are the actual, permanent implants that stay in the patient. Asepsis is maintained by never allowing used trial devices to touch the definitive zone. If fluid irrigation is required, suction must be used to prevent pooling beneath trays on the back table, as standing fluid corrodes metallic implants and creates contamination risk. Protective tray liners should be used when available to keep devices elevated and dry.

Counts and traceability begin at setup. All small implant parts—screws, washers, locking caps, wires—must be counted aloud with the circulating nurse and documented as part of the count; this process repeats with every hand-off of parts to the surgeon, and is described with further details in Surgical Counting - ECSACONM. If multiple similar parts are present, each must be arrayed in an orderly row or grid to allow visual tracking. Opened implant packages should be handed over only when the surgeon is ready to implant, so that the UDI and lot can be captured at the moment of use.

During surgery, the scrub nurse is responsible for passing implants safely and efficiently while preserving sterility. If wet or contaminated, gloves should be changed before handling any implant. When lifting implants, contact should be minimized and restricted to non-critical areas — for example, holding a plate by its outer edges rather than the screw holes or bone-contacting surface. Screws should always be mounted securely onto the correct screwdriver before they are passed. The scrub nurse should ensure that the driver tip is fully engaged with the screw head and should stabilize the screwdriver shaft with the opposite hand until the surgeon has a firm grip. This prevents wobbling or accidental dropping, which could render the screw unusable. Rods and plates must be oriented according to the patient’s anatomy before presentation. The scrub nurse should hold these at the far end so the surgeon can grasp the working end immediately without having to rotate or flip the implant - they should be presented in a steady, horizontal motion into the surgeon’s line of sight, rather than vertically over the wound, which reduces the chance of contamination. For good general surgical assistance technique see Surgical Assistance - ECSACONM.

When implants are returned to the table, trial implants in particular must be placed in a designated receptacle, never intermixed with definitive items. After each critical step, such as final tightening of locking caps, the scrub nurse must verify no small parts remain unused or unaccounted for. This reduces retained item risk and ensures that intraoperative implant logs are accurate for each component implanted.

Self-Assessment

Please complete the following: Quiz 1: Handling Implants and Devices - ECSACONM

Implant documentation begins before incision. The nurse records the indication for the procedure, the intended implant system, and the compatibility status with the patient’s anatomy. During surgery, each implant’s type, material, size, and location must be recorded as they are used. For example, in a hip arthroplasty, the stem size, head diameter, offset, and liner material must all be noted. Screw lengths and counts should be logged with precision, along with any torque limiters used.

UDI and lot numbers are captured in real time. Stickers from implant packages should be affixed directly to the operative record, with redundant manual entry if the sticker is damaged or incomplete. The log must link each lot number to the specific anatomical site, so that recalls or failures can be traced to the correct implant in the correct patient. If grafts or polymethylmethacrylate (PMMA) bone cement are used, the dose, additives, and mixing method are documented, along with any complications such as pressurization events.

Post-operative imaging performed intraoperatively must be recorded in the chart, noting what was imaged (for example, “anteroposterior fluoroscopy of femoral component alignment”) and the result. Any intraoperative complications—broken drill bits, off-angle screw placement, need for revision implant—must be described with the mitigation undertaken. These details are not optional; they form the medico-legal record and the clinical basis for safe patient follow-up.

Traceability extends beyond the operative record. A patient implant card should be completed before leaving the OR, listing each implant type, size, and lot number. Contact information for the manufacturer or distributor must be provided, in case recalls are issued. Loaner sets must be flagged for reprocessing priority, with damaged or missing items documented for procurement. If sets cannot be immediately sterilized, they should be kept moist to facilitate cleaning and prevent bioburden fixation.

The handoff to the Post-Anesthesia Care Unit (PACU) staff must be both verbal and written, using a structured implant map. This includes exactly what was implanted, in which anatomical location, and in what sequence. Non-standard steps—such as a substitute implant—must be highlighted explicitly. Imaging performed during surgery should be summarized, along with whether additional imaging is required post-operatively. Red-flag triggers to monitor in recovery, such as sudden pain increase, fever, or new neurologic deficits, must be emphasized.

Verbal communication should follow a set order. First, confirm the type and number of implants placed. Second, describe any intraoperative challenges or deviations from plan. Third, relay specific post-operative care needs, such as immobilizers, drains, or wound vacuums. Finally, specify follow-up imaging timelines and thresholds for urgent surgeon notification. Written notes should replicate this order, providing redundancy if verbal details are missed.

Immediate device care instructions are included in the handoff. If implants remain exposed—for example, external fixator pins—PACU staff must irrigate sites with sterile solution as ordered and avoid applying adherent dressings that may disrupt pin sites. Non-adherent interfaces should be placed, and the area kept dry. Exposure to corrosive cleaning chemicals or antiseptics not validated for implants must be avoided, as these may compromise device integrity.

The PACU nurse must also be told whether torque limiters, PMMA, or grafts were used, since these influence monitoring for systemic complications such as cement embolism (sudden drops in oxygen saturation, low blood pressure, shortness of breath, or unexpected cardiac instability immediately after cementing) or graft rejection (new redness, swelling, fever, worsening localized pain, or unusual drainage at the graft site). Clear instructions about neurovascular checks, wound assessments, and timing of prophylactic antibiotics should be provided. This ensures the implant remains safe and functional through the vulnerable immediate post-operative phase.

When working with limited personnel, nurses may need to assume multiple roles in implant handling and documentation. In such cases, prioritize traceability and sterility above non-essential tasks. For example, if no circulating nurse is available to double-count small parts, the scrub nurse should count parts while arranging them in clear grids or rows and photograph the setup (if policy and asepsis allows) to create a record. Documentation of UDI and lot numbers can be done immediately after surgery if real-time capture is not feasible, but stickers or empty packaging must be safeguarded until charting is complete.

Equipment shortages demand creative zoning and protection of implants. If separate tables for trial and definitive implants are not available, use sterile drapes or marked trays to create physical separation zones on a single surface. For implant exposure care in PACU, if non-adherent dressings are unavailable, sterile petrolatum gauze may substitute. When irrigation solutions are limited, prioritize irrigation at implant entry points or exposed hardware, ensuring bioburden is minimized without exhausting resources needed for other patients.

Self-Assessment

Please complete the following: Quiz 2: Handling Implants and Devices - ECSACONM

Cumulative Test

Please complete the following: Module Test: Handling Implants and Devices - ECSACONM

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