10 Tips for a Good Outcome in Total Knee Arthroplasty
Dr. Chitranjan Ranawat shares his thoughts on what the orthopaedic surgeon can do to improve outcomes in patients undergoing primary total knee arthroplasty.
Chitranjan S. Ranawat, MD – one of the premier orthopaedic surgeons in the world – shared with attendees at the 2nd Annual ICJR South/RLO Course his advice for achieving a good outcome with a primary total knee arthroplasty.
He discussed the Ranawat Technique, which focuses on the concept of balancing the extension gap first, then the extension gap, not by soft tissue releases, but by cutting the appropriate amount of bone.
The following are his top 10 tips:
1. Dr. Ranawat advocates epidural hypotensive anesthesia as part of his reduced tissue trauma surgery approach. Maintaining the mean systolic pressure at 60 to 65 mm Hg reduces blood loss, he said. He also limits the use of a tourniquet to less than 25 minutes, reserving it for cementation.
2. Provide pre-emptive analgesia and pain control. Before surgery, Dr. Ranawat’s patients receive oxycodone, celecoxib, gabapentin, tramadol, and Clonidine patch. During surgery, he injects the knee space with a periarticular “cocktail” consisting of Marcaine, morphine, epinephrine, an antibiotic, a corticosteroid, and normal saline.
3. Ensure proper exposure of the knee. Dr. Ranawat favors the Ransall maneuver, which brings the tibia in front of the femur. He also avoids unnecessary undermining of the skin by staying below the deep fascia.
4. Balance the extension then the flexion gap, making sure to maintain the joint line. During the presentation, Dr. Ranawat showed a video demonstrating his technique for exposure and for balancing the extension and flexion gaps.
5. The tibial cut – which Dr. Ranawat says is the most important cut in the knee – should be done 90° (plus or minus a couple of degrees) to the anatomic axis. An improper cut causes loosening, he said.
6. Proper femoral/tibial sizing and rotation are essential for restoring posterior offset and proper rotational alignment.
7. Ensure proper patellofemoral tracking.
8. Use proper cement technique.
9. Pay close attention to wound closure. Dr. Ranawat closes without the tourniquet.
10. Take appropriate preventive measures to reduce the risk of infection.
Dr. Ranawat is Clinical Professor of Orthopaedic Surgery at Weill Medical College and an Attending Orthopaedic Surgeon at the Hospital for Special Surgery in New York City. In addition, he is Director of the at Lenox Hill Hospital and at the Hospital for Special Surgery.
His presentation can be found here.