SURGICAL PEARLS: Tips and Techniques for Primary TKA from Dr. James Browne

    James A. Browne, MD, helps to train adult reconstruction fellows at the University of Virginia Health System in Charlottesville, and during ICJR’s Winter Hip & Knee Course, he shared with attendees the top 5 tips for primary total knee arthroplasty (TKA) that he imparts to the fellows during their training.

    Prep and Drape

    How to prep and drape a TKA patient is rarely, if ever, discussed at meetings. But as Dr. Browne noted, it’s critically important: How the surgical team preps the skin influences the infection rate. Native skin flora, he said, still account for most surgical site infection.

    Dr. Browne’s team does a 2-stage prep that he says makes intuitive sense and can easily be worked into the flow of the procedure. The skin is initially prepped in extension and the leg is then draped. The second prep is done with the knee in extension to get into areas that may have been missed with the first prep.


    Dr. Mark Pagnano taught Dr. Browne to place a Coker retractor above the medial meniscus on the medial retinaculum immediately after performing the arthrotomy. The Coker is left in for the entire procedure and allows Dr. Browne to safely and easily insert other retractors, such as curved Hohmann retractor, and access the back of the knee.

    Patella Resurfacing Technique

    As Dr. Browne noted, patella resurfacing can be challenging for many reasons, including the highly variable patellar anatomy. This makes it difficult for surgeons to get the cuts right every time – and there aren’t any definitive techniques to address the issue, he said.

    Dr. Browne compensates by carefully templating the patellar cuts he wants to make on the patient’s radiographs, which are displayed in the operating room as a reminder. By visualizing what he wants to do, he says he knows how much bone to cut medially and laterally, superiorly and inferiorly. He then makes the cuts freehand, which he finds to be more accurate than using any of the jigs he has tried.

    Surgical Wound Closure

    Dr. Browne closes the surgical wound with the knee in flexion. He prefers to use barbed locking sutures, but any type of suture can be used.

    With the knee in extension, Dr. Browne places 1 suture just above the patella to reapproximate the arthrotomy. He then flexes the knee and begins closing the wound distally with running locking sutures. At the same time, an assistant begins closing the wound proximally. By flexing the knee, there is enough room for 2 people to safely and efficiently work on closing the wound.

    Postoperative Management

    Dr. Browne personally calls every patient 2 to 3 weeks after surgery to check on how they are doing. This means a lot to patients who may be struggling after surgery and who would benefit from speaking with their surgeon for a few minutes to allay any concerns they’re having.

    Dr. Browne says this is the most important practice he has adopted, and it adds only 1 hour a week to his work – which is more efficient than seeing every patient in the office at 2 or 3 weeks.

    Click the image above to watch Dr. Browne’s presentation.


    Dr. Browne has disclosed that he has a consulting agreement with and receives royalties from DJO Surgical.