SURGICAL PEARLS: Keep It Simple, Plus More Tips for TKA
This week, we’re highlighting presentations from ICJR’s Pan Pacific Orthopaedic Congress that offered tips, tricks, and surgical pearls for primary and revision total knee arthroplasty. First up, Matthew S. Austin, MD, from The Rothman Institute in Philadelphia, Pennsylvania, on primary total knee arthroplasty.
Tip 1: Follow the KISS principle
Dr. Austin and his colleagues believe in the concept of Keep It Simple Stupid. With minimal instrument trays and well-defined protocols, he can run an efficient operating room where no one is rushing and everyone knows their role and the process.
Tip 2: Make a straight incision
Some surgeons have knee incisions that look like they were playing a game of Grand Theft Auto, Dr. Austin said. He prefers to make a straight incision perpendicular to Langer’s lines. He also does not draw the incision on the knee – when draping the knee, drawn lines tend to shift around and even disappear under the drape.
Tip 3: Seeing well means doing the surgery well
The surgeons at The Rothman Institute do not do a lot of minimally invasive surgery, Dr. Austin said; they want adequate exposure to see the knee. To facilitate this, Dr. Austin likes to dissect the soft tissue circumferentially from around the tibia.
Tip 4: Know how to hit the coronal alignment target
When cutting a slope into tibia, be sure to get the rotational alignment correct. Dr. Austin judges the rotational alignment from the top, not the front, of the knee. For the femur, align the distal cutting guide parallel to the epicondylar axis.
Tip 5: Use staples in a patient with valgus laxity
This is a trick Dr. Austin learned from The Rothman Institute’s founder, Richard H. Rothman, MD, PhD: The medial collateral ligament (MCL) can be advanced with staples in a patient with a valgus and an attenuated MCL.
With the knee in 30 flexion, apply varus force and then dissect out the retinaculum and some of the MCL. Pull this over and put in a few staples to hold it. This can avoid the use of a constrained liner.
Tip 6: Ensure adequate pain management
How the surgery is done and what implant are secondary to how well the patient’s pain is controlled after the procedure. Surgeons at The Rothman Institute follow a standard protocol for multimodal pain management, which Dr. Austin shared with attendees at the meeting.
Click the image above to watch Dr. Austin’s presentation.