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    What Top Knee Surgeons Have Learned in the OR

    Dr. Fred Tria and Dr. Del Schutte reveal their top moves in the operating room when performing a total knee arthroplasty.

    A number of sessions at ICJR’s Winter Hip & Knee Course gave attendees a glimpse into the ORs of successful joint replacement surgeons through presentations on the their top “moves” in primary and revision hip and knee arthroplasty.

    In this article, we focus on 2 presentations on primary knee arthroplasty by Alfred J. Tria, Jr., MD, from St. Peter’s University Hospital, Somerset, New Jersey, and H. Del Schutte, Jr., MD, from East Cooper Medical Center, Mount Pleasant, South Carolina.

    Dr. Tria’s tips involve 5 areas of the procedure:

    • Getting started. Dr. Tria advises against reusing the tourniquet to avoid the chance of cross-contamination between patients. The cost savings aren’t worth the potential infections.
    • Knee exposure. From Dr. John Insall, Dr. Tria learned to do a slight oblique release from proximal to distal of the parapatellar tendon. By doing this, he does not need to use pins around the tibial tubercle.
    • Instruments. In a minimally invasive approach, be sure to use appropriately sized instruments – regular, larger instruments will not work with a small incision. Dr. Tria says he uses smaller instruments for all procedures now, not just those with small incisions, because they’re easier to work with.
    • Pain control. Dr. Tria uses periarticular injections of local anesthetic/analgesic agents to control postoperative pain in his total and unicondular knee cases. He demonstrates his technique during his presentation. He believes femoral and adductor canal blocks are no longer necessary with the use of these injections.
    • Closure. Dr. Tria uses locking sutures to close surgical wounds. He used to suture all the way and then all the way back down the incision, but that caused some issues with the tissue weeks later. He still sutures all the way up, but then only 3 throws back. Plus he reinforces the incision with interrupted Ethibond sutures.

    Watch Dr. Tria’s presentation here.

    Dr. Schutte emphasized what he no longer does during TKA:

    • No Foley catheters
    • No tourniquet
    • No drains
    • No cement
    • No medial or lateral overhang

    During his training, Dr. Schutte heard surgeons saying that a little overhang on the lateral side was acceptable, but medial overhang was not. He says the lateral overhang is just as important, and he has now eliminated medial and lateral overhang due to the risk of knee pain.

    Dr. Schutte provided a sixth tip: Work from the end of the table. Most surgeons work from one side of the other, but he prefers being at the end of the table, as he finds it to be more efficient.

    When he is positioned at the end of the table, Dr. Schutte can pick up basic instruments himself, rather than have them passed to him. He can also deposit instruments, whether he picks them up himself or the nurse hands them to him, directly into the used instrument basin without the go-between of the nurse.

    Dr. Schutte and his team evaluated instrument transfers, and they discovered that when he stood on one side of the table, there were 170 transfers. When he moved to the end of the table, instrument transfers were cut 40% to 100, which Dr. Schutte said could decrease the chances of contaminating the field.

    Watch Dr. Schutte’s presentation here.

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