Experts Reveal Their Top 5 Moves in Primary TKA

    Dr. Del Schutte, Dr. William Long, and Dr. James Browne share their top moves in the operating room when performing a total knee arthroplasty.

    Multiple sessions at a recent ICJR Winter Hip & Knee Course were dedicated to discussions from leading orthopaedic surgeons about their top 5 moves in primary and revision total knee (TKA) and total hip arthroplasty (THA).

    In this article, we focus on primary TKA, with comments from H. Del Schutte Jr., MD; William J. Long, MD, FRCSC; and James A. Browne, MD.

    Del Schutte Jr., MD
    Director Joint Replacement Center, East Cooper Medical Center, Mount Pleasant, South Carolina

    Dr. Schutte advised meeting attendants to “Just Say No,” as his top 5 moves involve a process of elimination:

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

    Dr. Schutte quoted a colleague who said, “If you want to perform truly minimally invasive surgery, you should stop using a tourniquet.” After eliminating use of a tourniquet, Dr. Schutte found his patients did better in the first 3 months after surgery.

    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. Research has shown, he said, that as little as 3 mm of overhang is associated with an almost twofold increase in risk of knee pain.

    Dr. Schutte added a sixth tip: Operate from the end of the table, as he has found that this eliminates visual and “handedness” bias, allows him to make crucial cuts parallel to the floor, and eliminates up to 40% of instrument passes

    Finally Dr. Schutte advised meeting attendants to be aware of the increased occurrence of vitamin D deficiency in orthopaedic patients – up to 38% of arthroplasty patients in one study. [1] Normal vitamin D levels are associated with normal bone mineralization, reduction of inflammation, and prevention of infectious disease, he said.

    Click the image below to watch Dr. Schutte’s presentation.

    William J. Long, MD, FRCSC
    Insall Scott Kelly Institute, New York, New York

    Using surgical videos, Dr. Long demonstrated in detail his top moves:

    Respect the skin and soft tissues. For the difficult knee with multiple previous incisions, Dr. Long carefully plans his incision based on long-standing recommendations. If he is unsure of skin viability he uses tissue expanders to ensure enough skin for a complete, tensionless closure. Dr. Long makes the skin incision and arthrotomy with the knee in flexion, and makes sure the arthrotomy comes far enough distal to aid in exposure and subluxation of the knee. He also does not use skin rakes or develop skin flaps.

    Medial release. The knee is tensioned using spacer blocks, and if necessary, a medial release is performed using a three-quarter inch osteotome. Dr. Long preserves the Pes tendons in most cases, the exception being knees with a flexion contracture. Stabilized articulation is not necessary if the knee appears to be loose medially when he’s testing knee balance using trial components, he said, as the soft tissue closure will tighten up the soft tissue sleeve.

    Liberal use of a tibial stem. Dr. Long recommends using a tibial stem for patients who are obese, those who have bone defects, those with osteoporotic bone, and those undergoing a conversion from unicondylar knee arthroplasty to avoid tibial subsidence.

    Externally rotate the tibial component. Don’t let the patellar tendon push the tibial template into internal rotation, Dr. Long said. In a video, he showed how to avoid this by placing the template without the handle. Dr. Long also warned against using the same fixed point on the tibal tubercle as the landmark for rotation when lateralizing the tibial component, as this will lead to internal tibial rotation.

    Bilateral TKA. With less-invasive surgery, improved anesthesia and pain management, the use of tranexamic acid and periarticular injections, and the initiation of rapid rehabilitation protocols Dr. Long believes that well-selected patients can do very well with simultaneous bilateral TKA procedures.

    Click the image below to watch Dr. Long’s presentation.

    James A. Browne, MD
    Associate Professor, Chief of Adult Reconstruction, University of Virginia, Charlottesville

    Dr. Browne focused on these 5 steps of the TKA procedure:

    Prep and drape. The native skin flora is responsible for the majority of surgical site infections said Dr. Browne. To minimize infection risk, he utilizes a “double-scrub” prep, cleaning first with chlorhexidine and then cleaning the skin again with alcohol. Dr. Browne preps the foot as the first step, as contamination may come from an unprepped foot. Finally, after draping is complete, the surgical site is scrubbed again with the knee in flexion.

    Retractors. From Dr. Mark Pagnano, Dr. Browne learned to use a Kocher for retraction. The Kocher is placed on the medial retinaculum just proximal to the medial meniscus and stays in place during the entire procedure. Dr. Browne finds that the Kocher provides great retraction, which in turn improves visualization. At times the Kocher is the only retraction he uses, as shown in his surgical video.

    Implant selection. Dr. Browne is a proponent of all-polyethylene tibial components. He says an all-poly tibia provides excellent long-term results and eliminates backside wear at a lower cost – an important factor with bundled payments. There may be a learning curve to implanting an all-poly tibia, but Dr. Browne showed a surgical video of how easily this can be done.

    Closure. Dr. Browne recommends closing the arthrotomy with the knee in flexion, as it helps the soft tissues fall into place. Dr. Browne places a single #2.0 Vicryl suture just proximal to the patella with the knee in extension, then flexes the knee and completes the closure using a locking suture.

    Postoperative management. In Dr. Browne’s practice, all patients receive a phone call 2 to 3 weeks after surgery. Dr. Browne finds this to be one of the most important things he has implemented in his time in practice. These phone calls add only an hour to his work week, but contribute immensely to patient satisfaction.

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


    1. Bogunovic L, Kim AD, Beamer BS, Nguyen J, Lane JM. Hypovitaminosis D in patients scheduled to undergo orthopaedic surgery: a single-center analysis. J Bone Joint Surg Am. 2010 Oct 6;92(13):2300-4. doi: 10.2106/JBJS.I.01231.