Total Joint Replacement (TJR)

Total Joint Replacement
Draping
Shoulder roll
Head drape
Scrub and prep, towels on face
Scrub and prep, towels on abdomen (Fat graft)
Ioband
Second mayo stand (abdomen?)
Urology drape
Really large tegederms/opsite (for the mouth – central supply)
Peanut for the ear (after prep/drape)
Mark and inject off the field or on the field?
Accessories
bipolar
Epi dilution (1 mg in a 100 cc saline bag)
bovie
Nerve stimulator
TMJ concepts kit
Stryker core drill
Model/implant
Photos with pictures of model/implant and screw holes/numbers (in color)
3-0 vicryl, 5-0 nylon, 4-0 monocryl for the abdomen
2-0 silk vessel ties
Flash sterilize – if you need to remove a stock, make sure you have the screw driving for the plate, like if it was a Synthes plate
All the burs – round burs carbide, oscillating (IVRO saw), fissure burs, Sagittal (BSSO)
Head wrap stuff
Make sure you know the numbers for the screws
Make sure you check the loaner kit is available, model, prosthesis, case report printed in color
24 gauge wire

When doing TJR b/l
– arch bars on unsterilly, dont bother with elastics
⁃retro/preauricular both sides
⁃Skin, sq, temp fascia, protect facial nerve, go to arch, then go to capsule, need to see entire condylar head
⁃You are posterior to vessels, meaning the nerve is anterior to the vessels
⁃In the retromandibular incision, with a cutting guide, you need to see the sigmoid notch
⁃Submandibular
⁃Cut out the condyle
⁃Pull of the lateral pterygoid will be an issue, must release muscle attachment
⁃After fossa component is in both sides, slip ramal component in
⁃Imf
⁃Screw in ramal
⁃Throw in fat

Scrub and paint both the abdomen and the face surgical site
⁃go to the mouth last
⁃When you head wrap, you must be able to see the eyes so that you can assess facial nerve function

Opsites for the mouth and extra gloves for Dr. B.

For preauricular, antihelical, go through down to temporalis fascia, will end up going to the zygo arch and you should be able to find the superior joint space
⁃you retract anteriorly and the temporal vessels are posterior to the facial nerve
⁃Facial nerve should be found .8 cm from EAM so you want to be within that distance
⁃Use the nerve stimulator, it has a metal tip that goes in the skin and then you touch it in the hole to make sure the light is on so that you know the nerve stimulator is working
⁃Make sure you have the bipolar, bovie tip, and teflon tip
⁃The Stryker nosecone is used for the oscillating saw and round burs
⁃The Stryker mini drive with the Jacobs chuck is used for the TJR to drill holes
⁃When you dissed submandibular, you go down to platysma and then make a hole beaks down of hemostate to make a pocket
⁃Then beaks up, spread 5 mm, dont need to go wider
⁃Then spread 5 mm go anterior and posterior
⁃When you’re ready to make the exit pocket go in beaks closed, punch through, then open, then nerve stimulator, then cut. Don’t touch the metal
⁃If you have to tie vessels, then 2-0 silk on hemostat, the vessel is clipped on both ends with hemostat with beaks facing each other. Then cut in between, then wrap the 2-0 silk around the hemostat. If it is tight and you release the initial hemostat, then you know the vessel was tied tightly.
⁃Make sure you shove dermal fat laterally and medially before you start closing the preauricular/submandibular incisions
⁃3-0 vicryl on RB for deeps. You dont need to Bury these knots until you’re at subcutaneous layer where the knots will be shown.
⁃Make sure you’re fucking perpendicular when you use the drills
⁃Screw in perpendicular
⁃When doing the submandibular risdon incision. Palpate the angle, draw out the inferior border and posterior border. Make incision 1.5 cm below that.
⁃Through skin, SQ. Control bleeding points with coag
⁃Then through platysma, superficial cervical fascia. Feel the sling and inf border, try to go at the avascular area
⁃You must make sure the prosthesis is in the fossa component when you check the opening.
⁃If pt has teeth, needs archbars on prior to case starting
⁃Sound the bone with your instruments
⁃Use the broad end of periosteal/seldon if you have to strip the lateral ramus
⁃If you need to pull the mandible down, put a screw in the inferior border and attach a 24 gauge wire looped twice, rosette close to your double loop that engages the screw. Pull to tighten it and then use that as a joystick to pull the mandible down inferiorly
⁃Make sure you remove those screws at the end of the case