Sutures: 

1. #1 Vicryl   x 3
2. #2 Stratafix Spiral PDO x 1
3. #2-0  Vicryl   x 3 
4. #3-0 Vicryl  x 1
5. Staples for skin

Injection:

1. Marcaine 100mg ( 0.5% Marcaine 20ml or 0.25% Marcaine 40 ml)
2. Toradol 30 mg (15 mg if over 70 years old or poor renal function)
3. Morphine with epinephrine 4mg
4. Add Saline and mix up to 60 ml  ( total 60 ml liquid for injection ) 
5. 16 gauge needle, cut off needle protector (CHECK Allergy for medications)

Drain:

                1/8” Hemovac drain x1

Common Instruments or requirments:

1. Grasper x1
2. Ronguer x3
3. Army Navy Retractor x2
4. Rake retractor x2
5. Osteotome: straight - 1/8,1/4, ¾”;  Curved - All sizes
6. Towel Clamps x2
7. Kocher Clamps x2
8. Meniscal Clamp x1
9. Hoffmann retractor x2

Positioning: 

      Supine position

1. Green Pads
2. Bump, Leg stabilizer
3. “U” Drape

       Pre-incision

                  Leg Holder for surgical leg 

Procedure:

1. Retractors:
   1. Zigzag x2
   2. Medial and Lateral Tibial Retractor
   3. Posterior retractor (PCL retractor if CR knee)

1. Incision
   1. Esmarch bandage
   2. Flex knee to 90 degrees
   3. Midline incision w/ #20 Blade
   4. Suction to the assistant
   5. Peri-Patellar Incision w/Bovie into joint capsule
   6. Knee into extension
   7. Kocher Clamp, following by 3/8” Curved Osteotome and Mallet to elevate soft tissue from Proximal Tibia
   8. Pick-ups and Bovie to remove fat pad
   9. Hofmann x2, Pick-ups and Bovie to remove soft tissue from anterior femur
   10. Patella primary preparation : Towel Clamp x2, Bovie, Pick-ups and Large Ronguer

1. Distal Femur Cut (Have Femoral Starting Drill Loaded & Saw Blade)
   1. Knee into Deep Flexion
   2. “zigzag” retractor x2
   3. Pick-ups and Bovie to remove ACL / and PCL (if PS implant to use)
   4. Small Ronguer
   5. Use Femoral Starting Drill to open IM Canal
   6. Distal Femur Cutting Guide set on 6º R/L (5° for severely Varus knee). Set on 10 mm (increase  to 11 - 13mm if flexion contracture)
   7. Bladerunner
   8. Drill and 2 Bits
   9. Oscillating Saw Blade to cut distal femur
   10. Drill to remove 2 Bits

1. Proximal Tibia Cut
   1. Knee into Deep Flexion
   2. Place Lateral, Medial Retractor,  Posterior retractor, 
   3. Tibia Resection Guide w/ Tibia Cut Block
   4. ¼ straight osteotome and 1 drill bit
   5. Bladerunner
   6. 9 mm Resection Stylus
   7. Drill, Free Elevator and 3 drill bits
   8. Use ¼” osteotome to protect PCL W/ Mallet, If saving PCL,
   9. Oscillating Saw Blade
   10. 1” straight Osteotome to elevate Tibial Cut
   11. Grab with Meniscal Clamp, remove tibial bone using Bovie
   12. Remove Meniscus W/ Kocher x2 and Bovie if applicable
   13. Drill to remove bits

1. Gap Balance
   1. Remove osteophytes
   2. Place knee in extension
   3. Insert spacer block into extension gap
   4. Remove the spacer block
   5. Balance soft tissue
   6. Flex Knee into 90 degrees
   7. Insert the Sizer-Balancer, placing the feet between the cut tibial surface and the uncut posterior condyles
   8. Inserting a lamina spreader into the notch of the Sizer-Balancer
   9. Once equally tensioned, set and lock the gauge
   10. Insert Bladerunner and lateral slots on the Sizer-Balancer, size femur
   11. 1/8" Peg Drill to create fixation holes
   12. Remove Sizer-Balancer

1. Femoral Chamfer Resections
   1. Deep Flex the knee
   2. Insert 4:1 Cutting Block into femur
   3. Use Bladerunner assessing the resection
   4. Drill and 2 bits to fix Cutting block
   5. Oscillating Saw Blade to complete the remaining four femoral bone resections.
   6. Drill to remove drill bits, and cutting block
   7. 1” Curved Osteotome (variable size depending on the size of  bone)  to remove bone cuts
   8. Insert disc lamina DISC spreader
   9. 1” Curved Osteotome (variable size depending on the size of bone) and Mallet to remove posterior osteophytes; 90 degrees Curettes, Then Grasper.
   10. Remove Meniscus W/ Kocher x2 and Bovie if applicable
   11. Insert tibia and liner trial, then femoral trial.
   12. Check the balance of the knee.

1. Patella Cut (Saw Blade & Patella Drill Loaded)
   1. Extend the knee
   2. Evert the Patella with 2 Towel Clamps
   3. Measure the height of patella
   4. Patella Resection Guide (Claw)
   5. Oscillating Saw to resect patella
   6. Measure the height of patella again
   7. Patella Drill
   8. Patella Trial
   9. Bovie, Pick-ups and Large Ronguer to remove the extra bone
   10. Check the Stability of knee and Range of motion
   11. Remove all trials

1. Finish Tibia
   1. Deep flex the knee
   2. Place medial, lateral  tibial retractor, Posterior Retractor
   3. Tibia Sizing Plate Aligned w/ Tibial Tubercle, Free elevator
   4. insert Pins
   5. Tibia Punch Guide
   6. Tibia Drill
   7. Insert Keel Punch with Mallet
   8. Remove pins and Tibia Sizing Plate

1. Finish Femur and trial

                   Remove all osteophytes if applicable

                 ****** If PS knee********

1. Insert CS tibia liner trial
2. Insert CS femoral trial
3. Check the range of motion
4. Drill femoral Pug Holes
5. Remove femoral and tibia liner trial
6. Place PS Box Cutting Guide
7. Insert peg drill bit
8. Drill and 2 drill bits
9. Box Chisel with Mallet
10. Saw
11. Drill to remove drill bit, and remove PS Box Cutting Guide
12. Insert CS tibia liner trial
13. Insert PS femoral Trial
14. Check the range of motion

1. Injections:
   1. Remove Trials
   2. Injection

1. Implants preparation:
   1. Rep to open the implants
   2. Assemble the implants

1. Cement
   1. Irrigate knee with pulsatile lavage, and dry the bone surface
   2. Mix 2 bag of cement
   3. Cement tibia with impactor, Mallet
   4. Cement femur with impactor, Mallet
   5. Insert tibia liner
   6. Irrigate patella, dry and cement patella
   7. Deflated Tourniquet

1. Close of Incision
   1. Insert 1/8 “ Hemovac Drain W/Plier
   2. #1 Vicryl suture for the retinaculum
   3. #2 Stratafix Spiral PDO suture for the retinaculum
   4. # 2-0 Vicryl suture for subcutaneous tissue (#1 Vicryl with Large Needle if  thicker subcutaneous tissue )
   5. Running #4-0 Monocryl suture
   6. Staples for skin
   7. Sterile dressing