Steve Wurzelbacher, PA-C, on Bleeding Management in Orthopedic Joint Procedures
In this podcast, Senior Physician Assistant, Steven Wurzelbacher, PA-C, discusses his approach to bleeding management in his orthopedic joint procedures.
Steven Wurzelbacher, PA-C, is a senior physician assistant at the Wellington Mercy After Hours Clinic in Wellington, Ohio.
Moderator: This podcast is sponsored by Ethicon. The information contained in this podcast and findings and conclusions expressed are those reached independently by the authors.
Steven Wurzelbacher is presenting on behalf of Ethicon. The presentation reflects the opinions of the individual presenter and the steps described may not encompass the complete steps of the procedure. Additionally, other surgeons may prefer different techniques, approaches, et cetera, as individual surgeon experience in his or her clinical practice, as well as patient needs may dictate variation in procedure steps. Accordingly, results from any case studies reported in this presentation may not be predictive of results in other cases. Before using any medical device review all labeling, including without limitation, the instructions for use, IFU and relevant packet inserts with particular attention to the indications, contraindications, warnings and precautions, and steps for use of the devices. This presentation is not accredited for CE/CME. Steven Wurzelbacher is compensated by and presenting on behalf of Ethicon and must present information in accordance with the applicable regulatory requirements.
Jason Zweig: Hello everyone. My name is Jason Zweig, marketing manager for the topical absorbable hemostat platform supporting SURGICEL Powder. We are really excited to bring to you today's episode on SURGICEL Powder experience in orthopedic joint procedures. And we are very fortunate to have with us today Steve Wurzelbacher, PA-C, senior physician assistant at Mercy Orthopedic and Spine. Steve, welcome to the podcast.
Steve Wurzelbacker, PA-C: Good afternoon. Glad to be here.
Jason Zweig: Awesome. So just to open it up, if you wouldn't mind telling us a little bit about yourself and your practice.
Steve Wurzelbacker, PA-C: Okay. So I've been a PA for 33 years and I went to school at Xavier University and then to Kettering College for PA school. I've been in total joints for about 22 years and done a host of procedures between total joint, hips and knees, hips and knee revision.
Jason Zweig: Awesome. So specifically in the total joint realm, what type of procedures did you see yourself in most frequently?
Steve Wurzelbacker, PA-C: Most frequently, we were doing primary total knee and total knee revision. We did about 10% partial knee arthroplasties. We did a large volume of total hip replacements, and we did our own total hip revisions. We didn't do too many outside of the practice, total hip revisions. And we did probably on average about 300 total joints a year. So we did a fair amount.
Jason Zweig: Awesome. And when we think about the types of bleeding that you experience in these procedures, would you mind just walking us through, within each of the procedures that you identified, where you typically see bleeding, thinking about the site situation, and maybe some specific anatomy?
Steve Wurzelbacker, PA-C: Gotcha. So we start with primary total knee arthroplasties. In our practice, we didn't use a tourniquet other than for cementing the prosthesis. So we went through the knee with it inflexed and normally when you go through the incision with the knee inflection, you don't get as much bleeding which is really helpful. But when we would do our dissection and get into where we were making the bone cuts and actually placing the prosthesis, in a lot of times the areas around the tibial femoral joint and at the back of the knee where you're taking out osteophytes would have this continuous bleeding where there's not one specific site that you could see it coming from. And that's where we would use the SURGICEL Powder the most, is in those areas around the, like I said, the patella femoral joints at the posterior capsule of the knee.
In hips, we found that we used it a lot around the capsule and then in the soft tissues, as we came up and out of the tissue. Depending on the amount of adipose tissue a person had, whether or not that bleeds, and it's just really fryable tissues that if you use traditional cautery devices you don't necessarily get good hemostasis. And so that's where we were using the SURGICEL Powder a fair amount. We didn't use it very much in our partial knee arthroplasties just because we didn't get in that kind of bleeding. Revision surgeries of both knees and hips were really helpful to use SURGICEL Powder because that scar tissue that you go through, it just oozes and oozes. And so you would see it a lot in the soft tissue. You would see it a lot around the capsule. But once again, you're going to have a lot of bone loss and you're going to have areas where prosthesis don't cover, where you would need the SURGICEL Powder.
Jason Zweig: Awesome. And getting into the types of bleeding that you described, what does it mean to your patients when they experience that type of bleeding? What things concern you as you're seeing and going through that and what makes it so important to address during the procedure?
Steve Wurzelbacker, PA-C: There are so much variations in how this works with different surgeons, but because some surgeons leave the tourniquet in the total knee up the whole entire time they're doing the procedure and then they let it down right before they start closing, which then you get this huge rush of blood, which makes it very difficult to close. And if it makes it very difficult to close, you're not necessarily getting water tight closure. In those cases, if you're not controlling that bleeding, you're going to get a hemarthrosis, a soft tissue hematoma, you're going to get drainage, you're going to get wound complications because of the pressure in the joint, which then you can get cellulitis. So it's a big difference if you're controlling that bleeding, because now we can get better closure.
And what it means to the patient? Well now they're not worried about their wound. They're not getting stiffness because they got so much blood in their joint. That when they go to therapy, they can move better. They have less pain. And in the old days we were using a lot of drains in our knees, but then when patients start to go to the outpatient setting,we had to figure a way how we were going to get rid of all this post-op bleeding, which is oozing. It's not like a big, heavy bleeding, but it's oozing, which builds up over time. So that's where SURGICEL Powder came into use. And I'll tell you - probably we did 600 total joints as outpatients. And we did not have a significant amount of hemarthrosis.
Now granted, there are people that would then be placed on coumadin and sometimes injectable blood thinners. That can get some excessive bleeding at that point, but I'd say that was probably around 1% or less. So it means a lot to the patient to be able to have a wound that they don't have to worry about, that's not terribly swollen, and it's not terribly painful.
Jason Zweig: Thank you. So before you started using SURGICEL Powder, what was your previous approach to controlling bleeding in these procedures?
Steve Wurzelbacker, PA-C: So we had multiple approaches to that. Every patient got ivTXA. We used also obviously Bovie, but we also used a device called Aquamantys, which kind of thermo sealed the vessels. Even with all that, there was this oozing. And me as the assistant, I'm on the opposite side of the table as there's something else being done. I'm actually was constantly with the Aquamantys hitting bleeders and just constantly trying to control the bleeding. But at some point you're still going to have a fair amount of oozing, and that's why you get done and you say, "well, I could spend probably another 20 minutes here trying to seal all these vessels." But at some point you're not going to do that. So that's why the SURGICEL Powder was so much more effective because you got a broader area where you could cover and you could see it working right away because it turned black. And so I was covering it. And as you sit there for a second or two, as you spray it on and you go, "okay, that looks pretty good." And then we move on to closing. So it was really effective.
And there were a wide variety of products that was first used that I came across with them and some of them, I just thought, oh my gosh, between using topical TXA, which I thought was just totally ineffective because it just took way too long to work. And then using vancomycin powder, I thought, well, what's the purpose? We're using those 2 agents together that are very slow to work when we have one product we can do it all with.
Jason Zweig: Okay. And speaking of the TXA, tranexamic acid, is that something that you use in every procedure, maybe not topically but through IV?
Steve Wurzelbacker, PA-C: Yep. Every case got topical or got IV, not topical, ivTXA. You bet.
Jason Zweig: Okay. And how is that performed? I'm trying to get a sense of how SURGICEL Powder has either complimented that or how you view those as either working together or kind of doing separate jobs.
Steve Wurzelbacker, PA-C: I think they compliment each other. The TXA, we always would make sure that was in prior to making the incision. So they're getting the TXA going before they're putting them to sleep, they're hanging. So that's already in their system working. And I think that that was good for our long term success. And at the time with the bleeding that's going on in the case, that's where the SURGICEL Powder did it's job too. So hand in hand, I would say they worked really well.
Jason Zweig: Could you talk a little bit more about how your use of SURGICEL Powder plays a part in your overall wound closure strategy?
Steve Wurzelbacker, PA-C: So my strategy, since I use all the Ethicon barbed suture, it helps keep that blood contained and compartmentalized. It doesn't allow it to go from one tissue layer to the next tissue layer. So if we're controlling the bleeding down into capsule along the fascia, now we're not going to get it oozing into the soft tissue that can be expressed out through the wound. Because if we're not closing the dead space and we're not controlling the bleeding which go hand in hand, that blood can form a pocket and eventually it can express through the wound. Once it expresses itself through the wound, we have issues then, and now we have chances for an infection. So it really plays a part for me because now I'm not sewing through blood. I'm making sure that we don't have oozing coming through the tissue and that leads to the patient's success because now we don't have swollen joints. That's going to be tougher and more painful to work in physical therapy.
Jason Zweig: Awesome. Great. Well, Steve, that was all the questions I had. Can't thank you enough for your time. It was great getting to connect with you and learn more about your experience and using SURGICEL Powder in your procedures. Glad to hear that you've, seems like you and your patients have had a lot of success with it. So really appreciative of all your support. Thanks for being with us today.
Steve Wurzelbacker, PA-C: Awesome. Anytime.
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