Total Knee Tips & Pearls From Dr. Adam Rosen (A Virtual Total Knee Fellowship Podcast)

Finishing up the TKA the closure is extremely important.  I will review how I close and tips on what to watch out for to help get a "water tight seal."  I will also share my post-operative photo that I believe helps patients get motivated and obtain good flexion.

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Cementing is an art.  The cement can be affected by the room temperature, humidity or how it is mixed.  When you apply PMMA you want to be sure that the bone surface is dry.  As you apply your implants you want to be sure not to alter the bone preparation or alignment, especially in osteoporotic bone.

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Balancing a TKA is a long and complex topic.  It is also an art.  Individual biology can play a role.  I will review some tips on what I look for when balancing a knee.  The discussion will include both bony resections and soft tissue releases.  I will also cover some areas where you may inadvertently affect the balancing while implanting the TKA.

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In this episode I will go over how I expose and prepare the tibia cut.  I will go over things to be aware of such as the tibial slope, rotation, cut thickness and tips on how to accurately pin your block and cut the tibia.

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Here I will review my steps for the femur.  The debate between CR and PS is as old as the debate between which came first - the chicken or the egg.  The variables you control are the distal cut, the rotation, the sizing and more.

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The PFJ and its kinematics are quite complex.  When dealing with the patella during TKA you have many options on how to prepare the patella.  Here I will discuss some of the options and go into detail how I expose and prepare the patella.

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In this episode we get into the OR and start the surgery.  It all begins with the TIME OUT. I review my approach and tips on marking the arthrotomy.  I work in a circular fashion - medial release followed by superior followed by lateral and will review what I do and why.  The removal of osteophytes at this point are important in my mind to increase exposure and decrease the risk of marginal fractures when using the saw later.

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I review what I double check the day before: labs, deformity, X-rays, implants and other things such as MRSA status, pacemakers or DBS.  In the room I review my set up including the bed, lights, tourniquet and leg positioner.  Review the plan with anesthesia regarding pain management.  And sign your surgical site!

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I want to review the things that I look for in the pre-operative workup to help optimize patients in an effort to reduce the chance of a complication.  I will discuss clearances, social habits like tobacco use and alcohol consumption, lab tests and nasal swabs.  It is also important in my opinion to ask about prior anesthesia complications and potential allergies or reactions to materials that may be used during surgery.  You need to think about prior incisions, retained hardware and consider if you need special implants for added constraint based on a patients exam.

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Here I go into how I describe to a patient what a total knee replacement is by using a total knee model.  I make it a habit to not only detail all of the potential risks of the surgery but I go into detail when certain risks are higher in an individual patient (such as infection risk in a diabetic).  Explaining realistic expectations up front is extremely important in my opinion to create good patient satisfaction after total knee replacement surgery.  I review with my patients normal expectations such as warmth, night pain, lateral numbness and clicking that can be seen in the early post-operative period.

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