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

When you start practicing your salary will be much higher than what you were making in residency.  It is easy to spend, but the money may not always last.  Be smart and save and here I will offer some advice I was given early on in my career.

It is important to protect yourself and your family.  When you are young and healthy, you are in the best place to purchase insurance.  As you age you are more likely to have health conditions which will make obtaining insurance more expensive.

Although life insurance is important if you die, there is the possibility that something will happen to you which will prevent you from being able to work.  You want to protect yourself and your family by adequately covering your most important asset - you!

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Distal Femoral Replacements are commonly used for tumors but more frequently for periprosthetic fractures.  Here I will go over some of my tips for the next time you have one of these cases.  It is important to note the length of the limb - prior to removing the distal femur.  I review my landmarks for accurately restoring rotation.  You will commonly see hyperextension and I will discuss why you should avoid chasing it with a thicker poly.  And how I treat these patients postoperatively.

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I see many people struggle using the saw.  Having good hand and 3D spatial perception helps.  I find those that have built houses, cars, boats and other things have an advantage.  But everyone can learn to get better.  Watch surgeons that have good technique and watch how they hold the saw, where they hold their saw and how they brace their hands.  When you cut, cut on the guide, feel the saw, listen to the saw and look at the saw blade.  Many time the sound should let you know when your hand deviate from position.  Looking at where the saw blade is worn will let you know which direction you are torquing the saw and/or your hands.  Practice makes perfect so keep thinking, watching and practicing.  Over time you will develop the muscle memory you need.

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Patient education is so important.  Here I review what I do with my patients on morning rounds.  You can educated them on pain control, VTE prevention, wound care and the prevention of constipation.
It is so important that you ask permission to expose the patient to evaluate their wound. More often than not doctors throw back the sheets or lift up someones gown to expose them.  The intention was to care for the patient but you should ask permission and let them know what you plan to do.
What is most important in my opinion is reviewing range of motion exercises, specifically extension and flexion exercises. I sit down and go over the steps of two of these exercises with each of my patients every morning on rounds and I think the benefit for them is so valuable to obtaining a good outcome.

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TKA patients may develop a DVT or PE.  Patients are either at normal risk of developing a clot or higher than normal risk.  You should be aware of and have read the Academy guideline as well as Chest guidelines.  Here I will touch on VTE after TKA and the multimodal approach as well as the variability in normal risk patients and high risk individuals.

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I came from Philadelphia where I only saw PS knees.  I was told CR knees were hard to expose and hard to balance.  When I went west for my fellowship I saw predominantly CR knees.  In practice I perform CR knees for 95% of my primary TKAs.  I will share with you some of my thoughts and tips.

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It may not sound glorifying but I recommend you talk to your scrub tech and see if you can step in for a case and be the tech.  I used to have younger residents scrub the case for a DHS or IMHS.  At the time they didn't appreciate it but later on realized how much it helped them.

I believe that when you step into their shoes you will understand how difficult that job can be and it will also help your surgical skills.  During the case you may only be thinking one step ahead.  But if you are the scrub you need to be thinking three or four steps ahead.

Try it.

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I am a posterior guy.  Here I will try to walk you through some of the anatomy and offer my tips on what I do and how I do the posterior approach.  Being aware of the tension of the soft tissue on the way in can help you with your balancing during the case. I have a meticulous approach to the release of the piriformis and the capsulotomy.

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In keeping with the hip theme here I talk about my approach to the femoral preparation in total hip replacement.  As always exposure is key.  Opening the femur and initial broaching is important to keep you out of varus.  Be artful in broaching to prevent causing an iatrogenic fracture.

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The acetabulum is the part that I find many young surgeons have the least experience with.  In residency they become comfortable with the approach and the femur but get little exposure to the cup.  Here I try to share with you some of the key tips for doing the cup well.  Exposure is key.  Recognizing the real hip center is important.  Reaming well is an art that is dependent on the patient anatomy and the depth of the cup.  Cup implantation occurs with a crescendo decrescendo technique to be sure that you are down, that you can hear that the cup is seated and a way to prevent iatrogenic fractures.

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