Total Knee Tips & Pearls From Dr. Adam Rosen (A Virtual Total Knee Fellowship Podcast)
103 episodes - English - Latest episode: almost 2 years ago - ★★★★★ - 4 ratingsDr. Adam Rosen is an orthopedic surgeon who specializes in total joint replacement. He created this podcast which is aimed at interns, residents, fellows, and general orthopedists who are looking to dive into the details of total knee replacements. I do not claim that my way is the best way or the only way. My personal approach to my patients, total knee replacement surgery and the ever important post-operative recovery has been developed over the years. My protocols are ever changing based on scientific evidence and personal experience.I know many of you will want to jump right ahead to the operative step episodes - and that is okay. The first few episodes are not as exciting but they do contain important information in my opinion. If you jump ahead just be sure to come back and listen to the first few episodes.I will attempt to offer you my brain and the algorithm within it. Here I will share my thoughts and my approach to caring for total knee replacement patients. I hope that you learn something from this podcast. I hope that my thought process stimulates your thinking and approach. Most importantly I hope that I can offer one or more tips or pearls that may benefit your patients. If you like the information and have a friend or colleague that you think would benefit from the material please be sure to share this podcast with them. (Disclaimer: This is my opinion. Any information gathered is not medical education. Practitioners need to use their education and experience to determine how to treat their own patients.)
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Episodes
Consults for the Non-Orthopedic Specialists
November 15, 2020 21:00 - 26 minutes - 18.5 MBOrtho is consulted for many things. Here I would like to go over a few topics. First, for most ortho consults we need an x-ray. For a fracture or dislocation it is imperative. Even without trauma a bone can break if it had an un-diagnosed tumor. Even when the xray is normal, the information is important. I will discuss compartment syndrome, cellulitis, dog bites, and more. I also cover some classic knee jerk reactions in post-operative patients such as when to and when not to pan-cult...
Hip Fractures for the Hospitalist
November 07, 2020 08:00 - 26 minutes - 17.9 MBHip fractures are a frequent admission at hospitals. Here I will go over things that are helpful in getting patients to the OR safely and timely. It is not important for the medical team to attempt to classify the type of fracture, leave that up to the orthopedic team. Simply refer to it as a right or left hip fracture. Occasionally, the ER or radiologist is wrong and all you do is propagate the mistake in the medical record. Blood loss, VTE, prophylaxis, pain management as well as disc...
Pre-op Surgical Evaluation for the PCP
October 31, 2020 20:00 - 29 minutes - 20.1 MBI hate the word clearance, but prefer a pre-op eval or stratification. Here I will go into detail of the things I look for when a patient is referred to their PCP prior to elective orthopedic surgery. I will go over not only what, by why each item is important. For each test I will explain what peri-operative complications could occur and why we may want to correct certain things prior to surgery. Support the show
Pre-op Surgical Evaluation for the PCP
October 31, 2020 20:00 - 30 minutes - 20.6 MBI hate the word clearance, but prefer a pre-op eval or stratification. Here I will go into detail of the things I look for when a patient is referred to their PCP prior to elective orthopedic surgery. I will go over not only what, by why each item is important. For each test I will explain what peri-operative complications could occur and why we may want to correct certain things prior to surgery. On Medical Grounds OMG features interviews, mystery cases, slides, and select continuing edu...
Hip Pain for the PCP
October 24, 2020 07:00 - 22 minutes - 15.6 MBHere I am going to try to go through hip pain in the office setting in patients over 50. Think about location, is it in the groin, laterally or in the buttock. Take a good history and physical exam. Xray are beneficial but need to be WEIGHT BEARING to adequately assess for arthritis. Although MRI are useful for tumors, infections and osteonecrosis or fractures not seen on xray, the MRI is not as helpful in older individuals for certain diagnoses. Most patients over 50 and almost all w...
Achilles Injuries for the Primary Care Provider
October 17, 2020 07:00 - 22 minutes - 15.4 MBHere I will review the 3 common achilles problems - achilles tendinitis, achilles tendinosis and achilles tendon rupture. I will discuss the plantaris tendon rupture which can be mistaken for an achilles injury. I will briefly describe the symptoms, exam and workup for these diagnoses. I will explain why MRI's are not needed for the diagnosis of an achilles tendon rupture - the have been shown to be a waste of time and money and can delay care. Support the show
Knee Pain for the Primary Care Provider
October 10, 2020 22:00 - 36 minutes - 25.4 MBIn season 3 I am going to try to pass on some orthopedic knowledge to non-orthopedic health care providers. It has been shown that the MSK knowledge coming out of medical school is poor, yet a high number of visits in the office and ER are for orthopedic problems. Here I am starting with non-traumatic knee pain in patients over 50. I will attempt to cover other common presenting diagnoses in future episodes. The recommended xrays: 1. Standing (Weight Bearing) AP 2. Rosenberg view (Standi...
Choosing a Fellowship
October 05, 2020 07:00 - 24 minutes - 16.8 MBIt looks like things will be virtual for now. I am going to offer my thoughts on what I was looking for when I applied for a fellowship. I'll review things I think are important such as number and type of cases, office hours and education. Briefly, I touch on things I discuss as an overview of the fellowship I am involved in. Disclaimer: I work where I did my fellowship so there may be some bias. On Medical Grounds OMG features interviews, mystery cases, slides, and select continuing edu...
Choosing a Practice
October 04, 2020 07:00 - 14 minutes - 10.3 MBAfter medical school, residency and probably fellowship it is time to find a practice. Here I will try to offer my two cents on what to think about and what to look for when you start looking for that first job out of training. Support the show
Anterior vs Posterior Referencing
October 04, 2020 00:00 - 19 minutes - 13.5 MBTKA's are complicated and the femoral preparation is complicated. We are concerned about bone resection, rotation, sizing and more. If the implant is wide or gaps tight you may need to downsize. The initial referencing can be anterior or posterior. Each has its pro's and con's. Here I will try my best to explain the basic similarities and differences of anterior and posterior referencing. Support the show
Coding
September 26, 2020 07:00 - 22 minutes - 15.2 MBI am not a coding expert. I know that through med school, residency and fellowship I received little to no education on coding. Here I want to offer my simple overview of new versus established, level 3 vs level 4 and how to code based on time. I hope this offers an introduction and helps you dig further by asking questions and possibly taking a coding course. Support the show
Patient Improvements and Gain Sharing
September 20, 2020 17:00 - 29 minutes - 20.5 MBBeing in practice for 15 years has allowed me to see and be involved in many improvements in patient care. Here I will outline ten things that have evolved to improve outcomes. In addition they have helped control cost, which is beneficial to the health care system. On Medical Grounds OMG features interviews, mystery cases, slides, and select continuing education credits. Listen on: Apple Podcasts Spotify Support the show
TKA for tibial plateau fractures
September 05, 2020 07:00 - 13 minutes - 9.35 MBWhen there is a severely comminuted fracture of the distal femur in an older individual one usually considers a DFR. When the tibial plateau fractures we typically think either conservative care or ORIF. Occasionally patients may benefit from a TKA. This does require some special care to allow the tissue envelope to heal, to allow some early bone consolidation and to be able to comfortably use augments and other revision TKA components. I encourage you to search up studies and familiariz...
Marine Injuries
August 30, 2020 07:00 - 11 minutes - 7.83 MBLiving in San Diego summer is stingray season. If you train or work or travel to ocean environments it is good to be aware of potential injuries that can occur. To prevent disturbing a stingray it is recommended to do the stingray shuffle. If they do sting you immersing the body part in hot water typically denatures the protein and stops the burn. Rarely, an xray will show a retained barb. Jellyfish, depending on the type and location, can be treated with removal of the tentacle and vine...
Pes Planus and TKA
August 26, 2020 07:00 - 8 minutes - 5.91 MBPes planus can have an effect on TKA's. Be sure to examine the whole leg when evaluating patients. Be sure to check out the article by Meding et al in JBJS Aug 2005 on The planovalgus foot. Support the show
Gluteus Medius and Knee Pain
August 23, 2020 23:00 - 10 minutes - 7.41 MBKnee pain may be due to the hip. In a normal knee, mildly arthritic knee or TKA think about the hip - specifically the abductors. With a weak medius, the femur and knee may rotate inwards, which can lead to pain. Her I discuss some tips on the exam and what I recommend to my patients if I diagnose abductor weakness. Support the show
Patient Handouts
August 15, 2020 07:00 - 12 minutes - 8.46 MBThe patient experience is important, especially when you are starting out and working on building your practice. Patients tell their friends and that will be a way to steer more patients to you office. When you schedule a surgery that is a very tangible thing for patients and they will happy with the plan. More often than not we evaluate and give advice and offer some treatment plan. Although there is a lot of information in the spoken word patients may leave overwhelmed or forget key as...
Post-op wound management
August 12, 2020 07:00 - 14 minutes - 10.2 MBIn training many people are not exposed to the wounds in the early post-op period. Your experience may be limited to dressing changes in the hospital. Over the years my wound closure has evolved. Here is will talk about my experience with staples, dermabond and Prineo. I will go over how I deal with patients who are "spitting a stitch." Most importantly I recommend having your patients come in when they are having wound issues. Many times you can address something early before it become...
Revision TKA - Balancing
August 09, 2020 19:00 - 12 minutes - 8.27 MBBalancing is important whether or not you are doing a primary or a revision. Restoring the joint line is key. From that point you need to balance your extension and flexion gaps. Although a primary TKA the main variables are soft tissue releases or bone cuts, in a revision you have those options but more commonly you will use implant size, augments and offset to restore balancing. Rotation is another important factor, especially in fixed bearing knees. I balance initially with a CR to g...
Total Knee Revision - Bone Prep
August 05, 2020 07:00 - 20 minutes - 14.4 MBEverything is a series of steps. Once you have performed the approach and the implant removal it is time to prepare the bone. You can do this in many ways. I typically start with the tibia then move to the femur. Performing the distal femur and tibia cut and knowing my extension gap helps me size and position the femur. Knowing what size component and the size of the augments and potentially the need to offset helps balance the flexion gap with the extension gap. Support the show
Total Knee Revision - Approach and Implant Removal
July 29, 2020 07:00 - 28 minutes - 19.8 MBRevisions are hard. They may be for one component or all components. It may be for laxity, stiffness, poly wear, aseptic loosening, infection or fracture. In any event they can be difficult. Here I will talk through my approach to the exposure and how I remove the femoral and tibial components. In the next episode I will go into bone cuts, sizing, rotation and the joint line. On Medical Grounds OMG features interviews, mystery cases, slides, and select continuing education credits. Li...
Blood Conservation
July 25, 2020 07:00 - 11 minutes - 7.88 MBSimple - use TXA. Transfusion rates used to be high. Patients routinely auto-donated. We also used medications to prevent VTE which increased the risk of bleeding. The use of TXA has lowered transfusion rates significantly and has become a standard for total knee replacement surgery. Support the show
Insurance and Finances
July 22, 2020 07:00 - 11 minutes - 8.02 MBWhen 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. Althou...
DFR
July 18, 2020 19:00 - 13 minutes - 9.31 MBDistal 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. ...
Using the Saw
July 12, 2020 07:00 - 18 minutes - 12.5 MBI 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 han...
Morning Rounds
July 08, 2020 07:00 - 18 minutes - 12.9 MBPatient 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...
VTE in TKA
July 03, 2020 22:00 - 13 minutes - 9.04 MBTKA 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. Support the show
PS vs CR
July 01, 2020 07:00 - 12 minutes - 8.58 MBI 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. Support the show
Be the Tech
June 28, 2020 16:00 - 6 minutes - 4.79 MBIt 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 Hip - A Posterior Approach
June 27, 2020 07:00 - 18 minutes - 13 MBI 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. Support the show
Femur
June 24, 2020 07:00 - 21 minutes - 14.8 MBIn 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. Support the show
Acetabulum
June 20, 2020 16:00 - 22 minutes - 15.8 MBThe 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 b...
Painful TKA
June 04, 2020 15:00 - 32 minutes - 22.4 MBPatients present with painful total knees and the diagnosis is not always easy. Here I will talk about what I do in my workup of these patients. I go back to before surgery and get early xrays and listen to what conservative treatments they have had. A detailed peri-operative history and any complications is important. Labs, aspirations and special tests all have a role. The differential is large and you have to have a good plan an algorithm to go through all of the potential causes of ...
The Joint Line
May 28, 2020 18:00 - 11 minutes - 7.63 MBRestoring the joint line is the most important part of a total knee revision in my opinion. Restoring the JL in any total knee is important but it is most difficult to re-create in a revision due to the bone loss. Here I review my experiences and tips on what I do to restore the JL to the appropriate position. https://www.DrAdamRosen.com Support the show
Season 1 Wrap Up
May 20, 2020 07:00 - 8 minutes - 6 MBI have had the idea of creating a podcast for quite some time and it has been a really interesting learning experience for me. I am grateful for all of the listeners and subscribers. My hope has always been to share my thoughts and tips in an attempt to give you one tip or tool that allows you to help one patient obtain a better outcome. In this last episode of Season one I just wanted to review briefly what we have talked about but reiterate some important pearls. My plan for season two ...
One and three month TKA follow-up
May 17, 2020 07:00 - 17 minutes - 12.1 MBIn training we focus on the procedure. Unfortunately, some do not get enough exposure with the post-operative patient care issues. Here I will discuss some common things I see, how I educate my patients and what things to watch out for at both the one month and three month follow-up appointments. Support the show
Stiffness after TKA
May 14, 2020 21:00 - 19 minutes - 13.7 MBStiffness after TKA can be a big problem. The goal is to not develop stiffness and this begins with preoperative education, a technically well done TKA and appropriate post-op PT. Still, some patients may get stiff. Your goal is to capture those patients early so that there is still time to make a difference. Otherwise a MUA may be needed. Here I will share things that I have seen and tips that I have used to keep my rate of stiffness and need for MUA low. Support the show
Post-op PT
May 10, 2020 07:00 - 15 minutes - 10.9 MBThe surgery is just one part of obtaining a good total knee outcome. The patient and their participation in post-operative PT is just as important to obtain a good outcome. A good total knee needs good range of motion and strength that will result in a well functioning total knee. Here I will discuss some of the tips I have used with my patients, and the reasons behind them, which have resulted in good outcomes and good range of motion. Support the show
Post-op Pain Control
May 07, 2020 19:00 - 20 minutes - 13.9 MBPain control following a total knee is an art and a science. The idea of multimodal non-narcotic scheduled medication is a great improvement over the old way of treating pain. Here I will review my philosophy and algorithm for treating pain symptoms related to total knee replacement surgery. Support the show
Full steps of TKA
April 30, 2020 19:00 - 35 minutes - 24.5 MBHere I will give you a full audio walk thru of a typical TKA from draping to closure. Although previous episodes have gone into more detail of each individual part of the operation, this episode will take you through the procedure with a focus on knee position and retractor position from start to finish. This should hopefully build on what you have listened to in previous episodes. Again, I do not believe that this is the best or only way to do a TKA but it is a step-wise pattern that wor...
Tips - a review of surgical tips
April 29, 2020 07:00 - 13 minutes - 9.07 MBI believe that these are all important so I wanted to re-review some important operative tips. I will review ways that you could potentially alter the alignment during the procedure. We will also go over ways to control the saw and decrease potential contamination and infection. Lastly, I will go over ways to be more efficient. Remember: slow is smooth and smooth is fast. Having a plan, working with teams and being purposeful can make you a more efficient surgeon. Support the show
Closure of the TKA
April 27, 2020 18:00 - 17 minutes - 12.3 MBFinishing 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. Support the show
Cementing
April 22, 2020 17:00 - 25 minutes - 17.4 MBCementing 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. https://twitter.com/dradamrosen https://WWW.DRADAMROSEN.COM On Medical Grounds OMG features interviews, mystery cases, slides, and select continuing education credits. Listen on: Apple Podca...
Balancing Tips
April 19, 2020 21:00 - 35 minutes - 24.7 MBBalancing 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. On Medical Grounds OMG features interviews, mystery cases, slides, and select continuing education credits. Listen on: Apple Podcasts Spotify ...
The Tibia
April 18, 2020 20:00 - 13 minutes - 9.38 MBIn 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. Support the show
The Femur
April 16, 2020 20:00 - 20 minutes - 14.1 MBHere 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. Support the show
The Patella
April 14, 2020 17:00 - 18 minutes - 12.6 MBThe 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. Support the show
Surgical Approach
April 08, 2020 23:00 - 14 minutes - 10.2 MBIn 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. Support the show
Pre-op checklist the day before and Room set-up
April 07, 2020 23:00 - 12 minutes - 8.63 MBI 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! Support the show
Pre-op workup
March 27, 2020 23:00 - 16 minutes - 11.6 MBI 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 conside...