My name is Adam Rosen. I am an orthopedic surgeon in Southern California. I did my residency in Philadelphia and fellowship in La Jolla. I have been in practice since 2005 performing total knee replacements. I am part of a teaching fellowship program and I try to share my thought process with our fellows. I am going to share my thought process here in an attempt to help you and potentially the patients that you care for.

This podcast series is really geared towards orthopedic residents or fellows or the community surgeon looking to pick up a pearl or two about total knee replacements. I do not believe that my way is the best way or the only way to care for patients with knee arthritis. I only offer my thoughts, opinions and treatment algorithms in the hopes that it will help you care for your patients. This is my opinion. You need to determine how to treat your own patients based on your experience, education and available scientific data.

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Here I discuss some of the things I look for when seeing patients in the office when I am deciding on what treatment options are appropriate. Weight bearing x-rays are important. Ask patients to describe their symptoms. Do not simply ask someone to describe their pain on a scale of one to ten. Find out how their knee has affected their quality of life. Lastly, find out what treatment options have been tried and be sure to offer conservative treatment options to the patient before undergoing surgery.

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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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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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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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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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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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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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