Why I Chose Adult Hip and Knee Replacement as a Career

By Christopher Blair, DO, MBA

For those who decide on a fellowship in adult hip and knee reconstruction, application to the SF Match is required in the late summer/early fall of the fourth year of residency. This application will require amassing of the usual; medical school transcripts, board scores, letters of recommendation, and a personal statement as to why you want to be a hip and knee replacement surgeon, in addition to a detailed and lengthy online CAS application.

The major requirement of any successful fellowship application is time; something most fourth year residents have precious little of. My advice is to start as early as possible, not only with the application itself, but with the steps necessary to determine if life as an arthroplasty specialist is the right one for you. During my training, experiences in hip and knee replacement were what I found myself continually coming back to when reflecting on what I wanted out of a career. The very fact that we could remove a diseased part of a body and replace it with a durable prosthetic, providing a patient with lasting and often long sought improvement, simply called to me.

The American Academy of Hip and Knee Surgeons (AAHKS) annual meeting provides for resident participation in an expenses-paid resident course to help residents considering a career as an arthroplasty surgeon to determine if the field was right for them. An OK from my program director and a few telephone calls later, I was on my way to Dallas.   At the AAHKS course, I was amazed at the advances being made in the field of arthroplasty. Abstract after abstract was presented on various advancements in arthroplasty, including the use of tranexamic acid and its utility in reducing intra- and postoperative blood loss associated with both primary and revision arthroplasty. The economics of arthroplasty supply and demand were likewise a common theme, as well the strong message being sent regarding an overwhelming demand of patients who will be seeking arthroplasty procedures, and how important specialty training in total joint arthroplasty will be. My sense that hip and knee replacement was the career choice for me was taking a shape.

History has always been a particular interest of mine, and the history of arthroplasty continues to be no exception. To study past successes as well as failures, has always been an interest of mine. To this day, I keep a copy of the proceedings of the Royal College of Surgeons following the death of Sir John Charnley at my bedside, just to flip through on the infrequent occasion that sleep doesn’t assault me as soon as I wind my kids down for the night. This book chronicles the recollections of the various pioneers and close confidants of Sir John following his death, regarding how his discovery of the metal on polyethylene bearing surface came to be. His failures, and eventual triumphs, in hip arthroplasty read like a child’s fairytale to me, where good triumphs over evil and they all live happily ever after. Having read the volume countless times, I am all the more convinced that hip and knee replacement is what I was born to do.

I believe that this is an amazing time to be a joint surgeon. Bearing surface improvements continue, with ceramics and current generation polyethylene giving us what may well be thirty years of longevity with today’s prosthetic components. We continue to clean up the debris from fallout of the era of metal-on-metal bearing surfaces. We continue to learn that not all metal-on-metal surface implants need to be removed, but all warrant close clinical monitoring should they begin to cause harm. The very nature of the human body to continually change beyond the index arthroplasty makes revision surgery intriguing as to whether calcar support, metaphyseal support, or diaphyseal support is most appropriate for revision cases.

Multiple manufacturing companies turn out ongrowth, ingrowth, collared and collarless, pressfit and cemented components for both the hip and knee. The merits of one over another continue to be debated. New approach and implant techniques, including third generation cementing (primarily of knee components), modifications of traditional surgical approaches (Gibson interval of the Kocher-Langenbeck approach, modified Hardinge, and anterior supine intermuscular interval of the Smith Petersen approach), and even postoperative dressings (negative pressure, silver impregnation, and water-resistant occlusion) promise improvements in surgical implant precision and reproducibility, and more importantly, patient outcomes.

These are all of the reasons that I chose adult hip and knee reconstruction as a career. I truly believe that our story remains one in evolution. Those who have blazed the trail before us have achieved remarkable successes to arrive at the current collective ability to relieve pain and dysfunction, and to impart lasting relief to growing numbers of patients ravaged by trauma, disease, and the sands of time. However, I further believe that what is past is prelude in regards to our future possibilities. As I look to the future of our specialty, I think that there remain many new discoveries waiting to be found; new advancements in the areas of perioperative pain control, avoidance of perioperative infection, and in duration of implant lifetime to name but a few. The book of this specialty has chapters, and even volumes, yet to be written. I chose arthroplasty because I want to author a number of those tomes. During my fellowship interviews, an arthroplasty surgeon, who was also a keen businessman, said to me, “the best way to predict the future is to create it.” I couldn’t agree more.

For those residents who may consider adult hip and knee replacement as a subspecialty-trained career, I highly recommend attending the resident course held in connection with the annual AAHKS meeting in Dallas. Scrub into as many primary and complex revision hip and knee arthroplasty surgeries as possible. Consider if sculpture of the human body is right for you, as a focused career path or as a part of a more generalized orthopedic practice. The future is yours to determine.

Here’s to what has passed, and what is yet to come. I welcome the challenge.

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