Top 10 Surgical Skills to Master by PGY-2 – Continued

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William N. Levine, MD, FAAOS

May 29, 2026

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Here are the top 10 skills you should master by the end of your PG-2 year

  1. Pre-operative preparation
    • It all starts with anatomy! Know thy anatomy, know thy case!
    • Do not come to the OR unprepared
    • Where possible, perform virtual surgery before the real case
      • Trauma cases – wax paper preparation
      • Shoulder arthroplasty – use planning software to understand the pathology and best implants
    • Come prepared as if you are the treating surgeon
    • Have all appropriate imaging studies – Xrays, MRI, CT
    • Have all appropriate paperwork (past surgical history if it is a revision, for example).
  2. Patient Positioning
    • Cannot perform outstanding surgery if the patient is not positioned properly
    • Ensure that all bony prominences are well padded to avoid pressure ulcers
    • Avoidance of iatrogenic injury to patients
      • Skin lacerations/macerations, especially in elderly patients
      • Over-tightening of coban or other such wrapping materials can cause neurogenic injury
  3. Xray/Fluoroscopy Positioning
    • Many orthopaedic cases rely heavily on efficient, appropriate intraoperative fluoroscopic evaluation
    • After patient positioning, but BEFORE prep and drape
    • Ensure fluoroscopy unit can appropriately provide the images necessary to perform the surgery
    • Introduce yourself to the xray technician and learn their name (“hey fluoro” is rude and unprofessional – you can do better!)
    • Mark the wheels of the fluoro unit on the ground with tape to ensure that you can easily reproduce the position during the surgery
  4. Incision Planning
    • Again, if the incision is inadequate, the surgery may be compromised
    • Understand the anatomy
    • Understand the pathology
    • Understand the patient’s body habitus
  5. Soft Tissue Respect
    • Ensure that you are respectful of the soft tissues
    • Learn proper surgical technique
      • Incision
      • Dissection
  6. Exposure and Retraction
    • Cannot overstate how important this is and how easy it is to have incision “off” and negatively impact the surgical procedure
    • General exposure principles:
      • Make incision “long enough” to do the work safely and efficiently
      • All incisions perpendicular to tissue
    • Retractors can cause serious harm
      • DO NOT over-tension soft tissues
      • Understand where the neurovascular structures are and either identify when appropriate or ignore if possible
      • Special attention as PG-2: musculocutaneous nerve retracting during shoulder arthroplasty
  7. Knot Tying
    • Learn how to do it now! One handed, two-handed.
    • Understand loop security
    • Understand knot security
    • Get a knot pusher from your industry rep and practice at home. Make sure you practice through a cannula so that you get appropriate length-tension
  8. Instrument/Power Tool Handling
    • Spend time with the instruments outside the hospital in psychological “safe zone”
      • Basic instruments need to be mastered
        • Tissue forceps (do not grasp needle with it – use needle driver)
        • Understand forearm pronation and supination to regrasp needle in good position to avoid awkward handling of needle after its been passed through tissue
      • Work with your industry partners to gain access to instruments OUTSIDE the operating room
    • Power tools – saw/drill
      • Oscillating saws oscillate – understand the “zone of injury” that can incur if the skin incision and other important deeper structures are not properly protected with your retractors
      • THOU SHALL NOT PLUNGE! Tactile feedback is critical to know when 2nd cortex is breached to avoid plunging and causing potential neurovascular structures
  9. Fracture Care
    • Pre-operative surgical plan
    • Intraoperative patient positioning
    • Intraop fluoroscopic positioning
    • Basic fracture care
      • Reduction
      • Provisional fixation – avoid interfering with definitive internal fixation
    • Never leave the OR without final radiographic documentation of reduction and hardware position on 90-degree orthogonal views
  10. How to Crush your PGY-2 Year
    • Maximize your efficiency
    • Get as much rest as possible
    • Never come to the OR unprepared
    • Start thinking like you’re the only surgeon in the room
      • Stay 3 steps ahead
    • Keep a journal of all OR cases
      • Write down every step from getting the patient in the room to positioning to the actual procedure
      • Build upon this journal as you progress from PG-2 through PG-5 years. You will be amazed at how little you actually knew as a PG-2.

DISCLOSURES: Dr. Levine is on the Columbia faculty. Dr. Levine serves as a paid consultant and surgeon designer for Zimmer Biomet. International Board of Shoulder and Elbow Surgery – Treasurer : Type: Board of Directors or committee member: Self

Read the AAOS Code of Conduct for Discussion Group Terms, Conditions and Disclaimers HERE.

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