Deep vein thrombosis (calf blood clot) is an important complication after joint replacement, and strategies to reduce the risk include early mobilisation, compression stockings and medications.  For many years, I have prescribed aspirin for my patients having joint replacement, as prevention of DVT.  Although this was initially controversial, we felt that the evidence supporting that position was strong, and gradually this has become a mainstream approach.  Aspirin provides similar prevention of DVT to more expensive approaches, without the associated increased risks of wound leak that many of the alternatives have been dogged by.  There is now increasing evidence, including this recent paper , that the use of aspirin also provides a survival advantage for joint replacement patients.  Patients should discuss the risk of clots with their surgeon as part of the informed consent process.

Click here to go to the original piece in The Age 

I spent a really interesting and challenging 6 months as Julian Feller's Fellow in 2003, and took away his ACL reconstruction technique with me when I returned to Scotland to set up practice.  During the intervening 15 years, we have both made a few tweaks to our respective surgical approaches to ACLs, in line with new evidence as it emerges, but we remain pretty much aligned on the important points - put a good quality biological graft in the right place and fix it firmly, then do good rehab.

When I was learning from him, I asked about Julian's approach to placing the bone tunnels into which the graft was secured - do you use the lateral meniscus and/or PCL to guide placement?  "Put it in the right place" was his response.  An idiosyncratic answer at the time, but over the years I have increasingly appreciated his point that the individual patient's anatomy governs where the graft should go.

I now bring that and other insights to my clinical practice in Warrnambool.  I learnt from the best, and aim to reproduce that for all of my patients.

Julian Feller 2003

I recently created the following video for our local medical students.  Many people think that surgical consent is just a process of listing all the possible complications of an operation.  Of course it is both simpler and more complex than that.  I find that following a structured 5 point plan helps me to be sure to cover the important points and helps patient realise just what it is they are agreeing to.  Given the new legal requirements that demand that consent should reflect what the patient thinks is important, rather than what the surgeon thinks is important (radical thought, that one?), the emphasis should be on an open discussion rather than the old-fashioned "sign here" approach.

I recently created the following video for our local medical students, but offer it here to a wider audience.

http://www.freewanderer.net/wp-content/uploads/2016/05/8149-1038x576.jpg
​

​The recent ABC 4 Corners film about gap charges for private surgery raises many important questions.  There are many surgeons in Australia who think that ethical behaviour is all about following rules on advertising, but there is a great deal more to “doing the right thing” than that.  The programme presented a more or less balanced view, although it did focus on some extreme examples to make its point.
 
In the film it was pointed out that while we might consider private healthcare to be a free market, it rarely is because patients do not have all of the information required to make informed choices.  Asymmetric relationships generally put the surgeon in full control and patients at a disadvantage as they do not know their options.
 
The idea of “you get what you pay for” does not always hold in healthcare, and surgeons can play upon this to extract the highest possible fee that the market will stand.  The 4 Corners film focused upon a patient charged an out-of-pocket surgery fee of $7500 for his hip replacement, but there is more to high fee-structures than a minority of surgeons charging that far over the odds. The Australian Medical Association (AMA) has a recommended surgeon fee schedule that would leave even the best-insured patient out of pocket by $1000 for a hip replacement.
 
The value proposition of private health care balances coverage and faster access with price.  If the private system is perceived as being unfair, with excessive out of pocket fees, then patients will drop out and turn to the public system.  For the balanced system of public/private provision current in Australia to be sustained, confidence in the private system is critical.
 
So, what can I do as a surgeon?

1. Reasonable fees– my standard fees are those paid by BUPA.  If a patient has BUPA insurance, no gap.  Where other insurance companies pay less than that rate, then there will be a gap, generally under $450 for a major surgery such as joint replacement.  I do not think currently that the AMA fee schedule is justified in a regional setting where median incomes are lower than those in metro areas.
2. Charge only the gap – where there is a gap, that will be discussed.  The remainder of the fee will be billed to the Insurance Provider, rather than the patient paying the whole fee up front and claiming for themselves from their fund.
3. Informed financial consent– I discuss fees with patients directly; it is not passed over to a practice manager.
4. Predictable anaesthetic fees – I work regularly with two anaesthetists, and don’t take part in a roster, so I always know who my patients will meet in the anaesthetic room.  In that way, I am able to advise patients (in advance) what fees they will face from the anaesthetist (currently no gaps from either anaesthetist).  We are also able to develop sound co-operative care for patients.
5. No booking fees or hidden charges – policy excess charges differ between funds, but I will be completely transparent in what I charge.  No nasty surprises.
6. High quality, local, personal care – daily visits while patients in hospital, co-ordination with physios etc, easy access to out-patient review, patient-centred care including shared surgeon/independent physio review of joint replacements over the long term.  All while trying to take a balanced view on reasonable remuneration for that service. 

 
What can GPs do?

1. Find out what surgeons you refer to charge – not just for outpatient clinics, but what are their surgery gaps?  And if you think it is excessive, tell them and tell your patient.  If it is not easy to find out from the surgeon, then ask why and ask why you should refer to them.
2. Think local – surgery in the city will generally be more expensive for the patient, but is it better?  And what are the secondary costs for patients being far away from their surgeon and aftercare when they come home?  We value and support the GPs who choose to live in the region, and hope that surgeons who make the same choice will be valued by you.
3. Support local services - Currently, at least 40% of insured patients from south-west Victoria get their orthopaedic care outside the region, often in Melbourne, placing greater pressure on St John of God Warrnambool, which is under financial pressure.  The surgeons providing local private orthopaedic services are the same surgeons providing local public services, including trauma care, and for the system to remain viable, both sides have to function effectively.

 
What can patients do?

1. Ask questions – find out your costs and options, shop around.
2. Think local –local services can be cheaper and more convenient for you than metro services, without necessarily compromising care.
3. Support local services – so that they are there when you need them.

 
 
Alasdair Sutherland
June 2018

I gave a talk a couple of weeks ago to the Warrnambool Sports Practitioner Group and the Warrnambool Trainers Group, talking about management of ACL injuries. There are lots of points of argument in this area, but I think that the focus has to be on two main questions: does everyone who ruptures their ACL need a reconstruction (no, only patients who have functional instability after a period of rehab, about 60% of cases), and what is the best graft (something biological such as hamstring tendons rather than something artificial like goretex or carbon fibre).

There was a lot of general discussion, and of particular interest is the question is prevention of injury.  Surely better than surgery! Below are a couple of resources that link to neuromuscular coordination training programmes that have been shown to reduce the risk of ACL injury, and which have the secondary benefits of improving balance strength and speed, which are surely of benefit to athletes?

If you are interested in reading further, I have attached the links to the original sites.  The world expert in the area is Lars Engebretsen, from Norway, who is the senior author of the International Olympic Committee statement linked below.

Hopefully our trainers will be able to incorporate these training methods into player preparation, particularly young athletes, and we can stem the tide of ACL injuries and reduce the need for surgery in the longer term.  Meantime, those with ACL injuries should not be bullied into having surgery or into having "the latest thing" in artificial grafts, but should sit down with a knowledgable and experienced surgeon who can discuss the balance of what is truly important to them.

​

https://www.physio-network.com/acl-injury-prevention-better-cure/
​

www.thelancet.com Published online November 20, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32457-1

​In summary:  3 study groups; physiotherapy only, shoulder arthroscopy, shoulder arthroscopy + acromioplasty.  Decent numbers, robust follow up.  Both surgical groups did better than physio alone, but no difference between arthroscopy and arthroscopy with acromioplasty. 
 
Just before Christmas, I was at the Geelong Orthopaedic Society annual meeting, and the guest speaker was Prof Andy Carr, from Oxford UK.  He was the lead researcher in this really important study, and my old boss in Aberdeen was on the steering committee.  We had the chance to discuss the process of the study as well as the results and the response to it.  He told us that in less than a week from publication, he had over 700 emails relating to the study, many of them pretty negative, some frankly abusive.
 
Nobody likes to be told that they are wrong, but the defence of acromioplasty has been predictably vigorous, and  largely predictable in its form – everything from “it works in my hands”, to post hoc justifications of why it must work and why this research must be wrong.
 
This is not entirely new. There was a paper comparing acromioplasty with subacromial bursectomy, from Finland nearly 10 years ago, that showed similar outcomes.  The response also mirrors that to the 2002 Moseley study that showed that knee arthroscopy was of no benefit in treatment of OA (see my previous post).
 
Ultimately, the treatment of shoulder impingement symptoms should focus upon a combination of subacromial steroid injections and good quality physiotherapy to get the cuff muscles working more normally.  If that fails, patients do seem to benefit from shoulder arthroscopy and bursectomy, but there is no additional benefit of acromioplasty.

Something a little more philosophical, but very relevant to patient safety.
 
I was very taken by this excellent, thoughtful article, published recently in the Journal of Bone and Joint Surgery, and have been discussing it with our surgical trainees at our weekly teaching session.  http://dx.doi.org/10.2106/JBJS.16.01287
​

Briefly, the story is of an experienced surgeon who is operating in a new hospital doing a spinal case.  Prior to the start of surgery, after setup, the surgeon begins to inject what he thinks is local anaesthetic and dilute adrenaline into the area of the planned incision.  Due to a series of system errors, compounded by unfamiliarity of the team, he has been given concentrated adrenaline and the injection causes a crisis of high blood pressure that could have killed the patient.
 
Fortunately, high quality ICU care saved the patient, without any long term problems.
 
More importantly high quality personal skills, including honesty and humility on the part of the surgeon also saved the doctor-patient relationship, and the patient subsequently had the planned operation by the same surgeon some weeks later. 
 
The surgeon felt that he had learnt:

1. When giving medications, always check the original bottle, trust no-one else
2. When operating out of normal hospital, assume nothing and prepare thoroughly
3. Trust your instincts – if something does not feel right, question it until it does.
4. Honesty and humility in the face of complications are difficult but vital.

 
To which I would add that we should never be to old, too clever or too confident to realize that such incidents could happen to any of us and that patient safety is always our prime objective.
 
I strongly endorse the World Health Organisation Peri-Operative  Surgical Patient Check List in all surgical environments, and have been working with Mr Toma (plastic surgeon) and theatre management at South West Healthcare to improve our current procedures.  If you want to read more about the development of this key safety innovation, I would recommend the Checklist Manifesto by Atul Gawande (or his TED talk)  www.ted.com/talks/atul_gawande_how_do_we_heal_medicine

The recent newspaper and television publicity about PPS (Pentosan Polysulfate Sodium) is inevitably raising the discussion about treatment of arthritis.  But what is it? 

PPS has been shown, in a few papers, to be of some benefit in a specific form of virus-related arthritis, and is used by veterinary surgeons in treating horses and dogs with osteoarthritis (though by subcutaneous or intramuscular injection rather than into the joints).  There is no clear indication of how a drug previously used for treating blood clots and bladder complaints might help in osteoarthritis pain, but we have been introduced to patients who have had dramatic symptom improvements with PPS treatment.
 
Is it the end of joint replacements for osteoarthritis?
 
Best we look at the evidence to date.  All we have from the recent news is a so-far-unpublished case study, reported primarily by NewsCorp Health Reporter Sue Dunlevy  (http://www.heraldsun.com.au/lifestyle/health/a-breakthrough-treatment-for-osteoarthritis-could-delay-the-need-for-hip-and-knee-replacements/news-story/07b6142b4440b1d1316fcac066183c82 ).  Apparently there were 30 patients involved, getting 6 injections over 3 weeks, and 70% of the patients had significant reduction in arthritis pain.  The Herald Sun article continues “there has been no double-blind placebo controlled trial of the medicine”.   Which seems to ignore a 1996 abstract publication (Footnote 1), but does at least note that evidence is incomplete.
 
There is, according to the same newspaper article, a planned Phase 2 (Footnote 2) trial shortly to start.  
 
What about the individual patient that we saw on the news, walking with her horse? 

We know nothing about the lady’s xrays and the severity of her OA; we know nothing about whether the decision to offer a knee replacement, which she apparently now no longer needs, was reasonable.  But she says that the injections cured her, so there must be something in it?
 
Here, we need to go back in time a little to the famous Moseley trial, published in NEJM in 2002 (http://www.nejm.org/doi/full/10.1056/NEJMoa013259#t=article).  In this study, patients with knee OA were randomized to arthroscopic surgery (washout or active debridement) or placebo surgery, and to cut it short there was no difference between the groups.  There is a very good full hour documentary “Placebo: cracking the code” (https://www.youtube.com/watch?v=QvbQnMvhQFw  and a shorter clip from a BBC documentary on placebos https://www.youtube.com/watch?v=HqGSeFOUsLI ).  In both of these films patients from the Moseley study were interviewed, describing the improvement in their knee pain.  Would you be surprised to hear that these patients were in the placebo arm, and had no surgery beyond having minor cuts in the skin to mimic the arthroscopic surgery? 
 
The Moseley study, and subsequent studies, have led to a marked reduction in the number of arthroscopic knee operations across the world.
 
What does this mean for patients now?

Of course this is all complex, and it is not easy to deal with the individual  with knee pain who wants to try PPS, because it "helped a person on the TV news".  And of course the placebo effect is still an effect.  Nevertheless, we need to be both scientific and honest with patients:  PPS might work, but there is as yet no real proof that it does, and we should await proper randomized, placebo-controlled trials before promising them relief from their pain by a miracle injection.  There is still much else that we can do to help without rushing to surgery, which is the last resort.


But I won’t be giving up joint replacement surgery just yet.
 
 
 

 
Footnote 1: 
The earliest human use of PPS that I could find was an abstract published in 1996 by the same Dr Ghosh who was in the news this week ( Rasaratnam, I; Ryan, P; Bowman, L; Smith, M; Ghosh, P (1996). "A double-blind placebo-controlled study of intra-articular pentosan polysulphate (Cartrophen) in patients with gonarthritis: laboratory and clinical findings". Osteoarthritis Cartilage. 4: vi-vii. doi:10.1016/s1063-4584(96)80025-2. ).  Abstracts published in this form represent summaries of papers presented at conferences, and are not subject to the same peer review scrutiny as full papers.  When studies presented as abstracts don’t subsequently appear as full papers, you do wonder if that was because they did not withstand the peer review process.
 
Footnote 2:
We are told that there will be a Phase 2 study about the start, which sounds impressive.  It suggests that the process had passed the first hurdle and is moving on to more important testing.  In fact, Phase 2 studies are for formal testing of efficacy - does it have an effect?  For Phase 2 studies, the drug is not yet presumed to have any therapeutic effect https://en.wikipedia.org/wiki/Phases_of_clinical_research ).