Panel Discussion Dr Antony Kodsi, Prof Sam Adie, Dr Razvan Stoita

The podcast opens with a discussion around the decision-making process regarding prosthesis options in surgical orthopedics. One participant clarifies that while the fund doesn't dictate the type of implants used by surgeons, it does influence rehabilitation protocols, emphasizing a model where patients are encouraged to return home shortly after surgery. The conversation highlights that surgeons retain the autonomy to select implants based on individual patient needs, with one panelist explaining their personal disinterest in managed care because it challenges the equitable provision of patient care.

As the discussion transitions, a specific case is presented, who is described as a patient suffering from chronic pain post-repeated hip replacements. The experts address the complexities associated with distinguishing pain sources in patients who have undergone multiple revisions. They stress the importance of understanding multifactorial pain—where surgery is not necessarily a panacea for all patient issues. The panel agrees on the necessity for thorough diagnostic assessments and emphasizes the importance of patient involvement in their recovery. Treatment strategies discussed include targeted medication regimens, potential use of procedures like fascia iliaca blocks, and considering non-surgical contributions to pain, such as sensitization or issues related to surrounding joints.

The conversation evolves to include specific inquiries about lidocaine use in post-operative settings, where it is noted that its utility is often limited to intraoperative scenarios, particularly involving nerve structures. Michael, another participant, stresses the need for accurate diagnosis before considering further surgical interventions for painful joint replacements, reiterating that understanding the root cause of pain is critical.

Questions arise about the appropriateness of second opinions. The surgeons generally favor patients returning to their original surgeon unless there's a clear mechanical issue needing reevaluation. They advocate for continued patient support, focusing on reassurance and recovery guidance, indicating that unnecessary second opinions could lead to further anxiety rather than providing solutions.

The discussion then touches on the challenges of managing postoperative opioid prescriptions. The panel acknowledges common practices whereby patients leave hospitals on opioids, leading to a concerted effort in primary care to manage tapering and long-term use. They suggest that an effective pathway would involve early screening and referrals to pain specialists when red flags are present.

Next, the complex issue of medicinal cannabis is broached. Participants outline the current lack of robust evidence supporting its use in pain management, particularly emphasizing the need for more definitive research in the orthopedic space. While acknowledging its potential, they express skepticism about its efficacy and the risks involved.

A case study of a patient with bilateral knee replacements facing postoperative pain issues brings forth a discussion on chronic pain after surgery, where the challenges of knee interventions contrast with other joint surgeries. Noting a significant percentage of unhappy knee replacement patients, the participants stress that chronic pain management requires a multidisciplinary approach, incorporating psychological support and the continuous reassessment of the surgical intervention's outcomes.

Towards the end of the interview, they discuss initiatives aimed at establishing a more structured model of care to address the needs of patients suffering from chronic postoperative pain. This highlights the necessity for collaborative efforts among surgeons, primary care physicians, and allied health professionals in creating comprehensive care plans.

The discussion concludes with a recognition of the complexities involved in pain management after orthopedic surgeries and the ongoing need for collaboration, education, and patient support to improve outcomes and quality of life for individuals experiencing chronic pain. The session effectively demonstrates the multidimensional nature of pain management in orthopedic settings and the critical role of effective communication between healthcare providers and patients.

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Okay, I've got one of the first questions. With no gap, who determines what

prosthesis is used and can the

surgeons choose their preferred devices determined by patient uniqueness,

or is the fund dictating what devices we use?

I guess it's the idea of managed care.

The fund doesn't dictate anything is the bottom line.

Actually, one caveat, with HCF, they

do dictate the type of rehab that's provided

so they want the patient to

really lock into that sort of eras

model of care where they spend a

short time in hospital and then do their rehab from home so they want patients

to go home within like two or three days or whatever and then they send a physio

out to them um that's the only real thing i think that everything else is there's

no there's no caveat there's no

there's absolutely no constraint no constraint the surgeon can choose the implants

that they want to do the approach there's no there's not a managed care model

that's in the United States and to be honest if there was I probably wouldn't

participate we wouldn't do it yeah

I think that's an important consideration for us as surgeons for that reason

I don't participate in HCF because I think all patients should have equal access

to care not based on their comorbidities dictate where they go post-operatively.

Got a question at the top?

Yep. My name is Dr. Ben Tettua from Hornsby.

I have a patient and a friend actually who had multiple total hip replacement

and multiple revisions and still have a lot of pain.

How would you advise or manage those difficult? post-revision pains.

Tony? I think that's an answer for all of us.

Well, I do depend on the hip surgeon's assessment as well, that there is no

other periprosthetic fracture,

that the diagnosis was the right indication for the surgery,

what were the expectations that the surgery was supposed to deliver,

so perhaps they have multifactorial problems and the hip surgery was successful.

It helped a particular issue like their function, their range or something,

but it wasn't supposed to address their pain issue.

The hip surgeon might think the pain issue was due to another issue that wasn't

going to be relieved by the surgery.

So having that understanding is very important.

So sometimes patients have a very simplistic view of what surgery is supposed to fix.

Every issue that they present with and it's actually multifactorial and to get

a better understanding of what the surgery was intended, and what they did is important.

The active participation of patients and their self-efficacy can't be under

under emphasized actually.

So that is the core basis of managing chronic pain is getting patients to improve

their self-confidence and being able to understand their symptoms, their limitations,

and adapting to their new experience.

So I do try to exclude that there is another causative factor,

whether that's reversible.

And then I'd look at things like whether they're very sensitized.

And if they are sensitized, I use other medications.

Duloxetine has not been shown to be that beneficial for arthritis per se.

And has been useful in somewhat for other type of arthritic conditions, particularly the knee,

but that might be a useful option, other adjuvant analgesia is an option and

looking at whether there's other procedures.

From a procedural point of view from a pain specialist there's not many options

for if it's intra-articular hip.

We use fascia iliaca blocks intraoperatively but there's not much of a role

in the chronic paste section and I agree hyaluronic acid and other regenerative

approaches have not been shown to be successful for hip approaches.

Gluteal issues, that might be something worth exploring.

From a pain perspective of their sensitization, we use pulse treatments there.

We look at whether there's a contributor from the SIJ joint or particularly

the lumbar facet joint, L4, L5, seems to have a referred pattern to that hip.

So looking for other contributors is a key component of our looking at what

we could do about that. So yeah, thank you.

Got a couple of questions online, Anthony, so it might continue with you.

How long can the lignocaine infusion continue to reduce pain?

Yes, I do have to preface that there's a lot of surgeries that are going on

and a lot of conditions, and ibidocaine is not,

apart from neuropathic pain and some surgeries, There's not a lot of robust

information that it's all that helpful in many surgical circumstances.

So I have to say that.

Most of the lidocaine protocols are just intraoperatively, like with the bolus

and intraoperative use, rather than the post-surgical use.

It's very uncommon to use lidocaine, except when there's a lot of nerve structures

being involved, are being distracted, that we would use it in the post-operative

setting. So it's usually interoperative use.

Michael, if we go just a bit to the previous question, from our point of view

as orthopedic surgeons, if we've got a patient with a painful joint replacement,

in order to treat that, we need to understand where the pain's coming from.

So, you mentioned that the patient has had a number of revisions.

We would only do a revision if we know the reason why we're doing the revision.

Pain is not a reason for revision.

Pain is a symptom. We need to find a diagnosis, what's responsible for the patient's symptoms.

If we don't have that diagnosis, no matter how many revisions we do,

we'll get the same result.

Whether that's infection, implant loosening, implant malpositioning,

whatever it might be, we need to have a diagnosis in order to treat a painful joint replacement.

So Anthony, just on that, if you've got a patient in the community who's been

lettered back to the GP saying all is good with the hip replacement,

if the patient's still got pain,

should they come to you for an assessment first, Anthony, or should they be

sent for a second opinion with another surgeon?

How do you see your role and when do you come into play?

I do think that most patients benefit from seeing their hip surgeon,

not just because that there could be issues with their hip surgery,

but also to get that reassurance from the surgeon who put a lot of investment

in that patient and the patient has invested in a relationship with their surgeon

and getting that reassurance from them because in terms of their prognosis,

being able to be reassured that their pain issue is not due to the surgery or is very important.

And they might not agree, but

that needs to

be explored because a key component of

chronic pain is to see whether pain is

a symptom of harm or whether its pain is just a slow recovery or they're just

very sensitized and they need a bit more movement and exercise and other treatments

that they can manage their pain and improve their optimization of their functional outcomes.

And just, Mike, about your question about referring for a second opinion.

So, you know, Tony's talked about it a lot.

Chronic pain, multifactorial. There's so many different things that could,

you know, feed into that.

If you're going to put that patient in on the radar of another surgeon,

you know, we're equipped to deal with surgical problems, right?

So we're equipped to deal with mechanical issues, alignment issues, all of these things.

So if you think there's a problem like that, that, you know,

the first surgeon's missed or you feel that that's probably the diagnosis,

then yeah, sure, second opinion.

But if you think that it's a chronic pain issue and there's probably more likely

to be all of these other complex factors that are feeding into this issue,

that's probably not a wise thing to do because you're putting them,

like I said, in that zone of influence.

And then the surgeons really like, what do they do?

I mean, they do surgeries, right? That's probably one of the last things that

patient may need, right?

So I'm not sure if a second opinion is the first thing I'll do.

I'd probably more refer back to the original surgeon and

and obviously think about you know more broader referral patterns

and i do this just based on someone who sees them like how often do you see

the second opinions or someone who comes in and then you know that that patient's

much more complex and there's very little that i can do to help you know apart

from maybe just giving them more reassurance or further tests or something just

to confirm what we already know that there's no.

There's no significant sort of biomechanical or mechanical issue.

And the other thing is like if I do a joint replacement, I've got a patient

and I've done a joint replacement and they come, then they are dissatisfied

with it. Yes, I investigate it.

And so then if I can't find anything, then I would send the patient for a second

opinion to try to remove that surgeon bias.

Because as surgeons, we think, oh, no, we're great. We do everything that we

do is perfect and so on. It's not our fault.

So just removing yourself from that decision, allowing somebody with a fresh

set of eyes to look at it and assess that patient is also important.

It's important not only for you as a surgeon, but it's most important for the patient.

And providing that patient with that reassurance that, well,

yes, no, everything looks okay. Technically, everything has been done fine.

There is no reason to revise that joint.

So then they can explore additional treatment methods. Thank you.

Sorry, I've got a couple of questions. One for Dr. Coetzee.

A lot of surgical patients broadly, not just orthopedic patients,

obviously, are discharged from public hospitals, private hospitals on opioids.

And that obviously presents some challenges in a primary care setting or at

MISE in helping those patients transition.

So I'm wondering if you could sort of talk about that a little bit.

And then just the role, if any, you see cannabis-based analgesia playing,

given the controversy at the moment and the sort of upheaval that appears to

be occurring with the TGA wanting to constrain, to some extent, access to these things.

Then my second question for the orthopedic surgeons is really.

What you outlined about intra-articular steroid doesn't concur with my experience in primary care,

I mean obviously steroids are used broadly in various joints and I'm thinking

particularly maybe a younger patient who does probably merit a joint replacement

but is uninsured and so is looking at 12 months,

24 months on a public hospital waiting list.

I'd be interested in your thoughts in that context.

The bullet sticker first.

I'm going to be very blunt about the whole steroid in the joint issue.

I know Raz mentioned it, but...

There's definitely some data to suggest that if you've had a recent steroid

injection, you are at increased risk of complications, particularly infection.

But that is very flawed, okay? It's, you know, it's easily, if you were to just

read that evidence with, you know, any sort of critical appraisal approach,

you'll realize that it's confounded by lots and lots of things.

So the issue for me then is that I've got

this data that I now have sort of lower confidence in

in terms of whether this is a real thing but

then I've got a patient in front of me like you like you

sort of gave the example of that public patient who's like

struggling who just wants to get over the line before

they have their surgery I'm going to do that injection sorry

I'm going to do that injection I might the most

I'll do is I might mention it to the patient to say that there's a tiny increase

in you know chance that you might have the infection is it worth it for you

you know maybe because you do get that short-term relief just to get you over

the line to just improve your quality of life right so for me i.

I still use them um i still use them you know um i think a lot of the fear now

is going to be like a medico-legal one because it's become such routine accepted

sort of practice in our community,

and unfortunately you will find someone one colleague who

will say oh that was the wrong thing this is if something goes wrong

right something goes wrong they'll say that that's probably the wrong thing

to do even though it's based on data right so that's that's i think a probably

one of the main considerations for why people are now going off it but then

people are going to suffer right

people are suffering in the meantime and that's really really sad for me,

really sad but it's three months have you got a safe time frame if they they

know the surgery is not for the next three months that's safe or i think if

you know the problem is in a public sector you don't really know when their

time is going to come up as well like you know they're just given dates and I sort of rock up,

but private sectors a little bit more controlled.

Well, I think the three months, that seems to be the going time frame at the moment.

That's from a medical legal standpoint. The problem is what Sam said,

the problem is that in orthopedics it's very difficult to do high quality studies

to assess for just one issue,

like infection after corticosteroid injection in hip replacement.

There are so many factors that affect the risk of an infection in a patient

who undergoes joint replacement surgery.

And the data on the intra-articular corticosteroids, it comes from the knees.

It's been done in the knees, the studies, and they've been extrapolated to the hips.

In knee arthritis, yeah. But I don't use, well, the only time that I would use

a corticosteroid injection is at the first symptom of arthritis.

If that had recurrent exacerbation of arthritis, I do not find any benefit.

I do not use it. I don't think there is any strong evidence for use to provide.

What we're thinking here when we treat patients with arthritis,

arthritis is a long-term problem. We need to provide a treatment that provides

long-term pain reliefs. Well, the steroids do not.

So then I'm not using it. Just quickly, there's a question online and back to the first question.

Anthony, these patients that get dumped back to the GPs after they've had the

surgery, they're still in pain.

How many weeks before they come to see you? Have you got some recommendations

for the GPs regarding the opioid post-operative management?

Because, you know, we see a lot of GP bashing in the media. So can we give them

a safe pathway for what to do with the post-operative surgical patient?

Yeah, a few comments. My picture across the board has been more and more discussed.

What I'll be discussing five years ago is not the same that I'll be discussing

today and won't be the same in five years' time.

So it's an open space on how we can help patients use opioids wisely.

Function is important so getting them

to move using opioids appropriately we want them

to use opioids to to mobilize early because

that does improve all their outcomes so we have no

problems with that I it's true

that the issues of using opioids particularly after the first or two weeks that

is an issue some hospitals would have sub acute pain services for early referrals

patients that have been shown to be a higher risk because of those risk factors

that I've discussed before, female, younger.

A lot of anxiety issues or catastrophizing behaviors, for instance,

and some that is a bit of screening in postoperatively to try to get those patients

into those subacute units.

In the private space, particularly here, yes, I'm happy to see those type of

patients in the postoperative period.

Some of us pain specialists have less waiting periods and can be able to see

and accommodate these patients fairly quickly.

We'd like to see before they become a significant use.

One of their issues is that a lot of patients that come to see us,

they have a psychological distress and issues that are very difficult to just help in a very short,

time-limited way when you are not remunerated quite well for these short consultations

and trying to give them that education,

self-empowerment, improve their self-confidence, and trying to manage their

expectations and their opioid use more successfully.

And we have sometimes the language and expertise to be able to reach out to

even the more difficult patients that you routinely see,

because you probably do this successfully a lot of the times, eight out of 10 times.

It's just those few patients that you do think are going to be struggling with.

And also you want to keep that relationship with the patient and have that opioid

stewardship stuff happen with someone else that they might not have a longitudinal

relationship, we're happy to see and get referral early on, no problems at all.

The role of cannabis? Cannabis. My college has come out against the use of medicinal

cannabis due to just the lack of data.

So a lot of data is still unknown.

It seems to be more helpful for neuropathic pain, but even then the number needed

to treat is pretty high, around 15 to 20, which is higher than what we use for anything else.

So duloxetine is about 6 to 7, Pugabin 4, Tramadol 4, so it's and the number

needed to harm is also quite significant for all cannabinoids.

So the other way is how do we use it, also is another factor, how do we try to treat it.

There are more and more guidelines to use it. I

use in the palliative care space a lot for nausea vomiting and

appetite even then i'm not being

greatly impressed by the results uh from a

from my point of view um and the

uh so and the space is not that it's it's

coming more regulated but it's uh there's still uh there's

a lot of cowboy um stuff that's happening in that space too uh so uh cannabinoids

might have a place uh but i don't it's not definitely not a panacea and definitely

it's not defined compared to the conventional ways that we manage pain issues.

So that is just my two cents about cannabinoids.

I'm sorry this is actually a knee question but it is related to pain.

I've got a patient at the moment, lovely gentleman, used to have a very physical

job as a gardener and then did through workers comp get both knees bilateral knee replacements.

One knee going pretty well, the other knee or leg, constant pain,

rubbing, it's tight etc and not a man prone to exaggeration.

So you get concerned when the wife comes in to one of the consultations to make

sure that he's telling you that the pain is limiting his life.

He's also not happy with his orthopedic surgeon, no one here,

and has lost confidence, and I have become the go-to girl.

So what I have done is tried to come at it laterally.

I've called in the wonderful physios at MQ Health, and we had a conference because

my brain was, you know, getting overloaded. Where do we go next?

Alex and I workshopped some ideas. It made the patient feel listened to because

he hadn't felt listened to.

I had gone ahead and ordered an MRI of the knee in somewhat desperation.

Alex, the physio, did say he was an ex-smoker. Have you thought of doing Dopplers

just to make sure it's not arterial?

Turned out okay. because there was lots of bits and things on the MRI.

There was a larger fusion. There was a possible small ganglion.

I was on the edge of giving him pain relief options such as Cymbalta,

but then I saw stuff on the MRI.

Did I do the right thing? The physio said sometimes just doing plain x-rays

just to show the position of the implants is probably the better thing to do.

But now it's so hard to know which way is up and which way is down with this patient.

I have asked him just to go back to his surgeon to look at it,

But it is really hard from all these discussions to know when we go,

the more go back to your surgeon route versus when do I start duoxetine or CBT

or perhaps even ask one of your good selves to a conference with myself and

the physio. Do you do that?

So can I answer that? So knees are very different to hips as we've discovered.

So sorry I don't know the gentleman's name at the back but the story that you gave about your,

friend having repeat surgeries and being unhappy is

actually a rare story in hips okay in knees it's quite common okay knees you

know if you look at the literature 20-25 percent are unhappy with their knee

for one reason or another and a lot of those then get that chronic post-surgical pain In fact,

in Australia, we've got good data. It's about 10%.

Who have that chronic post-surgical pain, which is a large number when you think

about, what, 70,000 knee replacements a year?

So 10% of those potentially having that persistent pain down the track.

So the thing with knees is, thank you for looking after that patient,

right? You seem like you're doing all of the right things.

The thing is with knees is, you know, chronic post-surgical pain is quite complex.

It's not always those mechanical and loosening issues, right?

So sure, the surgeon is well-equipped to deal with that aspect of things.

Are we well-equipped to deal with chronic pain issues, neuropathic pain, psychological issues?

Absolutely not. We are hopeless at doing that sort of stuff.

And we don't have a good model of care to deal with that situation.

Like if you're seeing me, even me knowing about this stuff, because this is

a very much an academic interest of mine.

I'm not very well equipped to do it, so basically the best I can do is do my

bit. My bit is sort of examining the mechanics and alignment and making sure

that everything's good from a surgical point of view, exclude infection, etc.

But then I have to have a team around me. So the reason why I'm saying all of

those things is we're actually developing a model of care right now.

This is one of the big things that's taking up a lot of my time.

The project is called EPIC Early Pain Intervention and Knee Replacement,

you're not alone so it's got massive interest in

fact everyone was interested and they just threw it

we've got like 4 million dollars or something in grant

funding just to do this study and basically what we're doing is we're developing

this model of care that's led by this sort of clinician that's going to sort

of take them through and ask them about all of these potential problems that

they could be facing and then sort of tailoring a program for them and then

following them up because a lot of it is, as you've been doing,

is a lot of hand-holding and TLC and this is okay and listening and all of those

things to make sure that they're on the right track,

to deal with their problem.

I think in this patient's case, it's not sort of six months or a year.

It's sort of three to four years down the track. And I think it's just got into

a too hard basket for the surgeon, I think. Yeah.

And, yeah, do you ever do a conference as surgeons with the GPs and the physios

in a case like this? I have, yeah. Yeah.

Uncommonly, but I have. Sandra, I'm sorry. I'm going to have to call time.

We do need to go to morning tea. So if everybody can please thank our lovely

speakers for this morning and you can catch them over morning tea.