Session 2 Panel Discussion Dr Nargis Shaheen, Dr Jonathan Negus, Dr Bernard Zicat

The discussion focuses on the management of Prolia, an injectable osteoporosis medication, particularly in the context of total shoulder arthroplasty and its timing relative to surgical procedures. The discussion begins by highlighting the importance of educating general practitioners (GPs) regarding the administration and timing of Prolia in relation to arthroplasty surgeries, emphasizing a one to three-month window post-injection for optimal outcomes. The panelists agree on the critical nature of timing, noting that delaying the next dose of Prolia could lead to adverse effects such as rebound bone loss and challenges in implant integration.

The conversation expands to include variations in management approaches between shoulder and lower limb surgeries. While one panelist suggests referring patients to osteoporosis specialists managing Prolia, others share their experiences with knee and hip arthroplasties, indicating that many patients do not typically present with complications related to Prolia. The informative dialogue delves into the mechanism of action of Prolia and its impact on bone remodeling, detailing the balance between osteoblasts and osteoclasts and the potential implications for healing post-surgery.

Questioning the literature, the panel addresses concerns around stress fractures linked to Prolia and contrasts it with previous misconceptions about initiating osteoporosis medications in the hospital setting. They assert that recent studies have alleviated prior worries, encouraging a more integrated approach to managing osteoporosis medications in surgical patients since 2019. The discussion is enriched by an audience member's inquiry regarding the common advice found online about stopping osteoporosis medications around the time of surgery, leading to further clarification of Prolia's unique pharmacokinetics and implications for patient care during the perioperative period.

Transitioning to the subject of knee braces, the panel offers practical advice on recommending braces for various conditions, noting the challenges posed by the wide variety of products available. The focus shifts to the effectiveness of specific braces, particularly medial unloader braces, and the importance of basing recommendations on the individual patient's condition and personal experience with existing braces. The discussion touches on the psychological effect that braces may have on patients and their role in providing stability.

The latter part of the lecture examines negative pressure dressings commonly used post-knee replacement surgery, discussing the necessary follow-up procedures for managing these dressings, especially if they become compromised. Panelists emphasize the importance of maintaining a proper seal on these dressings and highlight the protocol for addressing issues such as leakage or discomfort, recommending that patients should promptly return to their surgeons if problems arise.

Lastly, the panel explores the incidence of delirium in postoperative patients, particularly the elderly, addressing how to make discharge decisions considering individual symptoms and needs. They discuss the potential benefits of returning to familiar environments for recovery, linking follow-up care with geriatricians to ensure comprehensive support. The session concludes with lighthearted remarks about weight gain post-arthroplasty, showcasing the panel's camaraderie and shared insights into the multifaceted considerations of surgical patient management.

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Just a question for the panel. In total shoulder arthroplasty,

there's evidence now that the prolia use and the timing of that is very important

because I think it's important for the GPs to understand how to manage prolia

at the time of arthroplasty surgery.

Certainly in the shoulder space there's evidence that the appropriate timing

for prolia is about one to three months.

You should time your arthroplast about one to three months post-prolia administration

but you should not delay your next dose because there's a rebound effect in

terms of bone loss and also osteointegration.

So I was wondering in the lower limb space how you guys manage prolia because

I think that's an important question that a lot of GPs would like an understanding of.

Just explain for a lot of me who don't understand what prolia is.

So prolia is obviously an injectable that GPs provide for osteoporosis.

It has an effect on balancing a bone remodeling.

And in the shoulder space, we are learning that if the prolia is not administered

at the right time, you can get defects on osteointegration.

So you can get effect of the implant not fully integrating into the bone.

So in our space, what we do is, for me, a patient cannot have a shoulder arthroplasty

if they are not within the timeframe frame of about one to three months post

the last prolio administration,

and it's not a good idea to completely cease the prolio too because you get

a rebound effect where it may not help integration as well.

Maybe Dr. Shaheen could start with hip and knee.

How she manages. I wasn't aware of prolia being withheld for the news.

Look, I have not been withholding.

So, Tumit, you're talking about cementless joint replacements.

What about cemented joint replacements?

In terms of cemented, there isn't much data, but for the cementless components,

which is a predominant sort of application in shoulders, is it seems that exactly

what you said, Bernie, that not ceasing prolia is important,

but the timing of the surgery is quite important.

And they suggest about one to three months post the administration and then

not ceasing afterwards.

So what I've done is I have referred patients back to the osteoporosis team

who is managing, usually endocrinology,

managing the prolia.

Because I wasn't switched on to the fact that there was a difficulty with joint replacements.

I haven't seen it as a problem in our patients.

I'm not sure that a lot of the patients that I do are on Prolia.

I don't think that that's common, but we do certainly see it from time to time.

Um you know the

there there are there are osteoporotic

patients who we operate on but generally patients who

are arthritic tend to have very dense

bone they they have very strong bone um so

in the areas where uh where where

i'm doing it i haven't seen that as an effect and i haven't seen it in

the hip or knee literature either so i

normally uh recommend they go back to the

original um sort of person who's

managing it because what what happens with prolia is

that um the way that it works for osteoporosis is

it um interferes with the balance

of the osteoblasts which make bone and the osteoclast the breakdown bone and

it interferes with osteoclast function And so even though you've got osteoblasts

that can make bone and presumably are involved in part of the healing process

with cementless implants,

the balance between the osteoclast taking away bone that is non-functional or

needs to be resorbed and the osteoblast is a problem.

And this, I'm not sure that, does prolia have the same risk of stress fractures.

Femoral stress fractures as others? Yes?

Yes, correct. Yeah, it has similar, if not more than Zomita as well.

So, Bernie, you might remember there was concern prior, before I started,

also, Jerry's, it was about 2017 when,

All the orthopedic surgeons were worried to start the inpatient osteoporotic

medications because of the bone remodeling.

But then there was good studies done to show that there was no effect.

Therefore, now in Australia and New Zealand, we do give osteoporotic medications,

especially for neck or femal fractures.

I've got a question in the audience. Interesting. Google says.

Sorry, just wait a moment so we can catch the recording. Thank you.

Mr. Google says, do not take any osteoporosis medication, Actonel,

Atelvia, Banosto, Bonivia, Evista, Fosamax, Prolia,

Reclass, etc., for one month before and three months after surgery,

unless it's specifically discussed with your surgeon.

So that's only one month. But Prolia, was Prolia on that list?

Because probably it's got a long active life.

I think it's six monthly, so maybe a bit different.

The other thing is, I think probably if you looked up the sort of risk profile

on the little very microscopically typewritten precautions with any medication,

you'll find just about everything on there.

But from a practical point of view, I haven't seen it as an issue.

And the fracture healing aspect of it has been highlighted because it doesn't

interfere with normal fracture healing because of that balance between the osteoclast and osteoblast.

And we talked about it last week in our M&M meeting as well.

But I don't think that I've ever seen that practically as a problem.

It hasn't been now that we have been quite comfortable starting the osteoporotic

medications in hospital since 2019 and we haven't had any issues so far with bone healing.

I think this is one of those occasions as well where it just highlights multidisciplinary teams.

So as we said, we don't see an awful lot of prolia and so if I see a drug or

a new biologic I haven't heard of, I'm just going to speak to the physician

who's managing that and see if there's anything that affects the patient from

their point of view in terms of timing.

And from our point of view, we'll check literature and say, I haven't seen anything in the literature.

So I'll be based on what's important for the timing of their injection for that

condition rather than necessarily the replacement.

Although we have obviously in the knee we have fully cemented

options and if someone's osteoporotic we're likely to use that anyway because

uh in blunt terms we just hit it a little

less hard to put it in and if you're putting an uncemented implant hitting it

hard in osteoporotic you're more risk of fracture so we tend to use the uncemented

not all of us tend to do that but um but on the subject of obesity definitely

obese patients all have very strong bones otherwise they They were collapsed and fractured long ago.

So their bone strength is actually quite good.

You rarely see an overweight or obese patient who is diagnosed with osteoporosis

and on osteoporotic medication.

Two questions about knee braces.

One is, what are the optimal braces that we can recommend to the patients?

What features they should have?

Because there are many in the market.

And what type duration? Because patients ask, should we wear it while sleeping?

For how long we should wear it? If we can have some advice, please.

Thank you. no of course i think

the thing with knee braces is you're trying

to treat uh often trying to treat different conditions

whether you're treating a patellofemoral issue patellofemoral arthritis or tracking

or whether you're treating a medial compartment arthritis or a lateral compartment

arthritis so depending on the condition that then will dictate the knee brace

to an extent um the the main brace i find to be reliable for arthritis is that medial unloader brace,

it's the only one that actively unloads the compartment otherwise most other

braces for me fall into the bracket if a patient's already using it and they

like it I think that's fine and they ask me to recommend and I don't tend to

recommend too many other braces because,

they're a variable it's often difficult to work out how they might be working for them.

Maybe offering some proprioception a little bit of stability especially in a

knee that's become a little unstable with arthritis but um and with patella

femoral sometimes the the braces that are uh centralize the kneecap and uh and

maybe take a little bit of pressure off the lateral side but um.

There are hundreds of braces out there and as I said,

it's difficult to see how a lot of them do work other than offering some psychological

reassurance for the patient and maybe a little bit of stability,

a little bit of proprioception.

So I don't tend to actually prescribe any other brace, but I'm happy for them to wear them.

I wouldn't recommend wearing them overnight as a compressive effect they're

likely to get more swelling and so it's really activity based for most of them.

Just a question about the negative pressure dressing that we often see for a

patient who had a total knee replacement.

And sometimes they come with yucky oozing or some of them are partially removed

and they come for advice or treatment.

Or what do we do and what can you advise for GPs for follow-up?

So negative pressure dressings, like the formal negative pressure dressing,

which is the Pravena, has a circumscribed area around it that should have a seal around it.

If the seal's not working, there's no point having the pressure dressing on.

If there's a wound that's leaking or draining after surgery,

you should send it back immediately to the surgeon who's looking after it.

Here at Macquarie probably if it was like on a weekend you'd be able to get

a dressing put on by the nurses up on the ward if you're able to maybe contact through the,

through the reception either directly to the surgeon or possibly to the team

on the ward who was looking after them but leaving it on particularly if there's

the ability for fluids to get in, you know, during showers,

that sort of thing, that type of messy dressing,

take it off, keep it dry.

And if it's oozing or draining, probably needs to be seen for another pressure dressing.

And I'm not sure if they like some, there are some, depending on how much leakage

there are, there are some dressings that are maybe easier to access like the

Pico dressing, but I'm not sure that you'd be able to get it like through a pharmacy or anything.

I think it's just probably just a hospital product I would say yeah I think very expensive mm-hmm.

But if it stops working, the wound's dry, happy for a normal disease to go back

on. Yes, that's right. So, I mean, timing's always difficult.

So, patients leave hospital with the dressing, say, and it may be a week or

two weeks before they go and see the GP.

Normally, they should be coming back to the hospital, the surgeon,

to have the negative pressure dressing managed, but they might sort of find

themselves with the dressing falling apart and they go to you and say,

you know, what should I do? Definitely contact us.

The dressings normally will stay on quite comfortably for at least a week or 10 days.

Some of them have got canisters and battery life, so two weeks now.

So we're not, we don't mind leaving them on as long as they're working.

It's quite safe, but if they're not working, I would just take it off.

And if the suction normally stops around seven days? Well, so that's a technique

that the company uses to protect their property rights, if you like.

And you can get them now that lasts for two weeks.

But if they're on a seven-day battery, then they should be instructed through

the surgeon's rooms to have it dealt with at that time.

I mean, they might say, leave it on for seven days and get your GP to take it off at that time.

That's fine just take it off but if it's leaking then we

need to have a look at it just because the battery stopped working doesn't

necessarily mean you need to change the dressing though does it's a

yes yeah no the the the uh

if the battery stops working there's no point having the dressing on it will

just lose its uh its pressure so you should take it off right question from

online dr shaheen and the panels can discuss um the delirious patient post-operatively

uh who decides when they're discharged and how do you decide that?

Delirium is very common in elderly patients and the delirium resolution depends.

Not every patient's delirium is similar.

Some people resolve within two days, some is much more prolonged.

About 20 to 25% of patients still leave the hospital with some sort of delirium.

Of course, we decide according to what their symptoms are, whether they need

to be monitored, whether they'll be better off at home or if they can be managed in rehab.

It's an individualized-based judgment, but

not all patients are kept in hospital till delirium resolves because sometimes

delirium can be much more prolonged and can last more few weeks to months on discharge.

Can going home help with the delirium in terms of going back to a common setting?

So they can go to a common setting. They can be discharged home after discussion with the families.

They understand what needs to be done. But as long as there's a follow-up,

usually delirious patients are followed up by geriatricians.

They can go back to nursing homes, residential cares, or even rehabs at times.

If they are following instructions, they don't need to necessarily be in acute hospitals.

Another question online, Dr. Zekert. Why do patients gain weight post-arphoplasty?

What's the reason? One of my old consultants used to say it's because they get

to the fridge quicker. Yes, that is the answer.

Or more frequently.

I think that's the simple answer.

I think they're able to get around more and the reason they're overweight because

they like eating. So they eat more.

Now, speaking of getting to the fridge faster, ladies and gentlemen,

we're going to wrap that up for this session. So please thank the panel.