Do Robots Improve Surgery?

Robots used in surgery

The Australian Orthopaedic Association, the Australian Knee Society & the Arthroplasty Society of Australia have just published a position statement on robotic surgery.  Meanwhile we continue to work hard on alignment and balance of knee replacement surgery.

We identify that the ZUK partial knee replacement at five years has a revision rate of 4.9%, the only registry data on robotic surgery is the Restoris with a rate of 1.2% at one year.  We are awaiting further data.

Position statement developed by the Arthroplasty Society of Australia together with the Australian Knee Society.

The Narcotics problem and how ‘LIA’ solves It

In the news at the moment is that oxycodone is addictive and a class action against the manufacturers is underway – but I’ve been avoiding narcotics for my patients for years.
In fairness to the narcotic crowd – they are useful painkillers for acute severe pain, and long acting patches have some value for residual pain after surgery, but otherwise – why bother?  

The combination of Meloxicam, Paracetamol and Tramadol as a top up covers just about every scenario. For surgery – Local Infiltration Analgesia, or LIA (Ropivicaine, Ketorolac, Dexamethasone, and Adrenaline) is critical.  Norspan (Buprenorphine 5ug/hr) for knee replacements, posterior approach to the hips seems to help and avoid peaks and troughs in pain control.  A little Amitriptyline for rare neuropathic pain is useful.  But I wonder whether the narcotics crowd has fanned the anxieties of prescribers, making narcotics the easy solution for doctors?

I accept that Tramadol is also potentially addictive, but I found a decade ago when I swapped using Endone to Tramal, that my patients no longer required another five boxes, but were likely to use just a bit over one box after knee replacement surgery.  Tramal is much less addictive than Endone.

Some surgeons are preferring Tapentadol – although I wonder whether less serotonergic effect is actually better, and the fast acting option is not covered by the Pharmaceutical Benefits Scheme.  Nausea is unlikely if the patients if the starting dose is 50mg at a time, and the patients actually have enough pain to justify it.  Hallucinations do rarely occur, in which case we swap to something else.  

Interaction with SSRI’s (Selective serotonin reuptake inhibitors) is rare – serotonin syndrome with normal doses of SSRIs or SNRIs (Serotonin and norepinephrine reuptake inhibitors) and normal doses of Tramal have not been observed by this author despite being used in hundreds of cases.  The more depressed a patient is – the more they should avoid narcotics!

Avoidance of NSAIDs (Nonsteroidal anti-inflammatory drugs) is another reason narcotics are overprescribed.  Celecoxib might upset asthma, and might cause nausea, so we use meloxicam.  After surgery 7.5mg twice daily hopefully improves its COX-2 selectivity.  Our patients are on a PPI (Proton-pump inhibitors) for the two weeks after surgery anyway, since this gastrointestinal bleeding has been rare, even with powerful anticoagulants in some patients.  Avoiding use of NSAIDs in patients with degrees of renal failure has been exchanged for reduced use.  
Our approach depends on the patient’s eGFR (Glomerular filtration rate) – given one third of patients have at least mild renal impairment – one needs a plan!  We limit intravenous fluids usually to a litre, but encourage oral fluids up to 2 hours prior to surgery, and straight into the oral fluid in recovery. NSAIDS are much more valuable than narcotics in orthopaedic surgery and injuries.

In the instance of joint replacement surgery – Torodol (ketorolac) is administer in the periarticular mix intra-operatively, and directly into the joint via a wound catheter with a 0.4um filter after surgery.  The evening dose is for morning patient, the morning after dose is received by all patients. The Mobic (meloxicam) is used typically for three weeks for hip and knee replacements.

eGFR
Intraoperative
Evening
Morning
Discharge
>90
30mg Torodol
30mg Torodol
30mg Torodol
7.5 Mobic bd
60-90
30mg Torodol
30mg Torodol
30mg Torodol
7.5 Mobic bd
55-59
30mg Torodol
30mg Torodol
7.5 Mobic bd
30-54
30mg Torodol
7.5 Mobic daily
15-29
30mg Torodol
<15
30mg Torodol
7.5 Mobic daily

We remeasured the eGFR in patients after surgery if their preoperative eGFR was abnormal.  The graph below is of 63 patients who had a followup eGFR in the two years prior to February 2018.  We note a dip in eGFR on day one after surgery, then recovery.  We’ll collect more data and hopefully get it into a peer reviewed journal.

In conclusion:
The down sides of narcotics are underestimated by most doctors, but they overstate the concerns about NSAIDs and tramadol.
The only narcotics we routinely use is a Norspan patch (buprenorphine) and even the concerns about NSAIDs are addressed by adjusting the doses, and keeping fluids up.  Having comfortable alert patients is better than narcotised ones.
The concerns about tramadol are addressed by starting with small doses, ensuring it is used sparingly, and checking any SSRI dose is reasonable.  Perhaps one or two percent of patients are not suitable for this approach.
Mr David Mitchell
Orthopaedic Surgeon

Men’s Health Pub Clinic

Men have traditionally been pretty slack about looking after themselves. We usually put things off until we REALLY have to do something about it. 
The recent advent of “Men’s Health” events have been a great way to get messages out to men about simple things they can do to look after themselves. One of those events is the “Pub Clinic”, run by Bacchus Marsh GP Dr Ravin Sadhai. Ravin has been putting on this event for over ten years, offering a free beer, some nibbles and a chat. 
The poster for the Men’s Health Pub Clinic
This year saw Shaun English and Greg Harris join rheumatologist Dr Kim le Marshall talking about joint health, exercise and ‘not getting broken’, to about 100 participants. There were plenty of good questions, and hopefully everyone learnt a thing or two. 
Dr Greg Harris, Dr Ravin Sadhai, Mr Shaun English and Dr Kim le Marshall at the 2019 Pub Clinic
For information about the Pub Clinic, go to their website at http://www.thepubclinic.com.au
Dr Greg Harris

Most people do not know how much they should weigh

The knee joint carries nine times your body weight as you use stairs.  The hip uses 3.3x your body weight with every step.  This is because of the amazing mechanics of the body, but it does have a downside – If you are overweight, you’re overworking your joints.

This graph shows with the green line, your maximum weight for a normal BMI.  BMI’s are argued about for a general health point of view.  Its is likely with a BMI of 30 you will still have a normal life expectancy, but your knee joint will not.  Even if you’re 6’6, 198cm, your knee will eventually struggle if you weigh 100kg.

Some people do not accept the target weight based on their height and a BMI of 25, and come up with ten reasons why they can’t get to that weight But we would like you to have a target weight, and make a plan as to how to get there.  The good news is that dropping 8 kilos for most people means the knee pain will improve.  Some people will find that exercise and a small weight reduction fixes their knee pain, diabetes, hypertension, and cholesterol.

At the very least, being Strong, Supple and Slim will make you healthier.

If you’re serious about losing weight, you’ll need help.  The Michael Mosley book – “The Fast 800” is an easy read plan as to how to lose weight.  Mosley initially wrote about the 5:2 diet, this takes the idea further, but gives you a few more calories! You will need to calorie count at least two days per week.  You should aim aim to introduce time restricted eating.  It is easier if you enlist the help of your family and the people you usually eat with.

 

The Fast 800 – by Dr Michael Mosley

Mr David Mitchell

Orthopaedic Surgeon

 

References:

Mosley, Michael. The Fast 800. 2019. Simon and Schuster (Australia)

Brukner, Peter. 2018. “Fat Lot of Good”.  How the experts got foot and diet wrong and what you can do to take back control of your health.”

What’s Cycling Got To Do With Orthopaedics?

Shaun English & David Mitchell have completed the 2019 Peaks Challenge!

This is a bike ride from Falls Creek, to Mount Hotham, Omeo, and back to Falls Creek.

11 hours 25 minutes (10 hours riding time) covered 235km, 4196 metres of climbing.

A tough day!

The track Mr Mitchell and Mr English rode on the weekend

To do a cycling event like that you need:

  •             training
  •             planning
  •             dedication
  •             persistance

This is how we do Orthopaedic Surgery too!

Shaun English and David Mitchell