“Our aim is the smallest possible hole in every patient’s life”

Hip resurfacing and single compartment knee replacement patients at home within 24 hours

Patients with osteoarthritis are not ill - this is the fundamental principle on which we have established a treatment concept in line with the patients’ needs in the Joint Orthopaedic Centre over the last 10 years.

Here in Sydney we have a dedicated team bringing together surgical, anaesthetic and nursing skills to benefit our patients.

85% of all patients we treat with either a single compartment knee replacement or hip resurfacing leave the hospital within 24 hours of the operation and go straight home, not to a rehabilitation centre.

Information first

The first step in a treatment program is to provide the patients with comprehensive information. We must get across to the patients that many of their fears, preconceptions, and much of what they have heard about joint replacement surgery has nothing to do with the treatment they will receive in our clinic. Pre-operative fear is a problem to be taken seriously, which we do.

Minimally invasive

The second step is to select an implant that is not only stable but can bear weight immediately.
The third step is an operative procedure that is preferably minimally invasive. The less tissue damage there is, the less pain the patient will feel. The operation must be performed carefully and gently so that bleeding is minimised, pain is diminished and recovery and mobility are maximised

Pain control

Knee Osteoarthritis

Fourthly we make use of pain control that initially includes a local anaesthetic injection around the operation site, so that the first painful stimulus is eradicated or minimised. This is just like the dentist minimising pain at the site of dental work. This is then supplemented with a combination of paracetamol, codeine and anti-inflammatory agents used in the immediate postoperative period. A short-acting spinal anaesthetic is used, not an epidural anaesthetic. Our experienced anaesthetist works with the smallest possible dosages and uses as few narcotic agents as possible because these can cause nausea and confusion and delay mobilisation. Because of the effective local anaesthetic block pain relief is generally good enough not to require intramuscular narcotics or patient controlled analgesic infusions. We like our patients to be on their feet again and walking as soon as possible and strongly encourage this. Generally, they should be mobile again and weight bearing within four hours of the operation.

Total Knee Replacement

Home circumstances paramount

And last but not least, the patient’s home circumstances are also considered. This is paramount in achieving a smooth transition from hospital to home. We try to ensure that the patient has a relative or friend to stay over during the first postoperative night, if there are no family members there. Whether the patient has to climb stairs, the presence of obstacles such as loose rugs, how far away the toilet facilities are, these are all factors which were discussed before the operation, and addressed. It is important that any potential problems and concerns are anticipated and dealt with before a return home is considered.

Over 1300 patients treated

85% of the patients who have had this treatment program have returned home within 24 hours. We have now been applying this short stay surgical procedure program for over eight years, and have treated over 1300 patients with hip and knee problems.

Complications have been few. We have had 2 non-fatal pulmonary emboli. In the 650 unicompartmental knee resurfacings there have been no emboli at all. Looking at all the operations, seven superficial infections occurred which were treated with antibiotics, and none required removal of the prosthesis.

Hospital treatment is essential in order to perform the surgical treatment. However, from the point of view of the end result and the avoidance of possible complications we consider our approach to be effective. In hospitals there are increased risks of infection, medication errors, and thrombo-embolic problems. Patients with osteoarthritis generally are not sick, and we must ensure that the treatment does not make them sick. If the patients are mobile, with minimal or manageable discomfort, and have a welcoming home environment, then the hospital really has nothing more to offer them.

I always tell my patients that the goal of our treatment is to create as small a hole as possible in their lives with our treatment program. In other words, the sooner they are back at their normal lives, the more likely we are to have a satisfactory result. This encourages a positive mental attitude, and leads to a high level of patient satisfaction.

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Letter from Dr Kohan

Internet Doctors?

Increasingly, patients are coming to consultations armed with comprehensive information, often obtained from the Internet. Informed patients are the most helpful patients that a doctor can have, as it makes discussing the treatment options, looking at benefits, risks of complications, rehabilitation and the myriad of other factors which make up a successful treatment program much more effective.

The problem with the Internet, however, is that while there is an enormous amount of information out there, there is little to guide the individual in terms of the relative value of each bit of information. Not all information available on the Internet is equal in terms of validity, honesty, and effectiveness.

It is dangerous for any individual looking at obtaining health information to assume that general information obtained on the Internet, newspapers, books, magazines, in fact from any source, is applicable to any individual’s specific circumstances. It is exactly for this reason that individualised assessment, careful evaluation of physical findings, in combination with test results, imaging, etc, is necessary to tailor any specific treatment plan.

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Mathys, an orthopaedic equipment manufacturing company, has recommended the adoption of several tips to evaluate the information available on the Web, and probably, a useful technique to evaluate any medical information before deciding its validity.

1. Transparency.
   The provider of the information should always identify themselves.
2. Distrust.
   Sensational promises, superlatives, promises of curing, should generally be distrusted.
3. Cross-reference.
   Confirm the information from other sources of possible.
4. Relevance.
   How new is this information?
5. Content
   Is the information clear, detailed, explaining benefits and disadvantages, alternatives, and references?
6. Confirmation.
   Check the information with your healthcare provider.

The availability of information has never been as great as it is now. That availability places an added responsibility on us to evaluate and criticise before making decisions, especially ones that may have serious consequences.

Lawrence Kohan

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Dr Kohan answers your questions

What is the best time to have surgery?

This is probably the most frequent question asked by patients when the symptoms are severe enough for them to seek advice from an orthopaedic surgeon.

There is no set time. For each individual patient, the decision that “ something must be done”, is a decision that comes more from the heart than from the painful joint. However, there is no doubt that for each patient, when that time comes, the decision is accompanied by a level of certainty that leaves the patient in no dilemma that further treatment, a new level of treatment, is required.

The decision is the result of a combination of factors, including pain, limitation of function, and stiffness, all leading to a loss of quality of life.

While this development may take a long period of time to come about, often many years, once this trigger point has been reached, the level of suffering, and the progressive loss of quality of life needs to be addressed. It is at this stage that the option of joint replacement surgery is explored. My advice to most patients is that, “when the time is right, you will know”.

For most patients who develop osteoarthritis, symptoms can be managed for some time with non-operative measures. If this is enough to control the discomfort and to allow a reasonable quality of life to be pursued, enough for the patient’s needs, then surgical intervention is not a consideration.

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Post-operative Pain Management

Post-operative pain is one of the major outcomes of surgery and relief of the patient’s distress is an important goal in its own right. Severe pain often leaves the patient permanently scarred and terrified of even minor surgery. Meticulous pain management is pivotal in achieving acute rehabilitation.

Our objectives are:

• No pain or low levels of discomfort for the entire peri-operative and convalescent period.
• Side effects limited or reduced to negligible levels.
• Acute rehabilitation and early discharge.

The Kohan - Kerr Technique places meticulous pain management at the centre of immediate post-operative care and it is central to achieving our stated goals. We believe that pain management is a process rather than an event and, in essence, our technique seeks to control pain for the entire post-operative period by graded interventions tailored for the severity of the pain.

In addition, we seek to control the pain peripherally rather than centrally so as to shorten the entire painful experience and to avoid the pitfalls of other techniques. To make it work it is necessary to provide a pain management service that extends through the entire post-operative and convalescent period.

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FOCUS ON...
Michelle Caira
RECEPTIONIST

For the past 6 years I have been employed as a bass player in the Australian Army Band. I have been posted from Melbourne all the way up to Townsville. From there, I got posted to the Australian Army Band Sydney in 2004. In October 2004, I got married at Cronulla to my lovely husband, Gary. I applied for the Receptionist’s position at Joint Orthopaedic Centre in December 2004, where Dr Kohan kindly offered me the position. Whilst I will keep playing my bass guitar, I will continue to enjoy my job at Joint Orthopaedic Centre.

Michelle Caira

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Unispacer treatment for early knee osteoarthritis

A further treatment option for early osteoarthritis symptomatic enough to warrant surgery.

The Unispacer was designed to address a specific population of patients. The target population is isolated, moderate degeneration of the medial compartment (grade 3-4 chondromalacia) with no more than minimal degeneration (grade 1-2 chondromalacia, no loss of joint space) in the lateral condyle or patellofemoral compartment.

Patient selection

• Significant narrowing of the medial compartment but not complete collapse
• No radiographic evidence of subchondral bone loss on the tibial plateau
• Minimal posterior osteophyte formation
• Minimal patellar osteophyte formation
• Symmetrical patellofemoral joint space in a skyline radiograph
• Minimal medial subluxation of the femur
• No radiographic evidence of impingement between the lateral condyle and tibial spine

Unispacer Prosthesis in place

Possible to delay more invasive treatment

This option provides an opportunity to delay more invasive treatment in a situation where conservative non-operative options have either failed, or for some other reason become ineffective. There are no long-term results as yet for this treatment or alternative, but in a small, selected group of patients, it would appear to be effective enough to warrant consideration.

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