N°275 - June/July 2018
Interview viewed 240 times
He is the APKASS president this year.
He practices in Sydney and specializes in knee surgery.
In this interview, he shares how he organises his time between surgery and research, the specificities of his work and his involvement in the international community.
How long have you been interested in APKASS?
I have been involved in APKASS now for several years. APKASS was officially formed in 2013, but it has been in existence under different names prior to this. Before 2013 it was known as the Asia Pacific Orthopaedic Sports Medicine Society, part of the Asia Pacific Orthopaedic Association, and APKASS in its current form evolved from this to become a stand alone society. It has the vision and mission to become the premier Knee surgery and Orthopaedic Sports Medicine and as our meeting in Sydney will show, it is well on the way to achieving that goal. As an Australian orthopaedic surgeon, it is very important to me that I stay engaged in the rapidly growing world of orthopaedics in Asia Pacific, and that the Australian orthopaedic community remains a major contributor to this.
As the President of APKASS, what does this society represent to you?
APKASS is the pre-eminent knee surgery and orthopaedic sports medicine society in Asia Pacific, the region in which I live, and therefore APKASS is particularly important in representing and showcasing the high quality, innovative, world leading work that is being done in the Asia Pacific region. APKASS is a partner society of ESSKA, AOSSM and SLARD, and also of ISAKOS, and as with other areas of global growth and development, the Asia Pacific region is the fastest growing and most rapidly evolving region of orthopaedics and sports medicine. As an Australian orthopaedic surgeon, APKASS is my regional society, and I look forward to watching this society grow rapidly to become the world leading society that orthopaedic surgeons around the world turn to.
You must be proud to host this congress in your hometown?
Yes, it is certainly a thrill to be able to bring the APKASS congress to Sydney. Having been to every APKASS meeting until now, I have been very keen to be able to show my Australian colleagues the fabulous work that is being done in the Asia Pacific region that they are not aware of, and this is definitely the best way to do it. It has been a lot of work putting the meeting together, but I have no doubt that it will be worth it in the end , to open my Australian colleagues eyes to the wonderful orthopaedic work and research being done in our region.
Are Australian surgeons connected with the Asian orthopaedic community?
That is a really good question, and I think the majority of Australian surgeons at this stage are probably not as connected with the Asian orthopaedic community as they could be. Whilst there are certainly a core group of surgeons who regularly participate in meetings in the Asia Pacific region, traditionally Australians have tended to turn to North America and the UK and Europe for furthering our knowledge and experience. Whilst these regions have excellent research and clinical education opportunities, the Asia Pacific region has some incredible world leaders, and I think as this meeting will attest, Australians can get a world class educational experience within their own region. I suspect that the more forward thinking Australian orthopaedic surgeons will continue to increase their involvement within the Asia Pacific orthopaedic community, as they will see that Asia Pacific is the fastest growing region in orthopaedics, as it is in so many other aspects of our world.
How does Australia differ from Asian countries in terms of your profession?
Being such a diverse region, there are a lot of differences throughout Asia Pacific in the pathways to specialisation, and the structure of a surgeon’s clinical practice and their involvement in research. In many countries throughout Asia, participation in high quality research is a fundamental component of training and progression through the orthopaedic hierarchy. In Australia, there is a small compulsory component of research required as part of orthopaedic training, but I think it would be fair to say that once surgeons have completed their training, an ongoing active participation in research is not as common as it would be in many other countries in Asia, and certainly not critical to developing a successful orthopaedic practice. Australia has private and public systems, and virtually all surgeons will work in private practice and not all will work in the public system. I believe that the standard of orthopaedics in Australia is very high, and whilst most surgeons will not have an active direct involvement in research, or present regularly at conferences, there is a strong desire from the vast majority of surgeons to remain very much up to date with the latest information and evidence, and provide high quality care for their patients.
Are there many differences between your indications and those of worldwide surgeons?
Australia is quite similar in many ways to other countries in that area, keeping in mind that we are very fortunate in Australia to be a wealthy country and have the best options available for our patients, with very little limitation from cost. I think that one of the main differences is that Australian surgeons certainly like to embrace new technologies. For example, computer-assisted knee replacement surgery is very popular, so much so that navigation is now used in around 50% of knee replacement surgeries in Australia. I have personally been using navigation for over 10 years, and when I first started I believe that only about 5% of knee replacement procedures used surgical navigation. It has since been growing steadily in Australia, while in many other countries such as the USA it never really took off. Robotics is the latest thing which has been well received in Australia, not in the least part due to a strong marketing campaign. I certainly believe that the Australian market is at the forefront of these new technologies. Australian surgeons are very well travelled, and have strong connections with America, as well as Europe, the UK, and Asia Pacific, so we know which technologies are being tested and used around the world, and we can pick the ones with the best results.
Do you work in the private or public sector?
I work in both. The Australian health system includes public and private systems. All Australian citizens are covered by Medicare and can be treated for free in a public hospital. We also have a private system, and around half of the Australian population has access to it in my area, which is the northern part of Sydney. I work in the main teaching hospital on the northern area of Sydney, the Royal North Shore Hospital. I also work in two nearby private hospitals, the North Shore Private Hospital and the Mater Private Hospital, which is renowned for carrying out more joint replacements than any other in the southern hemisphere.
Do you only do knee surgery?
Other than a small amount of trauma surgery that I do as part of my work at Royal North Shore Hospital, all of my work is knee surgery.
What about sports surgery?
I do all types of knee surgery. It’s quite different from the U.S where joint replacement surgeons usually don’t do sports medicine surgery and vice versa. In Australia, it’s more common for surgeons to carry out any and all procedures relating to the knee. If you’re a knee specialist you’ll be doing everything from cartilage grafts to full joint replacements. Of course, I have colleagues who do both hip and knee surgeries, but that depends on where you work and the level of demand. Most surgeons who work in the city will subspecialise.
What do you think about the use of navigation for ACL surgery?
I find it very interesting, and I’ve taken a look at the programs, but for the moment I don’t think it has any clear benefits without further research. Of course, if data collected during research uncovers interesting information about laxity that can be analyzed and presented at conferences, so much the better. However, for everyday surgery, I just don’t think that it has enough benefits to justify putting more tracking devices into a patient’s bones. ACL surgery is by definition minimally invasive, and the idea of putting a pin through the quadriceps bothers me. It’s different for a joint replacement or osteotomy as it really makes a difference in improving surgical precision. I think there will be a place for ACL surgery navigation in the future, as long as it’s used to locate the precise insertion points of the ACL and in doing so allow the graft to be positioned perfectly, but this will most likely need to be image based with less invasive tracking devices, but at this point in time I think it is not for routine surgery.
Do you ever carry out ACL surgery as an outpatient procedure?
ACL surgery is usually an outpatient procedure for my patients, unless they are from outside of Sydney. Occasionally a patient may feel ill from the anesthesia and need to stay overnight, but in Australia many surgeons have been doing outpatient ACL surgery for a long time. Personally I’ve been doing it for eight or nine years. It works well, and my patients are generally happy with this. In general they are comfortable even during the first 24 hours after surgery, and most people prefer to be at home.
What about outpatient joint replacement surgery?
We are all becoming increasingly aware of the trend towards this, particularly in the USA, and I know that some surgeons in Australia are starting to do this, but at this stage I haven’t seen any results presented or published from within our orthopaedic community. There are certainly also pressures from insurance companies to decrease costs, and a certain drive from the potential to also promote this commercially. I think there is a definite trend to reduce inpatient stay, which for the most part is good, as long as the appropriate supports are in place for the patients, and it is being done for the right reasons. Every patient is different, and has different needs and we need to be able to provide each with efficient cost effective care without compromising outcomes. It is certainly a moving space, and we will no doubt see a lot of developments and changes in this area over the next few years.
Do you have a lot of experience with bilateral knee replacements?
We do a lot of bilateral knee replacements in Australia, and I believe it is a well-accepted procedure. Historically there have been concerns about increased morbidity and mortality compared to single TKR or staged procedures, but that hasn’t been our experience. Indeed we are about to publish a series of over 400 Bilateral TKR in the KSSTA journal illustrating this. It is also the preferred option for the majority of patients with bilateral disease.
Australia is famous for its Joint Replacement Registry: how do you explain its success?
Our registry really is excellent and it’s interesting to see how certain visionaries have allowed us to set the standard for the rest of the world. It’s currently in its 18th year, and has a lot of influence here and in the rest of the world. The registry gives us a more objective, global view, instead of our practices simply being guided by our opinions. The Australian Registry also allow us to have early detection of issues that are now common knowledge, such as the problem with a particular type of metal on metal hip replacement. The overall benefit should in the end be for the joint replacement patient, giving them more reliable, safer procedures.
How difficult is it to set up a registry?
The Australian Registry was obviously a big job to establish, but the ongoing running requires almost no effort from the surgeon. The forms are simple and available in the operating theatre. A nurse can fill them in, and the only thing that the surgeon needs to do is specify a few details about the patient and the procedure, so there is minimal additional work for the surgeon and it’s all very simple. And since 2008, you can choose to enter your personal information, which allows us to check our results and compare them with the national average for the various prostheses on the market. It’s very useful, and although surgeons can obtain their own private information, it’s not open to the general public. Global information is available to the public but they can’t access individual surgeons’ results, which is really important to ensure that surgeons take part in the Registry. They need to feel that their input won’t have negative consequences.
What does the industry think of the Australian Registry?
That obviously will depend on the results for each company - companies who get good results for their implants in the registry will clearly be more positive than those who get worse results. Having an implant identified as a higher than expected revision rate can really be damaging for that implant, and particularly newer implants are thought to be more at risk due to the possible “learning curve” effect. A positive side effect of this however is that companies will be more cautious when introducing new implants, and usually make sure surgeons are well trained in the implant, as they realise how much registry results can impact on the success of an implant. In the end this should also be a positive for the orthopaedic patient.
Let’s talk about research – What got you interested in research? Do you have a dedicated structure?
I learned a lot about research during my fellowships in London Ontario in Canada: one in joint replacement surgery and the other in sports medicine. I’ve always been interested in clinical research and I was very impressed with what they got out of their database. When I came back, I decided that I needed to set up a similar system. When I set up practice in 2000-2001, my partner had been in practice for over
10 years but hadn’t done a great deal of research. He was however very enthusiastic about establishing a research program, and we set up a structure to evaluate our work and publish our results. We created the Sydney Orthopedic Research Institute, and to start with we only had one nurse who worked for us two days a week, filling in forms and databases. It gradually got bigger, and we now have a research team with six staff members, with PhD graduates, engineers and Clinical Research Associates. We also welcome clinical and research fellows from around the world, and currently have fellows from England, Brazil, India, France and Japan. These fellows will often remain ongoing partners in research projects with us after they have returned to their home.
Are your Australian colleagues interested in clinical research?
I think that in theory, most surgeons have an interest in doing research, but they often feel that they don’t have the time or resources to do so. To be done properly, research does take time and costs money, and this can certainly be a disincentive for many surgeons. Having said that, it is very noticeable that the scientific standard of presentations at meetings in Australia has improved markedly over the last 10 years, and is continuing to do so, and I do believe that more and more surgeons are becoming engaged in good clinical research. I really do hope that this is a trend that will continue. Involvement in research is the foundation for good clinical practice, and is the most important way in which we can continue to improve what we do, and improve outcomes for our patients.
Published in N°275 - June/July 2018