Considering Surgery


How do I decide if I need surgery?  

In general terms, we should take our time to carefully consider the need for surgery, as there is no surgery without an element of risk. The aim of your consultation is to establish a diagnosis and then weigh up the different risks vs benefits of the various options for treatment. A large proportion of orthopaedic complaints relate to degenerative conditions that are slowly progressive and are not a threat to life or limb, but are debilitating with regards to function. Often times a patient will be asked to decide whether they can manage with their symptoms if they were to modify their lifestyle, take anti-inflammatories or pain killers or even use a brace/splint. In some conditions, a perfectly acceptable result may be achieved by non-surgical methods – e.g. certain fractures can be treated in a simple plaster cast, some tendon and ligament injuries can be well-healed with the use of a splint for a few weeks. Clearly, these options may be preferable for patients who run significant risks from bleeding or infection, or have poor heart or lung function and couldn’t tolerate an anaesthetic. Alternatively, some low-demand patients may be willing to accept a degree of compromise of their pain/function in preference to the risk of an operation.

Surgery is frequently the preferred option for treating particular fractures, dislocated joints and for orthopaedic tumours/cancers. Setting aside these issues, when the patient has symptoms that are no longer manageable with non-operative methods, then surgery is useful for restoring range of movement, reducing or abolishing pain, correcting deformity, and improving mobility. In higher demand patients such as athletes it may help accelerate recovery/rehabilitation from injuries that may take substantially longer to heal if they were treated non-operatively.

As a rule of thumb, it may be worth considering surgery if the patient is unwilling/unable to manage their pain or symptoms despite having used some form of oral pain relief, if they have restricted movement despite having tried physiotherapy or similar, or if there is progressive or severe deformity of a joint or limb. Similarly, if mobility is limited, the patient finds it hard to maintain gainful employment or cannot sleep because of pain then these would often be reasonable indicators for operative treatment of conditions if non-operative treatment has been incompletely successful.

What happens leading up to my surgery?  

Months/Weeks leading up to surgery  
Prior to surgery, Mr Robin will often refer you on to a perioperative physician/anaesthetist who will make an assessment of your overall fitness for anaesthesia as well as ensure that you are as healthy as can be prior to surgery. You will be required to complete a health questionnaire in most cases, and in those patients who are either undergoing major surgery (e.g. joint replacement) or have significant heart, lung, bleeding/clotting or other general medical conditions, they may be seen by the physician/anaesthetist at a pre-anaesthetic consultation. They will make a clinical assessment of your conditions and may arrange further investigations such as blood tests, a heart ECG, lung function testing etc, as well as correspond with your treating specialists if need be. They will also advise you on whether or not to stop or start certain medications prior to surgery. A member of their team (usually the same physician) will also be your anaesthetist for your surgery with Mr Robin and if you are admitted to hospital overnight, they will also be involved in your post-operative care, in consultation with Mr Robin, helping to manage your pain relief, look after your heart and lung function and help to plan your discharge to home/rehabilitation.

Unless advised otherwise, you should try to maintain a balanced diet – there are no special supplements required unless you completely abstain from a particular food group (e.g. dairy or protein) although prior to major surgery it may be beneficial to ensure you have sufficient amounts of protein and energy to assist in wound healing post-operatively. You should also try to keep as active as you can without causing undue discomfort – this will help to maintain your overall fitness and flexibility, keep your weight under control and maintain bone quality. Physio, hydrotherapy and/or Pilates are usually helpful with this.

Please let Mr Robin know if you have Diabetes, are on medication to thin the blood such as aspirin, warfarin, rivaroxaban (Xarelto), clopidogrel (Iscover/Plavix), have any allergies, or if you can foresee any difficulties in getting home or having someone at home to help you once you’re discharged from hospital. These things will need to be addressed prior to your surgery.

Ideally, in the time leading up to surgery you should try to cut down on your alcohol consumption and if possible, cease smoking altogether in order to give you the best chance of good wound and bone healing, reduce your risk of contracting an infection or developing a blood clot in the calf (DVT) and have less chance of interactions with other medications. If possible, the week before your operation you should avoid anti-inflammatory medications such as diclofenac (Voltaren), naproxen (Naprosyn), indomethacin (Indocid) or ibuprofen (Nurofen) as they may increase the chance of bleeding. Paracetamol (Panadol, Panamax, Panadol Osteo) is fine and should be continued if being taken regularly. In general, if you usually take blood pressure medication, you should continue to take these at the usual time, with a small sip of fluid. Stopping aspirin prior to surgery should be discussed with your cardiologist (if you have one) and anaesthetist beforehand.

Please contact your peri-operative physician and Mr Robin’s rooms if you develop any symptoms of a cold, cough, fever or gastro-enteritis, or if you need to cancel your surgery for any other reason in the weeks leading up to surgery. Also, please let Mr Robin’s rooms know if there are any problems with your skin, such as cuts, grazes or rashes on the limb that is due to have the surgery, as these may pose an increased risk of infection and it may be safest to postpone any major surgery until the skin is back to normal.
Night Before Surgery  
You will have been given instructions by Mr Robin’s staff or your perioperative physician regarding fasting times and whether or not to take certain medications. In general, if your theatre time is in the morning, you should have nothing to eat or drink after midnight the night before your operation. If your operation is to be done after mid-day, then you should have absolutely nothing to eat or drink after 6am on that morning (including lollies, chewing gum, milk etc). In general, a light breakfast of toast and black tea is advisable, prior to this time. You may be able to take some medications with a sip of water up to three hours before your procedure. Usually you should continue to take your regular blood pressure medication, unless otherwise advised by your medical team.

You must not drink any alcohol or smoke cigarettes in the day leading up to surgery.

You should avoid wearing any makeup and remove any nail polish and all piercings the night before your procedure. Avoid bringing any jewellery to hospital with you, and do not wear contact lenses – please wear glasses instead. You should wear loose, comfortable clothing that is easy to remove and put on. If you are having an overnight stay you may wish to bring a pillow, toothbrush and a change of casual clothing as well as pyjamas.

You may (should) have a shower the night before/the morning of surgery, if possible with a chlorhexidine based skin wash which may be purchased from your local chemist. This will help reduce the numbers of germs on your skin. It is best that you don’t shave the operative region or apply any creams/moisturisers to the area.

What happens when I arrive at the hospital for my operation?  

You will usually be admitted to hospital on the day of your surgery. After checking in at Admissions you will be prepared for surgery by nursing staff. This will involve checking that your consent form is complete, getting changed into a hospital gown, having a patient ID bracelet put on one wrist and one ankle, and may involve you putting on special stockings (TEDS) to help prevent development of a blood clot in your calf (DVT).

Mr Robin and your anaesthetist will see you before your anaesthetic and will confirm with you which limb and what operation is being done. Nursing staff may mark the limb, and may remove hair from the operative region using electric clippers. The limb may also be given a “pre-wash” with antiseptic.

Will I be in pain after my operation?  

Mr Robin and your anaesthetist will do everything in their power to keep your pain to a minimum using a variety of medications and techniques. For joint replacement surgery, frequently patients will experience only very minor discomfort (while maintaining their mobility) in their hip or knee immediately after surgery and for up to 24 hours post-operatively, due to a combination of spinal anaesthetic and local infiltration analgesia. Occasionally there will be a modest increase in pain after the anaesthetic agents have worn off, but this is usually well controlled with a variety of oral (and/or intravenous) analgesics that will also be prescribed for you to take in case of “break through” pain. Despite this, however, there is no way to guarantee all patients a completely pain-free procedure.

As an example, after arthroscopic knee surgery there may be some mild discomfort within the knee joint or thigh discomfort from the use of a tourniquet. You should feel free to ask your nurse for pain relief if your pain is unmanageable – i.e. if you can’t get comfortable in bed or perform gentle movements of the operated limb when requested to do so.

Early Mobilisation Program  

Mr Robin learned this technique while performing total hip and total knee replacements during his post-fellowship training in Bristol and has adapted it to his own practice, using it in almost every hip and knee replacement performed.

For more information on this technique including Melbourne patient videos, click here to visit the full Early Mobilisation Page.

When will I be discharged from hospital?  

This depends on a number of factors, is different from patient to patient and depends on the nature and extent of the procedure. As a rule of thumb, most patients having arthroscopic knee surgery (e.g. meniscal surgery) are discharged the same day. Patients having knee ligament (e.g. ACL reconstruction) surgery, arthroscopic hip surgery (for FAI) and most fracture treatment are able and often safest to be discharged after a single overnight stay. In some instances a patient may need/wish to stay an extra night, although this is fairly uncommon.

Most patients having major surgery such as total hip replacement, (total/unicompartmental) knee replacement or treatment of major fractures may be suitable for discharge within 48 hours of their operation, but frequently feel unsure or too unsteady and require a further period of time improving their strength or co-ordination. This is often safest done in a Rehabilitation Hospital. Those patients who are comfortable on oral analgesics, have good endurance, are generally healthy, and who have sufficient assistance at home may be discharged to home with an intensive outpatient physiotherapy programme. You will not be discharged home if you or your physiotherapist doesn’t think you are ready or safe. It’s important to note as well, that some health insurance companies will only recognise a minimum of a 3-day admission for total joint replacement in order to cover your claim for this.

It’s also worth remembering that with hip and knee replacement surgery, these are operations that hopefully will give the patient an excellent result for the next 10-20 years. There is little sense in rushing a patient home to discharge for the sake of sparing a day in hospital if it unnecessarily compromises the long-term outcome of the procedure. These operations represent a “marathon”, not a “sprint” and need to last the distance.

If you have had surgery on your lower limb, a physiotherapist will see you prior to discharge to ensure you’re safe using crutches or a frame. Along with the nursing staff, they will show you techniques to allow you to safely get out of bed, shower, dress yourself and walk before you leave hospital. You will be given painkillers and other medication to take home with you, to help you manage over the first few days. When being discharged, please make sure there is a responsible adult to pick you up and who can be at home to help care for you for at least the first 24 hours – longer for patients undergoing major surgery.

With your consent, your GP will be sent a copy of your discharge summary from the Hospital.

Tips to prepare your home following your return from surgery  

As a rule of thumb, before your surgery, try to think a couple of steps ahead and make life easier for yourself for after you get home from hospital.

Reduce any clutter about the house, in particular clear out narrow passageways and living areas so that you can manoeuvre safely with crutches. Secure or remove any electrical cables, rugs or carpets so that you’re less likely to trip or catch your crutches on them. Simplify living arrangements so that you have fewer steps/stairs to climb to enter/exit the house or living areas. Sometimes you may have to move furniture (e.g. a bed) to another floor temporarily and/or you may re-arrange any cluttered furniture so you can manoeuvre about them safely.

Set up your “rest area” with things that you will use frequently – e.g. mobile/portable phone, laptop computer.

For patients having surgery from the elbow to the hand or from the knee to the toes, you will need to keep the operated limb elevated with pillows when you’re resting so try and find a few spares.

An assessment by an occupational therapist may be worthwhile prior to total hip or total knee replacement surgery – they can assist with making any household adjustments prior to elective surgery, such as installing handrails and ramps, providing access to special shower and toilet chairs and commodes, or altering the height of your bed if it’s particularly low. They can usually be accessed via the local council.

To keep the stress out of preparing meals after you’ve had your surgery, it may be extremely helpful if friends or family can freeze some meals for you to reheat, or you may do the same yourself prior to surgery.

Surgical complications to consider  

Every operation has a risk of complications attached to it – there is no such thing as an operation without risk. Mr Robin will make every effort to reduce your risk of complications to the lowest possible/acceptable. There are General Risks of surgery which are common to most orthopaedic procedures, and there are risks that may be specific to the particular operation required.

General Risks of Orthopaedic Surgery

  • Wound infection (superficial and deep) – Most frequently, wound infection occurs with the patient’s own skin germs which find their way into the surgical wound. This complication is kept to a minimum by judicious use of antibiotics during (and sometimes after) surgery. More rarely, the patient may contract a “hospital acquired infection” with a particular germ which may be more difficult to eradicate. Fortunately these latter infections are relatively uncommon in otherwise healthy patients undergoing elective surgery. Cigarette smoking, poorly controlled diabetes and the use of immunosuppressant drugs such as prednisolone, methotrexate, azathioprine (Imuran), leflunomide (Arava), adalimumab (Humira), etanercept (Enbrel), and patients undergoing chemotherapy will increase the possibility or severity of infection or may predispose to infection with more unusual germs – as such different or more antibiotics may be required to prevent and/or treat infections in these patients

  • Bleeding – the type of anaesthetic (spinal/regional) as well as certain medications may be used during your anaesthetic to reduce your risk of significant bleeding (i.e. enough to require a blood transfusion)

  • Nerve injury – this may occur with any operation on the limbs, causing partial or complete loss of skin sensation or muscle power, which results in loss of function in that limb. While this is usually temporary or partial, in some cases it may be permanent or may take many months to recover fully. The injured nerve must re-grow from the spinal cord, and does so at a rate of approximately 1mm per day! Fortunately, significant nerve injury in general is extremely rare. Some procedures are more prone to nerve injury than others. It is very common to have some minor or partial loss of sensation around the surgical wound and is not to be considered a complication of surgery per se, but normal for the course.

  • Major blood vessel injury – During most operations minor blood vessels must be cut and then the bleeding can be controlled. However, damage to a major blood vessel is extremely rare but can be very serious. In exceedingly rare circumstances, it may even result in gangrene and the loss of a limb.

  • Deep Vein Thrombosis (DVT) – when performing surgery on the lower limb or pelvis, the blood flow leaving the legs (heading back towards the heart and lungs) may be reduced to the point where it starts to form a blood clot (thrombus) in the deep veins of the calf. While in its own right a DVT is not a major complication (aside from discomfort and swelling in the leg), however, if a fragment of the blood clot breaks off and travels via the circulation into the lungs (known as a Pulmonary Embolus or “PE”) it can cause severe problems such as sudden chest pain, breathlessness, low oxygen levels in the blood stream and even potentially fatal cardiac arrest. While a PE is rare, it is a serious enough complication to warrant significant consideration, as prevention of DVT and therefore in theory, prevention of PE, requires the use of either medications to thin the blood (and these may increase the risk of wound infection and further bleeding) or mechanical means to encourage blood flow such as pneumatic foot or calf pumps. The pumps rapidly squeeze the slow-flowing blood from the calves back into the faster flowing main circulatory system to stop it from clotting.

Aside from these general complications there will be complications that are specific to the type of surgery you may require and Mr Robin will discuss these further with you. In brief, these may include post-operative stiffness, persistent instability, pain, delay in fracture healing (non-union), poor integration of bone onto prostheses (“aseptic loosening”), dislocation of prosthetic joints, and wearing out of moving parts in the prosthesis (and breakdown of nearby bone as a consequence, called “osteolysis”). Some procedures may require a second operation much later on to remove a device that has been inserted for temporary stabilisation of a fracture or dislocation (e.g. screws, plates, or wires).

As you can appreciate, there are a number of potential complications that need to be considered during or after surgery. Some of these complications can very rarely threaten life of limb, which is why the decision to operate should not be taken lightly, and these risks should be given due consideration and weighed up against the potential benefit. Despite this, fortunately the vast majority of complications are extremely rare and most, when they do occur, can be managed, although in some instances they may require further surgery. Certainly the risk to life and limb is extremely low in most cases of elective surgery.

How much will my surgery cost?  

For elective surgery (i.e. non-emergency operations), Mr Robin’s staff will be able to arrange a quotation for you, based on what the most likely operation is required to treat your condition, and as such, this will usually give a good indication as to roughly how much your surgery will cost you out of pocket. Occasionally more or less surgery may be required to achieve the desired result, but this is not common. Should this occur, your invoice may increase or decrease accordingly and you might be liable for a further payment or a refund, as necessary.

However, in emergency conditions (e.g. fractures/broken bones, dislocated or locked joints, tendon ruptures, or infections), where time is very much of the essence, it can be much more difficult to estimate how much the surgery will cost, accurately. Also, compared to elective surgery, the nature of the problem will more often require potentially unforeseen additional procedures and have a higher rate of possible complications. These too may also require further treatment, adding to your costs. As such, providing a quotation, while desirable, may not always be very accurate, not to mention can delay the provision of timely surgery.

Surgeons, hospitals, anaesthetists and surgical assistants each have their own fee policies and it is advised that you contact them directly if there are any concerns regarding these components of your bill. Mr Robin is not responsible for fees from other members of staff involved in your care.

The costs involved with healthcare can be confusing to the un-initiated. In the early 1980’s The Commonwealth Government established Medicare which is a system in which each medical service (consultations, investigations, operations) were described by an “item number” and a dollar value was attached to each item number – the Medicare Rebate for that service. In addition to this, the Private Health Insurance companies will contribute a small extra amount for most in-patient services (but not for outpatient consultations). Each time a medical service is rendered, the doctor can charge the Government the amount allocated to that service and the patient would not be out of pocket – this is known as “bulk billing”. Alternatively, the bill may paid by the patient and then claimed back from the Government. Thus, every patient could afford “free” healthcare and the Government footed the bill (via tax revenue).

Alternatively, the doctor may choose to charge more than the Medicare Rebate, for an outpatient service, in which case there will be an “out of pocket” cost to the patient – i.e. the difference between the billed amount and the Medicare Rebate for that item number.

For an inpatient service, (i.e. an operation) your Health Insurance company may also contribute an additional amount towards your medical bill, (Health Insurance “Schedule Fee”), according to the item number and the Medicare Rebate for that item. (The Insurer will pay their amount to the doctor and will in turn send the Medicare claim back to the Government for them to be reimbursed). However, again, as the Schedule Fees for these services are only proportions of the Medicare Rebate for this item number, there may still be an out of pocket cost to the patient (a “gap”) if the doctors’ fees are higher than the Health Insurance Schedule Fee.

Unfortunately, the amounts paid to doctors for each of these items have not been accurately indexed to average weekly earnings since 1983, while the cost of medical indemnity insurance, rental of premises, utilities, medical consumables (such as the plaster, bandaging, dressings, etc) and salaries and wages for the practice staff, have obviously increased substantially in the past 35 years. Unfortunately, there is now a significant “gap” between what the Government Medicare Rebate is to the doctor/patient, and what it costs to run a safe and effective medical practice in the early 21st century.

The Australian Medical Association independently publishes a document annually, which outlines suggested fees for doctors according to the Medicare Item Numbers. These are known as “AMA Rates”. In contrast to the Medical Benefits Schedule and the Health Insurers Schedules, these rates have kept pace with average weekly earnings. As a result, they are usually around two or three times the amount suggested by the Federal Government’s Medicare Benefits Schedule.

Mr Robin’s fees may be negotiable in certain cases. Please feel free to discuss this with Mr Robin or his staff if there is significant financial hardship. You will be given full informed financial consent, prior to undergoing any elective procedures, but as mentioned, it can be more difficult to give an accurate quotation in the case of trauma/emergency surgery. In general, there are no gaps charged for patients who have claims recognised by the Transport Accident Commission (TAC), WorkCover/WorkSafe or The Department of Veterans Affairs (DVA). While the informed financial consent gives as accurate an estimate of the costs of surgery, this is an estimate and occasionally extra procedures may be required during surgery to achieve the desired surgical result. In these instances, the amount billed compared to the payment required may increase.

Mr Robin sees uninsured patients and his staff will provide a financial quote for any surgical procedure required, if an uninsured patient should decide to have their treatment in a private hospital. Again, a proportion of this fee will be claimable via Medicare, the rest must be paid out of pocket by the patient.

  03 9044 4555

  03 9044 4555