March 2026 - Orthopaedic Myth-busting; COPD Clinical Care Standards

Dr Navi Bali - orthopaedic surgeon - talks about intra-articular injections, ablative techniques and robot-assisted joint replacement.

Dr Bob Edwards - respiratory physician - talk about applying the COPD Clinical Care Standards in general practice. 

Transcript

Dr Navi Bali

SPEAKER_01 0:04

Welcome to the Sunshine Coast Local Medical Association's Monthly Clinical Education. This is an audio recording of the evening's clinical presentations. You should also find the slides of the presentations on the SCLMA website so you can have a look through those as you listen.

SPEAKER_03 0:23

Join me in welcoming Dr. Numpy Balley.

SPEAKER_02 0:32

Awesome. Well, uh, thank you very much everyone for coming out tonight. The first thing I want to say is thank you so much to the SCLMA and to Ramsey and really everyone who I've met since we've been on the coast for the last three or four months. Everyone's been so friendly and approachable, and I really can't thank everybody enough for making us feel really welcome. We've got about 45 minutes, so the first four or five minutes will just be about me, which is great, and all that we offer, and then the second 40 minutes will be predominantly about orthopedic myth busting and how we can dispel some of those uh rumours that go around in the world of orthopedics. So essentially, um I haven't got rid of the accent yet, but I've been in Australia about 10 years now, UK trained. As per usual, we go for a little world trip, um, did hip and knee, arthroplasty, foreign ankle surgery, um, including ankle replacements, complex trauma, sports injuries. We ended up in Australia, found it was a pretty amazing place to live. Um, ended up on the Fraser Coast, which is a couple hours north of here. Um, spent 10 years there, had to work regional for a while, and the kids settled there and uh worked publicly for five, six years and then been private for the last four or five years. Pretty busy up there. We were number two VMO for the last two years, um, damn that urologist. Um and then essentially for Christmas last year, they gave me a really small Christmas hamper, which is why I decided, damn it, I'm gonna move. Um, but the real reason for moving was really because of family. So um these idiots there that I love to bits. Um my older boys, my other boys moving down, um, my stepson's dad's here, my wife's family all here, so that's the reason why we've moved down. Uh, and we've been here since uh January. In terms of what we offer, we do lots of uh hip and knee and part knee replacements. We do a lot of uh Mako robotic surgery, and we're a top 10 surgeon for the last couple of years for Queensland Volume. We do uh no gap joint replacements, which I think as um uh the price of living will go up over the next few years with Donald's efforts, I think that's going to become more relevant. Fore and ankle conditions from the ankle, hind and mid from forefoot, sports injuries, happy work cover cases. I still love trauma cases, so we run a fracture clinic as well. We also get involved with non-optive therapies such as PRP, hyonic acid, and radio frequency ablation. In terms of what I feel as of the clinic would be hopefully um will be known for, it's sound judgment. So we don't say everyone does or doesn't need surgery, we try to give a balanced approach to people to get them through their injury or their condition in the most sensible manner for them. In terms of where we're based, we're both uh based in the north and south of Sunny Coast. We also run connection Gimpy as well. Uh so that's us, me, and my wife. Um clearly uh batting above my average there. Um but uh if you ever want to call me or my wife, uh there's my mobile number, feel free to call it time to discuss cases. Um we've recently employed two amazing people at French to really give patients a good experience as they go through their treatment journey. So that's really all I wanted to say about us. That's really just the clinic and how we ended up in the sunny coast. So orthopedic myth busting. So, as we've spoken to a few GPs in the area, there's lots of questions really about what I should do for this case, should I give them this bulk build injection, should I give them PRP, what's the evidence? And so this would be a good opportunity to chat through those uh common questions that we get asked and try and get all those myths busted. So it's gonna be super informal. So if you want to ask any questions to go through, feel free to just ask away. I didn't just chat, just uh chat GPT lists. I spoke to quite a few people in the area, local experts to try and get as much information as possible. Let's try and disseminate that information to everybody here. Uh, there's a couple of new sportsmen people. Kimberly's there starting in Looser, and uh Mark Wilson's gave over the new King Koana to sportsmen people. He's he's does a lot of sports and pain as well. Um, we're all after this fictional um injection that's gonna help 100% of people and it's gonna have no complication profile, but we're clearly not there yet. And whilst people can sit in their academic RV towers and say, Oh, you don't have that injection yet, we have to make do with what we have available. So this talk is gonna be more pragmatic in terms of what's available and how can we help people. This is the standard pyramid that we used to have. Lose some weight, have some painkillers, have a steroid injection, have a joint replace, and that's really all we had. But things have evolved into more of a middle-aged spread. So this pyramid is now the the base is still there, but still we've got more options when we come to injections and laser techniques and surgery. We can go through each of those in turn. Sorry. Yeah, cool. So myth one, um, all arthritis patients must have physio. So that's clearly not true, although the GLAD program is amazing. It's it's it's a good program, and the the best thing about the GLAD program, for those that don't know it, is GLA is good life with arthritis, and the D stands for Denmark, where it was introduced in 2013. Came to Australia in 2016, and essentially it's physiotherapy with um education regarding weight and all different aspects of arthritis, 12 sessions over six weeks. There's just under 50% have a response initially, but that response comes down to 25 cents, 25% at 12 months. When I spoke to physios about this, they like the GLAD program, but they say it's just a bit prescriptive, it's not very individualized, so it's good for the average person, but you really need to pick your winners. So they're best in those deconditioned patients, they're motivated, they're early disease, but there's advanced disease, malalignment, and you have someone who's super fit anyway, then they're not going to get a great uh improvement with this GLAD program. Um, when it comes to analgesics, I don't teach you how to such suck eggs, but uh there's a common thought that no one should have opioids prior to surgery, but clearly that's not able to be possible for a lot of people. And up to 25% of people still need opioids. Sadly, 40% of them still need opioids at 12 months, and these patients it'd be difficult to control their pain post-operatively if they're not opioid naive, potentially lower functional improvement. It's clearly multifactorial, their HAD score, severity, and resilience all have components into how much opioids they take, but it's something we we should um be can be thinking about. So, now really to the meat of things. So, when it comes to intra-articular ejections, there's lots of discussion regarding this. And the common myth is that they're all pretty average, there's no evidence apart from steroids. So the three main hitters are steroids, hydronic classic PRP. These other four have some role, but the evidence is still early. We can talk about that in a bit. Clearly, again, it's all about choosing the winners for non-oxided management. It all depends on their disease burden, malignant, their weight, their HAD score, as well as their phenotype, which is a relatively new concept. So you have two phenotypes for the arthritis, so the inflammatory and the mechanical. So they're more those really acute swollen knees, they're the inflammatory ones, they're not going to do well with a uh viscous supplementation, but the ones that are mechanical, just a bit of a stiff, sore knee, and they're probably going to be do better with uh viscous supplementation and less the biologics. The steroids, um, quick to start, quick to finish, has had a bit of a bad rep in terms of chondriotoxicity. There's a lot of bouncing around in the literature saying, oh, this is going to destroy your joints, which is uh clearly not true because we still use a lot of it. Um, there is evidence that it will thin your cartilage with multiple injections, but is that clinically significant to push you towards surgery sooner rather than later? That's still debatable, but what we do know it does thin the cartilage, so it should be using caution in younger patients and with repeat injections. Get a lot of questions about when they should or shouldn't have surgery following an injection. Proven infection risk is within three months, with an odds ratio 1.4. So 40% risk of having a higher risk of infection if surgery is in three months of a steroid injection. There's another study looking at hydronic acid, and again, the odds ratio wasn't as high, but it certainly was a higher risk of infection with a recent injection. And potentially that's due to bacterial inoculation at the time of surgery. Sorry, at the time of the injection. There's a cumulative dose effects as well with steroids. So the more steroids you have in the first year, the higher your risk of infection. When it comes to hydronic acid, um predominantly viscous supplementation, there may be an anti-inflammatory component. It gets quite confusing with all the multiple preparations. It's all to do with molecular weight and cross-linking. So you can have a single injection of a high molecular weight and a highly cross-linked visible supplementation, but if it's uh more linear and low cross-linked, then you need three injections to get the effect. And the higher molecular weight and cross-linking, that potentially the higher the risk of flare, higher risk of cyanovitis. Although the risk of true infection really is quite low. So these are the ones that uh that are more commonly used. CINVISC is the one that everyone heard about for many years. It's an avian derivative. And so while it's got a high molecular weight, it does have a high flare rate because of its derivative. You can give it as a single or a triple dose. It all costs four to five hundred until you get to the bottom one. Duralane has become uh more popular in its usage, has a lower flare rate, high molecular weight, and theoretically lasts a bit longer. Uh, monovisc and single, singile is monovisque with a sterile injection, good for those inflammatory with mechanical symptoms. And again, have a lower flare rate. Eflexor is the one which is uh which has now been given as a vault-build injection over three dose, uh over three doses uh through the radiology clinics. Um that's funded uh through um through Medicare on the base that it's a CD CT guided injections. Um it's a low molecular weight linear viscous supplementation, which is why you need to give it three times. Has had a bit of a bad rep, hydalonic acid, in the literature, and there's some guidance recommending against routine use. Another guidance saying well, it should be used if other non-optive measures fail. Um, Alpharides Australia probably gave them the more reasonable view in terms of it should be offered to people who have failed other non-optive measures. It still has a role, there's still lots of people that use it, and we've all seen patients that have had a response. It's all about choosing the right patient for the right injection, and I think that's pretty true with hydronic acid. When it comes to PRP, that's been available for over 30 years now. It's pumps full of growth factors and signaling molecules, reduced inflammation, potentially reduces pain, and how it's different from the steroids and hyaluronic acids is chondrostabilizing. There are papers saying it grows cartilage back, which is clearly nonsense. It might grow back a little bit, but certainly not enough to have any chemical significance. The downside of PRP is that there's a huge amount of methodological inconsistencies. So you could have a PR. So I can take three mils of blood, spin it for two minutes and have a PRP. I take 120 ml of blood, spin it twice over 20 minutes and have a PRP. So they're two very different preparations and platelet dose. So the the platelet dose we think is about 10 billion platelets. So that's either 20 mils given three times or 60 mils if you have a normal platelet count. The leukocyte composition is important because it needs to be leukocyte record for osteoarthritis to reduce inflammation, and the double spinning is preparation protocol extracts the appropriate number, or it's about 80% of the platelets from the blood. So it's difficult to really state or to go through literature because there's so many so much inconsistencies in how the PRP is produced. When it comes to pre- and post-injection PRPs, you need to stop non-steroids for a week before, ideally a week or two afterwards. You can't use it in patients with hematological malignancies, and patients have a plate account of less than 100. It's not ideal for those patients. So does PRP work? It does, and it works best in knees. No one really understands, but it doesn't work quite as well in hips. But knee is the best joint that it works on, and again, it's to do with your plate concentration. So if you get the dose right, it's a useful medication for joint arthritis. People have tried to add the two together, so does it PRP or PRP and hyaluronic acid, which is the best option? You might get a modest increase in outcome, but it's not clearly proven. And I think if you get the dosing right in PRP, it's unlikely you'll need to add hyaluronic acid into the mix. These other injections are a failure. Pro therapy has been around for a while, and essentially it's dextrose causes inflammation, potentially uh fibroblast formation. It's good in those joints that potentially have micro instability causing pain. For those like Saco Wildac joints, it's useful. Um, less useful in the uh stuff and instability in knees and ankles, but but it does have a role with the uh with the sports physicians. N stride is quite an interesting drug, so that's uh that's new, it's an APS solution. So the best thing about um this is that it's standardized. Not like PRP, we have multiple different preparations. This is just you take 60 mils, you spin it for a period of time, and you get three mils out, there's your injection. So it's very standardized, and the results are actually pretty good, but it's about $1,500 to $2,000, so it's about three to four times the cost of a PRP injection, and there's no clear benefit that it's a better injection than the PRP apart from it's um more standardized. Orthrosm is an interesting injection. This is like viscamous supplementation, but uh a low resorbed hydrogen injection is thick, so theoretically it lasts a long, long time. This costs four to four and a half thousand, still experimental. You'd worry if you had an infection with something that doesn't resolve. So I think there may be a role for it, but not clear at this stage. Stem cells, if you have a spare $10,000 to $15,000, you can give it a crack, but there's no clear evidence it's any better than PRP. In terms of intraartical injections, I think it's best used in those earlier stage diseases. Have a think about if you have an inflammatory or mechanical patients. Most patients are inflammatory. Steroid, for me, I give at most a couple of doses. I worry about the chondrotoxic effect of it. PRP, if you get a dosing right, I think it's a good injection. Hydronic acid is good for those mechanical phenotypes. So if we escalate um up the ladder into ablative techniques, so another common is that RFA and low-dose radiotherapy, which I'm still fairly used to, it's still experimental in orthopedics. But there is still a fair amount of evidence base in all these areas. Uh, if we start with radio frequency ablation, everyone's arguing how big their tip is within the world of pain specialists, but essentially it's also with the size of the burn. So the bigger the burn, the more light you are to get the nerve that you're aiming to ablate. There's three largely different types: there's thermal, um, cord, and pulsed. Um, thermal and cord, essentially, if you have a cord RFA at the same tip, you have a slightly bigger burn. But it's these are the cords that probably are about nearly a thousand dollars, whereas a thermal one is sixty to eighty dollars, so it's a massive increase of expense for the patient. And so, therefore, lots of people are using bipolar thermal at a fraction of the cost of the call, but actually getting the same size of burn. Most of the research is in knees, it's about 70 to 80% successful at around 12 months. When I speak to pain specialists, they say they're quite happy to use shoulders and ankles. When it comes to hips, it's a bit not so sure that hips are that great for RFA. And one pain specialist said to me, Well, uh, God's gift of orthopedics is a hip replacement, so why would he use RFA? Which is uh has an element of truth to it. You can have the risk of temporary numbness, bruising, neuroma, as well as incomplete pain relief. I had one patient that went off for RFA that had um post-RFA neuritis, so it's not without a small element of uh complications. This is a child, not fit for a haircut, advanced medial compartment OA, had RFA, 12, 18 months down the line is still doing well. So it's a good option for those patients that don't require or don't require or can't have surgery. Low dose radiotherapy is something that's fairly new to me. I had a good chat to Brad Roman, super clever guy from Genesis Care. Um breast cancer radiotherapy is about 60-70 grays. This is three grays over six treatments over two weeks. There's maybe some ablative mechanism, or predominantly anti-inflammatory. You can use in any joint, but the closer you are to the actual skeleton, the higher you do get the higher chance you get hematological malignancies. The risk of a leukemia said it's about one in a thousand to one in ten thousand. Risk of solid tumors BCC one in a thousand. It's better for those multiple joints, and obviously the further you are away from the actual skeleton, I think it's useful. Again, 60-70% success are a year. Um, it can be used for knee arthritis. Um, I do have some thoughtfulness on operating on a site that has had previous irradiation once or twice. When I spoke about it, he said there's brought up at a conference and no one's got any clear evidence that having irradiation at a site and then having surgery have a higher infection or wound breakdown rate at this stage. This is quite an interesting um chap. He's he's uh been sent out for LDRT. I'm gonna wait and see his results. He's had an ankle fusion in the age of his mid-40s. Sadly, his hole and his high in the midfoot has just become extremely degenerative. And so I think bolting his whole foot together is not a good idea for him. He just wants to know the three years of remaining as a builder. So I think LDRT is a good option for these patients. It's uh peripheral, you have multiple joints involved. I think it's it's worth a try to try and help him with his pain. Surgical neurectomies. Um, the foreign ankle people got jealous of the uh upper limb people. They use anterior introsterous nerve and posterior introsteous nervous sections to help with joint pain. And this can be done in the foot and ankle as well. Uh, deep perineal neurectomy, it's quite easy to find that deep peroneal nerve. Start with a diagnostic injection, it was successful, and you remove it, then it's at 7 to 80% success. It's good for nervicular canoeform joints and the first to third TMTJs. So it does have a role, but in a selected proportion. So I think great again, grade two and three, more predictable. RFA is good for knees and ankles, decent for shoulders, okay for hips. Uh for me, and also when I spoke to Brad, he said LDRT is probably third line, so I'll try injections, RFA, if that doesn't work or they're not suitable, then try LDRT. Uh eurectomy is for selected cases. So, like uh any good horse race, you need to pick your winners. So stolen injections are useful, there's inflammatory, but not uh overdoing the number of injections, hyaluronic acid has a role. I guess I get asked, you know, should patients have the free bulk bed injections or should they have a single injection? I think whatever you decide to do, just make sure it's rationalised. I don't think someone should have an injection just because it's free. I think you should have an injection because the right indication for that patient for their condition. And for sure, then you've got the options of the bulk bed injection or the paid injection. PRPs, a little bit more expensive, 500 to 850, should last six to twelve months. RFAs, again, a bit more expensive, still 500 to 1000. LDRT has a mixed billing, but the full price is 2,000. So there's the the options you have before you head down the surgical route. Um if we then head to the last section, which is surgery. Again, surgery used to be joint replacement, but now we have a few options available. There's keyholder Brian's, you combine those radio frequency, realignment osteotomies, part and total joint replacements. And people and people say, well, if you use robots, why doesn't everybody use it? Um and that's a that's a valid question. So bit five is uh no one over the age of 60 can have a knee arthroscopy. There used to be, everyone used to have a kneearthroscopy to pay for their kids' private schools, I would imagine. But there was a fair amount of evidence saying that the research is no better than placebo, and that's true for general OA. So it reduces necessary operations. If we deprive meniscus, there doesn't need to, it can accelerate osteoarthritis. But there are a proportion of patients at any age that have mild OA, that have a relatively new meniscus error, they have mechanical. Symptoms and I don't think these patients will be subjected to a droid replacement if they don't need to. So I still do scopes at any age, irrespective, so long as they have minimal osteoarthritis, then it's not a contraindication for me for them to have an e-scope. And that's shown in that Cochrane review as well. So if you have mechanical symptoms, failed or not, you should have a scope. The other option you have single compartment osteoarthritis with a minus quartella, you probably head down the route for partial, and then try compartmentally where you're heading for a total. But it's still indicated. Realignment osteotomies are a good option. Again, it gets a bit confusing. Who does and doesn't need that? You need to have some mechanical access malignment, ideally a younger page, well, a younger patient. When do an osteotomy versus a partial, it largely depends on their function. So the general consensus is that if they are people who want to go back to a heavy trade, then they're better off having an osteotomy than they are a partial before the age of 55. After the age of 55, probably heading towards it, some form of replacement. This is pretty amazing. There's new technology that's come out the last few years. It's a reverse-engineered 3D model osteotomy jig. So essentially, you put the 3D planned for the correction and you put the jig on, you just drill the holes in, then you make the cut for the osteotomy, and then you put the plate on and put the screws in where you put the screws in before, and it automatically corrects it to the exact correction that's planned. It's pretty amazing how they've engineered it, but it's it's a great bit of technology for realignment osteotomies. Myth number six is partial knees or all knee changing to a total knee. Again, not true. Partially replaced, it's good for this patient, you can see at the top. Uh the current x-rays don't look too bad, failed injections, you do an MRI, lots of edema on the medial side, lost their cartilage and had a partial draw replacement, happy patient. It's good for those isolated medial or lateral disease. I think in PFJ you need to use it quite judiciously. The five-year revision rate for a PFJ is 10%, and 10 years is 25%. It's a high revision for PFJ, so again, need to choose those patients that do well. For most these surgeons, it's probably about 10 to 20% of your surgical practice because there's only a proportion of people that have ACL intact, supple deformity, isolated disease with a good range of motion. When you compare it to totals, there's an 80 to 85% satisfaction total, high with partials. It's gotten joint scores in terms of how natural does this feel. Again, high with partial survivorship is lower, but not massively. So 10 year survivorship is about 95, 96%, or 92, 93%. So again, there was a concern that your partials always can wear it for 10 years, but it still has a good survivorship if you do it in an appropriate manner. And what is a common thing that people are talking about? If I've got patients with an happy knee, would he have been a happy partial knee? And I think that's something that we're constantly asking ourselves, because there are a number of patients out there that just aren't happy with their knee replacement. Particularly those who had a pre-optive great range of motion and now they're stiff, they're just not happy. With partials, you can get a great range of motion. So it's something that I really push towards, or not push, but have a conversation with the patient about that that they've got an excellent range of motion but advanced disease. Um robotics are not a marketing gimmick, but they are certainly used in marketing, but I don't think they're a gimmick. Um, in terms of robotics that are out there, there are four main robots that are out there. There's a Meiko, Rosa, Cori, and Vallis. Essentially, if you look at market share across the world, 85% goes to the Mako, the one on the top left, and that's the one that has 3D planning and quite a rich history. That's the one I personally uh use and is the most robotic. Uh it came back in 2004. Stryker, a big American company, took it over in 2017 and brought it to the masses. There are over a million joints worldwide, and built out of the iPhone, we're now on Mako 4. It's a good delivery tool for 3D planning. So you there's, I guess you could do 3D planning, but if you can't deliver on that plan, then you're going to be compromising your accuracy. And I think that's where this comes in. So this is um for HIP probably the least useful platform that it uses. So it's not massive, it's kind of like waist high. This has an effector arm, and on the end, the effector arm is whatever you decide to use for whatever journey does. So this is for a hip replacement, yeah, but you have to have the remain that attaches onto the end. The way it works is you get a pre-optive CT scan, and that CT scan is done with a mark on the patient, so it calibrates exactly the correct size. That scan goes to the states, and you come back with a 3D model. That 3D model you can manipulate in any position that you want. It's great to see anatomy, where you want to position your implants, you can put the impact anywhere you want, the depth, the version, and you can imagine with a spinopelvic movement to try and uh see if it affects your stability. You live, you pop these bubbles alive on the patient, and when the patient model and the virtual model match up to a millimeter, then the robot sort of goes green and it's allowed to come in. The robot then comes in and it does the reaming for the acetabulum. Then it controls the positioning uh probably the most important part of the hit replacement is acetabulum positioning. So it controls where it goes in, and it's very accurate in terms of its uh uh closure and inclination, and it's useful for adding for assessing the offset and the leg length. It all sounds amazing, and it is an amazing piece of kit, but hasn't been shown to have amazingly improved results compared to standard. Um, this is a uh a uh prospective randomized controlled trial that said your accuracy is better, your sensor rotation is better, but it hasn't been borne out to you might have a couple of days less physio, but nothing that you can really hang your hat on and say, Well, this is amazing. There was a really good article a couple of years ago, and it looked at dislocation rates. And certainly it says if you go from the back a posterior approach, potentially, let's show in this paper, you have a lower dislocation rate if you do with robotic assistance. If you go from the front a direct anterior approach, um it doesn't matter whether you use robotics or fluoroscopy. But if you use one of those two, then your dislocation rate is still low, about 0.4%. So I think it's useful in the posterior, anterior, not that relevant. When it comes to total knees, this has seen a bit of a sturge to see the screen line, this is robotics, and now robotics is now the most common way that people do their total knee replacements. Rightly or wrongly. And then the triathlon, which is the knee replacement that goes with the Mako, which is the most commonly used knee replacement and the body replacement, um, currently used in Australia, has it shows a 25% reduction in revision after one and a half years, which I think is quite good. That's certainly an improvement, certainly not worse, but 25% reduction. In terms of how it works, uh, again, much like the hip, you have to take the uh you have to take the model and make sure the models match up. The most important thing with the knee replacement is getting the balance right. So you have to get the balance right, your medium, lateral, collateral. And it gives you some numbers on how tight your ligaments are, and you can just position the implants virtually, so then once you get the balance right, then you come and you can do the cuts. The cuts are held in these happy boundaries, which really shouldn't mean if you've done lots of knee replacements, but it's reports, those happy boundaries potentially reduce soft tissue damage and potentially uh give early recovery. And there are some papers showing that, but it's probably your approach that makes the biggest difference. Um when it comes to partial ease, it's actually my favourite operation because patients recover quickly, lower early complication, better proms. We do have an improved satisfaction compared to totally. If you look at the revision rate for partials, there's the green line is there are the restorations, which is the most common way the partials are done in Australia. Revision rate 10 years is lower than having uh the other unicompemental knee. So this is now the most common way that people are doing partials. And it's the easiest operation in the world. You use the spur, you take away the bone after balancing the knee. It's such an easy operation. From what was potentially a more technically challenging art. Uh knee revisions is now something that's uh coming uh into more fruition. You can see this chap had a partially replacement 10 years ago. He broke his poly and he had lateral OA. So essentially, all you need to do with this is bring the uh bring the line underneath his tibial component, and on the base of that, you can plan the ligament balance, and then you can move your thermal component around to make sure your balance and extension reflection is the same. Um, and then he has a fairly straightforward kinematic-aligned uh revision. So I think it's great for conversion of partials to totals and using robotics. And when it comes to hip revision, this is relatively new. Again, it's not world uh breaking, but it is quite useful. Uh maybe for those complex cases when you have a longer stems, uh, you can uh use orbits superlaterally and then plan it with robotics you can position where your screws need to be. Again, this is all progress in the world of robotics that you can use. So I think it's useful 3D planning. It's um they report that they uh accurate on delivery with plan to one millimeter and one degree. And my preference is partial knees and totals and total hips, uh, and it has a role in revision. So essentially, if I was with my favourite ballerina eating chocolate in BW and I had hip pain, what would I do? Or I had knee pain or ankle pain. What's my strategy of what I would use? If I had hip arthritis, I would lose a bit of weight, um, take some painkillers, be realistic. If I was deconditioned, I'd do a GLAD. I'd have a PRP injection, and maybe combine it with hyeronic cancer as a second injection if it didn't work. I don't think I'd use RFA unless there was something specific I needed to do for a year and I wanted to give it a go, like finish a job or whatever, or go on holiday, whatever it was. And then for me, I would I would have a direct anterior hip replacement as possible, and I'd have a 3D model planned. I don't think it matters if you use robotics or fluoroscopy, both show equivalent results. If I had knee arthritis again, I lose many weight, I use a knee brace. For me, I'd have a single shot PRP injection. I might combine hyaluronic acid if I was more mechanical, less inflammatory. If that didn't work, I'd go to RFA. If that didn't work and had mild away mechanic since I'm gonna have scope, but not many people sit in that category after the RFA. You may consider low-dose ready therapy if you're not going to have surgery for a long time and other things haven't worked. If I was suitable for a partial knee, that's what for me, that's personally what I would have, if if at all possible. If I had tricomplomental away, then I'd have a muscle-sparing survastis total knee replacement. If I had ankle arthritis, probably my least favourite out of all of them. Um again, lose some weight. I'd rather bolt the ankle from the outside rather than the inside, so I use a lace up ankle brace, try and reduce movement in the arthritic joint. I use orthotics to bring the foot below the ankle or bring the ground to the foot. I consider a PRP high volume. I think those are the better cases for RFA and low-dex radiotherapy. If I had a stiff ankle and no high foot away, I'm better off with an ankle fusion. I've got a stiff ankle anyway, I'm not going to get that moving back through the replacement. Had a mobile ankle with high foot OA, I'd probably have an ankle replacement, otherwise, I'm likely to wear out the remaining joints in my hind foot. Had a mobile ankle and no high foot away. I think that's a shared decision between myself and the surgeon. Um, so overall, these are the myths that we've covered. Hope it's been uh relatively interesting. Hopefully, we've had those myths clustered. Um does anybody have any questions or anything anybody wants to ask?

SPEAKER_03 33:42

Thank you, Doctor, for having me.

Dr Bob Edwards

SPEAKER_03 33:51

Join me in thanking a lot of his mind was kind enough to write him up here today, and you can see why. Um hopefully you can enjoy some of the sunshine things tomorrow. That's right. Make him feel welcome.

SPEAKER_00 34:10

Okay. Uh well, thank you very much um for uh inviting me to give this talk about deploying the new CRPD clinical care standards for general practice. It's a first certainly a is that better? Yeah. It's certainly a very interesting um process. Disclosure is obviously uh keys you're giving an honorarian to do this talk. And in terms of the CRPD clinical standard, it's really aiming to reduce the potential preventable hospitalisations, to improve patient outcomes, and to increase consideration of palliative care needs at towards the end stages of managing CAPD. The quality statements of focus is really diagnosis with spirometry, comprehensive assessment, and then the pharmacological management of a stable CAPD. And then making adjustments when it is not stable. So, in terms of making a diagnosis, you can only make a diagnosis to CAPD by doing sporometry. Clinical features aren't don't give you a diagnosis to CAPD, although they make you lead to suspect that someone might have it, then do the appropriate tests. A chest x-ray doesn't give you an answer to either, or a CT scan for that matter. You may have radiological emphysema, but you may have normal lung function, so you don't have, strictly speaking, you don't have CAPD. In terms of when to consider CAPD, uh it's getting younger and younger every year, but anyone over 35 years of age who has a risk factor of CAPD symptom or signs, they should undergo spirometry to enable the diagnosis. And of course, the diagnosis is the gold standard is that if the FEV1 force valour capacity is less than 70%, that confirms the presence of airway obstruction, and if it's not reversible, then it's chronic airway obstruction, and therefore you can make a diagnosis of chronic of CAPD. And in terms of a comprehensive assessment, it's very important to look at the medical history and the risk factors. Now, cigarette smoking is by far the commonest risk factor for CAPD, but you really need to consider occupations because there's a lot of people exposed to dust. Coal miners, hard metal miners, tunnellers, quarry workers, uh coal mine dust, lung disease, uh, and engineered bench tops. Luckily, with the engineered bench tops now that's been banned and the quality, the amount of silica in the stone has been reduced considerably. But it's not only and also the family history of CAPD. If you've got the family history of alpha-wide anti-tripsin deficiency, for example, then you've really got to consider it in the younger people as a cause, as a cause for their CAPD. And then you need to look at the severity, the symptom severity, its impact on people, uh, risk factors of exacerbations, the general physical health, and of course, if you can't breathe through the lung foundation, nothing else matters. But it but also when you can't breathe, it makes you it can make people quite anxious and depressed. You need to review their medication regularly and adjust treatment and update treatment if their symptoms are not adequately controlled. Then there's also that inhaler device technique to make sure that they're doing it properly, and that's something that should be checked at regular intervals and with at least an annual review. So the pharmacological management is you're only just to really you're aiming to continue the symptoms to prevent the exacerbations, and um based on the symptom exacerbation history, that'll tell you what to uh what you need to do and the inhaler technique. So, a step-wise management, a bit like managing aspir, but the step-like management, first of all, it's a short-acting bronchodilator, such as a short-acting um beta agonist or a short-acting anti muscarinic, as required for short-term relief. And in some people with mild disease, that'll be enough if they're only getting occasional wheeze and they're relieved rapidly. If that doesn't control their symptoms adequately, then using a combination of a long-acting bronchodolator, either one or both together, either a larva or a lama, for regular use, and then the short-acting bronchodilator as needed for breakthrough symptoms. And if the symptoms are still fairly significant, then the combined larva llama is obviously a better way to go. And in more severe cases, again, the triple therapy. And we'll talk about the indications for triple therapy a bit later on. So one of the best ways of doing this is with case studies. And first of all, as a gent who's 73 years old. He's a Caucasian-Australian, married, uh, BMA, BMI, not in the obese range but overweight. He's an ex-smoker, eight impact year smoking history, but he stopped smoking 23 years ago. He's got some hypertension, hypertension, osteoarthritis of his knees, but no history of childhood asthma and no allergies. And there's no family history of lung disease, particularly emphysema or chronic airway obstruction in anyone in his family. And five years ago, he developed a productive cough throughout winter. He was short of breath walking up slopes, even small ones. And therefore, he spits that criteria. Over 35 years old, one risk factor, and uh with a risk factor and CIPD symptoms that needs further assessment. Therefore, sporometry. Now in the sporometry, just have a think about this. Um there we have an FEV1 of 1.73, FVC of 3.08, the FEV1 VC ratio 56%, the FEV1 60% are predicted, the post bronchidolator FE1, no change, no significant change after the aerosol bronchido lato. And on the basis of the Z scores, we'll look at that a little later, he's got a moderate to moderate vinflatory defect. And so the sporometry, post-bronchadolator, is uh it's less than 70%. He's he's 65 years old, he's had previous smoker, and he's got symptoms consistent with COPD, therefore we can give him a diagnosis of COPD. And the treatment may be triotropia, uh, one puff a day, and then ventiline uh as required was what he was prescribed. That initially controlled his symptoms quite well, and within two years he again presented there's something missing that slide with more symptoms. And what we should have had there was a slide on the CAT score. The CAT test is a way to assess CAPD symptoms, and it's based on eight symptoms and the score from naught to five. So then depending on the the more symptoms, the more um the more the higher the score, the worse your symptoms from CAPD is. And at the moment, two years after first diagnosis, he's um waking up at night to urinate, but he gets short of breath and is hard to get in and out of bed, and he's short of breath at night. And that's also relieved by celbutamol. So he's fatigued at the end of the day, and it takes him a long time to get changed and to hop into bed. And then his cat's cat assessment between his cough, his sputum, chest tightness, breathlessness, his activity, confidence, sleep, energy, a score of total of 18. Now, a score of between 10 and 20 puts him into a moderate, a moderate range of um of COPD, how it's affecting his life. So the other thing to think about in investigating sleep disturbance at night, what else might be contributing? So obviously, does he have heart failure or clinical examination and investigations with the NT ProBNP being normal, so it's very various heart failure. He doesn't have any symptoms of sleep apnea, and therefore, and the fact that he's short of breath at night and it's relieved by ventilin tells us that he he does have airway obstruction and does get a little bit better, even though it's not completely reversible. So the nocturnal awakening is a system a bit like asthma. Nocturnal asthma is a symptom of poor control. Nocturnal symptoms in people with CRPD is a symptom of poor control. So the the um the impact of his symptoms, it's associated with exacerbations. They put out that you're more likely to have exacerbations, you're more likely to have admissions to hospital, and you've got a higher mortality rate as a result if you've got uncontrolled CAPD. And it's the night symptoms that are contributing to that. So at this stage, then they stepped up his treatment to a combined larva and llama twice a day and continued on the cell butamol and reviewed him four weeks later. And there had been some improvement in his symptoms. So the meaningful reduction in the CAT score is two points, and his CAT score had reduced from 18 to 10, and he felt that it Feeling much better and much easier to sleep at night with that treatment that he was using. And again, he relatively controlled for a while, and three years later, so he's now up to about 78 or so. Three years later, he's getting more short of breath during the day, interrupted sleep, exhaustion, increased coughing, and sputum changing from to dark green yellow, and he had a fever, so he had an acute respiratory infection. He'd been given a management plan, and he started to use more uh cell butamol and commestible course of doxycycline. So an examination is wheezy with no crackles. Um in the history then he had also had other flare-ups, the most recent one three months ago, and previous exacerbations of shortness of breath and cough and sputum and tire at the end of the day. So he started on the cell butamol and then some prednisolone, 30 milligrams a day for five days, and he was advised to continue the antibiotics. A chest x-ray was arranged and a review appointment again. And one week later, he was e. The chest x-ray showed hyperinflation, but no evidence of pneumonia. He was feeling a bit better in himself, and he returned to the pre-levels. But his CAT score was still high at a range of 21. So he hadn't returned to his previous level, so he's still still unwell. So he needs to have further assessment. He had no pneumonia, had a high burden CAT score. He's following his action plan, he's decreased energy, sleepy because he's um having sleep disorders because of shortness of breath. He's not smoking, he's that's one of the most important parts, obviously, in making sure that people don't smoke. And he has uh vaccinations are up to date. So as a result, he's had two exacerbations in the last four months uh with increasing CAPD symptoms, so therefore adding an inhaled steroid is indicated. And just as another coincidence, his eosinophil levels are a bit high. So, in terms of the indications for inhaled steroids and CAPD, is unstable CAPD with exacerbations, but also uh having a high higher bloody acinophil level uh gives us a more likely indicator that he will benefit from inhaled steroids. And of course, with all of these treatments now for airway disease, it's much better to have it in a single inhaler with a triple triple therapy in the one inhaler, because it hits the the relative receptor sites and is bound more effectively and gives better effect than if the inhalers are used uh separately or one at a time. So having a triple therapy it reduces the cost, it's only one prescription per month, and then so a triple therapy such as the becklomethasone for Motorol and glycopuronium, two puffs twice a day, you can still use uh ventilin as needed, and then you're scheduled for review because you need to review these people fairly regularly and make sure that their symptoms are adequately controlled. So the any questions on just any questions on that at this stage? No, it was a short shortened version. So really it's just yeah, CIPD isn't is still a major problem. Um it's poorly diagnosed still. Uh you need to ask more questions than just are you a smoking? You need to walk look at their occupational history because that's very important in terms of people getting uh chronic airway obstruction. And uh then treatment needs to be enough treatment to make sure that their condition is well controlled. And along with that is all their vaccines as well to stop them getting infection. So any vaccine that they can respiratory vaccine they can have to prevent respiratory viruses, they should have. Thank you.