Dr David Shooter

06/07/2025

I've now been doing patient-specific hip replacements for 10 years now, and they're still going strong. The brand I use, gets a preop CT, with sitting, standing and "step up" plain films (standing xrays with one foot up on a box, like you're about to go up a step). This maps out how your pelvis moves when you go from hip flexed to hip straight, to put your cup (the bit in the pelvis) in to the best position to optimise movement and reduce the risk of dislocation. It also allows leg length measurement. The system then produces 3D printed jigs, mapped to your anatomy, to reproduce in you, what the computer has calculated; and voila, a nice shiny new non-dislocating hip (that's the plan anyway).

Mr BH here, wasn't entirely straight forward. He developed a femoral neck fracture as a result of osteoporosis secondary to chemo some years ago. The fracture was fixed with 3 screws and healed; and he got over the cancer, but unfortunately had some collapse at the neck (see the change in shape and neck length from right to left), and developed arthritis with a hip joint contracture. He also had some back issues causing stiffness.

We got the computer modelling, which came back with a plan of what size gear to use, where to put it etc, and he's now much happier, walking pain free. A modern uncemented hip replacement can usually be done in well under an hour; and most patients will happily go home in 2-3 days, if not earlier.

24/06/2025

When too much metal is barely enough . . . Ms L unfortunately had a history of dislocating her knee cap; and one of those was bad enough in her teenage years she needed some major reconstructive surgery to stop it dislocating. Unfortunately that allowed her to develop some pretty severe arthritis, and some of her ligaments started failing along the way.

While often less is more, sometimes its simpler to give up on biology, and rely on metal! This is a "hinged" knee replacement; usually the stability comes from the patients own ligaments, but in this case they were weakened and not repairable, so the tibia and femur are physically connected by a rotating hinge. The patient gets her bend back, the patella stays where its meant to be, and voila . . . a stable bending pain free knee :)

22/02/2025

While primarily an oncology conference, have picked up some good tips on how to manage joint infections! Plus, excellent coffee 😎

15/12/2024

Hello poignant friends (anyone remember Flacco? No? Must just be me then 🥲)

The silly season approacheth; we've basically finished scheduled surgery for 2024 with the usual surge in late Nov / Dec; there's one more week of clinic, then we're shut until 13th Jan 2025; Carol needs a good break to recharge and recover from my rubbish!

Stay safe over the holidays :)

07/10/2024

Time for some refreshers!
International Sociey for Limb Salvage Surgery conference

25/08/2024

When should I have my knee replaced? The answer is actually simple; when you have enough pain, enough of the time, that its worth going through the surgery.

Everybody is different; and the answer shouldn't be based purely on the xray appearance. This is Mr B; I first met him around four years ago, sent in by his GP after flare of knee pain, subsequently finding quite bad knee arthritis (in both knees) on xray. When I saw him I thought his left knee was going to be the problem as it had the more severe changes on xray, and I thought I'd be booking him for surgery.

As is often the case, his left knee was not an issue at all, it was his right, and it was getting better by itself. It seems he'd had a bit of knee pain on and off for years, but had helped a grandson move house and it had all blown up; but after a bit of rest it was getting better.

This is actually the natural history of arthritis; a slow worsening over the years, often very subtle, with a series of waxings and wanings, often independent of the severity (or otherwise) of the arthritis. A joint replacement is the end of the line for pain relief, and thats how it should be approached.

I waved farewell to Mr B, and only saw him again six weeks ago, when he limped in, sat down, and simply said "I'm ready". His pain had been increasing over the last year; he was now on the verge of needing opioid analgesia; his sleep was routinely affected; and he'd given up the shopping six months before as he just couldn't do it.

His xrays were unchanged from those four years ago; still worse on the left, but the right was the painful one. He'd tried physio; had a couple of injections his GP had kindly organised for him; but couldn't have anti-inflammatories due to kidney issues. Surgery it was, with the trusty robot . . .

And a good time was had by all :)

13/08/2024

A "by the numbers" post . . .

1) 35% - the average increase in gold policy costs over the last three years. How can this be the case, you ask, when the insurers can only increase their premiums once per year and the government has to sign off on it? Easy; they "close" your particular policy, then release a slightly different "new" policy at a higher premium (H/T to CHOICE)

2) 17% - what the health insurance industry wants their profitability to be, same as the banking sector and other forms of insurance

3) 1.4% - the average "profitability" of private hospitals in Australia currently

4) 35% - the average increase in business expenses (electricity, wages, insurance etc) in Australia over the last three years (ABS)

5) 90% - the average number of No Gap or Known Gap operations performed over the last 18 months

6) $160 - when there is a gap, this is the average gap (H/T to APRA for points 5 and 6)

7) 70% - the amount of elective surgery performed in private hospitals; and despite record increased funding, most public hospitals have not returned to pre-Covid levels of activity

Sobering reading . . . but makes it clear the private insurance industry is feeding the general public (and policiticans) porkies . . .

and remember, particularly if you are a NIB member (or Qantas or APIA, run by NIB), you have the right to change your insurer without serving out a new waiting period

31/07/2024

NIB is topical again, in my opinion, the worst health fund in Australia. They pay the lowest rebates to patients yet have amongst the highest premiums. We don't deal with them; and shortly the St Vincents group won't either.

This means that you can still have surgery, but you will now have a much larger out of pocket cost to the hospital; they have estimated around $4K for a joint replacement.

Why? Basically NIB have refused to offer the hospital any increase in payments while negotiating the next agreement. You may be aware that these agreements run in a three year cycle; and everything has to be included at the time. All those extra costs associated with COVID compliance? Paid for by the hospital. Your operation runs late, or is done after hours because its urgent? The nurses get overtime; no extra payment for the hospital.

This is particulary galling as the health funds are making record profits, particulary NIB. According the latest APRA data, NIB has the highest operating expenses, highest executive salaries, and lowest return to fund members as a percentage of premiums received. It might be good to be a NIB shareholder, but not to have your health insurance with them.

At this stage, the changes will come in, in October.
More info at the link below

This issue solely affects nib members along with those health insurers nib underwrites. People who are members of other funds will not be affected. The full list of affected health funds and insurers are:

28/07/2024

General announcement - from the 5th August our consultations fees are going up; I've held off for some time, but everything else has gone up, and my secretary has holes in her shoes . . .

We'll be charging $240 for a new patient, and $120 for a review. We will still be doing Known Gap billing for the majority of surgical billing.

29/04/2024

Morning. Just a heads up, Carol is having a well-deserved holiday, and I'm flying solo for the next fortnight, so I apologise in advance for the missed phone calls etc . . .

The best contact method is via the contact page on the website, or via FB Messenger here, at least for now.

Phone messages will be listed to, but I don't have remote access on our current system.

25/02/2024

Welcome back! Before I get to the maths, a few more details about how health fund work . . .

Most health funds give different rebates in different states, and often even to different surgeons. Why? Because they can; and they do what they can get away with. If they have a big market share, the worse they behave . . .

One fund in particular; lets call it Men In Black (put the capitals together and you'll be close; rhymes with "bib"); specialises in this type of behaviour, in my opinion. It pays the lowest rebates to surgeons; often no more than the MBS "fee" in some operations and states; but has the highest premiums. Why? Because it can; its run some great advertising campaigns, has bought some other funds that had a good name; and they can always blame a greedy doctor for your big out of pocket. Win win!

Health funds also pay doctors whenever they feel like it; often 4-6 weeks after we submit the invoice. And sometimes they will randomly reject it; and when we ask why, we're usually told computer error, and resubmit please. Sometimes this goes on for months. So, if we as surgeons bill the patient directly, we get paid straight away; but the health funds consider that "private billing", and only rebate the patient the MBS "fee", not what the top up might have been.

Here are some examples for hip replacements. Remember, the AMA fee is $4600; the MBS "fee" is $1450; the MBS rebate is $1050; and the Poopa fee with top up is $2260 (I'm going to round numbers for convenience).

1) I bill you directly the AMA fee of $4600. I get paid immediately; but you only get a rebate of $1450, and are out of pocket around $3150.

2) I do No Gap billing; this means I submit an invoice via a computer program called Eclipse to your health fund. I get paid $2260; and I might get paid any time in the next 6-8 weeks; and you have no out of pocket cost. Yay you!

3) I do Known Gap billing; this means I charge you $500 up front, which I get straight away; then I send a bill by Eclipse to your health fund, and get anouther $2260 some time in the next 6-8 weeks; and you are $500 out of pocket.

4) Let say, just for example, I don't like waiting 6-8 weeks to get paid, and charge you the Poopa fee up front ie $2260. I get $2260 straight away; but your health fund says, uh uh girlfriend, thats private billing (even though its the same fee we'd normally pay); and you, the loyal Poopa customer, is punished by your health fund due to the temerity of your doctor wanting to get paid in a timely fashion, and they only rebate you the MBS fee of $1450. So you are out of pocket around $800, because your doctor didn't want to wait to get randomly paid some time in the next three months.

In a nutshell, this is why some doctors charge AMA rates; and some doctors don't deal with certain health funds. Bonzai!

18/02/2024

Welcome back, poignant friends (anyone remember Flacco? Good times).

So, why re some Gaps gaps, and some gaps are GAPS

Lets get back to our example last time, hip replacement item 49318. Remembering the government sets the MBS "fee" at $1450.55, or which it actually stumps up $1087.95, with your private health insurance required to pay a minimum of $363-ish.

Well, the health funds recognise that theres a big gap (see what I did there) between the government cash, and the AMA rates, and will usually pay more than the minimum; most fund offer a top up of around 20%. They do this to encourage surgeons to accept the fee they are offering, and not charge patients more (because then people will rightly question what the point of their insurance is).

Lets pick a big one; rhymes with "pooper", with fairly similar levels of service. Our anonymous health fund, if you (the surgeon) has signed up to their scheme, will actually pay you the princely sum of $2257.85 (but don't forget that $1087.95 still comes from Medicare); and if you've signed up as a "Known Gap" provider, you can bill the patient up to $500 on top of this, and still get the top up. So, $2257 + $500 . . . still doesn't equal the AMA fee of $4675 does it? Which is why many surgeons charge AMA rates . . .

Next time; some real world examples