About Surgery

Q36: Can you tell us in advance on the phone as to how much it will cost to have my surgery? Back To Top

Q1: Where are you located and how to get there? Is there any car park?

We are located at Suite 2.06, Level 2, Pindara Specialist Suites, 29 Carrara Street Benowa. Pindara Specialist Suites are located within the premises of Pindara Private Hospital, Benowa. The entrance to the suite is via Carrara Street behind Benowa Gardens shopping centre into Pindara multistorey free car park. Take the lift to Level 2 (green décor when you exit lift) and turn right into the Specialist Suites. There is also a drop off facility (5 minutes car park) in front of Hudson’s café at the ground level.

Q2: What are your business hours?

Our practice hours are from 9 am to 5 pm Mon-Fri – Dr Nihal consults on Monday am , Tuesday am & pm , Wednesday am & Thursday am & pm – Dr Nihal operates at Pindara every Monday & Wednesday afternoons. – Friday is Dr Nihal’s day off – admin/rest day!

Q3: What do I bring to my first appointment?

It would be useful and helpful if you could bring the following to your first appointment

• Referral letter from your GP or specialist or Emergency doctor is MUST
• All old X-rays/MRI/CT/Ultrasound films & scans with their reports (Not just the reports)
• Please make sure you have printed hard copies of your X ray (not only the CD copies). If you only have CD’s then please ask the imaging company to print hard copies for you to bring to this clinic. If we are unable to see the images then you may be asked to have a repeat X-ray at Pindara Hospital before the consultation, which will cost you time and money.
• All your Medicare/Health fund/ DVA Cards
• Any correspondence/letters from previous doctors/specialists
• List of your medical conditions/medications and details of any previous surgery
• List of questions which you wish to ask during consultation
• This practice is a private practice and is not a Bulk Billing or No Gap practice. Therefore consultation fee must be paid on the day of consultation. Please bring your EFTPOS/Visa/Master cards or cash. We do not accept American Express or cheques.

For WORK COVER /Third party patients: Please make sure you have the valid active claim number of your work-related injury as well as the name, address, contact number of your employer and case manager. It is your responsibility to get approval for consultation. We may be able to assist you regarding this. If you do not have the approval then you are liable to pay the consultation fee on the day of consultation and then claim back from work cover at a later date. PS. Please remember to download from our website and complete the “New Patient Registration Form” and bring to our practice on the day of your consultation.

Q4: Do you see Workers Compensation and third party insurance claim patients?

Yes, however we require written approval from either work cover or third party insurance claim before you can be seen. It is your responsibility to obtain an approval. We would be happy to provide assistance regarding this.

Q5: What is the procedure when I arrive?

You will be asked to complete the new patients registration form and/or work cover injury forms if you have not already downloaded and completed the new patient registration form. If your condition needs application of plaster, splint, moon boot or injection etc then there will be an extra cost for these services which will be fully discussed beforehand and paid for on the same day. If you have private insurance with extras cover then some health funds partly rebate the cost of splint/boot. Please check with your health funds and we will provide you with a receipt and supporting letter.

Q6: What types of conditions are treated at you practice?

• Bunion, hammer toe & foot deformity correction
• Arthritis of ankle & foot joints
• Ankle pain, sprain & instability
• Achilles tendon & heel pain
• Diabetes related foot disorders
• Special interest in sports & Dance (including ballet) related foot & ankle injuries
• In-growing toenail surgery
• Flat foot, foot drop and cavus foot reconstructive surgery
• Morton’s neuroma, Metatarsalgia
• General common orthopaedic trauma & fracture management
• Revision and Re do foot & ankle Surgery
• Paediatric & adult acute trauma/soft tissue / fracture management

Q7: My condition is not urgent but I want to be seen soon – do you have any cancellation list so that I could be contacted at short notice to attend an appointment?

Yes- Please ask our staff to put your name on our cancellation list and we will contact you to come early should an appointment become available due to a last minute cancellation.

Q8 : What is the training structure of a Consultant / Specialist Orthopaedic Surgeon/Orthopaedic Foot and Ankle surgeon?

• 5-6 years in Medical school to obtain MB BS, MBChB, or MD, comprising the basic medical degree
• 2-3 years or even longer basic internship, junior doctors training under supervision in various medical and surgical specialities within hospitals
• 5- 6 years of advanced training in orthopaedic surgery under supervision and attainment of a higher surgical degree for example FRCS, FRACS etc
• 1-2 years of sub-speciality training ( fellowship) under the supervision of an eminent orthopaedic surgeon either in the home country or overseas.
• After 15-16 years of medical and surgical training, only then can a surgeon work independently as a “Consultant Orthopaedic Surgeon”, “Orthopaedic Specialist” , “ Orthopaedic Foot & Ankle Surgeon”.

Q9: Is Dr Nihal only an Orthopaedic foot and ankle surgeon?

Dr Nihal is a fully trained Trauma and Orthopaedic Surgeon and takes all other general orthopaedic trauma and fractures including children’s fractures.

Q10: I have seen a podiatric surgeon who has suggested that I need my foot/ankle operation but Medicare won’t reimburse the rebate. However I do get a Medicare rebate when I see my GP or other medical specialist?

At present Medicare does not recognise Podiatric Surgeons as “ medical specialists” thus their fees do not attract any rebate. The majority of health funds also do not recognise Podiatric Surgeons as “Medical Specialists” thus your health fund may or may not pay the hospital and theatre costs if you chose to have surgery by non MBBS / non FRCS/non FRACS podiatric surgeon.

Please ask your treating podiatric surgeon and the hospital administration where you are having foot surgery as regards the costs and rebates. You must also ask the treating podiatric surgeon whether s/he has prescribing rights to prescribe antibiotics should you develop minor post-op infections or whether s/he has any admitting rights in a major private hospital should you develop a serious post op-infection requiring I/V antibiotics and/or wound washout and debridement under GA etc.

Q11: Can I send all my questions via e-mail for you to answer, as I do not have time to come to Dr Nihal’s room for consultation? E-mail correspondence is not a secure and confidential way to communicate discussions or confidential clinical information. Hence this practice does not partake in email consultations. Practice e-mail communication is only reserved for making, changing or cancelling appointments, making requests to issue sickness certificates, contacting us for non-urgent post-op queries and any other non-urgent matters, particularly if you are abroad. If you have a lot of clinical questions relating to your surgery then please make an appointment to discuss this in person.

Q12. Do you see patients soon in your clinic who have urgent foot/ankle fracture or Achilles tendon rupture?

Yes. Please let my staff know that you have sustained an acute fracture or tendon rupture we have urgent slots on Monday and Tuesday and would be more than happy to slot you in.

Q13. Do you see or operate on uninsured / self funded patients privately at Pindara Hospital?

Dr Nihal only works in private hospitals and has no practice privileges in the public hospitals. Therefore private health insurance is essential for any surgery carried out in a private hospital. (a) Dr Nihal provides a holistic treatment & service from start to finish. Even if you pay Dr Nihal’s surgical fees, the hospital & anaesthetic fees, unexpected complications such as infection do occur, particularly in the case of foot & ankle surgery, which is known to carry higher risks of post-op complications than for example knee & hip surgery. Should this happen, you will need readmission and further treatment in private hospital, the cost of which may run into thousands of dollars on a daily basis. Thus if you are self-funded, these unexpected costs may become unaffordable. (b) You may have question that you had “knee arthroscopy surgery: by Surgeon X and when you had a post op infection the surgeon X treated you in the public hospital at no added cost. This may be true where surgeon X works both in a private and a public hospital or treated you as a public or intermediate patient in the public hospital. However, Dr Nihal only works in the private sector and is therefore unable to admit you in a public hospital for any unexpected or expected complications and treat you personally. For the above reasons, Dr Nihal prefers not to operate on uninsured/self funded patients in the private hospital, only to send them off to the public system for another surgeon to deal with complications, either expected or unexpected. It is unlikely that this group of patients would be able to afford the $900 a day (or more) hospital admission fee and costs relating to any theatre/revision surgery/ICU etc. Apart from the many benefits offered by private health insurance, it should be taken into account that all hospital care, theatre and instrumentation costs are also covered by health funds which usually run into many thousands of dollars. (c ) Self-funded patients need to be aware of the other costs in addition to the Dr Nihal’s fees, for example surgeon’s assistant fee, anaesthetist fee, hospital ward, theatre costs, medication, fees for x-rays taken during & after surgery. Other hidden and unpredictable costs might include plates, screws or synthetic bone grafts or any other materials used during surgery. Again the cost of these items may be prohibitive. (d) The foot & ankle is a complex structure and surgery, by definition, is also complex and involved. It often results in prolonged periods of post-op care, requiring a longer stay in hospital, extended periods of rehabilitation & physiotherapy in a private rehab unit. This will also incur extra expenses for the uninsured/self funded patient. (e) In addition to the expected complications relating to foot & ankle surgery, there may be unexpected cardiac, anaesthetic or other complications requiring a period of in-patient stay either in the ward or even ICU or CCU. This would significantly inflate a patient’s medical expenses. However these situations would be covered by health insurance. Here is a case scenario of a patient undergoing routine knee arthroscopy. Post-operatively he developed a heart attack requiring admission to ICU, subsequent intervention & treatment. He received a hospital bill for $30,000 for a presumed routine procedure where he paid his orthopaedic surgeon only $1,200 for the knee arthroscopy. Now he is faced with a $30,000 bill to pay due to an unexpected complication. (f) If you are an uninsured/self funded patient, then please ask your GP to refer you to any other Orthopaedic foot & ankle surgeon who has practice privileges in both the private and public hospitals, so that should a complication develop post-operatively, you can be transferred to the public hospital for on-going care at no extra cost to you. (g) Should you wish to see Dr Nihal and have surgery by him, then it is up to you to join a health fund of your choice and serve the waiting period before coming to our clinic for treatment.

Q14: Is elective foot/ankle surgery more appropriate in my case or would non-surgical treatment suffice?

The decision to have elective foot/ankle surgery should not be made in a rush. Dr Nihal will always explain the non-surgical and surgical options available for your foot/ankle disorder. Please make a decision only when you have understood all the risks, benefits and limitations of each treatment. Please also keep in mind that the surgeon cannot give a 100% guarantee of perfect results since expected and un-expected surgical complications may arise through no fault of anyone. The vast majority of patients do not develop these surgical complications, but should you fall into that small percentage of those that do develop complications, then there is always the risk that you may be worse off after surgery. The more complex the condition you have, then the more complex will be the surgery. Complex operations may result in complex and serious complications.

The post-operative period after foot & ankle surgery is very cumbersome and can be very frustrating. This is due to the application of Plaster/Boot/Splint etc and a period of non-weight bearing on the operated leg. This period may last for 6-12 weeks, but in some complex cases, up to 20-24 weeks. Please make sure that you understand this period and arrange for someone to help with your daily chores etc.

Q15: What are the common foot/ankle surgical complications?

There are risks associated with any kind of surgery and foot and ankle surgery is no different. The mainstay of surgery involves either re-alignment or fusion of bones. Occasionally, however deformity can be over and under-corrected or bones fail to unite. Deformity can also recur despite an initial good correction. These complications may require further surgery or even amputation. Fusion of bones in the foot and ankle can also increase the risk of arthritis developing in adjacent joints in the long term. Other possible well-documented complications include: infection, wound problems, neuroma, numbness, under and over corrections, residual pain and swelling, nerve, vessels, tendon damage, fracture of bone or implant, compartment syndrome, stiffness, non-union, malunion, recurrence of initial problem, re-operation, scar tenderness, metalwork problems and removal, blood clots in legs/lungs, Sudeks’s atrophy, post-op temporary\permanent use of insoles, splint or modified footwear, circularity problems in toes/foot which may require amputation. Apart from anaesthetic and medical complications, there is a small risk of being worse off after surgery. There is also the possible risk of long-term diminished function in walking, dance, sports or daily activities.

Q16: Can I smoke before and after foot/ankle surgery?

Smoking must be ceased at least 6 weeks before the surgery and until full healing of your condition. Smoking significantly increases foot and ankle surgical complications for example interference of bone & wound healing, infection & non-union to name a few. There are also issues with anaesthetic complications and increased risks of blood clots to the legs & lungs. It is in the best interest of the patient, surgeon & anaesthetist that the patient ceases smoking completely – both active and passive smoking.

Q17: Do I need Physiotherapy after surgery?

In some cases, you may need physiotherapy but in the majority of cases when foot bones are fused, you do not need formal physiotherapy. Dr Nihal will advise you accordingly after the operation.

Q18: Can I drive after foot/Ankle surgery?

If you had surgery on your left foot/ankle then you can drive an automatic car, two weeks post surgery once the surgical wound has healed. You cannot drive a manual car until the fracture/osteotomy/fusion has completely healed and once you are allowed to fully weight bear. This may vary from 6-12 weeks.

If your right foot/ankle has been operated on then you cannot drive until your operated condition has fully healed and you are able to fully weight bear. Again this may vary from 6-12 weeks. If you have a right Achilles tendon rupture then you may not be able to drive for approximately 3-4 months post injury/post surgical repair.

Q19: I have already had X-rays of the foot/ankle done. Do I need more X-rays & if so, why?

If you have any chronic condition of the foot/ankle then we need a weight-bearing/standing X-ray of both the foot and ankle. It is important to have the X- ray of the foot as well as the ankle as many X-rays miss one or other part! We need to see both.

However if you have a fracture or suspected fracture or you are unable or are unsafe to weight-bear, then non-weight-bearing X-rays of both the foot & ankle would suffice.

Q20: How long will I be in the hospital?

Minor foot/ankle operations are performed as a day case. For the majority of operations, the hospital stay is around 1-2 days. However, complex operations may require 5-7 days stay in hospital. If you have or develop an infection, then the hospital stay is unpredictable, as it will depend on how quickly we can eradicate the infection with surgical debridement, IV antibiotics and regular dressings etc. This will obviously vary widely between individual patients.

Q21. What is the recovery time after foot/ankle surgery?

This depends on the type of surgery you had. Generally the recovery time is longer in foot/ankle surgery as compared to surgery to other parts of the body such as carpal tunnel release, hip and knee replacement surgery. Foot/ankle surgeries usually require a period of non-weight bearing and application of a plaster splint, Moon boot and frequent wound care etc. The usual recovery time for minor operations is approximately 3-6 weeks, fractures around 6-12 weeks, and major operations about 6-9 months.

Q22: How long does it take for the swelling on my foot/ankle/toe to go down after surgery?

Post-op swelling on the foot/ankle/toe is normal & may last for approximately 3-6 months and in some cases take 18 months to fully resolve. This is due to the foot being a gravity-dependent extremity with a natural tendency to swell. Also the venous and lymphatic drainage may be impaired due to the initial injury, ensuing surgery, immobilisation, varicose veins, gravity, advancing age etc.

Q23: Do you have any general pre operative advice leaflet?

Yes- as follows

PRE-OPERATIVE ADVICE

Now that you have signed the consent form and booked your surgery, please note the following information: –

1. If you are over 60 years of age, or under 60 with medical conditions, then you will be asked to attend Pindara Hospital Pre Admission Clinic for a Preoperative Assessment before your elective surgery date. This will include doctor examination, various tests; to make sure you are fit to have a general /spinal anaesthetic. Pindara Pre Admission Clinic phone number is on the front page of the Pindara Patient Admission Guide. Please read carefully the Front page of Pindara Patient Admission Guide and follow all the instructions written on it. Any questions regarding Pindara Admission Guide booklet please contact the numbers written on the front page.
2. Dr Nihal only operates at Pindara Private Hospital. His operating days are Monday PM and Wednesday PM.
3. As you have already been given a date for surgery, my secretary will ring you 5-7 days prior to the surgery date to discuss with you the approximate time of admission, fasting time and the payment (Dr Nihal’s and his Assistant fee). My secretary will also give you a provisional financial breakdown of Surgeon and Assistant’s fees (gap, known gap, or full private fee), which is payable one week in advance of your proposed surgery date. Information regarding this is written on the Gold Coast Foot & Ankle Specialist Clinic, Clinical & Financial Consent Form, which you have signed during pre op consultation with Dr Nihal. If you are not sure about this or have any questions, please do ask before the surgery date either on the phone or in person for 2^nd consultation with Dr Nihal. It is very important to understand the clinical and financial consent, which is essential for a good doctor-patient relationship and mutual trust.
4. Regarding the name of anaesthetists and their fees, my secretary will also inform you of which anaesthetist group is booked on your surgery day. Dr Nihal uses anaesthetic group – Coast Anaesthesia Tel number 07 5598 0663). You may receive a call from Coast Anaesthetic to pay the anaesthetist fee, either a deposit, gap or full fee in advance. Dr Nihal has no control over anaesthetist’s fees. Any questions regarding their fees, please call the anaesthetist group directly.
5. You must bring (a) Pindara Consent form (b) Pindara Admission booklet (c) all investigations, in particular hard copies of X-Rays, CT scans, MRI’s etc. If you do not bring any of the above, especially the Pindara Consent form and X-Rays, then this may result in delay, postponement or even cancellation of your surgery.
6. Following surgery, my office will ring you for a post-op appointment, usually 8 to 14 days following surgery.

Some facts about Foot & Ankle Surgery

Foot & ankle surgery carries a slightly higher risk of wound complications, as compared to shoulder, elbow, face surgery etc. The foot and ankle is a dependent part of the body, and during walking/standing, gravity tends to result in more oedema/swelling and wound break down. Circulatory problems are more common in the foot and ankle than in the shoulder or elbow, especially in smokers, thus resulting in would healing/ulcer problems.

Post operative period after foot & ankle surgery is very cumbersome and can be very frustrating. This is due to the application of Plaster/Boot/Splint etc and a period of non-weight bearing on the operated leg. This period may last for 6-12 weeks, but in some complex cases, up to 20-24 weeks. Please make sure that you understand this period and arrange for someone to help with your daily chores etc.

If your right foot/ankle is operated on, then you may not be able to drive an automatic car for a period of non-weight bearing as above.

SMOKING MUST BE CEASED before undergoing surgery, and for 8-12 weeks after the surgery. Smokers have a higher risk of complications, including wound-healing problems.

If you have any history of DVT (clot in the legs), Pulmonary embolism (PE), or if you are a young female taking the oral contraceptive pill, then please inform us, or the pre admission clinic. Foot and ankle surgery carries a risk of residual postoperative swelling on the ankle/foot/toes, which may take 6-18 months to disappear.

Last but not least, no surgeon will give you a 100% guarantee of a perfect result after foot/ankle surgery, as expected and unexpected complications can occur. However, even if you do not suffer from any complications, statistics shows us that 5-10% of patients are unhappy after foot and ankle surgery, in spite of appropriate surgery performed.

If you have any questions, please discuss before booking surgery on Ph: 07 5564 6877.

Copyright: The Gold Coast Foot & Ankle Specialist Clinic Benowa – Jan 2015

Q24. Do you have any general post operative advice leaflet?

Yes- as follows

10 Rules: For 10-14 days Post Op. Instructions for Patients Following Foot & Ankle Surgery – Plaster/Splint/Moonboot/Foot booty/Dressing

1. Keep dressing / plaster clean and dry avoiding water, ice, dust, dirt, sand, heat, moisture, sweat etc.
2. Stay indoors in a cool environment (fan, a/c) and maximally elevate the operated leg with the knee in slight flexion (knee bent) of about 10-20 degrees; do not sit in the sun as heat and moisture may cause sweating resulting in wound infection. Avoid any long distance car and air travel until your first post-op appointment with Dr. Nihal. If your leg is immobilized in plaster and Non-Weight Bearing, then long distance car/air/cruise travel restriction may last 6-12 weeks approximately. This is due to the risk of wound breakdown, infection and or blood clots in the legs and lungs and pulmonary embolism causes death.
3. When you shower ensure your operated leg is covered securely with a waterproof bag (no holes in the bag) and completely sealed with paper tape applied (not sellotape) to non-hairy skin. Alternatively have a sponge bath. Do not allow your post-op dressing or plaster to get wet or soaked. A moist wound results in maceration of the skin; wound infection including Golden Staph Infection. Should your dressing/plaster become soaked, please contact us, as it will need to be redressed by Dr Nihal at your expense.
4. Continue with the DVT prevention exercises as described in the white leaflet provided to you by the hospital Physiotherapist. Wear your TED stockings for 6 weeks post-op or as otherwise instructed. If you have a plaster/splint on your leg and you have associated risk factors for DVT, then Dr Nihal will advise you to have a blood-thinning injection – Clexane for 2-6 weeks (if no contraindication) or in some other cases, you will be advised to take Aspirin (150mg) daily for the duration as advised by Dr. Nihal.
5. Use crutches / walker / hopper / rollator / moon boot / post-op shoe provided to you, as per instructions from the Physiotherapist & Dr. Nihal. Follow the hospital Physiotherapist’s instructions regarding weight-bearing status on the operated foot/ankle. Avoid the use of a knee walker during the early post-period op period as flexed (bent) knee may result in circulation issues and excessive foot swelling. For a non weight bearing patients a wheel chair be used for the initial 4 weeks for transportation to your appointment with Dr. Nihal, the Physiotherapist and for X ray appointment.
6. Please make sure you have help available at home for the first 10-14 days to look after your basic needs. Please make sure you have someone who can bring you for your first post-op appointment at my clinic preferably in a wheel chair, particularly if you are in a cast/splint/moon boot and you are non-weight bearing.
7. Do not use a hair dryer to dry the wet cast or put talcum or any powder or poke anything inside the cast or attempt to interfere with the cast/dressing in any way.
8. Do not apply any ointment, antibiotic cream, steroid cream or ice on or around the healing immature post-operative wound. Steroid creams cause thinning of the skin and predisposes the wound to breakdown and infection.
9. Do not smoke (active or passive) for at least 6-12 weeks post-op. Smoking increases the risk of bone non-healing and wound complications.
10. Please report to us: any excessive painful swelling, cast digging in, severe tightness of dressing / plaster any offensive smell or discharge, excessive bleeding from the operative dressing wound. If you develop severe cramping of calf muscles and/or breathing problems, shortness of breath and or chest pain this may indicate a blood clot in the lungs, which is an emergency. Dial 000 for the Qld Emergency Service or attend your nearest Emergency Dept. a.s.a.p.

Post-Op Pain Relief Please take any ordinary pain medications eg. Panadol, Nurofen, Brufen (if no contraindication) or any other strong pain medication for which either script or medications were given to you on discharge. If you have any concerns regarding your post-operative dressing/plaster/splint/wound infection, please contact Dr. Nihal’s rooms first before contacting your GP, as Dr. Nihal is responsible for your immediate post-operative care after surgery. Please contact us on Tel: (07) 55 646 877 during normal business hours Mon – Fri. If assistance is needed out of business hours, contact or attend Pindara Accident & Emergency Tel: (07) 5588 9000 or any other local public or private emergency department/GP surgery.

Q25: Can you give us a guarantee that my foot/ankle will be perfect after surgery so that I can return to do all sorts of activities, which I use to do before. I need to know more about foot & ankle surgery before I commit to have surgery?

Foot & ankle surgery carries a slightly higher risk of wound complications, as compared to shoulder, elbow, face surgery etc. The foot and ankle is a dependent part of the body, and during walking/standing, gravity tends to result in more oedema/swelling and wound break down. Circulatory problems are more common in the foot and ankle than in the shoulder or elbow, especially in smokers, thus resulting in wound healing/ulcer problems. Apart from anaesthetic and medical complications, there is a small risk of being worse off after surgery. A possible risk of diminished function in walking, dance, sports or daily activities. The outcome of surgery depends on so many factors and one of the important factors is the raw material you have to start. The foot and ankle is a complex structure with so many bones, joints, ligaments, muscles and tendons working together and if we operate on one structure then the other adjacent structure/s are likely to ache/ pain or swell, thus this is a likely outcome of any foot and ankle surgery. As we grow or get older and/or subject our foot/ankle to more stresses by walking, running gym and sporty activities, then the existing pathology progresses over a period of time and the new pathology may appear in operated foot/ankle resulting more pain, swelling down the track. with your daily chores etc. Post operative period after foot & ankle surgery is very cumbersome and can be very frustrating. This is due to the application of Plaster/Boot/Splint etc. and a period of non-weight bearing on the operated leg. This period may last for 6-12 weeks, but in some complex cases, up to 20-24 weeks. Please make sure that you understand this period and arrange for someone to help Foot and ankle surgery carries a risk of residual post-operative swelling on the ankle/foot/toes, which may take 6-18 month to disappear. Last but not least, no surgeon will give you a 100% guarantee of a perfect result after foot/ankle surgery, as expected and unexpected complications can occur. However, even if you do not suffer from any complications, statistics shows us that 5-10% of patients are unhappy after foot and ankle surgery, in spite of appropriate surgery performed. Dr Nihal would try his best to do good operation so that you have a good outcome but unable to give you 100% guarantee of perfect results. If you are unsure about surgery, please try non-surgical treatment. If you have any questions, please discuss before booking surgery on Ph.: 07 5564 6877.

Q26. What are Dr Nihal’s consultation and surgery fees based upon?

Dr Nihal is a member of the Australian Medical Association (AMA) and the majority of his fee structure is based upon the recommendations/guidelines of the AMA and has no relationship whatsoever with the Medicare rebate. Please phone our reception staff will be able to provide costs for initial and follow up consultations at the time of making your appointment. The cost of initial and follow up consultation is variable depending upon the length of the consult and complexity of the case The consultation fees must be paid on the day of your appointment. Our clinic does not offer discounts for Healthcare card holders/Pensioners/Children etc. If you have a current referral from your local GP/doctor or another specialist, then you are able to claim a rebate through Medicare. Regarding the cost of surgery fees: Unfortunately, our receptionist staff are unable to provide the quote for foot and ankle surgery until you have had a consultation with Dr Nihal. This is because our reception staff are unable to determine which foot and ankle operation you will require. Once you have had your consultation with Dr Nihal and you decide to proceed with surgery, then we will be able to provide you with a fully itemised quote. This approximate quote will outline surgeons’ fees, based on the proposed surgery, the amount rebatable through Medicare and your private health fund, and the out of pocket expense you will incur for surgery. Our room will provide you with the Anaesthetic Group, the name of the anaesthetist and their phone number, as well as the contact details of Pindara Private Hospital. You are then able to make inquiries in regards to their fees. You may be asked to attend pre-op clinic in Pindara Hospital and/or attend Dr Nihal’s recommended Physio for BP-FASA, which is ‘Be Prepared Foot & Ankle Surgery Assessment’ to ensure you understand the post op period and mobility aids, which you may need after having foot and ankle surgery. This whole process will enable you to fully prepare for your surgery and understand the expenses that you will incur for the proposed surgery, despite you having Medicare and Private Health insurance. The foot and ankle is a complex structure consisting of approximately 26 small bones, 39 joints, 19 muscles/tendons and 107 ligaments. Hence any surgery is bound to be tricky, fiddly, intricate and complex. Medicare pays a relatively large rebate for fixing fractures of large bones i.e. femur (thigh bone) /tibia (lower leg bone), but pays a much smaller rebate for fixing fractures of small bones such as those in the foot. The amount of Medicare rebate for foot and ankle surgery does not therefore reflect the surgical complexity, duration of operating time, technical operative skills required, as well as the number of post-op visits in the ward and repeated and recurrent review appointments in the private rooms. Post-op reviews are a necessity and are more frequent following foot/ankle surgery than reviews following large bone/joint surgery such as hip or knee replacements. Dr Nihal’s surgery fee also includes an assistant fee. We will give you the approximate cost of the total fee i.e. surgeon fee & assistant fee before the surgery.

Q27. Why we have to pay “Gap” for Surgeons fee?

Dr Nihal’s and the surgical assistant’s fee for the proposed operation will vary according to the complexity of the procedure. If the procedure is more complex and the rebate from Medicare/Health funds is lower and not proportional to the complexity of the procedure then a higher “gap” amount will be payable by yourself. The majority of Dr Nihal’s fee structures are based upon the standard AMA rate guidelines. Thus foot & ankle operations performed by Dr Nihal will often incur “out of pocket expenses – “gap” payment.

The foot & ankle are complex structures & Dr Nihal’s surgery fees are determined by the followings factors:

• Complexity of the operation
• Duration of operation
• Technical skills involved
• Hospital stay
• Number and length of post-operative follow-ups in the clinic & dressing changes etc
• Rebate from your health funds

Our practice will give you the approximate breakdown of the cost for the proposed operation. It is then your responsibility to ask you health fund as to how much money you will get back. Your health fund and the level of cover you have taken determine this amount.

Operations on smaller bones and joints in the foot and ankle attract smaller rebates, so patients will receive less rebate as compared to patients undergoing hip and knee replacements.

The rebate you will receive from Medicare/Health funds is not determined by Dr Nihal but is pre-determined and set by your health funds/Medicare. This amount does not represent the total surgeon’s fee but is financial assistance to cover part of the surgeon’s fee.

If you feel concerned that this amount is low, then you should raise this issue with Medicare Australia and your health fund as to why the rebate for the surgeon’s fee is lower than the AMA recommendations.

Needless to mention, your health fund & Medicare pay a very substantial amount (mostly in thousands of dollars) to the hospital where the procedure is being carried out. Thus it is very important to understand that your health fund primarily operates to cover the large amount of costs involved in hospitalisation for the proposed surgery. This includes the operating theatre costs, ward admission, nursing care, cost of anaesthetic drugs, surgical implants, plates, screws metal rods, ICU care if needed etc.

Q28: Why I have to pay the full amount? Why can’t you charge a “gap” and the rest you collect from my health funds?

Some health funds are strictly “No Gap” health funds. These “No Gap” health funds” prevent us from charging you a “Gap” & restrict us to accept their lower surgery fee which in no way reflects the complexity of foot and ankle surgery. Thus if you are a member of the “No Gap Health funds” then you will have to pay the full amount of Dr Nihal’s fees in advance. After the surgery we will give you the receipt to lodge a two-way claim with Medicare/health fund for your rebate. The amount you will get back will again depend on your health fund & your policy cover.

However should you be a member of the “Gap health funds” then for Dr Nihal’s surgery fee, you may be asked to pay the permissible “gap” called the “Known Gap” (depending on the complexity of the case and rebate from your health funds) and the rest we will collect from your health funds. We will inform you in advance regarding this.

Q29. I am confused about “ gap payment”, “ out of pocket expenses”, “known gap” rebate from Medicare and rebate from health funds etc? Please explain.

The “gap payment” is actually the “out of pocket expenses” which you will incur after claiming your rebate from Medicare and your health fund. For example, you had surgery where the surgeon and assistant’s fee was $2500, which you paid in advance. After surgery you lodged a two-way claim to Medicare and our health fund. You received $250 from your health fund and $750 from Medicare thus your out-of-pocket expenses for the surgeon’s fee was $1500. The amount of $1500 is the “gap payment” or “out of pocket expenses”.

About the “ Known gap”: the majority of health funds in Australia are “ Gap Health funds”. These funds allow the surgeon to charge a permissible gap from the patient called a “Known gap”. The remaining balance of surgical fees is collected directly from your health fund after your surgery. If you are a member of the “ Gap Health Funds” then you may be asked to pay the “Known gap” only and the rest we collect from your health funds. However this “Known gap” is not accepted by our practice for the more complex foot and ankle surgery cases but may be permissible for the more straightforward procedures. You will be informed before the scheduled surgery regarding “out of pocket” expenses and the “Known gap” if applicable. We will obtain informed consent from you before the surgery.

Q30: My friend Mr Smith had knee replacement surgery done by surgeon Dr X at Pindara hospital and my other friend Mr Willis had a knee arthroscopy keyhole surgery by surgeon Dr Y at John Flynn Hospital but these surgeons did not ask Mr Smith and Mr Willis for any fees at all. Why are you asking for the full surgery fee or “gap“ fee in advance?

Dr Nihal is also happy to do knee arthroscopy or knee replacement surgery on you at no cost to you at all! As mentioned previously the Medicare/health funds rebate for small bones in the foot is comparatively small and does not reflect the complexity of the case as well as not taking into consideration the multiple post-op review appointments following foot surgery. The rebate from Medicare/health funds for surgery to large bones i.e. knee arthroscopy, total knee and hip replacement is a reasonable amount so most surgeons do not need to charge you a gap at all. This practice is also happy to provide “no gap” for knee arthroscopy, hip and knee replacement etc.

Q31: We pay a lot of money to health funds every month; the insurance premium goes up regularly as well as the Medicare levy! In spite of this we had to pay a “gap” to the surgeon, “gap” to the anaesthetist etc and the rebate we got from the health funds/Medicare was a very small amount? Is it worth having private health insurance?

The Medicare rebate is an arrangement between the government and the patient. The Medicare rebate has not increased substantially for many years as compared to the large & ever-increasing costs of running a private practice, inflation and the associated cost of providing quality care to the patients. Medicare/Health funds do not fully cover the surgeon and anaesthetist’s fees. Needless to mention, the surgeon’s and anaesthetist’s fees are only a minor component of the cost for your surgery as compared to the theatre fees, hospital stay, nursing care in the ward, the cost of prostheses, insertion of plates, screws and provision of ICU care if needed. Thus this cost can run into many thousands of dollars, which is fully paid by your health fund/ Medicare. If you do not have private insurance then the amount payable from an uninsured patient for a complex operation may be anywhere from $10,000 – $30,000 upwards!

The health fund rebate again depends on the type of health fund you are a member with since the rebate amount varies between the health funds. The Medicare and health fund rebates you receive are independent & not determined by your treating surgeon.

Should you feel concerned about the level of your Medicare rebate then please write to Medicare Australia, Federal Health Minister or to your local federal MP regarding this.

Q32: Apart from Dr Nihal’s fee, do we have to pay any more costs towards the proposed private surgery?

Yes. The Anaesthetist’s fee is different and Dr Nihal has no control on the anaesthetist’s fee. My secretary will give you the telephone numbers of the Anaesthetic group and it is your responsibility to contact them and to ask them an estimate anaesthetic cost for your surgery. Most Anaesthetists charge a gap & you will most likely incur out-of-pocket expenses.

If you are privately insured and have full private hospital cover then generally hospital admission, theatre fees, theatre prostheses, metal plates and screws used, nursing care in the ward, meals etc are all covered. You may have to pay the hospital access to your health funds if you have any access on your policy. Please ask the hospital and your health funds regarding this. You may incur small extra expenses for radiology, pathology, pharmacy and the use of newspapers/ internet/ telephone etc. Please ask the hospital reception staff regarding this.

Q33: I want Dr Nihal to fill income protection forms/ air travel insurance cancellation claim/school insurance claim. / Life insurance claim forms etc- Do I have to pay any fee?

We issue standard medical sickness certificate or a certificates of attendance free of charge to all patients. However other claim forms as mentioned above usually take considerable time to complete and will therefore incur a small fee. Please ask our staff for the current fees for completing these forms.

Q34: Can we see Dr Nihal privately and then he can do operation on me as public patient in public hospital.

Dr Nihal only provides a private service. Dr Nihal does not have admitting rights in public hospital. If you agree to have surgery by Dr Nihal then this will be carried out in the Private hospitals.

Q35: What methods of payment do you accept for consultation/surgery fees?

We accept Visa, MasterCard, EFTPOS or cash. The consultation fee is paid on the day of consultation and the total surgery fee or permissible health funds gap is payable 5-7 days in advance before the surgery date. This can be done over the phone. We do not accept American Express or Diners Club cards.

Q36: Can you tell us in advance on the phone as to how much it will cost to have my surgery?

Unfortunately, we cannot tell you the exact costs for the out-of-pocket expenses until Dr Nihal sees you in the clinic and decides which operation and what item numbers are the most appropriate for your case. We are therefore unable to provide you with any quote for surgery until after the clinical consultation with Dr Nihal. Once you have decided to proceed with surgery then we will provide you with an approximate quote for surgery, along with associated costs and approximate rebates from Medicare/health funds. Please refer to FAQ 26 for further answer to this question.

Q37. I saw Dr Nihal the other day for consultation and I want you to send my clinic consultation letter to my solicitor, insurance company, income protection company, employer ?

I want my medical records; copies of the imaging results and clinic letter be posted to me. The clinic letter and your medical information is a confidential document and we cannot discuss this with any third person or party or send details via email. My clinic letter is written in response to a request from your GP/specialist & this will only be sent to your GP/Specialist & other allied health professionals who are treating you or who will be treating your medical condition. Please be advised that Dr Nihal’s clinic consultation letter is written using medical terminology and is intended for your GP/Specialist in response to the referral from them. It is the usual and standard practice that the patient should visit their referring GP/Specialist after consultation with Dr Nihal, to discuss the contents of Dr Nihal’s clinic letter in regards to what was the possible diagnosis, the management plan and/or any further recommendations about the patient’s clinical condition. Thus, the GP/Specialist can translate the medical terminology into simple plain English & relay the correct and relevant information to the patient. As mentioned above, my clinic letter to your GP is written using medical terminology and often contains complex medical language, which a non-medical layperson may not be able to correctly interpret, understand or comprehend. Thus, the patient may misinterpret the complex medical words and Google the  each and every medical word written in my letters, which may result in stress and anxiety for the patient. Medical information held in my private room regarding a patient is accessible in accordance with Commonwealth legislation. If you are unsure of the relevant Commonwealth legislation please seek independent legal advice. However, should a patient request access to medical records/clinic letters, then this request should be done in writing and be signed and dated by the patient and sent to my room via fax, e-mail or via registered post to my office. My receptionist will then contact you to inform you of the admin fee to release the clinic letters/imaging results/medical records. The clinic letter is only to be used for medical treatment purposes and cannot be used as a medicolegal letter or for any other purposes to gain income protection or to obtain a disability certificate etc. If any third party requests any medical information/medical records for the treatment you received under my care, then they should obtain written consent from you and send it to my office with a request letter. The admin fee applies which would be advised to the requesting party and is payable in advance. The admin fee varies depending on time involved in correspondence, photocopy, postage, length of files etc. If your solicitor/Insurance policy would like a medical report then they should contact my office with your written consent. Fees for medical reports vary depending upon the complexity of the case, size of medical records and the time consumed to prepare medical reports.

Q38. I saw Dr Nihal last week and could you post Dr Nihal clinic to my home address?

My clinic letter is a communication between myself and your treating doctors about your medical condition. Dr Nihal writes this letter to your GP in medical language often containing complex medical jargon which a non-medical person may not be able to correctly interpret, understand or comprehend. I would therefore suggest that the patient visits his/her GP to discuss Dr Nihal’s letter so that the GP can translate the medical language into plain English & relay the correct information to the patient. However, if you would like your clinic letter, then please send a written request to our office and we will post it to you. If the clinic letter contains too much medical jargon then Dr Nihal will include a simple translation. As this involves extra time for both my staff and myself, a small fee would be incurred. Please refer to FAQ 37 for further answer to this question.

Q39. Can I get Queensland temporary disable parking permit as I had surgery by Dr Nihal / or I have broken my ankle and foot and currently I have plaster/moon boot and have difficulty walking and parking?

Please carefully read Queensland temporary disable parking permit guidelines written on the permit application form which says that temporary disability has to be for 6 months, before you qualify for a temporary permit. As most of the fractures in foot/ankle heal in around 3 months, most patients do not qualify for a temporary disabled parking permit.

Q40. I have had other scans (MRI/CT/Ultrasound, Bone scan) but not X-rays, and/or I had X-rays but they did not give me printed hard copies but gave me on CD and login details and radiology company told me it will be sent to your doctor?

Plain X-ray is a very important base line investigation and in some clinical conditions weight bearing Foot/Ankle X ray gives me more information than MRI or ultrasound scan. Thus it is very important to have plain foot/ankle X ray done even if you had MRI scan or ultrasound. My room will inform you whether you need weight bearing (standing) or non-weight bearing (lying down or sitting down) X-rays. I want to see X rays /CAT /MRI scan with my own eyes and do not rely only on the radiologist report. The quality of foot/ankle imaging report depends on the expertise and the knowledge of the radiologist in the field of foot & ankle. Thus I have seen many radiology reports as ” no fracture seen” but have found missed fractures, just by looking at the original plain X ray. The radiology dept. will not arrange for the X rays/MRI scan to be sent to my room. The only way the X rays will be available in my room, when you bring them with you. I am unable to give you a quality care or make any diagnosis with out your X rays so please be sure that you bring them with you. “NO X ray- NO consultation” rule apply in my practice. If you do not bring them, then either I will send you to get new X ray or have repeat consultation. The radiology companies usually prefer to give you the X rays on a CD because it is cheaper for them than printing films. You should ask the radiology company to print your X ray on film at the end of your visit, in order for me to show your X ray and discuss the management. These printed X rays films you must bring in my room. Please remember if you bring your X rays/MRI on a CD then it will waste considerable amount of my clinical time, which I could give you or could have given other patients rather than fiddling with computer buttons! If you bring the images on the CD then I will have to do followings steps:

• Load the CD on my computer, it may take 5 minutes, depends on the size of file
• Open the imaging program on the CD
• Learn this imaging program as how to see all the images (it may take another 5-10 minutes)
• Open each image
• Magnify the image
• Copy the image
• Import the image on to my desk top
• Crop, de-rotate and label the image
• Copy or link the images to your clinical file on my computer
• Possibly print the relevant images so that I can bring in to theatre, should you need surgery
• Unexpected computer problems – like screen freeze, mouse click freeze, virus import, force quit – computer shut down and start again etc.

This takes a lot of my clinical time in a busy clinic when I should be spending this time taking history and examination and discussing management about your clinical condition. Thus if you bring your imaging on CDs then please inform my room and we will book extra computer time to open your CD, thus it will incur extra extended consultation fee for you. My secretary will inform extra fee at the time of booking or before the consultation. Thus it is important that you must bring printed films of your imaging especially X-ray CT and MRI scan. I do not need hard copies of ultrasound scan.

Q41. I have Income protection, life Insurance; Super; Return to Work; MASS forms for shoes/ orthoses, temporary / permanent disability, Health insurance claim forms, school sports injury claim forms, car parking permit application form etc., Could I ask Dr Nihal to complete these forms during consultation? Is there any extra fee for this service and how long does it take?

Our practice receives daily various forms from patients who are either consulting me or have consulted me in the past. These forms are: income protection, super funds forms, partial or total disability, life insurance, health insurance claims forms, government medical subsidy scheme MASS for shoes / orthoses, school sports insurance forms, mortgage exemption and financial hardship forms, car park permit, return to work form and various others etc. These forms range from 2 pages to 10 pages and mostly these forms require very detailed information including the details of injury or pathology present, and/or date and type of operation/s, length of stay in hospital, results of investigations, examination findings, past medical history and type of present and past work/ occupation, and what patient can do or cannot do as well as any temporary and permanent disability, when, where and why ?? etc.  These forms cannot be filled during the clinic consultation or at the end of the consultation or on the same day of the consultation. The consult time is only allowed for clinic consultations and the consult fee is for: taking history, clinic examination, looking at investigations, giving expert opinion, offering treatment options non-surgical or surgical or referral for further investigations and/or treatment by the allied health professionals physiotherapist, podiatrist. If Dr Nihal was to completes these various forms during consultation or at the end of each patient’s consultation then this could take an extra 20-40 minutes, which invariably will delay the next patient consult and then the next patient and so on… creating a domino effect and clinic may finish by midnight! Therefore, we respectfully advise that patient should complete the relevant section of these forms (name, DOB, address, dates of operation, admission etc) and then these forms are handed over to my receptionist after the consult. Dr Nihal usually completes these forms in the evening or over the weekend, in his own family and personal time, and then these completed forms are ready to be collected in 7-10 business days. Mostly these forms are long and may take 20 to 40 minutes or even longer to complete These forms also create extra administration work for me and the staff: collecting, scanning, contacting and sending forms to the patients via post with postage stamp or via fax or email. Therefore, our practice charges a fee for this service   the fee is variable and depends on the pages, type of information required and time consumed. Patient will be informed by my practice staff about the approx. admin fee and the approx.  time, it will take to complete, which is in most case is 7-10 business day. However, if your forms are urgent then could you please kindly ask your GP to complete. However, our practice provides free of charge the following certificates: medical sick certificate, career and attendance certificate, return to work certificate, which are printed on our clinic letterhead paper and these could be obtained on the same day of consultation from my staff. I trust this information is satisfactory in relation to NOT filling out the forms during clinic consultation time and/or on the same day and the application of an admin fee. Thank you.

Back To Top

Q42. I have had MRI scan /CT scan/Ultrasound and I do not want to come for follow-up visit to discuss the findings as I do not have time and also it would cost me another consult fee so I want to know the report, the diagnosis and treatment on the phone or via email.

Please also refer to the answer in Q11 as above and further explanation below: If you have had Foot & Ankle MRI or CT scan then Dr Nihal cannot consult and discuss the results via phone or e-mail.  Foot & Ankle is a complex structures thus MRI / CT scan is also a complex with more than 500-1000 small images to look at, and these many hundreds small images and findings have to be co-related with patient’s sings and symptoms. The MRI/CT/SPECT CT reports are only valid and clinically important if co-related with patient’s history and physical examination. Thus patient has to book follow up appointment to see Dr Nihal face to face discussion and to have 2nd foot & ankle examination, in order to co-relate the findings on the report and relevant pathology in the patient’s foot and ankle. Needless to mention many pathologies mentioned in the reports may not be clinically relevant to patient’s symptoms. As we all know: 1. MRI over diagnoses so many conditions, which may not be relevant to patient’s medical condition, thus may not need treatment. 2. We as clinicians do not treat MRI report but patient’s medical condition, which are relevant to patient’s symptoms and signs. Thus we clinician match the MRI findings with patient’s signs and symptoms For example MRI scan may show a ganglion in the toe but patient has an ankle pain thus we do not go and remove the ganglion from the toe just because MRI report says there is ganglion. 3. Thus it is absolutely essential that MRI report and findings be co related with patient’s symptoms and signs, thus patient has to be in front of surgeon for clinical examination to co -relate MRI findings with patient’s signs and symptoms That’s why all patients undergoing MRI scan have to return to see referring doctor to discuses MRI scan findings as which one are relevant and which one or not.

Back To Top

Q43. Are the MRI scan reports 100% accurate? Is MRI scan god and will tell me diagnosis with 100% accuracy as what is wrong with in my foot and ankle? Do all the MRI scan performed at different radiology companies are the same in quality in relation to the image quality and the quality of reports?

The answers to all questions above in Q:43 is : NO, explanation below: (a) MRI scan is non-weight bearing investigation: MRI scan is not 100% accurate and does not show all pathologies present with 100% sensitivity and/or with 100% specificity. As some bony pathologies are better seen on X ray, CT and SPECT scan than on the MRI scan. The small avulsion fracture could easily be missed on MRI scan. The MRI is a static non weight bearing investigation as the patient is lying down in the MRI machine cubicle, while X ray and WB CT scan is a dynamic study and shows some foot and ankle pathologies better on weight bearing. (b) MRI scan 1.5 Tesla or 3 Tesla: All MRI scans machine’s resolution is not the same as some machines are 1.5 Tesla (old) and new one are 3 Tesla, thus resolution of 3T MRI is better than 1.5T MRI scanner. This is similar to I-Phone numbers as resolution of I-Phone X camera is better than I-phone 5. (c) Where the MRI scans Coil was placed: Good MRI scan also depends where the MRI scan coil was placed on the foot and ankle by the technician. The MRI scan will show only the pathology where the MRI coils was placed by technician, if the technician put the coil on the PIP joints of the toes then DIP joints in toes will not be seen on MRI, thus the pathology present in the DIPJ of the toe could be missed. Similarly if the ankle MRI coil is not placed on the base of 5th metatarsal then the fracture of the base of 5th metatarsal or peroneus brevis tendon insertion pathology could be missed on MRI scan. (d) Different MRI sequences, axis, Gadolinium contrast: Foot and ankle MRI is a complex as it has many bones. joints and tendons and ligaments. There are various MRI sequences like T1 and T2 weighted images, fat suppression images, proton density images, stir images with or with out contrat (Gadolinium). These images are done in various planes /axis for example sagittal coronal and axial images. Thus if MRI technician does not do all relevant MRI sequences or all axis are not done then some foot and ankle pathologies could be missed. For example if T1 axial MRI sequence is not done in the forefoot then Morton’s neuroma could easily be missed as Morton’s neuroma in the forefoot is best seen on T1 weighted axial images of the foot MRI scan. (e) Who is reporting the foot and ankle MRI scans: General public and layperson assumes that every MRI scan report is good. Unfortunately this is not the case. There are good radiologists and there are some very good radiologists and there are some excellent radiologists who have special interest in foot and ankle MRI scan reporting. This is similar in every profession, whether the electrician, plumber, motor mechanic industry you may encounter is a good one or a bad one or may be an excellent electrician/plumber/motor, mechanic. The same is true in the medical profession.  I prefer foot and ankle MRI scans to be reported by excellent MSK radiologists who have special interest in reporting foot and ankle MRI scan. The foot and ankle MRI scan reporting is not an easy report because of complexity of foot and ankle anatomy and pathology as foot/ankle has 26 bones, 33 joints, 19 tendons and more than 107 ligaments. When GP/Physio request MRI scans then it may be reported by non foot & ankle radiologist thus the report may not be as good one as compare to if reported by an excellent MSK foot and ankle radiologist. If I request MRI then my requested MRI scans are only reported only handful of MSK foot and ankle radiologists. (f) Plain foot & ankle X-ray must prior to MRI scan: The good foot and ankle MRI scan report also depends whether patient had plain X rays of foot and ankle prior to MRI scan or not. In my opinion it is essential to have plain foot and ankle X rays first then report MRI scan so both could be co related. I have seen on many occasions when plain foot and ankle X rays have detected abnormality, which was missed on, MRI scan. In summary: All above-mentioned points in a b c d and e are important for good MRI scans and good report and should clear the layperson misconception that MRI scan can diagnose all the conditions and all MRI scans are the same and have the same excellent quality reporting obviously not, due to above mentioned reasons. I have done audit of foot and ankle MRI scan reports at my practice when patient have been referred to my room and have found 20% of foot and ankle MRI scan reports are either incomplete or incorrect or wrong. Many radiologists have missed many injuries on MRI scan as foot and ankle MRI is complex because the radiologist has to see 26 bones, 33 joints, 19 tendons and 107 ligaments and if specific clinical history is not given to the radiologist or if they are reported by non-MSK radiologists who have had no training in reporting the foot & ankle MRI scans.  Knee MRI scans are be easy to report because radiologist has to see one knee joint, two cruciates ligaments and two mensici and two collateral ligaments

1. There are so many constitutional conditions and if you do MRI scan on a 50 years old man with no shoulder pain, you will find that 50% of these patient will degenenerated rotator cuff tendons and bursitis and will be reported on MRI scan. This does not mean that surgeon go and operated on MRI scan reports when patient has no symptoms. If surgeon operates on the MRI scan reports only then surgeon is committing V.O.M.I.T that is abbreviation for Victim Of Medical Imaging Technology  – that is unnecessary operation performed based on MRI scan findings.

2. That’s why all patient undergoing MRI scan has to return to see referring doctor to discuses MRI scan findings and specialist has to perform 2^nd clinical examination as which MRI scan findings reported are relevant and which one or not and which needs surgery and which needs non surgical treatment.

3. I regularly informed the patients that please do not read the MRI reports of foot and ankle which is mostly on 2-3 pages long and then please do not try to understand the medical jargon written in it or or searching on Google , each and every word written in the MRI scan reports as this will cause anxiety, sleepless night and confusion. Therefore I always suggest to patient that patients should discuss the any imaging reports with the medical practitioner or specialist who has requested it.

Back To Top

Q44. I want bilateral foot and ankle MRI scans, as I know that MRI scan will show everything as what’s wrong in my both feet and ankles? Please refer to the answer in above Q.43 which explains about the MRI scan sequences and the MRI report. The MRI scan report is not a “Word of God” or word “Written in Stone”. The MRI scan report is only reliable and valid when the above mentioned criterion in Q.43 are met and  when the clinician compares the MRI scan findings with patient’s symptoms & signs and then decides as to which ones are pathological and responsible for patient’s symptoms and which ones are just normal physiological and constitutional normal findings, for a particular age group. The foot and ankle is a complex structure made up of approx. 26 bones, 33 joints, 19 muscles and tendons and more than 107 ligaments and nerves, thus interpretation and reporting of the MRI scan of foot and ankle is also not easy. The reporting radiologist has to look at least 185 different structures in the foot & ankle as well as has to differentiate normal from abnormal. Thus, If I send a patient to have bilateral foot and ankle MRI scan then poor radiologist has to look at approx. 370 parts of foot and ankle bones, tendons, joints, ligament, muscles, tendons and nerves etc This invariably results in some errors and misreporting, as the radiologist is a human, who is sitting in a dark room, looking at more than 1000 small MRI scan images and trying to  find abnormality in 370 various structural parts of the foot and ankle. In my past professional experience as a specialist orthopaedic foot and ankle surgeon for 21 years, I have seen more mistakes, errors in MRI reporting when bilateral foot and ankle MRI scan is requested and is done at the same time and the same day and reported by the same radiologist.  The common errors, I have encountered are:

1. MRI technician may put R sign on left foot or vice versa, (Human error). I have seen many bilateral feet MRI scan where R is placed on Left foot or vice versa. This could potentially result in an operation being performed on wrong foot for wrong pathology, if surgeon is not careful and is not an attention to detail surgeon.
2. The radiologist while reporting a pathology which is in the left foot MRI scan, may inadvertently say while dictating the report as in right foot MRI, (Human error), thus report will be reported as pathology in the wrong foot. This could potentially result an operation performed on wrong foot for wrong pathology, if surgeon is not careful and is not an attention to detail surgeon.
3. The radiologist who has dictated the report is then typed by typist and typist may type left than right foot MRI scan (Human error). This could potentially result in an operation performed on the wrong foot for wrong pathology, if surgeon is not careful and not an attention to detail surgeon.
4. The surgeon who is going to look at bilateral foot and ankle MRI scan, has to go through more than 1000 MRI images in order to look at 370 various foot and ankle structures in a busy clinic, which will invariably result in errors seeing all the pathologies present. The surgeon is also human and time pressured in the clinic, running late in the clinic, not eating lunch, interruption by emergency phone calls from hospital etc may divert his or her attention away from the pathology present in MRI scan, thus surgeon could miss the pathology present, especially looking at bilateral foot and ankle MRI scan

Thus, I have seen all above mentioned errors in my professional life of 21 years being specialist  orthopaedic foot and ankle surgeon, so I have learnt my lesson and have decided that I would (in most cases) avoid requesting bilateral foot and ankle MRI scans especially when patient has complex bilateral pathologies or chronic pain of uncertain aetiology. However, in simple cases of foot and ankle condition like Morton’s neuroma, I have requested bilateral foot MRI scan as a radiologist and I have to only look at only a specific area of the forefoot only. I am aware of recent incident in a hospital where surgeon operated on a wrong knee and removed the cartilage from normal knee as patient has bilateral knee MRI scans and radiologist reported torn cartilage in the wrong knee in the left rather than in the right. Thus, to avoid these errors and be attention to detail surgeon, I will request one foot and ankle MRI scan especially if patient has complex and chronic multiple pathologies.  I trust you (patient) understand my above reasons, which I have learnt after seeing many mistakes and errors in bilateral foot and ankle MRI reporting.

Back To Top

Q45. I have been seen by Doctor X and have had MRI scan/CT scan/Bone scan/Ultrasound in Melbourne, Bali, Nigeria, Dubai, London, Singapore, Perth, Darwin etc. Why should I have new scans at Gold Coast?  and why can’t Dr Nihal see these reports and scans?

Please also refer to the answer in above Q.43 which explains about the MRI /CT /SPECT and Ultrasound reports.

It is important for treating surgeon to know as who is reporting the foot and ankle scans: General public and layperson assumes that every MRI /CT/SPECT/Ultrasound scan report is good. Unfortunately, this is not the case. There are good radiologists and there are some very good radiologists and there are some excellent radiologists who have special interest in foot and ankle scan reporting. This is similar in every profession, whether the electrician, plumber, motor mechanic industry you may encounter is a good one or a bad one or may be an excellent electrician/plumber/motor, mechanic. The same is true in the medical profession.  I prefer foot and ankle scans to be reported by excellent MSK (musculoskeletal) radiologists who have special interest in reporting foot and ankle scan.

Again, my past experience has taught me that foot & ankle scans should be reported by radiologists who are MSK radiologist and have special interest in foot and ankle imaging.  The quality of CT scan / SPECT scan and 3D CT scan and MRI sequences may not be the same if you have had scans done in Dubai, Nigeria, Bali, Sydney, Singapore, Perth or Melbourne. Thus, in most complex foot and ankle cases I would ask you to have repeat scan to be done at Gold Coast and be reported by a specific foot and ankle MSK radiologist.  I also do not rely on the reports and prefer to see images and if you have on-line access username and password then I would be happy to access the on -line radiology web portal if accessible. The radiology images on CD-DVD are not acceptable, please refer to answer in Q40 as above.

Back To Top

Q46: Could Dr Nihal formulate my return-to-work plan?” also called a suitable duties plan (SDP), and sign it as what I can do and cannot do?

Frequently my room receives requests from patients asking “Could Dr Nihal formulate my return-to-work plan?” also called a suitable duties plan (SDP), as what I can and cannot do at my work place?” keeping in view of the injury sustained and/ or surgery performed”.

Dr Nihal is an orthopaedic surgeon who consults with many patients all of which have varied occupations. Therefore, it is very difficult for Dr Nihal to know and then determine as what each patient’s occupational duties are and their working conditions or the set- up in their factory, school, child care centre, construction sites, mines and various local company along with the local health and safety rules etc. Some patient’s jobs may be a very manual job requiring them to be on their feet all day, whilst another patient ‘s job may be more sedentary and office based so would require a very different return to work plan (SDP).

While Dr Nihal is happy to give you a letter to confirm whether you are able to do sitting admin duties, light physical or return to work/ sports, but is unable to write each and every task what you can or cannot do at your workplace and how many hours or days etc.

Thus, the usual protocol for Workcover injured/ operated patient and formulation of SDP is that the “Workcover Case Manager “will arranges a trained occupational therapist (OT) or Return to Work (RTW) physiotherapist / RTW rehab consultant, to do work site assessment. Thus, the patient and RTW consultant, along with employer, will meet at the site where worker normally works and assesses the injured / operated worker and his work and the work place and local health and safety protocols and formulate a plan as to what the Worker can and cannot do, including how many hours or days a week the worker can work etc. This SDP program is first signed by the worker, their employer and RTW consultant and then is sent to Dr Nihal for final approval and /or for any changes/ amendments.

Some employers may have their own RTW or health and safety officer, please contact your employer and arrange a work site assessment and formulated SDP and then send the patient signed SDP paper work to my room. Please allow 3 – 5 business days for assessment by Dr Nihal, once the admin fee is paid then the signed SDP form will be sent to you. If you are Workcover patient then the Workcover case manager will authorise Dr Nihal admin fee payment and if you are not Workcover patient then the you (the patient) is responsible to pay this admin SDP fee to Dr Nihal’s office.

Dr Nihal is unable to take calls from your employer regarding your return to work, or SDP duties, this is due to privacy and confidentiality issues.