The evolution of orthopaedics - and how greater insight is needed as funding pressures increase
Elvio Gramignano, global strategic marketing director of orthopaedics technology group, Corin, discusses the advancements being made in orthopaedics and what is needed to combat increased funding pressures .
2018 sees three major healthcare anniversaries. The 5th July saw the UK’s National Health Service, and with it universal healthcare, celebrate its 70th birthday. In addition to this, the year also celebrates two major orthopaedic anniversaries. It’s 50 years since the first knee replacement surgery was undertaken and 60 years since Professor Sir John Charnley began his pivotal hip replacement research and surgery that led to the low friction arthroplasty concept.
A lot has changed in this time: not just advancing technologies, but also increased funding pressures on healthcare systems (both here in the UK and around the world) to meet the needs of an ageing population. In this article we examine how emerging trends are shaping changes to orthopaedic surgery.
The basis of current orthopaedic trends
Three fundamental trends are influencing the direction the orthopaedic industry is facing.
In excess of 200,000 hip and knee operations take place annually in the UK, and over 600,000 knee replacements take place in the US; with a prosthesis survival rate over 97% at 10 years. Replacements for the large joints - hip, shoulder, knee - are performing extremely well and this shift to becoming a mature set of procedures is affecting both how we, as an industry, are developing prostheses, and also how surgeons and administrations are treating the orthopaedics.
Added to this, the industry is affected by the fallout from the failure of metal on metal hip replacements, with many patients undergoing revision surgery and needing tests to monitor for metallosis. This significant event has almost completely eliminated the use of this technology and other related designs, and has forced the industry to carefully evaluate any innovation with a clinical history less than five years - increasing the regulatory demand to approve and sell products in the market.
And the industry has been affected by the pressures placed on healthcare systems, with consolidation in the industry: ten years ago we had hundreds of small and midsize orthopaedic companies, which is now no longer the case.
These have culminated in a need to provide ever increasing numbers of surgeries, to do them more safely and to do them with decreasing budgets.
The arrival of technology
One of the most interesting industry trends seems to be the arrival of technology to support the surgeon: initially navigation aids to guide the surgery, and following this robotic supported surgery.
While early implementations have improved the clinical outcome slightly, they haven’t yet been as successful as hoped; with time required for system validation and additional procedures, coupled with the increased cost of robotic surgery means it is adding a significant cost to the cycle of care with only limited gain in performance.
I should say that robotics is still in its infancy field, with less than 10-years of evidence, and using implants designed for manual surgery - it will be interesting to see how this changes as we alter the implant designs to better-suit robotic surgeons. But the fundamental issue related to this technology will remain: Robots and Navigation guide the surgeons towards generic implant positions; but technology should instead provide surgeons with patient specific implant positions based on anatomical and biomechanical information.
In hip arthroplasty, by analysing the pelvic movement and the spinal-pelvic relationship you may discover that, even if the implants have been positioned perfectly, if your pelvis rotates more anteriorly or posteriorly than the standard there may be complications that lead to decreased mobility, increased wear rate, dislocation and ultimately earlier revision.
Corin’s OPS™ technology (Optimised Positioning System), for example, takes 3 x-rays in specific positions plus a CT scan to determine a person’s pelvic biomechanics and provides insights on the positioning of the implants. A detailed report with all the information is provided to the surgeon who has the final decision on the implant positioning. The positioning decided by the surgeon is accurately achieved through a laser guided system and 3D printed cutting guides.
8,000 simulations have been completed since 2012 and the latest data will be presented later this year at key orthopaedic congresses in the UK, US and Australia.
Data to improve post-operative recovery
Data can also be used in planning and recovery, with the internet of things (from web-connected scales to motion tracking devices that communicate with a user’s smartphone or PC), giving orthopaedic surgeons more-reliable information on a patient - allowing for improved communication on progress with the patient.
Motion-tracking devices, such as those by Garmin’s Vivosmart, or the Fitbit have been in popular usage since 2015, with a handful of apps very recently becoming available for healthcare scenarios - the Corin RPM, for example launched last November.
Traditionally, both the decision to treat and the post-operative recovery are based on patient interviews, which are subjective, can focus on how they are feeling on that day, prone to having patient questions forgotten, and liable to information being withheld due to a patient’s conscious or subconscious fears.
By sharing data in real-time - via a smartphone app - on specific metrics from connected devices, with analysis and visualisation, the surgeon can personalise and adjust the patient’s pathway from the decision to treat through to post-operative recovery and the patient can report pain and ask questions enabling a shared decision making process.
Personalisation in orthopaedics will be required as funding models change - but it must come through greater insight
One of the major consequences of the change in how healthcare is funded will be an increased level of patient engagement. This can already be seen in the US, where reimbursements are starting to bundled with the quality of rehab - with future reimbursement based on reduction in 90 day re-admission rates.
Personalisation of surgery and of recovery programmes through greater insight will be essential in enabling this patient satisfaction. For many areas of healthcare, personalisation has delivered significant benefits in terms of improved outcomes and/or decreased costs. If we look to pharmaceuticals, the rise of pharmacogenomics has allowed medical teams to optimise the type and dosage of a drug administered, basing calculations not just on sex and weight, but on how an individual will metabolise it. Pharmacogenetics has similarly been used to identify those who will likely suffer side effects to the HIV antiretroviral drug abacavir, and to determine if the breast cancer drug trastuzumab will be effective. Such personalisation enabled the right drug to be administered at the right dosage, with fewer complications seen.
The orthopaedic industry has interpreted this healthcare trend by mainly modifying the implant design to make it closer to the anatomy, increasing the number of size options and, more recently, scaling up the creation of customised implants with the use of 3D printing technology.
Personalisation of orthopaedic procedures through greater insight is already improving the patients’ outcomes and this principle can be taken further. The next generation of personalisation will not just gather the available information about a patient’s biomechanics, but also their psychology, social environment, rehabilitation pathway; understanding the relationship between these parameters and how they can affect the outcome of the patients. This information should be made available to surgeons, healthcare providers and to patients at the level of depth appropriate for each in their orthopaedic experience. This connected information will turn into insight supporting the true personalisation of the patient’s treatment.