Products entering the knee replacement market have been met with excitement due to the reported enhancements they bring to patient care and their plain newness. Orthopedic companies are touting enabling and digital tools, cementless implant fixation and adaptability to the ambulatory surgery center (ASC) market.
For perspective on today’s trends, we turned to Richard A. Berger, M.D., a pioneer in minimally invasive joint replacement surgery. Dr. Berger performed more than 1,100 primary arthroplasties last year at Rush University Medical Center and in several ASCs in the Chicago area. Nearly 90% of his patients went home within hours of their procedures thanks to his ability to avoid cutting muscle, ligaments and tendons during surgery. Dr. Berger also has a mechanical engineering background that has helped him design gender-specific implants and specialized instruments for joint replacement surgery.
We found his comments insightful and restrained compared to the hype from the industry. The full interview with Dr. Berger can be found at ORTHOWORLD.com.
Enabling technologies are entering the joint replacement space. How are they impacting surgeons who perform cases at ASCs?
Dr. Berger: More surgeons would use robotic assistance or surgical navigation if the platforms significantly improved the accuracy of surgery and were affordable and easier to set up and employ. Many ASCs don’t have the capital dollars to purchase a million-dollar robot, plus $250,000 to spend each year on upkeep and software updates.
The literature doesn’t yet show that robotic assistance or surgical navigation increases how long implants last or improves long-term joint function. The alignment of implants might look better on postoperative x-rays, but that hasn’t translated into increased functional longevity.
Currently, the technologies add time and expense to a healthcare system that seeks to reduce the cost of care. Perhaps cost and proven clinical benefit will converge when platforms are less expensive and increase in popularity among surgeons. Right now, they’re divergent factors.
Handheld navigation devices are more in line with the interests of surgeons who operate at ASCs. During difficult cases, I use a handheld smart tool to check the accuracy of implant placement because it’s a cost-effective solution that’s quick and easy to use.
Cementless knee replacements are trending upward, but the widespread use of the technique is lacking. What are your thoughts on the practice?
Dr. Berger: I perform about 1,000 knee replacement surgeries every year. Using cement adds 10 to 15 minutes to each case — or 10,000 to 15,000 minutes to my work year. No one hates bone cement more than me. However, I also understand the clinical benefit it provides.
Early in my career, I used cementless knee implants, many of which resulted in failure of ingrowth. At the time, I thought the purported benefits of cementless fixation — improved outcomes, longer-lasting prostheses — were worth the risk of performing revision surgery on a small number of patients who experienced implant failure.
Many surgeons in ASCs want to perform knee replacements as quickly as possible, and cementless fixation shaves several minutes off procedure times. But are a couple of minutes saved worth an increased risk of ingrowth failure?
It’s well known that up to 20% of patients aren’t satisfied with the outcomes of knee replacement surgery. When cemented fixation is used, surgeons can review postoperative x-rays and know for certain whether a patient’s discomfort is caused by implant loosening.
When cementless fixation is used, surgeons are unable to determine if the implant is loose on x-rays and fluoroscopic images. It’s more difficult to determine the root cause of a patient’s concerns with the outcome of surgery.
We now know that implants placed with cementless fixation don’t last longer than cemented implants. Plus, the bone behind cementless implants is often less robust than the bone behind cemented implants. This means surgeons don’t have solid bone left to work with if revision surgery is needed.
I’ve been replacing knees for more than 20 years. Throughout my career, surgeons have made changes to how surgery is performed with the laudable intention of improving patient care. I’ve also seen surgeons change how they perform surgery with the intention of making procedures easier on themselves.
Cementless knee replacement falls into the latter category. The practice allows surgeons to perform faster surgeries and move on to the next case sooner, but those interests come at the expense of improved patient care.
What can orthopedic companies do to meet the needs of surgeons who operate primarily in ASCs?
Dr. Berger: When I’m operating at Rush’s main hospital, I have access to a seemingly unlimited inventory of implants and instruments. At surgery centers, it feels like I’m working on an island. I must make do with a limited number of supplies and loaner tools and implants brought in for specific procedures.
Having access to a spectrum of prostheses that could easily convert to proximal- or distal-coated tips or from a non-constrained knee to a more constrained knee — and have those capabilities in an easily integrated single system — would provide significant benefit. Some companies offer these solutions, but more could add them to their portfolios.
Companies spend plenty of resources on developing innovative implants and new technologies but don’t focus as much on surgeon education and training. The pandemic prevented in-person skill courses from occurring, but companies should renew efforts to help train surgeons on the devices they offer to perform better surgery.