Innovations in Orthopaedic Surgery
By Jonathan C. Levy, MD, Chief of Orthopedic Surgery, Holy Cross Hospital
The impact of innovation in modern healthcare has been dramatic over the past decade. While technology has certainly impacted many areas of medicine, the developments within Orthopaedic Surgery have the potential to dramatically change the way patients with orthopaedic conditions are managed.
The ability to execute a surgical plan has seen tremendous attention for both trauma and joint reconstruction. With the use of advanced imaging like CT and MRI, virtual planning software now helps surgeons anticipate challenges in pathology pre-operatively, and utilize this data to develop a customized surgical plan. Joint replacements are now being carried out with high level of precision, as robotic technology has facilitated sub-millimeter accuracy for placement of implants. With a highly detailed surgical plan, intra-operative innovations in sensor technology now allow surgeons to balance soft-tissues which are often not appreciated during virtual planning software efforts. While patient specific guides and instrumentation have seen more limited roles in hip and knee arthroplasty, their role in shoulder replacement surgery continues to expand. The ability to integrate technology that allows static instrumentation to be adjusted relative to the patients dynamic signature, improves the surgeons’ ability to reach their targets related to precision implantation, stability, and functional motion.
Over the past decade, possibly the greatest single disruptive innovation with an orthopaedic space was the success of the reverse shoulder arthroplasty. The clinical success combined with an expansion of indications has created exponential growth in shoulder arthroplasty. Innovations within the reverse shoulder arthroplasty space have been focused on biologic fixation with ingrowth metals and maximizing function.
“Software systems are recently being used to improve a physician’s ability to efficiently improve care pathways, and potentially improve patient outcomes”
Spine surgery has seen similar efforts in innovation, with virtual planning and intra-operative ultrasonics, robotic assistance is seeing larger roles. Improvements in implant technology have helped fuel the transition from spinal fusion to disc replacement. The ability to neuromodulate pain pathways such as the dorsal root ganglion in the spinal cord, together with stable reimbursement model, has lead to the commercialization of multiple offerings.
The ability to 3D print personalized implants has been commercialized; and as cost and speed of production improves this may increase their utilization. Improved inventory management will be required. This ability to surface coat has re-invigorated the press fit implant offerings in joint reconstruction. The advancement of Robotics will enable resurfacing implants with various geometries to enhance minimally invasive approaches, and achieving primary fixation stability.
Sports medicine continues to see rapid innovation with a continued emphasis on minimally invasive surgical techniques. While fixation of ligaments and tendons using modern anchors continues to allow for strong structural support of the repair, much of the future will be focused on improving the biology of healing. Disruptive technology within sports medicine will certainly focus on the integration of specific growth factors and soft tissue augmentation to enhance healing of surgical repairs and reconstructions. This is witnessed by the recent purchase of Rotation Medical by Smith Nephew, emphasizing the important role of tissue augmentation and biologic scaffolds for rotator cuff repair.
The role of “Stem Cells”, platelet-rich-plasma, and future biologics will require future randomized controlled studies. Presently, there is not a clear understanding of their role in the treatment pathways for arthritic and sports related injuries. However, without question, there exists a growing demand for utilization of these products.
Despite enormous momentum with the orthopaedic space, reimbursement for new technology continues to be a challenge. As innovations in technologies like robotics, patient specific instruments, intra-operative sensors, biologics, and ingrowth metals continue, the question of who ultimately pays for the added costs remains a heated debate. Hospitals have traditionally absorbed the added costs. However, with the transition to outpatient surgery and physician-owned hospitals and surgical centers, value justification will continue to create barriers to growth for many companies. Industry partners have recognized the need to have data in support of innovation, as providing proof of value for innovations is becoming the rule.
Software systems are recently being used to improve a physician’s ability to efficiently improve care pathways, and potentially improve patient outcomes. How “Big Data” within HIPPA protected parameters changes behavior and decreases costs needs further study.
Patient pre-operative risk modification pathways are improving knowledge of patient selection, helping to improve value-based care delivery by proactively identifying reversible risk factors and avoiding higher risk procedures prematurely. Wearable technologies for post-op activity oversight will allow the interpretation recovery pathways and the ability for healthcare systems to enter population management “at-risk” models.
Transition of orthopaedic care out of the hospital has been vastly improved with multimodal pain management. With a growing opiod crisis, the use of multi-modal pain management strategies have not only helped patients recover faster, but have been a driving force to allowing historically inpatient procedures to be done as an outpatient in carefully screened patients. The use of long acting local anesthetics like Exparel, and regional nerve blocks have helped to lead this transition. Furthermore, innovations in implant instrumentation will need to focus on the needs of outpatient facilities, which are often ill equipped to manage large number of instruments in a high-volume environment.
One thing is clear, the demand for orthopaedic solutions will continue. With a growing aging and more active population, orthopaedics will remain a growing market for years to come.