New Study Shows How to Drive Savings in Hip Surgery
While the cost of orthopedic trauma implants has risen over the years, the fractures they are used to treat remain the same. Although some cost increases with improved technology is to be expected, indiscriminant use of costly implants when not needed should be examined. The orthopedic traumatologists are making progress in this arena that could benefit all their orthopedic colleagues…how to cut costs and maintain quality, that is. Ken Egol, M.D., is Professor and vice chair of orthopaedic surgery at the NYU Hospital for Joint Diseases at Langone Medical Center. He tells OTW, “We’re looking at cost savings and quality measures, specifically, looking at ways to reduce hospital cost on the surgery side while still maintaining quality. In fracture care, we have looked at standardizing the type of fracture implants for the treatment of one type of hip fracture. Using the evidence-based literature as a guide to determine which implant to use for each specific fracture pattern, we examined 220 cases and found that it was possible to have significantly lower costs per operation without a reduction in quality. In fact, we had a lower readmission rate and lower complication rates. These hip implants can range from $800 to $4, 000. What we did was standardize the way of fixing these fractures; while all fractures received the appropriate implant, the less complex fractures received less complex and thus less expensive plates and the more complex fractures were treated with the required more expensive nails. We determined that just by implementing these measures we were able to save an average of $700 per hip fracture surgery.”
“While this should be a ‘no-brainer, ’ the fact is that some doctors may have an implant ‘bias’ based on their training or potential conflicts of interest. This pilot study has already been submitted for publication. The next step is to look at other fractures types and see if a similar algorithm can be applied.”
Knee Redesign Prompts Biggest Product Launch in History
While we may never reach 100% patient satisfaction, a recognized knee and hip surgeon says that the release of the two newest knee platforms may hopefully get us to about 90% patient satisfaction. He tells OTW, “Only about 85% of people who undergo total knee surgery say that they are satisfied postoperatively; perhaps this is because conventional knee components are too mechanical and lack options to match the components to the specific size and shape of each patient’s anatomy. With the release of the Zimmer Persona Knee and the DePuy Attune, however, we should be able to close that gap and more accurately match the components to the patient’s anatomy…this will hopefully get us above the 90% satisfaction rate. Now that we know how the patella tracks and have more specifics on the knee kinematics, things are progressing with the design of these new knee systems. Soft tissue balancing is easier, and there are more sizing options so we can customize these for patients. In older knee platforms there were five or six size options and only 2/3 mm incremental polyethylene thickness options; the new ones have 10 or 12 options on the on tibia and femur—and 1 mm incremental poly spacers.”
“These have probably been the two biggest launches in history as far as a complete redesign of a knee line; I’ve heard that each company spent approximately a billion dollars each to develop these systems. Time will give us more information, of course. The Persona has been out six months, while the Attune was just released to research centers (and is not yet commercially available). Although this will likely help us narrow the gap, I do not think that we will get to the same patient satisfaction rate as we have had in the hip (about 95%).”
Spinal Deformity: Follow the Data
To obtain the most relevant, accurate data, says a veteran spine surgeon, we need to look at the right questions and have massive numbers of patients. Tom Errico, M.D. is chief of the Division of Spine Service at NYU Langone Medical Center and Hospital for Joint Diseases. He shares his take on spinal deformity research: “We have done a lot of papers looking at a large national inpatient sample database and I am starting to realize that most researchers are satisfied with just analyzing a small issue, i.e., ‘This procedure yielded a higher fusion rate’ or ‘This procedure is good at getting patients out of the OR sooner’. The world and payers are interested from a 35, 000 foot level to see if they are getting enough bang for their buck. There was a recent New York Times article about a study from Barcelona about the Mediterranean diet. The smart thing was that the authors measured the final outcomes, i.e., were people less likely to die of a heart attack or have a stroke. That is why this paper was on the front page of the New York Times. So often in orthopedics—and perhaps especially in spine—we measure an isolated outcome measure alone in a small fractionated group.”
“But since we should really be focused on final overall outcomes we need look at larger numbers of patients. There are two recent groups that have done great work on spinal deformity: the International Spine Study Group (which looks at adult deformity patients) and the Harms Study Group (focusing on childhood patients). When starting to look at ‘bang for the buck’ we need large amounts of patients, and these groups have been very successful at multicenter collaborative research and therefore getting abstracts into the important societies and expanding our knowledge base. What is most relevant is that people are pushing the envelope and enhancing their knowledge by joining other centers to collaborate on data collection. There have been a number of efforts over the years to do this, but these two groups stand out in my mind as being highly successful. The future comes when large groups like this can associate with each other to collaborate and create even larger databases. This effort has started but is in its infancy.
Accelerate Fracture Repair in a Single Injection!
Statistically significant healing attained…nothing fancy needed. Scott Boden, M.D. is director of The Emory Orthopaedics & Spine Center and Professor of Orthopaedic Surgery at Emory University School of Medicine. He is excited about his team’s recent work. “We are continuing to develop small molecules that may play a role in skeletal regeneration for the spine and possibly the disc. Thus far, we have identified four families of these molecules that we think will enhance local bone formation, and possibly enhance cartilage and soft tissue regeneration. They may also enhance bone void fillers in that category of less active graft materials.”
“Next month we have a study being published showing that one of those compounds can accelerate fracture repair in a single injection. It is truly striking that we only need a single injection of a small molecule—without any fancy drug delivery—to obtain a statistically significant increase in healing properties. I would have thought that it might require a time release delivery or some type of gel, but we just squirted it into a fracture hematoma. It’s a nice proof of concept experiment; the main thing is to be able to get to clinical trials. Emory finalized a license agreement for this technology to a company called SkelRegen, and they will assemble strategic and financial partners to move the project forward.”
Daniel Cooper, M.D. Wins NFL Award
ESPNDallas.com is reporting that Daniel Cooper, an orthopedic surgeon and team physician for the Dallas Cowboys, has received the Jerry “Hawk” Rhea Award from the National Football League (“Cowboys’ team physician honored” Todd Archer, February 26, 2013). Dr. Cooper, who practices at the Carrell Clinic, has been the Cowboys’ head physician for the last 13 years. Dr. Cooper attended The University of Texas Southwestern Medical School, then did an orthopedic residency at the University of Texas Health Science Center. He then completed an Orthopaedic Sports Medicine Fellowship at Cornell University’s Hospital for Special Surgery in New York City. Dr. Cooper is past president of the Texas Society of Sports Medicine.
