Medical Device Daily

NEW YORK In orthopedics, minimally invasive surgery (MIS) is here to stay. But other advances in this field are coming a bit more slowly.

More important in orthopedic repair are the changing patterns of what is happening to our hips and knees, both old and young.

These were very much the consensus views Wednesday during a hospital-oriented panel titled “Current and Future Trends in Orthopedics“ during this year's edition — the 17th — of the Piper Jaffray Health Care Conference, which concludes its three-day run today at the Pierre Hotel in midtown Manhattan.

Generally establishing these parameters during the panel was Richard Laskin, co-chief of the Knee Service at the Hospital for Special Surgery (New York) and professor of orthopedic surgery at the Weill Medical College of Cornell University (also New York).

Early on, Laskin did a bit of balloon puncturing, calling “minimally invasive“ the “wrong term.“ Rather, he said MIS should be described as offering surgical incisions “smaller than what we used to do last year [or] years ago.“

He granted that the incisions in hip and knee surgeries “are generally smaller, some really small, some medium-small — we're all trying to do less tissue damage. All our incisions are smaller.“

While saying that this equates to less trauma to bone and soft tissue, he also pointed to a range of undocumented variables, including differences in patient sizes and lengths of their hospitalizations.

While it is assumed that MIS shortens hospital stays, and Laskin said this is probably true, he added: “nobody has proven that.“

Rich Seldes, MD, an orthopedic surgeon and director of orthopedics at North Shore University Hospital (Forest Hills, New York), emphasized that the physician's judgment trumps the incision size since doing the procedure correctly is the main goal, not procedural elegance.

While agreeing with Laskin that MIS may be a “misnomer,“ he said that “in terms of results, [MIS] patients do require less pain medication and they do rehab a little quicker.

“Smaller and smaller incisions [are] here to stay as the techniques continue to evolve and operations are even less invasive,“ Seldes said. But he added a qualification: “Bottom line, it is still a major operation, no matter how small the incision, no matter how you [reduce disruption of] the small tissues.“

Laskin and Seldes were equally cautious concerning any projected rapid uptake of robotically assisted orthopedic hip and knee replacement, citing long learning curves, increased procedural times and the resultant reduced patient throughput in the operating room.

Seldes said, however, “Computer-assisted technology will help with MIS, and that's where orthopedics is going.“

Maryellen Keenan, the third panelist and an operating room business manager at the Hospital for Special Surgery, said that the best approach was for a “champion“ to lead a hospital's efforts in pursuing this technology.

Another trend that the panelists clearly had issues with is the increasing number of direct-to-consumer advertisements pushing orthopedic procedures.

Patients, Laskin said, are going to orthopedic surgeons and saying, “I want that total hip that Arnold Palmer has, or I saw a patient going up and down a hill in San Francisco — that's the total knee I want.“

“I don't like the idea, but companies love it,“ he said. “It gets them much more bang for the buck with the public.“

But TV advertising is too susceptible to being “pseudo-scientific,“ he charged.

Not disagreeing, Keenan said that orthopedic firms apparently would continue the direct-to-consumer approach for one simple reason: “it's working.“

Besides expressing their concerns about some of the much-bannered trends in orthopedics, the panelists agreed that new technologies need to be adopted according to cost-control guidelines carefully set by their hospitals and thus perhaps limiting adoption. Another control, cited by Keenan, is physician peer pressure.

Laskin emphasized also that while new technologies might be promoted as superior, hospitals would not find small improvements easily rationalized by large pricing increases.

Overall, and perhaps most importantly, the panelists were very much in agreement that hip, knee and other orthopedic reconstructions are likely to grow — and keep on growing.

Seldes described his center, North Shore University Hospital, as seeing orthopedics as “an area of growth that we're currently trying to develop. We're developing certain pathways in terms of making surgeries efficient, every step of the way planned [with] specialized staff and instrumentation, coordination of a lot of different disciplines.“

A key incentive, he acknowledged, is that “reimbursements are generally higher for joint replacement than other procedures.“

Laskin described a “steady increase in the number of implants“ at his center at the rate of 15% to 20% per year, with knee replacements growing faster than hip replacements.

While the panelists pointed to the oft-repeated and well-recognized fact of aging demographics as a key driver for this trend, they noted various other factors related to damaged hips and knees.

“We have a large cadre of people who have done something to their knees in their 20s and 30s,“ Laskin said, “and in their 50s their knees start going. From age 65 to 100, we have garden-variety arthritis, but now [also] a younger group with post-traumatic arthritis.“

Besides this growth on the “younger side,“ he pointed to seeing “an older side — super-old people, 85 and up. Both of these groups are adding on at a tremendous rate.“

Still another growth area noted by Laskin is revision surgeries — “a lot of implants [used] in the 1980s wearing out“ and making up about 20% of total procedures. “As patients live longer, the chance of patients outlasting the implant is greater and greater.

“And if you want to do more, you can do even more,“ he added.

“It is a market that will continue to grow,“ said Keenan. “It's trending more towards knees than hips, but both are growing. As baby boomers age, there's a high demand for these types of procedures.“

She too saw the target populations expanding with “younger and older patients that we haven't been doing before, whole areas never captured before. We're doing hip replacements in 40-year-old patients, with ceramic-on-ceramic hips. A lot of times that patient wasn't even touched 10 years ago.“

Is there a limit? Not really, the panelists agreed.

“Topping off depends on the number of beds you have,“ Laskin said, noting that his hospital is putting in more beds to meet demand, even building more operating rooms. “The limiting number is nothing but capacity of hospitals to take care of these people.“

Seldes echoed that point, commenting that if hospitals cannot expand rapidly enough, specialty hospitals will absorb the further growth that will surely come.

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